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Primary prophylaxis with granulocyte colony-stimulating factor (GCSF) reduces the incidence of febrile neutropenia in patients with non-Hodgkin lymphoma (NHL) receiving CHOP chemotherapy treatment without adversely affecting their quality of life: cost-benefit and quality of life analysis |
Lee S, Knox A, Zeng IS, Coomarasamy C, Blacklock H, Issa S |
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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. CRD summary This study evaluated the cost-effectiveness of adding granulocyte-colony stimulating factor (G-CSF) to chemotherapy containing cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP), with or without rituximab, for patients with non-Hodgkin's lymphoma. The authors concluded that G-CSF prophylaxis was effective at preventing febrile neutropenia, and it was cost-effective. The study was generally well conducted, but the small sample, unclear follow-up, retrospective cohort design, and issues in generalising the results, make their validity uncertain. Type of economic evaluation Cost-effectiveness analysis Study objective This study evaluated the cost-effectiveness of adding granulocyte-colony stimulating factor (G-CSF) to chemotherapy containing cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP), with or without rituximab, for patients with non-Hodgkin's lymphoma. Interventions G-CSF prophylaxis was compared with no G-CSF prophylaxis. Location/setting New Zealand/secondary care. Methods Analytical approach:The economic evaluation was based upon the results of one clinical study. The study was conducted between December 2006 and May 2009. The perspective was not explicitly stated. Effectiveness data:The primary effectiveness measure was the incidence of febrile neutropenia with prophylaxis, compared with no prophylaxis. These data were from a retrospective cohort study of 65 consecutive patients in one lymphoma unit. Patients who were diagnosed before December 2007, or received CHOP with rituximab on a 21-day cycle and were under 65 years old, did not receive prophylaxis; all other patients received prophylaxis. Absolute risk reductions, comparing these two treatments, for the incidence of febrile neutropenia, were calculated. Quality of life data were collected from a subset of patients who were receiving prophylaxis, using the Functional Assessment of Cancer Therapy: General questionnaire; changes in this were compared with baseline at two, and six cycles. Other clinical effectiveness measures, such as achieving remission and mortality, were recorded at last follow-up. Monetary benefit and utility valuations:Not relevant. Measure of benefit:The primary measure of benefit was the number of cases of febrile neutropenia avoided. Cost data:The cost data were from the clinical study hospital, and they were the costs of febrile neutropenia. These included hospital admission and secondary prophylaxis after admission. All costs were reported in New Zealand dollars (NZD). Analysis of uncertainty:Differences in the number of episodes of febrile neutropenia between the two cohorts were assessed for statistical significance, for all patients; for the subgroup who received CHOP with rituximab on a 21-day cycle; and for the two subgroups of these patients who were over or under 65 years old. Results Fewer febrile neutropenia episodes occurred in the prophylaxis group; 5% of patients receiving prophylaxis had episodes, while 60% of patients who did not receive it had episodes (p<0.0001). This was a 55% absolute risk reduction (95% CI 34 to 64). The number-needed-to-treat to prevent one episode of febrile neutropenia was 1.8 (95% CI 1.6 to 2.9). The subgroup analyses had similar results. The cost of hospital admission for febrile neutropenia, including secondary prophylaxis, was NZD 9,640. The average cost of primary G-CSF for six cycles of CHOP with rituximab was NZD 5,670. Using the number-needed-to-treat, the cost of preventing one episode of febrile neutropenia was NZD 10,206. The estimated savings from primary prophylaxis, excluding indirect costs, were NZD 238. Authors' conclusions The authors concluded that G-CSF prophylaxis was effective at preventing febrile neutropenia in patients with non-Hodgkin's lymphoma who were receiving CHOP, and it was cost-effective. CRD commentary Interventions:The interventions were only generally described. No details were provided on the drug doses, making it unclear whether the results of this study could be generalised. The proportion of patients who received CHOP with rituximab was also unclear. Effectiveness/benefits:The primary measure of effectiveness was well defined and reported. A secondary measure was quality of life, but this was not compared between groups, as the authors acknowledged. The effects of febrile neutropenia on quality of life were not measured. The effectiveness data were from a retrospective cohort, with different inclusion criteria for the treatment groups. It is not clear what effect this had on the results. Retrospective, observational studies are susceptible to bias, and this study was small. The cohort was from one centre, so it is unclear how generalisable the results would be to other settings. Costs:The costs were reported only as totals, the separate costs of different aspects of treating febrile neutropenia or administering G-CSF were not reported. The price year was not stated. These aspects of the study make it difficult to generalise the results. The costing perspective was not stated, but it appears to have been that of the hospital. Analysis and results:The analysis was generally well conducted, but little was done to address the effects of uncertainty in the sample. Given the small sample, these effects could be significant. Bootstrapping the study data could have produced estimates of the likelihood of the results. The study had some limitations. The authors did not state the follow-up time, so the time horizon was unclear. They stated that there was no difference in achieving remission, and in overall mortality, but no data were presented. The authors thoroughly discussed the external validity of their results, and addressed limitations in the ability to generalise the results. Concluding remarks:The study was generally well conducted, but the small sample, unclear follow-up, retrospective cohort design, and issues in generalising the results, make their validity uncertain. Bibliographic details Lee S, Knox A, Zeng IS, Coomarasamy C, Blacklock H, Issa S. Primary prophylaxis with granulocyte colony-stimulating factor (GCSF) reduces the incidence of febrile neutropenia in patients with non-Hodgkin lymphoma (NHL) receiving CHOP chemotherapy treatment without adversely affecting their quality of life: cost-benefit and quality of life analysis. Supportive Care in Cancer 2013; 21(3): 841-846 Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Aged, 80 and over; Antineoplastic Combined Chemotherapy Protocols /adverse effects /therapeutic use; Cohort Studies; Cost-Benefit Analysis; Cyclophosphamide /adverse effects /therapeutic use; Doxorubicin /adverse effects /therapeutic use; Female; Fever /chemically induced /epidemiology /prevention & Filgrastim; Granulocyte Colony-Stimulating Factor /economics /therapeutic use; Humans; Incidence; Lymphoma, Non-Hodgkin /drug therapy; Male; Middle Aged; Neutropenia /chemically induced /epidemiology /prevention & Prednisone /adverse effects /therapeutic use; Quality of Life; Recombinant Proteins /economics /therapeutic use; Retrospective Studies; Surveys and Questionnaires; Vincristine /adverse effects /therapeutic use; Young Adult; control; control AccessionNumber 22013011309 Date bibliographic record published 08/04/2013 Date abstract record published 16/06/2014 |
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