For curative treatment of Hodgkin lymphoma, radiotherapy benefit must be weighed against toxicity. Although more costly, proton radiotherapy reduces dose to healthy tissue, potentially improving the therapeutic ratio compared to photons. We sought to determine the cost-effectiveness of proton versus photon therapy for mediastinal Hodgkin lymphoma (MHL) based on reduced heart disease.
Our model approach was two-fold: (1) Utilize patient-level dosimetric information for a cost-effectiveness analysis using a Markov cohort model. (2) Utilize population-based data to develop guidelines for policy-makers to determine thresholds of proton therapy favorability for a given photon dose. The HD14 trial informed relapse risk; coronary heart disease risk was informed by the Framingham risk calculator modified by the mean heart dose (MHD) from radiation. Sensitivity analyses assessed model robustness and identified the most influential model assumptions. A 30-year-old adult with MHL was the base case using 30.6-Gy proton therapy versus photon intensity-modulated radiotherapy.
Proton therapy was not cost-effective in the base case for male ($129K/QALY) or female patients ($196/QALY). A 5-Gy MHD decrease was associated with proton therapy incremental cost-effectiveness ratio<$100K/QALY in 40% of scenarios. The hazard ratio associating MHD and heart disease was the most influential clinical parameter.
Proton therapy may be cost-effective a select minority of patients with MHLbased on age, sex, and MHD reduction. We present guidance for clinicians utilizing MHD to aid decision-making for radiotherapy modality.

Copyright © 2021. Published by Elsevier Inc.

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