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Park HL, Boo SH, Park SY, Moon SW, Yoo IR. Prognostic value of TLR from FDG PET/CT in patients with margin-negative stage IB and IIA non-small cell lung cancer. Eur Radiol 2023; 33:7274-7283. [PMID: 37060445 DOI: 10.1007/s00330-023-09641-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES To evaluate the prognostic value of TLR from PET/CT in patients with resection margin-negative stage IB and IIA non-small cell lung cancer (NSCLC) and compare high-risk factors necessitating adjuvant treatment (AT). METHODS Consecutive FDG PET/CT scans performed for the initial staging of NSCLC stage IB and IIA were retrospectively reviewed. The maximum standardized uptake value (SUVmax) of the primary tumor and mean SUV of the liver were acquired. The tumor-to-liver SUV ratio (TLR) was also calculated. Charts were reviewed for basic patient characteristics and high-risk factors for considering AT (poor differentiation, visceral pleura invasion, vascular invasion, tumors > 4 cm, and wedge resection). Statistical analysis was performed using Cox regression analysis and the Kaplan-Meier method. RESULTS Of the 112 patients included, 15 (13.4%) died, with a median overall survival (OS) of 43.8 months. Twenty-two patients (19.6%) exhibited recurrence, with median disease-free survival (DFS) of 36.0 months. In univariable analysis, pathology, poor differentiation, and TLR were associated with shorter DFS and OS. In multivariable analysis, TLR (hazard ratio [HR] = 1.263, p = 0.008) and differentiation (HR = 3.087, p = 0.012) were associated with shorter DFS. Also, TLR (HR = 1.422, p < 0.001) was associated with shorter OS. CONCLUSION TLR from FDG PET/CT was an independent prognostic factor for recurrence and survival. PET parameters constitute risk factors for consideration in the decision-making for AT in margin-negative stage IB and IIA NSCLC. CLINICAL RELEVANCE STATEMENT In this study, TLR from FDG PET/CT was an independent prognostic factor in stage IB-IIA non-small cell cancer patients. Although additional validation studies are warranted, TLR has the potential to be used to determine the need for adjuvant therapy. KEY POINTS • High TLR is an independent poor prognostic factor in stage IB-IIA NSCLC. • Adjuvant treatment should be considered in patients with high TLR following complete tumor resection.
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Affiliation(s)
- Hye Lim Park
- Division of Nuclear Medicine, Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Ha Boo
- Division of Nuclear Medicine, Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Korea
| | - Sonya Youngju Park
- Division of Nuclear Medicine, Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Korea
| | - Seok Whan Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ie Ryung Yoo
- Division of Nuclear Medicine, Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Korea.
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Everest L, Chen BE, Hay AE, Cheung MC, Chan KKW. Power and sample size calculation for incremental net benefit in cost effectiveness analyses with applications to trials conducted by the Canadian Cancer Trials Group. BMC Med Res Methodol 2023; 23:179. [PMID: 37537545 PMCID: PMC10398980 DOI: 10.1186/s12874-023-01956-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 05/20/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Historically, a priori power and sample size calculations have not been routinely performed cost-effectiveness analyses (CEA), partly because the absence of published cost and effectiveness correlation and variance data, which are essential for power and sample size calculations. Importantly, the empirical correlation between cost and effectiveness has not been examined with respect to the estimation of value-for-money in clinical literature. Therefore, it is not well established if cost-effectiveness studies embedded within randomized-controlled-trials (RCTs) are under- or over-powered to detect changes in value-for-money. However, recently guidelines (such as those from ISPOR) and funding agencies have suggested sample size and power calculations should be considered in CEAs embedded in clinical trials. METHODS We examined all RCTs conducted by the Canadian Cancer Trials Group with an embedded cost-effectiveness analysis. Variance and correlation of effectiveness and costs were derived from original-trial data. The incremental net benefit method was used to calculate the power of the cost-effectiveness analysis, with exploration of alternative correlation and willingness-to-pay values. RESULTS We identified four trials for inclusion. We observed that a hypothetical scenario of correlation coefficient of zero between cost and effectiveness led to a conservative estimate of sample size. The cost-effectiveness analysis was under-powered to detect changes in value-for-money in two trials, at willingness-to-pay of $100,000. Based on our observations, we present six considerations for future economic evaluations, and an online program to help analysts include a priori sample size and power calculations in future clinical trials. CONCLUSION The correlation between cost and effectiveness had a potentially meaningful impact on the power and variance of value-for-money estimates in the examined cost-effectiveness analyses. Therefore, the six considerations and online program, may facilitate a priori power calculations in embedded cost-effectiveness analyses in future clinical trials.
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Affiliation(s)
- Louis Everest
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Bingshu E Chen
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's, University, Kingston, ON, Canada
| | - Annette E Hay
- Department of Public Health Sciences, Canadian Cancer Trials Group, Queen's, University, Kingston, ON, Canada
| | - Matthew C Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
- University of Toronto, Toronto, ON, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
| | - Kelvin K W Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
- University of Toronto, Toronto, ON, Canada.
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada.
- Cancer Care Ontario, Toronto, ON, Canada.
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3
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Leiter A, Kong CY, Gould MK, Kale MS, Veluswamy RR, Smith CB, Mhango G, Huang BZ, Wisnivesky JP, Sigel K. The benefits and harms of adjuvant chemotherapy for non-small cell lung cancer in patients with major comorbidities: A simulation study. PLoS One 2022; 17:e0263911. [PMID: 36378625 PMCID: PMC9665372 DOI: 10.1371/journal.pone.0263911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) have demonstrated a survival benefit for adjuvant platinum-based chemotherapy after resection of locoregional non-small cell lung cancer (NSCLC). The relative benefits and harms and optimal approach to treatment for NSCLC patients who have major comorbidities (chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], and congestive heart failure [CHF]) are unclear, however. METHODS We used a simulation model to run in-silico comparative trials of adjuvant chemotherapy versus observation in locoregional NSCLC in patients with comorbidities. The model estimated quality-adjusted life years (QALYs) gained by each treatment strategy stratified by age, comorbidity, and stage. The model was parameterized using outcomes and quality-of-life data from RCTs and primary analyses from large cancer databases. RESULTS Adjuvant chemotherapy was associated with clinically significant QALY gains for all patient age/stage combinations with COPD except for patients >80 years old with Stage IB and IIA cancers. For patients with CHF and Stage IB and IIA disease, adjuvant chemotherapy was not advantageous; in contrast, it was associated with QALY gains for more advanced stages for younger patients with CHF. For stages IIB and IIIA NSCLC, most patient groups benefited from adjuvant chemotherapy. However, In general, patients with multiple comorbidities benefited less from adjuvant chemotherapy than those with single comorbidities and women with comorbidities in older age categories benefited more from adjuvant chemotherapy than their male counterparts. CONCLUSIONS Older, multimorbid patients may derive QALY gains from adjuvant chemotherapy after NSCLC surgery. These results help extend existing clinical trial data to specific unstudied, high-risk populations and may reduce the uncertainty regarding adjuvant chemotherapy use in these patients.
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Affiliation(s)
- Amanda Leiter
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Chung Yin Kong
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Michael K. Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
| | - Minal S. Kale
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Rajwanth R. Veluswamy
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Cardinale B. Smith
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Grace Mhango
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Brian Z. Huang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Keith Sigel
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
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Benefits from Adjuvant Chemotherapy in Patients with Resected Non-Small Cell Lung Cancer: Possibility of Stratification by Gene Amplification of ACTN4 According to Evaluation of Metastatic Ability. Cancers (Basel) 2022; 14:cancers14184363. [PMID: 36139525 PMCID: PMC9497297 DOI: 10.3390/cancers14184363] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Surgical treatment is the best curative treatment option for patients with non-small cell lung cancer (NSCLC), but some patients have recurrence beyond the surgical margin even after receiving curative surgery. Therefore, therapies with anti-cancer agents also play an important role perioperatively. In this paper, we review the current status of adjuvant chemotherapy in NSCLC and describe promising perioperative therapies, including molecularly targeted therapies and immune checkpoint inhibitors. Previously reported biomarkers of adjuvant chemotherapy for NSCLC are discussed along with their limitations. Adjuvant chemotherapy after resective surgery was most effective in patients with metastatic lesions located just outside the surgical margin; in addition, these metastatic lesions were the most sensitive to adjuvant chemotherapy. Thus, the first step in predicting patients who have sensitivity to adjuvant therapies is to perform a qualified evaluation of metastatic ability using markers such as actinin-4 (ACTN4). In this review, we discuss the potential use of biomarkers in patient stratification for effective adjuvant chemotherapy and, in particular, the use of ACTN4 as a possible biomarker for NSCLC.
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Optimizing the use of adjuvant chemotherapy in non-small cell lung cancer patients with comorbidities. Curr Probl Cancer 2022; 46:100867. [DOI: 10.1016/j.currproblcancer.2022.100867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 03/23/2022] [Accepted: 04/27/2022] [Indexed: 11/21/2022]
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Cheung MC, Chan KK, Golden S, Hay A, Pater J, Prica A, Chen BE, Leighl N, Mittmann N. Minimization of resource utilization data collected within cost-effectiveness analyses conducted alongside Canadian Cancer Trials Group phase III trials. Clin Trials 2021; 18:500-504. [PMID: 33866856 PMCID: PMC8290988 DOI: 10.1177/17407745211005045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Cost-effectiveness analyses embedded within randomized trials allow for evaluation of value alongside conventional efficacy outcomes; however, collection of resource utilization data can require considerable trial resources. Methods We re-analyzed the results from four phase III Canadian Cancer Trials Group trials that embedded cost-effectiveness analyses to determine the impact of minimizing potential cost categories on the incremental cost-effectiveness ratios. For each trial, we disaggregated total costs into component incremental cost categories and recalculated incremental cost-effectiveness ratios using (1) only the top 3 cost categories, (2) the top 5 cost categories, and (3) all cost components. Using individual trial-level data, confidence intervals for each incremental cost-effectiveness ratio simulation were generated by bootstrapping and descriptively presented with the original confidence intervals (and incremental cost-effectiveness ratios) from the publications. Results Drug acquisition costs represented the highest incremental cost category in three trials, while hospitalization costs represented the other consistent cost driver and the top incremental cost category in the fourth trial. Recalculated incremental cost-effectiveness ratios based on fewer cost components (top 3 and top 5) did not differ meaningfully from the original published results. Based on conventional willingness-to-pay thresholds (US$50,000–US$100,000 per quality-adjusted life-year), none of the re-analyses would have changed the original perception of whether the experimental therapies were considered cost-effective. Conclusions These results suggest that the collection of resource utilization data within cancer trials could be narrowed. Omission of certain cost categories that have minimal impact on incremental cost-effectiveness ratio, such as routine laboratory investigations, could reduce the costs and undue burden associated with the collection of data required for cancer trial cost-effectiveness analyses.
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Affiliation(s)
- Matthew C Cheung
- Division of Hematology, Department of Medicine, Odette Cancer Centre and University of Toronto, Toronto, ON, Canada.,Committee on Economic Analysis, Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kelvin Kw Chan
- Division of Hematology, Department of Medicine, Odette Cancer Centre and University of Toronto, Toronto, ON, Canada.,Committee on Economic Analysis, Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Shane Golden
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Annette Hay
- Committee on Economic Analysis, Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Joseph Pater
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Anca Prica
- Division of Hematology, Department of Medicine, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada
| | - Bingshu E Chen
- Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada
| | - Natasha Leighl
- Division of Hematology, Department of Medicine, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada
| | - Nicole Mittmann
- Committee on Economic Analysis, Canadian Cancer Trials Group, Queens University, Kingston, ON, Canada.,Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
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Li W, Guo H, Li L, Cui J. Comprehensive Comparison Between Adjuvant Targeted Therapy and Chemotherapy for EGFR-Mutant NSCLC Patients: A Cost-Effectiveness Analysis. Front Oncol 2021; 11:619376. [PMID: 33842322 PMCID: PMC8027108 DOI: 10.3389/fonc.2021.619376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/05/2021] [Indexed: 12/20/2022] Open
Abstract
Background Chemotherapy has been the current standard adjuvant treatment for early-stage non-small-cell lung cancer (NSCLC) patients, while recent studies showed benefits of epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI). We conducted a cost-effectiveness analysis to comprehensively evaluate the benefit of EGFR-TKI compared with chemotherapy for early-stage EGFR-mutant NSCLC patients after resection from the perspective of the Chinese health care system. Method A Markov model was established. Clinical data were based on the phase 3, ADJUVANT trial, where stage II-IIIA, EGFR-mutant NSCLC patients were randomized into gefitinib group or chemotherapy group after resection. Cost parameters mainly included costs of drugs, examinations, and adverse events (AEs). Effect parameters were evaluated by quality-adjusted life year (QALY). Outcomes contained incremental cost-effective ratio (ICER), average cost-effective ratio (ACER), and net benefit. The willingness-to-pay threshold was set as 3 times per capita gross domestic product ($30,828/QALY). Sensitivity analyses were also conducted to verify the stability of the model. Results Patients who received gefitinib had both a higher cost ($12,057.98 vs. $11,883.73) and a higher QALY (1.55 vs. 1.42) than patients who received chemotherapy. With an ICER of $1,345.62/QALY, adjuvant gefitinib was of economic benefit compared with chemotherapy. The ACER and net benefit were also consistent (gefitinib vs. chemotherapy, ACER: $7,802.30/QALY vs. $8,392.77/QALY; net benefit: $35,584.85 vs. $31,767.17). Sensitivity analyses indicated the stability of the model and the impact of utility. Conclusion Adjuvant EGFR-TKI application for early-stage EGFR-mutant NSCLC patients was cost-effective compared with chemotherapy, which might provide a reference for clinical decision-making and medical insurance policy formulation in China.
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Affiliation(s)
- Wenqian Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Hanfei Guo
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Lingyu Li
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Jiuwei Cui
- Cancer Center, The First Hospital of Jilin University, Changchun, China
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Lau VI, Cook DJ, Fowler R, Rochwerg B, Johnstone J, Lauzier F, Marshall JC, Basmaji J, Heels-Ansdell D, Thabane L, Xie F. Economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (E-PROSPECT): study protocol. BMJ Open 2020; 10:e036047. [PMID: 32595159 PMCID: PMC7322334 DOI: 10.1136/bmjopen-2019-036047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit (ICU). Probiotics are defined as live microorganisms that may confer health benefits when ingested. Prior randomised trials suggest that probiotics may prevent infections such as VAP and Clostridioides difficile-associated diarrhoea (CDAD). PROSPECT (Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial) is a multicentre, double-blinded, randomised controlled trial comparing the efficacy of the probiotic Lactobacillus rhamnosus GG with usual care versus usual care without probiotics in preventing VAP and other clinically important outcomes in critically ill patients admitted to the ICU. METHODS AND ANALYSIS The objective of E-PROSPECT is to determine the incremental cost-effectiveness of L. rhamnosus GG plus usual care versus usual care without probiotics in critically ill patients. E-PROSPECT will be performed from the public healthcare payer's perspective over a time horizon from ICU admission to hospital discharge.We will determine probabilities of in-ICU and in-hospital events from all patients alongside PROSPECT. We will retrieve unit costs for each resource use item using jurisdiction-specific public databases, supplemented by individual site unit costs if such databases are unavailable. Direct costs will include medications, personnel costs, radiology/laboratory testing, operative/non-operative procedures and per-day hospital 'hoteling' costs not otherwise encompassed. The primary outcome is the incremental cost per VAP prevented between the two treatment groups. Other clinical events such as CDAD, antibiotic-associated diarrhoea and in-hospital mortality will be included as secondary outcomes. We will perform pre-specified subgroup analyses (medical/surgical/trauma; age; frailty status; antibiotic use; prevalent vs no prevalent pneumonia) and probabilistic sensitivity analyses for VAP, then generate confidence intervals using the non-parametric bootstrapping approach. ETHICS AND DISSEMINATION Study approval for E-PROSPECT was granted by the Hamilton Integrated Research Ethics Board of McMaster University on 29 July 2019. Informed consent was obtained from the patient or substitute decision-maker in PROSPECT. The findings of this study will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT01782755; Pre-results.
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Affiliation(s)
- Vincent Issac Lau
- Department of Critical Care, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Robert Fowler
- Sunnybrook Health Sciences Institute, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Jennie Johnstone
- Public Health Ontario, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care, Western University, London, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Moldaver D, Hurry M, Evans WK, Cheema PK, Sangha R, Burkes R, Melosky B, Tran D, Boehm D, Venkatesh J, Walisser S, Orava E, Grima D. Development, validation and results from the impact of treatment evolution in non-small cell lung cancer (iTEN) model. Lung Cancer 2019; 139:185-194. [PMID: 31812889 DOI: 10.1016/j.lungcan.2019.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Treatment of advanced NSCLC (aNSCLC) is rapidly evolving, as new targeted and immuno-oncology (I-O) treatments become available. The iTEN model was developed to predict the cost and survival benefits of changing aNSCLC treatment patterns from a Canadian healthcare system perspective. This report describes iTEN model development and validation. MATERIALS & METHODS A discrete event patient simulation of aNSCLC was developed. A modified Delphi process using Canadian clinical experts informed the development of treatment sequences that included commonly used, Health Canada approved treatments of aNSCLC. Treatment efficacy and the timing of progression and death were estimated from published Kaplan-Meier progression free and overall survival data. Costs (2018 CDN$) included were: drug acquisition and administration, imaging, monitoring, adverse events, physician visits, best supportive care, and end-of-life. RESULTS AND CONCLUSION Clinical validity of the iTEN model was assessed by comparing model survival predictions to published real-world evidence (RWE). Four RWE studies that reported the overall survival of patients treated with a broad sampling of common aNSCLC treatment patterns were used for validation. The validation coefficient of determination was R2 = 0.95, with the model generally producing estimates that were neither optimistic nor conservative. The model estimated that current Canadian practice patterns yield a median survival of almost 13 months, a five-year survival rate of 3% and a life-time per-treated-patient cost of $110,806. Cost and survival estimates are presented and were found to vary by aNSCLC subtype. In conclusion, the iTEN model is a reliable tool for forecasting the impact on cost and survival of new treatments for aNSCLC.
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Affiliation(s)
| | | | | | | | | | | | | | - Diana Tran
- Cornerstone Research Group, Burlington, Ontario, Canada
| | - Darryl Boehm
- Saskatchewan Cancer Agency, Regina, Saskatchewan, Canada
| | - Jaya Venkatesh
- Saskatchewan Cancer Agency, Regina, Saskatchewan, Canada
| | - Susan Walisser
- BC Cancer (Retired), Vancouver, British Columbia, Canada
| | - Erik Orava
- AstraZeneca Canada, Mississauga, Ontario, Canada
| | - Daniel Grima
- Cornerstone Research Group, Burlington, Ontario, Canada.
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10
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Cheung WY, Kornelsen EA, Mittmann N, Leighl NB, Cheung M, Chan KK, Bradbury PA, Ng RCH, Chen BE, Ding K, Pater JL, Tu D, Hay AE. The economic impact of the transition from branded to generic oncology drugs. ACTA ACUST UNITED AC 2019; 26:89-93. [PMID: 31043808 DOI: 10.3747/co.26.4395] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Economic evaluations are an integral component of many clinical trials. Costs used in those analyses are based on the prices of branded drugs when they first enter the market. The effect of genericization on the cost-effectiveness (ce) or cost-utility (cu) of an intervention is unknown because economic analyses are rarely updated using the costs of generic drugs. Methods We re-examined the ce or cu of regimens previously evaluated in Canadian Cancer Trials Group (cctg) studies that included prospective economic evaluations and where genericization has occurred or is anticipated in Canada. We incorporated the new costs of generic drugs to characterize changes in ce or cu. We also determined acceptable cost levels of generic drugs that would make regimens reimbursable in a publicly funded health care system. Results The four randomized controlled trials included (representing 1979 patients) were cctg br.10 (early lung cancer, adjuvant vinorelbine-cisplatin vs. observation, n = 172), cctg br.21 (metastatic lung cancer, erlotinib vs. placebo, n = 731), cctg co.17 (metastatic colon cancer, cetuximab vs. best supportive care, n = 557), and cctg ly.12 (relapsed or refractory lymphoma, gemcitabine-dexamethasone-cisplatin vs. cytarabine-dexamethasone-cisplatin, n = 619). Since the initial publication of those trials, the genericization of vinorelbine, erlotinib, cetuximab, and cisplatin has taken place or is expected in Canada. Costs of generics improved the ces and cus of treatment significantly. For example, genericization of erlotinib ($1460.25 per 30 days) resulted in an incremental cost-effectiveness ratio (icer) of $45,746 per life-year gained compared with $94,638 for branded erlotinib. Likewise, genericization of cetuximab ($275.80 per 100 mg) produced an icer of $261,126 per quality-adjusted life-year (qaly) gained compared with $299,613 for branded cetuximab. Decreases in the cost of generic cetuximab to $129.39 and $63.51 would further improve the icer to $150,000 and $100,000 per QALY respectively. Conclusions Genericization of a costly oncology drug can modify the ce and cu of a regimen significantly. Failure to revisit economic analyses with the costs of generics could be a missed opportunity for funding bodies to optimize value-based allocation of health care resources. At current levels, the costs of generics might not be sufficiently low to sustain publicly funded health care systems.
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Affiliation(s)
| | | | | | | | - M Cheung
- University of Toronto, Toronto, ON
| | - K K Chan
- University of Toronto, Toronto, ON
| | | | - R C H Ng
- University of Toronto, Toronto, ON
| | - B E Chen
- Queen's University, Kingston, ON
| | - K Ding
- Queen's University, Kingston, ON
| | | | - D Tu
- Queen's University, Kingston, ON
| | - A E Hay
- Queen's University, Kingston, ON
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11
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Vergnenègre A, Chouaïd C. Review of economic analyses of treatment for non-small-cell lung cancer (NSCLC). Expert Rev Pharmacoecon Outcomes Res 2018; 18:519-528. [PMID: 29869900 DOI: 10.1080/14737167.2018.1485099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION During the past few years, medical-economic evaluation of lung cancers (LCs) has become unavoidable. Total management costs have been rising constantly, with values almost doubling every 10 years. The financial impact will be even greater with the new molecules now marketed. The methodology for these studies conforms with international recommendations but must be adapted to the new stakes of LC management. AREAS COVERED This review provides an overview of the available literature concerning the economics of treating non-small-cell lung cancer (NSCLC). We first address the global costs of LCs. Detailed analyses were then computed for the different LC stages: localized, locally advanced and metastatic. For metastatic NSCLC, subsections are devoted to targeted therapies and immunotherapies. EXPERT COMMENTARY Drug costs are one of the major challenges of LC management. The multiplication of medical-economic analyses will assure better access to the marketing of these new and expensive therapeutic agents, but also to the selection of the best management strategy for these cancers.
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Affiliation(s)
- Alain Vergnenègre
- a Unité d'Oncologie Thoracique et Cutanée , Hôpital Dupuytren , Limoges , France
| | - Christos Chouaïd
- b Service de Pathologie Respiratoire , Centre Hospitalier Intercommunal de Créteil , Créteil , France
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12
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Evans WK, Stiff J, Woltman KJ, Ung YC, Su-Myat S, Manivong P, Tsang K, Nazen-Rad N, Gatto A, Tyrrell A, Anas R, Darling G, Sawka C. How equitable is access to treatment for lung cancer patients? A population-based review of treatment practices in Ontario. Lung Cancer Manag 2017; 6:77-86. [PMID: 30643573 PMCID: PMC6310344 DOI: 10.2217/lmt-2017-0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 01/16/2023] Open
Abstract
Aim: Guideline concordance is one of the metrics used by the Cancer Quality Council of Ontario and Cancer Care Ontario to assess the quality of cancer care and to drive quality improvement. Materials & Methods: The rates for lung cancer surgical resection and concordance with the Cancer Care Ontario postoperative adjuvant chemotherapy (AC) guideline were assessed by health region during two time periods (2010–2011 and 2012–2013) according to five equity measures (age, sex, neighborhood income, location of residence and size of immigrant population). Results: Of the patients with stage I/II NSCLC, 52.2% to 63.0% underwent surgical resection in the province of Ontario, Canada; for patients with stage IIIA disease, the rate was 26.4%. The probability of a surgical resection decreased substantially with age; only 26.9% of those with potentially resectable (stage I–IIIA) disease over 80 years underwent surgery. The use of postoperative AC increased modestly over the time of the study but the rate of use varied widely by health region (34.6 to 84.6%). Patients in rural areas were as likely to receive AC as urban dwellers; however, older aged patients (≥65 years) and those from the lowest income neighborhoods were significantly less likely to receive AC. Conclusion: Surgical rates and the use of AC vary by health region in Ontario and by age and level of neighborhood income despite universal access in a publicly funded health care system. The reasons for this variance are unclear but warrant further study. Presented in part at the 15th World Conference on Lung Cancer, Sydney, Australia, 27–30 October 2013
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Affiliation(s)
- William K Evans
- McMaster University, Department of Oncology, Hamilton, Ontario, Canada.,McMaster University, Department of Oncology, Hamilton, Ontario, Canada
| | - Jennifer Stiff
- Cancer Quality Council of Ontario Secretariat, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada.,Cancer Quality Council of Ontario Secretariat, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Kelly J Woltman
- Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada.,Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Yee C Ung
- Odette Cancer Center, University of Toronto, Toronto, Ontario, Canada.,Odette Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | - Sue Su-Myat
- Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada.,Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Phongsack Manivong
- Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada.,Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Kyle Tsang
- Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada.,Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Narges Nazen-Rad
- Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada.,Cancer Analytics, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Aryn Gatto
- Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada.,Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Ashley Tyrrell
- Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada.,Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Rebecca Anas
- Cancer Quality Council of Ontario Secretariat, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada.,Cancer Quality Council of Ontario Secretariat, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Gail Darling
- Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada.,Disease Pathway Management, Clinical Programs & Quality Initiatives, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Carol Sawka
- Cancer Care Ontario, University of Toronto, Toronto, Ontario, Canada.,Cancer Care Ontario, University of Toronto, Toronto, Ontario, Canada
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Addition of Docetaxel and/or Zoledronic Acid to Standard of Care for Hormone-naive Prostate Cancer: A Cost-effectiveness Analysis. TUMORI JOURNAL 2016; 103:380-386. [PMID: 28009424 DOI: 10.5301/tj.5000583] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2016] [Indexed: 02/05/2023]
Abstract
Background The effectiveness of the addition of docetaxel and/or zoledronic acid to the standard of care (SOC) for hormone-naive prostate cancer has been evaluated in the STAMPEDE trial. The object of the present analysis was to evaluate the cost-effectiveness of these treatment options in the treatment of advanced hormone-naive prostate cancer in China. Methods A cost-effectiveness analysis using a Markov model was carried out from the Chinese societal perspective. The efficacy data were obtained from the STAMPEDE trial and health utilities were derived from previous studies. Transition probabilities were calculated based on the survival in each group. The primary endpoint in the analysis was the incremental cost-effectiveness ratio (ICER), and model uncertainties were explored by 1-way sensitivity analysis and probabilistic sensitivity analysis. Results SOC alone generated an effectiveness of 2.65 quality-adjusted life years (QALYs) at a lifetime cost of $20,969.23. At a cost of $25,001.34, SOC plus zoledronic acid was associated with 2.69 QALYs, resulting in an ICER of $100,802.75/QALY compared with SOC alone. SOC plus docetaxel gained an effectiveness of 2.85 QALYs at a cost of $28,764.66, while the effectiveness and cost data in the SOC plus zoledronic acid/docetaxel group were 2.78 QALYs and $32,640.95. Conclusions Based on the results of the analysis, SOC plus zoledronic acid, SOC plus docetaxel, and SOC plus zoledronic acid/docetaxel are unlikely to be cost-effective options in patients with advanced hormone-naive prostate cancer compared with SOC alone.
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A Cost-Effectiveness Analysis of Using the JBR.10-Based 15-Gene Expression Signature to Guide Adjuvant Chemotherapy in Early Stage Non-Small-Cell Lung Cancer. Clin Lung Cancer 2016; 18:e41-e47. [PMID: 27502323 DOI: 10.1016/j.cllc.2016.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 06/01/2016] [Accepted: 06/13/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adjuvant chemotherapy (ACT) improved survival in the NCIC Clinical Trials Group JBR.10 trial of resected stage IB/II non-small-cell lung cancer. A prognostic 15-gene expression signature was developed, which may also predict for benefit from ACT. An exploratory economic analysis was conducted to assess the potential cost-effectiveness of using the 15-gene signature in guiding ACT decisions. METHODS A decision analytic model was populated by study patients with quantitative reverse transcription polymerase chain reaction tumor profiling, current costs, and quality-adjusted survival. Analysis was performed over the 6-year follow-up from the perspective of the Canadian public health care system in 2015 Canadian dollars (discounted 5%/year). Incremental cost-effectiveness and cost-utility ratios were determined for ACT versus observation using clinical stage, gene signature, or a combined approach to select treatment. RESULTS The mean survival gain of ACT versus observation was higher using the gene signature (1.86 years) compared with clinical stage (1.28 years). Although more costly, ACT guided by the gene signature remained cost-effective at $10,421/life-year gained (95% confidence interval [CI], $466-$19,568 Canadian), comparable to stage-directed selection ($7081/life-year gained; 95% CI, -$2370 to $14,721; P = .52). Incremental cost-utility ratios were $13,452/quality-adjusted life-year (95% CI, $373-$31,949) and $9194/quality-adjusted life-year (95% CI, -$4104 to $23,952), respectively (P = .53). Comparing the standard and test-and-treat approaches, use of the gene signature did not significantly alter survival compared with the standard strategy, but it reduced the ACT rate by 25%. CONCLUSION If validated, the use of the 15-gene expression signature to select patients for ACT may increase the survival gain of treatment in patients with high-risk stage IB/II non-small-cell lung cancer, while avoiding toxicities in low-risk patients.
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Pirker R. Adjuvant chemotherapy in patients with completely resected non-small cell lung cancer. Transl Lung Cancer Res 2015; 3:305-10. [PMID: 25806316 DOI: 10.3978/j.issn.2218-6751.2014.09.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 09/28/2014] [Indexed: 01/16/2023]
Abstract
Adjuvant chemotherapy has been established as a standard for patients with completely resected non-small cell lung cancer (NSCLC). Adjuvant chemotherapy increased the 5-year survival rates by 4% to 15% within randomized trials and, based on a meta-analysis of five cisplatin-based trials, by 5.4%. Adjuvant chemotherapy consists of a cisplatin-based doublet, preferentially cisplatin plus vinorelbine. Future improvements in outcome of adjuvant therapy are expected by customized chemotherapy and the integration of targeted therapies or immunotherapy.
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Affiliation(s)
- Robert Pirker
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
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16
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Non-Small-Cell Lung Cancer Clinicopathologic Features and Survival Outcomes in Asian Pacific Islanders Residing in the United States: A SEER Analysis. J Cancer Epidemiol 2015; 2015:269304. [PMID: 25685148 PMCID: PMC4312650 DOI: 10.1155/2015/269304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 11/27/2014] [Accepted: 11/27/2014] [Indexed: 12/13/2022] Open
Abstract
Background. The objective of our study was to ascertain racial/ethnic disparities in Asian/Pacific Islanders (API) for non-small-cell lung cancer (NSCLC) clinicopathologic features and survival outcomes based on various tumor characteristics and treatment modalities. Method. SEER database identified invasive NSCLC cases from 2004 to 2010. Variables included American Joint Committee on Cancer (AJCC) stage 7, tumor grade, tumor size, histology, age, marital status, radiation, surgery, and reason for no surgery. The Kruskall-Wallis test and the Z test were used to examine differences between races/ethnicities and the referent, non-Hispanic white (NHW). Multivariate Cox proportional analyses were used to establish the weight of the prognostic significance contributing to disease-specific survival (DSS) in each AJCC stage. Result. Improved DSS was seen in API across stage I (HR: 0.78), stage II (HR: 0.79), and stage IV (HR: 0.86), respectively, compared to the referent NHW (P < 0.01). Prognosis was improved by being married, being female gender, AIS histology, and birth outside the US (P < 0.01). Conclusion. We have demonstrated improved survival among API in early stage and stage IV NSCLC. Further research is necessary to clarify the role of lifestyle and tumor biology for these differences.
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Fowler RA, Mittmann N, Geerts WH, Heels-Ansdell D, Gould MK, Guyatt G, Krahn M, Finfer S, Pinto R, Chan B, Ormanidhi O, Arabi Y, Qushmaq I, Rocha MG, Dodek P, McIntyre L, Hall R, Ferguson ND, Mehta S, Marshall JC, Doig CJ, Muscedere J, Jacka MJ, Klinger JR, Vlahakis N, Orford N, Seppelt I, Skrobik YK, Sud S, Cade JF, Cooper J, Cook D. Economic evaluation of the prophylaxis for thromboembolism in critical care trial (E-PROTECT): study protocol for a randomized controlled trial. Trials 2014; 15:502. [PMID: 25528663 PMCID: PMC4413997 DOI: 10.1186/1745-6215-15-502] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 11/25/2014] [Indexed: 11/22/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a common complication of critical illness with important clinical consequences. The Prophylaxis for ThromboEmbolism in Critical Care Trial (PROTECT) is a multicenter, blinded, randomized controlled trial comparing the effectiveness of the two most common pharmocoprevention strategies, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) dalteparin, in medical-surgical patients in the intensive care unit (ICU). E-PROTECT is a prospective and concurrent economic evaluation of the PROTECT trial. Methods/Design The primary objective of E-PROTECT is to identify and quantify the total (direct and indirect, variable and fixed) costs associated with the management of critically ill patients participating in the PROTECT trial, and, to combine costs and outcome results to determine the incremental cost-effectiveness of LMWH versus UFH, from the acute healthcare system perspective, over a data-rich time horizon of ICU admission and hospital admission. We derive baseline characteristics and probabilities of in-ICU and in-hospital events from all enrolled patients. Total costs are derived from centers, proportional to the numbers of patients enrolled in each country. Direct costs include medication, physician and other personnel costs, diagnostic radiology and laboratory testing, operative and non-operative procedures, costs associated with bleeding, transfusions and treatment-related complications. Indirect costs include ICU and hospital ward overhead costs. Outcomes are the ratio of incremental costs per incremental effects of LMWH versus UFH during hospitalization; incremental cost to prevent a thrombosis at any site (primary outcome); incremental cost to prevent a pulmonary embolism, deep vein thrombosis, major bleeding event or episode of heparin-induced thrombocytopenia (secondary outcomes) and incremental cost per life-year gained (tertiary outcome). Pre-specified subgroups and sensitivity analyses will be performed and confidence intervals for the estimates of incremental cost-effectiveness will be obtained using bootstrapping. Discussion This economic evaluation employs a prospective costing methodology concurrent with a randomized controlled blinded clinical trial, with a pre-specified analytic plan, outcome measures, subgroup and sensitivity analyses. This economic evaluation has received only peer-reviewed funding and funders will not play a role in the generation, analysis or decision to submit the manuscripts for publication. Trial registration Clinicaltrials.gov Identifier: NCT00182143. Date of registration: 10 September 2005. Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-502) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert A Fowler
- Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
| | - Nicole Mittmann
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Department of Pharmacology, University of Toronto, 2075 Bayview Avenue, E240, Toronto, ON, M4N 3M5, Canada.
| | - William H Geerts
- Department of Medicine, Room D674, Sunnybrook Health Sciences Centre, Room D674, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSC-2C12, Hamilton, ON, L8S 4K1, Canada.
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles, Pasadena, CA, 91101, USA.
| | - Gordon Guyatt
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSC-2C12, Hamilton, ON, L8S 4K1, Canada.
| | - Murray Krahn
- Department of Medicine, 144 College Street, Room 600, Toronto, ON, M5S 3M2, Canada.
| | - Simon Finfer
- The George Institute for Global Health, Royal North Shore Hospital, University of Sydney, Pacific Highway, St Leonards, NSW, 2065, Australia.
| | - Ruxandra Pinto
- Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
| | - Brian Chan
- Institute of Health Policy, Management and Evaluation University of Toronto Health Sciences Building, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Orges Ormanidhi
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 144 College Street, 6th Floor, Toronto, ON, M5S 3M2, Canada.
| | - Yaseen Arabi
- Intensive Care Department, Medical Director, Respiratory Services, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.
| | - Ismael Qushmaq
- Department of Medicine, King Faisal Specialist Hospital & Research Centre-Gen. Org, PO Box 40047, Jeddah, 21499 MBC# J-46, Saudi Arabia.
| | - Marcelo G Rocha
- Department of Intensive Care, Hospitalar Santa Casa, Rua Professor Annes Dias, 295 - Centro Histórico, Porto Alegre, RS, 90020-200, Brazil.
| | - Peter Dodek
- Division of Critical Care Medicine, Center for Health Evaluation and Outcome Sciences, St Paul's Hospital and University of British Columbia, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Center for Health Evaluation and Outcome Sciences, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), Ottawa Hospital, Ottawa Hospital Research Institute, Centre for Transfusion and Critical Care Research, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada.
| | - Richard Hall
- Departments of Anesthesiology, Medicine, Pharmacology and Surgery, Dalhousie University and the Capital District Health Authority, Halifax NS, Room 5452-Halifax Infirmary, 1796 Summer St, Halifax, NS, B3H 3A7, Canada.
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine and Departments of Medicine & Physiology, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care, Mount Sinai Hospital and University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - John C Marshall
- Department of Surgery, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, 4-007 Bond Wing, St Michael's Hospital, 30 Bond Street, Toronto, M5B 1W8, Canada.
| | - Christopher James Doig
- Department of Community Health Sciences, Departments of Critical Care Medicine, Attending Physician, Foothills Medical Centre Multisystem Intensive Care Unit, Alberta Health Services, University of Calgary, Room 3D39, Teaching Research and Wellness Building, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
| | - John Muscedere
- Department of Medicine, Angada 4 Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Michael J Jacka
- Department of Anesthesiology and Critical Care, University of Alberta Hospital, 8440-112 St, Edmonton, AB, T6G 2B7, Canada.
| | - James R Klinger
- Division of Pulmonary, Sleep and Critical Care Medicine, Rhode Island Hospital, Professor of Medicine, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI, 02903, USA.
| | - Nicholas Vlahakis
- Department of Pulmonary & Critical Care Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
| | - Neil Orford
- Intensive Care Barwon Health, Australian and New Zealand Intensive Care Research Centre, Monash University School of Medicine, 99 Commercial Road, Geelong, VIC, 3004, Australia. .,Intensive Care Barwon Health, Australian and New Zealand Intensive Care Research Centre, Deakin University, 1 Gheringhap Street, Geelong, VIC, 3220, Australia.
| | - Ian Seppelt
- Critical Care Medicine, Nepean Hospital, Derby Street, Penrith, NSW, 2747, Australia.
| | - Yoanna K Skrobik
- Critical Care Medicine, Hôpital Maisonneuve-Rosemont, 5415 Blvd. De l'Assomption, Montreal, QC, H1T 2M4, Canada.
| | - Sachin Sud
- Department of Medicine, University Trillium Hospital, 100 Queensway West, Toronto, ON, L5B 1B8, Canada.
| | - John F Cade
- Intensive Care Unit, Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3050, Australia.
| | - Jamie Cooper
- ANZIC-RC Department of Epidemiology and Preventive Medicine Monash University, The Alfred Centre Level 6, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Deborah Cook
- Departments of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
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Delea TE, Amdahl J, Nakhaipour HR, Manson SC, Wang A, Fedor N, Chit A. Cost-effectiveness of pazopanib in advanced soft-tissue sarcoma in Canada. ACTA ACUST UNITED AC 2014; 21:e748-59. [PMID: 25489263 DOI: 10.3747/co.21.1899] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In the phase iii palette trial of pazopanib compared with placebo in patients with advanced or metastatic soft-tissue sarcoma (sts) who had received prior chemotherapy, pazopanib treatment was associated with improved progression-free survival (pfs). We used an economic model and data from palette and other sources to evaluate the cost-effectiveness of pazopanib in patients with advanced sts who had already received chemotherapy. METHODS We developed a multistate model to estimate expected pfs, overall survival (os), lifetime sts treatment costs, and quality-adjusted life-years (qalys) for patients receiving pazopanib or placebo as second-line therapy for advanced sts. Cost-effectiveness was calculated alternatively from the health care system and societal perspectives for the province of Quebec. Estimated pfs, os, incidence of adverse events, and utilities values for pazopanib and placebo were derived from the palette trial. Costs were obtained from published sources. RESULTS Compared with placebo, pazopanib is estimated to increase qalys by 0.128. The incremental cost of pazopanib compared with placebo is CA$20,840 from the health care system perspective and CA$15,821 from the societal perspective. The cost per qaly gained with pazopanib in that comparison is CA$163,336 from the health care system perspective and CA$124,001 from the societal perspective. CONCLUSIONS Compared with placebo, pazopanib might be cost-effective from the Canadian health care system and societal perspectives depending on the threshold value used by reimbursement authorities to assess novel cancer therapies. Given the unmet need for effective treatments for advanced sts, pazopanib might nevertheless be an appropriate alternative to currently used treatments.
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Affiliation(s)
- T E Delea
- Policy Analysis Inc. ( pai ), Brookline, MA, U.S.A
| | - J Amdahl
- Policy Analysis Inc. ( pai ), Brookline, MA, U.S.A
| | - H R Nakhaipour
- Health Outcomes-Oncology, Medical Division, GlaxoSmithKline, Mississauga, ON
| | - S C Manson
- Global Health Outcomes-Oncology, GlaxoSmith-Kline, Stockley Park, Uxbridge, Middlesex, U.K
| | - A Wang
- Policy Analysis Inc. ( pai ), Brookline, MA, U.S.A
| | - N Fedor
- Policy Analysis Inc. ( pai ), Brookline, MA, U.S.A
| | - A Chit
- Health Outcomes-Oncology, Medical Division, GlaxoSmithKline, Mississauga, ON. ; University of Toronto, Toronto, ON
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Lim C, Sergi M, Leighl NB. Targeted therapy for lung cancer: reviewing the cost and its effect on treatment decisions. Lung Cancer Manag 2014. [DOI: 10.2217/lmt.14.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Novel targeted therapies that improve outcome in advanced lung cancer should be adopted. However, given the high costs of targeted therapies and companion molecular testing, the affordability and cost–effectiveness of novel agents are of growing relevance in policy decisions. Incremental cost–effectiveness ratios in excess of US$200,000 per quality-adjusted life year have been described in published literature evaluating currently approved agents. Differing willingness to pay thresholds in different countries determine which therapies will be funded in a given healthcare system. Cost-containment strategies to address costs of molecular testing and drug acquisition need to be implemented. Drug manufacturers, healthcare payers and oncologists have a shared responsibility to ensure that novel therapies are affordable and accessible to patients in need.
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Affiliation(s)
- Charles Lim
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Melissa Sergi
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Natasha B Leighl
- Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Mahar AL, Coburn NG, Johnson AP. A population-based study of the resource utilization and costs of managing resectable non-small cell lung cancer. Lung Cancer 2014; 86:281-7. [DOI: 10.1016/j.lungcan.2014.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 09/09/2014] [Accepted: 09/13/2014] [Indexed: 10/24/2022]
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21
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Roth JA, Billings P, Ramsey SD, Dumanois R, Carlson JJ. Cost-effectiveness of a 14-gene risk score assay to target adjuvant chemotherapy in early stage non-squamous non-small cell lung cancer. Oncologist 2014; 19:466-76. [PMID: 24710309 DOI: 10.1634/theoncologist.2013-0357] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Life Technologies has developed a 14-gene molecular assay that provides information about the risk of death in early stage non-squamous non-small cell lung cancer patients after surgery. The assay can be used to identify patients at highest risk of mortality, informing subsequent treatments. The objective of this study was to evaluate the cost-effectiveness of this novel assay. Patients and Methods. We developed a Markov model to estimate life expectancy, quality-adjusted life years (QALYs), and costs for testing versus standard care. Risk-group classification was based on assay-validation studies, and chemotherapy uptake was based on pre- and post-testing recommendations from a study of 58 physicians. We evaluated three chemotherapy-benefit scenarios: moderately predictive (base case), nonpredictive (i.e., the same benefit for each risk group), and strongly predictive. We calculated the incremental cost-effectiveness ratio (ICER) and performed one-way and probabilistic sensitivity analyses. Results. In the base case, testing and standard-care strategies resulted in 6.81 and 6.66 life years, 3.76 and 3.68 QALYs, and $122,400 and $118,800 in costs, respectively. The ICER was $23,200 per QALY (stage I: $29,200 per QALY; stage II: $12,200 per QALY). The ICER ranged from "dominant" to $92,100 per QALY in the strongly predictive and nonpredictive scenarios. The model was most sensitive to the proportion of high-risk patients receiving chemotherapy and the high-risk hazard ratio. The 14-gene risk score assay strategy was cost-effective in 68% of simulations. Conclusion. Our results suggest that the 14-gene risk score assay may be a cost-effective alternative to standard guideline-based adjuvant chemotherapy decision making in early stage non-small cell lung cancer.
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Affiliation(s)
- Joshua A Roth
- Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Group Health Research Institute, Group Health, Seattle, Washington, USA; Life Technologies Corporation, Carlsbad, California, USA; Department of Pharmacy, University of Washington, Seattle, Washington, USA
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Valutazione economica in base allo studio NAVoTRIAL01 con riferimento al contesto sanitario italiano: Vinorelbine orale e Cisplatino o Pemetrexed e Cisplatino seguiti da mantenimento rispettivamente con Vinorelbine orale e Pemetrexed nel trattamento del Carcinoma Polmonare Non a Piccole Cellule Non Squamoso (NS-NSCLC) in stadio avanzato. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s40276-014-0019-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Matsangou M, Santos ES, Raez LE, Gomez JE, Dinh V, Savaraj N. Early-stage non-small-cell lung cancer: overview of adjuvant chemotherapy and promising advances. Lung Cancer Manag 2014. [DOI: 10.2217/lmt.13.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Adjuvant cisplatin-based chemotherapy for early-stage non-small-cell lung cancer has become standard of care, after three recent meta-analyses validated survival benefit of approximately 5% at 5 years. Subgroup analyses, however, demonstrated that the benefit appears largely confined to patients with stage II disease; however, 25–30% of patients with stage I disease are at high risk of relapse and death within 5 years. Therefore, there is a need to predict more accurately which patients are likely to relapse after surgery and thus benefit from adjuvant therapy. Recent studies indicate that molecular biomarkers, gene-expression profiling and gene-mutation analysis may not only identify those tumors that are more likely to respond to adjuvant chemotherapy, but also to specific cytotoxic agents. These novel bioanalyses will allow physicians to deliver personalized medicine that utilizes cancer therapeutic drugs more cost effectively, thereby improving response rates and, hopefully, conferring survival advantage.
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Affiliation(s)
- Maria Matsangou
- Department of Internal Medicine, Section on Hematology & Oncology, Wake Forest University School of Medicine, Comprehensive Cancer Center of Wake Forest University, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Edgardo S Santos
- Thoracic & Head & Neck Cancer Programs, Cancer Research at Lynn Cancer Institute, 701 Northwest 13th Street, Boca Raton, FL 33486, USA
| | - Luis E Raez
- Thoracic Oncology, Memorial Cancer Institute, 801 North Flamingo Road, Suite 11, Pembroke Pines, FL 33028, USA
| | - Jorge E Gomez
- Thoracic Oncology Program, Mount Sinai Hospital, 1470 Madison Avenue, 3rd floor, New York, NY 1002, USA
| | - Vy Dinh
- University of Miami Leonard M Miller School of Medicine, Sylvester Comprehensive Cancer Center, 1475 Northwest 12th Avenue, Suite 3510, Miami, FL 33136, USA
| | - Niramol Savaraj
- Department of Medicine, Division of Hematology/Medical Oncology, Miami Veterans Affairs Hospital, 1201 Northwest 16th Street, Miami, FL 33125, USA
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Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e278S-e313S. [PMID: 23649443 DOI: 10.1378/chest.12-2359] [Citation(s) in RCA: 884] [Impact Index Per Article: 80.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined. METHODS The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. RESULTS Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
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Affiliation(s)
- John A Howington
- NorthShore HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, IL.
| | - Matthew G Blum
- Penrose Cardiothoracic Surgery, Memorial Hospital, University of Colorado Health, Colorado Springs, CO
| | | | - Alex A Balekian
- Division of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
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Remon J, Lianes P, Martínez S, Velasco M, Querol R, Zanui M. Adjuvant treatment in resected non-small cell lung cancer: current and future issues. Crit Rev Oncol Hematol 2013; 88:375-86. [PMID: 23809199 DOI: 10.1016/j.critrevonc.2013.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 05/17/2013] [Accepted: 05/31/2013] [Indexed: 12/25/2022] Open
Abstract
The cornerstone of treatment for early-stage non-small cell lung cancer (NSCLC) has been surgical resection. In the last five years two phase III trials have provided evidence of adjuvant platinum-based chemotherapy for completely resected stage II-IIIA patients. We review the evidence supporting adjuvant therapy in early-stage NSCLC; we discuss new issues surrounding adjuvant therapy such as treatment in the elderly-unfit population, treatment toxicity and its influence on outcomes, the importance of histology and gender in adjuvant treatment; and we discuss the future landscape of early-stage NSCLC research, namely, therapeutic strategies exploiting pharmacogenomic and gene-expression profiling, in an attempt to customize the treatment.
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Affiliation(s)
- Jordi Remon
- Medical Oncology Department, Hospital de Mataró, Carretera de la Cirera, s/n, 08304 Mataró, Barcelona, Spain.
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Kirkwood JM, Tarhini A, Sparano JA, Patel P, Schiller JH, Vergo MT, Benson Iii AB, Tawbi H. Comparative clinical benefits of systemic adjuvant therapy for paradigm solid tumors. Cancer Treat Rev 2013; 39:27-43. [PMID: 22520262 PMCID: PMC8555872 DOI: 10.1016/j.ctrv.2012.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/16/2012] [Accepted: 03/18/2012] [Indexed: 01/15/2023]
Abstract
Adjuvant therapy employing cytotoxic chemotherapy, molecularly targeted agents, immunologic, and hormonal agents has shown a significant impact upon a variety of solid tumors. The principles that guide adjuvant therapy differ among various tumor types and specific modalities, but generally indicate a greater impact of therapy in the postsurgical setting of micrometastatic disease, for which adjuvant therapy is commonly pursued, vs. the setting of gross unresectable disease. This review of adjuvant therapies in current use for five major solid tumors highlights the rationale for current effective adjuvant therapy, and draws comparisons between the adjuvant regimens that have found application in solid tumors.
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Affiliation(s)
- John M Kirkwood
- University of Pittsburgh Cancer Institute, Pittsburgh, PA 15213-1862, USA.
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Horgan A, Bradbury P, Amir E, Ng R, Douillard J, Kim E, Shepherd F, Leighl N. An economic analysis of the INTEREST trial, a randomized trial of docetaxel versus gefitinib as second-/third-line therapy in advanced non-small-cell lung cancer. Ann Oncol 2011; 22:1805-11. [DOI: 10.1093/annonc/mdq682] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Horgan AM, Knox JJ, Liu G, Sahi C, Bradbury PA, Leighl NB. Capecitabine or infusional 5-fluorouracil for gastroesophageal cancer: a cost-consequence analysis. ACTA ACUST UNITED AC 2011; 18:e64-70. [PMID: 21505591 DOI: 10.3747/co.v18i2.730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with advanced gastroesophageal cancer, the phase iii Randomized ECF for Advanced and Locally Advanced Esophagogastric Cancer 2 (real-2) trial demonstrated equivalent clinical efficacy when capecitabine (x) was substituted for 5-fluorouracil (5fu) in the epirubicin-cisplatin-5fu (ecf) regimen. The present analysis compares the direct medical costs associated with both regimens. METHODS This cost-consequence analysis of direct medical costs took resource utilization data from the real-2 trial where available. Direct medical costs were derived from the perspective of the Canadian public health care system in 2008 Canadian dollars. Mean cost per patient on each treatment arm was calculated. RESULTS Drug costs from start of treatment until first progression, including pre- and post-chemotherapy medications and administration costs, totalled $5,344 for ecx as compared with $3,187 for ecf. Costs for treatment of adverse events were estimated at $2,621 for ecx as compared with $3,397 for ecf. An additional cost of $873 was associated with insertion of an implanted venous access. Total incremental cost of ecx over ecf was $508. CONCLUSIONS In advanced gastroesophageal cancer, capecitabine is an attractive alternative to 5fu. Although the drug cost per se is greater, use of capecitabine is associated with decreased consumption of hospital resources. Not only does capecitabine fit with patient preference for oral therapy, it also avoids the inconvenience and complications of central venous access.
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Affiliation(s)
- A M Horgan
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, ON
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Bradbury PA, Tu D, Seymour L, Isogai PK, Zhu L, Ng R, Mittmann N, Tsao MS, Evans WK, Shepherd FA, Leighl NB. Economic analysis: randomized placebo-controlled clinical trial of erlotinib in advanced non-small cell lung cancer. J Natl Cancer Inst 2010; 102:298-306. [PMID: 20160168 DOI: 10.1093/jnci/djp518] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The NCIC Clinical Trials Group conducted the BR.21 trial, a randomized placebo-controlled trial of erlotinib (an epidermal growth factor receptor tyrosine kinase inhibitor) in patients with previously treated advanced non-small cell lung cancer. This trial accrued patients between August 14, 2001, and January 31, 2003, and found that overall survival and quality of life were improved in the erlotinib arm than in the placebo arm. However, funding restrictions limit access to erlotinib in many countries. We undertook an economic analysis of erlotinib treatment in this trial and explored different molecular and clinical predictors of outcome to determine the cost-effectiveness of treating various populations with erlotinib. METHODS Resource utilization was determined from individual patient data in the BR.21 trial database. The trial recruited 731 patients (488 in the erlotinib arm and 243 in the placebo arm). Costs arising from erlotinib treatment, diagnostic tests, outpatient visits, acute hospitalization, adverse events, lung cancer-related concomitant medications, transfusions, and radiation therapy were captured. The incremental cost-effectiveness ratio was calculated as the ratio of incremental cost (in 2007 Canadian dollars) to incremental effectiveness (life-years gained). In exploratory analyses, we evaluated the benefits of treatment in selected subgroups to determine the impact on the incremental cost-effectiveness ratio. RESULTS The incremental cost-effectiveness ratio for erlotinib treatment in the BR.21 trial population was $94,638 per life-year gained (95% confidence interval = $52,359 to $429,148). The major drivers of cost-effectiveness included the magnitude of survival benefit and erlotinib cost. Subgroup analyses revealed that erlotinib may be more cost-effective in never-smokers or patients with high EGFR gene copy number. CONCLUSION With an incremental cost-effectiveness ratio of $94 638 per life-year gained, erlotinib treatment for patients with previously treated advanced non-small cell lung cancer is marginally cost-effective. The use of molecular predictors of benefit for targeted agents may help identify more or less cost-effective subgroups for treatment.
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Navaratnam S, Kliewer EV, Butler J, Demers AA, Musto G, Badiani K. Population-based patterns and cost of management of metastatic non-small cell lung cancer after completion of chemotherapy until death. Lung Cancer 2010; 70:110-5. [PMID: 20153911 DOI: 10.1016/j.lungcan.2010.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 12/11/2009] [Accepted: 01/17/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to examine the patterns and costs of management of non-small cell lung cancer (NSCLC) after completion of chemotherapy until death in a population of patients in Manitoba, Canada. PATIENTS AND METHODS Stage IIIB and IV NSCLC patients diagnosed between January 1997 and June 2000 who received chemotherapy as the primary treatment, completed their chemotherapy and survived for at least 28 days since their last treatment, and were on best supportive care (BSC) were selected. Treatment, services received, costs, and survival were determined by chart review and examining various databases including the Manitoba Cancer Registry, medical claims, hospitalizations, and prescription drugs. Costs of treatment, average cost per patient, and lifetime treatment costs were calculated. RESULTS Of the 2463 patients diagnosed with NSCLC over the study period, 150 patients matched our study criteria. From the beginning of the first chemotherapy treatment, the median survival time was 31.8 weeks, while from the date of BSC the median survival time was 13.8 weeks. The average cost per case was $10,805 from last date of chemotherapy and $8654 during the BSC period. The average cost per patient-month ranged from $1645 to $1792 in current prices. Lifetime treatment costs ranged from $8702 to $11,057. Hospitalizations accounted for 80% of the total treatment costs. CONCLUSION The largest overall component of cost after the end of chemotherapy was hospitalizations. Effective new therapies that reduce the episodes of hospitalizations would have a significant impact on decreasing aggregate costs.
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Affiliation(s)
- Sri Navaratnam
- Department of Internal Medicine, University of Manitoba, Faculty of Medicine, 675 McDermot Avenue, Winnipeg, R3E 0V9 Canada.
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Cisplatin versus carboplatin in NSCLC: is there one "best" answer? Curr Treat Options Oncol 2009; 9:326-42. [PMID: 19225891 DOI: 10.1007/s11864-009-0085-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 01/14/2009] [Indexed: 12/26/2022]
Abstract
Platinum-based chemotherapeutic doublets have produced significant survival benefits for patients with non-small cell lung cancer of all disease stages. The optimal combination of chemotherapy has been the subject of much investigation, and the ideal platinum agent the subject of ongoing and heated debate. For patients with resected disease, all evidence of survival advantage rests with cisplatin, and the only clinical trial to evaluate carboplatin-based therapy failed to show a survival benefit. In the setting of locally advanced lung cancer, no comparative data exist, and even randomized phase III trials are largely lacking. Cisplatin-based doublets provide the most consistent evidence of superior survival when coupled with definitive thoracic radiation. Meta-analyses of palliative chemotherapy indicate consistent survival advantages with cisplatin-based therapy over carboplatin; however, the relative advantage is small. Cisplatin carries a higher toxicity profile, including nausea, vomiting, neuropathy, renal insufficiency, and alopecia in comparison to carboplatin. When the goal of therapy is curative, the survival benefits with cisplatin are in most circumstances worth the increased toxicities. When the goal of therapy is palliation, the relative price of toxicity needs to be weighed on the basis of the individual patient in an effort to maximize quality of life.
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Kuwabara K, Matsuda S, Fushimi K, Anan M, Ishikawa KB, Horiguchi H, Hayashida K, Fujimori K. Differences in Practice Patterns and Costs between Small Cell and Non-Small Cell Lung Cancer Patients in Japan. TOHOKU J EXP MED 2009; 217:29-35. [DOI: 10.1620/tjem.217.29] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kazuaki Kuwabara
- Department of Health Care Administration and Management, Kyushu University, Graduate School of Medical Sciences
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Graduate School of Medicine
| | - Makoto Anan
- Health information management, Kyushu Medical Center
| | | | - Hiromasa Horiguchi
- Health Management and Policy, University of Tokyo, Graduate School of Medicine
| | - Kenshi Hayashida
- Department of Healthcare Economics and Quality Management, Kyoto University, Graduate School of Medicine
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Chouaid C, Atsou K, Hejblum G, Vergnenegre A. Economics of treatments for non-small cell lung cancer. PHARMACOECONOMICS 2009; 27:113-125. [PMID: 19254045 DOI: 10.2165/00019053-200927020-00003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The purpose of this article is to review the economics of treatments for non-small cell lung cancer (NSCLC). We systematically analysed the cost effectiveness of treatments for the different stages of NSCLC, with particular emphasis on more recently approved agents. Numerous economic analyses in NSCLC have been conducted, with a variety of methods and in a number of countries. In patients with localized disease, adjuvant chemotherapy appears to have greater cost effectiveness than observation; however, there are few published data. In locally advanced disease, combined modalities (chemotherapy, surgery and/or radiotherapy) are probably cost effective, but high-quality economic analyses are lacking. In advanced NSCLC, third-generation chemotherapies used in the first-line setting can be administered with acceptable incremental cost effectiveness. In the second-line setting, new agents (docetaxel, pemetrexed and erlotinib) have acceptable cost effectiveness. The lack of cost-utility analyses for elderly patients and patients with a poor prognosis rules out firm conclusions. This review suggests that most therapies for NSCLC are cost effective when the patient has a good performance status, with an incremental cost-effectiveness ratio under USD 50,000 per life-year gained in the majority of cases.
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Vergnenègre A, Atsou K, Molinier L, Chouaïd C. Les analyses économiques des cancers bronchopulmonaires (CBP). Rev Mal Respir 2008. [DOI: 10.1016/s0761-8425(08)82018-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Carlson JJ, Veenstra DL, Ramsey SD. Pharmacoeconomic evaluations in the treatment of non-small cell lung cancer. Drugs 2008; 68:1105-13. [PMID: 18484801 DOI: 10.2165/00003495-200868080-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Non-small cell lung cancer (NSCLC) creates a large economic and disease burden worldwide. In an era of evidence-based medicine and increasing cost pressures, it is important to understand the relative clinical and economic impact of the many drug treatment strategies available for NSCLC. A systematic review of the peer-reviewed literature for pharmacoeconomic evaluations in the primary treatment of NSCLC published over the past decade (1 June 1997 to 1 June 2007) was conducted using the PubMed, EMBASE, BIOSIS Previews, Harvard Review of Economic Analyses, National Institute for Health and Clinical Excellence and Canadian Agency for Drugs and Technologies in Health databases. A total of 19 studies met the inclusion/exclusion criteria. Of these studies, 58% were cost-effectiveness studies, 37% were cost-minimization studies and 5% were cost-utility studies. Most were from the EU (63%), were from the payer perspective (89%), were in advanced (stage IIIB/IV) NSCLC (84%) and were funded by drug manufacturers (68%). Drug treatments generally were found to be cost effective compared with best supportive care. In addition, cisplatin alone or in combination appeared to provide better value than carboplatin alone or in combination. We did not identify any studies of recently approved therapeutics (e.g. erlotinib or bevacizumab). The quality of studies varied but the majority did not meet recommended guidelines for economic evaluations, with only 43% using direct comparisons, 5% of studies being cost-utility studies and 26% using either statistical analysis of patient-level data or probabilistic sensitivity analyses. In conclusion, there are a multitude of studies examining drug treatment for NSCLC; however, few of these utilized methodological approaches consistent with recommended guidelines. Despite these limitations, it appears that drug therapy compared with no treatment provides reasonable value for money, but carrying out more detailed comparisons of various agents is challenging. Given the absence of studies on newer therapeutics and the lack of cost-utility studies, additional studies are warranted.
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Affiliation(s)
- Josh J Carlson
- School of Public Health and Community Medicine, Institute for Public Health Genetics, University of Washington, Seattle, Washington, USA
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Shih YCT, Halpern MT. Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean? CA Cancer J Clin 2008; 58:231-44. [PMID: 18596196 DOI: 10.3322/ca.2008.0008] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
While the past decade has seen the development of multiple new interventions to diagnose and treat cancer, as well as to improve the quality of life for cancer patients, many of these interventions have substantial costs. This has resulted in increased scrutiny of the costs of care for cancer, as well as the costs relative to the benefits for cancer treatments. It is important for oncologists and other members of the cancer community to consider and understand how economic evaluations of cancer interventions are performed and to be able to use and critique these evaluations. This review discusses the components, main types, and analytic issues of health economic evaluations using studies of cancer interventions as examples. We also highlight limitations of these economic evaluations and discuss why members of the cancer community should care about economic analyses.
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Affiliation(s)
- Ya-Chen Tina Shih
- Department of Biostatistics, Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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