Economic evaluation of chemotherapy with mitoxantrone plus prednisone for symptomatic hormone-resistant prostate cancer: based on a Canadian randomized trial with palliative end points

Cost-effectiveness analyses and cost analyses in castration-resistant prostate cancer: A systematic review

Background

Treatment of metastatic prostate cancer is associated with high personal and economic burden. Recently, new treatment options for castration-resistant prostate cancer became available with promising survival advantages. However, cost-effectiveness of those new treatment options is sometimes ambiguous or given only under certain circumstances. The aim of this study was to systematically review studies on the cost-effectiveness of treatments and costs of castration-resistant prostate cancer (CRPC) and metastasizing castration-resistant prostate cancer (mCRPC) on their methodological quality and the risk of bias.

Methods

A systematic literature search was performed in the databases PubMed, CINAHL Complete, the Cochrane Library and Web of Science Core Collection for costs-effectiveness analyses, model-based economic evaluations, cost-of-illness analyses and budget impact analyses. Reported costs were inflated to 2015 US$ purchasing power parities. Quality assessment and risk of bias assessment was performed using the Consolidated Health Economic Evaluation Reporting Standards checklist and the Bias in Economic Evaluations checklist, respectively.

Results

In total, 38 articles were identified by the systematic literature search. The methodological quality of the included studies varied widely, and there was considerable risk of bias. The cost-effectiveness treatments for CRPC and mCRPC was assessed with incremental cost-effectiveness ratios ranging from dominance for mitoxantrone to $562,328 per quality-adjusted life year gained for sipuleucel-T compared with prednisone alone. Annual costs for the treatment of castration-resistant prostate cancer ranged from $3,067 to $77,725.

Conclusion

The cost-effectiveness of treatments of CRPC strongly depended on the willingness to pay per quality-adjusted life year gained/life-year saved throughout all included costs-effectiveness analyses and model-based economic evaluations. High-quality cost-effectiveness analyses based on randomized controlled trials are needed in order to make informed decisions on the management of castration-resistant prostate cancer and the resulting financial impact on the healthcare system.

Vinorelbine and Prednisone in older Cancer Patients with Hormone-Refractory Metastatic Prostate Cancer a Phase II Study

Aims and Background

Prostate cancer is a common disease in older men. Since it is hormone resistant, no treatment may improve survival. In patients with hormone-refractory prostate cancer, clinical benefit is an important treatment end point.

Study Design

This study evaluated the efficacy and toxicity of a vinorelbine and prednisone combination in hormone-refractory prostate cancer patients. Vinorelbine was administered at the dose of 25 mg/m2 on days 1 and 8, every three weeks; prednisone was administered orally at the dose of 12 mg/day. Thirty consecutive patients, 65 years or older, with progressive (PSA increase or increase in bidimensionally measurable lesion) metastatic prostate adenocarcinoma were enrolled. Four patients (13%) had a partial response and 14 (46%) stable disease. Time to progression for the entire group was 4.5 months (range, 2–13) and 7.5 months for the group of responders (range, 3–13). A PSA decrease >50% was registered in 36% of the patients. Pain reduction was recorded in 44.4% of the patients and stability in 14.8%.

Results

The treatment was well tolerated and grade 3 toxicity was found in 2 cases of anemia and 2 cases of leukopenia without fever.

Conclusions

The schedule is able to control the evolution of hormone-refractory prostate cancer and to give a clinical benefit. These results provide information for further clinical trials in a large series of elderly cancer patients.

Anti-tumor and anti-angiogenic effects of Fucoidan on prostate cancer: possible JAK-STAT3 pathway

BACKGROUND

Prostate cancer is the most common cancer in men in the United States. Fucoidan is a bioactive polysaccharide extracted mainly from algae. The aim of this study was to investigate anti-tumor and anti-angiogenic effects of fucoidan in both cell-based assays and mouse xenograft model, as well as to clarify possible role of JAK-STAT3 pathway in the protection.

METHODS

DU-145 human prostate cancer cells were treated with 100-1000 μg/mL of fucoidan. Cell viability, proliferation, migration and tube formation were studied using MTT, EdU, Transwell and Matrigel assays, respectively. Athymic nude mice were subcutaneously injected with DU-145 cells to induce xenograft model, and treated by oral gavage with 20 mg/kg of fucoidan for 28 days. Tumor volume and weight were recorded. Vascular density in tumor tissue was determined by hemoglobin assay and endothelium biomarker analysis. Protein expression and phosphorylation of JAK and STAT3 were determined by Western blot. Activation of gene promoters was investigated by chromatin Immunoprecipitation.

RESULTS

Fucoidan could dose-dependently inhibit cell viability and proliferation of DU-145 cells. Besides, fucoidan also inhibited cell migration in Transwell and tube formation in Matrigel. In animal study, 28-day treatment of fucoidan significantly hindered the tumor growth and inhibited angiogenesis, with decreased hemoglobin content and reduced mRNA expression of CD31 and CD105 in tumor tissue. Furthermore, phosphorylated JAK and STAT3 in tumor tissue were both reduced after fucoidan treatment, and promoter activation of STAT3-regulated genes, such as VEGF, Bcl-xL and Cyclin D1, was also significantly reduced after treatment.

CONCLUSIONS

All these findings provided novel complementary and alternative strategies to treat prostate cancer.

Median-Based Incremental Cost-Effectiveness Ratio (ICER)

Cost-effectiveness analysis (CEA) is a type of economic evaluation that examines the costs and health outcomes of alternative strategies and has been extensively applied in health sciences. The incremental cost-effectiveness ratio (ICER), which represents the additional cost of one unit of outcome gained by one strategy compared with another, has become a popular methodology in CEA. Despite its popularity, limited attention has been paid to summary measures other than the mean for summarizing cost as well as effectiveness in the context of CEA. Although some apparent advantages of other central tendency measures such as median for cost data that are often highly skewed are well understood, thus far, the median has rarely been considered in the ICER. In this paper, we propose the median-based ICER, along with inferential procedures, and suggest that mean and median-based ICERs be considered together as complementary tools in CEA for informed decision making, acknowledging the pros and cons of each. If the mean and median-based CEAs are concordant, we may feel reasonably confident about the cost-effectiveness of an intervention, but if they provide different results, our confidence may need to be adjusted accordingly, pending further evidence.

Minimal modeling approaches to value of information analysis for health research

Value of information (VOI) techniques can provide estimates of the expected benefits from clinical research studies that can inform decisions about the design and priority of those studies. Most VOI studies use decision-analytic models to characterize the uncertainty of the effects of interventions on health outcomes, but the complexity of constructing such models can pose barriers to some practical applications of VOI. However, because some clinical studies can directly characterize uncertainty in health outcomes, it may sometimes be possible to perform VOI analysis with only minimal modeling. This article 1) develops a framework to define and classify minimal modeling approaches to VOI, 2) reviews existing VOI studies that apply minimal modeling approaches, and 3) illustrates and discusses the application of the minimal modeling to 2 new clinical applications to which the approach appears well suited because clinical trials with comprehensive outcomes provide preliminary estimates of the uncertainty in outcomes. The authors conclude that minimal modeling approaches to VOI can be readily applied in some instances to estimate the expected benefits of clinical research.

High-resolution flow cytometry: a suitable tool for monitoring aneuploid prostate cancer cells after TMZ and TMZ-BioShuttle treatment

If metastatic prostate cancer gets resistant to antiandrogen therapy, there are few treatment options, because prostate cancer is not very sensitive to cytostatic agents. Temozolomide (TMZ) as an orally applicable chemotherapeutic substance has been proven to be effective and well tolerated with occasional moderate toxicity especially for brain tumors and an application to prostate cancer cells seemed to be promising. Unfortunately, TMZ was inefficient in the treatment of symptomatic progressive hormone-refractory prostate cancer (HRPC). The reasons could be a low sensitivity against TMZ the short plasma half-life of TMZ, non-adapted application regimens and additionally, the aneuploid DNA content of prostate cancer cells suggesting different sensitivity against therapeutical interventions e.g. radiation therapy or chemotherapy. Considerations to improve this unsatisfying situation resulted in the realization of higher local TMZ concentrations, sufficient to kill cells regardless of intrinsic cellular sensitivity and cell DNA-index. Therefore, we reformulated the TMZ by ligation to a peptide-based carrier system called TMZ-BioShuttle for intervention. The modular-composed carrier consists of a transmembrane transporter (CPP), connected to a nuclear localization sequence (NLS) cleavably-bound, which in turn was coupled with TMZ. The NLS-sequence allows an active delivery of the TMZ into the cell nucleus after transmembrane passage of the TMZ-BioShuttle and intra-cytoplasm enzymatic cleavage and separation from the CPP. This TMZ-BioShuttle could contribute to improve therapeutic options exemplified by the hormone refractory prostate cancer. The next step was to syllogize a qualified method monitoring cell toxic effects in a high sensitivity under consideration of the ploidy status. The high-resolution flow cytometric analysis showed to be an appropriate system for a better detection and distinction of several cell populations dependent on their different DNA-indices as well as changes in proliferation of cell populations after chemotherapeutical treatment.

Determining optimal sample sizes for multi-stage randomized clinical trials using value of information methods

Background Traditional sample size calculations for randomized clinical trials depend on somewhat arbitrarily chosen factors, such as Type I and II errors. An effectiveness trial (otherwise known as a pragmatic trial or management trial) is essentially an effort to inform decision-making, i.e., should treatment be adopted over standard? Taking a societal perspective and using Bayesian decision theory, Willan and Pinto (Stat. Med. 2005; 24:1791-1806 and Stat. Med. 2006; 25:720) show how to determine the sample size that maximizes the expected net gain, i.e., the difference between the cost of doing the trial and the value of the information gained from the results.

Methods These methods are extended to include multi-stage adaptive designs, with a solution given for a two-stage design. The methods are applied to two examples.

Results As demonstrated by the two examples, substantial increases in the expected net gain (ENG) can be realized by using multi-stage adaptive designs based on expected value of information methods. In addition, the expected sample size and total cost may be reduced.

Limitations Exact solutions have been provided for the two-stage design. Solutions for higher-order designs may prove to be prohibitively complex and approximate solutions may be required.

Conclusions The use of multi-stage adaptive designs for randomized clinical trials based on expected value of sample information methods leads to substantial gains in the ENG and reductions in the expected sample size and total cost. Clinical Trials 2008; 5: 289-300. http://ctj.sagepub.com

Feasibility of using administrative claims data for cost-effectiveness analysis of a clinical trial

OBJECTIVE

This study was performed retrospectively to determine if Medicare claims data could be used to evaluate the cost effectiveness, from a payer perspective, of different radiation treatment schedules evaluated in a national clinical trial.

METHODS

Medicare costs from all providers and all places of service were obtained from the Centers for Medicare & Medicaid Services for patients treated in the period 1992-1996 on Radiation Therapy Oncology Group 90-03, and combined with data on outcomes from the trial.

RESULTS

Of the 1,113 patients entered, Medicare cost data and clinical outcomes were available for 187 patients. Significant differences in tolerance of treatment and outcome were noted between patients with Medicare data included in the study and patients without Medicare data, and non-Medicare patients excluded from it. Ninety-five percent confidence ellipses on the incremental cost-effectiveness scatterplots crossed both axes, indicating non-significant differences in cost effectiveness between radiation treatment schedules.

CONCLUSIONS

Claims data permit estimation of cost effectiveness, but Medicare data provide inadequate representation of results applicable to patients from the general population.

A Decision analysis to determine the appropriate treatment for low-risk myelodysplastic syndromes

BACKGROUND

The myelodysplastic syndromes (MDS) are divided into low-risk and high-risk diseases. Predictive models for response to growth factors (GF) have been developed based on red blood cell transfusion needs and erythropoietin levels. For low-risk MDS the optimal initial therapy (GF vs nongrowth factor [NGF] therapies, including differentiation and immunomodulatory agents) based on response rates to NGF and GF and survival, has not been defined.

METHODS

A Markov decision analysis was performed on 799 low-risk MDS patients treated with either GF or NGF to determine the appropriate initial therapy. The treatment strategies analyzed included initial GF or NGF therapies, assuming 3 different states: Patients were either in the good GF predictive group (low transfusion needs and low erythropoietin levels), intermediate, or the poor GF predictive group (high transfusion needs and high erythropoietin levels).

RESULTS

In the good GF predictive group, initial therapy with GF improved survival compared with NGF therapies at 3.38 years vs 2.57 years for a typical MDS patient. The advantage of GF to NGF was lost when NGF therapies produced a response in >or=46% of patients. In the intermediate or poor GF predictive groups, NGF maximized survival, provided response rates for NGF were >14% and 4%, respectively, for each predictive group. Quality of life adjustment did not alter the preferred strategy.

CONCLUSIONS

Modeling estimates suggest that patients who fall into a good GF predictive group should almost always receive GF initially, whereas those in intermediate and poor predictive groups should almost always be treated with NGF.

Intermittent chemotherapy for metastatic hormone refractory prostate cancer

While docetaxel/prednisone chemotherapy has demonstrated a survival advantage in metastatic hormone refractory prostate cancer (HRPC) patients, the optimal duration of chemotherapy has not yet been established. Currently, a standard practice is to treat patients indefinitely until unacceptable toxicity or disease progression. A systematic approach to providing breaks in treatment schedules (intermittent chemotherapy) for patients who experience an initial response to chemotherapy may avoid or delay the development of progressive toxicity. Whether continuous therapy offers an advantage over intermittent therapy, in terms of balancing disease control and overall survival with treatment-related toxicities and quality-of-life (QOL) is yet unanswered. This article will: (1) review the data from prior studies of intermittent versus continuous chemotherapy in other solid tumors, (2) review existing trials of intermittent chemotherapy in prostate cancer, (3) discuss intermittent chemotherapy clinical trial design considerations, and (4) discuss the future role of intermittent chemotherapy for the treatment of prostate cancer.

The role of external beam radiotherapy in the management of bone metastases

External beam radiotherapy is effective in the management of bone metastases for both local and more widespread pain. It is effective in spinal canal compression and pathological fracture where it also may have a prophylactic role. Single dose radiotherapy for bone metastases is a highly cost effective palliative treatment.

Pharmacoeconomics of available treatment options for metastatic prostate cancer

The resources devoted to managing metastatic prostate cancer are enormous, yet little attention has been given to directly measuring the economic consequences of treatment alternatives. The purpose of this article was to evaluate the pharmacoeconomics of available treatments for metastatic prostate cancer, including hormone-sensitive disease, androgen-independent prostate cancer and locally advanced/progressive disease. We identified 58 articles addressing economic issues related to metastatic prostate cancer. Treatment alternatives with considerably different costs are available in many areas of disease management, most notably, medical androgen deprivation therapy (ADT) versus surgical castration; combined androgen blockage (CAB) versus monotherapy for initial treatment of hormone-sensitive disease; as well as bisphosphonates and bone-targeted radioisotopes for palliation. The few available pharmacoeconomic studies indicate that the additional costs are not supported by clear and compelling evidence of differences in survival or quality-of-life (QOL) outcomes. Our review revealed that authors often use considerably different assumptions about efficacy and survival outcomes in their analyses, which may be due to the inconsistency of available clinical evidence. Although there have been many clinical trials comparing various therapies, we identified only three trials that included economic assessments. Thus, few sources of economic data are available and most pharmacoeconomic studies rely on information mined from indirect sources. We note that, while there has been considerable enthusiasm about the role of docetaxel regimens in the past 2 years, no study has yet examined the costs of these therapies. Survival remains poor for metastatic disease, thus QOL is the primary consideration for many therapies. However, QOL for treatment of metastatic disease is poorly measured and, in most analyses, the impact of therapy on QOL was inferred based on speculation by the authors. Given the large cost burdens of these treatments, it is essential that we more fully understand the true QOL gains potentially offered by more expensive therapies. The economic studies of advanced prostate cancer highlight several aspects of clinical care that are filled with considerable uncertainty and remain guided by forces other than optimal resource allocation. It is essential that we address the weaknesses in our understanding of the economic consequences of therapies for prostate cancer, and find ways to include economic information into the process of determining optimal therapy.

Management of the Spectrum of Hormone Refractory Prostate Cancer

INTRODUCTION

In its advanced stages, hormone refractory prostate cancer (HRPC) is an incurable condition which consists of a spectrum of disease. This requires an integrated multidisciplinary approach by an uro-oncologic team supported by radiologists, skeletal surgeons and palliative care. Aim of this review was to critically evaluate the current and potential approaches to patients affected by HRPC.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1981 to January 2006. Official proceedings of internationally known scientific societies held in the same time period were also assessed.

RESULTS

Most men with hormone refractory prostate cancer will die of their disease in the absence of intercurrent illness, and the various conditions arising as a consequence of local and distal cancer progression commonly lead to a spectrum of morbidity requiring treatment. Recent data regarding docetaxel-based chemotherapy have shown small but significant improvements in survival and improvement in quality of life in men receiving treatment. However, this therapy may not be suitable for all patients. New agents used alone or in combination with docetaxel currently are under trial in an attempt to provide much needed improvements in outcome. Bone-targeted treatments, particularly late-generation bisphosphonates, have added to the range of options, reducing the incidence of skeletal complications in some men. Further work is needed to target their use more effectively, to explore their efficacy in combination with existing proven therapies and to develop new approaches to treat bone metastases. Complications arising as a consequence of upper and lower tract dysfunction, haematologic, neurologic and psychologic disorders are common. These complications often are amenable to effective treatment, but interventions may engender difficult clinical and ethical decisions.

CONCLUSIONS

Although HRPC is incurable, it is not untreatable, and that the clinical management embraces not just chemotherapy, but many interventional and supportive therapies. A holistic and supportive approach to patient care is vital for optimal management, and is best provided by a coordinated, multidisciplinary team including urologists and oncologists.

The changing pattern of management for hormone-refractory, metastatic prostate cancer

Prostate cancer responds initially to hormonal manipulation by androgen withdrawal and peripheral androgen blockade. The inevitable progression to a hormone-refractory state is accompanied by an exacerbation of local symptoms and metastatic spread, principally to the bones, which has a considerable impact on quality of life and survival. Treatment of hormone-refractory prostate cancer is palliative, and surgery and radiotherapy are used for the relief of lower urinary tract symptoms and localized painful bony metastases. Systemic treatments are not widely accepted in this setting, but clinical trials have demonstrated the potential for bone targeting agents such as strontium-89 and the bisphosphonates to palliate painful bone metastases and to delay progression in certain settings. Chemotherapy with mitozantrone in combination with steroids has previously been shown to have palliative benefits and to delay progression. The additional costs incurred by the use of chemotherapy or bone-targeting therapies may be offset by gains in overall care with fewer in-patient admissions compared with steroid monotherapy. Recent clinical trials have demonstrated that docetaxel significantly improves patient quality of life, and importantly, increases survival. Future studies investigating the timing of chemotherapy, combinations with existing treatments or other novel therapies are underway.

Chemotherapy for metastatic disease: current status

Chemotherapy now has an established role in the treatment of hormone-refractory metastatic prostate cancer. This review summarises the results of the latest trials and discusses ongoing studies investigating the role of chemotherapy earlier in the disease.

Actualización del tratamiento del cáncer de próstata avanzado y de sus complicaciones

Prostate adenocarcinoma is the leading cause of cancer in Spain, among men older than 65. 1,200 new cases out of every 100,000 males are diagnosed with prostate cancer on an annual basis. In the United States, this illness represents the second leading cause of death due to cancer in males. In those patients whose prostate tumors progress after surgery or radiotherapy, or have metastatic disease when diagnosed, a systemic approach in order to improve their quality of life and overall survival is mandatory. First line hormone therapies usually reach a proper control of the tumor maintaining an acceptable quality of life. However, most of these tumors becomes androgen-independent over time and behave as a more aggressive cancer type. In these patients, combination therapy protocols have recently demonstrated a benefit not only in terms of symptoms control and response rates but also in improving survival. In addition, several new molecules are currently under study. The accurate knowledge of the symptoms due to disease spreading as well as treatment's side effects is necessary to provide an appropriate palliative management that contributes to an improvement of the quality of life in advanced prostate cancer patients.

The value of information and optimal clinical trial design

Traditional sample size calculations for randomized clinical trials depend on somewhat arbitrarily chosen factors, such as type I and II errors. Type I error, the probability of rejecting the null hypothesis of no difference when it is true, is most often set to 0.05, regardless of the cost of such an error. In addition, the traditional use of 0.2 for the type II error means that the money and effort spent on the trial will be wasted 20 per cent of the time, even when the true treatment difference is equal to the smallest clinically important one and, again, will not reflect the cost of making such an error. An effectiveness trial (otherwise known as a pragmatic trial or management trial) is essentially an effort to inform decision-making, i.e. should treatment be adopted over standard? As such, a decision theoretic approach will lead to an optimal sample size determination. Using incremental net benefit and the theory of the expected value of information, and taking a societal perspective, it is shown how to determine the sample size that maximizes the difference between the cost of doing the trial and the value of the information gained from the results. The methods are illustrated using examples from oncology and obstetrics.

Le maniement des médicaments anticancéreux chez les malades âgés

The management of elderly patients with cancer is not established. The use of antineoplastic agents (particularly of chemotherapy) raises a lot of questions. Efficiency and toxicity. Data come from subgroups of clinical trials and from selected populations. Chronological age itself does not contra-indicate chemotherapy. Pharmacokinetics. Physiologic and functional changes occur with aging but there is great inter-patient variability. Oral chemotherapy. Oral treatments underline the problem of compliance. Under-treatment. Elderly patients are under-represented in clinical trials. Relevant issues have to be defined individually and cancer's real place in patient's general situation has to be specified. Geriatric assessment. This tool has proved its usefulness in many domains for global management of elderly patients. A multidisciplinary team is necessary, under geriatrician coordination. The aim is to elaborate an individualized medico-social intervention program. Geriatric assessment in oncology. Its interest for cancer patients is shown by emerging reports but its routine use by oncologists is impossible. Treatment strategies. They are not validated.

FUTURE

New clinical and pharmacokinetic studies are necessary in order to specify the place of the various tools and to enhance the handling of such molecules.

Radiotherapy is a cost-effective palliative treatment for patients with bone metastasis from prostate cancer

BACKGROUND

To evaluate the various treatments for patients with hormone-refractory prostate cancer with bone metastases using a Markov model.

METHODS AND MATERIALS

The base case to be evaluated was of a man with hormone-refractory prostate cancer. The evaluated palliative treatments were pain medication only, chemotherapy consisting of mitoxantrone and prednisone, and single- and multifraction radiotherapy (RT). A literature search was used to generate the transition probabilities and patient utilities. Modeling was used to generate the cost estimates. Expert opinion was used to generate utilities and cost estimates in the absence of literature data. Second-order Monte Carlo simulation produced incremental cost-effectiveness scatterplots and 95% confidence ellipses.

RESULTS

Pain medication had the least expected mean cost of all the treatment options at 11,700 US dollars but also the second lowest quality-adjusted survival at 5.75 quality-adjusted life months. Chemotherapy had the highest expected mean cost, 15,300 US dollars, but the lowest quality-adjusted life months (4.93). Incremental cost-effectiveness analysis revealed that single-fraction RT was the most cost-effective treatment, with a cost of 6,857 US dollars/quality-adjusted life year; multifraction RT had an incremental cost-effectiveness ratio of 36,000 US dollars/quality-adjusted life year. Chemotherapy was dominated by pain medication.

CONCLUSION

Within the limits of the established model, single-fraction RT was the most cost-effective palliative treatment compared with pain medication, chemotherapy, and multifraction RT. The use of this model allowed comparison of different treatment regimens that could never be evaluated together in a randomized clinical trial.

Can Patients' Likelihood of Benefiting from Primary Chemotherapy for Breast Cancer Be Predicted Before Commencement of Treatment?

PURPOSE

Primary chemotherapy is commonly used in patients with breast cancer to downstage the primary tumour prior to surgery. There is a need to establish, prior to commencement of chemotherapy, predictors of clinical and pathological response, which may then be surrogate markers for patient survival and thus allow identification of patients who are most likely to benefit from such treatment.

PATIENTS AND METHODS

A total of 104 patients with large and locally advanced breast cancers received an anthracycline/docetaxel-based regimen prior to surgery. Immunohistochemistry was carried out on pre-treatment core biopsies of the tumour to detect hormone receptors (oestrogen-ER; progesterone-PR), a proliferation marker (MIB-1), the oncoprotein Bcl-2, an extracellular matrix degradation enzyme (cathepsin D), p53, and an oestrogen associated protein (pS2). Both clinical and pathological response were assessed following completion of chemotherapy.

RESULTS

Patients whose tumours did not express oestrogen receptor (p = 0.02) or did not express Bcl-2 (p < 0.01) had a better pathological response in a univariate analysis. However, in a multivariate model, it was only the absence of detectable Bcl-2 protein that predicted a better pathological response (p = 0.001).

CONCLUSIONS

This study has identified that patients whose breast cancers are most likely to experience the greatest degree of tumour destruction by primary chemotherapy do not express either oestrogen receptors or Bcl-2. This may have important implications in the selection of patients with breast cancer for primary chemotherapy who are most likely to gain a survival benefit.

Two schedules of second-line irinotecan for metastatic colon carcinoma

BACKGROUND

In a recently reported, randomized trial, it was found that a regimen of irinotecan once every 3 weeks for patients with advanced colorectal carcinoma was associated with a lower incidence of severe diarrhea compared with weekly treatment, and both regimens had similar efficacy.

METHODS

Resource utilization was captured prospectively for all 291 patients who were included in the trial. Utilities were estimated by transformation of the global quality-of-life (QOL) item on the Eastern Organization for Research and Treatment of Cancer QLQ-C30 instrument.

RESULTS

Patients in the every-3-week arm incurred an average incremental cost of $1362, because they received higher average weekly doses and because the every-3-week regimen resulted in less toxicity, allowing delivery of 97% of the planned doses compared with delivery of only 75% of the planned doses in the weekly arm. This lower toxicity also resulted in offsetting savings from decreased hospitalization and less requirement for supportive medications. Non-chemotherapy-related treatment administration costs also were lower, because the every-3-week regimen could be delivered with half the number of infusions. Utility declined less in the every-3-week arm, resulting in a saving of 6.3 quality-adjusted days. The base-case cost:utility ratio was $78,627 per quality-adjusted life year for patients on the every-3-week schedule. However, that ratio was very sensitive to the cost of irinotecan.

CONCLUSIONS

The schedule of irinotecan once every 3 weeks schedule was more costly but achieved lower toxicity, resulting in modestly improved utility. The cost-per-utility ratio was comparable to other commonly accepted contemporary treatments.

Phase I trial of patient-oriented vaccination in HLA-A2-positive patients with metastatic hormone-refractory prostate cancer

To evaluate the safety and toxicity of peptide vaccination for patients with metastatic hormone-refractory prostate cancer (HRPC) based on pre-existing peptide-specific cytotoxic T-lymphocyte (CTL) precursors in the circulation, 10 patients positive for human leukocyte antigen (HLA)-A2 with metastatic HRPC were enrolled in a phase I study. Peptide-specific CTL-precursors reactive to 16 kinds of vaccine candidates in the pre-vaccination peripheral blood mononuclear cells (PBMCs) were measured, and patients were followed by vaccination with only positive peptides (up to 4 kinds of peptides). Serum prostate-specific antigen (PSA) levels were monitored regularly. The peptide vaccination was safe and well tolerated with no major adverse effects. The most common toxicities were dermatologic reactions at the injection site. Increased CTL response to peptides was observed in 4 of 10 patients. Anti-peptide IgG was also detected in post-vaccination sera of 7 of 10 patients. One patient showed the disappearance of a pelvic bone metastasis after five vaccinations. Three patients showed a decrease of serum PSA level from the baseline after the vaccination, but no patients showed a serum PSA level decrease of >/= 50%. The median survival duration of study patients was 22 months with follow-up from 3 to 27 months. We consider that the increase in cellular and humoral immune responses, and decrease in PSA level in some patients justify further development of peptide vaccination for metastatic HRPC patients.

Surrogate end points of quality of life assessment: have we really found what we are looking for?

Outcome research is a new interesting field in medical research. Some years ago, a document of the American Society of Clinical Oncology distinguished the outcomes of a treatment into patient-outcomes (overall survival and quality of life) and cancer-outcomes (response rate), giving higher priority to patient outcomes. This document is one of the best structured instruments to evaluate and classify the outcomes in clinical oncology. Nevertheless, although overall survival and quality of life represent the main patient outcomes in clinical oncology, in the last years many researchers tried to overcome these recommendations, creating new surrogate end points to assess overall survival and quality of life. Surrogate end points can be useful tools when they are used to achieve preliminary data that anticipate the evaluation of the final outcome, but the use of surrogate end points instead of the main outcomes is quite dangerous, as it can provide wrong answers to clinical questions. The use (or abuse) of surrogate end points of quality of life has recently favoured some questionable decisions of the main regulator organs, such as the approval by the Food and Drugs Administration of the use of gemcitabine in advanced chemotherapy-naive pancreatic cancer, or mitoxantrone in the palliative treatment of hormone-resistant pancreatic cancer, based on the improvement in clinical benefit (a non-validated instrument to evaluate the outcome of palliative chemotherapy) besides a minimal and questionable overall survival, or pain control (evaluated with a non-validated instrument). A correct use of surrogate end points of quality of life within and not instead of quality of life assessment should be the engagement of our further efforts in quality of life research.

Effect of endothelin-A receptor blockade with atrasentan on tumor progression in men with hormone-refractory prostate cancer: a randomized, phase II, placebo-controlled trial

PURPOSE

To evaluate the efficacy and safety of atrasentan (ABT-627), an endothelin-A receptor antagonist, in the treatment of asymptomatic, hormone-refractory prostatic adenocarcinoma.

PATIENTS AND METHODS

A double-blind, randomized, placebo-controlled clinical trial of hormone-refractory prostate cancer (HRPCa) patients was conducted in the United States and Europe. Two hundred eighty-eight asymptomatic patients with HRPCa and evidence of metastatic disease were randomly assigned to one of three study groups receiving a once-daily oral dose of placebo, 2.5 mg atrasentan, or 10 mg atrasentan, respectively. Primary end point was time to progression; secondary end points included time to prostate-specific antigen (PSA) progression, bone scan changes, and changes in bone and tumor markers.

RESULTS

The three treatment groups were similar in all baseline characteristics. Median time to progression in intent-to-treat (ITT) patients (n = 288) was longer in the 10-mg atrasentan group compared with the placebo group: 183 v 137 days, respectively; (P =.13). Median time to progression in evaluable patients (n = 244) was significantly prolonged, from 129 days (placebo group) to 196 days (10-mg atrasentan group; P =.021). For both ITT and evaluable populations in the 10-mg atrasentan group, median time to PSA progression was twice that of the placebo group (155 v 71 days; P =.002). Patients who received placebo continued to have significant increases from baseline in serum (lactate dehydrogenase [LDH]), a marker of disease burden; elevations in LDH were uniformly attenuated by atrasentan in the ITT population. Headache, peripheral edema, and rhinitis were primary side effects, typically of mild to moderate severity. Quality of life was not adversely affected by atrasentan.

CONCLUSION

Atrasentan is an oral, targeted therapy with favorable tolerability and the potential to delay progression of HRPCa.

Health related quality of life in prostate carcinoma patients: a systematic review of randomized controlled trials

BACKGROUND

Health related quality of life (HRQOL) is increasingly reported as an important endpoint in cancer clinical trials. However, evidence suggests that HRQOL reporting is often inadequate. Given this, the authors undertook a systematic review to evaluate HRQOL assessment methodology and reported outcomes of randomized controlled clinical trials (RCTs) with prostate carcinoma patients.

METHODS

A comprehensive search of the literature from 1980 to 2001, mainly on the following databases, was undertaken: MedLine, Cancerlit, and the Cochrane Controlled Trials Register. Studies were identified according to a predefined coding scheme, including HRQOL measure, cultural validity, compliance data reported and the clinical significance of the results.

RESULTS

Twenty-five RCTs were identified, involving 8015 patients primarily with metastatic cancer. Bicalutamide was the medical treatment against which most treatment comparisons were made. Limitations identified included the fact that only 44% of the studies gave a rationale for selecting a specific HRQOL measure, 64% of the studies failed to report information about the administration of the HRQOL measure, and 56% failed to report compliance at baseline. The measure most often used was the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Care 30 (EORTC QLQ-C30), although some studies used non-validated HRQOL tools.

CONCLUSIONS

The current study revealed a lack of a uniform approach to HRQOL assessment and several methodologic limitations. It is possible that such methodologic limitations have influenced trial findings for HRQOL outcomes.

Could we measure the efficiency of prostate cancer treatment? A critical appraisal of economic evaluation studies

The objective of this paper is to introduce the methodology of economic analysis in health care, and its application to the measurement of the efficiency analysis of prostate cancer treatment. We presented the methodology of economic analysis. To review its application in prostate cancer treatment, we performed a bibliographic search in the main biomedical databases (February 1988-January 2001) to identify economic evaluation studies that compared both costs and effects of prostate cancer treatments. The lack of economic studies for localized prostate cancer and the diversity of treatments for advanced prostate cancer make it difficult to make comparisons across studies and to make therapeutic recommendations.Prostate Cancer and Prostatic Diseases (2001) 4, 217-220.

The palliative benefit of irinotecan in 5-fluorouracil-refractory colorectal cancer: its prospective evaluation by a Multicenter Canadian Trial

Most patients with colorectal cancer (CRC) who have failed initial 5-fluorouracil (5-FU) chemotherapy have worsening of disease-related symptoms (DRS) and quality of life (QOL). Irinotecan has a reported response rate of 10%-20% in such patients. The aim of this phase II trial was to prospectively determine the palliative benefit of irinotecan utilizing DRS as primary endpoints of response. Patients had advanced CRC refractory to 5-FU with at least 1 DRS defined as (1) Karnofsky performance status (KPS) 60%-80%, (2) baseline analgesic use > or = 10 mg morphine/day (or equivalent), or (3) disease-related pain score > 1 cm on a 10-cm linear analogue self-assessment (LASA) scale. Patients received irinotecan 125 mg/m2 weekly for 4 weeks on an every-6-weeks schedule. The primary endpoint was palliative response defined as > or = 50% decrease in pain score or analgesic usage, or 10% increase in KPS, from baseline for 4 weeks. QOL was assessed by the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 30 (EORTC QLQ-C30) version 2 instrument. A total of 65 patients were entered onto the study. Median baseline parameters were KPS 70%, analgesic score 11 mg/day, and pain score 2.4 cm. A palliative response was achieved in 27 patients (42%), improvement in pain score predominated. LASA and EORTC QLQ-C30 instruments showed parallel changes in DRS. The radiological response rate was 11% (complete responses and partial responses, n = 46); 23 patients achieved stable disease. Median overall survival was 7.2 months. Irinotecan provides a rate of palliative benefit higher than the radiological response rate. Patients-oriented palliative endpoints can be useful in assessing the benefit of agents in early-phase clinical trials.

Visualization of advanced human prostate cancer lesions in living mice by a targeted gene transfer vector and optical imaging

Non-invasive imaging and transcriptional targeting can improve the safety of therapeutic approaches in cancer. Here we demonstrate the ability to identify metastases in a human-prostate cancer model, employing a prostate-specific adenovirus vector (AdPSE-BC-luc) and a charge-coupled device-imaging system. AdPSE-BC-luc, which expresses firefly luciferase from an enhanced prostate-specific antigen promoter, restricted expression in the liver but produced robust signals in prostate tumors. In fact, expression was higher in advanced, androgen-independent tumors than in androgen-dependent lesions. Repetitive imaging over a three-week period after AdPSE-BC-luc injection into tumor-bearing mice revealed that the virus could locate and illuminate metastases in the lung and spine. Systemic injection of low doses of AdPSE-BC-luc illuminated lung metastasis. These results demonstrate the potential use of a non-invasive imaging modality in therapeutic and diagnostic strategies to manage prostate cancer.

Mitoxantrone and Prednisone for Hormone-Resistant Prostate Cancer

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column reviews various issues related to the preparation, dispensing, and administration of cancer chemotherapy, both commercially available and investigational.

The business of palliative medicine--Part 2: The economics of acute inpatient palliative medicine

Economic feasibility is a major factor in the viability of established acute inpatient palliative medicine. Several clinical, administrative, and financial parameters determine the financial health of inpatient care. Financial management metrics include case mix index (CMI) (as determined by the Federal Register as an assigned relative weight to the diagnosis-related group (DRG) reflecting resource consumption), direct costs, indirect costs, contribution margin, and in the future of all patient revised-DRG (APR-DRG). Both census and length of stay will have a major impact on these financial metrics. The type of patient referral and clinical decisions will influence direct costs and revenues. In the future, an international CMI or APR-DRG will allow palliative inpatient units to compare disease severity, resource utilization, and outcome measures.

An economic overview of prostate carcinoma

BACKGROUND

In the United States in 2000, 180,400 new cases of prostate carcinoma were expected to occur, with 31,900 men expected to die from this illness. In addition, prostate carcinoma is the cause of over half a million disability-adjusted life-years. This study summarizes the current body of published literature about the economics of prostate carcinoma.

METHODS

The authors used a MEDLINE-based literature review for relevant articles from 1990 to the present.

RESULTS

The authors' search returned 216 articles, 56 of which met the criteria of interest. Prostate carcinoma is costly to treat, currently averaging above $20,000 per case. Cost of care is directly related to stage of disease and comorbidity. Substantial geographic variation exists, even within small locales, with regard to care patterns and cost. In-hospital mortality, length of stay, and cost are inversely related to case volume. Care rendered in health maintenance organizations is generally less technologically intensive than in the fee-for-service sector. Out of the 18 cost studies examined, 13 were cost-minimization analyses and five assessed cost-effectiveness. From a cost perspective, laparoscopic pelvic node dissection was favored over an open pelvic procedure; 3D conformal radiation therapy was favored over 2D; and radiation therapy was favored over radical prostatectomy. Cost-effectiveness analyses favored the use of metastron, mitroxantone plus prednisone over prednisone alone, flutamine with either medical or surgical castration, and orchiectomy as the androgen suppression therapy.

CONCLUSIONS

The literature on the economics of prostate carcinoma is relatively meager. Most cost studies were done on small samples, had short follow-up periods, used charges rather than cost data, and did not include adequate representation of all stages of disease. Additional research is needed.

Cost-effectiveness analysis when the WTA is greater than the WTP

The incremental cost effectiveness ratio has long been the standard parameter of interest in the assessment of the cost-effectiveness of a new treatment. However, due to concerns with interpretability and statistical inference, authors have suggested using the willingness-to-pay for a unit of health benefit to define the incremental net benefit as an alternative. The incremental net benefit has a more consistent interpretation and is amenable to routine statistical procedures. These procedures rely on the fact that the willingness-to-accept compensation for a loss of a unit of health benefit (at some cost saving) is the same as the willingness-to-pay for it. Theoretical and empirical evidence suggest, however, that in health care the willingness-to-accept is about twice as much as the willingness-to-pay. We use Bayesian methods to provide a statistical procedure for the cost-effectiveness comparison of two arms of a randomized clinical trial that allows the willingness-to-pay and the willingness-to-accept to have different values. An example is provided.

On the probability of cost-effectiveness using data from randomized clinical trials

BACKGROUND

Acceptability curves have been proposed for quantifying the probability that a treatment under investigation in a clinical trial is cost-effective. Various definitions and estimation methods have been proposed. Loosely speaking, all the definitions, Bayesian or otherwise, relate to the probability that the treatment under consideration is cost-effective as a function of the value placed on a unit of effectiveness. These definitions are, in fact, expressions of the certainty with which the current evidence would lead us to believe that the treatment under consideration is cost-effective, and are dependent on the amount of evidence (i.e. sample size).

METHODS

An alternative for quantifying the probability that the treatment under consideration is cost-effective, which is independent of sample size, is proposed.

RESULTS

Non-parametric methods are given for point and interval estimation. In addition, these methods provide a non-parametric estimator and confidence interval for the incremental cost-effectiveness ratio. An example is provided.

CONCLUSIONS

The proposed parameter for quantifying the probability that a new therapy is cost-effective is superior to the acceptability curve because it is not sample size dependent and because it can be interpreted as the proportion of patients who would benefit if given the new therapy. Non-parametric methods are used to estimate the parameter and its variance, providing the appropriate confidence intervals and test of hypothesis.

Cost-effectiveness analysis with risk aversion

This paper discusses why, in a medical context, the standard assumption of a risk-neutral social planner is inappropriate and develops a framework for conducting cost-effectiveness (CE) analysis when social planners are risk-averse. This framework demonstrates that if new medical interventions are variance increasing (decreasing), the risk-neutral approach will approve (reject) projects that should be rejected (accepted). This methodology is applied to two medical interventions that have been previously evaluated and considered cost-effective in the published literature. Since both conclusions assumed risk neutrality we determine the level of societal risk-aversion that would be necessary to reject these new interventions and compare these levels to previous estimates of risk-aversion in the economics literature. We find that for reasonable values of the risk-aversion parameter, only one of the two interventions should be approved. It is our recommendation that the cut-off risk aversion parameter (the level of risk-aversion above which a project would be rejected) should become a standard reported figure in future CE studies.

Incremental net benefit in randomized clinical trials

There are three approaches to health economic evaluation for comparing two therapies. These are (i) cost minimization, in which one assumes or observes no difference in effectiveness, (ii) incremental cost-effectiveness, and (iii) incremental net benefit. The latter can be expressed either in units of effectiveness or costs. When analysing data from a clinical trial, expressing incremental net benefit in units of cost allows the investigator to examine all three approaches in a single graph, complete with the corresponding statistical inferences. Furthermore, if costs and effectiveness are not censored, this can be achieved using common two-sample statistical procedures. The above will be illustrated using two examples, one with censoring and one without.

Analysis, sample size, and power for estimating incremental net health benefit from clinical trial data

Stinnett and Mullahy recently introduced the concept of net health benefit as an alternative to cost-effectiveness ratios for the statistical analysis of patient-level data on the costs and health effects of competing interventions. Net health benefit addresses a number of problems associated with cost-effectiveness ratios by assuming a value for the willingness-to-pay for a unit of effectiveness. We extend the concept of net health benefit to demonstrate that standard statistical procedures can be used for the analysis, power, and sample size determinations of cost-effectiveness data. We also show that by varying the value of the willingness-to-pay, the point estimate and confidence interval for the incremental cost-effectiveness ratio can be determined. An example is provided.

A phase II trial of estramustine and etoposide in hormone refractory prostate cancer: A Southwest Oncology Group trial (SWOG 9407)

BACKGROUND

The combination of oral estramustine and oral etoposide has generated response rates of 40-50% in patients with hormone refractory prostate cancer in single institution trials. This study tested this regimen in a multi-institutional setting.

METHODS

Fifty-five patients were accrued over a period of 4 months between 1 March 1996 and 1 July 1996. Two patients were not analyzable and two patients were ineligible. They were given an oral regimen consisting of estramustine 15 mg/kg/day (capped at 1120 mg per day) and etoposide 50 mg/M(2)/day, days 1-21 every 28 days. Patients received a median of two cycles of therapy.

RESULTS

Toxicities included 11 patients (20%) with grades 3 or 4 granulocytopenia, 5 patients (10%) with grades 3 or 4 edema, and 3 patients (6%) with a thrombotic event. There were two treatment-related deaths, one as a result of anemia and the other as a result of a myocardial infarction. Of the 32 men who received at least 2 cycles of therapy, 7 men (22%) demonstrated a partial response to this regimen as measured by prostate-specific antigen (PSA) criteria of a 50% decline from pretreatment values.

CONCLUSIONS

This trial demonstrates the toxicity of estramustine delivered in high dose. It also illustrates the difficulty of conducting phase II trials in prostate cancer in the cooperative group setting where the experience and comfort level of oncologists with new agents is less than that of the physicians at the institution where the therapy was developed. As the activity of this regimen with low-dose estramustine is defined, further multi-institutional studies may be warranted.

Chemotherapy in advanced androgen-independent prostate cancer 1990-1999: a decade of progress?

BACKGROUND AND PURPOSE

A great number of clinical research studies have been reported in the field of chemotherapy for advanced androgen-independent prostate cancer during the last ten years. The aims of the present review were to assess their impact on management of the disease and on survival of patients.

METHODS

The review of full published reports was facilited by the use of a MEDLINE computer search.

RESULTS

Clinical research studies have focused on defining guidelines for eligibility criteria and accurate endpoints for patients to be enrolled onto clinical trials and developing new agents or combination of drugs including estramustine phosphate. Any combination of current chemotherapy has no impact on overall survival of patients. Among drugs in development, only the promising activity observed with docetaxel deserves randomized trials to assess its impact on survival. The major innovative advance of the 90s is the demonstration of the impact of chemotherapy (mitoxantrone + prednisone) on quality of life as compared to prednisone alone. A greater and longer-lasting improvement in quality of life along with a concomitant decrease in costs was observed.

CONCLUSIONS

At the present time, chemotherapy should be considered as a palliative treatment in patients with symptomatic androgen-independent disease. The enrollment of patients into clinical trials dealing with quality of life as primary endpoint is strongly solicited. A standard methodology should be used in phase II trials with a primary goal of selection of agents which should progress to randomized trials using survival as an endpoint. Hopefully new specific strategies targeted to reverse the molecular changes that underlie prostate tumorigenesis should rapidly impact the multimodality management of AIPC in the third millenium.

Report on the quality of life analysis from the phase III trial of pion versus photon radiotherapy in locally advanced prostate cancer

This report examines the quality of life (QOL) of 215 patients entered into a randomised trial between pion and photon radiotherapy for prostate cancer at a single institution. The survival and local control results of the trial were equivalent in both arms. A modification of the Rotterdam Symptom Checklist (RSCL) was used to assess QOL. Global QOL, toxicity and physical scores were found to be worse in pion-treated patients at the end of treatment (P<0.001, P<0.001, and P=0.02 respectively). There are no long-term differences in the QOL of pion- versus photon-treated patients. Sexual function was a concern for patients even at baseline. There was a progressive loss of sexual interest and erectile function. There was a significant impact from hormonal therapy at relapse. Hormonal treatment produced a stepwise significant worsening in global QOL, particularly for physical and psychological domains.

Cost-utility analysis of chemotherapy using paclitaxel, docetaxel, or vinorelbine for patients with anthracycline-resistant breast cancer

PURPOSE

Paclitaxel, docetaxel, and vinorelbine have been approved for chemotherapy in patients with advanced breast cancer that is resistant to anthracyclines. Selecting which agent to use is difficult because each possesses advantages and disadvantages related to clinical response, toxicity, method of administration, and cost. A cost-utility analysis was therefore performed to create a rank order on the basis of effectiveness, quality of life, and economic considerations.

PATIENTS AND METHODS

Eighty-eight anthracycline-resistant breast cancer patients who had received paclitaxel (n = 34), docetaxel (n = 29), or vinorelbine (n = 25) during the past 2 years were identified. Total resource consumption was collected, which included expenditures for chemotherapy, supportive care, laboratory tests, management of adverse effects, and all related physician fees. Utilities from 25 oncology care providers and 25 breast cancer patients were estimated using the time trade-off technique. The economic estimates from the chart review and clinical data from the literature were then modeled using the principles of decision analysis.

RESULTS

Each of the three drugs led to a similar duration of quality-adjusted progression-free survival (paclitaxel, 37.2 days; docetaxel, 33.6 days; vinorelbine, 38.0 days). Vinorelbine was the least costly strategy, with an overall treatment expenditure of Can $3,259 per patient, compared with Can $6,039 and Can $10,090 for paclitaxel and docetaxel, respectively.

CONCLUSION

Palliative chemotherapy with vinorelbine in anthracycline-resistant metastatic breast cancer patients has economic advantages over the taxanes and provides at least equivalent quality-adjusted progression-free survival. These benefits are largely related to its lower drug acquisition cost and better toxicity profile.

Advances in prostate cancer

The causes of prostate cancer reflect a complex interaction between environmental and genetic factors. Improvement in screening has reduced the incidence of prostate cancer, and risk assessment schemata have enhanced therapy, both for localized disease and for locally recurrent prostate cancer. The use of hormone therapy has been further evaluated, as primary therapy for locally advanced cancers, for lymph node-positive cancers, and for de novo metastatic cancer. Modest inroads have been made in the treatment and understanding of androgen-independent prostate cancer. Advances have been made in the understanding of the risk factors, genetic and environmental, associated with the development and progression of prostate cancer; in screening; and in optimizing therapy for localized, locally recurrent, and advanced disease. This article reviews the most salient observations reported between November 1, 1997 and October 31, 1998.

Third line chemotherapy in patients with metastatic breast cancer: an evaluation of quality of life and cost

Many patients with metastatic breast cancer receive several types of chemotherapy, although it is recognized that there is a declining probability of response. A major problem confronts oncologists in deciding when to recommend to patients that no further chemotherapy should be given. To address this problem we have assessed prospectively, health-related quality of life (HRQL) and costs of health care for 35 patients with metastatic breast cancer receiving third line chemotherapy in a representative clinical situation. HRQL and utilities were measured longitudinally using the EORTC QLQ-C30 questionnaire and the time trade-off method. Patients received a median of 2 cycles of chemotherapy and lived a median of 4.3 months. Twelve patients (34%) had substantial (> 10 points) improvement in the Global QL subscale and more than 30% of patients had similar changes in emotional and social function. The median baseline utility score was 0.9 and utilities correlated poorly with HRQL subscale. Eighteen patients had measurable disease and one patients experienced a partial response. Grade 3/4 toxicity occurred in 30% of patients. The average cost of management from study entry to death was CDN$ 17,260 (approximately US$ 12,000). Sixteen percent of this cost was associated directly with chemotherapy while hospital admissions and outpatient visits accounted for 50% and 14% of the total cost respectively. We conclude that: (a) many patients receiving third line chemotherapy maintain or improve indices of HRQL despite short survival and a low response rate: this might be due to chemotherapy, placebo effect, or a shift in frame of reference for HRQL; (b) patients were unwilling to trade quantity for quality of life; and (c) response rates and survival may be overestimated in patients selected for clinical trials.