Comments International Journal of Radiation Oncology � Biology � Physics246

5. Knoos T, Wieslander E, Cozzi L, et al. Comparison of dose

calculation algorithms for treatment planning in external photon

beam therapy for clinical situations. Phys Med Biol 2006;51:

5785-5807.

6. Fogliata A, Vanetti E, Albers D, et al. On the dosimetric behaviour of

photon dose calculation algorithms in the presence of simple geo-

metric heterogeneities: Comparison with Monte Carlo calculations.

Phys Med Biol 2007;52:1363-1385.

7. Bertelsen A, Hansen O, Brink C. Does VMAT for treatment of

NSCLC patients increase the risk of pneumonitis compared to IMRT?

A planning study. Acta Oncol 2012;51:752-758.

8. Schytte T, Nielsen TB, Brink C, et al. Pattern of loco-regional failure

after definitive radiotherapy for non-small cell lung cancer. Acta Oncol

2014;53:336-341.

9. Hansen O, Schytte T, Nielsen M, et al. Age dependent prognosis in

concurrent chemo-radiation of local regional advanced NSCLC. Acta

Oncol (accepted for publication).

Cost-effectiveness of IMRTversus 3D-CRT

In Regard to Hodges et al

To the Editor: I read with great interest the article by Hodgeset al (1) and would like to commend them on a very rigorouscost-effectiveness analysis study. The accuracy of the anal-ysis is dependent on cost inputs, the probabilities, and theoutcomes that are factored into the model. Some of the lim-itations have been nicely outlined by the authors and in theeditorial accompanying the article. My comments are on theactual cost of treatment listed in Table 2 of the article.Although it does include the immobilization device on theday of simulation, it does not include the treatment devicesused for the 3-dimensional (3D) plan. Given that 8 basicdosimetry calculations are listed for the 3D and complexisodose plan, it typically is associated with the use of 8complex devices to deliver this plan. This would increase themean cost of 3D treatment by 8 � $152 Z $1216, signifi-cantly narrowing the current difference in mean cost, whichis currently around $3847. This can reduce the incrementalcost-effectiveness ratio (ICER) significantly downward from$128,233/Quality-Adjusted Life-Year (QALY), and it maystill be above the very conservative, inflation-unadjusted$50,000/QALY established many years ago but possibly

below the more relaxed willingness to pay (WTP) thresholdof $100,000/QALY and certainly below other publishedWTP thresholds (2, 3). This will also affect the probabilisticsensitivity analysis at different WTP thresholds.

Although the ICER is an important tool to evaluatetherapeutic interventions, there are limitations in the in-formation that it provides. The cost inputs currently comefrom Current Procedural Terminology codes and not truecosts spanning a patient’s entire care cycle. Also, as notedby the authors and in the editorial, mature data on out-comes, including patient-reported outcomes, preferablyfrom randomized clinical trials, should be factored intothese models before any conclusions can be drawn becausethe analysis is very sensitive to changes in these endpoints.This is an important analysis, and the information hasclinical and health policy implications. If the authors agreewith the additional cost inputs as discussed above and thenumbers are revised, I would hope that the Payers andTechnology Evaluation Committees (who also keenlyfollow these articles) notice the corrected data and thelimitations and not rush to make any change in coveragepolicy, because currently the use of intensity modulatedradiation therapy for anal cancer is a covered indication forMedicare and most private insurance companies.

Najeeb Mohideen, MDNorthwest Community Hospital

Arlington Heights, Illinois

http://dx.doi.org/10.1016/j.ijrobp.2014.09.003

References

1. Hodges JC, Beg MS, Das P, et al. Cost-effectiveness analysis of in-

tensity modulated radiation therapy versus 3-dimensional conformal

radiation therapy for anal cancer. Int J Radiat Oncol Biol Phys 2014;89:

773-783.

2. Devlin N, Parkin D. Does NICE have a cost-effectiveness threshold and

what other factors influence its decisions? A binary choice analysis.

Health Econ 2004;13:437-452.

3. Braithwaite RS, Meltzer DO, King JT Jr, et al. What does the value of

modern medicine say about the $50,000 per quality-adjusted life-year

decision rule? Med Care 2008;46:349-356.