HNSCC: Outpatient ChemoRT Regimen Offers Outcomes Equal to Inpatient at Lower Cost

“The study found that the two definitive regimens, one outpatient and one inpatient—both considered standards of care at Cleveland Clinic and across the country—had equal outcomes but lower costs for the outpatient treatment,” says John F. Greskovich, Jr., MD, radiation oncologist in Cleveland Clinic’s Taussig Cancer Institute and lead author of the study. The findings have the potential to change practice patterns for the better, he says.

“This type of study exemplifies value-based decision-making centered on three factors: clinical benefit to the patient, typically measured by disease-free survival; toxicity of therapy, measured by acute and late toxicities and quality of life; and cost of therapy—cost to the patient and cost to society, including payer costs,” Dr. Greskovich says.

A research first

Researchers evaluated the two arms of a phase 3, definitive ChemoRT trial in which 69 non-nasopharynx HNSCC patients were assigned to concurrent radiotherapy and either an outpatient (cisplatin [CDDP], 100 mg/m2, weeks 1, 4, 7) or an inpatient (CDDP, 20 mg/m2/d and 5FU, 1000 mg/m2/d by continuous intravenous infusion x 4 days, weeks 1,4) regimen. The two arms were well-balanced in pretreatment variables, including HPV-positive status.

“This is the first randomized prospective trial that has been done directly comparing the outcomes and cost of these two regimens commonly used for head and neck cancers,” Dr. Greskovich says.

The study measured local, regional and distant control as well as overall and relapse-free survival outcomes. Researchers compiled revenue and cost data, pulled from Cleveland Clinic’s accounting database, from treatment start date to 6 months post-treatment.

Study findings and significance

“When we looked at outcomes at two years, they were statistically the same in the two arms of the study,” Dr. Greskovich says. “There was no statistical difference between the two treatments with respect to overall survival, relapse-free survival, locoregional or distant control.”

From an economic standpoint, the analysis found that while net income was similar between the two study groups, net revenue and total cost differed significantly. The inpatient group realized $19,338 higher net revenue but also had $18,664 higher total cost per patient, making the outpatient regimen the better value-based therapy, he says. The higher inpatient treatment arm cost largely reflects the cost of planned and unplanned hospitalizations.

Implementing value-based changes

Based on the findings, Cleveland Clinic made a value-based practice change. The change was successfully implemented, with 45 percent, 19 percent and 0 percent of patients treated with the inpatient regimen in 2011, 2012 and 2013, respectively. “Measuring the outcomes and cost of the two treatment regimens for a full cycle of care enabled us to change our practice pattern by appropriately reducing cost without sacrificing tumor outcomes,” Dr. Greskovich says.

The study results were presented at the K. Kian Ang, MD, PhD, FASTRO, Commemorative Plenary Session of the 2014 Multidisciplinary Head and Neck Cancer Symposium in Scottsdale, Arizona.