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Tan SX, Pumpalova Y, Rogers AM, Bhatt K, Herbst C, Ruff P, Neugut AI, Hur C. Cost-effectiveness of adjuvant chemotherapy for high-risk stage II and stage III colon cancer in South Africa. Cancer Med 2023; 12:15515-15529. [PMID: 37318753 PMCID: PMC10417185 DOI: 10.1002/cam4.6199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 03/30/2023] [Accepted: 05/23/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Colon cancer incidence is rising in low- and middle-income countries (LMICs), where resource limitations and cost often dictate treatment decisions. In this study, we evaluate the cost-effectiveness of adjuvant chemotherapy for high-risk stage II and stage III colon cancer treatment in South Africa (ZA) and illustrate how such analyses can inform cancer treatment recommendations in a LMIC. METHODS We created a decision-analytic Markov model to compare lifetime costs and outcomes for patients with high-risk stage II and stage III colon cancer treated with three adjuvant chemotherapy regimens in a public hospital in ZA: capecitabine and oxaliplatin (CAPOX) for 3 and 6 months, and capecitabine for 6 months, compared to no adjuvant treatment. The primary outcome was the incremental cost-effectiveness ratio (ICER) in international dollars (I$) per disability-adjusted life-year (DALY) averted, at a willingness-to-pay (WTP) threshold equal to the 2021 ZA gross domestic product per capita (I$13,764/DALY averted). RESULTS CAPOX for 3 months was cost-effective for both patients with high-risk stage II and patients with stage III colon cancer (ICER = I$250/DALY averted and I$1042/DALY averted, respectively), compared to no adjuvant chemotherapy. In subgroup analyses of patients by tumor stage and number of positive lymph nodes, for patients with high-risk stage II colon cancer and T4 tumors, and patients with stage III colon cancer with T4 or N2 disease. CAPOX for 6 months was cost-effective and the optimal strategy. The optimal strategy in other settings will vary by local WTP thresholds. Decision analytic tools can be used to identify cost-effective cancer treatment strategies in resource-constrained settings. CONCLUSION Colon cancer incidence is increasing in low- and middle-income countries, including South Africa, where resource constraints can impact treatment decisions. This cost-effectiveness study evaluates three systemic adjuvant chemotherapy options, compared to surgery alone, for patients in South African public hospitals after surgical resection for high-risk stage II and stage III colon cancer. Doublet adjuvant chemotherapy (capecitabine and oxaliplatin) for 3 months is the cost-effective strategy and should be recommended in South Africa.
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Affiliation(s)
- Sarah Xinhui Tan
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Yoanna Pumpalova
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Alexandra M. Rogers
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Kishan Bhatt
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Candice‐lee Herbst
- Department of Internal Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Paul Ruff
- Noncommunicable Diseases Research Division, Wits Health Consortium (PTY) LtdJohannesburgSouth Africa
- SAMRC/Wits Developmental Pathways to Health Research Unit, Department of Paediatrics, Faculty of the Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Division of Medical Oncology, Department of Medicine, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Alfred I. Neugut
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNew YorkUSA
| | - Chin Hur
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNew YorkUSA
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To YH, Degeling K, Kosmider S, Wong R, Lee M, Dunn C, Gard G, Jalali A, Wong V, IJzerman M, Gibbs P, Tie J. Circulating Tumour DNA as a Potential Cost-Effective Biomarker to Reduce Adjuvant Chemotherapy Overtreatment in Stage II Colorectal Cancer. PHARMACOECONOMICS 2021; 39:953-964. [PMID: 34089503 DOI: 10.1007/s40273-021-01047-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Substantial adjuvant chemotherapy (AC) overtreatment for stage II colorectal cancer results in a health and financial burden. Circulating tumour DNA (ctDNA) can improve patient selection for AC by detecting micro-metastatic disease. We estimated the health economic potential of ctDNA-guided AC for stage II colorectal cancer. METHODS A cost-utility analysis was performed to compare ctDNA-guided AC to standard of care, where 22.6% of standard of care patients and all ctDNA-positive patients (8.7% of tested patients) received AC and all ctDNA-negative patients (91.3%) did not. A third preference-sensitive ctDNA strategy was included where 6.8% of ctDNA-negative patients would receive AC. A state-transition model was populated using data from a prospective cohort study and clinical registries. Health and economic outcomes were discounted at 5% over a lifetime horizon from a 2019 Australian payer perspective. Extensive scenario and probabilistic analyses quantified model uncertainty. RESULTS Compared to standard of care, the ctDNA and preference-sensitive ctDNA strategies increased quality-adjusted life-years by 0.20 (95% confidence interval - 0.40 to 0.81) and 0.19 (- 0.40 to 0.78), and resulted in incremental costs of AUD - 4055 (- 16,853 to 8472) and AUD - 2284 (- 14,685 to 10,116), respectively. Circulating tumour DNA remained cost effective at a willingness to pay of AUD 20,000 per quality-adjusted life-year gained throughout most scenario analyses in which the proportion of ctDNA-positive patients cured by AC and compliance to a ctDNA-negative test results were decreased. CONCLUSIONS Circulating tumour-guided AC is a potentially cost-effective strategy towards reducing overtreatment in stage II colorectal cancer. Results from ongoing randomised clinical studies will be important to reduce uncertainty in the estimates.
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Affiliation(s)
- Yat Hang To
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia.
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Koen Degeling
- Cancer Health Services Research, Centre for Cancer, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Suzanne Kosmider
- Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
| | - Rachel Wong
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Eastern Health, Melbourne, VIC, Australia
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Margaret Lee
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
- Department of Medical Oncology, Eastern Health, Melbourne, VIC, Australia
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Catherine Dunn
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Grace Gard
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
| | - Azim Jalali
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
- Department of Medical Oncology, LaTrobe Regional Hospital, Traralgon, VIC, Australia
| | - Vanessa Wong
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Ballarat Health, Ballarat, VIC, Australia
| | - Maarten IJzerman
- Cancer Health Services Research, Centre for Cancer, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Peter Gibbs
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
- Faculty of Medicine and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Jeanne Tie
- Personalised Oncology Division, Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Medical Oncology, Western Health, Melbourne, VIC, Australia
- Faculty of Medicine and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
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Jongeneel G, Greuter MJE, Kunst N, van Erning FN, Koopman M, Medema JP, Vermeulen L, Ijzermans JNM, Vink GR, Punt CJA, Coupé VMH. Early Cost-effectiveness Analysis of Risk-Based Selection Strategies for Adjuvant Treatment in Stage II Colon Cancer: The Potential Value of Prognostic Molecular Markers. Cancer Epidemiol Biomarkers Prev 2021; 30:1726-1734. [PMID: 34162659 DOI: 10.1158/1055-9965.epi-21-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/28/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To explore the potential value of consensus molecular subtypes (CMS) in stage II colon cancer treatment selection, we carried out an early cost-effectiveness assessment of a CMS-based strategy for adjuvant chemotherapy. METHODS We used a Markov cohort model to evaluate three selection strategies: (i) the Dutch guideline strategy (MSS+pT4), (ii) the mutation-based strategy (MSS plus a BRAF and/or KRAS mutation or MSS plus pT4), and (iii) the CMS-based strategy (CMS4 or pT4). Outcomes were number of colon cancer deaths per 1,000 patients, total discounted costs per patient (pp), and quality-adjusted life-years (QALY) pp. The analyses were conducted from a Dutch societal perspective. The robustness of model predictions was assessed in sensitivity analyses. To evaluate the value of future research, we performed a value of information (VOI) analysis. RESULTS The Dutch guideline strategy resulted in 8.10 QALYs pp and total costs of €23,660 pp. The CMS-based and mutation-based strategies were more effective and more costly, with 8.12 and 8.13 QALYs pp and €24,643 and €24,542 pp, respectively. Assuming a threshold of €50,000/QALY, the mutation-based strategy was considered as the optimal strategy in an incremental analysis. However, the VOI analysis showed substantial decision uncertainty driven by the molecular markers (expected value of partial perfect information: €18M). CONCLUSIONS On the basis of current evidence, our analyses suggest that the mutation-based selection strategy would be the best use of resources. However, the extensive decision uncertainty for the molecular markers does not allow selection of an optimal strategy at present. IMPACT Future research is needed to eliminate decision uncertainty driven by molecular markers.
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Affiliation(s)
- Gabrielle Jongeneel
- Department of Epidemiology and Data Science, Amsterdam UMC, VU University, Amsterdam, the Netherlands.
| | - Marjolein J E Greuter
- Department of Epidemiology and Data Science, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Natalia Kunst
- Department of Epidemiology and Data Science, Amsterdam UMC, VU University, Amsterdam, the Netherlands.,Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, Connecticut.,Public Health Modeling Unit, Yale University School of Public Health, New Haven, Connecticut
| | - Felice N van Erning
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Miriam Koopman
- University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jan P Medema
- Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Center for Experimental Molecular Medicine (CEMM), Amsterdam, the Netherlands.,Oncode Institute, Amsterdam, the Netherlands
| | - Louis Vermeulen
- Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Center for Experimental Molecular Medicine (CEMM), Amsterdam, the Netherlands.,Oncode Institute, Amsterdam, the Netherlands
| | - Jan N M Ijzermans
- Department of General Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Geraldine R Vink
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands.,University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Cornelis J A Punt
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Veerle M H Coupé
- Department of Epidemiology and Data Science, Amsterdam UMC, VU University, Amsterdam, the Netherlands
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Jongeneel G, Greuter MJE, van Erning FN, Koopman M, Vink GR, Punt CJA, Coupé VMH. Model-based effectiveness and cost-effectiveness of risk-based selection strategies for adjuvant chemotherapy in Dutch stage II colon cancer patients. Therap Adv Gastroenterol 2021; 14:1756284821995715. [PMID: 33786064 PMCID: PMC7958170 DOI: 10.1177/1756284821995715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/28/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We aimed to evaluate the cost-effectiveness of risk-based strategies to improve the selection of surgically treated stage II colon cancer (CC) patients for adjuvant chemotherapy. METHODS Using the 'Personalized Adjuvant TreaTment in EaRly stage coloN cancer' (PATTERN) model, we evaluated five selection strategies: (1) no chemotherapy, (2) Dutch guideline recommendations assuming observed adherence, (3) Dutch guideline recommendations assuming perfect adherence, (4) biomarker mutation OR pT4 stage strategy in which patients with MSS status combined with a pT4 stage or a mutation in BRAF and/or KRAS receive chemotherapy assuming perfect adherence and (5) biomarker mutation AND pT4 stage strategy in which patients with MSS status combined with a pT4 stage tumor and a BRAF and/or KRAS mutation receive chemotherapy assuming perfect adherence. Outcomes were number of CC deaths per 1000 patients and total discounted costs and quality-adjusted life-years (QALYs) per patient (pp). Analyses were conducted from a societal perspective. The robustness of model predictions was assessed in sensitivity analyses. RESULTS The reference strategy, that is, no adjuvant chemotherapy, resulted in 139 CC deaths in a cohort of 1000 patients, 8.077 QALYs pp and total costs of €22,032 pp. Strategies 2-5 were more effective (range 8.094-8.217 QALYs pp and range 118-136 CC deaths per 1000 patients) and more costly (range €22,404-€25,102 pp). Given a threshold of €50,000/QALY, the optimal use of resources would be to treat patients with either the full adherence strategy and biomarker mutation OR pT4 stage strategy. CONCLUSION Selection of stage II CC patients for chemotherapy can be improved by either including biomarker status in the selection strategy or by improving adherence to the Dutch guideline recommendations.
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Affiliation(s)
- Gabrielle Jongeneel
- Department of Epidemiology and Data Science,
Amsterdam UMC, VU University, PO Box 7057, MF F-wing, Amsterdam, 1007 MB,
the Netherlands
| | - Marjolein J. E. Greuter
- Department of Epidemiology and Data Science,
Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Felice N. van Erning
- Department of Research and Development,
Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The
Netherlands
| | - Miriam Koopman
- Department of medical oncology, University
Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Geraldine R. Vink
- Department of Research and Development,
Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The
Netherlands
- Department of medical oncology, University
Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis J. A. Punt
- Department of Epidemiology, University Medical
Center Utrecht, Julius Center for Health Sciences, Utrecht, The
Netherlands
| | - Veerle M. H. Coupé
- Department of Epidemiology and Data Science,
Amsterdam UMC, VU University, Amsterdam, The Netherlands
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Jongeneel G, Greuter MJE, van Erning FN, Koopman M, Vink GR, Punt CJA, Coupé VMH. Model-based evaluation of the cost effectiveness of 3 versus 6 months' adjuvant chemotherapy in high-risk stage II colon cancer patients. Therap Adv Gastroenterol 2020; 13:1756284820954114. [PMID: 32994804 PMCID: PMC7502861 DOI: 10.1177/1756284820954114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/11/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Our aim was to evaluate the cost effectiveness of 3 months' adjuvant chemotherapy versus 6 months in high-risk (T4 stage + microsatellite stable) stage II colon cancer (CC) patients. METHODS Using the validated PATTERN Markov cohort model, which simulates the disease progression of stage II CC patients from diagnosis to death, we first evaluated a reference strategy in which high-risk patients were treated with chemotherapy for 6 months. In the second strategy, treatment duration was shortened to 3 months. Both strategies were evaluated for CAPOX (capecitabine plus oxaliplatin) and FOLFOX (fluorouracil, leucovorin and oxaliplatin). Based on trial data, we assumed that shortened treatment duration compared with a 6-month regimen was equally effective for CAPOX and less effective for FOLFOX. Adverse events were highest in the 6-month strategy. Analyses were conducted from a societal perspective using a lifelong time horizon. Outcomes were number of CC deaths per 1000 patients and total discounted costs and quality-adjusted life-years (QALYs) per patient (pp). Incremental net monetary benefit (iNMB) was calculated using a willingness-to-pay value of €50,000/QALY. RESULTS For CAPOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €41,257 pp. The 3-month strategy resulted in an equal number of CC deaths, but higher QALYs (6.80 pp) and lower costs (€37,645 pp), leading to a iNMB of €8454 per person for 3 months versus 6 months. For FOLFOX, the 6-month strategy resulted in 316 CC deaths per 1000 patients, 6.71 QALYs pp and total costs of €47,135 pp. The 3-month strategy resulted in more CC deaths (393), lower QALYs (6.19 pp) and lower costs (€44,389 pp). An iNMB of -€23,189 was found for 3 months versus 6 months. CONCLUSION Our findings indicate that 3 months' adjuvant chemotherapy should be considered as standard of care in high-risk stage II CC patients for CAPOX, but not for FOLFOX.
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Affiliation(s)
| | | | - Felice N. van Erning
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Miriam Koopman
- University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Geraldine R. Vink
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands,University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cornelis J. A. Punt
- Department of Medical Oncology, University of Amsterdam, Amsterdam, The Netherlands
| | - Veerle M. H. Coupé
- Department of Epidemiology and Biostatistics, VU University, Amsterdam, The Netherlands
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