Economic analysis of the use of recombinant human granulocyte colony stimulating factor in autologous bone marrow transplantation

Value of postoperative thyroglobulin and ultrasonography for the indication of ablation and ¹³¹I activity in patients with thyroid cancer and low risk of recurrence

BACKGROUND

This study investigated the value of postoperative stimulated thyroglobulin (Tg) combined with neck ultrasonography for the prediction of the posttherapy whole-body scanning (RxWBS) and the efficacy of ablation with 30 mCi ¹³¹I in patients with thyroid cancer and low risk of recurrence to identify those who do not require ablation or only need a low ¹³¹I activity.

METHODS

A total of 237 consecutive patients with well-differentiated thyroid cancer and low risk of recurrence who were initially treated by total thyroidectomy followed by remnant ablation with 1.1 or 3.7 GBq (30 or 100 mCi) ¹³¹I were studied. Neck ultrasonography, Tg after levothyroxine withdrawal, and anti-Tg antibodies (TgAb) were obtained before, and RxWBS was performed 7 days after ¹³¹I administration. Patients with TgAb were excluded.

RESULTS

Postoperative ultrasonography revealed lymph node metastases in 5/237 (2%) patients. RxWBS showed ectopic uptake in 3/232 (1.3%) patients with negative ultrasonography. The negative predictive value of postoperative stimulated Tg <1 ng/mL (n = 132) or <10 ng/mL (n = 213) combined with negative ultrasonography was 100%. Among patients with detectable postoperative stimulated Tg <10 ng/mL and negative ultrasonography, 50 received 1.1 GBq ¹³¹I and 31 received 3.7 GBq. In the control assessment, stimulated Tg <1 ng/mL and neck ultrasonography without anomalies were achieved in 47/50 (94%) and in 29/31 patients (93.5%). All patients with stimulated Tg ≤1 ng/mL, negative TgAb, and normal ultrasonography before ablation continued to show the same results 8-12 months after initial therapy as expected, irrespective of the administration of 1.1 GBq (n = 82) or 3.7 GBq ¹³¹I (n = 50).

CONCLUSIONS

Measurement of stimulated Tg combined with neck ultrasonography after total thyroidectomy may exclude the need for ablation in 56% of low-risk patients without TgAb (Tg <1 ng/mL) and permit the administration of an activity of 1.1 GBq ¹³¹I in another 34% with low Tg levels.

Kinetics of peg-filgrastim after high-dose chemotherapy and autologous peripheral blood stem cell transplantation

Peg-filgrastim is a form of G-CSF with a sustained duration of action due to self-limited clearance. We administered 6 mg peg-filgrastim to 18 autograft recipients on day +1 after transplantation for hematologic malignancies. Plasma samples were collected at baseline and during transplantation. Hematopoietic recovery and clinical outcomes were compared to the historical data of 54 patients not receiving G-CSF. Patients receiving peg-filgrastim achieved a serum level of 115 000 pg/ml on day +2, 24 h after drug administration. Drug level maintained a plateau until day +8 and, after day +10, declined concomitantly with myeloid recovery. Patients experienced prompt neutrophil recovery: days +9 and +10 to 500 and 1000 neutrophils per microliter, and 4 days with an absolute neutrophil count <100 cells per microliter. Duration of antibiotic therapy was significantly shortened, but we did not observe significant differences in other end points. In conclusion, peg-filgrastim was well tolerated and efficacious, and hastened myeloid recovery.

Economic assessment in the management of non-Hodgkin’s lymphoma

An increasing need for economic evaluations of non-Hodgkin's lymphoma (NHL) treatments exists. We performed a literature review on the currently available NHL economic evaluations, using PubMed and the Cochrane database. English and Dutch language papers on treatment in adults were selected. A total of 88 publications were found, 44 of which were included. Of these, 6 economic evaluation-specific methodological items are evaluated (study perspective, overhead costs, data sources, charges or prices, sensitivity analysis, presentations of resource use and unit costs), enabling readers to judge the value of these studies. The 11 subjects covered by the economic evaluations are discussed. Many NHL treatments remain to be studied in economic evaluations. Future publications should report on the six methodological items in more detail, and preferably tackle them in the recommended way.

Aggressive non-Hodgkin's lymphoma: economics of high-dose therapy

High-intermediate grade non-Hodgkin's lymphoma (NHL) is an aggressive form of the disease, which can respond well to combination chemotherapy, with long-term survival seen in 40-50% of patients. When NHL relapses following standard treatment, high-dose chemotherapy with peripheral blood stem cell or bone marrow support may still cure a significant proportion of patients. Despite a significant rise in the incidence of NHL over recent years, there remains only limited published economic study concerning the overall lifetime cost of treatment, the cost effectiveness of specific treatments or the overall societal cost burden of the disease. The majority of studies identified for the purposes of this review considered the cost of alternative forms of chemotherapy and bone marrow support strategies for patients with advanced disease. Data from these studies suggest that there is a definite trend towards reduced costs for high-dose therapy, possibly reflecting increasing technical experience and improved bone marrow recovery through the use of stem cell transplantation and growth factors. The limited number of cost-effectiveness evaluations suggest that high-dose therapy, following a chemosensitive relapse, is likely to be considered favourable against commonly quoted cost-effectiveness thresholds. Cost effectiveness is becoming an increasingly important factor to consider in the formal assessment of new interventions conducted by groups such as the UK National Institute for Clinical Excellence. In light of the increasing incidence of NHL and the extended use of high-dose treatments in other subgroups of patients, there is a need for increased research into the economics of new interventions for NHL.

Cost-benefit analysis of granulocyte colony-stimulating factor in the management of elderly cancer patients

Health care costs continue to rise, and hospitalization represents the single largest component of direct medical costs associated with cancer care. Neutropenia and its complications including febrile neutropenia (FN) remain the major dose-limiting toxicity of systemic cancer chemotherapy. The risk of FN varies considerably across treatment regimens but appears to be significantly higher among elderly patients. The colony-stimulating factors (CSFs) have been used effectively in a variety of clinical settings to prevent or treat FN and to assist patients receiving dose-intensive chemotherapy with or without stem cell support. Several randomized controlled trials (RCTs) have demonstrated the clinical efficacy of the prophylactic use of CSFs. A recently presented meta-analysis of the available RCTs has confirmed the efficacy of prophylactic CSFs. The cost of these agents, along with their large-scale clinical use, has prompted a number of economic investigations. Economic models based on measures of resource utilization derived from RCTs have provided FN risk threshold estimates for the cost-saving use of prophylactic CSF. A number of important studies concerning the clinical and economic impact of these agents in elderly cancer patients have been reported during the past year. Continuing clinical and economic evaluation along with an updating of clinical practice guidelines especially related to elderly patients is recommended because of rapid technologic and clinical advances.

Colony-Stimulating Factors in Stem Cell Transplantation: Effect on Quality of Life

Health-related quality of life (QOL) is poorest during the immediate post-transplantation period, but the impact of medical interventions during this period has not been studied. Colony-stimulating factors (CSFs), which are used to minimize short-term negative outcomes, might be expected to improve QOL; however, little is published about their impact on QOL during this period. We conducted a MEDLINE search to identify studies reporting on outcomes of stem cell transplantation (SCT) affected by the CSFs, mainly sargramostim and filgrastim. End points studied were: mucositis, incidence and type of infection, duration of hospitalization, time to myeloid engraftment, and quantity and quality of harvested cells. To impute the impact of CSFs on QOL post-SCT, we also reviewed the association between QOL and CSF outcomes in other circumstances. Data suggest that both CSFs improve QOL in the early autologous or allogeneic post-bone marrow transplantation period. Poor QOL caused by infection and increased length of hospital stay is expected to be improved by sargramostim. Time to myeloid engraftment, when negatively affecting QOL, is expected to be improved with both CSFs; however, the time to myeloid engraftment is consistently shorter with filgrastim. Current prospective trials designed to study the effects of CSFs in the immediate post-SCT period should collect QOL data.

Federation of European Cancer Societies. Full report. Economic evaluation in cancer care: questions and answers on how to alleviate conflicts between rising needs and expectations and tightening budgets

All Western countries have experienced a fast growth in their healthcare expenses over recent decades. It is expected that pressure for such growth will continue in the future. But spending an ever larger share of our nation's resources on healthcare cannot be afforded. As a consequence, making choices will become more and more inevitable, even in cancer care. Economic evaluation is a very supportive tool for such decisions. This position statement concludes with recommendations for providers and healthcare policy-makers, to safeguard and further improve good clinical decision making and healthcare policy in cancer care under tightening budgets.

Cost analysis of autologous peripheral stem cell transplantation versus autologous bone marrow transplantation for patients with non Hodgkin's lymphoma and acute lymphoblastic leukaemia

We evaluated the costs of unpurged autologous stem cell transplantation in a non-randomised study of 54 consecutive patients with lymphoproliferative malignancies who have been transplanted at the Nijmegen University Hospital between July 1992 and March 1998. Thirty-five patients were transplanted with autologous peripheral stem cells (APSCT): 30 had non Hodgkin's lymphoma (NHL) and 5 acute lymphoblastic leukaemia (ALL). Nineteen patients were transplanted with autologous bone marrow stem cells (ABMT): 17 had NHL and 2 ALL. The number of progenitor cells (CFU-GM, BFU-E) and nucleated cells was significantly higher in peripheral blood transplants. The duration of cytopenia was shorter after APSCT. The leucocyte recovery to 0.5 x 10(9)/L was 13 days for recipients of peripheral stem cells compared to 20 days for bone marrow recipients (P <0.001). The platelet recoveries to 20 x 10(9)/L were 13 and 29 days, respectively (P = 0.001). This resulted in significantly shorter admission duration 24 days after APSCT versus 30 days (P = 0.003) after ABMT. Furthermore, a statistically significant difference between both groups was observed for antimicrobial costs (mean: fl 2,939 vs fl 4,888; P = 0.008), platelet transfusions (median: 3 vs 7 units; P = 0.01) and erythrocyte transfusions (median: 6 vs 10 units; P = 0.03). The mean overall costs were lower in patients transplanted with stem cells from peripheral blood: fl 34,178 versus fl 43,469 (P = 0.007). This study suggests that the APSCT results in significant cost savings due to shorter hospital stay and less costs of supportive care, despite higher mobilisation costs. The costs of blood transfusions and antimicrobials for patients with ALL were significantly higher when compared to patients with NHL.

Update of the economic analyses of the use of the colony-stimulating factors

The colony-stimulating factors have been used effectively in a variety of clinical settings to prevent febrile neutropenia and to assist patients receiving dose-intensive chemotherapy with or without stem cell support. Several studies have confirmed the clinical efficacy of the colony-stimulating factors used prophylactically in both solid tumors and the hematologic malignancies. The cost of these agents, along with their large scale clinical use, has prompted a number of economic investigations. Economic analyses based on measures of resource utilization derived from randomized clinical trials have provided febrile neutropenia risk threshold estimates for the cost saving use of prophylactic colony-stimulating factor. A number of important studies concerning the clinical and economic impact of these agents have been reported over the past year. These include a revised cost minimization study based on improved febrile neutropenia cost information and a cost-effectiveness analysis in the adjuvant breast cancer setting based on a clinical prediction model to select patients at high risk for neutropenic complications. Continuing clinical and economic evaluation along with updating of clinical practice guidelines is needed due to rapid technologic and clinical advances in this area.

The economics of febrile neutropenia: implications for the use of colony-stimulating factors

The occurrence of fever and neutropenia following cancer chemotherapy generally prompts hospitalisation for evaluation and treatment. Colony-stimulating factors (CSFs) have been shown to reduce the risk of febrile neutropenia (FN) and the need for hospitalisation in such patients. This study was undertaken to obtain estimates of the actual institutional costs associated with FN and the impact of these costs on threshold estimates for the appropriate use of CSFs. Total hospital expenditures for patients admitted with FN over a 2 year period were studied. A cost allocation function was utilised to allocate all direct costs for non-revenue-generating support centres to revenue-generating service centres as indirect costs. A cost accounting function was then utilised to allocate direct and indirect costs for each service centre to the charge code level. Two groups of patients were defined based on diagnostic codes to represent the spectrum of patients with FN. Total hospital costs were estimated and incorporated into a cost model for the use of CSFs. Variation in the total cost of hospitalisation for FN relates primarily to differences in the average length of stay. The daily cost of hospitalisation was comparable in the groups studied, averaging between US$1675 and US$1892. Incorporation of these cost estimates into the cost model yielded FN risk threshold projections for CSF use in the range of 20-25%. Preliminary studies suggest that incorporation of non-medical, indirect and intangible costs into the CSF decision models will further decrease FN risk threshold projections. Total hospitalisation cost estimates for managing patients with FN are greater than those previously reported, reducing projected FN risk thresholds for CSF use.

Cost Effectiveness of G:CSF in Chemotherapy and Transplant-related Neutropenia

Sustained fever over 38°C is potentially lethal when neutrophil counts remain below 0.1 × 10(9)/L. To determine whether the addition of a haematopoietic stimulatory peptide to conventional supportive care and antibiotic management was cost-effective, 74 such episodes were analysed. Group I (5μg/kg G: CSF: n = 41); Group II (10 μg/kg: n = 19) and Group III (controls: n = 14): these were similar in respect of race, gender, age and body weight. The median days and range of neutrophil count below 0.1 × 10(9)/Lw as 6 (0-12), 7 (0-20) and 8 (0-20) and the corresponding figures for 0.5 × 10(9)/L were 8 (0-19), 8 (1-23) and 13.5 (3-30) days respectively, while the median hospital period was 26 (18-49), 30 (9-86) and 35 (13-44). Mean, standard deviation and range for bed costs in Group I was R9,528 (2125:6120-1660), the corresponding figures for Group II were Rll,453 (5570:3060-2924), and for Group III Rll,366 (2755: 4420-1496). The approximate fate of exchange is: Rl = US$5.87. When expenditure for growth factor was integrated these figures were approximately R26,071, R37,787 and R27,376. There were no advantages in 10 over 5 μg/kg G: CSF. More red cell transfusions were needed in Group III. The days requiring antimicrobial therapy were 14, 16 and 20 respectively. It is concluded from this study, carried out in reverse isolation at a University Teaching Hospital, that duration of neutropenic fever was significantly shortened on G: CSF but there was no benefit in using the higher dose. Additionally, at equivalent cost, there was a shorter period of hospitalisation thereby reducing risk of acquiring nosocomial infections. Finally, there was concurrently a decreased exposure to potentially nephrotoxic antibiotics. Accordingly, this regimen can be justified in the routine management of this category of patient.