Brachytherapy commissioning tools

Brachytherapy commissioning tools

PowerPoint presentations and other document templates are provided in this section. It is hoped that these will help speed and streamline the commissioning of care process for brachytherapy services based on the following decision-making flow. Information contained in other sections of prostatebrachytherapyinfo.net and links to additional sources of information are indicated.

Factors considered by the Prostate Cancer Advisory Group include:

• guidance/recommendations from DH and NICE
• long-term outcomes
• patient benefits
• cost of care.
• comparative effectiveness and value

Guidance/recommendations from DH and NICE

In order to best implement the DH advice and meet future service levels, the Prostate Brachytherapy Advisory Group recommends that it would be most effective to concentrate efforts on and commision services from centres who have the personnel and capacity to undertake 25+ procedures per year, and to develop the highest-quality services in these centres.

This approach becomes even more critical given that the NICE guideline on the diagnosis and treatment of localised prostate cancer (February 2008) described LDR brachytherapy as one of the three radical treatment options recommended for the treatment of men diagnosed with either low- or intermediate-risk localised disease and emphasised that all treatment decisions should be made in conjunction with men and their families. Thus, a significant level of expertise should be available to increased numbers of men seeking more information about and opting for this treatment option.

See ‘Brachytherapy guidance and guidelines’ section and ‘UK brachytherapy centres’ section for detailed information and data from each centre.

Long-term outcomes

A number of recent papers have been published reporting PSA progression-free survival for patients with intermediate-/high-risk prostate cancer treated with seed implant/EBRT combined treatment. The findings are summarised in Table 7.

Table 7 PSA progression-free survival

Series	Year	No of patients	PSA failure definition	Follow-up years	PSA progression-free survival intermediate/high risk (%)
Sylvester et al1	2007	223	ASTRO modified to two rises	15	80 / 67
Critz et al2	2004	1469	PSA <0.2ng/ml	10	80 / 61

For survival data from UK centres of excellence, refer to individual entries in the section 'UK brachytherapy centres'

Patient benefits

Increasingly, healthcare professionals are becoming conscious of quality-of-life issues relating to treatment. The attached mini-review looks at this important issue, illustrating that patients often want to choose a treatment that will more certainly guarantee a better quality of life.

Studies have shown that prostate brachytherapy impacts less on patient quality of life than other treatment options (incontinence and sexual dysfunction). Longer-term data suggest that brachytherapy is a well-tolerated treatment for localised prostate cancer.

Brachytherapy versus prostatectomy in localized prostate cancer: results of a French multicenter prospective medico-economic study

Health-related quality of life after prostate brachytherapy

Comparative effectiveness and value

The Institute for Clinical and Economic Review (ICER), is an independent research and policy group based at the Massachusetts General Hospital’s Institute for Technology Assessment (ITA).  It provides independent evaluation of the comparative clinical effectiveness and comparative value of new and emerging technologies.
The latest prostate cancer review (January 2010) represents a summary of three prior technology appraisals of management options for clinically-localised, low-risk prostate cancer published between November 2007 – September 2009:

• intensity-modulated radiation therapy (IMRT)
• brachytherapy and proton beam therapy
• active surveillance and radical prostatectomy

The report presents a systematic review of published evidence on the treatment of low-risk prostate cancer as well as simulation modelling to project the long-term effects of each treatment approach.  The evidence on radical prostatectomy, brachytherapy, and IMRT was judged to demonstrate comparable overall clinical effectiveness for most men although important quality-of-life differences are noted.
The ICER model calculates the lifetime cost per quality-adjusted life-year (QALY) gained. Of the definitive treatments examined (surgery, brachytherapy and IMRT) brachytherapy was found to be the most effective form of treatment according to the model. Using radical prostatectomy as the reference strategy, brachytherapy was found to save nearly $3,000 per QALY whilst other radiation treatments were associated with higher costs than surgery. Taking into account cure rate, quality of life and cost factors, brachytherapy emerged as a cost-saving alternative to radical prostatectomy and was deemed to be the only ‘high value’ definitive treatment alternative.

Table 1. Lifetime quality-adjusted life expectancy and costs for 65-year-old men with clinically-localised, low-risk prostate cancer, by treatment type

Strategy	QALYs	Incremental QALYs	Cost	Incremental cost	Cost/QALY
AS	8.97	1.15	$30,422	$2,074	$1,803
Brachytherapy	8.12	0.30	$25,484	($2,864)	N/A†
IMRT	8.09	0.27	$37,861	$9,513	$35,233*
Proton Beam	7.97	0.15	$53,828	$25,480	$169,867*
RP	7.82	Reference	$28,348	Reference
NOTES: All incremental costs and QALYs calculated relative to radical prostatectomy. QALY, quality-adjusted life year; AS, active surveillance; IMRT, intensity-modulated radiation therapy; RP, radical prostatectomy. *Incremental cost-effectiveness ratios presented for purposes of transparency; findings of the ICER systematic review do NOT support substantial differences in overall effectiveness. † Strategy is less costly and more effective than radical prostatectomy (reference strategy)

 

Reference:
Ollendorf DA, Hayes J, McMahon P et al. Management options for low-risk prostate cancer: a report on comparative effectiveness and value. Boston, MA: Institute for Clinical and Economic Review, December 2009.

Full report available at: http://www.icer-review.org/index.php/mgmtoptionlrpc.html

Outcomes data management

BrachyBaseTM is a new web-based registry for the prospective collection and reporting of prostate brachytherapy permanent seed implantation data, designed specifically for prostate brachytherapy and developed in conjunction with leading experts. It is a unique resource designed to enable centres offering brachytherapy to collect, store and analyse their data in a convenient and secure fashion, and is an ideal tool for studies, publications and presentations, permitting data to be pooled if required for multi-centre studies, both national and international. A number of leading brachytherapy centres in Europe and the US are currently using BrachyBaseTM to collect and analyse patient outcomes data, and the publication of centre-specific and pooled data is anticipated. For further information click here.

Table 8 — Accumulated mean prostate cancer-related costs by cost category, primary treatment, and risk factor ⁵

	Medication costs, $			Office visit costs, $			Hospitalization costs, $			Total all costs, $			Total, $
Primary Treatment	Low Risk	Med. Risk	High risk	Low Risk	Med. Risk	High risk	Low Risk	Med. Risk	High risk	Low Risk	Med. risk	High risk	All risk
Brachytherapy	3741 (316)	4940 (213)	9050 (99)	18,844	23,873	24,153	5780	12,605	9832	28,366	41,419	43,035	35,143
Radical prostatectomy	2832 (1,124)	6869 (856)	19,781 (375)	18,116	18,180	24,085	11,847	9989	10,188	32,795	35,037	54,055	36,888
External beam radiation	6615 (106)	9164 (146)	23,195 (145)	36,446	43,327	40,874	5879	4234	8668	48,840	56,725	72,737	59,455
Androgen deprivation therapy	14,261 (120)	20,905 (150)	50,632 (309)	26,236	30,155	30,884	4599	5682	6007	45,095	56,738	87,523	69,244
Cryotherapy	7768 (36)	3346 (38)	25,697 (57)	17,533	21,912	20,756	6,301	7555	7288	31,602	32,814	53,741	43,108
Watchful waiting	5269 (127)	5098 (51)	4854 (33)	19,716	21,757	20,235	6886	4934	1795	31,871	31,789	26,884	32,135
All treatments	4154 (1829)	8329 (1454)	28,138 (1018)	19,875	22,775	28,268	9564	8777	8086	33,593	39,882	64,491	42,570
Total all treatments	10,932	22,721	8917	42,570
Data in parentheses are MCE mean cumulative function cost.

Cumulative Cost Pattern Comparison of Prostate Cancer Treatments.

Prospective quality of life and cost utility data

The recently published NICE guideline on prostate cancer diagnosis and treatment highlighted the need for prospective quality of life and cost utility data comparing the radical treatment options available for localised prostate cancer. The Prostate Brachytherapy Advisory Group (PBAG) recognise the urgent need for high quality comparative data investigating the length of hospital stay, patients' recovery time and side-effects as this will help commissioners and providers of care, and patients, to make informed decisions. To address this issue PBAG have therefore commissioned the internationally recognised York Health Economics Consortium to conduct an analysis using data prospectively collected during the Prostate Cancer Symptoms Study (PCSS) - itself carried out at four leading UK prostate cancer treatment centres. Findings and conclusions from this analysis are expected to be available in the second half of 2008.

Executive report

The following document summarises relevant information in the form of an executive report.

Low dose-rate brachytherapy

References