Review of cost-effectiveness assessments of chemotherapy in adjuvant and advanced breast cancer

Assessing cost-utility of predictive biomarkers in oncology: a streamlined approach

Evaluation of cost-utility is critical in assessing the medical utility of predictive or prognostic biomarkers. Current methods involve complex state-transition models, requiring comprehensive data inputs. We propose a simplified decision-analytic tool to explore the relative effect of factors contributing to the cost-utility of a biomarker. We derived a cost-utility metric, the "test incremental cost-effectiveness ratio" (TICER) for biomarker-guided treatment compared to no biomarker use. This method uses data inputs readily accessible through clinical literature. We compared our results with traditional cost-effectiveness analysis of predictive biomarkers for established (HER2-guided trastuzumab, ALK-guided crizotinib, OncotypeDX-guided adjuvant chemotherapy) and emerging (ROS1-guided crizotinib) targeted treatments. We conducted sensitivity analysis to determine which factors had the greatest impact on TICER estimates. Base case TICER for HER2 was $149,600/quality-adjusted life year (QALY), for ALK was $22,200/QALY, and for OncotypeDX was $11,600/QALY, consistent with literature-reported estimates ($180,000/QALY, $202,800/QALY, $8900/QALY, respectively). Base case TICER for ROS1-guided crizotinib was $205,900/QALY. Generally, when treatment cost is considerably greater than biomarker testing costs, TICER is driven by clinical outcomes and health-related quality of life, while biomarker prevalence and treatment cost have a lesser effect. Our simplified decision-analytic approach produces values consistent with existing cost-effectiveness analyses. Our results suggest that biomarker value is mostly driven by the clinical efficacy of the targeted agent. A user-friendly web tool for complete TICER analysis has been made available for open use at http://medicine.yale.edu/lab/pusztai/ticer/ .

Impact of uncertainty on cost-effectiveness analysis of medical strategies: The case of high-dose chemotherapy for breast cancer patients

Objectives: The object of this study was to determine, taking into account uncertainty on cost and outcome parameters, the cost-effectiveness of high-dose chemotherapy (HDC) compared with conventional chemotherapy for advanced breast cancer patients.

Methods: An analysis was conducted for 300 patients included in a randomized clinical trial designed to evaluate the benefits, in terms of disease-free survival and overall survival, of adding a single course of HDC to a four-cycle conventional-dose chemotherapy for breast cancer patients with axillary lymph node invasion. Costs were estimated from a detailed observation of physical quantities consumed, and the Kaplan–Meier method was used to evaluate mean survival times. Incremental cost-effectiveness ratios were evaluated successively considering disease-free survival and overall survival outcomes. Handling of uncertainty consisted in construction of confidence intervals for these ratios, using the truncated Fieller method.

Results: The cost per disease-free life year gained was evaluated at 13,074€, a value that seems to be acceptable to society. However, handling uncertainty shows that the upper bound of the confidence interval is around 38,000€, which is nearly three times higher. Moreover, as no difference was demonstrated in overall survival between treatments, cost-effectiveness analysis, that is a cost minimization, indicated that the intensive treatment is a dominated strategy involving an extra cost of 7,400€, for no added benefit.

Conclusions: Adding a single course of HDC led to a clinical benefit in terms of disease-free survival for an additional cost that seems to be acceptable, considering the point estimate of the ratio. However, handling uncertainty indicates a maximum ratio for which conclusions have to be discussed.

Economic evaluation of aromatase inhibitors for the treatment of breast cancer

Breast cancer affects 1 million women a year. Hormonal therapy has been a mainstay of treatment for women with hormone-sensitive breast cancer. The newer class of aromatase inhibitors has challenged the use of the previous standard agent, tamoxifen, in the treatment and prevention of breast cancer. This article will provide a thorough review of the literature on the newer generation aromatase inhibitors and examine their role in metastatic, adjuvant, neoadjuvant and prevention settings. An in-depth review of the cost-efficiency analyses is also performed. Recent studies on the newer, third-generation aromatase inhibitors have challenged the previous gold standard (tamoxifen) in the prevention and management of hormone-sensitive breast cancer in postmenopausal women. These studies have supported the use of aromatase inhibitors as first-line therapy in both early (adjuvant) and advanced breast cancer management. Whether aromatase inhibitors should replace tamoxifen in these settings is still a matter of debate. Augmenting these studies and providing additional information to the debate are pharmacoeconomic appraisals, which help to place a societal value on newer therapies as compared with the previously established therapy. This review discusses the pharmacology and efficacy of the newer aromatase inhibitors as it applies to their role in the metastatic, adjuvant, neoadjuvant and prevention settings. The pharmacoeconomic studies performed on these agents are also discussed.

Costs of high-dose chemotherapy and peripheral blood progenitor cell autograft for breast cancer

The aim of the study was to analyze the real cost of single or tandem high-dose chemotherapy (HDC) and peripheral blood progenitor cell autologous transplant (PBPCT) in patients with breast cancer. We analyzed the costs of 40 PBPCT performed in 20 patients. Tandem transplant was planned for each patient. Resources used and direct costs were identified for each patient. The study was carried out using the hospital perspective and monetary values were reported in 1999 Euro. The mean cost of whole procedure for single transplant was 20,816.63 Euro, while the mean cost of tandem transplant was 38,770.83 Euro. The cost distribution in the two groups was similar: the most expensive phase of procedure was the supportive phase post transplant (about 60% of total cost), with the categories of cost most represented being professional fees (about 28%) and pharmacy (about 35%). Awaiting more convincing trials of the clinical advantage of HDC in breast cancer, our analytical evaluation of transplant costs for different therapeutic options, single or tandem, permits identification of the most expensive categories in order to intervene for cost savings.

Carcinoma of the male breast

Male breast cancer accounts for less than 1% of all breast cancers in the United States. The low incidence of this disease prevents therapeutic questions from being addressed in prospective randomized trials. As such, treatment algorithms have generally been extrapolated from those used in female breast cancer. Similar to female breast cancer, lymph node involvement and the size of the primary tumor are the most important factors in predicting disease-free and overall survival. Modified radical mastectomy remains the standard local therapeutic approach, with radiation therapy indicated for patients who have clinicopathologic features associated with a high risk for postmastectomy chest wall or lymph node recurrence. Similar to female breast cancer, adjuvant chemotherapy or hormonal therapy is indicated in the majority of men with breast cancer, specifically those with tumors larger than 1 cm or those with lymph node-positive disease.