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Raphael MJ, Raskin W, Habbous S, Tai X, Beca J, Dai WF, Arias J, Forbes L, Gavura S, Biagi JJ, Earle CC, Chan KKW. The Association of Drug-Funding Reimbursement With Survival Outcomes and Use of New Systemic Therapies Among Patients With Advanced Pancreatic Cancer. JAMA Netw Open 2021; 4:e2133388. [PMID: 34779846 PMCID: PMC8593760 DOI: 10.1001/jamanetworkopen.2021.33388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 09/10/2021] [Indexed: 12/29/2022] Open
Abstract
Importance Gemcitabine-nab-paclitaxel (GEMNAB) and fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) both improve survival of patients with advanced pancreatic cancer when compared with single-agent gemcitabine in clinical trials. Objective To describe changes in the survival of patients with advanced pancreatic cancer associated with sequential drug-funding approvals and to determine if there exist distinct patient populations for whom GEMNAB and FOLFIRINOX are associated with survival benefit. Design, Setting, and Participants This population-based, retrospective cohort study examined all incident cases of advanced pancreatic cancer treated with first-line chemotherapy in Ontario, Canada (2008-2018) that were identified from the Cancer Care Ontario (Ontario Health) New Drug Funding Program database. Statistical analysis was performed from October 2020 to January 2021. Exposures First-line chemotherapy for advanced pancreatic cancer. Main Outcomes and Measures The main outcomes were the proportion of patients treated with each chemotherapy regimen over time and overall survival for each regimen. Cox proportional hazards regression models were used to compare overall survival between treatment regimens after adjustment for confounding variables, inverse probability of treatment weighting, and matching. Results From 2008 to 2018, 5465 patients with advanced pancreatic cancer were treated with first-line chemotherapy in Ontario, Canada. The median (range) age of patients was 66.9 (27.8-93.4) years; 2447 (45%) were female; 878 (16%) had prior pancreatic resection, and 328 (6%) had prior adjuvant gemcitabine. During the time period when only gemcitabine and FOLFIRINOX were funded (2011-2015), 49% (929 of 1887) received FOLFIRINOX. When GEMNAB was subsequently funded (2015-2018), 9% (206 of 2347) received gemcitabine, 44% (1034 of 2347) received FOLFIRINOX, and 47% (1107 of 2347) received GEMNAB. The median overall survival increased from 5.6 months (95% CI, 5.1-6.0 months) in 2008 to 2011 to 6.9 months (95% CI, 6.5-7.4 months) in 2011 to 2015 to 7.6 months (95% CI, 7.1-8.0 months) in 2015 to 2018. Patients receiving FOLFIRINOX were younger and healthier than patients receiving GEMNAB. After adjustment and weighting, FOLFIRINOX was associated with better overall survival than GEMNAB (hazard ratio [HR], 0.75 [95% CI, 0.69-0.81]). In analyses comparing patients treated with GEMNAB and gemcitabine, GEMNAB was associated with better overall survival (HR, 0.86 [95% CI, 0.78-0.94]). Conclusions and Relevance This cohort study of patients with advanced pancreatic cancer receiving first-line palliative chemotherapy within a universal health care system found that drug funding decisions were associated with increased uptake of new treatment options over time and improved survival. Both FOLFIRINOX and GEMNAB were associated with survival benefits in distinct patient populations.
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Affiliation(s)
- Michael J. Raphael
- Division of Medical Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - William Raskin
- Department of Oncology, William Osler Health System, Brampton, Ontario, Canada
| | - Steven Habbous
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Xiaochen Tai
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Jaclyn Beca
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Wei F. Dai
- Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Jessica Arias
- Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Leta Forbes
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Scott Gavura
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - James J. Biagi
- Department of Oncology, Queen’s University, Kingston, Ontario, Canada
| | - Craig C. Earle
- Division of Medical Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Kelvin K. W. Chan
- Division of Medical Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
- Provincial Drug Reimbursement Program, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
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Kharat AA, Nelson R, Au T, Biskupiak J. Cost-effectiveness analysis of FOLFIRINOX vs gemcitabine with nab-paclitaxel as adjuvant treatment for resected pancreatic cancer in the United States based on PRODIGE-24 and APACT trials. J Manag Care Spec Pharm 2021; 27:1367-1375. [PMID: 34595948 PMCID: PMC10391115 DOI: 10.18553/jmcp.2021.27.10.1367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Pancreatic cancer is associated with low median overall survival. Combination chemotherapy regimens FOLFIRINOX and gemcitabine with nab-paclitaxel (GemNab) are the new adjuvant treatment standards for resectable pancreatic cancer. PRODIGE-24 and APACT trials demonstrated superior clinical outcomes with FOLFIRINOX and GemNab, each vs gemcitabine monotherapy. OBJECTIVE: To evaluate the cost-effectiveness of FOLFIRINOX vs GemNab for resectable pancreatic cancer in adults from the U.S. payer perspective, in order to inform decision makers about which of these treatments is optimal. METHODS: A Markov model with 3 disease states (relapse free, progressive disease, and death) was developed. Cycle length was 1 month, and time horizon was 10 years. Transition probabilities were derived from PRODIGE-24 and APACT survival data. All cost and utility input parameters were obtained from published literature. Cost-effectiveness analysis was performed to obtain total costs, quality-adjusted life-years (QALYs), life-years (LYs), and incremental cost-effectiveness ratio (ICER). A 3% annual discount rate was applied to costs and outcomes. The effect of uncertainty on model parameters was assessed with 1-way and probabilistic sensitivity analysis (PSA). RESULTS: Our analysis estimated that the cost for FOLFIRINOX was $40,831 higher than GemNab ($99,669 vs. $58,837). Despite increased toxicity, FOLFIRINOX was associated with additional 0.18 QALYs and 0.25 LYs compared with GemNab (QALY: 1.65 vs. 1.47; LY: 2.09 vs. 1.84). The ICER for FOLFIRINOX vs GemNab was $226,841 per QALY and $163,325 per LY. FOLFIRINOX was not cost-effective at a willingness-to-pay (WTP) threshold of $200,000 per QALY, and this was confirmed by the PSA. CONCLUSIONS: Total monthly cost for FOLFIRINOX was approximately 1.7 times higher than GemNab. If the WTP threshold increases to or above $250,000 per QALY, FOLFIRINOX then becomes a cost-effective treatment option. DISCLOSURES: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to declare.
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Affiliation(s)
- Aditi A Kharat
- Department of Pharmacotherapy, University of Utah, Salt Lake City
| | - Richard Nelson
- Department of Pharmacotherapy, University of Utah, Salt Lake City
| | - Trang Au
- Department of Pharmacotherapy, University of Utah, Salt Lake City
| | - Joseph Biskupiak
- Department of Pharmacotherapy, University of Utah, Salt Lake City
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Bullock A, Rowan CG, Oestreicher N, Yeganegi H, Chiorean EG. Real-World Assessment of Health Care Costs for Patients with Metastatic Pancreatic Cancer Following Initiation of First-Line Chemotherapy. J Manag Care Spec Pharm 2020; 26:872-878. [PMID: 32584677 PMCID: PMC10391015 DOI: 10.18553/jmcp.2020.26.7.872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Management of metastatic pancreatic ductal adenocarcinoma (mPDA) places a significant financial burden on the U.S. health care system because of such factors as treatment with multidrug chemotherapy regimens, management of chemotherapy-related adverse events, and disease- or treatment-related hospitalizations. Depending on functional status, first-line chemotherapy regimens that are guideline recommended include nab-paclitaxel with gemcitabine (AG) and FOLFIRINOX (FFX), the combination of fluorouracil, leucovorin, irinotecan, and oxaliplatin. However, few previous studies have examined overall health care costs associated with mPDA management. OBJECTIVE To describe health care costs following initiation of first-line treatment with AG or FFX among patients with mPDA. METHODS Retrospective cohorts of first-line AG and FFX initiators were constructed from the MarketScan database (2014-2017). The index date was the date of first-line AG or FFX initiation. Included patients had insurance enrollment for 6 months before the index date. Total cumulative health care costs and costs from outpatient services, inpatient admissions, emergency department visits, chemotherapy administrations, and pharmacy dispensing were assessed within 12 months after the index date (i.e., 0-1, 0-2, …, 0-12 months). Patient-level cost data began accruing from the first paid claim and continued accruing until the censoring date. RESULTS A total of 2,199 patients with mPDA initiated first-line AG (n = 1,352) or FFX (n = 847). Compared with AG initiators, FFX patients were younger (mean age 59 vs. 63 years) and had better baseline health status, with fewer having diabetes (43% vs. 57%) or coronary artery disease (12% vs. 22%). Median follow-up was 5.4 and 7.2 months for AG and FFX, respectively. Median first-line treatment duration was 2.1 months with AG and 2.3 months with FFX. Six months following first-line treatment initiation, total cumulative health care costs (median) were $85,714 (95% CI = $79,683-$91,788) and $114,116 (95% CI = $105,816-$119,591) for AG and FFX initiators, respectively. Outpatient services contributed the largest fractional cost for both groups. CONCLUSIONS Total health care costs for patients with mPDA who initiated FFX or AG are driven mostly by outpatient rather than inpatient costs. Further research, using comparative methodology, is warranted to fully understand cost drivers and whether higher costs for FFX patients relate primarily to use of FFX or higher underlying use of outpatient care among FFX patients. DISCLOSURES This study was funded by Halozyme Therapeutics. Oestreicher and Yeganegi were employees of Halozyme Therapeutics at the time of the study and were involved in study design, data interpretation, and the decision to submit the data for publication. Bullock reports advisory board fees from Eisai, Exelixis, Bayer, and Taiho and consulting fees from Halozyme Therapeutics, outside the submitted work. Rowan reports consulting fees from Halozyme Therapeutics, during the conduct of the study. Chiorean reports grants and consulting fees from Celgene and Halozyme Therapeutics; grants from Lilly, Stemline, Ignyta, Roche, Merck, Boehringer-Ingelheim, Bristol Meyer Squibb, Incyte, Macrogenics, Rafael, and AADi; and consulting fees from Astra Zeneca, Array, Eisai, Ipsen, Five Prime Therapeutics, Seattle Genetics, Vicus, and Legend, outside the submitted work.
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Affiliation(s)
- Andrea Bullock
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - E. Gabriela Chiorean
- Department of Medicine, University of Washington School of Medicine, Seattle, and Fred Hutchinson Cancer Research Center, Seattle, Washington
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Soefje SA. Managing the economic impact of advanced pancreatic cancer. Am J Manag Care 2019; 25:S11-S16. [PMID: 30681820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Pancreatic cancer is typically diagnosed in the late stage of the disease, making it the fourth leading cause of cancer-related death in the United States. It is also one of the few cancers with an increasing incidence, particularly in the younger population. By 2030, it is expected to become the second leading cause of cancer-related death. Patients with pancreatic cancer encounter monthly medical costs 15 times higher than those without, with costs highest in the later stages of the disease. Treatments for pancreatic cancer include surgery (available to fewer than 20% of newly diagnosed patients) and, for advanced disease, chemotherapy with gemcitabine with nab-paclitaxel or FOLFIRINOX, which can increase overall survival (OS) by a few months. Economic and outcome analyses of clinical data find no significant difference in OS between the 2 regimens, although FOLFIRINOX carries a much higher rate of serious adverse effects, limiting its use to patients with good performance status. In 2017, the FDA approved immunotherapy for patients with microsatellite instability-high or mismatch repair-deficient solid tumors, which occurs in approximately 1% of pancreatic cancer diagnoses. Several immunotherapies and targeted therapies are currently in clinical trials and may significantly alter the trajectory of the disease. However, they typically cost more than $100,000 per year, putting significant strain on payers. Thus, it is important that payers plan now for the potential arsenal of new treatments and identify opportunities to manage their utilization as well as patients with the disease to contain costs.
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Affiliation(s)
- Scott A Soefje
- Director, Pharmacy Cancer Center, Department of Pharmacy, Mayo Clinic, Rochester, MN.
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da Silva WC, de Araujo VE, Lima EMEA, dos Santos JBR, Silva MRRD, Almeida PHRF, de Assis Acurcio F, Godman B, Kurdi A, Cherchiglia ML, Andrade EIG. Comparative Effectiveness and Safety of Monoclonal Antibodies (Bevacizumab, Cetuximab, and Panitumumab) in Combination with Chemotherapy for Metastatic Colorectal Cancer: A Systematic Review and Meta-Analysis. BioDrugs 2018; 32:585-606. [PMID: 30499082 PMCID: PMC6290722 DOI: 10.1007/s40259-018-0322-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The last decade has seen the increasing use of biological medicines in combination with chemotherapy containing 5-fluorouracil/oxaliplatin or irinotecan for the treatment of metastatic colorectal cancer (mCRC). These combinations have resulted in increased progression-free survival (PFS) in patients with mCRC; however, there are remaining concerns over the extent of their effect on overall survival (OS). Published studies to date suggest no major differences between the three currently available monoclonal antibodies (MoAbs); however, there are differences in costs. In addition, there is rising litigation in Brazil in order to access these medicines as they are currently not reimbursed. OBJECTIVE The aim was to investigate the comparative effectiveness and safety of three MoAbs (bevacizumab, cetuximab and panitumumab) associated with fluoropyrimidine-based chemotherapy regimens and compared to fluoropyrimidine-based chemotherapy alone in patients with mCRC, through an updated systematic review and meta-analysis of concurrent or non-concurrent observational cohort studies, to guide authorities and the judiciary. METHOD A systematic review and meta-analysis was performed based on cohort studies published in databases up to November 2017. Effectiveness measures included OS, PFS, post-progression survival (PPS), Response Evaluation Criteria In Solid Tumors (RECIST), response rate, metastasectomy and safety. The methodological quality of the studies was also evaluated. RESULTS A total of 21 observational cohort studies were included. There were statistically significant and clinically relevant benefits in patients treated with bevacizumab versus no bevacizumab mainly around OS, PFS, PPS and the metastasectomy rate, but not for the disease control rates. However, there was an increase in treatment-related toxicities and concerns with the heterogeneity of the studies. CONCLUSION The results pointed to an advantage in favor of bevacizumab for OS, PFS, PPS, and metastasectomy. Although this advantage may be considered clinically modest, bevacizumab represents a hope for increased survival and a chance of metastasectomy for patients with mCRC. However, there are serious adverse events associated with its use, especially severe hypertension and gastrointestinal perforation, that need to be considered.
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Affiliation(s)
- Wânia Cristina da Silva
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vânia Eloisa de Araujo
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- School of Dentistry, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Jessica Barreto Ribeiro dos Santos
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Michael Ruberson Ribeiro da Silva
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Francisco de Assis Acurcio
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Postgraduate Program in Public Health, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Health Economics Centre, University of Liverpool Management School, Liverpool, UK
- School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Mariângela Leal Cherchiglia
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Postgraduate Program in Public Health, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Eli Iola Gurgel Andrade
- Postgraduate Program in Medicines and Pharmaceutical Services, School of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Postgraduate Program in Public Health, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
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Gharaibeh M, McBride A, Alberts DS, Erstad B, Slack M, Alsaid N, Bootman JL, Abraham I. Economic Evaluation for the UK of Systemic Chemotherapies as First-Line Treatment of Metastatic Pancreatic Cancer. Pharmacoeconomics 2018; 36:1333-1343. [PMID: 29981004 DOI: 10.1007/s40273-018-0684-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Gemcitabine (GEM), oxaliplatin plus GEM (OX + GEM), cisplatin plus GEM (CIS + GEM), capecitabine plus GEM (CAP + GEM), FOLFIRINOX (FFX), and nab-paclitaxel plus GEM (NAB-P + GEM) are the most commonly used regimens as first-line treatment of metastatic pancreatic cancer (MPC) in the UK. Independent economic evaluation of these regimens simultaneously has not been conducted for the UK. OBJECTIVE Using data from a network meta-analysis as efficacy measures, we estimated the cost effectiveness and cost utility of these regimens for the UK. METHODS A three-state Markov model (progression-free, progressed-disease, and death) simulating the total costs and health outcomes (quality-adjusted life-years [QALYs] gained and life-years [LYs]) was developed to estimate the incremental cost-utility (ICUR) and incremental cost-effectiveness ratios (ICER) for patients with MPC, from the payer perspective. The model was specified to calculate total costs in 2017 British pounds (GBP, £). All values were discounted at 3.5% per year over a full lifetime horizon. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the impact of parameter uncertainty on the results. RESULTS FFX was the most effective regimen, NAB-P + GEM was the most costly regimen, and GEM was the least costly and least effective regimen. OX + GEM, CIS + GEM, and NAB-P + GEM were dominated by CAP + GEM and FFX. Compared with GEM, the ICUR for CAP + GEM and FFX was £28,066 and £33,020/QALY gained, respectively; compared with GEM, the ICER for CAP + GEM and FFX was £17,437 and £22,291/LY gained, respectively; and compared with CAP + GEM, the ICUR and ICER for FFX were £34,947/QALY gained and 24,414/LY gained, respectively. CONCLUSIONS At a threshold value of £30,000/QALY, CAP + GEM was found to be the only cost-effective regimen in the management of MPC in the UK.
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Affiliation(s)
- Mahdi Gharaibeh
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Ali McBride
- University of Arizona Cancer Center, Tucson, AZ, USA
- Banner University Medical Center-Tucson, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Drachman Hall B-306, 1295 N. Martin Ave, Tucson, AZ, 85721, USA
| | | | - Brian Erstad
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Drachman Hall B-306, 1295 N. Martin Ave, Tucson, AZ, 85721, USA
| | - Marion Slack
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Drachman Hall B-306, 1295 N. Martin Ave, Tucson, AZ, 85721, USA
| | - Nimer Alsaid
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Drachman Hall B-306, 1295 N. Martin Ave, Tucson, AZ, 85721, USA
| | - J Lyle Bootman
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Drachman Hall B-306, 1295 N. Martin Ave, Tucson, AZ, 85721, USA
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA.
- University of Arizona Cancer Center, Tucson, AZ, USA.
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Drachman Hall B-306, 1295 N. Martin Ave, Tucson, AZ, 85721, USA.
- Department of Family and Community Medicine, College of Medicine-Tucson, University of Arizona, Tucson, AZ, USA.
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Stainthorpe A, Greenhalgh J, Bagust A, Richardson M, Boland A, Beale S, Duarte R, Kotas E, Banks L, Palmer D. Paclitaxel as Albumin-Bound Nanoparticles with Gemcitabine for Untreated Metastatic Pancreatic Cancer: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. Pharmacoeconomics 2018; 36:1153-1163. [PMID: 29600384 PMCID: PMC6132498 DOI: 10.1007/s40273-018-0646-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
As part of the single technology appraisal (STA) process, the National Institute for Health and Care Excellence (NICE) invited Celgene Ltd to submit clinical and cost-effectiveness evidence for paclitaxel as albumin-bound nanoparticles (Nab-Pac) in combination with gemcitabine (Nab-Pac + Gem) for patients with untreated metastatic pancreatic cancer. The STA was a review of NICE's 2015 guidance (TA360) in which Nab-Pac + Gem was not recommended for patients with untreated metastatic pancreatic cancer. The review was prompted by a proposed Patient Access Scheme (PAS) discount on the price of Nab-Pac and new evidence that might lead to a change in the guidance. The Liverpool Reviews and Implementation Group at the University of Liverpool was the Evidence Review Group (ERG). This article summarises the ERG's review of the company's evidence submission for Nab-Pac + Gem, and the Appraisal Committee (AC) decision. The final scope issued by NICE listed three comparators: gemcitabine monotherapy (Gem), gemcitabine in combination with capecitabine (Gem + Cap), and a combination of oxaliplatin, irinotecan, leucovorin and fluorouracil (FOLFIRINOX). Clinical evidence for the comparison of Nab-Pac + Gem versus Gem was from the phase III CA046 randomized controlled trial. Analysis of progression-free survival (PFS) and overall survival (OS) showed statistically significant improvement for patients treated with Nab-Pac + Gem versus Gem. Clinical evidence for the comparison of Nab-Pac + Gem versus FOLFIRINOX and versus Gem + Cap was derived from a network meta-analysis (NMA). Results of the NMA did not indicate a statistically significant difference in OS or PFS for the comparison of Nab-Pac + Gem versus either Gem + Cap or FOLFIRINOX. The ERG's main concerns with the clinical effectiveness evidence were difficulties in identifying the patient population for whom treatment with Nab-Pac + Gem is most appropriate, and violation of the proportional hazards (PH) assumption in the CA046 trial. The ERG highlighted methodological issues in the cost-effectiveness analysis pertaining to the modelling of survival outcomes, estimation of drug costs and double counting of adverse-event disutilities. The AC accepted all the ERG's amendments to the company's cost-effectiveness model; however, these did not make important differences to the incremental cost-effectiveness ratios (ICERs). The company's base-case ICER was £46,932 per quality-adjusted life-year (QALY) gained for the comparison of Nab-Pac + Gem versus Gem. Treatment with Nab-Pac + Gem was dominated both by treatment with Gem + Cap and with FOLFIRINOX in the company's base case. The AC concluded that the most plausible ICER for treatment with Nab-Pac + Gem versus Gem was in the range of £41,000-£46,000 per QALY gained. The AC concluded that Nab-Pac + Gem was not cost effective compared with Gem + Cap or FOLFIRINOX, and accepted that treatment with Nab-Pac + Gem met the end-of-life criteria versus Gem but did not consider Nab-Pac + Gem to meet the end-of-life criteria compared with Gem + Cap or FOLFIRINOX. The AC also concluded that although patients who would receive Nab-Pac + Gem rather than FOLFIRINOX or Gem + Cap were difficult to distinguish, they were identifiable in clinical practice. The AC recommended treatment with Nab-Pac + Gem for patients with untreated metastatic pancreatic cancer for whom other combination chemotherapies were unsuitable and who would otherwise receive Gem.
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Affiliation(s)
- Angela Stainthorpe
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK.
| | - Janette Greenhalgh
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
| | - Adrian Bagust
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
| | - Marty Richardson
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
| | - Angela Boland
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
| | - Sophie Beale
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
| | - Eleanor Kotas
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
| | - Lindsay Banks
- North West Medicines Information Centre, Liverpool, L69 3GF, UK
| | - Daniel Palmer
- Liverpool Reviews and Implementation Group, University of Liverpool, Whelan Building, Brownlow Hill, Liverpool, L69 3GB, UK
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Fleeman N, Abdulla A, Bagust A, Beale S, Richardson M, Stainthorpe A, Boland A, Kotas E, McEntee J, Palmer D. Pegylated Liposomal Irinotecan Hydrochloride Trihydrate for Treating Pancreatic Cancer After Gemcitabine: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. Pharmacoeconomics 2018; 36:289-299. [PMID: 29178025 DOI: 10.1007/s40273-017-0592-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The National Institute for Health and Care Excellence (NICE) invited the manufacturer (Shire Pharmaceuticals) of pegylated liposomal irinotecan hydrochloride trihydrate (liposomal irinotecan) to submit clinical and cost-effectiveness evidence for its use in combination with 5-fluorouracil (5-FU) and folic acid/leucovorin (LV) for treating patients with pancreatic cancer following prior treatment with gemcitabine as part of the institute's Single Technology Appraisal process. The Liverpool Reviews and Implementation Group at the University of Liverpool was commissioned to act as the Evidence Review Group (ERG). This article presents a summary of the company's evidence, the ERG review and the resulting NICE guidance (TA440), issued on 26 April 2017. Clinical evidence for liposomal irinotecan + 5-FU/LV versus 5-FU/LV was derived from 236 patients with metastatic pancreatic cancer in the multinational, open-label, randomised controlled NAPOLI-1 trial. Results from analyses of progression-free survival and overall survival showed statistically significant improvements for patients treated with liposomal irinotecan + 5-FU/LV compared with those treated with 5-FU/LV. However, 5-FU/LV alone is rarely used in National Health Service clinical practice for patients with metastatic pancreatic cancer previously treated with gemcitabine. The company, ERG and Appraisal Committee (AC) all agreed that oxaliplatin + 5-FU/LV is the most commonly used treatment. Oxaliplatin + 5-FU/LV was compared with 5-FU/LV in two trials identified by the company. However, the company and the ERG both considered attempts to compare the efficacy of liposomal irinotecan + 5-FU/LV with oxaliplatin + 5-FU/LV to be methodologically flawed; not only was there heterogeneity between trials and their populations but also the proportional hazards assumption required to conduct a robust indirect treatment comparison (ITC) was violated. Nonetheless, data derived from an ITC were used to inform the company's economic model. Using the discounted patient access scheme price for liposomal irinotecan + 5-FU/LV, the company reported an incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained of £54,412 for the comparison with oxaliplatin + 5-FU/LV. The ERG considered that the company's base-case cost-effectiveness results for the comparison of liposomal irinotecan + 5-FU/LV versus oxaliplatin + 5-FU/LV were underestimates and should be interpreted with extreme caution. Following implementation of a number of model amendments, the ERG's modified exploratory ICER for the comparison of liposomal irinotecan + 5-FU/LV versus oxaliplatin + 5-FU/LV was £106,898 per QALY gained. The AC accepted the majority of the ERG's amendments to the model, and also highlighted that the total QALYs for oxaliplatin + 5-FU/LV were lower than for 5-FU/LV in the company's model, which the AC considered to be clinically implausible. The AC therefore considered results from exploratory analyses, undertaken by the ERG, which included altering the QALY difference between liposomal irinotecan + 5-FU/LV and oxaliplatin + 5-FU/LV by ± 10%. These analyses resulted in ICERs for the comparison of liposomal irinotecan + 5-FU/LV versus oxaliplatin + 5-FU/LV of between £201,019 per QALY gained to liposomal irinotecan + 5-FU/LV being dominated by oxaliplatin + 5-FU/LV. Therefore, despite uncertainty around the clinical-effectiveness evidence and cost-effectiveness results, the AC was confident that the ICER was in excess of £50,000 per QALY gained. The final guidance issued by NICE is that liposomal irinotecan + 5-FU/LV is not recommended within its marketing authorisation for treating metastatic adenocarcinoma of the pancreas in adults whose disease has progressed after gemcitabine-based therapy.
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Affiliation(s)
- Nigel Fleeman
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK.
| | - Ahmed Abdulla
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK
| | - Adrian Bagust
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK
| | - Sophie Beale
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK
| | - Marty Richardson
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK
| | - Angela Stainthorpe
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK
| | - Angela Boland
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK
| | - Eleanor Kotas
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, L69 3GB, UK
| | - Joanne McEntee
- North West Medicines Information Centre, Liverpool, L69 3GF, UK
| | - Daniel Palmer
- Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, L69 3BX, UK
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