Cost-Effectiveness of interferon alfa-2b added to chemotherapy for high-tumor-burden follicular non-Hodgkin's lymphoma

Granulocyte colony-stimulating factor in secondary prophylaxis for advanced-stage Hodgkin lymphoma treated with ABVD chemotherapy: a cost-effectiveness analysis

Granulocyte colony-stimulating factor (G-CSF) is commonly administered to patients with Hodgkin lymphoma (HL) with neutropenia. We constructed a decision-analytic model to compare the cost-effectiveness of secondary prophylaxis with G-CSF to a strategy of 'no G-CSF' in response to severe neutropenia for adults with advanced-stage HL treated with ABVD. A Canadian public health payer's perspective was considered and costs were presented in 2013 Canadian dollars. The quality-adjusted life years (QALYs) attained with the G-CSF and 'no G-CSF' strategies were 1.403 and 1.416, respectively. Costs for the strategies with and without G-CSF were $38,971 and $33,982, respectively. In the base case analysis, the 'no G-CSF' strategy was associated with cost savings and improved QALYs; therefore, 'no G-CSF' was the dominant approach. For patients with severe neutropenia during ABVD chemotherapy for advanced-stage HL, a strategy without G-CSF support is associated with improved quality-adjusted outcomes, cost savings, and is the preferred approach.

Determinants of the optimal first-line therapy for follicular lymphoma: a decision analysis

Combination immunochemotherapy is the most common approach for initial therapy of patients with advanced-stage follicular lymphoma, but no consensus exists as to the optimal selection or sequence of available regimens. We undertook this decision analysis to systematically evaluate the parameters affecting the choice of early therapy in patients with this disease. We designed a Markov model incorporating the three most commonly utilized regimens (RCVP, RCHOP, and RFlu) in combinations of first- and second-line therapies, with the endpoint of number of quality-adjusted life years (QALYs) until disease progression. Data sources included Phase II and Phase III trials and literature estimates of long-term toxicities and health state utilities. Meta-analytic methods were used to derive the values and ranges of regimen-related parameters. Based on our model, the strategy associated with the greatest number of expected quality-adjusted life years was treatment with RCHOP in first-line therapy followed by treatment with RFlu in second-line therapy (9.00 QALYs). Strategies containing RCVP either in first- or second-line therapy resulted in the lowest number of QALYs (range 6.24-7.71). Sensitivity analysis used to determine the relative contribution of each model parameter identified PFS after first-line therapy and not short-term QOL as the most important factor in prolonging overall quality-adjusted life years. Our results suggest that regimens associated with a longer PFS provide a greater number of total QALYs, despite their short-term toxicities. For patients without contraindications to any of these regimens, use of a more active regimen may maximize overall quality of life.

Interferon-alpha for maintenance of follicular lymphoma

BACKGROUND

Indolent non-Hodgkin's lymphoma, in particular follicular lymphoma (FL), is characterized by multiple remissions and relapses. Several studies have used interferon-alpha (IFN) to control this disease, both as induction and as maintenance therapy. It is not yet clear whether IFN can be associated with a survival benefit although it may prolong progression-free survival.

OBJECTIVES

To determine the effects of IFN in the maintenance therapy of FL.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2008), MEDLINE (1966 to 2008), DARE (1990 to 2008), SCOPUS (searched December 2008) and Current Contents (1975 to 2008). .

SELECTION CRITERIA

Randomised controlled trials of IFN versus no intervention or placebo, or IFN plus chemotherapy versus chemotherapy alone, in a maintenance setting in patients with non-Hodgkin's FL. Primary outcomes were overall survival and progression-free survival.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse events information from the trials.

MAIN RESULTS

We included eight trials (1563 patients). The drug was IFN alfa-2b in six trials and alfa-2a in two. Trials were heterogeneous in terms of diagnosis of FL, using several classification systems. IFN had been compared with placebo/no intervention in five trials and other chemotherapy in three. The effect of IFN was similar to that of placebo on overall survival (hazard ratio (HR) 0.90, 95% CI 0.61 to 1.34) whereas IFN was more effective when added to chemotherapy (HR 0.68, 95% confidence interval (CI) 0.52 to 0.90). Considering IFN versus all comparators, IFN was effective in prolonging progression-free survival (HR 0.66, 95% CI 0.57 to 0.77) and overall survival (fixed effects HR 0.79, 95% CI 0.67 to 0.94, I(2) = 52%). After adjustment for heterogeneity this statistically significance disappeared (random effects HR 0.82, 95% CI 0.63 to 1.08). Toxicity and patients lost to follow up were significantly higher in the IFN groups.

AUTHORS' CONCLUSIONS

There is evidence that addition of IFN as maintenance therapy for FL improves progression-free survival. A net benefit for overall survival is less evident. In the included studies, IFN was associated with significant toxicities that may have a major impact on a patient's quality of life.

Medical costs associated with non-Hodgkin's lymphoma in the United States during the first two years of treatment

OBJECTIVES

To determine the direct costs of medical care associated with aggressive and indolent non-Hodgkin's lymphoma (NHL) in the United States; to show how costs for aggressive NHL change over time by examining costs related to initial, secondary and palliative treatment phases; and to evaluate the economic consequences of treatment failure in aggressive NHL.

PATIENTS AND METHODS

A retrospective cohort analysis of 1999 - 2000 direct costs in newly diagnosed NHL patients and controls (subjects without any cancer) was conducted using the MarketScan medical and drug claims database of large employers across the United States. Treatment failure analysis was conducted for aggressive NHL patients, and was defined by the need for secondary treatment or palliative care after initial therapy. Cost of treatment failure was calculated as difference in regression-adjusted costs between patients with initial therapy only and patients experiencing initial treatment failure.

RESULTS

Patients with aggressive (n = 356) and indolent (n = 698) NHL had significantly greater health service utilization and associated costs (all P < 05) than controls (n = 1068 for aggressive, n = 2094 for indolent). Mean monthly costs were 5871 dollars for aggressive NHL vs. 355 dollars for controls (P < 0001) and 3833 dollars for indolent NHL vs. 289 dollars for controls (P < 0001). The primary cost drivers were hospitalization (aggressive NHL = 44% of total costs, indolent NHL = 50%) and outpatient office visits (aggressive NHL = 39%, indolent NHL = 34%). For aggressive NHL, mean monthly initial treatment phase costs (10,970 dollars) and palliative care costs (9836 dollars) were higher than costs incurred during secondary phase (3302 dollars). The mean cost of treatment failure in aggressive NHL was 14,174 dollars per month, and 85,934 dollars over the study period.

CONCLUSION

The treatment of NHL was associated with substantial health care costs. Patients with aggressive lymphomas tended to accrue higher costs, compared with those with indolent lymphomas. These costs varied over time, with the highest costs occurring during the initial treatment and palliative care phases. Treatment failure was the most expensive treatment pattern. New strategies to prevent or delay treatment failure in aggressive NHL could help reduce the economic burden of NHL.

Economic burden of follicular non-Hodgkin's lymphoma

Follicular non-Hodgkin's lymphoma (FNHL), a slow-growing cancer of the immune system, constitutes about 15-30% of all incident non-Hodgkin's lymphoma in developed countries. Its incidence is rising worldwide. Patients can live many years, but FNHL is considered incurable. We systematically reviewed the English-language MEDLINE-indexed and non-indexed economic literature published in the past 10 years on FNHL, identifying 23 primary economic studies. The economic burden of FNHL is significant, but available data are generally limited to retrospective considerations of hospital-based direct treatment costs, with little information available regarding societal cost of illness. Most direct cost information originates from the US, with one estimate of $US36 000 for the per-patient incremental cost of FNHL care during the first year following diagnosis. The most studied treatment is rituximab, which may offer similar overall costs to fludarabine considering higher resource use with fludarabine complications. Nearly all cost-effectiveness models identified by this review evaluated rituximab for relapsed/refractory FNHL responding to chemotherapy induction. Rituximab is supported as a cost-effective addition to standard chemotherapy by two models in the UK and one in the US, as maintenance therapy instead of stem-cell transplant by one UK model, and as maintenance therapy instead of observation alone by one model each in France, Spain and Canada. The UK National Institute for Health and Clinical Excellence updated guidance on rituximab in February 2008, concluding that it is cost effective when added to induction chemotherapy, and when used as maintenance therapy. No studies of per-patient or national indirect costs of illness were identified, with the only study of indirect costs a Canadian survey documenting lost work productivity. Across all study types identified by our review, the most common focus was on the direct costs of rituximab. As new treatments for FNHL come to market, more real-life cost data are imperative to calculate their relative cost effectiveness.

Oral cyclophosphamide for active scleroderma lung disease: a decision analysis

BACKGROUND

Results from the recent Scleroderma Lung Study (SLS) show that oral cyclophosphamide (CYC) is better than placebo in preventing the progression of scleroderma-related interstitial lung disease (SSc-ILD) at 12 mo but is associated with adverse events. Also, the long-term balance of risk and benefit remains unclear.

METHODS

The authors evaluate the risk-benefit tradeoffs using a Markov decision analytic model to project the quality-adjusted life years (QALYs) for strategies of CYC versus no CYC in SSc-ILD. The base case examined a 50-y-old woman with SSc of 1.5 y, SSc-ILD with moderate ventilatory restriction. The authors analyze the decision to treat with 1 y of daily CYC versus no SSc-ILD-specific therapy. Based on 2-y data from the SLS, the authors assume CYC resulted in no survival benefit and only a transient beneficial impact on pulmonary function. They explore the impact of changes in model parameters through sensitivity analyses, including the efficacy of CYC in preventing progression of lung disease and SSc-ILD- related death. Results. In the base-case analysis, CYC-treated patients fared worse, with a small loss of 0.21 QALYs (16.84 v. 17.15). CYC remained inferior across sensitivity analyses for most variables. In analyses assuming a survival benefit with CYC, CYC resulted in a clinically significant gain (18.17 v. 17.15 QALYs).

CONCLUSIONS

CYC therapy for 1 y results in a small loss in QALYs compared with no CYC for SSc-ILD. The lack of a beneficial impact on survival and the transience of CYC's impact on decline in pulmonary function drive this conclusion.

Analyzing oncology clinical trial data using the Q-TWiST method: clinical importance and sources for health state preference data

PURPOSE

The Quality-adjusted Time Without Symptoms of disease and Toxicity (Q-TWiST) analysis method is frequently applied to evaluating outcomes in cancer clinical trials, but there is little information on what constitutes a clinically important difference (CID). We reviewed the Q-TWiST, health-related quality of life (HRQL) and utility measurement literature to develop recommendations for CID for the Q-TWiST. We also provide recommendations for measuring health utilities and for the design of Q-TWiST studies.

METHODS

The English language literature was searched between 1986 and 2003 for Q-TWiST studies in oncology. We estimated the percent differences between treatments based on median follow-up duration for overall, progression-free and quality-adjusted survival. We also reviewed the relevant HRQL and utility literature on clinical importance.

RESULTS

The overall differences between treatments for most (56%) of the observed, published values for Q-TWiST analyses ranged between 12% and 19%. Three-fourths of the Q-TWiST studies had gains in survival of 12%-17%, while differences in progression-free survival ranged from 12% to 26%. Studies that have evaluated the clinical importance of changes in HRQL scores suggest that changes of 5%-10% are clinically meaningful, and other research suggests that 0.5 standard deviation is a reasonable threshold for changes in HRQL for chronic diseases. Similarly, one guideline from the health state utility literature is that a 5%-10% difference in standard gamble utility scores is clinically important. Various sources are available for health utilities for Q-TWiST studies and the most valid are derived from patients or the general public, although most studies rely on sensitivity analyses with no collection of utilities.

CONCLUSIONS

We recommend that the CID for Q-TWiST is 10% of overall survival in a study, and differences of 15% are clearly clinically important. If less is known about a specific treatment and/or disease area, the CID should be greater than 5% but not more than 10% in planning sample size and statistical power. These CID estimates should be interpreted with caution, pending confirmation in future studies by direct patient assessment of the clinically relevant health states for Q-TWiST.

Economic assessment in the management of non-Hodgkin’s lymphoma

An increasing need for economic evaluations of non-Hodgkin's lymphoma (NHL) treatments exists. We performed a literature review on the currently available NHL economic evaluations, using PubMed and the Cochrane database. English and Dutch language papers on treatment in adults were selected. A total of 88 publications were found, 44 of which were included. Of these, 6 economic evaluation-specific methodological items are evaluated (study perspective, overhead costs, data sources, charges or prices, sensitivity analysis, presentations of resource use and unit costs), enabling readers to judge the value of these studies. The 11 subjects covered by the economic evaluations are discussed. Many NHL treatments remain to be studied in economic evaluations. Future publications should report on the six methodological items in more detail, and preferably tackle them in the recommended way.

[Current framework of biotechnology products according to the available pharmacoeconomic studies]

BACKGROUND AND OBJECTIVE

Biotechnologic drugs have a high impact in health system because they contribute in new indications as well as in its high cost. The study's aim is to do a descriptive analysis from the pharmacoeconomic studies. The objective of the study was to establish the standards of efficiency and utility, as well as to know its therapeutic usefulness and rationale.

MATERIAL AND METHOD

The detection and selection of originals has been made through repeated searches in MEDLINE (PubMed) with every one of the different biotechnology products crossing the product name with life, year and saved. In function of the cost for year of life saved (YLS) were defined categories: saving of cost (< 0$/YLS), highly cost-effectiveness (0-20000$/YLS), cost-effectiveness (20001-40000$/YLS), doubtfully cost-effectiveness (40001-60000$/YLS), and no cost-effectiveness (> 60001$/YLS).

RESULTS

There are published figures only in 31% of the total of the searched biotechnological drugs. In 2 clinic conditions the drug reduces the cost, in 33 is highly cost-effectiveness, in 11 is cost-effectiveness, in 4 occasions is doubtfull cost-effectiveness and in 14 is no cost-effectiveness.

CONCLUSIONS

In spite of the high heterogeneity of methodology used in the pharmacoeconomic studies about biotechnological products, in the majority of the clinic situations evaluated we observed a good cost-effectiveness relation in the use of the biotechnological products.