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Journal of Contemporary Brachytherapy
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ABS 2015
vol. 10
Original paper

Cost in perspective: direct assessment of American market acceptability of Co-60 in gynecologic high-dose-rate brachytherapy and contrast with experience abroad

Raymond B. Mailhot Vega, David Barbee, Wesley Talcott, Tamara Duckworth, Bhartesh A. Shah, Omar F. Ishaq, Christina Small, Anamaria R. Yeung, Carmen A. Perez, Peter B. Schiff, Ophira Ginsburg, William Small Jr, May Abdel-Wahab, Gustavo Sarria Bardales, Matthew Harkenrider

J Contemp Brachytherapy 2018; 10, 6: 503–509
Online publish date: 2018/11/27
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While Ir-192 remains the mainstay isotope for gynecologic high-dose-rate (HDR) brachytherapy in the U.S., Co-60 is used abroad. Co-60 has a longer half-life than Ir-192, which may lead to long-term cost savings; however, its higher energy requires greater shielding. This study analyzes Co-60 acceptability based on a one-time expense of additional shielding and reports the financial experience of Co-60 in Peru’s National Cancer Institute, which uses both isotopes.

Material and methods
A nationwide survey was undertaken assessing physician knowledge of Co-60 and willingness-to-pay (WTP) for additional shielding, assuming a source more cost-effective than Ir-192 was available. With 440 respondents, 280 clinicians were decision-makers and provided WTPs, with results previously reported. After completing a shielding report, we estimated costs for shielding expansion, noting acceptability to decision makers’ WTP. Using activity-based costing, we note the Peruvian fiscal experience.

Shielding estimates ranged from $173,000 to $418,000. The percentage of respondents accepting high-density modular or lead shielding (for union and non-union settings) were 17.5%, 11.4%, 3.9%, and 3.2%, respectively. Shielding acceptance was associated with greater number of radiation oncologists in a respondent’s department but not time in practice or the American Brachytherapy Society membership. Peru’s experience noted cost savings with Co-60 of $52,400 annually.

By comparing the cost of additional shielding for a sample institution’s HDR suite with radiation oncologists’ WTP, this multi-institutional collaboration noted < 20% of clinicians would accept additional shielding. Despite low acceptability in the US, Co-60 demonstrates cost-favorability in Peru and may similarly in other locations.


brachytherapy, cobalt-60, costs and cost analysis, economics, decision-making, gynecologic tumor, HDR, survey

Danlos H, Bloch P. Note sur le traitement du lupus erythématéux par des applications du radium. Ann Dermatol Syphilog 1901; 2: 986-988.
Mould RF. The historical roots of modern brachytherapy for cervical and endometrial cancer. In: Vahrson HW (ed.). Radiation oncology of gynecological cancers. Springer, Berlin, Heidelberg 1997.
Myers WG. Applications of artificially radioactive isotopes in therapy: I. Cobalt-60. Am J Roentgenol 1948; 60: 816-823.
Williamson JF. Brachytherapy technology and physics practice since 1950: a half-century of progress. Phys Med Biol 2006; 51: R303-325.
Horwitz H, Kereiakes JG, Bahr GK et al. An after-loading system utiziling cesium-137 for the treatment of carcinoma of the cervix. Am J Roentgenol Radium Ther Nucl Med 1964; 91: 176-191.
Schulz U, Busch M, Bormann U. Interstitial high dose-rate brachytherapy: principle, practice and first clinical experiences with a new remote-controlled afterloading system using Ir-192. Int J Radiat Oncol Biol Phys 1984; 10: 915-920.
Grover S, Harkenrider MM, Cho LP et al. Image Guided Cervical Brachytherapy: 2014 Survey of the American Brachytherapy Society. Int J Radiat Oncol Biol Phys 2016; 94: 598-604.
Harkenrider MM, Grover S, Erickson BA et al. Vaginal brachytherapy for postoperative endometrial cancer: 2014 Survey of the American Brachytherapy Society. Brachytherapy 2016; 15: 23-29.
Patel FD, Sharma SC, Negi PS et al. Low dose rate vs. high dose rate brachytherapy in the treatment of carcinoma of the uterine cervix: a clinical trial. Int J Radiat Oncol Biol Phys 1994; 28: 335-341.
Hareyama M, Sakata K, Oouchi A et al. High-dose-rate versus low-dose-rate intracavitary therapy for carcinoma of the uterine cervix: a randomized trial. Cancer 2002; 94: 117-124.
Lertsanguansinchai P, Lertbutsayanukul C, Shotelersuk K et al. Phase III randomized trial comparing LDR and HDR brachytherapy in treatment of cervical carcinoma. Int J Radiat Oncol Biol Phys 2004; 59: 1424-1431.
Aronowitz JN. Afterloading: the technique that rescued brachytherapy. Int J Radiat Oncol Biol Phys 2015; 92: 479-487.
O’Connell D, Howard N, Joslin CA et al. A new remotely controlled unit for the treatment of uterine carcinoma. Lancet 1965; 2: 570-571.
Papagiannis P, Angelopoulos A, Pantelis E et al. Monte Carlo dosimetry of [sup 60]Co HDR brachytherapy sources. Med Phys 2003; 30: 712-721.
Strohmaier S, Zwierzchowski G. Comparison of 60 Co and 192 Ir sources in HDR brachytherapy. J Contemp Brachytherapy 2011; 3: 199-208.
Ntekim A, Adenipekun A, Akinlade B et al. High dose rate brachytherapy in the treatment of cervical cancer: Preliminary experience with cobalt 60 radionuclide source-a prospective study. Clin Insights Oncol 2010; 4: 89-94.
Zakaria GA, Schütte W, Azhari HA. Dosimetrie an HDR-Afterloading-Geräten mit Ir-192- und Co-60-Strahler: Vergleich verschiedener internationaler Dosimetrieprotokolle. Z Med Phys 2010; 20: 215-224.
Ballester F, Granero D, Pérez-Calatayud J et al. Monte Carlo dosimetric study of the BEBIG Co-60 HDR source. Phys Med Biol 2005; 50: N309-N316.
Richter J, Baier K, Flentje M. Comparison of 60 Cobalt and 192 Iridium sources in high dose rate afterloading brachytherapy. Strahlenther Onkol 2008; 184: 187-192.
Palmer A, Hayman O, Muscat S. Treatment planning study of the 3D dosimetric differences between Co-60 and Ir-192 sources in high dose rate (HDR) brachytherapy for cervix cancer. J Contemp Brachytherapy 2012; 4: 52-59.
Mailhot Vega R, Talcott W, Ishaq O et al. A national survey of HDR source knowledge among practicing radiation oncologists and residents: Establishing a willingness-to-pay threshold for cobalt-60 usage. Brachytherapy 2017; 16: 910-915.
National Council on Radiation Protection. NCRP Report #116, Limitation of Exposure to Ionizing Radiation. Bethesda, MD. 1994.
Sherer MAS, Visconti PJ, Ritenour ER, Haynes K. Radiation Protection in Medical Radiography. 7th ed. Elsevier Health Sciences, Mosby 2014.
National Council on Radiation Protection and Measurements. NCRP Report #49, Structural Shielding Design and Evaluation for Medical Use of X-Rays and Gamma Rays of Energies up to 10MV. Bethesda, MD. 1976.
INEN. 2016 annual metrics of INEN management. http://www.inen.sld.pe/portal/documentos/pdf/estadistica/datos_estadisticos/01032017_Estadindgest2016.pdf. Published 2017, accessed May 3, 2018.
Thaker NG, Pugh TJ, Mahmood U et al. Defining the value framework for prostate brachytherapy using patient-centered outcome metrics and time-driven activity-based costing. Brachytherapy 2016; 15: 274-282.
Kaplan RS, Anderson SR. Time-driven activity-based costing. Harv Bus Rev 2004; 82: 131-138, 150.
IAEA. DIrectory of RAdiotherapy Centres (DIRAC) [Internet]. NAHU. 1959-present [cited 18 April 2018]. Available from: https://dirac.iaea.org/.
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