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A comparison of the costs of paclitaxel and best supportive care in stage IV non-small-cell lung cancer |
Earle C C, Evans W K |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Use of single-agent paclitaxel (Taxol-TM) 214 mg/m^2 (3 week schedule and a median of 3 treatment cycles) in the treatment of stage IV non-small-cell lung cancer (NSCLC).
Type of intervention Treatment and supportive care.
Economic study type Cost-effectiveness analysis.
Study population Patients suffering from stage IV non-small-cell lung cancer (NSCLC).
Setting Hospital. The economic study was carried out in Canada.
Dates to which data relate Effectiveness and resource use data were extracted from literature published between 1988 and 1993. The price year was 1993 (inflated to 1995 dollars, but reported in 1993 prices).
Source of effectiveness data Effectiveness data were derived from a review of the literature and from assumptions made by the authors.
Modelling The POpulation HEalth Model (POHEM), developed by Statistics Canada, was used to integrate the effectiveness and cost data to estimate costs and effects associated with each strategy.
Outcomes assessed in the review 1-year survival and median survival duration were reported from published studies and the observed survival curve for BSC was plotted.
Study designs and other criteria for inclusion in the review The review included a 3-armed randomized trial comparing BSC to 2 chemotherapy regimens (the National Cancer Institute of Canada BR 5 study), a phase II trial (the Eastern Cooperative Oncology Group (ECOG)), a second phase II study at the M D Anderson Cancer Center, and Bristol Myers-Squibb survival data of patients on the 2 phase II studies.
Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Not reported. Original/raw data from 2 individual studies on patients treated with paclitaxel were reported.
Number of primary studies included Four studies were included in the review.
Methods of combining primary studies It was reported that the combined data of the ECOG and M D Anderson studies were used to estimate the average survival duration of patients treated with paclitaxel.
Investigation of differences between primary studies The patients' characteristics in 2 individual studies on patients treated with paclitaxel were reported to be comparable.
Results of the review The 1-year survival rate from the ECOG study was reported to be 41.7% and from the M D Anderson Study was 40%. The corresponding values for median survival duration were 24.1 from the ECOG study and 40 weeks from the M D Anderson Study. The observed survival curve for BSC was plotted.
Methods used to derive estimates of effectiveness The authors also made assumptions about effectiveness.
Estimates of effectiveness and key assumptions It was assumed that the baseline survival rate of patients suffering from stage IV disease was equal to the survival rate of patients in the BSC group of the NCIC BR 5 study. Furthermore, it was assumed that the benefit associated with the use of paclitaxel was similar to that of the chemotherapy arm in the NCIC BR 5 study.
Measure of benefits used in the economic analysis The benefit measure was life years saved based on modelled 5-year survival curves.
Direct costs Costs were not discounted since the average duration of survival was less than 1 year. Some quantities were reported separately from the costs. Cost items were reported separately. Cost analysis covered the costs of diagnostic tests, staging tests, hospitalisation, chemotherapy, follow-up, and terminal care. The perspective adopted in the cost analysis was that of the government as payer in a universal health care system. The sources of resource use data were pooled drug administration records for 49 stage IV patients in the ECOG and M D Anderson studies, assumptions made by the authors based on the current practice in the study region, and measurement of time spent by nursing and pharmacy personnel made by the staff of the Ottawa Regional Cancer Center (ORCC). The sources of cost data were different regional and national institutions or NCIC BR study. The date of the price data was 1993 (inflated to 1995 but reported in 1993 values). The costs of complicated admissions were not included since the model calculations were based on uncomplicated paclitaxel administration.
Sensitivity analysis One-way and two-way sensitivity analyses were performed on a number of selected parameters including terminal care hospitalisation, cycles of paclitaxel, and survival gain.
Estimated benefits used in the economic analysis The use of paclitaxel was associated with an extra survival of 7.9 months on average compared to BSC.
Cost results The total costs for BSC were Can$28,617 versus Can$31,992 for the paclitaxel, treatment.
Synthesis of costs and benefits The cost per life-year saved was calculated as the measure of cost-effectiveness analysis, yielding a value of Can$4,778 per life-year saved. The sensitivity analyses had a range of values for cost-effectiveness ratio from Can$6,420 to Can$21,377.
Authors' conclusions If large phase III trials confirm the survival benefits observed in the phase II trials, paclitaxel can be considered to be a cost-effective agent in the management of advanced NSCLC.
CRD COMMENTARY - Selection of comparators A justification was given for the choice of the comparator (BSC). It represented the current practice for the majority of patients with stage IV disease. You, as a database user, should consider whether this is a widely used health technology in your own setting.
Validity of estimate of measure of benefit The internal validity of the estimates of benefit cannot be reasonably guaranteed due to lack of evidence of a systematic literature review and quality assessment of the primary studies included in the review, and the lack of randomised trials comparing paclitaxel with BSC in the literature (as acknowledged by the authors). The authors did not fully explain their choice of sources of effectiveness or whether other studies were relevant/available in the literature. The authors acknowledged that the study could have been performed in a cost-utility framework to incorporate the impacts of paclitaxel's toxic effects on patients' quality of life.
Validity of estimate of costs Some quantities were reported separately from the costs. Adequate details of methods of cost estimation were given. However, the cost results may not be generalisable to other settings or countries.
Other issues Given the limitations of the effectiveness analysis, the authors did take account of variability in their data by performing sensitivity analyses. The issue of generalisability to other settings or countries was not addressed but appropriate comparisons were made with other studies.
Implications of the study It was reported that docetaxel (with similar acquisition costs and shorter infusion period) and gemcitabine, two new drugs for stage IV NSCLC, are expected to be at least as cost-effective as paclitaxel. This report is a first step toward a comprehensive cost-effectiveness study that will compare paclitaxel (with or without cisplatin) with other chemotherapy regimens, such as vinorelbine and cisplatin.
Source of funding Grant from Bristol-Myers Squibb to the Ottawa Regional Cancer Centre.
Bibliographic details Earle C C, Evans W K. A comparison of the costs of paclitaxel and best supportive care in stage IV non-small-cell lung cancer. Cancer Prevention and Control 1997; 1(4): 282-288 Other publications of related interest Comment in: Cancer Prevention & Control 1997;1(4):277,279.
Comment in: Cancer Prevention & Control 1998;2(4):191-2.
Indexing Status Subject indexing assigned by NLM MeSH Antineoplastic Agents, Phytogenic /therapeutic use; Carcinoma, Non-Small-Cell Lung /drug therapy /pathology; Cost-Benefit Analysis; Health Care Costs; Humans; Lung Neoplasms /drug therapy /pathology; Neoplasm Staging; Paclitaxel /therapeutic use AccessionNumber 21998006965 Date bibliographic record published 31/08/2000 Date abstract record published 31/08/2000 |
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