Medical resource use and cost of different first-line treatments for metastatic colorectal cancer in Brazil

Health Economic Evaluations of Cancer in Brazil: A Systematic Review

Background: A large number of health economic evaluation (HEE) studies have been published in developed countries. However, Brazilian HEE literature in oncology has not been studied.

OBJECTIVE

To investigate whether the scientific literature has provided a set of HEE in oncology capable of supporting decision making in the Brazilian context. Methods: A systematic review was conducted to identify and characterize studies in this field. We searched multiple databases selecting partial and full HEE studies in oncology (1998-2013). Results: Fifty-five articles were reviewed, of these, 33 (60%) were full health economic evaluations. Type of cancers most frequently studied were: breast (38.2%), cervical (14.6%), lung (10.9%) and colorectal (9.1%). Procedures (47.3%) were the technologies most frequently evaluated. In terms of the intended purposes of the technologies, most (63.6%) were treatments. The majority of the incremental cost-effectiveness ratios (ICERs) reported have been below the cost-effectiveness threshold suggested by the World Health Organization (WHO). Conclusions: There has been an increase in the number of HEEs related to cancer in Brazil. These studies may support decision-making processes regarding the coverage of and reimbursement of healthcare technologies for cancer treatment in Brazil.

Factors Impacting Treatment Choice in the First-Line Treatment of Colorectal Cancer

INTRODUCTION

To investigate the factors that affect the choice of 5-fluorouracil (5-FU) or its oral alternative, capecitabine, as first-line treatment in patients with colorectal cancer (CRC).

METHODS

Patients treated with 5-FU or capecitabine for CRC between January 1, 2011 and December 31, 2013 in a teaching hospital in the Sydney metropolitan area, Australia were identified using the hospital's database MOSAIQ^®. The electronic medical record of each patient was manually reviewed to extract factors potentially affecting treatment choice. Logistic regression was used to assess which patient and/or treatment factors could explain the choice between 5-FU or capecitabine. Where it was available in the medical correspondence, the explicit reason for the choice made was extracted.

RESULTS

170 CRC patients were included; 119 on 5-FU, and 51 on capecitabine. The odds of receiving capecitabine as a first-line treatment were positively associated with giving patients a choice in the decision (OR = 17.51, 95% CI: 5.37-57.08). Qualitative data suggest treatment choices were motivated by convenience (oral administration) and tolerability. Time from diagnosis to treatment commencement (OR = 1.02 per month, 95% CI 1.00-1.04) was also found to be positively associated with the choice of capecitabine. The odds of being treated with capecitabine were lower for patients who lived further from the treating hospital (OR = 0.22, 95% CI 0.05-0.94).

CONCLUSION

This study suggests that patient choice, favoring oral capecitabine over i.v. 5-FU, was a key factor influencing first-line treatment for CRC in this cohort. To respect their autonomy, patients should be involved in the clinical decision making process.

Economic evaluations in gastroenterology in Brazil: A systematic review

AIM

To systematically review economic evaluations in gastroenterology, relating to Brazil, published between 1980 and 2013.

METHODS

We selected full and partial economic evaluations from among those retrieved by searching the following databases: MEDLINE (PubMed); Excerpta Medica; the Latin American and Caribbean Health Sciences Literature database; the Scientific Electronic Library Online; the database of the Centre for Reviews and Dissemination; the National Health Service (NHS) Economic Evaluation Database; the NHS Health Technology Assessment database; the Health Economics database of the Brazilian Virtual Library of Health; Scopus; Web of Science; and the Brazilian Network for the Evaluation of Health Technologies. Two researchers, working independently, selected the studies and extracted the data.

RESULTS

We identified 535 health economic evaluations relating to Brazil and published in the 1980-2013 period. Of those 535 articles, only 40 dealt with gastroenterology. Full and partial economic evaluations respectively accounted for 23 (57.5%) and 17 (42.5%) of the 40 studies included. Among the 23 full economic evaluations, there were 11 cost-utility analyses, seven cost-effectiveness analyses, four cost-consequence analyses, and one cost-minimization analysis. Of the 40 studies, 25 (62.5%) evaluated medications; 7 (17.5%) evaluated procedures; and 3 (7.5%) evaluated equipment. Most (55%) of the studies were related to viral hepatitis, and most (63.4%) were published after 2010. Other topics included gastrointestinal cancer, liver transplantation, digestive diseases and hernias. Over the 33-year period examined, the number of such economic evaluations relating to Brazil, especially of those evaluating medications for the treatment of hepatitis, increased considerably.

CONCLUSION

Further studies are needed in order to ensure that expenditures on health care in Brazil are made as fairly and efficiently as possible.

Impact of metastatic colorectal cancer stage and number of treatment courses on patient health care costs and utilization

BACKGROUND

Advances in colorectal cancer (CRC) treatment and improved survival rates have led to higher costs associated with treating CRC.

OBJECTIVE

To examine health care costs and utilization by initial CRC stage at diagnosis and the number of lines of treatment received by patients with metastatic CRC.

METHODS

Adult patients with a diagnosis of CRC made from January 1, 2005 to May 31, 2010 were identified from the Oncology Management registry. Patients with stage IV CRC at initial diagnosis or who had advanced to stage IV CRC at the time of the study were included. Registry data included initial CRC stage and the date of diagnosis. Linked health care claims from a large US health insurance database affiliated with Optum were used to identify health care costs and patient characteristics. Multivariate regression analysis was used to estimate total 4-year health care costs stratified by stage and adjusted for patient characteristics. Follow-up ended at patient death, disenrollment from the health care plan, or study end (November 30, 2010).

RESULTS

A total of 598 patients, followed for an average of 653 days after first evidence of metastasis, were included. At initial diagnosis, 91 patients had stages 0 to III CRC, 310 patients had stage IV CRC, and 197 patients had an unknown stage of CRC. The mean unadjusted total cost per patient (medical + pharmaceutical costs) was $252 200; outpatient hospital visits (excluding radiation and surgery) contributed most to the total cost, at a mean cost of $71 334. Hospitalization costs, with or without surgery (mean, $56 862), accounted for 33% of the $176 135 unadjusted mean cost for medical services (ambulatory visits [office and outpatient], emergency department visits, laboratory/radiology services, and inpatient admission). Chemotherapy and biologics were also costly (mean, $31 112 and $38 276, respectively). A general linear model analysis of estimated 4-year total costs showed that both CRC stage at diagnosis and the number of lines of treatment after metastasis had a statistically significant association with cost (P < 0.001).

CONCLUSION

Variables that had a statistically significant association with cost (P < 0.05) were sex, age group, and follow-up Charlson Comorbidity Index score after metastases. After adjusting for the number of lines of treatment received, total 4-year costs were highest among patients who presented with stage IV CRC and lowest among patients who presented with stage III CRC and developed metastatic disease.

Economic evaluation of capecitabine as adjuvant or metastatic therapy in colorectal cancer

Capecitabine, an oral prodrug of 5-fluorouracil, is indicated for adjuvant treatment in patients with Dukes' C colon cancer and for subsequent lines in metastatic colorectal cancer. The aim of this article is to review the literature on the economics of capecitabine for the treatment of colon cancer. A systematic review was conducted to search for articles published from January 2003 to December 2009 that met the inclusion criteria. For abstracts that were considered acceptable, full-text articles were then reviewed. Of the 42 potential studies that were identified, 13 original studies (16 publications) met the inclusion criteria. To date, the economic evaluation literature has consistently projected or found that capecitabine is not only a cost-effective treatment for adjuvant or for metastatic colorectal cancer (i.e., providing good value for money) but, furthermore, would actually be cost saving in the majority of country settings.