Cost-effectiveness analysis of pegylated-liposomal doxorubicin and liposomal daunorubicin treatments in patients with Kaposi's sarcoma

Cost-Effectiveness Analysis Comparing Chemotherapy Regimens in the Treatment of AIDS-Related Kaposi’s Sarcoma in Brazil

BACKGROUND

Economic analyses of agents used in the treatment of AIDS and opportunistic diseases are particularly important in developing countries.

PURPOSE

To analyze the cost-effectiveness of AIDS-related Kaposi's sarcoma (AIDS-KS) chemotherapy regimens in Brazil.

METHOD

A decision-analysis model was developed, and effectiveness data were derived from randomized phase III trials evaluating pegylated liposomal doxorubicin (PLD), liposomal daunorubicin (DNX), and the ABV regimen (doxorubicin, bleomycin, and vincristine). Resource data on direct medical costs were obtained from local sources.

RESULTS

The cost-effectiveness estimates (defined as average costs per patient who responds completely or partially) favored PLD (US $10,272/responder) in comparison to DNX (US $16,263/responder). Regarding cost-effectiveness, the ABV regimen that is widely used in developing countries had better results when compared to both PLD (US $1,268 vs. US $10,271) and DNX (US $1,268 vs. US $16,260). The incremental cost per additional responder of using PLD instead of ABV was US $20,990. Sensitivity analyses suggest that these results hold over a wide range of assumptions.

CONCLUSION

ABV seems to be the most reasonable treatment option for AIDS-KS patients in resource-limited countries like Brazil.

Assessing the need for quality-adjusted cost-effectiveness studies of nanotechnological cancer therapies

New therapies, such as nanotechnology-based cancer treatments, typically entail high acquisition costs. Their use can be justified, however, by their superior cost-effectiveness. This article assesses the quality of cost-effectiveness analyses of nanotechnological cancer therapies by screening nine major studies. They conclude that nanotherapies are cost effective for the treatment of ovarian and breast cancer, as well as multiple myeloma, but not for other types of cancer. However, these studies have some serious methodological flaws. Typically, the results are not quality adjusted, although both length and quality of life are affected. Moreover, only fragmented direct medical costs are included, neglecting indirect costs that impose a significant economic burden on patients and society. Finally, cost definitions differ widely making any comparison between studies virtually impossible. This article concludes that economic research of nanotechnology-based therapeutics is still in its infancy. It warns that incomplete economic analysis may lead to inefficient policy recommendations.

The cost offsets and cost-effectiveness associated with pegylated drugs: a review of the literature

Pegylation (PEG) is used as both a drug-delivery and a drug-modification technology in ten drugs approved by the US FDA. Benefits of PEG drugs can include increased plasma half-life, longer absorption, improved tumor targeting and less antigenicity and immunogenicity. Clinical benefits of PEG drugs over non-PEG drugs may include reduced administration, improved efficacy, improved tolerability, and decreased severity and incidence of adverse events. This study reviews 37 economic literature publications featuring PEG drugs versus non-PEG versions. PEG drugs showed some reductions in overall costs resulting from various offsets including fewer administrations, lower adverse event treatment costs, reduced disease complication costs or reduced inpatient/outpatient costs. Of the 18 cost-effectiveness studies reviewed, 17 of them found PEG drugs to be cost effective versus the non-PEG drugs. Cost offsets and cost-effectiveness of PEG drugs have been demonstrated in multiple studies across various therapies, indications and country settings, and the results have been found to be stable when key parameters were varied in analyses. Further studies are needed to assess the potential for cost savings and cost-effectiveness for new PEG therapies in development.

Cost effectiveness of liposomal doxorubicin vs. paclitaxel for the treatment of advanced AIDS-Kaposi's sarcoma

OBJECTIVE

Epidemic Kaposi's sarcoma (KS) is one of the most common acquired immune deficiency syndrome (AIDS) defining malignancies, a disease with stigmatized clinical features that characterizes the diagnosis of AIDS. This study aims to perform a cost-effectiveness analysis between liposomal doxorubicin and paclitaxel in treating AIDS-KS.

METHODS

A 21 week decision tree analysis was created using a hospital perspective to compare treatment patterns with liposomal doxorubicin and paclitaxel. All costs were calculated in 2011 US dollars and obtained from an academic treatment center. Acquisition costs were obtained from public estimates using wholesale acquisition cost (WAC). Effectiveness was estimated based on a Phase 3 study of liposomal doxorubicin and paclitaxel (Von-Roenn et al.). Adverse events (AEs) associated with treatment and not the disease were included in the analysis. One-way sensitivity analysis was performed to test the robustness of the results.

RESULTS

Cost minimization analysis showed that treatment with liposomal doxorubicin was $18,125 whereas paclitaxel costs $12,347. After accounting for response rate, the results showed that liposomal doxorubicin costs $39,403 versus $21,661 for paclitaxel. This study has some limitations. Clinical data were derived from different clinical trials. In addition, many assumptions were made.

CONCLUSION

Paclitaxel is dominant due to its lower acquisition cost and high response rate. Acquisition cost of liposomal doxorubicin and paclitaxel are significantly different. After accounting for all the factors that contribute to cost and response rate, paclitaxel is more cost effective than liposomal doxorubicin.

Review on early technology assessments of nanotechnologies in oncology

Nanotechnology is expected to play an increasingly important role in the diagnostics, prognostics, and management of targeted cancer treatments. While papers have described promising results for nanotechnology in experimental settings, the translation of fundamental research into clinical applications has yet to be widely adopted. In future, policy makers will need to anticipate new developments for clinical implementation and introduce technology assessments. Here we present an overview of the literature on the technology assessments that have already been undertaken on early stage nanotechnology in cancer care, with particular emphasis placed on clinical efficacy, efficiency, logistics, patient-related features and technology dynamics. Owing to the current stage of development of most nanotechnologies, we found only a limited number of publications describing the application of either Health Technology Assessment (HTA) or Constructive Technology Assessment (CTA). In spite of the promising conclusions of most papers concerning the benefits of clinical implementation, actual clinically relevant applications were rarely encountered, and so far only a few publications report application of systematic forms of technology assessment. Most articles consider aspects of environmental safety, regulation and ethics, often mentioning the need to investigate such issues more thoroughly. Evaluation of financial and organizational aspects is often missing. In order to obtain a realistic perspective on the translation and implementation process there is a need for a broad and systematic evaluation of nanotechnologies at early stages of development. Assessment methods taking technology dynamics into account, such as Constructive Technology Assessment (CTA) should be considered for evaluation purposes.

Safety and efficacy of pegylated liposomal doxorubicin in HIV-associated Kaposi's sarcoma

Kaposi’s sarcoma is a vascular tumor linked to the presence of Kaposi’s sarcoma-associated herpesvirus (human herpesvirus-8) and the incidence of which has increased considerably the world over after the onset of the human immunodeficiency virus (HIV) pandemic. Antiretroviral therapy combined with cytotoxic agents has been established as the treatment of choice in the past 10 years. Among chemotherapeutic agents, pegylated liposomal doxorubicin has become the preferred one for patients with HIV-associated Kaposi’s sarcoma in Western countries. The drug in this formulation localizes better to the tumor and has higher efficacy. Skin toxicity, mucositis, and leukopenia/neutropenia are the main side effects. Hepatotoxicity and mild cardiotoxicity are observed less frequently. Pegylated liposomal doxorubicin impacts favorably on quality of life. Although cost effective in Western countries, the drug is less so in developing countries.

Pharmacoeconomics of liposomal anthracycline therapy

Pharmacoeconomic analyses are being used with greater frequency in clinical oncology trials. These analyses provide guidelines for prioritizing competing interventions and allocating health care resources, particularly when deciding whether to use a drug with a higher acquisition cost. For liposomal anthracyclines, the competing treatments are other liposomal anthracyclines and nonliposomal chemotherapy agents with similar activity. Pharmacoeconomic analyses of data from clinical trials in patients with Kaposi's sarcoma determined that the overall cost to achieve objective response was substantially lower with pegylated liposomal doxorubicin (Doxil/Caelyx [PLD]) than with liposomal daunorubicin (DaunoXome [DNX]). Additional economic analyses in patients with ovarian cancer showed that PLD has lower overall treatment costs than topotecan because it is administered less frequently and requires fewer interventions for toxicity. The decision to allocate health care resources to liposomal anthracycline treatment must therefore include consideration of cost-effectiveness and potential cost savings owing to improved tolerability.

Human herpesvirus 8

Human herpesvirus 8 (HHV 8), also known as Kaposi's sarcoma-associated herpesvirus (KSHV) is a g2 herpesvirus and the most recently identified human tumor virus. HHV 8 has been consistently implicated in the pathogenesis of all clinical variants of Kaposi's sarcoma, as well as in the plasma cell variant of multicentric Castleman's disease and primary effusion lymphomas. Pathogenicity of the virus is increased in the host who is immunosuppressed, either iatrogenically or through H1V-1 infection. The HHV 8 genome contains several homologues of cellular genes that regulate cell growth and differentiation, and the exact mechanisms of the virus' oncogenicity using molecular piracy are still being investigated and elucidated. In this article, the authors review the epidemiology, transmission, clinical manifestations, and molecular genetics of HHV 8 infection and provide a summary of the current treatment modalities available to the clinician.

Long-term chemotherapy of HIV-associated Kaposi's sarcoma with liposomal doxorubicin

The aim of this study was to examine the outcome, adverse events and clinical complications of long-term chemotherapy with pegylated liposomal doxorubicin (PegLiposomal DOX) for human immunodeficiency virus (HIV)-associated Kaposi's sarcoma (KS) in the pre-highly active antiretroviral therapy (HAART) era. A phase II study over a 4-year period in a tertiary care university hospital was carried out. 52 acquired immunodeficiency syndrome (AIDS)-patients with advanced KS received long-term chemotherapy (71+/-51 weeks) with a mean of 22.8+/-18.2 cycles and a mean cumulative liposomal doxorubicin dose of 456+/-364 mg/m(2) (120-1040 mg/m(2)). Tumour burden, duration and dosage of PegLiposomal DOX, adverse events, opportunistic infections, immunological parameters and HIV load were measured. A complete (10%) or partial response (56%) was achieved while on chemotherapy. 10 patients (19%) showed stable disease. Tumour progression was observed in 8 patients (15%). Importantly, chemotherapy with PegLiposomal DOX was also successful after previous cytostatic therapy with bleomycin and vincristine. The most common adverse events included leucopenia, neutropenia, anaemia, and increased liver function tests. 34 patients (65%) developed new opportunistic infections and 29 patients (56%) died during the study period. To conclude, pegylated liposomal doxorubicin is a safe and effective drug for long-term chemotherapy of advanced (AIDS) KS without adverse effects on CD4 cell counts and HIV viral load.

Caelyx (stealth liposomal doxorubicin) in the treatment of advanced breast cancer

Anthracyclines are amongst the most active drugs in the treatment of breast cancer. Stealth liposomal doxorubicin (Caelyx, Doxil, Alza Pharmaceuticals Inc.) is a promising new agent under investigation for the treatment of breast cancer and other solid tumours. The liposomal encapsulation alters drug pharmacokinetics and leads to a marked change in toxicity profile compared to non-liposomal doxorubicin. The results of recently completed and ongoing clinical trials in breast cancer are reviewed.