Abstract
INTRODUCTION: Treatment options for brain metastases include whole-brain radiation therapy (WBRT), stereotaxic radiosurgery (SRS), and surgical resection followed by adjuvant therapy. Although SRS provides similar survival benefits and poses less morbidity-related costs than WBRT, it may predispose patients to higher recurrence risk and later utilization of salvage therapies. In today’s limited spending climate, it is critical to find the most medically sound and economical uses for these therapies. METHODS: We conducted a critical literature review, searching the MEDLINE, EMBASE, Cochrane, CRD, and EconLit databases using keywords pertaining to brain metastases, radiotherapy, and health economic evaluations, without limits on publication date or language. RESULTS: 12 studies were identified (nine American, one German, one Vietnamese, and one Taiwanese). Six used modelling but only one applied discounting. Survival with SRS was at least equivalent to surgical resection and WBRT. SRS – even with salvage therapy and routine MRI surveillance – was more cost-effective than surgical resection and WBRT. For patients expected to survive longer, between 12–24 months, SRS combined with hippocampal-sparing WBRT (ICER $80,253) or hippocampal-sparing WBRT alone (ICER $24,701) were cost-effective compared to surgical resection and WBRT. For tumors not amenable to SRS, surgical resection with intra-operative brachytherapy was more cost-effective than surgery followed by SRS ($19,271/QALY vs. $44,219/QALY). CONCLUSIONS: Though further modelling work is needed, we propose the following cost-effective pathway: tumors smaller than 3cm may be managed by SRS with MRI surveillance every three months and salvage therapy (SRS or WBRT) on evidence of recurrence. Hippocampal-sparing WBRT could serve as a valuable adjuvant therapy in patients surviving longer than 12 months. Tumors larger than 3cm or not amenable to SRS could be surgically resected with intraoperative brachytherapy or cavity SRS, followed by routine MRI surveillance every three months and additional salvage therapy (SRS or WBRT) on evidence of recurrence.