Health Services and Outcomes
DOI: 10.1200/JCO.21.02473 Journal of Clinical Oncology - published online before print September 2, 2022
Cost-Effectiveness of Pharmacologic Treatment Options for Women With Endocrine-Refractory or Triple-Negative Metastatic Breast Cancer
2Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
3Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC
4Division of Medical Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
5Division of Cancer Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, GA
6Division of Hematology/Oncology, Departments of Medicine and Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL
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.
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.
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.
To estimate cost-effectiveness of therapeutic alternatives in first- to third-line systemic treatment sequences among three cohorts of patients with endocrine-refractory or triple-negative metastatic breast cancer (mBC), based upon prior chemotherapy exposure: (1) those unexposed to either taxane or anthracycline, (2) those taxane- and anthracycline-exposed, and (3) those taxane-exposed/anthracycline-naive.
In the mBC setting—where multiple therapeutic options are recommended by guidelines and share similar survival and adverse event trajectories—large incremental differences in costs are not associated with better outcomes at the population level.
Given the substantial cost burden associated with mBC, treatment sequencing approaches that minimize costs early may lead to higher-value care.
Supported by the Centers for Disease Control and Prevention through the Prevention Research Centers Program (5-U48-DP005017-04-01, PIs: J.G.T. and S.B.W.).
Conception and design: Stephanie B. Wheeler, Jason Rotter, Anagha Gogate, Katherine E. Reeder-Hayes, Temeika Fairley, Justin G. Trogdon
Financial support: Sarah Drier
Administrative support: Sarah Drier
Collection and assembly of data: Stephanie B. Wheeler, Anagha Gogate, Katherine E. Reeder-Hayes, Sarah Drier
Data analysis and interpretation: Stephanie B. Wheeler, Jason Rotter, Anagha Gogate, Katherine E. Reeder-Hayes, Donatus U. Ekwueme, Gabrielle Rocque
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
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Stephanie B. Wheeler
This author is an Associate Editor for Journal of Clinical Oncology. Journal policy recused the author from having any role in the peer review of this manuscript.
Research Funding: Pfizer (Inst)
Travel, Accommodations, Expenses: Pfizer
Employment: Bristol Myers Squibb/Celgene
Stock and Other Ownership Interests: Bristol Myers Squibb/Celgene
Katherine E. Reeder-Hayes
Research Funding: Pfizer (Inst)
Consulting or Advisory Role: Pfizer, Flatiron Health, Gilead Sciences
Research Funding: Carevive Systems, Genentech, Pfizer
No other potential conflicts of interest were reported.