COST-BENEFIT OF EMERGING TECHNOLOGY IN LOCALIZED CARCINOMA OF THE PROSTATE

Purpose: In a health care environment strongly concerned with cost con tainment, cost-benefit studies of new technology must include analyses of loco-regional tumor control, morbidity, impact on quality of life, and financial considerations. Methods and Materials: This nonrandomiz ed study analyzes 124 patients treated with three-dimensional conforma l radiation therapy (3D CRT) and 153 with standard irradiation (SRT) b etween January 1992 and December 1995, for histologically proven adeno carcinoma of prostate, clinical Stage T1 or T2. Mean follow-up is 1.4 years. Three-dimensional CRT consisted of six or seven coplanar obliqu e and lateral and, in some patients, AP fields designed to treat the p rostate with a 1 to 1.7 cm margin. SRT consisted of 120 degrees bilate ral are rotation. Total doses to prostate were 67 to 70 Gy when pelvic lymph nodes were irradiated or 68.4 to 73.8 Gy when prostatic volume only was treated; dose per fraction was 1.8 Gy. Patients were intervie wed weekly for severity of 12 acute intestinal and urinary pelvic irra diation side effects (0 to 4+ grading). Time and effort for 3D RTP and daily treatment with 3D CRT and SRT were recorded. Dose-volume histog rams (DVHs) were calculated for gross tumor volume, planning target vo lume, bladder, and rectum. Actual reimbursement to the hospital and un iversity was determined for 41 3D CRT, 43 SRT, and 40 radical prostate ctomy patients treated during the same period. Results: Average treatm ent planning times (in minutes) were: 101 for 3D conformal therapy sim ulation, 66 for contouring of target volume and sensitive structures, 55 for virtual simulation, 39 for plan preparation and documentation, 65 for physical simulation, and 20 for approval of treatment plan. Dai ly mean treatment times were 19 min for 3D CRT with Cerrobend blocking , 16 with multileaf collimation, and 10 with bilateral are rotation. D osimetric analysis (DVHs) showed a reduction of 50% in volume of bladd er or rectum receiving doses higher than 65 Gy. Acute side effects inc luded dysuria, moderate difficulty in urinating, and nocturia in 25-39 % of both SRT and CRT patients; loose stools or diarrhea in 5-12% of 3D CRT and 16-22% of SRT patients; moderate proctitis in 3% of 3D CRT and 12% of SRT patients (p = 0.01). Chemical disease-free survival (pr ostate-specific antigen less than or equal to 2 ng/ml) at 3 years was 90% with 3D CRT and 80% with SRT (p = 0.01). Average initial treatment reimbursements were $13,823 (3D CRT), $10,864 (SRT), and $12,250 (rad ical prostatectomy). Average total treatment reimbursement and project ed cost of management of initial therapy failures per patients were $1 5,173, $16,264, and $16,405, respectively. Conclusions: Three-dimensio nal CRT irradiated less bladder and rectum volume than SRT; CRT initia l reimbursement was 28% higher than SRT and 12% higher than radical pr ostatectomy. Because of projected better local tumor control, average total cost of treating a patient with 3D CRT or radical prostatectomy is equivalent to cost of SRT. Treatment morbidity was lower with 3D CR T. Our findings reflect an overall benefit with 3D CRT as a new promis ing technology in treatment of localized prostate cancer. Dose-escalat ion studies may enhance its efficacy and cost benefit. (C) 1997 Elsevi er Science Inc.