Cost-effectiveness of anastrozole versus tamoxifen as first-line therapy for postmenopausal women with advanced breast cancer

Economic evaluations of oral medications for breast cancer treatment in the U.S.: a systematic review with a focus on cost-effectiveness threshold

Introduction: With the advent of targeted therapy, the U.S. Food and Drug Administration has recently approved several oral anticancer medications (OAMs) for breast cancer (BC). Despite the improved effectiveness of those OAMs, the high financial burden is an issue. Evidence from cost-effectiveness analysis (CEA) can provide valuable information for decision-makers when deciding whether to use these high-priced medications. Many CEAs on OAMs have been conducted using various analytical approaches and cost-effectiveness thresholds (CETs). However, there is no comprehensive systematic review of CEAs across all OAMs.Area covered: PubMed and Cochrane library were used to select for CEAs of OAM for BC in the U.S. published by May 2019. Among the 25 included studies, studies published between 1993 and 2011 analyzed either early BC (n = 11) or advanced/metastatic BC (n = 5), those between 2012-2019 analyzed advanced/metastatic BC (n = 9). Studies including targeted therapies were published after 2009. The CETs tended to increase over time and were higher in the studies for advanced/metastatic BC (median = $125,000) than those for early BC (median = $50,000).Expert commentary: The target population and medications of interest have changed and the methods of articles have evolved. The range of CETs tends to differ by study setting with an increase over time.

Cost-effectiveness analysis of ribociclib versus palbociclib in the first-line treatment of HR+/HER2- advanced or metastatic breast cancer in Spain

PURPOSE

The aim of this study was to evaluate the cost-effectiveness of ribociclib compared to palbociclib, both in combination with letrozole, in the first-line treatment of postmenopausal women with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) advanced or metastatic breast cancer (ABC) from the perspective of the Spanish National Health System (NHS).

PATIENTS AND METHODS

Disease progression was simulated with a partitioned survival model developed from the parameterization and extrapolation of survival curves of postmenopausal women with HR+/HER2- ABC from clinical trials with ribociclib or palbociclib, both in combination with letrozole. The model was structured on the basis of three health states (progression-free, progressed disease, and death), with a 1-month cycle length and inclusion of subsequent treatments administered for disease progression, over a time horizon of 15 years. Clinical, economic, and quality of life parameters were drawn from clinical trials and the literature. The use of resources and clinical practice in the Spanish setting was validated by a panel of experts. The Spanish NHS perspective was adopted, taking into account exclusively direct health costs from 2017 expressed in Euros. Drug prices used were the reported ex-factory prices. Uncertainty of the parameters and robustness of the results were evaluated using deterministic and probabilistic sensitivity analyses (2,000 iterations).

RESULTS

This cost-effectiveness analysis showed a greater benefit (0.437 and 0.285 life-years gained [LYGs] and quality-adjusted life years [QALYs] gained, respectively) and a slightly higher cost (€439.86) for ribociclib+letrozole compared to palbociclib+letrozole. The resulting incremental cost-effectiveness and cost-utility ratios were €1,007.69 per LYG and €1,543.62 per QALY gained, respectively. The results of the multiple sensitivity analyses showed limited dispersion of the outcomes, thus corroborating their robustness.

CONCLUSION

From the NHS perspective, considering the most commonly established willingness-to-pay thresholds in the Spanish setting, ribociclib+letrozole would represent a cost-effective therapeutic option compared to palbociclib+letrozole in the first-line treatment of HR+/HER2- ABC in postmenopausal women.

Cost-effectiveness analysis of fulvestrant versus anastrozole as first-line treatment for hormone receptor-positive advanced breast cancer

Although recent studies demonstrated that fulvestrant is superior to anastrozole as first-line treatment for hormone receptor (HR)-positive advanced breast cancer, the cost-effectiveness of fulvestrant versus anastrozole remained uncertain. Thus, the current study aimed to evaluate the cost-effectiveness of fulvestrant compared with anastrozole in the first-line setting. A Markov model consisting of three health states (stable, progressive and dead) was constructed to simulate a hypothetical cohort of patients with HR-positive advanced breast cancer. Costs were calculated from a Chinese societal perspective. Health outcomes were measured in quality-adjusted life-year (QALY). The incremental cost-effectiveness ratio (ICER) was expressed as incremental cost per QALY gained. Model results suggested that fulvestrant provides an additional effectiveness gain of 0.11 QALYs at an incremental cost of $32,654 compared with anastrozole, resulting in an ICER of $296,855/QALY exceeding the willingness-to-pay threshold of $23,700/QALY. Hence, fulvestrant is not a cost-effective strategy compared with anastrozole as first-line treatment for HR-positive advanced breast cancer.

Cost-utility analyses of drug therapies in breast cancer: a systematic review

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.

Considerations for payers in managing hormone receptor-positive advanced breast cancer

Breast cancer (BC) is the second most common cause of death in women. In 2010, the direct cost associated with BC care in the US was $16.5 billion, the highest among all cancers. By the year 2020, at the current rates of incidence and survival, the cost is projected to increase to approximately $20 billion. Although endocrine therapies to manage hormone receptor-positive (HR+) BC are highly effective, endocrine resistance results in disease progression. Increased understanding of endocrine resistance and the mechanisms of disease progression has led to development and subsequent approval of novel targeted treatments, resulting in the expansion of the therapeutic armamentarium to combat HR+ BC. Clear guidelines based on the safety and efficacy of treatment options exist; however, the optimal sequence of therapy is unknown, and providers, payers, and other key players in the health care system are tasked with identifying cost-effective and evidence-based treatment strategies that will improve patient outcomes and, in time, help curb the staggering increase in cost associated with BC care. Safety and efficacy are key considerations, but there is also a need to consider the impact of a given therapy on patient quality of life, treatment adherence, and productivity. To minimize cost associated with overall management, cost-effectiveness, and financial burden that the therapy can impose on patients, caregivers and managed care plans are also important considerations. To help evaluate and identify the optimal choice of therapy for patients with HR+ advanced BC, the available data on endocrine therapies and novel agents are discussed, specifically with respect to the safety, efficacy, financial impact on patients and the managed care plan, impact on quality of life and productivity of patients, and improvement in patient medication adherence.

An economic evaluation of colesevelam when added to metformin-, insulin- or sulfonylurea-based therapies in patients with uncontrolled type 2 diabetes mellitus

BACKGROUND

Several early studies demonstrated that bile acid sequestrants were useful for lowering lipid levels in patients with hypercholesterolaemia and may also be useful for lowering glucose levels in patients with type 2 diabetes mellitus (T2DM) uncontrolled on existing treatment (metformin-, insulin- or sulfonylurea-based therapies).

OBJECTIVE

This study modelled efficacy and safety data from the three clinical trials to evaluate the cost effectiveness to US Managed Care Organizations of add-on treatment with colesevelam for reducing diabetes-related complications.

METHODS

Three randomized controlled trials in patients with T2DM and one in hyperlipidaemia established that colesevelam lowered both glycaemic and lipid parameters in adult patients participating in the studies. The validated 'diabetic risk equation' (DRE) and the 'LIPID cardiovascular risk equation' (LCRE) were used to translate the observed clinical benefits (surrogate markers related to T2DM [glycosylated haemoglobin {HbA(1c)} and fasting plasma glucose] and cardiovascular disease [low-density lipoprotein cholesterol {LDL-C}]). Performing an appropriate economic evaluation required the use of both the DRE and the LCRE. These equations parameterize the clinical efficacy measures as continuous, facilitating their application to clinical trial results as well as the replication of other well established epidemiological data. Tobit regressions were applied to a large commercially available managed care administrative claims database (2000-6), Integrated Health Care Services (IHCS), to evaluate the incremental costs associated with each type of diabetic complication. Costs were inflated to 2010 values using the Healthcare Consumer Price Index, while second- and third-year cost savings were discounted at 5% to the current year. Bootstrap sampling with 5000 samples of 100 patients per cohort was conducted, varying the number of events avoided as well as their associated cost.

RESULTS

With established metformin-, insulin- or sulfonylurea-based therapies, the addition of colesevelam significantly reduced HbA(1c) by approximately 0.5% (p < 0.001) in all three studies. In addition, colesevelam reduced placebo-adjusted LDL-C by 12.8-16.7% (p < 0.001). Using the DRE and LCRE equations, the total savings from reductions in diabetes-related and cardiovascular events were $US3543, $US4074 and $US3855 for colesevelam added to metformin-, insulin- and sulfonylurea-based regimens in patients with normal lipid levels. After subtracting the cost of colesevelam, first-year savings were $US1326, $US1852 and $US1629 in the metformin, insulin and sulfonylurea studies, respectively, for patients with raised lipid levels.

CONCLUSIONS

In adult patients with T2DM, the addition of colesevelam to metformin-, insulin- or sulfonylurea-based therapies significantly improves glycaemic control while also reducing LDL-C, and these improvements could translate into substantial cost reductions due to reductions in the rates of diabetes-related and cardiovascular complications.

Comparative economic analysis of aromatase inhibitors and tamoxifen in the treatment of hormone-dependent breast cancer

Within the past 2 years three separate groups reported marked improvements in relapse-free survival when trastuzumab was added to adjuvant chemotherapy in patients with HER2-overexpressing breast cancer. Notwithstanding the significance of this molecular target, the discovery of the estrogen receptor (ER) may be of even greater importance. Although tamoxifen has long been considered the hormonal therapy of choice for patients with estrogen-responsive breast cancer, accumulating clinical data suggest the new generation of aromatase inhibitors (AIs) is more effective and less toxic. With the availability of new information, guidelines have been updated and reformulated regarding the use of AIs as first-line hormonal therapy in postmenopausal women with ER-positive breast cancer. This paper, a product of the ongoing advances in oncology, incorporates two distinct, yet important, features of oncology; first, clinical concepts related to hormone-dependent breast cancer and second, pharmacoeconomic evaluation of the antiestrogen tamoxifen and the new generation of antiaromatase agents.

Pharmacoeconomic analysis of adjuvant therapy with exemestane, anastrozole, letrozole or tamoxifen in postmenopausal women with operable and estrogen receptor-positive breast cancer

OBJECTIVE

To compare the efficiency of adjuvant therapy with aromatase inhibitors or with tamoxifen in postmenopausal women with operable breast cancer and positive estrogen receptors.

MATERIAL AND METHODS

A cost-utility analysis was performed based on a Markov model, from the Spanish National Health Care System perspective, comparing the treatment with exemestane (EXE: 25 mg/day) or tamoxifen (TAM: 20 mg/day) after 2-3 years of monotherapy with TAM; anastrozole (ANA, 1 mg/day) or TAM (20 mg/day) without previous TAM therapy; and letrozole (LET: 2.5 mg/day) or placebo after 5 years of monotherapy with TAM. The follow-up of a hypothetical cohort of women starting treatment at 63 years of age was simulated during 10 and 20 years. The probabilities of transition between health states and quality adjusted life years (QALYs) were obtained from the literature, and the unit costs (euro corresponding to 2004) from a Spanish database.

RESULTS

After 10 and 20 years of follow-up, more QALYs per patient would be gained with the EXE scheme (0.230-0.286 and 0.566-0.708, respectively) than with ANA (0.114 and 0.285) and LET (0.176 and 0.474). The cost of gaining one QALY was lower with the EXE scheme (50,801-62,522 euro and 28,849- 35,371 euro, respectively) than with ANA (104,272 euro and 62,477 euro) and LET (91,210 euro and 49,460 euro). The result was stable for the cost per life-year gained (LYG) and in the sensitivity analysis.

CONCLUSIONS

The EXE scheme after TAM is more cost-effective than the ANA and LET schemes.

Review of cost-effectiveness analyses in hormonal therapies in advanced breast cancer

Many new cancer treatments that slow progression and extend survival are emerging. These advances bring new hope to patients and physicians, but often increase health expenditures in an already cost-conscious environment. To help guide resource allocation decisions, cost-effectiveness models are constructed to compare the costs and outcomes of new treatments with current options, and to encourage the uptake of new technologies. This study focuses on the cost-effectiveness studies published since 1997 for hormonal treatment options in advanced breast cancer. This paper: i) examines the quality of studies in terms of reporting methods and transparency of the models; ii) compares the calculated cost-effectiveness ratios; and iii) makes recommendations for future cost-effectiveness models in advanced breast cancer.

Role of Quality of Life in Men with Metastatic Hormone-Refractory Prostate Cancer: How Does Atrasentan Influence Quality of Life?

OBJECTIVE

Progression of hormone-refractory prostate cancer (HRPC) is associated with skeletal complications and bone pain, which contribute to deterioration in quality of life (QOL). The effects of new HRPC therapies on patients' QOL need to be studied. Patient-based assessments that help quantify the risk-benefit profile of HRPC therapies are warranted. This review summarizes the known QOL literature and estimates the potential effect of atrasentan, a novel, selective endothelin A receptor antagonist (SERA), on the QOL of HRPC patients.

METHODS

Published studies were identified through a structured, detailed literature review. Clinical studies that report QOL data were reviewed, along with recent QOL data from atrasentan studies.

RESULTS

HRPC studies have begun to use QOL assessments as primary endpoints, but different assessments and therapies are not comparable. Very few data integrate QOL with clinical endpoints. Atrasentan clinical trials demonstrated a statistically significant difference in the prostate cancer-specific QOL in favor of atrasentan (p=.032) and an increased quality-adjusted time to progression in men with HRPC.

CONCLUSIONS

Atrasentan provides QOL benefits relevant to HRPC. The quality-adjusted analyses applied in the atrasentan studies have begun to lay the foundation for interpreting clinical endpoints in conjunction with QOL. These analyses will facilitate better QOL comparisons within studies and across trials. Further evaluation of atrasentan in HRPC is warranted.

The state of cost-effectiveness analysis in American managed care

In 1996, the US Panel on Cost-Effectiveness in Health and Medicine published detailed recommendations for the conduct and use of cost-effectiveness analyses (CEA) of medical technologies. These recommendations were expected to promote the use of CEA to inform the resource allocation decisions of a diverse audience including, among others, American managed care organizations. Yet, nearly 10 years later, the limited explicit use of CEA in the USA remains a prominent discussion topic, with few signs of resolution. Its limited use within managed care is especially striking given the industry's stated interest in efficient healthcare and historically unstable finances in the face of continually rising healthcare costs.