Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What is the comparative effectiveness of image-guided radiotherapy (IGRT) with conventional intensity-modulated radiotherapy (IMRT) (sometimes called 4D IMRT) versus IMRT alone for improving outcomes among cancer patients?

Given the probably scant literature comparing IGRT and IMRT alone, this topic may be a good candidate for a Technical Brief. Such a Technical Brief should address the various sources of movement and missed targeting, their variation across organ systems, and the need to follow the chain from use of IGRT through patient outcomes.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

IMRT versus IMRT with IGRT for specific cancers (such as head and neck, prostate), where IGRT is used to deal with both inter- and intrafraction variation.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Adult patients with specific cancers (such as head and neck, prostate)

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Adult cancer patients with critical organs close to the tumor site.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Overall survival
• Progression-free survival
• Quality of life

Describe any health-related risks, side effects, or harms that you are concerned about.

• Short and long term toxicities

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cancer

AHRQ Priority Populations

• Elderly

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

• Cancer is a common disease among adults and numerous types are often treated with radiotherapy.
• There is uncertainty about the benefits versus risks of using IGRT and whether it will permit dose escalation without substantial increases in toxicity.
• The addition of IGRT may increase costs and take longer.
• Many cancer patients are older, especially those with prostate cancer, are older and likely to be covered by Medicare.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

At the 2010 annual meeting of the American Society of Radiation Oncology (ASTRO), IGRT was discussed extensively, as well as some of the challenges in using it.

The Blue Cross Blue Shield Plans are interested in the use of radiotherapy to treat cancer and evaluate new approaches as they have been developed. As with patients and clinicians, the Plans support the use of those technologies most likely to improve patient outcomes. The results of the proposed research would provide BCBS Plan decision-makers with information for medical policies decision-making.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Discussions about IGRT at the 2010 annual ASTRO meeting pointed out challenges in incorporating this technology into practice, including importance of quality assurance, the time it takes to adjust treatment plans to changes in tumor size or location if it is used for adaptive planning, and the need to demonstrate improvement in patient outcomes. At the 2010 annual meeting of the Radiological Society of North America, a session on “Is More Better? Which and How Much Imaging in Radiation Oncology” included a point-counterpoint discussion on this issue.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

BlueCross BlueShield Plan Medical Directors will use the results in the development of medical policies.

Describe the timeframe in which an answer to your question is needed.

This topic needs to be addressed quickly within 12 months, as providers are currently making decisions about acquisition of this technology, which requires large capital expenditures.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

This question will apply disproportionately to the elderly, because the prevalence of many cancers increases with age.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

BlueCross BlueShield Plan Medical Directors will use the results in the development of medical policies.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

BlueCross BlueShield Plans routinely use information issued by the EHC. The BlueCross BlueShield Association Technology Evaluation Center is an Evidence-based Practice Center of AHRQ. BCBS EPC staff were consulted in the preparation of this nomination. This topic nomination was based on input from the BlueCross BlueShield Plan Medical Directors.