Derivation of Utility Values from European Organization for Research and Treatment of Cancer Quality of Life-Core 30 Questionnaire Values in Lung Cancer

Comparing the EORTC QLQ-LC13, EORTC QLQ-LC29, and the FACT-L for assessment of quality of life in patients with lung cancer - an updated systematic review

PURPOSE OF REVIEW

Two commonly used quality of life (QoL) questionnaires in lung cancer patients are the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Lung Cancer 13 (QLQ-LC13) and the Functional Assessment of Cancer Therapy-Lung (FACT-L). More recently, the EORTC QLQ-LC29 was developed. This systematic review compares the EORTC QLQ-LC29, EORTC QLQ-LC13 and FACT-L in terms of the content, validity and psychometric properties in assessing the QoL of lung cancer patients.

RECENT FINDINGS

Fourteen studies were included. The EORTC QLQ-LC29 is a 29-item scale that serves as an update of the EORTC QLQ-LC13 to include symptoms from surgery and new targeted therapies. It shows validity, high internal consistency, test-retest reliability, and sensitivity. The FACT-L continues to assess general quality of life and lung cancer-specific symptoms.

SUMMARY

The EORTC QLQ-LC29, EORTC QLQ-LC13, and FACT-L were reviewed to assess their validity in measuring QoL of lung cancer patients. All were found to be sufficiently validated, The choice of which to use should depend on the primary goals of the study.

Using a Sample Size Calculation Framework for Clinical Prediction Models When Developing and Selecting Mapping Algorithms Based on Linear Regression

PURPOSE

To propose using a framework for calculating the sample size for clinical prediction models when developing and selecting mapping algorithms from a health-related quality-of-life (HRQOL) measure onto the score of a preference-based measure (PBM) using linear regression.

METHODS

The framework was summarized for health economics researchers. Mapping studies that mapped the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 onto the EQ-5D-3L index using linear regression were evaluated in terms of sample size. The required sample size for each study was calculated using 4 criteria: global shrinkage factor ≥ 0.9, difference between the apparent and adjusted R2 ≤ 0.05, multiplicative margin of error in the estimated residual standard deviation ≤ 1.1, and absolute margin of error in the estimated model intercept ≤ 0.025.

RESULTS

Ten mapping studies were identified. The information required to calculate the sample size was successfully extracted from previous mapping studies. Four of 10 mapping studies did not have sufficient sample sizes.

LIMITATIONS

Further extension of this framework to other regression approaches used in mapping studies is necessary.

CONCLUSIONS

The sample size should be considered when developing and selecting a mapping algorithm based on linear regression.

HIGHLIGHTS

No recommendation or guidance is available for the sample size to develop and select a mapping algorithm from a health-related quality-of-life measure onto the score of a preference-based measure.This research proposes using a framework for calculating the sample size for clinical prediction models in sample size consideration for mapping algorithms using linear regression.A survey showed that the information required to calculate the sample size could be successfully extracted from previous mapping studies and that 4 of 10 mapping studies did not have sufficient sample sizes.

Health State Utility Values in Early-Stage Non-small Cell Lung Cancer: A Systematic Literature Review

BACKGROUND

Non-small cell lung cancer (NSCLC) is the predominant histological subtype of lung cancer and is the leading cause of cancer-related deaths globally. Quality of life is an important consideration for patients and current treatments can adversely affect health-related quality of life (HRQoL).

OBJECTIVE

The objectives of this systematic literature review (SLR) were to identify and provide a comprehensive catalogue of published health state utility values (HSUVs) in patients with early-stage NSCLC and to understand the factors impacting on HSUVs in this indication.

METHODS

Electronic searches of Embase, MEDLINE and Evidence-Based Medicine Reviews were conducted via the Ovid platform in March 2021 and June 2022 and were supplemented by grey literature searches of conference proceedings, reference lists, health technology assessment bodies, and other relevant sources. Eligibility criteria were based on patients with early-stage (stage I-III) resectable NSCLC receiving treatment in the adjuvant or neoadjuvant setting. No restriction was placed on interventions or comparators, geography, or publication date. English language publications or non-English language publications with an English abstract were of primary interest. A validated checklist was applied to conduct quality assessment of the full publications.

RESULTS

Twenty-nine publications (27 full publications and two conference abstracts) met all eligibility criteria and reported 217 HSUVs and seven disutilities associated with patients with early NSCLC. The data showed that increasing disease stage is associated with decreasing HRQoL. It was also indicated that utility values vary by treatment approach; however, the choice of treatment may be influenced by the patients' disease stage at presentation. Few studies aligned with the requirements of health technology assessment (HTA) bodies, indicating a need for future studies to conform to these preferences, making them suitable for use in economic evaluations.

CONCLUSIONS

This SLR found that disease stage and treatment approach were two of several factors that can impact patient-reported HRQoL. Additional studies are warranted to confirm these findings and to investigate emerging therapies for early NSCLC. In collecting a catalogue of HSUV data, this SLR has begun to identify the challenges associated with identifying reliable utility value estimates suitable for use in economic evaluations of early NSCLC.

Prediction study of prognostic nutrition index on the quality of life of patients with cervical cancer undergoing radiotherapy and chemotherapy

Objective

To assess the prognostic nutritional index (PNI) and quality of life (QOL) of patients with cervical cancer (CC) who underwent radiotherapy and chemotherapy and to reveal the effect of PNI on QOL and its prognostic value.

Methods

A total of 138 CC patients who underwent radiotherapy and chemotherapy in the Second Affiliated Hospital of Fujian Medical University from January 2020 to October 2022 were selected as the study subjects via convenient sampling. According to the PNI cut-off value of 48.8, they were divided into a high-PNI group and a low-PNI group, and the quality of life of the two groups was compared. The Kaplan-Meier method was used to draw the survival curve, and the Log-Rank test was employed to compare the survival rates of the two groups.

Results

The scores of physical functioning and overall QOL in the high-PNI group were significantly higher than those in the low-PNI group (P < 0.05). The scores of fatigue, nausea and vomiting, pain and diarrhea were higher than those in the low-PNI group, and the difference was statistically significant (P < 0.05). The objective response rates were 96.77% and 81.25% in the high-PNI group and the low-PNI group, respectively, and the difference was statistically significant (P = 0.045). The 1-year survival rates of patients with high PNI and low PNI were 92.55% and 72.56% in the high-PNI group and the low-PNI group, respectively; the difference in survival rates was statistically significant (P = 0.006).

Conclusion

The overall quality of life of CC patients with low PNI receiving radiotherapy and chemotherapy is lower than that of patients with high PNI. Low PNI reduces the tolerance to radiotherapy and chemotherapy and the objective response rate, which can be used as a prognostic indicator for cervical cancer patients.

Cost-effectiveness of first-line immunotherapies for advanced non-small cell lung cancer

BACKGROUND

Researchers have not simultaneously compared the cost-effectiveness of six immunotherapies with chemotherapy for advanced non-small cell lung cancer. This study evaluated the cost-effectiveness across different programmed death-ligand 1 (PD-L1) levels.

METHODS

A Markov model with lifetime horizon was created for seven regimens: pembrolizumab plus chemotherapy (pembro-chemo), nivolumab plus ipilimumab (nivo-ipi), nivolumab, ipilimumab plus chemotherapy (nivo-ipi-chemo), atezolizumab plus chemotherapy (atezo-chemo), atezolizumab, bevacizumab plus chemotherapy (atezo-beva-chemo), single-agent pembrolizumab, and chemotherapy alone. Input parameters were derived from trial data, a network meta-analysis, and other literature. We conducted the analysis from the perspective of US health care sector.

RESULTS

For all patients without considering PD-L1 expression, the incremental cost-effectiveness ratio (ICER) of pembro-chemo versus chemotherapy was $183,299 per quality-adjusted life year (QALY). The preferred regimens based on ICERs differed by PD-L1 levels. For patients with PD-L1 ≥50%, pembrolizumab versus chemotherapy and pembro-chemo versus pembrolizumab resulted in ICERs of $96,189 and $198,913 per QALY, respectively. The other strategies were dominated. For patients with PD-L1 of 1%-49%, the ICER of pembro-chemo comparing to chemotherapy was $218,159 per QALY. The other regimens were dominated by pembro-chemo. For patients with PD-L1 <1%, nivo-ipi versus chemotherapy and nivo-ipi-chemo versus nivo-ipi resulted in ICERs of $161,277 and $881,975 per QALY, and the other regimens were dominated strategies. At the willingness-to-pay threshold of $150,000 per QALY, pembrolizumab had 87% and pembro-chemo had 1% probabilities being cost-effective in patients with PD-L1 ≥50% and 1%-49%, respectively. Nivo-ipi had a 34% probability being cost-effective in patients with PD-L1 <1%.

CONCLUSIONS

The PD-L1 level should be incorporated into treatment decision-making. Our findings suggest that first-line pembrolizumab, pembro-chemo, and nivo-ipi are the preferred strategies for patients with PD-L1 ≥50%, 1%-49%, and <1%, respectively.

Cost-effectiveness analysis of adjuvant atezolizumab in stage II-IIIA non-small cell lung cancer expressing ≥50% PD-L1: A United Kingdom health care perspective

OBJECTIVES

Atezolizumab monotherapy has marketing authorisation by the Medicines and Healthcare products Regulatory Agency as adjuvant treatment following complete resection for adults with stage II-IIIA non-small cell lung cancer (NSCLC) whose tumours have PD-L1 expression on ≥ 50% of tumour cells and whose disease has not progressed following adjuvant platinum-based chemotherapy. This study evaluated the cost-effectiveness of atezolizumab vs best supportive care (BSC) in the licensed patient population from a UK perspective.

MATERIALS AND METHODS

Patient characteristics and clinical inputs were derived from the global, randomised, open-label, phaseIII IMpower010 trial. A Markov model with the following health states was developed: disease-free survival (DFS), locoregional recurrence, first-line metastatic recurrence, second-line metastatic recurrence, and death (all partitioned based on receipt of treatment, excluding death). The base case model used a lifetime time horizon (40 years) and 3.5% discounting annually after the first year. DFS from IMpower010 was analysed with parametric survival models to extrapolate outcomes for time points beyond trial follow-up. The models were adjusted to avoid overestimating results for patients with recurrences in the longer term. Grade ≥ 3 treatment-related adverse events with incidences ≥ 2% were included. Health state utility values were derived from the literature and past NICE appraisals. Sensitivity and scenario analyses assessed uncertainty around assumptions and parameter estimates.

RESULTS

In the base case analysis, atezolizumab therapy resulted in an expected gain of 1.87 quality-adjusted life-years (QALYs) corresponding to an incremental cost-effectiveness ratio of £20,392/QALY for atezolizumab vs BSC, demonstrating cost-effectiveness. Results were most influenced by discount effects and utility in the on-treatment DFS state. Scenario analyses were consistent with the base case results.

CONCLUSION

Atezolizumab after adjuvant chemotherapy is cost-effective for adults with NSCLC in the UK.

An Item-Response Mapping from General Health Questionnaire Responses to EQ-5D-3L Using a General Population Sample from England

BACKGROUND

The 12-item General Health Questionnaire (GHQ-12) is widely used to measure mental health and well-being; however, it is not possible to estimate values on the full health = 1, dead = 0 scale used to construct quality-adjusted life-years (QALYs) from GHQ-12 responses as it is not preference-based.

OBJECTIVE

The aim of this study was to create an item-response mapping between GHQ-12 and EQ-5D-3L health states, for which several value sets exist.

METHODS

Data from the 2012 Health Survey for England with complete GHQ-12 and EQ-5D-3L descriptive system responses were used for analysis. Data were split 70/30 into estimation/test samples. Four modelling approaches, with EQ-5D-3L levels on each dimension as dependent variables and GHQ-12 responses as independent variables were assessed: non-parametric, simple ordered logit (OL), extended OL, and least absolute shrinkage and selection operator (LASSO). Approaches were assessed using Akaike and Bayesian information criteria, predictive accuracy measured using root mean squared error (RMSE), and simplicity.

RESULTS

A total of 8114 responses became 6924 after discarding missing values, with 4847 used in estimation and 2077 used for testing. LASSO had a better model fit on the pain/discomfort dimension, but no model had markedly superior predictive accuracy. The non-parametric approach was chosen for the mapping algorithm based on simplicity. Predicted and observed EQ-5D-3L values for the test sample had a correlation of 0.488. Prediction accuracy was better for GHQ-12 scores below 20 than scores above 20.

CONCLUSION

The mapping allows EQ-5D-3L responses to be predicted using GHQ-12 responses, which may be useful in estimating utility values and QALYs. An R script and Microsoft Excel spreadsheet are provided to facilitate calculations.

Economic impact of using risk models for eligibility selection to the International lung screening Trial

OBJECTIVES

Using risk models as eligibility criteria for lung screening can reduce race and sex-based disparities. We used data from the International Lung Screening Trial(ILST; NCT02871856) to compare the economic impact of using the PLCOm2012 risk model or the US Preventative Services' categorical age-smoking history-based criteria (USPSTF-2013).

MATERIALS AND METHODS

The cost-effectiveness of using PLCOm2012 versus USPSTF-2013 was evaluated with a decision analytic model based on the ILST and other screening trials. The primary outcomes were costs in 2020 International Dollars ($), quality-adjusted life-years (QALY) and incremental net benefit (INB, in $ per QALY). Secondary outcomes were selection characteristics and cancer detection rates (CDR).

RESULTS

Compared with the USPSTF-2013 criteria, the PLCOm2012 risk model resulted in $355 of cost savings per 0.2 QALYs gained (INB=$4294 at a willingness-to-pay threshold of $20 000/QALY (95 %CI: $4205-$4383). Using the risk model was more cost-effective in females at both a 1.5 % and 1.7 % 6-year risk threshold (INB=$6616 and $6112, respectively), compared with males ($5221 and $695). The PLCOm2012 model selected more females, more individuals with fewer years of formal education, and more people with other respiratory illnesses in the ILST. The CDR with the risk model was higher in females compared with the USPSTF-2013 criteria (Risk Ratio = 7.67, 95 % CI: 1.87-31.38).

CONCLUSION

The PLCOm2012 model saved costs, increased QALYs and mitigated socioeconomic and sex-based disparities in access to screening.

Cost-effectiveness of adjuvant atezolizumab versus best supportive care in the treatment of patients with resectable early-stage non-small cell lung cancer and overexpression of PD-L1

AIMS

To assess the cost-effectiveness of adjuvant atezolizumab in the treatment of early-stage NSCLC patients (stage II-IIIA) with expression PD-L1 ≥ 50% without mutations in EGFR or ALK rearrangements in Spain.

MATERIALS AND METHODS

A 5-states Markov model (DFS, locoregional recurrence, 1 L-metastatic recurrence, 2 L-metastatic recurrence, and death states) was adapted to the Spanish setting. Demographic characteristics of the hypothetical cohort, transition probabilities from the DFS state, and safety parameters were obtained from IMpower010 study (GO29527). Transition probabilities from locoregional and metastatic health states were obtained from the literature. The usual clinical practice in Spain (use of health resources, management of the disease, etc.) was obtained from a previous analysis carried out by the authors of this study. A societal perspective was considered so both direct and indirect costs were included (expressed in € of 2021). A lifetime horizon was used, so costs and health outcomes were discounted at 3% per year. Sensitivity analyses were performed to evaluate uncertainty.

RESULTS

Over a lifetime horizon, treatment with adjuvant atezolizumab provided greater effectiveness (+2.61 life years [LY] and +1.95 quality-adjusted life years [QALY]) and higher cost (€+22,538) than BSC. The incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratios (ICUR) of the analysis were €8,625/LY gained and €11,583/QALY gained, respectively. Robustness of these base-case results was confirmed by the sensitivity analyses performed. In the probabilistic sensitivity analysis, 90% of the simulations performed showed that adjuvant atezolizumab is cost-effective versus BSC, considering a threshold of €30,000/QALY.

CONCLUSIONS

Our results showed that adjuvant treatment with atezolizumab in patients with early-stage resected NSCLC with overexpression of PD-L1 and without EGFR and ALK mutations is cost-effective versus BSC as the ICERs and ICURs obtained are below the cost-effectiveness thresholds commonly considered in Spain, thus offering a new treatment alternative for these patients.

Indirect and Direct Mapping of the Cancer-Specific EORTC QLQ-C30 onto EQ-5D-5L Utility Scores

OBJECTIVE

The aim of this study was to develop a response mapping algorithm to predict EQ-5D-5L utilities from European Organisation for Research and Treatment Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) scores and compare performance with direct mapping approaches to identify the best performing algorithm.

METHODS

The Multi-Instrument Comparison dataset contains responses to both the EQ-5D-5L and QLQ-C30 questionnaires from 692 individuals with a broad range of cancers. Response mapping was conducted, fitting ordered logistic regressions to predict response levels for each of the five EQ-5D dimensions and utilities were predicted using the US and Japanese EQ-5D-5L value sets to test the algorithm performance. Various direct mapping models were fitted: ordinary least squares, tobit, two-part (TPM), adjusted limited dependent variable mixture and beta mixture models. Model assessment and recommendations regarding the best mapping algorithm was based on goodness-of-fit statistics, predictive ability (measures of error, distribution of predicted utilities) and in sample cross-validation.

RESULTS

The response mapping model performed well in terms of predictive ability and measurement error using the US or Japanese value set, with mean absolute error ranging from 0.0708 to 0.0988, and comparably to the TPM, which was the best performing direct algorithm.

CONCLUSION

The developed mapping algorithms enable the prediction of EQ-5D-5L utilities from QLQ-C30 scores when EQ-5D-5L data have not been directly collected in clinical trials. The response mapping model offers the possibility of predicting EQ-5D-5L utility values using any national value set and can be generalised to multiple countries and oncology settings.

Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes.

OBJECTIVES

To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes.

DESIGN

Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results.

SETTING

Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes.

PARTICIPANTS

Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes.

INTERVENTIONS

Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies.

MAIN OUTCOME MEASURES

Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events.

DATA SOURCES

Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019.

REVIEW METHODS

Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model.

RESULTS

Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard.

LIMITATIONS

Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified.

CONCLUSIONS

Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK.

FUTURE WORK

Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041302.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 59. See the NIHR Journals Library website for further project information.

Current Status of Research on the Mapping Function of Health Utility Values in the Asia Pacific Region: A Systematic Review

OBJECTIVES

This systematic review aimed to analyze the published studies on the use of the mapping method between generic scales and disease-specific scales as well as between 2 universal scales.

METHODS

A systematic literature search was conducted using PubMed, ScienceDirect, Web of Science, CNKI, Weipa Database, Wanfang Database, and HERC Database to collect articles about the application of the mapping method to the measurement of health utility value from January 2000 to December 2019.

RESULTS

Overall, 59 articles met the inclusion requirements, and most of them were a mapping study between a disease-specific scale and a generic scale. Then all these articles were classified by the following study types: a clear functional relationship; unclear functional relationship; disease-specific scale and universality; mapping between generic scales and disease-specific scales, and mapping between universal scales. Most studies derived the best mapping model from the ordinary least squares regression, and fewer studies chose to use new regression methods. Sample sizes in the retrieved studies generally affected the reliability of the study results.

CONCLUSIONS

In recent years, as more attention has been paid to the research of the mapping method, a large number of problems have followed, such as the selection of scale types, the coverage of the study sample, and the selection of evaluation index of model performance and sample size. It is hoped that these problems can be properly solved in the future research.

Assessing the Value of Cemiplimab for Adults With Advanced Cutaneous Squamous Cell Carcinoma: A Cost-Effectiveness Analysis

OBJECTIVES

To evaluate the cost-effectiveness of cemiplimab in patients with advanced cutaneous squamous cell carcinoma (CSCC) from a payer perspective in the United States.

METHODS

A partitioned survival model was developed to assess the cost-effectiveness of cemiplimab versus historical standard of care (SOC). All inputs were identified based on a systematic literature review, supplemented by expert opinion where necessary. Clinical inputs for cemiplimab were based on individual patient data from a cemiplimab phase 2 single-arm trial (NCT27060498). For SOC, analysis was based on a pooled analysis of single-arm clinical trials and retrospective studies evaluating chemotherapy and epidermal growth factor receptor inhibitors (cetuximab, erlotinib, and gefitinib) identified via a systematic literature review (6 of the 27 included studies). Overall survival and progression-free survival were extrapolated over a lifetime horizon. Costs were included for drug acquisition, drug administration, management of adverse events, subsequent therapy, disease management, and terminal care. Unit costs were based on published 2019 US list prices.

RESULTS

In the base case, cemiplimab versus SOC resulted in an incremental cost-effectiveness ratio of $99 447 per quality adjusted-life year (QALY), where incremental costs and QALYs were $372 108 and 3.74, respectively. At a willingness-to-pay threshold of $150 000/QALY, the probabilistic sensitivity analysis suggests a 90% probability that cemiplimab is cost-effective compared to SOC. Scenario analyses resulted in incremental cost-effectiveness ratios ranging from $90 590 to $148 738.

CONCLUSIONS

Compared with historical SOC, cemiplimab is a cost-effective use of US payer resources for the treatment of advanced CSCC and is expected to provide value for money.

Mapping of the EORTC QLQ-C30 to EQ-5D-5L index in patients with lymphomas

OBJECTIVE

The objective of this study was to develop algorithms to map the EORTC QLQ-C30 (QLQ-C30) onto EQ-5D-5L in a sample of patients with lymphomas.

METHODS

An online nationwide survey of patients with lymphoma was carried out in China. Ordinary least squares (OLS), beta-based mixture, adjusted limited dependent variable mixture regression, and a Tobit regression model were used to develop the mapping algorithms. The QLQ-C30 subscales/items, their squared and interaction terms, and respondents' demographic variables were used as independent variables. The root mean square error (RMSE), mean absolute error (MAE), and R-squared (R²) were estimated based on tenfold cross-validation to assess the predictive ability of the selected models.

RESULTS

Data of 2222/4068 respondents who self-completed the online survey were elicited for analyses. The mean EQ-5D-5L index score was 0.81 (SD 0.21, range - 0.81-1.0). 19.98% of respondents reported an index score at 1.0. In total, 72 models were generated based on four regression methods. According to the RMSE, MAE and R², the OLS model including QLQ-C30 subscales, squared terms, interaction terms, and demographic variables showed the best fit for overall and the Non-Hodgkin's lymphoma sample; for Hodgkin's lymphoma, the ALDVMM with 1-component model, including QLQ-C30 subscales, squared terms, interaction terms, and demographic variables, showed a better fit than the other models.

CONCLUSION

The mapping algorithms enable the EQ-5D-5L index scores to be predicted by QLQ-C30 subscale/item scores with good precision in patients living with lymphomas.

Mapping EORTC-QLQ-C30 and QLQ-CR29 onto EQ-5D-5L in Colorectal Cancer Patients

PURPOSE

Patient-level utility data are needed for cost-utility analysis; in oncology, however, the data are commonly gathered using disease-specific questionnaires that are often not appropriate. Present study aimed to derive an algorithm which can map the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) scales and the Colorectal Cancer-Specific Quality Of Life Questionnaire (QLQ-CR29) scales onto the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) values in patients with colorectal cancer (CRC).

METHODS

Using the Ordinary Least Square (OLS) model, a cross-sectional dataset of 252 patients with CRC were gathered from three academic centers of cancer treatment in Tehran in 2017. The predicted R² (Pred R²) and adjusted R² (Adj R²) are used to evaluate model goodness of fit. Additionally, mean absolute error (MAE), root mean square error (RMSE), Spearman's correlation coefficients (ρ), and intraclass correlation (ICC) are applied to assess predictive ability of models. The tenfold cross-validation procedure was applied for validation models.

RESULTS

According to the results of our study, the model C4 from EORTC QLQ-C30 was the best predictive model (Pred R² = 66.57%, Adj R² = 67.67%, RMSE = 0.10173, MAE = 0.07840). Also, the model R4 from QLQ-CR29 performed the best for EQ-5D-5L (Adj R2 = 48.42%, Pred R² = 45.54%, MAE = 0.10051, RMSE = 0.12997).

CONCLUSIONS

The mapping algorithm successfully mapped the EORTC QLQ-C30 and QLQ-CR29 scales onto the EQ-5D-5L values; therefore, it enables policymakers to convert cancer-specific questionnaires scores to the preference-based scores.

Systematic Review and Meta-Analysis of Community- and Choice-Based Health State Utility Values for Lung Cancer

BACKGROUND

Using appropriate health state utility values (HSUVs) is critical for economic evaluation of new lung cancer interventions, such as low-dose computed tomography screening and immunotherapy. Therefore, we provide a systematic review and meta-analysis of community- and choice-based HSUVs for lung cancer.

METHODS

On 6 March 2017, we conducted a systematic search of the following databases: Embase, Ovid MEDLINE, Web of Science, Cochrane CENTRAL, Google Scholar, and the School of Health and Related Research Health Utility Database. The search was updated on 17 April 2019. Studies reporting mean or median lung cancer-specific HSUVs including a measure of variance were included and assessed for relevance and validity. Studies with high relevance (i.e. community- and choice-based) were further analysed. Mean HSUVs were pooled using random-effects models for all stages, stages I-II, and stages III-IV. For studies with a control group, we calculated the disutility due to lung cancer. A sensitivity analysis included only the methodologically most comparable studies (i.e. using the EQ-5D instrument and matching tariff). Subgroup analyses were conducted by time to death, histology, sex, age, treatment modality, treatment line, and progression status.

RESULTS

We identified and analysed 27 studies of high relevance. The pooled HSUV was 0.68 (95% confidence interval [CI] 0.61-0.75) for all stages, 0.78 (95% CI 0.70-0.86) for stages I-II, and 0.69 (95% CI 0.65-0.73) for stages III-IV (p = 0.02 vs. stage I-II). Heterogeneity was present in each pooled analysis (p < 0.01; I2 = 92-99%). Disutility due to lung cancer ranged from 0.11 (95% CI 0.05-0.17) to 0.27 (95% CI 0.18-0.36). In the sensitivity analysis with the methodologically most comparable studies, stage-specific HSUVs varied by country. Such studies were only identified for Canada, China, Spain, the UK, the USA, Denmark, Germany, and Thailand. In the subgroup analysis by time to death, HSUVs for metastatic non-small-cell lung cancer ranged from 0.83 (95% CI 0.82-0.85) at ≥ 360 days from death to 0.56 (95% CI 0.46-0.66) at < 30 days from death. Among patients with metastatic non-small-cell lung cancer, HSUVs were lower for those receiving third- or fourth-line treatment and for those with progressed disease. Results of subgroup analyses by histology, sex, age, and treatment modality were ambiguous.

CONCLUSIONS

The presented evidence supports the use of stage- and country-specific HSUVs. However, such HSUVs are unavailable for most countries. Therefore, our pooled HSUVs may provide the best available stage-specific HSUVs for most countries. For metastatic non-small-cell lung cancer, adjusting for the decreased HSUVs in the last year of life may be considered, as may further stratification of HSUVs by treatment line or progression status. If required, HSUVs for other health states may be identified using our comprehensive breakdown of study characteristics.

Meeting psychosocial needs to improve health: a prospective cohort study

Background

Cancer impacts on patients and their families across a range of different domains. For that reason, optimal cancer care has moved away from a disease-centric focus to a more holistic approach in order to proactively support people with their individual needs and concerns. While international policy clearly advocates this agenda, implementation into routine care is limited. Therefore, relevant interventions that measurably improve patient outcomes are essential to understand if this ideal is to become routine multidisciplinary practice. The aim of this study was to analyse the impact of a proactive, holistic, community-based intervention on health-related quality of life in a cohort of people diagnosed with cancer. Secondary aim was to explore the relationship between changes in health status and: cancer type, cancer stage, number of concerns expressed and change in severity of concerns pre and post intervention.

Method

Prospective observational cohort study. A convenience sample of 437 individuals were referred to the service ‘Improving the Cancer Journey (ICJ) in the UK. Each completed the Euroqol EQ-5D-3 L and visual analogue scale (VAS) and a Holistic Needs Assessment (HNA) during initial visit to the service and again at follow-up review, median 84 days later. Change between scores was tested with paired t-tests and relationships between variables with multiple regression models with heteroscedasticity-consistent standard errors.

Results

Participants were White British with median age between 50 and 64 years. Cancer type and stage were varied. EQ-5D utility scores improved at follow-up by 0.121 [0.0891–0.153], p < .001, and VAS scores improved by 7.81 [5.88–9.74], p < .001. The strongest predictor of change was a decrease in severity of concerns. Cancer stage ‘palliative care’ contributed to a reduction in health status.

Conclusion

This study is the first to show that a holistic community intervention dedicated to supporting the individual concerns of participants had both a statistically significant and clinically meaningful impact on participants’ health-related quality of life. The mean change in EQ-5D scores was more than the ‘minimally important clinical difference’ described in the literature. This is important because while quality of life has multiple determinants, this study has shown for the first time that it is possible to capture a clinically meaningful improvement as a function of reducing someone’s personally identified concerns.

'Mapping' Health State Utility Values from Non-preference-Based Measures: A Systematic Literature Review in Rare Diseases

BACKGROUND

The use of patient-reported outcome measures (PROMs) to monitor the effects of disease and treatment on patient symptomatology and daily life is increasing in rare diseases (RDs) (i.e. those affecting less than one in 2000 people); however, these instruments seldom yield health state utility values (HSUVs) for cost-utility analyses. In such a context, 'mapping' allows HSUVs to be obtained by establishing a statistical relationship between a 'source' (e.g. a disease-specific PROM) and a 'target' preference-based measure [e.g. the EuroQol-5 Dimension (EQ-5D) tool].

OBJECTIVE

This study aimed to systematically review all published studies using 'mapping' to derive HSUVs from non-preference-based measures in RDs, and identify any critical issues related to the main features of RDs, which are characterised by small, heterogeneous, and geographically dispersed patient populations.

METHODS

The following databases were searched during the first half of 2019 without time, study design, or language restrictions: MEDLINE (via PubMed), the School of Health and Related Research Health Utility Database (ScHARRHUD), and the Health Economics Research Centre (HERC) database of mapping studies (version 7.0). The keywords combined terms related to 'mapping' with Orphanet's list of RD indications (e.g. 'acromegaly') in addition to 'rare' and 'orphan'. 'Very rare' diseases (i.e. those with fewer than 1000 cases or families documented in the medical literature) were excluded from the searches. A predefined, pilot-tested extraction template (in Excel^®) was used to collect structured information from the studies.

RESULTS

Two groups of studies were identified in the review. The first group (n = 19) developed novel mapping algorithms in 13 different RDs. As a target measure, the majority used EQ-5D, and the others used the Short-Form Six-Dimension (SF-6D) and 15D; most studies adopted ordinary least squares (OLS) regression. The second group of studies (n = 9) applied previously published algorithms in non-RDs to comparable RDs, mainly in the field of cancer. The critical issues relating to 'mapping' in RDs included the availability of very few studies, the relatively high number of cancer studies, and the absence of research in paediatric RDs. Moreover, the reviewed studies recruited small samples, showed a limited overlap between RD-specific and generic PROMs, and highlighted the presence of cultural and linguistic factors influencing results in multi-country studies. Lastly, the application of existing algorithms developed in non-RDs tended to produce inaccuracies at the bottom of the EQ-5D scale, due to the greater severity of RDs.

CONCLUSIONS

More research is encouraged to develop algorithms for a broader spectrum of RDs (including those affecting young children), improve mapping study quality, test the generalisability of algorithms developed in non-RDs (e.g. HIV) to rare variants or evolutions of the same condition (e.g. AIDS wasting syndrome), and verify the robustness of results when mapped HSUVs are used in cost-utility models.

Converting EORTC QLQ-C30 scores to utility scores in the brigatinib ALTA study

Aims: Health utilities summarize a patient's overall health status. This study estimated utilities based on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30), a widely used measure of health-related quality-of-life (HRQoL) in oncology, using published mapping algorithms. Materials and methods: Data were from the Anaplastic Lymphoma Kinase (ALK) in Lung Cancer Trial of brigatinib (ALTA; NCT02094573), an open-label, international, phase 2 study. ALTA evaluated the efficacy and safety of two randomized dosing regimens of brigatinib in patients with locally advanced or metastatic ALK + non-small cell lung cancer (NSCLC) that had progressed on prior therapy with crizotinib. QLQ-C30 scores were mapped to European Quality-of-Life-5 Dimensions (EQ-5D) utility scores using two published algorithms (Khan et al. for EQ-5D-5L; Longworth et al. for EQ-5D-3L). The impact of brigatinib treatment on health utilities over time was assessed. Results: The analysis included 208 subjects. Mean baseline utility scores for both algorithms ranged between 0.60 - 0.71 and increased to 0.78 by cycle 5. Utility improvements were sustained during most of the treatment, before disease progression. Minor variations were observed between utility scores; Khan et al. estimates were approximately 0.01 or 0.02 points lower than Longworth et al. estimates. Limitations: Algorithms considered were limited to those available in the published literature at the time of the study. This utility analysis was exploratory, and the ALTA trial did not include an internal control group (i.e. standard of care) and was not powered to detect differences in QoL/utility outcomes between treatment arms. Conclusions: Converting QLQ-C30 scores into utilities in trials using established mapping algorithms can improve evaluation of medicines from the patient perspective. Both algorithms suggested that brigatinib improved health utility in crizotinib-refractory ALK + NSCLC patients, and improvements were maintained during most of the treatment. Clinicaltrials.gov identifier: NCT02094573.

Dynamic Changes of Health Utility in Lung Cancer Patients Receiving Different Treatments: A 7-Year Follow-up

INTRODUCTION

This study aimed to estimate the utility values of all subtypes of lung cancer. The trajectories after different kinds of treatments and their major determinants were explored on the basis of real-world data and repeated measurements.

METHODS

From 2011 to 2017, all patients with lung cancer who visited a medical center were invited to fill out the EuroQol Five-Dimension and WHO Quality of Life-Brief questionnaires at each visit. Utility values of quality of life (QoL) after diagnosis and treatments were depicted using a kernel smoothing method. We constructed linear mixed models to predict health utility in each time period and cross-validated them with domain scores of the WHO Quality of Life-Brief.

RESULTS

A total of 1715 patients were enrolled, with 6762 QoL measurements. Utility values were lower in patients with advanced-stage disease and older patients. Patients receiving second-line targeted therapy showed higher utility values at 0 to 3 months, 3 to 6 months, and 6 months and beyond (0.89, 0.90, and 0.88, respectively) than did those undergoing chemotherapy (0.81, 0.85, and 0.80, respectively). After using mixed models to control confounders, including poor performance status and disease progression, patients receiving second-line chemotherapy showed health utility similar to that at quasi-baseline, whereas utility values related to second-line targeted therapy were higher at 3 to 6 months and 6 months and beyond (β = 0.07, p = 0.010 and β = 0.07, p < 0.001, respectively). There was convergent validity between the utility values and scores of the physical and psychological domains.

CONCLUSION

Targeted therapy provided treated patients with a higher health utility value than was provided to those treated with chemotherapy. Development of the longitudinal trajectory may help predict changes in QoL and improve the care of lung cancer survivors.

An Updated Systematic Review of Studies Mapping (or Cross-Walking) Measures of Health-Related Quality of Life to Generic Preference-Based Measures to Generate Utility Values

BACKGROUND

Mapping is an increasingly common method used to predict instrument-specific preference-based health-state utility values (HSUVs) from data obtained from another health-related quality of life (HRQoL) measure. There have been several methodological developments in this area since a previous review up to 2007.

OBJECTIVE

To provide an updated review of all mapping studies that map from HRQoL measures to target generic preference-based measures (EQ-5D measures, SF-6D, HUI measures, QWB, AQoL measures, 15D/16D/17D, CHU-9D) published from January 2007 to October 2018.

DATA SOURCES

A systematic review of English language articles using a variety of approaches: searching electronic and utilities databases, citation searching, targeted journal and website searches.

STUDY SELECTION

Full papers of studies that mapped from one health measure to a target preference-based measure using formal statistical regression techniques.

DATA EXTRACTION

Undertaken by four authors using predefined data fields including measures, data used, econometric models and assessment of predictive ability.

RESULTS

There were 180 papers with 233 mapping functions in total. Mapping functions were generated to obtain EQ-5D-3L/EQ-5D-5L-EQ-5D-Y (n = 147), SF-6D (n = 45), AQoL-4D/AQoL-8D (n = 12), HUI2/HUI3 (n = 13), 15D (n = 8) CHU-9D (n = 4) and QWB-SA (n = 4) HSUVs. A large number of different regression methods were used with ordinary least squares (OLS) still being the most common approach (used ≥ 75% times within each preference-based measure). The majority of studies assessed the predictive ability of the mapping functions using mean absolute or root mean squared errors (n = 192, 82%), but this was lower when considering errors across different categories of severity (n = 92, 39%) and plots of predictions (n = 120, 52%).

CONCLUSIONS

The last 10 years has seen a substantial increase in the number of mapping studies and some evidence of advancement in methods with consideration of models beyond OLS and greater reporting of predictive ability of mapping functions.

Low-dose computed tomography for lung cancer screening in high-risk populations: a systematic review and economic evaluation

BACKGROUND

Diagnosis of lung cancer frequently occurs in its later stages. Low-dose computed tomography (LDCT) could detect lung cancer early.

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of LDCT lung cancer screening in high-risk populations.

DATA SOURCES

Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library.

METHODS

Clinical effectiveness - a systematic review of randomised controlled trials (RCTs) comparing LDCT screening programmes with usual care (no screening) or other imaging screening programmes [such as chest X-ray (CXR)] was conducted. Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library. Meta-analyses, including network meta-analyses, were performed. Cost-effectiveness - an independent economic model employing discrete event simulation and using a natural history model calibrated to results from a large RCT was developed. There were 12 different population eligibility criteria and four intervention frequencies [(1) single screen, (2) triple screen, (3) annual screening and (4) biennial screening] and a no-screening control arm.

RESULTS

Clinical effectiveness - 12 RCTs were included, four of which currently contribute evidence on mortality. Meta-analysis of these demonstrated that LDCT, with ≤ 9.80 years of follow-up, was associated with a non-statistically significant decrease in lung cancer mortality (pooled relative risk 0.94, 95% confidence interval 0.74 to 1.19). The findings also showed that LDCT screening demonstrated a non-statistically significant increase in all-cause mortality. Given the considerable heterogeneity detected between studies for both outcomes, the results should be treated with caution. Network meta-analysis, including six RCTs, was performed to assess the relative clinical effectiveness of LDCT, CXR and usual care. The results showed that LDCT was ranked as the best screening strategy in terms of lung cancer mortality reduction. CXR had a 99.7% probability of being the worst intervention and usual care was ranked second. Cost-effectiveness - screening programmes are predicted to be more effective than no screening, reduce lung cancer mortality and result in more lung cancer diagnoses. Screening programmes also increase costs. Screening for lung cancer is unlikely to be cost-effective at a threshold of £20,000/quality-adjusted life-year (QALY), but may be cost-effective at a threshold of £30,000/QALY. The incremental cost-effectiveness ratio for a single screen in smokers aged 60-75 years with at least a 3% risk of lung cancer is £28,169 per QALY. Sensitivity and scenario analyses were conducted. Screening was only cost-effective at a threshold of £20,000/QALY in only a minority of analyses.

LIMITATIONS

Clinical effectiveness - the largest of the included RCTs compared LDCT with CXR screening rather than no screening. Cost-effectiveness - a representative cost to the NHS of lung cancer has not been recently estimated according to key variables such as stage at diagnosis. Certain costs associated with running a screening programme have not been included.

CONCLUSIONS

LDCT screening may be clinically effective in reducing lung cancer mortality, but there is considerable uncertainty. There is evidence that a single round of screening could be considered cost-effective at conventional thresholds, but there is significant uncertainty about the effect on costs and the magnitude of benefits.

FUTURE WORK

Clinical effectiveness and cost-effectiveness estimates should be updated with the anticipated results from several ongoing RCTs [particularly the NEderlands Leuvens Longkanker Screenings ONderzoek (NELSON) screening trial].

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016048530.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Depression and Anxiety as Key Factors Associated With Quality of Life Among Lung Cancer Patients in Hai Phong, Vietnam

Background: Cancer is a leading cause of death. People living with cancer experience a variety of symptoms that might profoundly affect their quality of life (QoL). Objective: The study aims to identify factors associated with the QoL of patients with lung cancer at the oncology department of Viet Tiep Hospital, Hai Phong city, Vietnam in 2018. Methods: A cross-sectional study was conducted to collect data from lung cancer inpatients in Hai Phong city, Vietnam. The EQ-5D-5L and the EuroQol (EQ)-visual analogue scale (EQ VAS) were used to assess health-related quality of life (QoL). A multivariable regression analysis was performed on the EQ-5D utility score and the EQ VAS score as dependent variables, and socioeconomic, social support, and psychological factors as potential predictors. Results: A total of 125 lung cancer patients were enrolled in this study. The highest proportion of respondents reporting any problems was in anxiety/depression (92.8%), pain/discomfort (81.2%), usual activities (75.2%), and mobility (60%) dimensions, while the lowest percentage was in self-care dimension (40.8%). The multivariate analyses showed that a low QoL score was significantly associated with depression, incapacity to pay, low response to treatment, and presence of side effects. Conclusion: QoL of lung cancer patients is associated with anxiety/depression and other factors that can be modified by specific interventions. It is therefore possible to take care of psychological aspects to improve the QoL of Vietnamese people suffering from this condition.

Mapping the EORTC-QLQ-C30 to the EQ-5D-3L: An Assessment of Existing and Newly Developed Algorithms

Objectives. To assess the external validity of mapping algorithms for predicting EQ-5D-3L utility values from EORTC QLQ-C30 responses not previously validated and to assess whether statistical models not previously applied are better suited for mapping the EORTC QLQ-C30 to the EQ-5D-3L. Methods. In total, 3866 observations for 1719 patients from a longitudinal study (Cancer 2015) were used to validate existing algorithms. Predictive accuracy was compared to previously validated algorithms using root mean squared error, mean absolute error across the EQ-5D-3L range, and for 10 tumor-type specific samples as well as using differences between estimated quality-adjusted life years. Thirteen new algorithms were estimated using a subset of the Cancer 2015 data (3203 observations for 1419 patients) applying various linear, response mapping, beta, and mixture models. Validation was performed using 2 data sets composed of patients with varying disease severity not used in the estimation and all available algorithms ranked on their performance. Results. None of the 5 existing algorithms offer an improvement in predictive accuracy over preferred algorithms from previous validation studies. Of the newly estimated algorithms, a 2-part beta model performed the best across the validation criteria and in data sets composed of patients with different levels of disease severity. Validation results did, however, vary widely between the 2 data sets, and the most accurate algorithm appears to depend on health state severity as the distribution of observed EQ-5D-3L values varies. Linear models performed better for patients in relatively good health, whereas beta, mixture, and response mapping models performed better for patients in worse health. Conclusion. The most appropriate mapping algorithm to apply in practice may depend on the disease severity of the patient sample whose utility values are being predicted.

Systematic review of health state utility values in metastatic non-small cell lung cancer with a focus on previously treated patients

BACKGROUND

Health state utility values (HSUVs) are an important input to economic evaluations and the choice of HSUV can affect the estimate of relative cost-effectiveness between interventions. This systematic review identified utility scores for patients with metastatic non-small cell lung cancer (mNSCLC), as well as disutilities or utility decrements relevant to the experience of patients with mNSCLC, by treatment line and health state.

METHODS

The MEDLINE®, Embase and Cochrane Library databases were systematically searched (September 2016) for publications describing HSUVs in mNSCLC in any treatment line. The EQ-5D website, the School of Health and Related Research Health Utilities Database (ScHARRHUD) and major pharmacoeconomic and clinical conferences in 2015-2016 were also queried. Studies in adults with previously treated mNSCLC were selected for further analysis. The information extracted included study design, description of treatment and health state, respondent details, instrument and tariff, HSUV or (dis) utility decrement estimates, quality of study, and appropriateness for use in economic evaluations.

RESULTS

Of 1883 references identified, 36 publications of 34 studies were included: 19 reported EQ-5D scores; eight reported HSUVs from valuations of vignettes made by members of the public using standard gamble (SG) or time trade-off (TTO); two reported SG or TTO directly elicited from patients; two reported EQ-5D visual analogue scale scores only; one reported Assessment of Quality of Life instrument scores; one reported HSUVs for caregivers to patients with mNSCLC using the 12-item Short-Form Health Survey; and one estimated HSUVs based on expert opinion. The range of HSUVs identified for comparable health states showed how differences in study type, tariff, health state and the measures used can drive variation in HSUV estimates.

CONCLUSIONS

This systematic review provides a set of published HSUVs that are relevant to the experience of adult patients previously treated for mNSCLC. Our review begins to address the challenge of identifying reliable estimates of utility values in mNSCLC that are suitable for use in economic evaluations, and also highlights how varying estimates result from differences in methodology.

Economic Analysis of Neoadjuvant Chemotherapy Versus Primary Debulking Surgery for Advanced Epithelial Ovarian Cancer Using an Aggressive Surgical Paradigm

OBJECTIVES

Neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced epithelial ovarian cancer (AEOC) remains controversial in the United States. Generalizability of existing trial results has been criticized because of less aggressive debulking procedures than commonly used in the United States. As a result, economic evaluations using input data from these trials may not accurately reflect costs and outcomes associated with more aggressive primary surgery. Using data from an ongoing trial performing aggressive debulking, we investigated the cost-effectiveness and cost-utility of NACT versus PDS for AEOC.

METHODS

A decision tree model was constructed to estimate differences in short-term outcomes and costs for a hypothetical cohort of 15,000 AEOC patients (US annual incidence of AEOC) treated with NACT versus PDS over a 1-year time horizon from a Medicare payer perspective. Outcomes included costs per cancer-related death averted, life-years and quality-adjusted life-years (QALYs) gained. Base-case probabilities, costs, and utilities were based on the Surgical Complications Related to Primary or Interval Debulking in Ovarian Neoplasms trial. Base-case analyses assumed equivalent survival; threshold analysis estimated the maximum survival difference that would result in NACT being cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds. Probabilistic sensitivity analysis was used to characterize model uncertainty.

RESULTS

Compared with PDS, NACT was associated with $142 million in cost savings, 1098 fewer cancer-related deaths, and 1355 life-years and 1715 QALYs gained, making it the dominant treatment strategy for all outcomes. In sensitivity analysis, NACT remained dominant in 99.3% of simulations. Neoadjuvant chemotherapy remained cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds if survival differences were less than 2.7 and 1.4 months, respectively.

CONCLUSIONS

In the short term, NACT is cost-saving with improved outcomes. However, if PDS provides a longer-term survival advantage, it may be cost-effective. Research is needed on the role of patient preferences in tradeoffs between survival and quality of life.

Direct Mapping of the QLQ-C30 to EQ-5D Preferences: A Comparison of Regression Methods

BACKGROUND

Several mapping or cross-walking algorithms for deriving utilities from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Cancer (EORTC QLQ-C30) scores have been published in recent years. However, the large majority used ordinary least squares (OLS) regression, which proved to be not very accurate because of the specifics of the quality-of-life measures.

OBJECTIVE

Our objective was to compare regression methods that have been used to map EuroQol 5 Dimensions 3 Levels (EQ-5D-3L) utility values from the general EORTC QLQ-C30 using OLS as a benchmark while fixing the number of explanatory variables and to explore an alternative three-part model.

METHODS

We conducted a regression analysis of predicted EQ-5D-3L utilities generated using data from an observational study in ambulatory patients with non-small-cell lung cancer in a Toronto hospital. Six alternative regression methods were compared with a simple OLS regression as benchmark. The six alternative regression models were Tobit, censored least absolute deviation, normal mixture, beta, zero-one inflated beta and a mix of piecewise OLS and logistic regression.

RESULTS

The best predictive fit was obtained by a mix of OLS regression(s) for utilities lower than 1 with a cut-off point of 0.50 and a separate binary logistic regression for utilities equal to one. Zero-one inflated beta regression was also promising. However, OLS regression proved to be the most accurate for the mean. The prediction of utilities equal to one was poor in all regression approaches.

CONCLUSIONS

Three-part regression methods that separately target low, medium and high (<0.50, 0.51-0.99 or 1) utilities seem to have better prediction power than OLS with EQ-5D-3L data, although OLS also seems quite robust. Exploration of three-part approaches compared with single (OLS) regression should be further tested in other similar datasets or using individual pooled data from various clinical or observational studies. The use of alternative goodness-of-fit measures for mapping studies and their influence on the choice of the best performing methods should also be investigated.

The Cost-Effectiveness of High-Risk Lung Cancer Screening and Drivers of Program Efficiency

INTRODUCTION

Lung cancer risk prediction models have the potential to make programs more affordable; however, the economic evidence is limited.

METHODS

Participants in the National Lung Cancer Screening Trial (NLST) were retrospectively identified with the risk prediction tool developed from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. The high-risk subgroup was assessed for lung cancer incidence and demographic characteristics compared with those in the low-risk subgroup and the Pan-Canadian Early Detection of Lung Cancer Study (PanCan), which is an observational study that was high-risk-selected in Canada. A comparison of high-risk screening versus standard care was made with a decision-analytic model using data from the NLST with Canadian cost data from screening and treatment in the PanCan study. Probabilistic and deterministic sensitivity analyses were undertaken to assess uncertainty and identify drivers of program efficiency.

RESULTS

Use of the risk prediction tool developed from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial with a threshold set at 2% over 6 years would have reduced the number of individuals who needed to be screened in the NLST by 81%. High-risk screening participants in the NLST had more adverse demographic characteristics than their counterparts in the PanCan study. High-risk screening would cost $20,724 (in 2015 Canadian dollars) per quality-adjusted life-year gained and would be considered cost-effective at a willingness-to-pay threshold of $100,000 in Canadian dollars per quality-adjusted life-year gained with a probability of 0.62. Cost-effectiveness was driven primarily by non-lung cancer outcomes. Higher noncurative drug costs or current costs for immunotherapy and targeted therapies in the United States would render lung cancer screening a cost-saving intervention.

CONCLUSIONS

Non-lung cancer outcomes drive screening efficiency in diverse, tobacco-exposed populations. Use of risk selection can reduce the budget impact, and screening may even offer cost savings if noncurative treatment costs continue to rise.

Utility values associated with advanced or metastatic non-small cell lung cancer: data needs for economic modeling

INTRODUCTION

Cost-effectiveness analyses often inform healthcare reimbursement decisions. The preferred measure of effectiveness is the quality adjusted life year (QALY) gained, where the quality of life adjustment is measured in terms of utility. Areas covered: We assessed the availability and variation of utility values for health states associated with advanced or metastatic non-small cell lung cancer (NSCLC) to identify values appropriate for cost-effectiveness models assessing alternative treatments. Our systematic search of six electronic databases (January 2000 to August 2015) found the current literature to be sparse in terms of utility values associated with NSCLC, identifying 27 studies. Utility values were most frequently reported over time and by treatment type, and less frequently by disease response, stage of disease, adverse events or disease comorbidities. Expert commentary: In response to rising healthcare costs, payers increasingly consider the cost-effectiveness of novel treatments in reimbursement decisions, especially in oncology. As the number of therapies available to treat NSCLC increases, cost-effectiveness analyses will play a key role in reimbursement decisions in this area. Quantifying the relationship between health and quality of life for NSCLC patients via utility values is an important component of assessing the cost effectiveness of novel treatments.

Mapping EORTC-QLQ-C30 to EQ-5D-3L in patients with colorectal cancer

AIMS

The primary aim of this study was to perform a mapping of the EORTC-QLQ-C30 scores to EQ-5D-3L for the SIRFLOX study; a large dataset of patients with previously untreated liver-only or liver-dominant metastatic colorectal cancer (mCRC). A secondary aim was to compare the predictive validity of existing mappings from EORTC-QLQ-C30 to EQ-5D-3L conducted in other cancers.

METHODS AND MATERIALS

Questionnaires (completed within 529 patients) were used in a linear mixed regression to model EQ-5D-3L utility values (scored using the UK tariff) as a function of the five function scores, nine symptom scores, and the global score from the EORTC-QLQ-C30 questionnaire. A Tobit regression was also performed. The mean EQ-5D-3L values for the SIRFLOX trial were calculated and compared with predicted EQ-5D-3L values derived using published mapping algorithms.

RESULTS

The linear mixed regression model provided a satisfactory mapping between the EORTC-QLQ-C30 and the EQ-5D-3L, whilst the Tobit model did not perform as well. When utilities from the SIRFLOX data were calculated with previously published mapping studies, three out of five studies performed well (< 10% mean difference).

LIMITATIONS

The main limitation of the study was the lack of meaningful observations post-progression (67 paired observations). For this reason, this study was unable to test whether the mapping holds by disease stage. Additionally, although the study adds to the literature of mappings to the EQ-5D-3L, it is not known how results would differ using the EQ-5D-5L.

CONCLUSION

This study is the first of its kind in liver-only or liver-dominant mCRC, and mCRC in general. The mapping constructed showed a good fit to the data and provides practitioners with an additional mapping between EORTC-QLQ-C30 to EQ-5D-3L using a large dataset (529 patients, 707 paired observations). The study also confirmed the generalizability of mappings published by Proskorovsky, Kontodimopoulos, and Longworth to liver-only or liver-dominant mCRC.

Comparison of generic and lung cancer-specific quality of life instruments for predictive ability of survival in patients with advanced lung cancer

Background

Our purpose is to examine the relationship of Health related quality of life measured by EORTC QLQc30, QLQ-LC13; FACT-L, LCSS, Eq5D) with survival in advanced lung cancer patients. A total of 299 Lung Cancer (LC) patients were, included in this national multicenter Project entitled of “the LC Quality of Life Project (AKAYAK). Baseline scores were analyzed by using Cox’s proportional hazard regression to identify factors that influenced survival. Univariate and multivariate models were run for each of the scales included in the study.

Results

Mean and median survival were 12.5 and 8.0 months respectively. Clinical stage (as TNM), comorbidity; symptom scales of fatigue, insomnia, appetit loss and constipation were associated with survival after adjustment for age and sex. Global, physical and role functioning scales of QLQc30; physical and functional scales of LCS and TOI of the FACT-L was also associated with survival. Mobility and Usual activities dimensions of the Eq5D; Physical functioning and the constipation symptom scale of the QLQ-c30; and LCS and TOI scores of the FACT-L remained statistically significant after adjustment. LC13 and LCSS scales were not predictors of survival.

Conclusions

HRQOL serves as an additional predictive factor for survival that supplements traditional clinical factors. Besides the strong predictive ability of ECOG on survival, FACT-L and the Eq5D are the most promising HRQOL instruments for this purpose.

A Cost-Effectiveness Analysis of Using the JBR.10-Based 15-Gene Expression Signature to Guide Adjuvant Chemotherapy in Early Stage Non-Small-Cell Lung Cancer

BACKGROUND

Adjuvant chemotherapy (ACT) improved survival in the NCIC Clinical Trials Group JBR.10 trial of resected stage IB/II non-small-cell lung cancer. A prognostic 15-gene expression signature was developed, which may also predict for benefit from ACT. An exploratory economic analysis was conducted to assess the potential cost-effectiveness of using the 15-gene signature in guiding ACT decisions.

METHODS

A decision analytic model was populated by study patients with quantitative reverse transcription polymerase chain reaction tumor profiling, current costs, and quality-adjusted survival. Analysis was performed over the 6-year follow-up from the perspective of the Canadian public health care system in 2015 Canadian dollars (discounted 5%/year). Incremental cost-effectiveness and cost-utility ratios were determined for ACT versus observation using clinical stage, gene signature, or a combined approach to select treatment.

RESULTS

The mean survival gain of ACT versus observation was higher using the gene signature (1.86 years) compared with clinical stage (1.28 years). Although more costly, ACT guided by the gene signature remained cost-effective at $10,421/life-year gained (95% confidence interval [CI], $466-$19,568 Canadian), comparable to stage-directed selection ($7081/life-year gained; 95% CI, -$2370 to $14,721; P = .52). Incremental cost-utility ratios were $13,452/quality-adjusted life-year (95% CI, $373-$31,949) and $9194/quality-adjusted life-year (95% CI, -$4104 to $23,952), respectively (P = .53). Comparing the standard and test-and-treat approaches, use of the gene signature did not significantly alter survival compared with the standard strategy, but it reduced the ACT rate by 25%.

CONCLUSION

If validated, the use of the 15-gene expression signature to select patients for ACT may increase the survival gain of treatment in patients with high-risk stage IB/II non-small-cell lung cancer, while avoiding toxicities in low-risk patients.

Cost-Effectiveness Model for Chemoimmunotherapy Options in Patients with Previously Untreated Chronic Lymphocytic Leukemia Unsuitable for Full-Dose Fludarabine-Based Therapy

OBJECTIVES

To evaluate the cost-effectiveness of treatment with anti-CD20 monoclonal antibody obinutuzumab plus chlorambucil (GClb) in untreated patients with chronic lymphocytic leukemia unsuitable for full-dose fludarabine-based therapy.

METHODS

A Markov model was used to assess the cost-effectiveness of GClb versus other chemoimmunotherapy options. The model comprised three mutually exclusive health states: "progression-free survival (with/without therapy)", "progression (refractory/relapsed lines)", and "death". Each state was assigned a health utility value representing patients' quality of life and a specific cost value. Comparisons between GClb and rituximab plus chlorambucil or only chlorambucil were performed using patient-level clinical trial data; other comparisons were performed via a network meta-analysis using information gathered in a systematic literature review. To support the model, a utility elicitation study was conducted from the perspective of the UK National Health Service.

RESULTS

There was good agreement between the model-predicted progression-free and overall survival and that from the CLL11 trial. On incorporating data from the indirect treatment comparisons, it was found that GClb was cost-effective with a range of incremental cost-effectiveness ratios below a threshold of £30,000 per quality-adjusted life-year gained, and remained so during deterministic and probabilistic sensitivity analyses under various scenarios.

CONCLUSIONS

GClb was estimated to increase both quality-adjusted life expectancy and treatment costs compared with several commonly used therapies, with incremental cost-effectiveness ratios below commonly referenced UK thresholds. This article offers a real example of how to combine direct and indirect evidence in a cost-effectiveness analysis of oncology drugs.

Impact of cancer anorexia-cachexia syndrome on health-related quality of life and resource utilisation: A systematic review

INTRODUCTION

Cancer anorexia-cachexia syndrome (CACS) negatively impacts patients' quality of life (QoL) and increases the burden on healthcare resources.

OBJECTIVES

To review published CACS data regarding health-related QOL (HRQoL) and its economic impact on the healthcare system.

METHODS

Searches were conducted in MEDLINE, EMBASE, DARE, and NHS EED databases.

RESULTS

A total of 458 HRQoL and 189 healthcare resources utilisation abstracts were screened, and 42 and 2 full-text articles were included, respectively. The EORTC QLQ-C30 and FAACT instruments were most favoured for assessing HRQOL but none of the current tools cover all domains affected by CACS. Economic estimates for managing CACS are scarce, with studies lacking a breakdown of healthcare resource utilisation items.

CONCLUSIONS

HRQoL instruments that can better assess and incorporate all the domains affected by CACS are required. Rigorous assessment of costs and benefits of treatment are needed to understand the magnitude of the impact of CACS.

Cost-Utility of a Prognostic Test Guiding Adjuvant Chemotherapy Decisions in Early-Stage Non-Small Cell Lung Cancer

BACKGROUND

A prognostic test was developed to guide adjuvant chemotherapy (ACT) decisions in early-stage non-small cell lung cancer (NSCLC) adenocarcinomas. The objective of this study was to compare the cost-utility of the prognostic test to the current standard of care (SoC) in patients with early-stage NSCLC.

MATERIALS AND METHODS

Lifetime costs (2014 U.S. dollars) and effectiveness (quality-adjusted life-years [QALYs]) of ACT treatment decisions were examined using a Markov microsimulation model from a U.S. third-party payer perspective. Cancer stage distribution and probability of receiving ACT with the SoC were based on data from an academic cancer center. The probability of receiving ACT with the prognostic test was estimated from a physician survey. Risk classification was based on the 5-year predicted NSCLC-related mortality. Treatment benefit with ACT was based on the prognostic score. Discounting at a 3% annual rate was applied to costs and QALYs. Deterministic one-way and probabilistic sensitivity analyses examined parameter uncertainty.

RESULTS

Lifetime costs and effectiveness were $137,403 and 5.45 QALYs with the prognostic test and $127,359 and 5.17 QALYs with the SoC. The resulting incremental cost-effectiveness ratio for the prognostic test versus the SoC was $35,867/QALY gained. One-way sensitivity analyses indicated the model was most sensitive to the utility of patients without recurrence after ACT and the ACT treatment benefit. Probabilistic sensitivity analysis indicated the prognostic test was cost-effective in 65.5% of simulations at a willingness to pay of $50,000/QALY.

CONCLUSION

The study suggests using a prognostic test to guide ACT decisions in early-stage NSCLC is potentially cost-effective compared with using the SoC based on globally accepted willingness-to-pay thresholds.

IMPLICATIONS FOR PRACTICE

Providing prognostic information to decision makers may help some patients with high-risk early stage non-small cell lung cancer receive appropriate adjuvant chemotherapy while avoiding the associated toxicities and costs in patients with low-risk disease. This study used an economic model to assess the effectiveness and costs associated with using a prognostic test to guide adjuvant chemotherapy decisions compared with the current standard of care in patients with non-small cell lung cancer. When compared with current standard care, the prognostic test was potentially cost effective at commonly accepted thresholds in the U.S. This study can be used to help inform decision makers who are considering using prognostic tests.

Mapping the EORTC QLQ-C30 onto the EQ-5D-3L: assessing the external validity of existing mapping algorithms

PURPOSE

To determine the external validity of existing mapping algorithms for predicting EQ-5D-3L utility values from EORTC QLQ-C30 responses and to establish their generalizability in different types of cancer.

METHODS

A main analysis (pooled) sample of 3560 observations (1727 patients) and two disease severity patient samples (496 and 93 patients) with repeated observations over time from Cancer 2015 were used to validate the existing algorithms. Errors were calculated between observed and predicted EQ-5D-3L utility values using a single pooled sample and ten pooled tumour type-specific samples. Predictive accuracy was assessed using mean absolute error (MAE) and standardized root-mean-squared error (RMSE). The association between observed and predicted EQ-5D utility values and other covariates across the distribution was tested using quantile regression. Quality-adjusted life years (QALYs) were calculated using observed and predicted values to test responsiveness.

RESULTS

Ten 'preferred' mapping algorithms were identified. Two algorithms estimated via response mapping and ordinary least-squares regression using dummy variables performed well on number of validation criteria, including accurate prediction of the best and worst QLQ-C30 health states, predicted values within the EQ-5D tariff range, relatively small MAEs and RMSEs, and minimal differences between estimated QALYs. Comparison of predictive accuracy across ten tumour type-specific samples highlighted that algorithms are relatively insensitive to grouping by tumour type and affected more by differences in disease severity.

CONCLUSIONS

Two of the 'preferred' mapping algorithms suggest more accurate predictions, but limitations exist. We recommend extensive scenario analyses if mapped utilities are used in cost-utility analyses.

Mapping Functions in Health-Related Quality of Life: Mapping from Two Cancer-Specific Health-Related Quality-of-Life Instruments to EQ-5D-3L

Background. Clinical trials in cancer frequently include cancer-specific measures of health but not preference-based measures such as the EQ-5D that are suitable for economic evaluation. Mapping functions have been developed to predict EQ-5D values from these measures, but there is considerable uncertainty about the most appropriate model to use, and many existing models are poor at predicting EQ-5D values. This study aims to investigate a range of potential models to develop mapping functions from 2 widely used cancer-specific measures (FACT-G and EORTC-QLQ-C30) and to identify the best model. Methods. Mapping models are fitted to predict EQ-5D-3L values using ordinary least squares (OLS), tobit, 2-part models, splining, and to EQ-5D item-level responses using response mapping from the FACT-G and QLQ-C30. A variety of model specifications are estimated. Model performance and predictive ability are compared. Analysis is based on 530 patients with various cancers for the FACT-G and 771 patients with multiple myeloma, breast cancer, and lung cancer for the QLQ-C30. Results. For FACT-G, OLS models most accurately predict mean EQ-5D values with the best predicting model using FACT-G items with similar results using tobit. Response mapping has low predictive ability. In contrast, for the QLQ-C30, response mapping has the most accurate predictions using QLQ-C30 dimensions. The QLQ-C30 has better predicted EQ-5D values across the range of possible values; however, few respondents in the FACT-G data set have low EQ-5D values, which reduces the accuracy at the severe end. Conclusions. OLS and tobit mapping functions perform well for both instruments. Response mapping gives the best model predictions for QLQ-C30. The generalizability of the FACT-G mapping function is limited to populations in moderate to good health.

Testing mapping algorithms of the cancer-specific EORTC QLQ-C30 onto EQ-5D in malignant mesothelioma

Background

In order to estimate utilities for cancer studies where the EQ-5D was not used, the EORTC QLQ-C30 can be used to estimate EQ-5D using existing mapping algorithms. Several mapping algorithms exist for this transformation, however, algorithms tend to lose accuracy in patients in poor health states. The aim of this study was to test all existing mapping algorithms of QLQ-C30 onto EQ-5D, in a dataset of patients with malignant pleural mesothelioma, an invariably fatal malignancy where no previous mapping estimation has been published.

Methods

Health related quality of life (HRQoL) data where both the EQ-5D and QLQ-C30 were used simultaneously was obtained from the UK-based prospective observational SWAMP (South West Area Mesothelioma and Pemetrexed) trial. In the original trial 73 patients with pleural mesothelioma were offered palliative chemotherapy and their HRQoL was assessed across five time points. This data was used to test the nine available mapping algorithms found in the literature, comparing predicted against observed EQ-5D values. The ability of algorithms to predict the mean, minimise error and detect clinically significant differences was assessed.

Results

The dataset had a total of 250 observations across 5 timepoints. The linear regression mapping algorithms tested generally performed poorly, over-estimating the predicted compared to observed EQ-5D values, especially when observed EQ-5D was below 0.5. The best performing algorithm used a response mapping method and predicted the mean EQ-5D with accuracy with an average root mean squared error of 0.17 (Standard Deviation; 0.22). This algorithm reliably discriminated between clinically distinct subgroups seen in the primary dataset.

Conclusions

This study tested mapping algorithms in a population with poor health states, where they have been previously shown to perform poorly. Further research into EQ-5D estimation should be directed at response mapping methods given its superior performance in this study.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-014-0196-y) contains supplementary material, which is available to authorized users.

Mapping algorithms from QLQ-C30 to EQ-5D utilities: no firm ground to stand on yet

AIM

Over the last years several mapping or cross-walking algorithms for deriving utilities from QLQ-C30 scores have been published. However their external predictive accuracy has not yet been systematically compared.

METHODS

We tested the external validity of previously published mapping algorithms to transform the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire responses to EQ-5D derived Utilities.

RESULTS

When applied to different data sets, the currently published mapping showed a large variation between algorithms of the values of the mapped utilities, a low accuracy of the mapping compared to the observed EQ-5D utilities and no consistent performance between competing algorithms.

DISCUSSION

Therefore direct mapping from QLQ-C30 profiles to EQ-5D utilities using published algorithms should be viewed cautiously.

Mapping the FACT-G cancer-specific quality of life instrument to the EQ-5D and SF-6D

Objective

To help facilitate economic evaluations of oncology treatments, we mapped responses on cancer-specific instrument to generic preference-based measures.

Methods

Cancer patients (n = 367) completed one cancer-specific instrument, the FACT-G, and two preference-based measures, the EQ-5D and SF-6D. Responses were randomly divided to form development (n = 184) and cross-validation (n = 183) samples. Relationships between the instruments were estimated using ordinary least squares (OLS), generalized linear models (GLM), and censored least absolute deviations (CLAD) regression approaches. The performance of each model was assessed in terms of how well the responses to the cancer-specific instrument predicted EQ-5D and SF-6D utilities using mean absolute error (MAE) and root mean squared error (RMSE).

Results

Physical, functional, and emotional well-being domain scores of the FACT-G best explained the EQ-5D and SF-6D. In terms of accuracy of prediction as measured in RMSE, the CLAD model performed best for the EQ-5D (RMSE = 0.095) whereas the GLM model performed best for the SF-6D (RMSE = 0.061). The GLM predicted SF-6D scores matched the observed values more closely than the CLAD and OLS.

Conclusion

Our results demonstrate that the estimation of both EQ-5D and SF-6D utility indices using the FACT-G responses can be achieved. The CLAD model for the EQ-5D and the GLM model for the SF-6D are recommended. Thus, it is possible to estimate quality-adjusted life years for economic evaluation from studies where only cancer-specific instrument have been administered.

Predicting SF-6D from the European Organization for Treatment and Research of Cancer Quality of Life Questionnaire scores in patients with colorectal cancer

OBJECTIVES

To develop a mapping model for estimating six-dimensional health state short form (SF-6D) utility scores from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (QLQ-C30 and QLQ-CR29) scores in patients with colorectal cancer (CRC), with and without adjustment for clinical and demographic characteristics.

METHODS

Ordinary least squares regression models were applied to a cross-sectional data set of 216 patients with CRC collected from a regional hospital in Hong Kong. Item responses or scale scores of cancer-specific (QLQ-C30) and colorectal-specific health-related quality-of-life (QLQ-CR38/CR29) data and selected demographic and clinical characteristics of patients were used to predict the SF-6D scores. Model goodness of fit was examined by using exploratory power (R(2) and adjusted R(2)), Akaike information criterion, and Bayesian information criterion, and predictive performance was evaluated by using root mean square error, mean absolute error, and Spearman's correlation coefficients between predicted and observed SF-6D scores. Models were validated by using an independent data set of 56 patients with CRC.

RESULTS

Both scale and item response models explained more than 67% of the variation in SF-6D scores. The best-performing model based on goodness of fit (R(2) = 75.02%), predictive ability in the estimation (root mean square error = 0.080, mean absolute error = 0.065), and validation data set prediction (root mean square error = 0.103, mean absolute error = 0.081) included variables of main and interaction effects of the QLQ-C30 supplemented by QLQ-CR29 subset scale responses and a demographic (sex) variable.

CONCLUSIONS

SF-6D scores can be predicted from QLQ-C30 and QLQ-CR38/CR29 scores with satisfactory precision in patients with CRC. The mapping model can be applied to QLQ-C30 and QLQ-CR38/CR29 data sets to produce utility scores for the appraisal of clinical interventions targeting patients with CRC using economic evaluation.

Treating alcoholism reduces financial burden on care-givers and increases quality-adjusted life years

AIMS

The study assessed the alcoholism-related financial burden borne by informal care-givers and relatives of German alcoholic patients.

DESIGN

By using an exploratory approach, care-giver burden was assessed both prior to and 12 months after detoxification and withdrawal. Quality-of-life data for care-givers collected during follow-up were used to calculate the number of quality-adjusted life years (QALYs) gained by alcoholics' family members while their relatives are undergoing treatment.

PARTICIPANTS

Forty-eight informal care-givers and relatives of alcoholic patients.

SETTING

In-patient and out-patient departments of three psychiatric university hospitals in Germany.

MEASUREMENTS

Expenditures of families related directly to the addiction disorder of alcoholic patients, quality of life of care-givers, relapses of patients.

FINDINGS

Families' expenditures related directly to their addicted member's alcoholism decreased from an average of €676.44 per month (or 20.2% of the total pre-tax family income) at baseline to an average of €145.40 per month at 12 months after the beginning of treatment. The average time spent caring for the affected family member was reduced from 32.3 hours per month to 8.2 hours per month (P = 0.0109), and quality-of-life total scores increased from 60.6 to 68.0. The total gain in QALYs for family members was 0.108. When weighed against the average cost of the alcoholism treatment, the cost of one QALY for care-giving family members was €20,398 on average.

CONCLUSIONS

Among the families of German alcoholics who receive detoxification, there is a substantial reduction in family expenditures, time spent caring and an increase in quality of life at 1 year. These are important but often neglected additional measures of the burden on family members and also treatment benefits.

Comparison of generic, condition-specific, and mapped health state utility values for multiple myeloma cancer

OBJECTIVE

Resource allocation informed by cost-utility analysis requires that the benefits be comparable across patient groups and interventions. One option is to recommend the use of one generic utility measure, but this raises the issue of comparability when the preferred measure is inappropriate or unavailable. Many cancer trials do not include generic measures such as the EuroQol five-dimensional (EQ-5D) questionnaire and instead include condition-specific measures and use these to generate utility estimates. We analyze the comparability of generic, condition-specific, and mapped utility values for a multiple myeloma cancer patient data set.

METHODS

Generic EQ-5D, condition-specific EORTC-8D, and EQ-5D utility values mapped from the EORTC QLQ-C30 were compared by using psychometric and statistical analysis to determine discrimination across severity groups, responsiveness, and agreement.

RESULTS

Generic, condition-specific, and mapped utility estimates were responsive over time and show discriminative validity. The EQ-5D had higher responsiveness and detected a greater change across severity groups and treatment periods than did the EORTC-8D but has a higher proportion of responses at full health (12.8%). Differences in the EQ-5D and the EORTC-8D were due at least in part to differences in the classification system. Mapped EQ-5D estimates had a smaller SD and do not reflect the severe range of health states reported by using the EQ-5D.

CONCLUSIONS

Our findings suggest that condition-specific EORTC-8D or mapped EQ-5D utility estimates are broadly comparable to directly obtained EQ-5D utilities for a multiple myeloma patient data set. However, EORTC-8D estimates captured changes in quality of life for patients in mild health states that were not captured by the EQ-5D, but estimated lower utility gains than did the use of the EQ-5D directly.

An assessment of the external validity of mapping QLQ-C30 to EQ-5D preferences

BACKGROUND

Although cancer-specific Health-related Quality-of-Life measures are commonly included in randomized clinical trials or other prospective non-randomized clinical studies, it is rare that preference-based instruments are used, which allow the calculation of a Utility weight suitable for estimating Quality-adjusted Life-Years gained.

OBJECTIVE

To test the external validity of a previously published mapping algorithm to transform the EORTC QLQ-C30 questionnaire responses into EQ-5D-derived utilities by predicting EQ-5D utilities from QLQ-C30 scores.

STUDY DESIGN AND METHODS

Comparative retrospective data analysis of four multicentre, prospective clinical trials in Breast, Multiple Myeloma, Non-Hodgkin Lymphoma and Non-Small-Cell Lung cancer patients with, respectively, 219, 172, 132 and 172 patients. Regression analysis of individual pairs of EQ-5D and QLQ-C30 scores.

RESULTS

Although the internal predictive power of a previously published mapping equation was high, its external validity when tested on a set of unrelated external data sets in other cancers proved to underestimate both the mean and variance of the mapped EQ-5D utilities. Furthermore, it appears that the relationship between QLQ-C30 scores and EQ-5D values is not stable across the different data sets.

CONCLUSIONS

Validation of the proposed algorithm in other external clinical data sets should be encouraged as well as the application of other more complex mapping methods to enhance accuracy of mapping. In the meanwhile, direct mapping from QLQ-C30 profiles to EQ-5D utilities using published algorithms should be performed with reservations.