You are currently viewing a new version of our website. To view the old version click .
MDPIMDPI
Search all articles
International Journal of Environmental Research and Public Health
Download PDF
  • Review
  • Open Access

7 March 2023

Health Economic Evaluation of Proton Therapy for Lung Cancer: A Systematic Review

,
,
,
,
and
1
Department of Radiation Oncology, China Medical University Hospital, Taichung 40402, Taiwan
2
School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan
3
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40402, Taiwan
4
Ph.D. Program for Health Science and Industry, College of Health Care, China Medical University, Taichung 40402, Taiwan
Int. J. Environ. Res. Public Health2023, 20(6), 4727;https://doi.org/10.3390/ijerph20064727
This article belongs to the Section Health Economics
Version Notes
Order Reprints

Abstract

Background: To our knowledge, there have been no systematic reviews of health economic evaluations of proton therapy specific to lung cancer. Methods: We conducted this systematic review according to the predefined protocol [PROSPERO CRD42022365869]. We summarized the results of the included studies via structured narrative synthesis. Results: We identified four studies (all used passively scattered proton therapy) from 787 searches. Two cost analyses reported that proton therapy was more costly than photon therapy for early- or locally advanced-stage non-small cell lung cancer, one cost-utility analysis reported that proton therapy was dominated by nonproton therapy in early-stage non-small cell lung cancer, and one cost-utility analysis reported that proton therapy was not cost-effective (vs. photon) in locally advanced non-small cell lung cancer. Conclusions: Passively scattered proton therapy was more costly and not cost-effective than photon therapy for early- and locally advanced-stage non-small cell lung cancer. Further health economic evaluations regarding modern proton therapy (such as scanning beam) for common radiotherapy indications of lung cancer are eagerly awaited.

1. Introduction

1.1. Lung Cancer Radiotherapy

Lung cancer is one of the leading causes of cancer mortality worldwide []. Lung cancer is usually classified as non-small cell lung cancer (NSCLC, the majority) or small cell lung cancer (SCLC). Radiotherapy is a common modality in the treatment of lung cancer, whether for SCLC or NSCLC [,,]. Currently, radiotherapy is usually delivered via photons [,]. There are many photon radiotherapy technologies available in the treatment of lung cancer, including the minimal standard of 3-dimensional conformal radiotherapy (3D-CRT, also called 3DRT) [,,,] or more advanced technologies such as intensity-modulated radiotherapy (IMRT).

1.2. Proton Therapy Is an Advanced Radiotherapy Technology

With the theoretical benefit of a lower normal tissue dose, proton therapy is advocated as an advanced form of radiotherapy [] and may be used to limit normal tissue toxicity to deliver radiotherapy safely [,,]. This benefit was contributed by the physical characteristics (Bragg peak) of particle therapy (including protons or carbon ions), which are not available in commonly used photon radiotherapy [,]. As shown in Figure 1, proton therapy typically delivered most of the radiotherapy dose at the desired body depth (Bragg peak) with much lower dose before and almost no dose after that depth. On the contrary, photon therapy delivered much of the dose close to body surface (usually not the desired depth). Therefore, the use of proton therapy has been expanded from the 1st hospital based one in 1990 to more than 100 proton centers in operation around the world [] and advocated for the treatment of various cancer types, including lung cancer [,,]. However, the technology for delivering protons is evolving as well, similar to the history of delivering photon radiotherapy, which has evolved from 3DRT to IMRT. In the past, most proton therapy was delivered via passively scattered proton therapy (PSPT), whereas the use of scanning beam proton therapy has emerged to deliver intensity-modulated proton therapy (IMPT) []. In the field of thoracic radiation oncology, an earlier randomized controlled trial (RCT) using PSPT vs. IMRT reported similar results for locally advanced NSCLC (LA-NSCLC) [], whereas a more recent RCT allowing scanning beam proton therapy [] reported significantly fewer side effects while maintaining similar progression-free survival (PFS) when proton therapy was compared with IMRT in the treatment of locally advanced esophageal cancer. New RCTs (such as NCT01993810) allowing scanning beam proton therapy in the treatment of lung cancer are ongoing [].
Figure 1. Illustrative dose distribution of proton therapy (bold line) vs. photon therapy (thin line).

1.3. Health Economic Evaluation of Proton Therapy for Lung Cancer

Financial toxicity has been a common challenge to modern cancer therapy [,]. Due to the high cost of proton therapy with initial investment far greater than that of a photon unit [,], health economic evaluation (HEE) is of tremendous importance in the evaluation of proton therapy [,]. An earlier systematic review found no papers reporting the cost-effectiveness of particle therapy []. Since then, to our knowledge, no systematic review specifically of HEE of lung cancer has been published, although HEE or the cost-effectiveness of proton therapy in general (not limited to lung cancer) has been reviewed [,,,,]. However, the most recent systematic review was conducted in July 2019 [], more than three years ago. Furthermore, this systematic review only focused on the narrow cost-effectiveness analyses rather than the broader HEE [,,]. Therefore, the aim of our study was to systematically review the health economic evaluation of lung cancer patients treated with proton vs. alternative radiotherapeutic approaches from which future research priorities can be identified.

2. Materials and Methods

We conducted this systematic review according to the predefined protocol [PROSPERO CRD42022365869, registered in Oct 2022]. The target population was adult lung cancer patients treated with radiotherapy via either proton (monotherapy or combination therapy with other treatment modalities) or nonproton (including but not limited to photons or carbon ions). The inclusion criteria were health economic evaluation [,,] in original full English papers that reported the economic (with/without health) outcomes of proton and nonproton therapies without limitations regarding time horizon, study perspective or study design. We searched PubMed, EMBASE, and Cochrane during October 2022 for the initial search and January 2023 for the final search. The selection of these databases was based on recommendations in the literature [] and our previous experience []. We used the following search strategy in PubMed as modified from the literature [] and our previous experience []: (lung) AND ((carcinoma) OR (neoplasm) OR (cancer)) AND (proton) AND ((“costs and cost analysis” [MeSH] OR costs [Title/Abstract] OR cost effective* [Title/Abstract]) OR (cost* [Title/Abstract] OR “costs and cost analysis” [MeSH:noexp] OR cost benefit analysis* [Title/Abstract] OR cost–benefit analysis [MeSH] OR health care costs [MeSH:noexp])). We modified the strategy for EMBASE as follows: (‘lung’/exp OR lung) AND (‘carcinoma’/exp OR carcinoma OR ‘neoplasm’/exp OR neoplasm OR ‘cancer’/exp OR cancer) AND (‘proton’/exp OR proton) AND (‘cost’/exp OR cost). We modified the strategy for Cochrane as follows: “((lung) AND ((carcinoma) OR (neoplasm) OR (cancer)) AND (proton) AND (cost))”. We performed further supplementary searching by checking the bibliographies of all included studies and systematic reviews identified via the above search in PubMed. We followed the PRISMA 2020 flow diagram [,] to identify studies to be included in our systematic review. After the above study identification from the search, duplicated records were excluded, and two reviewers independently screened the title and abstract to identify potentially eligible reports for full paper retrieval. Of the retrieved reports, we screened full-text articles to determine if they met the criteria to be included in the final analyses. We used CHEERS 2022 [] for quality assessment of the included studies and then synthesized the results of the included studies via structured narrative synthesis (tabulation, see Section 3 for details). For the convenience of the intended readers around the world, costs (rounded as integral) were normalized to 2023 USD by the inflation factor and Purchasing Power Parities using the CCEMG–EPPI-Centre Cost Converter (https://eppi.ioe.ac.uk/costconversion/, accessed on 10 January 2023) in the summary tables, whereas both the updated dollar values and the original (shown in square brackets if different from the updated value) were reported in the text. We extracted the following elements into the summary table, as modified from the literature and our experiences [,]: author, study year, type of health economic evaluation, conflict of interest, source of funding, studied population, ethnicity, country, treatment setting, study design, analytic approach, study perspective, time horizon, discount rate, type of costs, cost year, type of effectiveness, compliance with treatment, statistical software, intervention and comparator, (incremental) cost, incremental cost-effectiveness ratio, (incremental) effectiveness, sensitivity analyses, and conclusion. We used the year reported in the paper as the reference year for cost. If such information was not reported, we then used the reference year based on the most relevant year of data used or the year in which the paper was published []. All the above assessments and data extraction were performed by two reviewers (Li C.C. & Chien C.R.) independently, with input from the third (Lin Y.C.) if there was no consensus after face-to-face discussion between Li and Chien.

3. Results

After the final search in January 2023, the flow diagram of the literature search (combining the initial and final searches) is illustrated in Figure 2. Among the 787 searches, we included four studies in our final analyses [,,,].
Figure 2. Flow diagram of the literature search.
We determined that there was high variability in clinical (stage I vs. III) and health settings (Netherland vs. USA with time span from 2007~2019) among these included studies, so we performed the planned structured narrative synthesis of available studies as a summary table (Table 1) rather than formal meta-analyses []. There were two cost analyses and two cost-utility analyses. Two study [,] investigated definitive radiotherapy +/− chemotherapy for LA-NSCLC (stage III) in the US or the Netherlands, whereas two studies [,] investigated definitive radiotherapy for early-stage (stage I) NSCLC in the Netherlands. All studies investigated passively scattered proton therapy, employed modeling approaches, and found that PSPT was more costly than photon therapy (Table 1). Two studies [,] (from the same study group) stated that “cost difference between particle and photon therapies is relatively small for lung cancer” but “proton therapy was dominated by both carbon-ion therapy and stereotactic body radiotherapy (SBRT)” for early-stage NSCLC. One study [] reported that protons were more costly than photons (48,559 vs. 22,767 vs. 30,593 (42,975 vs. 20,149 vs. 27,075 USD) for proton vs. photon-3DCRT vs. photon-IMRT) in definitive concurrent chemoradiotherapy (CCRT) for LA-NSCLC. Even in the group with the highest risk of radiation pneumonitis in which proton therapy might lead to additional cost savings, proton therapy was still much more costly than either IMRT or 3DCRT. In another study investigating radiotherapy for LA-NSCLC [], the authors stated “Currently, proton therapy is not cost-effective for all patients”. However, “individualized proton” may be cost-effective at threshold of 104,121 USD [EUR 76,299] per QALY if equal minutes per fraction for either proton or photon.
Table 1. Summary table of the included health economic evaluations (HEE).
The quality assessment is shown in Supplementary Table S1. All studies reported (at least partially) most of the required items suggested in the literature []. Heterogeneity was only explored in one study [] in which the results remained similar.

4. Discussion

We systematically reviewed the published HEEs regarding proton therapy for lung cancer. In addition to the CEA published in 2010 [], which was summarized by the most recent systematic review in general (not specific for lung cancer) [], we further summarized other broader [,] or more recent [] HEEs. We found that the available HEEs regarding proton therapy for lung cancer were limited to specific scenarios of lung cancer radiotherapy, whereas no HEE was available for the vast majority of common radiotherapy indications for lung cancer (Table 2) [,]. Our study was, to our knowledge, the first systematic review specifically for HEE of lung cancer proton therapy.
Table 2. Summary table by common lung cancer radiotherapy indications [modified from [,,,]].
The results summarized in our systematic review seem to be relatively homogenous (regardless of whether sponsorship was reported or not []) in that proton therapy was more costly than photon therapy, as expected. However, there were only four studies included, and the investigated scenarios were limited (Table 2), so this observation should be interpreted with caution with limitations in generalizability. Furthermore, the clinical and health setting was quite variable [] and limited (Table 2).
There were some limitations to our study. First, we did not use gray literature as emphasized in the literature [] because it was potentially nonreproducible [] and, thus, less scientific to our way of thinking. Second, we did not consider the risk of bias in the included studies during data synthesis. This was because the risk of bias was not mentioned in the modern CHEERS 2022 checklist [] for HEE. Furthermore, there were only four studies included in our study, and the clinical and health settings were quite variable, as mentioned above. Finally, we did not identify HEEs investigating more modern proton therapy such as scanning beam protons [] or magnetic resonance guided proton therapy [,]. When more clinical results of modern proton therapy are available in the future, the cost and cost effectiveness of modern proton therapy may be clarified in the future. These relied on the collaborative work among various stakeholders, including patients, health care professionals, manufactures, insurance agencies, and the governments. The future of proton therapy for lung cancer also relates to the advancement of other treatment modalities such as radiofrequency ablation [], surgery [], and systemic therapy [,].

5. Conclusions

In this systematic review, we found that PSPT was reported to be dominated by both carbon-ion therapy and photons (SBRT) for early-stage NSCLC and was also more costly and not as cost effective than photons for locally advanced-stage NSCLC. There were no HEEs available for the vast majority of common radiotherapy indications for lung cancer. Further HEEs regarding modern proton therapy (such as scanning beam) for common radiotherapy indications of lung cancer are eagerly awaited.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph20064727/s1, Table S1. Quality assessment of the included studies.

Author Contributions

C.-R.C. participated in the conception and design of the study, data extraction/assessment, interpretation of data, and drafting of the manuscript. C.-C.L. and Y.-C.L. participated in the conception of the study, data extraction/assessment, and drafting of the manuscript. J.-A.L., K.S.C.C. and T.-C.H. participated in the conception of the study, interpretation of data, and drafting of the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Ethical review and approval were waived for this study due to that the current study was a systematic review which utilized published data.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Acknowledgments

The corresponding author would like to thank Ya-Chen Tina Shih for her mentoring. The authors thank American Journal Experts for their editorial contributions.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Kim, J.; Lee, H.; Huang, B.W. Lung Cancer: Diagnosis, Treatment Principles, and Screening. Am. Fam. Physician 2022, 105, 487–494. [Google Scholar] [PubMed]
  2. Khalifa, J.; Lerouge, D.; Le Péchoux, C.; Pourel, N.; Darréon, J.; Mornex, F.; Giraud, P. Radiotherapy for primary lung cancer. Cancer Radiother. 2022, 26, 231–243. [Google Scholar] [CrossRef] [PubMed]
  3. National Comprehensive Cancer Network Guidelines for Non-Small Cell Lung Cancer, Version 5. 2022. Available online: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf (accessed on 3 November 2022).
  4. National Comprehensive Cancer Network Guidelines for Small Cell Lung Cancer, Version 2. 2023. Available online: https://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf (accessed on 3 November 2022).
  5. Chandra, R.A.; Keane, F.K.; Voncken, F.E.M.; Thomas, C.R., Jr. Contemporary radiotherapy: Present and future. Lancet 2021, 398, 171–184. [Google Scholar] [CrossRef] [PubMed]
  6. Mohan, R. A Review of Proton Therapy—Current Status and Future Directions. Precis. Radiat. Oncol. 2022, 6, 164–176. [Google Scholar] [CrossRef] [PubMed]
  7. Finazzi, T.; Schneiders, F.L.; Senan, S. Developments in radiation techniques for thoracic malignancies. Eur. Respir. Rev. 2021, 30, 200224. [Google Scholar] [CrossRef]
  8. Zehentmayr, F.; Grambozov, B.; Kaiser, J.; Fastner, G.; Sedlmayer, F. Radiation dose escalation with modified fractionation schedules for locally advanced NSCLC: A systematic review. Thorac. Cancer 2020, 11, 1375–1385. [Google Scholar] [CrossRef]
  9. Goetz, G.; Mitic, M.; Mittermayr, T.; Wild, C. Health Technology Assessment of Carbon-ion Beam Radiotherapy: A Systematic Review of Clinical Effectiveness and Safety for 54 Oncological Indications in 12 Tumour Regions. Anticancer Res 2019, 39, 1635–1650. [Google Scholar] [CrossRef]
  10. ASTRO Model Policies—PROTON BEAM THERAPY (PBT). Available online: https://www.astro.org/uploadedFiles/_MAIN_SITE/Daily_Practice/Reimbursement/Model_Policies/Content_Pieces/ASTROPBTModelPolicy.pdf (accessed on 30 June 2022).
  11. Liao, Z.; Lee, J.J.; Komaki, R.; Gomez, D.R.; O’Reilly, M.S.; Fossella, F.V.; Blumenschein, G.R., Jr.; Heymach, J.V.; Vaporciyan, A.A.; Swisher, S.G.; et al. Bayesian Adaptive Randomization Trial of Passive Scattering Proton Therapy and Intensity-Modulated Photon Radiotherapy for Locally Advanced Non-Small-Cell Lung Cancer. J. Clin. Oncol. 2018, 36, 1813–1822. [Google Scholar] [CrossRef]
  12. Lin, S.H.; Hobbs, B.P.; Verma, V.; Tidwell, R.S.; Smith, G.L.; Lei, X.; Corsini, E.M.; Mok, I.; Wei, X.; Yao, L.; et al. Randomized Phase IIB Trial of Proton Beam Therapy Versus Intensity-Modulated Radiation Therapy for Locally Advanced Esophageal Cancer. J. Clin. Oncol. 2020, 38, 1569–1579. [Google Scholar] [CrossRef]
  13. Chang, F.U.; Chien, C.R. The importance of out-of-pocket cost information in the era of financial toxicity of cancer care. Support Care Cancer 2021, 29, 1149. [Google Scholar] [CrossRef]
  14. PDQ Adult Treatment Editorial Board. Financial Toxicity and Cancer Treatment (PDQ®): Health Professional Version, 2022. In PDQ Cancer Information Summaries [Internet]; National Cancer Institute (US): Bethesda, MD, USA, 2002. [Google Scholar]
  15. Jones, D.A.; Smith, J.; Mei, X.W.; Hawkins, M.A.; Maughan, T.; van den Heuvel, F.; Mee, T.; Kirkby, K.; Kirkby, N.; Gray, A. A systematic review of health economic evaluations of proton beam therapy for adult cancer: Appraising methodology and quality. Clin. Transl. Radiat. Oncol. 2019, 20, 19–26. [Google Scholar] [CrossRef] [PubMed]
  16. Ontario Health (Quality). Proton Beam Therapy for Cancer in Children and Adults: A Health Technology Assessment. Ont. Health Technol. Assess Ser. 2021, 21, 1–142. [Google Scholar]
  17. Pijls-Johannesma, M.; Grutters, J.P.; Verhaegen, F.; Lambin, P.; De Ruysscher, D. Do we have enough evidence to implement particle therapy as standard treatment in lung cancer? A systematic literature review. Oncologist 2010, 15, 93–103. [Google Scholar] [CrossRef]
  18. Terasawa, T.; Dvorak, T.; Ip, S.; Raman, G.; Lau, J.; Trikalinos, T.A. Systematic review: Charged-particle radiation therapy for cancer. Ann. Intern. Med. 2009, 151, 556–565. [Google Scholar] [CrossRef] [PubMed]
  19. Verma, V.; Mishra, M.V.; Mehta, M.P. A systematic review of the cost and cost-effectiveness studies of proton radiotherapy. Cancer 2016, 122, 1483–1501. [Google Scholar] [CrossRef]
  20. Husereau, D.; Drummond, M.; Augustovski, F.; de Bekker-Grob, E.; Briggs, A.H.; Carswell, C.; Caulley, L.; Chaiyakunapruk, N.; Greenberg, D.; Loder, E.; et al. CHEERS 2022 ISPOR Good Research Practices Task Force: Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) Statement: Updated Reporting Guidance for Health Economic Evaluations. Value Health 2022, 25, 3–9. [Google Scholar] [CrossRef]
  21. Husereau, D.; Drummond, M.; Augustovski, F.; de Bekker-Grob, E.; Briggs, A.H.; Carswell, C.; Caulley, L.; Chaiyakunapruk, N.; Greenberg, D.; Loder, E.; et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Explanation and Elaboration: A Report of the ISPOR CHEERS II Good Practices Task Force. Value Health 2022, 25, 10–31. [Google Scholar] [CrossRef]
  22. Drummond, M. Methods for the Economic Evaluation of Health Care Programmes, 4th ed.; Oxford University Press: Oxford, UK, 2015. [Google Scholar]
  23. Mandrik, O.L.; Severens, J.L.H.; Bardach, A.; Ghabri, S.; Hamel, C.; Mathes, T.; Vale, L.; Wisløff, T.; Goldhaber-Fiebert, J.D. Critical Appraisal of Systematic Reviews with Costs and Cost-Effectiveness Outcomes: An ISPOR Good Practices Task Force Report. Value Health 2021, 24, 463–472. [Google Scholar] [CrossRef]
  24. Chien, C.R.; Geynisman, D.M.; Kim, B.; Xu, Y.; Shih, Y.T. Economic Burden of Renal Cell Carcinoma-Part I: An Updated Review. Pharmacoeconomics 2019, 37, 301–331. [Google Scholar] [CrossRef]
  25. HIRU. Search Filters for MEDLINE in Ovid Syntax and the PubMed Translation. Available online: https://hiru.mcmaster.ca/hiru/hiru_hedges_medline_strategies.aspx (accessed on 13 August 2022).
  26. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021, 372, n71. [Google Scholar] [CrossRef]
  27. Page, M.J.; Moher, D.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. PRISMA 2020 explanation and elaboration: Updated guidance and exemplars for reporting systematic reviews. BMJ 2021, 372, n160. [Google Scholar] [CrossRef] [PubMed]
  28. Smith, W.P.; Richard, P.J.; Zeng, J.; Apisarnthanarax, S.; Rengan, R.; Phillips, M.H. Decision analytic modeling for the economic analysis of proton radiotherapy for non-small cell lung cancer. Transl. Lung Cancer Res. 2018, 7, 122–133. [Google Scholar] [CrossRef] [PubMed]
  29. Peeters, A.; Grutters, J.P.; Pijls-Johannesma, M.; Reimoser, S.; De Ruysscher, D.; Severens, J.L.; Joore, M.A.; Lambin, P. How costly is particle therapy? Cost analysis of external beam radiotherapy with carbon-ions, protons and photons. Radiother. Oncol. 2010, 95, 45–53. [Google Scholar] [CrossRef]
  30. Grutters, J.P.; Pijls-Johannesma, M.; Ruysscher, D.D.; Peeters, A.; Reimoser, S.; Severens, J.L.; Lambin, P.; Joore, M.A. The cost-effectiveness of particle therapy in non-small cell lung cancer: Exploring decision uncertainty and areas for future research. Cancer Treat. Rev. 2010, 36, 468–476. [Google Scholar] [CrossRef] [PubMed]
  31. Aldenhoven, L.; Ramaekers, B.; Degens, J.; Oberije, C.; van Loon, J.; Dingemans, A.C.; De Ruysscher, D.; Joore, M. Cost-effectiveness of proton radiotherapy versus photon radiotherapy for non-small cell lung cancer patients: Exploring the model-based approach. Radiother. Oncol. 2022; in press. [Google Scholar] [CrossRef]
  32. Suwinski, R. Prophylactic cranial irradiation in SCLC. Transl. Lung Cancer Res. 2021, 10, 2071–2078. [Google Scholar] [CrossRef] [PubMed]
  33. Hoffmann, A.; Oborn, B.; Moteabbed, M.; Yan, S.; Bortfeld, T.; Knopf, A.; Fuchs, H.; Georg, D.; Seco, J.; Spadea, M.F.; et al. MR-guided proton therapy: A review and a preview. Radiat. Oncol. 2020, 15, 129. [Google Scholar] [CrossRef]
  34. Castelluccia, A.; Mincarone, P.; Tumolo, M.R.; Sabina, S.; Colella, R.; Bodini, A.; Tramacere, F.; Portaluri, M.; Leo, C.G. Economic Evaluations of Magnetic Resonance Image-Guided Radiotherapy (MRIgRT): A Systematic Review. Int. J. Environ. Res. Public Health 2022, 19, 10800. [Google Scholar] [CrossRef] [PubMed]
  35. Sher, D.J.; Wee, J.O.; Punglia, R.S. Cost-effectiveness analysis of stereotactic body radiotherapy and radiofrequency ablation for medically inoperable, early-stage non-small cell lung cancer. Int. J. Radiat. Oncol. Biol. Phys. 2011, 81, e767–e774. [Google Scholar] [CrossRef]
  36. Altorki, N.; Wang, X.; Kozono, D.; Watt, C.; Landrenau, R.; Wigle, D.; Port, J.; Jones, D.R.; Conti, M.; Ashrafi, A.S.; et al. Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer. N. Engl. J. Med. 2023, 388, 489–498. [Google Scholar] [CrossRef]
  37. Spigel, D.R.; Faivre-Finn, C.; Gray, J.E.; Vicente, D.; Planchard, D.; Paz-Ares, L.; Vansteenkiste, J.F.; Garassino, M.C.; Hui, R.; Quantin, X.; et al. Five-Year Survival Outcomes from the PACIFIC Trial: Durvalumab After Chemoradiotherapy in Stage III Non-Small-Cell Lung Cancer. J. Clin. Oncol. 2022, 40, 1301–1311. [Google Scholar] [CrossRef] [PubMed]
  38. Wang, X.S.; Bai, Y.F.; Verma, V.; Yu, R.L.; Tian, W.; Ao, R.; Deng, Y.; Xia, J.L.; Zhu, X.Q.; Liu, H.; et al. Randomized Trial of First-Line Tyrosine Kinase Inhibitor with or Without Radiotherapy for Synchronous Oligometastatic EGFR-Mutated NSCLC. J. Natl. Cancer Inst. 2022, 114, djac015. [Google Scholar] [CrossRef] [PubMed]
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Article Metrics

Citations

Article Access Statistics

Journal Statistics
Multiple requests from the same IP address are counted as one view.
Download PDF
Does Environmental Education Always Contribute to Remanufacturing Supply Chain Development?
Previous
Preliminary Support for the Use of Motivational Interviewing to Improve Parent/Adult Caregiver Behavior for Obesity and Cancer Prevention
Next