Cost-Effectiveness of Pharmacologic Treatment Options for Women With Endocrine-Refractory or Triple-Negative Metastatic Breast Cancer

Abstract

PURPOSE Treatments for endocrine-refractory or triple-negative metastatic breast cancer (mBC) are modestly effective at prolonging life and improving quality of life but can be extremely expensive. Given these tradeoffs in quality of life and cost, the optimal choice of treatment sequencing is unclear. Cost-effectiveness analysis can explicitly quantify such tradeoffs, enabling more informed decision making. Our objective was to estimate the societal cost-effectiveness of different therapeutic alternatives in the first- to third-line sequences of single-agent chemotherapy regimens among patients with endocrine-refractory or triple-negative mBC. METHODS Using three dynamic microsimulation models of 10,000 patients each, three cohorts were simulated, based upon prior chemotherapy exposure: (1) unexposed to either taxane or anthracycline, (2) taxane- and anthracycline-exposed, and (3) taxane-exposed/anthracycline-naive. We focused on the following single-agent chemotherapy regimens as reasonable and commonly used options in the first three lines of therapy for each cohort, based upon feedback from oncologists treating endocrine-refractory or triple-negative mBC: (1) for taxane- and anthracycline-unexposed patients, paclitaxel, capecitabine (CAPE), or pegylated liposomal doxorubicin; (2) for taxane- and anthracycline-exposed patients, Eribulin, CAPE, or carboplatin; and (3) for taxane-exposed/anthracycline-naive patients, pegylated liposomal doxorubicin, CAPE, or Eribulin. RESULTS In each cohort, accumulated quality-adjusted life-years were similar between regimens, but total societal costs varied considerably. Sequences beginning first-line treatment with paclitaxel, carboplatin, and CAPE, respectively, for cohorts 1, 2, and 3, had lower costs and similar or slightly better outcomes compared with alternative options. CONCLUSION In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.

A Novel Approach to Computing Preference Estimates for Different Treatment Pathways: An Application in Oncology

“…However, although this methodology accounts for all treatments along a pathway, it does not account for the sequence of these treatments, i.e., the timing at which a treatment was given along the pathway. As found by Wheeler et al [ 15 ], for some types of metastatic breast cancer, giving standard chemotherapy drugs in a specific sequence can reduce overall costs and improve the value of care while preserving QoL.…”

Sequential Targeted Therapy for Advanced, Metastatic, and Recurrent Cervical Cancer: A Cost-Effectiveness Analysis of the Patient Journey

“…For example, in liver cancer, Sherrow et al utilized a Markov model to investigate optimal and cost-effectiveness of several agents in various sequencies 12 and has been done in breast cancer as well. 13 To our knowledge, there have been no such studies in cervical cancer. To that end, we performed a cost analysis of various sequences of upfront and second-line treatment of novel cervical cancer agents in the recurrent and metastatic setting.…”

Economic Analysis of Screening, Diagnostic, and Treatment Technologies for Cancer: Reflections and a Roadmap for Prospective Authors

“…In the article that accompanies this editorial, Wheeler et al 13 used a microsimulation model to demonstrate similar outcomes regardless of therapy sequencing in patients with endocrine-refractory or triple-negative breast cancer, meaning therapeutic decisions in this setting may prioritize costs without affecting clinical outcomes. This manuscript exemplifies the type of high-quality, transparent, and accessible economic analysis that has a direct impact on patient care and is of interest to JCO and JCO OP .…”

“…In companion to this article, Wheeler et al 13 exemplifies the type of approach that provides effective policy and clinical guidance for a common clinical problem: therapy sequencing for women with endocrine-refractory or triple-negative metastatic breast cancer. Using a sophisticated and well-described microsimulation model that was informed through multiple discussions with oncologists, the authors show that in this setting, the clinical outcomes are so similar that consideration of cancer care costs can be prioritized in most cases without sacrificing care quality.…”