Toxicity and cost-effectiveness analysis of intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy for postoperative treatment of gynecologic cancers

•IMRT is associated with significant reductions in late toxicity compared to 3DCRT, without compromising clinical outcome.•While the reductions in late toxicity come at an increased cost, IMRT becomes more cost-effective over time.•Long-term survivors may realize the most economic benefit of post-hysterectomy IMRT.

ObjectiveTo evaluate toxicity and cost-effectiveness of intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3DCRT) in the postoperative treatment of uterine and cervical cancer.MethodsBetween 2000 and 2012, eighty patients at our institution received post-hysterectomy 3DCRT (46) or IMRT (34) for uterine or cervical cancer. Baseline characteristics, outcome, and ≥ CTCAE grade 2 toxicities were compared between the two groups. Predictors of toxicity-free survival were identified. A decision analysis model was designed to capture individual health states at 1, 2, and 3 years after treatment. Micro-costing technique and estimated quality-adjusted life years (QALYs) were used to calculate incremental cost-effectiveness ratio (ICER).ResultsUtilization of IMRT increased from 25% (2005–2007) to 75% (2008–2012). Recurrence-free and overall survival rates were not different between the two groups. Toxicity rates were reduced with IMRT versus 3DCRT (HR 0.42, p = 0.04). Women who received IMRT had numerically lower rates of late gastrointestinal and genitourinary toxicity and significantly lower rates of late overall toxicity at 3 years (16% vs. 45%, p = 0.04). On univariate analysis, IMRT was associated with decreased late toxicity (HR 0.43, p = 0.04). Treatment costs were higher and toxicity costs were lower with IMRT. IMRT had an ICER of $235,233 (year 1), $114,270 (year 2), and $75,555 (year 3) per QALY gained.ConclusionIMRT is associated with reduced late overall toxicity compared to 3DCRT without compromising clinical outcome. IMRT is not cost-effective during the early chronic toxicity phase, but it becomes more cost-effective over time.