RESUMEN
When using chemotherapy in patients with a short life expectancy, outcomes such as symptom improvement or clinical benefit receive increasing attention. Outcomes of subjective benefit to the patient can be rated as a utility in order to perform health economic analyses and comparisons with other treatment conditions. A cost-utility analysis has been performed alongside a prospective randomised clinical trial comparing single agent gemcitabine to cisplatin-based chemotherapy in symptomatic advanced nonsmall cell lung cancer patients. Global quality of life as well as resource utilisation data were collected during first-line chemotherapy for both treatment arms. Incremental costs, utilities and cost-utility ratio were calculated. Per patient, an incremental cost of 1,522 was obtained for gemcitabine compared to cisplatin-vindesine, mainly as a consequence of the direct cost of the cytotoxic drugs. When combined with utilities, this resulted in an incremental cost-utility ratio for gemcitabine of 13,836 per quality-adjusted life year gained. In conclusion, although the least expensive strategy is cisplatin-vindesine, the greater clinical benefit of gemcitabine, resulting in an acceptable incremental cost-utility ratio as compared with other healthcare interventions, balances its higher cost. The gains in subjective outcome achieved with palliative chemotherapy are critical from both a clinical and a health economic point of view.
Asunto(s)
Antineoplásicos/economía , Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico , Carcinoma de Pulmón de Células no Pequeñas/economía , Cisplatino/economía , Cisplatino/uso terapéutico , Desoxicitidina/análogos & derivados , Neoplasias Pulmonares/tratamiento farmacológico , Neoplasias Pulmonares/economía , Vindesina/economía , Vindesina/uso terapéutico , Adulto , Anciano , Antineoplásicos/uso terapéutico , Análisis Costo-Beneficio , Desoxicitidina/economía , Desoxicitidina/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana Edad , GemcitabinaRESUMEN
INTRODUCTION: This article is devoted to the critical appraisal of cost-effectiveness analysis. METHODS: The example chosen concerns the choice of first line chemotherapy for a patient with stage IV non small cell bronchial carcinoma; a common problem in thoracic oncology. It compares three chemotherapy regimes: vinorelbine alone, cisplatin-vinorelbine and cisplatin-vindesine. PERSPECTIVES: The guide used allows evaluation of the validity of the methodology and, therefore, of the results obtained. CONCLUSION: The article studies the possible application of these results to the patient whose clinical history was presented as an introduction. The limitations of cost-effectiveness analyses are also considered.
Asunto(s)
Antineoplásicos Fitogénicos/economía , Antineoplásicos Fitogénicos/uso terapéutico , Antineoplásicos/economía , Antineoplásicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/economía , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico , Carcinoma de Pulmón de Células no Pequeñas/economía , Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/economía , Cisplatino/economía , Cisplatino/uso terapéutico , Análisis Costo-Beneficio , Medicina Basada en la Evidencia , Neoplasias Pulmonares/tratamiento farmacológico , Neoplasias Pulmonares/economía , Vinblastina/análogos & derivados , Vinblastina/economía , Vinblastina/uso terapéutico , Vindesina/economía , Vindesina/uso terapéutico , Antineoplásicos/administración & dosificación , Antineoplásicos Fitogénicos/administración & dosificación , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Carcinoma de Células Escamosas/diagnóstico , Cisplatino/administración & dosificación , Ensayos Clínicos como Asunto , Interpretación Estadística de Datos , Humanos , Modelos Logísticos , Neoplasias Pulmonares/diagnóstico , Masculino , Persona de Mediana Edad , Vinblastina/administración & dosificación , Vindesina/administración & dosificación , VinorelbinaRESUMEN
The costs and cost-effectiveness of different treatments are increasing concerns in healthcare. Vinorelbine (Navelbine; Burroughs Wellcome Co, Research Triangle Park, NC; Pierre Fabre Medicament, Paris, France), the first new agent approved for the treatment of metastatic non-small cell lung cancer (NSCLC) in more than a decade, was recently approved in the United States. In this report the terminology of cost-effectiveness analysis is reviewed and the findings from a comparative cost-effectiveness analysis of three regimens for NSCLC are discussed. The findings are from a randomized clinical trial of vinorelbine alone versus vinorelbine plus cisplatin versus vindesine plus cisplatin in 612 European patients with NSCLC (J Clin Oncol 12:360-367, 1994) and from cost data from the Medical College of Virginia. In this study the vinorelbine plus cisplatin regimen was the most effective, with a mean survival of 49.6 weeks. Using vinorelbine alone as the baseline, vinorelbine plus cisplatin added 56 days of life at an additional cost of $2,700, resulting in an incremental cost-effectiveness ratio of $17,700 per year of life gained. Similarly, vindesine plus cisplatin added 19 days of life at a cost of $1,150, or $22,100 per year of life gained. Compared with vindesine plus cisplatin, vinorelbine plus cisplatin added 37 days of life at a cost of $1,570, or $15,500 per year of life gained. The cost-effectiveness of the vinorelbine plus cisplatin regimen was within the accepted limits for medical interventions. If vinorelbine is preferred because of its more favorable toxicity profile, adding cisplatin to the treatment regimen substantially increases efficacy at an acceptable cost. The study demonstrated that, compared with other available medical interventions, chemotherapy for NSCLC has acceptable efficacy and cost effectiveness. Access to treatment should not be denied on the basis of clinical or economic grounds.
Asunto(s)
Antineoplásicos Fitogénicos/uso terapéutico , Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico , Neoplasias Pulmonares/tratamiento farmacológico , Vinblastina/análogos & derivados , Antineoplásicos/administración & dosificación , Antineoplásicos/economía , Antineoplásicos Fitogénicos/administración & dosificación , Antineoplásicos Fitogénicos/efectos adversos , Antineoplásicos Fitogénicos/economía , Protocolos de Quimioterapia Combinada Antineoplásica/economía , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Pulmón de Células no Pequeñas/economía , Carcinoma de Pulmón de Células no Pequeñas/secundario , Cisplatino/administración & dosificación , Cisplatino/economía , Protocolos Clínicos , Costo de Enfermedad , Análisis Costo-Beneficio , Costos de los Medicamentos , Europa (Continente) , Humanos , Neoplasias Pulmonares/economía , Ensayos Clínicos Controlados Aleatorios como Asunto , Tasa de Supervivencia , Estados Unidos , Valor de la Vida , Vinblastina/administración & dosificación , Vinblastina/efectos adversos , Vinblastina/economía , Vinblastina/uso terapéutico , Vindesina/administración & dosificación , Vindesina/economía , Vinorelbina , VirginiaRESUMEN
STUDY OBJECTIVES: compare the costs of two regimens of chemotherapy. Apply weighted costs to an economic model in a hospital perspective. DESIGN: prospective randomized study of two groups of patients receiving: branch B, mitomycin-navelbine-cisplatin (MNP); branch A, mitomycin-vindesine-cisplatin (MVP). SETTING: pneumologic units of University and non-University hospitals. METHODS: clinical evaluation during chemotherapy incorporated events enabling construction of an event tree. Direct hospital costs included those of: cytostatic agents, materials used and nursing time; costs of side-effects (medical and paramedical time, diagnostic and therapeutic examinations). Effectiveness was measured in terms of response rates. PATIENTS: 209 patients were included, 100 in arm B, 109 in arm A. RESULTS: the response rates were 25% in branch B, 17% in branch A. In the hypothesis of equivalence of the two strategies, we compared only overall mean cost per patient. Despite the fact arm B needed more hospital injections, the difference was low (+4.6%). For a difference in effectiveness, the opposite was observed for the average cost-effectiveness ratio: arm B was less costly (-12 339.40 FF for a responder). CONCLUSION: incorporation of economic parameters was found to have a bearing on the choice of chemotherapeutic regimen for the treatment of non-small cell lung cancer. Economic analyses of this kind can provide useful extra information for rational therapeutic decisions.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Pulmón de Células no Pequeñas/economía , Costos de Hospital/estadística & datos numéricos , Neoplasias Pulmonares/economía , Servicio de Oncología en Hospital/economía , Adulto , Anciano , Antibióticos Antineoplásicos/economía , Antibióticos Antineoplásicos/uso terapéutico , Antineoplásicos Fitogénicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/economía , Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico , Cisplatino/economía , Cisplatino/uso terapéutico , Análisis Costo-Beneficio , Costos Directos de Servicios/estadística & datos numéricos , Costos de los Medicamentos/estadística & datos numéricos , Femenino , Francia , Investigación sobre Servicios de Salud/métodos , Humanos , Neoplasias Pulmonares/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Mitomicinas/economía , Mitomicinas/uso terapéutico , Modelos Económicos , Estudios Prospectivos , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Sensibilidad y Especificidad , Resultado del Tratamiento , Vinblastina/análogos & derivados , Vinblastina/economía , Vinblastina/uso terapéutico , Vindesina/economía , Vindesina/uso terapéutico , VinorelbinaRESUMEN
PURPOSE: To estimate the comparative cost-effectiveness of three regimens for metastatic non-small-cell lung cancer (NSCLC). METHODS: Results from a randomized clinical trial of 612 European patients with NSCLC, and cost data from an academic cancer center, the Medical College of Virginia, were analyzed. In this post-hoc economic analysis, we compared vinorelbine alone, vinorelbine plus cisplatin, and a common regimen of vindesine plus cisplatin. RESULTS: Vinorelbine plus cisplatin resulted in the longest mean survival time of the three regimens, 49.6 weeks, followed by vindesine plus cisplatin, 44.3 weeks, and vinorelbine, 41.6 weeks. Compared with vinorelbine alone, vinorelbine plus cisplatin added 56 days at a cost of $2,700, resulting in a cost-effectiveness ratio of $17,700 per year of life gained. Similarly, vindesine plus cisplatin added 19 days at a cost of $1,150, or $22,100 per year of life gained. Compared with vindesine plus cisplatin, vinorelbine plus cisplatin added 37 days at a cost of $1,570, or $15,500 per year of life gained. CONCLUSION: The most effective regimen of vinorelbine plus cisplatin added substantial benefit compared with vinorelbine alone or another common treatment, vindesine plus cisplatin, at a cost-effectiveness within accepted limits for medical interventions. Vindesine plus cisplatin also added benefit at an acceptable cost per year of life gained. If vinorelbine is preferred because of its toxicity profile, the additional effectiveness of cisplatin added substantial benefit at an acceptable cost. Compared with other common medical interventions, chemotherapy for NSCLC has acceptable efficacy and cost-effectiveness and should not be arbitrarily denied based on clinical or economic grounds.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/economía , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico , Carcinoma de Pulmón de Células no Pequeñas/economía , Neoplasias Pulmonares/tratamiento farmacológico , Neoplasias Pulmonares/economía , Anciano , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Cisplatino/administración & dosificación , Cisplatino/economía , Análisis Costo-Beneficio , Costos de la Atención en Salud , Humanos , Neoplasias Pulmonares/mortalidad , Persona de Mediana Edad , Tasa de Supervivencia , Vinblastina/administración & dosificación , Vinblastina/análogos & derivados , Vinblastina/economía , Vindesina/administración & dosificación , Vindesina/economía , VinorelbinaRESUMEN
Polychemotherapy is the therapeutic option recommended for nonresectable, non-small cell lung cancer (NSCLC). However, the modest gains in survival, and the frequent and often serious adverse effects, associated with chemotherapy should also be considered when deciding on therapy. We therefore performed a cost-utility analysis of chemotherapy and best supportive care in NSCLC. Effectiveness and costs were analysed on 70 patients who were randomised to receive one of 3 treatments: VP (vindesine and cisplatin), CAP (cyclophosphamide, doxorubicin and cisplatin), or best supportive care. Subsequently, an assessment of the value of polychemotherapy and best supportive care was performed by oncology personnel using the time trade-off technique. Polychemotherapy was found to be more effective than best supportive care, but was also more costly and had a lower value score. Because of its cost utility and its higher value, best supportive care should not be discarded as an alternative for the treatment of NSCLC.