Proton therapy of cancer: Potential clinical advantages and cost-effectiveness

Figures & data

Figure 1.  Basic structure of simulation models. The same tree structure as in the conventional tree branch is used in the proton branch, but is not displayed in the figure.

Table I.  Standard case assumptions used in simulation models.

Parameter	Risk	Cost (€)	Utility reduction	Relative risk^****
Breast cancer
Increased risk of ischemic heart disease	43%^1	6466 first year, 616 second and following years^*	10%	0.24
Increased risk of other cardiovascular disease	27%^1	4265 first year, €796 second and following years^*	20%	0.24
Pneumonitis	14%^*	1706^*	–	0.04
Prostate cancer
Prostate cancer related death	2.5% for 15 years	–	–	0.8
Mild GI adverse event	14%^*	105.2^*	7%^*	0.6
Severe GI adverse event	4%^*	1774.9^*	7%^*	0.6
Mild UG adverse event	9%^*	242.2^*	7%^*	0.6
Severe UG adverse event	0.5%^*	571.3^*	7%^*	0.6
Head and neck cancer
Overall mortality	16% for 8 years^*****	–	–	0.76
Dental care	–	1608.7 the first year, then 271.7 per year on average	–	–
Medulloblastoma
Death due to subsequent cancer	0.11%^**	–	–	0.48
Death due to cardiac disease and other deaths	0.056%^**	–	–	0.77
Hearing loss	13%	5054^*	18%	0.12
IQ loss	4.25 points	2448^***		0.12
Hypothyroidism	33%	114^*	10% during one year	0.12
Growth hormone deficiency	18.7%	13 478 up to the age of 19 and 1348 for older persons^***	20%	0.12
Osteoporosis	2.4%	363 above 50 years^***	2%	0.12
Non-fatal cancers	0.32%	19 565^*	–	0.12

¹ Compared with general population. The risk of cardiac diseases was applied from year 10 after radiation treatment and during the remaining lifetime.

^* Per event or one year only.

^** Per year, between 10 to 20 years after diagnosis.

^*** Per year for the remaining lifetime.

^**** Proton versus conventional radiation.

^***** Average figure. Highest mortality during the first years after diagnoses.

Table II.  Results from simulation models.

Sensitivity scenario	Δ Cost^*	Δ QALY^*	Cost per QALY
Breast cancer
Average breast cancer patient	6243.1	0.0937	66 608
High risk population (assuming double risk of cardiac disease)	5920.0	0.1726	34 290
High proton radiation cost estimate^**	8834.2	0.0937	94 282
Low proton radiation cost estimate ^***	5692.9	0.0937	60 757
Risk reduction of cardiac events (standard case 76%)
50%	6386.7	0.0606	105 474
90%	6163.0	0.1121	54 977
Risk reduction of pneumonitis (standard case 96%)
70%	6301.6	0.0937	67 232
90%	6256.6	0.0937	66 752
Prostate cancer
Standard case results	7952.6	0.297	26 776
High proton radiation cost estimate^**	10 485.2	0.297	35 304
Low proton radiation cost estimate ^***	7343.9	0.297	24 727
Relative risk of tumour death (standard case 0.8)
0.6	7954.3	0.596	13 346
1.0	7950.8	0.012	662 571
Relative risk of adverse events (standard case 0.6)
0.4	7920.4	0.302	26 227
0.8	7984.8	0.291	27 439
Head and neck cancer
Standard case results	3887.2	1.02	3811
High proton radiation cost estimate^**	6430.7	1.02	6305
Low proton radiation cost estimate ^***	3289.4	1.02	3225
50% less favourable hazard rate	4061.1	0.61	6658
75% less favourable hazard rate	4191.6	0.3	13 972
90% less favourable hazard rate	4245.9	0.16	26 537
25% more favourable hazard rate	3713.3	1.43	2597
50% more favourable hazard rate	3582.9	1.73	2071
No dentistry cost savings	7506.8	1.02	7360
Medulloblastoma
Standard case results	−23 646.5	0.683	Dominates
High proton radiation cost estimate^**	−21 602.9	0.683	Dominates
Low proton radiation cost estimate ^***	−25 690.1	0.683	Dominates
Relative risk of subsequent cancers (standard case 0.6)
0.8	−23 594.6	0.672	Dominates
1	−23 594.0	0.660	Dominates
Relative risk of non-fatal adverse events (standard case 0.12)
0.3	−17 446.2	0.590	Dominates
0.5	−10 568.0	0.487	Dominates
IQ loss from radiation (standard case 4.25 points)
0 points	−11 439.7	0.683	Dominates
3 points	−20 056.7	0.683	Dominates
Radiation-induced deaths and cancers applied for 20 years (standard case 10 years)	−23 203.5	2.377	Dominates

^* Proton radiation versus conventional radiation

^**Assuming a 20-year facility lifetime, a higher investment cost for proton facility (M€66.3) and no investment cost for conventional radiation

^***Assuming a 40-year facility lifetime and a lower investment cost for proton facility (M€58.2)

Table III.  Proton versus conventional therapy outcome.

	Breast cancer^1	Prostate cancer	Head & neck cancer	Medulloblastoma	Total
Number of patients per year	300	300	300	25	925
Δ Cost^*	5920.0	7952.6	3887.2	−23 646.5
Δ QALY^*	0.1726	0.297	1.02	0.683
Cost per QALY	34 290	26 776	3811	Cost saving
Total cost difference (M€)^**	1.8	2.4	1.2	−0.6	4.7
Total difference in QALYs^**	51.8	89.1	306.0	17.1	464.0

¹ Assuming that a population at high risk of cardiac diseases is treated.

^* Per patient, proton – conventional radiation.

^** For all treated patients during one year.