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Wu VS, Khlopin M, Chadha M, Smith-Graziani DJ, Jagsi R, McClelland S. Out-of-Pocket Cost Modeling of Adjuvant Antiestrogen and Radiation Therapy After Lumpectomy for Early-Stage Breast Cancer Across Medicaid and Medicare Plans. Int J Radiat Oncol Biol Phys 2024; 119:1379-1385. [PMID: 38432284 DOI: 10.1016/j.ijrobp.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/11/2024] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The optimal adjuvant therapy (antiestrogen therapy [ET] + radiation therapy or ET alone, or in some reports radiation therapy alone) in older women with early-stage breast cancer has been highly debated. However, granular details on the role of insurance in the out-of-pocket cost for patients receiving ET with or without radiation therapy are lacking. This project disaggregates out-of-pocket costs by insurance plans to increase treatment cost transparency. METHODS AND MATERIALS Several radiation therapy schedules are accepted standards as per the National Comprehensive Cancer Network guidelines. For our financial estimate model, we used the 5-fraction and 15-fraction radiation therapy and ET prescribed over a 5-year duration. The total aggregate out-of-pocket costs were determined from the sum of treatment costs, deductibles, and copays/coinsurance based on Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx plans. The model assumes a Medicare- and/or Medicaid-eligible patient ≥70 years of age with node-negative, early-stage estrogen-receptor-positive breast cancer. Patient out-of-pocket costs were estimated from publicly available insurance data from plan-specific benefit coverage materials using a 5-year time horizon. RESULTS Original Medicare beneficiaries face a total out-of-pocket treatment charge of $2738.52 for ET alone, $2221.26 for 5-fraction radiation therapy alone, $2573.92 for 15-fraction radiation therapy alone, $3361.26 for combined ET+ 5-fraction radiation therapy, and $3713.92 for combined ET + 15-fraction radiation therapy. Medigap Plan G beneficiaries have an out-of-pocket charge of $1130.00 with radiation therapy alone and face an out-of-pocket of $2270.00 for ET alone and combined ET+ radiation therapy. For Medicaid beneficiaries, all treatments approved by Medicaid are covered without limit, resulting in no out-of-pocket expense for either adjuvant treatment option. CONCLUSIONS This model (based on actual cost estimates per insurance plan rather than claims data), by estimating expenses within Medicare and Medicaid plans, provides a level of transparency to patient cost. With knowledge of the costs borne by patients themselves, treatment decisions informed by patients' individual priorities and preferences may be further enhanced.
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Affiliation(s)
- Victoria S Wu
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Martha Khlopin
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Manjeet Chadha
- Department of Radiation Oncology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Demetria J Smith-Graziani
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Reshma Jagsi
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Shearwood McClelland
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio; Department of Neurological Surgery, University Hospitals Cleveland Medical Center Case Western Reserve University, Cleveland, Ohio.
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [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: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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Lee W, Carlson JJ, Basu A, Veenstra D. Quantifying the value of older adult-specific clinical trials: Post-lumpectomy irradiation among older adults with early-stage breast cancer. J Geriatr Oncol 2023; 14:101487. [PMID: 37075565 DOI: 10.1016/j.jgo.2023.101487] [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: 07/08/2022] [Revised: 02/26/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Although there is increasing interest in conducting cancer clinical trials in older adults, the benefit of such trials is unclear. We aimed to quantify the real-world clinical and economic effects of two phase 3 trials (CALGB 9343 and PRIME II) which showed that post-lumpectomy radiation therapy (RT) improves loco-regional recurrence but makes no improvement in overall survival among older women with early-stage breast cancer (ESBC). MATERIALS AND METHODS We developed a health-transition model to quantify the incremental clinical and economic outcomes between scenarios with vs. without older adult-specific trial results from a societal perspective between 2004 and 2018. The transition probabilities in the model were mainly derived from the 10-year results of CALGB 9343. The total number of the affected patient population in the US and the change in the probability of omitting post-lumpectomy RT due to the CALGB 9343 and PRIME II results were derived from a retrospective analysis of the SEER registry data for patients with ESBC. Sensitivity analyses were conducted to calculate the 95% credible interval (CR) of the incremental clinical and economic outcomes between the two scenarios. RESULTS Between 2004 and 2018, 32,936 (95% CR: 31,512, 34,357) fewer patients received post-lumpectomy RT among those aged 70 years or older diagnosed with ESBC in the US and there was a decrease cost of $419 M USD (95% CR: -$238 M, -$689 M) in scenarios with vs. without older adult-specific trial results. The difference in projected life years (1083 years, 95% CI: -2542, 7985) and QALYs (866 years, 95% CI: -2561, 7780) were not significant. At a willingness-to-pay threshold of $100 k/QALY, the probability of older adult-specific trial results generating a positive net monetary benefit was 98%. DISCUSSION The CALGB 9343 and PRIME II trial results were associated with a substantial cost-saving in the US society. Our results suggest that older adult-specific clinical trials that demonstrate no survival benefit of an intervention in older adults could be correlated with a significant monetary benefit. Further case studies are needed for different types of older adult-specific trials to understand the value of older adult-specific trials comprehensively.
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Affiliation(s)
- Woojung Lee
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA.
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
| | - David Veenstra
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
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Chen X, Yang Z, Xiang G, Gu L, Qi Z, Wan B, Lu Y, Chang F, Zhu Y. Durvalumab consolidation therapy in patients with stage III non-small cell lung cancer after concurrent chemoradiation: a China-based cost-effectiveness analysis. Expert Rev Pharmacoecon Outcomes Res 2021; 22:647-654. [PMID: 34643129 DOI: 10.1080/14737167.2022.1993062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of durvalumab in post-chemoradiotherapy patients with unresectable stage III NSCLC from the Chinese healthcare system perspective. METHODS The study developed a five-health state Markov model to evaluate the cost-effectiveness of durvalumab consolidation therapy in post-chemoradiotherapy patients based on the PACIFIC clinical trial. Sensitivity and scenario analyses were performed to evaluate the model uncertainty. RESULTS Durvalumab consolidation therapy provided an additional 1.22 quality-adjusted life-years (QALYs), with an incremental cost of $24,397 compared to no consolidation therapy in unselected patients. Durvalumab consolidation therapy was cost-effective as it yielded an incremental cost-effectiveness ratio (ICER) of $20,000 per QALY gained at a willingness-to-pay (WTP) threshold of $31,494 per QALY. In the patient subgroup with PD-L1-expressing tumors (≥1%), durvalumab was associated with an ICER of $33,058/QALY, resulting in a slight skewing away from the given cost-effectiveness threshold. The sensitivity analysis showed that ICERs were most sensitive to the cost of durvalumab, the cost of pembrolizumab, and the body weight of patients, regardless of PD-L1 expression selection. CONCLUSION Durvalumab consolidation therapy is likely to be cost-effective in China, which indicates that expensive immunotherapies can gain clinical benefits at a justifiable cost in developing countries as well.
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Affiliation(s)
- Xuan Chen
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Zhiguang Yang
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China.,Department of Healthcare Reform, National Health Commission of the People's Republic of China, Beijing, China
| | - Guiyuan Xiang
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Lingna Gu
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Ziheng Qi
- Nanjing Foreign Language School, Nanjing, China
| | - Bin Wan
- Department of Health Insurance Management, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yun Lu
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Feng Chang
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
| | - Yumei Zhu
- School of International Pharmaceutical Business, China Pharmaceutical University, Jiangsu, China
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