Advanced breast cancer: use of resources and cost implications

JMJD family proteins in cancer and inflammation

The occurrence of cancer entails a series of genetic mutations that favor uncontrollable tumor growth. It is believed that various factors collectively contribute to cancer, and there is no one single explanation for tumorigenesis. Epigenetic changes such as the dysregulation of enzymes modifying DNA or histones are actively involved in oncogenesis and inflammatory response. The methylation of lysine residues on histone proteins represents a class of post-translational modifications. The human Jumonji C domain-containing (JMJD) protein family consists of more than 30 members. The JMJD proteins have long been identified with histone lysine demethylases (KDM) and histone arginine demethylases activities and thus could function as epigenetic modulators in physiological processes and diseases. Importantly, growing evidence has demonstrated the aberrant expression of JMJD proteins in cancer and inflammatory diseases, which might serve as an underlying mechanism for the initiation and progression of such diseases. Here, we discuss the role of key JMJD proteins in cancer and inflammation, including the intensively studied histone lysine demethylases, as well as the understudied group of JMJD members. In particular, we focused on epigenetic changes induced by each JMJD member and summarized recent research progress evaluating their therapeutic potential for the treatment of cancer and inflammatory diseases.

De-escalation of bone-modifying agents in patients with bone metastases from breast cancer: a systematic review and meta-analysis

PURPOSE

Bone-modifying agents (BMAs) such as bisphosphonates and denosumab are usually administered every 4 weeks (standard) in patients with bone metastases from breast cancer to prevent skeletal-related events (SREs). Recent randomized controlled trials suggest every 12-week (de-escalated) dosing interval may be non-inferior. The objective of this systematic review and meta-analysis was to compare the efficacy and harms of standard with de-escalated administration of BMA's in patients with bone metastases from breast cancer.

METHODS

We searched Medline, PubMed, and the Cochrane Register of Controlled Trials from 1947 to March 14, 2018 and conference abstracts from (2014-March 14, 2018) for randomized clinical trials comparing every 4-week and every 12-week dosing interval of bone-modifying agents. Using PRISMA guidelines, meta-analyses were performed using random-effects models, with findings reported as risk ratios with 95% confidence intervals (CI).

RESULTS

From a total of 1311 citations, we identified 8 full-text articles and 1 abstract comprising data from 5 completed randomized clinical trials (n = 1807). Zoledronate administration every 12 weeks compared to every 4 weeks produced a summary risk ratio of 1.05 (95% CI 0.88-1.25) for patients with ≥ 1 on-study SRE indicating similar efficacy. These results did not differ whether patients had received prior intravenous bisphosphonate. De-escalation was associated with a non-statistically significant lower risk of increased creatinine (summary risk ratio 0.41 [95% CI 0.15-1.16]). Currently, there are insufficient data for pamidronate and denosumab de-escalation.

CONCLUSIONS

These data are supportive of de-escalation of zoledronate from onset for patients with bone metastases from breast cancer.

Multidisciplinary Approach to the Treatment of Bone Metastases: Osteo-Oncology Center, a New Organizational Model

Aims and background

Bone metastases are responsible for high morbidity in cancer patients. The frequency of pain and other serious complications associated with such metastases depends on the site and type of lesions and preventive therapy. The present paper aims to inform the scientific community about a new organizational health care model specifically designed for patients with bone metastases, in the hope of stimulating the creation of similar initiatives whose goals are to decrease the high morbidity of this pathology, reduce the frequency of complications, limit psychophysical distress of patients, and improve quality of life.

Methods

In January 2005, an Osteo-Oncology Center was opened in our institute to provide multidisciplinary care (19 specialists involved) for patients with bone metastases, to train physicians, and to conduct research in the field.

Results

In its first three years of activity, 601 multidisciplinary team consultations were made and a total of 425 patients were seen. The most frequent primary tumor site was the lung in males and the breast in females. Upon presentation at the Center, 79% of patients reported experiencing a level of pain (median pain intensity, 3.69) that interfered with normal daily activities. An anonymous questionnaire was also completed on the quality of the service provided: 75% of patients were very satisfied, 23% were satisfied, 1% responded “I don't know”, and only 1% expressed dissatisfaction.

Conclusions

Our preliminary results confirm the usefulness of a multidisciplinary center for the management of patients with bone metastases, especially in terms of decreasing psychophysical suffering.

Metastatic Bone Disease in the Era of Bone-Targeted Therapy: Clinical Impact

Advances in the diagnosis and treatment of tumors by surgery, chemotherapy, biotherapy, radiotherapy and other modalities have increased the survival of cancer patients over the last 20 years. As a consequence, bone now represents the third most common site of metastatic involvement after the lung and liver. Approximately 20–25% of patients with neoplastic disease develop clinically evident bone metastases (BMs) during the natural course of their illness, with a further 50% of such lesions being identified during autopsy. BMs are the major cause of morbidity in cancer patients because of their epidemiological and clinical impact. Pain is the most frequent symptom in about 75% of patients but other serious complications can also occur, such as pathological fractures, spinal cord compression, hypercalcemia and bone marrow suppression. These complications worsen the patient's general condition and reduce patients’ mobility, facilitating the development of lung infections, skin ulcers, deep vein thrombosis, etc., and ultimately reducing prognosis and quality of life. The frequency of serious complications depends on the site and type of lesions and the treatment administered. Over the last 10 years, the introduction of bisphosphonates for the treatment of patients with BMs has led to a marked decrease in the frequency of complications, thus improving quality of life and clinical outcome. Furthermore, progress in understanding the pathophysiology of bone metastases has resulted in the development of new bone-targeted molecules such as denosumab. We therefore felt it would be useful to report on the epidemiological, clinical and economic impact of bone disease in a cancer setting.

Hospital resource utilization and treatment cost of skeletal-related events in patients with metastatic breast or prostate cancer: estimation for the Portuguese National Health System

BACKGROUND

Skeletal-related events (SREs) occur frequently in patients with bone metastases as a result of breast (BC) and prostate (PC) cancers. They increase both morbidity and mortality and lead to extensive health-care resource utilization.

METHODS

Health care resource utilization by BC/PC patients with at least one SRE during the preceding 12 months was assessed through retrospective chart review. SRE-treatment costs were estimated using the Portuguese Ministry of Health cost database and analyzed using generalized linear models.

RESULTS

This study included 152 patients from nine hospitals. The mean (SD) annual SRE-treatment cost per patient was €5963 (€3646) and €5711 (€4347), for BC (n=121) and PC (n=31) patients, respectively. Mean cost per single episode ranged between €1485 (radiotherapy) and €13,203 (spinal cord compression). Early onset of bone metastasis (P = 0.03) and diagnosis of bone metastases at or after the occurrence of the first SRE (P < 0.001) were associated with higher SRE-treatment costs.

CONCLUSION

These results reveal the high hospital SRE-treatment costs, highlighting the need for early diagnosis and treatment, and identify key factors determining the economic value of therapies for patients with skeletal metastases.

Cost-effectiveness of early detection of breast cancer in Catalonia (Spain)

Background

Breast cancer (BC) causes more deaths than any other cancer among women in Catalonia. Early detection has contributed to the observed decline in BC mortality. However, there is debate on the optimal screening strategy. We performed an economic evaluation of 20 screening strategies taking into account the cost over time of screening and subsequent medical costs, including diagnostic confirmation, initial treatment, follow-up and advanced care.

Methods

We used a probabilistic model to estimate the effect and costs over time of each scenario. The effect was measured as years of life (YL), quality-adjusted life years (QALY), and lives extended (LE). Costs of screening and treatment were obtained from the Early Detection Program and hospital databases of the IMAS-Hospital del Mar in Barcelona. The incremental cost-effectiveness ratio (ICER) was used to compare the relative costs and outcomes of different scenarios.

Results

Strategies that start at ages 40 or 45 and end at 69 predominate when the effect is measured as YL or QALYs. Biennial strategies 50-69, 45-69 or annual 45-69, 40-69 and 40-74 were selected as cost-effective for both effect measures (YL or QALYs). The ICER increases considerably when moving from biennial to annual scenarios. Moving from no screening to biennial 50-69 years represented an ICER of 4,469€ per QALY.

Conclusions

A reduced number of screening strategies have been selected for consideration by researchers, decision makers and policy planners. Mathematical models are useful to assess the impact and costs of BC screening in a specific geographical area.

Health care costs for the treatment of breast cancer recurrent events: estimates from a UK-based patient-level analysis

Cost pressures and the need to demonstrate cost-effectiveness of new interventions require consideration of the costs of treating disease. This study presents analyses of resource use data covering 199 postmenopausal women who experienced a breast cancer recurrent event between 1991 and 2004 and were treated at the Western General Hospital, Edinburgh. Aggregate (5-year) treatment costs for alternative recurrent events were estimated, as well as the annual costs incurred by patients experiencing contralateral, locoregional, or distant recurrence, who remained alive without further recurrence for a year. The 95% confidence intervals for the 5-year costs of recurrence ranged from pounds 10,000 to pounds 37,000 for locoregional recurrence, and pounds 14,500- pounds 20,000 for distant recurrence. No evidence of significant variations in these costs across time periods between 1991 and 2004 was identified. Annual costs for patients remaining in the same health state showed high initial costs for contralateral and locoregional recurrence, with low costs in subsequent years, while costs associated with distant recurrence declined at a slower rate and plateaued at 4-5 years post-diagnosis. The cost estimates presented in this paper not only inform the magnitude of the resource consequences of breast cancer recurrences, but they are also better suited to informing cost-effectiveness analyses, which have a far greater role in allocating health-care resources.

Resource utilization for ovarian cancer patients at the end of life: How much is too much?

OBJECTIVE

End-of-life (EOL) medical care consumes 10-12% of national health care expenditures and 27% of Medicare dollars annually. Studies suggest that hospice services decrease EOL expenditures by 25-40%. The goal of this study was to compare the total cost of hospital-based resources utilized in ovarian cancer patients during their last 60 days of life for those enrolled in hospice versus those not on hospice.

METHODS

Study eligibility included patients who expired from ovarian cancer from 1999 to 2003. Medical records were reviewed for demographic data as well as treatment, response and recurrence rates, histologic type, grade and stage. Billing records were analyzed for costs of inpatient and outpatients visits, including radiologic, laboratory and pharmacy charges. Total cost of hospital resources was compared between patients managed on hospice for >10 days (hospice group) versus <10 days (non-hospice group) using the following methods: Mann-Whitney U, Kruskal-Wallis and Student's t tests. Overall survival was compared using Kaplan-Meier statistics.

RESULTS

Of the 84 patients analyzed, 67 (79.8%) were in the non-hospice group and 17 (20.2%) were in the hospice group. Demographic, histologic and staging characteristics as well as platinum sensitivity were similar between the two groups before the last 60 days of life. Mean number of chemotherapy cycles before the study period was also similar (20.4 and 21.0, respectively). However, during the study period, the mean total cost per patient in the non-hospice group was dollar 59,319 versus dollar 15,164 in the hospice group (P = 0.0001). A significant difference in cost was noted for mean inpatient days (dollar 6584 vs. dollar 1629, P = 0.0007), radiology (dollar 6063 vs. dollar 2343, P = 0.003), laboratory (dollar 12,281 vs. dollar 2026, P = 0.0004) and pharmacy charges (dollar 13,650 vs. dollar 4465, P = 0.0017) as well as for treating physician per patient (dollar 112,707 vs. dollar 34,677, P = 0.04). Overall survival for the two groups was the same.

CONCLUSIONS

Our findings demonstrate that there is a significant cost difference with no appreciable improvement in survival between ovarian cancer patients treated aggressively versus those enrolled in hospice at the EOL. These data suggest that earlier hospice enrollment is beneficial. Furthermore, cost variations between physicians and patients imply that education may be an important variable.

Cyclophosphamide-methotrexate 'metronomic' chemotherapy for the palliative treatment of metastatic breast cancer. A comparative pharmacoeconomic evaluation

BACKGROUND

Metronomic chemotherapy-the chronic administration of chemotherapy at relatively low, minimally toxic doses on a frequent schedule of administration at close regular intervals, with no prolonged drug-free breaks-is a potentially novel approach to the control of advanced cancer disease. It is thought to work primarily through antiangiogenic mechanisms and has, as an advantage, the property of significantly reducing undesirable toxic side-effects. The aim of the present study was to evaluate the cost effectiveness of cyclophosphamide-methotrexate 'metronomic' chemotherapy in the palliative treatment of pretreated metastatic breast cancer.

METHODS

Low-dose cyclophosphamide-methotrexate 'metronomic' chemotherapy was compared with outcome and resource utilisation data of published phase II trials regarding metastatic breast cancer, performed in western countries, mostly in Europe. All direct costs associated with metastatic breast cancer treatment were included and adjusted to year 2003 values. Sensitivity analyses were performed and variations to the values of key parameters were assessed.

RESULTS

Low-dose cyclophosphamide-methotrexate 'metronomic' therapy was assessed to be a cost-effective/cost-saving therapy for palliative treatment for metastatic breast cancer when compared with novel chemotherapy strategies (phase II trials). Compared with the 11 phase II mono- and combination chemotherapies, metronomic treatment showed marked cost savings in each case and improved cost effectiveness. Sensitivity analyses showed the results were robust to variations to the values of key parameters with very few exceptions.

CONCLUSIONS

Metronomic cyclophosphamide-methotrexate is significantly cost effective. If validated by prospective randomized trials, the treatment concept could reduce healthcare costs, especially those associated with the combined use of new, highly expensive, molecularly targeted therapies.

Pharmacological management of metastatic boney pain

Many malignancies metastasise to the skeleton. This often results in a relatively unique pain process, which dramatically affects a patient's quality of life. With one in three members of the population likely to develop cancer at some stage in their lives, the prevalence of bone metastases is high. Despite the large financial investment on therapies for these patients, treatment is still suboptimal. In this article, the various treatments available are reviewed. Opiates and bisphosphonates, the mainstays in current practise, are covered in detail, and evolving therapies that may shape future management are also discussed.

Role of bone scintigraphy and tumor marker-Ca 15-3 in detection of bone metastases in patients with breast cancer

Breast cancer is one of the most frequent types of cancer affecting women. After hematogenous spreading of cancer, axial skeleton is most frequently involved. Bone scintigraphy is commonly performed in detection and evaluation of bone metastases. In breast cancer, marker Ca 15-3 is widely accepted in follow-up and detection of disease recurrence. Aim of the study was to correlate levels of tumor marker Ca 15-3 and presence of bone metastases detected by bone scintigraphy. Study included 25 patients with breast cancer, previously surgically treated. All patients underwent total body scintigraphy. Ca 15-3 was measured by radioimmunoassay. Presence, number and location of bone metastases were correlated with Ca 15-3 levels. Bone scintigraphy revealed bone metastases in 16 (64%) patients. 11 (44%) patients with metastases and 1 patient (4%) without scintigraphically visible metastases had elevated Ca 15-3 levels. Significant difference in distribution of metastases was found for spine (t=3.930, p=0.008). Correlation between intensity of radiopharmaceutical uptake and level of Ca 15-3 in patients was positive (r =0.405). A weak correlation was found between number of metastases and level of Ca 15-3 (r=0.139). Significant differences in Ca 15-3 level was found in patients with metastases compared to patients without metastases (chi square 0, p =1.0). Since no significant correlation was found between level of Ca 15-3 and number of metastases, we consider scintigraphy an appropriate method for assessment of bone metastases in breast cancer.

Costs and effects of ultrasonography in the evaluation of palpable breast masses

OBJECTIVE

To study the costs and effects of incorporating ultrasonography in the triple assessment of palpable breast masses.

METHODS

A decision analytic model was designed to compare a conventional strategy of performing fine-needle aspiration cytology after clinical examination and mammography, with three different experimental strategies of preceding ultrasonography. Empirical data were used from a prospective study in 522 breasts in 492 patients with a palpable mass, including 93 malignancies. In strategy 1, cases with probably benign, suspect malignant, and malignant ultrasonography results were referred for fine-needle aspiration cytology; in strategy 2, benign cases were also referred for fine-needle aspiration cytology; and in strategy 3, ultrasonography was only performed in patients with benign results on clinical examination and mammography, whereas immediate fine-needle aspiration cytology was performed in patients with suspicious lesions. Outcome variables included the total costs and the expected number of life years. Sensitivity analysis was performed on all parameters in the model.

RESULTS

All strategies reported a similar life expectancy of 31.0 years. Cost-minimization demonstrated that experimental strategy 3 was the least expensive strategy (3013 Euro). Experimental strategy 2 was the most costly one (3512 Euro). Compared with the conventional strategy of immediate fine-needle aspiration cytology (3087 Euro), both ultrasonography strategies 1 and -3 were preferred.

CONCLUSIONS

Incorporating ultrasonography in the triple assessment of palpable breast masses can result in a reduction of the total costs for the diagnosis and treatment of breast cancer.

Cost of managing women presenting with stage IV breast cancer in the United Kingdom

This study estimated lifetime cost of treatment for patients in the United Kingdom (UK) presenting with stage IV breast cancer. To determine patterns of treatment and resource use in the absence of direct observational data, a cancer physician panel was surveyed. The survey questionnaire described four predefined treatment phases: active treatment; follow-up after active treatment until disease progression; active supportive care after progression; and end-of-life care. Physicians were asked their major treatment strategies for each phase. Monthly cost and average lifetime cost per patient were calculated. Only five cancer registries in the UK document the proportion of breast cancer patients diagnosed with stage IV disease. Their data was used to estimate the incidence of metastatic breast cancer at presentation throughout the UK. This value, together with lifetime cost per patient and projected survival time, allowed approximation of the overall cost for this population of cancer patients in the UK. Annual incidence of stage IV breast cancer at presentation in the UK is approximately 2100; according to treatment practice in 2002, lifetime cost per patient is pound 12 500 and total population cost is approximately pound 26 million. The substantial economic burden associated with patients diagnosed with metastatic breast cancer should be considered when developing strategies for reducing its incidence such as increased awareness, screening and preventative measures.

Achieving change in the NHS: a study to explore the feasibility of a home-based cancer chemotherapy service

A major focus of current health policy in the United Kingdom is the development of services that meet the public's expectations. To achieve this there is a need to evaluate current provision to ensure that the best use is made of finite resources. The study reported here adopted an interview approach to examine an existing outpatient chemotherapy service, and to consider the feasibility of introducing a home based model. Following a review of literature on this topic data were obtained from in-depth interviews with patients and professionals regarding the present service. These were then combined with an analysis of service contracts and financial estimates. The poor quality of much of the cost-related information limited the conclusions which could be drawn, and emphasised the need for access to more accessible and robust financial information upon which to base change. The study also illustrated the benefits of feasibility studies; especially when cost-effectiveness and patient satisfaction are the driving forces behind proposed changes to clinical services.

Bone resorption predicts for skeletal complications in metastatic bone disease

Relationships between the rate of bone resorption (measured by urinary N-telopeptide (Ntx) excretion) and a range of skeletal complications have been evaluated in patients with metastatic bone disease. A total of 121 patients had monthly measurements of Ntx during treatment with bisphosphonates. All skeletal-related events, plus hospital admissions for bone pain and death during the period of observation, were recorded. Data were available for 121 patients over the first 3-month period of monitoring (0-3 months) and 95 patients over the second 3-month period (4-6 months). N-telopeptide levels were correlated with the number of skeletal-related events and/or death (r=0.62, P<0.001 for 0-3 months and r=0.46, P<0.001 for 4-6 months, respectively). Patients with baseline Ntx values > or =100 nmol mmol(-1) creatinine (representing clearly accelerated bone resorption) were 19.48 times (95% CI 7.55, 50.22) more likely to experience a skeletal-related event/death during the first 3 months than those with Ntx <100 (P<0.001). In a multivariate logistic regression model, Ntx was highly predictive for events/death. This study is the first to indicate a strong correlation between the rate of bone resorption and the frequency of skeletal complications in metastatic bone disease. N-telopeptide appears useful in the prediction of patients most likely to experience skeletal complications and thus benefit from bisphosphonate treatment.

Bone resorption predicts for skeletal complications in metastatic bone disease

Relationships between the rate of bone resorption (measured by urinary N-telopeptide (Ntx) excretion) and a range of skeletal complications have been evaluated in patients with metastatic bone disease. A total of 121 patients had monthly measurements of Ntx during treatment with bisphosphonates. All skeletal-related events, plus hospital admissions for bone pain and death during the period of observation, were recorded. Data were available for 121 patients over the first 3-month period of monitoring (0–3 months) and 95 patients over the second 3-month period (4–6 months). N-telopeptide levels were correlated with the number of skeletal-related events and/or death (r=0.62, P<0.001 for 0–3 months and r=0.46, P<0.001 for 4–6 months, respectively). Patients with baseline Ntx values ⩾100 nmol mmol⁻¹ creatinine (representing clearly accelerated bone resorption) were 19.48 times (95% CI 7.55, 50.22) more likely to experience a skeletal-related event/death during the first 3 months than those with Ntx <100 (P<0.001). In a multivariate logistic regression model, Ntx was highly predictive for events/death. This study is the first to indicate a strong correlation between the rate of bone resorption and the frequency of skeletal complications in metastatic bone disease. N-telopeptide appears useful in the prediction of patients most likely to experience skeletal complications and thus benefit from bisphosphonate treatment.

Clinical and economic issues in the treatment of advanced breast cancer with bisphosphonates

An ideal palliative therapy for bone metastases would successfully reduce skeletal complications in several thousands of breast cancer patients. Second- and third-generation bisphosphonates are effective in reducing the overall skeletal complication rate and the time to first skeletal complication. Nevertheless, not enough evidence supports their benefit on quality of life. Furthermore, bisphosphonates are expensive (up to 775 US dollars per month, 2002 value) and cost-effectiveness evaluations have been limited to pamidronate (pamidronic acid). In economic evaluations of pamidronate, resulting incremental dollar per quality-adjusted life year gained ranged from cost savings to 108,000 US dollars per quality-adjusted life year. The data were quite sensitive to quality-of-life estimates and country-specific cost values. Because of the wide range of the cost-effectiveness ratio, it is uncertain whether the universal prescription of bisphosphonates in this setting represents an efficient use of healthcare resources. Probably, country- and drug-specific policies might increase the efficiency of this treatment. Further outcomes research is required to assess these agents more fully.

Economic evaluation of aromatase inhibitors for the treatment of breast cancer

Breast cancer affects 1 million women a year. Hormonal therapy has been a mainstay of treatment for women with hormone-sensitive breast cancer. The newer class of aromatase inhibitors has challenged the use of the previous standard agent, tamoxifen, in the treatment and prevention of breast cancer. This article will provide a thorough review of the literature on the newer generation aromatase inhibitors and examine their role in metastatic, adjuvant, neoadjuvant and prevention settings. An in-depth review of the cost-efficiency analyses is also performed. Recent studies on the newer, third-generation aromatase inhibitors have challenged the previous gold standard (tamoxifen) in the prevention and management of hormone-sensitive breast cancer in postmenopausal women. These studies have supported the use of aromatase inhibitors as first-line therapy in both early (adjuvant) and advanced breast cancer management. Whether aromatase inhibitors should replace tamoxifen in these settings is still a matter of debate. Augmenting these studies and providing additional information to the debate are pharmacoeconomic appraisals, which help to place a societal value on newer therapies as compared with the previously established therapy. This review discusses the pharmacology and efficacy of the newer aromatase inhibitors as it applies to their role in the metastatic, adjuvant, neoadjuvant and prevention settings. The pharmacoeconomic studies performed on these agents are also discussed.

Mammographic screening: evidence from randomised controlled trials

BACKGROUND

All randomised breast cancer screening trials have shown a reduction in breast cancer mortality in the 'invited for mammography' screening arm compared with the 'control arm' for women aged 50 years and older at randomisation (overall 25%). However, individually published point estimates differ and concern has been raised about methodological quality and outcome measures. Materials and Methods Review of the evidence on breast cancer mortality reduction and discussion of the causes of difference in point estimates in the five Swedish and Canadian trials. A summary of the prerequisites for methodological quality and its available evidence from the trials is given. Data to support breast cancer mortality as a correct outcome measure are presented.

RESULTS

There is no reason not to use breast cancer mortality as an outcome measure for trials intended to reduce breast cancer mortality, both from a clinical and a methodological point of view. Everything possible was performed in these trials in order to determine this outcome measure as accurately as possible. The fact that a few of the trials showed a relatively large breast cancer mortality reduction and others far lower reduction rates is irrelevant, if one does not consider the background situation in the region before the trial started, the design of the trial or quality of screening.

CONCLUSIONS

There seems no reason to change or halt the current nation-wide population-based screening programmes. Nor is there any justifiable reason for negative reports towards women or professionals.

Efficacy and economics of hormonal therapies for advanced breast cancer

Breast cancer is a leading cause of cancer-related mortality among postmenopausal women in the US, and the economic burden of breast cancer care comprises a large percentage of the healthcare budget. Hormonal therapies have a proven place in the management of advanced breast cancer. This type of therapy is more likely to be used in older, compared with younger, women, because tumours in older women are more likely to express estrogen and progesterone receptors. While it is difficult to measure the costs of cancer care because of variation in extent and duration of treatment, treatment-related costs including costs of hormonal agents used for advanced disease account for a relatively small component of the overall costs. Newer hormonal regimens such as the new third generation nonsteroidal (letrozole, anastrozole) and steroidal (exemestane) aromatase inhibitors have shown improved clinical efficacy compared with standard regimens such as megestrol and tamoxifen in the metastatic setting in terms of objective responses or time to tumour progression. In addition the newer agents have improved toxicity profiles. Cost analyses of the newer aromatase inhibitors (anastrozole and letrozole), compared with megestrol, show an optimistic outlook for these agents. Additional work needs to be done looking at a comparison of the efficacy and costs of the aromatase inhibitors relative to the currently recommended hormonal treatments used for women with metastatic breast cancer.

Bisphosphonates in the treatment of metastatic breast cancer

The skeleton is the most common site of metastatic disease in breast cancer and the most common site of first distant relapse. Bone metastases in breast cancer are the source of considerable morbidity, including severe pain, pathological fractures, need for radiotherapy or surgery, and hypercalcemia. Bisphosphonates are potent inhibitors of osteoclast-mediated bone resorption, and it is well known that breast cancer cells in bone can stimulate osteoclast formation and activity leading to the release of growth factors and cytokines, which will further stimulate cancer cell growth and their secretion of osteolytic factors. We are thus typically dealing with a vicious cycle, as the bone resorption-induced release of growth factors from the bone matrix will stimulate breast cancer cell growth (probably mainly by IGFs) and the production of the osteolytic factor PTHrP (probably mainly by TGF-beta but also by extracellular calcium). Clodronate, but not the aminobisphosphonates, can be metabolized to an ATP analog that is toxic for osteoclasts. Nitrogen-containing bisphosphonates, such as pamidronate, ibandronate, and zoledronate, interfere with the mevalonate pathway that is crucial to maintain cell membrane integrity. The net result, regardless of the mechanism, is osteoclast apoptosis, notably through the induction of caspase-3. Bisphosphonates are now the standard treatment for cancer hypercalcemia. Repeated bisphosphonate infusions also exert clinically relevant analgesic effects in at least one half of the patients with metastatic bone pain. Most importantly, prolonged administration of bisphosphonates (for at least 1 year) reduces the frequency of morbid skeletal events by 30-40% in breast cancer metastatic to bone and in up to 50% in patients with multiple myeloma. Newer bisphosphonates, such as ibandronate and zoledronate, will simplify the current therapeutic schemes and improve the cost-effectiveness ratio, and they have the potential to improve the therapeutic efficacy, at least in patients with aggressive osteolytic disease or in the adjuvant setting.

The role of nuclear medicine in monitoring treatment in skeletal malignancy

The nuclear medicine bone scan has historically been one of the most common investigations to stage and monitor skeletal malignancy. Current guidelines for using radiographs to assess the response of skeletal metastases to systemic therapy are limited in their ability to give a timely result. Despite some minor limitations caused by the flare phenomenon, skeletal scintigraphy remains widely used for this purpose, both clinically and in trials of new cancer treatments. Nuclear medicine has also played an important role in the posttherapy evaluation of primary bone tumors, both with bone agents and nonspecific tumor agents, such as 201Tl. In the future, it is possible that positron emission tomography radiopharmaceuticals such as 18F-fluorodeoxyglucose may prove to be superior in predicting and measuring treatment response in primary and metastatic bone and bone marrow disease, but further work is required in this area.

'More than just money' -- widening the understanding of the costs involved in cancer care

AIM

This paper examines the literature relating to the wider concept of cost in cancer care and the implications this has for the development of services particularly within the changing context of cancer care.

BACKGROUND

Cancer remains a major cause of morbidity and mortality in the United Kingdom (UK), treatment is often complex and expensive; both in financial and human terms. Service patterns for cancer care are shifting away from traditional inpatient, hospital settings towards short stay/day-care and home care models. This is in response to developments in health care policy, but it is also because of the availability of better tolerated treatments and demand for more patient-focused health care.

REVIEW OF THE LITERATURE

The databases of Cinhahl and Medline were accessed using the keywords of costs, treatment, outpatients, home care and cancer. Additional sources of literature were also accessed through hand searching key journals. The paper explores the literature in three themes. First, the cost-effectiveness of cancer treatment; second, the often invisible indirect or 'out of pocket' costs incurred by patients and their families during cancer treatment and finally, the 'human costs' of a cancer diagnosis and cancer therapy.

CONCLUSIONS

In view of recent calls to improve the effectiveness of cancer care in the UK, we suggest that research is needed to address all the dimensions of cost. It is only by exploring total costs from this broad perspective that appropriate, effective and holistic services can be planned for the future.

New treatments for advanced cancer: an approach to prioritization

The allocation of funding for new anticancer treatments within the UK has not kept pace with demand. Clinicians find themselves restricted in the use of licensed drugs which they feel are in the best interests of individual patients. Against this, health authorities have a duty to ensure that scarce resources are used equitably to meet the needs of the local population as a whole. Differential levels of funding for new treatments across the country have led to concerns about rationing by postcode. This paper outlines an approach to the prioritization of new treatment for advanced cancer developed jointly by clinicians and health authorities in South London. The approach involves evidence reviews and consensus meetings. Existing and new treatments are rated on a four-point 'relative effectiveness scale', which takes account of the impact of the treatment on quality of life and on survival. The strength of evidence supporting each effectiveness rating is also classified. Health Authorities have used these ratings to determine overall funding levels, while leaving decisions on individual patients to the relevant Trusts.

Estimates of the lifetime costs of breast cancer treatment in Canada

A comprehensive understanding of the cost components of common illnesses is a necessary first step towards ensuring optimal use of scarce healthcare resources. Since breast cancer is the commonest malignancy affecting Canadian women, we estimated the direct healthcare costs associated with the lifetime management of a cohort of 17700 women diagnosed in 1995. Using a multiplicity of data sources, treatment algorithms, follow-up and disease progression patterns were determined by age (<50; >/=50 years) for all four stages of breast cancer at diagnosis, as well as for the management of local and distant recurrence. Statistics Canada's Population Health Model (POHEM) was used to integrate the data from the different sources and to estimate the lifetime costs, discounted at 0, 3 and 5% rates. The average undiscounted lifetime cost per case of treating women diagnosed with breast cancer varied by stage, from $36,340 for stage IV or metastatic disease, to $23,275 for stage I patients. The total cost of treatment for the cohort diagnosed in 1995 was estimated to be over 454 million Canadian dollars. Hospitalisation (mainly for initial treatment and terminal care) represented 63% of the lifetime costs of care delivery. Disease costing models are valuable tools for optimising the use of scare resources without compromising the health status of individual patients. The breast cancer costing model has recently been used to assess the cost impact and cost-effectiveness of providing radiotherapy to all patients undergoing breast surgery, and of performing outpatient breast surgery.

Economic evaluation of letrozole in the treatment of advanced breast cancer in postmenopausal women in Canada

OBJECTIVE

To determine the cost-effectiveness of initiation of second-line hormone therapy with letrozole in the treatment of advanced breast cancer in postmenopausal women in Canada, compared to megestrol acetate.

METHODS

A modified Markov model, incorporating seven health states, was designed to simulate the treatment of patients with advanced breast cancer from second-line hormone therapy to death. The model was constructed with data from a clinical trial, literature sources, and interviews with breast cancer treatment experts. Canadian experts provided information on resource utilization patterns and local costs were attached to these resources. The model was used to calculate mean survival time, time without progression, and total direct medical costs for patients initiating treatment with letrozole 2.5 mg or megestrol acetate 160 mg.

RESULTS

The mean survival time and time without progression for letrozole 2.5 mg patients were 28.3 months and 19.0 months, respectively, compared to 25.7 months and 16.5 months for megestrol acetate 160 mg patients. Total treatment costs for both groups were similar with the letrozole 2.5 mg group costing dollar 20,068 per patient, dollar 1061 more than the megestrol acetate 160 mg group (dollar CAN, 1996). The cost-effectiveness ratio for letrozole 2.5 mg with respect to megestrol was dollar 5051 per year of life gained. Sensitivity analysis showed that this ratio was sensitive to variations in the probabilities governing disease progression.

CONCLUSIONS

Advanced breast cancer patients initiating second-line hormone therapy with letrozole 2.5 mg have better clinical outcomes than patients receiving megestrol acetate 160 mg. Furthermore, this benefit comes at an acceptable cost to the Canadian health care system.

Estimates of the lifetime direct costs of treatment for metastatic breast cancer

OBJECTIVE

Breast cancer remains the highest incident cancer among females in the United States and previous research suggests that a considerable portion of patients will eventually progress to the metastatic phase of the disease. This paper provides the first estimate of the lifetime direct costs of treating metastatic disease for one annual diagnostic cohort of breast cancer patients.

METHODS

Incidence rates were combined with US population counts to estimate the number of breast cancer cases diagnosed in 1994. Estimates of progression to metastatic disease (from Canadian provincial cancer registry data), costs of care (derived from patients' claims histories), survival (from SEER data), and national mortality rates (from US Census Bureau) were integrated, using Statistics Canada's Population Health Model (POHEM) to calculate lifetime costs.

RESULTS

This study estimates that more than 40% of the women diagnosed with breast cancer will progress to metastatic disease. On average, women with metastatic disease are expected to live 3 years and to incur direct treatment costs of approximately dollar 60,000 per case, resulting in a total lifetime cost for the cohort of almost dollar 4.2 billion.

CONCLUSIONS

The high rate of recurrence of breast cancer argues for the development of interventions that can prevent or delay the onset of metastatic disease. These estimates of lifetime costs and the methodology on which they are based can be used to evaluate the cost-effectiveness of such secondary prevention strategies. These estimates also can serve as a benchmark against which the lifetime costs of treating other diseases can be assessed.

Cost effectiveness of letrozole in the treatment of advanced breast cancer in postmenopausal women in the UK

OBJECTIVE

To simulate the treatment of postmenopausal women with advanced breast cancer from second-line hormone therapy to death, and to generate estimates of the cost and effectiveness of letrozole and megestrol in order to determine the incremental cost effectiveness of letrozole, expressed as cost per life-years gained.

DESIGN

A decision-analytic model, using Markov process techniques, was designed to evaluate the lifetime clinical and economic consequences of treatment with letrozole compared with standard care with megestrol. The model was based on clinical trial results showing a clear advantage of letrozole in terms of time to progression and duration of response.

SETTING

The setting of the study was that of the UK healthcare system in 1996.

PATIENTS AND PARTICIPANTS

A hypothetical cohort of patients, identical to the patients recruited for the AR/BC2 clinical trial, who were postmenopausal women with advanced breast cancer who had previously failed to respond to first-line or adjuvant anti-estrogen therapy.

INTERVENTIONS

The dosages of medications were 2.5 and 160 mg/day for letrozole and megestrol, respectively. The analysis covered the period from treatment initiation until death (lifetime model). Effectiveness was expressed as survival and time without progression, and the model also included all relevant economic measures.

MAIN OUTCOME MEASURES AND RESULTS

Based on the model, the average survival time of the letrozole group was 2.1 years (25.3 months) versus 1.9 years (21.5 months) for the megestrol group, a gain in survival of 2.4 months (10.5%). The average time without progression, cumulatively calculated over the different treatment options, amounted to 20.2 months for letrozole and 17.8 months for megestrol, an increase of 13.7% for the former patients. The total average cost per patient for the treatment of advanced breast cancer starting from second-line hormone therapy until death was higher in the letrozole group at 7547 Pounds versus 6820 Pounds for the megestrol group (discounted at an annual rate of 5%), leading to an incremental cost-effectiveness ratio of 3588 Pounds per life-year gained (1996 values).

CONCLUSIONS

Based on the assumptions used in this model, letrozole offers a suitable alternative to megestrol in the treatment of second-line hormone therapy.

Assessing the cost-effectiveness of postmastectomy radiation therapy

PURPOSE

To assess the cost-effectiveness of postmastectomy local-regional radiation therapy (RT) for patients with breast cancer with regard to local-regional relapse (LRR) and quality-adjusted life years (QALY).

METHODS AND MATERIALS

Data from the literature are used to estimate the risk of LRR, and the impact of RT on the risk of LRR and survival. The risk of LRR is related linearly to the number of positive axillary nodes 1% rate of LRR = 10 + (4 x number of positive nodes)]. RT reduces the risk of LRR by 67%. LRRs are treated with excision or biopsy followed by RT; half being controlled locally and half receiving additional salvage surgery and chemotherapy. Absolute improvements in 10-year overall survival due to RT are assumed to vary between 1 and 12%; and accrue linearly during the initial 10-year follow-up period. Professional and technical charges are used as a surrogate for costs. Money spent and benefits recognized in future years are discounted to 1997 values using a 3% annual rate. Quality factors are used to adjust for treatment, disease, and toxicity status.

RESULTS

The cost per LRR prevented with the addition of routine postmastectomy RT is highly dependent upon the number of positive axillary nodes and ranges from $100,000-$200,000 for patients with 0-2 nodes, and $25,000-$75,000 for > or = 4 nodes. The cost per QALY gained at 10 years is $10,000-$110,000 for survival benefits > or = 3%.

CONCLUSIONS

The cost per LRR prevented decreases with increasing numbers of positive axillary nodes. There is not a sharp cutoff at the < or = 3 vs. > or = 4 lymph node number, suggesting that using this cutoff for recommending or not recommending RT following mastectomy is not economically logical. The cost per QALY of $10,000-$100,000 compares favorably to that of other accepted medical procedures. Modest changes in the quantitative assumptions do not qualitatively alter the results. Concerns regarding costs should not generally preclude the use of postmastectomy RT.

Third line chemotherapy in patients with metastatic breast cancer: an evaluation of quality of life and cost

Many patients with metastatic breast cancer receive several types of chemotherapy, although it is recognized that there is a declining probability of response. A major problem confronts oncologists in deciding when to recommend to patients that no further chemotherapy should be given. To address this problem we have assessed prospectively, health-related quality of life (HRQL) and costs of health care for 35 patients with metastatic breast cancer receiving third line chemotherapy in a representative clinical situation. HRQL and utilities were measured longitudinally using the EORTC QLQ-C30 questionnaire and the time trade-off method. Patients received a median of 2 cycles of chemotherapy and lived a median of 4.3 months. Twelve patients (34%) had substantial (> 10 points) improvement in the Global QL subscale and more than 30% of patients had similar changes in emotional and social function. The median baseline utility score was 0.9 and utilities correlated poorly with HRQL subscale. Eighteen patients had measurable disease and one patients experienced a partial response. Grade 3/4 toxicity occurred in 30% of patients. The average cost of management from study entry to death was CDN$ 17,260 (approximately US$ 12,000). Sixteen percent of this cost was associated directly with chemotherapy while hospital admissions and outpatient visits accounted for 50% and 14% of the total cost respectively. We conclude that: (a) many patients receiving third line chemotherapy maintain or improve indices of HRQL despite short survival and a low response rate: this might be due to chemotherapy, placebo effect, or a shift in frame of reference for HRQL; (b) patients were unwilling to trade quantity for quality of life; and (c) response rates and survival may be overestimated in patients selected for clinical trials.

Skeletal metastases from breast cancer: imaging with nuclear medicine

Breast cancer is a disease that commonly metastasizes to bone, increasing morbidity, mortality, and health service costs. The 99m technetium (99mTc) diphosphonate bone scan historically has played a significant part in the evaluation of skeletal disease and continues to be one of the most clinically utilized investigations in the staging and follow up of breast cancer patients. More tumor-specific radiopharmaceuticals are now being evaluated and, in particular, 18-fluoro-2-deoxyglucose positron emission tomography (18FDG PET) may have a greater role in this disease in the future.

Docetaxel. A pharmacoeconomic review of its use in the treatment of metastatic breast cancer

Advanced breast cancer has a poor prognosis (median duration of survival about 2 years); thus, treatment options are largely palliative. Recent studies with the taxoids docetaxel and paclitaxel suggest that these agents are effective second-line therapy in patients with metastatic breast cancer. Objective response rates range from 30 to 57% with docetaxel monotherapy in clinical trials in patients with advanced disease who had failed to respond to previous therapy, and the median time to disease progression ranges from 17 to 20 weeks. Currently available pharmacoeconomic data relating to docetaxel in the treatment of women with metastatic breast cancer include a cost-minimisation study and 3 cost-utility studies which relate to the UK, French and US healthcare systems. All analyses compared docetaxel with paclitaxel. Since no direct clinical comparisons of these 2 agents have been performed, model assumptions were based on available, rather than comparative, clinical data. The French model also considered vinorelbine monotherapy as a comparator. Considering direct costs only, costs associated with docetaxel ranged from < 0.3% less to 13% more than those of paclitaxel. When utilities were evaluated, docetaxel was associated with incremental gains versus paclitaxel of 33 and 75 additional days of quality-adjusted health in the UK and US studies, respectively, and 22 additional days of quality-adjusted progression-free survival (QPFS) in the French analysis. Thus, the incremental cost utility of docetaxel versus paclitaxel was an estimated Pounds 2431 per quality-adjusted life-year (QALY) in the UK analysis (1994 values) and US$8615 per QALY in the US analysis (1997 values). The French model found that docetaxel cost 700 French francs less for the extra days of QPFS (1993 costs).

CONCLUSIONS

Cost-utility analyses, compiled in the absence of direct comparative data, show that docetaxel offers utility gains versus paclitaxel in the treatment of metastatic breast cancer. The incremental cost for these gains is within the accepted range for healthcare interventions.

Health service studies in the terminally ill cancer patient

The number of high quality health service research studies in care of the terminally ill patient is very limited. For some areas of care, such as coordination of care for the dying, the clinical benefit is not clear, but the cost-effectiveness evidence seems compelling enough to provide services. For others, such as the use of advanced directives or hospice care, the ethical and medical rationale is compelling, but the evidence of clinical benefit or better cost-effectiveness is limited.

The costs of treating breast cancer in the United Kingdom: implications for screening

Total treatment costs by stage at diagnosis are estimated for a sample of breast cancer patients. At 4 years, stage 4 cancers emerge as being more expensive to treat than those at earlier stages, although this difference fails to achieve significance when expected lifetime costs are considered. The inclusion of treatment cost estimates in a screening model indicates that screening may increase expected treatment costs by a marginal amount, although the model also suggests that the cost-effectiveness ratio of breast cancer screening might be better than had originally been thought.

Hematopoietic progenitor cell transplantation in breast cancer: current status and future directions

Breast cancer remains the second leading cause of cancer death despite numerous advances in medical science. In vitro, preclinical, and clinical trials have shown that chemotherapy dose intensity is an important component of therapy. Many clinical trials addressing the use of high-dose chemotherapy and hematopoietic cellular rescue have been conducted over the past decade. Early trials undertaken in heavily pretreated patients who had metastatic disease were associated with high treatment-related mortality rates; good response rates were noted but overall survivals were short. Subsequent technological advances, including the use of recombinant hematopoietic growth factors and peripheral blood progenitor cells as the source of cellular rescue, have dramatically lowered the morbidity and mortality of the procedure, as well as shortened hospital stay and markedly reduced cost. As a result, the high-dose chemotherapy approach has been used earlier in the disease course, both in patients with metastatic disease who were responding and in the adjuvant setting in patients at high risk for relapse. Results of many of these phase II trials are extremely encouraging, and phase III prospective, randomized trials comparing autotransplant to conventional approaches are currently under way. This review discusses past, current, and future initiatives of this modality. Included is a discussion of new preparative regimens, the addition of agents such as biochemical modifiers to enhance antitumor activity, and issues regarding timing of autotransplant, stem cell technology, use of allogeneic stem cells, and posttransplantation therapies.

Inequalities in breast cancer care and outcome

Comparisons across Europe suggest that survival from breast cancer is less good in the United Kingdom than in many countries. The care given in some UK breast cancer units is exemplary. However, it is difficult to escape the conclusion that a substantial number of women who present with breast cancer receive suboptimal care. Cancer registry-based studies have clearly demonstrated variations between surgeons and between hospitals in the management of early breast cancer. Although variations in surgical practice per se may have little impact on survival, there is evidence that differences in the use of systemic adjuvant therapy influence outcome. Five-year survival seems to be greater in women treated by surgeons seeing more than 30-50 new cases of breast cancer each year. This may be because such patients are more likely to be treated by a multidisciplinary team and to receive adjuvant therapy. Proposals that would increase the overall quality of breast cancer care and remove current inequalities must be carefully considered and should then be implemented.

Is paclitaxel and cisplatin a cost-effective first-line therapy for advance ovarian carcinoma?

BACKGROUND

Paclitaxel and cisplatin use for the treatment of advanced ovarian carcinoma (AOC) has been shown to increase median survival duration. An evaluation was performed on the economic consequences of treating AOC patients with combined paclitaxel and cisplatin chemotherapy compared with current usual care, i.e., combined cyclophosphamide and cisplatin chemotherapy.

METHODS

Linear modeling techniques combined with retrospective chart analysis were used to predict the clinical progression and treatment of AOC patients until death. Cost-effectiveness analysis comparing paclitaxel and cisplatin and usual care was performed from a simplified Ministry of Health perspective.

RESULTS

Assuming a 50% increase in survival for paclitaxel and cisplatin patients, an assumption supported by recent clinical trial data, this treatment showed an average lifetime cost per patient of $50,054 Cdn compared with a cost of $36,837 Cdn for usual care. The incremental cost of the paclitaxel and cisplatin treatment over the usual treatment was $20,355 Cdn per life year gained. These results withstood extensive sensitivity analyses.

CONCLUSIONS

Paclitaxel, in combination with cisplatin, appears to be a cost-effective first-line treatment for AOC. A moderate increase in incremental cost compares favorably with other life-saving strategies currently in use. As more data become available for the use of paclitaxel, this pilot study will provide a basis for more extensive economic evaluation of paclitaxel.

Key issues in the treatment of advanced breast cancer. Expectations and outcomes

Advanced breast cancer is common and can cause extensive morbidity, often over long periods of time. A variety of treatments, including symptomatic measures, surgery, radiotherapy, endocrine treatment and cytotoxic drugs, may be applicable for individual patients. Cytotoxic chemotherapy is the most contentious therapy because of its potentially severe adverse effects. While clinical trials give information concerning objective response rates, they are of relatively little value in ascertaining the true value of treatment in routine practice. In recent years, increasing importance has been attached to the evaluation of symptom relief and quality of life. A scoring method for outcome analysis has been developed, in which the resultant of beneficial and adverse effects of treatments is estimated. Sensitivity analysis demonstrated the robustness of this method, which indicated that only about 20% of all patients with advanced breast cancer given first-line chemotherapy gain net benefit. This result was corroborated in a prospective study in which patient reports of benefit were systematically recorded. Most of the expenditure incurred when treating patients with advanced breast cancer is derived from treatment of serious illness rather than from specific antitumour treatment; cytotoxic drug therapy accounts for less than 10% of total expenditure.