Cost-effectiveness of cancer chemotherapy: an economic evaluation of a randomized trial in small-cell lung cancer

Systematic Review and Meta-Analysis of Community- and Choice-Based Health State Utility Values for Lung Cancer

BACKGROUND

Using appropriate health state utility values (HSUVs) is critical for economic evaluation of new lung cancer interventions, such as low-dose computed tomography screening and immunotherapy. Therefore, we provide a systematic review and meta-analysis of community- and choice-based HSUVs for lung cancer.

METHODS

On 6 March 2017, we conducted a systematic search of the following databases: Embase, Ovid MEDLINE, Web of Science, Cochrane CENTRAL, Google Scholar, and the School of Health and Related Research Health Utility Database. The search was updated on 17 April 2019. Studies reporting mean or median lung cancer-specific HSUVs including a measure of variance were included and assessed for relevance and validity. Studies with high relevance (i.e. community- and choice-based) were further analysed. Mean HSUVs were pooled using random-effects models for all stages, stages I-II, and stages III-IV. For studies with a control group, we calculated the disutility due to lung cancer. A sensitivity analysis included only the methodologically most comparable studies (i.e. using the EQ-5D instrument and matching tariff). Subgroup analyses were conducted by time to death, histology, sex, age, treatment modality, treatment line, and progression status.

RESULTS

We identified and analysed 27 studies of high relevance. The pooled HSUV was 0.68 (95% confidence interval [CI] 0.61-0.75) for all stages, 0.78 (95% CI 0.70-0.86) for stages I-II, and 0.69 (95% CI 0.65-0.73) for stages III-IV (p = 0.02 vs. stage I-II). Heterogeneity was present in each pooled analysis (p < 0.01; I2 = 92-99%). Disutility due to lung cancer ranged from 0.11 (95% CI 0.05-0.17) to 0.27 (95% CI 0.18-0.36). In the sensitivity analysis with the methodologically most comparable studies, stage-specific HSUVs varied by country. Such studies were only identified for Canada, China, Spain, the UK, the USA, Denmark, Germany, and Thailand. In the subgroup analysis by time to death, HSUVs for metastatic non-small-cell lung cancer ranged from 0.83 (95% CI 0.82-0.85) at ≥ 360 days from death to 0.56 (95% CI 0.46-0.66) at < 30 days from death. Among patients with metastatic non-small-cell lung cancer, HSUVs were lower for those receiving third- or fourth-line treatment and for those with progressed disease. Results of subgroup analyses by histology, sex, age, and treatment modality were ambiguous.

CONCLUSIONS

The presented evidence supports the use of stage- and country-specific HSUVs. However, such HSUVs are unavailable for most countries. Therefore, our pooled HSUVs may provide the best available stage-specific HSUVs for most countries. For metastatic non-small-cell lung cancer, adjusting for the decreased HSUVs in the last year of life may be considered, as may further stratification of HSUVs by treatment line or progression status. If required, HSUVs for other health states may be identified using our comprehensive breakdown of study characteristics.

"C" is for costs, and cancer, and conference: Highlights of the First European Conference on the Economics of Cancer

The first European conference on the economics of cancer was held in Brussels, Belgium on November 19-21, 1997. This international meeting was organized under the European Organization for Research and Treat ment of Cancer. Approximately 300 participants from around the world, including physicians, health care econ omists, epidemiologists, pharmaceutical industry repre sentatives, pharmacists, and other researchers, clinicians, and administrators attended the sessions. This interna tional mix of professions, along with the 12 plenary sessions, 4 tutorials, and over 100 contributed oral and poster presentations, made for a very interesting and informative conference. This review will focus on out comes measurement tools, pharmacoeconomics in clini cal trials, issues regarding the improvement of the quality and usability of pharmacoeconomic evaluations, and state of the art pharmacoeconomic reviews of hematopoietic growth factors and lung cancer. Abstracts of contributed presentations have already been published.1

Evaluation of Published Pharmacoeconomic Studies

Studies involving economic analyses are being published with increasing frequency in medical and pharmacy literature. As members of pharmacy and therapeutics committees, or as clinicians dealing directly with patient management, pharmacists will be expected to evaluate published economic studies and apply results of such publications to their respective practice settings. The purpose of this article is to provide insight for practitioners into the evaluation of published pharmacoeconomic studies. Although pharmacoeconomic analyses may take many forms, there are several methodological concerns that are common to all. In light of this, we first discuss the evaluation of economic studies in general terms. Following this, two recently published pharmacoeconomic analyses are reviewed as examples of what one might consider in the critical evaluation of published pharmacoeconomic studies. Copyright © 1995 by W.B. Saunders Company

A Review and Meta-Analysis of Utility Values for Lung Cancer

Background. Published utility estimates for lung cancer are plentiful and vary greatly. The reason for this variability is unclear, but may result from differences in the methods used to elicit each utility. Purpose. To identify a set of pooled lung cancer utility estimates reflective of the available literature and determine which methodological factors significantly influence the value of lung cancer utility. Data Sources. Searches of PubMed, the NHS Economic Evaluation Database, and the Cost Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Study Selection. English-language studies were included if they presented at least one previously unpublished lung cancer utility value, noted the elicitation technique and utility value provider. Data Extraction and Analysis. Two trained readers independently reviewed each article and extracted information for analysis. A hierarchical linear model (HLM) was used to perform a meta-regression with cancer stage, lower bound of scale, upper bound of scale, respondent, elicitation method, and lung cancer subtype as explanatory variables. Data Synthesis. Twenty-three articles containing 223 unique utility values were included. Lung cancer stage and subtype, the upper bound label of the utility scale, and respondent identity were significant predictors of utility (P < 0.05), while the lower bound label of utility scale was not. The HLM provided a set of pooled utility values for metastatic (0.57), mixed or nonspecified stage (0.77), and nonmetastatic lung cancer (0.87 )—for the case of standard gamble as method, patients as respondents, non-small-cell lung cancer and scale labeled death to perfect health. Conclusion. Methodological factors significantly affect lung cancer utilities; therefore, analysts should avoid direct comparisons of lung cancer utility values elicited with dissimilar methods.

Factors influencing hospital costs of lung cancer patients in Northern Ireland

Lung cancer is a major cause of morbidity and mortality. In this paper, the hospital costs incurred by 724 lung cancer patients diagnosed in 2001 were determined by review of case notes. These represented all patients diagnosed with lung cancer in Northern Ireland on whom data existed in that year. Total hospital costs in the 12 months from presentation for the 724 patients were 3.99 million pounds. Average patient costs were 5,956 pounds for patients diagnosed with non-small cell lung cancer and 5,876 pounds for those with small cell lung cancer. The main component of cost was inpatient stay, representing between 62 and 84% of costs depending on cell type. Multivariate analyses revealed significant differences in cost related to staging, co-morbidities, age, and deprivation. Total annual hospital costs were 13 times as high as the estimated enforcement cost of the smoke-free legislation in Northern Ireland.

An unadjusted NNT was a moderately good predictor of health benefit

BACKGROUND AND OBJECTIVE

Whether the number needed to treat (NNT) is sufficiently precise to use in clinical practice remains unclear. We compared unadjusted NNTs to quality-adjusted life years (QALYs) gained, a more comprehensive measures of health benefit.

STUDY DESIGN AND SETTING

From a subset (n = 65) of a dataset of 228 cost-effectiveness analyses, we compared how well NNTs predicted clinically important QALY gains using correlation analysis, multivariable models and receiver-operator curve (ROC) analysis.

RESULTS

NNT was inversely correlated with QALY gains (P < .001); this relationship was affected by quality of life and life-expectancy gains of treatment (P <or= .04). The NNT is a moderately accurate predictor of treatments that provide large health benefits (area under ROC 0.74-0.81). For ruling out therapies with low QALY gains (threshold <or=0.125 to <or=0.5 QALYs), an NNT >15 had a sensitivity of 82% to 100%. For ruling in therapies with high QALY gains (threshold >or=0.125 to >or=0.5 QALYs), an NNT <or=5 had a specificity of 77%.

CONCLUSION

Using NNT thresholds of <or=5 and >15 to rule in and out therapies with large QALY gains may provide general guidance regarding the magnitude of health benefit.

Estimating the benefit and cost of radiotherapy for lung cancer

Purpose: To estimate the benefit and cost of using radiotherapy (RT) in the initial management of lung cancer in the general population.

Methods: We identified indications for RT in the initial management of small cell and non–small cell lung cancer through a review of the literature. The proportion of patients with each specific indication for treatment was determined using epidemiological observations from cancer registry data and from the literature. We estimated the benefit gained from RT use for each indication in the model using values published in the literature. We estimated the cost of RT for each indication using published Canadian data. The total benefit and cost was calculated for all indications combined. Results are reported in 2001 Canadian dollars.

Results: The mean benefit was 7 months of survival for each lung cancer patient treated with curative intent and 3 months of symptom control for each patient treated with palliative intent. The average cost was $9,881 per life year gained and $13,938 per year of symptom control gained. Sensitivity analysis revealed values between $7,905 and $19,762 per year of survival gain and between $10,368 and $27,875 per year of symptom control gained.

Conclusions: Using RT in the initial management of lung cancer can provide considerable gains in survival and symptom control. The cost of RT for the initial management of lung cancer is inexpensive compared with a common cut off of $50,000 per life year gained.

Cost analysis of secondary prophylaxis with oral clodronate versus pamidronate in metastatic breast cancer patients

OBJECTIVE

We compared the direct medical costs of secondary prophylaxis with bisphosphonates (BPs) in bone metastases (BMs) of breast cancer (BCa) from a payer perspective.

PATIENTS AND METHODS

This study adopted an incidence-based chart review of consecutive BCa patients with BMs who received prophylactic treatment with orally administered (po) clodronate (CLODpo group), or intravenously administered (iv) pamidronate (PAM group) in 1997 at two large oncology centers in Toronto, Ontario. We evaluated the difference in costs of management of patients among the CLODpo and PAM groups using an intent-to-treat analysis from diagnosis of BMs to death, or last follow-up. The results are presented as observed mean and average lifetime (including terminal care) costs per patient.

RESULTS

The observed mean costs in the PAM and CLODpo groups were 49,472 dollars and 50,307 dollars (2002 Canadian dollars), respectively. The difference in costs between the CLODpo (n=34) and PAM (n=18) groups was not significant (P=0.64), and remained robust after sensitivity analyses. The corresponding average lifetime costs were 65,677 dollars in the CLODpo group and 61,254 dollars in the PAM group. Inpatient and terminal care were the major cost drivers, comprising 45% and 25% of overall costs. Of all hospitalizations, 46% were associated with complications from BMs.

CONCLUSIONS

Our analysis, which was based on a convenience sample, failed to reveal a statistically significant difference in the observed mean costs between groups of patients who initiated treatment with po clodronate versus iv pamidronate. The cost estimates from this study can be used for future corroborative economic analyses.

Economics of the clinical management of lung cancer in France: an analysis using a Markov model

To evaluate, according to the histologic type and initial stage, the mean cost (MC) of managing patients with lung cancer and the costs of the different management phases. A Markov approach was used to model these costs, based on the management of a representative nation-wide sample of 428 patients with newly diagnosed lung cancer. The 18-month MC ranged from US$ 20 691 (95% CI: 5777–50 380 for diffuse non-small-cell lung cancer (NSCLC) to US$ 31 833 (95% CI: 15 866–64 455) for localised small-cell lung cancer (SCLC); first-line treatment costs ranged from 33.8% of MC for medically inoperable localised NSCLC to 74.6% for diffuse SCLC; second- or third-line treatment costs ranged from 7.8% of MC for surgically treated localised NSCLC to 32% for locally advanced NSCLC; and the cost of palliative care ranged from 9.1% of MC for locally advanced NSCLC to 39.9% for medically inoperable localised NSCLC. The cost of first-line chemotherapy and the percentage of actively treated patients impacted more on MC than did the cost of second- or third-line chemotherapy regimens or the cost of palliative care. In conclusion, this model provides a robust economic analysis of the cost of lung cancer management, and will be useful for assessing the economic consequences of future changes in patient management.

Cost-effectiveness versus cost-utility analysis of interventions for cancer: does adjusting for health-related quality of life really matter?

OBJECTIVE

The US Public Health Service Panel on Cost-Effectiveness has recommended the use of quality-adjusted life-years (QALYs) as the best way to estimate outcomes in a cost-effectiveness analysis. We evaluate the importance of this recommendation by assessing whether adjusting for health-related quality of life affects the ultimate resource allocation decision implied by the cost-effectiveness ratio for interventions aimed at cancer prevention and control.

METHODS

We identified 110 interventions in 39 articles for which both cost/life-year and cost/QALY were reported. Interventions were forms of prevention, early detection, or treatment of cancer. We calculated a Spearman correlation to assess the ordinal relationship between cost/life-year and cost/QALY. In addition, we employed various decision thresholds to assess whether the use of cost/life-year would yield different resource allocation decisions than the use of cost/QALY.

RESULTS

The correlation between cost/life-year and cost/QALY is 0.96 (P <.0001). Assuming a US dollars 50000 decision threshold, adjustment for quality of life would affect the implied choice in 5% of cases. With a US dollars 400000 threshold, adjustment for quality of life would affect choice for 2% of interventions.

CONCLUSIONS

For interventions aimed at cancer, the outcome measures of cost/life-year and cost/QALY are highly correlated with one another. Although adjusting for quality of life can make an important difference in the evaluation of alternative approaches to cancer prevention and control, it often does not.

Prophylactic cranial irradiation revisited: cost-effectiveness and quality of life in small-cell lung cancer

PURPOSE

To investigate the therapeutic usefulness and cost-effectiveness of prophylactic cranial irradiation (PCI) in patients with limited-stage small-cell lung cancer (SCLC) who had achieved a complete remission.

METHODS

A retrospective chart review was undertaken of all patients diagnosed in Saskatchewan with SCLC between 1987 and 1998 inclusive. Patients who achieved a complete remission were divided into two groups, depending on whether they underwent PCI (PCI+ and PCI-, respectively). The quality-of-life-adjusted survival was estimated by the Q-TWiST method (quality time without symptoms and toxicity). The mean incremental costs per month of incremental OS were calculated in a cost-effectiveness analysis.

RESULTS

Among the 98 complete remission patients, the median OS for PCI+ and PCI- patients was 20.0 and 19.0 months, respectively (p > 0.05, nonsignificant). The median disease-free survival was 14.7 and 10.0 months, respectively (p < 0.05). The difference in the mean Q-TWiST survival was significant (p < 0.01). The mean marginal cost was $18,834/PCI+ patient and $17,885/PCI- patient (p > 0.05, nonsignificant). The cost-effectiveness ratio was $70/mo of incremental OS if u(tox) and u(rel) (the utility coefficients to reflect the value of time in health states of toxicity and relapse) were assumed to be 1.0.

CONCLUSION

PCI is a cost-effective treatment that improves the quality-of-life-adjusted survival for patients with a complete remission of SCLC.

Outcomes and cost-effectiveness of alternative staging strategies for non-small-cell lung cancer

PURPOSE

To identify the optimal strategy for staging the mediastinum of patients with known non-small-cell lung cancer (NSCLC), stratified by tumor (T) classification.

METHODS

We used a decision-analytic model to compare the health outcomes and cost-effectiveness of three staging strategies: (1) chest computed tomography alone, (2) selective mediastinoscopy, and (3) routine mediastinoscopy. The overall effectiveness and cost of each strategy was a function of the proportion of patients accurately staged and the risks, benefits, and costs of the diagnostic tests and treatments used. Probability estimates and costs were derived from primary data and the literature. We adopted a societal perspective and calculated incremental cost-effectiveness ratios (ICERs) as cost per quality-adjusted life year (QALY) gained.

RESULTS

Both mediastinoscopy strategies correctly identified more patients with mediastinal involvement (N2/N3 disease) and assigned them to multimodal regimens. Routine mediastinoscopy maximized quality-adjusted life expectancy in all patients, irrespective of T classification, and this result was robust to varying the model estimates over their reported ranges. In T1 patients, selective mediastinoscopy cost $24,500 per QALY gained, compared with $78,800 per QALY gained for routine mediastinoscopy. In T2 and T3 patients, the ICER of routine mediastinoscopy was more favorable ($42,800 and $53,400 per QALY gained, respectively).

CONCLUSION

Routine mediastinoscopy maximizes quality-adjusted life expectancy in patients with known NSCLC, and its ICER compares favorably with other currently accepted medical technologies. The survival benefit and cost-effectiveness of this strategy are greater in patients with T2 and T3 tumors and are likely to improve with advances in multimodal therapy.

Treatment pathways, resource use and costs in the management of small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) represents about 20% of primary lung tumours and the costs associated with the management of SCLC can be significant. The main objective of this study was to obtain information on current patterns of care and associated resource use and costs for patients with SCLC from initial diagnosis and treatment phase, throughout disease progression and terminal care.

METHODS

A 4 year retrospective patient chart analysis (1994-7) was conducted on a consecutive series of 109 patients diagnosed with SCLC in two Newcastle hospitals. For this consecutive series of patients all details about care received including tests and procedures, treatment, and medication from diagnosis till death were recorded. Pathways of care and forms were designed to enable resource use to be captured for different disease phases. Unit costs were determined from a variety of sources including the Newcastle Hospitals NHS Trust Finance Department and the British National Formulary.

RESULTS

The average total cost per patient calculated for the full cohort of 109 patients was pound 11,556. Initial treatment was the most resource use intensive constituting 48.2% of the total cost. The major cost element throughout all disease phases was hospitalisation. Twenty eight percent of the total costs of care occur after recurrence of the disease until death, of which 73% are generated by terminal care.

CONCLUSION

The results of this retrospective medical chart analysis show that the costs of care of SCLC are considerable, although the variability between patients in terms of the type and quantity of resource use is very high. Analyses such as this provide a useful insight into resources used in actual clinical practice.

Economic analysis of randomized, controlled trials

To facilitate the comparison of different treatment strategies, measures have been developed that bring together clinical, quality-of-life, and economic outcomes into summary measures such as the quality-adjusted life year, cost-effectiveness, and cost-utility ratios. A number of different types of economic evaluations have been developed, including cost-minimization, cost-effectiveness, and cost-utility analyses. Performance of economic analyses in association with randomized, controlled trials (RCT) has gained increasing enthusiasm in recent years. However, economic measures in RCTs are often outcomes of secondary interest and associated with frequent missing data and inadequate sample size. Variability in the cost measures used and the lack of agreement on clinically meaningful cost differences further limit the conclusions derived from such studies. Economic analyses should be limited to large trials with important trade-offs between efficacy and cost. The strengths and limitations of such analyses are discussed, and guidelines are offered for proper economic analyses in randomized, controlled trials.

The cost-effectiveness and cost-utility of high-dose palliative radiotherapy for advanced non-small-cell lung cancer

PURPOSE

To compute cost-effectiveness/cost-utility (CE/CU) ratios, from the treatment clinic and societal perspectives, for high-dose palliative radiotherapy treatment (RT) for advanced non-small-cell lung cancer (NSCLC) against best supportive care (BSC) as comparator, and thereby demonstrate a method for computing CE/CU ratios when randomized clinical trial (RCT) data cannot be generated.

METHODS AND MATERIALS

Unit cost estimates based on an earlier reported 1989-90 analysis of treatment costs at the Vancouver Island Cancer Centre, Victoria, British Columbia, Canada, are updated to 1997-1998 and then used to compute the incremental cost of an average dose of high-dose palliative RT. The incremental number of life days and quality-adjusted life days (QALDs) attributable to treatment are from earlier reported regression analyses of the survival and quality-of-life data from patients who enrolled prospectively in a lung cancer management cost-effectiveness study at the clinic over a 2-year period from 1990 to 1992.

RESULTS

The baseline CE and CU ratios are $9245 Cdn per life year (LY) and $12,836 per quality-adjusted life year (QALY), respectively, from the clinic perspective; and $12,253/LY and $17,012/QALY, respectively, from the societal perspective. Multivariate sensitivity analysis for the CE ratio produces a range of $5513-28,270/LY from the clinic perspective, and $7307-37,465/LY from the societal perspective. Similar calculations for the CU ratio produce a range of $7205-37, 134/QALY from the clinic perspective, and $9550-49,213/QALY from the societal perspective.

CONCLUSION

The cost effectiveness and cost utility of high-dose palliative RT for advanced NSCLC compares favorably with the cost effectiveness of other forms of treatment for NSCLC, of treatments of other forms of cancer, and of many other commonly used medical interventions; and lies within the US $50, 000/QALY benchmark often cited for cost-effective care.

Systematic overview of cost-utility assessments in oncology

PURPOSE

Cost-utility analyses (CUAs) present the value of an intervention as the ratio of its incremental cost divided by its incremental survival benefit, with survival weighted by utilities to produce quality-adjusted life years (QALYs). We critically reviewed the CUA literature and its role in informing clinical oncology practice, research priorities, and policy.

METHODS

The English-language literature was searched between 1975 and1997 for CUAs. Two readers abstracted from each article descriptions of the clinical situation and patients, the methods used, study perspective, the measures of effectiveness, costs included, discounting, and whether sensitivity analyses were performed. The readers then made subjective quality assessments. We also extracted utility values from the reviewed papers, along with information on how and from whom utilities were measured.

RESULTS

Our search yielded 40 studies, which described 263 health states and presented 89 cost-utility ratios. Both the number and quality of studies increased over time. However, many studies are at variance with current standards. Only 20% of studies took a societal perspective, more than a third failed to discount both the costs and QALYs, and utilities were often simply estimates from the investigators or other physicians.

CONCLUSION

The cost-utility literature in oncology is not large but is rapidly expanding. There remains much room for improvement in the methodological rigor with which utilities are measured. Considering quality-of-life effects by incorporating utilities into economic studies is particularly important in oncology, where many therapies obtain modest improvements in response or survival at the expense of nontrivial toxicity.

Use of resources and costs of palliative care with parenteral fluids and analgesics in the home setting for patients with end-stage cancer

BACKGROUND

In 1992 a home care technology project was started in which infusion therapy in the home setting was made available for patients with end-stage cancer. Beside aspects of feasibility and quality of life the resource utilization and costs of this transition was studied.

PATIENTS AND METHODS

We conducted a cost evaluation study, to determine the actual cost of managing patients with endstage cancer who require parenteral administration of fluid or analgesics in the home setting. A total of 128 patients were prospectively followed, with a detailed analysis of some aspects in a sample of 24 patients.

RESULTS

The cost for each patient was found to be between $250.00 and $300.00 per day, half of which are for hospital charges, even with this active home care technology program. One-third of the costs can be attributed to primary health care activities, in particular those of the district nurses. A hypothetical control group (n = 25) was constructed based on current practice and chart review. Patients in this group would have cost around $750.00 per day. With a median treatment period of 16 days this means a saving of $8000.00 per patient.

CONCLUSION

Our data suggest that significant savings can be obtained by implementing programs transferring palliative care technology to the home setting.

The distribution of health care costs and their statistical analysis for economic evaluation

OBJECTIVE

Where patient level data are available on health care costs, it is natural to use statistical analysis to describe the differences in cost between alternative treatments. Health care costs are, however, commonly considered to be skewed, which could present problems for standard statistical tests. This review examines how authors report the distributional form of health care cost data and how they have analysed their results.

METHOD

A review of cost-effectiveness studies that collected patient-level data on health care costs. To supplement the review, five datasets on health care costs are examined. Consideration is given to the use of parametric methods on the transformed scale and to non-parametric methods of analysing skewed cost data.

RESULTS

Since economic analysis requires estimation in monetary units, the usefulness of transformation-based methods is limited by the inability to retransform cost differences to the original scale. Non-parametric rank sum methods were also found to be of limited use for economic analysis, partly due to the focus on hypothesis testing rather than estimation. Overall, the non-parametric approach of bootstrapping was found to offer a useful test of the appropriateness of parametric assumptions and an alternative method of estimation where those assumptions were found not to hold.

CONCLUSIONS

Guidelines for the analysis of skewed health care cost data are offered.

Health service studies in the terminally ill cancer patient

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

Gains in life expectancy from medical interventions--standardizing data on outcomes

BACKGROUND

The gain in life expectancy is an important measure of the effectiveness of medical interventions, but its interpretation requires that it be placed in context. The interpretation of gains in life expectancy is particularly problematic for preventive interventions, for which the gains are often just weeks or even days when averaged across the entire target population.

METHODS

We tabulated the gains in life expectancy from a variety of medical interventions as reported in 83 published sources and categorized them according to target population and disease. We considered prevention in populations at average risk for particular diseases, prevention in populations at elevated risk, and treatments in populations with established disease.

RESULTS

The gains in life expectancy from preventive interventions in populations at average risk ranged from less than one month to slightly more than one year per person receiving the intervention, but the gains were as high as five years or more if the prevention was targeted at persons at especially high risk. The gains in life expectancy from treatments of established disease ranged from several months (for coronary thrombolysis and revascularization to treat heart disease) to as long as nine years (for chemotherapy to treat advanced testicular cancer).

CONCLUSIONS

A gain in life expectancy from a medical intervention can be categorized as large or small by comparing it with gains from other interventions aimed at the same target population. A gain in life expectancy of a month from a preventive intervention targeted at populations at average risk and a gain of a year from a preventive intervention targeted at populations at elevated risk can both be considered large. The framework we developed for standardizing gains in life expectancy can be used in the interpretation of data on the outcomes of interventions.

Cost-effectiveness assessment of interferon alfa-2b as adjuvant therapy of high-risk resected cutaneous melanoma

The use of interferon alfa-2b (IFN-alpha 2b) as adjuvant therapy of high-risk resected cutaneous melanoma was recently found to significantly improve relapse-free and overall survival in the Eastern Cooperative Oncology Group trial 1684 (E1684). However, treatment toxicities and costs may limit its widespread use. A cost-effectiveness and cost-utility analysis of this therapy was conducted using a hypothetical cohort of patients as if they had entered E1684. Survival and recurrence rates were calculated at 7 and 35 years for typical 50-year-old melanoma patients based on the clinical results of E1684 and natural history databases. Costs included all treatment-related costs (i.e. drug acquisition and administration, monitoring and treatment-related toxicity) and the costs of treating recurrences. Estimated utility values were assigned based on data from other oncology trials. The model predicted that IFN-alpha 2b provided an extra 0.52 years of life compared with observation at 7 years; however, at 35 years, the survival benefit of IFN-alpha 2b increased almost 4-fold to nearly 2 years. At 7 years, the cost per year of life gained was U.S. $32,600 and the cost per quality-adjusted life-year (QALY) gained was U.S. $43,200. At 35 years, these costs decreased to U.S. $13,700 and $15,200, respectively. These costs are comparable with those of other well-established medical interventions. Although these results require confirmation in a prospective study, it appears that the use of high-dose IFN-alpha 2b for patients with high-risk melanoma is cost-effective.

Are quality of life, patient preferences, and costs realistic outcomes for clinical trials?

Health-related quality of life (HRQL) is a relatively new outcome, which is being considered for incorporation into randomized, controlled clinical trials. Instruments that detect different aspects of HRQL include health profiles and utility measurements. While the results of the former are highly responsive to change over time but not easily comparable between studies, utility measurements are not as responsive to change, but as single numerical values are more comparable between studies. With the growing number of multidimensional instruments available for measurement of the quality of life, investigators must be careful to select instruments that are reliable and have been validated for incorporation into clinical trials. Similarly, investigators must choose an instrument or instruments which are best suited to detection of the primary HRQL outcomes of interest for a specific population. A relatively new method for describing the quality of life during different health states is Q-TWiST analysis. An example is provided, demonstrating how the different short-term health states of patients with small cell lung cancer can be presented and quantified. While economic evaluation has often included quality of life within the concept of the quality-adjusted life year ( QALY ), determination of utilities within this concept has been highly variable and the validity of the QALY as a concept has been questioned. The healthy years equivalent ( HYE ) has been proposed as a more appropriate alternative. At the health policy decision-making level, controversy persists over how much society should pay for expansive new interventions and what boundaries for allocation should be established. Much work is still needed to improve comparability of HRQL results and to incorporate these results into clinical decision making involving individual patients and health policy makers.

Costing methods in the Canadian literature on the economic evaluation of health care. A survey and assessment

We reviewed the Canadian literature on cost-effectiveness from 1980-95 with regard to costing methodologies. We abstracted each study using a list of data elements that describe costing methodology, and evaluated costing methodologies in the light of biases in costing methods, site, and case-mix selection.

The economics of lung cancer management in Canada

Because lung cancer is a major health care problem in Canada, it is imperative to understand how resources are used to diagnose and treat this disease. This paper describes a method of modelling the direct patient care costs for lung cancer from the perspective of the government as payer in a universal health care system. Clinical algorithms were developed to describe the management of non-small cell (NSCLC) and small cell (SCLC) lung cancer. Patients were allocated to the treatment algorithms in the model based on a knowledge of their distribution by cell type and stage in Canadian cases. A microsimulation model developed by Statistics Canada was used to integrate the data on type of lung cancer, extent of disease, clinical management, survival and health care resource utilization. The direct care costs for diagnosis and treatment of NSCLC ranged from $Cdn 17 889 for the surgery/post-operative radiotherapy treatment of Stages I and II to $Cdn 6333 for supportive care for patients with Stage IV disease. The costs of determining relapse for NSCLC were estimated to be $Cdn 1528 and terminal care costs, made up largely of hospitalization charges and some palliative radiotherapy, were $Cdn 10 331. Direct care costs for the diagnosis and initial treatment of SCLC ranged from $Cdn 18 691 for management of limited stage disease to $Cdn 4739 for the supportive care of patients with extensive disease. The cost of determining relapse for SCLC was estimated to be $Cdn 1590 and terminal care costs averaged $Cdn 9966. For all 15 624 cases of lung cancer diagnosed in Canada in 1988, it was estimated that the total cost of providing treatment and follow-up, and managing relapse over 5 years was $Cdn 328 million. Despite the large total cost of lung cancer management, estimates of cost effectiveness of therapy showed that the cost per life year gained was approximately $Cdn 11 000 for NSCLC and $Cdn 19 560 for SCLC. These estimates of the direct health care costs assume that all patients have access to care, treatment is uncomplicated and practice is standard, and must be viewed as an idealized assessment of the cost of lung cancer management. The microsimulation model, however, does provide a useful framework for evaluating the costs of new diagnostic procedures, treatment strategies and new drugs.

Diagnostic and therapeutic approaches to lung cancer in Canada and their costs

Escalating health care costs have made it imperative to evaluate the resources required to diagnose and treat major illnesses in Canadians. For Canadian men, lung cancer is not only the most common malignancy, but also the major cancer killer. As of 1994, lung cancer is expected to overtake breast cancer as the leading cause of cancer deaths in women. This paper presents a detailed description of the methodology used to determine the direct health care costs associated with 'standard' diagnostic and therapeutic approaches for lung cancer in Canada in 1988. Clinical algorithms were developed for each stage of non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC). The algorithms were designed to take the form of decision trees for each clinical stage of lung cancer. The proportion of patients assigned to each branch was based upon questionnaire responses obtained from thoracic surgeons and radiation oncologists when presented with clinical scenarios, and information from provincial cancer registries. Direct care costs were derived primarily from one provincial fee schedule (Ontario), and costing information obtained during the conduct of several Canadian clinical trials in lung cancer. Direct costs for diagnosis and initial treatment of NSCLC (excluding relapse and terminal care costs) ranged from $17,889 for the surgery/post-operative radiotherapy arm of stages I and II to $6,333 for the supportive care arm (stage IV). The cost of determining relapse for NSCLC was estimated to be $1,528, and terminal care costs, which included palliative radiotherapy and hospitalisation, were $10,331. Direct costs for diagnosis and initial treatment of SCLC ranged from $18,691 for limited stage disease to $4,739 for the supportive care arm of extensive disease. The cost of diagnosing relapse for SCLC was estimated to be $1,590, and terminal care costs averaged $9,966. This report provides an estimate of the Canadian costs of managing lung cancer by stage and treatment modality. Because the actual costs of all components of care are not available from any combination of sources, these cost estimates must be viewed as an idealised estimate of the cost of lung cancer management. However, we believe that the lung cancer costing model that we have developed provides a level of sophistication which gives a reasonable estimate of the cost per case of treating NSCLC and SCLC.

Cost-effectiveness analysis of interventions for congenital heart disease

Expansion of the options available for the treatment of congenital heart disease has been accompanied by an increasing realization of the limits of our available health care resources. Cost-effectiveness analysis is one of several analytic approaches that can improve decisions about the appropriate use of technology in interventional pediatric cardiology and other fields. In this article, cost-effectiveness analysis is distinguished from related approaches, such as cost-benefit analysis. Then, basic principles of cost-effectiveness analysis are described. Next, the application of these principles is illustrated, using a recently published comparison of transcatheter versus surgical closure of patent ductus arteriosus. Finally, potential research implications of the surprising findings of this study are discussed.

A cost-effectiveness study of a randomised trial of laparoscopy versus laparotomy for ectopic pregnancy

We compared the cost-effectiveness of therapeutic laparoscopy and open laparotomy for treatment of laparoscopically diagnosed ectopic pregnancy. Clinical outcomes of ectopic pregnancy treatment were based on results of a randomised trial done between 1987 and 1989 at Sahlgrenska University Hospital (Göteborg, Sweden). We estimated costs for inpatient and follow-up care of ectopic pregnancy by the two methods. Observed resource use (eg, procedure duration) was multiplied by 1992 estimates of resource unit cost (eg, cost per minute of laparoscopy time), based on detailed internal cost accounting data from Huddinge University Hospital. By specified criteria, the initial procedure eliminated trophoblastic activity without major complications in 81% (95% CI: 68-90) of 52 laparoscopy patients, versus 95% (85-99) of 57 laparotomy patients. Residual trophoblast or complications were successfully treated in all remaining patients. Mean simulated costs (standard error) for the overall laparoscopy strategy were 28,058 (1780) Swedish kronor versus 32,699 (1080) kronor for laparotomy (p = 0.03). In the baseline simulation and most sensitivity analyses, laparoscopy produced final outcomes equivalent to those of laparotomy at lower costs. As laparoscopic outcomes improve, this newer approach should become increasingly preferable.

Reimbursement issues facing patients, providers, and payers

Escalating costs of health care delivery and the current constraints imposed by the federal budget deficit seriously threaten to compromise patient care and innovative biomedical research. Recent third-party refusal to cover some patients treated in protocols has had considerable impact on trial research. In addition, reimbursement for conventional care sometimes has been refused if delivered as part of a study (e.g., MOPP therapy versus ABVD therapy) or for an indication that is not specifically cited on the Food and Drug Administration label. Who should cover the patient care costs of patients participating in clinical trials? One approach would have patients cover these costs themselves. A second approach is the reinstitution of patient care costs into research grants. A third possibility is that the pharmaceutical industry support patient care costs of clinical research. Historically, hospital expenses of patients participating in studies have been paid by health insurance policies. In the absence of a clinical trial, many patients would be treated with Food and Drug Administration-approved therapies despite a lack of substantial benefit. Such marginal treatments are compensated by third-party payers routinely. The current system is arbitrary and expensive, compromises research and development, and equates new treatment with no treatment. By refusing to reimburse the patient care costs of investigational therapy, third-party carriers are, in fact, making medical decisions. There is a growing and legitimate concern that the pace of clinical research will be impeded significantly at a time when many exciting developments will be ready for clinical trials. The molecular steps in carcinogenesis are being documented rapidly for common malignancies, such as colon cancer. Immunologic, biologic, and hormonal approaches, and emerging technologies, such as marrow transplant or antibody toxin conjugates, already are being studied in the clinic. Health policy legislation and decisions by the insurance industry have a direct impact on physicians, facilitating, or often impeding, the care physicians are able to provide. Who makes health policy decisions? Increasingly, these decisions are being made not by physicians, but by public health experts, economists, and, more recently, large industries grappling with the cost of providing insurance coverage (and its effects on competitive pricing in a world market). Therefore, physicians need to position themselves to influence the development of medical policy, particularly as it relates to the prevention, diagnosis, and treatment of patients with cancer.

Setting priorities in the new NHS: can purchasers use cost-utility information?

It could be argued that the success of the new NHS depends, to some extent, on the production of accurate cost-utility information. This raises questions about the quality of this information, whether it can be transferred from one study setting to another and whether such information can reasonably be used 'at the negotiating table'. The quality of some studies is open to question. Some agreement is needed on issues of principle and more work is required to make cost-utility analyses more applicable locally.

Quality of life. 2. Economic analysis of drug therapies

In 1990, health care expenditures in the United States reached $666.2 billion, 12.2% of the gross domestic product (GDP). It is projected for the year 2000, the USA will spend $1.6 trillion for health care which will be comparable to 16.4% of that year's GDP. As a result of the rapid increase in costs of health care and limited resources available, patients, third-party payers and the government have initiated and implemented more rigid cost control measures. Economic analyses can help ensure the efficient use of health care dollars in areas such as drug therapy. The four methodologies available are cost-benefit analysis, cost-effectiveness analysis, cost-minimization analysis and cost-utility analysis. This article reviews methods and provides examples from the medical literature. These tools can assist care providers in determining which treatments are most cost-effective.

The restaging of responding patients with limited small cell lung cancer. Is it really useful?

A retrospective review of data on patients entered on two limited small cell lung cancer studies of the National Cancer Institute of Canada (BR.3 and BR.6) was undertaken to determine the value of restaging and rebronchoscopy in responding patients. An economic evaluation was also done. Repeat scans (brain, liver) and bronchoscopy were carried out in 190 patients and 5 (2.6 percent) were positive, despite other evidence suggesting response. One hundred thirty-nine of 324 patients who achieved complete response on the two trials underwent rebronchoscopy. Among these, 122 (87.7 percent) were negative and eight (5.8 percent) were inconclusive. Nine (6.5 percent) were positive despite other evidence suggesting the patient had achieved a complete response. A small group of nine patients with positive rebronchoscopy survived for a shorter time than the group with negative or inconclusive rebronchoscopies. The survival difference was only statistically significant when analyzed using the log rank test, but it was not significant when analyzed by the Wilcoxon test. The economic analysis showed that it costs $11,333 per patient reclassified when scans were redone in these patients. The cost could even have been higher had we used present-day scanning techniques (computed tomography and magnetic resonance imaging), although they might be slightly more sensitive. The cost of rebronchoscopy per patient reclassified was $14,960. Therefore, we recommend that restaging (scans or rebronchoscopy) not be done in responding patients with limited small cell lung cancer, thus potentially saving health care dollars as well as reducing patient inconvenience with no detrimental effect on survival.

Cost-utility in practice: a policy maker's guide to the state of the art

In recent years QALYs (quality adjusted life years) have achieved considerable fame or perhaps even notoriety in health services policy making. Yet little has been done to date to assess the potential benefit in policy terms of studies that have used cost-utility analysis (CUA). It was in recognition of this fact that this particular investigation was undertaken. An evaluation of 51 cost-utility studies is reported in the paper. Several criteria were applied to each study including aspects of technical and policy relevance. The main findings were: few studies had been undertaken; they were limited to few areas of health care; their technical execution was often of poor quality; the majority of studies used the empirical findings of health state valuations obtained from original developers of different quality of life techniques; and many claimed their results to be 'favourable' (i.e. efficient interventions). This claim, however, is misguided because individual results get fed into generalised QALY league tables which ignore the context of specific studies and use results not performed on a common basis. Consequently, the state of the applied art of CUA is currently open to considerable question.

The cost of treating small cell lung cancer

OBJECTIVE

To determine the cost of treating small cell lung cancer (SCLC) and to assess quality-adjusted survival in these patients.

DESIGN

Retrospective analysis.

SETTING

Westmead Hospital, a tertiary referral institution.

PATIENTS

Consecutive sample of 31 patients with histologically proved SCLC, treated between January 1987 and December 1987.

MAIN OUTCOME MEASURES

The cost of investigation, hospitalisation, chemotherapy, radiotherapy and follow-up of patients overall and for those with limited and extensive disease respectively. Quality-adjusted survival was based on a Q-TWiST analysis.

RESULTS

The median overall cost per patient was $14,413 (range, $1188-$39,598) for all patients and for limited disease and extensive disease was $18,234 (range, $1914-$39,598) and $13,177 (range, $1188-$32,798) respectively. The two major costs were hospitalisation (42%) and chemotherapy (18%). Radiotherapy accounted for 11% of all costs. The Q-TWiST analysis suggests that for patients with limited disease, quality-adjusted survival is similar to absolute survival.

CONCLUSIONS

The treatment of SCLC at our institution was expensive but the cost may be reduced by reduction in the duration of hospitalisation, the use of less expensive combination drug regimens, or the use of "true" outpatient chemotherapy. Despite intensive therapy, patients with limited disease maintained a reasonable quality of life.

The use of a Markov process to simulate and assess follow-up policies for patients with malignant disease: surveillance for stage I nonseminomatous tumors of the testis

Using a Markov process to simulate and assess surveillance policies for stage I nonseminomatous germ cell tumors, the authors analyzed costs and effectiveness for the various policies that have been used clinically. They found no real differences in effectiveness, defined as probability of surviving two years, between the policies. There were significant differences in costs. The model is used to suggest schedules that might be more cost-effective than those currently employed. The model suggests that computed tomographic scanning of the abdomen may not be essential to the effectiveness of surveillance protocols.

A cost-minimization study of cancer patients requiring a narcotic infusion in hospital and at home

We conducted a retrospective, non-randomized, cost-minimization study, from the perspective of the Ministry of Health, to compare the cost of managing cancer patients who required narcotic infusions, in hospital and at home. Our medical costs averaged $369.72 per inpatient day and $150.24 per outpatient day (saving $219.48 per diem, 1988 Canadian dollars), while narcotic costs were the same for any given patient in both settings. Sensitivity analysis showed that no reasonable changes in the quantity and cost of services reduced our savings by more than 50%. During incremental analysis, savings increased as more outpatient days were managed by our centre, from $0.00 for 318 days, to more than $500,000 for over 2000 days per annum. As this program has been extremely cost effective and preferred by our patients, other hospitals and central funding agencies might consider establishing a regional outpatient narcotic infusion program to reduce their costs.

Economic evaluation of trends in cancer therapy. Marginal or average costs?

Evaluating the use of resources as well as outcomes in cancer therapy is increasingly becoming recognized by both clinicians and others as a legitimate and indeed even desirable activity. While this trend is to be welcomed if it facilitates the efficient use of resources for cancer care, there are dangers in applying estimates of unit costs, in particular average costs to the evaluation of trends in practice in cancer therapies. This article examines the use of appropriate measures of average and marginal cost in the economic evaluation of developments in cancer therapy, taking illustrations from radiotherapy and chemotherapy.