Economic evaluation of three two-drug chemotherapy regimens in advanced non-small-cell lung cancer

Economic evaluation of first-line and maintenance treatments for advanced non-small cell lung cancer: a systematic review

During these last years, there have been an increased number of new drugs for non-small cell lung cancer (NSCLC), with a growing financial effect on patients and society. The purpose of this article was to review the economics of first-line and maintenance NSCLC treatments. We reviewed economic analyses of NSCLC therapies published between 2004 and 2014. In first-line settings, in unselected patients with advanced NSCLC, the cisplatin gemcitabine doublet appears to be cost-saving compared with other platinum doublets. In patients with nonsquamous NSCLC, the incremental cost-effectiveness ratios (ICERs) per life-year gained (LYG) were $83,537, $178,613, and more than $300,000 for cisplatin-pemetrexed compared with, respectively, cisplatin-gemcitabine, cisplatin-carboplatin-paclitaxel, and carboplatin-paclitaxel-bevacizumab. For all primary chemotherapy agents, use of carboplatin is associated with slightly higher costs than cisplatin. In all the analysis, bevacizumab had an ICER greater than $150,000 per quality-adjusted life-year (QALY). In epidermal growth factor receptor mutated advanced NSCLC, compared with carboplatin-paclitaxel doublet, targeted therapy based on testing available tissue yielded an ICER of $110,644 per QALY, and the rebiopsy strategy yielded an ICER of $122,219 per QALY. Compared with the triplet carboplatin-paclitaxel-bevacizumab, testing and rebiopsy strategies had ICERs of $25,547 and $44,036 per QALY, respectively. In an indirect comparison, ICERs per LYG and QALY of erlotinib versus gefitinib were $39,431 and $62,419, respectively. In anaplastic lymphoma kinase-positive nonsquamous advanced NSCLC, the ICER of first-line crizotinib compared with that of chemotherapy was $255,970 per QALY. For maintenance therapy, gefitinib had an ICER of $19,214 per QALY, erlotinib had an ICER of $127,343 per LYG, and pemetrexed had an ICER varying between $183,589 and $205,597 per LYG. Most recent NSCLC strategies are based on apparently no cost-effective strategies if we consider an ICER below $50,000 per QALY an acceptable threshold. We need, probably on a countrywide level, to have a debate involving public health organizations and pharmaceutical companies, as well as clinicians and patients, to challenge the rising costs of managing lung cancer.

Cost effectiveness of treatment with new agents in advanced non-small-cell lung cancer: a systematic review

In past decades, studies focusing on new chemotherapeutic agents for patients with inoperable non-small-cell lung cancer have reported only modest gains in survival. These health gains are achieved at considerable cost, but economic evidence is lacking on superiority of one agent in terms of cost effectiveness. The objective of this systematic review was to assess fully published cost-effectiveness studies comparing the new agents docetaxel, paclitaxel, vinorelbine, gemcitabine and pemetrexed, and the targeted therapies erlotinib and gefitinib with one another. We performed systematic searches in the bibliographic databases PubMed, EMBASE and Health Economic Evaluations (HEED) [via the Cochrane Library] for fully published studies from the past 10 years. Studies were screened by two independent reviewers according to a priori inclusion criteria. The methodological quality of the included studies was evaluated by two independent reviewers using standardized assessment tools. A total of 222 potential studies were identified; 11 studies and six reviews were included. The methodological quality of the full economic evaluations was fairly good. Transparency in costs and resource use, details on statistical tests and sensitivity analysis were points for improvement. In first-line treatment, gemcitabine+cisplatin was cost effective compared with other platinum-based regimens (paclitaxel, docetaxel and vinorelbine). In one study, pemetrexed+cisplatin was cost effective compared with gemcitabine+cisplatin in patients with non-squamous-cell carcinoma. In second-line treatment, docetaxel was cost effective compared with best supportive care; erlotinib was cost effective compared with placebo; and docetaxel and pemetrexed were dominated by erlotinib. We found indications of superiority in terms of cost effectiveness for gemcitabine+cisplatin in a first-line setting, and for erlotinib in a second-line setting.

How affordable are targeted therapies in non-small cell lung cancer?

As the treatment of non-small cell lung cancer (NSCLC) evolves to include more targeted therapies, costs of treatment have increased significantly. Advances in NSCLC treatment include longer survival duration, and in some cases, better progression-free survival and quality of life, and the potential for decreased toxicity. Through pharmacoeconomic analyses, payors seek to value the improvements in outcomes from novel therapies, and relate these improvements to their costs. In NSCLC, three categories of novel agents have been introduced into clinical practice: (1) agents targeting the epidermal growth factor receptor (EGFR); (2) agents targeting the vascular endothelial growth factor (VEGF) and (3) novel chemotherapy agents, specifically pemetrexed. Here we review published economic analyses for these agents in lung cancer, and their potential impact on treatment decisions.

Economics of treatments for non-small cell lung cancer

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.

Pharmacoeconomic evaluations in the treatment of non-small cell lung cancer

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.

Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean?

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.

Guidelines for selecting among different types of bootstraps

BACKGROUND

The bootstrap has become very popular in health economics. Its success lies in the ease of estimating sampling distribution, standard error and confidence intervals with few or no assumptions about the distribution of the underlying population.

OBJECTIVE

The purpose of this paper is three-fold: (1) to provide an overview of four common bootstrap techniques for readers who have little or no statistical background; (2) to suggest a guideline for selecting the most applicable bootstrap technique for your data; and (3) to connect guidelines with a real world example, to illustrate how different bootstraps behave in one model, or in different models.

RESULTS

The assumptions of homoscedasticity and normality are key to selecting the best bootstrapping technique. These assumptions should be tested before applying any bootstrapping technique. If homoscedasticity and normality hold, then parametric bootstrapping is consistent and efficient. Paired and wild bootstrapping are consistent under heteroscedasticity and non-normality assumptions.

CONCLUSION

Selecting the correct type of bootstrapping is crucial for arriving at efficient estimators. Our example illustrates that if we selected an inconsistent bootstrapping technique, results could be misleading. An insignificant effect of controller treatment on total health expenditures among asthma patients would have been found significant and negative by an improperly chosen bootstrapping technique, regardless of the type of model chosen.