Costs of treatment of colorectal cancer in different settings in Germany

Cost-minimisation analysis of rectal cancer neoadjuvant chemoradiotherapy based on fluoropyrimidines (capecitabine versus 5-fluorouracil)

OBJECTIVES

The current standard treatment for patients with rectal cancer stage II-III is neoadjuvant chemoradiotherapy followed by surgery. Neoadjuvant chemoradiotherapy can be performed with 5-fluorouracil (5-FU) or capecitabine (CPC) considered to be equivalent therapies. Medication cost is higher for CPC than for 5-FU, however, the administration of continuous 5-FU intravenous infusion is related to other costs such as those associated with outpatient facilities or central venous catheter insertion.

METHODS

This retrospective study analysed the direct sanitary costs associated with the treatments and their complications from a hospital perspective. Costs in patients treated with 5-FU or CPC were measured between January 2010 and July 2018 at Mataró Hospital. The aim of this study was to perform a cost-minimisation analysis between the two treatments. We aimed to assess the cost associated with the complications related to each drug and the economic impact of applying the most efficient option.

RESULTS

Ninety-eight patients were analysed: 32 were treated with CPC and 66 with 5-FU. Treatment cost was significantly higher for 5-FU than for CPC (2560.86±99.17 and 563.10±9.52 respectively, P=0.0001). No significant differences were found in the costs associated with treatment complications between groups (148.21±934.91 and 41.41±102.50 euros respectively, P=0.322).

CONCLUSIONS

Considering the clinical equivalence shown in the available trials and previous reviews, the most efficient treatment is neoadjuvant chemoradiotherapy with CPC. Complications associated with the treatments did not significantly modify these results. Other studies gave similar results both in the neoadjuvant and adjuvant context, reaffirmed in this study.

Cost-utility analysis of 5-fluorouracil and capecitabine for adjuvant treatment in locally advanced rectal cancer

Background

Adjuvant chemotherapy at concurrent time with radiation therapy (RT) or at adjuvant time alone in locally advanced rectal cancer (LARC) is used with several regimens. The cost-utility analysis was conducted to compare administration of two 5-FU regimens and capecitabine in the aspect of provider and societal viewpoint.

Methods

Stage II or III rectal cancer patients who received pre-operative or post-operative concurrent chemoradiotherapy and adjuvant chemotherapy were compared by using decision tree model between (I) 5-FU plus leucovorin (LV) for 5 days per cycle (Mayo Clinic regimen); (II) 5-FU continuous infusion (CI) for 120-h per cycle (CAO/ARO/AIO-94 protocol); (III) standard regimen of capecitabine. All probability data were extracted from landmark study. Direct medical costs were the cost from database of Drug Medical Supply Information Center, while direct non-medical cost and utility were interviewed from stage II and III rectal cancer patients. The time horizon of this study was 5 years. Incremental cost-effectiveness ratio (ICER) was the final result in this study, which determined as the numerator of the difference of costs among three drug regimens, and the difference of quality-adjusted life years (QALYs) from each drug was the denominator.

Results

5-FU plus LV was the cheapest and least efficacy for adjuvant treatment of LARC in both provider and societal viewpoint. In provider viewpoint, the ICERs of 5-FU CI and capecitabine were 334,550 THB/QALY (US $9,840/QALY) and 189,935 THB/QALY (US $5,586/QALY), respectively, with the corresponding societal viewpoint of 264,447 THB/QALY (US $7,778/QALY) and 119,120 THB/QALY (US $3,504/QALY) when 5-FU plus LV was used as comparator. The most influential parameter for value of treatment was acquisition cost of capecitabine. At the willingness to pay for one QALY gained in Thailand (160,000 THB or US $4,706), 5-FU plus LV, 5-FU CI and capecitabine had probabilities of cost-effectiveness of 63%, 2% and 35%, respectively.

Conclusions

Capecitabine was the most expensive regimen but produced the higher effectiveness than 5-FU plus LV and 5-FU CI. The most influential parameter in the model was acquisition cost of capecitabine.

Recommendations and expert opinion on the adjuvant treatment of colon cancer in Spain

Adjuvant chemotherapy is the current standard in the management of patients with localised colon cancer (CC) following curative resection. The use of oxaliplatin plus 5 fluorouracil/leucovorin (FOLFOX) or oxaliplatin plus capecitabine-based (XELOX) regimens, both approved in Europe as adjuvant treatment for stage III CC, has improved prognosis in this stage, but questions on their usefulness in high-risk stage II or elderly CC patients and on the role of some prognostic biomarkers are still pending. In April 2010, a consensus meeting on adjuvant CC treatment based on a revision of the most recent literature was held in Spain. The panel considered the use of adjuvant chemotherapy for high-risk stage II CC patients to be justified. Additionally, the more convenient administration of oral fluoropyrimidines vs. IV continuous infusion 5-FU would make XELOX a more suitable alternative for the patient. A more cautious decision should be taken when prescribing oxaliplatin treatment in patients aged ≥70.

The unit costs of inpatient hospital days, outpatient visits, and daycare treatments in the fields of oncology and hematology

OBJECTIVES

Many economic evaluations are conducted in the fields of oncology and hematology, partially owing to the introduction of new expensive drugs in this field. Even though inpatient days, outpatient visits, and daycare treatments are frequently the main drivers of total treatment costs, their unit costs often lack generalizability. Therefore, we aimed to determine the unit costs of inpatient hospital days, outpatient visits, and daycare treatments specifically for oncological and hematological diseases in The Netherlands from the hospital's perspective.

METHODS

Unit costs were collected from 30 oncological and hematological departments of 6 university and 24 general hospitals. Costs included direct labor and indirect labor, hotel and nutrition, overheads and capital. Ordinary least squares regression models were constructed to examine the degree of association between unit costs and hospital and hospital department characteristics. All costs were based on Euro 2007 cost data.

RESULTS

At university hospitals, the unit costs per inpatient day were determined at €633 in oncological and €680 in hematological departments. At general hospitals, the mean costs per inpatient day were €400. Unit costs for inpatient hospital days, outpatient visits. and daycare treatments equalled the relative ratio 100:21:44. Direct labor costs were the major cost driver and the type of hospital (university, yes/no) was a strong predictor of unit costs.

CONCLUSIONS

The present study provided unit costs for inpatient hospital days, outpatient visits, and daycare treatments in the fields of oncology and hematology. The results may be used as Dutch reference unit prices in economic evaluations assessing oncological and hematological diseases.

Economic evaluation of capecitabine as adjuvant or metastatic therapy in colorectal cancer

Capecitabine, an oral prodrug of 5-fluorouracil, is indicated for adjuvant treatment in patients with Dukes' C colon cancer and for subsequent lines in metastatic colorectal cancer. The aim of this article is to review the literature on the economics of capecitabine for the treatment of colon cancer. A systematic review was conducted to search for articles published from January 2003 to December 2009 that met the inclusion criteria. For abstracts that were considered acceptable, full-text articles were then reviewed. Of the 42 potential studies that were identified, 13 original studies (16 publications) met the inclusion criteria. To date, the economic evaluation literature has consistently projected or found that capecitabine is not only a cost-effective treatment for adjuvant or for metastatic colorectal cancer (i.e., providing good value for money) but, furthermore, would actually be cost saving in the majority of country settings.

Cancer management and reimbursement aspects in Germany: an overview demonstrated by the case of colorectal cancer

This paper provides an overview of cancer management, particularly with respect to colorectal cancer (CRC), in Germany. The information presented reflects findings from the peer-review literature and government documentation, as well as interviews with cancer and CRC specialists. Topics such as epidemiology, expenditure, CRC screening, pharmaceutical and non-pharmaceutical treatment are discussed in this paper. Furthermore, insights into the German reimbursement system with regard to cancer management as well as regulatory aspects are presented.

XELOX versus FOLFOX6 as an adjuvant treatment in colorectal cancer: an economic analysis

OBJECTIVES

An economic analysis (based on interim data from a long-term, randomised, multi-centre, controlled, clinical trial) to evaluate chemotherapy with XELOX (capecitabine/oxaliplatin) versus FOLFOX6 (5Fluorouracil/leucovorin/oxaliplatin) as an adjuvant treatment for high risk colorectal cancer patients in Greece.

METHODS

As survival rate was the same in the two arms, a cost-minimisation analysis was carried out, from the perspectives of the National Health Service (NHS), Social Insurance Funds (SIF) and patients in Greece. Patient data were combined with 2008 unit prices to estimate the total cost of patient care, the patients' travelling expenditure and their productivity losses. Raw data were bootstrapped 5000 times in order to allow statistical testing.

RESULTS

From an NHS perspective, the mean chemotherapy cost was 8762 euro with FOLFOX6 and 9713 euro with XELOX; costs of administration and hospitalisations were 5154 euro and 1050 euro, respectively. Total treatment cost with FOLFOX6 reached 17,480 euro and with XELOX 12 525 euro, a difference of 4955 euro (p < 0.001) in favour of the latter therapy. From an SIF perspective, the total cost of treatment was 16,240 euro with FOLFOX6 and 12,617 euro with XELOX, a reduction of 3623 euro (p < 0.001) with the latter therapy. Mean patient travelling cost was 184 euro with FOLFOX6 and 80 euro with XELOX, a difference of 104 euro (p < 0.001). Mean productivity loss was 100 euro with FOLFOX6 and 31 euro with XELOX, a difference of 69 euro (p < 0.001).

CONCLUSIONS

Chemotherapy combining oral capecitabine and oxaliplatin reduces total treatment cost for the Greek National Health Service and Social Insurance Funds, mainly through a reduction in the cost of administration. From patients' perspective, it reduces travelling expenditure and productivity losses. Therefore, this combination may be a cost-effective approach for the management of colorectal cancer patients who have had surgery in Greece. This is an analysis alongside a clinical trial, and should be interpreted in this specific context in which it was undertaken.

A systematic review of economic analyses of pharmaceutical therapies for advanced colorectal cancer

Colorectal cancer is one of the most common causes of cancer in the Western world. New drugs in the treatment of advanced colorectal cancer, such as irinotecan and oxaliplatin, have substantially increased the cost of treatment. A systematic literature review on the cost (-effectiveness) of pharmaceutical therapies for advanced colorectal cancer was conducted, in which 13 articles were included. The main topics were: orally versus intravenously administered fluoropyrimidine, raltitrexed, irinotecan and oxaliplatin. Additional information was collected on the cost (-effectiveness) of the monoclonal antibodies, cetuximab and bevacizumab. Only five articles had taken the societal perspective, in most articles no data on quality of life was presented, and only two reported the cost per quality-adjusted life year. As only a limited amount of information is available on the cost-effectiveness of pharmaceutical therapies for advanced colorectal cancer, there is a need for more cost-effectiveness studies. These studies are preferably performed by taking a societal perspective and including quality of life outcomes.

Cost considerations in the treatment of colorectal cancer

Colorectal cancer is among the most common malignancies in developed countries. Screening can reduce mortality significantly, although the most appropriate method is still under debate. Observational studies have revealed that lifestyle measures may also be beneficial for prevention of colorectal cancer. Surgery is still the most effective treatment modality for colorectal cancer. The survival benefits of chemotherapy are only modest. For nearly 5 decades, 5-fluorouracil (5-FU) has been the main cytotoxic agent for treatment of colorectal cancer. In the last decade, the new cytotoxic agents raltitrexed, irinotecan and oxaliplatin have been introduced, next to the oral 5-FU analogues capecitabine and tegafur in combination with uracil (UFT). Moreover, the immunotherapeutics bevacizumab and cetuximab have become approved for treatment of metastatic colorectal cancer. The economic implications of colorectal cancer treatment are substantial. The costs of treatment are mainly attributable to the early and terminal stage of the disease (i.e. surgery, hospitalisation, chemo- and immunotherapy and supportive care). The introduction of new chemo- and immunotherapeutics has caused a continuing increase of treatment expenditures. Therefore, comparative costs and cost effectiveness are important for assessing the value of new treatment regimens. The available study results suggest that addition of irinotecan or oxaliplatin to 5-FU/folinic acid dosage regimens is cost effective. Also, capecitabine is calculated to be cost effective when compared with 5-FU/folinic acid. For UFT, no comparative studies of cost effectiveness were found. Since raltitrexed and 5-FU/folinic acid have shown equal efficacy in terms of survival, cost-effectiveness analysis is considered not to be applicable and cost-minimisation analysis may be sufficient. At present, pharmacoeconomic analyses of combination treatment with the immunotherapeutics bevacizumab or cetuximab are not available, except for recent cost-effectiveness considerations by the UK National Institute for Health and Clinical Excellence with negative recommendations for both agents in the treatment of metastatic colorectal cancer. Given the high treatment costs, substantial toxicity and relatively limited efficacy of the fast changing chemo- and immunotherapeutic combinations for colorectal cancer, examination of cost-effectiveness studies should be conducted on a routine basis along with determination of clinical benefits.

Economic impact of simplified de Gramont regimen in first-line therapy in metastatic colorectal cancer

The cost of chemotherapy has dramatically increased in advanced colorectal cancer patients, and the schedule of fluorouracil administration appears to be a determining factor. This retrospective study compared direct medical costs related to two different de Gramont schedules (standard vs. simplified) given in first-line chemotherapy with oxaliplatin or irinotecan. This cost-minimization analysis was performed from the French Health System perspective. Consecutive unselected patients treated in first-line therapy by LV5FU2 de Gramont with oxaliplatin (Folfox regimen) or with irinotecan (Folfiri regimen) were enrolled. Hospital and outpatient resources related to chemotherapy and adverse events were collected from 1999 to 2004 in 87 patients. Overall cost was reduced in the simplified regimen. The major factor which explained cost saving was the lower need for admissions for chemotherapy. Amount of cost saving depended on the method for assessing hospital stay. In patients treated by the Folfox regimen the per diem and DRG methods found cost savings of Euro 1,997 and Euro 5,982 according to studied schedules; in patients treated by Folfiri regimen cost savings of Euro 4,773 and Euro 7,274 were observed, respectively. In addition, travel costs were also reduced by simplified regimens. The robustness of our results was showed by one-way sensitivity analyses. These findings demonstrate that the simplified de Gramont schedule reduces costs of current first-line chemotherapy in advanced colorectal cancer. Interestingly, our study showed several differences in costs between two costing approaches of hospital stay: average per diem and DRG costs. These results suggested that standard regimen may be considered a profitable strategy from the hospital perspective. The opposition between health system perspective and hospital perspective is worth examining and may affect daily practices. In conclusion, our study shows that the simplified de Gramont schedule in combination with oxaliplatin or irinotecan is an attractive option from the French Health System perspective. This safe and less costly regimen must compared to alternative options such as oral fluoropyrimidines.