Economic value of toripalimab plus axitinib as first-line treatment for advanced renal cell carcinoma in China: a model-based cost-effectiveness analysis

OBJECTIVE

The current analysis aimed to evaluate the economic benefit of toripalimab plus axitinib for previously untreated RCC patients from the Chinese healthcare system perspective.

METHODS

The partitioned survival model was developed to simulate 3-week patients' transition in 20-year time horizon to evaluate the cost-effectiveness of toripalimab plus axitinib compared with sunitinib for advanced RCC. Survival data were gathered from the RENOTORCH trial, and cost and utility inputs were obtained from the database and published literature. Total cost, life-years (LYs), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were the model outputs. Subgroup analyses and sensitivity analyses were conducted to increase the comprehensiveness and estimate the robustness of the model results.

RESULTS

In the base-case analysis, compared with sunitinib, toripalimab plus axitinib could bring additional 1.19 LYs and 0.65 QALYs, with the marginal cost of $41,499.23, resulting in the ICER of $64,337.49/QALY, which is higher than the WTP threshold. And ICERs were always beyond the WTP threshold of all subgroups. Sensitivity analyses demonstrated the model results were robust.

CONCLUSIONS

Toripalimab plus axitinib was unlikely to be the cost-effective first-line therapy for patients with previously untreated advanced RCC compared with sunitinib from the Chinese healthcare system perspective.

A Cost-effectiveness Analysis Comparing Pembrolizumab-Axitinib, Nivolumab-Ipilimumab, and Sunitinib for Treatment of Advanced Renal Cell Carcinoma

OBJECTIVES

The US Food and Drug Administration (FDA) approved nivolumab-ipilimumab and pembrolizumab-axitinib as first-line treatments for metastatic, clear-cell, renal cell carcinoma (mRCC) based on results from CheckMate 214 and KEYNOTE-426. Our objective was to compare the adjusted, lifetime cost-effectiveness between nivolumab-ipilimumab, pembrolizumab-axitinib, and sunitinib for patients with mRCC.

MATERIALS AND METHODS

A 3-state Markov model was developed comparing nivolumab-ipilimumab and pembrolizumab-axitinib to each other and sunitinib, over a 20-year lifetime horizon from a US medical center perspective. The clinical outcomes of nivolumab-ipilimumab and pembrolizumab-axitinib were compared using matching-adjusted indirect comparison. Costs of drug treatment, adverse events, and utilities associated with different health states and adverse events were determined using national sources and published literature. Our outcome was incremental cost-effectiveness ratio (ICER) using quality-adjusted life years (QALY). One-way and probabilistic sensitivity analyses were conducted.

RESULTS

Nivolumab-ipilimumab was the most cost-effective option in the base case analysis with an ICER of $34,190/QALY compared with sunitinib, while the pembrolizumab-axitinib ICER was dominated by nivolumab-ipilimumab and was not cost-effective (ICER=$12,630,828/QALY) compared with sunitinib. The mean total costs per patient for the nivolumab-ipilimumab and pembrolizumab-axitinib arms were $284,683 and $457,769, respectively, compared with sunitinib at $241,656. QALY was longer for nivolumab-ipilimumab (3.23 QALY) than for adjusted pembrolizumab-axitinib (1.99 QALY), which was longer than sunitinib's (1.98 QALY). These results were most sensitive to treatment cost in both groups, but plausible changes did not alter the conclusions.

CONCLUSIONS

The base case scenario indicated that nivolumab-ipilimumab was the most cost-effective treatment option for mRCC compared with pembrolizumab-axitinib and sunitinib.

Evaluation of Insurance Coverage and Cancer Stage at Diagnosis Among Low-Income Adults With Renal Cell Carcinoma After Passage of the Patient Protection and Affordable Care Act

IMPORTANCE

The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown.

OBJECTIVE

To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not.

EXPOSURES

Implementation of the ACA.

MAIN OUTCOMES AND MEASURES

The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed.

RESULTS

The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, -1.14% [95% CI, -1.98% to -1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P < .001). Implementation of the ACA was also associated with an increase in detection of stage I and II disease (APC, 4.0% [95% CI, 1.6%-6.3%]; P = .001) among low-income patients in expansion states.

CONCLUSIONS AND RELEVANCE

Among patients with RCC, ACA implementation was associated with an increase in insurance coverage status in both expansion and nonexpansion states for all income groups, but to a greater degree in expansion states. The proportion of patients with localized disease increased among low-income patients in both states. These data suggest that ACA implementation is associated with earlier RCC detection among lower-income patients.

Cost-effectiveness of Pembrolizumab Plus Axitinib Vs Nivolumab Plus Ipilimumab as First-Line Treatment of Advanced Renal Cell Carcinoma in the US

IMPORTANCE

Checkpoint inhibitor combination therapy represents a major advance in the first-line treatment of advanced renal cell carcinoma. Pembrolizumab-axitinib and nivolumab-ipilimumab have become standard of care options after demonstrating clinical efficacy against sunitinib in separate phase 3 trials. The cost-effectiveness of these regimens is unknown.

OBJECTIVE

To evaluate the cost-effectiveness of pembrolizumab-axitinib and nivolumab- ipilimumab in the first-line treatment of advanced renal cell carcinoma.

DESIGN, SETTING, AND PARTICIPANTS

For this economic evaluation, a primary microsimulation model was developed and run between August and December 2019. Separate analyses were conducted for an intermediate- and poor-risk patient population (base case) and a favorable-risk population (exploratory analysis) because prognosis is known to differ between risk groups; 100 000 patients with advanced renal cell carcinoma were simulated in each treatment arm. Survival, treatment regimens, and other relevant conditions were based on data from the phase 3 KEYNOTE-426 and CheckMate214 clinical trials. The study perspective was the US health care sector.

MAIN OUTCOMES AND MEASURES

An incremental cost-effectiveness ratio was calculated for each of the 2 analyses and compared with a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY).

RESULTS

Pembrolizumab-axitinib was estimated to add 0.60 QALYs compared with nivolumab-ipilimumab in the base case analysis (3.66 vs 3.05 QALYs) and 0.25 QALYs compared with nivolumab-ipilimumab in the exploratory analysis (4.55 vs 4.30 QALYs), and was more costly (base case analysis: $562 927 vs $458 961; exploratory analysis: $589 035 vs $470 403). The incremental cost-effectiveness ratio was $172 532 per QALY in the base case analysis and $468 682 per QALY in the exploratory analysis. One-way sensitivity analyses revealed that the base case model was most sensitive to first-line drug prices (incremental cost-effectiveness ratio at upper limit of nivolumab price and lower limits of axitinib and pembrolizumab prices: $89 983, $102 287, and $114 943 per QALY, respectively). The exploratory analysis model was most sensitive to overall survival rates (incremental cost-effectiveness ratio at lower limit of pembrolizumab-axitinib rate and upper limit of nivolumab-ipilimumab rate: $278 644 and $285 684 per QALY, respectively).

CONCLUSIONS AND RELEVANCE

The findings suggest that pembrolizumab-axitinib treatment is associated with greater QALYs compared with nivolumab/ipilimumab treatment in patients with advanced renal cell carcinoma but may not be cost-effective. Price reductions may make the cost of pembrolizumab-axitinib proportional to its clinical value and less financially burdensome to the US health care system.

Evaluating Partitioned Survival and Markov Decision-Analytic Modeling Approaches for Use in Cost-Effectiveness Analysis: Estimating and Comparing Survival Outcomes

OBJECTIVE

The objective of this study was to assess long-term survival outcomes for nivolumab and everolimus in renal cell carcinoma predicted by three model structures, a partitioned survival model (PSM) and two variations of a semi-Markov model (SMM), for use in cost-effectiveness analyses.

METHODS

Three economic model structures were developed and populated using parametric curves fitted to patient-level data from the CheckMate 025 trial. Models consisted of three health states: progression-free, progressed disease, and death. The PSM estimated state occupancy using an area under-the-curve approach from overall survival (OS) and progression-free survival (PFS) curves. The SMMs derived transition probabilities to calculate patient flow between health states. One SMM assumed that post-progression survival (PPS) was independent of PFS duration (PPS Markov); the second SMM assumed differences in PPS based on PFS duration (PPS-PFS Markov).

RESULTS

All models provide a reasonable fit to the observed OS data at 2 years. For estimating cost effectiveness, however, a more relevant comparison is between estimates of OS over the modeling horizon, because this will likely impact differences in costs and quality-adjusted life-years. Estimates of the incremental mean survival benefit of nivolumab versus everolimus over 20 years were 6.6 months (PSM), 7.6 months (PPS Markov), and 7.4 months (PPS-PFS Markov), reflecting non-trivial differences of + 14% and + 11%, respectively, compared with PSM.

CONCLUSIONS

The evidence from this study and previous work highlights the importance of the assumptions underlying any model structure, and the need to validate assumptions regarding survival and the application of treatment effects against what is known about the characteristics of the disease.

Rising Economic Burden of Renal Cell Carcinoma among Elderly Patients in the USA: Part II-An Updated Analysis of SEER-Medicare Data

BACKGROUND

The influx of new oncologic technologies has changed the treatment landscape of renal cell carcincoma (RCC) in the last decade. This study updated a previously published paper on the economic burden of RCC in the USA by using more recent data to examine the impact of various forms of new oncologic technologies on the economic burden of RCC.

METHODS

Using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we employed prevalence and incidence costing approaches to estimate RCC costs from the payer's perspective. We conducted a longitudinal analysis of cost data per patient per month for a prevalence cohort of patients with RCC to determine which category of new technology (surgery, radiation, or cancer drugs) was the major cost driver for RCC. We then applied the incidence costing approach to estimate costs related to RCC by care phase (initial, continuing, and terminal) and compared costs between two incidence cohorts to examine how new technology affected the economic burden of RCC over time.

RESULTS

After controlling for demographic factors, clinical characteristics, neighborhood socioeconomic status, and time trend, we found that rising per patient per month costs were driven by new technologies in cancer drugs. Incidence-based analysis showed the annual net cost (2018 US$) for patients with distant-stage RCC diagnosed between 2002 and 2006 was $51,639, $19,025, $76,603, and $29,045 for the initial, continuing (year 1), terminal (died from RCC), and terminal (died from other causes) care phases, respectively. Costs increased to $70,703, $34,716, $107,989, and $47,538, respectively, for the incidence cohort diagnosed between 2007 and 2011.

CONCLUSION

The rising economic burden of RCC was most pronounced among patients with distant-stage RCC, and driven primarily by new cancer drugs.

Treatment sequences for advanced renal cell carcinoma: A health economic assessment

Objective

Advanced renal cell carcinoma (RCC) is commonly treated with vascular endothelial growth factor or mammalian target of rapamycin inhibitors. As new therapies emerge, interest grows in gaining a deeper understanding of treatment sequences. Recently, we developed a patient-level, discretely integrated condition event (DICE) simulation to estimate survival and lifetime costs for various cancer therapies, using a US payer perspective. Using this model, we explored the impact of treatments such as nivolumab and cabozantinib, and compared the clinical outcomes and cost consequences of commonly used treatment algorithms for patients with advanced RCC.

Methods

Included treatment sequences were pazopanib or sunitinib as first-line treatment, followed by nivolumab, cabozantinib, axitinib, pazopanib or everolimus. Efficacy inputs were derived from the CheckMate 025 trial and a network meta-analysis based on available literature. Safety and cost data were obtained from publicly available sources or literature.

Results

Based on our analysis, the average cost per life-year (LY) was lowest for sequences including nivolumab (sunitinib → nivolumab, $75,268/LY; pazopanib → nivolumab, $84,459/LY) versus axitinib, pazopanib, everolimus and cabozantinib as second-line treatments. Incremental costs per LY gained were $49,592, $73,927 and $30,534 for nivolumab versus axitinib, pazopanib and everolimus-containing sequences, respectively. The model suggests that nivolumab offers marginally higher life expectancy at a lower cost versus cabozantinib-including sequences.

Conclusion

Treatment sequences using nivolumab in the second-line setting are less costly compared with sequential use of targeted agents. In addition to efficacy and safety data, cost considerations may be taken into account when considering treatment algorithms for patients with advanced RCC.

Economic Burden of Renal Cell Carcinoma-Part I: An Updated Review

BACKGROUND

The economic burden of renal cell carcinoma (RCC) had been reported to be significant in a previous review published in 2011.

OBJECTIVE

The objective of this study was to perform an updated review by synthesizing economic studies related to the treatment of RCC that have been published since the previous review.

METHODS

We performed a literature search in PubMed, EMBASE, and the Cochrane Library, covering English-language studies published between June 2010 and August 2018. We categorized these articles by type of analyses [cost-effectiveness analysis (CEA), cost analysis, and cost of illness (COI)] and treatment setting (cancer status and treatment), discussed findings from these articles, and synthesized information from each article in summary tables.

RESULTS

We identified 52 studies from 2317 abstracts/titles deemed relevant from the initial search, including 21 CEA, 23 cost analysis, and 8 COI studies. For localized RCC, costs were found to be positively associated with the aggressiveness of the local treatment. For metastatic RCC (mRCC), pazopanib was reported to be cost effective in the first-line setting. We also found that the economic burden of RCC has increased over time.

CONCLUSION

RCC continues to impose a substantial economic burden to the healthcare system. Despite the large number of treatment alternatives now available for advanced RCC, the cost effectiveness and budgetary impact of many new agents remain unknown and warrant greater attention in future research.

Cost variation and savings opportunities in the Oncology Care Model

OBJECTIVES

This study seeks to identify service categories that present the greatest opportunities to reduce spending in oncology care episodes, as defined by the CMS Oncology Care Model (OCM). Regional variation in spending for similar patients is often interpreted as evidence that resources can be saved, because higher-spending regions could achieve savings by behaving more like their lower-spending counterparts.

STUDY DESIGN

We used Surveillance, Epidemiology, and End Results Medicare data from 2006-2013 for this retrospective observational cohort study. Analysis focused on patients with non-small cell lung cancer, advanced (stage III or IV) breast cancer, renal cell carcinoma, multiple myeloma, or chronic myeloid leukemia.

METHODS

Episodes were identified for patients with the 5 included cancers, following the episode definition used in the OCM. We estimated standardized episode-level spending for a standard patient across subcategories of care for each hospital referral region (HRR) defined by the Dartmouth Atlas. The contribution of each subcategory to interregional variation in total spending reflects that subcategory's potential to yield savings.

RESULTS

Chemotherapy and acute inpatient hospital care tended to be the highest contributors to interregional variation. Imaging, nonchemotherapy Part B drugs, physician evaluation and management services, and diagnostics were negligible contributors to interregional variation for all 5 cancers.

CONCLUSIONS

Chemotherapy and inpatient hospital care offer the most potential to reduce spending within OCM-defined episodes. Other sources of savings differ by type of cancer. Assuming patient outcomes are not compromised, low-spending HRRs may be models for lowering cost in cancer care.

The Costly War Against Cancer Treatment: The Example of Metastatic Renal Cell Carcinoma in Portugal

N/A.

The Additional Costs per Month of Progression-Free Survival and Overall Survival: An Economic Model Comparing Everolimus with Cabozantinib, Nivolumab, and Axitinib for Second-Line Treatment of Metastatic Renal Cell Carcinoma

BACKGROUND

When considering optimal second-line treatments for metastatic renal cell carcinoma (mRCC), clinicians and payers seek to understand the relative clinical benefits and costs of treatment.

OBJECTIVE

To use an economic model to compare the additional cost per month of overall survival (OS) and of progression-free survival (PFS) for cabozantinib, nivolumab, and axitinib with everolimus for the second-line treatment of mRCC from a third-party U.S. payer perspective.

METHODS

The model evaluated mean OS and PFS and costs associated with drug acquisition/administration; adverse event (AE) treatment; monitoring; and postprogression (third-line treatment, monitoring, and end-of-life costs) over 1- and 2-year horizons. Efficacy, safety, and treatment duration inputs were estimated from regimens' pivotal clinical trials; for everolimus, results were weighted across trials. Mean 1- and 2-year OS and mean 1-year PFS were estimated using regimens' reported OS and PFS Kaplan-Meier curves. Dosing and administration inputs were consistent with approved prescribing information and the clinical trials used to estimate efficacy and safety inputs. Cost inputs came from published literature and public data. Additional cost per additional month of OS or PFS was calculated using the ratio of the cost difference per treated patient and the corresponding difference in mean OS or PFS between everolimus and each comparator. One-way sensitivity analyses were conducted by varying efficacy and cost inputs.

RESULTS

Compared with everolimus, cabozantinib, nivolumab, and axitinib were associated with 1.6, 0.3, and 0.5 additional months of PFS, respectively, over 1 year. Cabozantinib and nivolumab were associated with additional months of OS compared with everolimus (1 year: 0.7 and 0.8 months; 2 years: 1.6 and 2.3 months; respectively); axitinib was associated with fewer months (1 year: -0.2 months; 2 years: -0.7 months). The additional costs of treatment with cabozantinib, nivolumab, or axitinib versus everolimus over 1 year were $34,141, $19,371, and $17,506 higher, respectively. Everolimus had similar OS and lower costs compared with axitinib. The additional cost per month of OS was $48,773 for cabozantinib and $24,214 for nivolumab versus everolimus. The additional treatment cost with cabozantinib, nivolumab, or axitinib versus everolimus for each additional month of PFS was estimated at $21,338, $64,570, and $35,012, respectively. Over 2 years, the additional costs per additional month of OS for nivolumab and axitinib versus everolimus were similar to the 1-year analysis; for cabozantinib, the cost was lower. Results were sensitive to changes in mean OS, mean PFS, therapy duration, and drug costs estimates.

CONCLUSIONS

Everolimus for second-line mRCC was associated with similar OS and lower costs compared with axitinib over 1- and 2-year horizons. The additional cost per additional month of OS and PFS associated with cabozantinib or nivolumab versus everolimus creates a metric for evaluating the cost of second-line therapies in relation to their respective treatment effects.

DISCLOSURES

Funding for this research was provided by Novartis, which was involved in all stages of study research and manuscript preparation. Ghate and Perez are employees of Novartis and own stock/stock options. Swallow, Messali, McDonald, and Duchesneau are employees of Analysis Group, which has received consultancy fees from Novartis. Study concept and design were contributed by Swallow, Messali, Ghate, and Perez, along with McDonald and Duchesneau. Swallow, Messali, McDonald, and Duchesneau collected the data, and all authors participated in data interpretation. The manuscript was written by Swallow, Messali, and Ghate, along with the other authors, and revised by Swallow, Messali, Ghate, and Perez. A synopsis of the current research was presented in poster format at the 15th International Kidney Cancer Symposium on November 4-5, 2016, in Miami, Florida.

Association of high cost sharing and targeted therapy initiation among elderly Medicare patients with metastatic renal cell carcinoma

High out-of-pocket costs may limit access to oral therapies covered by patients' prescription drug benefits. We explored financial barriers to treatment initiation in patients newly diagnosed with metastatic renal cell carcinoma (mRCC) by comparing Medicare Part D patients with low out-of-pocket costs due to receipt of full low-income subsidies (LIS beneficiaries) to their counterparts who were responsible for more than 25% cost sharing during Medicare's initial coverage phase (non-LIS beneficiaries). We used 2011-2013 100% Medicare claims for non-LIS and LIS beneficiaries newly diagnosed with metastases in the liver, lung, or bone to examine targeted therapy treatment initiation rates and time to initiation for (1) oral medications (sorafenib, sunitinib, everolimus, pazopanib, or axitinib) covered under Medicare's prescription drug benefit (Part D); (2) injected or infused medications (temsirolimus or bevacizumab) covered by Medicare's medical benefit (Part B); and (3) any (Part D or Part B) targeted therapy. The final sample included 1721 patients. On average, non-LIS patients were responsible for out-of-pocket costs of ≥$2,800 for their initial oral prescription, as compared to ≤$6.60 for LIS patients. Compared to LIS patients, a lower percentage of non-LIS patients initiated oral therapies (risk-adjusted rates, 20.7% vs. 33.9%; odds ratio [OR] = 0.49, 95% CI: 0.36-0.67, P < 0.001) and any targeted therapies (26.7% vs. 40.4%, OR = 0.52, 95% CI: 0.38-0.71, P < 0.001). Non-LIS patients were also slower to access therapy. High cost sharing was associated with reduced and/or delayed access to targeted therapies under Medicare Part D, suggesting that financial barriers play a role in treatment decisions.

Cost-effectiveness of pazopanib versus sunitinib for metastatic renal cell carcinoma in the United Kingdom

Background

Sunitinib and pazopanib are the only two targeted therapies for the first-line treatment of locally advanced or metastatic renal cell carcinoma (mRCC) recommended by the United Kingdom’s National Institute for Health and Care Excellence. Pazopanib demonstrated non-inferior efficacy and a differentiated safety profile versus sunitinib in the phase III COMPARZ trial. The current analysis provides a direct comparison of the cost-effectiveness of pazopanib versus sunitinib from the perspective of the United Kingdom’s National Health Service based on data from COMPARZ and other sources.

Methods

A partitioned-survival analysis model with three health states (alive with no progression, alive with progression, or dead) was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained for pazopanib versus sunitinib over five years (duration of follow-up for final survival analysis in COMPARZ). The proportion of patients in each health state over time was based on Kaplan–Meier distributions for progression-free and overall survival from COMPARZ. Utility values were based on EQ-5D data from the pivotal study of pazopanib versus placebo. Costs were based on medical resource utilisation data from COMPARZ and unit costs from secondary sources. Probabilistic and deterministic sensitivity analyses were conducted to assess uncertainty of model results.

Results

In the base case, pazopanib was estimated to provide more QALYs (0.0565, 95% credible interval [CrI]: −0.0920 to 0.2126) at a lower cost (−£1,061, 95% CrI: −£4,328 to £2,067) versus sunitinib. The probability that pazopanib yields more QALYs than sunitinib was estimated to be 76%. For a threshold value of £30,000 per QALY gained, the probability that pazopanib is cost-effective versus sunitinib was estimated to be 95%. Pazopanib was dominant in most scenarios examined in deterministic sensitivity analyses.

Conclusions

Pazopanib is likely to be a cost-effective treatment option compared with sunitinib as first-line treatment of mRCC in the United Kingdom.

Effect of median household income on surgical approach and survival in renal cell carcinoma

PURPOSE

We sought to determine whether median household income (MHI) independently predicts surgical approach (partial vs. radical nephrectomy) and survival in patients with renal cell carcinoma.

METHODS

The U.S. Surveillance Epidemiology and End Results Database (1988-2011) was queried to examine kidney cancer cases and linked to the Area Health Resources File. We correlated surgical approach and survival, both overall and cancer-specific, with tumor stage, age, race, sex, and income data.

RESULTS

Of 152,589 patients diagnosed with renal cell carcinoma, 24,221 (16%) patients underwent partial nephrectomy, 102,771 (67%) patients underwent radical nephrectomy, and 25,597 (17%) patients had no surgery. There was no significant difference in stage of presentation between the wealthiest and poorest MHI quartiles, with approximately 35% of patients in each quartile presenting with T1aN0M0 disease and 17% of patients presenting with metastatic disease. Despite this, 18% of patients in the wealthiest quartile underwent partial nephrectomy compared to 14% of patients in the poorest quartile. Although the percentage of patients undergoing partial nephrectomy rose over the timeframe studied in both the wealthiest and poorest quartiles, the rate of rise was highest in the wealthier group. Those in the poorest quartile were 0.10 times more likely to die of all causes (95% CI: 1.09-1.11, P<0.001) and 0.09 times more likely to die of kidney cancer (95% CI: 1.05-1.10, P<0.001) than those in the wealthiest quartile over the timeframe studied.

CONCLUSIONS

Despite presenting with similar stage, patients with lower MHI less commonly undergo partial nephrectomy and are more likely to die of kidney cancer than those in the highest MHIs.

Can a Joint Assessment Provide Relevant Information for National/Local Relative Effectiveness Assessments? An In-Depth Comparison of Pazopanib Assessments

BACKGROUND

In many European jurisdictions, relative effectiveness assessments (REAs) of pharmaceuticals are performed during the reimbursement decision-making process. International collaboration in the production of these assessments may prevent the duplication of information in various jurisdictions. A first pilot of a joint REA (pazopanib for the treatment of renal cell carcinoma) was published in 2011.

OBJECTIVE

The objective was to investigate how well the methods used in the joint REA match the methods used in the national/local assessments on the same topic.

METHODS

National/local assessments from European jurisdictions, available in English language, were identified through a literature search and an e-mail request to health technology assessment organizations. Data were abstracted from joint and national/local assessments using a structured data abstraction form. Results were compared for differences and similarities.

RESULTS

In total, five national/local reports were included (Belgium, England/Wales, France, The Netherlands, and Scotland). The general methods (indication, main comparator, main end points, main trial) were similar. The details of the assessment (e.g., exact wording of indication, additional comparators, additional trials included, and method of indirect comparison), however, varied. Despite these differences, the joint REA included nearly all comparators, end points, trials, and methods of analysis that were used in national/local REA reports.

CONCLUSIONS

This study has shown overlap in the methods national/local REA bodies in Europe have chosen for a pazopanib REA for renal cell carcinoma, except for the use and methods of indirect comparisons. Although some additional comparators and outcomes differed between national/local REAs, they can be captured in a comprehensive joint REA.

Cost-effectiveness of pazopanib versus sunitinib for renal cancer in the United States

BACKGROUND

Current first-line treatments for metastatic renal cell carcinoma (mRCC) include the multityrosine kinase inhibitors pazopanib and sunitinib. Both agents had similar progression-free survival (PFS) and overall survival (OS) in the COMPARZ trial (Comparing the Efficacy, Safety and Tolerability of Pazopanib versus Sunitinib); however, the adverse event profiles of the 2 agents are different. In the PISCES trial (Patient Preference Study of Pazopanib versus Sunitinib in Advanced or Metastatic Kidney Cancer), patients and physicians preferred pazopanib primarily because it offered better health-related quality of life (HRQoL) and caused less fatigue.

OBJECTIVE

To compare the cost-effectiveness of pazopanib versus sunitinib from a U.S. health care system perspective in the first-line treatment of patients with mRCC.

METHODS

A partitioned-survival analysis model with 3 health states (preprogression, postprogression, and dead), data from 2 randomized controlled trials of pazopanib versus sunitinib (COMPARZ and PISCES), and secondary sources were used to calculate the incremental cost per quality-adjusted life-year (QALY) gained for pazopanib versus sunitinib. A time horizon of 37.5 months was used in the base case, consistent with the duration of follow-up used in the COMPARZ trial. The proportion of patients in each health state over time was based on Kaplan-Meier survival distributions for PFS and OS from the COMPARZ trial. Utility values were obtained from the PISCES trial. Costs were based on medical resource utilization data from the COMPARZ trial and unit costs from secondary sources. Probabilistic sensitivity analyses and deterministic sensitivity analyses were conducted.

RESULTS

In the base case, pazopanib was estimated to provide more QALYs at a lower cost compared with sunitinib (pazopanib dominant). In probabilistic sensitivity analyses, pazopanib was projected to be dominant in 69% of the simulations. The probability that pazopanib was more cost-effective than sunitinib was ≥ 90% for threshold values of cost-effectiveness between the range of $10,000-$160,000 per QALY gained. In deterministic sensitivity analyses, pazopanib was dominant in all scenarios examined.

CONCLUSION

Results of this study suggest that pazopanib is cost-effective compared with sunitinib as the first-line treatment of patients with mRCC in the United States.

Health care costs among renal cancer patients using pazopanib and sunitinib

BACKGROUND

Pazopanib was noninferior to sunitinib in progression-free survival in a phase III, open-label, randomized clinical trial comparing the efficacy and safety of the 2 drugs for treatment of patients with advanced renal cell carcinoma (RCC). A secondary analysis of this trial conducted on patient-reported health care resource utilization (HCRU) endpoints revealed significantly fewer monthly telephone consultations and emergency department visits among patients treated with pazopanib over the first 6 months of treatment.

OBJECTIVES

To (a) compare total costs of HCRU and adverse events (AEs) in patients with advanced RCC receiving first-line pazopanib or sunitinib from the phase III clinical trial and (b) perform a post hoc economic analysis that applied direct medical care and pharmacy unit costs, obtained from the Truven Health MarketScan Databases, to HCRU and AE rates.

METHODS

Total HCRU costs included components for provider contacts, diagnostics, hospitalizations, procedures, and study/nonstudy drugs. Patients were stratified by the presence or absence of an AE in order to estimate costs attributable to AEs. Costs were adjusted to 2013 U.S. dollars. The highest 1% of cost outliers were equally excluded from each group. Univariate (t-test and Kaplan-Meier sample average [KMSA]) and multivariate (using treatment group and region as covariates) analyses were performed.

RESULTS

A total of 906 patients (pazopanib, n = 454; sunitinib, n = 452) reported HCRU; higher rates were observed for sunitinib. In unadjusted cost analyses, the mean total costs for pazopanib-treated patients were 8.0% lower than those treated with sunitinib ($80,464 vs. $86,886; P = 0.20). The difference in KMSA-estimated costs was significantly higher for sunitinib versus pazopanib ($156,128 vs. $143,585; P = 0.003). Adjusted cost differences between arms consistently suggested higher costs for sunitinib. Among patients who experienced greater than or equal to 1 AE, costs were $8,118 higher for pazopanib-treated patients and $14,343 for sunitinib-treated patients.

CONCLUSIONS

The findings suggest that health care costs were lower among patients with advanced RCC treated first-line with pazopanib versus sunitinib.

Economic burden of repeat renal surgery on solitary kidney--do the ends justify the means? A cost analysis

PURPOSE

Despite the high morbidity of repeat renal surgery in patients with multifocal recurrent renal carcinoma, in most patients adequate renal function is preserved to obviate the need for dialysis. To our knowledge the economic burden of repeat renal surgery has not been evaluated. We provide a cost analysis for patients requiring repeat renal surgery on a solitary kidney.

MATERIALS AND METHODS

We reviewed the charts of patients treated at the National Cancer Institute who required repeat renal surgery from 1989 to 2010. Functional, oncological and surgical outcomes were evaluated and the costs of repeat renal surgery were calculated. We then compared costs in a cohort of 33 patients who underwent repeat renal surgery on a solitary kidney and in a hypothetical patient cohort treated with uncomplicated nephrectomy, fistula placement and dialysis. All costs were calculated based on Medicare reimbursement rates derived from CPT codes. Cost analysis was performed.

RESULTS

Despite a high 45% complication rate, 87% of patients maintained renal function that was adequate to avoid dialysis and 96% remained metastasis free at an average followup of 3.12 years (range 0.3 to 16.4). Compared to the hypothetical dialysis cohort, the financial benefit of repeat renal surgery was reached at 0.68 years.

CONCLUSIONS

Repeat renal surgery is a viable alternative for patients with multifocal renal cell carcinoma requiring multiple surgical interventions, especially when left with a solitary kidney. Despite the high complication rate, renal function is preserved in most patients and they have an excellent oncological outcome. The financial benefit of repeat renal surgery is reached at less than 1 year.

Pharmacoeconomics of bisphosphonates for skeletal-related event prevention in metastatic non-breast solid tumours

Bisphosphonates reduce the risk of skeletal-related events (SREs; i.e. spinal cord compression, pathological fracture, radiation or surgery to the bone, and hypercalcaemia) in patients with metastatic cancer. A number of analyses have been conducted to assess the cost effectiveness of bisphosphonates in patients with bone metastases secondary to breast cancer, but few in other solid tumours. This is a review of cost-effectiveness analyses in patients with non-breast solid tumours and bone metastases. A literature search was conducted to identify cost-effectiveness analyses reporting the cost per QALY gained of bisphosphonates in patients with metastatic bone disease secondary to non-breast solid tumours. Four analyses met inclusion criteria. These included two in prostate cancer (one of which used a global perspective but expressed results in $US, and the other reported from a multiple country perspective: France, Germany, Portugal and the Netherlands). The remaining analyses were in lung cancer (in the UK, France, Germany, Portugal and the Netherlands), and renal cell carcinoma (in the UK, France and Germany). In each analysis, the cost effectiveness of zoledronic acid versus placebo was analysed. Zoledronic acid was found to be cost effective in all European countries across all three indications but not in the sole global prostate cancer analysis. Across countries and indications, assumptions regarding patient survival, drug cost and baseline utility (i.e. patient utility with metastatic disease but without an SRE) were the most robust drivers of modelled estimates. Assumptions of SRE-related costs were most often the second strongest cost driver. Further review indicated that particular attention should be paid to the inclusion or exclusion of nonsignificant survival benefits, whether health state utilities were elicited from community or patient samples or author assumptions, delineation between symptomatic and asymptomatic SREs, and the methods with which SRE disutility was modelled over time. While the field of cost-effectiveness analysis in solid tumours other than breast cancer is still evolving, outcomes will likely continue to be driven by drug cost and assumptions regarding treatment benefits. Although considerations such as adverse events and administration costs are important, they were not found to influence cost-effectiveness estimates greatly. As zoledronic acid will lose patent protection in 2013 and subsequently be greatly reduced in price, it is likely that the field of cost effectiveness will change with regard to SRE-limiting agents. Meanwhile, research should be conducted to improve our understanding of the impact on quality of life and medical costs of preventing SREs.

Tyrosine kinase inhibitors for metastatic renal cell carcinoma

Renal cell carcinoma accounts for 2-3% of all adult malignancies worldwide, and around 30% of patients with the condition present with advanced or metastatic disease.1,2 Until recently, cytokine therapy (e.g. interleukin-2 or interferon-alfa) was the standard treatment for metastatic renal cell carcinoma but provided only a small survival advantage (e.g. extending life by a median of 2.5 months).3 A key development has been the introduction of drugs known as receptor tyrosine kinase inhibitors, which include ▾sunitinib (Sutent-Pfizer), ▾sorafenib (Nexavar-Bayer) and ▾pazopanib (Votrient-GlaxoSmithKline). Here we review the evidence on the efficacy, tolerability and cost-effectiveness of these treatments in renal cell carcinoma.

Determinants of medicare all-cause costs among elderly patients with renal cell carcinoma

BACKGROUND

Renal cell carcinoma (RCC) is the third most common genitourinary cancer and the most common primary renal neoplasm. Estimates of the economic burden of RCC in the United States range from approximately $400 million (in year 2000 dollars) to $4.4 billion (in year 2005 dollars). Actual costs associated with RCC, particularly for elderly Medicare patients who account for 46% of U.S. patients hospitalized for RCC, are poorly understood.

OBJECTIVE

To estimate all-cause health care costs associated with RCC using the combined Surveillance Epidemiology and End Results (SEER)-Medicare database.

METHODS

The sample was limited to non-HMO patients aged 65 years or older who were diagnosed with a first primary RCC (SEER site recode 59, kidney and renal pelvis) between 1995 and 2002. Our final sample included 4,938 patients with RCC and 9,876 non-HMO noncancer comparison group cases without chronic renal disease drawn from the SEER 5% Medicare sample and matched by a propensity score calculated from age, gender, race/ethnicity, and comorbidities. Costs were defined as payments made by Medicare for all-cause medical treatments including inpatient stays, emergency room visits, outpatient procedures, office visits, home health visits, durable medical equipment, and hospice care, but excluding out-patient prescription drugs. Using the method of Bang and Tsiatis (2000), we estimated cumulative costs at 1 and 5 years by estimating average costs for each patient in each month up to 60 months following diagnosis. Total costs were weighted sums of monthly costs, where weights were the inverse probability that the patient was not censored, and inverse probabilities were estimated by Kaplan-Meier estimates of time to censoring. Using the method of Lin (2000), we performed multivariate analyses of costs by fitting each of the 60 monthly costs to linear models that controlled for demographic characteristics and comorbidities. Marginal effects of covariates on 1- and 5-year costs were obtained by summing the coefficients for months 1 through 12 and months 1 through 60, respectively. Confidence intervals were obtained by bootstrapping.

RESULTS

Patients with RCC and matched comparison group cases had similar demographic characteristics, comorbidities, and chronic conditions. At the start of the fifth year post-diagnosis, there were 1,208 Medicare RCC cases of the original 4,938 (20.8%). Mean costs per patient per month (PPPM) in the first year were $3,673 for patients with RCC and $793 for comparison group patients. PPPM costs were higher for RCC patients with more advanced stage (i.e., regional or distant) disease. Average cumulative total costs for RCC patients were $33,605 per patient in the first year following diagnosis and $59,397 per patient in the first 5 years following diagnosis. Several patient-specific factors were associated with 1- and 5-year costs in multivariate analyses, including age, race/ethnicity, and comorbidities. Among RCC patients, treatment with surgery and radiation was associated with higher costs per patient than treatment with surgery alone at 1 year ($24,556, 95% CI = $16,673-$32,940) and 5 years ($30,540, 95% CI = $17,853-$43,648). RCC patients who received chemotherapy as part of their treatment regimen also had significantly higher costs per patient than those who received surgery alone at 1 year ($15,144, 95% CI = $ 9,979-$20,344) and 5 years ($13,440, 95% CI = $1,257-$27,572).

CONCLUSIONS

Newly diagnosed RCC is associated with a significant economic burden, which is largely determined by several patient characteristics, disease stage, and treatment choice.

Economic burden of renal cell carcinoma in the US: Part II--an updated analysis

INTRODUCTION

The economic burden of renal cell carcinoma (RCC) came into sharp focus when the UK's National Institute for Health and Clinical Excellence denied coverage (later reversed) of sunitinib for metastatic RCC. Following an updated review of RCC-related economic studies, we supplemented the costs of RCC reported in the literature with estimates from the latest US databases that capture the utilization of several newly approved targeted agents.

METHOD

We conducted analyses using the 1991-2007 SEER (Surveillance, Epidemiology and End Results)-Medicare and 1996-2007 MarketScan Commercial Claims and Encounter (CCAE) and Medicare Supplemental databases, and based our estimates on a prevalent cohort of patients with RCC or kidney cancer constructed from each database. All cost estimates were normalized to $US, year 2009 values. The incremental costing approach was applied to estimate the annual cost of RCC by treatment phases using a prevalent cohort of patients with RCC identified from the 2005 SEER-Medicare database. We used the method of extended estimation equations to estimate the impact of patients' use of targeted therapies on the annual costs of RCC, while controlling for confounding factors such as patients' age, sex, tumour characteristics, co-morbidity and geographic regions. The method was applied to two elderly cohorts of RCC patients identified from the SEER-Medicare and the MarketScan Medicare Supplemental databases and a non-elderly cohort of patients with RCC identified from the MarketScan CCAE database.

RESULTS

Compared with the cost of treating an elderly, non-cancer patient in the matched sample, the average cost of treating an elderly patient with RCC was $US11,169 (95% CI 10,683, 11,655) more per year, based on our analyses of the latest SEER-Medicare data. The annual cost to treat patients with RCC who received targeted therapies was 3- to 4-fold greater than the cost to treat patients with RCC who received other therapies. Results from the multivariate analysis showed that, after controlling for potential confounders, the annual medical cost was $US31,000-65,000 higher for RCC patients treated with targeted therapies, with the largest increase observed among the non-elderly patients.

CONCLUSION

The economic burden of RCC is likely to grow with an increasing use of targeted therapies. Future research is needed to understand the impact of various forces on the economic burden of RCC, such as increased disease incidence, use of minimally invasive surgical techniques and more prevalent adoption of emerging targeted therapies.

Economic burden of renal cell carcinoma: Part I--an updated review

The economic burden of renal cell carcinoma (RCC) came into sharp focus when the UK National Institute for Health and Clinical Excellence (NICE) denied coverage (later reversed) of sunitinib for metastatic RCC. In the first of two articles that provide updated reviews and analyses of the economic burden of RCC, we conducted an updated literature review of RCC-related economic studies. We performed a literature search of PubMed, EMBASE and the Cochrane Library for English-language studies published from 1 January 2000 to 15 June 2010. We also performed a separate search for related studies in the Health Technology Assessment (HTA) reports published by the National Institute for Health Research HTA Programme in the UK. Identified articles were classified into three categories: cost studies, cost-effectiveness/cost-utility studies and cost-of-illness studies. All cost estimates were normalized to $US, year 2009 values. We identified 20 articles, including six cost, six cost-utility and eight cost-of-illness studies. In general, the studies found new surgical techniques, such as laparoscopic partial nephrectomy, to be potentially cost saving (in the range of $US181-5842). Targeted agents, such as bevacizumab, sunitinib, sorafenib and temsirolimus, were associated with higher lifetime costs ($US8537-72 254) and were not always considered to be cost effective by authors of the cost-effectiveness studies included in this review (incremental cost-effectiveness ratio [ICER]: $US49 959-272 418 per QALY). The literature reported annual estimates of the US economic burden of RCC between $US0.60 billion and $US5.19 billion, with per-patient costs of $US16 488-43 805. RCC is associated with substantial economic burden, although the estimates are wide ranging. Comparisons of the estimates across studies were hindered by variations in study methodology, choice of database and the associated timeframe, and limitations inherent to each database. More research is needed to assess the quality of the economic studies of RCC and to understand why the estimated costs differ across studies.

Inverse probability weighting to control for censoring in a post hoc analysis of quality-adjusted survival data from a clinical trial of temsirolimus for renal cell carcinoma

OBJECTIVE

This post hoc analysis evaluated treatment-associated quality-adjusted survival (QAS) in patients randomly assigned to temsirolimus or interferon alfa (IFN-alfa), corrected for censoring using inverse probability weighting (IPW), in the Advanced Renal Cell Carcinoma (ARCC) trial.

METHODS

Follow-up was divided into 11 time intervals; Kaplan-Meier estimates for not being censored were estimated for each interval. The QAS for each interval was weighted by the inverse probability of not being censored in that interval. Overall treatment-associated QAS was calculated as the sum of the weighted QAS across all follow-up intervals. Differences in mean QAS between temsirolimus and IFN-alfa were evaluated with t-statistics at a two-sided α = 0.05.

RESULTS

In total, 416 patients were randomly assigned to temsirolimus (n = 209) or IFN-alfa (n = 207); 400 patients were included in this analysis. Overall weighted mean (standard deviation) QAS during progression-free survival was 111.9 (5.3) days with temsirolimus (n = 204) and 75.7 (6.3) days with IFN-alfa (n = 196). The mean weighted QAS difference of 36.2 days in favor of temsirolimus was significant (p < 0.05).

LIMITATIONS

One potential limitation is that the weights developed by the Kaplan-Meier estimates did not allow for covariates to be adjusted among treatment arms. Another possible limitation is that the ARCC trial included patients with advanced renal cell carcinoma, and thus it cannot be conclusively determined how our findings would apply to patients with less advanced disease.

CONCLUSIONS

Patients with poor-prognosis advanced renal cell carcinoma treated with temsirolimus had an incremental gain of 48% (36.2 days) in QAS compared with patients treated with IFN-alfa.

How do cost-effectiveness analyses inform reimbursement decisions for oncology medicines in Canada? The example of sunitinib for first-line treatment of metastatic renal cell carcinoma

BACKGROUND

Canadian oncology decision-makers have reimbursed cancer drugs at incremental cost-effectiveness ratios (ICER) higher than those considered acceptable in other therapeutic areas. Sunitinib is a multitargeted receptor tyrosine kinase inhibitor, indicated for metastatic renal-cell carcinoma (MRCC) of clear cell histology. Canadian decision-makers evaluated sunitinib funding in the presence of important data limitations (including interim analysis of a surrogate outcome) and in the context of a high ICER.

METHODS

First, a description was presented of the cost-effectiveness analysis submitted for sunitinib reimbursement decision-making in Canada before conclusive survival evidence had been available. Second, sunitinib access decisions and the oncology drug reimbursement literature were reviewed to explore the interpretation of sunitinib perceived value in the context of the decision-making framework in Canada.

RESULTS

The economic evaluation yielded an ICER of $144K/quality-adjusted life-year gained for sunitinib compared with interferon-alfa. This high ratio was not an insurmountable barrier to access in Canada because all provinces now reimburse sunitinib for first-line treatment of MRCC. In this particular instance, payers were receptive to immature survival data but substantial progression-free gains, for patients with a relatively rare cancer and few treatment options.

CONCLUSION

  This demonstrates that the cost-effectiveness ratio is only one of many factors that affect an access decision in oncology.

Current and predicted cost of metastatic renal cell carcinoma in Finland

Information on detailed treatment costs and the economic burden of renal cell carcinoma (RCC) is rare. The current study provides treatment costs and outcomes of patients with metastatic RCC (mRCC), as well as estimates of the future burden from the perspective of Finnish health care. These results offer a baseline against which the impact of emerging treatments may be evaluated.

MATERIALS AND METHODS

Information on treatment modalities, survival, and the cost of treatment was retrospectively gathered from mRCC patients (n = 83) receiving first-line interferon-alpha (IFN). Predictions of the number of new cases, premature deaths, and productivity losses were made using local epidemiological data, which were projected to the future using population growth forecasts. The future costs of mRCC treatment and the budget impact of sunitinib were estimated through modeling.

RESULTS

Patients survived 11.9 months (median; 95% CI 9.2-14.7) after initiation of active IFN treatment, accruing an average total treatment cost of 951 euros. Most of the treatment costs were due to hospitalization and active IFN treatment. The aging of the population leads to nearly a 2% increase in the absolute number of new diagnoses annually, while at the same time it results in declining productivity losses. The estimated five-year population cost of IFN-based treatment was 16M euros-26M euros. Adding sunitinib to the first-line treatment protocol increased this cost by 13M eruos-41M euros.

CONCLUSIONS

Despite the limited number of patients, metastatic renal cell carcinoma places a considerable economic burden on Finnish society. Treatment costs are likely to increase substantially due to the adoption of new and more expensive medications, the aging population, and enhanced survival times.

[Economic evaluation of targeted biologic therapy in metastatic renal cell carcinoma]

BACKGROUND

Targeted biologic therapy has been proven to be effective compared to the current therapy of metastatic renal cell carcinoma (mRCC) in clinical studies as well as in actual clinical practice, but its high cost is a potentially limiting factor. Since the local cost-effectiveness analysis is missing, we assessed the cost of sunitinib and sorafenib in the treatment of mRCC in a comprehensive cancer centre.

PATIENTS AND METHODS

A total of 31 patients were treated with sunitinib and/or sorafenib between 06/2006 and 09/2009 and then followed for at least 12 months. Clinical (disease progression, adverse events, dose reduction) and cost data (medication, examination, hospitalization) were assessed in the comprehensive cancer centre (1 Euro = 25.78 CZK).

RESULTS

The multikinase inhibitors were the second line treatment for most patients after INF-alpha therapy failure (86.7%). The mean cost per month to progression (PD) was 94,141.8 CZK/3651.7 Euro (sunitinib: 11 months to PD, cost to PD 1,267,648.5 CZK/49,171.8 Euro; sorafenib: 8 months to PD, cost to PD 896,670.1 CZK / 34,781.6 Euro). The incremental cost-effectiveness ratio was 123,659.5 CZK / 4796.7 Euro per progression-free month in sunitinib vs sorafenib patients. The mean cost per month after PD was 45,767.0 CZK/1775.3 Euro with sequential therapy (sorafenib after sunitinib failure and vice-versa in more than half of patients) or best supportive care. 16 patients died during the study period with mean cost of 1,180,795.4CZK/45,802.8 Euro per 12 months (median between treatment initiation with sunitinib or sorafenib and death). 8 patients (26%) did not achieve progression (median progression-free survival to 09/2009: sunitinib 18 months, sorafenib 14 months).

CONCLUSION

The cost of medication made up more than 95% of total costs to PD and more than 90% after PD. The cost per progression-free month was 123,659.5 CZK/4796.7 Euro in mRCC patients treated with sunitinib vs sorafenib.

Cost-effectiveness of temsirolimus for first line treatment of advanced renal cell carcinoma

OBJECTIVES

To estimate the cost-effectiveness of temsirolimus compared to interferon-alpha for first line treatment of patients with advanced, poor prognosis renal cell carcinoma, from the perspective of the UK National Health Service.

METHODS

A decision-analytic model was developed to estimate the cost-effectiveness of temsirolimus. The clinical effectiveness of temsirolimus compared with interferon-alpha and the utility values (using EQ-5D tariffs) were taken from a recent phase III randomized clinical trial. Cost data were obtained from published literature and based on current UK practice. The effect of parameter uncertainty on cost-effectiveness was explored through extensive one-way and probabilistic sensitivity analyses.

RESULTS

Compared to interferon-alpha, temsirolimus treatment resulted in an incremental cost per QALY gained of pound94,632; based on an estimated mean gain of 0.24 quality-adjusted life years (QALYs) per patient, at a mean additional cost of pound22,331 (inflated to 2007/8). The cost per QALY for patient subgroups ranged from pound74,369 to pound154,752. The probability that temsirolimus is cost-effective compared to interferon-alpha at a willingness to pay threshold of pound30,000 per QALY for all patient groups is expected to be close to zero. The cost per QALY was sensitive to the clinical effectiveness parameters, health state utilities, drug costs and the cost of administration of temsirolimus.

CONCLUSIONS

Temsirolimus has been shown to be clinically effective compared to interferon-alpha offering additional health benefits, however, with a cost per QALY in excess of pound90,000, it may not be regarded as a cost-effective use of resources in some health care settings.

Cost-effectiveness of sorafenib for second-line treatment of advanced renal cell carcinoma

OBJECTIVES

To estimate the cost-effectiveness of sorafenib (Nexavar, Bayer, Leverkusen, Germany) versus best supportive care (BSC) for second-line treatment of advanced renal cell carcinoma from the perspective of the UK National Health Service.

METHODS

A decision analytic model was developed to estimate the cost-effectiveness of sorafenib. The clinical effectiveness of sorafenib versus BSC was taken from a recent randomized phase III trial. Utility values were taken from a phase II trial of sunitinib, using EQ-5D tariffs. Cost data were obtained from published literature and were based on current UK practice. The effect of parameter uncertainty on cost-effectiveness was explored through extensive one-way and probabilistic sensitivity analyses.

RESULTS

Compared to BSC, sorafenib treatment resulted in an incremental cost per quality-adjusted life year (QALY) gained of pound75,398, based on an estimated mean gain of 0.27 QALYs per patient, at a mean additional cost of pound20,063 (inflated to 2007/2008). The probability that sorafenib is cost-effective compared to BSC at a willingness to pay threshold of pound30,000 per QALY is 0.0%. In sensitivity analysis, estimates of cost per QALY were sensitive to changes in the clinical effectiveness parameters, and to health state utilities and drug costs.

CONCLUSIONS

Sorafenib has been shown to be clinically effective compared to BSC, offering additional health benefits; however, with a cost per QALY in excess of pound70,000, it may not be regarded as a cost-effective use of resources in some health-care settings.

Economic evaluation of sunitinib malate in second-line treatment of metastatic renal cell carcinoma in Finland

BACKGROUND

Cytokine therapy is currently used as first-line treatment of metastatic renal cell carcinoma (mRCC). Until recently, treatments with proven efficacy after the failure of first-line cytokine therapy were not available. In recent clinical trials, sunitinib has been associated with good response rates in patients with mRCC.

OBJECTIVE

The aim of this study was to analyze the cost-effectiveness of sunitinib as second-line therapy for cytokine-refractory mRCC compared with current routine clinical practice in Finland (ie, best supportive care [BSC], including palliative biochemotherapy).

METHODS

A probabilistic decision-analytic model was developed to estimate the cost-effectiveness of sunitinib. Data were gathered from clinical trials, literature sources, and expert opinions, as well as from a local sample (n = 39) from 2 university hospitals in Finland. Clinical experts treating patients with mRCC in Finland provided the information on care practices of prescribing sunitinib. The analysis was conducted from the perspective of the health care payer in Finland.

RESULTS

According to estimated incremental cost-effectiveness ratios (ICERs), 1 progression-free month gained cost euro4802 (2005 Euros); 1 life-year gained cost euro30,831; and 1 quality-adjusted life-year (QALY) gained cost euro43,698, compared with BSC, in the treatment of mRCC. The expected mean cost in BSC was euro5543. When parameter uncertainty was considered, the probability of sunitinib being the more cost-effective choice of treatment was ~70% at the willingness-to-pay level of euro45,000/QALY gained.

CONCLUSIONS

Based on the results of this cost-effectiveness analysis, sunitinib is potentially cost-effective as a second-line treatment of mRCC compared with the treatment currently practiced in Finnish hospitals. The ICER (euro/QALY gained) obtained in the present study was less than the value considered suitable for novel oncology treatments.

The burden of illness associated with renal cell carcinoma in the United States

BACKGROUND

There were over 36,000 new cases of kidney cancer reported in the United States in 2004, the most common type being renal cell carcinoma (RCC). Available treatments for localized RCC frequently lead to cure; however RCC patients with advanced disease have limited treatment options and low survival rates. Data on the economic burden of RCC are limited.

METHODS

A prevalence-based model was used to estimate the aggregate annual societal cost burden of RCC in the U.S., including costs of treatment and lost productivity. Key parameters in the model include: the annual number of patients treated for RCC by age group and cancer stage; utilization of cancer treatments; unit costs; work-days missed; and wage rates. Multiplying stratum-specific distributions of treatment by annual quantities of treatments and unit costs yields estimates of RCC-related health-care costs. Multiplying stratum-specific estimates of annual workdays missed by average wage rates yields estimates of RCC-related lost productivity.

RESULTS

The annual prevalence of RCC in the U.S. was estimated to be 109,500 cases. The associated annual burden (inflated to 2005 U.S.$) was approximately $4.4 billion ($40,176 per patient). Health-care costs and lost productivity accounted for 92.4% ($4.1 billion) and 7.6% ($334 million), respectively. Reflecting its higher prevalence, the total cost associated with localized RCC accounted for the greatest share (78.2%), followed by regional, distant, and unstaged RCC, at 18.3%, 2.8%, and 0.7%, respectively.

CONCLUSIONS

The economic burden of RCC in the U.S. is substantial. Interventions to reduce the prevalence of RCC have the potential to yield considerable economic benefits.

Laparoscopic partial nephrectomy: how far have we gone?

PURPOSE OF REVIEW

Several technical modifications of laparoscopic partial nephrectomy have resulted in a reduction of complications and warm ischemia time. The most recent results are reviewed with a focus on oncologic outcome and postoperative renal function.

RECENT FINDINGS

The indications for laparoscopic partial nephrectomy are the same as for open surgery. All tumors up to 4 cm should be included and selected tumors up to 7 cm may be considered as well. In experienced hands, the complication rate is considerably low. Oncologic outcome is comparable with open partial nephrectomy and 5-year survival data have been published recently. Long warm ischemia time may be of some concern. The published functional results are excellent. Cost should not be the main argument in favor of a method. Laparoscopic partial nephrectomy, however, combines advantages for the patient with lower cost as shown by two studies.

SUMMARY

Laparoscopic partial nephrectomy duplicates the principles of open surgery and has been standardized to a great extent. It is technically difficult and is being performed by a small number of centers only; however, the interest of the urologists and patient demand is growing quickly. At the present time, laparoscopic partial nephrectomy cannot be considered a standard of care, but excellent results have been reported when performed by experienced laparoscopists.

Single-center comparison of purely laparoscopic, hand-assisted laparoscopic, and open radical nephrectomy in patients at high anesthetic risk

BACKGROUND AND PURPOSE

The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications.

PATIENTS AND METHODS

All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnett's T for pairwise comparisons.

RESULTS

The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN ($6089 v $7678; P = 0.57) and open surgery ($6089 v $7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12).

CONCLUSIONS

Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.

A comparison of hospital-based charges following partial and radical nephrectomy

OBJECTIVE

Recent studies demonstrate similar survival rates in patients treated with either partial or radical nephrectomy for renal tumors less than 4 cm. We retrospectively compared the hospital based charges for these two procedures in a similar cohort of patients treated at Memorial Sloan-Kettering Cancer Center.

PATIENTS AND METHODS

A retrospective review of 103 consecutive cases of renal tumors less than 4 cm treated by either radical or partial nephrectomy from 1996 to 1999 was conducted. Overall hospital charges were calculated by analyzing 18 separate departmental charge categories including room and board, pharmacy, radiologic tests, operating room charges, and laboratory services.

RESULTS

A total of 66 partial and 37 radical nephrectomies were analyzed. No difference was found in the mean charge per procedure ($16,660, partial and $16,545, radical); (p > .05). The major cost drivers for partial and radical nephrectomy respectively were: 1) room and board, 42% and 44%; 2) operating room charges, 28% and 25%; 3) pathology, 6% and 6%; 4) recovery room, 6% and 7%; and 5) biochemistry, 5% and 5%. Significant increases in charges for partial nephrectomy were noted from the blood bank services and intraoperative surgical supplies. The median length of stay (5 days) was identical for partial and radical nephrectomy. No difference was found in the complication rate for these procedures (p > .05).

CONCLUSION

Hospital-based charges for radical and partial nephrectomy are similar at when performed at a tertiary care referral center.

Staging of 119 patients with renal cell carcinoma: the yield and cost-effectiveness of pelvic CT

OBJECTIVE

The goal of this study was to determine the yield and cost-effectiveness of pelvic CT in staging renal cell carcinoma.

MATERIALS AND METHODS

The records of 119 patients who underwent preoperative CT of the abdomen and pelvis during a 6-year interval and then underwent partial or radical nephrectomy for renal cell carcinoma were reviewed for CT findings and pathologic stage. Pelvic CT findings were divided into three categories: benign and likely insignificant, benign and likely significant, and probably malignant. The effect of CT findings on further testing and the scheduling of surgery was assessed. An estimate of the cost of pelvic CT scans and other radiologic tests was made using 1997 Medicare reimbursement rates.

RESULTS

Total estimated cost of the 119 CT examinations of the pelvis was $40,698 ($342 each). No findings of probable malignancy were identified. In 27 patients, CT showed benign findings; these results did not cause planned surgery to be delayed. Three of these 27 patients underwent further radiologic tests at an estimated total cost of $243.

CONCLUSION

CT of the pelvis has a negligible yield in the staging of renal cell carcinoma and should not be routinely performed. The findings on CT of the pelvis did not generate a significant number of other tests.

[Immunotherapy of metastatic renal cell carcinoma. Is clinical use justified in view of outcome, side effects and costs?]

The immunogenic potential of renal cell carcinoma and the resistance of its metastases against chemotherapy, radiation and hormonal treatment have led to the development of a great number and variety of different strategies, summarized under the term immunotherapy. Objective remissions can be expected in about 20-40% of patients. Another 30-40% show stable disease for a limited time, only occasionally for longer. Most results are from uncontrolled phase II studies. A cancer cure can usually not be expected, long-term remissions are rare (5%), and high remission rates are only observed in studies with strong patient selection. Some authors have reported a higher survival rate in patients treated with IL-2 or IFN. Survival of patients with objective remissions is significantly improved. A standard therapy cannot be defined. Even presuming an increased survival rate, the toxicity, which can lead to a dramatic reduction in quality of life, and the high costs have to be considered carefully. We think that in view of the lack of therapeutic alternatives, the improving efficacy, the potential survival benefit, the reduction of toxicity and the perspectives, immunotherapy is essential in the treatment of metastatic renal cell carcinoma. Its use should be confined to clinical studies.

Cost-effectiveness and reimbursement issues in renal cell carcinoma

The increasing focus on cost-effectiveness in all cancer care and the decision of many third-party payers to deny funding for investigational therapy is of particular concern in metastatic renal cell carcinoma. There is as yet no effective standard treatment for this disease; surgery, radiotherapy, and chemotherapy have all proved inadequate. The use of "investigational" therapy with biologic response modifiers, such as alpha interferon and interleukin-2, however, has shown promise. Investigational therapy, therefore, actually represents state-of-the-art treatment that offers the patient the best chance for increased survival, tumor regression, and improved quality of life. Under the current method of insurance reimbursement, however, investigational research is threatened despite the numerous reasons that such treatment is both cost-effective and therapeutically sound.