Stated Preferences in Non-Small-Cell Lung Cancer: A Discrete Choice Experiment

INTRODUCTION

The different alternatives for non-small-cell lung cancer (NSCLC) treatment can increase survival but cause important adverse events. Therefore, patients' preference can play a critical role in decision-making. Among stated preference methods, discrete choice experiment (DCE) is the most applied in health care to elicit preferences. This research aims to elicit patients' preference evaluating the trade-off between the risks (adverse events) and benefits (survival) of systemic treatments, from the perspective of Brazilian patients with locally advanced, metastatic or recurrent NSCLC.

METHODS

A DCE was performed following the steps of attributes selection; construction of tasks and respondents' preference elicitation. Patients chose between 2 hypothetical treatments described by the attributes tiredness, hair loss, skin rash, hospitalization, administration mode and survival. A paper-and-pencil survey method was used to elicit the answers from the participants. The statistical data analysis used a mixed logit model to predict the relative importance of the attributes.

RESULTS

Most of the 65 patients interviewed were men (53.8%), mean age of 65 (95% confidence interval [CI]: 63-67) years and lung cancer stage IV (67.7%). Except for hospitalization and administration mode, the attributes coefficients were statistically significant (p < 0.005) for patients' preferences. Patients would require a minimum survival gain of 11.72 (CI: 10.28-4.22) months and 19.72 (CI: 17.31-7.09) months to accept a treatment that causes severe tiredness and severe skin rash, respectively. The market share of the treatments was calculated according to the DCE aggregate-level estimation, considering the impact of each treatment's side effects. Paclitaxel plus carboplatin had an estimated market share of 31%, followed by gefitinib (27%), erlotinib (24%) and docetaxel (18%).

CONCLUSION

In general, less than a year of survival gain would not suffice for the appearance of severe skin rash or tiredness.

The Assessment for Disinvestment of Intramuscular Interferon Beta for Relapsing-Remitting Multiple Sclerosis in Brazil

In Brazil, inclusion and exclusion of health technologies within the Unified Health System (SUS) is the responsibility of the National Committee for Health Technology Incorporation (CONITEC). A recent Cochrane systematic review demonstrated that intramuscular interferon beta 1a (IFN-β-1a-IM) was inferior to the other beta interferons (IFN-βs) for multiple sclerosis (MS). As a result, CONITEC commissioned an analysis to review possible disinvestment within SUS. The objective of this paper is to describe the disinvestment process for IFN-β-1a-IM in Brazil. The first assessment comprised a literature review and mixed treatment comparison meta-analysis. The outcome of interest was the proportion of relapse-free patients in 2 years. This analysis confirmed the inferiority of IFN-β-1a-IM. Following this, CONITEC recommended disinvestment, with the decision sent for public consultation. More than 3000 contributions were made on CONITEC's webpage, most of them against the preliminary decision. As a result, CONITEC commissioned a study to assess the effectiveness of IFN-β-1a-IM among Brazilian patients in routine clinical care. The second assessment involved an 11-year follow-up of a non-concurrent cohort of 12,154 MS patients developed by deterministic-probabilistic linkage of SUS administrative databases. The real-world assessment further demonstrated that IFN-β-1a-IM users had a statistically higher risk of treatment failure, defined as treatment switching or relapse treatment or death, with the assessment showing that IFN-β-1a-IM was inferior to the other IFN-βs and to glatiramer acetate in both direct and indirect analysis. In the drug ranking with 40,000 simulations, IFN-β-1a-IM was the worst option, with a success rate of only 152/40,000. Following this, CONITEC decided to exclude the intramuscular presentation of IFN-β from the current MS treatment guidelines, giving patients who are currently on this treatment the option of continuing until treatment failure. In conclusion, we believe this is the first example of this new disinvestment process in action, providing an exemplar for other treatments in Brazil as well as other countries.