We evaluated a Phase II study which was designed to assess the effectiveness of intraocular brachytherapy in conjunction with
VEGF inhibitor therapy as a treatment for subfoveal choroidal neovascularization. One treatment naive eye of each participant
with subfoveal choroidal neovascularization was treated and 34 consecutive participants completed treatment with follow-up
of at least 12 months.
Radiation therapy was administered using the Epiretinal Brachytherapy System (NeoVista, Fremont, CA), an intravitreal applicator
containing a Strontium/Yttrium 90 (90Sr /90Yr) β-emitting isotope, referred to from hereon as 90Sr brachytherapy. The 90Sr applicator was inserted through a pars plana incision and, after vitrectomy, was held for 3 to 5 minutes over the neovascular
AMD lesion until a dose of 24Gy was delivered to the lesion base.
The 90Sr brachytherapy was given in conjunction with two 1.25mg intravitreal injections of bevacizumab. The first intravitreal injection
was given within 1 week before the 90Sr administration to the time of 90Sr administration, and a second injection was routinely given 1 month later.
This intervention, similar to many other ophthalmic interventions, demonstrates considerable value for patients and is highly
cost-effective. Traditional Anti-VEGF treatments require frequent injections for an indefinite period of time. Should the
data prove as equally favourable in continued studies, anti-VEGF treatments with brachytherapy will decrease the patient burden
of treatment, as well as the direct medical costs of therapy Evaluating cost-effectiveness
Cost-effectiveness is defined by what a society is willing to pay for a particular healthcare service. It is typically measured
using a cost-utility ratio, or money expended per QALY (quality-adjusted life-year) gained. The World Health Organization
suggests that interventions costing less than approximately 1 x per capita GDP (US$ 46,600)/QALY are very cost-effective,
and procedures costing less than approximately 3 x per capita GDP (US$139,800)/QALY are cost effective.1 The National Institute for Health and Clinical Excellence (NICE) in the UK views interventions as cost-effective if they
have a cost utility ratio (CUR) of less than £20,000/QALY, with some exceptions made to include interventions up to £30,000/QALY.2
The direct medical cost incurred with 90Sr brachytherapy/bevacizumab treatment of neovascular AMD, including initial treatment and 12 years of follow-up treatments,
is $11,227 if treated in an ambulatory medical center or $13,697 if in a hospital inpatient setting. If bevacizumab injections
are administered 5x yearly (as demonstrated effective in the PRONTO study) from years 2 through 13, for a total of 62.3 doses,
the total cost is $28,274. The third party insurer CUR for the intervention is $10,973/QALY.
While the value gain conferred by interventions across medicine is defined by the improvement in length-of-life and/or quality-of-life, the
value gain for most ophthalmic procedures is defined by the improvement in quality-of-life alone. Nonetheless, the QALY is
an outcome that takes into account both.
The primary direct cost most often not analysed by third party insurers is caregiver expense. Paid non-family caregivers account
for 27.7% of the overall caregiver expense, resulting in an annual payment of $5548 per patient. Therapy also theoretically
frees up the 72.3% of the non-paid cohort of caregivers so they can also undertake gainful employment, accruing $14,482 annually
to the GDP in the form of newly created wages that otherwise would not be possible.
