Klazien Matter-Walstra

Bevacizumab in combination with paclitaxel for HER-2 negative metastatic breast cancer: An economic evaluation

The addition of bevacizumab to weekly paclitaxel as primary chemotherapy for HER-2 negative metastatic breast cancer (MBC) prolongs progression-free survival without a substantial increase of toxicity. A Markov cohort simulation was used to follow the clinical course of typical patients with MBC. Information on response rates and major adverse effects was derived, and transition probabilities were estimated, based on the results of the E2100 clinical trial. Direct costs were assessed from the perspective of the Swiss health system. The addition of bevacizumab to weekly paclitaxel is estimated to cost an additional 40,369euro and to yield a gain of 0.22 quality-adjusted life years (QALYs), resulting in an incremental cost-effectiveness ratio of 189,427euro/QALY gained. Probabilistic sensitivity analysis showed that the willingness-to-pay threshold of 60,000euro was never reached. The addition of bevacizumab to paclitaxel in MBC patients is expensive given the clinical benefit in terms of QALYs gained.

A cost-effectiveness analysis of nivolumab versus docetaxel for advanced nonsquamous NSCLC including PD-L1 testing

Introduction Nivolumab (NIV) was recently approved in several countries for patients with pretreated advanced NSCLC. NIV is not cost‐effective compared with docetaxel (DOC) for the treatment of squamous NSCLC. However, its cost‐effectiveness for nonsquamous NSCLC and the consequences of programmed death ligand 1 (PD‐L1) testing are unknown. Methods This literature‐based health economic study used CheckMate‐057 trial data to model the incremental cost‐effectiveness ratio (ICER) of NIV versus DOC in the Swiss health care setting. The effect of PD‐L1 positivity for patient selection was assessed. Results In the base case model, NIV (mean cost CHF66,208; mean effect 0.69 quality‐adjusted life‐years [QALYs]) compared with DOC (mean cost CHF37,618; mean effect 0.53 QALYs) resulted in an ICER of CHF177,478/QALY gained. Treating only patients with PD‐L1–positive tumors (threshold ≥10%) with NIV compared with treating all patients with DOC produced a base case ICER of CHF124,891/QALY gained. Reduced drug price, dose, or treatment duration decreased the ICER partly below a willingness‐to‐pay threshold of CHF100,000/QALY. Health state utilities strongly influenced cost‐effectiveness. Conclusions Compared with DOC, NIV is not cost‐effective for the treatment of nonsquamous NSCLC at current prices in the Swiss health care setting. Price reduction or PD‐L1 testing and selection of patients for NIV on the basis of test positivity improves cost‐effectiveness compared with DOC.

Trastuzumab beyond progression: a cost-utility analysis

BACKGROUND The continuation of trastuzumab beyond progression in combination with capecitabine as secondary chemotherapy for HER2-positive metastatic breast cancer (MBC) prolongs progression-free survival without a substantial increase in toxicity. PATIENTS AND METHODS A Markov cohort simulation was used to follow the clinical course of typical patients with MBC. Information on response rates and major adverse effects was derived, and transition probabilities were estimated, based on the results of the Breast International Group 03-05 clinical trial. Direct costs were assessed from the perspective of the Swiss health care system. RESULTS The 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. CONCLUSION The addition of trastuzumab to capecitabine in MBC patients is more expensive than what is typically regarded as cost-effective but falls within the value ranges found for established regimens in the treatment of MBC.

Cost-effectiveness of maintenance pemetrexed in patients with advanced nonsquamous-cell lung cancer from the perspective of the swiss health care system

OBJECTIVES A recent randomized study showed switch maintenance with pemetrexed after nonpemetrexed-containing first-line chemotherapy in patients with advanced nonsmall-cell lung cancer to prolong overall survival by 2.8 months. We examined the cost-effectiveness of pemetrexed in this indication, from the perspective of the Swiss health care system, and assessed the influence of the costs of best supportive care (BSC) on overall cost-effectiveness. METHODS A Markov model was constructed based on the pemetrexed maintenance study, and the incremental cost-effectiveness ratio (ICER) of adding pemetrexed until disease progression was calculated as cost per quality-adjusted life-year gained. Uncertainties concerning the costs of BSC on the ICER were addressed. RESULTS The base case ICER for maintenance therapy with pemetrexed plus BSC compared to BSC alone was €106,202 per quality-adjusted life-year gained. Varying the costs for BSC had a marked effect. Assuming a reduction of the costs for BSC by 25% in the pemetrexed arm resulted in an ICER of €47,531 per quality-adjusted life-year, which is below predefined criteria for cost effectiveness in Switzerland. CONCLUSIONS Switch maintenance with pemetrexed in patients with advanced nonsquamous-cell lung cancer after standard first-line chemotherapy is not cost-effective. Uncertainties on the resource use and costs for BSC have a large influence on the cost-effectiveness calculation and should be reported in more detail.

Addition of cetuximab to first-line chemotherapy in patients with advanced non-small-cell lung cancer: a cost–utility analysis

BACKGROUND Adding cetuximab to standard chemotherapy results in a moderate increase of overall survival in patients with advanced non-small-cell lung cancer (NSCLC), but the cost-effectiveness is unknown. MATERIALS AND METHODS A Markov model was constructed based on the results of the First-Line ErbituX in lung cancer randomized trial, adding cetuximab to cisplatin-vinorelbine first-line chemotherapy in patients with advanced NSCLC. The primary outcome was the incremental cost-effectiveness ratio (ICER) of adding cetuximab, expressed as cost per quality-adjusted life year (QALY) gained, and relative to a willingness-to-pay threshold of €60 000/QALY. The impact of cetuximab intermittent dosing schedules on the ICER was also evaluated. RESULTS Adding cetuximab to standard chemotherapy leads to a gain of 0.07 QALYs per patient at an additional cost of €26 088. The ICER for adding cetuximab to chemotherapy was €376 205 per QALY gained. Intermittent cetuximab dosing schedules resulted in ICERs per QALY gained between €31 300 and €83 100, under the assumption of equal efficacy. CONCLUSIONS From a health economic perspective, the addition of cetuximab to standard first-line chemotherapy in patients with epidermal growth factor receptor-expressing advanced NSCLC cannot be recommended to date, due to a high ICER compared with other health care interventions. Treatment schedules resulting in more favorable cost-utility ratios should be evaluated.

Atypical cells in effusions: diagnostic value of cell image analysis combined with immunocytochemistry.

The reliable identification of tumor cells in populations of atypical cells occurring in body cavity effusions is a well‐known diagnostic problem. In order to improve tumor cell detection and to predict disease progression, we developed a cell scoring strategy based on a combination of DNA cytophotometry and immunocytochemistry. For this purpose, morphologically atypical cells obtained from 33 effusion samples were submitted to DNA content analysis and tested for Ber‐EP4 immunoreactivity. It turned out that elevated DNA content alone has a low specificity (true negative ratio) and sensitivity (true positive ratio) in predicting disease outcome, whereas Ber‐EP4 immunoreactivity alone has a high specificity (100%) but a low sensitivity (56%). In contrast, the use of a scoring system combining the two techniques and relating scores to the previous disease state and the cytomorphology of the atypical cells results in highly specific and sensitive prediction of the disease outcome. We therefore suggest that this approach is a valuable tool for reliably identifying tumor cells in effusions containing populations of cytologically suspect cells. Diagn Cytopathol 1996;15: 263–269.

A cost-effectiveness analysis of trametinib plus dabrafenib as first-line therapy for metastatic BRAF V600-mutated melanoma in the Swiss setting

The treatment of patients with metastatic melanomas that harbour BRAF V600E or V600K mutations with trametinib plus dabrafenib appears to be superior to treatment with vemurafenib alone. This treatment regimen is likely to become available in Switzerland in the near future.

Analysis of patient flows for orthopedic procedures using small area analysis in Switzerland

BackgroundIn general cantons regulate and control the Swiss health service system; patient flows within and between cantons are thereby partially disregarded. This paper develops an alternative spatial model, based upon the construction of orthopedic hospital service areas (HSAOs), and introduces indices for the analysis of patient streams in order to identify areas, irrespective of canton, with diverse characteristics, importance, needs, or demands.MethodsHSAOs were constructed using orthopedic discharge data. Patient streams between the HSAOs were analysed by calculating three indices: the localization index (% local residents discharged locally), the netindex (the ratio of discharges of nonlocal incoming residents to outgoing local residents), and the market share index (% of local resident discharges of all discharges in local hospitals).ResultsThe 85 orthopedic HSAOs show a median localization index of 60.8%, a market share index of 75.1%, and 30% of HSAOs have a positive netindex. Insurance class of bed, admission type, and patient age are partially but significantly associated with those indicators. A trend to more centrally provided health services can be observed not only in large urban HSAOs such as Geneva, Bern, Basel, and Zurich, but also in HSAOs in mountain sport areas such as Sion, Davos, or St.Moritz. Furthermore, elderly and emergency patients are more frequently treated locally than younger people or those having elective procedures.ConclusionThe division of Switzerland into HSAOs provides an alternative spatial model for analysing and describing patient streams for health service utilization. Because this small area model allows more in-depth analysis of patient streams both within and between cantons, it may improve support and planning of resource allocation of in-patient care in the Swiss healthcare system.

Cancer-Related Therapies at the End of Life in Hospitalized Cancer Patients from Four Swiss Cantons : SAKK 89/09

The use of cancer-related therapies in cancer patients hospitalized at the end of life has increased in many countries over time. Given the scarcity of published Swiss data, the objective of this study was to evaluate the influence of hospital type and other factors on the delivery of health care during the last month before death. Claims data were used to assess health care utilization of cancer patients (identified by cancer registry data of four participating Swiss cantons) who deceased between 2006 and 2008. Primary endpoints were delivery of cancer-related therapies during the last 30 days before death. Multivariate logistic regression assessed the explanatory value of hospital type, patient and geographic characteristics. Of 3,809 identified cancer patients in the claims database, 2,086 patients dying from cancer were hospitalized during the last 30 days before death, generating 2,262 inpatient episodes. Anticancer drug therapy was given in 22.2% and radiotherapy in 11.7% of episodes. Besides age and cancer type, the canton of residence and hospital type showed independent, statistically significant associations with intensity of care, which was highest in university hospitals. These results should initiate a discussion among oncologists in Switzerland and may question the compliance with standard of care guidelines for terminal cancer patients. i 2014 S. Karger AG, Basel

Is the EQ-5D suitable for use in oncology? An overview of the literature and recent developments.

ABSTRACT The European Quality of Life-5 Dimensions (EQ-5D) questionnaire is widely used in oncology to generate quality of life weights (utilities). The typical purpose is to inform health economic evaluation studies. The EQ-5D is generally suitable for this purpose; it has shown a reasonable degree of reliability, content validity, construct validity and responsiveness in the majority of the available studies. In situations of doubt, combination with other quality-of-life instruments may be an option. The authors expect that the five-level version of the EQ-5D will gradually replace the three-level version, due to reduced ceiling effects and more appropriate responsiveness. Further research should address the benefits achievable through additional dimensions or patient-based valuation, and the validity of EQ-5D versions for proxy respondents.