Cost-effectiveness of zoledronic acid in the management of skeletal metastases in patients with lung cancer in France, Germany, Portugal, the Netherlands, and the United kingdom

Exploration of the Effect of Icariin on Nude Mice with Lung Cancer Bone Metastasis via the OPG/RANKL/RANK System

Epimedium is a traditional Chinese medicine that is most commonly prescribed by practitioners of Chinese medicine for the clinical treatment of malignant tumor bone metastasis. The main component of Epimedium is icariin (ICA). Studies have shown that ICA inhibits bone resorption of osteoclasts through the OPG/RANKL/RANK signaling pathway. Osteoclasts are the only cells in the body that have a bone-destroying capability. The OPG/RANKL/RANK system consists of cytokines that play major roles in osteoclast formation. Therefore, our study selected the OPG/RANKL/RANK system as the research target to investigate the effect of ICA on nude mice with lung cancer bone metastasis. We established the model of bone metastasis in nude mice, intervened the model with icariin and zoledronic acid, and detected the levels of OPG and RANKL by ELISA and western blot. The results showed that ICA had a significant inhibitory effect on bone metastases in nude mice. ICA achieved its antibone metastasis effect in nude mice with lung cancer via inhibiting RANKL expression and simultaneously increasing OPG expression. ICA not only alleviated osteolytic bone destruction caused by bone metastases, but it also reduced weight loss in tumor-bearing nude mice at the late stage of the experiment. The role of ICA in preventing bone metastasis of lung cancer merits further investigation.

A Tailored Approach for Appendicular Impending and Pathologic Fractures in Solid Cancer Metastases

Simple Summary

Patients with bone metastases often suffer with complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results, a tailored approach should be defined for managing impending or pathologic fractures in each individual case. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow.

Abstract

Advances in medical and surgical treatment have played a major role in increasing the survival rates of cancer patients with metastatic bone disease. The clinical course of patients with bone metastases is often impaired by bone complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results and prevent a detrimental impact on patients’ health, a tailored approach should be defined for any given patient. The optimal management of impending or pathologic fractures is unknown and relies on a multidisciplinary approach to tailor clinical decisions to each individual patient. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow. The present review covers the most recent data regarding impending and pathologic fractures in patients with bone metastases, and discusses the medical and surgical management of patients presenting with metastatic bone disease in different clinical settings.

German value sets for the EORTC QLU-C10D, a cancer-specific utility instrument based on the EORTC QLQ-C30

PURPOSE

The EORTC QLU-C10D is a new multi-attribute utility instrument derived from the EORTC QLQ-C30, a widely used cancer-specific quality of life questionnaire. It covers ten dimensions: physical, role, social, emotional functioning, pain, fatigue, sleep, appetite, nausea, and bowel problems. To allow national health attitudes to be reflected, country-specific valuations are being performed by collaboration of the Multi-Attribute Utility Cancer (MAUCa) Consortium and the EORTC. The purpose of this paper is to provide German value sets (utility weights) for the QLU-C10D.

METHODS

Valuations were run in a web-based setting in two general population samples of approximately 2000 adults in total. As the German version of the QLQ-C30 is presently undergoing a revision of the wording of one response category, valuations for both the current and the new version were performed (Germany 1 and 2). Utilities were elicited using a discrete choice experiment (DCE). Data were analyzed by conditional logistic regression and mixed logits.

RESULTS

Completion rates were 88.3% (1002/1135) and 90.4% (1016/1124) for Germany 1 and Germany 2 valuations, respectively. Dimensions with the largest impact on utility weights were, in this order: physical functioning, pain, role functioning, social functioning and nausea (same ordering for both German versions). Several violations of the logical ordering of levels were observed for Germany 1; this was largely improved for Germany 2.

CONCLUSION

This study established German utility weights for the cancer-specific utility instrument QLU-C10D.

Cost-effectiveness of standard utilization of zoledronic acid for bone metastases from advanced lung cancer in China

Aim: To assess the cost-effectiveness of standard utilization of zoledronic acid (ZA) relative to real-world utilization of ZA for bone metastasis (BM) in Chinese patients with advanced lung cancer. Materials & methods: A decision analytic model was constructed to simulate health benefits and medical costs associated with standard and real-world utilization of ZA for BM in Chinese patients with advanced lung cancer. Results: Compared with real-world utilization of ZA, standard utilization of ZA reduced cumulative risk of skeletal-related events (45.7 vs 63.6%), increased quality-adjusted life years (0.673 vs 0.626 QALY) and saved cumulated medical costs (¥343,163 vs ¥376,943). Conclusion: Standard utilization of ZA dominated real-world utilization of ZA for BM in Chinese patients with advanced lung cancer from cost-effectiveness perspective.

Cost-Effectiveness of Treatments for the Management of Bone Metastases: A Systematic Literature Review

BACKGROUND

Metastatic cancers occur when cancer cells break away from the primary tumour. One of the most common sites of metastasis is the bone, with several therapeutic options currently available for managing bone metastases. In a resource-constrained environment, policy makers and practitioners need to know which options are cost effective.

OBJECTIVE

The aim of this systematic review was to review and appraise published economic evaluations on treatments for the management of bone metastases.

METHODS

We searched eight bibliographic databases (MEDLINE, MEDLINE in Process, EMBASE, CSDR, DARE, HTA, EED and CPCI) for relevant economic evaluations published from each database's inception date until March 2017. Study selection, quality assessment and data extraction were carried out according to published guidelines.

RESULTS

Twenty-four relevant economic analyses were identified. Seventeen of these studies focused on bone metastases resulting from a particular type of cancer, i.e. prostate (n = 8), breast (n = 7), lung (n = 1) or renal (n = 1), while seven report results for various primary tumours. Across types of cancer, evidence suggests that bisphosphonates result in lower morbidity and improved quality of life, for an additional cost, which is typically below conventional cost-effectiveness thresholds. While denosumab leads to health gains compared with zoledronic acid, it also results in substantial additional costs and is unlikely to represent value for money. The limited literature on the radiopharmaceutical strontium-89 (Sr89) and external beam radiotherapy (EBR) suggest that these treatments are cost effective compared with no treatment.

CONCLUSIONS

The reviewed evidence suggests that bisphosphonate treatments are cost-effective options for bone metastases, while denosumab is unlikely to represent value for money. Evidence on EBR and Sr89 is limited and less conclusive.

Clinical, economic and humanistic burdens of skeletal-related events associated with bone metastases

Despite effective skeletal-related event (SRE)-limiting therapies such as zoledronic acid and denosumab, SREs continue to place a meaningful burden on patients, providers and payers. However, studies of SRE-related effects on clinical (i.e., survival), economic (i.e., cost per event) and humanistic (i.e., quality of life) outcomes often report results in a composite manner and frequently do not differentiate the effects by SRE-type (i.e., bone radiation, bone surgery, hypercalcemia, pathological fracture and spinal cord compression). Nevertheless, understanding the differential burdens of individual SRE types, which vary in severity and duration of effect, is an important consideration - particularly in pharmacoeconomic evaluations of SRE-limiting therapies. In this review of the clinical, economic and humanistic SRE burden, it was found that SRE types can be differentiated by these outcomes, although economic outcomes are far more frequently reported than clinical or humanistic.

Clinical significance of zoledronic acid and strontium-89 in patients with asymptomatic bone metastases from non-small-cell lung cancer

BACKGROUND

The purpose of this study was to clarify the treatment value of zoledronic acid (ZA) and/or strontium-89 (Sr-89) in patients with non-small-cell lung cancer (NSCLC) with asymptomatic bone metastases (BMs).

PATIENTS AND METHODS

Eligible patients were those with resectable NSCLC and asymptomatic BMs. These candidates were randomized into 4 groups: group A was treated with ZA and Sr-89 simultaneously, group B was treated with ZA, group C was treated with Sr-89, and group D was untreated. Patients were monitored and analyzed for the first skeletal-related event (SRE), overall survival (OS), and annual incidence of SREs.

RESULTS

One hundred eighty patients were enrolled. Time to first SRE in group A was 15 months (95% confidence interval [CI], 14.0-16.0 months), in group B it was 12 months (95% CI, 11.1-13.0 months), in group C it was 9 months (95% CI, 8.5-9.5 months), and in group D it was 8 months (95% CI, 7.1-8.9 months) (P = .000). The overall survival (OS) in group A was 17 months (95% CI, 16.0-18.1 months); in group B, it was 16 months (95% CI, 14.2-17.8 months); in group C, it was 12 months (95% CI, 11.1-12.9 months); and in group D, it was 12 months (95% CI, 10.8-13.2 months). The annual incidence of SREs in group A was 24.4%; in group B, it was 55.6%; in group C, it was 75.6%; in group D, it was 91.1% (P = .000).

CONCLUSIONS

Treatment with ZA and/or Sr-89 significantly extended the time to first SRE as well as survival time and reduced the annual incidence of SREs. Treatment with the combined use of ZA and Sr-89 was safe and well tolerated and achieved the best effect on asymptomatic BMs of NSCLC.

Bisphosphonates in the treatment of patients with lung cancer and metastatic bone disease: a systematic review and meta-analysis

PURPOSE

Bisphosphonates are known to prevent skeletal-related events (SREs) in advanced breast cancer, prostate cancer, and multiple myeloma. This systematic review assessed the efficacy of bisphosphonates in preventing SREs, controlling pain, and overall survival in patients with bone metastases from lung cancer.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library databases through November 10, 2011 for controlled trials that included lung cancer patients with bone metastases treated with bisphosphonates. Two reviewers independently extracted data on pain control, survival, and SREs and evaluated the quality of each study. Meta-analyses were performed when there were two or more trials with similar outcomes.

RESULTS

Twelve trials met our inclusion criteria and included 1,767 patients. Studies were placebo-controlled, or had compared bisphosphonates with other modalities (chemotherapy, radiation therapy, or radioisotope therapy), or had used different bisphosphonates as active controls. Randomized controlled trials did not report adequate descriptions of randomization procedures, allocation concealment, and blinding, resulting in low-quality scores. Patients treated with zoledronic acid + chemotherapy had fewer SREs than those receiving chemotherapy alone (relative risk (RR) 0.81, 95 % confidence interval (CI) 0.67-0.97). Pain control improved when a bisphosphonate was added to another treatment modality (chemotherapy or radiation; RR 1.18, 95 %CI 1.0-1.4). Bisphosphonate therapy improved survival compared to controls, but the difference failed to reach statistical significance (mean of 72 days, 95 %CI -8.9 to 152.9).

CONCLUSIONS

Treatment with bisphosphonates reduced SREs, improved pain control, and showed a trend to increased survival. Bisphosphonates should be used in the treatment of patients with lung cancer and bone metastases.

Pharmacoeconomics of bisphosphonates for skeletal-related event prevention in metastatic non-breast solid tumours

Bisphosphonates reduce the risk of skeletal-related events (SREs; i.e. spinal cord compression, pathological fracture, radiation or surgery to the bone, and hypercalcaemia) in patients with metastatic cancer. A number of analyses have been conducted to assess the cost effectiveness of bisphosphonates in patients with bone metastases secondary to breast cancer, but few in other solid tumours. This is a review of cost-effectiveness analyses in patients with non-breast solid tumours and bone metastases. A literature search was conducted to identify cost-effectiveness analyses reporting the cost per QALY gained of bisphosphonates in patients with metastatic bone disease secondary to non-breast solid tumours. Four analyses met inclusion criteria. These included two in prostate cancer (one of which used a global perspective but expressed results in $US, and the other reported from a multiple country perspective: France, Germany, Portugal and the Netherlands). The remaining analyses were in lung cancer (in the UK, France, Germany, Portugal and the Netherlands), and renal cell carcinoma (in the UK, France and Germany). In each analysis, the cost effectiveness of zoledronic acid versus placebo was analysed. Zoledronic acid was found to be cost effective in all European countries across all three indications but not in the sole global prostate cancer analysis. Across countries and indications, assumptions regarding patient survival, drug cost and baseline utility (i.e. patient utility with metastatic disease but without an SRE) were the most robust drivers of modelled estimates. Assumptions of SRE-related costs were most often the second strongest cost driver. Further review indicated that particular attention should be paid to the inclusion or exclusion of nonsignificant survival benefits, whether health state utilities were elicited from community or patient samples or author assumptions, delineation between symptomatic and asymptomatic SREs, and the methods with which SRE disutility was modelled over time. While the field of cost-effectiveness analysis in solid tumours other than breast cancer is still evolving, outcomes will likely continue to be driven by drug cost and assumptions regarding treatment benefits. Although considerations such as adverse events and administration costs are important, they were not found to influence cost-effectiveness estimates greatly. As zoledronic acid will lose patent protection in 2013 and subsequently be greatly reduced in price, it is likely that the field of cost effectiveness will change with regard to SRE-limiting agents. Meanwhile, research should be conducted to improve our understanding of the impact on quality of life and medical costs of preventing SREs.