Cost-Effectiveness Modeling of Surgery Plus Adjuvant Endocrine Therapy Versus Primary Endocrine Therapy Alone in UK Women Aged 70 and Over With Early Breast Cancer

OBJECTIVES

Approximately 20% of UK women aged 70+ with early breast cancer receive primary endocrine therapy (PET) instead of surgery. PET reduces surgical morbidity but with some survival decrement. To complement and utilize a treatment dependent prognostic model, we investigated the cost-effectiveness of surgery plus adjuvant therapies versus PET for women with varying health and fitness, identifying subgroups for which each treatment is cost-effective.

METHODS

Survival outcomes from a statistical model, and published data on recurrence, were combined with data from a large, multicenter, prospective cohort study of over 3400 UK women aged 70+ with early breast cancer and median 52-month follow-up, to populate a probabilistic economic model. This model evaluated the cost-effectiveness of surgery plus adjuvant therapies relative to PET for 24 illustrative subgroups: Age {70, 80, 90} × Nodal status {FALSE (F), TRUE (T)} × Comorbidity score {0, 1, 2, 3+}.

RESULTS

For a 70-year-old with no lymph node involvement and no comorbidities (70, F, 0), surgery plus adjuvant therapies was cheaper and more effective than PET. For other subgroups, surgery plus adjuvant therapies was more effective but more expensive. Surgery plus adjuvant therapies was not cost-effective for 4 of the 24 subgroups: (90, F, 2), (90, F, 3), (90, T, 2), (90, T, 3).

CONCLUSION

From a UK perspective, surgery plus adjuvant therapies is clinically effective and cost-effective for most women aged 70+ with early breast cancer. Cost-effectiveness reduces with age and comorbidities, and for women over 90 with multiple comorbidities, there is little cost benefit and a negative impact on quality of life.

Cost sharing for breast cancer hormone therapy: How do dual eligible patients' copayment impact adherence

Objective

To examine the different levels of copayment assistance and treatment adherence among Medicare and Medicaid dual eligible beneficiaries with breast cancer in the U.S.

Research design

Propensity Score methodology was adopted to minimize potential selection bias from the nonrandom allocation of the treatment group (i.e., full Medicaid beneficiaries) and control group (i.e., Medicare Savings Programs [MSPs] beneficiaries). Longitudinal hierarchical model and Cox proportional-hazard model were adopted to examine patients’ adherence over their full five-year course of adjuvant hormone therapy.

Results

Our study cohort consisted of 1,133 dual eligible beneficiaries diagnosed with hormone receptor-positive early stage breast cancer in years 2007 –mid 2009. About 80.5% of them received MSPs benefits, while the rest received full Medicaid benefits. On average for a standardized 30-day hormone therapy medication, full Medicaid beneficiaries spent $0.5-$2.0 and MSP beneficiaries spent $1.4-$4.8 in copayment. After adjusting for other factors, this copayment reduction wasn’t associated with a significantly better adherence. However, when the catastrophic coverage threshold was reached (copayments reduced to zero), significant improvement in adherence was found in both groups.

Conclusions

Our study found that small amount of cost-sharing reduction did not affect Medicare and Medicaid dual eligible patients’ medication treatment adherence, however, the elimination of cost-sharing (even a minimal amount) was associated with improved adherence. Future legislative and advocacy efforts should be paid on eliminating cost sharing for dual eligibles, and possibly even a broader group of financially vulnerable patients.

Half-dose fulvestrant plus anastrozole as a first-line treatment for hormone receptor-positive metastatic breast cancer: a cost-effectiveness analysis

OBJECTIVE

The S0226 trial demonstrated that the combination of half-dose fulvestrant (FUL) and anastrozole (ANA) (F&A) caused a significant improvement in overall survival (OS) versus ANA monotherapy for first-line treatment of postmenopausal women with hormone receptor-positive metastatic breast cancer (PMW-MBC (HR+)). The objective of this study was to evaluate the cost-effectiveness of F&A in the first-line treatment for PMW-MBC (HR+) in China.

DESIGN

We constructed a Markov model over a life-time horizon. The clinical outcomes and utility data were obtained from published literature. Cost data were obtained from official Chinese websites. Sensitivity analyses were performed to test result uncertainty.

SETTING

Chinese healthcare system perspective.

POPULATION

A hypothetical cohort of adult patients presenting with PMW-MBC (HR+).

INTERVENTIONS

F&A compared with full-dose FUL and ANAmonotherapy.

MAIN OUTCOME MEASURES

The main outcome of this study was the incremental cost-effectiveness ratio (ICER) and quality-adjusted life-years (QALY).

RESULTS

ANA was estimated to have the lowest cost and minimum life-years. The ICER of F&A versus ANA was US$15 665.891/QALY with incremental cost and QALY of US$12 401.120 and 0.792, respectively, which was less than the willingness-to-pay of US$29 383/QALY. Compared with F&A, FUL yielded a higher cost and a shorter lifetime; hence, it was identified as a dominated strategy. The univariate sensitivity analysis indicated the price of FUL was the most influential factor in our study. The probability that F&A was cost-effective at a threshold of US$29 383/QALY in China was 86.5%.

CONCLUSION

F&A is a cost-effective alternative to FUL and ANA monotherapy for the first-line treatment of PMW-MBC (HR+) in China. F&A is a promising first-line treatment for PMW-MBC (HR+), and more research is needed to evaluate the economy of using F&A in other countries.

Effects of Previous Medication Regimen Factors and Bipolar and Psychotic Disorders on Breast Cancer Endocrine Therapy Adherence

BACKGROUND

Endocrine therapy adherence remains a barrier to optimal estrogen receptor-positive breast cancer outcomes. We theorized that experience navigating difficult medication regimen factors, such as route of administration complexity, might improve subsequent adherence after stressful cancer diagnoses but not for patients with bipolar and psychotic disorders at risk of poor access and nonadherence.

MATERIALS AND METHODS

We included 21,894 women aged ≥ 68 years at their first surgically treated stage I-IV estrogen receptor-positive breast cancer (2007-2013) from the Surveillance, Epidemiology, and End Results-Medicare data set, of whom 5.8% had bipolar or psychotic disorders. We required continuous fee-for-service Medicare (parts A and B) data for ≥ 36 months before and 18 months after the cancer diagnosis. The medication regimen factors in the part D claims for 4 months before included the number of all medications used, pharmacy visits, and administration complexity (medication regimen complexity index subscale). Cox regression analysis was used to model the time to initiation and discontinuation, with longitudinal linear regression for adherence to endocrine therapy.

RESULTS

Women with more frequent previous medication use and pharmacy visits were more likely to initiate, 4+ medications and 2+ visits versus no medication (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.33-1.63), to adhere (6.0%; 95% CI, 4.3-7.6), and to continuously use their endocrine therapy (discontinuation HR, 0.48; 95% CI, 0.39-0.59). Medication administration complexity had modest effects. Difficult medication regimens were more common for patients with bipolar and psychotic disorders but had no statistically significant effects.

CONCLUSIONS

Experience with frequent previous medication use and pharmacy visits might increase the likelihood of endocrine therapy use for most patients but not for those with bipolar and psychotic disorders.

Identifying accessible prognostic factors for breast cancer relapse: a case-study on 405 histologically confirmed node-negative patients

BACKGROUND

Histologically, node-negative breast cancer generally have a good prognosis. However, 10 to 30% of the cases present local relapses or metastasis. This group of people has high chances of remission if detected early. The aim of this study is to identify financial affordability for developing countries to adjust treatment.

METHODS

We selected 405 patients with histologically confirmed node-negative breast cancer in our institution between January 2001 and December 2003. Patients with metastasis were excluded. The statistical analysis was conducted using SPSS ver. 18 (SPSS, Inc., Chicago, Illinois).

RESULTS

The medial age was 51 years old. The medial tumor size was 35.4 mm. Clinically, 67.2% of the patients were staged cT2 and 63.2%, cN1i. Breast conservation was achieved in 41% of cases. In the histologic examination, the medial size was 30 mm. Grade III tumors were found in 50.1% of patients and positive hormonal receptors in 53.4%. The mean number of lymph nodes was 14. Eight patients had neoadjuvant chemotherapy. Adjuvant locoregional radiation and adjuvant chemotherapy were prescribed respectively in 70.6 and 64.4% of cases. 59.7% had adjuvant hormonal therapy. The follow-up showed 17.7% cases of relapse either locally or in a metastatic way in a mean time of 57.4 months. The disease-free survival at 5 years was 82.1%, and the overall survival for the same period was 91.5%. The histologic tumor size and the grade and number of lymph node dissected were shown to be influencing the disease-free survival. Radiation therapy and hormone therapy showed improved disease-free survival and overall survival.

CONCLUSION

Our study found interesting results that may help personalize the treatment especially for patient living in underdeveloped countries, but further studies are needed to evaluate those and more accessible prognostic factors for a more accessible healthcare.

Cost analysis of leuprorelin acetate in Japanese pre-menopausal breast-cancer patients: comparison between 6-month and 3-month depot formulations

AIMS

The aim in this study is to evaluate economic value for leuprorelin acetate 6-month depot compared with leuprorelin acetate 3-month depot in Japanese pre-menopausal breast cancer patients from a societal perspective.

METHODS

The cost analysis was conducted by estimating direct and indirect cost, and intangible costs associated with one 6-month injection compared with two 3-month injections. Claims data were used for the analyses of direct and indirect cost and Medical Fee Schedule Table for direct cost. Discrete choice experiments were conducted by web-based survey to determine the intangible costs. Another web-based survey was also conducted on premenopausal breast cancer patients with injections of leuprorelin acetate, to calibrate the results of discrete choice experiments.

RESULTS

The medical costs saved for having one less injection in pre-menopausal breast cancer patients with leuprorelin acetate injection were JPY 6,183. The productivity loss saving was JPY 1,419. An estimation of intangible costs saved for having one less injection of leuprorelin acetate was JPY 58,430, which included the disbenefit due to pain (JPY 8,535), injection site reactions (JPY 44,051), waiting time (JPY 9,595), and subtracting value in medical consultation (JPY 3,751). The total cost saved for having one less injection was JPY 66,032.

LIMITATIONS

The respondents from the internet panel provided by a survey company do not necessarily reflect a population of Japanese society.

CONCLUSIONS

Leuprorelin acetate 6-month depot demonstrates a higher value than leuprorelin acetate 3-month depot through saving medical costs and loss of productivity, as well as intangible costs saved for having one less injection when treating pre-menopausal breast cancer patients. In the costs for treating with leuprorelin acetate, the percentage of intangible costs might not be negligible. The intangible costs will probably be actively evaluated to proceed to patient-centered healthcare in society.

Cost analysis of leuprorelin acetate in Japanese prostate cancer patients: comparison between 6-month and 3-month depot formulations

AIMS

This study aimed to evaluate the economic value for leuprorelin acetate 6-month depot compared with leuprorelin acetate 3-month depot from a societal perspective in Japanese prostate cancer patients.

METHODS

The cost analysis estimated the reduction in direct and indirect costs as well as intangible costs saved by having one less injection. Claims data were used for the analyses of direct and indirect costs reduction. A discrete choice experiment based on a web-based survey estimated the monetary value of the intangible costs for one injection. Another web-based survey of prostate cancer patients, who had received treatment with leuprorelin acetate injections, was carried out to calibrate the results of the discrete choice experiment.

RESULTS

Reductions in medical costs and loss of productivity for having one less injection in prostate cancer patients receiving leuprorelin acetate were JPY 5,670 and JPY 1,723, respectively. Intangible costs saved by using a 6-month depot formulation instead of a 3-month depot formulation for the injection of leuprorelin acetate were estimated to be JPY 19,872, including the values for a reduction in pain (JPY 3,131), injection site reactions (JPY 11,545), waiting time (JPY 9,479), and subtracting the value of medical consultation (JPY 4,283). The total cost reduction for having one less injection was JPY 27,265.

LIMITATIONS

The respondents from the internet panel provided by a survey company are not necessarily a representative population of Japanese society.

CONCLUSIONS

Leuprorelin acetate 6-month depot has an advantage in monetary value in the reduction in medical costs, loss of productivity, and intangible costs for having one less injection in prostate cancer patients compared with leuprorelin acetate 3-month depot. In the costs for treating with leuprorelin acetate, the percentage of intangible costs might not be negligible. The intangible costs will probably be actively evaluated to proceed to patient-centered healthcare in society.

Number needed to treat and associated incremental costs of treatment with enzalutamide versus abiraterone acetate plus prednisone in chemotherapy-naïve patients with metastatic castration-resistant prostate cancer

OBJECTIVE

Enzalutamide (ENZA) and abiraterone acetate plus prednisone (AA) are approved second-generation hormone therapies for chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC). This study compared ENZA with AA in chemotherapy-naïve mCRPC by calculating the number needed to treat (NNT) and associated incremental costs to achieve one additional chemotherapy-naïve patient with mCRPC free of radiographic progression, chemotherapy, or death over a 1-year time horizon.

METHODS

Clinical outcomes were obtained from the PREVAIL and COU-AA-302 trials. Three outcomes were evaluated: radiographic progression-free survival, time to cytotoxic chemotherapy initiation, and overall survival at 1 year. NNT was calculated as the reciprocal of the outcome event rate difference for ENZA compared with AA. The incremental costs to achieve one additional outcome at 1 year were calculated as the difference in cost per treated patient multiplied by the NNT. Per-treated-patient costs were considered from a US payer perspective and included medications, monitoring, adverse events, post-progression treatments, and end-of-life care.

RESULTS

Within a 1-year time horizon, the total cost per treated patient for ENZA was $2,666 less than AA. Compared with AA, treating 14 patients with ENZA resulted in one additional patient free of progression or death over 1 year; treating 26 patients with ENZA resulted in one additional patient with chemotherapy delayed over 1 year; and treating 91 patients with ENZA resulted in one additional patient free of death over 1 year. Therefore, ENZA is cost-effective compared with AA for all three outcomes evaluated, and the modeled results suggest ENZA is associated with potentially improved clinical outcomes in delaying chemotherapy initiation and disease progression for chemotherapy-naïve patients. The results are robust in sensitivity analyses, where the effect of changes in key model inputs and assumptions were tested.

CONCLUSION

The results modeled in the present study suggest ENZA is cost-effective compared with AA for treating chemotherapy-naïve patients with mCRPC.

Expected 10-year treatment cost of breast cancer detected within and outside a public screening program in Norway

BACKGROUND

The shift towards earlier stages of disease advancement at diagnosis when introducing mammography screening is expected to affect the treatment costs of breast cancer.

MATERIALS AND METHODS

We collected data on hospital resource use in Norway following a breast cancer diagnosis for the period 1 January, 2008 through 31 December, 2009 for women aged 50-69 years, diagnosed with breast cancer during the period 1 January, 1999 through 31 December, 2009. We estimated treatment costs using a function that included the probability of being at risk for receiving treatment, estimated by means of the Cox proportional hazard model.

RESULTS

In total, 16,045 patients were included for the analyses among which 10.5 % died during the study period. The mean 10-year per-person treatment cost was €31,940 (95 % CI €31,030-32,880), and lower for cancers detected within the public screening program (€30,730) than for those detected elsewhere (€36,230). For ductal carcinoma in situ (DCIS) and cancers in stages I thru IV, treatment costs were €15,740, €23,570, €46,550, €55,230 and €60,430, respectively. Interval cancers occurring within the screening program were generally more resource demanding than both cancers detected at screening or elsewhere.

CONCLUSIONS

Ten-year treatment costs increased by increasing stage at diagnosis. Patients whose cancer was detected within the public screening program had lower treatment costs than those detected elsewhere. Interval cancers had higher costs than others.

A cost-utility analysis of degarelix in the treatment of advanced hormone-dependent prostate cancer in the United Kingdom

OBJECTIVE

To determine the cost-effectiveness of the treatment of advanced hormone-dependent prostate cancer with degarelix compared to luteinizing hormone-releasing hormone (LHRH) agonists in the UK using the latest available evidence and the model submitted to AWMSG.

METHODS

A cost-effectiveness model was developed from the perspective of the UK National Health Service evaluating monthly injection of degarelix against 3-monthly leuprorelin therapy plus anti-androgen flare cover for the first-line treatment of patients with advanced (locally advanced or metastatic) hormone-dependent prostate cancer. A Markov process model was constructed using the patient population characteristics and efficacy information from the CS21 Phase III clinical trial and associated extension study (CS21A). The intention-to-treat (ITT) population and a high-risk sub-group with a PSA level >20 ng/mL were modeled.

RESULTS

In the base-case analysis using the patient access scheme (PAS) price, degarelix was dominant compared to leuprorelin with cost savings of £3633 in the ITT population and £4310 in the PSA > 20 ng/mL sub-group. The chance of being cost-effective was 95% in the ITT population and 96% in the PSA > 20 ng/mL sub-group at a threshold of £20,000 per quality-adjusted life-year (QALY). In addition, degarelix remained dominant when PSA progression was assumed equal and only the benefits of preventing testosterone flare were taken into account. Treatment with degarelix also remained dominant in both populations when the list price was used. The additional investment required to treat patients with degarelix could be offset in 19 months for the ITT population and 13 months for the PSA > 20 ng/mL population. The model was most sensitive to the hazard ratio assumed for PSA progression between degarelix and leuprorelin and the quality-of-life (utility) of patients receiving palliative care.

CONCLUSION

Degarelix is likely to be cost-effective compared to leuprorelin plus anti-androgen flare cover in the first-line treatment of advanced hormone-dependent prostate cancer.

Cost effectiveness of a 21-gene recurrence score assay versus Canadian clinical practice in post-menopausal women with early-stage estrogen or progesterone-receptor-positive, axillary lymph-node positive breast cancer

BACKGROUND

A 21-gene recurrence score (RS) assay provides a method of guiding treatment decisions in women with early-stage breast cancer (ESBC). We investigated the cost effectiveness of using the RS assay versus current clinical practice (CCP) in post-menopausal women with estrogen- or progesterone-receptor-positive, one to three positive axillary lymph-node ESBC from the perspective of the Canadian public healthcare system.

METHODS

We developed a decision analytic model to project the lifetime clinical and economic consequences of ESBC. We assumed that the RS assay would classify patients among risk levels (low, intermediate and high) and corresponding adjuvant treatment regimens. The model was parameterized using 7-year follow-up data from the Manitoba Cancer Registry, cost data from Manitoba Health administrative databases and secondary sources. Costs are presented in 2012 Canadian dollars, and future costs and benefits were discounted at 5 %.

RESULTS

In the base case analysis, the RS assay compared with CCP led to an increase of 0.08 quality-adjusted life-year (QALY) and an increase in cost of Can$36.2 per person, resulting in an incremental cost-effectiveness ratio (ICER) of Can$464/QALY gained. The ICER was most sensitive to the proportion of women classified to intermediate risk by the RS assay who received adjuvant chemotherapy, and absolute risk of relapse among patients receiving the RS assay.

CONCLUSIONS

The RS assay is likely to be cost effective in the Canadian healthcare system. Field evaluations of the assay in this patient population will help reduce uncertainty in clinical guidelines for intermediate-range RS-assay values and specific disease outcomes by the RS assay, which are important drivers of ICER.

The impact of structural uncertainty on cost-effectiveness models for adjuvant endocrine breast cancer treatments: the need for disease-specific model standardization and improved guidance

INTRODUCTION

Structural uncertainty relates to differences in model structure and parameterization. For many published health economic analyses in oncology, substantial differences in model structure exist, leading to differences in analysis outcomes and potentially impacting decision-making processes. The objectives of this analysis were (1) to identify differences in model structure and parameterization for cost-effectiveness analyses (CEAs) comparing tamoxifen and anastrazole for adjuvant breast cancer (ABC) treatment; and (2) to quantify the impact of these differences on analysis outcome metrics.

METHODS

The analysis consisted of four steps: (1) review of the literature for identification of eligible CEAs; (2) definition and implementation of a base model structure, which included the core structural components for all identified CEAs; (3) definition and implementation of changes or additions in the base model structure or parameterization; and (4) quantification of the impact of changes in model structure or parameterizations on the analysis outcome metrics life-years gained (LYG), incremental costs (IC) and the incremental cost-effectiveness ratio (ICER).

RESULTS

Eleven CEA analyses comparing anastrazole and tamoxifen as ABC treatment were identified. The base model consisted of the following health states: (1) on treatment; (2) off treatment; (3) local recurrence; (4) metastatic disease; (5) death due to breast cancer; and (6) death due to other causes. The base model estimates of anastrazole versus tamoxifen for the LYG, IC and ICER were 0.263 years, €3,647 and €13,868/LYG, respectively. In the published models that were evaluated, differences in model structure included the addition of different recurrence health states, and associated transition rates were identified. Differences in parameterization were related to the incidences of recurrence, local recurrence to metastatic disease, and metastatic disease to death. The separate impact of these model components on the LYG ranged from 0.207 to 0.356 years, while incremental costs ranged from €3,490 to €3,714 and ICERs ranged from €9,804/LYG to €17,966/LYG. When we re-analyzed the published CEAs in our framework by including their respective model properties, the LYG ranged from 0.207 to 0.383 years, IC ranged from €3,556 to €3,731 and ICERs ranged from €9,683/LYG to €17,570/LYG.

CONCLUSION

Differences in model structure and parameterization lead to substantial differences in analysis outcome metrics. This analysis supports the need for more guidance regarding structural uncertainty and the use of standardized disease-specific models for health economic analyses of adjuvant endocrine breast cancer therapies. The developed approach in the current analysis could potentially serve as a template for further evaluations of structural uncertainty and development of disease-specific models.

Managed care implications in castration-resistant prostate cancer

The management of prostate cancer (PrCa) and especially castration-resistant disease can be complex, challenging, and costly. Significant developments in the field of oncology have led to the further development of safe and effective therapies that are better targeted to particular tumor types and to individual patients. This is evident in castration-resistant prostate cancer (CRPC), where 5 new therapies proved to increase overall survival have debuted in just the past few years. With new therapies, however, come new treatment paradigms and new potential costs. It is vital that managed care clinicians and providers analyze the burden and the costs of cancer in the United States, especially those relating to PrCa and especially CRPC. This will allow a better understanding of how costs and issues relating to healthcare utilization affect the treatment of patients with CRPC, and impact individualized therapy and management decisions.

A systematic review and methodological evaluation of published cost-effectiveness analyses of aromatase inhibitors versus tamoxifen in early stage breast cancer

BACKGROUND

A key priority in developing policies for providing affordable cancer care is measuring the value for money of new therapies using cost-effectiveness analyses (CEAs). For CEA to be useful it should focus on relevant outcomes and include thorough investigation of uncertainty. Randomized controlled trials (RCTs) of five years of aromatase inhibitors (AI) versus five years of tamoxifen in the treatment of post-menopausal women with early stage breast cancer, show benefit of AI in terms of disease free survival (DFS) but not overall survival (OS) and indicate higher risk of fracture with AI. Policy-relevant CEA of AI versus tamoxifen should focus on OS and include analysis of uncertainty over key assumptions.

METHODS

We conducted a systematic review of published CEAs comparing an AI to tamoxifen. We searched Ovid MEDLINE, EMBASE, PsychINFO, and the Cochrane Database of Systematic Reviews without language restrictions. We selected CEAs with outcomes expressed as cost per life year or cost per quality adjusted life year (QALY). We assessed quality using the Neumann checklist. Using structured forms two abstractors collected descriptive information, sources of data, baseline assumptions on effectiveness and adverse events, and recorded approaches to assessing parameter uncertainty, methodological uncertainty, and structural uncertainty.

RESULTS

We identified 1,622 citations and 18 studies met inclusion criteria. All CE estimates assumed a survival benefit for aromatase inhibitors. Twelve studies performed sensitivity analysis on the risk of adverse events and 7 assumed no additional mortality risk with any adverse event. Sub-group analysis was limited; 6 studies examined older women, 2 examined women with low recurrence risk, and 1 examined women with multiple comorbidities.

CONCLUSION

Published CEAs comparing AIs to tamoxifen assumed an OS benefit though none has been shown in RCTs, leading to an overestimate of the cost-effectiveness of AIs. Results of these CEA analyses may be suboptimal for guiding policy.

Reviewing the cost-effectiveness of endocrine early breast cancer therapies: influence of differences in modeling methods on outcomes

OBJECTIVES

The purpose of this systematic review is primarily to identify published cost-effectiveness analyses and cost-utility analyses of endocrine therapies for the treatment of early breast cancer. A secondary objective is to identify whether differences in seven modeling characteristics are related to differences in outcome of these cost-effectiveness and cost-utility analyses.

METHODS

A systematic literature review was conducted to identify peer-reviewed full economic evaluations of endocrine treatments of early breast cancer published in the English language between 2000 and December 2010. Information from these publications was abstracted regarding outcome, quality, and modeling methods.

RESULTS

We identified 20 economic evaluations comprising 5 different endocrine therapeutic strategies, which are all assessed more then once. The incremental cost-effectiveness ratios (ICERs) of the reported outcomes varied widely for identical therapies. For anastrazole compared to tamoxifen, incremental life-years gained even ranged from 0.16 to 0.550 with an ICER ranging from €3,958 to €75,331. Incremental quality-adjusted life-years (QALYs) gained ranged from 0.092 to 0.378 with a cost per QALY gained varying from €3,696 to €120,265. These large differences in outcome were related to different modeling methods, with differences in time horizon and use of a carryover effect as most prominent causes.

CONCLUSION

Despite similar comparators and logical differences due to transferability issues, the outcomes of the included studies varied widely. To increase comparability and transparency of pharmacoeconomic evaluations, standardization of modeling methods for different therapeutic groups/diseases and the availability of a detailed and complete description of the model used in the evaluation is advocated. Recommendations for standardization in modeling treatment strategies in early breast cancer are presented.

Prioritizing pharmacogenetic research: a value of information analysis of CYP2D6 testing to guide breast cancer treatment

OBJECTIVES

To demonstrate how value of information (VOI) analysis can be used to establish research priorities regarding the use of pharmacogenetic tests using CYP2D6 testing to select adjuvant hormonal therapy in early stage breast cancer as a case study.

METHODS

The following four treatment pathways are compared in a Markov model: tamoxifen treatment; CYP2D6 test and treat homozygous and heterozygous wild type patients (wt/wt; wt/*4) with tamoxifen and *4/*4 patients with anastrozole (HetTam); CYP2D6 test and treat homozygous wild type patients with tamoxifen and others with anastrozole (HomTam); and anastrozole treatment. Pharmacogenetic testing efficacy is estimated by synthesizing randomized controlled trial data comparing tamoxifen to anastrozole with observational data linking CYP2D6 genotype to tamoxifen outcomes.

RESULTS

In order of increasing effectiveness the comparators are tamoxifen, HetTam, HomTam, anastrozole. Health outcomes for test and treatment strategies are highly uncertain. Differences in comparator costs depend on assumptions made regarding anastrozole patent expiry. The expected value of a decision taken with perfect information is £69 to £106 million (pound sterling) for the United Kingdom depending on patent expiry assumptions and the acceptable cost-effectiveness threshold. The most valuable research (VOI £53-£82 million) elucidates the relationship between CYP2D6 genotype and tamoxifen effectiveness. It is uncertain whether values of other research designs would exceed their costs.

CONCLUSIONS

Retrospective analysis of one of the large adjuvant aromatase inhibitor trials is warranted to better understand any association between CYP2D6 genotype and tamoxifen outcomes. VOI approaches may be helpful for prioritising evidence needs and structuring coverage with evidence development agreements for pharmacogenetics.

Association between prescription co-payment amount and compliance with adjuvant hormonal therapy in women with early-stage breast cancer

PURPOSE

Noncompliance with adjuvant hormonal therapy among women with breast cancer is common. Little is known about the impact of financial factors, such as co-payments, on noncompliance.

PATIENTS AND METHODS

We conducted a retrospective cohort study by using the pharmacy and medical claims database at Medco Health Solutions. Women older than age 50 years who were taking aromatase inhibitors (AIs) for resected breast cancer with two or more mail-order prescriptions, from January 1, 2007, to December 31, 2008, were identified. Patients who were eligible for Medicare were analyzed separately. Nonpersistence was defined as a prescription supply gap of more than 45 days without subsequent refill. Nonadherence was defined as a medication possession ratio less than 80% of eligible days.

RESULTS

Of 8110 women younger than age 65 years, 1721 (21.1%) were nonpersistent and 863 (10.6%) were nonadherent. Among 14,050 women age 65 years or older, 3476 (24.7%) were nonpersistent and 1248 (8.9%) were nonadherent. In a multivariate analysis, nonpersistence (ever/never) in both age groups was associated with older age, having a non-oncologist write the prescription, and having a higher number of other prescriptions. Compared with a co-payment of less than $30, a co-payment of $30 to $89.99 for a 90-day prescription was associated with less persistence in women age 65 years or older (odds ratio [OR], 0.69; 95% CI, 0.62 to 0.75) but not among women younger than age 65, although a co-payment of more than $90 was associated with less persistence both in women younger than age 65 (OR, 0.82; 95% CI, 0.72 to 0.94) and those age 65 years or older (OR, 0.72; 95% CI, 0.65 to 0.80). Similar results were seen with nonadherence.

CONCLUSION

We found that higher prescription co-payments were associated with both nonpersistence and nonadherence to AIs. This relationship was stronger in older women. Because noncompliance is associated with worse outcomes, future policy efforts should be directed toward interventions that would help patients with financial difficulties obtain life-saving medications.

Laparoscopic salpingo-oophorectomy for ovarian ablation in women with hormone-sensitive breast cancer

OBJECTIVE

To evaluate institutional experiences regarding laparoscopic salpingo-oophorectomy in breast cancer patients and to compare the technique with gonadotropin-releasing hormone (GnRH) analogs among premenopausal women with hormone-sensitive breast cancer.

METHODS

Between 2004 and 2009, 103 women with breast cancer underwent laparoscopic salpingo-oophorectomy at Addenbrooke's Hospital, Cambridge, UK. All relevant medical records-including reasons for salpingo-oophorectomy, peri-operative events, and subsequent follow-up-were reviewed.

RESULTS

In the study period, 3 (2.9%) women experienced a recurrence of breast cancer but none had primary peritoneal/ovarian cancer within a median follow-up interval of 34 months (range, 0-70 months). No operative complications were noted among these women and all of them went home on the day of their operation.

CONCLUSION

Laparoscopic salpingo-oophorectomy seems to be a safe, permanent, and cost-effective method of ovarian ablation compared with the use of GnRH analogs. Salpingo-oophorectomy also considerably reduces the risk of subsequent ovarian/fallopian tube malignancy in this high-risk population.

Cost-effectiveness analysis of LHRH agonists in the treatment of metastatic prostate cancer in Italy

OBJECTIVES

Luteinizing hormone-releasing hormone (LHRH) agonists represent one of the main cost factors in the management of patients with metastatic prostate cancer. We compared the cost-effectiveness of the five different 3-month formulations of LHRH agonists currently available for advanced prostate cancer in Italy, because these differ both in their capacity to suppress testosterone and in their acquisition costs.

METHODS

A probabilistic, patient-level simulation model was developed to compare the cost-effectiveness, from the perspective of the Italian National Health Service (INHS), of leuprorelin 11.25 mg and 22.5 mg, triptorelin 11.25 mg, buserelin 9.9 mg, and goserelin 10.8 mg. The model incorporated testosterone-dependent progression-free and cancer-specific survival functions, LHRH agonist effectiveness data, and national costs and tariffs. Cox's proportional hazard models were used to compute total and progression-free survival functions based on clinical data from 129 patients with metastatic prostate cancer treated in an Italian center. Bayesian random effects models were employed to summarize evidence from published literature on testosterone suppression obtained with the available LHRH agonists.

RESULTS

Estimated total survival was ≈5 years, with a maximum difference between treatment options of ≈2 months. There was a mean difference of almost €2,500 in lifetime total costs between the least costly option (leuprorelin 22.5 mg) and the most expensive (goserelin). In the incremental cost-effectiveness analysis, leuprorelin 22.5 mg dominated all alternatives except buserelin, which had an incremental cost-effectiveness ratio versus leuprorelin 22.5 mg of ≈€12,000 per life-month gained.

CONCLUSIONS

Based on modelling with meta-analysis of comparative survival data, leuprorelin 22.5 mg was the most cost-effective treatment of the available depot formulation LHRH agonists.

[Assessment of annual health insurance reimbursement for oncology drugs in Hungary]

The aim of our study is to analyse the health insurance reimbursement of oncology drugs in outpatient care, inpatient care and named patient system. Data were derived from the database of the National Health Insurance Fund Administration (OEP). The analysis covers data of pharmaceuticals with health insurance reimbursement between 1 January and 31 December, 2008. We performed the analysis according to the ATC group "L" and ICD codes C00-C99 and D00-D48. Within "L" ATC group, for ICD codes C00-C99 and D00-D48 the annual health insurance expenditure for outpatient and named patient drugs were 36.3 billion Hungarian Forints (HUF) (144.5 million EUR, 211.3 million USD). For drugs used in the acute inpatient care, we found 22.59 billion HUF (89.9 million EUR, 131.5 million USD) annual health insurance expenditure. The Hungarian National Health Insurance Fund Administration (OEP) spent altogether 58.9 billion HUF (234.4 million EUR, 342.8 million USD) for the reimbursement of oncological drugs in outpatient, named patient and inpatient care. The reimbursement of oncological drugs represents a significant expenditure for the Hungarian National Health Insurance Fund Administration (OEP). Boncz I, Donka-Verebes É, Oberfrank F, Kásler M. Assessment of annual health insurance reimbursement of oncology drugs in Hungary.

[Cost-benefit analysis of anastrazol and tamoxifen in adjuvant treatment of hormone receptor-positive, post-menopausal breast cancer]

INTRODUCTION

In high-income countries, tamoxifen has been replaced by aromatase inhibitors such as anastrozole in adjuvant hormone therapy for early breast cancer. These drugs target patients with positive hormone receptors, due to the better results achieved for disease-free survival. The cost-effectiveness of this treatment change has not been evaluated in middle income countries.

OBJECTIVE

The cost effectiveness of anastrozole vs tamoxifen was assessed during five-years of adjuvant treatment of hormone receptor-positive, post-menopausal early breast cancer patients.

MATERIALS AND METHODS

This is a literature-based analysis. The natural history of the breast cancer and the effects of treatment were modeled as a Markov process. Effectiveness was defined as disease-free survival. Transition probabilities for the disease and adverse effects were obtained from the literature. Costs were defined as the median of actual costs provided by health insurance companies and the Colombian National Cancer Institute expressed in 2007 Colombian pesos. Probabilistic sensitivity analysis was performed, along with one way sensitivity analysis was for the costs.

RESULTS

Compared with tamoxifen, anastrazol results in an additional relapse-free period of 0.5 years. Each relapse-free year obtained by tamoxifen cost 27,210,604 pesos, or with anastrazol 37,071,337 pesos with a discount rate of 3%. The cost for a sustained-effects scenario were 23,617,400 pesos for tamoxifen and $16,140.282 for anastrazol.

CONCLUSIONS

The use of anastrazol has an additional cost per relapse-free year of 7,521,363 pesos (2007). Therefore, for postmenopausal, early breast cancer hormone receptor positive women in Colombia, the cost-effective alternative is tamoxifen used as adjuvant therapy for five years.

Healthcare costs in postmenopausal women with hormone-positive metastatic breast cancer

OBJECTIVES

This study examines costs for postmenopausal women with hormone receptor positive (HR+) metastatic breast cancer (mBC).

METHODS

Data were obtained from the IHCIS National Managed Care Benchmark Database from 1/1/2001 to 6/30/2006. Women aged 55-63 years were selected for the study if they met the inclusion criteria, including diagnoses for breast cancer and metastases, and at least two fills for a hormone medication. Patients were followed from the onset of metastases until the earliest date of disenrollment from the health plan or 6/30/2006. Patient characteristics were examined at time of initial diagnoses of metastases, while costs were examined post-diagnosis of metastases and prior to receipt of chemotherapy (pre-chemotherapy initiation period) and from the date of initial receipt of chemotherapy until end of data collection (post-chemotherapy initiation period). Costs were adjusted to account for censoring of the data.

RESULTS

The study population consisted of 1,266 women; mean (SD) age was 59.05 (2.57) years. Pre-chemotherapy initiation, unadjusted inpatient, outpatient, and drug costs were $4,392, $47,731, and $5,511, while these costs were $4,590, $57,820, and $38,936 per year, respectively, post-chemotherapy initiation. After adjusting for censoring of data, total medical costs were estimated to be $55,555 and $70,587 in the first 12 months and 18 months, respectively in the pre-chemotherapy initiation period. Post-chemotherapy initiation period, 12-month and 18-month adjusted total medical costs were estimated to be $87,638 and $130,738.

LIMITATIONS

The use of an administrative claims database necessitates a reliance upon diagnostic codes, age restrictions, and medication use, rather than formal assessments to identify patients with post-hormonal women with breast cancer. Furthermore, such populations of insured patients may not be generalizable to the population as a whole.

CONCLUSIONS

These findings suggest that healthcare resource use and costs - especially in the outpatient setting - are high among women with HR+ metastatic breast cancer.

Recent case developments in health law. Pharmaceutical price-fixing and consumer protection: Blue Cross & Blue Shield v. AstraZeneca Pharmaceuticals LP

In September 2009, the First Circuit Court of Appeals decidedBlue Cross & Blue Shield v. AstraZeneca Pharmaceuticals LP,part of the class action suit known asIn re Pharmaceutical Industry Average Wholesale Price Litigation. The First Circuit upheld a Massachusetts District Court finding that AstraZeneca violated Massachusetts’ consumer protection laws by manipulating the “average wholesale price” of its physician-administered injectable cancer drug Zoladex, leading to overpayment by the government, third-party payers, and consumers. This case, which highlights the persistent tension between pharmaceutical pricing flexibility and consumer protection, has important implications for similar pending class actions.

Between 1991 and 2003, Medicare, as well as many private insurance companies, pegged reimbursement for certain pharmaceutical products to a national “average wholesale price” (AWP) for each drug. Although the amended 1991 Medicare Part B regulations3 that introduced the term “average wholesale price” failed to define it explicitly, there is some indication in the legislative history that AWP was intended to refer to the prices that physicians and pharmacists actually pay to the drug manufacturers.

Value of information and value of implementation: application of an analytic framework to inform resource allocation decisions in metastatic hormone-refractory prostate cancer

OBJECTIVE

In a budget-constrained health-care system, decisions about investing in strategies to promote implementation have to be made alongside decisions about health-care provision and research funding. Using a Bayesian decision-theoretic approach, an analytic framework has been developed to inform these separate but related decisions, establishing the expected value of both perfect information (EVPI) and perfect implementation (EVPIM). We applied this framework to inform decision-making about resource allocation to metastatic hormone-refractory prostate cancer (mHRPC) in the UK.

METHODS

Based on available evidence on the cost-effectiveness of all plausible treatments for mHRPC, we determined which treatment option(s) were cost-effective and explored the uncertainty surrounding this decision. Given the decision uncertainty and the variation in care provided by health-care professionals, we then determined the EVPI and EVPIM. Finally, we performed sensitivity analyses to explore the influence of alternative assumptions regarding various decision parameters on the efficiency of resource allocation.

RESULTS

Depending on the cost-effectiveness threshold (lambda), we identified mitoxantrone plus prednisone/prednisolone and docetaxel plus prednisone/prednisolone (3 weekly) as the optimal treatments for mHRPC. Given current clinical practice, there appears to be considerable scope for improving the efficiency of health-care provision: the EVPI (estimated to be over pound13 million) indicates that acquiring further information could be cost-effective; and the EVPIM (estimated to be over pound4 million) suggests that investing in strategies to implement the treatments regimens being identified as optimal is potentially worthwhile. Through sensitivity analyses, we found that the EVPI and EVPIM are mainly driven by lambda, the number of treatment options being considered, the current level of implementation, and the size of the eligible patient population.

CONCLUSION

The application demonstrates that the framework provides a simple and useful analytic tool for decision-makers to address resource allocation problems between health-care provision, further research, and implementation efforts.

Cost utility analysis of early adjuvant letrozole or anastrozole versus tamoxifen in postmenopausal women with early invasive breast cancer: the UK perspective

Five years with the aromatase inhibitors letrozole or anastrozole is clinically superior to 5 years tamoxifen in postmenopausal women with early breast cancer. This paper analyses the cost-effectiveness of the aromatase inhibitors compared to tamoxifen using the same health economic model. A Markov model describes lifetime incidence of breast cancer events and treatment-related adverse events. Probabilities of disease progression, adverse events, and utility values were estimated using secondary sources; costs of breast-cancer care were obtained from a primary costing study. The incremental cost per QALY gained of letrozole vs. tamoxifen is 10,379pounds (95% CI 6,705-23,574pounds), and of anastrozole versus tamoxifen is 11,428pounds (95% CI 6,211-48,795pounds). If a 5-year carry over effect for the reduction in breast cancer events is assumed, the incremental costs per QALY gained compared to tamoxifen are 6,253pounds (95% CI 3,675-14,766pounds) for letrozole and 7,015pounds (95% CI 3,316-31,997pounds) for anastrozole. Five years of letrozole or anastrozole therapy is cost-effective in postmenopausal women with early breast cancer. Though the respective confidence intervals show significant overlap, letrozole has a 95% probability of being more cost-effective than tamoxifen at a 20,000pounds QALY value, whilst anastrozole has an 85% probability.

Maximal androgen blockade for advanced prostate cancer

Maximal androgen blockade (MAB) refers to the combination of medical (gonadotrophin-releasing hormone agonist) or surgical castration with an anti-androgen for the treatment of advanced prostate cancer. A substantial body of basic research has improved our understanding of the interactions between the anti-androgens, the androgen receptor, and androgen response elements in the genome. Anti-androgens act by two primary mechanisms: inhibition of ligand (androgen) binding to the androgen receptor, and inhibition of androgen-independent activation of the receptor. The latter mechanism occurs via several pathways, including inhibiting nuclear co-activators, activating co-suppressors, and inhibiting transcription of a variety of androgen-regulated genes. It is more accurate to refer to these compounds as androgen-receptor antagonists, since they inhibit activation whether this is androgen-mediated or not. Within the class of non-steroidal anti-androgens, there is variation in the degree to which ligand-independent activation is inhibited. Over the last 25 years, approximately 30 clinical trials have addressed the benefit of MAB versus monotherapy. Most of these trials have evaluated flutamide or nilutamide. Several meta-analyses suggest a modest survival benefit of these drugs, amounting to an 8% mortality reduction at 5 years. Preclinical data and two randomized trials -- one historic and one current -- suggest that bicalutamide may be a more effective drug in this respect. This requires confirmation pending further maturity of the current trial, which is the only one directly comparing bicalutamide plus castration to castration alone. In prostate cancer patients at high risk for mortality (based on extent of disease or prostate-specific antigen kinetics), combination therapy with bicalutamide should be considered in preference to monotherapy.

Primary combined androgen blockade in localized disease and its mechanism

In spite of clinical practice guidelines such as NCI-PDQ - in which primary androgen deprivation therapy (PADT) is not recommended as the primary treatment for localized prostate cancer - many patients have been treated with PADT. One of the reasons is that urologists themselves permit patients' desire because they know the effectiveness of PADT for some patients in their experiences. In this review we demonstrate basic mechanisms and the clinical efficacy of primary combined androgen blockade (PCAB) for localized or locally advanced prostate cancer. Then we discuss which patients are candidates for PCAB, and show that more than 30% of low- or intermediate-risk localized prostate cancers could be controlled in the long term with only PCAB. Short-term or intermittent PADT could not be recommended because of the possibilities of changing the character of the cancer cells by incomplete androgen ablation. We propose algorithms for the treatment of localized prostate cancer not only in low- and intermediate-risk groups but also in the high-risk group.

The benefits and costs of tamoxifen for breast cancer prevention

OBJECTIVE

To estimate the effects of key uncertainties on the effectiveness and cost-effectiveness of breast cancer prevention with tamoxifen.

METHODS

The incremental cost-effectiveness ratio of tamoxifen therapy relative to placebo was estimated using decision analysis with Markov modelling of health states, outcomes and costs for a simulated cohort of women at high risk for breast cancer. Relative effects of tamoxifen's benefits and harms were estimated from meta-analyses of randomised controlled trials. Cost estimates were based on Australian treatment patterns and costs. The main outcome measure was cost per quality-adjusted life year (QALY) gained with costs and effects discounted at a 5% annual rate.

RESULTS

Tamoxifen therapy over five years reduces the incidence of breast cancer by approximately 1.4%, which is offset by an increase in endometrial cancer of 0.7% and pulmonary embolism of 0.2%. If the reduction is permanent (preventing new breast cancers emerging over five years and no further treatment effect thereafter), the model estimates an increase in life expectancy of 0.057 QALYs and an extra cost of $2,193; or $38,271/QALY gained. A model assuming further treatment effects of tamoxifen preventing new breast cancers emerging for up to 10 years results in an incremental cost of $19,354/QALY. However, if five years of tamoxifen therapy merely delays when these breast cancers appear (such that by 10 years there is no longer a reduced incidence), the incremental cost per QALY saved is estimated to be $199,149.

CONCLUSIONS

Tamoxifen is potentially cost-effective in preventing breast cancer in women at high risk. However, its cost-effectiveness as a preventive therapy is highly sensitive to whether these cancers are permanently prevented or their clinical presentation is only delayed. Long-term follow-up in randomised controlled trials is therefore crucial in forming health policy.

Cost-effectiveness of letrozole versus tamoxifen as initial adjuvant therapy in postmenopausal women with hormone-receptor positive early breast cancer from a Canadian perspective

BACKGROUND

In the primary core analysis of BIG 1-98, a randomized, double-blind trial comparing 5 years of initial adjuvant therapy with letrozole versus tamoxifen in postmenopausal women with hormone receptor-positive (HR+) early breast cancer, letrozole significantly improved disease-free survival by 19% and reduced the risk of breast cancer recurrence by 28% and distant recurrence by 27%.

METHODS

A Markov model was used to estimate the incremental cost per quality-adjusted life year (QALY) gained with 5 years of initial adjuvant therapy with letrozole versus tamoxifen from a Canadian healthcare system perspective. Probabilities of recurrence and side effects for tamoxifen were based on published results of BIG 1-98 and other published population-based studies. Corresponding probabilities for letrozole were calculated by multiplying probabilities for tamoxifen by estimated relative risks for letrozole versus tamoxifen from BIG 1-98. Other probabilities, costs of breast-cancer care and treatment of side effects, and health-state utilities were obtained from published studies. Costs and QALYs were estimated over the lifetime of a cohort of postmenopausal women with HR+ early breast cancer, aged 60 years at initiation of therapy, and discounted at 5% annually.

RESULTS

Compared with tamoxifen, letrozole yields an additional 0.368 life-years (12.453 vs. 12.086) and 0.343 QALYs (11.582 vs. 11.239). These benefits are obtained at an additional cost of Can$ 8,110 (Can$ 30,819 vs. Can$ 22,709). Cost per QALY gained for letrozole versus tamoxifen is Can$ 23,662 (95% CI Can$ 15,667-Can$ 52,014).

CONCLUSION

In postmenopausal women with HR+ early breast cancer, initial adjuvant treatment with letrozole is cost-effective from the Canadian healthcare system perspective.

Eliciting patient preferences for hormonal therapy options in the treatment of metastatic prostate cancer

Treatment choices for metastatic prostate cancer are complex and can involve men balancing survival versus quality of life. The present study aims to elicit patient preferences with respect to the attributes of treatments for metastatic prostate cancer through a discrete choice experiment (DCE) questionnaire. Men with recently diagnosed localized prostate cancer were asked to envisage that they had metastatic disease when completing a survey. As expected, men with prostate cancer placed considerable importance on gains in survival; however, avoiding side effects of treatment was also clearly important. Survival gains should be considered alongside side effects when discussing treatment options in metastatic disease.

Cost-effectiveness analysis of anastrozole vs tamoxifen in adjuvant therapy for early stage breast cancer in the United Kingdom: the 5-year completed treatment analysis of the ATAC ('Arimidex', Tamoxifen alone or in combination) trial

Results from the completed treatment analysis of the ATAC (Arimidex, Tamoxifen alone or in combination) trial indicated that anastrozole was significantly superior to tamoxifen in terms of efficacy and safety in the adjuvant treatment of postmenopausal women with hormone receptor-positive (HR+) early breast cancer. On the basis of these results, this study estimated the cost-effectiveness of anastrozole vs tamoxifen, from the perspective of the UK National Health Service (NHS). A Markov model was developed using the 5-year completed treatment analysis from the ATAC trial (ISRCTN18233230), as well as data obtained from published literature and expert opinion. Resource utilisation data and associated costs (2003-4 UK pound) were compiled from standard sources and expert opinion. Utility scores for a number of health states were obtained from a cross-sectional study of 26 representative patients using the standard gamble technique. The utility scores were then inserted into the model to obtain cost per quality adjusted life-year (QALY) gained. Costs and benefits were discounted at recommended annual rates of the UK Treasury (3.5%). Modelled for 25 years, anastrozole, relative to generic tamoxifen, was estimated to result in 0.244 QALYs gained per patient at an additional cost of pound4315 per patient). The estimated incremental cost-effectiveness of anastrozole compared with tamoxifen was pound17 656 per QALY gained. There was a greater than 90% probability that the cost-effectiveness of anastrozole was below pound30 000 per QALY gained and of the order of 65% that it was below pound20 000 per QALY gained. The results were robust to all parameters tested in sensitivity analysis. Compared with commonly accepted thresholds, anastrozole is a cost-effective alternative to generic tamoxifen in adjuvant treatment of postmenopausal women with HR+ early breast cancer from the UK NHS perspective.

Hormonal therapies for early breast cancer: systematic review and economic evaluation

OBJECTIVES

To establish the clinical and cost-effectiveness of aromatase inhibitors (AIs) anastrozole, letrozole and exemestane compared with tamoxifen in the adjuvant treatment of early oestrogen receptor-positive breast cancer in postmenopausal women.

DATA SOURCES

Major electronic databases and three trials registers were searched from May to June 2005. Three conference abstract databases were searched in December 2005. Industry submissions.

REVIEW METHODS

Studies evaluating the clinical effectiveness of AIs against 5 years' tamoxifen treatment were included and critically appraised. The review of the health economics of AIs in early breast cancer in comparison with standard therapies included a review of existing economic evaluations of the relevant therapies, a critique of each of the economic evaluations submitted to the National Institute for Health and Clinical Excellence (NICE) by pharmaceutical manufacturers and a detailed explanation of the methodologies and results of the authors' economic model. The three treatment strategies (primary adjuvant therapy, unplanned switch therapy and extended adjuvant therapy) were considered separately within the authors' economic analysis.

RESULTS

A meta-analysis of three trials found a significant difference in overall survival when an unplanned anastrozole switching strategy was compared with 5 years' tamoxifen. Significant improvements in overall survival are yet to be demonstrated in other strategies. Compared with 5 years' tamoxifen, disease-free survival (disease recurrence or death from any cause) was significantly improved in the primary adjuvant setting with anastrozole and letrozole, and with an exemestane switching strategy. Other trials did not report this outcome. Breast cancer recurrence (censoring death as an event) was significantly improved with primary adjuvant anastrozole and letrozole, anastrozole switching, extended adjuvant anastrozole or letrozole. The AIs and tamoxifen have different side-effect profiles, with tamoxifen responsible for small but statistically significant increases in endometrial cancer and, sometimes, thromboembolic events and stroke. AIs show a trend towards increases in osteoporosis, the statistical significance of which increases with follow-up time. The absence of tamoxifen treatment also increases the risk of hypercholesterolaemia and cardiac events in postmenopausal women. There was no significant difference in overall health-related quality of life between standard treatment and either primary adjuvant anastrozole and extended adjuvant letrozole strategies. The cost-effectiveness results for AIs compared with tamoxifen in the primary adjuvant setting, are estimated to be between 21,000 pounds and 32,000 pounds per quality-adjusted life-year (QALY) based on an analysis over 35 years. There is currently no trial evidence for exemestane in this setting. The cost-effectiveness results for anastrozole and exemestane, compared with tamoxifen in the unplanned switching setting, are estimated to be 23,200 pounds and 19,200 pounds per QALY, respectively, based on an analysis over 35 years. There is currently no trial evidence for letrozole in this setting. In the extended adjuvant setting, the cost per QALY for letrozole compared with placebo is estimated to be 9800 pounds, based on an analysis over 35 years. All these results are considered to be conservative. In the base case it is assumed that the benefits of AIs over tamoxifen or placebo seen during the therapy period are gradually lost during the following 10 years. An alternative scenario, the 'benefits maintained' scenario, is tested in sensitivity analysis. Here it is assumed that following the treatment period the annual rate of recurrence in both arms is the same. This reduces the cost-effectiveness ratio by over 50%, to around 10,000-12,000 pounds, 5000 pounds and 3000 pounds in the primary adjuvant, unplanned switching and extended adjuvant setting, respectively. The limited evidence to date of benefits after the therapy period suggests that the 'benefits maintained' scenario may be realistic. The results from the economic analyses within the industry submissions are generally lower than the results from the authors' model and are close to or below 12,000 pounds in all three settings. The authors' analyses generally produce a lower estimate of QALY gain for the aromatase inhibitors, due to the more conservative assumption regarding benefits, along with differences in the utility values used in the their analysis.

CONCLUSIONS

On the basis of the current data and within their licensed indications, AIs can be considered clinically effective compared with standard tamoxifen treatment. However, their long-term effects, in terms of both benefits and harms, remain unclear. Under the conservative assumption that benefits gained by AIs during the treatment period are gradually lost over the following 10 years, the cost per QALY for AIs compared with tamoxifen is estimated to be between 21,000 pounds and 32,000 pounds in the primary adjuvant setting and around 20,000 pounds in the unplanned switch setting. The cost per QALY for AIs compared with placebo in the extended adjuvant setting is estimated to be around 10,000 pounds. Under the less conservative assumption that rates of recurrence are the same in both arms after the therapy period is complete, the incremental cost-effectiveness ratios are typically at least 50% lower, suggesting that AIs are likely to be considered cost-effective in all three settings. Understanding of the long-term treatment effects on cost-effectiveness is, however, incomplete. Data on the impact of AIs on survival are awaited from the majority of the trials to confirm whether or not the benefits seen in disease-free survival and recurrence rates are translated into overall survival benefit in the medium to long-term.

Cost-effectiveness of anastrozole compared to tamoxifen in hormone receptor-positive early breast cancer. Analysis based on the ATAC trial

The 5-year completed treatment analysis of the Anastrozole and Tamoxifen-Alone or in Combination (ATAC) trial showed the superiority of anastrozole over tamoxifen for reduction of disease progression in patients with hormone receptor-positive (HR+) early breast cancer (EBC). The objective was to evaluate the cost-effectiveness of anastrozole versus tamoxifen in this setting. A health economic model was developed comparing the natural history of EBC patients treated with anastrozole or tamoxifen. The perspective of the Belgian health care system was taken. Disease progression from EBC was obtained from the ATAC trial and further progression beyond the clinical trial from published literature. Resource use data were obtained from the ATAC study and from published local retrospective data. Anastrozole was cost-effective versus tamoxifen, provided that a time horizon of at least 9 years is taken. This sensitivity to time horizon is inherently associated with the adjuvant setting due to the different evolution of costs and outcomes over time. Costs are incurred solely during the first 5 years, whereas outcomes are cumulated beyond adjuvant treatment. In conclusion, provided that a sufficient time horizon is taken and that long-term model predictions are confirmed from further follow-up from the ATAC study, anastrozole is a highly cost-effective adjuvant therapy compared to tamoxifen.

SERMs: Meeting the Promise of Multifunctional Medicines

The successful development and clinical evaluation of the selective estrogen receptor modulators in the Study of Tamoxifen and Raloxifene trial provides an occasion to reflect on the milestone that has been achieved and the potential for further progress in the chemoprevention of breast cancer. The evolution of tamoxifen from a successful treatment for breast cancer to the first chemopreventive for any cancer took two decades. Clinicians gained an enormous amount of experience with the use of tamoxifen as a treatment, and, as a result, there were few surprises in terms of efficacy or the side effect profile when the medicine was used to prevent breast cancer in high-risk women. In contrast, raloxifene emerged via the novel path of the evidence-based hypothesis that a drug targeted at one disease, osteoporosis, could also prevent breast cancer. Changes in health care strategies to implement chemoprevention take time, but the evidence now suggests that chemoprevention has become a reality in clinical practice.

Modeling for cost-effective-adjuvant aromatase inhibitor strategies for postmenopausal women with breast cancer

BACKGROUND

To determine cost-effective (CE) strategies comparing adjuvant upfront aromatase inhibitor (AI) with sequential tamoxifen (TAM) AI in postmenopausal (PM) women with breast cancer (BC).

DESIGN

A Markov model was constructed to calculate cumulative costs and quality-adjusted life year (QALY) gains for upfront AI and TAM-AI in a hypothetical cohort of 60-year-old PM women with BC. Costs, utilities and probabilities were derived from the literature. The hazard ratios (HRs) of AI strategies were applied to a baseline cancer recurrence risk (RR) to determine CE strategies at the $50,000/QALY gain threshold. A direct payer perspective is utilized, and costs and benefits were discounted at 3%.

RESULTS

Two-way sensitivity analyses are presented to determine CE strategies across a wide range of HRs and in different clinical scenarios including varying RRs (low, average, high and very high). TAM-AI is the preferred CE strategy at low and average RR, while upfront AI is CE at very high RR. The CE strategy in patients with high RR was dependent on the scenario examined.

CONCLUSIONS

This model may help health care providers select CE-adjuvant AI strategies in PM women with BC, until further direct evidence is available from randomized clinical trials.

Cost-effectiveness analysis of anastrozole versus tamoxifen as primary adjuvant therapy for postmenopausal women with early breast cancer: a US healthcare system perspective. The 5-year completed treatment analysis of the ATAC ('Arimidex', Tamoxifen Alone or in Combination) trial

BACKGROUND

This study evaluated the cost-effectiveness of anastrozole versus generic tamoxifen for primary adjuvant treatment of postmenopausal women with hormone receptor-positive (HR+) early breast cancer (EBC), from a US healthcare perspective.

METHODS

A probabilistic Markov model was developed using the 5-year completed treatment analysis of the ATAC ('Arimidex', Tamoxifen Alone or in Combination) trial (ISRCTN 18233230) to project outcomes for anastrozole and tamoxifen to 25 years. Resource utilization data were obtained primarily from published literature and a physician survey (including expert opinion from ATAC Steering Committee members). Drug costs were taken from published wholesale acquisition costs (anastrozole $6.56/day, generic tamoxifen $1.33/day). Other unit costs ($US 2003-4) were from standard sources. Utility estimates of relevant health states, used to compute quality-adjusted life-years (QALYs), were collected using the standard gamble technique in a cross-sectional sample of 44 patients. Costs and benefits were discounted 3% annually.

RESULTS

In a cohort of 1000 postmenopausal women with HR+ EBC, the model showed anastrozole treatment (versus tamoxifen) would lead to 257 QALYs gained (0.26 QALYs gained per patient), at an additional cost of $5.21 million over 25 years ($5,212 per patient). The estimated incremental cost-effectiveness ratio (ICER) of anastrozole compared with tamoxifen was $20,246 per QALY gained ($23,541 per life-year gained). Cost-effectiveness acceptability curves indicated a >90% probability that the cost per QALY gained with anastrozole would be <$50,000. Results were robust in a sensitivity analysis.

CONCLUSION

Anastrozole is a cost-effective alternative to tamoxifen for the primary adjuvant treatment of postmenopausal women with HR+ EBC.

Economic evaluation of the prevention and treatment of breast cancer-present status and open issues

BACKGROUND

More effective methods of preventing and treating breast cancer are being sought by clinicians every day, and new drugs and interventions for overcoming this cancer are being energetically evaluated. At present, there are wide treatment options and many different objectives for breast cancer. These circumstances led us to seek information about the relative costs of the different medical options for the prevention and treatment of breast cancer and to try to ascertain whether one course of action is more efficient than other courses. Economic evaluation of healthcare is indispensable for selection of the best alternatives among medical interventions which are becoming more diverse day after day. The total medical expenditure continues to rise each year and some sort of evaluation from an objective and external viewpoint is required to provide the information with which to suppress this rise.

METHODS

This paper surveys the three major reports published on this topic to date, for the purpose of demonstrating the importance and necessity of performing an economic analysis of the treatment and prevention of breast cancer. The three reports to be surveyed pertain to: (1) cost-effectiveness analysis of adjuvant chemotherapy for patients with lymph node negative breast cancer, (2) cost utility analysis of first-line hormonal therapy in advanced breast cancer, namely comparison of two aromatase inhibitors to tamoxifen, and (3) cost-effectiveness analysis of tamoxifen in the prevention of breast cancer. In addition, this paper discusses the advantages, limitations and perspective for the future of the economic evaluation of healthcare for breast cancer.

RESULTS

(1) The authors concluded that if the average risk of all women of undergoing recurrence after this therapy is assumed to be 4% per year, adjuvant chemotherapy is definitely of benefit for node-negative, estrogen receptor-negative breast cancer patients. They additionally stated that this benefit decreases markedly if the changes in long-term survival are less than those in disease-free survival. In this connection, they pointed out that the benefit is considerably smaller among postmenopausal 60-year-old women. (2) The incremental cost per quality-adjusted progression-free life year (QAPFY) for letrozole and anastrozole, relative to tamoxifen, was Can $12,500-19,600, which was lower than the criterion level (US $50,000). On the basis of this result, the authors concluded that these two drugs are economically acceptable. Furthermore, when efficacy and cost effectiveness were analyzed together, it was concluded that letrozole is in fact preferable to anastrozole. (3) The model analysis of tamoxifen's cost effectiveness among women at increased risk for breast cancer yielded the following results. In the base-case analysis, involving the calculation of the costs and benefits of 5-year tamoxifen administration, the incremental cost effectiveness of tamoxifen was $41,372 per life-year gained for women age 35 to 49 years, whereas for women age 50 to 59 years and 60 to 69 years, these values were $68,349 and $74,981, respectively. For women who had undergone hysterectomy and thus had no risk of the onset of endometrial cancer, the incremental cost effectiveness of tamoxifen was $46,060 per life-year gained.

CONCLUSION

Medico-economic evaluation of breast cancer is very significant and valuable and is expected to stimulate efficient utilization of healthcare resources. It can provide important information to physicians, patients, insurers, pharmaceutical and other industries, healthcare policy planners, and others.

Comparing results after surgery in patients with clinical unilateral T3a prostate cancer treated with or without neoadjuvant androgen-deprivation therapy

OBJECTIVE

To compare the results in patients with unilateral cT3 prostate cancer treated with or with no neoadjuvant androgen-deprivation therapy (nADT), as nADT might have benefit in cT2 prostate cancer, but for cT3 tumours its use remains controversial, and it is unclear whether it can prevent or delay progression after surgery.

PATIENTS AND METHODS

Between 1987 and 2004, 235 patients were assessed as having unilateral cT3 disease by a digital rectal examination; before surgery, 200 patients were not treated with nADT and 35 were. The Kaplan-Meier method was used to calculate survival rates.

RESULTS

With no nADT the biochemical progression-free survival (PFS) was 59.5%, the clinical PFS was 95.9%, the cancer-specific survival (CSS) was 98.7%, and overall survival was 95.9% at 5 years. With nADT, the biochemical PFS was 43.4%, clinical PFS was 77.6%, CSS was 88.7%, and overall survival was 79.8% at 5 years. The positive surgical margin rate with no nADT and with nADT was 33.5% and 57.1%, respectively, and the respective mean cancer volume was 6.6 mL and 4.0 mL.

CONCLUSION

nADT can decrease tumour size but does not reduce the positive surgical margin rate, nor improve the survival rate in unilateral cT3a disease. Because of side-effects and treatment costs, we do not advise nADT in patients with unilateral cT3a prostate cancer.

Pharmacoeconomic analysis of adjuvant therapy with exemestane, anastrozole, letrozole or tamoxifen in postmenopausal women with operable and estrogen receptor-positive breast cancer

OBJECTIVE

To compare the efficiency of adjuvant therapy with aromatase inhibitors or with tamoxifen in postmenopausal women with operable breast cancer and positive estrogen receptors.

MATERIAL AND METHODS

A cost-utility analysis was performed based on a Markov model, from the Spanish National Health Care System perspective, comparing the treatment with exemestane (EXE: 25 mg/day) or tamoxifen (TAM: 20 mg/day) after 2-3 years of monotherapy with TAM; anastrozole (ANA, 1 mg/day) or TAM (20 mg/day) without previous TAM therapy; and letrozole (LET: 2.5 mg/day) or placebo after 5 years of monotherapy with TAM. The follow-up of a hypothetical cohort of women starting treatment at 63 years of age was simulated during 10 and 20 years. The probabilities of transition between health states and quality adjusted life years (QALYs) were obtained from the literature, and the unit costs (euro corresponding to 2004) from a Spanish database.

RESULTS

After 10 and 20 years of follow-up, more QALYs per patient would be gained with the EXE scheme (0.230-0.286 and 0.566-0.708, respectively) than with ANA (0.114 and 0.285) and LET (0.176 and 0.474). The cost of gaining one QALY was lower with the EXE scheme (50,801-62,522 euro and 28,849- 35,371 euro, respectively) than with ANA (104,272 euro and 62,477 euro) and LET (91,210 euro and 49,460 euro). The result was stable for the cost per life-year gained (LYG) and in the sensitivity analysis.

CONCLUSIONS

The EXE scheme after TAM is more cost-effective than the ANA and LET schemes.

Cost-effectiveness of extended adjuvant letrozole therapy after 5 years of adjuvant tamoxifen therapy in postmenopausal women with early-stage breast cancer

OBJECTIVE

To estimate the cost-effectiveness of extended adjuvant letrozole in postmenopausal women with early breast cancer and estrogen or progesterone receptor-positive tumors who had completed 5 years of adjuvant tamoxifen.

STUDY DESIGN

Cost-effectiveness analysis using a Markov model.

METHODS

Using a Markov model, we estimated the incremental cost per quality-adjusted life-year (QALY) gained with extended adjuvant letrozole vs no extended adjuvant therapy. Probabilities of breast cancer recurrence or new contralateral tumor adverse effects and death were estimated using data from the MA.17 study and other secondary sources. Costs (in 2004 US dollars) and quality-of-life effects (utilities) of breast cancer events and adverse effects were derived from the literature.

RESULTS

In base-case analyses, extended adjuvant letrozole vs no extended adjuvant therapy results in an expected gain of 0.34 QALYs per patient (13.62 vs 13.28 QALYs), at an additional lifetime cost of 9699 dollars per patient (55,254 dollars vs 45,555 dollars). The incremental cost per QALY gained with letrozole is 28,728 dollars. Cost-effectiveness is sensitive to the assumed reduction in risk of breast cancer events with letrozole but is insensitive to the risks, costs, and quality-of-life effects of osteoporosis and hip fracture. Cost-effectiveness is less than 100,000 dollars per QALY for node-positive patients younger than 81 years and for node-negative patients younger than 73 years.

CONCLUSION

For postmenopausal women with early breast cancer who have completed 5 years of adjuvant tamoxifen, the cost-effectiveness of extended adjuvant letrozole is within the range of other generally accepted medical interventions in the United States.

Review of cost-effectiveness analyses in hormonal therapies in advanced breast cancer

Many new cancer treatments that slow progression and extend survival are emerging. These advances bring new hope to patients and physicians, but often increase health expenditures in an already cost-conscious environment. To help guide resource allocation decisions, cost-effectiveness models are constructed to compare the costs and outcomes of new treatments with current options, and to encourage the uptake of new technologies. This study focuses on the cost-effectiveness studies published since 1997 for hormonal treatment options in advanced breast cancer. This paper: i) examines the quality of studies in terms of reporting methods and transparency of the models; ii) compares the calculated cost-effectiveness ratios; and iii) makes recommendations for future cost-effectiveness models in advanced breast cancer.

Anastrozole is cost-effective vs tamoxifen as initial adjuvant therapy in early breast cancer: Canadian perspectives on the ATAC completed-treatment analysis

GOALS OF WORK

To conduct an economic analysis comparing tamoxifen and anastrozole (Arimidex) in the adjuvant treatment of hormone receptor-positive (HR+), post-menopausal early breast cancer patients.

MATERIALS AND METHODS

An economic model examined typical patients (64 years of age, HR+, 64% node negative) from the Arimidex, tamoxifen alone, or in combination (ATAC) trial over a lifetime horizon. Rates of events were derived from ATAC trial results. Post-trial event rates were drawn from the literature for tamoxifen; event rates for anastrozole were modified by the relative risks observed in the ATAC trial. Resource utilization was drawn from Statistics Canada's Population Health Model for breast cancer, supplemented by an expert panel. A public health care system perspective, 2004 Canadian prices and a 5% discount rate were employed.

RESULTS

Anastrozole-taking patients incurred additional hormonal treatment costs compared to tamoxifen-taking patients (incremental lifetime cost, 6,974 Canadian dollars per patient), partially offset by reduced downstream recurrences of breast cancer (1,143 Canadian dollars lifetime savings per patient) for a net incremental cost of 5,796 Canadian dollars per patient on anastrozole. The anastrozole-treated patients were projected to experience a 5.6% absolute risk reduction of first breast cancer recurrence and a 2.8% absolute risk reduction in breast cancer death. This corresponded to 30,000 Canadian dollars per life year gained and 28,000 Canadian dollars per quality-adjusted life year gained (95% confidence interval, 17,428 to 54,605 Canadian dollars). The results were affected by the duration and extent of anastrozole benefit under sensitivity analysis but remained cost-effective.

CONCLUSION

Compared to tamoxifen, anastrozole therapy is effective and cost-effective as initial adjuvant therapy in post-menopausal, HR+ early breast cancer patients.

Long-term hormone therapy and radiation is cost-effective for patients with locally advanced prostate carcinoma

BACKGROUND

In Radiation Therapy Oncology Group (RTOG) trial 92-02, after men received neoadjuvant hormone cytoreduction and radiotherapy for locally advanced prostate carcinoma, they were randomized to receive either 2 years of long-term androgen-deprivation (LTAD) or no further treatment (short-term androgen-deprivation [STAD]). The specific objective of the current study was to determine whether LTAD was a cost-effective treatment for patients with locally advanced prostate carcinoma.

METHODS

The cost-effectiveness of LTAD was tested using a Markov model that was designed using proprietary software. The analysis took a payor's perspective. Unit costs were obtained by estimation using a global Medicare fee schedule. Costs and outcomes were discounted by 3%. Distributions were sampled at random from the treatment utilities, transition probabilities, and costs using a second-order Monte Carlo simulation technique.

RESULTS

The expected mean cost was 32,564 dollars for LTAD compared with 33,039 dollars for STAD after accounting for the additional cost of salvage treatment for men who were treated with STAD. The mean number of quality-adjusted life years (QALYs) for men who received LTAD was 4.13 QALYs compared with a mean of 3.68 QALYs for men who received STAD. The cost-effectiveness acceptability curve analysis showed a 91% probability that LTAD was cost-effective compared with STAD. Although overall survival was similar in the LTAD and STAD groups, the patients who received LTAD experienced gains in QALYs and had lower costs, because LTAD prevented biochemical failure and the necessitating salvage hormone therapy.

CONCLUSIONS

The current analysis showed that LTAD was cost-effective for the entire population studied in RTOG trial 92-02.

Economic analysis of a phase III clinical trial evaluating the addition of total androgen suppression to radiation versus radiation alone for locally advanced prostate cancer (Radiation Therapy Oncology Group protocol 86-10)

PURPOSE

To evaluate the cost-effectiveness of adding hormone therapy to radiation for patients with locally advanced prostate cancer, using a Monte Carlo simulation of a Markov Model.

METHODS AND MATERIALS

Radiation Therapy Oncology Group (RTOG) protocol 86-10 randomized patients to receive radiation therapy (RT) alone or RT plus total androgen suppression (RTHormones) 2 months before and during RT for the treatment of locally advanced prostate cancer. A Markov model was designed with Data Pro (TreeAge Software, Williamstown, MA). The analysis took a payer's perspective. Transition probabilities from one state of health (i.e., with no disease progression or with hormone-responsive metastatic disease) to another were calculated from published rates pertaining to RTOG 86-10. Patients remained in one state of health for 1 year. Utility values for each health state and treatment were obtained from the literature. Distributions were sampled at random from the treatment utilities according to a second-order Monte Carlo simulation technique.

RESULTS

The mean expected cost for the RT-only treatments was 29,240 dollars (range, 29,138-29,403 dollars). The mean effectiveness for the RT-only treatment was 5.48 quality-adjusted life years (QALYs) (range, 5.47-5.50). The mean expected cost for RTHormones was 31,286 dollars (range, 31,058-31,555 dollars). The mean effectiveness was 6.43 QALYs (range, 6.42-6.44). Incremental cost-effectiveness analysis showed RTHormones to be within the range of cost-effectiveness at 2,153 dollars/QALY. Cost-effectiveness acceptability curve analysis resulted in a >80% probability that RTHormones is cost-effective.

CONCLUSIONS

Our analysis shows that adding hormonal treatment to RT improves health outcomes at a cost that is within the acceptable cost-effectiveness range.