Modelling the cost-effectiveness of sentinel lymph node mapping and adjuvant interferon treatment for stage II melanoma

Sentinel Lymph Node Biopsy for T1b Melanoma: Balancing Prognostic Value and Cost

BACKGROUND

The purpose of this study is to report the additional prognostic information and cost associated with sentinel lymph node biopsy (SLNB) for patients with T1b melanoma.

PATIENTS AND METHODS

An institutional database was queried for patients with T1b melanoma (0.8-1.0 mm or < 0.8 mm with ulceration) with at least 5 years of follow-up. Results of SLNB, completion lymphadenectomy (CLND), recurrence, and melanoma-specific survival (MSS) were assessed. Institutional costs of melanoma care were converted to Medicare proportional dollars. A Markov model was created to estimate long-term costs.

RESULTS

Among the total 392 patients, 238 underwent SLNB. Median follow-up was 10.5 years. SLNB was positive in 19 patients (8.0%). Patients who underwent SLNB had higher 10-year nodal recurrence-free survival (98.6% vs. 91.2%, p < 0.001) but not MSS (94.4% vs. 93.2%, p = 0.55). Ulceration (HR 4.7, p = 0.022) and positive sentinel node (HR 11.5, p < 0.001) were associated with worse MSS. Estimates for 5-year costs reflect a fourfold increase in total costs of care associated with SLNB. However, a treatment plan that forgoes adjuvant therapy for resected stage IIIA melanoma but offers systemic therapy for a node-basin recurrence would nullify the additional cost of SLNB.

CONCLUSIONS

SLNB is prognostic for T1b melanoma. Its impact on the overall cost of melanoma care is intimately tied to systemic therapy in the adjuvant and recurrent settings.

Cost-Effectiveness of Drug Treatments for Advanced Melanoma: A Systematic Literature Review

BACKGROUND

Until recently, advanced melanoma (unresectable and metastatic) has had a poor prognosis and has been treated with chemotherapy. The introduction of new treatments (BRAF and MEK inhibitors and immunotherapy) has improved overall survival and progression-free survival of some patients.

OBJECTIVE

The objective of this study was to review the published evidence on the cost-effectiveness of pharmacological treatments for advanced melanoma.

METHODS

A systematic literature search was conducted, without date or language restrictions, in PubMed, EMBASE, Scopus, the Cochrane Library, the UK National Institute for Health and Care Excellence databases and the Health Technology Assessment journal. Internet searches were also made to identify possible grey literature. Main study characteristics, methods and outcomes were extracted and critically assessed. The quality of health economic studies was assessed by the Quality Assessment of Economic Evaluation in Health Care checklist.

RESULTS

The search identified nine full-text pharmacoeconomic analyses of advanced melanoma treatments. According to the economic analyses published in the articles, the new treatments have been shown to be more effective (with more life-years and quality-adjusted life-years) than chemotherapy, although generally the cost per quality-adjusted life-year gained was above the commonly accepted threshold. Because of the variability of the available analyses comparing the new treatments, we cannot determine which treatment is the most cost-effective.

CONCLUSIONS

From the available data, it cannot be concluded that the new drugs (BRAF and MEK inhibitors and immunotherapy) are cost effective compared with chemotherapy or which is the most cost-effective new treatment.

Cost-effectiveness of therapies for melanoma

Melanoma presents an important burden worldwide. Until recently, the prognosis for unresectable and metastatic melanoma was poor, with 10% of metastatic melanoma patients surviving for 2 years. The introduction of newer therapies including ipilimumab, vemurafenib, dabrafenib and trametinib improved progression-free survival, with additional benefits anticipated from the forthcoming class of programmed cell death 1 inhibitors. Cost of therapy and resulting cost-effectiveness is an important factor in determining patient access to specific treatments. The objective of this study was to review the published evidence regarding cost-effectiveness of melanoma therapies and provide an overview of the relative cost-effectiveness of available therapies by disease stage. For earlier-stage disease, IFN-α has been found to be cost-effective, although its clinical benefits have not been well established. For unresectable and metastatic melanoma, newer therapies provide benefits over standard-of-care chemotherapy, but comprehensive analyses will need to be conducted to determine the most cost-effective therapy.

Assessment of patient-reported outcomes in patients with melanoma

Assessment of patient-reported outcomes (PROs) provides important information to assist with clinical decision making. There has been significant progress in the field of PROs over the past 2 decades with the introduction of validated disease- and symptom-specific instruments. The Functional Assessment of Cancer Therapy-Melanoma (FACT-M) is a melanoma-specific module to accompany the FACT-General, which was validated to assess health-related quality of life for patients with all stages of melanoma. Melanoma-specific health state utilities also have been reported from a number of studies. Assessment of PROs should be incorporated into routine clinical practice to inform clinicians and researchers of the patient perspective for clinical decision making and to evaluate the effects of psychosocial and medical interventions.

A prospective cohort study defining utilities using time trade-offs and the Euroqol-5D to assess the impact of cancer-related lymphedema

BACKGROUND

The devastating impact of lymphedema on cancer survivors' quality of life has prompted consideration of several changes in medical and surgical care. Unfortunately, our understanding of the benefits gained from these approaches relative to their cost remains limited. This study was designed to estimate utilities for lymphedema and characterize how utilities differ between subgroups defined by lymphedema etiology and distribution.

METHODS

A consecutive sample of 236 subjects with lymphedema seen at a lymphedema clinic completed both a time trade-off (TTO) exercise and the Euroqol 5D. Responses were adjusted in multivariate regression models for demographic factors, comorbidities, and lymphedema severity/location.

RESULTS

Most participants (167 of 236, 71%) had lymphedema as a consequence of cancer treatment; 123 with breast cancer and upper extremity involvement. Mean TTO utility estimates were consistently higher than Euroqol 5D estimates. Unadjusted TTO (0.85; standard deviation [SD], 0.21) and Euroqol 5D (0.76; SD, 0.18) scores diminished with increasing lymphedema stage and patient body mass index (BMI). Adjusted utility scores were lowest in patients with cancer-related lower extremity lymphedema (TTO=0.82; SD, 0.04 and Euroqol 5D=0.80; SD, 0.03). Breast cancer patients also had lower adjusted Euroqol 5D scores (0.80; SD, 0.02).

CONCLUSIONS

Lymphedema-associated utilities are in the range of 0.80. Lower utilities are observed for patients with higher lymphedema stages, elevated BMI, and cancer-related lymphedema. Greater expenditures for the prevention and treatment of cancer-related lymphedema are warranted.

The cost-effectiveness of sentinel node biopsy in patients with intermediate thickness primary cutaneous melanoma

BACKGROUND

The aim of this study was to determine the cost-effectiveness of wide excision (WEX) + sentinel node biopsy (SNB) compared with WEX only in patients with primary melanomas >/=1 mm in thickness.

METHODS

A Markov model was populated with probabilities of disease progression and survival from the published literature. Costs were obtained from diagnostic-related group weightings and health outcomes were measured in quality-adjusted life years (QALYs).

RESULTS

Base case analyses suggested that, over a 20-year timeframe, the mean total cost per patient receiving WEX only was AU $23,182 with 10.45 life years (LY) and 9.90 QALYs. The mean cost per patient for WEX + SNB was AU $24,045 with 10.77 LY and 10.34 QALYs. The incremental cost effectiveness ratio for WEX + SNB was AU $2,770 per LY and AU $1,983 per QALY.

CONCLUSION

WEX + SNB appears to offer an improvement in health outcomes (in both LYs and QALYs) with only a slight increase in cost.

Interpreting the Economic Literature in Oncology

New treatment options provide hope for patients with localized and advanced cancer. However, these advances are associated with cost, both in terms of treatment-related expenditures and effects on quality of life. It is important that patients, physicians, insurers, and policymakers understand the relationship between costs and outcomes of new cancer treatments. Various methods of cost analysis can provide a structured manner to assess cost. Cost-effectiveness analysis (CEA) compares the cost of the intervention with the effect, resulting in a cost per effect (eg, cost per year of life gained) that can be compared across interventions. In this article, we review three recent CEAs in the oncology literature, including chemoprevention in breast cancer, adjuvant endocrine therapy in early-stage breast cancer, and salvage chemotherapy in advanced ovarian cancer. The important elements of CEA, including the recommendations of the US Public Health Service Panel on Cost Effectiveness in Health and Medicine as they relate to cancer treatments, are discussed. Many well-done CEAs in cancer treatment have been performed during the last decade. As with clinical trials, the rigor and methods of the analysis are critical to the reliability of the results. Therapies with high cost and small incremental improvement in survival and/or quality of life may find it difficult to meet the societal thresholds for what is considered cost effective. CEA is a method to assess the cost and effect of cancer treatments, providing important insights into the best use (ie, obtaining the most value for) of health care expenditures. As the literature indicates, one must be cognizant of the fact that there can be extraordinary costs associated with some newer cancer therapies that provide small incremental clinical benefit. Better understanding of the cancer economic literature can help lead to an informed dialogue on the health policy implications of resource allocation in cancer care.

Cost-effectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression

PURPOSE

A recent randomized clinical trial has demonstrated that direct decompressive surgery plus radiotherapy was superior to radiotherapy alone for the treatment of metastatic epidural spinal cord compression. The current study compared the cost-effectiveness of the two approaches.

METHODS AND MATERIALS

In the original clinical trial, clinical effectiveness was measured by ambulation and survival time until death. In this study, an incremental cost-effectiveness analysis was performed from a societal perspective. Costs related to treatment and posttreatment care were estimated and extended to the lifetime of the cohort. Weibull regression was applied to extrapolate outcomes in the presence of censored clinical effectiveness data.

RESULTS

From a societal perspective, the baseline incremental cost-effectiveness ratio (ICER) was found to be $60 per additional day of ambulation (all costs in 2003 Canadian dollars). Using probabilistic sensitivity analysis, 50% of all generated ICERs were lower than $57, and 95% were lower than $242 per additional day of ambulation. This analysis had a 95% CI of -$72.74 to 309.44, meaning that this intervention ranged from a financial savings of $72.74 to a cost of $309.44 per additional day of ambulation. Using survival as the measure of effectiveness resulted in an ICER of $30,940 per life-year gained.

CONCLUSIONS

We found strong evidence that treatment of metastatic epidural spinal cord compression with surgery in addition to radiotherapy is cost-effective both in terms of cost per additional day of ambulation, and cost per life-year gained.

The economic implications of non-adherence after renal transplantation

BACKGROUND

The economic impact of therapeutic non-adherence in chronic diseases has rarely been examined using qualitative standards for economic evaluation. This study illustrates the impact of non-adherence on the cost utility of renal transplantation versus haemodialysis from the societal perspective and examines the scope for adherence-enhancing interventions.

METHODS

Long-term costs and outcomes in adherent and non-adherent renal transplant patients were simulated in a Markov model. The cost (euros, year 2000 values) and outcome data that were imputed in the model were derived from a prospective study in renal transplantation candidates performed in 2002. Probabilities of adverse events, graft rejection, graft loss and death in adherent and non-adherent renal transplant patients were derived from literature.

RESULTS

Compared with dialysis, renal transplantation offers a better outcome in both adherent and non-adherent patients. Lifetime costs after transplantation in the adherent patient group are higher than lifetime dialysis costs and lifetime costs in the non-adherent patient group, mainly because adherent patients live longer after transplantation. Long-term outcomes after transplantation are better for adherent than for non-adherent patients. The mean cost per QALY gained in adherent patients relative to non-adherent patients was euro 35 021 per QALY (95% CI 26 959, 46 620).

CONCLUSION

Compared with established healthcare interventions, such as haemodialysis, renal transplantation can be considered a cost-effective therapy for patients with end-stage renal disease, even if patients are non-adherent after transplantation. The low incremental cost per QALY calculated in this model for adherent renal transplant patients, suggests there may be scope for adherence-enhancing interventions (provided that such interventions with a sufficiently high effectiveness exist or can be developed). As the findings are based on simulated long-term costs and outcomes, they should not be considered as precise estimates of the impact of non-adherence. This study is rather meant as an illustration of how non-adherence may impact on the results of cost-effectiveness analyses.