Cardiac toxicity of mediastinal radiotherapy: which are the critical structures?

canceled, will generate the resources necessary to implement the new treatment, and whose cancellation will reduce community well-being by less than the incremental gain expected from the new treatment. Until both conditions are met researchers should not infer cost effectiveness or “value for the money” for particular therapies—a result prematurely suggested by van den Brink et al in their economic evaluation of PRT and rectal cancer. In their recent response, the authors also state that “data on cost effectiveness are then one of many pieces of information. . .that might be weighed”. In other words, cost-effectiveness analysis is about efficiency only and does not involve equity considerations. However, assuming that efficiency and equity considerations are separable is wrong. For example, in the analysis presented by the authors they assumed that a QALY is a QALY regardless of who gains it or who loses it. This is an equity assumption. If this equity assumption does not reflect the one held by a decision maker, then the results of the analysis are of no use to the particular decision maker. We do not negate the numerous useful insights presented by van den Brink et al in their paper, or the importance of PRT in the treatment paradigm for some patients undergoing rectal cancer surgery. But in the era of TME it is not yet decided which patients should receive radiotherapy, an observation driven home by the original results of the Dutch TME Trial. Moreover, we encourage researchers performing cost-effectiveness analyses to either consider the opportunity costs of implementing the interventions analyzed, or to avoid concluding that such interventions are cost effective.