Cost-effectiveness analysis of intraoperative radiation therapy versus external beam radiation therapy for the adjuvant treatment of early breast cancer: A systematic review

Breast-conserving surgery (BCS) is the recommended treatment for early breast cancer. After BCS. Whole-breast external beam radiotherapy (WB-EBRT) is the standard of care. A possible alternative to post-operative WB-EBRT is intraoperative radiation therapy (IORT). The objectives of this systematic review were to analyses the cost-effectiveness of IORT versus EBRT for early-stage breast cancer and to assess the reporting quality of the included studies to inform future studies.

A systematic literature search was carried out in five main databases (PubMed, Scopus, Embase, Cochrane library, and Web of Science) to identify original studies published to June 25, 2020. We included all full economic evaluation studies (cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA), Model-based or trial-based) that assessed and compared IORT and EBRT in patients with early operable breast cancer. Study outcomes included cost per life-years gained or cost per quality-adjusted life-years (QALYs) gained or in monetary units or incremental cost-effectiveness ratio (ICER). The quality of the included articles was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. This review has been conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Of 1155 studies identified, eight studies met the inclusion criteria. In four studies, IORT was associated with lower costs and higher effectiveness than EBRT. In three studies, the dominant option was EBRT. In these studies, IORT also had lower costs and lower effectiveness than EBRT. Existing evidence suggests that IORT can be a cost-effective alternative to early breast cancer treatment by reducing therapeutic costs. Variables of cost-effectiveness were treatment costs, health state utilities, local and distant recurrence rates, and the probabilities of metastasis after treatment, recurrent cancer and death for both IORT and EBRT. The reporting quality of the included studies was “high” in five, “medium quality” in one and “low” in two studies.

Current evidence is sparse, and the number of studies was small but this evidence proposes that IORT can be a potential cost-saving strategy to the health systems for the adjuvant treatment of early breast cancer if the technology was carried out routinely in eligible patients.  However, these results should be interpreted with caution because of the heterogeneity of studies and possible publication bias.