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During these ever changing times between dynamic innovation and
rising health care costs, health care decision makers call for
complete substantiation of the value of new drugs, devices,
procedures, and biologics. Policy makers and proponents of health
care system reform thus routinely argue that simultaneously meeting
the goals of sustained innovation, cost control, and improved
quality within the health care system will require more explicit
appraisal of the clinical effectiveness and comparative value of new
and existing interventions. The Institute for Clinical and Economic
Review (ICER) was created to fill this evidence gap.
Mission
The mission of the Institute for Clinical and Economic Review (ICER)
is to be the most trusted source of information on the clinical
effectiveness and comparative value of new and existing healthcare
interventions for the benefit of all stakeholders in health and the
health care system. ICER produces rigorous assessments of new
medical interventions, and translates its findings into integrated
ratings specifically formatted to support value-based insurance
benefit designs, coverage and reimbursement policy, and
patient-clinician decision support tools.
Completed Appraisal:
BRACHYTHERAPY & PROTON BEAM THERAPY
FOR TREATMENT OFCLINICALLY-LOCALIZED, LOW-RISK PROSTATE CANCER
The ICER review of clinical effectiveness provided the base case
assumption that the effectiveness of brachytherapy, IMRT, and PBT
are equivalent; therefore, the economic model results show life
expectancy for a 65-year old man to be approximately 17 years no
matter which treatment is selected or whether such treatment is
immediate or deferred. Toxicities for each treatment option reduce
the final total of quality-adjusted life years to a narrow range.
The systematic review provided base case estimates of relatively
similar toxicity rates for these treatments, and therefore only
small differences are found in overall quality-adjusted life
expectancy. Large differences are observed in lifetime cost,
however, with immediate or deferred brachytherapy having costs 30%
and 60% lower than those of strategies involving IMRT and PBT,
respectively.
Summary
In summary, the assumption of no difference in survival or
biochemical recurrence among all treatment modalities produces model
findings of very small differences in quality adjusted life
expectancy. The sparse and highly variable nature of data on
toxicities must be stressed again, as the nominal differences
arising from the meta-analysis are uncertain and suggest differences
that amount to “tradeoffs” by type of toxicity. In short, even
though brachytherapy appears to be marginally superior in lifetime
quality-adjusted expectancy, neither the findings from the
systematic review nor those from the economic
model suggest a clear pattern of significant clinical superiority
for any treatment modality. While the uncertainties described in
this summary might merit prospective comparative study to further
refine our understanding of each treatment approach’s relative
benefits and harms, such study could only be supported if there is
reasonable likelihood of demonstrating a substantial improvement in
net health benefit for the newer technologies over brachytherapy,
given the wide disparity in current reimbursement levels and the
significant opportunity cost in conducting prospective research.
The group was unanimous in considering brachytherapy a “High Value”
technology, whether compared to PBT or to IMRT.
Source of information: ICER –
www.icer-review.org
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