Cost an QALY Studies at 2010 AXCO

In review of the over 5000 abstracts presented at the recently concluded ASCO 2010 meeting, just 169 reports contained the word cost or costs.

Of these only 52 look at cost effectiveness. Most of these aimed at documenting cost rather than evaluating effectiveness.

Just 19 studies used the widely accepted QALY estimation to evaluate the cost effectiveness.

Of these 19 abstracts just three looked at the effectiveness of new targeted treatments, the most expensive medications ever marketed. These drugs cost more than the median and average income of U.S. citizens and one would have thought there would be interest in checking out the value of these advances.

The following are the three abstracts looking at cost-effectiveness:

Abstract # 6037 Cost-effectiveness of lapatinib plus capecitabine (LAP+C) versus capecitabine alone (C-only) or trastuzumab plus capecitabine (TZ+C) in women with HER2-positive metastatic breast cancer (MBC) who have received prior therapy with trastuzumab (TZ) from the U.K. National Health Service (NHS) perspective. British National Health Service

This study looked at time to progression and costs of the various regimens and then extrapolated from other studies survival data to provide cost effectiveness data. For the addition of lapatinib to capecitabine (the “standard treatment) the QALY was found to be 77,996 british pounds or about $109,000.

Abstract 3623 Cost-effectiveness analysis of the addition of bevacizumab to first-line chemotherapy in metastatic colorectal cancer. British Columbia Cancer Agency

Results: 943 patients were included: 611 from 2003/04 (pre-Bev era) and 332 from 2006 (Bev era). Median overall survival improved from 15.6 months in the pre-Bev era to 19.5 months in the Bev era (p=0.03). The weighted average cost of treatment per patient was $34,972 and $38,764 in the pre-Bev and Bev eras, respectively. In the Bev era, the cost of treatment resulted in an incremental cost-effectiveness ratio of $15,617/LYG, which translates into $62,468/QALY gained. Probabilistic sensitivity analyses produced an interquartile range of $38,900-$85,800/QALY, suggesting that the model is sensitive to the cost of systemic therapy. Conclusions: Even though Bev incurs in a high acquisition cost, it has also improved the cost-effectiveness of systemic therapy during the era in which it has been used.

link: Cost-effectiveness analysis of the addition of bevacizumab to first-line chemotherapy in metastatic colorectal cancer.

Abstract 1035: Indirect comparison of the cost-effectiveness of letrozole plus lapatinib (LET+LAP) versus anastrozole plus trastuzumab (ANA+TZ) as first-line treatment for postmenopausal women with HER2+ and HR+ metastatic breast cancer (MBC) from the U.K. National Health Service (NHS) perspective.

Shown in the Table (all results are discounted). LET+LAP yields more progression-free life years (PFLYs), life years (LYs), and QALYs than ANA+TZ. Medication costs are greater with LET+LAP, partly due to longer PFS. These higher costs are offset by savings in costs of drug administration. LAP+LET is therefore dominant (less costly and more QALYs) versus ANA+TZ. Conclusions: Letrozole plus lapatinib has greater effectiveness and lower cost from the U.K. NHS perspective when indirectly compared with anastrozole plus trastuzumab. Medicynical Note: The problem with this study is that the incremental benefit, cost effectivenenss, of trastuzumab in breast cancer is open to questionThe addition of trastuzumab to capecitabine is estimated to cost on average an additional of €33 980 and to yield a gain of 0.35 quality-adjusted life years (QALYs), resulting in an incremental cost-effectiveness ratio of €98 329/QALYs gained. Probabilistic sensitivity analysis showed that the willingness-to-pay threshold of €60 000/QALY was reached in 12% of cases.” You read that right a gain of .35 QALY’s for about $50,000. The question is whether any health care system can afford such expensive drugs.

Medicynical Note: Given that our health care system is number 1 in the world in inefficiency, one would have thought there would have been a number of studies from the U.S. evaluating cost efficacy. At this meeting there appears to have been no study of these high cost drugs from a U.S. institution. On second thought maybe there is a nexus here.

Unfortunately, in a “market” driven system with no checks on costs, no one is really interested in value. Our insurers, doctors and technology suppliers simply charge what they can/wish and pass the costs on to consumers, without regard for efficacy or cost. We need a brake in the system. It’s open to question whether the new health care law will provide it. What a non-system.

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