Pamidronate in prevention of bone complications in metastatic breast cancer: a cost-effectiveness analysis

Developing the Breast Utility Instrument to Measure Health-Related Quality-of-Life Preferences in Patients with Breast Cancer: Selecting the Item for Each Dimension

Introduction. Generic preference-based instruments inadequately measure breast cancer (BrC) health-related quality-of-life preferences given advances in therapy. Our overall purpose is to develop the Breast Utility Instrument (BUI), a BrC-specific preference-based instrument. This study describes the selection of the BUI items. Methods. A total of 408 patients from diverse BrC health states completed the EORTC QLQ-C30 and BR45 (breast module). For each of 10 dimensions previously assessed with confirmatory factor analysis, we evaluated data fit to the Rasch model based on global model and item fit, including threshold ordering, item residuals, infit and outfit, differential item functioning (age), and unidimensionality. Misfitting items were removed iteratively, and the model fit was reassessed. From items fitting the Rasch model, we selected 1 item per dimension based on high patient- and clinician-rated item importance, breadth of item thresholds, and clinical relevance. Results. Global model fit was good in 7 and borderline in 3 dimensions. Separation index was acceptable in 4 dimensions. Item selection criteria were maximized for the following items: 1) physical functioning (trouble taking a long walk), 2) emotional functioning (worry), 3) social functioning (interfering with social activities), 4) pain (having pain), 5) fatigue (tired), 6) body image (dissatisfied with your body), 7) systemic therapy side effects (hair loss), 8) sexual functioning (interest in sex), 9) breast symptoms (oversensitive breast), and 10) endocrine therapy symptoms (problems with your joints). Conclusions. We propose 10 items for the BUI. Our next steps include assessing the measurement properties prior to eliciting preference weights of the BUI.

Highlights

A previous confirmatory factor analysis established 10 dimensions of the European Organisation for Research and Treatment of Cancer (EORTC) core quality of life questionnaire (QLQ-C30) and its breast module (BR45). In this study, we selected 1 item per dimension based on fit to the Rasch model, patient- and clinician-rated item importance, breadth of item thresholds, and clinical relevance. These items form the core of the future Breast Utility Instrument (BUI). The future BUI will be a novel breast cancer–specific preference-based instrument that potentially will better reflect women’s preferences in clinical decision making and cost utility analyses.

Cost-Effectiveness and Estimated Health Benefits of Treating Patients with Vitamin D in Pre-Dialysis

Background The optimal timing of treatment with vitamin D therapy for patients with chronic kidney disease (CKD), vitamin D insufficiency, and secondary hyperparathyroidism (SHPT) is a pressing question in nephrology with economic and patient outcome implications. Objective The objective of this study was to estimate the cost-effectiveness of earlier vitamin D treatment in CKD patients not on dialysis with vitamin D insufficiency and SHPT. Design A cost-effectiveness analysis based on a Markov model of CKD progression was developed from the Medicare perspective. The model follows a hypothetical cohort of 1000 Stage 3 or 4 CKD patients over a 5-year time horizon. The intervention was vitamin D therapy initiated in CKD stages 3 or 4 through CKD stage 5/end-stage renal disease (ESRD) versus initiation in CKD stage 5/ESRD only. The outcomes of interest were cardiovascular (CV) events averted, fractures averted, time in CKD stage 5/ESRD, mortality, quality-adjusted life years (QALYs), and costs associated with clinical events and CKD stage. Results Vitamin D treatment in CKD stages 3 and 4 was a dominant strategy when compared to waiting to treat until CKD stage 5/ESRD. Total cost savings associated with treatment during CKD stages 3 and 4, compared to waiting until CKD stage 5/ESRD, was estimated to be $19.9 million. The model estimated that early treatment results in 159 averted CV events, 5 averted fractures, 269 fewer patient-years in CKD stage 5, 41 fewer deaths, and 191 additional QALYs. Conclusions Initiating vitamin D therapy in CKD stages 3 or 4 appears to be cost-effective, largely driven by the annual costs of care by CKD stage, CV event costs, and risks of hypercalcemia. Further research demonstrating causal relationships between vitamin D therapy and patient outcomes is needed to inform decision making regarding vitamin D therapy timing.

Cost-effectiveness of standard utilization of zoledronic acid for bone metastases from advanced lung cancer in China

Aim: To assess the cost-effectiveness of standard utilization of zoledronic acid (ZA) relative to real-world utilization of ZA for bone metastasis (BM) in Chinese patients with advanced lung cancer. Materials & methods: A decision analytic model was constructed to simulate health benefits and medical costs associated with standard and real-world utilization of ZA for BM in Chinese patients with advanced lung cancer. Results: Compared with real-world utilization of ZA, standard utilization of ZA reduced cumulative risk of skeletal-related events (45.7 vs 63.6%), increased quality-adjusted life years (0.673 vs 0.626 QALY) and saved cumulated medical costs (¥343,163 vs ¥376,943). Conclusion: Standard utilization of ZA dominated real-world utilization of ZA for BM in Chinese patients with advanced lung cancer from cost-effectiveness perspective.

Lung cancer with bone metastases in the United States: an analysis from the Surveillance, Epidemiologic, and End Results database

The present study used the Surveillance, Epidemiology and End Results (SEER) database to identify demographic and prognostic characteristics of lung cancer with bone metastases in the United States from 2010 to 2014. 30,364 patients with metastatic lung cancer to bones were identified in the SEER database. Their information on the basic characteristics and the histological signatures of the cancer was extracted and analyzed. Joinpoint analysis was used to test the trends in annual percentage change (APC) of the incidence. 1-year survival rate among patients with metastatic lung cancer to bones was only 20.2%, and median survival time was about 3.0 months for those patients. Young age, female sex, race other than white and black, tumor in lobes, smaller tumor, adenocarcinoma, and surgery for primary site were associated with a significant survival benefit. APC of the incidence almost increased steadily on the whole and reached the level of statistical significance among the patients older than age 60. Although there are some signatures associated with better prognosis, the overall outcome remains very poor in patients with metastatic lung cancer to bones. In addition, the incidence of lung cancer with bone metastases is increasing in certain subgroups in the United States.

Cost-Effectiveness of Treatments for the Management of Bone Metastases: A Systematic Literature Review

BACKGROUND

Metastatic cancers occur when cancer cells break away from the primary tumour. One of the most common sites of metastasis is the bone, with several therapeutic options currently available for managing bone metastases. In a resource-constrained environment, policy makers and practitioners need to know which options are cost effective.

OBJECTIVE

The aim of this systematic review was to review and appraise published economic evaluations on treatments for the management of bone metastases.

METHODS

We searched eight bibliographic databases (MEDLINE, MEDLINE in Process, EMBASE, CSDR, DARE, HTA, EED and CPCI) for relevant economic evaluations published from each database's inception date until March 2017. Study selection, quality assessment and data extraction were carried out according to published guidelines.

RESULTS

Twenty-four relevant economic analyses were identified. Seventeen of these studies focused on bone metastases resulting from a particular type of cancer, i.e. prostate (n = 8), breast (n = 7), lung (n = 1) or renal (n = 1), while seven report results for various primary tumours. Across types of cancer, evidence suggests that bisphosphonates result in lower morbidity and improved quality of life, for an additional cost, which is typically below conventional cost-effectiveness thresholds. While denosumab leads to health gains compared with zoledronic acid, it also results in substantial additional costs and is unlikely to represent value for money. The limited literature on the radiopharmaceutical strontium-89 (Sr89) and external beam radiotherapy (EBR) suggest that these treatments are cost effective compared with no treatment.

CONCLUSIONS

The reviewed evidence suggests that bisphosphonate treatments are cost-effective options for bone metastases, while denosumab is unlikely to represent value for money. Evidence on EBR and Sr89 is limited and less conclusive.

Cost-utility analyses of drug therapies in breast cancer: a systematic review

The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.

Health resource utilization associated with skeletal-related events: results from a retrospective European study

BACKGROUND

Bone complications, also known as skeletal-related events (SREs), are common in patients with bone metastases secondary to advanced cancers.

OBJECTIVE

To provide a detailed estimate of the health resource utilization (HRU) burden associated with SREs across eight European countries.

METHODS

Eligible patients from centers in Austria, the Czech Republic, Finland, Greece, Poland, Portugal, Sweden, and Switzerland with bone metastases or lesions secondary to breast cancer, prostate, or lung cancer or multiple myeloma who had experienced at least one SRE (defined as radiation to bone, long-bone pathologic fracture, other bone pathologic fracture, surgery to bone or spinal cord compression) were entered into this study. HRU data were extracted retrospectively from the patients' charts from 3.5 months before the index SRE until 3 months after the index SRE (defined as an SRE preceded by an SRE-free period of at least 6.5 months).

RESULTS

Overall, the mean number of inpatient stays per SRE increased from baseline by approximately 0.5-1.5 stays, with increases in the total duration of inpatient stays of approximately 6-37 days per event. All SREs were associated with substantial increases from baseline in the frequency of procedures and the number of outpatient and day-care visits.

CONCLUSIONS

SREs are associated with substantial HRU owing to considerable increases in the number and duration of inpatient stays, and in the number of procedures, outpatient visits, and day-care visits. These data collectively provide a valuable summary of the real-world SRE burden on European healthcare systems.

Cost of skeletal complications from bone metastases in six European countries

Objective Patients with bone metastases or lesions secondary to solid tumors or multiple myeloma often experience bone complications (skeletal-related events [SREs]-radiation to bone, pathologic fracture, surgery to bone, and spinal cord compression); however, recent data that can be used to assess the value of treatments to prevent SREs across European countries are limited. This study aimed to provide estimates of health resource utilization (HRU) and cost associated with all SRE types in Europe. HRU data were reported previously; cost data are reported herein. Methods Eligible patients from 49 centers across Austria (n = 57), the Czech Republic (n = 59), Finland (n = 60), Greece (n = 59), Portugal (n = 59), and Sweden (n = 62) had bone metastases or lesions secondary to breast, lung, or prostate cancer, or multiple myeloma, and ≥1 index SRE (a SRE preceded by a SRE-free period of ≥ 6.5 months). SRE-related costs were estimated from a payer perspective using health resource utilization data from patient charts (before and after the index SRE diagnosis). Country-specific unit costs were from 2010 and local currencies were converted to 2010 euros. Results The mean costs across countries were €7043, €5242, €11,101, and €11,509 per radiation to bone, pathologic fracture, surgery to bone, and spinal cord compression event, respectively. Purchasing power parity (PPP)-adjusted mean cost ratios were similar in most countries, with the exception of radiation to bone. Limitations The overall burden of SREs may have been under-estimated owing to home visits and evaluations outside the hospital setting not being reported here. Conclusions All SREs were associated with substantial costs. Variation in SRE-associated costs between countries was most likely driven by differences in treatment practices and unit costs.

Clinical, economic and humanistic burdens of skeletal-related events associated with bone metastases

Despite effective skeletal-related event (SRE)-limiting therapies such as zoledronic acid and denosumab, SREs continue to place a meaningful burden on patients, providers and payers. However, studies of SRE-related effects on clinical (i.e., survival), economic (i.e., cost per event) and humanistic (i.e., quality of life) outcomes often report results in a composite manner and frequently do not differentiate the effects by SRE-type (i.e., bone radiation, bone surgery, hypercalcemia, pathological fracture and spinal cord compression). Nevertheless, understanding the differential burdens of individual SRE types, which vary in severity and duration of effect, is an important consideration - particularly in pharmacoeconomic evaluations of SRE-limiting therapies. In this review of the clinical, economic and humanistic SRE burden, it was found that SRE types can be differentiated by these outcomes, although economic outcomes are far more frequently reported than clinical or humanistic.

Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a cost-effectiveness analysis

OBJECTIVE

Denosumab has been approved in the US for skeletal-related event (SRE) prevention in bone-metastatic prostate cancer on the basis of a phase III clinical trial in which denosumab reduced SREs relative to zoledronic acid. Overall survival, disease progression, and serious adverse events did not differ significantly between groups. This analysis assessed the cost-effectiveness of denosumab vs zoledronic acid in bone-metastatic prostate cancer from a US payer perspective.

METHODS

A literature-based Markov model, wherein inputs were selected to reproduce clinical trial outcomes, was developed to estimate the survival, quality-adjusted life-years (QALYs), number and costs of SREs, and drug and administration costs for patients receiving denosumab or zoledronic acid over 27 months. QALYs were estimated by assigning health-state utilities. SRE-related costs and utilities were literature-based. Outcomes were discounted 3% per annum, and model robustness was tested via scenario, univariate, and probabilistic sensitivity analyses.

RESULTS

Denosumab resulted in fewer estimated SREs (-0.241; 1.036 vs 1.277), more QALYs (0.0074; 0.9306 vs 0.9232), and lower SRE-related costs (-$2340; $8824 vs $11,164), but higher drug-related costs ($10,181; $23,144 vs $12,963) and total costs ($7841; $31,968 vs $24,127) vs zoledronic acid. The base case estimated cost per QALY-gained was $1,058,741.

CONCLUSION

This analysis was limited by the restricted availability of clinical data and the need to use projection methods beyond the trial time frame. However, a wide range of scenarios predicted denosumab to have an incremental cost/QALY gained above what may be considered acceptable value for money in the US. This raises important questions regarding the pharmacoeconomic value of denosumab in bone-metastatic prostate cancer.

Patient-reported outcome instruments used to assess pain and functioning in studies of bisphosphonate treatment for bone metastases

Purpose

When treating metastatic bone disease, relief of bone pain is often a key outcome. Because pain cannot be quantified with objective clinical measures, patient-reported outcome (PRO) measures are required to assess patients' subjective experience. The goal of the current review was to examine measures used to assess pain, as well as the impact of pain on functional status and health-related quality of life (HRQL), in trials of bisphosphonates for the treatment of bone metastases.

Methods

A literature search focused on articles published from January 1999 to April 2009.

Results

A total of 49 articles were located that used PROs to assess pain-related outcomes of bisphosphonate treatment for bone metastases. The Brief Pain Inventory was the most commonly used multi-item instrument. However, the most common approach for assessing pain was to administer a single-item scale such as a visual analog scale, numerical rating scale, or verbal rating scale. Of the 49 studies, 19 included a PRO assessing functional status or HRQL.

Conclusions

Although pain is an important outcome of trials examining treatment for bone metastases, the current review suggests that there is little consistency in PRO measurement across studies. Furthermore, presentation of measures often lacked clear description, information on measurement properties, citations, clarity regarding method of administration, and consistent instrument names. Recommendations are provided for instrument validation within the target population, assessment of content validity, use of PRO instruments recently developed for patients with bone metastases, clear description of instruments, and implementation of measures consistent with recommendations from instrument developers.

Cost-effectiveness of denosumab compared with zoledronic acid in patients with breast cancer and bone metastases

BACKGROUND

Results from a phase III clinical trial showed that denosumab significantly reduced the risk of first on-study and subsequent skeletal-related events (SREs) compared with zoledronic acid. This study aims to assess the cost-effectiveness of denosumab vs. zoledronic acid in the prevention of SREs in patients with advanced breast cancer and bone metastases.

MATERIALS AND METHODS

A Markov model was developed with 4-week model cycles and a 1-year time horizon. The health states were defined by SRE status (no SRE, first on-study SRE, subsequent SRE, no SRE but history of SRE) and SRE type (pathologic fracture, radiation to the bone, surgery to the bone, spinal cord compression). Costs (in 2011 US dollars) included drug, SRE treatment, and adverse event (AE) costs and were assessed from a third-party payer perspective. The primary outcome was incremental total cost per SRE avoided; the secondary outcome was incremental total cost per pathologic fracture avoided. One-way and probabilistic sensitivity analyses were used to assess the robustness of the model.

RESULTS

During the 1-year treatment period, denosumab incurred $7522 higher costs ($30,033 for denosumab and $23,511 for zoledronic acid), 0.06 fewer SREs, and 0.02 fewer pathologic fractures per patient, which led to an incremental total cost per SRE and pathologic fracture avoided of $114,628 and $290,136, respectively, compared with zoledronic acid. Results were robust to 1-way and probabilistic sensitivity analyses.

CONCLUSION

Although denosumab demonstrated superiority in preventing SREs in the phase III trial, it may not be cost-effective compared with zoledronic acid because of its high cost.

Cost-effectiveness of denosumab versus zoledronic acid in the management of skeletal metastases secondary to breast cancer

BACKGROUND

Denosumab has been approved in the United States for the prevention of skeletal-related events (SREs) in metastatic breast cancer. In a Phase III trial in patients with bone-metastatic breast cancer (N = 2033), denosumab was associated with a significantly delayed time to first SRE (by 18%; P < 0.001 noninferiority; P = 0.01 superiority) and time to first and subsequent SREs (by 23%; P = 0.001). Overall survival (HR = 0.95; 95% CI, 0.81-1.11; P = 0.49) and disease progression (HR = 1.00; 95% CI, 0.89-1.11; P = 0.93) did not differ significantly between groups. Denosumab was associated with a nonsignificant reduction in serious adverse events (44.4% vs 46.5%).

OBJECTIVES

Given the current ambiguity regarding the cost-effectiveness of these agents in light of these trial outcomes, the present analysis assessed, from a US payer perspective, the cost-effectiveness of denosumab versus zoledronic acid in patients with bone metastases secondary to breast cancer.

METHODS

A literature-based Markov model was developed to estimate the survival, quality-adjusted life-years (QALYs) gained, number and costs of SREs, and drug and administration costs in patients receiving denosumab or zoledronic acid over 27 and 60 months. Clinical inputs reproduced the trial outcomes. SRE-related costs and utilities were literature based. Costs and QALYs were discounted 3% annually.

RESULTS

In the 27-month base-case analysis, denosumab was associated with fewer SREs (-0.298), more QALYs (+0.0102), and lower SRE-related costs (-$2016), but higher drug-related (+$9123) and total costs (+$7107) versus zoledronic acid. The cost per QALY gained (ie, incremental cost-effectiveness ratio [ICER]) was $697,499. In sensitivity analyses, the ICER ranged from $192,472 to $1,340,901/QALY, depending on assumptions regarding treatment benefits, drug costs, and analytical horizon. In the probabilistic sensitivity analysis, denosumab was cost-effective in 2 of 5000 modeled replicates (0.04%).

CONCLUSIONS

Despite the limitations of restricted availability of clinical data and uncertainty regarding the price of generic zoledronic acid, the findings from the present analysis suggest that the use of denosumab is associated with a high ICER compared with zoledronic acid. This finding may raise important questions regarding the economic value of denosumab in bone-metastatic breast cancer.

Pharmacoeconomics of bisphosphonates for skeletal-related event prevention in metastatic non-breast solid tumours

Bisphosphonates reduce the risk of skeletal-related events (SREs; i.e. spinal cord compression, pathological fracture, radiation or surgery to the bone, and hypercalcaemia) in patients with metastatic cancer. A number of analyses have been conducted to assess the cost effectiveness of bisphosphonates in patients with bone metastases secondary to breast cancer, but few in other solid tumours. This is a review of cost-effectiveness analyses in patients with non-breast solid tumours and bone metastases. A literature search was conducted to identify cost-effectiveness analyses reporting the cost per QALY gained of bisphosphonates in patients with metastatic bone disease secondary to non-breast solid tumours. Four analyses met inclusion criteria. These included two in prostate cancer (one of which used a global perspective but expressed results in $US, and the other reported from a multiple country perspective: France, Germany, Portugal and the Netherlands). The remaining analyses were in lung cancer (in the UK, France, Germany, Portugal and the Netherlands), and renal cell carcinoma (in the UK, France and Germany). In each analysis, the cost effectiveness of zoledronic acid versus placebo was analysed. Zoledronic acid was found to be cost effective in all European countries across all three indications but not in the sole global prostate cancer analysis. Across countries and indications, assumptions regarding patient survival, drug cost and baseline utility (i.e. patient utility with metastatic disease but without an SRE) were the most robust drivers of modelled estimates. Assumptions of SRE-related costs were most often the second strongest cost driver. Further review indicated that particular attention should be paid to the inclusion or exclusion of nonsignificant survival benefits, whether health state utilities were elicited from community or patient samples or author assumptions, delineation between symptomatic and asymptomatic SREs, and the methods with which SRE disutility was modelled over time. While the field of cost-effectiveness analysis in solid tumours other than breast cancer is still evolving, outcomes will likely continue to be driven by drug cost and assumptions regarding treatment benefits. Although considerations such as adverse events and administration costs are important, they were not found to influence cost-effectiveness estimates greatly. As zoledronic acid will lose patent protection in 2013 and subsequently be greatly reduced in price, it is likely that the field of cost effectiveness will change with regard to SRE-limiting agents. Meanwhile, research should be conducted to improve our understanding of the impact on quality of life and medical costs of preventing SREs.

Cost-effectiveness of zoledronic acid in the prevention of skeletal-related events in patients with bone metastases secondary to advanced renal cell carcinoma: application to France, Germany, and the United Kingdom

BACKGROUND

The use of zoledronic acid (ZOL) has recently been shown to significantly reduce the risk of new skeletal-related events (SREs) in renal cell carcinoma (RCC) patients with bone metastases. The present exploratory study assessed the cost-effectiveness of ZOL in this population, adopting a French, German, and United Kingdom (UK) government payer perspective.

MATERIALS AND METHODS

This cost-effectiveness model was based on a post hoc retrospective analysis of a subset of patients with RCC who were included in a larger randomized clinical trial of patients with bone metastases secondary to a variety of cancers. In the trial, patients were randomized to receive ZOL (n = 27) or placebo (n = 19) with concomitant antineoplastic therapy every 3 weeks for 9 months (core study) plus 12 months during a study extension. Since the trial did not collect costs or data on the quality-adjusted life years (QALYs) of the patients, these outcomes had to be assumed via modeling exercises. The costs of SREs were estimated using hospital DRG tariffs. These estimates were supplemented with literature-based costs where possible. Drug, administration, and supply costs were obtained from published and internet sources. Consistent with similar economic analyses, patients were assumed to experience quality of life decrements lasting 1 month for each SRE. Uncertainty surrounding outcomes was addressed via multivariate sensitivity analyses.

RESULTS

Patients receiving ZOL experienced 1.07 fewer SREs than patients on placebo. Patients on ZOL experienced a gain in discounted QALYs of approximately 0.1563 in France and Germany and 0.1575 in the UK. Discounted SRE-related costs were substantially lower among ZOL than placebo patients (-€ 4,196 in France, - € 3,880 in Germany, and -€ 3,355 in the UK). After taking into consideration the drug therapy costs, ZOL saved € 1,358, € 1,223, and € 719 in France, Germany, and the UK, respectively. In the multivariate sensitivity analyses, therapy with ZOL saved costs in 67-77% of simulations, depending on the country. The cost per QALY gained for ZOL versus placebo was below € 30,000 per QALY gained threshold in approximately 93-94% of multivariate sensitivity analyses simulations.

CONCLUSIONS

The present analysis suggests that ZOL saves costs and increases QALYs compared to placebo in French, German, and UK RCC patients with bone metastases. Additional prospective research may be needed to confirm these results in a larger sample of patients.

Cost-effectiveness of zoledronic acid in the management of skeletal metastases in patients with lung cancer in France, Germany, Portugal, the Netherlands, and the United kingdom

BACKGROUND

Zoledronic acid (ZOL) significantly reduces the risk of new skeletal-related events (SREs) in patients with non-small cell lung cancer (NSCLC) who have bone metastases.

OBJECTIVE

The purpose of this study was to assess the cost and cost-effectiveness of ZOL in the management of skeletal metastases in this population across 5 European countries (France, Germany, United Kingdom, Portugal, and the Netherlands) from the perspective of national health care.

METHODS

This cost-effectiveness analysis was based on a subset of patients with NSCLC who were enrolled in a Phase III trial of patients with bone metastases secondary to a variety of solid tumors. In this trial, patients were randomized to receive ZOL or placebo every 3 weeks for up to 21 months. Survival, SRE incidence, and number of infusions administered were derived from the clinical trial. Costs of SREs were estimated using hospital Diagnosis Related Group tariffs and published data. Drug, drug administration, and supply costs were obtained from published and internet sources. Quality-adjusted life-years (QALYs) were estimated based on the published utilities and modeled survival and frequency of SREs. Uncertainty surrounding outcomes was addressed via univariate and probabilistic sensitivity analyses.

RESULTS

Compared with patients receiving placebo (n = 120), patients receiving ZOL (n = 124) experienced an estimated 0.79 fewer SREs and gained an estimated 0.02 QALYs. ZOL use in patients with NSCLC and bone metastases was associated with a reduction in SRE costs (ranging from €1547 to €1893 [2007-2008 €], depending on the country). After adding drug and drug administration costs, ZOL use resulted in a net savings of €288 per patient in Germany, €209 in the United Kingdom, and €113 in Portugal. In France and the Netherlands, costs increased (€17 and €178, respectively), but the costs per QALY gained were low (€786 and €8278, respectively). In univariate sensitivity analyses, the cost per QALY for ZOL versus placebo was ≤€50,000 for all scenarios tested. The results were most sensitive to assumptions regarding survival, number of ZOL infusions, and the costs of SREs. The probabilistic sensitivity analysis indicated that ZOL cost ≤€50,000 per QALY in 65% to 83% of model simulations (depending on country). However, some degree of uncertainty remained as the 95th percentile of cost per QALY was high.

CONCLUSIONS

This analysis is subject to the usual limitations of cost-effectiveness models, which combine assumptions and data from multiple sources. Nevertheless, based on the assumptions used herein, the present model suggests that ZOL increases QALYs and is cost saving and/or cost effective compared with placebo in patients with NSCLC in France, Germany, the United Kingdom, Portugal, and the Netherlands.

A primer of bone metastases management in breast cancer patients

Bone is the most common site for distant spread of breast cancer. Following a diagnosis of metastatic bone disease, patients can suffer from significant morbidity because of pain and skeletal related events (SRES). Bisphosphonates are potent inhibitors of osteoclastic function and the mainstay of bone-directed therapy for bone metastases. The aims of bisphosphonates are to prevent and delay SRES, to reduce bone pain, and to improve quality of life. Bisphosphonate therapy appears to have revolutionized treatment of bone metastases, but bisphosphonate use has several limitations. Those limitations include the high cost of the agents and the need for return trips to the clinic for intravenous treatment. Moreover, many uncertainties surround bisphosphonate use-for example, the timing of bisphosphonate initiation, the choice of bisphosphonate to use, the optimal duration of treatment, and the appropriate means to identify patients who will and will not benefit. In addition, potentially serious adverse effects have been associated with bisphosphonate use-for example, renal toxicity, gastrointestinal side effects, and osteonecrosis of the jaw. The present review is intended as a primer for oncology specialists who treat patients with bone metastases secondary to breast cancer. It focuses on bisphosphonate treatment guidelines, the evidence for those guidelines, and a discussion of new therapeutic agents. It also discusses the use of biochemical markers of bone metabolism, which show promise for predicting the risk of a patient's developing a SRE and of benefiting from bisphosphonate treatment.

Epidemiology and treatment costs of bone metastases from lung cancer: a French prospective, observational, multicenter study (GFPC 0601)

INTRODUCTION

The aim of this prospective, observational, multicenter study was to examine the epidemiology and management costs of bone metastatic disease (BMD) in patients with lung cancer.

METHODS

The analysis included all patients with BMD from lung cancer diagnosed between May 2006 and May 2007 in 40 centers. We analyzed their management and the direct costs of BMD from the health care provider's perspective, using a Markov model. Skeletal-related event (SRE) was defined as pathological fractures, spinal cord compression, or hypercalcemia (clinical SRE [cSRE]) for an initial analysis; a second analysis included palliative radiotherapy and surgery (therapeutic SRE [tSRE]).

RESULTS

Among the 554 patients enrolled (62 ± 11 years, 76.5% males, 69.3% performance status 0/1, 91% non-small cell lung cancer), 24.7% had a cSRE and 26.7% a tSRE at baseline and 9% and 39% during follow-up, respectively; 81.8% received at least one chemotherapy cycle. The median survival time was 5.8 months, and the 1- and 2-year survival rates were 22% and 7%, respectively; there was no significant difference in overall survival between the patients with and without SRE at enrollment. The main BMD treatments were opiate therapy (77.7%), biphosphonates (52.3%), radiotherapy (42.1%), and surgery (9.2%). The mean monthly BMD treatment costs in euros were €190, €374, and €4672 for asymptomatic patients, symptomatic patients, and patients with SRE, respectively. The average first-year BMD management cost in euros was €3999 ± 4135 (95% confidence interval: 374-15,886), and 49.5% of this cost was attributable to patients with SRE.

CONCLUSIONS

This analysis confirms the poor prognosis of BMD from lung cancer and underlines the burden of SRE in overall treatment costs.

Cost-utility analysis of palonosetron-based therapy in preventing emesis among breast cancer patients

We estimated the cost-utility of palonosetron-based therapy compared with generic ondansetron-based therapy throughout four cycles of anthracycline and cyclophosphamide for treating women with breast cancer. We developed a Markov model comparing six strategies in which ondansetron and palonosetron are combined with either dexamethasone alone, dexamethasone plus aprepitant following emesis, or dexamethasone plus aprepitant up front. Data on the effectiveness of antiemetics and emesis-related utility were obtained from published sources. Relative to the ondansetron-based two-drug therapy, the incremental cost-effectiveness ratios for the palonosetron-based regimens were $115,490/quality-adjusted life years (QALY) for the two-drug strategy, $199,375/QALY for the two-drug regimen plus aprepitant after emesis, and $200,526/QALY for the three-drug strategy. In sensitivity analysis, using the $100,000/QALY benchmark, the palonosetron-based two-drug strategy and the two-drug regimen plus aprepitant following emesis were shown to be cost-effective in 39% and 26% of the Monte Carlo simulations, respectively, and with changes in values for the effectiveness of antiemetics and the rate of hospitalization. The cost-utility of palonosetron-based therapy exceeds the $100,000/QALY threshold. Future research incorporating the price structure of all antiemetics following ondansetron's recent patent expiration is needed.

Quality of life implications of bisphosphonate-associated osteonecrosis of the jaw

PURPOSE

Potentially debilitating, osteonecrosis of the jaw (ONJ) is an emerging complication of bisphosphonates. However, its effect on quality of life (QoL) is unknown. We determined the ONJ-related QoL decline in a cancer patient cohort.

PATIENTS AND METHODS

Thirty-four cancer patients with bisphosphonate-associated ONJ completed a telephone survey (October 2007 through May 2008). The Oral Health Impact Profile 14 (OHIP) retrospectively assessed participant oral health-related QoL before and after ONJ. Standardized ONJ descriptions were developed in a multidisciplinary, iterative process and were evaluated with three frequently used preference-based QoL measurement methods on a 0 (death) to 1 (perfect health) scale: Visual Analogue Scale (VAS), Time Trade-Off (TTO), and EQ-5D.

RESULTS

ONJ significantly (p < .001) increased OHIP scores (worse QoL) for additive (3.56-16.53) and weighted (7.0-17.5) methods. Seven individual OHIP items significantly increased (Bonferroni correction p < .0035): pain, eating discomfort, self-consciousness, unsatisfactory diet, interrupted meals, irritability, and decreased life satisfaction. Mean preference-based QoL values significantly decreased (p < .001) with worsening ONJ stage (VAS, TTO, and EQ-5D): no ONJ (0.76, 0.86, 0.82), ONJ stage 1 (0.69, 0.82, 0.78), ONJ stage 2 (0.51, 0.67, 0.55), and ONJ stage 3 (0.37, 0.61, 0.32). As ONJ worsened, EQ-5D domain scores significantly increased (p < .001). Pain/discomfort and anxiety/depression contributed most to declining QoL.

CONCLUSIONS

ONJ significantly affects QoL, a detriment that increases with worsening ONJ. QoL impairments for ONJ stages 2 and 3 are similar to other treatment side effects that influence decision-making. Bisphosphonate-associated ONJ QoL is an important consideration for patients, clinicians, and policy makers.

Integrated positron emission tomography/computed tomography may render bone scintigraphy unnecessary to investigate suspected metastatic breast cancer

PURPOSE

Although the accurate detection of osseous metastases in the evaluation of patients with suspected metastatic breast cancer (MBC) has significant prognostic and therapeutic implications, the ideal diagnostic approach is uncertain. In this retrospective, single-institution study, we compare the diagnostic performance of integrated positron emission tomography/computed tomography (PET/CT) and bone scintigraphy (BSc) in women with suspected MBC.

PATIENTS AND METHODS

Women with suspected MBC evaluated with PET/CT and BSc (within 30 days) between January 1, 2003 and June 30, 2008, were identified through institutional databases. Electronic medical records were reviewed, and radiology reports were classified as positive/negative/equivocal for osseous metastases. A nuclear medicine radiologist (blinded to correlative and clinical end points) reviewed all equivocal PET/CT and BSc images and reclassified some reports. Final PET/CT and BSc classifications were compared. Baseline patient/tumor characteristics and bone pathology were recorded and compared to the final imaging results.

RESULTS

We identified 163 women who had a median age of 52 years (range, 30 to 90 years); 32% had locally advanced breast cancer, 42% had been diagnosed with breast cancer less than 12 weeks before identification. Twenty studies were originally deemed equivocal (five with PET/CT, and 15 with BSc), and 13 (65%) of these studies were reclassified after radiology review. Overall, PET/CT and BSc were highly concordant for reporting osseous metastases with 132 paired studies (81%); 32 (20%) were positive, and 100 (61%) were negative. Thirty-one occurrences (19%) were discordant. Twelve of these (39%) had pathology confirming osseous metastases: nine (of 18) were PET/CT positive and BSc negative; one (of three) was PET/CT positive and BSc equivocal; and two (of two) were PET/CT equivocal and BSc negative.

CONCLUSION

This study supports the use of PET/CT in detecting osseous metastases for suspected MBC. Whether PET/CT may supplant BSc in this setting is unknown.

Zoledronic acid delays wound healing of the tooth extraction socket, inhibits oral epithelial cell migration, and promotes proliferation and adhesion to hydroxyapatite of oral bacteria, without causing osteonecrosis of the jaw, in mice

Nitrogen-containing bisphosphonates such as zoledronic acid (ZOL) and pamidronate have been widely and successfully used for the treatment of cancer patients with bone metastases and/or hypercalcemia. Accumulating recent reports have shown that cancer patients who have received these bisphosphonates occasionally manifest bisphosphonate-related osteonecrosis of the jaw (BRONJ) following dental treatments, including tooth extraction. However, little is known about the pathogenesis of BRONJ to date. Here, to understand the underlying pathogenesis of BRONJ, we examined the effects of ZOL on wound healing of the tooth extraction socket using a mouse tooth extraction model. Histomorphometrical analysis revealed that the amount of new bone and the numbers of blood vessels in the socket were significantly decreased in ZOL-treated mice compared to control mice. Consistent with these results, ZOL significantly inhibited angiogenesis induced by vascular endothelial growth factor in vivo and the proliferation of endothelial cells in culture in a dose-dependent manner. In contrast, etidronate, a non-nitrogen-containing bisphosphonate, showed no effects on osteogenesis and angiogenesis in the socket. ZOL also suppressed the migration of oral epithelial cells, which is a crucial step for tooth socket closure. In addition, ZOL promoted the adherence of Streptococcus mutans to hydroxyapatite and the proliferation of oral bacteria obtained from healthy individuals, suggesting that ZOL may increase the bacterial infection. In conclusion, our data suggest that ZOL delays wound healing of the tooth extraction socket by inhibiting osteogenesis and angiogenesis. Our data also suggest that ZOL alters oral bacterial behaviors. These actions of ZOL may be relevant to the pathogenesis of BRONJ.

Intravenous bisphosphonate therapy does not acutely alter nuclear bone scan results

INTRODUCTION

Theoretically, the bisphosphonates used to treat metastatic bone disease could influence the results of nuclear bone scans which use the structurally similar technetium 99m methylene diphosphonate (99mTc MDP). A prospective clinical study was designed to explore this hypothesis.

PATIENTS AND METHODS

Patients with metastatic breast cancer receiving intravenous bisphosphonate (IVBP) therapy who had > or =3 osseous lesions on nuclear bone scan were eligible. A baseline bone scan (number 1) was performed as clinically indicated and IVBP with zoledronic acid was administered within 72 hours. A second bone scan (number 2) was performed within 72 hours of zoledronic acid dosing. Both bone scans were reviewed in a blinded fashion and assessed for changes in the number and intensity of osseous lesions. Ten patients were planned to yield at least 30 lesions.

RESULTS

Ten patients were enrolled. One patient withdrew consent and 1 was excluded due to protocol deviation. Among the 8 patients were 163 assessable osseous lesions. The median time from bone scan number 1 to IVBP was 1 day (range, 1-2 days). The median time from IVBP to bone scan number 2 was 2 days (range, 1-3 days). The paired imaging showed no changes in the total number of bone metastases. One hundred sixty-one lesions were identical in both scans; in 1 patient there were 2 lesions that were discordant, one more intense, the other less intense.

CONCLUSION

These data do not support the hypothesis that IVBP therapy interferes with bone scan results.

Bisphosphonate incorporation in surgical implant coatings by fast loading and co-precipitation at low drug concentrations

The objectives of the present work was to evaluate the possibility for fast loading by soaking of bisphosphonates (BPs) into hydroxylapatite (HA) implant coatings biomimetically grown on crystalline TiO(2) surfaces, and also investigate the influence of different BP loading concentrations in a buffer during co-precipitation of a calcium phosphate containing layer onto these surfaces. The co-precipitation method created coatings that contained BPs throughout most of the coating layer, but the presence of BPs in the buffer hindered the formation of a bulk HA-layer, thus resulting in very thin coatings most likely consisting of islands built up by a calcium phosphate containing BPs. The coatings biomimetically grown on TiO(2) surfaces, were shown to consist of crystalline HA. Soaking of these coatings during 15 min only in a low BPs concentration containing buffer yielded a concentration on the coating surface of the same order of magnitude as obtained with soaking during 60 min in significantly higher concentrated buffers. This could be of advantage during surgery since the operating surgeon could make a fast decision whether or not to include the drugs in the coating based on the need of the particular patient at hand. The BPs present on the surface of the fast-loaded HA coatings were found to be strongly bound, something which should be beneficial for in vivo use. Both the co-precipitation method and the fast loading by soaking method investigated here are promising techniques for loading of BPs onto surgical implants. The simplicity of both methods is an advantage since implants can have spatially complicated structures.

Cost-effectiveness of pegfilgrastim versus filgrastim primary prophylaxis in women with early-stage breast cancer receiving chemotherapy in the United States

BACKGROUND

Prophylaxis with granulocyte colony-stimulating factor reduces the risk for febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy.

OBJECTIVE

We estimated the incremental cost-effectiveness of primary prophylaxis (starting in cycle 1 of chemotherapy) with pegfilgrastim versus filgrastim in women with early-stage breast cancer receiving myelosuppressive chemotherapy in the United States.

METHODS

A decision-analytic model was constructed from a health payer's perspective with a lifetime study horizon. The model considered direct medical costs and outcomes related to reduced FN and potential survival benefits due to reduced FN-related mortality and on-time receipt of full-dose chemotherapy. Sensitivity analyses were conducted.

RESULTS

Pegfilgrastim was cost-saving and more effective (ie, dominant strategy) than 11-day filgrastim. The incremental cost-effectiveness ratio (ICER) for pegfilgrastim versus 6-day filgrastim was $12,904 per FN episode avoided. Adding the survival benefit due to reduced FN mortality and receipt of optimal chemotherapy dose yielded an ICER of $31,511 per quality-adjusted life year (QALY) gained and $14,415 per QALY gained, respectively. The most influential factors included inpatient FN case-fatality rate, cost of pegfilgrastim and filgrastim, baseline probability of FN, relative risk for FN between filgrastim and pegfil-grastim, and cost of administration of filgrastim.

CONCLUSION

Pegfilgrastim was cost-saving compared with 11-day filgrastim and cost-effective compared with 6-day filgrastim from a health payer's perspective for the primary prophylaxis of FN in these women with early-stage breast cancer receiving myelosuppressive chemotherapy.

Therapeutic guidelines for the treatment of bone metastasis: a report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology

Bone metastases remain a therapeutic challenge because of the diversity of the problems they cause, the relative paucity of data regarding their treatment, and the necessity for management by a multidisciplinary palliative care team. The American College of Radiology convened an Appropriateness Criteria Expert Panel on Radiation Oncology for the treatment of bone metastasis to create representative clinical case scenarios and then rank the appropriate use of treatment modalities as well as the most reasonable radiotherapy dose schema and treatment planning methods. Here we present both the resulting Appropriateness Criteria and the rationale for making these decisions. The treatment recommendations are placed within the larger framework of the role of radiation in palliative care by discussing the efficiency of palliative radiotherapy schedules, cost effectiveness issues, and the need for additional research regarding the proper multidisciplinary care of patients with symptomatic bone metastasis.

Preserving functional independence in elderly patients with cancer-associated bone disease: the role of zoledronic acid

Increases in life expectancy in the developed world will inevitably lead to larger numbers of elderly patients with cancer-associated (malignant) bone disease. Most elderly patients with metastatic cancer also suffer from numerous comorbidities. The management of bone health in this setting requires special consideration. This article centers on malignant bone disease in the elderly and the role of bisphosphonates in geriatric oncology. The challenges involved in the treatment of older patients with bone metastases are described, and the potential utility of bisphosphonates, such as zoledronic acid, is discussed. Moreover, recent data from several large clinical trials suggest that zoledronic acid provides additional benefits, including antitumor effects that may extend beyond the preservation of bone health and prevention of skeletal-related events.

Cost-utility analysis of the cyberknife system for metastatic spinal tumors

OBJECTIVE

Using decision analysis, a cost-utility study evaluated the cost-effectiveness of CyberKnife (Accuray, Inc., Sunnyvale, CA) stereotactic radiosurgery (SRS) in comparison to external beam radiation therapy in the treatment of metastatic spinal malignancies.

METHODS

The published literature provided evidence on the effectiveness of the comparator interventions in the absence of primary outcomes data. Costs of care were derived from Centers for Medicare and Medicaid Services fee schedules. A Markov model was constructed from the payer perspective to simulate the outcomes of patients undergoing nonchemotherapeutic interventions for metastatic spinal tumors. Because cancer therapies bear significant health and economic consequences, the impact of treatment-related toxicities was integrated into the model. Given the terminal nature of these conditions and the limited life expectancy of the patient population, the time horizon for the analysis was limited to 12 months.

RESULTS

Patients treated with CyberKnife SRS gained an additional net health benefit of 0.08 quality-adjusted life year; the calculated cost of CyberKnife SRS was $1933 less than external beam radiation therapy for comparable effectiveness. The incremental cost per benefit for this strategy ($41 500 per quality-adjusted life year) met payers' willingness-to-pay criteria.

CONCLUSION

Cost-utility analysis demonstrated that CyberKnife SRS was a superior, cost-effective primary intervention for patients with metastatic spinal tumors compared with conventional external beam radiation therapy.

Cost-effectiveness of primary versus secondary prophylaxis with pegfilgrastim in women with early-stage breast cancer receiving chemotherapy

OBJECTIVE

Prophylaxis with granulocyte colony-stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. We estimated the incremental cost-effectiveness of G-CSF pegfilgrastim primary (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) versus secondary (only after an FN event) prophylaxis in women with early-stage breast cancer receiving myelosuppressive chemotherapy with a >or=20% FN risk.

METHODS

A decision-analytic model was constructed from a health insurer's perspective with a lifetime study horizon. The model considers direct medical costs and outcomes related to reduced FN and potential survival benefits because of reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values.

RESULTS

The incremental cost-effectiveness ratio (ICER) of pegfilgrastim as primary versus secondary prophylaxis was $48,000/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $110,000/life-year gained (LYG) or $116,000/quality-adjusted life-year (QALY) gained. The most influential factors included FN case-fatality, FN relative risk reduction from primary prophylaxis, and age at diagnosis.

CONCLUSIONS

Compared with secondary prophylaxis, the cost-effectiveness of pegfilgrastim as primary prophylaxis may be equivalent or superior to other commonly used supportive care interventions for women with breast cancer. Further assessment of the direct impact of G-CSF on short- and long-term survival is needed to substantiate these findings.

Cost-effectiveness of pegfilgrastim versus 6-day filgrastim primary prophylaxis in patients with non-Hodgkin's lymphoma receiving CHOP-21 in United States

OBJECTIVES

Prophylaxis with granulocyte-colony stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. Randomized clinical trials have shown that pegfilgrastim, a 2nd-generation G-CSF, is at least as effective as the 1st-generation G-CSF filgrastim. In the meta-analysis of trials pegfilgrastim performed better than filgrastim with respect to FN risk. The incremental cost-effectiveness of primary prophylaxis (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) with pegfilgrastim versus filgrastim used for 6 days (as is often used in clinical practice) was estimated in patients with aggressive non-Hodgkin's lymphoma (NHL) receiving myelosuppressive chemotherapy in the United States.

METHODS

A decision-analytic model was constructed from a health insurer's perspective with a life-time study horizon. The model considered direct medical costs and outcomes related to reduced FN and potential survival benefits due to reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values.

RESULTS

The incremental cost-effectiveness (ICER) of pegfilgrastim versus 6-day filgrastim primary prophylaxis was $2167/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $5532/LY gained or $6190/QALY gained. When the potential benefit of optimized chemotherapy was included, the ICER was $1494/LY gained or $1677/QALY gained. The most influential factors included cost of pegfilgrastim, relative risk of FN between pegfilgrastim and filgrastim, FN case-fatality rate, cost of filgrastim and baseline FN risk.

CONCLUSIONS

Pegfilgrastim is cost-effective in primary prophylaxis of FN compared to 6 days per cycle of filgrastim, in patients with NHL receiving myelosuppressive chemotherapy (e.g., cyclophosphamide + doxorubicin + vincristine + prednisolone [CHOP-21]) chemotherapy. Study limitations included lack of direct evidence linking G-CSF use with a reduction in FN-related mortality and limited data that show a relationship between relative dose intensity (RDI) and cancer-specific patient survival.

Pharmacotherapy of bone metastases in breast cancer patients

A diagnosis of bone metastases is often a devastating occurrence in breast cancer patients. Bone metastases are associated with increased morbidity as reflected through pain, reduced quality of life and skeletal-related events. This paper reviews the role of different pharmacotherapeutic agents in the treatment of bone metastases from breast cancer. Randomised controlled trials of osteoclast-inhibiting agents, that is the bisphosphonates, have shown significant patient benefit. The aims of bisphosphonates are to prevent and delay skeletal-related events, reduce bone pain and improve quality of life. However, there are some limitations with bisphosphonate treatment. Biochemical markers of bone turnover seem to be a promising tool in guiding bisphosphonate treatment and future research directions. Hopefully, patient management will be further improved as new agents become available such as denosumab, osteoprotegerin analogues and anti-angiogenic agents.

Cost-effectiveness of Oral Clodronate Compared with Oral Ibandronate, Intravenous Zoledronate or Intravenous Pamidronate in Breast Cancer Patients

This study aimed to identify the effects of different bisphosphonates in reducing skeletal-related events, and to determine whether there are any differences in their cost-effectiveness, taking into account their efficacy, safety profile and administration routes. A systematic literature search of databases, such as PubMed and the Cochrane Controlled Trials Register, supplemented by the latest congress abstracts from meetings of the European Hematology Association and the American Society of Clinical Oncology was conducted up to November 2006. Important references in reviews published by peer-reviewed journals were also taken into consideration. Our base-case cost-effectiveness analysis for Germany and the UK showed cost savings for oral clodronate therapy compared with other bisphosphonate therapies. In Germany, costs per patient of treatment with oral clodronate were €1092.38, €2360.40 and €2500.29 less than with oral ibandronate, intravenous pamidronate and intravenous zoledronate, respectively. The UK results were similar, the costs per patient of treatment with oral clodronate being €841.79, €2989.99 and €3669.19 less than with oral ibandronate, intravenous pamidronate and intravenous zoledronate, respectively.

Cost-effectiveness analysis of adjuvant docetaxel, doxorubicin, and cyclophosphamide (TAC) for node-positive breast cancer: modeling the downstream effects

PURPOSE

BCIRG 001 demonstrated prolonged disease-free (DFS) and overall survival (OS) but increased toxicity for adjuvant docetaxel, doxorubicin, and cyclophosphamide (TAC) versus 5-fluorouracil, doxorubicin, cyclophosphamide (FAC) in women with node positive breast cancer (BC). This study evaluates quality-adjusted survival and cost-effectiveness of adjuvant TAC versus FAC, taking downstream decisions and events into account, including palliative chemotherapy with taxanes.

METHODS

We developed a Markov model for a cohort of women with node positive BC eligible for adjuvant anthracyclines. Data input included clinical and resource utilization data collected prospectively from BCIRG 001. Treatment decisions and outcomes with disease recurrence were based on a systematic literature review with validity reviewed by a national panel of Canadian BC oncologists. Direct costs for resource utilization following Canadian practice patterns were included. Unit costs were obtained from provincial cost list and published drug list prices. Utility scores were derived from the literature. An incremental cost-effectiveness ratio (ICER) in cost per quality-adjusted life-years (QALY) gained for TAC versus FAC was calculated.

RESULTS

For 1,000 women with node positive BC, the model showed that TAC would lead to a gain of 313 QALY (370 life years) at an additional cost of $5.8 Million Canadian dollars (Cdn) compared to FAC, over a 10-year time horizon. The ICER of TAC versus FAC was $18,505.54 Cdn per QALY gained. Sensitivity analyses supported the robustness of the model. By one-way sensitivity analyses of over 50 model variables, 95% of the cumulative ICER variation was from $6,000 to $28,000 Cdn/QALY. By multivariate Monte Carlo simulation, there was a 70% probability that the ICER would be under $50,000 CdN/QALY.

CONCLUSION

For women with node positive BC, TAC improves DFS and OS compared to FAC and is a cost-effective adjuvant chemotherapy strategy.

Zoledronic acid: a pharmacoeconomic review of its use in the management of bone metastases

Zoledronic acid (Zometa is a third-generation nitrogen-containing parenteral bisphosphonate indicated for the treatment of bone metastases due to solid tumours or multiple myeloma and for hypercalcaemia of malignancy (HCM). In patients with advanced breast or prostate cancer, zoledronic acid 4 mg every 3-4 weeks for up to 15 months significantly reduced the proportion of patients with > or =1 skeletal-related event (SRE), excluding HCM, compared with placebo. In patients with advanced breast cancer or multiple myeloma, the incidence of SREs was similar in patients treated with zoledronic acid 4 mg or pamidronic acid 90 mg every 3-4 weeks for up to 25 months but, in breast cancer patients, zoledronic acid reduced the risk of SREs, including HCM, by an additional 20% compared with pamidronic acid. In modelled cost-utility studies comparing direct costs based on efficacy and resource-use data from these and/or other trials, results have varied. In the most recent study performed from the perspective of the UK NHS and modelled over a 10-year treatment period in women with advanced breast cancer, intravenous zoledronic acid and oral ibandronic acid were dominant over no treatment. Intravenous zoledronic acid was the most cost effective, in terms of incremental costs per QALY gained, followed by oral ibandronic acid, intravenous pamidronic acid and intravenous ibandronic acid. Two other modelled analyses in patients with advanced breast cancer, also conducted from the perspective of the NHS, evaluated the cost utility of three bisphosphonate therapies in patients receiving hormonal therapy or intravenous chemotherapy. Analyses were modelled over 14.3 months (i.e. expected survival) and assumptions varied markedly from results in clinical breast cancer trials. Also, efficacy assumptions for zoledronic acid were not based on clinical trials with the drug. The results of these analyses suggest that oral ibandronic acid is more cost effective than intravenous zoledronic acid and intravenous pamidronic acid in terms of incremental cost per QALY gained. In a global, 15-month modelled cost-effectiveness analysis of patients with advanced prostate cancer, conducted from a third-party perspective, the incremental cost per QALY gained for zoledronic acid versus no treatment was $US159 200 (year 2000 value), which is about 3-fold greater than commonly accepted thresholds for cost effectiveness. In conclusion, a recent modelled economic analysis suggests that intravenous zoledronic acid 4 mg is dominant relative to no treatment in the management of bone metastases in patients with advanced breast cancer. In contrast, in patients with advanced prostate cancer, the incremental cost per QALY gained for zoledronic acid 4 mg versus no treatment was predicted to be higher than commonly accepted thresholds. Compared with other bisphosphonates in the setting of advanced breast cancer, intravenous zoledronic acid was more cost effective than oral or intravenous ibandronic acid and intravenous pamidronic acid in one study, but less cost effective than oral ibandronic acid in another. Further efficacy and economic data comparing intravenous zoledronic acid with oral ibandronic acid are needed. Meanwhile, zoledronic acid appears to be the most cost effective intravenous bisphosphonate for the management of bone metastases in patients with advanced breast cancer and possibly in patients with different types of advanced solid tumours.

New research findings on zoledronic acid: survival, pain, and anti-tumour effects

OBJECTIVES

To summarize the current evidence for clinical, anti-tumour, and survival benefits from zoledronic acid in patients with genitourinary cancers.

METHODS

Studies were identified through MEDLINE searches, review of bibliographies of relevant articles, and review of abstracts from scientific meetings.

RESULTS

Among patients with bone metastases from prostate cancer or renal cell carcinoma, zoledronic acid significantly delayed the onset and reduced the incidence of skeletal complications compared with placebo. Zoledronic acid is also the only bisphosphonate that has demonstrated a trend toward improved survival and delayed progression of bone lesions in patients with urologic malignancies. Furthermore, zoledronic acid reduced the incidence of pathologic fracture, a skeletal-related event known to be associated with reduced survival. Bisphosphonates have also demonstrated significant palliative benefits, and preclinical evidence indicates that bisphosphonates may have direct anti-tumour effects.

CONCLUSIONS

Zoledronic acid is the only bisphosphonate that has demonstrated statistically significant, long-term clinical benefits through the prevention and delay of skeletal-related events in patients with metastatic prostate cancer or renal cell carcinoma.

Adjuvant chemotherapy for breast cancer: a cost-utility analysis of FEC-D vs. FEC 100

BACKGROUND

Adjuvant 5-flurouracil, epirubicin and cyclophosphamide-docetaxel (FEC-D) has been shown to improve disease-free and overall survival (DFS and OS), compared to FEC 100, for node-positive breast cancer. An economic evaluation was undertaken to examine the cost-utility (CU) of FEC-D relative to FEC 100 given possible differences in cost between the two regimens.

METHODS

A Markov model was developed to calculate the cumulative costs and quality-adjusted life years (QALY) gained over a 10-year horizon for a hypothetical cohort of 1,000 women with node-positive breast cancer treated with FEC 100 or FEC-D. Event rates, costs, and utilities were derived from the literature. Efficacy outcomes were based primarily on the hazard ratio of DFS for all patients, but separate analyses were also conducted according to age and menopausal status as per the PACS 01 subgroup analysis results. The model took a third-party direct payer perspective and reports results in 2006 Canadian dollars ($). Both costs and benefits were discounted at 3%.

RESULTS

FEC-D is associated with 0.156 QALY gain and a $2,280 incremental cost compared to FEC 100, with a CU of $14,612/QALY gained. Results were robust to model assumptions and input parameters in a sensitivity analysis but were marginal in pre-menopausal and younger women.

CONCLUSIONS

Adjuvant FEC-D is a cost-effective alternative to FEC 100, with a cost-effectiveness ratio well below commonly employed thresholds. The CU according to age and menopausal status should be considered in view of the potential differences in efficacy in these subgroups, if any.

The use of bisphosphonates in cancer patients

Skeletal-related events resulting from bone metastases or osteoporosis can significantly contribute to morbidity and mortality in cancer patients. Expert opinion on the effectiveness of bisphosphonates in this setting is evolving. Here we review current evidence on the risks and benefits of bisphosphonate therapy for a wide variety of cancers, as well as clinical management of its adverse effects. A MEDLINE search of English-language literature (1966 through May 2006) was conducted using the terms bisphosphonate, cancer, multiple myeloma, malignancy, and randomized controlled clinical studies. Studies were selected based on clinical pertinence, with an emphasis on phase III clinical trials. We reviewed bibliographies for other relevant articles. Accumulating evidence reveals that bisphosphonate therapy has a significant effect in preventing skeletal complications in multiple myeloma, breast cancers, and prostate cancer, and in reducing skeletal complications in other metastatic bone malignancies. Emerging data indicate that bisphosphonates are useful for preventing bone loss resulting from cancer or its therapy. The efficacy of bisphosphonates for early-stage breast cancers remains controversial. Significant risks of bisphosphonate therapy include nephrotoxicity, electrolyte abnormalities, and osteonecrosis of the jaw. Bisphosphonate therapy has a clear role in the management of skeletal metastases associated with a variety of cancers. However, significant side effects require ongoing monitoring and treatment.

Biphosphonate-associated osteonecrosis can be controlled by nonsurgical management

Sixteen patients with jaw biphosphonate-osteonecrosis and with exposed bone areas were subdivided into 2 treatment groups. The first group (7 patients) underwent superficial or radical surgical therapy, while the second (9 patients) underwent antibiotic treatment. A slight reduction of the necrotic areas was observed in 5 of 7 patients in the first group, whereas no change was observed in the remaining 2 patients at 22- and 24-month follow-up. A slight reduction of the necrotic areas was observed in 7 of 9 patients in the second group, whereas no change was observed in the remaining 2 patients at 5- and 24-month follow-up. The statistical analysis showed that the treatment regimen did not significantly influence the dimensional change in the exposed bone. The preliminary results seem to suggest that biphosphonate-associated osteonecrosis can be well controlled by a nonsurgical protocol consisting in long-term administration of antibiotics.

[An economic analysis of the management of bone metastases in lung cancer]

BACKGROUND

Bone metastases are common in lung cancer and are leading to increasing consumption of health care resources. The therapeutic choice for the clinician is extensive, from biphosphonates to percutaneous vertebroplasty. In the absence of official guidelines the management varies from centre to centre. There are very few economic analyses of these patients.

METHODS

Study 06-01 of the French Lung Oncology Group is a medico-economic analysis of the management of bone metastases in lung cancer. It is a national, multicentre, observational, epidemiological study. The primary objective is to assess the epidemiology, the management strategies and the costs of bone metastases in lung cancer. The secondary objective is to develop a medico-economic model of the management based on a Markov model in order to evaluate the effectiveness of different therapeutic strategies.

EXPECTED RESULTS

The aim of this study is a better understanding of theses patients at a time when few observational studies have been undertaken.

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.

Palliation and supportive care in radiation medicine

The treatment of bone metastases represents a paradigm for evaluating palliative care in terms of symptom relief, toxicities of therapy, and the financial burden to the patient, caregivers, and society. Despite enormous expenditures to treat metastases, patients continue to sustain symptoms of the disease, and uninterrupted aggressive therapies are pursued until death that incur toxicity in approximately 25% of patients. This approach is inconsistent with the goals of palliative care, which should efficiently provide comfort using antineoplastic therapies or supportive care approaches to the patient with the fewest treatment-related side effects, recognizing that the patient will die of the disease.The development of therapies such as bisphosphonates is important in advancing options for palliative care; however, clinical trials demonstrating the efficacy of bisphosphonates have not addressed important issues for clinical practice. The primary study endpoints should primarily address pertinent patient outcomes such as pain relief rather than asymptomatic radiographic findings. These studies should define clear indications of when to start and stop the therapy, the appropriate patient populations to receive the therapy, and the cost effectiveness of the treatment relative to other available therapies such as radiation. Cost-utility analyses, which account for a broader domain of cost effectiveness, need to be performed as part of clinical trials, especially for palliative care endpoints. Clinical trials that include these criteria are critical to future practice guideline development. As health care resources continue to become more limited, the criteria for care must be better defined to avoid administration of therapy with limited benefit. Leadership must come from the specialty as clinical trials and clinical practice increasingly interface with health care policy. Goals of therapy must remain clear for the benefit of the individual and all patients.

Cost effectiveness of bisphosphonates in the management of breast cancer patients with bone metastases

BACKGROUND

Bisphosphonates are recommended to prevent skeletal related events (SREs) in patients with breast cancer and bone metastases (BCBM). However, their clinical and economic profiles vary from one agent to the other.

MATERIALS AND METHODS

Using modeling techniques, we simulated from the perspective of the UK's National Health Service (NHS) the cost and quality adjusted survival (QALY) associated with five commonly-used bisphosphonates or no therapy in this patient population. The simulation followed patients into several health states (i.e. alive or dead, experiencing an SRE or no SRE, and receiving first or second line therapy). Drugs costs, infusion costs, SREs costs, and utility values were estimated from published sources. Utilities were applied to time with and without SREs to capture the impact on quality of life.

RESULTS

Compared to no therapy, all bisphosphonates are either cost saving or highly cost-effective (with a cost per QALY < or = 6126 pounds sterlings). Within this evaluation, zoledronic acid was more effective and less expensive than all other options.

CONCLUSIONS

Based on our model, the use of bisphosphonates in breast cancer patients with bone metastases should lead to improved patient outcomes and cost savings to the NHS and possibly other similar entities.