This is DRAFT presentation. See https://www.slideshare.net/goldwein/is-radiation-therapy-a-costeffective-cancer-treatment-an-evidencebased-analysis for final presentation.

1. Copyright © 2021 XRTMD Networks LLC
Cost-effective - (adj) An intervention that is
considered financially optimal if there is no other
available intervention that offers a clinically
appropriate benefit at a lower cost.
: producing good results without costing a lot of
money.
A cost-effectiveness analysis is a way to examine
both the costs and health outcomes of one or
more interventions. It compares an intervention
to another intervention (or the status quo) by
estimating how much it costs to gain a unit of a
health outcome, like a life year gained or a death
prevented.
Is Radiation
Therapy a Cost-
Effective Cancer
Treatment?
An evidence-
based analysis
Joel Goldwein, MD, FACR
XRTMD Networks, LLC

2. Copyright © 2021 XRTMD Networks LLC
Executive Summary
The relatively low
spending for RT services
and low cost per
beneficiary along with
its ubiquity and
associated positive
outcomes altogether
infer high value and
cost-effectiveness
Broad and rigorous comparative analyses of
Radiation Therapy (RT) cost-effectiveness do not exist
RT costs represent a
relatively small proportion
of direct spending on cancer
treatment in multiple
marketsS-7 and at relatively
low cost per beneficiaryS-9
RT is integral to, and an
irreplaceable component of
approximately half of all
cancer treatments
worldwide1,2,3
Outcomes of radiotherapy,
definitive or palliative, are
generally positive and
constantly improving4,5,6
HOWEVER

3. Copyright © 2021 XRTMD Networks LLC
Numerous
claims have
been made with
respect to cost-
effectiveness of
radiotherapy
Social Media
•“Radiation therapy is a cost-effective cancer treatment modality that
targets the most common & costly cancers…” 7
Online Promotional Material
•“Radiation therapy contributes to 40% of all cancer cures world-wide as
well as improving the quality of life for many others. Despite this great
benefit, the total cost of radiation therapy to the Commonwealth
government is less than 9 cents in every dollar spent on all cancer
diagnosis and treatment. Each year of life saved in Australia by radiation
therapy costs us less than one saved using other cancer treatments. In
other words, radiation therapy is a very cost-effective cancer
treatment”8
Peer Literature
•“RT is one of the more cost-effective cancer treatment modalities…” 9
•“… radiotherapy remains an important modality used in cancer
treatment being a highly cost-effective single modality treatment …” 10
•“Available evidence points to its cost-effectiveness, especially when
value is measured in factors other than survival” 11
•“RT IS A CRUCIAL AND COST-EFFECTIVE CANCER TREATMENT” 12

4. Copyright © 2021 XRTMD Networks LLC
Cost-
effectiveness
Claims Made
by Professional
Organizations
ESTRO 13
“Radiotherapy is an inexpensive
treatment option. While it requires a
well-planned initial investment in
equipment, infrastructure and training,
the long-term costs are low. Even where
radiotherapy is a major component of
cancer care, it only accounts for a small
proportion of the cancer budget”.
ASTRO
No publicly identifiable statements.

5. Copyright © 2021 XRTMD Networks LLC
Broad and
rigorous
RT cost-
effectiveness
analyses do
not exist
Few rigorous (contemporary) comparative analyses have been
performed
Those that have been performed tend to fall on the lower-level side of the evidentiary scale,
or are introspective (EBRT vs BT), and/or isolated (RP vs RT for prostate cancer).
Costs/payment models across locales are highly variable, and thus not
necessarily reliable indicators or parameters for use in value or cost-
effectiveness analyses
Overall results of analyses are highly variable and often inconclusive
Virtually no studies look broadly at QALYs comparisons
RT (along with other therapeutic modalities) is so tightly integrated
and embedded into cancer treatment pathways that any rigorous
cost-effectiveness comparative analyses would be of very limited use

6. Copyright © 2021 XRTMD Networks LLC
While RT use is
ubiquitous, it
rarely replaces
chemotherapy,
immunotherapy
or surgery…
An important component and option for virtually all cancer typesS-9
• An extraordinary breadth and depth of indications
• Few cancer types where RT is not a part of the treatment pathway
Highly useful in virtually all cancer treatment scenarios
• Definitive, palliative, adjuvant, preparatory (e.g. – transplants), inoperable, medically
unfit…
RT technology is widely available in many forms delivered by many
different devices (External beam, Particles, Linacs, Gamma Knife,
Brachytherapy …)
RT technologies accessible in virtually every health system across the world
RT is / should be administered to approximately 50% of cancer
patients14,15,16

7. Copyright © 2021 XRTMD Networks LLC
Radiotherapy Cost Estimates in
Various Markets Suggest
Relatively Low Spending
Country
Approx. Direct
Cancer Spending
for RT Services
Sweden17,18 5%
England19 5%
UK20 5%
Australia20 9%
EU21,22 7.8%-10.6%
Canada/Ontario23 9%
USA† 5%
Varian Tweet from ESTRO 2009 based on data from
reference 22
† Assumes 2020 RT total cost to Medicare is ~$5B and total Medicare cancer spending is ~ $97 B since projected total USA cancer spend is approx. $180 B and Medicare covers approx. 54% of
all US cancer patients. The $5 B RT cost is derived from RO Episodes File 2017-2019 which includes data on [top] 15 cancer types, but excludes brachytherapy data, inpatient treatment data
and data from VT and MD. Cancer Types include Anal, Bladder, Bone Metastases, Brain Metastases, Breast, Cervical, CNS Tumor, Colorectal, Head & Neck, Lung, Lymphoma, Pancreatic,
Prostate, Upper GI, and Uterine cancer. The $2.607 B 2019 spend for RT has been upscaled to $5 B to conservatively account for the excluded data. Therefore, $5 B/$97 B is approx. 5%.
Copyright © 2021 XRTMD Networks LLC

8. Copyright © 2021 XRTMD Networks LLC
The 11 most
costly cancer
treatment
agents cost USA
Medicare $28.5
billion in 2019
Agent
Total Cost
($ million)††
Revlimid/lenalidomide24,25,27 $ 4,674
Darzalex/daratumumab24,25,27 $ 3,647
Keytruda/pembrolizumab24,25,27 $ 3,278
Radiotherapy26 $ 2,607
Rituxan/rituximab24,25,27 $ 2,598†
Opdivo/nivolumab24,25,27 $ 2,491
Imbruvica/ibrutinib24,25,27 $ 2,440
Neulasta/pegfilgrastim24,25,27 $ 1,989
Ibrance/palbociclib24,25,27 $ 1,826
Avastin/bevacizumab24,25,27 $ 1,567
Xtandi/enzalutamide24,25,27 $ 1,421
Total $ 28,538
† Includes rituximab costs associated with 3 non-oncologic indications. See slide 7 for explanation and caveats.
†† Drug data includes infusion costs but not E & M costs. RT data does not include E & M costs or brachytherapy costs. See
Slide 7 for other caveats.

9. Copyright © 2021 XRTMD Networks LLC
Comparison of
USA Medicare’s
11 Most Costly
Cancer Agents†
† See Slide 8 and references for detailed source information
‡ As counted from the list of Indications for Use in the most recent FDA
drug labeling as of August 2021
†
†RT has an unequalled depth and breadth of approved Indications for
Use. For example, FDA Pre-Market Notification lists the approved
Indications for Use of Elekta Linear Accelerators as “… for the delivery of
curative and palliative intent EBRT to Adult and Pediatric patients with
primary benign and malignant tumor and metastasis (or secondaries)
anywhere in the body”32. The Varian Halcyon Linear Accelerator use is
approved “… for the delivery of stereotactic radiosurgery and precision
radiotherapy for lesions, tumors and conditions anywhere in the body
where radiation is indicated for adults and pediatric patients”.33
Data scaled and normalized from worst to best (0-10)
Entity Cost Total Beneficiaries Cost per Beneficiary
Number of
Indications
Revlimid 3.0 1.9 6.5 0.4
Darzalex 5.2 0.5 0.2 0.2
Keytruda 6.0 2.3 8.1 4.0
Radiotherapy 7.4 7.7 9.7 10.0
Rituxan 7.4 3.3 9.0 0.4
Opdivo 7.7 1.4 7.5 2.0
Imbruvica 7.8 1.2 7.0 1.2
Neulasta 8.7 3.7 9.4 0.4
Ibrance 9.1 1.0 7.3 0.2
Avastin 9.6 10.0 10.0 1.4
Xtandi 10.0 1.0 8.0 0.2
Ideal 10.0 10.0 10.0 10.0
Raw Data
Entity
Total Cost
($ million) Total Beneficiaries Cost per Beneficiary
Number of
Indications ‡
Revlimid $ 4,674 42,215 $ 110,719 2
Darzalex $ 3,647 12,076 $ 302,004 1
Keytruda $ 3,278 50,535 $ 64,866 20
Radiotherapy $ 2,607 170,647 $ 15,277 >50 28,29,30,31,†
†
Rituxan $ 2,598 72,160 $ 36,003 2
Opdivo $ 2,491 30,480 $ 81,726 10
Imbruvica $ 2,440 25,475 $ 95,780 6
Neulasta $ 1,989 81,175 $ 24,503 2
Ibrance $ 1,826 21,130 $ 86,417 1
Avastin $ 1,567 221,035 $ 7,089 7
Xtandi $ 1,421 21,644 $ 65,653 1

10. Copyright © 2021 XRTMD Networks LLC
Radiotherapy is a safe and effective agent for a broader range of
indications, for a wider population, and at lower cost
†Based on material from previous slides with associated citations
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
Cost to Medicare
Beneficiaries
Cost per Beneficiary
Indications
Revlimid Darzalex Keytruda Radiotherapy Rituxan Opdivo Imbruvica Neulasta Ibrance Avastin Xtandi Ideal
Radar Chart Comparison of Most
Costly Cancer Treatment Agents. †
A higher score is better.
Ideal
Radiotherapy

11. Copyright © 2021 XRTMD Networks LLC
Conclusion
The relatively low spending for Radiation Therapy Services, its relatively
low cost per beneficiary, its ubiquity and its associated positive outcomes
altogether infer high value and cost-effectiveness

12. Copyright © 2021 XRTMD Networks LLC
References I
[1] International Atomic Energy Agency. Planning National Radiotherapy Services: a Practical Tool. (Vienna: IAEA Human Health Series
Publications, 2010)
[2] Parker, T. Radiotherapy Services in England 2012 (London: Department of Health, 2012). Pg 25, top
[3] Atun R, et al. Expanding global access to radiotherapy. Lancet Oncol. 2015;16:1153–1186.
[4] Ringborg U, et al. The Swedish Council on Technology Assessment in Health Care (SBU) Systematic Overview of Radiotherapy for Cancer
including a Prospective Survey of Radiotherapy Practice in Sweden 2001*/ Summary and Conclusions. Acta Oncol. 2003;426:357–365.
[5] Thompson MK, Poortmans P, Chalmers AJ, Faivre-Finn C, Hall E, Huddart RA, Lievens Y, Sebag-Montefiore D, Coles CE. Practice-changing
radiation therapy trials for the treatment of cancer: where are we 150 years after the birth of Marie Curie? Br J Cancer. 2018 Aug;119(4):389-
407.
[6] Tepper and Gunderson: Clinical Radiation Oncology, 4th Edition., 2016
[7] https://twitter.com/varianmedsys/status/986645317704560640
[8] https://www.targetingcancer.com.au/about-radiation-oncology/benefits-and-effectiveness/ - Faculty of Radiation Oncology, The Royal
Australian and New Zealand College of Radiologists
[9] David A Jaffray and Mary K Gospodarowicz. Jaffray and Gospodarowicz Cancer: Disease Control Priorities, Third Edition (Volume 3).
Chapter 14 - Radiation Therapy for Cancer
[10] Baskar R, Lee KA, Yeo R, Yeoh KW. Cancer and radiation therapy: current advances and future directions. Int J Med Sci. 2012;9(3):193-9.
doi: 10.7150/ijms.3635. Epub 2012 Feb 27. PMID: 22408567; PMCID: PMC3298009.
[11] Rodin D, Jaffray D, Atun R, Knaul FM, Gospodarowicz M; Global Task Force on Radiotherapy for Cancer Control and the Union for
International Cancer Control. The need to expand global access to radiotherapy. Lancet Oncol. 2014 Apr;15(4):378-80. doi: 10.1016/S1470-
2045(14)70121-4. PMID: 24694630.
[12] Thompson MK, Poortmans P, Chalmers AJ, Faivre-Finn C, Hall E, Huddart RA, Lievens Y, Sebag-Montefiore D, Coles CE. Practice-changing
radiation therapy trials for the treatment of cancer: where are we 150 years after the birth of Marie Curie? Br J Cancer. 2018 Aug;119(4):389-
407.
[13] Radiotherapy: seizing the opportunity in cancer care. November 2018 - Marie Curie Legacy . From
https://www.estro.org/ESTRO/media/ESTRO/About/Radiotherapy_seizing_the_opportunity_in_cancer_care.pdf
[14] International Atomic Energy Agency. Planning National Radiotherapy Services: a Practical Tool. (Vienna: IAEA Human Health Series
Publications, 2010)
[15] Parker, T. Radiotherapy Services in England 2012 (London: Department of Health, 2012). Pg 25, top
[16] Atun R, et al. Expanding global access to radiotherapy. Lancet Oncol. 2015;16:1153–1186.

13. Copyright © 2021 XRTMD Networks LLC
References II
[17] Norlund A. 2003. Costs of radiotherapy. Acta Oncol 42(5-6): 411-5
[18] Ringborg U et al. The Swedish Council on Technology Assessment in Health Care (SBU) systematic overview of radiotherapy for cancer
including a prospective survey of radiotherapy practice in Sweden 2001--summary and conclusions. Acta Oncol. 2003;42(5-6):357-65
[19] Department of Health Cancer Policy Team. 2012 Radiotherapy Services in England 2012. London: Department of Health (See pg. 12, 2.4)
[20] Social and General Statistics, House of Commons Library 2018 cited in
https://www.gilliankeegan.com/sites/www.gilliankeegan.com/files/2018-07/Manifesto.pdf
[21] Lievens Y, Defourny N, Corral J, Gasparotto C, Grau C, Borras JM; ESTRO–HERO Consortium Collaborators. How public health services pay
for radiotherapy in Europe: an ESTRO-HERO analysis of reimbursement. Lancet Oncol. 2020 Jan;21(1):e42-e54. doi: 10.1016/S1470-
2045(19)30794-6. PMID: 31908306.
[22] Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis.
Lancet Oncol. 2013 Nov;14(12):1165-74. doi: 10.1016/S1470-2045(13)70442-X. Epub 2013 Oct 14. PMID: 24131614. Table 1 – Outpatient Care
[23] de Oliveira C, Weir S, Rangrej J, Krahn MD, Mittmann N, Hoch JS, Chan KKW, Peacock S. The economic burden of cancer care in Canada: a
population-based cost study. CMAJ Open. 2018 Jan 4;6(1):E1-E10 (See Table 4)
[24] Medicare Part B Drug Spending 2019
[25] Medicare Part D Drug Spending 2019
[26] RO Episodes File 2017-2019 which includes data on 15 cancer types, excludes brachytherapy data, inpatient treatment data and data
from VT and MD. Canter Types include Anal, Bladder, Bone Metastases, Brain Metastases, Breast, Cervical, CNS Tumor, Colorectal, Head &
Neck, Lung, Lymphoma, Pancreatic, Prostate, Upper GI, and Uterine. Available at https://innovation.cms.gov/innovation-models/radiation-
oncology-model
[27] CY2019 NFRM OPPS Cost Statistics Files: CY2019 NFRM Drug Blood and Brachy Cost Statistics. 11012018.xls Includes only inpatient
infusion costs for drugs.
[28] Tisdale BA. When to consider radiation therapy for your patient. Am Fam Physician. 1999 Mar 1;59(5):1177-84. PMID: 10088874.
[29] Gunderson and Tepper’s Clinical Radiation Oncology, 5th Edition which consists of 53 site/disease specific sections
[30] Evicore Radiation Oncology Clinical Guidelines which consists of radiation oncology guidelines for 31 individual sites
[31] ASTRO Model Policies which consist of Medical Necessity-related ICD-10-CM code sets for IMRT treatment corresponding to 51
individual sites, 15 ICD-10-CM site/code sets for Proton treatment, 27 for SBRT treatment, and 12 for malignant SRS treatment
[32] Elekta Synergy, Elekta Harmony, Elekta Infinity, Versa HD FDA Pre-market Notification approval – June 11, 2021.
[33] Varian Halcyon Pre-market Notification approval – June 27, 2017

14. Copyright © 2021 XRTMD Networks LLC
Credits
• Stephanie Kriston, Director of Health
Policy, Market Access and Reimbursement,
Elekta
• Sarah Edwards, Director of Access
Strategy, Elekta
• John Christodouleas, MD, MPH, Senior
Vice President, Medical Affairs, Elekta
• Dave Adler, Vice President of Advocacy,
ASTRO

15. Copyright © 2021 XRTMD Networks LLC
Disclosure
Work on this material is my own with some
assistance from others. It has been performed
under contract with Elekta. I have no
employment, fiduciary or other Conflicts of
Interest.
Please contact me with questions or comments.
All citations are hyperlinked to original sources,
and derivative data files are available upon
request. I will be placing the final version of
this presentation in the public domain once
comments and queries have been addressed.
Joel Goldwein, MD, FACR