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Khoirunnisa SM, Suryanegara FDA, Setiawan D, Postma MJ. Quality-adjusted life years for HER2-positive, early-stage breast cancer using trastuzumab-containing regimens in the context of cost-effectiveness studies: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2024; 24:613-629. [PMID: 38738869 DOI: 10.1080/14737167.2024.2352006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION This study aims to provide a comprehensive assessment of economic and health-related quality of life (HRQoL) outcomes for human epidermal growth factor receptor 2 (HER2)-positive, early-stage breast cancer patients treated with trastuzumab-containing regimens, by focusing on both Incremental Cost-Effectiveness Ratios (ICERs) and quality-adjusted life years (QALYs). METHODS A systematic search was conducted across PubMed, Embase, and Scopus databases without language or publication year restrictions. Two independent reviewers screened eligible studies, extracted data, and assessed methodology and reporting quality using the Drummond checklist and Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022), respectively. Costs were converted to US dollars (US$) for 2023 for cross-study comparison. RESULTS Twenty-two articles, primarily from high-income countries (HICs), were included, with ICERs ranging from US$13,176/QALY to US$254,510/QALY, falling within country-specific cost-effectiveness thresholds. A notable association was observed between higher QALYs and lower ICERs, indicating a favorable cost-effectiveness and health outcome relationship. EQ-5D was the most utilized instrument for assessing health state utility values, with diverse targeted populations. CONCLUSIONS Studies reporting higher QALYs tend to have lower ICERs, indicating a positive relationship between cost-effectiveness and health outcomes. However, challenges such as methodological heterogeneity and transparency in utility valuation persist, underscoring the need for standardized guidelines and collaborative efforts among stakeholders. REGISTRATION PROSPERO ID: CRD42021259826.
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Affiliation(s)
- Sudewi Mukaromah Khoirunnisa
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Research Institute Science in Healthy Aging and healthcaRE, Groningen, the Netherlands
- Department of Pharmacy, Institut Teknologi Sumatera, Lampung Selatan, Indonesia
| | - Fithria Dyah Ayu Suryanegara
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Research Institute Science in Healthy Aging and healthcaRE, Groningen, the Netherlands
- Department of Pharmacy, Universitas Islam Indonesia, Yogyakarta, Indonesia
| | - Didik Setiawan
- Faculty of Pharmacy, Universitas Muhammadiyah Purwokerto, Banyumas, Indonesia
- Center for Health Economic Studies, Universitas Muhammadiyah Purwokerto, Banyumas, Indonesia
| | - Maarten Jacobus Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Research Institute Science in Healthy Aging and healthcaRE, Groningen, the Netherlands
- Department of Economics, Econometrics and Finance, University of Groningen, Groningen, the Netherlands
- Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
- Centre of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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Epstein N, Simon-Tuval T, Berchenko Y. Context-Specific Estimation of Future Unrelated Medical Costs and Their Impact on Cost-Effectiveness Analyses. PHARMACOECONOMICS 2023; 41:1275-1286. [PMID: 37329391 DOI: 10.1007/s40273-023-01290-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES This study constructed and applied procedures for the estimation of unrelated future medical costs (UFMC) of women with breast cancer in Israel (as a case study) and examined the influence of including UFMC in cost-effectiveness analyses (CEAs). METHODS Part I consisted of a retrospective cohort study based on patient-level claims data of both patients with breast cancer and matched controls during 14 years of follow-up. UFMC were estimated as (a) the annual average all-cause healthcare costs of the control subjects, and (b) as predicted values based on a generalized linear model (GLM) adjusted to patients' characteristics. Part II consisted of a CEA performed using a Markov simulation model comparing regimens of chemotherapy with/without trastuzumab, both excluding and including UFMC and for each of the UFMC estimates separately. All costs were adjusted to 2019 prices. Costs and QALYs were discounted at a yearly rate of 3%. RESULTS The average annual healthcare costs in the control group were $2328 (± $5662). The corresponding incremental cost-effectiveness ratio (ICER) was $53,411/QALY and $55,903/QALY, when UFMC were excluded or included, respectively. Hence, trastuzumab was not considered cost-effective compared with a threshold of willingness-to-pay of $37,000 per QALY, regardless of the inclusion of UFMC. When UFMC were estimated on the basis of the prediction model, the ICERs were $37,968/QALY and $39,033/QALY, when UFMC were excluded or included, respectively. Thus, in this simulation, trastuzumab was not considered cost-effective, independent of the inclusion of UFMC. CONCLUSION Our case study revealed that the inclusion of UFMC had modest effect on the ICERs, and thus did not alter the conclusion. Thus, we should estimate context-specific UFMC if they are expected to change the ICERs significantly, and transparently report the corresponding assumptions to uphold the integrity and reliability of the economic evaluation.
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Affiliation(s)
- Noga Epstein
- Department of Industrial Engineering and Management, Faculty of Engineering Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tzahit Simon-Tuval
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O Box 653, 8410501, Beer-Sheva, Israel.
| | - Yakir Berchenko
- Department of Industrial Engineering and Management, Faculty of Engineering Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Huang Y, Huang X, Huang X, Lin S, Luo S, Gu D, Weng X, Xu X. Cost-effectiveness analysis of ovarian function preservation with GnRH agonist during chemotherapy in premenopausal women with early breast cancer. Hum Reprod 2023:7131352. [PMID: 37075316 DOI: 10.1093/humrep/dead073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 03/25/2023] [Indexed: 04/21/2023] Open
Abstract
STUDY QUESTION Is it economically worthwhile to use GnRH agonist (GnRHa) to prevent menopausal symptoms (MS) and protect fertility in premenopausal women with breast cancer (BC) during chemotherapy from the US perspective? SUMMARY ANSWER It is cost-effective to administer GnRHa during chemotherapy in order to forefend MS in premenopausal patients with BC when the willingness-to-pay (WTP) threshold is $50 000.00 per quality-adjusted life-year (QALY), and to preserve fertility in young patients with BC who undergo oocyte cryopreservation (OC), or no OC, when the WTP thresholds per live birth are $71 333.33 and $61 920.00, respectively. WHAT IS KNOWN ALREADY Chemotherapy often results in premature ovarian insufficiency (POI) in premenopausal survivors of BC, causing MS and infertility. Administering GnRHa during chemotherapy has been recommended for ovarian function preservation by international guidelines. STUDY DESIGN, SIZE, DURATION Two decision-analytic models were developed, respectively, for preventing MS and protecting fertility over a 5-year period, which compared the cost-effectiveness of two strategies: adding GnRHa during chemotherapy (GnRHa plus Chemo) or chemotherapy alone (Chemo). PARTICIPANTS/MATERIALS, SETTING, METHODS The participants were early premenopausal women with BC aged 18-49 years who were undergoing chemotherapy. Two decision tree models were constructed: one for MS prevention and one for fertility protection from the US perspective. All data were obtained from published literature and official websites. The models' primary outcomes included QALYs and incremental cost-effectiveness ratios (ICERs). The robustness of the models was tested by sensitivity analyses. MAIN RESULTS AND THE ROLE OF CHANCE In the MS model, GnRHa plus Chemo resulted in an ICER of $17 900.85 per QALY compared with Chemo, which was greater than the WTP threshold of $50 000.00 per QALY; therefore, GnRHa plus Chemo was a cost-effective strategy for premenopausal women with BC in the USA. Probabilistic sensitivity analysis (PSA) results showed an 81.76% probability of cost-effectiveness in the strategy. In the fertility model, adding GnRHa for patients undergoing OC and those who were unable to undergo OC resulted in ICERs of $67 933.50 and $60 209.00 per live birth in the USA, respectively. PSA indicated that GnRHa plus Chemo was more likely to be cost-effective over Chemo when the WTP for an additional live birth exceed $71 333.33 in Context I (adding GnRHa to preserve fertility in young patients with BC after OC) and $61 920.00 in Context II (adding GnRHa to preserve fertility in young patients with BC who cannot accept OC). LIMITATIONS, REASONS FOR CAUTION The indirect costs, such as disease-related mental impairment and non-medical costs (e.g. transportation cost) were not included. All data were derived from previously published literature and databases, which might yield some differences from the real world. In addition, the POI-induced MS with a lower prevalence and the specific strategy of chemotherapy were not considered in the MS model, and the 5-year time horizon for having a child might not be suitable for all patients in the fertility model. WIDER IMPLICATIONS OF THE FINDINGS When considering the economic burden of cancer survivors, the results of this study provide an evidence-based reference for clinical decision-making, showing that it is worthwhile to employ GnRHa during chemotherapy to prevent MS and preserve fertility. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the Natural Science Foundation of Fujian Province [2021J02038]; and the Startup Fund for Scientific Research, Fujian Medical University [2021QH1059]. All authors declare no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Yaping Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoting Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaojia Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shen Lin
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shaohong Luo
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dian Gu
- Institute for Health & Aging, University of California, San Francisco, CA, USA
| | - Xiuhua Weng
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiongwei Xu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Takumoto Y, Shiroiwa T, Shimozuma K, Iwata H, Takahashi M, Baba S, Kobayashi K, Hagiwara Y, Kawahara T, Uemura Y, Mukai H, Taira N, Sawaki M. Cost-Effectiveness of Trastuzumab With or Without Chemotherapy as Adjuvant Therapy in HER2-Positive Elderly Breast Cancer Patients: A Randomized, Open-Label Clinical Trial, the RESPECT Trial. Clin Drug Investig 2022; 42:253-262. [PMID: 35233755 PMCID: PMC8930935 DOI: 10.1007/s40261-022-01124-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 11/30/2022]
Abstract
Background and Objective Trastuzumab is a standard care as adjuvant chemotherapy (AdjCT) for patients with human epidermal growth factor receptor 2 (HER2)-positive primary breast cancer (BC) in Japan. However, no reports have evaluated its economics for patients with HER2-positive BC over 70 years of age. The objective of this study was to evaluate the cost-effectiveness of HER2-targeted trastuzumab + chemotherapy in Japan, comparing it with trastuzumab monotherapy. Methods A three-state-partitioned survival model was developed to evaluate the cost-effectiveness of trastuzumab + chemotherapy versus trastuzumab monotherapy for AdjCT in elderly patients with HER2-positive BC. We derived the efficacy data, utilities, and costs of both arms from individual patient data in the RESPECT trial (NCT01104935) and published studies. The costs and quality-adjusted life years (QALYs) were discounted at 2% per annum using a payer perspective. The respective cost estimates were reported in 2019 Japanese Yen (JPY) or US dollars (US$). The primary outcome was the incremental cost-effectiveness ratio (ICER). We assured robustness with deterministic and probabilistic sensitivity analyses. Results The cost per patient for trastuzumab + chemotherapy was JPY 14.6 million (US$137,000), and their QALYs were 9.308, compared with JPY 14.2 million (US$131,000) and 9.101, respectively, for trastuzumab monotherapy. The ICER of trastuzumab + chemotherapy versus trastuzumab monotherapy was JPY 2.7 milllion/QALY (US$17,200/QALY). The ICER for trastuzumab with chemotherapy varied from "Dominant" to "Dominated" in one-way sensitivity analysis. Conclusions The base-case analysis suggests that AdjCT with trastuzumab + chemotherapy is likely to be a cost-effective choice for patients with HER2-positive BC aged 70 years or older. However, the sensitivity analysis suggested uncertainty regarding the cost-effectiveness of trastuzumab + chemotherapy. Supplementary Information The online version contains supplementary material available at 10.1007/s40261-022-01124-y.
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Affiliation(s)
- Yuki Takumoto
- Department of Health and Welfare Services, Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, 2-3-6, Wako, Saitama, 351-0104, Japan. .,Meiji Pharmaceutical University, Tokyo, Japan.
| | - Takeru Shiroiwa
- Department of Health and Welfare Services, Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, 2-3-6, Wako, Saitama, 351-0104, Japan
| | - Kojiro Shimozuma
- Department of Biomedical Sciences, College of Life Sciences, Ritsumeikan University, Kusatsu, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masato Takahashi
- Department of Breast Surgery, NHO Hokkaido Cancer Center, Sapporo, Japan
| | - Shinichi Baba
- Department of Surgery, Sagara Hospital, Kagoshima, Japan
| | - Kokoro Kobayashi
- Department of Medical Oncology, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yasuhiro Hagiwara
- Department of Biostatistics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuya Kawahara
- Biostatistics Division, Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hirofumi Mukai
- Department of Breast and Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Naruto Taira
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
| | - Masataka Sawaki
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
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Normanno N, Apostolides K, de Lorenzo F, Beer PA, Henderson R, Sullivan R, Biankin AV, Horgan D, Lawler M. Cancer Biomarkers in the era of precision oncology: Addressing the needs of patients and health systems. Semin Cancer Biol 2021; 84:293-301. [PMID: 34389490 DOI: 10.1016/j.semcancer.2021.08.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
Cancer Biomarkers are the key to unlocking the promise of precision oncology, selecting which patients will respond to a more personalised treatment while sparing non-responders the therapy-related toxicity. In this paper, we highlight the primacy of cancer biomarkers, but focus on their importance to patients and to health systems. We also highlight how cancer biomarkers represent value for money. We emphasise the need for cancer biomarkers infrastructure to be embedded into European health systems. We also highlight the need to deploy multiple biomarker testing to deliver the optimal benefit for patients and health systems and consider cancer biomarkers from the perspective of cost, value and regulation. Cancer biomarkers must also be situated in the context of the upcoming In Vitro Diagnostics Regulation, which may pose certain challenges (e.g. non-compliance of laboratory developed tests, leading to cancer biomarker shortages and increased costs) that need to be overcome. Cancer biomarkers must be embedded in the real world of oncology delivery and testing must be implemented across Europe, with the intended aim of narrowing, not widening the inequity gap for patients. Cancer patients must be placed firmly at the centre of a cancer biomarker informed precision oncology care agenda.
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Affiliation(s)
- Nicola Normanno
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - "Fondazione G. Pascale", Napoli, Italy
| | - Kathi Apostolides
- European Cancer Patient Coalition, Rue Montoyer 40, 1000, Brussels, Belgium
| | | | - Philip A Beer
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow, Scotland, G61 1QH, United Kingdom; Sanger Institute, Wellcome Trust Genome Campus, Cambridge, CB10 1SA, United Kingdom
| | - Raymond Henderson
- Diaceutics PLC, Belfast, United Kingdom; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, United Kingdom
| | - Richard Sullivan
- King's College London, Institute of Cancer Policy, Guy's Hospital, Great Maze Pond, London, SE1 9RT, United Kingdom
| | - Andrew V Biankin
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow, Scotland, G61 1QH, United Kingdom; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, G31 2ER, United Kingdom; South Western Sydney Clinical School, Goulburn St, Liverpool, NSW, 2170, Australia
| | - Denis Horgan
- European Alliance for Personalised Medicine, Avenue de l'Armee Legerlaan 10, 1040, Brussels, Belgium
| | - Mark Lawler
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, United Kingdom.
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Gupta N, Verma RK, Gupta S, Prinja S. Cost Effectiveness of Trastuzumab for Management of Breast Cancer in India. JCO Glob Oncol 2020; 6:205-216. [PMID: 32045547 PMCID: PMC7051799 DOI: 10.1200/jgo.19.00293] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 12/30/2022] Open
Abstract
PURPOSE We undertook this study to evaluate the incremental cost per quality-adjusted life-year (QALY) gained with use of adjuvant trastuzumab as compared with chemotherapy alone among patients with nonmetastatic breast cancer in India. METHODS We used a Markov model to estimate the incremental cost of using trastuzumab (for 1 year, 6 months, or 9 weeks) as compared with chemotherapy alone using a societal perspective, excluding indirect productivity losses. Although the outcomes (QALYs) in the standard chemotherapy arm were estimated after calibrating the model as per survival data from 2 Indian cancer registries, effectiveness estimates from the HERA trial and a joint analysis of the NSABP B-31 and NCCTG N9831 trials were used to estimate the consequences of 1-year trastuzumab use. The cost of treatment was estimated using national standard treatment guidelines and real-world use estimates for different treatment modalities as per data from Indian cancer registries. Probabilistic sensitivity analysis was undertaken to evaluate parameter uncertainty. RESULTS For 1 year of trastuzumab use, the incremental benefit per patient, incremental cost per QALY gained, and probability of being cost effective using HERA trial estimates were 1.29 QALYs, 178,877 Indian national rupees (INRs; US$2,558), and 4%, respectively, whereas the corresponding figures using joint analysis estimates were 1.69 QALYs, INR 134,413 (US$1,922), and 57.3%, respectively. CONCLUSION Use of trastuzumab for 1 year is not cost effective in India at the current price. However, trastuzumab use for 9 weeks is cost effective and should be included in clinical guidelines and reimbursement policies. A price reduction of 15% to 35% increases the probability of 1-year trastuzumab use being cost effective, to 90%.
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Affiliation(s)
- Nidhi Gupta
- Department of Radiation Oncology, Government Medical College and Hospital, Chandigarh, India
| | - Rohan Kumar Verma
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sudeep Gupta
- Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, India
| | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Wright SJ, Newman WG, Payne K. Accounting for Capacity Constraints in Economic Evaluations of Precision Medicine: A Systematic Review. PHARMACOECONOMICS 2019; 37:1011-1027. [PMID: 31087278 PMCID: PMC6597608 DOI: 10.1007/s40273-019-00801-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Precision (stratified or personalised) medicine is underpinned by the premise that it is feasible to identify known heterogeneity using a specific test or algorithm in patient populations and to use this information to guide patient care to improve health and well-being. This study aimed to understand if, and how, previous economic evaluations of precision medicine had taken account of the impact of capacity constraints. METHODS A meta-review was conducted of published systematic reviews of economic evaluations of precision medicine (test-treat interventions) and individual studies included in these reviews. Due to the volume of studies identified, a sample of papers published from 2007 to 2015 was collated. A narrative analysis identified whether potential capacity constraints were discussed qualitatively in the studies and, if relevant, which quantitative methods were used to account for capacity constraints. RESULTS A total of 45 systematic reviews of economic evaluations of precision medicine were identified, from which 222 studies focusing on test-treat interventions, published between 2007 and 2015, were extracted. Of these studies, 33 (15%) qualitatively discussed the potential impact of capacity constraints, including budget constraints; quality of tests and the testing process; ease of use of tests in clinical practice; and decision uncertainty. Quantitative methods (nine studies) to account for capacity constraints included static methods such as capturing inefficiencies in trials or models and sensitivity analysis around model parameters; and dynamic methods, which allow the impact of capacity constraints on cost effectiveness to change over time. CONCLUSIONS Understanding the cost effectiveness of precision medicine is necessary, but not sufficient, evidence for its successful implementation. There are currently few examples of evaluations that have quantified the impact of capacity constraints, which suggests an area of focus for future research.
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Affiliation(s)
- Stuart J Wright
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - William G Newman
- Manchester Centre for Genomic Medicine, Division of Evolution and Genomic Sciences, The University of Manchester, Manchester, UK
- North West Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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Abdul Rafar NR, Hong YH, Wu DBC, Othman MF, Neoh CF. Cost-Effectiveness of Adjuvant Trastuzumab Therapy for Early Breast Cancer in Asia: A Systematic Review. Value Health Reg Issues 2019; 18:151-158. [PMID: 31082795 DOI: 10.1016/j.vhri.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/29/2019] [Accepted: 02/24/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To systematically review and assess the quality of the economic evidence of adjuvant trastuzumab usage in early breast cancer in Asian countries. METHODS Literature search was performed using 6 electronic databases (PubMed, Scopus, Ovid MEDLINE, EconLit, National Health Service Economic Evaluation Database, and ISI Web of Knowledge). The final search was performed in October 2018. All potential economic studies were then checked for eligibility. The reporting and methodological qualities of each study were independently assessed by 2 authors of this review, using the Consolidated Health Economic Evaluation Reporting Standards, Drummond, and Philips checklists. To compare the different currencies used in these studies, all costs were converted into US dollars (2016). RESULTS A total of 6 studies were included; most of them were performed from the healthcare provider perspective. The incremental cost-effectiveness ratio for evaluation performed for a lifetime horizon were reported at $8573 and $20 816 per quality-adjusted life-year in 2 studies. The model outcome was generally sensitive to the changes in trastuzumab drug acquisition cost and discount rate, as well as its clinical effectiveness. For the quality assessment, all studies fulfilled more than 50% of the requirements in the Consolidated Health Economic Evaluation Reporting Standards, Drummond, and Philips checklists. CONCLUSIONS Adjuvant trastuzumab therapy is considered a cost-effective option for early breast cancer in Asian countries including China, Iran, Japan, Singapore, and Taiwan. All studies were generally well conducted. Economic evaluations from the societal perspective, with inclusion of indirect and informal care costs, are warranted to facilitate informed decision making among policy makers.
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Affiliation(s)
| | - Yet Hoi Hong
- Department of Physiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - David Bin-Chia Wu
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia; Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes, Health and Well-Being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Muhamad Faiz Othman
- Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia
| | - Chin Fen Neoh
- Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia; Collaborative Drug Discovery Research Group, Pharmaceutical and Life Sciences Community of Research, Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia.
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Gershon N, Berchenko Y, Hall PS, Goldstein DA. Cost effectiveness and affordability of trastuzumab in sub-Saharan Africa for early stage HER2-positive breast cancer. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2019; 17:5. [PMID: 30867655 PMCID: PMC6396469 DOI: 10.1186/s12962-019-0174-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 02/19/2019] [Indexed: 01/20/2023] Open
Abstract
Background Breast cancer is the second most common cancer worldwide, the most common among women, and the most frequent cause of death among women in less developed regions. Trastuzumab is a humanized monoclonal antibody that downregulates the extracellular domain of the HER2 protein. Using trastuzumab to treat women with localized HER2-positive breast cancer has been shown to improve survival. The objective of this study is to explore the cost-effectiveness of adjuvant trastuzumab, from a societal perspective, in 11 African countries. In addition, we aimed to establish value-based prices for trastuzumab based on the gross domestic product per capita in each country. Methods We developed a Markov model in order to assess the costs and benefits associated with trastuzumab treatment over a lifetime horizon. A probabilistic sensitivity analysis was performed in order to estimate the impact of uncertainty of parameter-values on the results. Efficacy inputs were derived using clinical trial data from non-African countries. Results In the base case analysis, trastuzumab yielded a gain ranging from 0.92 LYs in Nigeria to 1.07 LYs in South Africa, and 0.9 QALYs in Nigeria to 1.02 QALYs in South Africa. The incremental cost ranged from 19,561 USD in Nigeria to 19,997 USD in Congo, and an incremental cost-effectiveness ratio ranging from 19,534 USD/QALY in South Africa to 21,697 USD/QALY in Nigeria. Using willingness to pay estimates based on World Health Organization recommendations, trastuzumab appear to not be cost-effective in all countries analyzed. Cost-effectiveness estimates were most sensitive to the discount rate, trastuzumab cost, and the hazard ratio. Conclusions Trastuzumab does not appear to be cost effective in the African countries analyzed. In order for trastuzumab to be cost-effective, the costs of treatment would require significant discounts. Electronic supplementary material The online version of this article (10.1186/s12962-019-0174-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Noga Gershon
- 1Ben-Gurion University of the Negev, P.O.B. 653, Beer-Sheva, 8410501 Israel
| | - Yakir Berchenko
- 1Ben-Gurion University of the Negev, P.O.B. 653, Beer-Sheva, 8410501 Israel
| | - Peter S Hall
- 2Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh, UK
| | - Daniel A Goldstein
- 3Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel.,4Department of Health Policy and Management, University of North Carolina, Chapel Hill, USA
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Faruque F, Noh H, Hussain A, Neuberger E, Onukwugha E. Economic Value of Pharmacogenetic Testing for Cancer Drugs with Clinically Relevant Drug-Gene Associations: A Systematic Literature Review. J Manag Care Spec Pharm 2019; 25:260-271. [PMID: 30698084 PMCID: PMC7397474 DOI: 10.18553/jmcp.2019.25.2.260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pharmacogenetic testing can provide predictive insights about the efficacy and safety of drugs used in cancer treatment. Although many drug-gene associations have been reported in the literature, the strength of evidence supporting each association can vary significantly. Even among the subgroup of drugs classified by the PharmGKB database to have a high or moderate level of evidence, there is limited information regarding the economic value of pharmacogenetic testing. OBJECTIVES To: (a) summarize the available pharmacoeconomic evidence assessing the value of pharmacogenetic testing for cancer drugs with clinically relevant drug-gene associations; (b) determine the quality of the studies that contain this evidence; and (c) discuss the quality of this evidence with respect to the level of evidence of the drug-gene associations. METHODS The PharmGKB database was used to identify cancer drugs with clinically relevant drug-gene associations graded high (1A, 1B) or moderate (2A, 2B). A systematic literature review was conducted using these drugs. Ovid MEDLINE and Embase databases were searched to identify cost-effectiveness, cost-utility, or cost-minimization studies comparing pharmacogenetic testing to an alternative. Cost and effect values from every relevant comparison within the studies were extracted, and the incremental cost-effectiveness ratio (ICER) was either extracted or calculated for each comparison. Quality assessment was conducted for each study using the Quality of Health Economic Studies (QHES) instrument. Qualitative synthesis was used to summarize the data. RESULTS The search yielded 2,191 citations, of which 35 studies met the inclusion criteria. Pharmacoeconomic studies were available for the following drugs from the PharmGKB database: fluoropyrimidine, 6-mercaptopurine, irinotecan, carboplatin, cisplatin, erlotinib, gefitinib, cetuximab, panitumumab, and trastuzumab. The studies were conducted in Asia, Europe, Canada, the United States, and Mexico and reported cost-utility, cost-effectiveness, and cost-minimization outcomes. The mean QHES score was 80 (SD = 22) for the studies of drug-gene pairs with high (1A, 1B) and moderate (2A, 2B) levels of evidence (1A = 82, 1B = 93, 2A = 71, and 2B = 74). There was variation across studies in terms of reporting. 109 relevant comparisons were identified within the studies. Of those that reported cost per life-year or cost per quality-adjusted life-year (n = 58 comparisons), pharmacogenetic testing was dominant in 21% overall and 42%, 21%, 17%, and 5% of the comparisons in Asia, Europe, Canada, and the United States, respectively. Variability was observed in the ICER values regardless of geographic region or drug. Pharmacogenetic testing was cost saving in 17 of 19 cost-minimization comparisons and was favored most frequently when compared with genetically indiscriminate strategies containing the drug of interest. CONCLUSIONS There was mixed evidence regarding the value of pharmacogenetic testing to guide cancer treatment. For future pharmacogenomic-related economic studies, we recommend prioritizing clinically relevant drug-gene associations and greater adherence to available best practice guidelines for conducting and reporting economic evaluation studies. DISCLOSURES No outside funding supported this review. Part of Hussain's research time was supported by a Merit Review Award (I01 BX000545), Medical Research Service, U.S. Department of Veterans Affairs. Hussain also reports personal fees from Bristol-Myers Squibb, AstraZeneca, Novartis, Bayer HealthCare Pharmaceuticals, and France Foundation, outside the submitted work. Onukwugha reports grants from Pfizer and Bayer HealthCare Pharmaceuticals, along with advisory board fees from Novo Nordisk, outside the submitted work. Faruque, Neuberger, and Noh have nothing to disclose.
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Affiliation(s)
- Fahim Faruque
- University of Maryland School of Pharmacy, Baltimore
| | - Heejung Noh
- University of Maryland School of Pharmacy, Baltimore
| | - Arif Hussain
- Baltimore VA Medical Center and University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore
| | | | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
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Nixon N, Hannouf M, Verma S. A review of the value of human epidermal growth factor receptor 2 (HER2)-targeted therapies in breast cancer. Eur J Cancer 2018; 89:72-81. [DOI: 10.1016/j.ejca.2017.10.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/26/2017] [Accepted: 10/31/2017] [Indexed: 11/28/2022]
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12
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Sabale U, Ekman M, Thunström D, Telford C, Livings C. Economic Evaluation of Fulvestrant 500 mg Compared to Generic Aromatase Inhibitors in Patients with Advanced Breast Cancer in Sweden. PHARMACOECONOMICS - OPEN 2017; 1:279-290. [PMID: 29441507 PMCID: PMC5711749 DOI: 10.1007/s41669-017-0031-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES In Sweden, breast cancer (BC) represents 30% of newly diagnosed cancers and is the most common cancer in women. For hormone-dependent BC, endocrine therapies varying in efficacy and price are available. The aim of this study is to assess the cost effectiveness of fulvestrant 500 mg as a second-line hormonal therapy for postmenopausal women with estrogen receptor-positive metastatic or locally advanced BC versus letrozole, anastrozole, and exemestane in Sweden. METHODS A three-state (pre-progression, post-progression, and death) partitioned-survival model was used to estimate progression-free (PFS) and overall survival (OS) by extrapolating trial results beyond the trial period to capture costs and benefits over a lifetime perspective. The comparative effectiveness was sourced from a network meta-analysis. The evaluation was conducted from a Swedish national payer perspective; costs, resource use, and quality of life were based on published sources and expert opinion. RESULTS Compared to anastrozole, letrozole, and exemestane the incremental cost-effectiveness ratios (ICERs) were €33,808, €33,883, and €49,225 per QALY with incremental costs of €13,283, €14,986, and €13,862, and incremental QALYs of 0.393, 0.442, and 0.282, respectively. Incremental cost per life-year (LY) gained €21,312 (incremental LY of 0.623), €20,338 (incremental LY of 0.737), and €27,854 (incremental LY of 0.498) for respective comparators. Applying the upper and lower credible intervals for PFS/OS from the meta-analysis had the greatest effect on the ICER in the sensitivity analysis. The results were relatively stable when varying other parameters. CONCLUSIONS Our results indicate that fulvestrant 500 mg may be a cost-effective alternative to aromatase inhibitors at a threshold of €100,000/QALY.
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Affiliation(s)
- Ugne Sabale
- Department of Health Economics, AstraZeneca Nordic-Baltic, 151 85, Södertälje, Sweden.
| | - Mattias Ekman
- Department of Health Economics, AstraZeneca Nordic-Baltic, 151 85, Södertälje, Sweden
| | - Daniel Thunström
- Department of Health Economics, AstraZeneca Nordic-Baltic, 151 85, Södertälje, Sweden
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Chicaíza-Becerra L, García-Molina M, Gamboa O, Castañeda-Orjuela C. ErbB2+ metastatic breast cancer treatment after progression on trastuzumab: a cost-effectiveness analysis for a developing country. Rev Salud Publica (Bogota) 2016; 16:270-80. [PMID: 25383500 DOI: 10.15446/rsap.v16n2.31690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/18/2013] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Breast cancer (BC) and metastatic breast cancer (MBC) are significant causes of deaths amongst women worldwide, including developing countries. The cost of treatment in the latter is even more of an issue than in higher income countries. ErbB2 overexpression is a marker of poor prognosis and the goal for targeted therapy. This study was aimed at evaluating the cost-effectiveness in Colombia of ErbB2+ MBC treatment after progression on trastuzumab. METHODS A decision analytic model was constructed for evaluating such treatment in a hypothetical cohort of ErbB2+MBC patients who progressed after a first scheme involving trastuzumab. The alternatives compared were lapatinib+capecitabine (L+C), and trastuzumab+a chemotherapy agent (capecitabine, vinorelbine or a taxane). Markov models were used for calculating progression-free time and the associated costs. Effectiveness estimators for such therapy were identified from primary studies; all direct medical costs based on national fees-guidelines were included. Sensitivity was analyzed and acceptability curves estimated. A 3 % discount rate and third-payer perspective were used within a 5-year horizon. RESULTS L+C dominated its comparators. Its cost-effectiveness ratio was COP $49,725,045 per progression-free year. The factors most influencing the results were the alternatives' hazard ratios and the cost of trastuzumab. CONCLUSION Lapatinib was cost-effective compared to its alternatives for treating MBC after progression on trastuzumab using a Colombian decision analytic model.
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Affiliation(s)
| | | | - Oscar Gamboa
- Instituto Nacional de Cancerología, Bogotá, Colombia
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14
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de Boer PT, Frederix GWJ, Feenstra TL, Vemer P. Unremarked or Unperformed? Systematic Review on Reporting of Validation Efforts of Health Economic Decision Models in Seasonal Influenza and Early Breast Cancer. PHARMACOECONOMICS 2016; 34:833-845. [PMID: 27129572 PMCID: PMC4980411 DOI: 10.1007/s40273-016-0410-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Transparent reporting of validation efforts of health economic models give stakeholders better insight into the credibility of model outcomes. In this study we reviewed recently published studies on seasonal influenza and early breast cancer in order to gain insight into the reporting of model validation efforts in the overall health economic literature. METHODS A literature search was performed in Pubmed and Embase to retrieve health economic modelling studies published between 2008 and 2014. Reporting on model validation was evaluated by checking for the word validation, and by using AdViSHE (Assessment of the Validation Status of Health Economic decision models), a tool containing a structured list of relevant items for validation. Additionally, we contacted corresponding authors to ask whether more validation efforts were performed other than those reported in the manuscripts. RESULTS A total of 53 studies on seasonal influenza and 41 studies on early breast cancer were included in our review. The word validation was used in 16 studies (30 %) on seasonal influenza and 23 studies (56 %) on early breast cancer; however, in a minority of studies, this referred to a model validation technique. Fifty-seven percent of seasonal influenza studies and 71 % of early breast cancer studies reported one or more validation techniques. Cross-validation of study outcomes was found most often. A limited number of studies reported on model validation efforts, although good examples were identified. Author comments indicated that more validation techniques were performed than those reported in the manuscripts. CONCLUSIONS Although validation is deemed important by many researchers, this is not reflected in the reporting habits of health economic modelling studies. Systematic reporting of validation efforts would be desirable to further enhance decision makers' confidence in health economic models and their outcomes.
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Affiliation(s)
- Pieter T de Boer
- Department of Pharmacy, PharmacoTherapy, -Epidemiology and -Economics (PTEE), University of Groningen, Groningen, The Netherlands
| | - Geert W J Frederix
- Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
| | - Talitha L Feenstra
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
- Centre for Nutrition, Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Pepijn Vemer
- Department of Pharmacy, PharmacoTherapy, -Epidemiology and -Economics (PTEE), University of Groningen, Groningen, The Netherlands.
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
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Cost-utility analyses of drug therapies in breast cancer: a systematic review. Breast Cancer Res Treat 2016; 159:407-24. [PMID: 27572551 DOI: 10.1007/s10549-016-3924-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/20/2016] [Indexed: 01/08/2023]
Abstract
The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.
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Leung W, Kvizhinadze G, Nair N, Blakely T. Adjuvant Trastuzumab in HER2-Positive Early Breast Cancer by Age and Hormone Receptor Status: A Cost-Utility Analysis. PLoS Med 2016; 13:e1002067. [PMID: 27504960 PMCID: PMC4978494 DOI: 10.1371/journal.pmed.1002067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 05/26/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The anti-human epidermal growth factor receptor 2 (HER2) monoclonal antibody trastuzumab improves outcomes in patients with node-positive HER2+ early breast cancer. Given trastuzumab's high cost, we aimed to estimate its cost-effectiveness by heterogeneity in age and estrogen receptor (ER) and progesterone receptor (PR) status, which has previously been unexplored, to assist prioritisation. METHODS AND FINDINGS A cost-utility analysis was performed using a Markov macro-simulation model, with a lifetime horizon, comparing a 12-mo regimen of trastuzumab with chemotherapy alone using the latest (2014) effectiveness measures from landmark randomised trials. A New Zealand (NZ) health system perspective was adopted, employing high-quality national administrative data. Incremental quality-adjusted life-years for trastuzumab versus chemotherapy alone are two times higher (2.33 times for the age group 50-54 y; 95% CI 2.29-2.37) for the worst prognosis (ER-/PR-) subtype compared to the best prognosis (ER+/PR+) subtype, causing incremental cost-effectiveness ratios (ICERs) for the former to be less than half those of the latter for the age groups from 25-29 to 90-94 y (0.44 times for the age group 50-54 y; 95% CI 0.43-0.45). If we were to strictly apply an arbitrary cost-effectiveness threshold equal to the NZ gross domestic product per capita (2011 purchasing power parity [PPP]-adjusted: US$30,300; €23,700; £21,200), our study suggests that trastuzumab (2011 PPP-adjusted US$45,400/€35,900/£21,900 for 1 y at formulary prices) may not be cost-effective for ER+ (which are 61% of all) node-positive HER2+ early breast cancer patients but cost-effective for ER-/PR- subtypes (37% of all cases) to age 69 y. Market entry of trastuzumab biosimilars will likely reduce the ICER to below this threshold for premenopausal ER+/PR- cancer but not for ER+/PR+ cancer. Sensitivity analysis using the best-case effectiveness measure for ER+ cancer had the same result. A key limitation was a lack of treatment-effect data by hormone receptor subtype. Heterogeneity was restricted to age and hormone receptor status; tumour size/grade heterogeneity could be explored in future work. CONCLUSIONS This study highlights how cost-effectiveness can vary greatly by heterogeneity in age and hormone receptor subtype. Resource allocation and licensing of subsidised therapies such as trastuzumab should consider demographic and clinical heterogeneity; there is currently a profound disconnect between how funding decisions are made (largely agnostic to heterogeneity) and the principles of personalised medicine.
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Affiliation(s)
- William Leung
- Department of Public Health, University of Otago, Wellington, New Zealand
- Department of Medicine, University of Auckland, Auckland, New Zealand
- * E-mail:
| | - Giorgi Kvizhinadze
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nisha Nair
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Tony Blakely
- Department of Public Health, University of Otago, Wellington, New Zealand
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Krol M, Papenburg J, Tan SS, Brouwer W, Hakkaart L. A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:391-402. [PMID: 25876834 PMCID: PMC4837201 DOI: 10.1007/s10198-015-0685-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 03/18/2015] [Indexed: 05/06/2023]
Abstract
Productivity costs can strongly impact cost-effectiveness outcomes. This study investigated the impact in the context of expensive hospital drugs. This study aimed to: (1) investigate the effect of productivity costs on cost-effectiveness outcomes, (2) determine whether economic evaluations of expensive drugs commonly include productivity costs related to paid and unpaid work, and (3) explore potential reasons for excluding productivity costs from the economic evaluation. We conducted a systematic literature review to identify economic evaluations of 33 expensive drugs. We analysed whether evaluations included productivity costs and whether inclusion or exclusion was related to the study population's age, health and national health economic guidelines. The impact on cost-effectiveness outcomes was assessed in studies that included productivity costs. Of 249 identified economic evaluations of expensive drugs, 22 (9 %) included productivity costs related to paid work. One study included unpaid productivity. Mostly, productivity cost exclusion could not be explained by the study population's age and health status, but national guidelines appeared influential. Productivity costs proved often highly influential. This study indicates that productivity costs in economic evaluations of expensive hospital drugs are commonly and inconsistently ignored in economic evaluations. This warrants caution in interpreting and comparing the results of these evaluations.
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Affiliation(s)
- Marieke Krol
- Department of Health Policy and Management, Erasmus University, P.O. Box 1738, 3000, Rotterdam, The Netherlands.
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
| | | | - Siok Swan Tan
- Department of Health Policy and Management, Erasmus University, P.O. Box 1738, 3000, Rotterdam, The Netherlands
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
| | - Werner Brouwer
- Department of Health Policy and Management, Erasmus University, P.O. Box 1738, 3000, Rotterdam, The Netherlands
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
| | - Leona Hakkaart
- Department of Health Policy and Management, Erasmus University, P.O. Box 1738, 3000, Rotterdam, The Netherlands
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
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Economic Evaluations of Pharmacogenetic and Pharmacogenomic Screening Tests: A Systematic Review. Second Update of the Literature. PLoS One 2016; 11:e0146262. [PMID: 26752539 PMCID: PMC4709231 DOI: 10.1371/journal.pone.0146262] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/15/2015] [Indexed: 01/29/2023] Open
Abstract
Objective Due to extended application of pharmacogenetic and pharmacogenomic screening (PGx) tests it is important to assess whether they provide good value for money. This review provides an update of the literature. Methods A literature search was performed in PubMed and papers published between August 2010 and September 2014, investigating the cost-effectiveness of PGx screening tests, were included. Papers from 2000 until July 2010 were included via two previous systematic reviews. Studies’ overall quality was assessed with the Quality of Health Economic Studies (QHES) instrument. Results We found 38 studies, which combined with the previous 42 studies resulted in a total of 80 included studies. An average QHES score of 76 was found. Since 2010, more studies were funded by pharmaceutical companies. Most recent studies performed cost-utility analysis, univariate and probabilistic sensitivity analyses, and discussed limitations of their economic evaluations. Most studies indicated favorable cost-effectiveness. Majority of evaluations did not provide information regarding the intrinsic value of the PGx test. There were considerable differences in the costs for PGx testing. Reporting of the direction and magnitude of bias on the cost-effectiveness estimates as well as motivation for the chosen economic model and perspective were frequently missing. Conclusions Application of PGx tests was mostly found to be a cost-effective or cost-saving strategy. We found that only the minority of recent pharmacoeconomic evaluations assessed the intrinsic value of the PGx tests. There was an increase in the number of studies and in the reporting of quality associated characteristics. To improve future evaluations, scenario analysis including a broad range of PGx tests costs and equal costs of comparator drugs to assess the intrinsic value of the PGx tests, are recommended. In addition, robust clinical evidence regarding PGx tests’ efficacy remains of utmost importance.
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San Miguel L, Hulstaert F. The importance of test accuracy in economic evaluations of companion diagnostics. J Comp Eff Res 2015; 4:569-77. [PMID: 26529499 DOI: 10.2217/cer.15.41] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Economic evaluations of companion diagnostics often fail to include the impact that tests have on the overall economic value of test-drug combinations. METHODS To illustrate the importance of test accuracy on the cost-effectiveness of companion diagnostics by means of examples. Data were extracted from the literature. RESULTS The accuracy of a test and in particularly its specificity, is often more influential on the overall cost-effectiveness results than the price of the test. Specificity becomes more crucial when prevalence of the biomarker is low. Multiple, simultaneous testing faces specific challenges regarding its overall specificity. CONCLUSION This article opens a discussion on some fundamental points linked to economic evaluations of test-therapy combinations.
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Affiliation(s)
- Lorena San Miguel
- KCE Belgian Health Care Knowledge Centre, Doorbuilding (9th Floor), Boulevard du Jardin Botanique 55, 1000 Brussels, Belgium
| | - Frank Hulstaert
- KCE Belgian Health Care Knowledge Centre, Doorbuilding (9th Floor), Boulevard du Jardin Botanique 55, 1000 Brussels, Belgium
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Bahreini F, Soltanian AR, Mehdipour P. A meta-analysis on concordance between immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) to detect HER2 gene overexpression in breast cancer. Breast Cancer 2015; 22:615-25. [PMID: 24718809 DOI: 10.1007/s12282-014-0528-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 03/17/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND We performed this meta-analysis study to evaluate the concordance and discordance between immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) in detecting HER2 alteration in human breast cancer. METHODS As a meta-analysis, the present study evaluated the available data from previous studies on the HER2 gene detected by IHC and FISH. To indicate the meta-analysis results, a forest plot was used. RESULTS We identified 172 citations, for which our inclusion criteria were met by 18 articles, representing 6629 cases. The overall concordance and discordance rate between IHC staining with score 0/1+ and FISH for detection failure of HER2 expression was 96 and 4 %, respectively. The present study showed that the overall proportion of FISH positive and negative rate for IHC score 2+ for detection of HER2 expression was 36 and 64 %, respectively; and 91 and 9 % for 3+ IHC scores. CONCLUSION The results of this study show that IHC score 0/1+ and 3+ cannot be completely considered as negative and positive breast cancer test, respectively. Therefore, we suggest a valid and complementary test, the same as FISH, to explore HER2 expression.
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Affiliation(s)
- Fatemeh Bahreini
- Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Pour Sina Avenue, 14176-13151, Tehran, Iran.
| | - Ali Reza Soltanian
- Department of Biostatistics and Epidemiology, Modeling of Noncommunicable Diseases Research Center, School of Public Health, Hamadan University of Medical Sciences, Shahid Fahmideh Street, P.O.Box 4171, 65155, Hamadan, Iran.
| | - Parvin Mehdipour
- Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Pour Sina Avenue, 14176-13151, Tehran, Iran.
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IMPLICATIONS OF GLOBAL PRICING POLICIES ON ACCESS TO INNOVATIVE DRUGS: THE CASE OF TRASTUZUMAB IN SEVEN LATIN AMERICAN COUNTRIES. Int J Technol Assess Health Care 2015; 31:2-11. [PMID: 25989703 DOI: 10.1017/s0266462315000094] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Differential pricing, based on countries' purchasing power, is recommended by the World Health Organization to secure affordable medicines. However, in developing countries innovative drugs often have similar or even higher prices than in high-income countries. We evaluated the potential implications of trastuzumab global pricing policies in terms of cost-effectiveness (CE), coverage, and accessibility for patients with breast cancer in Latin America (LA). METHODS A Markov model was designed to estimate life-years (LYs), quality-adjusted life-years (QALYs), and costs from a healthcare perspective. To better fit local cancer prognosis, a base case scenario using transition probabilities from clinical trials was complemented with two alternative scenarios with transition probabilities adjusted to reflect breast cancer epidemiology in each country. RESULTS Incremental discounted benefits ranged from 0.87 to 1.00 LY and 0.51 to 0.60 QALY and incremental CE ratios from USD 42,104 to USD 110,283 per QALY (2012 U.S. dollars), equivalent to 3.6 gross domestic product per capita (GDPPC) per QALY in Uruguay and to 35.5 GDPPC in Bolivia. Probabilistic sensitivity analysis showed 0 percent probability that trastuzumab is CE if the willingness-to-pay threshold is one GDPPC per QALY, and remained so at three GDPPC threshold except for Chile and Uruguay (4.3 percent and 26.6 percent, respectively). Trastuzumab price would need to decrease between 69.6 percent to 94.9 percent to became CE in LA. CONCLUSIONS Although CE in other settings, trastuzumab was not CE in LA. The use of health technology assessment to prioritize resource allocation and support price negotiations is critical to making innovative drugs available and affordable in developing countries.
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Levy JF, Meek PD, Rosenberg MA. US-Based Drug Cost Parameter Estimation for Economic Evaluations. Med Decis Making 2014; 35:622-32. [PMID: 25532826 DOI: 10.1177/0272989x14563987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 11/08/2014] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In the United States, more than 10% of national health expenditures are for prescription drugs. Assessing drug costs in US economic evaluation studies is not consistent, as the true acquisition cost of a drug is not known by decision modelers. Current US practice focuses on identifying one reasonable drug cost and imposing some distributional assumption to assess uncertainty. METHODS We propose a set of Rules based on current pharmacy practice that account for the heterogeneity of drug product costs. The set of products derived from our Rules, and their associated costs, form an empirical distribution that can be used for more realistic sensitivity analyses and create transparency in drug cost parameter computation. The Rules specify an algorithmic process to select clinically equivalent drug products that reduce pill burden, use an appropriate package size, and assume uniform weighting of substitutable products. Three diverse examples show derived empirical distributions and are compared with previously reported cost estimates. RESULTS The shapes of the empirical distributions among the 3 drugs differ dramatically, including multiple modes and different variation. Previously published estimates differed from the means of the empirical distributions. Published ranges for sensitivity analyses did not cover the ranges of the empirical distributions. In one example using lisinopril, the empirical mean cost of substitutable products was $444 (range = $23-$953) as compared with a published estimate of $305 (range = $51-$523). CONCLUSIONS Our Rules create a simple and transparent approach to creating cost estimates of drug products and assessing their variability. The approach is easily modified to include a subset of, or different weighting for, substitutable products. The derived empirical distribution is easily incorporated into 1-way or probabilistic sensitivity analyses.
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Affiliation(s)
- Joseph F Levy
- University of Wisconsin-Madison Department of Population Health Sciences, Madison, WI, USA (JFL)
| | - Patrick D Meek
- Albany College of Pharmacy and Health Sciences Department of Pharmacy, Research Institute for Health Outcomes, Albany, NY, USA (PDM)
| | - Marjorie A Rosenberg
- University of Wisconsin-Madison Department of Actuarial Science, Risk Management and Insurance and Department of Biostatistics and Medical Informatics, Madison, WI, USA (MAR)
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Garattini L, van de Vooren K, Curto A. Cost-effectiveness of trastuzumab in metastatic breast cancer: mainly a matter of price in the EU? Health Policy 2014; 119:212-6. [PMID: 25523144 DOI: 10.1016/j.healthpol.2014.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 11/19/2014] [Accepted: 12/01/2014] [Indexed: 10/24/2022]
Abstract
Trastuzumab (TR), a monoclonal antibody approved by EMA in 2000 and one of the first examples of "targeted therapy", is indicated to treat human epidermal growth factor receptor 2 (HER2) positive breast cancer. TR, whose patent will expire in 2015 in Europe, has been judged positively for reimbursement by most public authorities in the EU. Here we critically review the existing evidence on TR in metastatic breast cancer (MBC), in line with the multidisciplinary health technology assessment (HTA) approach, to assess whether the existing evidence supports TR positive reimbursement decisions taken in MBC by EU health authorities. We did a literature search for the main HTA topics (efficacy, quality of life and ethics) on the PubMed international database (2000-2013). Then, we did a specific literature search to select the full economic evaluations (FEEs) conducted in EU countries focused on TR as first-line innovative therapy in MBC. We retrieved scant evidence in the literature to support TR reimbursement in MBC. We found only two clinical trials and their results were unclear because of the large proportion of patients who crossed over. Moreover, the quality of methods was poor in all four European FEEs selected. This example of HTA exercise on a mature monoclonal antibody in a specific indication casts doubts on how often the reimbursement decisions taken by EU health authorities in emotional pathologies like cancer are rational. These decisions should at least be reconsidered periodically on the basis of the latest evidence.
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Affiliation(s)
- Livio Garattini
- CESAV, Centre for Health Economics, IRCCS 'Mario Negri' Institute for Pharmacological Research, Via Camozzi, 3 c/o Villa Camozzi, 24020 Ranica (Bergamo), Italy.
| | - Katelijne van de Vooren
- CESAV, Centre for Health Economics, IRCCS 'Mario Negri' Institute for Pharmacological Research, Via Camozzi, 3 c/o Villa Camozzi, 24020 Ranica (Bergamo), Italy
| | - Alessandro Curto
- CESAV, Centre for Health Economics, IRCCS 'Mario Negri' Institute for Pharmacological Research, Via Camozzi, 3 c/o Villa Camozzi, 24020 Ranica (Bergamo), Italy
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Ades F, Senterre C, Zardavas D, de Azambuja E, Popescu R, Parent F, Piccart M. An exploratory analysis of the factors leading to delays in cancer drug reimbursement in the European Union: The trastuzumab case. Eur J Cancer 2014; 50:3089-97. [DOI: 10.1016/j.ejca.2014.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/03/2014] [Accepted: 09/10/2014] [Indexed: 11/28/2022]
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Doble B, Tan M, Harris A, Lorgelly P. Modeling companion diagnostics in economic evaluations of targeted oncology therapies: systematic review and methodological checklist. Expert Rev Mol Diagn 2014; 15:235-54. [DOI: 10.1586/14737159.2014.929499] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Trosman JR, Weldon CB, Schink JC, Gradishar WJ, Benson AB. What do providers, payers and patients need from comparative effectiveness research on diagnostics? The case of HER2/Neu testing in breast cancer. J Comp Eff Res 2014; 2:461-77. [PMID: 24236686 DOI: 10.2217/cer.13.42] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AIMS Comparing effectiveness of diagnostic tests is one of the highest priorities for comparative effectiveness research (CER) set by the Institute of Medicine. Our study aims to identify what information providers, payers and patients need from CER on diagnostics, and what challenges they encounter implementing comparative information on diagnostic alternatives in practice and policy. MATERIALS & METHODS Using qualitative research methods and the example of two alternative protocols for HER2 testing in breast cancer, we conducted interviews with 45 stakeholders: providers (n = 25) from four academic and eight nonacademic institutions, executives (n = 13) from five major US private payers and representatives (n = 7) from two breast cancer patient advocacies. RESULTS The need for additional scientific evidence to determine the preferred HER2 protocol was more common for advocates than payers (100 vs 54%; p = 0.0515) and significantly more common for advocates than providers (100 vs 40%; p = 0.0077). The availability of information allowing assessment of the implementation impact from alternative diagnostic protocols on provider institutions may mitigate the need for additional scientific evidence for some providers and payers (24 and 46%, respectively). The cost-effectiveness of alternative protocols from the societal perspective is important to payers and advocates (69 and 71%, respectively) but not to providers (0%; p = 0.0001 and p = 0.0001). The lack of reporting laboratory practices is a more common implementation challenge for payers and advocates (77 and 86%, respectively) than for providers (32%). The absence of any mechanism for patient involvement was recognized as a challenge by payers and advocates (69 and 100%, respectively) but not by providers (0%; p = 0.0001 and p = 0.0001). CONCLUSION Comparative implementation research is needed to inform the stakeholders considering diagnostic alternatives. Transparency of laboratory practices is an important factor in enabling implementation of CER on diagnostics in practice and policy. The incongruent views of providers versus patient advocates and payers on involving patients in diagnostic decisions is a concerning challenge to utilizing the results of CER.
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Yang M, Patel DS, Tufail W, Issa AM. The quality of economic studies of cancer pharmacogenomics: a quantitative appraisal of the evidence. Expert Rev Pharmacoecon Outcomes Res 2014; 13:597-611. [PMID: 24138646 DOI: 10.1586/14737167.2013.838023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This study evaluated the quality of health economic studies of cancer pharmacogenomics (PGx). A systematic search of the literature for economic studies of PGx was conducted in four common cancers. Evaluation of study quality was carried out using the quality of health economic studies instrument. Thirty-nine articles met our eligibility criteria and were selected and accepted for further statistical analyses. The majority of articles (85%) were studies focusing on breast cancer. The overall weighted mean quality score was 85.10, with a range from 21 to 100. Eighty-seven percent of articles were categorized as good quality, whereas some 10 and 3% were categorized as moderate and poor quality, respectively. The quality of economic studies of cancer PGx is generally good but varied widely. We identified several attributes that are predictive of quality. Our findings may be useful for oncologists, health economists and decision makers interested in evaluating studies involving PGx.
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Affiliation(s)
- Mo Yang
- Program in Personalized Medicine & Targeted Therapeutics, University of the Sciences, Philadelphia, 600 S. 43rd St., Philadelphia, PA, USA
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Pavic M, Pfeil AM, Szucs TD. Estimating the potential annual welfare impact of innovative drugs in use in Switzerland. Front Public Health 2014; 2:48. [PMID: 24904912 PMCID: PMC4033008 DOI: 10.3389/fpubh.2014.00048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 05/05/2014] [Indexed: 11/13/2022] Open
Abstract
Expenditures of health care systems are increasing from year to year. Therefore, this study aimed to estimate the difference in costs and benefits of innovative pharmaceuticals launched 2000 onward compared to standard treatment on the national economy of Switzerland in 2010. The approach and formula described in the pilot study by Tsiachristas et al. (1), which analyzed the situation of welfare effects in the Netherlands, served as a model for our own calculations. A literature search was performed to identify cost-utility or cost-effectiveness studies of drugs launched 2000 onward compared to standard treatment. All parameters required for the calculation of welfare effects were derived from these analyses. The base-case threshold value of a quality-adjusted life year was set to CHF 100,000. Overall, 31 drugs were included in the welfare calculations. The introduction of innovative pharmaceuticals since 2000 onward to the Swiss market led to a potential welfare gain of about CHF 781 million in the year 2010. Univariate sensitivity analysis showed that results were robust. Probably because of the higher benefits of new drugs on health and quality of life compared to standard treatment, these drugs are worth the higher costs. The literature search revealed that there is a lack of information about the effects of innovative pharmaceuticals on the overall economy of Switzerland. Our study showed that potential welfare gains in 2010 by introducing innovative pharmaceuticals to the Swiss market were substantial. Considering costs and benefits of new drugs is important.
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Affiliation(s)
| | - Alena M. Pfeil
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Thomas D. Szucs
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
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Hatz MHM, Schremser K, Rogowski WH. Is individualized medicine more cost-effective? A systematic review. PHARMACOECONOMICS 2014; 32:443-55. [PMID: 24574059 DOI: 10.1007/s40273-014-0143-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Individualized medicine (IM) is a rapidly evolving field that is associated with both visions of more effective care at lower costs and fears of highly priced, low-value interventions. It is unclear which view is supported by the current evidence. OBJECTIVE Our objective was to systematically review the health economic evidence related to IM and to derive general statements on its cost-effectiveness. DATA SOURCES A literature search of MEDLINE database for English- and German-language studies was conducted. STUDY APPRAISAL AND SYNTHESIS METHOD Cost-effectiveness and cost-utility studies for technologies meeting the MEDLINE medical subject headings (MeSH) definition of IM (genetically targeted interventions) were reviewed. This was followed by a standardized extraction of general study characteristics and cost-effectiveness results. RESULTS Most of the 84 studies included in the synthesis were from the USA (n = 43, 51 %), cost-utility studies (n = 66, 79 %), and published since 2005 (n = 60, 71 %). The results ranged from dominant to dominated. The median value (cost-utility studies) was calculated to be rounded $US22,000 per quality-adjusted life year (QALY) gained (adjusted to $US, year 2008 values), which is equal to the rounded median cost-effectiveness in the peer-reviewed English-language literature according to a recent review. Many studies reported more than one strategy of IM with highly varying cost-effectiveness ratios. Generally, results differed according to test type, and tests for disease prognosis or screening appeared to be more favorable than tests to stratify patients by response or by risk of adverse effects. However, these results were not significant. LIMITATIONS Different definitions of IM could have been used. Quality assessment of the studies was restricted to analyzing transparency. CONCLUSIONS IM neither seems to display superior cost-effectiveness than other types of medical interventions nor to be economically inferior. Instead, rather than 'whether' healthcare was individualized, the question of 'how' it was individualized was of economic relevance.
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Affiliation(s)
- Maximilian H M Hatz
- Hamburg Center for Health Economics, University of Hamburg, 20354, Hamburg, Germany,
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Pearce A, Haas M, Viney R. Are the true impacts of adverse events considered in economic models of antineoplastic drugs? A systematic review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:619-637. [PMID: 24129649 DOI: 10.1007/s40258-013-0058-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Antineoplastic drugs for cancer are often associated with adverse events, which influence patients' physical health, quality of life and survival. However, the modelling of adverse events in cost-effectiveness analyses of antineoplastic drugs has not been examined. AIMS This article reviews published economic evaluations that include a calculated cost for adverse events of antineoplastic drugs. The aim is to identify how existing models manage four issues specific to antineoplastic drug adverse events: the selection of adverse events for inclusion in models, the influence of dose modifications on drug quantity and survival outcomes, the influence of adverse events on quality of life and the consideration of multiple simultaneous or recurring adverse events. METHODS A systematic literature search was conducted using MESH headings and key words in multiple electronic databases, covering the years 1999-2009. Inclusion criteria for eligibility were papers covering a population of adults with solid tumour cancers, the inclusion of at least one adverse event and the resource use and/or costs of adverse event treatment. RESULTS From 4,985 citations, 26 eligible articles were identified. Studies were generally of moderate quality and addressed a range of cancers and treatment types. While the four issues specific to antineoplastic drug adverse events were addressed by some studies, no study addressed all of the issues in the same model. CONCLUSION This review indicates that current modelling assumptions may restrict our understanding of the true impact of adverse events on cost effectiveness of antineoplastic drugs. This understanding could be improved through consideration of the selection of adverse events, dose modifications, multiple events and quality of life in cost-effectiveness studies.
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Affiliation(s)
- Alison Pearce
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, PO BOX 123, Broadway, NSW, 2007, Australia,
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Retèl VP, Joore MA, Drukker CA, Bueno-de-Mesquita JM, Knauer M, van Tinteren H, Linn SC, van Harten WH. Prospective cost-effectiveness analysis of genomic profiling in breast cancer. Eur J Cancer 2013; 49:3773-9. [PMID: 23992641 DOI: 10.1016/j.ejca.2013.08.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/31/2013] [Accepted: 08/01/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The cost-effectiveness of the 70-gene signature (70-GS) (MammaPrint®) has earlier been estimated using retrospective validation data. Based on the prospective 5-year survival data of the microarRAy-prognoSTics-in-breast-cancER (RASTER) study, the aim here was to evaluate the cost-effectiveness reflecting the actual use in clinical practice, including reality-based compliance rates. METHODS Costs and outcomes (quality-adjusted-life-years (QALYs)) were calculated in node-negative (N-) patients included in the RASTER study (n=427). Sensitivity and specificity of the 70-gene and Adjuvant! Online (AO) were based on 5-year distant-disease-free survival (DDFS). Subgroup analyses were performed for two groups for whom benefit of the 70-gene had earlier been reported: (1) ductal, oestrogen receptor-positive (ER+), tumour diameter 10-30 mm, grade II, age 40-70; (2) ductal, oestrogen receptor-positive, tumour diameter 5-30 mm, grade II/III and age 40-70. RESULTS Based on 5-year survival data, the cost-effectiveness of the 70-gene signature versus AO was prospectively confirmed. The total health care costs per patient were €26,786 for the 70-gene and €29,187 for AO. The quality adjusted life years yielded 12.49 and 11.88, respectively. The subgroups retrieved slightly higher life gains and higher costs, but all resulted finally in a favourable position for the 70-gene signature. CONCLUSIONS The use of the 70-gene signature, as judged appropriate by doctors and patients and supported by a low risk 70-gene signature as an oncological safe choice, was also found to be cost-effective.
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Affiliation(s)
- V P Retèl
- Netherlands Cancer Institute (NKI-AVL), Department of Psychosocial Research and Epidemiology, Amsterdam, The Netherlands
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Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, Augustovski F, Briggs AH, Mauskopf J, Loder E. Consolidated Health Economic Evaluation Reporting Standards (CHEERS)--explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:231-50. [PMID: 23538175 DOI: 10.1016/j.jval.2013.02.002] [Citation(s) in RCA: 1498] [Impact Index Per Article: 136.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Economic evaluations of health interventions pose a particular challenge for reporting because substantial information must be conveyed to allow scrutiny of study findings. Despite a growth in published reports, existing reporting guidelines are not widely adopted. There is also a need to consolidate and update existing guidelines and promote their use in a user-friendly manner. A checklist is one way to help authors, editors, and peer reviewers use guidelines to improve reporting. OBJECTIVE The task force's overall goal was to provide recommendations to optimize the reporting of health economic evaluations. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement is an attempt to consolidate and update previous health economic evaluation guidelines into one current, useful reporting guidance. The CHEERS Elaboration and Explanation Report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force facilitates the use of the CHEERS statement by providing examples and explanations for each recommendation. The primary audiences for the CHEERS statement are researchers reporting economic evaluations and the editors and peer reviewers assessing them for publication. METHODS The need for new reporting guidance was identified by a survey of medical editors. Previously published checklists or guidance documents related to reporting economic evaluations were identified from a systematic review and subsequent survey of task force members. A list of possible items from these efforts was created. A two-round, modified Delphi Panel with representatives from academia, clinical practice, industry, and government, as well as the editorial community, was used to identify a minimum set of items important for reporting from the larger list. RESULTS Out of 44 candidate items, 24 items and accompanying recommendations were developed, with some specific recommendations for single study-based and model-based economic evaluations. The final recommendations are subdivided into six main categories: 1) title and abstract, 2) introduction, 3) methods, 4) results, 5) discussion, and 6) other. The recommendations are contained in the CHEERS statement, a user-friendly 24-item checklist. The task force report provides explanation and elaboration, as well as an example for each recommendation. The ISPOR CHEERS statement is available online via Value in Health or the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices - CHEERS Task Force webpage (http://www.ispor.org/TaskForces/EconomicPubGuidelines.asp). CONCLUSIONS We hope that the ISPOR CHEERS statement and the accompanying task force report guidance will lead to more consistent and transparent reporting, and ultimately, better health decisions. To facilitate wider dissemination and uptake of this guidance, we are copublishing the CHEERS statement across 10 health economics and medical journals. We encourage other journals and groups to consider endorsing the CHEERS statement. The author team plans to review the checklist for an update in 5 years.
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Affiliation(s)
- Don Husereau
- Institute of Health Economics, Edmonton, Canada.
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Hingorani AD, Windt DAVD, Riley RD, Abrams K, Moons KGM, Steyerberg EW, Schroter S, Sauerbrei W, Altman DG, Hemingway H. Prognosis research strategy (PROGRESS) 4: stratified medicine research. BMJ 2013; 346:e5793. [PMID: 23386361 PMCID: PMC3565686 DOI: 10.1136/bmj.e5793] [Citation(s) in RCA: 319] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In patients with a particular disease or health condition, stratified medicine seeks to identify those who will have the most clinical benefit or least harm from a specific treatment. In this article, the fourth in the PROGRESS series, the authors discuss why prognosis research should form a cornerstone of stratified medicine, especially in regard to the identification of factors that predict individual treatment response
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Affiliation(s)
- Aroon D Hingorani
- Department of Epidemiology and Public Health, University College London, London WC1E 7HB, UK
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Seferina SC, Nap M, van den Berkmortel F, Wals J, Voogd AC, Tjan-Heijnen VCG. Reliability of receptor assessment on core needle biopsy in breast cancer patients. Tumour Biol 2012; 34:987-94. [PMID: 23269610 DOI: 10.1007/s13277-012-0635-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/13/2012] [Indexed: 01/13/2023] Open
Abstract
We compared the breast core needle biopsy and the resection specimen with respect to estrogen (ER), progesterone (PR) and human epidermal growth factor receptor 2 (HER2) status to identify predictors for discordant findings. We retrospectively collected data from 526 newly diagnosed breast cancer patients. ER, PR and HER2 status had been assessed in both the core needle biopsy and resection specimen. The assessment of ER by immunohistochemistry (IHC) in core needle biopsy was false negative in 26.5% and false positive in 6.8% of patients. For the PR status the false negative and false positive results of core needle biopsy were 29.6% and 10.3%, respectively. The results of the HER2 status, as determined by IHC and silver in situ hybridization (SISH), were false negative in 5.4% and false positive in 50.0%. We need to be aware of the problem of false negative and false positive test results in ER, PR and HER2 assessment in core needle biopsy and the potential impact on adjuvant systemic treatment. With current techniques, we recommend using the resection specimen to measure these receptors in patients without neoadjuvant treatment. A better alternative might be the use of tissue microarray, combining both core needle biopsy and resection specimen.
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Affiliation(s)
- S C Seferina
- Department of Internal Medicine, Division of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands
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Younis T, Skedgel C. Is trastuzumab a cost-effective treatment for breast cancer? Expert Rev Pharmacoecon Outcomes Res 2012; 8:433-42. [PMID: 20528328 DOI: 10.1586/14737167.8.5.433] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Trastuzumab is a recombinant humanized monoclonal antibody that is currently approved for the treatment of HER2-neu-positive breast cancer. From a clinical perspective, it is an effective treatment with a relatively favorable benefit/risk profile. From an economic perspective, trastuzumab is an expensive treatment that is associated with high drug acquisition cost. Overall, it appears to provide reasonable 'value for money' (i.e., is cost-effective), especially in the adjuvant as opposed to the palliative setting. Trastuzumab's cost-effectiveness appears to be driven primarily by trastuzumab costs and the magnitude of benefit derived. Longer follow-up of clinical trials is, therefore, required to better estimate the long-term benefits associated with adjuvant trastuzumab, and its true cost-effectiveness in the treatment of HER2-neu-positive breast cancer.
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Affiliation(s)
- Tallal Younis
- Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada; 454 Bethune Building. 1278 Tower Road, Halifax, Nova Scotia, B3H 2Y9, Canada.
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Costs of trastuzumab in combination with chemotherapy for HER2-positive advanced gastric or gastroesophageal junction cancer: an economic evaluation in the Chinese context. Clin Ther 2012; 34:468-79. [PMID: 22325735 DOI: 10.1016/j.clinthera.2012.01.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adding trastuzumab to a conventional regimen of chemotherapy can improve survival in patients with human epidermal growth factor receptor 2 (HER2)-positive advanced gastric or gastroesophageal junction (GEJ) cancer, but the economic impact of this practice is unknown. OBJECTIVE The purpose of this cost-effectiveness analysis was to estimate the effects of adding trastuzumab to standard chemotherapy in patients with HER2-positive advanced gastric or GEJ cancer on health and economic outcomes in China. METHODS A Markov model was developed to simulate the clinical course of typical patients with HER2-positive advanced gastric or GEJ cancer. Five-year quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) were estimated. Model inputs were derived from the published literature and government sources. Direct costs were estimated from the perspective of Chinese society. One-way and probabilistic sensitivity analyses were conducted. RESULTS On baseline analysis, the addition of trastuzumab increased cost and QALY by $56,004.30 (year-2010 US $) and 0.18, respectively, relative to conventional chemotherapy, resulting in an ICER of $251,667.10/QALY gained. Probabilistic sensitivity analyses supported that the addition of trastuzumab was not cost-effective. Budgetary impact analysis estimated that the annual increase in fiscal expenditures would be ~$1 billion. On univariate sensitivity analysis, the median overall survival time for conventional chemotherapy was the most influential factor with respect to the robustness of the model. CONCLUSIONS The findings from the present analysis suggest that the addition of trastuzumab to conventional chemotherapy might not be cost-effective in patients with HER2-positive advanced gastric or GEJ cancer.
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Economic evaluation of targeted cancer interventions: critical review and recommendations. Genet Med 2012; 13:853-60. [PMID: 21637102 DOI: 10.1097/gim.0b013e31821f3e64] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Scientific advances have improved our ability to target cancer interventions to individuals who will benefit most and spare the risks and costs to those who will derive little benefit or even be harmed. Several approaches are currently used for targeting interventions for cancer risk reduction, screening, and treatment, including risk prediction algorithms for identifying high-risk subgroups and diagnostic tests for tumor markers and germline genetic mutations. Economic evaluation can inform decisions about the use of targeted interventions, which may be more costly than traditional strategies. However, assessing the impact of a targeted intervention on costs and health outcomes requires explicit consideration of the method of targeting. In this study, we describe the importance of this principle by reviewing published cost-effectiveness analyses of targeted interventions in breast cancer. Few studies we identified explicitly evaluated the relationships among the method of targeting, the accuracy of the targeting test, and outcomes of the targeted intervention. Those that did found that characteristics of targeting tests had a substantial impact on outcomes. We posit that the method of targeting and the outcomes of a targeted intervention are inextricably linked and recommend that cost-effectiveness analyses of targeted interventions explicitly consider costs and outcomes of the method of targeting.
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Simmons LA, Dinan MA, Robinson TJ, Snyderman R. Personalized medicine is more than genomic medicine: confusion over terminology impedes progress towards personalized healthcare. Per Med 2012; 9:85-91. [PMID: 29783292 DOI: 10.2217/pme.11.86] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Over the last decade, scientific discovery and technological advances have created great anticipation for capabilities to tailor individual medical decisions and provide personalized healthcare. Despite some advances, adoption has been sporadic and there remains a lack of consensus about what personalized healthcare actually means. This confusion has often resulted from the mistake of equating personalized medicine with genomic medicine, and thereby, attributing it as yet unfulfilled expectations of genomic medicine to the broader application of personalized medicine. The lack of a clear understanding of personalized medicine has limited its adoption within clinical delivery models. It is thus essential to reach a consensus regarding what personalized healthcare and its components mean. We propose that personalized healthcare is an approach to care that utilizes personalized medicine tools to deliver patient-centered, predictive care within the context of coordinated service delivery, and it is poised to improve healthcare delivery today.
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Affiliation(s)
- Leigh Ann Simmons
- Center for Research on Prospective Health Care, Department of Medicine, Duke University, 3475 Erwin Road, Aesthetics Room 271, Durham, NC 27705, USA
| | - Michaela Ann Dinan
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
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Fang C, Otero HJ, Greenberg D, Neumann PJ. Cost-utility analyses of diagnostic laboratory tests: a systematic review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:1010-8. [PMID: 22152169 DOI: 10.1016/j.jval.2011.05.044] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 05/20/2011] [Accepted: 05/20/2011] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To review and evaluate the literature of cost-utility analyses (CUAs) regarding diagnostic laboratory testing. METHODS We reviewed all articles related to diagnostic laboratory testing in the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), which contains detailed information on over 2000 published CUAs through 2008. We analyzed the extent to which the studies adhered to recommended practices for conducting and reporting cost-effectiveness analyses. We also recorded whether the studies contained information on diagnostic test accuracy and costs, and whether any account was taken of potential benefits or harms of testing that are unrelated to subsequent treatment, such as the reassurance value of testing. RESULTS We identified 141 published CUAs pertaining to diagnostic laboratory testing published through 2008 which contained 433 separate incremental cost-effectiveness ratios. Prior to 2000, there were only 20 CUAs published, but the number averaged 13.4 annually thereafter. Most studies focused on hematology/oncology (n = 42, 30%) and obstetrics/gynecology (n = 36, 26%) applications. Approximately 63% (n = 89) of studies clearly reported information about the accuracy of the test, but only 10% (n = 14) mentioned test safety or possible risks. A small number (n = 10, 7%) mentioned or considered the potential value or harm of testing unrelated to treatment consequences. Over 55% of the reported incremental cost-effectiveness ratios (ICERs) were either dominant (more quality-adjusted life years for less cost), or below $50,000 per quality-adjusted life years gained (in 2008 US dollars). CONCLUSION The number of CUAs investigating laboratory diagnostic testing has increased substantially with applications to diverse clinical areas. The literature reveals many areas in which testing represents good value for money. The vast majority of studies have not considered preferences for test information unrelated to treatment consequences.
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Affiliation(s)
- ChiHui Fang
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
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Lee JA, Shaheen M, Walke T, Daly M. Clinical and health economic outcomes of alternative HER2 test strategies for guiding adjuvant trastuzumab therapy. Expert Rev Pharmacoecon Outcomes Res 2011; 11:325-41. [PMID: 21671702 DOI: 10.1586/erp.11.25] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM To evaluate the clinical outcomes and cost-effectiveness of human epidermal growth factor receptor 2 (HER2) testing strategies to guide adjuvant trastuzumab (AT) therapy in women with HER2-positive breast cancer. METHODS A literature review produced 72 studies comparing HER2 test methods, and we computed concordance (assuming fluorescence in situ hybridization [FISH] as a reference assay) to assess performance relative to American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines. An economic analysis provided cost-effectiveness of alternative strategies, including a Monte Carlo simulation to vary key assumptions such as test price and performance. RESULTS Of 46 studies comparing immunohistochemistry (IHC) and FISH, only seven met the ASCO/CAP guideline of 95% or better concordance. A total of 14 out of 21 studies comparing chromogenic in situ hybridization and three out of five studies comparing silver-enhanced in situ hybridization met the guideline. Confirmation of IHC 2+ and 3+ and primary FISH strategies are likely to reduce costs and improve quality of life relative to confirmation of IHC 2+ only. Initial testing with a gene amplification-based assay is probably a cost-effective alternative to confirmation of IHC 2+ and 3+. The results are not sensitive to varying test price but are sensitive to test accuracy below 98%. CONCLUSION Using a primary gene amplification-based assay to guide AT therapy for HER2-positive breast cancer probably results in lower US medical costs, increased life-years and increased quality of life compared with confirmation of IHC 2+ with a gene amplification-based assay. We recommend the ASCO/CAP guidelines reflect 98% or greater concordance relative to a reference assay. Additional research regarding therapy response is required to further differentiate between gene amplification-based assays.
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Affiliation(s)
- James A Lee
- Altarum Institute, 3520 Green Court, Suite 300, Ann Arbor, MI 48105, USA.
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Park S, Park HS, Koo JS, Yang WI, Kim SI, Park BW. Breast cancers presenting luminal B subtype features show higher discordant human epidermal growth factor receptor 2 results between immunohistochemistry and fluorescence in situ hybridization. Cancer 2011; 118:914-23. [PMID: 21800290 DOI: 10.1002/cncr.26406] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 03/16/2011] [Accepted: 06/08/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aims of this study were to compare human epidermal growth factor receptor 2 (HER2) results between immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH), and to investigate the clinicopathological characteristics and outcomes according to their results. METHODS Using consecutive tissue microarrays, IHC and FISH were performed as guidelines in 950 invasive breast cancers treated between November 1999 and August 2005. Characteristics and outcomes were retrospectively analyzed using a chi-square test, the Kaplan-Meier method, and Cox's model. RESULTS FISH-positivity was observed in 2.6%, 4.8%, 28.1%, and 93.8% of IHC 0, 1+, 2+, and 3+, respectively, and the concordance rate between the 2 assays was 95.5%. IHC-positive or FISH-positive cases were associated with poorer differentiation, negative expression of hormone receptors, and higher proliferative index. Among IHC-equivocal or IHC-negative patients, positive FISH was negatively associated with survival in univariate and multivariate analyses. Among IHC-negative patients, tumors showing luminal B subtype features such as estrogen receptor (ER)-positive, grade II/III, and high Ki-67 presented discordantly high FISH-positivity. Among IHC-positive cases, FISH was not related to outcomes. CONCLUSIONS The result of FISH is significantly related to prognosis of patients with IHC-negative or IHC-equivocal result. Therefore, FISH should be performed in IHC-equivocal cases. FISH assay might be considered for a selected group of patients with IHC-negative tumors showing luminal B subtype features of ER-positive, grade II/III, and high Ki-67 expression.
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Affiliation(s)
- Seho Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Grutters JPC, Seferina SC, Tjan-Heijnen VCG, van Kampen RJW, Goettsch WG, Joore MA. Bridging trial and decision: a checklist to frame health technology assessments for resource allocation decisions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:777-784. [PMID: 21839418 DOI: 10.1016/j.jval.2011.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 01/26/2011] [Accepted: 01/31/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Health technology assessments (HTAs) intend to inform real-world decisions. They often draw on data from explanatory trials and hence are not always applicable to the decision problem. HTAs may therefore not meet the needs of decision makers. Our objective was to develop and apply a checklist to: 1) systematically frame HTAs in a way that they are applicable to the decision problem; and 2) assess if a decision problem can be informed by an available HTA. METHODS We reviewed published literature to identify factors that should be considered when framing HTAs for resource allocation decisions. The checklist was finalized in collaboration with clinicians and policy makers. We applied the checklist to the economic evaluation of trastuzumab in early breast cancer. We defined a reference case and for each study, retrieved through a systematic review, we examined if each factor was explicitly considered. RESULTS A checklist was developed with 11 factors (e.g., clinical practice, consequences, and patient use). In the case of trastuzumab, most factors were considered by the 11 retrieved economic evaluations. Two factors, being the inclusion of all relevant comparators and professional use, were considered by none of the studies. CONCLUSIONS We developed a comprehensive checklist with 11 factors to frame HTAs and to assess the applicability of HTAs to resource allocation decisions. Economic evaluations on trastuzumab considered some of these factors, but overlooked others. The proposed checklist assists in systematically considering all factors in developing the conceptual model of an HTA, to make HTAs better reflect the decision problem.
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Affiliation(s)
- Janneke P C Grutters
- Department of Health Organization, Policy, and Economics, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
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Ferrusi IL, Leighl NB, Kulin NA, Marshall DA. Do economic evaluations of targeted therapy provide support for decision makers? J Oncol Pract 2011; 7:36s-45s. [PMID: 21886518 PMCID: PMC3092467 DOI: 10.1200/jop.2011.000315] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Decision makers must make decisions without complete information. That uncertainty can be decreased when economic evaluations use local data and can be quantified by considering the variability of all model inputs concurrently per international evaluation guidelines. It is unclear how these recommendations have been implemented in evaluations of targeted cancer therapy. By using economic evaluations of adjuvant trastuzumab, we have assessed the extent to which decision support recommendations were adopted. STUDY DESIGN Systematic review. METHODS Published economic evaluations of adjuvant trastuzumab treatment in early-stage breast cancer were examined as an established example of targeted therapy. Canadian, United Kingdom, and US economic evaluation guidelines were reviewed to establish extraction criteria. Extraction characterized the use of effectiveness evidence and local data sources for model parameters, sensitivity analysis methods (scenario, univariate, multivariate, and probabilistic) and uncertainty representation (ie, cost-effectiveness plane, scatterplot, confidence ellipses, tornado diagrams, cost-effectiveness acceptability curve). RESULTS Fifteen economic evaluations of adjuvant trastuzumab were identified in the literature. Local data were used to estimate costs (15 of 15) and utilities rarely (two of 15) but not trastuzumab efficacy. Univariate sensitivity analysis was most common (12 of 15), whereas probabilistic analysis was less frequent (10 of 15). Two thirds of all studies provided visual representation of results and decision uncertainty. CONCLUSION Authors of adjuvant trastuzumab economic evaluations rarely use local data beyond costs. Quantification of uncertainty and its representation also fell short of guideline recommendations. This review demonstrates that economic evaluations of adjuvant trastuzumab, as an example of targeted cancer therapy, can be improved for decision-making support.
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Affiliation(s)
- Ilia L. Ferrusi
- Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton; McMaster University, Hamilton; University of Toronto; Princess Margaret Hospital, University Health Network, Toronto, Ontario; University of Calgary, Calgary, Alberta, Canada
| | - Natasha B. Leighl
- Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton; McMaster University, Hamilton; University of Toronto; Princess Margaret Hospital, University Health Network, Toronto, Ontario; University of Calgary, Calgary, Alberta, Canada
| | - Nathalie A. Kulin
- Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton; McMaster University, Hamilton; University of Toronto; Princess Margaret Hospital, University Health Network, Toronto, Ontario; University of Calgary, Calgary, Alberta, Canada
| | - Deborah A. Marshall
- Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton; McMaster University, Hamilton; University of Toronto; Princess Margaret Hospital, University Health Network, Toronto, Ontario; University of Calgary, Calgary, Alberta, Canada
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Hall PS, Hulme C, McCabe C, Oluboyede Y, Round J, Cameron DA. Updated cost-effectiveness analysis of trastuzumab for early breast cancer: a UK perspective considering duration of benefit, long-term toxicity and pattern of recurrence. PHARMACOECONOMICS 2011; 29:415-432. [PMID: 21504241 DOI: 10.2165/11588340-000000000-00000] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Trastuzumab has significantly improved survival outcomes for women with Human Epidermal growth factor Receptor 2 (HER2)-positive early breast cancer. Trastuzumab was established as a cost-effective adjuvant treatment in 2006. We present an updated cost-effectiveness analysis from the UK perspective, which explores assumptions about the duration of benefit from treatment, pattern of metastatic recurrence and long-term cardiac toxicity. OBJECTIVE The objective of this study was to calculate, from the UK NHS perspective, expected costs (year 2008 values) and benefits over the lifetime of an average cohort of women with HER2-positive early breast cancer treated with or without 1 year of adjuvant trastuzumab sequentially after chemotherapy. METHODS A cost-utility analysis was performed using a discrete-state time-dependent semi-Markov model. Probabilistic sensitivity analysis was used to characterize uncertainty around expected outcomes. Value-of-information (VOI) analysis was used to identify areas of priority for further research. RESULTS The cost-effectiveness estimates were highly sensitive to the estimated duration of treatment benefit. Trastuzumab remained a cost-effective treatment strategy at a willingness-to-pay threshold of £30,000 per QALY provided the duration of benefit was more than 3.6 years from treatment initiation, assuming the hazard ratio for disease-free survival was 0.63. An increasing proportion of brain metastases with trastuzumab produced a small change towards worse cost effectiveness. Long-term cardiac toxicity needed to rise to high levels to affect overall life expectancy and cost effectiveness. VOI analysis placed highest value on research into the duration of treatment benefit. The relationships between progression-free survival and overall survival and the costs of cancer recurrence were also important. CONCLUSION The cost effectiveness of adjuvant trastuzumab remains uncertain and dependent on assumptions regarding its clinical effect. Uncertainty around cost effectiveness could be reduced by further research into the duration of treatment effect, particularly in subgroups where this may be shorter. Long-term follow-up is warranted and methods to accurately measure duration of treatment effect and late toxicities should be developed for future adjuvant drug studies.
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MESH Headings
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/economics
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/economics
- Antineoplastic Agents/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/mortality
- Chemotherapy, Adjuvant
- Clinical Trials as Topic
- Cost-Benefit Analysis
- Disease-Free Survival
- Female
- Health Care Costs/standards
- Health Care Costs/trends
- Humans
- Markov Chains
- Models, Economic
- Neoplasm Recurrence, Local/economics
- Neoplasm Recurrence, Local/mortality
- Time Factors
- Trastuzumab
- United Kingdom
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Affiliation(s)
- Peter S Hall
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
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Fukutomi A, Hatake K, Matsui K, Sakajiri S, Hirashima T, Tanii H, Kobayashi K, Yamamoto N. A phase I study of oral panobinostat (LBH589) in Japanese patients with advanced solid tumors. Invest New Drugs 2011; 30:1096-106. [PMID: 21484248 DOI: 10.1007/s10637-011-9666-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 03/31/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective was to determine the maximum tolerated dose and the dose-limiting toxicity of panobinostat (LBH589) when administered as a single agent to adult patients with advanced solid tumors or cutaneous T-cell lymphoma whose disease had progressed despite standard therapy or for whom no standard therapy existed. METHODS Panobinostat was administered orally once daily on Monday, Wednesday, and Friday of each week. A total of 13 patients were treated with one of three initial doses: 10 mg (n = 3), 15 mg (n = 4), or 20 mg (n = 6). RESULTS No dose-limiting toxicity was observed in 12 evaluable patients. The most frequently reported adverse events, regardless of whether they were related to the study drug, were diarrhea and nausea in 10 patients (76.9%). Thrombocytopenia was reported in 12 of 13 patients (92.3%). Five of 11 patients (45.4%) had stable disease. CONCLUSION Panobinostat administered orally once daily on Monday, Wednesday, and Friday of each week was well tolerated at doses up to 20 mg in Japanese patients. Dose escalation did not proceed after exploration of the 20 mg dose due to emerging global clinical data at that time.
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Purmonen TT, Pänkäläinen E, Turunen JHO, Asseburg C, Martikainen JA. Short-course adjuvant trastuzumab therapy in early stage breast cancer in Finland: cost-effectiveness and value of information analysis based on the 5-year follow-up results of the FinHer Trial. Acta Oncol 2011; 50:344-52. [PMID: 21299447 DOI: 10.3109/0284186x.2011.553841] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Trastuzumab is a standard treatment of HER2-positive early breast cancer in many countries, and it is usually given as a one year adjuvant treatment. However, its cost-effectiveness has not been assessed in Finland. The Finland Herceptin (FinHer) trial has compared a shorter 9-week treatment protocol against no trastuzumab with promising results. The aim of this study was to assess the potential cost-effectiveness of the 9-week treatment based on the recently published five-year follow-up results of the FinHer trial. METHODS An evaluation model of breast cancer treatment was constructed using fitted survival estimates and a long-term Markov model. The cost-effectiveness of 9-week adjuvant treatment was assessed in a Finnish setting, compared to treatment without trastuzumab. The analysis was performed from a societal perspective, and a 3% discount rate was applied for future costs and outcomes. Value of information analysis was performed to estimate the potential value of further research. RESULTS According to the probabilistic analysis, the incremental cost-effectiveness ratio was €12 000 per quality adjusted life year (QALY), and €9300 per life year gained (LYG), when comparing adjuvant trastuzumab therapy to standard treatment without trastuzumab. The modelled incremental outcomes for trastuzumab treatment were 0.66 QALY and 0.85 LYG for a lifetime perspective. Value of information analysis showed that additional research on treatment effects would be most valuable for reducing uncertainty in the adoption decision. CONCLUSIONS Adjuvant 9-week trastuzumab is likely to be a cost-effective treatment in the Finnish setting. Results from an ongoing trial comparing adjuvant 9-week treatment with the 12-month treatment will play a key role in addressing the uncertainty related to the treatment effect and potential cost-effectiveness of these two treatment protocols.
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Affiliation(s)
- Timo T Purmonen
- University of Eastern Finland, School of Pharmacy, Pharmacoeconomics and Outcomes Research Unit, Kuopio, Finland.
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Vegter S, Jansen E, Postma MJ, Boersma C. Economic evaluations of pharmacogenetic and genomic screening programs: update of the literature. Drug Dev Res 2010. [DOI: 10.1002/ddr.20424] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Wilking U, Jönsson B, Wilking N, Bergh J. Trastuzumab use in breast cancer patients in the six Health Care Regions in Sweden. Acta Oncol 2010; 49:844-50. [PMID: 20615172 DOI: 10.3109/0284186x.2010.492790] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Approximately 14% of Early Breast Cancers, EBCs, and 25% of Metastatic BCs, MBCs, are HER2 positive. There is an effective treatment (trastuzumab) for both EBC (9% increased absolute disease free survival at five years) and MBC (five to nine months' prolonged overall survival). Patients with BC are treated within each of the six different Health Care Regions (HCRs) in Sweden. This aim of this project was to study the introduction and usage of trastuzumab in BC in the six HCRs in Sweden. MATERIALS AND METHODS We used official sales data and cancer statistics in the model, and HER2 positive proportions of 25% (prevalent population in year 2000; first year of trastuzumab sales) and 14% and treatment times of 38 weeks and 52 weeks for MBC and EBC, respectively, based on clinical trial data. We used years 2000-2004 for the MBC analyses. In year 2005 data on trastuzumab in EBC were presented, and approval came in year 2006. We studied years 2006-2008 for the use in both EBC and MBC. RESULTS The percentage trastuzumab treated MBC patients for the entire period in the different HCRs (quarter 4 2000 to end 2004) was: North 57%, Stockholm 48%, South East 40%, South 17%, Uppsala 52%, West 34%. The Sweden average was 40%. The percentage treated patients (MBC and EBC), years 2006-2008 in the different HCRs was: North 68%, Stockholm 75%, South East 43%, South 44%, Uppsala 74%, West 43%. The Sweden average was 59%. CONCLUSION The differences in usage of trastuzumab may be explained by variable interpretations of the clinical data and applications in clinical practice, budget issues and differences in coordination, experience and training.
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Affiliation(s)
- Ulla Wilking
- Karolinska Institutet, Department of Oncology-Pathology, Stockholm, Sweden.
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