Intensity-modulated radiotherapy (IMRT) - KCE

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Intensity-modulated radiotherapy (IMRT) - KCE

iv Intensity-modulated radiotherapy KCE reports 62C

BUDGET IMPACT SCENARIOS

Based on epidemiologic data for Flanders in 2001, international data on treatment rates

for external radiotherapy and current regulations for public reimbursement of

radiotherapy in Belgium, we assessed the potential impact on the public healthcare

budget IMRT may hold. In doing so, we made budgetary simulations for the period

between 2002 and 2006. The fundamental hypothesis underlying our model is that IMRT

patient would otherwise, i.e. in absence of IMRT as a therapeutic option, would have

been treated as 3DCRT patients (prostate and head and neck cancer) or through

conventional two-dimensional radiation (breast cancer patients).

The budget impact of treating all prostate and head and neck cancer patients with IMRT,

given current (2007) regulations would apply, was estimated at around 5 000 000€ in

2003 (breaking down into 72.2% of added fee-for-service expenses, 7.4% of investment

costs and 20.4% of operational costs). This would imply that about 5.4% would be

added to the running budget for external radiotherapy. Furthermore, the extension of

current IMRT reimbursement to breast cancer patients may prove to be a sizeable cost

inducing measure, raising the overall budget impact to approximately 17 000 000€ in

2003, amounting to an estimated increase of the overall budget for external

radiotherapy with 18.7%. This result is modelled on the assumption that all breast

cancer patients qualify for IMRT, implying that 50% of all externally radiated cancer

patients would receive IMRT. Experts, however, put forth 40% as more in check with

clinical reality. The latter budget impact estimate should consequently be interpreted as

maximal.

By intent we publish our estimates as the results of an updatable model. Future

innovations should foremost concern a detailed analysis of patient distribution across

RT departments, the inclusion of IMRT uptake rates per tumour site applying specifically

to Belgium and the inclusion of net budgetary effects generated by therapeutic shifts

from cancer care interventions other than external radiotherapy (chemotherapy,

brachytherapy, etc).

Recommendations

In general, more long term data are needed for IMRT treated patients, to

confirm any survival advantage and to assess the increased risk of secondary

malignancies in comparison with standard external radiotherapy techniques.

Manufacturers and users of IMRT hardware and software should be made

more aware of this risk of induction of secondary malignancies, and product

improvement is to be stimulated.

As IMRT for head and neck cancer is more difficult to plan and deliver, and

still an area of investigation, for the time being its use in these patients

should be restricted to centres with the necessary expertise and

preferentially those that are performing research in this area. The IMRT

expertise at a centre could be assessed based on quality assurance measures

in place, monitoring of patient outcomes and participation in clinical trials. A

more appropriate financing of complex IMRT planning in head and neck

cancer is to be considered.

IMRT or (3D) conformal radiation therapy (3DCRT) is recommended for

high dose external radiotherapy in prostate cancer.

Use of IMRT may reduce skin complications in breast cancer radiotherapy,

primarily in heavy breasted women. Long term studies are required to

assess the risk of induction of a secondary tumour in the contralateral breast

after IMRT before introduction into common practice. Specific research

financing of IMRT in breast cancer should be considered.

More frequent imaging for guidance of IMRT is expected to further improve

the efficacy and safety of IMRT, particularly in targets showing internal

movement, e.g. in case of prostate cancer. Financing of imaging for IMRT

should be re-assessed in the future.

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