Early mortality, quality of life and cost-effectiveness of palliative radiotherapy for bone metastases in the English NHS

Introduction: Palliative radiotherapy is a standard of care for localised pain due to bone metastases. International guidance recommends single fraction treatment in preference to multiple fractions, but variation in practice exists. The cost-effectiveness of stereotactic radiotherapy in this setting is unclear. This study aimed to assess the quality of life benefits from response to treatment, cost-effectiveness and routine use of these treatments in the context of varying survival. Methods: A mixed methods approach was used: A systematic review; secondary use of trial data to assess an alternative trial end-point and support multi-level regression modelling of treatment related quality of life benefits; a qualitative interview study to understand patients values and experiences of treatment; time-driven activity-based costing to determine radiotherapy cost; cost-utility analysis, to balance the quality of life benefits and cost of treatment in the context of varying survival and identify levels of 30-day mortality which reflect cost-effective care; and an analysis of the national radiotherapy dataset to provide insight into current practice and outcomes in the English NHS. Results: With increasing proximity to death the quality of life benefits of palliative radiotherapy diminish markedly, to the extent that in the final months of life, treatment is unlikely to be cost-effective and may be associated with a net harm to the healthcare system. For those with longer survival, stereotactic radiotherapy may offer a cost-effective means to improve the quality and durability of pain control, once treatment costs have reduced beyond an initial learning-curve. Wide variation in fractionation pattern persists, with marked variation in 30-day mortality. Conclusions: A value-based approach to the use of palliative radiotherapy for bone metastases offers an opportunity for improved decisions that avoid futile treatment and improve the cost-effectiveness of care. These analyses can form the basis of a novel approach to the commissioning of stereotactic radiotherapy.