A Value Analysis of Y90 Radioembolization vs Transarterial Chemoembolization: An Interview With Joseph Kallini, MD

Joseph Kallini, MD, is a clinical research fellow at Northwestern University in the department of radiology, section of interventional radiology. 

His research mentor is Riad Salem MD, MBA, Chief of Interventional Radiology. At the 2016 Annual Scientific Meeting of the Society of Interventional Radiology, he presented a cost/value analysis using the 2015 ASCO (American Society of Clinical Oncology) framework comparing two intra-arterial therapies, yttrium-90 (Y90) radioembolization and transarterial chemoembolization (TACE). 

IO360: Tell us a little bit about the study design.

Kallini: It is a retrospective study looking at 245 patients, 123 randomized to Y90, 122 to TACE, comparing the value for each of those. Value is defined by the ASCO framework as the sum of clinical benefit, toxicity, and “bonus points,” which refers to palliation. 

IO360: Can you give us some details about the results?

Kallini: The way the ASCO value framework works is you look at what you have. We had data on overall survival, which is considered, in terms of clinical benefit, the pinnacle. So looking at our overall survival, the 123 Y90 patients had an overall survival of 20.5 months and the TACE patients had about 17 months. That was an overall clinical benefit in favor of Y90. In terms of toxicity profile, you are supposed to look at adverse events that were classified as grade 3 or higher in the Common Terminology Criteria for Adverse Events. We did not have any clinical adverse events, but in terms of laboratory toxicity, that was comparable. And, although there was a 40% decrease in the adverse event profile in the Y90 category, it’s awarded bonus points for a toxicity score of zero because it needs to be within 50% change. In terms of palliation, we have significant data on 86 patients, 43 randomized to each group, that show that there is an event-free survival benefit of 17.7 months in the Y90 group vs 7 months in the TACE group that awarded an extra 20 points. So there is a net health benefit in favor of Y90. In terms of the cost differential, we did it from a payer perspective looking at actual Medicare data from each of the subgroups and it shows about a $10,000 differential.

IO360: What does this mean for interventionalists doing an IO procedure in the future? How would this affect their decision making process?

Kallini: There are many studies out there that look at value. In terms of cost models, there are decision-tree analyses and Markov analyses. Looking at value all together, ASCO provided a set of guidelines that are used for medical oncologists. I think as interventional radiologists, it’s important to try to use the existing frameworks and to try to match them so that as a group we are able to do comparative analyses that can be standardized across multiple disciplines.

IO360: How about other similar studies? Have there been other studies that have looked at similar groups and found similar or not similar results?

Kallini: There are no studies similar to this one because the ASCO value framework came out in 2015. There were analyses looking at cost itself. There is a recent paper by Baman Roudsari, MD, from UCLA Medical Center that addresses various ways to do cost analyses.1 This is different because the cost aspect in the ASCO framework is somewhat rudimentary. It recommends accounting only for drug acquisition costs, which is only applicable to medical oncologic treatments. Value is also defined differently in the literature. Some researchers look at quality-adjusted life years; others look at other metrics for value. The ASCO analysis is actually a different metric, but it does resonate along the same lines in that you look at monetary costs and you also look at clinical benefit or net health benefit. So, this study is different. It’s somewhat new in that it is using a new framework and hopefully, if this framework catches on, we’ll have more studies like it so we can have comparative analyses. 

IO360: Are there other parameters that might be useful for IO?

Kallini: The ASCO value framework looked at a lot of parameters. In terms of value itself, there were parameters that they did not look at that could be useful. For example, besides palliation of symptoms, there’s the whole idea of quality of life. The framework didn’t take into consideration the fact that certain therapies, for example Y90, have been shown to have a significant improvement in quality of life when looking at the physician-validated FACT Hepatobiliary survey. There are also other uses besides survival, besides tumor control. For example, radiation lobectomy when used with Y90 is a method to increase the size of the future liver remnant (the healthy portion of the liver), which would buy patients some time to move to resection. Also, radiation segmentectomy, which is a very focused delivery of treatment to the tumor, can act analogously to radiofrequency ablation at higher target threshold of 190 Gy. Those things really can’t be compared to TACE, but these are other concepts to consider for the future. Finally, one last consideration is that locoregional therapies are currently only indicated for palliation of liver cancer. One further thing we can look at is comparing Y90 to TACE in terms of downstaging patients so that they can undergo transplantation, which is a potential cure for HCC.

Editor’s note: Dr. Kallini reports no conflicts of interest related to the content herein. 

Suggested citation: Ford J. A value analysis of Y90 radioembolization vs transarterial chemoembolization: an interview with Joseph Kallini, MD. Intervent Oncol 360. 2016;4(8):E130-E132.

References

1. Roudsari B, McWilliams J, Bresnahan B, Padia SA. Introduction to cost analysis in IR: challenges and opportunities. J Vasc Intervent Radiol. 2016;27(4):539-545.