Cost versus benefit in non-surgical management of patients with cancer

Economic evaluation of 4% albumin solution, gelatine, and hydroxyethylamidon for plasma volume expansion in cancer patients

Purpose. Given the potential advantages of the use of hydroxyethylamidon, the purpose of this cost analysis was to examine the economic consequences of the use of such derivatives compared to albumin and gelatine for fluid resuscitation in patients with various types of cancer.

Methods. We report on the economic evalua tion conducted at the Montpellier Anticancer Center between July 1989 and December 1995. Patients with various types of cancer were included in the study. About 310 patients were treated each year. Since January 1991, an economic policy was undertaken to reduce the cost of treatment by volume expanders.

Results. During the study period, the pharma ceutical price of these drugs, the number of patients, and the number of days of hospitalization remained relatively stable. From 1991 to 1995 of this economic evaluation, we observed a regular decrease in the utilization of fluid expanders. Indeed, 2370 vials were used in 1990 and only 868 in 1995. In 1991, a new plasma volume expander, hydroxyethylamidon, be

came commercially available. Consequently, from 1992, we observed a decrease in the use of 4% albumin; then, from 1993, there was a decrease in the use of gelatine. In 1989, the mean cost of each vial was $46; it was $16 in 1995. This decrease is attrib utable to a progressive substitution of 4% albumin, then of gelatine, by hydroxyethylamidon. During the 24 first months of the present study, the total cost of plasma volume expanders was approximately $180,000 (July 1989 to June 1991); it was $164,000 during the following 54 months (July 1991 to Decem ber 1995).

Conclusion. The pharmaceutical economic pol icy and the risk of using blood product have contrib uted to a decrease in the total cost of the different drugs used as plasma volume expanders. To date, the savings realized have been ∼$75,000 annually.

Skeletal metastases

This synthesis of the literature on radiotherapy for skeletal metastases is based on 171 scientific articles, including 13 randomized studies, 24 prospective studies, and 79 retrospective studies. These studies involve 13054 patients. Radiotherapy has been well documented as a method for alleviating pain, but the mechanisms underlying this effect are largely unknown. When used for pain palliation, radiotherapy achieves freedom from pain, or substantial alleviation of pain in nearly all cases, with few side effects. Half-body irradiation is effective in treating multiple metastatic sites and should be considered for use more frequently. However, this increases the requirements on equipment, dosimetry, and hospital beds. Systemic radiotherapy with radionuclides may be indicated for generalized skeletal pain. The role of radiotherapy in preventing or healing fractures is not fully evaluated. Optimum dose levels and fractionation schedules have not been established. Early radiotherapy for spinal cord compression may prevent symptoms from worsening, but the effects on existing paralysis are modest.

A clinical audit of glottic cancer in Nova Scotia: a paradigm for effectiveness research

We conducted a clinical audit of the recurrence-free rates and absolute survival of 146 patients who presented with T1-T3 glottic cancer and received primary radiotherapy treatment at the Nova Scotia Cancer Centre between 1984 and 1990. The outcomes are compared with a review of published results from other centres. We used stage T3 glottic cancer as an example to illustrate concepts of effectiveness research which are used to determine at what level interventions operate in the day to day practice of medicine. The actuarial recurrence-free rates at 5 years are: T1 91%, T2 73%, and T3 44%. The actuarial absolute survival rates are: T1 84%, T2 68%, and T3 52%. Effectiveness research may utilize efficacy research, clinical audit, quality of life assessment and decision making theory. Its objective is to aid the implementation of appropriate clinical management for specific individuals and defined communities. Expert computer systems may be necessary to synthesize the data and to enhance communication and decision making.

Treating acute leukaemias--a venture into economic uncertainty? A method for estimating the cost of treating patients with acute myelocytic leukaemia

The objective of this paper is to report a method for estimating the cost of treating acute myelocytic leukaemia (AML). It is based on individual data from 54 patients treated with aggressive induction courses of chemotherapy. The study records the cost of the entire survival period for 40 patients and of at least 16 months' survival for the remaining 14 patients. All treatment activities were registered from the patient records and the price of each activity was estimated. As far as possible the principle of opportunity cost was used. The median survival time was 50 weeks and the average cost per patient was c. 300,000 SEK (= c. USD 50,000) in 1988 prices. A young man who achieved three remissions and lived for five years had the highest cost, c. 1 million SEK (= USD 155,000). The costs for AML treatment was higher in the 1980s than in the 1970s but led to longer survival for patients who survived the initial period.

Economic evaluation of trends in cancer therapy. Marginal or average costs?

Evaluating the use of resources as well as outcomes in cancer therapy is increasingly becoming recognized by both clinicians and others as a legitimate and indeed even desirable activity. While this trend is to be welcomed if it facilitates the efficient use of resources for cancer care, there are dangers in applying estimates of unit costs, in particular average costs to the evaluation of trends in practice in cancer therapies. This article examines the use of appropriate measures of average and marginal cost in the economic evaluation of developments in cancer therapy, taking illustrations from radiotherapy and chemotherapy.

Diethylstilbestrol revisited in advanced breast cancer management

Prior to the introduction of tamoxifen, diethylstilbestrol (DES) was widely used as the first-line endocrine therapy in postmenopausal women with advanced breast cancer. Since randomized trials reported that tamoxifen has a similar response rate but fewer side effects than DES, its use has declined markedly. We administered DES in a dose of 10-20 mg daily to 11 postmenopausal women with advanced breast cancer, all of whom had received previous endocrine and some cytotoxic therapy also. Four women showed tumour responses to DES (1 complete and 3 partial), 5 had stable disease, and 2 progressive disease. Amongst the patients who responded, 2 had previously been unresponsive to other endocrine treatments. Of the women with stable disease, 3 had prolonged relief of symptoms. No withdrawal responses were noted. The major side effects were nausea (severe in 2 patients, mild in 1) and cardiac failure (2 patients). We conclude that DES remains a useful, active agent in the management of advanced breast cancer in postmenopausal women, even in patients with tumours unresponsive to other endocrine therapy.

Why don't British radiotherapists give single fractions of radiotherapy for bone metastases?

A sample of 42 out of 80 delegates at RADIOLOGY '87 were asked about their treatment of a hypothetical patient with bone metastases from carcinoma of the breast. Details of their experience, the proportion of palliative work performed and the location of their centre were obtained. Only 36% gave a single fraction of radiotherapy, whereas 64% used multiple fractions. This confirms that despite many publications suggesting single fractions of radiotherapy are more cost effective and as good as fractionated treatment schedules in terms of pain relief, the need for retreatment and side-effects, the majority of British radiotherapists still use multiple fractions. Of the group using multiple fractions, 67% gave training as a reason for not using a single fraction, departmental policy being the second most quoted reason. Fear of recurrence, problems of retreatment and acute nausea were more of an influence than initial response or long-term effects. The presence of neurological signs or symptoms made the majority of delegates choose multiple fractions. An increased use of single fractions was noted in the Midlands and North of England compared with the South. Practice is unlikely to change unless there is an increased emphasis on palliative techniques in training.

Treatment of the terminal stages of breast cancer

To assess the intensity of and changes in diagnostic investigations and treatment in the terminal stages of breast cancer 555 patients in the area of Tampere University Central Hospital in whom breast cancer had been diagnosed from 1977 to 1980 were followed up for five years. The case notes for the last visit of 519 patients were analysed. The amount of diagnostic activity was similar for those who died and for the survivors. A higher proportion of women who died than of women who survived received treatment at the last follow up visit, and 2.6 times as many of those dying within one week of the last visit were given chemotherapy as were survivors with recurrent disease. Resources devoted to diagnostic investigations and treatment of cancer in terminally ill patients could be better used for care of the patients. This would be more likely to improve the patients' quality of life and conserve resources.