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Tseng TH, Chiang SC, Hsu JC, Ko Y. Cost-effectiveness analysis of granulocyte colony-stimulating factors for the prophylaxis of chemotherapy-induced febrile neutropenia in patients with breast cancer in Taiwan. PLoS One 2024; 19:e0303294. [PMID: 38857244 PMCID: PMC11164394 DOI: 10.1371/journal.pone.0303294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/22/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVES To examine the cost-effectiveness of using granulocyte colony-stimulating factor (G-CSF) for primary or secondary prophylaxis in patients with breast cancer from the perspective of Taiwan's National Health Insurance Administration. METHODS A Markov model was constructed to simulate the events that may occur during and after a high-risk chemotherapy treatment. Various G-CSF prophylaxis strategies and medications were compared in the model. Effectiveness data were derived from the literature and an analysis of the National Health Insurance Research Database (NHIRD). Cost data were obtained from a published NHIRD study, and health utility values were also obtained from the literature. Sensitivity analyses were performed to assess the uncertainty of the cost-effectiveness results. RESULTS In the base-case analysis, primary prophylaxis with pegfilgrastim had an incremental cost-effectiveness ratio (ICER) of NT$269,683 per quality-adjusted life year (QALY) gained compared to primary prophylaxis with lenograstim. The ICER for primary prophylaxis with lenograstim versus no G-CSF prophylaxis was NT$61,995 per QALY gained. The results were most sensitive to variations in relative risk of febrile neutropenia (FN) for pegfilgrastim versus no G-CSF prophylaxis. Furthermore, in the probabilistic sensitivity analysis, at a willingness-to-pay threshold of one times Taiwan's gross domestic product per capita, the probability of being cost-effective was 88.1% for primary prophylaxis with pegfilgrastim. CONCLUSIONS Our study suggests that primary prophylaxis with either short- or long-acting G-CSF could be considered cost-effective for FN prevention in breast cancer patients receiving high-risk regimens.
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Affiliation(s)
- Tzu-Hsuan Tseng
- Department of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Shao-Chin Chiang
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University (Yang Ming Campus), Taipei, Taiwan
- Center for Advanced Pharmacy Education, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Jason C. Hsu
- International PhD Program in Biotech and Healthcare Management, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Yu Ko
- Department of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Research Center for Pharmacoeconomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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ELKasar AO, Hussien FZ, Abdel-Hamied HE, Saleh IG, Mahgoup EM, El-Arabey AA, Abd-Allah AR. Effect of lithium on chemotherapy-induced neutropenia in Egyptian breast cancer patients; a prospective clinical study. Cancer Chemother Pharmacol 2024; 93:541-554. [PMID: 38324036 DOI: 10.1007/s00280-023-04620-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE Myelosuppressive chemotherapy-induced neutropenia (CIN) remains a major limitation of cancer treatment efficacy, necessitating very expensive supportive care. Lithium carbonate, an inexpensive drug, can increase the number of neutrophils, possibly providing an efficacious and cost-effective alternative for treating CIN. The aim of this study was to determine whether lithium therapy can attenuate chemotherapy-induced neutropenia and leukopenia in breast cancer patients. METHODS A total of 50 breast cancer patients were enrolled in this prospective, interventional, randomized, controlled, and single-blind study. The patients were divided into two groups: a control group (group 1, N = 25 patients) and a lithium-treated (treatment) group (group 2, N = 25 patients). Group 1 patients were further subclassified into a non-neutropenic control group (N = 16) and a neutropenic control (N = 9) based on the subsequent development of severe neutropenia, or not. The control group received 4 cycles of doxorubicin or epirubicin plus cyclophosphamide followed by 2 cycles of paclitaxel. The treatment group received the same regimen as the control group as well as oral lithium carbonate throughout the chemotherapy cycles. RESULTS The results showed that the absolute neutrophil count (ANC) was increased in the lithium-treated group, while it was markedly reduced in both the non-neutropenic and neutropenic control groups (by 55.56% and 65.42% post-4 chemotherapy cycles, and by 19.57% and 39.90% post-6 cycles, respectively). The same pattern of alterations was observed for the total white blood cell count in both the control and treatment groups. In addition, the incidence and period prevalence were greatly reduced in the lithium-treated group compared to non-neutropenic and neutropenic control groups. CONCLUSION Lithium therapy ameliorated chemotherapy-induced leukopenia and neutropenia in breast cancer patients. This may provide a new strategy for cost-effective treatment of CIN, particularly in Egyptian cancer patients.
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Affiliation(s)
- Ahmed O ELKasar
- Department of Pharmacology and Toxicology, Faculty of Pharmacy (Boys), Al-Azhar University, Cairo, 11751, Egypt
| | - Fatma Z Hussien
- Department of Clinical Oncology and Nuclear Medicine, Oncology Center, Faculty of Medicine, Tanta University Hospital, Tanta, Egypt
| | - Hala E Abdel-Hamied
- Department of Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ibrahim G Saleh
- Department of Pharmacology and Toxicology, Faculty of Pharmacy (Boys), Al-Azhar University, Cairo, 11751, Egypt
| | - Elsayed M Mahgoup
- Department of Pharmacology and Toxicology, Faculty of Pharmacy (Boys), Al-Azhar University, Cairo, 11751, Egypt.
| | - Amr A El-Arabey
- Department of Pharmacology and Toxicology, Faculty of Pharmacy (Boys), Al-Azhar University, Cairo, 11751, Egypt
| | - Adel R Abd-Allah
- Department of Pharmacology and Toxicology, Faculty of Pharmacy (Boys), Al-Azhar University, Cairo, 11751, Egypt.
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Edelsberg J, Weycker D, Bensink M, Bowers C, Lyman GH. Prophylaxis of febrile neutropenia with colony-stimulating factors: the first 25 years. Curr Med Res Opin 2020; 36:483-495. [PMID: 31834830 DOI: 10.1080/03007995.2019.1703665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Filgrastim prophylaxis, both primary and secondary, was rapidly incorporated into clinical practice in the 1990s. When pegfilgrastim became available in 2002, it quickly replaced filgrastim as the colony-stimulating factor (CSF) of choice for prophylaxis. Use of prophylaxis increased markedly in the first decade of this century and has stabilized during the present decade. Data concerning real-world CSF prophylactic practice patterns are limited but suggest that both primary and secondary prophylaxis are common, and that use is frequently inappropriate according to guidelines. The extent of inappropriate use is controversial, as are issues concerning the cost-effectiveness of prophylaxis versus no prophylaxis and the cost-effectiveness of primary prophylaxis versus secondary prophylaxis. Nevertheless, CSF prophylaxis is firmly established as a valuable adjunct to chemotherapy and will almost certainly continue to be widely used for the foreseeable future. In this article, we chronicle the use and impact of CSF prophylaxis in US patients receiving myelosuppressive chemotherapy for non-myeloid malignancies. We emphasize the interplay of expert opinion, clinical evidence, and economic factors in shaping the use of CSFs in clinical practice over time, and, with the recent introduction of new CSF agents and options, we aim to provide useful clinical and economic information for healthcare decision makers.
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Affiliation(s)
| | | | | | | | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
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Gao L, Li SC. Cost-effectiveness analysis of lipegfilgrastim as primary prophylaxis in women with breast cancer in Australia: a modelled economic evaluation. Breast Cancer 2018; 25:671-680. [PMID: 29802592 DOI: 10.1007/s12282-018-0872-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 05/19/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To examine the cost-effectiveness of lipegfilgrastim versus pegfilgrastim as primary prophylaxis in women with early stage breast cancer. METHODS Two Markov models including a chemotherapy and a post-chemotherapy models were constructed with a time horizon of 12 weeks and 30 years, respectively. All the transition probabilities and utility weights were derived from clinical trials and/or published literatures. The costs populated in the chemotherapy model were extracted from Medicare, Pharmaceutical Benefit Scheme and the Independent Hospital Pricing Authority. No cost was considered in the post-chemotherapy model. Sensitivity analyses were performed to test the robustness of the results. RESULTS From the first chemotherapy model, lipegfilgrastim was associated with fewer episodes of severe neutropenia (SN) (N = 142 per 1000 patients treated), febrile neutropenia (FN) (N = 29 per 1000 patients treated), infection (N = 17 per 1000 patients treated) and chemotherapy delayed (N = 170 per 1000 patients treated) and lower cost ($116.88 less per patient treated). The post-chemotherapy model indicated lipegfilgrastim led to higher gains in both life years (18.72 versus 18.61) and quality-adjusted life years (17.28 versus 17.18) in comparison to pegfilgrastim. Sensitivity analysis showed that the results from the chemotherapy model is very sensitive to the baseline risk of SN; while from the probabilistic sensitivity analysis, lipegfilgrastim was likely to be more cost-effective than pegfilgrastim based on two models. CONCLUSIONS Lipegfilgrastim was likely to be a cost-effective alternative to pegfilgrastim as primary prophylaxis. The sensitivity analysis showed the confidence interval for the cost and benefit outcomes overlapped to a great extent, suggesting an insignificant difference.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Centre for Population Health Research, Faculty of Health, Deakin University, 1 Gheringhap St, Geelong, VIC, 3220, Australia.
| | - Shu-Chuen Li
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
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Fust K, Parthan A, Maschio M, Gu Q, Li X, Lyman GH, Tzivelekis S, Villa G, Weinstein MC. Granulocyte colony-stimulating factors in the prevention of febrile neutropenia: review of cost-effectiveness models. Expert Rev Pharmacoecon Outcomes Res 2017; 17:39-52. [DOI: 10.1080/14737167.2017.1276829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kelly Fust
- Health Economics & Outcomes Research, Optum, Boston, MA, USA
| | - Anju Parthan
- Health Economics & Outcomes Research, Optum, Boston, MA, USA
| | - Michael Maschio
- Health Economics & Outcomes Research, Optum, Burlington, ON, Canada
| | - Qing Gu
- Health Economics & Outcomes Research, Optum, Boston, MA, USA
| | - Xiaoyan Li
- Global Health Economics, Amgen Inc., Thousand Oaks, CA, USA
| | - Gary H. Lyman
- Public Health Sciences Division and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Guillermo Villa
- Global Health Economics, Amgen (Europe) GmbH, Zug, Switzerland
| | - Milton C. Weinstein
- Department of Health Policy and Management; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Affiliation(s)
- G. Moroni
- Nephrological Unit, Divisione di Nefrologia e Dialisi, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C. Ponticelli
- Nephrological Unit, Humanitas Clinical and Research Center, Rozzano (Milano), Italy
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Fernandes R, Mazzarello S, Stober C, Vandermeer L, Dudani S, Ibrahim MFK, Majeed H, Perdrizet K, Shorr R, Hutton B, Fergusson D, Clemons M. Optimal primary febrile neutropenia prophylaxis for patients receiving docetaxel-cyclophosphamide chemotherapy for breast cancer: a systematic review. Breast Cancer Res Treat 2016; 161:1-10. [PMID: 27783280 DOI: 10.1007/s10549-016-4028-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 10/18/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Due to the high rate of febrile neutropenia (FN) with docetaxel-cyclophosphamide (DC) chemotherapy, primary FN prophylaxis is recommended. However, the optimal choice of prophylaxis [i.e., granulocyte-colony stimulating factors (G-CSF) or antibiotics] is unknown. A systematic review was performed to address this knowledge gap. METHODS Embase, Ovid Medline, Pubmed, the Cochrane database of systematic reviews, and Cochrane register of controlled trials were searched from 1946 to April 2016 for studies evaluating primary prophylactic FN treatments in breast cancer patients receiving DC chemotherapy. Outcome measures evaluated included: incidence of FN and treatment-related hospitalizations, chemotherapy dose reduction/delays/discontinuations, and adverse events. Screening and data collection were performed by two independent reviewers. RESULTS Of 2105 identified records, 7 studies (n = 2535) met the pre-specified eligibility criteria. Seven additional studies (n = 621) were identified from prior systematic reviews. There were 3 randomized controlled trials (RCTs) (n = 2256) and 11 retrospective studies (n = 900). Study sample sizes ranged from 30 to 982 patients (median 99.5), evaluating pegfilgrastim (n = 1274), filgrastim (n = 1758), and oral ciprofloxacin (n = 108). Given the heterogeneity of patients and study design, a narrative synthesis of results was performed. Median FN rates with and without primary prophylaxis were 6.6 % (IQR 3.9-10.6 %) and 31.3 % (IQR 25-33 %), respectively. No FN-related deaths were reported. No RCT directly compared G-CSF with antibiotic interventions. CONCLUSIONS Primary FN prophylaxis reduces the incidence of FN. Despite considerable cost and toxicity differences between G-CSF and antibiotics, there is insufficient data to make a recommendation of one strategy over another.
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Affiliation(s)
- Ricardo Fernandes
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | | | - Carol Stober
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Shaan Dudani
- Department of Medicine, Division of General Internal Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Mohamed F K Ibrahim
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | - Habeeb Majeed
- Department of Medicine, Division of General Internal Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Kirstin Perdrizet
- Department of Medicine, Division of General Internal Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | | | - Brian Hutton
- Department of Medicine, Clinical Epidemiology Program, The Ottawa Hospital and University of Ottawa, Ottawa, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Dean Fergusson
- Department of Medicine, Clinical Epidemiology Program, The Ottawa Hospital and University of Ottawa, Ottawa, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada. .,Ottawa Hospital Research Institute, Ottawa, Canada. .,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada.
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Activation of Nrf2-ARE signaling mitigates cyclophosphamide-induced myelosuppression. Toxicol Lett 2016; 262:17-26. [PMID: 27633142 DOI: 10.1016/j.toxlet.2016.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/06/2016] [Accepted: 09/11/2016] [Indexed: 11/21/2022]
Abstract
Myelosuppression is the most common dose-limiting adverse effect of chemotherapies. In the present study, we investigated the involvement of nuclear erythroid 2-related factor 2 (Nrf2) in cyclophosphamide-induced myelosuppression in mice, and evaluated the potential of activating Nrf2 signaling as a preventive strategy. The whole blood from Nrf2-/- mice exhibited decreased antioxidant capacities, while the bone marrow cells, peripheral blood mononuclear cells and granulocytes from Nrf2-/- mice were more susceptible to acrolein-induced cytotoxicity than those from wild type mice. Single dosage of cyclophosphamide induced significantly severer acute myelosuppression in Nrf2-/- mice than in wild type mice. Furthermore, Nrf2-/- mice exhibited greater loss of peripheral blood nucleated cells and recovered slower from myelosuppression nadir upon multiple consecutive dosages of cyclophosphamide than wild type mice did. This was accompanied with decreased antioxidant and detoxifying gene expressions and impaired colony formation ability of Nrf2-/- bone marrow cells. More importantly, activation of Nrf2 signaling by CDDO-Me significantly alleviated cyclophosphamide-induced myelosuppression, while this alleviation was diminished in Nrf2-/- mice. In conclusion, the present study shows that Nrf2 plays a protective role in cyclophosphamide-induced myelosuppression and activation of Nrf2 is a promising strategy to prevent or treat chemotherapy-induced myelosuppression.
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Younis T, Rayson D, Jovanovic S, Skedgel C. Cost-effectiveness of febrile neutropenia prevention with primary versus secondary G-CSF prophylaxis for adjuvant chemotherapy in breast cancer: a systematic review. Breast Cancer Res Treat 2016; 159:425-32. [PMID: 27572552 DOI: 10.1007/s10549-016-3954-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/22/2016] [Indexed: 11/24/2022]
Abstract
The adoption of primary (PP) versus secondary prophylaxis (SP) of febrile neutropenia (FN), with granulocyte colony-stimulating factors (G-CSF), for adjuvant chemotherapy (AC) regimens in breast cancer (BC) could be affected by its "value for money". This systematic review examined (i) cost-effectiveness of PP versus SP, (ii) FN threshold at which PP is cost-effective including the guidelines 20 % threshold and (iii) potential impact of G-CSF efficacy assumptions on outcomes. The systematic review identified all cost-effectiveness/cost-utility analyses (CEA/CUA) involving PP versus SP G-CSF for AC in BC that met predefined inclusion/exclusion criteria. Five relevant CEA/CUA were identified. These CEA/CUA examined different AC regimens (TAC = 2; FEC-D = 1; TC = 2) and G-CSF formulations (filgrastim "F" = 4; pegfilgrastim "P" = 4) with varying baseline FN-risk (range 22-32 %), mortality (range 1.4-6.0 %) and utility (range 0.33-0.47). The potential G-CSF benefit, including FN risk reduction with P versus F, varied among models. Overall, relative to SP, PP was not associated with good value for money, as per commonly utilized CE thresholds, at the baseline FN rates examined, including the consensus 20 % FN threshold, in most of these studies. The value for money associated with PP versus SP was primarily dependent on G-CSF benefit assumptions including reduced FN mortality and improved BC survival. PP G-CSF for FN prevention in BC patients undergoing AC may not be a cost-effective strategy at the guidelines 20 % FN threshold.
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Affiliation(s)
- T Younis
- Department of Medicine at Dalhousie University and the Atlantic Clinical Cancer Research Unit (ACCRU) at the Queen Elizabeth II Health Sciences Centre, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.
| | - D Rayson
- Department of Medicine at Dalhousie University and the Atlantic Clinical Cancer Research Unit (ACCRU) at the Queen Elizabeth II Health Sciences Centre, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada
| | - S Jovanovic
- Department of Medicine at Dalhousie University and the Atlantic Clinical Cancer Research Unit (ACCRU) at the Queen Elizabeth II Health Sciences Centre, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada
| | - C Skedgel
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
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