Abstract
Objectives
Intensity-modulated radiotherapy (IMRT) is a dose-delivery technology allowing for a reduction in radiotherapy side effects. It has been rapidly adopted despite the lack of prospective studies showing improved outcomes.
We sought to compare the cost through Medicare reimbursement patterns of surgery, IMRT, and conventional XRT in treating head and neck cancer. We then identified factors that correlate with these differences.
Methods
Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data were examined to determine treatment patterns for 47,237 patients with head and neck carcinoma from 2000 to 2007. We identified 14,748 patients that met our inclusion criteria. We then compared cost related to head and neck cancer treatments on the basis of Medicare payments.
Results
From 2000 to 2007, the usage of IMRT increased from 1.5% to 48.6% while the usage of conventional XRT decreased from 98.5% to 51.4% (p < 0.0001). During this time, patients undergoing IMRT had a mean cost of $101,099 compared to $42,843 for XRT. For patients with early stage tumors, surgery alone cost $18,140, traditional XRT $32,296 while IMRT cost $95,047 (p < 0.0001). When removing patients who underwent concomitant chemotherapy, patients treated with IMRT cost $67,576 compared to $24,955 for non-IMRT patients (p < 0.0001).
Conclusions
IMRT has become widely adopted as a primary treatment modality in head and neck cancer. We demonstrated that IMRT is significantly more costly than traditional treatment for head and neck cancers. Prospective studies investigating the comparative efficacy of IMRT will be needed in order to determine if this increased cost correlates with patient outcomes.
Level of Evidence: 2b
1
Introduction
Radiation therapy (XRT) is a well-accepted primary and adjuvant tool in the treatment of head and neck squamous cell carcinoma (HNSCC). However, this therapy can also be associated with life-altering toxic injury to surrounding tissues including the spinal cord, brainstem, parotid glands, lacrimal glands, auditory structures, eyes and optic tracts .
Intensity-modulated radiotherapy (IMRT) was developed within the last decade to reduce these toxic effects since it permits a greater precision and modulation of the radiation beam in order to sculpt high doses away from vital structures. The early data regarding improved clinical outcomes with IMRT were primarily retrospective . As IMRT was rapidly adopted as a primary treatment modality, the emerging data had equivocal outcomes. In one randomized control trial there was no difference in patient-reported outcome of xerostomia between IMRT and traditional radiotherapy groups . It was not until 2007 that the first prospective study demonstrated patients undergoing IMRT with improved clinical outcomes . In another randomized control study, IMRT was found to reduce the incidence of xerostomia and was associated with an improved quality of life . Although patients receiving IMRT will likely have reduced xerostomia and improved quality of life, it is likely not cost-effective in the short term compared to traditional radiotherapy .
The current national conversation over increasing costs of health care delivery prompted our study. We sought to compare the cost of IMRT compared to other treatments of head and neck squamous cell cancer (HNSCC) through Medicare reimbursement patterns.
2
Materials and methods
SEER Cancer Registry, a National Cancer Institute-supported database, records incident cancer cases from 16 separate registries, which cover 26% of the US population. The Medicare program then links patients in the SEER database with their Medicare payments for hospital, physician and outpatient medical services.
Our study was approved by the UCLA Institutional review board and a data-use agreement was in place with the Centers for Medicare and Medicare Services; patient data were de-identified and the requirement for consent was waived. All patients diagnosed and treated for HNSCC within the SEER-Medicare database were identified between 2000 and 2007, a time period coinciding with the advent of IMRT. Patients were included if diagnosis of HNSCC was their first and only cancer diagnosis based on International Classification of Disease (ICD)-9 Codes. Patients in the cohort were enrolled in Medicare Parts A and B and had no evidence of distant disease. Head and neck tumor sites were categorized according to SEER coding of tumor sites as follows: oral cavity (lip, tongue, floor of mouth, gum or other mouth), oropharynx including tonsil, larynx, nasopharynx, hypopharynx, and salivary gland.
Once this initial cohort was identified we further divided groups by treatment modality: primary surgery, surgery with adjuvant therapy, and primary radiation therapy with or without chemotherapy. Patients undergoing radiotherapy were identified using the Medicare claims codes as follows: the Current Procedural Terminology (CPT) codes for claim of radiation therapy (77401–77499 or 77750–77799) and radiation planning (77261–77399). Furthermore, we then further stratified data for those patients who were treated with IMRT by using the Medicare billing including the CPT code for either Planning or Delivery of IMRT (CPT codes 77418 or 77301). All patients who had at least one claim for IMRT were included in that group. ICD-9-CM procedure code (22–26) of 9925 and V codes of V58.1, V66.2, or V67.2; the CPT codes of 96400 through 96549, J8530 through J8999, J9000 through J9999, or Q0083 through Q0085; or revenue center codes of 0331, 0332, or 0335 .To determine the cost of therapy, we summed the claim payment amounts associated with each treatment claim code for one year after cancer diagnosis. A correlation analysis was then performed between the reimbursement for delivery and planning for surgery, IMRT, or XRT. No attempt was made to determine clinical outcomes since this was not the aim of the present study.
2.1
Statistical analysis
We analyzed the rates of use of IMRT, XRT, and surgery. Patient demographics and disease characteristics were compared using chi-square tests. The Odds Ratios (OR) and 95% Confident Intervals were calculated using SPSS Software Version 21 (Chicago, IL). Costs between treatment groups were analyzed using unpaired t test.
2
Materials and methods
SEER Cancer Registry, a National Cancer Institute-supported database, records incident cancer cases from 16 separate registries, which cover 26% of the US population. The Medicare program then links patients in the SEER database with their Medicare payments for hospital, physician and outpatient medical services.
Our study was approved by the UCLA Institutional review board and a data-use agreement was in place with the Centers for Medicare and Medicare Services; patient data were de-identified and the requirement for consent was waived. All patients diagnosed and treated for HNSCC within the SEER-Medicare database were identified between 2000 and 2007, a time period coinciding with the advent of IMRT. Patients were included if diagnosis of HNSCC was their first and only cancer diagnosis based on International Classification of Disease (ICD)-9 Codes. Patients in the cohort were enrolled in Medicare Parts A and B and had no evidence of distant disease. Head and neck tumor sites were categorized according to SEER coding of tumor sites as follows: oral cavity (lip, tongue, floor of mouth, gum or other mouth), oropharynx including tonsil, larynx, nasopharynx, hypopharynx, and salivary gland.
Once this initial cohort was identified we further divided groups by treatment modality: primary surgery, surgery with adjuvant therapy, and primary radiation therapy with or without chemotherapy. Patients undergoing radiotherapy were identified using the Medicare claims codes as follows: the Current Procedural Terminology (CPT) codes for claim of radiation therapy (77401–77499 or 77750–77799) and radiation planning (77261–77399). Furthermore, we then further stratified data for those patients who were treated with IMRT by using the Medicare billing including the CPT code for either Planning or Delivery of IMRT (CPT codes 77418 or 77301). All patients who had at least one claim for IMRT were included in that group. ICD-9-CM procedure code (22–26) of 9925 and V codes of V58.1, V66.2, or V67.2; the CPT codes of 96400 through 96549, J8530 through J8999, J9000 through J9999, or Q0083 through Q0085; or revenue center codes of 0331, 0332, or 0335 .To determine the cost of therapy, we summed the claim payment amounts associated with each treatment claim code for one year after cancer diagnosis. A correlation analysis was then performed between the reimbursement for delivery and planning for surgery, IMRT, or XRT. No attempt was made to determine clinical outcomes since this was not the aim of the present study.
2.1
Statistical analysis
We analyzed the rates of use of IMRT, XRT, and surgery. Patient demographics and disease characteristics were compared using chi-square tests. The Odds Ratios (OR) and 95% Confident Intervals were calculated using SPSS Software Version 21 (Chicago, IL). Costs between treatment groups were analyzed using unpaired t test.
3
Results
The characteristics of the study cohort are listed in Table 1 . We identified 5076 patients who fulfilled our inclusion criteria. There were 9510 males (65.7%) and 4974 females (34.3%) for a male:female ratio of 2:1. Of the cohort, 37.7% underwent surgery alone while 62.3% had some form of radiotherapy during their treatment. Of the patients receiving radiation, 16.8% were treated with IMRT and 83.2% were treated with traditional radiation therapy.
| Characteristic | N (%) |
|---|---|
| Age | |
| 65–69 | 3909 (27.0%) |
| 70–74 | 3672 (25.4%) |
| 75–79 | 3126 (21.6%) |
| 80 + | 3777 (26.1%) |
| Gender | |
| Male | 9510 (65.7%) |
| Female | 4974 (34.3%) |
| Race | |
| Caucasian | 12608 (87.0%) |
| African American | 827 (5.7%) |
| Other | 1049 (7.2%) |
| Socioeconomic status | |
| First quartile | 3588 (24.8%) |
| Second quartile | 3582 (24.7%) |
| Third quartile | 3594 (24.8%) |
| Fourth quartile | 3602 (24.9%) |
| Unknown | 118 (0.8%) |
| Tumor site | |
| Oral cavity | 8168 (56.4%) |
| Oropharynx | 1497 (10.3%) |
| Larynx | 3114 (21.5%) |
| Hypopharynx | 862 (6.0%) |
| Nasopharynx | 305 (2.1%) |
| Salivary Gland | 538 (3.7%) |
| Overall Stage | |
| Early | 6659 (46.0 %) |
| Advanced | 7282 (50.3) |
| Unknown | 543 (3.7%) |
| Treatment | |
| Surgery alone | 5414 (37.7%) |
| Radiation alone | 5175 (35.7%) |
| Surgery + Radiation | 3895 (26.9%) |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
