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Brunt AM, Haviland JS, Wheatley DA, Sydenham MA, Bloomfield DJ, Chan C, Cleator S, Coles CE, Donovan E, Fleming H, Glynn D, Goodman A, Griffin S, Hopwood P, Kirby AM, Kirwan CC, Nabi Z, Patel J, Sawyer E, Somaiah N, Syndikus I, Venables K, Yarnold JR, Bliss JM. One versus three weeks hypofractionated whole breast radiotherapy for early breast cancer treatment: the FAST-Forward phase III RCT. Health Technol Assess 2023; 27:1-176. [PMID: 37991196 PMCID: PMC11017153 DOI: 10.3310/wwbf1044] [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] [Indexed: 11/23/2023] Open
Abstract
Background FAST-Forward aimed to identify a 5-fraction schedule of adjuvant radiotherapy delivered in 1 week that was non-inferior in terms of local cancer control and as safe as the standard 15-fraction regimen after primary surgery for early breast cancer. Published acute toxicity and 5-year results are presented here with other aspects of the trial. Design Multicentre phase III non-inferiority trial. Patients with invasive carcinoma of the breast (pT1-3pN0-1M0) after breast conservation surgery or mastectomy randomised (1 : 1 : 1) to 40 Gy in 15 fractions (3 weeks), 27 Gy or 26 Gy in 5 fractions (1 week) whole breast/chest wall (Main Trial). Primary endpoint was ipsilateral breast tumour relapse; assuming 2% 5-year incidence for 40 Gy, non-inferiority pre-defined as < 1.6% excess for 5-fraction schedules (critical hazard ratio = 1.81). Normal tissue effects were assessed independently by clinicians, patients and photographs. Sub-studies Two acute skin toxicity sub-studies were undertaken to confirm safety of the test schedules. Primary endpoint was proportion of patients with grade ≥ 3 acute breast skin toxicity at any time from the start of radiotherapy to 4 weeks after completion. Nodal Sub-Study patients had breast/chest wall plus axillary radiotherapy testing the same three schedules, reduced to the 40 and 26 Gy groups on amendment, with the primary endpoint of 5-year patient-reported arm/hand swelling. Limitations A sequential hypofractionated or simultaneous integrated boost has not been studied. Participants Ninety-seven UK centres recruited 4096 patients (1361:40 Gy, 1367:27 Gy, 1368:26 Gy) into the Main Trial from November 2011 to June 2014. The Nodal Sub-Study recruited an additional 469 patients from 50 UK centres. One hundred and ninety and 162 Main Trial patients were included in the acute toxicity sub-studies. Results Acute toxicity sub-studies evaluable patients: (1) acute grade 3 Radiation Therapy Oncology Group toxicity reported in 40 Gy/15 fractions 6/44 (13.6%); 27 Gy/5 fractions 5/51 (9.8%); 26 Gy/5 fractions 3/52 (5.8%). (2) Grade 3 common toxicity criteria for adverse effects toxicity reported for one patient. At 71-month median follow-up in the Main Trial, 79 ipsilateral breast tumour relapse events (40 Gy: 31, 27 Gy: 27, 26 Gy: 21); hazard ratios (95% confidence interval) versus 40 Gy were 27 Gy: 0.86 (0.51 to 1.44), 26 Gy: 0.67 (0.38 to 1.16). With 2.1% (1.4 to 3.1) 5-year incidence ipsilateral breast tumour relapse after 40 Gy, estimated absolute differences versus 40 Gy (non-inferiority test) were -0.3% (-1.0-0.9) for 27 Gy (p = 0.0022) and -0.7% (-1.3-0.3) for 26 Gy (p = 0.00019). Five-year prevalence of any clinician-assessed moderate/marked breast normal tissue effects was 40 Gy: 98/986 (9.9%), 27 Gy: 155/1005 (15.4%), 26 Gy: 121/1020 (11.9%). Across all clinician assessments from 1 to 5 years, odds ratios versus 40 Gy were 1.55 (1.32 to 1.83; p < 0.0001) for 27 Gy and 1.12 (0.94-1.34; p = 0.20) for 26 Gy. Patient and photographic assessments showed higher normal tissue effects risk for 27 Gy versus 40 Gy but not for 26 Gy. Nodal Sub-Study reported no arm/hand swelling in 80% and 77% in 40 Gy and 26 Gy at baseline, and 73% and 76% at 24 months. The prevalence of moderate/marked arm/hand swelling at 24 months was 10% versus 7% for 40 Gy compared with 26 Gy. Interpretation Five-year local tumour incidence and normal tissue effects prevalence show 26 Gy in 5 fractions in 1 week is a safe and effective alternative to 40 Gy in 15 fractions for patients prescribed adjuvant local radiotherapy after primary surgery for early-stage breast cancer. Future work Ten-year Main Trial follow-up is essential. Inclusion in hypofractionation meta-analysis ongoing. A future hypofractionated boost trial is strongly supported. Trial registration FAST-Forward was sponsored by The Institute of Cancer Research and was registered as ISRCTN19906132. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 09/01/47) and is published in full in Health Technology Assessment; Vol. 27, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Adrian Murray Brunt
- School of Medicine, University of Keele and University Hospitals of North Midlands, Staffordshire, UK
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Duncan A Wheatley
- Department of Oncology, Royal Cornwall Hospital NHS Trust, Truro, UK
| | - Mark A Sydenham
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - David J Bloomfield
- Sussex Cancer Centre, Brighton and Sussex University Hospitals, Brighton, UK
| | - Charlie Chan
- Women's Health Clinic, Nuffield Health Cheltenham Hospital, Cheltenham, UK
| | - Suzy Cleator
- Department of Oncology, Imperial Healthcare NHS Trust, London, UK
| | | | - Ellen Donovan
- Centre for Vision, Speech and Signal Processing, University of Surrey, Guildford, UK
| | - Helen Fleming
- Clinical and Translational Radiotherapy Research Group, National Cancer Research Institute, London, UK
| | - David Glynn
- Centre for Health Economics, University of York, York, UK
| | | | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | - Penelope Hopwood
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Anna M Kirby
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK and Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Cliona C Kirwan
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Zohal Nabi
- RTQQA, Mount Vernon Cancer Centre, Middlesex, UK
| | - Jaymini Patel
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
| | - Elinor Sawyer
- Comprehensive Cancer Centre, King's College London, London, UK
| | - Navita Somaiah
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK and Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Isabel Syndikus
- Clatterbridge Cancer Centre, Clatterbridge Hospital NHS Trust, Cheshire, UK
| | | | - John R Yarnold
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK and Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Judith M Bliss
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, London, UK
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Rojas L, Rojas-Reyes MX, Rosselli D, Ariza JG, Ruiz-Patiño A, Cardona AF. Cost-utility analysis of genomic profiling in early breast cancer in Colombia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:42. [PMID: 37430303 DOI: 10.1186/s12962-023-00449-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/14/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND In Colombia, the best strategy to establish indication for adjuvant chemotherapy in early breast cancer (EBC) remains unknown. This study aimed to identify the cost-utility of Oncotype DX™ (ODX) or Mammaprint™ (MMP) tests to establish the necessity of adjuvant chemotherapy. METHODS This study used an adapted decision-analytic model to compare cost and outcomes of care between ODX or MMP tests and routine care without ODX or MMP tests (adjuvant chemotherapy for all patients) over a 5-year time horizon from the perspective of the Colombian National Health System (NHS; payer). Inputs were obtained from national unit cost tariffs, published literature, and clinical trial database. The study population comprised women with hormone-receptor-positive (HR +), HER2-negative, lymph-node-negative (LN0) EBC with high-risk clinical criteria for recurrence. The outcome measures were discounted incremental cost-utility ratio (ICUR; 2021 United States dollar per quality-adjusted life-year [QALY] gained) and net monetary benefit (NMB). Probabilistic (PSA) and deterministic sensitivity analysis (DSA) were performed. RESULTS ODX increases QALYs by 0.05 and MMP by 0.03 with savings of $2374 and $554 compared with the standard strategy, respectively, and were cost-saving in cost-utility plane. NMB for ODX was $2203 and for MMP was $416. Both tests dominate the standard strategy. Sensitivity analysis revealed that with a threshold of 1 gross domestic product per capita, ODX will be cost-effective in 95.5% of the cases compared with 70.2% cases involving MMP.DSA showed that the variable with significant influence was the monthly cost of adjuvant chemotherapy. PSA revealed that ODX was a consistently superior strategy. CONCLUSIONS Genomic profiling using ODX or MMP tests to define the need of adjuvant chemotherapy treatment in patients with HR + and HER2 -EBC is a cost-effective strategy that allows Colombian NHS to maintain budget.
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Affiliation(s)
- Leonardo Rojas
- Thoracic and GU Unit, Fundación Centro de Tratamiento en Investigación Sobre Cáncer Luis Carlos Sarmiento Angulo (CTIC), Carrera 14 # 169 -49, Office 204, Bogotá, Colombia.
- Molecular Oncology and Biology Systems Research Group (Fox-G), Universidad El Bosque, Bogotá, Colombia.
| | | | - Diego Rosselli
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | | | - Andrés F Cardona
- Molecular Oncology and Biology Systems Research Group (Fox-G), Universidad El Bosque, Bogotá, Colombia
- Foundation for Clinical and Applied Cancer Research-FICMAC, Bogotá, Colombia
- Direction of Research, Science and Education, Fundación Centro de Tratamiento en Investigación Sobre Cáncer Luis Carlos Sarmiento Angulo (CTIC), Bogotá, Colombia
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McKenzie GAG, Johnson MJ, Lind MJ, Kelly C, Parrott S. Geriatric assessment prior to cancer treatment: A health economic evaluation. J Geriatr Oncol 2023; 14:101504. [PMID: 37320931 DOI: 10.1016/j.jgo.2023.101504] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/16/2022] [Accepted: 04/12/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION To address uncertainty regarding the cost-effectiveness of implementing geriatric assessment (GA) in oncology practice, we undertook a synthetic, model-based economic evaluation. MATERIALS AND METHODS A decision-analytic model with embedded Markov chains was developed to simulate a cost-effectiveness analysis of implementing GA within standard oncological care compared to current practice. This was for patients aged 77 years (the mean age in included trials) receiving chemotherapy or surgery as first-line treatment. Assumptions were made about model parameters, based on available literature, to calculate the incremental net health benefit (INHB) of GA, using a data synthesis. RESULTS GA has additional costs over standard care alone of between £390 and £576, depending upon implementation configuration. When major assumptions about the effectiveness of GA were modelled, INHB was marginally positive (0.09-0.12) at all cost-effectiveness thresholds (CETs). If no reduction in postoperative complications was assumed, the intervention was shown not to be cost-effective (INHB negative at all CETs). When used before chemotherapy, with minimal healthcare staffing inputs and technological assistance, GA is cost-effective (INHB positive between 0.06 and 0.07 at all CETs). DISCUSSION Considering emerging evidence that GA improves outcomes in oncology, GA may not be a cost-effective intervention when used for all older adults with cancer. However, with judicious selection of implementation models, GA has the potential to be cost-effective. Due to significant heterogeneity and centre dependent success in implementation and effectiveness, GA is difficult to study in oncology settings. Stakeholders could take a pragmatic approach towards GA introduction with local evaluation favoured over generalisable research. Because GA tends towards utilitarianism and has no safety issues, it is a suitable intervention for more widespread implementation.
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Affiliation(s)
- Gordon A G McKenzie
- Cancer Research Group, Hull York Medical School, University of Hull, Hull, UK.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Michael J Lind
- Cancer Research Group, Hull York Medical School, University of Hull, Hull, UK
| | - Charlotte Kelly
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
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Curtit E, Bellanger MM, Nerich V, Hequet D, Frenel JS, Cristeau O, Rouzier R. Genomic signature to guide adjuvant chemotherapy treatment decisions for early breast cancer patients in France: a cost-effectiveness analysis. Front Oncol 2023; 13:1191943. [PMID: 37427133 PMCID: PMC10327821 DOI: 10.3389/fonc.2023.1191943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction Chemotherapy (CT) is commonly used as an adjuvant treatment for women with early breast cancer (BC). However, not all patients benefit from CT, while all are exposed to its short- and long-term toxicity. The Oncotype DX® test assesses cancer-related gene expression to estimate the risk of BC recurrence and predict the benefit of chemotherapy. The aim of this study was to estimate, from the French National Health Insurance (NHI) perspective, the cost-effectiveness of the Oncotype DX® test compared to standard of care (SoC; involving clinicopathological risk assessment only) among women with early, hormone receptor-positive, human epidermal growth factor receptor 2-negative BC considered at high clinicopathological risk of recurrence. Methods Clinical outcomes and costs were estimated over a lifetime horizon based on a two-component model that comprised a short-term decision tree representing the adjuvant treatment choice guided by the therapeutic decision support strategy (Oncotype DX® test or SoC) and a Markov model to capture long-term outcomes. Results In the base case, the Oncotype DX® test reduced CT use by 55.2% and resulted in 0.337 incremental quality-adjusted life-years gained and cost savings of €3,412 per patient, compared with SoC. Being more effective and less costly than SoC, Oncotype DX® testing was the dominant strategy. Discussion Widespread implementation of Oncotype DX® testing would improve patient care, provide equitable access to more personalized medicine, and bring cost savings to the health system.
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Affiliation(s)
- Elsa Curtit
- University of Franche-Comté, University Hospital of Besançon J. Minjoz, INSERM, EFS UMR 1098, Besançon, France
| | - Martine Marie Bellanger
- UMR CNRS6051, Ecole des Hautes Etudes en Santé Publique - School of Public Health (EHESP), University of Rennes, Rennes, France
| | - Virginie Nerich
- Department of Pharmacy, University Hospital of Besançon, France; INSERM, EFS-BFC, UMR 1098, University of Franche-Comté, Besançon, France
| | - Delphine Hequet
- Institut Bourdonnais, Clinique Saint Jean de Dieu, Paris, France
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Glynn D, Bliss J, Brunt AM, Coles CE, Wheatley D, Haviland JS, Kirby AM, Longo F, Faria R, Yarnold JR, Griffin S. Cost-effectiveness of 5 fraction and partial breast radiotherapy for early breast cancer in the UK: model-based multi-trial analysis. Breast Cancer Res Treat 2023; 197:405-416. [PMID: 36396774 PMCID: PMC9672618 DOI: 10.1007/s10549-022-06802-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE We estimated the cost-effectiveness of 4 radiotherapy modalities to treat early breast cancer in the UK. In a subgroup of patients eligible for all modalities, we compared whole-breast (WB) and partial breast (PB) radiotherapy delivered in either 15 (WB15F, PB15F) or 5 fractions (WB5F, PB5F). In a subgroup ineligible for PB radiotherapy, we compared WB15F to WB5F. METHODS We developed a Markov cohort model to simulate lifetime healthcare costs and quality-adjusted life years (QALYs) for each modality. This was informed by the clinical analysis of two non-inferiority trials (FAST Forward and IMPORT LOW) and supplemented with external literature. The primary analysis assumed that radiotherapy modality influences health only through its impact on locoregional recurrence and radiotherapy-related adverse events. RESULTS In the primary analysis, PB5F had the least cost and greatest expected QALYs. WB5F had the least cost and the greatest expected QALYs in those only eligible for WB radiotherapy. Applying a cost-effectiveness threshold of £15,000/QALY, there was a 62% chance that PB5F was the cost-effective alternative in the PB eligible group, and there was a 100% chance that WB5F was cost-effective in the subgroup ineligible for PB radiotherapy. CONCLUSIONS Hypofractionation to 5 fractions and partial breast radiotherapy modalities offer potentially important benefits to the UK health system.
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Affiliation(s)
- David Glynn
- Centre for Health Economics, University of York, Heslington, UK
| | - Judith Bliss
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, UK
| | - Adrian Murray Brunt
- School of Medicine, University of Keele, Staffordshire & Institute of Cancer Research, London, UK
| | - Charlotte E. Coles
- University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Joanne S. Haviland
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, UK
| | - Anna M. Kirby
- Royal Marsden NHS Foundation Trust & Institute of Cancer Research, Sutton, UK
| | - Francesco Longo
- Centre for Health Economics, University of York, Heslington, UK
| | - Rita Faria
- Centre for Health Economics, University of York, Heslington, UK
| | - John R. Yarnold
- The Institute of Cancer Research: Royal Cancer Hospital, Sutton, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, Heslington, UK
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Berdunov V, Millen S, Paramore A, Griffin J, Reynia S, Fryer N, Brown R, Longworth L. Cost-Effectiveness Analysis of the Oncotype DX Breast Recurrence Score ® Test in Node-Negative Early Breast Cancer. Clinicoecon Outcomes Res 2022; 14:619-633. [PMID: 36157054 PMCID: PMC9505370 DOI: 10.2147/ceor.s360049] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/13/2022] [Indexed: 11/23/2022]
Abstract
Background The 21-gene assay (the Oncotype DX Breast Recurrence Score® test) is a validated multigene assay which produces the Recurrence Score® result (RS) to inform decisions on the use of adjuvant chemotherapy in human epidermal growth factor receptor 2-negative (HER2-), hormone receptor positive (HR+) early invasive breast cancer. A model-based economic evaluation estimated the cost-effectiveness of the 21-gene assay against the use of clinical risk tools alone based on the latest evidence from prospective studies. Methods The proportion of patients assigned to chemotherapy conditional on their RS result was obtained from retrospective data from the Clalit registry. The probability of distant recurrence with endocrine and chemo-endocrine therapy conditional on RS result was obtained from TAILORx and NSABP B-20 trials. The cost-effectiveness of the 21-gene assay compared to using clinical risk tools alone was estimated in terms of cost per quality-adjusted life-year (QALY) over a lifetime horizon. Results The 21-gene assay was more effective (0.17 more quality-adjusted life years) at a lower cost (-£519) over a lifetime compared to clinical risk alone. The model results were sensitive to assumptions around the magnitude of benefit of chemotherapy in the high RS result subgroup. Other assumptions underpinning the model, such as the proportion of patients assigned to chemotherapy in the low and mid-range RS result subgroups and long-term distant recurrence probabilities, had a smaller impact on the results. Conclusion The analysis showed that the cost-effectiveness of the 21-gene assay is sensitive to assumptions for chemotherapy sparing for patients with RS 0–25 whose outcomes with endocrine therapy are no worse compared to chemotherapy-assigned patients, and a chemotherapy benefit in the RS 26–100 group. Future studies need to incorporate a wider set of tumour profiling tests other than the 21-gene assay to allow a direct comparison of their cost-effectiveness.
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7
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Berdunov V, Millen S, Paramore A, Hall P, Perren T, Brown R, Griffin J, Reynia S, Fryer N, Longworth L. Cost-effectiveness analysis of the Oncotype DX Breast Recurrence Score test in node-positive early breast cancer. J Med Econ 2022; 25:591-604. [PMID: 35416089 DOI: 10.1080/13696998.2022.2066399] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Given the high rate of adverse events and high cost of adjuvant chemotherapy, it is optimal to avoid its use when endocrine therapy is equally effective at preventing distant recurrence of early breast cancer. The Oncotype DX test is a predictive and prognostic multigene assay used to guide adjuvant chemotherapy decisions in early breast cancer based on a Recurrence Score (RS) result. A model-based cost-effectiveness analysis compared the Oncotype DX test to clinical risk tools alone for HR+/HER2- node-positive (1-3 axillary lymph nodes) early breast cancer patients based on results from the RxPONDER trial. MATERIALS AND METHODS A decision-tree and Markov model was developed in Microsoft Excel. Distributions of patients and distant recurrence probabilities with endocrine and chemo-endocrine therapy were derived from the RxPONDER trial, TransATAC and SWOG-8814. Chemotherapy assignment data were obtained from the Clalit registry. The cost of adjuvant chemotherapy was based on the distribution of treatments used in the UK combined with published drug unit costs in the UK. The cost of distant recurrence and health state utility values were obtained from literature. RESULTS The Oncotype DX test was found to be more effective (with an estimated 0.02 additional QALYs) at a lower estimated cost (-£989) compared to clinical risk tools alone. The results did not substantially change with more conservative clinical and cost scenarios. The RxPONDER trial was restricted to RS 0-25, and data synthesis with other studies was required to inform the analysis, which increased uncertainty. CONCLUSIONS The Oncotype DX test is highly likely to be cost-effective in node-positive early breast cancer. The results were driven by reduction in the use of chemotherapy with consequence avoidance of the costs and harmful effects of chemotherapy. Targeted treatment of a minority (11%) of women with RS 26-100 who benefit from chemotherapy reduced cost and improved survival.
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Affiliation(s)
| | | | | | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
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Holmes GR, Ward SE, Brennan A, Bradburn M, Morgan JL, Reed MWR, Richards P, Rafia R, Wyld L. Cost-Effectiveness Modeling of Surgery Plus Adjuvant Endocrine Therapy Versus Primary Endocrine Therapy Alone in UK Women Aged 70 and Over With Early Breast Cancer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:770-779. [PMID: 34119074 DOI: 10.1016/j.jval.2020.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 10/27/2020] [Accepted: 12/02/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Approximately 20% of UK women aged 70+ with early breast cancer receive primary endocrine therapy (PET) instead of surgery. PET reduces surgical morbidity but with some survival decrement. To complement and utilize a treatment dependent prognostic model, we investigated the cost-effectiveness of surgery plus adjuvant therapies versus PET for women with varying health and fitness, identifying subgroups for which each treatment is cost-effective. METHODS Survival outcomes from a statistical model, and published data on recurrence, were combined with data from a large, multicenter, prospective cohort study of over 3400 UK women aged 70+ with early breast cancer and median 52-month follow-up, to populate a probabilistic economic model. This model evaluated the cost-effectiveness of surgery plus adjuvant therapies relative to PET for 24 illustrative subgroups: Age {70, 80, 90} × Nodal status {FALSE (F), TRUE (T)} × Comorbidity score {0, 1, 2, 3+}. RESULTS For a 70-year-old with no lymph node involvement and no comorbidities (70, F, 0), surgery plus adjuvant therapies was cheaper and more effective than PET. For other subgroups, surgery plus adjuvant therapies was more effective but more expensive. Surgery plus adjuvant therapies was not cost-effective for 4 of the 24 subgroups: (90, F, 2), (90, F, 3), (90, T, 2), (90, T, 3). CONCLUSION From a UK perspective, surgery plus adjuvant therapies is clinically effective and cost-effective for most women aged 70+ with early breast cancer. Cost-effectiveness reduces with age and comorbidities, and for women over 90 with multiple comorbidities, there is little cost benefit and a negative impact on quality of life.
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Affiliation(s)
- Geoffrey R Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK.
| | - Sue E Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Alan Brennan
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Michael Bradburn
- Department of Statistics, ScHARR, University of Sheffield, England, UK
| | - Jenna L Morgan
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, England, UK
| | - Malcolm W R Reed
- Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, England, UK
| | - Paul Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Rachid Rafia
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, England, UK
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Kunst N, Wang SY, Hood A, Mougalian SS, DiGiovanna MP, Adelson K, Pusztai L. Cost-Effectiveness of Neoadjuvant-Adjuvant Treatment Strategies for Women With ERBB2 (HER2)-Positive Breast Cancer. JAMA Netw Open 2020; 3:e2027074. [PMID: 33226431 PMCID: PMC7684449 DOI: 10.1001/jamanetworkopen.2020.27074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The neoadjuvant treatment options for ERBB2-positive (also known as HER2-positive) breast cancer are associated with different rates of pathologic complete response (pCR). The KATHERINE trial showed that adjuvant trastuzumab emtansine (T-DM1) can reduce recurrence in patients with residual disease compared with patients treated with trastuzumab; however, T-DM1 and other ERBB2-targeted agents are costly, and understanding the costs and health consequences of various combinations of neoadjuvant followed by adjuvant treatments in the United States is needed. OBJECTIVE To examine the costs and disease outcomes associated with selection of various neoadjuvant followed by adjuvant treatment strategies for patients with ERBB2-positive breast cancer. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation, a decision-analytic model was developed to evaluate various neoadjuvant followed by adjuvant treatment strategies for women with ERBB2-positive breast cancer from a health care payer perspective in the United States. The model was informed by the KATHERINE trial, other clinical trials with different regimens from the KATHERINE trial, the Flatiron Health Database, McKesson Corporation data, and other evidence in the published literature. Starting trial median age for KATHERINE patients was 49 years (range, 24-79 years in T-DM1 arm and 23-80 years in trastuzumab arm). The model simulated patients receiving 5 different neoadjuvant followed by adjuvant treatment strategies. Data analyses were performed from March 2019 to August 2020. EXPOSURE There were 4 neoadjuvant regimens: (1) HP: trastuzumab (H) plus pertuzumab (P), (2) THP: paclitaxel (T) plus H plus P, (3) DDAC-THP: dose-dense anthracycline/cyclophosphamide (DDAC) plus THP, (4) TCHP: docetaxel (T) plus carboplatin (C) plus HP. All patients with pCR, regardless of neoadjuvant regimen, received adjuvant H. Patients with residual disease received different adjuvant therapies depending on the neoadjuvant regimen according to the 5 following strategies: (1) neoadjuvant DDAC-THP followed by adjuvant H, (2) neoadjuvant DDAC-THP followed by adjuvant T-DM1, (3) neoadjuvant THP followed by adjuvant DDAC plus T-DM1, (4) neoadjuvant HP followed by adjuvant DDAC/THP plus T-DM1, or (5) neoadjuvant TCHP followed by adjuvant T-DM1. MAIN OUTCOMES AND MEASURES Lifetime costs in 2020 US dollars and quality-adjusted life-years (QALYs) were estimated for each treatment strategy, and incremental cost-effectiveness ratios were estimated. A strategy was classified as dominated if it was associated with fewer QALYs at higher costs than the alternative. RESULTS In the base-case analysis, costs ranged from $415 833 (strategy 3) to $518 859 (strategy 4), and QALYs ranged from 9.67 (strategy 1) to 10.73 (strategy 3). Strategy 3 was associated with the highest health benefits (10.73 QALYs) and lowest costs ($415 833) and dominated all other strategies. Probabilistic analysis confirmed that this strategy had the highest probability of cost-effectiveness (>70% at willingness-to-pay thresholds of $0-200,000/QALY) and was associated with the highest net benefit. CONCLUSIONS AND RELEVANCE These results suggest that neoadjuvant THP followed by adjuvant H for patients with pCR or followed by adjuvant DDAC plus T-DM1 for patients with residual disease was associated with the highest health benefits and lowest costs for women with ERBB2-positive breast cancer compared with other treatment strategies considered.
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MESH Headings
- Ado-Trastuzumab Emtansine/economics
- Ado-Trastuzumab Emtansine/therapeutic use
- Adult
- Aged
- Anthracyclines/economics
- Anthracyclines/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/economics
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Agents, Phytogenic/economics
- Antineoplastic Agents, Phytogenic/therapeutic use
- Breast Neoplasms/genetics
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Case-Control Studies
- Cost-Benefit Analysis
- Cross-Linking Reagents/economics
- Cross-Linking Reagents/therapeutic use
- Drug Therapy, Combination
- Female
- Humans
- Immunosuppressive Agents/economics
- Immunosuppressive Agents/therapeutic use
- Middle Aged
- Neoadjuvant Therapy/economics
- Paclitaxel/economics
- Paclitaxel/therapeutic use
- Quality-Adjusted Life Years
- Receptor, ErbB-2/genetics
- Trastuzumab/economics
- Trastuzumab/therapeutic use
- Tubulin Modulators/economics
- Tubulin Modulators/therapeutic use
- United States/epidemiology
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Affiliation(s)
- Natalia Kunst
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Public Health Modeling Unit, Yale University School of Public Health, New Haven, Connecticut
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut
| | - Annette Hood
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut
| | - Sarah S. Mougalian
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | | | - Kerin Adelson
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - Lajos Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
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10
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Harnan S, Tappenden P, Cooper K, Stevens J, Bessey A, Rafia R, Ward S, Wong R, Stein RC, Brown J. Tumour profiling tests to guide adjuvant chemotherapy decisions in early breast cancer: a systematic review and economic analysis. Health Technol Assess 2020; 23:1-328. [PMID: 31264581 DOI: 10.3310/hta23300] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Breast cancer and its treatment can have an impact on health-related quality of life and survival. Tumour profiling tests aim to identify whether or not women need chemotherapy owing to their risk of relapse. OBJECTIVES To conduct a systematic review of the effectiveness and cost-effectiveness of the tumour profiling tests oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA), MammaPrint® (Agendia, Inc., Amsterdam, the Netherlands), Prosigna® (NanoString Technologies, Inc., Seattle, WA, USA), EndoPredict® (Myriad Genetics Ltd, London, UK) and immunohistochemistry 4 (IHC4). To develop a health economic model to assess the cost-effectiveness of these tests compared with clinical tools to guide the use of adjuvant chemotherapy in early-stage breast cancer from the perspective of the NHS and Personal Social Services. DESIGN A systematic review and health economic analysis were conducted. REVIEW METHODS The systematic review was partially an update of a 2013 review. Nine databases were searched in February 2017. The review included studies assessing clinical effectiveness in people with oestrogen receptor-positive, human epidermal growth factor receptor 2-negative, stage I or II cancer with zero to three positive lymph nodes. The economic analysis included a review of existing analyses and the development of a de novo model. RESULTS A total of 153 studies were identified. Only one completed randomised controlled trial (RCT) using a tumour profiling test in clinical practice was identified: Microarray In Node-negative Disease may Avoid ChemoTherapy (MINDACT) for MammaPrint. Other studies suggest that all the tests can provide information on the risk of relapse; however, results were more varied in lymph node-positive (LN+) patients than in lymph node-negative (LN0) patients. There is limited and varying evidence that oncotype DX and MammaPrint can predict benefit from chemotherapy. The net change in the percentage of patients with a chemotherapy recommendation or decision pre/post test ranged from an increase of 1% to a decrease of 23% among UK studies and a decrease of 0% to 64% across European studies. The health economic analysis suggests that the incremental cost-effectiveness ratios for the tests versus current practice are broadly favourable for the following scenarios: (1) oncotype DX, for the LN0 subgroup with a Nottingham Prognostic Index (NPI) of > 3.4 and the one to three positive lymph nodes (LN1-3) subgroup (if a predictive benefit is assumed); (2) IHC4 plus clinical factors (IHC4+C), for all patient subgroups; (3) Prosigna, for the LN0 subgroup with a NPI of > 3.4 and the LN1-3 subgroup; (4) EndoPredict Clinical, for the LN1-3 subgroup only; and (5) MammaPrint, for no subgroups. LIMITATIONS There was only one completed RCT using a tumour profiling test in clinical practice. Except for oncotype DX in the LN0 group with a NPI score of > 3.4 (clinical intermediate risk), evidence surrounding pre- and post-test chemotherapy probabilities is subject to considerable uncertainty. There is uncertainty regarding whether or not oncotype DX and MammaPrint are predictive of chemotherapy benefit. The MammaPrint analysis uses a different data source to the other four tests. The Translational substudy of the Arimidex, Tamoxifen, Alone or in Combination (TransATAC) study (used in the economic modelling) has a number of limitations. CONCLUSIONS The review suggests that all the tests can provide prognostic information on the risk of relapse; results were more varied in LN+ patients than in LN0 patients. There is limited and varying evidence that oncotype DX and MammaPrint are predictive of chemotherapy benefit. Health economic analyses indicate that some tests may have a favourable cost-effectiveness profile for certain patient subgroups; all estimates are subject to uncertainty. More evidence is needed on the prediction of chemotherapy benefit, long-term impacts and changes in UK pre-/post-chemotherapy decisions. STUDY REGISTRATION This study is registered as PROSPERO CRD42017059561. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sue Harnan
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katy Cooper
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alice Bessey
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rachid Rafia
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sue Ward
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert C Stein
- University College London Hospitals Biomedical Research Centre, London, UK.,Research Department of Oncology, University College London, London, UK
| | - Janet Brown
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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11
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Cost-effectiveness analysis of the 70-gene signature compared with clinical assessment in breast cancer based on a randomised controlled trial. Eur J Cancer 2020; 137:193-203. [PMID: 32795875 DOI: 10.1016/j.ejca.2020.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The clinical utility of the 70-gene signature (MammaPrint®) to guide chemotherapy use in T1-3N0-1M0 breast cancer was demonstrated in the Microarray in Node-Negative and 1 to 3 Positive Lymph Node Disease May Avoid Chemotherapy (MINDACT) study. One thousand four ninety seven of 3356 (46.2%) enrolled patients with high clinical risk (in accordance with the modified Adjuvant! Online clinical-pathological assessment) had a low-risk 70-gene signature. Using patient-level data from the MINDACT trial, the cost-effectiveness of using the 70-gene signature to guide adjuvant chemotherapy selection for clinical high risk, estrogen receptor positive (ER+), human epidermal growth factor 2 negative (HER2-) patients was analysed. PATIENTS AND METHODS A hybrid decision tree-Markov model simulated treatment strategies in accordance with the 70-gene signature with clinical assessment versus clinical assessment alone, over a 10-year time horizon. Primary outcomes were quality-adjusted life years (QALYs), country-specific costs and incremental cost-effectiveness ratios (ICERs) for six countries: Belgium, France, Germany, Netherlands, UK and the US. RESULTS Treatment strategies guided by the 70-gene signature result in more QALYs compared with clinical assessment alone. Costs of the 70-gene signature strategy were lower in five of six countries. This led to dominance of the 70-gene signature in Belgium, France, Germany, Netherlands and the US and to a cost-effective situation in the UK (ICER £22,910/QALY). Annual national cost savings were €4.2M (Belgium), €24.7M (France), €45.1M (Germany), €12.7M (Netherlands) and $244M (US). UK budget increase was £8.4M. CONCLUSION Using the 70-gene signature to safely guide chemotherapy de-escalation in clinical high risk patients with ER+/HER2- tumours is cost-effective compared with using clinical assessment alone. Long-term follow-up and outcomes from the MINDACT trial are necessary to address uncertainties in model inputs.
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12
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Kunst NR, Alarid-Escudero F, Paltiel AD, Wang SY. A Value of Information Analysis of Research on the 21-Gene Assay for Breast Cancer Management. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1102-1110. [PMID: 31563252 PMCID: PMC7343670 DOI: 10.1016/j.jval.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/14/2019] [Accepted: 05/15/2019] [Indexed: 05/02/2023]
Abstract
OBJECTIVES The 21-gene assay Oncotype DX (21-GA) shows promise as a guide in deciding when to initiate adjuvant chemotherapy in women with hormone receptor-positive early-stage breast cancer. Nevertheless, its routine use remains controversial, owing to insufficient evidence of its clinical utility and cost-effectiveness. Accordingly, we aim to quantify the value of conducting further research to reduce decision uncertainty in the use of the 21-GA. METHODS Using value of information methods, we first generated probability distributions of survival and costs for decision making with and without the 21-GA alongside traditional risk prediction. These served as the input to a comparison of 3 alternative study designs: a retrospective observational study to update risk classification from the 21-GA, a prospective observational study to estimate prevalence of chemotherapy use, and a randomized controlled trial (RCT) of the 21-GA predictive value. RESULTS We found that current evidence strongly supports the use of the 21-GA in intermediate- and high-risk women. Further research should focus on low-risk women, among whom the cost-effectiveness findings remained equivocal. For this population, we identified a high value of reducing uncertainty in the 21-GA use for all proposed research studies. The RCT had the greatest potential to efficiently reduce the likelihood of choosing a suboptimal strategy, providing a value between $162 million and $1.1 billion at willingness-to-pay thresholds of $150 000 to $200 000/quality-adjusted life years. CONCLUSION Future research to inform 21-GA decision making is of high value. The RCT of the 21-GA predictive value has the greatest potential to efficiently reduce decision uncertainty around 21-GA use in women with low-risk early-stage breast cancer.
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Affiliation(s)
- Natalia R Kunst
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway; Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Department of Epidemiology and Biostatistics, Amsterdam UMC, Amsterdam, the Netherlands; LINK Medical Research, Oslo, Norway.
| | - Fernando Alarid-Escudero
- Drug Policy Program, Center for Research and Teaching in Economics (CIDE), Aguascalientes, Mexico; National Council on Science and Technology (CONACyT), Mexico City, Mexico
| | - A David Paltiel
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, USA; Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA
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13
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Prospective, multicenter study on the economic and clinical impact of gene-expression assays in early-stage breast cancer from a single region: the PREGECAM registry experience. Clin Transl Oncol 2019; 22:717-724. [DOI: 10.1007/s12094-019-02176-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/01/2019] [Indexed: 01/09/2023]
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14
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Hinde S, Theriou C, May S, Matthews L, Arbon A, Fallowfield L, Bloomfield D. The cost-effectiveness of EndoPredict to inform adjuvant chemotherapy decisions in early breast cancer. HEALTH POLICY AND TECHNOLOGY 2019. [DOI: 10.1016/j.hlpt.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Caruana E, Foucher Y, Tessier P, Frenel JS, Classe JM, Dantan E. Patient-centered simulations to assess the usefulness of the 70-gene signature for adjuvant chemotherapy administration in early-stage breast cancer. Breast Cancer Res Treat 2019; 174:537-542. [PMID: 30603997 DOI: 10.1007/s10549-018-05107-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/16/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE From the MINDACT trial, Cardoso et al. did not demonstrate a significant efficacy for adjuvant chemotherapy (CT) for women with early-stage breast cancer presenting high clinical and low genomic risks. Our objective was to assess the usefulness of the 70-gene signature in this population by using an alternative endpoint: the number of Quality-Adjusted Life-Years (QALYs), i.e., a synthetic measure of quantity and quality of life. METHODS Based on the results of the MINDACT trial, we simulated a randomized clinical trial consisting of 1497 women with early-stage breast cancer presenting high clinical and low genomic risks. The individual preferences for the different health states and corresponding decrements were obtained from the literature. RESULTS The gain in terms of 5-year disease-free survival was 2.8% (95% CI from - 0.1 to 5.7%, from 90.4% for women without CT to 93.3% for women with CT). In contrast, due to the associated side effects, CT significantly reduced the number of QALYs by 62 days (95% CI from 55 to 70 days, from 4.13 years for women without CT to 3.96 years for women with CT). CONCLUSION Our results support the conclusions published by Cardoso et al. by providing additional evidence that the 70-gene signature can be used to avoid overtreatment by CT for women with high clinical risk but low genomic risk.
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Affiliation(s)
- Emmanuel Caruana
- INSERM UMR 1246 -SPHERE, Nantes University, Tours University, Nantes, France
| | - Yohann Foucher
- INSERM UMR 1246 -SPHERE, Nantes University, Tours University, Nantes, France.,Nantes University Hospital, Nantes, France
| | - Philippe Tessier
- INSERM UMR 1246 -SPHERE, Nantes University, Tours University, Nantes, France
| | - Jean-Sébastien Frenel
- Institut de Cancérologie de l'Ouest, Centre René Gauducheau, Bd Jacques Monod, 44800, Saint-Herblain, France
| | - Jean-Marc Classe
- Institut de Cancérologie de l'Ouest, Centre René Gauducheau, Bd Jacques Monod, 44800, Saint-Herblain, France
| | - Etienne Dantan
- INSERM UMR 1246 -SPHERE, Nantes University, Tours University, Nantes, France.
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16
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Hall PS, Smith A, Hulme C, Vargas-Palacios A, Makris A, Hughes-Davies L, Dunn JA, Bartlett JMS, Cameron DA, Marshall A, Campbell A, Macpherson IR, Francis A, Earl H, Morgan A, Stein RC, McCabe C. Value of Information Analysis of Multiparameter Tests for Chemotherapy in Early Breast Cancer: The OPTIMA Prelim Trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1311-1318. [PMID: 29241890 DOI: 10.1016/j.jval.2017.04.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 04/19/2017] [Accepted: 04/26/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Precision medicine is heralded as offering more effective treatments to smaller targeted patient populations. In breast cancer, adjuvant chemotherapy is standard for patients considered as high-risk after surgery. Molecular tests may identify patients who can safely avoid chemotherapy. OBJECTIVES To use economic analysis before a large-scale clinical trial of molecular testing to confirm the value of the trial and help prioritize between candidate tests as randomized comparators. METHODS Women with surgically treated breast cancer (estrogen receptor-positive and lymph node-positive or tumor size ≥30 mm) were randomized to standard care (chemotherapy for all) or test-directed care using Oncotype DX™. Additional testing was undertaken using alternative tests: MammaPrintTM, PAM-50 (ProsignaTM), MammaTyperTM, IHC4, and IHC4-AQUA™ (NexCourse Breast™). A probabilistic decision model assessed the cost-effectiveness of all tests from a UK perspective. Value of information analysis determined the most efficient publicly funded ongoing trial design in the United Kingdom. RESULTS There was an 86% probability of molecular testing being cost-effective, with most tests producing cost savings (range -£1892 to £195) and quality-adjusted life-year gains (range 0.17-0.20). There were only small differences in costs and quality-adjusted life-years between tests. Uncertainty was driven by long-term outcomes. Value of information demonstrated value of further research into all tests, with Prosigna currently being the highest priority for further research. CONCLUSIONS Molecular tests are likely to be cost-effective, but an optimal test is yet to be identified. Health economics modeling to inform the design of a randomized controlled trial looking at diagnostic technology has been demonstrated to be feasible as a method for improving research efficiency.
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Affiliation(s)
- Peter S Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK; Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Alison Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Armando Vargas-Palacios
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Andreas Makris
- Department of Clinical Oncology, Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, Northwood, UK
| | - Luke Hughes-Davies
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Janet A Dunn
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - David A Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Andrea Marshall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Campbell
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iain R Macpherson
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | - Adele Francis
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Helena Earl
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Robert C Stein
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, London, UK
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17
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Jahn B, Rochau U, Kurzthaler C, Hubalek M, Miksad R, Sroczynski G, Paulden M, Bundo M, Stenehjem D, Brixner D, Krahn M, Siebert U. Personalized treatment of women with early breast cancer: a risk-group specific cost-effectiveness analysis of adjuvant chemotherapy accounting for companion prognostic tests OncotypeDX and Adjuvant!Online. BMC Cancer 2017; 17:685. [PMID: 29037213 PMCID: PMC5644100 DOI: 10.1186/s12885-017-3603-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 08/23/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Due to high survival rates and the relatively small benefit of adjuvant therapy, the application of personalized medicine (PM) through risk stratification is particularly beneficial in early breast cancer (BC) to avoid unnecessary harms from treatment. The new 21-gene assay (OncotypeDX, ODX) is a promising prognostic score for risk stratification that can be applied in conjunction with Adjuvant!Online (AO) to guide personalized chemotherapy decisions for early BC patients. Our goal was to evaluate risk-group specific cost effectiveness of adjuvant chemotherapy for women with early stage BC in Austria based on AO and ODX risk stratification. METHODS A previously validated discrete event simulation model was applied to a hypothetical cohort of 50-year-old women over a lifetime horizon. We simulated twelve risk groups derived from the joint application of ODX and AO and included respective additional costs. The primary outcomes of interest were life-years gained, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness (ICER). The robustness of results and decisions derived were tested in sensitivity analyses. A cross-country comparison of results was performed. RESULTS Chemotherapy is dominated (i.e., less effective and more costly) for patients with 1) low ODX risk independent of AO classification; and 2) low AO risk and intermediate ODX risk. For patients with an intermediate or high AO risk and an intermediate or high ODX risk, the ICER is below 15,000 EUR/QALY (potentially cost effective depending on the willingness-to-pay). Applying the AO risk classification alone would miss risk groups where chemotherapy is dominated and thus should not be considered. These results are sensitive to changes in the probabilities of distant recurrence but not to changes in the costs of chemotherapy or the ODX test. CONCLUSIONS Based on our modeling study, chemotherapy is effective and cost effective for Austrian patients with an intermediate or high AO risk and an intermediate or high ODX risk. In other words, low ODX risk suggests chemotherapy should not be considered but low AO risk may benefit from chemotherapy if ODX risk is high. Our analysis suggests that risk-group specific cost-effectiveness analysis, which includes companion prognostic tests are essential in PM.
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Affiliation(s)
- Beate Jahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall i.T, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Karl-Kapferer-Straße 5, A-6020 Innsbruck, Austria
| | - Ursula Rochau
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall i.T, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Karl-Kapferer-Straße 5, A-6020 Innsbruck, Austria
| | - Christina Kurzthaler
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall i.T, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Karl-Kapferer-Straße 5, A-6020 Innsbruck, Austria
- Institut für Theoretische Physik, Universität Innsbruck, Technikerstraße 21A, A-6020 Innsbruck, Austria
| | - Michael Hubalek
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Christoph-Probst-Platz, Innrain 52, A-6020 Innsbruck, Austria
| | - Rebecca Miksad
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, 02215 MA USA
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 101 Merrimac St., 10th FL, Boston, MA 02114 USA
| | - Gaby Sroczynski
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall i.T, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Karl-Kapferer-Straße 5, A-6020 Innsbruck, Austria
| | - Mike Paulden
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto General Hospital, 10EN, Room 249, 200 Elizabeth Street, Toronto, M5G 2C4 ON Canada
- Department of Emergency Medicine, University of Alberta, 116 St. and 85 Ave., Edmonton, AB T6G 2R3 Canada
| | - Marvin Bundo
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall i.T, Austria
| | - David Stenehjem
- Department of Pharmacotherapy, University of Utah, 30 South 2000 East Room 4781, Salt Lake City, UT 84108 USA
- Huntsman Cancer Institute, University of Utah Hospitals & Clinics, 2000 Cir of Hope Dr, Salt Lake City, 84112 UT USA
| | - Diana Brixner
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall i.T, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Karl-Kapferer-Straße 5, A-6020 Innsbruck, Austria
- Department of Pharmacotherapy, University of Utah, 30 South 2000 East Room 4781, Salt Lake City, UT 84108 USA
- Program in Personalized Health, University of Utah, 15 North 2030 East, Room 2160, Salt Lake City, 84112 UT USA
| | - Murray Krahn
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto General Hospital, 10EN, Room 249, 200 Elizabeth Street, Toronto, M5G 2C4 ON Canada
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall i.T, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Karl-Kapferer-Straße 5, A-6020 Innsbruck, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H Chan School of Public Health, 718 Huntington Ave. 2nd Floor, Boston, 02115 MA USA
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 101 Merrimac St., 10th FL, Boston, MA 02114 USA
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Stein RC, Dunn JA, Bartlett JMS, Campbell AF, Marshall A, Hall P, Rooshenas L, Morgan A, Poole C, Pinder SE, Cameron DA, Stallard N, Donovan JL, McCabe C, Hughes-Davies L, Makris A. OPTIMA prelim: a randomised feasibility study of personalised care in the treatment of women with early breast cancer. Health Technol Assess 2016; 20:xxiii-xxix, 1-201. [PMID: 26867046 DOI: 10.3310/hta20100] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is uncertainty about the chemotherapy sensitivity of some oestrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancers. Multiparameter assays that measure the expression of several tumour genes simultaneously have been developed to guide the use of adjuvant chemotherapy for this breast cancer subtype. The assays provide prognostic information and have been claimed to predict chemotherapy sensitivity. There is a dearth of prospective validation studies. The Optimal Personalised Treatment of early breast cancer usIng Multiparameter Analysis preliminary study (OPTIMA prelim) is the feasibility phase of a randomised controlled trial (RCT) designed to validate the use of multiparameter assay directed chemotherapy decisions in the NHS. OBJECTIVES OPTIMA prelim was designed to establish the acceptability to patients and clinicians of randomisation to test-driven treatment assignment compared with usual care and to select an assay for study in the main RCT. DESIGN Partially blinded RCT with adaptive design. SETTING Thirty-five UK hospitals. PARTICIPANTS Patients aged ≥ 40 years with surgically treated ER-positive HER2-negative primary breast cancer and with 1-9 involved axillary nodes, or, if node negative, a tumour at least 30 mm in diameter. INTERVENTIONS Randomisation between two treatment options. Option 1 was standard care consisting of chemotherapy followed by endocrine therapy. In option 2, an Oncotype DX(®) test (Genomic Health Inc., Redwood City, CA, USA) performed on the resected tumour was used to assign patients either to standard care [if 'recurrence score' (RS) was > 25] or to endocrine therapy alone (if RS was ≤ 25). Patients allocated chemotherapy were blind to their randomisation. MAIN OUTCOME MEASURES The pre-specified success criteria were recruitment of 300 patients in no longer than 2 years and, for the final 150 patients, (1) an acceptance rate of at least 40%; (2) recruitment taking no longer than 6 months; and (3) chemotherapy starting within 6 weeks of consent in at least 85% of patients. RESULTS Between September 2012 and 3 June 2014, 350 patients consented to join OPTIMA prelim and 313 were randomised; the final 150 patients were recruited in 6 months, of whom 92% assigned chemotherapy started treatment within 6 weeks. The acceptance rate for the 750 patients invited to participate was 47%. Twelve out of the 325 patients with data (3.7%, 95% confidence interval 1.7% to 5.8%) were deemed ineligible on central review of receptor status. Interviews with researchers and recordings of potential participant consultations made as part of the integral qualitative recruitment study provided insights into recruitment barriers and led to interventions designed to improve recruitment. Patient information was changed as the result of feedback from three patient focus groups. Additional multiparameter analysis was performed on 302 tumour samples. Although Oncotype DX, MammaPrint(®)/BluePrint(®) (Agendia Inc., Irvine, CA, USA), Prosigna(®) (NanoString Technologies Inc., Seattle, WA, USA), IHC4, IHC4 automated quantitative immunofluorescence (AQUA(®)) [NexCourse BreastTM (Genoptix Inc. Carlsbad, CA, USA)] and MammaTyper(®) (BioNTech Diagnostics GmbH, Mainz, Germany) categorised comparable numbers of tumours into low- or high-risk groups and/or equivalent molecular subtypes, there was only moderate agreement between tests at an individual tumour level (kappa ranges 0.33-0.60 and 0.39-0.55 for tests providing risks and subtypes, respectively). Health economics modelling showed the value of information to the NHS from further research into multiparameter testing is high irrespective of the test evaluated. Prosigna is currently the highest priority for further study. CONCLUSIONS OPTIMA prelim has achieved its aims of demonstrating that a large UK clinical trial of multiparameter assay-based selection of chemotherapy in hormone-sensitive early breast cancer is feasible. The economic analysis shows that a trial would be economically worthwhile for the NHS. Based on the outcome of the OPTIMA prelim, a large-scale RCT to evaluate the clinical effectiveness and cost-effectiveness of multiparameter assay-directed chemotherapy decisions in hormone-sensitive HER2-negative early breast would be appropriate to take place in the NHS. TRIAL REGISTRATION Current Controlled Trials ISRCTN42400492. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 10. See the NIHR Journals Library website for further project information. The Government of Ontario funded research at the Ontario Institute for Cancer Research. Robert C Stein received additional support from the NIHR University College London Hospitals Biomedical Research Centre.
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Affiliation(s)
- Robert C Stein
- Department of Oncology, University College London Hospitals, London, UK
| | - Janet A Dunn
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Amy F Campbell
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter Hall
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | | | - Sarah E Pinder
- Research Oncology, Division of Cancer Studies, King's College London, London, UK
| | - David A Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Christopher McCabe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Luke Hughes-Davies
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundations Trust, Cambridge, UK
| | - Andreas Makris
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
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de Boer PT, Frederix GWJ, Feenstra TL, Vemer P. Unremarked or Unperformed? Systematic Review on Reporting of Validation Efforts of Health Economic Decision Models in Seasonal Influenza and Early Breast Cancer. PHARMACOECONOMICS 2016; 34:833-845. [PMID: 27129572 PMCID: PMC4980411 DOI: 10.1007/s40273-016-0410-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Transparent reporting of validation efforts of health economic models give stakeholders better insight into the credibility of model outcomes. In this study we reviewed recently published studies on seasonal influenza and early breast cancer in order to gain insight into the reporting of model validation efforts in the overall health economic literature. METHODS A literature search was performed in Pubmed and Embase to retrieve health economic modelling studies published between 2008 and 2014. Reporting on model validation was evaluated by checking for the word validation, and by using AdViSHE (Assessment of the Validation Status of Health Economic decision models), a tool containing a structured list of relevant items for validation. Additionally, we contacted corresponding authors to ask whether more validation efforts were performed other than those reported in the manuscripts. RESULTS A total of 53 studies on seasonal influenza and 41 studies on early breast cancer were included in our review. The word validation was used in 16 studies (30 %) on seasonal influenza and 23 studies (56 %) on early breast cancer; however, in a minority of studies, this referred to a model validation technique. Fifty-seven percent of seasonal influenza studies and 71 % of early breast cancer studies reported one or more validation techniques. Cross-validation of study outcomes was found most often. A limited number of studies reported on model validation efforts, although good examples were identified. Author comments indicated that more validation techniques were performed than those reported in the manuscripts. CONCLUSIONS Although validation is deemed important by many researchers, this is not reflected in the reporting habits of health economic modelling studies. Systematic reporting of validation efforts would be desirable to further enhance decision makers' confidence in health economic models and their outcomes.
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Affiliation(s)
- Pieter T de Boer
- Department of Pharmacy, PharmacoTherapy, -Epidemiology and -Economics (PTEE), University of Groningen, Groningen, The Netherlands
| | - Geert W J Frederix
- Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
| | - Talitha L Feenstra
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
- Centre for Nutrition, Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Pepijn Vemer
- Department of Pharmacy, PharmacoTherapy, -Epidemiology and -Economics (PTEE), University of Groningen, Groningen, The Netherlands.
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
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Cost-utility analyses of drug therapies in breast cancer: a systematic review. Breast Cancer Res Treat 2016; 159:407-24. [PMID: 27572551 DOI: 10.1007/s10549-016-3924-7] [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: 04/01/2016] [Accepted: 07/20/2016] [Indexed: 01/08/2023]
Abstract
The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.
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21
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Lairson DR, Parikh RC, Cormier JN, Chan W, Du XL. Cost-Effectiveness of Chemotherapy for Breast Cancer and Age Effect in Older Women. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:1070-1078. [PMID: 26686793 DOI: 10.1016/j.jval.2015.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 07/08/2015] [Accepted: 08/03/2015] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- David R Lairson
- Division of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Rohan C Parikh
- Division of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Janice N Cormier
- Division of Surgical Oncology and Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wenyaw Chan
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Xianglin L Du
- Division of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA; Division of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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22
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Yeo B, Zabaglo L, Hills M, Dodson A, Smith I, Dowsett M. Clinical utility of the IHC4+C score in oestrogen receptor-positive early breast cancer: a prospective decision impact study. Br J Cancer 2015; 113:390-5. [PMID: 26180920 PMCID: PMC4522631 DOI: 10.1038/bjc.2015.222] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 05/13/2015] [Accepted: 05/25/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Most oestrogen receptor (ER)-positive early breast cancer diagnosed today is highly curable with multimodality treatment. Systemic adjuvant treatments including endocrine therapy and chemotherapy have made a significant contribution to the increasing cure rates over the past three decades. However not all women will require chemotherapy. The IHC4+C score is a prognostic tool that integrates four immunohistochemical measures with clinicopathological features to estimate the residual risk of distant recurrence at 10 years in post-menopausal women with ER-positive breast cancer who have received 5 years of endocrine therapy. Retrospective studies indicate that the test can identify a set of women that are at such low risk of recurrence that chemotherapy can be of little benefit. METHODS In this study, 124 patients were prospectively selected from the multidisciplinary team meeting between January 2013 and April 2014 for IHC4+C testing. Adjuvant systemic treatment recommendations by clinicians were recorded without and with the availability of the score in addition to the patient's decision. RESULTS There was concordance in the MDT's recommendation without and with the availability of the score in 73% of cases. Clinicians recommended chemotherapy or at least its discussion to 74 (59%) patients, which fell to 32 (34%) patients after the IHC4+C score was made available, sparing one in four tested patients a chemotherapy recommendation, along with its toxicity and expense. CONCLUSION This decision impact study shows that when used by clinicians in the multidisciplinary team meeting for adjuvant decision-making, a significant proportion of patients are spared chemotherapy recommendations.
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Affiliation(s)
- B Yeo
- Department of Medicine, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
| | - L Zabaglo
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
| | - M Hills
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - A Dodson
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - I Smith
- Department of Medicine, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - M Dowsett
- Academic Department of Biochemistry, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
- Institute of Cancer Research, Fulham Road, London SW3 6JB, UK
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Abstract
Radiation therapy significantly reduces by at least 70% the relative risk of local and regional recurrences for breast cancer after surgery. A positive influence on overall survival has been clearly demonstrated, especially for patients with a high absolute risk for locoregional recurrences. However, this is partially counterbalanced by late toxicity (dependent upon the radiation dose) especially to cardiac structures. Apart from this toxicity, a clear influence of radiation-therapy-related factors on functional and cosmetic outcome has also been demonstrated. Over time, technical improvements have led to a marked reduction in dose to the neighbouring organs, with a consequent drop in acute and late toxicity. This has also allowed the introduction of shorter radiation schedules, lowering the burden of treatment to the patient and the hospital. Several tools, techniques and guidelines have been developed to optimise the balance between the desired reduction in recurrence rates and side effects. The multidisciplinary team should discuss all available treatment options for every individual breast cancer patient. Individualisation of the selection of the optimal combination of treatments, depending on patient and tumour-related factors, is of utmost importance. Apart from direct tumour-related outcomes, cosmesis and potential side effects have to be taken into account. Counselling should include known risk factors for survival and complications, including comorbidity.
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Affiliation(s)
- Philip Poortmans
- Institute Verbeeten, Department of Radiation Oncology, Tilburg, The Netherlands
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Bonastre J, Marguet S, Lueza B, Michiels S, Delaloge S, Saghatchian M. Reply to V.P. Retèl et al, D. Gauchan et al, and C. Rahilly-Tierney et al. J Clin Oncol 2015; 33:1629-30. [PMID: 25847933 DOI: 10.1200/jco.2014.60.5568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Julia Bonastre
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
| | - Sophie Marguet
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
| | - Beranger Lueza
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
| | - Stefan Michiels
- Institute Gustave Roussy; and Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale U1018, Paris-Sud University, Villejuif, France
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Mandelblatt JS, Huang K, Makgoeng SB, Luta G, Song JX, Tallarico M, Roh JM, Munneke JR, Houlston CA, McGuckin ME, Cai L, Clarke Hillyer G, Hershman DL, Neugut AI, Isaacs C, Kushi L. Preliminary Development and Evaluation of an Algorithm to Identify Breast Cancer Chemotherapy Toxicities Using Electronic Medical Records and Administrative Data. J Oncol Pract 2014; 11:e1-8. [PMID: 25161127 DOI: 10.1200/jop.2013.001288] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Breast cancer chemotherapy toxicity is not well documented outside of randomized trials. We developed and conducted preliminary evaluation of an algorithm to detect grade 3 and 4 toxicities using electronic data from a large integrated managed care organization. METHODS The algorithm used administrative, pharmacy, and electronic data from outpatient, emergency room, and inpatient records of 99 women diagnosed with breast cancer from 2006 to 2009 who underwent chemotherapy. Data were abstracted for 12 months post-treatment initiation (24 months for trastuzumab recipients). An oncology nurse independently blindly reviewed records; these results were the "gold standard." Sensitivity and specificity were calculated for overall toxicity, categories of toxicities, and toxicity by age or regimen. The algorithm was applied to an independent sample of 1,575 patients with breast cancer diagnosed during the study period to estimate prevalence rates. RESULTS The overall sensitivity for detecting chemotherapy-related toxicity was 89% (95% CI, 77% to 95%). The highest sensitivity was for identification of hematologic toxicities (97%; 95% CI, 84% to 99%). There were good sensitivities for infectious toxicity, but rates dropped for GI and neurological toxicities. Specificity was high within each category (89% to 99%), but when combined to measure any toxicity, it was lower (70%; 95% CI, 57% to 81%). When applied to an independent chemotherapy sample, the algorithm estimates a 26% rate of hematologic toxicity; rates were higher among patients age ≥ 65 years versus less than 65 years. CONCLUSIONS If validated in other samples and health care settings, algorithms to capture toxicity could be useful in comparative and cost-effectiveness evaluations of community practice-delivered treatment.
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Affiliation(s)
- Jeanne S Mandelblatt
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Karl Huang
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Solomon B Makgoeng
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Gheorghe Luta
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Jun X Song
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Michelle Tallarico
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Janise M Roh
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Julie R Munneke
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Cathie A Houlston
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Meghan E McGuckin
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Ling Cai
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Grace Clarke Hillyer
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Dawn L Hershman
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Alfred I Neugut
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Claudine Isaacs
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
| | - Larry Kushi
- Georgetown University Medical Center; Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC; Kaiser Permanente Medical Group, Oakland, CA; and Columbia Presbyterian Medical Center, New York, NY
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Taylor-Phillips S, Wallis MG, Parsons H, Dunn J, Stallard N, Campbell H, Sellars S, Szczepura A, Gates S, Clarke A. Changing case Order to Optimise patterns of Performance in mammography Screening (CO-OPS): study protocol for a randomized controlled trial. Trials 2014; 15:17. [PMID: 24411004 PMCID: PMC3899604 DOI: 10.1186/1745-6215-15-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/09/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND X-ray mammography remains the predominant test for screening for breast cancer, with the aim of reducing breast cancer mortality. In the English NHS Breast Screening Programme each woman's mammograms are examined separately by two expert readers. The two readers read each batch in the same order and each indicates if there should be recall for further tests. This is a highly skilled, pressurised, repetitive and frequently intellectually unchallenging activity where readers examine one or more batches of 30-50 women's mammograms in each session. A vigilance decrement or performance decrease over time has been observed in similar repetitive visual tasks such as radar operation. METHODS/DESIGN The CO-OPS study is a pragmatic, multi-centre, two-arm, double blind cluster randomised controlled trial of a computer software intervention designed to reduce the effects of a vigilance decrement in breast cancer screening. The unit of randomisation is the batch. Intervention batches will be examined in the opposite order by the two readers (one forwards, one backwards). Control batches will be read in the same order as one another, as is current standard practice. The hypothesis is that cancer detection rates will be higher in the intervention group because each readers' peak performance will occur when examining different women's mammograms. The trial will take place in 44 English breast screening centres for 1 year and 4 months. The primary outcome is cancer detection rate, which will be extracted from computer records after 1 year of the trial. The secondary outcomes include rate of disagreement between readers (a more statistically powerful surrogate for cancer detection rate), recall rate, positive predictive value, and interval cancer rate (cancers found between screening rounds which will be measured three years after the end of the trial). DISCUSSION This is the first trial of an intervention to ameliorate a vigilance decrement in breast cancer screening. TRIAL REGISTRATION ISRCTN46603370 (submitted: 24 October 2012, date of registration: 26 March 2013).
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Faria R, McKenna C, Wade R, Yang H, Woolacott N, Sculpher M. The EOS 2D/3D X-ray imaging system: A cost-effectiveness analysis quantifying the health benefits from reduced radiation exposure. Eur J Radiol 2013; 82:e342-9. [DOI: 10.1016/j.ejrad.2013.02.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 02/05/2013] [Accepted: 02/08/2013] [Indexed: 11/26/2022]
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Health economic impact of risk group selection according to ASCO-recommended biomarkers uPA/PAI-1 in node-negative primary breast cancer. Breast Cancer Res Treat 2013; 138:839-50. [DOI: 10.1007/s10549-013-2496-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 03/20/2013] [Indexed: 10/27/2022]
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Adjuvant epirubicin followed by cyclophosphamide, methotrexate and fluorouracil (CMF) vs CMF in early breast cancer: results with over 7 years median follow-up from the randomised phase III NEAT/BR9601 trials. Br J Cancer 2012; 107:1257-67. [PMID: 23047592 PMCID: PMC3494422 DOI: 10.1038/bjc.2012.370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The National Epirubicin Adjuvant Trial (NEAT) and BR9601 trials tested the benefit of epirubicin when added to cyclophosphamide, methotrexate and 5-fluorouracil (E-CMF) compared with standard CMF in adjuvant chemotherapy for women with early breast cancer. This report details longer follow-up with interesting additional time-dependent analyses. METHODS National Epirubicin Adjuvant Trial used epirubicin (E) 3-weekly for four cycles followed by classical (c) CMF for four cycles (E-CMF) compared with cCMF for six cycles. BR9601 used E 3-weekly for four cycles followed by CMF 3-weekly for four cycles, compared with CMF 3-weekly for eight cycles. RESULTS In all, 2391 eligible patients were randomised and with a median 7.4-year follow-up, E-CMF confirmed a significant benefit over CMF in both relapse-free survival (RFS) (78% vs 71% 5 years RFS, respectively, hazard ratio (HR)=0.75 (95% CI: 0.65-0.86), P<0.0001) and overall survival (OS) (84% vs 78% 5 years OS, respectively, HR=0.76 (95% CI: 0.65-0.89), P=0.0007). Interaction of treatment effect and prognostic factors was demonstrated for duplication of chromosome 17 centromeric enumeration (Ch17CEP) as previously reported. Poor prognostic factors at diagnosis (ER and PR negative and HER2 positive) showed time-dependent annual hazard rates for RFS and OS. In univariate analysis, these factors demonstrated more favourable HRs for RFS after 5 years. Treatment effects also suggested a differential benefit for E-CMF within the first 5 years for poor prognosis tumours. CONCLUSION Longer follow-up has confirmed E-CMF as significantly superior to CMF for all patients. Ch17CEP duplication was the only biomarker that demonstrated significant treatment interaction. Standard poor prognostic factors at diagnosis were time-dependent, and after 5 years disease-free, poor prognosis patients demonstrated favourable HRs for survival.
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