Costs of managing adverse events in the treatment of first-line metastatic renal cell carcinoma: bevacizumab in combination with interferon-alpha2a compared with sunitinib

BACKGROUND

Bevacizumab plus interferon-alpha2a (IFN) prolongs progression-free survival to >10 months, which is comparable with sunitinib as first-line treatment of metastatic renal cell carcinoma (RCC). The two regimens have different tolerability profiles; therefore, costs for managing adverse events may be an important factor in selecting therapy.

METHODS

Costs of managing adverse events affecting patients with metastatic RCC eligible for treatment with bevacizumab plus IFN or sunitinib were evaluated using a linear decision analytical model. Management costs were calculated from the published incidence of adverse events and health-care costs for treating adverse events in the United Kingdom, Germany, France and Italy.

RESULTS

Adverse event management costs were higher for sunitinib than for bevacizumab plus IFN. The average cost per patient for the management of grade 3-4 adverse events was markedly lower with bevacizumab plus IFN compared with sunitinib in the United Kingdom (euro1475 vs euro804), Germany (euro1785 vs euro1367), France (euro2590 vs euro1618) and Italy (euro891 vs euro402). The main cost drivers were lymphopaenia, neutropaenia, thrombocytopaenia, leucopaenia and fatigue/asthaenia for sunitinib; and proteinuria, fatigue/asthaenia, bleeding, anaemia and gastrointestinal perforation for bevacizumab plus IFN.

CONCLUSION

The costs of managing adverse events are lower for bevacizumab plus IFN than for sunitinib. The potential for cost savings should be considered when selecting treatments for RCC.

Costs and consequences of different chemotherapy regimens in metastatic colorectal cancer

An economic sub-study was run alongside a large multi-centre randomised trial (MRC-CR06) comparing three chemotherapy regimens; de Gramont, Lokich and raltitrexed in patients with metastatic colorectal cancer. Patients in six of 45 centres in the main trial were approached to take part in the sub-study. Chemotherapy delivery costs were assessed in each sub-study centre with external validity verified by questionnaire to all other centres. Patient representativeness was assessed. Stochastic resource use data, including patient borne costs and non-hospital health service resource use were monitored prospectively. Mean total societal costs were de Gramont= 5051 pounds sterling (s.d. 1910 pounds sterling ), raltitrexed= 2616 pounds sterling (s.d. 991 pounds sterling ) and Lokich= 2576 pounds sterling (s.d. 1711 pounds sterling ). In pairwise comparisons, statistically significant mean total cost differences were shown for de Gramont vs Lokich (mean difference= 2475 pounds sterling , 95%CI 914 pounds sterling - 4037 pounds sterling , P<0.01) and for de Gramont vs raltitrexed (mean difference= 2435 pounds sterling, 95%CI 922 pounds sterling - 2948 pounds sterling , P<0.01). Sensitivity analyses showed little effect on overall costs. The main trial showed de Gramont and Lokich to be equally effective in terms of survival, quality of life and response rates but Lokich had higher toxicity and hand-foot syndrome. Raltitrexed showed similar response rates and overall survival but increased toxicity and inferior quality of life making it a clinically inferior regimen despite its ease of administration and costs. For a comparable clinical outcome, Lokich can be administered for approximately half the cost of de Gramont.

Costs incurred by patients undergoing advanced colorectal cancer therapy. A comparison of raltitrexed and fluorouracil plus folinic acid

BACKGROUND

To assess the cost effectiveness of healthcare interventions from a societal perspective, it is necessary to include costs such as patients' travel costs and the opportunity cost of patients' time spent consuming healthcare.

OBJECTIVE

To analyse patients' travel and time costs associated with 2 alternative drug therapies for advanced colorectal cancer: raltitrexed and fluorouracil plus folinic acid (leucovorin) [5FU + FA].

DESIGN AND SETTING

The analysis is based on a prospective substudy within a multinational randomised controlled trial of raltitrexed versus 5FU + FA.

PATIENTS AND PARTICIPANTS

495 patients with advanced colorectal cancer were enrolled in the trial, 270 of whom completed the questionnaire on costs.

METHODS

Data were collected within the trial to estimate the numbers of journeys made to and from hospital by patients and the time lost from usual activities over the period of therapy. A subset of patients were asked to complete a questionnaire to provide the information necessary to value time and travel costs in monetary terms. These data, together with UK transport costs and forgone time values, were used to value the transport and opportunity costs of time of all patients in the trial.

RESULTS

The total travel cost per patient was statistically significantly higher in the 5FU + FA group (p < 0.001; median of 31.50 Pounds with raltitrexed, 96.00 Pounds with 5FU + FA; 1997 prices). Overall time cost per patient was also higher in the 5FU + FA group (p = 0.005; median of 168.80 Pounds with raltitrexed, 224.04 Pounds with 5FU + FA). Adding the two gives a median total cost per patient of 206.08 Pounds [interquartile range (IQR) 108 Pounds to 482 Pounds] among patients randomised to raltitrexed and 342.25 Pounds (IQR 214 Pounds to 555 Pounds) for those in the 5FU + FA group (p < 0.001). The sensitivity analysis showed that, even under extreme assumptions, raltitrexed imposed fewer time and travel costs on patients. These cost differences are likely, in part, to reflect the longer treatment times for 5FU + FA patients (median 16.9 vs 12.7 weeks).

CONCLUSIONS

Different chemotherapy regimens for advanced colorectal cancer can impose different travel and time costs on patients. Over the period of treatment in a randomised controlled trial of 495 patients, those randomised to 5FU + FA were found to have a median travel plus time cost 136 Pounds per patient higher than those randomised to raltitrexed.

Chemotherapy for advanced colorectal cancer: ‘Tomudex™’

Palliative chemotherapy in advanced colorectal cancer prolongs survival and maintains quality of life, compared with best supportive care alone. For several decades, only chemotherapy regimens based on 5-fluorouracil, with or without leucovorin (LV), were available, and the recent availability of ‘Tomudex’ (raltitrexed) has provided an additional therapeutic option. The efficacy of ‘Tomudex’ (response rates, survival and palliative benefits) is similar to that of 5-fluorouracil-based regimens. A large clinical trial (495 patients with advanced colorectal cancer) showed that the superior tolerability profile of ‘Tomudex’ compared with 5-fluorouracil/LV, especially during the first cycle of treatment, led to better maintained quality of life (Zalcberg, 1997). Furthermore, the administration of ‘Tomudex’ is simpler for patients and nurses, and patients have identified the side-effect and administration profiles of ‘Tomudex’ as less upsetting than standard chemotherapy regimens. Where chemotherapy regimens provide equivalent response rates and survival, treatment should be guided by additional criteria that are relevant to the ways in which chemotherapy affects patients’ day-to-day lives. In this regard, ‘Tomudex’ displays a number of important advantages over standard 5-fluorouracil-based chemotherapy. The discovery of ‘Tomudex’ is a significant step forward in the development of chemotherapy for advanced colorectal cancer.