1 of 1

Hypofractionated and ultra-hypofractionated RT were both cost- and DALY-saving relative to conventional RT regimens
Breast cancer: 15- and 5-fraction RT saved $1,493 and $2,680 and 0.0034 and 0.0063 pollution-associated DALYs, respectively, per patient
Prostate cancer: 20- and 5-fraction RT saved $1,484 and $3,037 and 0.0035 and 0.0077 DALYs, respectively, per patient
Modeling ultra-hypofractionated RT for clinically eligible patients (n=49,909), national savings up to $133.8 million/year and 314 DALYs/year

Results

Energy-Saving Radiotherapy Paths:

Cost-Effectiveness Analysis of Environmental Health Co-Benefits

Genevieve S. Silva MD MBA,¹ Chirjiv Anand PhD,² Zachary McSween MS,³ Cassandra Thiel PhD,⁴ Matthew Eckelman PhD,⁵ Allison L. Matous MD,² Surbhi Grover MD MPH,⁶ Katie E. Lichter MD MPH^2,7

¹Penn Medicine Doylestown Transitional Residency Program, Doylestown, PA; ²Department of Radiation Oncology and Applied Sciences at Dartmouth Hitchcock Medical Center; Dartmouth Cancer Center, Lebanon, NH; ³St. George’s University School of Medicine, St. George, Grenada; ⁴New York University (NYU) Langone Health, Departments of Population Health and Ophthalmology, New York, NY; ⁵Northeastern University, Environmental Health Research Institute, Boston, MA; ⁶University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA; ⁷The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Geisel School of Medicine

> Hypofractionated RT regimens with fewer, higher concentration doses for breast & prostate cancer may reduce downstream pollution-associated health risks, environmental impact, and health system costs – in addition to their clinical and patient benefits (e.g., reduced transit burden, financial costs)

> By adopting moderately and ultra-hypofractionated RT, when clinically appropriate, radiation oncology can advance sustainable cancer care, promoting both improved health outcomes for patients and environmental stewardship

Methods

Healthcare delivery contributes to pollutants such as greenhouse gases (GHG), particulate matter, and carcinogens (e.g., benzene), which pose health risks.¹
Oncology has helped lead the movement toward reducing the environmental externalities of healthcare delivery.^2-4
The energy consumption associated with radiotherapy (RT) – a key treatment for >6 million patients annually – represents one promising target⁵
Here, we characterize the potential for hypofractionated RT (evidence-based regimens with fewer, higher-dose [fraction] treatments) to enhance value by limiting (1) downstream environmental health risks and (2) costs of cancer care delivery

Background

Similarly co-beneficial intervention points across other cancer care pathways
Opportunities to reinvest cost savings into patient care, enhancing care access for cancer patients
How appropriate screening can avert downstream resource utilization and the generation of associated environmental exposures

Future Directions for Research

Thank you to the Lichter Lab for their assistance obtaining health system energy billing costs.

Please direct all study-related questions to katie.e.lichter@dartmouth.edu

Acknowledgements

	Cost	GHG emissions (kg CO₂e)	Respiratory effects (PM2.5)	Carcinogenic pollution (CTUh)	Non- carcinogenic pollution (CTUh)	Acidification (kg SO₂e)	Ozone depletion (kg CFC-11e)	DALYs Lost	Cost Savings	DALY Savings
Conventional Breast RT (25-33 fraction [fx])	$3,624.83	12,800	8.87	0.0004	0.0012	16.2	0.0018	0.0089	-	-
Moderately Hypofractionated Breast RT (15 fx)	$2,132.13	8,150	5.22	0.0003	0.0007	10.1	0.0012	0.0055	$1,492.69	0.0034
Ultra-hypofractionated Breast RT (5 fx)	$945.16	4,330	2.22	0.0001	0.0003	5.06	0.0006	0.0026	$2,679.67	0.0063
Conventional Prostate RT (28 or 38-45 fx)	$4,133.46	14,800	10.4	0.0005	0.0014	18.8	0.0021	0.0104	-	-
Moderately Hypofractionated Prostate RT (20 fx)	$2,649.92	10,100	6.72	0.0003	0.0012	12.6	0.0014	0.0069	$1,483.54	0.0035
Ultra-hypofractionated Prostate RT (5 fx)	$1,096.73	4,330	2.22	0.0003	0.0004	5.06	0.0006	0.0026	$3,036.73	0.0077

Cost and environmental impact savings of moderately hypofractionated and ultra-hypofractionated RT (external beam radiation therapy) compared to conventional RT for breast and prostate cancer. Cost (USD) reflects costs of electricity and natural gas associated with energy use over the course of RT. Cost and DALY savings and ICERs are relative to conventional RT. DALYs: disability-adjusted life-years.Fx: number of fractions. CFC: chlorofluorocarbons; CO₂e: carbon dioxide equivalents; SO₂e: sulfur dioxide equivalents; CTUh: comparative toxic unist; PM2.5: particulate matter with diameter <2.5 micrometers.

Data Sources

Data obtained from prior life cycle assessment of RT: energy consumption (electricity, natural gas) and environmental impacts⁵

Health System Costs

Energy consumption per RT course derived from life cycle assessment of RT
Costs of energy consumption calculated using UCSF energy billing data

$1.82/therm (gas)
$0.19/kwh/hr (electricity)

Cost-Effectiveness Analysis

Using 2019 National Cancer Database treatment volumes, extrapolated national-level cost-saving impact of hypofractionated RT for patients eligible, per START-B and UK FAST/-Forward trials^6,7
Compared cost and DALY savings across hypofractionated vs. conventional RT regimens

Pollution-Associated Health Impacts

Environmental impacts per units of energy use (kWh and therms) estimated using TRACI conversion factors⁵
Associated DALY impacts calculated using conversion factors for environmental pollutants’ impacts on health⁵

Radiotherapy Regimens

Breast Cancer: Conventional (25-33 fractions) vs. Moderately Hypofractionated or Ultra-Hypofractionated (15 or 5 fractions)
Prostate Cancer: Conventional (28-45 fractions) vs. Moderately Hypofractionated or Ultra-Hypofractionated (20 or 5 fractions)

1. Eckelman MJ, Huang K, Lagasse R, et al. Health Care Pollution and Public Health Damage in the United States: An Update. Health Affairs. 2020;39(12):2071-2079. 2. American Society for Radiation Oncology. ASTRO Climate Change Statement. ASTRO, n.d. Accessed March 3, 2025. https://www.astro.org/provider-resources/climate-change-statement. 3. Lichter KE, et al. Transitioning to Environmentally Sustainable, Climate-Smart Radiation Oncology Care. Int J Radiat Oncol Biol Phys. 2022;113(5):915-924. https://doi.org/10.1016/j.ijrobp.2022.04.039. 4. Bernicker E, Averbuch SD, Edge S, et al. Climate Change and Cancer Care: A Policy Statement From ASCO. JCO Oncol Pract. 2024 Feb;20(2):178-186. doi: 10.1200/OP.23.00637. Epub 2023 Nov 27. PMID: 38011607. 5. Lichter KE, Charbonneau K, Lewy JR, et al. Quantification of the environmental impact of radiotherapy and associated secondary human health effects: a multi-institutional retrospective analysis and simulation. Lancet Oncol. 2024;25(6):790-801. 6. Haviland JS, Owen JR, Dewar JA, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14(11):1086-1094. https://doi.org/10.1016/S1470-2045(13)70386-3. 7. Murray Brunt A, Haviland JS, Wheatley DA, et al. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effects results from a multicentre, non-inferiority, randomised, phase 3 trial. Lancet. 2020;395(10237):1613-1626. https://doi.org/10.1016/S0140-6736(20)30932-6.