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Title:
Gamma knife radiosurgery October 2000
Agency:
Medicare Services Advisory Committee (MSAC)
Commonwealth Department of Health and Ageing
GPO Box 9848 Canberra ACT 2601 Australia
http://www.msac.gov.au
Reference:
MSAC application 1028. Assessment report ISSN 1443-7120
Aim
To assess the safety and effectiveness of the service and under what circumstances public
funding should be supported for the service in relation to the treatment of arteriovenous
malformation (AVM), cerebral metastases and acoustic neuroma.
Conclusions and results
Methodological limitations of studies and patient heterogeneity preclude comprehensive
assessment of the safety and effectiveness of gamma knife radiosurgery relative to alternative
treatment.
Indication
AVM
Cerebral metastases
Acoustic neuroma
Safety
There is insufficient information to assess
the relative safety of gamma knife or linear
accelerator (LINAC) radiosurgery and
microsurgery. Studies contain
methodological limitations, patient
selection biases and inconsistent adverse
event definitions. Permanent neurological
complications occurred in 1-10% of
radiosurgery patients and up to 15% of
microsurgery patients (5% for small
accessible lesions).
The only useful data is from
case series: 10% incidence of
radiation necrosis (1%fatal),
20% incidence of acute
radiation induced odema 20%.
One study suggests
radiosurgery and whole brain
radiotherapy (WBRT) incur
similar complication rates.
Complication rates
are similar for
radiosurgery and
microsurgery:
facial nerve
problems (20%)
and hearing
preservation (30-
90%). Few studies
reported other
complications.
Effectiveness
Two year AVM obliteration rates are 26-
35% for gamma knife radiosurgery and 44-
68% for LINAC radiosurgery as a
percentage of patients eligible for
angiography. These are likely to be
overestimates as only some of the patients
eligible for angiography undertook the
procedure and patient follow up was
inadequate. This compares to 85-100%
obliteration rates for microsurgery (higher
for small accessible lesions).
One randomised trial (and
some supportive case series
data) suggest that radiosurgery
in addition to WBRT shows no
survival benefit, but may
provide slightly improved local
control when compared just to
WBRT.
Microsurgical
excision rates are
close to 100% and
tumour control
rates with
radiosurgery are
measured at 80-
100%.
Cost
effectiveness
Gamma knife was 1.7-2.9 times more expensive than LINAC radiosurgery. Uncertainties as to
safety and effectiveness preclude an economic evaluation of gamma knife and comparators.
Recommendation
Public funding should not be supported for gamma knife radiosurgery at this time.
Method
MSAC conducted a systematic review of medical literature using Medline, PreMedline, EmBase,
the Cochrane Library, ISTAHC, Current Contends, HealthSTAR and NHS databases: (DARE,
EED, HTA) from commencement until March 2000. Internet sites of certain health technology
assessment groups were also included. The AANS and CNS Meeting Abstract Archive and the
table of contents for Radiosurgery were also searched.
HOPE THIS DECISION HAS BEEN CHANGED!