Subgroup Economic Evaluation of Radiotherapy for Breast Cancer After Mastectomy

Cost-effectiveness of Post-Mastectomy Radiotherapy (PMRT) for breast cancer in India: An economic modelling study

Background

The role of post-mastectomy radiotherapy (PMRT) for breast cancer is controversial when 3-or-less lymph nodes are metastatic. Apart from local control, survival and toxicity, cost also plays an important role in decision-making.

Methods

A Markov model was designed to assess cost, health outcomes and cost-effectiveness of different radiotherapy techniques for management of PMRT patients. Thirty-nine scenarios were modelled based on type of radiotherapy, laterality, pathologic nodal burden, and dose fractionation. We considered a societal perspective, lifetime horizon and a 3% discount rate. The data on quality of life (QoL) was derived using the cancer database on cost and QoL. Published data on cost of services delivered in India were used.

Findings

Post-mastectomy radiotherapy results in incremental quality adjusted life years (QALYs) that ranged from -0.1 to 0.38 across different scenarios. The change in cost ranged from estimated median savings of USD 62 (95% confidence intervals: -168 to -47) to incurring an incremental cost of USD 728 (650-811) across different levels of nodal burden, breast laterality and dose fractionation. For women with node-negative disease, disease-specific systemic therapy remains to be the preferred strategy. For women with node-positive disease, two-dimensional radiotherapy (2DRT) with hypofractionation is the most cost-effective strategy. However, a CT based planning is preferred when maximum heart distance (MHD) >1cm, irregular chest wall contour and inter-field separation >18cm.

Interpretation

PMRT is cost-effective for all node-positive patients. With similar toxicity and effectiveness profile compared with conventional fractionation, moderate hypofractionation significantly reduces the cost of treatment and should be the standard of care. Conventional techniques for PMRT are cost-effective over newer modalities which provide minimal additional benefit, at high cost.

Funding

The funding to collect primary data for study was provided by Department of Health Research, Ministry of Health and Family Welfare, New Delhi, wide letter number F. No. T.11011/02/2017-HR/3100291.

Quantifying Societal Burden of Radiation-Induced Cardiovascular Events in Breast Cancer Survivors

Background and Purpose

Radiation-induced cardiotoxicity is an important health concern for clinicians during treatment of breast cancer (BC) patients. Underlying mechanisms are well-documented, whereas little is known about the societal impact of this long-term effect. This study aimed to quantify the additional burden of radiation-induced cardiovascular (CV) diseases in BC survivors.

Materials and Methods

Conventional health economic modelling techniques were applied to estimate attributed CV-related costs and disutility in a hypothetical cohort of BC survivors. A situation in which radiotherapy caused an additional CV risk was compared with a situation in which this risk was not taken into account. Uncertainty was assessed via deterministic and probabilistic sensitivity analyses. Analyses were performed from a broad societal perspective up until 20 years after BC treatment.

Results

Radiation-induced cardiotoxicity evokes a mean incremental cost of €275.10 per woman over a time horizon of 20 years after BC treatment. An additional decrement of 0.017 QALYs (per woman) might be expected when taking the radiation-induced cardiotoxic risk into account in BC survivors. Incremental costs and disutility increased with age. A scenario analysis showed that these results were more profound in women with more advanced staging.

Conclusion

Our analyses suggest that with current radiation techniques, rather minor costs and disutility are to be expected from radiation-induced cardiotoxicity in BC survivors. The cost of past investments in order to achieve current mean heart dose (MHD) seems justified when considering the gains from cost and disutility reduction resulting from radiation-induced cardiovascular events. The question we might consider is whether future opportunity costs associated with investments on further technological advancements offset the expected marginal benefit from further reducing the MHD.

Economic Evaluations of Breast Cancer Care in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

Understanding the cost of delivering breast cancer (BC) care in low- and middle-income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations.

MATERIALS AND METHODS

A systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist.

RESULTS

Ninety-one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low-income countries (2%) and countries in Sub-Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs.

CONCLUSION

There has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses.

IMPLICATIONS FOR PRACTICE

There has been substantial growth in the number of breast cancer economic evaluations in low- and middle-income countries (LMICs) in the past decade, but there remain limited data from low-income countries. Breast cancer economic evaluations should be prioritized in low-income countries and in Sub-Saharan Africa. Researchers should strive to use and report a costing perspective and time horizon that captures all costs relevant to the study objective, including those such as direct nonmedical and indirect costs. Use of existing frameworks for economic evaluations in LMICs may help achieve comparable, transparent costing analyses in order to guide breast cancer control strategies.

Cost-effectiveness of postmastectomy hypofractionated radiation therapy vs conventional fractionated radiation therapy for high-risk breast cancer

Background

The phase 3 NCT00793962 trial demonstrated that postmastectomy hypofractionated radiation therapy (HFRT) was noninferior to conventional fractionated radiation therapy (CFRT) in patients with high-risk breast cancer. This study assessed the cost-effectiveness of postmastectomy HFRT vs CFRT based on the NCT00793962 trial.

Methods

A Markov model was adopted to synthesize the medical costs and health benefits of patients with high-risk breast cancer based on data from the NCT00793962 trial. Main outcomes were discounted lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). We employed a time-dependent horizon from Chinese, French and USA payer perspectives. Model robustness was evaluated with one-way and probabilistic sensitivity analyses.

Results

Patients receiving CFRT versus HFRT gained an incremental 0.0163 QALYs, 0.0118 QALYs and 0.0028 QALYs; meanwhile an incremental cost of $2351.92, $4978.34 and $8812.70 from Chinese, French and USA payer perspectives, respectively. Thus CFRT versus HFRT yielded an ICER of $144,281.47, $420,636.10 and $3,187,955.76 per QALY from Chinese, French and USA payer perspectives, respectively. HFRT could maintain a trend of >50% probabilities of cost-effectiveness below a willingness-to-pay (WTP) of $178,882.00 in China, while HFRT was dominant relative to CFRT, regardless of the WTP values in France and the USA. Sensitivity analyses indicated that the ICERs were most sensitive to the parameters of overall survival after radiotherapy.

Conclusions

Postmastectomy HFRT could be used as a cost-effective substitute for CFRT in patients with high-risk breast cancer and should be considered in appropriately selected patients.

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HFRT is a cost-effective substitute for CFRT for women with high-risk breast cancer.

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The incremental cost-effectiveness ratio varied in a time-dependent manner and increased with the time horizon.

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Overall survival were the most influential parameter on the incremental cost-effectiveness ratio.

Ribociclib in hormone-receptor-positive advanced breast cancer: Establishing a value-based cost in China

BACKGROUND

The addition of ribociclib (RIB) to letrozole (LET) significantly increases progression free survival for patients with hormone-receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (ABC). We identified the range of drug costs for which RIB could be considered cost effective from a Chinese perspective.

METHODS

A discrete event simulation model was developed to model the treatment sequences among patients with ABC. Life years (LYs), quality-adjusted LYs (QALYs) and lifetime costs were estimated. Costs were estimated for Chinese health care systems. Three times the per capita gross domestic product (GDP) of China 2016 ($24,360) and three times the per capita GDP of Beijing city 2016 ($53,384) were used as the willingness-to-pay threshold. Probabilistic sensitivity analyses were performed.

RESULTS

In the base case analysis, RIB + LET provided an incremental survival benefit of 0.631 LYs and 0.451 QALYs. When RIB costs less than $721 or $1170 per 4 weeks, there was a nearly 90% likelihood that the incremental cost-effectiveness ratio for RIB + LET would be less than $24,360 per QALY or $53,384 per QALY, respectively.

CONCLUSION

A value-based price for the cost of RIB is $732 or $1170 per 4 weeks for China and Beijing City, respectively. Our study is helpful to inform the multilateral drug price negotiations in China that may be upcoming for RIB.

Adjuvant breast radiotherapy: How to trade-off cost and effectiveness?

INTRODUCTION

A series of health economic evaluations (HEE) has analysed the efficiency of new fractionation schedules and techniques for adjuvant breast radiotherapy. This overview assembles the available evidence and evaluates to what extent HEE-results can be compared.

METHODS

Based on a systematic literature review of HEEs from 1/1/2000 to 30/10/2016, all cost comparison (CC) and cost-effectiveness analyses (CEA) comparing different adjuvant breast radiotherapy approaches were analysed. Costs were extracted and converted to Euro 2016 and costs per QALY were summarized in cost-effectiveness planes.

RESULTS

Twenty-four publications are withheld, comparing different fractionation schedules and/or irradiation techniques or evaluating the value of adding radiotherapy. Normofractionation and intensity-modulated, interstitial or intraluminal techniques are important cost-drivers. Highest reimbursements are observed in the US, but may overestimate the real cost. Hypofractionation is cost-effective compared to normofractionation, the results of partial breast irradiation are less unequivocal. Intra-operative and external beam approaches seem the most cost-effective for favourable risk groups, but whole breast irradiation is superior in terms of health effect and omission of radiotherapy in terms of costs.

CONCLUSION

Hypofractionation may be considered the most relevant comparator for new strategies in adjuvant breast radiotherapy, with omission of radiotherapy as an interesting alternative in the very favourable subcategories, especially for partial breast techniques. Although comparison of CC and CEA is hampered by the variability in clinical and economic settings, HEE-based evidence can guide decision-making to tailor-made strategies, allocating the optimal treatment in terms of effectiveness as well as efficiency to the right indication.

A systematic review of health economic evaluation in adjuvant breast radiotherapy: Quality counted by numbers

BACKGROUND

Evolving practice in adjuvant breast radiotherapy inevitably impacts healthcare budgets. This is reflected in a rise of health economic evaluations (HEE) in this domain. The available HEE literature was analysed qualitatively and quantitatively, using available instruments.

METHODS

HEEs published between 1/1/2000 and 31/10/2016 were retrieved through a systematic search in Medline, Cochrane and Embase. A quality-assessment using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) was translated into a quantitative score and compared with Tufts Medical Centre CEA registry and Quality of Health Economic Studies (QHES) results.

RESULTS

Twenty cost-effectiveness analyses (CEA) and thirteen cost comparisons (CC) were analysed. In qualitative evaluation, valuation or justification of data sources, population heterogeneity and discussion on generalizability, in addition to declaration on funding, were often absent or incomplete. After quantification, the average CHEERS-scores were 74% (CI 66.9-81.1%) and 75.6% (CI 70.7-80.5%) for CEAs and CCs respectively. CEA-scores did not differ significantly from Tufts and QHES-scores.

CONCLUSION

Quantitative CHEERS evaluation is feasible and yields comparable results to validated instruments. HEE in adjuvant breast radiotherapy is of acceptable quality, however, further efforts are needed to improve comprehensive reporting of all data, indispensable for assessing relevance, reliability and generalizability of results.