Economic aspects of chemotherapy

Aspects on priority settings in cancer treatment and care

The widening gap between available resources and increasing possibilities to diagnose and treat different medical conditions has resulted in new attention to priority setting. The issue is complicated and harbours several obstacles because of different valuations concerning the needs of patient groups, the true results (patient benefit) of medical actions, and also important ethical considerations. Earlier attempts have been unsuccessful in introducing a prioritization milieu into the medical profession, probably due to vague requests for an open and sharp prioritization process. With a sharpened competition of allocating resources for different medical actions, the medical profession of the cancer sector needs to have a tool for explaining consequences for the different cancer patient groups and what is achieved by the cancer treatments and the care. A model for ranking lists consisting of pairs of patient conditions and medical actions is presented, and the principle for using these lists for priority setting in medical society is discussed.

Local treatment pattern versus trial-based data: a cost-effectiveness analysis of drotrecogin alfa (activated) in the treatment of severe sepsis in Sweden

Three methodological approaches were applied to analyze whether the cost-effectiveness of drotrecogin alfa (activated) (Xigris) as an adjunct to standard care compared with standard care alone is a cost-effective alternative for the treatment of Swedish patients with severe sepsis and organ dysfunction. Health-economic model simulations were applied to (1) Swedish treatment pattern data, (2) international trial data and local unit prices, and (3) Swedish local patient data combined with trial age structure to adjust for differences in the age structure between the trial and the Swedish patient sample. The methodological approach had no effect on the overall conclusion that the intervention was cost-effective in the treatment of Swedish patients with severe sepsis and organ dysfunction. However, the cost-effectiveness ratios were sensitive to the approach applied. The results indicate the importance of collecting not only information on local prices but also information about treatment pattern and patient characteristics when conducting country-specific health-economic model applications.

Benefit-risk assessment of irinotecan in advanced colorectal cancer

Irinotecan exerts its cytotoxic activity through inhibition of the nuclear enzyme topoisomerase I. It has been approved in most countries worldwide for treatment of patients with advanced colorectal cancer (CRC). Activity is seen in previously untreated patients and in patients refractory to fluorouracil treatment, whether it is given alone or in combination with other cytotoxic drugs. Irinotecan was first developed in patients refractory to fluorouracil. Activity in terms of tumour responses and patient benefit was seen in several phase II trials that used either a weekly or a three-weekly schedule. In two randomised trials (irinotecan vs best supportive care, and irinotecan vs an infused fluorouracil-based regimen), irinotecan prolonged median survival by approximately 2.5 months without any deterioration in quality-of-life. It was later studied in previously untreated patients with advanced CRC in combination with fluorouracil/folinic acid (leucovorin). In three large randomised trials, median time to tumour progression was prolonged by approximately 2.5 months and overall survival by about 2.5 months compared with fluorouracil/folinic acid alone. Tumour responses were also seen more frequently in the irinotecan arm (35-40% vs 20%). Again, quality-of-life scores were not deteriorated by the addition of irinotecan. Irinotecan has many acute adverse effects. The most prominent and dose limiting being diarrhoea and neutropenia. With irinotecan monotherapy, diarrhoea was seen in 80% of patients and severe grade 3 to 4 diarrhoea occurred in 30-40% of the patients. The severity of diarrhoea can be diminished by preventive actions. Less risk of diarrhoea is generally seen when irinotecan is combined with fluorouracil. Neutropenia is generally short-lived, but may be severe if diarrhoea is also present. This has been noticed particularly when irinotecan has been given in combination with a bolus fluorouracil/folinic acid regimen. Other toxicities include acute cholinergic-like symptoms, nausea and vomiting, and alopecia. In spite of these adverse effects, irinotecan has been accepted as an important first-line treatment for patients with advanced CRC, in combination with, preferably, an infused fluorouracil-based regimen, and has been approved for use as monotherapy in the second-line indication.

Out of touch or on the money: Do the clinical objectives of addiction treatment coincide with economic evaluation results?

Previous economic studies have examined the association between substance abuse treatment and reduced costs to society, but it remains uncertain whether the economic measures used in cost and benefit-cost analyses of treatment programs correspond in direction and magnitude with clinical outcomes. In response to this uncertainty, the present study analyzed a longitudinal data set of addiction treatment clients to determine the statistical agreement between clinical and economic outcomes over time. Data were collected from 1,326 clients in the Chicago cohort of the Persistent Effects of Treatment Study. These individuals were interviewed at baseline as well as at 6-, 24-, 36-, and 48-month followup periods (91.6% followup). Correlations between clinical and economic measures were generally small (rho of 0.1 to 0.3) and often became non-significant once we controlled for baseline severity. The results demonstrate that although some associations exist, outcomes should be evaluated along both clinical and economic dimensions.

Palliative treatment of patients with colorectal cancer

BACKGROUND

Metastatic colorectal cancer has a poor prognosis, and the majority of patients are left with palliative measures. The development seen using palliative chemotherapy is reviewed.

MATERIAL AND METHODS

A systematic approach to the literature-based evidence was aimed at.

RESULTS

The continuous improvements during the past 13-15 years have been documented in several large conclusive trials. At the end of the 1980s, the evidence that chemotherapy should be used at all was very limited, whereas presently most patients can be offered two lines of chemotherapy based upon good scientific evidence. Median survival has gradually improved from below 6 months to above 18 months in some recent trials. Several important issues remain to be solved, such as the best sequence of treatments, what regimens to use in various situations, when to start and when to stop if a response is seen, and whether cure may be possible in a small subset of patients.

CONCLUSIONS

Progress has been rapid in advanced colorectal cancer. This is likely a result of well-designed trials in collaboration between academy and industry, showing a great interest in the disease. Future collaborations may hopefully introduce new treatment concepts, further improving outcome.

Cost-effectiveness of preoperative radiotherapy in rectal cancer: results from the Swedish Rectal Cancer Trial

PURPOSE

The Swedish Rectal Cancer Trial (SRCT) demonstrated that a short-term regimen of high-dose fractionated preoperative radiotherapy (5 x 5 Gy) reduced the local recurrence rates and improved overall survival. This has had an impact on the primary treatment of rectal cancer. The current study investigated the cost-effectiveness of the new combined approach.

METHODS AND MATERIALS

After an 8-year follow-up, in-hospital and outpatient costs related to the treatment of rectal cancer and its complications were analyzed for 98 randomly allocated patients who participated in the SRCT from a single Swedish health care region. The costs were then related to the clinical data from the SRCT regarding complications, local and distant recurrences, and survival.

RESULTS

The total cost for a nonirradiated patient was US$30,080 compared with US$35,268 for an irradiated patient. The surgery-alone group had increased costs related to local recurrences, and the radiotherapy group had increased costs for irradiation and complications. With a survival benefit of 21 months (retrieved from the SRCT), the cost for a saved year was US$3654. Sensitivity analyses for different rates of local recurrences, the costs related to complications and less marked survival benefit showed that this figure could vary up to US$15,228.

CONCLUSION

The cost for a life-year saved in these data was US$3654. This figure could reach US$15,228 in the most pessimistic setting of the sensitivity tests, a cost still comparable with other well-accepted medical interventions.