Economic evaluation of fulvestrant as an extra step in the treatment sequence for ER-positive advanced breast cancer

Abstract

Drug therapies for advanced breast cancer in hormone-receptor-positive disease include both hormonal and chemotherapies. Current UK practice is to minimise toxicity by using sequential hormonal agents for as long as clinically appropriate. A Markov model was developed to investigate the cost effectiveness of different sequences of therapies, particularly exploring the effects of adding an additional hormonal agent, fulvestrant, to the treatment pathway. A systematic review was undertaken and a panel of seven UK oncologists validated assumptions used for treatment efficacy, treatment pathways and resources used. Fulvestrant was found to be a cost-effective treatment option when added to the treatment sequence as a second-or third-line hormonal therapy for advanced disease. For a cohort of 1000 patients, fulvestrant as a second-line hormone therapy provided an additional 47 life years and 41 quality-adjusted life years (QALYs), at an additional cost of d301 359. This equated to d6500 per life years gained and d7500 per QALY. When used as a third-line option, the fulvestrant arm was dominant providing an increase in health benefit of 27 QALYs for the whole cohort, at a mean overall cost reduction of d430 per patient. Sensitivity analyses showed these results to be robust, demonstrating that fulvestrant is an economically viable additional endocrine option in the United Kingdom for the treatment of hormone responsive advanced breast cancer.

Economic Evaluation of Fulvestrant 500 mg Compared to Generic Aromatase Inhibitors in Patients with Advanced Breast Cancer in Sweden

“…Fulvestrant was found to be a cost-effective treatment alternative in ER+ ABC at a lower dose of 250 mg. The cost effectiveness of a second-line treatment sequence with and without fulvestrant 250 mg was assessed in Germany [ 45 ] and the UK [ 46 ]. Both studies concluded that fulvestrant 250 mg is a valuable ET in ABC, leading to cost savings in the German study and an ICER of £7500/QALY in the UK study.…”

Quantitative Evidence Synthesis Methods for the Assessment of the Effectiveness of Treatment Sequences for Clinical and Economic Decision Making: A Review and Taxonomy of Simplifying Assumptions

“…Decision models that start at the point of diagnoses are more likely to reflect the complete sequence of treatments used in chronic conditions, for example, some studies of biologics in rheumatoid arthritis developed the decision population within the actual model, with patients entering the model being newly diagnosed with early disease [67,75,83,85,99,122]. However, the likelihood that there is no matching evidence is increased, and more assumptions are required.…”

Treating Elderly Patients with Hormone Receptor–Positive Advanced Breast Cancer

“…66,67 Second-line therapy options after progression on an AI include switching to another endocrine therapy (including fulvestrant), or everolimus plus exemestane (after anastrozole or letrozole only). 41,58,73,74 Evidence from clinical trials indicates that following progression with a nonsteroidal AI (anastrozole or letrozole), it is possible to obtain clinical benefit with a steroidal AI (exemestane) and vice versa. [75][76][77] Other endocrine options after progression on an AI include fulvestrant or tamoxifen.…”