1. The document discusses health economics principles as they relate to radiation oncology, including concepts of scarcity, opportunity cost, efficiency, and equity in healthcare resource allocation. 2. Models of healthcare systems and cost analysis methods are presented, including Donabedian and newer integrated practice unit models. Cost-effectiveness is analyzed for various cancer types and treatment techniques. 3. Clinical examples show increased cost-effectiveness of intensity-modulated radiation therapy (IMRT) over conventional RT for anal cancer and head and neck cancer, and proton beam therapy for select pediatric cancers. Advanced techniques require higher investment but can improve outcomes and reduce adverse effects.

1. HEALTH
ECONOMICS IN
RADIATION
ONCOLOGY
YAMINI BAVISKAR
CARLTON JOHNNY

2. We should know
1. We choose for the patients
2. We are involved in making
institutional policies, national
health policy impacting vast
majority of people.

3. FLOW OF SEMINAR
1. ECONOMICS
2. HEALTH ECONOMICS
3. PRINCIPLES
4. MODELS
5. CLINICAL EXAMPLES

4. ECONOMICS
• The study of how society decides what, how and for whom to produce.
• The social science of SCARCITY!
• DECISION MAKING
• RESOURCE ALLOCATION
Begg, Fischer and Dornbusch, 2005

5. Health Care Is An Economic Good..
1. Resources used to provide health are finite
2. Society’s wants for health care - what society would consume in the
absence of constraints on its ability to pay for it, have no known
bounds.
• Health economics is a branch of economics concerned with issues
related to efficiency, effectiveness, value and behavior in the production
and consumption of health and healthcare.
Any good/service that is
scarce relative to our
want for it

6. • Application of economic theory, models and empirical techniques to
the analysis of decision-making by individuals, health care providers
and governments with respect to health and health care.
• Study the functioning of healthcare systems and health-affecting
behaviors
• Uses mathematical models to synthesize data from biostatistics and
epidemiology
• Analyses the data
• Helps medical decision-making by addressing difficult questions of
appropriate and efficient allocation of resources in the health care
setting.

7. SEMINAL CHARACTERISTICS OF HEALTH CARE
• Patients do not behave the same
way as consumers
1. Cannot try/ test the product
2. Less knowledgeable about the
product than the seller
• Doctors do not behave the same
as other firms
1. No advertising/ overt
competition
2. Advices have no self interest
and based on clinical needs
3. Fee structure varied

8. Principles Of Health Economics
1. Notions of scarcity, supply and demand,
2. Distinctions between need and demand,
3. Opportunity cost, discounting,
4. Time horizons, margins
5. Efficiency and equity
We need to
CHOOSE

9. NEED AND SCARCITY!
• Ageing of the population - increases in new diagnoses
• Persistence of risk-increasing behaviors
• Earlier diagnoses via improved cancer screening
o Global cancer incidence – 18.1 million/year
o Cancer incidence in India – 1.16 million/year (Prevalence – 2.25 million)
 More than 50% of all cancer patients would require radiotherapy during
the course of their disease and its treatment.

10. External Radiation and Brachytherapy Resource Deficit for Cervical Cancer in India:
Call to Action for Treatment of All
Supriya Chopra, MD, Shyam Kishore Shrivastava, MD

11. • ~ 50% patients requiring
RT in LMICs do not have
access
• Access rate - The
proportion of cancer
patients receiving
appropriate RT at least once
during the treatment of
their malignancy
• Unavailable need is 90% in
low-income countries
• Asia Pacific, due to its high
population density, has
large absolute needs in RT
treatments and resources,
and hence in associated
costs.

13. NEED VS DEMAND
• Deciding Who Gets What in Health Care  The government, The
institution, The treating physician
• India’s expenditure on health sector 1.4 % (public), 4.1 % (total)
• Example –
• Investigations
• Choice of immobilization
• Technique of RT – Conventional vs 3DCRT vs IMRT
• Cobalt vs Xrays

14. CHOOSE WISELY
INITIATIVE
1. Don’t recommend radiation following
hysterectomy for endometrial cancer
patients with low-risk disease.
2. Don’t routinely offer RT for resected
NSCLC, negative margins, N0-1
disease.
3. Don’t initiate non-curative RT without
defining the goals of treatment with
the patient and considering palliative
care referral
4. Don’t routinely recommend follow-up
mammograms more often than
annually for women who have had
radiotherapy following BCS.
5. Don’t routinely add adjuvant WBRT to
SRS for limited brain metastases.
ASTRO

15. OPPORTUNITY COST
• The next – highest – valued alternative use of that resource
• The opportunity cost of committing resources to produce a
good/service is the benefits forgone from those same resources not
being used in their next best alternative.
• Protracted course of RT in patients with
CURATIVE
INTENT
WITH LONG
SURVIVAL
PALLIATIVE
INTENT
1. Evidence based approach
2. Clinical Judgement
3. Crude Financial work up
4. Ask the patient! – QoL, Patient’s
attitude towards treatment

16. • EFFICIENCY
• Allocation of scarce resources that maximizes the achievement of aims.
• Aim to obtain the “best” set of uses for the resources
• To analyse the production & relationship between
resource inputs & outputs.
• If most output possible is produced from a given set of
inputs / fewest inputs possible are used to produce a
given amount of output.
Techni
cal
efficien
cy
• Cost of those inputs.
• If the most output possible is produced for a given
cost, or a given amount of output is produced at the
lowest possible cost
Economic
efficiency

17. EQUITY
• Fair distribution of health and health care between people and fairness
in the burden of financing health care
• Equal treatment of equals
• Do people who have the same health
needs have equal access to health care?
Horizontal
equity
• Unequal treatment of unequals
• Do people who have worse levels of health
have greater access to health care?
Vertical
equity

18. Conceptual framework
for evaluating the
quality of medical care.
Here, assessments are
drawn from three
dimensions of care:
Structure, process, and
outcomes
Donabedian’s Model

19. a• INPUT – What you put in - Man Money Material
• PROCESS - What you make the patient go through -
Investigations, Treatment protocol, Follow-up,
Administrative
• OUTPUT - No. of beneficiaries
• OUTCOME – Unit morbidity/mortality prevented
• BENEFIT – Overall gain provided to the society/Monetary
• VALUE - OUTCOME & BENEFIT /COST

20. NEWER
MODELS

22. STRUCTURE & INPUT
• Staffing –
• Labour intensive due to its technological complexity and the associated challenge of
maintaining accuracy and safety along the entire treatment pathway.
• Integrated practice unit (IPU) model –
• Via coordination between multiple specialties in complex decision-making, the
multidisciplinary model may allow for higher attainment of benchmark measures for quality
care, better cost savings & patient satisfaction
• Clinical and nonclinical personnel deliver evidence based care including inpatient, outpatient,
rehabilitative care, and supporting services, such as nutrition and social work.
• With feedback mechanisms for refinement of care delivery, economic efficiency, and patient
convenience, all relevant to the value proposition
• Pure prospective payment –
• Reimburses providers a fixed amount independent of the volume of services provided for
promoting efficiency via incentivizing providers away from costly treatments.

23. IDEAL HEALTH POLICY
Should ensure
(1) that all patients get all necessary care,
(2) that equivocal and nonindicated treatment be excluded
(3) that cost of care be socially responsible
(4) that variation in the quality of care be so small from a technical
perspective that does not matter from which facility or provider a patient
receives treatment
(5) that when competition occurs, it should be over the quality of the art of
care, such as how patient centered it is and how well staff and physicians
communicate with patients

24. ESTRO HERO PROJECT
• Provision and accessibility of radiotherapy: Assessment of the
actual status of radiotherapy, in terms of treatments delivered on an
annual basis per country, equipment, staffing and guidelines.
• Need for radiotherapy: Definition of an optimum radiotherapy,
defining the patients who should receive radiotherapy, those who
got it, existing gap and the growing future need for RT.
• Cost-accounting programme for RO: Development of a costing tool,
providing insight on the national cost of radiotherapy: per
treatment, on average and for various tumour types and techniques
used, but also on the resources required based on national patterns
of care, allowing to perform sensitivity analysis.
• Economic evaluation models for RO: Engagement in economic
evaluations of radiotherapy for estimates on gains in outcome,
different costs and techniques.

25. OUTCOMES
• Survival
• Disease control, disease recurrence,
• Functional status
• Complications of treatment.
• Subjective –
• patient-reported outcomes
• psychosocial ramifications of disease or treatment
• Ability to maintain employment status
• Patient’s understanding of disease
The outcome measures hierarchy as defined by Porter.

27. ANALYSES
• Decision analysis uses a set of mathematical tools designed to determine
the most favorable outcome with regard to a particular endpoint (such
as overall survival or time without recurrence) for individuals with a
given starting situation under many different sets of circumstances,
using existing data or assumptions regarding the effectiveness and
toxicities of treatments.
• INPUT/ OUTPUT ANALYSIS
• COST EFFECTITVENESS ANALYSIS
• COST UTILITY ANANLYSIS
• COST BENEFIT ANALYSIS

28. Forms of economic evaluation
• Cost consequences analysis examines costs and consequences without
attempting to isolate a single consequence or aggregate consequences into a
single measure
• Cost minimisation analysis (CMA) The consequences of compared
interventions are required to be equivalent, and only relative costs are
compared
• Cost effectiveness analysis (CEA) measures consequences in natural units,
such as life years gained, disability days avoided, or cases detected. In a
variant of CEA, often called cost utility analysis, consequences are measured
in terms of preference-based measures of health, such as quality adjusted
life years or disability adjusted life years.
• Cost benefit analysis—Consequences are valued in monetary units.

29. FINANCIAL TOXICITY!!
• Patient-incurred financial strain that may diminish quality of life
• Sequela of cancer treatment
• Cancer patients are 3 times more likely than the general population to declare
bankruptcy
• Maximizing billable units -
• By using advanced treatment modalities when not clinically indicated
• By dividing dose over an increased number of fractions
• Facilitated by the technologic and complex nature of radiation oncology
Chemotherapy administered the last 2 weeks of life is an emerging quality indicator
employed by the ASCO Quality Oncology Practice Initiative

30. CLINICAL EXAMPLES
ESTRO HERO, Lievens et al 2014

32. • Most common cancer in women
Median follow up of
more than 5 years,
shows no
statistically
significant
difference in local
control, survival, or
cosmesis between
traditional
fractionation and
schedules
delivering 13 -16
fractions in 3 weeks

33. • Active Surveillance (AS) represents a cost-effective management strategy for localized
PCa during the initial several years after diagnosis.
• Relative cost effectiveness of treatment emerges with extended follow up, both Radical
Prostatectomy ($5,627/QALY) and Radiation Therapy ($78,291/QALY) were found to be
more cost-effective than AS.
Cost-Effectiveness of Active Surveillance, Radical Prostatectomy and External Beam
Radiotherapy of Localized Prostate Cancer: An Analysis of the ProtecT Trial
• Incorporation of Genomic Prostate Score as
part of decision algorithm for patients with
NCCN very-low-risk and low risk cancer led
to substantial increase in active surveillance
and substantial cost savings (average, $2286
per patient) for insurance carriers.
• GPS list price of $4520

34. • Grade 2 or worse xerostomia
• At 12 months significantly
lower in the IMRT (15%) than
in the Conv. RT (74%)
• 24 months, IMRT – 29% vs
Conv. RT 83%
• At 12 and 24 months,
significant benefits seen in
recovery of saliva secretion
with IMRT compared with
Conv. RT
PARSPORT , Lancet Onc. 2011
The cost of TomoTherapy is higher
than that of RapidArc therapy in HN
Ca., due to longer treatment
sessions, higher price of the
accelerator, and higher costs of
maintenance.
Acute adverse events during RT
not significantly different, VMAT
RapidArc, with a lower cost, should
be considered superior in head and
neck patients given the current state
of knowledge.

35. • IMRT for LA anal canal cancer
• 42 % less likely to require a break from radiation treatment of more
than 5 days.
• 40 % lower risk of needing ostomy surgery related to the cancer
progressing or recurring.
• 19% more likely to receive and complete two cycles of chemotherapy,
the conventional treatment course
Intensity Modulated Radiation Therapy Versus Conventional
Radiation for Anal Cancer in the Veterans Affairs System

36. • Limited data
 Promising cost effectiveness in
1. Pediatric brain tumours - medulloblastoma , PBT -
$12,364, Conv RT $5,129, Total costs of adverse effects (IQ,
hearing loss, and growth hormone deficiency) PBT - $5,121,
Conv RT - $40,967, Total cost decreases by 2.6-fold with PBT
2. Well selected breast cancers – left sided, existing
cardiac comorbidities
3. High risk HN Ca - Post t/t 1 yr - Xerostomia and dysphagia
rates 22% and 18% respectively, with IMPT, 44% and 23%,
respectively with IMRT. Similar gains in QALYs with ($61,697 for
IMPT, $49,656 for IMRT)
PBT is NOT cost-effective for prostate cancer or early stage NSCLC
• higher capital
investments
• higher personnel
requirements
• higher operating and
maintenance costs
Proton center has 4 times
higher capital investment
costs, 2.5 times higher
operational costs
3 times higher cost per
fraction

37. • SPECIAL THANKS TO
DR. ANIL SIR