The impact of pamidronate on inpatient and outpatient services among metastatic breast cancer patients

Canadian health care institution resource utilization resulting from skeletal-related events

PURPOSE

We describe the types of major institution health care resources consumed as a result of skeletal-related events (SREs) [ie, pathological fracture, bone surgery, radiation to bone, spinal cord compression].

METHODS

A retrospective multicenter chart review of cancer patients with bone metastases who experienced SREs was conducted. Patients with multiple SREs occurring during the same hospitalization within 21 days of each other were grouped into SRE clusters.

RESULTS

We reviewed 156 patient charts from 4 Canadian institutions, accounting for 358 SREs and 259 SRE clusters. Of the total patients, 63% experienced 1 SRE; 19%, 2 SREs; 10%, 3 SREs; and 8%, ≥ 4 events. Health care resource utilization was captured for ≥ 90 days following each SRE: 54% of all SRE events resulted in an inpatient stay; 34% in an emergency visit; 85% of SREs required the use of diagnostic procedures (including radiography, magnetic resonance imaging, Computerized Axial Tomography scans, and radio scans); 57% required radiation treatment; 34% required a surgical procedure; 35% received outpatient treatment visits (ie, physiotherapy or occupational therapy). Bone surgery and spinal cord compression were more often associated with hospitalization than were other SRE types. Spinal cord compression was associated with the greatest number of inpatients stays (1.09 per SRE), longest duration of hospital stay (mean 26.18 days per SRE), and more outpatient visits, relative to other SRE types.

CONCLUSION

Results of our Canadian retrospective study clearly demonstrate that SREs occur in cancer patients and each SRE is associated with considerable institutional consumption of health care resources.

Cost-effectiveness of oral ibandronate compared with intravenous (i.v.) zoledronic acid or i.v. generic pamidronate in breast cancer patients with metastatic bone disease undergoing i.v. chemotherapy

BACKGROUND

Ibandronate is the first third-generation bisphosphonate to have both oral and intravenous (i.v.) efficacy. An incremental cost-effectiveness model compared oral ibandronate with i.v. zoledronic acid and i.v. generic pamidronate in female breast cancer patients with metastatic bone disease, undergoing i.v. chemotherapy.

METHODS

A global economic model was adapted to the UK National Health Service (NHS), with primary outcomes of direct healthcare costs and quality-adjusted life years (QALYs). Efficacy, measured as relative risk reduction of skeletal-related events (SREs), was obtained from clinical trials. Resource use data for i.v. bisphosphonates and the cost of managing SREs were obtained from published studies. Hospital management and SRE treatment costs were taken from unit cost databases. Monthly drug acquisition costs were obtained from the British National Formulary. Utility scores were applied to time with/without an SRE to adjust survival for quality of life. Model design and inputs were validated through expert UK clinician review.

RESULTS

Total cost, including drug acquisition, was pound 386 less per patient with oral ibandronate vs. i.v. zoledronic acid and pound 224 less vs. i.v. generic pamidronate. Oral ibandronate gained 0.019 and 0.02 QALYs vs. i.v. zoledronic acid and i.v. pamidronate, respectively, making it the economically dominant option. At a threshold of pound 30,000 per QALY, oral ibandronate was cost-effective vs. zoledronic acid in 85% of simulations and vs. pamidronate in 79%.

CONCLUSIONS

Oral ibandronate is a cost-effective treatment for metastatic bone disease from breast cancer due to reduced SREs, bone pain, and cost savings from avoidance of resource use commonly associated with bisphosphonate infusions.

Cost analysis of secondary prophylaxis with oral clodronate versus pamidronate in metastatic breast cancer patients

OBJECTIVE

We compared the direct medical costs of secondary prophylaxis with bisphosphonates (BPs) in bone metastases (BMs) of breast cancer (BCa) from a payer perspective.

PATIENTS AND METHODS

This study adopted an incidence-based chart review of consecutive BCa patients with BMs who received prophylactic treatment with orally administered (po) clodronate (CLODpo group), or intravenously administered (iv) pamidronate (PAM group) in 1997 at two large oncology centers in Toronto, Ontario. We evaluated the difference in costs of management of patients among the CLODpo and PAM groups using an intent-to-treat analysis from diagnosis of BMs to death, or last follow-up. The results are presented as observed mean and average lifetime (including terminal care) costs per patient.

RESULTS

The observed mean costs in the PAM and CLODpo groups were 49,472 dollars and 50,307 dollars (2002 Canadian dollars), respectively. The difference in costs between the CLODpo (n=34) and PAM (n=18) groups was not significant (P=0.64), and remained robust after sensitivity analyses. The corresponding average lifetime costs were 65,677 dollars in the CLODpo group and 61,254 dollars in the PAM group. Inpatient and terminal care were the major cost drivers, comprising 45% and 25% of overall costs. Of all hospitalizations, 46% were associated with complications from BMs.

CONCLUSIONS

Our analysis, which was based on a convenience sample, failed to reveal a statistically significant difference in the observed mean costs between groups of patients who initiated treatment with po clodronate versus iv pamidronate. The cost estimates from this study can be used for future corroborative economic analyses.

Clinical and economic issues in the treatment of advanced breast cancer with bisphosphonates

An ideal palliative therapy for bone metastases would successfully reduce skeletal complications in several thousands of breast cancer patients. Second- and third-generation bisphosphonates are effective in reducing the overall skeletal complication rate and the time to first skeletal complication. Nevertheless, not enough evidence supports their benefit on quality of life. Furthermore, bisphosphonates are expensive (up to 775 US dollars per month, 2002 value) and cost-effectiveness evaluations have been limited to pamidronate (pamidronic acid). In economic evaluations of pamidronate, resulting incremental dollar per quality-adjusted life year gained ranged from cost savings to 108,000 US dollars per quality-adjusted life year. The data were quite sensitive to quality-of-life estimates and country-specific cost values. Because of the wide range of the cost-effectiveness ratio, it is uncertain whether the universal prescription of bisphosphonates in this setting represents an efficient use of healthcare resources. Probably, country- and drug-specific policies might increase the efficiency of this treatment. Further outcomes research is required to assess these agents more fully.

American Society of Clinical Oncology 2003 update on the role of bisphosphonates and bone health issues in women with breast cancer

PURPOSE

To update the 2000 ASCO guidelines on the role of bisphosphonates in women with breast cancer and address the subject of bone health in these women.

RESULTS

For patients with plain radiographic evidence of bone destruction, intravenous pamidronate 90 mg delivered over 2 hours or zoledronic acid 4 mg over 15 minutes every 3 to 4 weeks is recommended. There is insufficient evidence supporting the efficacy of one bisphosphonate over the other. Starting bisphosphonates in women who demonstrate bone destruction through imaging but who have normal plain radiographs is considered reasonable treatment. Starting bisphosphonates in women with only an abnormal bone scan but without evidence of bone destruction is not recommended. The presence or absence of bone pain should not be a factor in initiating bisphosphonates. In patients with a serum creatinine less than 3.0 mg/dL (265 mumol/L), no change in dosage, infusion time, or interval is required. Infusion times less than 2 hours with pamidronate or less than 15 minutes with zoledronic acid should be avoided. Creatinine should be monitored before each dose of either agent in accordance with US Food and Drug Administration (FDA) labeling. Oncology professionals, especially medical oncologists, need to take an expanded role in the routine and regular assessment of the osteoporosis risk in women with breast cancer. The panel recommends an algorithm for patient management to maintain bone health.

CONCLUSION

Bisphosphonates provide a supportive, albeit expensive and non-life-prolonging, benefit to many patients with bone metastases. Current research is focusing on bisphosphonates as adjuvant therapy. Although new data addressing when to stop therapy, alternative doses or schedules for administration, and how to best coordinate bisphosphonates with other palliative therapies are needed, they are not currently being investigated.

Therapeutic benefit of bisphosphonates in the management of prostate cancer-related bone disease

A diversity of bone pathology is present in men with prostate cancer. Androgen deprivation therapy (ADT) can cause significant and progressive osteopoenia and osteoporosis. Bone is also the primary site for metastases leading to associated pain, skeletal fractures and hypercalcaemia. Bisphosphonate therapy decreases bone resorption, which may prevent or reverse loss of bone mineral density. Both pamidronate and zoledronic acid have proven efficacy in preventing ADT-induced bone loss. In a randomised, placebo-controlled trial, in men with hormone-refractory prostate cancer, there was a decreased incidence of skeletal- related adverse events in men receiving zoledronic acid. So far, randomised trials have failed to show improved pain control. Formalised guidelines are needed to help clinicians decide which patients should be treated with bisphosphonates, when to initiate therapy and for what duration.

Effectiveness and cost of bisphosphonate therapy in tumor bone disease

BACKGROUND

Tumor-induced osteolysis due to breast carcinoma and myeloma is responsible for a considerable morbidity that severely impairs patients'quality of life. Osteoclast-mediated bone resorption is reported to be increased markedly in patients with tumor bone disease and can be inhibited by bisphosphonate therapy.

METHODS

The incidence of skeletal complications and the effectiveness of bisphosphonate therapy in patients with breast carcinoma metastatic to bone or in those with myeloma were derived from large-scale, long-term, placebo-controlled trials with clodronate or pamidronate. To the authors' knowledge, there are few studies published to date evaluating the cost-effectiveness of bisphosphonate therapy, and the majority that do exist often are based on models and are applicable only to a particular health care system.

RESULTS

From the placebo groups of the above-mentioned trials, one can estimate that approximately 25-40% of the patients with breast carcinoma metastatic to bone will require radiotherapy for bone pain and approximately 17-50% will sustain incident vertebral fractures yearly. The incidence of complications is reported to be lower in myeloma patients. The prolonged administration of bisphosphonates reportedly can reduce the frequency of skeletal-related events by approximately 25-50%. Maximal efficacy appears to have been achieved with the current therapeutic schemes based on monthly intravenous infusions. Beneficial effects appear to be obtained more readily using the intravenous route rather than the oral route. The costs of bisphosphonate therapy appear to be higher than the cost savings from the prevention of skeletal-related events. The costs per quality of life-adjusted year have been estimated to be > $100,000, but more research is needed. Limited data suggest that zoledronic acid will not reduce treatment costs but the short infusion time will lead to substantial time savings for patients and for outpatient oncology facilities.

CONCLUSIONS

As is the case for many agents used in oncology, bisphosphonates remain a relatively expensive therapy. More studies are needed to evaluate their cost-effectiveness ratio correctly. A ceiling effect has been reached with current therapeutic schemes and tailoring therapy to the individual patient needs to be evaluated correctly to increase therapeutic effectiveness and improve quality of life further without increasing treatment costs.