ICARO 2009 Round Table Discussion 

Cost & Economic Analyses in  Radiation Oncology

Prof. Rajiv

Sarin, MD, FRCR

Director

Advanced Centre for Treatment, Research & Education in Cancer (ACTREC)

TATA MEMORIAL CENTRE

MUMBAI

INDIA

rsarin@actrec.gov.in

Criteria for deciding cost effectiveness for  expensive new anti‐cancer agents

Sarin

R (Editorial), Jr. Cancer Res. Ther. 4(1) 2008.

•

New Radiation Technologies should be subjected to same analyses  and same cut offs as for other health interventions including the 

new molecular targeted therapies

•

WHO recommends using per capita GDP (adjusted for Purchase  Power Parity) of a country for deciding the cut off for cost 

effectiveness of health interventions

IF additional cost incurred to gain 1 quality adjusted life year

is< 1 times the GDP: 

COST EFFECTIVE INTERVENTION

1 – 3 times the GDP: 

PROBABLY COST EFFECTIVE INTERVENTION

> 3 times the GDP: 

NOT COST EFFECTIVE INTERVENTION

INDIA: Per capita GDP adjusted for Purchase Power Parity: 3800 US$ 

Radiotherapy is one of the most cost  effective modality for cancer management

Cost effectiveness analyses for radiotherapy is  complicated by major global differences in 

•

Type and stages of cancers to be treated

•

Throughput ‘required’

per unit & handicaps in expertise

•

Work practices (Monday – Friday: 9am – 5pm or weekends also)

•

Initial Capital Cost of Equipment 

•

Interest rates

•

Cost of maintenance

•

Downtime of the machine

•

Replacement cycle or life of machine

UNIVERSAL PROBLEMIntegration of New

Technology in ‘Routine Care’without proper analysis of

‘Clinical Benefit’ complicates Cost effectiveness analyses

How New Technology is being Integrated in How New Technology is being Integrated in Radiation Oncology in Radiation Oncology in ‘‘most partsmost parts’’ of the worldof the world

We start with & often get lost in discussing the technical capabilities, finesse, &

precision of new technology & how good it would be for our patients.

Soon we say that patients want this new technology & it becomes ‘standard of care’

Evidence Based Assessment & Integration of Evidence Based Assessment & Integration of Technology in Radiation OncologyTechnology in Radiation Oncology

Societal Costs

Technical Capabilities &

Precision

Clinical Benefit

Research (Clinical and Health Economic Evaluation) in Emerging Technology becomes a necessity in Emerging economies to provide a solid foundation

Could be the starting point

BUT not the Centre point

How should we integrate New Technology in How should we integrate New Technology in  ‘‘Routine Clinical PracticeRoutine Clinical Practice’’

•

Overwhelming superiority in the clinical 

outcome with new technology OR

•

Modest but definite benefit 

•

Results are generally reproducible

•

Possible to integrate the new technology in a 

particular health care system 

Emerging Technology PromisesEmerging Technology Promises

•

Lower toxicity  

•

Improved Patient and Personnel Safety

•

Better documentation and validation 

<< Improved cure rates >>

May be Higher Throughput & Cost effectiveness in certain clinical contexts

Emerging Technology Generally EntailsEmerging Technology Generally Entails

•

Higher initial and maintenance Cost

•

Uncertainty of clinical benefits

•

Uncertainty of sturdy performance

•

Human resource implications

•

Skepticism of the critics & health economists

May prove to be expensive experimental tool, especially in emerging economies

Cost –

effectiveness of RT can be improved by

•

Optimal utilization of the conventional  technologies and better work practices

–

Indications and prioritization

–

Fractionation

–

Audits, QA and QC programme

•

New Technologies–

For better case selection (e.g. PET imaging)

–

Hypo‐fractionation in select indications

•

Indigenous Technology –

May have lower initial / maintenance cost

–

Better suited for local conditions 

α/β ratio of tumour

(7-10Gy) much higher than late responding

normal tissues (2-4Gy); e.g. Squamous Ca

H&N, Lung, Cervix

α/β ratio of Tumour

(1.5 - 2Gy) < late

responding normal tissue (2-4Gy);

e.g. Prostate Cancer

HYPERRACTIONATED / ACCELERATED RT

HYPERRACTIONATED / ACCELERATED RT

Improve tumour control without increasing late

toxicity (possibly more acute toxicity)HYPOFRACTIONATED RT

HYPOFRACTIONATED RT

Better utilisation of health resources

Tumour control &late toxicity comparableα/β ratio of Tumour (3 – 5Gy) similar

or slightly higher than late

responding normal tissue (2-4Gy);

e.g. Breast Cancer

HYPOFRACTIONATED RT

HYPOFRACTIONATED RT

Improve tumour control

with similar or reduced

late & acute toxicity

Evidence Based Clinico-Radiobiological Fractionation Pyramid

New Technology generally permits greater normal tissue sparing, thereby facilitating hypo-fractionation in ‘certain clinical contexts’ with similar / better Therapeutic Ratio

SarinSarin R, Lancet R, Lancet OncolOncol. 2006 (7); 445. 2006 (7); 445--47 47

Higher initial cost of new technology may be

partly offset if it provides clinical benefit to sufficient number of patients with suitable

tumours types

Use of fewer fractions, if safe would be to

great advantage for patients and

‘professionals’ alike

BHABHATRON BHABHATRON --

TELECOBALTTELECOBALTDeveloped by BARC, Dept.

of Atomic Energy in 2004Technology Transferred to

Panacea Tech. Ltd. BangaloreDosimetric & Clinical

evaluation of Prototype unit at ACTREC in 2005 - 06

Refined version Bhabhatron-II in use at ACTREC and in almost dozen Indian centres

Integrated in Indian National Cancer Control Programme in the 11th Five Year Plan in 2008

VISIONVISIONDept. of Atomic Energy of India set up a special Apex committee in 2003 to develop

high quality & cost effective indigenous equipment with initial emphasis on Telecobalt

Indian Indigenous Cancer Technology Development Programme

MISSION MODE Academia – Industry

partnership can facilitate development of high quality

and cost effective indigenous technology in developing countries with some pre-

existent technological base.

Indian Indigenous Cancer Technology Development Programme

The Dept. of Atomic Energy & Tata Memorial Centre are continuing with coordinated efforts to develop and validate Indigenous Equipment for Cancer (LINAC, PACS, SIMULATOR etc.)

Bhabhatron II

India is donating India is donating BhabhatronBhabhatron

TelecobaltTelecobalt

to Vietnam under the to Vietnam under the  IAEA IAEA ‐‐

PACT (Programme Action for Cancer Therapy)PACT (Programme Action for Cancer Therapy)

Building SustainableBuilding Sustainable Cancer Control Capacity and InfrastructureCancer Control Capacity and Infrastructure

in Developing Countries in Developing Countries 

Chairman, Atomic Energy Commission of India handing over a model of Bhabhatron to IAEA Director General, Dr El-Baradei at ACTREC, Mumbai (2007)

Emerging economies have TWIN REALITIES which pose Special Challenges of Optimizing limited resources through Indigenous R&D;

Evaluation of new technology & Cost effectiveness studies

Two localities in Mumbai few miles apart Two bunkers in ACTREC sharing a wall

Indigenous Indigenous TelecobaltTelecobalt

TomotherapyTomotherapy