Cost-utility analysis of chemotherapy regimens in elderly patients with stage III colon cancer

Health economic evidence for adjuvant chemotherapy in stage II and III colon cancer: a systematic review

OBJECTIVE

The aims of this study was to appraise the health economic evidence for adjuvant chemotherapy (AC) strategies in stage II and III colon cancer (CC) and identify gaps in the available evidence that might inform further research.

METHOD

A systematic review of published economic evaluations was undertaken. Four databases were searched and full-text publications in English were screened for inclusion. A narrative synthesis was performed to summarise the evidence.

RESULTS

Thirty-eight studies were identified and stratified by cancer stage and AC strategy. The majority (89%) were full economic evaluations considering both health outcomes, usually measured as quality-adjusted life years (QALYs), and costs. AC was found to be cost-effective compared to no AC for both stage II and III CC. Oral and oxaliplatin-based AC was cost-effective for stage III. Three months of CAPOX was cost-effective compared to 6-month in high-risk stage II and stage III CC. Preliminary evidence suggests that biomarker approaches to AC selection in stage II can reduce costs and improve health outcomes. Notably, assessment of QALYs were predominantly reliant on a small number of non-contemporary health-utility studies. Only 32% of studies considered societal costs such as travel and time off work.

CONCLUSIONS

Published economic evaluations consistently supported the use of AC in stage II and III colon cancer. Biomarker-driven approaches to patient selection have great potential to be cost-effective, but more robust clinical and economic evidence is warranted. Patient surveys embedded into clinical trials may address critical knowledge gaps regarding accurate assessment of QALYs and societal costs in the modern era.

Cost-effectiveness of adding Endocuff® to standard colonoscopies for interval colorectal cancer screening

Background and aims: Higher screening colonoscopy adenoma detection rates (ADRs) correlate with reduced risk of interval colorectal cancer (CRC). The Endocuff® device has been shown to improve ADRs compared to standard colonoscopy (SC). This cost-effectiveness analysis compared interval CRC screening using Endocuff®-assisted colonoscopy (EC) vs SC. Methods: A decision-analytic Markov model followed patients through screening, CRC diagnosis, progression, remission, and death. ADRs, CRC progression, and utilities were from literature. CRC incidence, stage distribution, and mortality were from the Surveillance, Epidemiology, and End Results (SEER) and SEER-Medicare linked databases. Screening and annual patient costs were from public databases and literature. Endocuff® device average sales price was applied. Lifetime device and medical costs were evaluated separately for device purchaser, health plan, and accountable care organization (ACO) perspectives. Results: Consistent use of EC instead of SC was expected to reduce lifetime risks of interval CRC and related death by 0.98% and 0.19%, respectively, preventing one case per 102 patients and one death per 526 patients. Survival and quality-of-life (QoL) improved by 0.025 life-years and 0.011 quality-adjusted life-years (QALYs) per patient on average. EC instead of SC led to incremental cost-effectiveness ratios to the device purchaser of $4,421 per life-year gained and $9,843 per QALY gained, and $199 or $87 average cost-savings per patient to the health plan or ACO, respectively. Conclusion: Endocuff® for screening colonoscopies was expected to reduce interval CRC incidence and death, improve QoL, and be cost-effective to the device purchaser and cost-saving to a health plan or ACO.

Monitoring treatment response in metastasic colorectal cancer: Economic evaluation of PrediCTC versus computed tomography scan

Background: Late state colorectal cancer treatments have important side effects that should be avoided in patients where drug effectiveness is not adequate. PrediCTC is a new biomarkers blood test developed to determinate the chemotherapy response in unresectable metastatic colorectal cancer patients that could allow to obviate unnecessary treatments. Aim: To assess from the Spanish Societal Perspective the cost-utility of the test PrediCTC compared to the computed tomography in aim to evaluate chemotherapy treatment response in late stage colorectal cancer patients. Methods: Based on the results of Barbazán et al., a Markov model has been developed, in which the different lines and cycles that the colorectal patient can receive and how they can move between them according to the computed tomography or PrediCTC have been represented. The effectiveness has been expressed in quality adjusted life years (QALYs), avoiding adverse events. Results: Base case analysis shows savings in different types of costs for PrediCTC (per patient): €14.30 in those arise from adverse events, €22,345.73 in chemotherapy costs, €4849.61 in other direct costs, and €306.21 in indirect costs. Although computed tomography 12-week assessed patients gain 0.17 QALYs compared with PrediCTC. Conclusions: From the Spanish Societal Perspective, PrediCTC is not a cost-utility option but allows to identify earlier patients who are not benefiting from first-line chemotherapy avoiding unnecessary side effects and costs.

Use of the Medicare database in epidemiologic and health services research: a valuable source of real-world evidence on the older and disabled populations in the US

Medicare is the federal health insurance program for individuals in the US who are aged ≥65 years, select individuals with disabilities aged <65 years, and individuals with end-stage renal disease. The Centers for Medicare and Medicaid Services grants researchers access to Medicare administrative claims databases for epidemiologic and health outcomes research. The data cover beneficiaries’ encounters with the health care system and receipt of therapeutic interventions, including medications, procedures, and services. Medicare data have been used to describe patterns of morbidity and mortality, describe burden of disease, compare effectiveness of pharmacologic therapies, examine cost of care, evaluate the effects of provider practices on the delivery of care and patient outcomes, and explore the health impacts of important Medicare policy changes. Considering that the vast majority of US citizens ≥65 years of age have Medicare insurance, analyses of Medicare data are now essential for understanding the provision of health care among older individuals in the US and are critical for providing real-world evidence to guide decision makers. This review is designed to provide researchers with a summary of Medicare data, including the types of data that are captured, and how they may be used in epidemiologic and health outcomes research. We highlight strengths, limitations, and key considerations when designing a study using Medicare data. Additionally, we illustrate the potential impact that Centers for Medicare and Medicaid Services policy changes may have on data collection, coding, and ultimately on findings derived from the data.

Cost-Effectiveness of Treatment Sequences of Chemotherapies and Targeted Biologics for Elderly Metastatic Colorectal Cancer Patients

BACKGROUND

Treatment patterns for metastatic colorectal cancer (mCRC) patients have changed considerably over the last decade with the introduction of new chemotherapies and targeted biologics. These treatments are often administered in various sequences with limited evidence regarding their cost-effectiveness.

OBJECTIVE

To conduct a pharmacoeconomic evaluation of commonly administered treatment sequences among elderly mCRC patients.

METHODS

A probabilistic discrete event simulation model assuming Weibull distribution was developed to evaluate the cost-effectiveness of the following common treatment sequences: (a) first-line oxaliplatin/irinotecan followed by second-line oxaliplatin/irinotecan + bevacizumab (OI-OIB); (b) first-line oxaliplatin/irinotecan + bevacizumab followed by second-line oxaliplatin/irinotecan + bevacizumab (OIB-OIB); (c) OI-OIB followed by a third-line targeted biologic (OI-OIB-TB); and (d) OIB-OIB followed by a third-line targeted biologic (OIB-OIB-TB). Input parameters for the model were primarily obtained from the Surveillance, Epidemiology, and End Results-Medicare linked dataset for incident mCRC patients aged 65 years and older diagnosed from January 2004 through December 2009. A probabilistic sensitivity analysis was performed to account for parameter uncertainty. Costs (2014 U.S. dollars) and effectiveness were discounted at an annual rate of 3%.

RESULTS

In the base case analyses, at the willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life-year (QALY) gained, the treatment sequence OIB-OIB (vs. OI-OIB) was not cost-effective with an incremental cost-effectiveness ratio (ICER) per patient of $119,007/QALY; OI-OIB-TB (vs. OIB-OIB) was dominated; and OIB-OIB-TB (vs. OIB-OIB) was not cost-effective with an ICER of $405,857/QALY. Results similar to the base case analysis were obtained assuming log-normal distribution. Cost-effectiveness acceptability curves derived from a probabilistic sensitivity analysis showed that at a WTP of $100,000/QALY gained, sequence OI-OIB was 34% cost-effective, followed by OIB-OIB (31%), OI-OIB-TB (20%), and OIB-OIB-TB (15%).

CONCLUSIONS

Overall, survival increases marginally with the addition of targeted biologics, such as bevacizumab, at first line and third line at substantial costs. Treatment sequences with bevacizumab at first line and targeted biologics at third line may not be cost-effective at the commonly used threshold of $100,000/QALY gained, but a marginal decrease in the cost of bevacizumab may make treatment sequences with first-line bevacizumab cost-effective. Future economic evaluations should validate the study results using parameters from ongoing clinical trials.

DISCLOSURES

This study was supported in part by a grant from the Agency for Healthcare Research and Quality (R01-HS018956) and in part by a grant from the Cancer Prevention and Research Institute of Texas (RP130051), which were obtained by Du. The authors report no conflicts of interest. Study concept and design were primarily contributed by Parikh, along with the other authors. All authors participated in data collection, and Parikh took the lead in data interpretation and analysis, along with Lairson and Morgan, with assistance from Du. The manuscript was written primarily by Parikh, along with Lairson, Morgan, and Du, and revised by Parikh.

Patterns of Treatment Sequences in Chemotherapy and Targeted Biologics for Metastatic Colorectal Cancer: Findings from a Large Community-Based Cohort of Elderly Patients

Background

Over the last decade, multiple chemotherapies/targeted biologics have been approved for metastatic colorectal cancer (mCRC). However, evidence is limited with regards to the array of treatments received by mCRC patients.

Objective

This study examines treatment sequences (first- to third-line chemotherapy/targeted biologics) and the factors associated with first-line targeted biologics and common treatment sequences for elderly mCRC patients treated in a community setting.

Methods

A retrospective cohort study was conducted in mCRC patients diagnosed from January 2004 through December 2009 using the Surveillance, Epidemiology and End Results Medicare-linked database. The treatment sequences administered to elderly mCRC patients were empirically identified.

Results

Of 4418 mCRC patients who received treatment, 1370 (31 %) received first, second, and third line; 1164 (26 %) received first and second line; and 1884 (43 %) received only first line. The most common first line of treatment for mCRC patients was 5-fluorouracil/leucovorin + oxaliplatin (FOLFOX) + bevacizumab (23 %) and FOLFOX (23 %). 5-fluorouracil/leucovorin + irinotecan (FOLFIRI)-based regimens were commonly (22 %) administered in second line. The most common treatment sequence was first-line oxaliplatin or irinotecan followed by second-line oxaliplatin or irinotecan + bevacizumab followed by a third-line targeted biologic. Of patients who received first-line therapy, 47 % also received a targeted biologic, and the factors associated were age, comorbidity score, cancer site, geographic location, and year of diagnosis.

Conclusion

Elderly mCRC patients receive a multitude of treatments in various sequences. Further exploration of the comparative effectiveness of treatment sequences may yield important information for improving mCRC survival.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0059-9) contains supplementary material, which is available to authorized users.

Cost-Effectiveness of Chemotherapy for Breast Cancer and Age Effect in Older Women

BACKGROUND

Previous economic evaluations compared specific chemotherapy agents using input parameters from clinical trials and resource utilization costs. Cost-effectiveness of treatment groups (drug classes) using community-level effectiveness and cost data, however, has not been assessed for elderly patients with breast cancer.

OBJECTIVE

To assess the cost-effectiveness of chemotherapy regimens by age and disease stage under "real-world" conditions for patients with breast cancer.

METHODS

The Surveillance Epidemiology and End Results-Medicare data were used to identify patients with breast cancer with American Joint Committee on Cancer stage I/II/IIIa, hormone receptor-negative (estrogen receptor-negative and progesterone receptor-negative) patients from 1992 to 2009. Patients were categorized into three adjuvant treatment groups: 1) no chemotherapy, 2) anthracycline, and 3) non-anthracycline-based chemotherapy. Median life-years and quality-adjusted life-years (QALYs) were measured using Kaplan-Meier analysis and were evaluated against average total health care costs (2013 US dollars).

RESULTS

A total of 4575 patients (propensity score-matched) were included for the primary analysis. The anthracycline group experienced 12.05 QALYs and mean total health care costs of $119,055, resulting in an incremental cost-effectiveness ratio of $7,688 per QALY gained as compared with the no chemotherapy group (QALYs 7.81; average health care cost $86,383). The non-anthracycline-based group was dominated by the anthracycline group with lower QALYs (9.56) and higher health care costs ($122,791). Base-case results were found to be consistent with the best-case and worst-case scenarios for utility assignments. Incremental cost-effectiveness ratios varied by age group (range $3,790-$90,405 per QALY gained).

CONCLUSIONS

Anthracycline-based chemotherapy was found cost-effective for elderly patients with early stage (stage I, II, IIIa) breast cancer considering the US threshold of $100,000 per QALY. Further research may be needed to characterize differential effects across age groups.

Bioinformatic analyses revealed underlying biological functions correlated with oxaliplatin responsiveness

Colorectal cancer is one of the most common cancers worldwide. Surgery is usually the primary treatment for colon cancers that have not spread to distant sites. However, chemotherapy may be considered after surgery to eliminate remaining cancer cells or in case the cancer has a high risk of recurrence. Oxaliplatin is often used in combination regimens such as FOLFOX, CapeOX, and FOLFOXIRI because of the cost-effectiveness of adjuvant treatment for patients and also the good tolerability profile. However, some patients show resistance to oxaliplatin which causes poor treatment outcomes. Most colon cancer studies focused on treatments and patient survival. Some studies focused on genetic associations of specific genes. However, pathway and network analyses of oxaliplatin resistance in colon cancer cells using gene expression patterns are still lacking. We performed a microarray analysis and found that endothelin-1 (EDN1), dishevelled segment polarity protein (DV1), toll-like receptor 5(TLR5), mitogen-activated protein kinase 3 (MAP2K3), phosphatidylinositol-4,5-bisphosphate 3-kinase, and catalytic subunit beta (PIK3CB) were closely related to responsiveness to oxaliplatin treatment. Furthermore, we found that the signal transduction, melanogenesis, and toll-like receptor signaling pathways might be involved in oxaliplatin-resistant colon cancer. These genes and pathways might be potential targets for improving oxaliplatin treatment in colon cancer patients.