Authors' objectives: This report aims to identify and summarise evidence that addresses the following questions: 1. Is contact x-ray brachytherapy (CXB) boost as part of a watch and wait strategy clinically and cost-effective for the treatment of early-stage rectal cancer in people who are unable or unwilling to have surgery? 2. Is contact x-ray brachytherapy (CXB) boost as part of a watch and wait strategy clinically and cost-effective for the treatment of operable early-stage rectal cancer?

Authors' results and conclusions: HTW identified one randomised controlled trial comparing CXB to external beam boost in operable patients, and no evidence for the use of CXB in inoperable patients or those unwilling to undergo surgery. The rates of clinical complete response by 24 weeks and organ preservation at three years favoured CXB. Rates of surgery overall were reduced with CXB, and there was no difference in the rates of local recurrence, disease free survival or overall survival. There was also no difference in rates of early adverse events or changes in bowel function between the CXB and external beam boost arms. Rectal bleeding was more common in patients who received CXB, but had resolved by the three-year timepoint. HTW reviewed two published health economic studies for patients with T2-3, NX, M0 rectal cancer from a UK NHS perspective. They reported watch and wait including CXB would be dominant over surgery, and CXB was also dominant compared to watch and wait alone. An original cost-utility analysis was undertaken by HTW and indicated CXB would be cost effective as part of a watch and wait strategy in patients with T2-3b, N0-1, M0 rectal cancer who are fit for surgery. Delay or avoidance of surgery provided improvements in quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) was calculated to be £4,463 per QALY gained and remained cost effective in 91% estimates. Patient testimonials from the Papillon Patient Support group and a survey of the All Wales Cancer network via TENOVUS also showed patient support for CXB.

Authors' recommendations: The evidence supports the routine adoption of CXB in addition to chemoradiotherapy for people with early-stage rectal cancer who are suitable for surgery. The use of CXB boost increases treatment response rates and organ preservation and reduces the need for subsequent surgery compared with external beam radiotherapy boost. Economic modelling suggests that CXB boost is cost effective compared with external beam boost, with an ICER of £4,463 per QALY gained.

Authors' methods: The Evidence Appraisal Report is based on a literature search (strategy available on request) for published clinical and economic evidence on the health technology of interest. It is not a full systematic review but aims to identify the best available evidence on the health technology of interest. Researchers critically evaluate and synthesise this evidence. We include the following clinical evidence in order of priority: systematic reviews; randomised trials; non-randomised trials. We only include evidence for “lower priority” evidence where outcomes are not reported by a “higher priority” source. We also search for economic evaluations or original research that can form the basis of an assessment of costs/cost comparison. We carry out various levels of economic evaluation, according to the evidence that is available to inform this.

Project Status: Completed

Year Published: 2024

URL for published report: https://healthtechnology.wales/reports-guidance/low-energy-contact-x-ray-brachytherapy-cxb/

English language abstract: An English language summary is available

Publication Type: Rapid Review

Country: Wales, United Kingdom

Organisation Name: Health Technology Wales

Contact Address: c/o Digital Health Care Wales, 21 Cowbridge Road East Cardiff CF11 9AD

Contact Name: Susan Myles, PhD

Contact Email: healthtechnology@wales.nhs.uk