Cost-effectiveness analyses and cost analyses in castration-resistant prostate cancer: A systematic review

Background

Treatment of metastatic prostate cancer is associated with high personal and economic burden. Recently, new treatment options for castration-resistant prostate cancer became available with promising survival advantages. However, cost-effectiveness of those new treatment options is sometimes ambiguous or given only under certain circumstances. The aim of this study was to systematically review studies on the cost-effectiveness of treatments and costs of castration-resistant prostate cancer (CRPC) and metastasizing castration-resistant prostate cancer (mCRPC) on their methodological quality and the risk of bias.

Methods

A systematic literature search was performed in the databases PubMed, CINAHL Complete, the Cochrane Library and Web of Science Core Collection for costs-effectiveness analyses, model-based economic evaluations, cost-of-illness analyses and budget impact analyses. Reported costs were inflated to 2015 US$ purchasing power parities. Quality assessment and risk of bias assessment was performed using the Consolidated Health Economic Evaluation Reporting Standards checklist and the Bias in Economic Evaluations checklist, respectively.

Results

In total, 38 articles were identified by the systematic literature search. The methodological quality of the included studies varied widely, and there was considerable risk of bias. The cost-effectiveness treatments for CRPC and mCRPC was assessed with incremental cost-effectiveness ratios ranging from dominance for mitoxantrone to $562,328 per quality-adjusted life year gained for sipuleucel-T compared with prednisone alone. Annual costs for the treatment of castration-resistant prostate cancer ranged from $3,067 to $77,725.

Conclusion

The cost-effectiveness of treatments of CRPC strongly depended on the willingness to pay per quality-adjusted life year gained/life-year saved throughout all included costs-effectiveness analyses and model-based economic evaluations. High-quality cost-effectiveness analyses based on randomized controlled trials are needed in order to make informed decisions on the management of castration-resistant prostate cancer and the resulting financial impact on the healthcare system.

Sipuleucel-T for the Treatment of Metastatic Hormone-Relapsed Prostate Cancer: A NICE Single Technology Appraisal; An Evidence Review Group Perspective

The National Institute for Health and Care Excellence (NICE) invited Dendreon, the company manufacturing sipuleucel-T, to submit evidence for the clinical and cost effectiveness of sipuleucel-T for asymptomatic or minimally symptomatic, metastatic, non-visceral hormone-relapsed prostate cancer patients in whom chemotherapy is not yet clinically indicated, as part of NICE's single technology appraisal process. The comparator was abiraterone acetate (AA) or best supportive care (BSC). The School of Health and Related Research at the University of Sheffield was commissioned to act as the Evidence Review Group (ERG). This paper describes the company submission (CS), ERG review, and subsequent decision of the NICE Appraisal Committee (AC). The ERG produced a critical review of the clinical and cost-effectiveness evidence of sipuleucel-T based upon the CS. Clinical-effectiveness data relevant to the decision problem were taken from three randomised controlled trials (RCTs) of sipuleucel-T and a placebo (PBO) comparator of antigen-presenting cells (APC) being re-infused (APC-PBO) (D9901, D9902A and D9902B), and one RCT (COU-AA-302) of AA plus prednisone vs. PBO plus prednisone. Two trials reported a significant advantage for sipuleucel-T in median overall survival compared with APC-PBO: for trial D9901, an adjusted hazard ratio (HR) 0.47; (95 % confidence interval [CI] 0.29, 0.76) p < 0.002; for D9902B, adjusted HR 0.78 (95 % CI 0.61, 0.98) p = 0.03. There was no significant difference between groups in D9902A, unadjusted HR 0.79 (95 % CI 0.48, 1.28) p = 0.331. Sipuleucel-T and APC-PBO groups did not differ significantly in time to disease progression, in any of the three RCTs. Most adverse events developed within 1 day of the infusion, and resolved within 2 days. The CS included an indirect comparison of sipuleucel-T (D9902B) and AA plus prednisone (COU-AA-302). As trials differed in prior use of chemotherapy, an analysis of only chemotherapy-naïve patients was included, in which the overall survival for sipuleucel-T and AA was not significantly different, HR 0.94 (95 % CI 0.69, 1.28) p = 0.699. The ERG had several concerns regarding the data and assumptions incorporated within the company's cost-effectiveness analyses and conducted exploratory analyses to quantify the impact of making alternative assumptions or using alternative data inputs. The deterministic incremental cost-effectiveness ratio (ICER) for sipuleucel-T vs. BSC when using the ERG's preferred data and assumptions was £ 108,585 per quality-adjusted life-year (QALY) in the whole licensed population and £ 61,204/QALY in the subgroup with low prostate-specific antigen at baseline. The ERG also conducted an incremental analysis comparing sipuleucel-T with both AA and BSC in the chemotherapy-naïve subgroup. Sipuleucel-T had a deterministic ICER of £ 111,682/QALY in this subgroup, when using the ERG's preferred assumptions, and AA was extendedly dominated. The ERG also concluded that estimates of costs and benefits for AA should be interpreted with caution given the limitations of the indirect comparison. The AC noted that the ICER for sipuleucel-T was well above the range usually considered cost effective, and did not recommend sipuleucel-T for the treatment of asymptomatic or minimally symptomatic, metastatic, non-visceral hormone-relapsed prostate cancer.

Sipuleucel-T (Provenge(®))-Autopsy of an Innovative Paradigm Change in Cancer Treatment: Why a Single-Product Biotech Company Failed to Capitalize on its Breakthrough Invention

Approved by the US Food and Drug Administration (FDA) in 2010, sipuleucel-T (Provenge(®)) was the first 'personalized' cancer vaccine for the treatment of prostate cancer in a metastatic, non-symptomatic population of 30,000 men in the USA. Sipuleucel-T is prepared individually for each patient and infused in three sessions over a period of 1 month. However, in 2015, Dendreon, the owner of sipuleucel-T, filed for bankruptcy. This opinion paper reviews the probable reasons this innovative product failed to achieve commercial success. PubMed and internet searches were performed focused on pricing, reimbursement, and market access. We found that sipuleucel-T's FDA approval was delayed by 3 years, reportedly because of the vaccine's new mechanism of action. Sipuleucel-T was cleared by the European Medicines Agency 2 years later, but other national agencies were not approached. It was priced at $US93,000 for a course of treatment, and this high price combined with the company's late securement of reimbursement for the vaccine by the US Centers for Medicare and Medicaid Services (CMS) resulted in another year's delay in accessing the market. Despite a positive recommendation by the National Comprehensive Cancer Network, sipuleucel-T's complex administration, high price, and uncertainty about the reimbursement status deterred doctors from prescribing the product. Furthermore, the vaccine's supply was limited during the first year of launch due to limited manufacturing capacity. In addition, two oral metastatic prostate cancer drugs with similar survival benefits reached the US market 1 and 2 years after sipuleucel-T. Also, even though Dendreon's market capitalization topped $US7.5 billion following the FDA's approval of sipuleucel-T, this value degraded gradually until the firm's bankruptcy 5 years later. We conclude that the bankruptcy of Dendreon was largely due to the delay in securing FDA approval and CMS coverage, as well as the high cost that had to be incurred by providers up-front. Licensing sipuleucel-T to a pharmaceutical company more experienced in the market access pathway may have saved the company and the product.

Recent advances in the therapy of castration-resistant prostate cancer: the price of progress

Within the past two years, three agents have garnered approval from the US FDA for the specific treatment of metastatic castration resistant prostate cancer (mCRPC) - (1) abiraterone, (2) cabazitaxel and (3) sipuleucel-T. In separate phase III studies, each agent led to an improvement in overall survival (OS) of 2-4 months over a suitable comparator. With these costly therapies all having potential application in the patient with mCRPC, multiple entities (industry, government, and the general public) must strategize to determine how the cost burden of these agents can be balanced with the potential gains for the individual patient. Herein, we provide a framework with which to approach this dilemma.

Catrix: an easy-to-use collagen treatment for wound healing

Collagen plays a major role in wound healing. Its presence is important in all stages of the healing process. Catrix is a new collagen wound-healing powder that has been shown to be effective in the treatment of wounds healing by secondary intent such as pressure ulcers, venous stasis ulcers and diabetic ulcers as well as second-degree burns and post-radiation dermatitis. Catrix has also been shown to be effective in the treatment of wounds unresponsive to conventional treatments. It promotes the growth of fibroblasts and keratinocytes in the wound, prevents loss of fluid from the wound and protects the wound from bacterial infections and other agents. Catrix is biodegradable and therefore does not require removal from the wound bed before re-application.

[Collagen powder dressing in the treatment of pressure ulcer. Multicenter comparative study assessing effectiveness and cost]

INTRODUCTION

Pressure ulcers are lesions that usually occur to people to whom the social and economical repercusions are quite serious. Although present treatments with moisture cure dressings are efficient and have a lot of advantages than traditional cure, they do not solve the problem in a significant group of patients, whose ulcers do not heal or need a much longer treatment. Collagen dressings represent an important improvement, since collagen is a key element for wound scarring.

PATIENTS, MATERIAL AND METHODS

We conducted a prospective, comparative and multicentrical study with Catrix, using as a control the same lesion. We compared pressure ulcers that had been previously treated on an average of 6 months without success with Catrix treatment within 7 weeks. We compared different variables, efficacy, opinion on the use of Catrix and economic cost.

RESULTS

We included 104 pressure ulcers that fulfilled the inclusion requirements in the study. Three of them were excluded from the efficiency analysis because of a lack of data since they passed away 7 weeks later. We performed a statistical analysis on all the ulcers (GT) and we also analyzed the pressure ulcer subgroup (SG) included in this study because of a deterioration or a stagnation of the lesion despite previous treatments. Seven weeks after the beginning of the treatment with Catrix the healing or the stage change was observed in 73.3% of lesions of GT group and in 77.8% of lesions of SG group (p < 0.0001). The average material cost and nursing cost from all the lesions that scarred within 7 weeks (n = 39) with previous treatment was 17.234, 10 euros and 10.920 euros with Catrix. The average material cost per lesion used in the previous treatments was 441.9 euros and 280 euros with Catrix.

DISCUSSION

These results prove that the treatment with Catrix significantly reduces the treatment length and therefore leads to a reduction of the sanitary cost in this kind of patients. Adding Catrix to the pressure ulcers treatment helps to increase significantly the scarring and improvement percentage of those pressure ulcers that do not respond to other treatments. It helps to improve patient's quality of life, and to reduce the costs of the treatment.

[Neytumorin as biomodular onco-therapy--allegations without documentation]

NeyTumorin is a combination of peptides and proteins of 15 different organs from fetal and young pigs and cows. The list of indications ranges from cancer prevention to long-term treatment of malignancies. One vial of NeyTumorin-Sol costs DM 122.34. The therapy for a patient with a T1-2N0M0 cancer costs about DM 16,500 and an advanced stage up to over DM 100,000. The inventor of the Cytoplasmatic Therapy is K.E. Theurer. About 40 years ago, he founded the Vitorgan-Pharmaceutical Company which produces and distributes NeyTumorin. It is claimed that "physiological repair aids" from the cytoplasm of healthy animal organs induce a "hygiogenization" of the disturbed metabolism and NeyTumorin has immunogenic and immuno-modulatory effects which are important for the efficacy. The promotors classify NeyTumorin as a biological response modifier. The components of NeyTumorin are not defined. Preclinical investigations showing direct cytostatic and immunomodulatory effects are not sufficiently documented. Often extremely high concentrations of NeyTumorin were used. Clinical studies including prospective randomized trials are not conclusive because of false or insufficient documentation. There is no proof for either the claimed mechanism of action nor for a clinical efficacy.