Things We Don't Like to Know: The High Cost of New Cancer Treatment
Things We Don't Like to Know: The High Cost of New Cancer Treatment
Abstract & commentary
By William B. Ershler, MD
Synopsis: Median survival for patients with metastatic colorectal cancer has nearly doubled over the past 15 years with the introduction of several new drugs, including monoclonal antibodies. The increments in survival, however, have been relatively modest when placed in the context of the costs of therapy. Using a Markhov model on a hypothetical cohort of 1,000 patients, the incremental cost-effectiveness ratio per documented life-year was greater than $170,000, well beyond the usual standards for cost effectiveness.
Source: Wong Y-N, et al. Cost implications of new treatments for advanced colorectal cancer. Cancer. 2009;115: 2081-2091.
Although new and increasingly effective treatments for metastatic colorectal cancer have been introduced, the disease remains incurable in the majority of cases. Since 1996, several new drugs have been approved; irinotecan (1996), oxaliplatin (2000), cetuximab (2004), bevacizumab (2004), and panitumumab (2006), and median survival has increased two-fold when compared with 5-FU alone. With the exception of 5-FU and irinotecan (which recently came off patent), these drugs are very expensive, and the cost implications of these promising medications are the subject of significant debate.1,2 There are limited data in the published literature regarding the cost-effectiveness of treatments for patients with metastatic colorectal cancer. Hillner et al used data from the multicenter North Central Cancer Treatment Group (NCCTG) study 9741 to compare treatment with IFL vs. treatment with FOLFOX, and observed that the 4.4-month median survival benefit of the FOLFOX arm was accompanied by an incremental cost of $29,953, resulting in an incremental cost-effectiveness ratio (ICER) of $80,410 per life-year gained.3 Starling et al examined the role of cetuximab and irinotecan compared with best supportive care from the perspective of the United Kingdom National Health Service, and reported an ICER of £42,975 per life-year gained.4 To provide a comprehensive cost-effectiveness analysis that included multiple lines of therapy, Wong et al at the Fox Chase Cancer Center undertook a study to determine the cost implications of treatment with sequential regimens that included chemotherapy and/or monoclonal antibodies.
A Markhov model was used to evaluate a hypothetical cohort of 1,000 patients with newly diagnosed, metastatic colorectal cancer. Patients supposedly received up to three lines of treatment before supportive care and subsequent death. Data were obtained from published, multicenter phase II and randomized phase III clinical trials. Sensitivity analyses were conducted on the efficacy, toxicity, and cost.
Using drug costs alone, treatment that included new chemotherapeutic agents increased survival at an ICER of $100,000 per discounted life-year (DLY). The addition of monoclonal antibodies improved survival at an ICER of > $170,000 per DLY. The results were most sensitive to changes in the initial regimen. Even with significant improvements in clinical characteristics (efficacy and toxicity), treatment with the most effective regimens still had very high ICERs.
Commentary
Thus, although survival increases with the sequential use of newly approved therapies, the increments in survival are relatively small, and the costs are very high. In fact, the cost exceeds commonly accepted cost-effectiveness thresholds.5 Furthermore, these results are similar to an analysis of salvage chemotherapy in platinum-refractory ovarian cancer, in which second-line monotherapy reportedly came at an ICER of $57,000/DLY, but the benefits of second-line doublet therapy and third-line monotherapy came at unacceptably high incremental cost.6
Thus, in this analysis, the treatment of metastatic colorectal cancer with the most effective regimens came at very high incremental costs. Wong et al concluded that cost-effectiveness analyses should be a routine component of the drug development process, so that physicians and patients are informed appropriately regarding the value of new innovations.
The findings present a number of ethical dilemmas, particularly for the practicing oncologist who, aware of findings such as these, might find him or herself in an uncomfortable position of making decisions based not upon what is best for the patient, but on economic factors and overall societal costs. Understanding that these are important concerns, additional considerations must be undertaken to determine just how data such as these are to be used. In the current economic environment, and at a time when the government is exploring forms of national insurance, policies regarding the use of new drugs must include both demonstrated efficacy and reasonable cost-effectiveness.
References
1. Meropol NJ, Schulman KA. Cost of cancer care: issues and implications. J Clin Oncol. 2007;25:180-186.
2. Schrag D. The price tag on progress chemotherapy for colorectal cancer. N Engl J Med. 2004;351:317-319.
3. Hillner BE, et al. Cost-effectiveness projections of oxaliplatin and infusional fluorouracil versus irinotecan and bolus fluorouracil in first-line therapy for metastatic colorectal carcinoma. Cancer. 2005;104:1871-1884.
4. Starling N, et al. Cost-effectiveness analysis of cetuximab/irinotecan vs. active/best supportive care for the treatment of metastatic colorectal cancer patients who have failed previous chemotherapy treatment. Br J Cancer. 2007;96:206-212.
5. Zimmermann C, et al. Effectiveness of specialized palliative care: a systematic review. JAMA. 2008;299: 1698-1709.
6. Rocconi RP, et al. Role of chemotherapy for patients with recurrent platinum-resistant advanced epithelial ovarian cancer: A cost-effectiveness analysis. Cancer. 2006;107:536-543.
Median survival for patients with metastatic colorectal cancer has nearly doubled over the past 15 years with the introduction of several new drugs, including monoclonal antibodies. The increments in survival, however, have been relatively modest when placed in the context of the costs of therapy. Using a Markhov model on a hypothetical cohort of 1,000 patients, the incremental cost-effectiveness ratio per documented life-year was greater than $170,000, well beyond the usual standards for cost effectiveness.Subscribe Now for Access
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