Cost effectiveness of mammography screening for Chinese women

BACKGROUND: Although the cost effectiveness of screening mammography in most western developed populations has been accepted, it may not apply to Chinese women, who have a much lower breast cancer incidence. The authors estimated the cost effectiveness of biennial mammography in Hong Kong Chinese women to inform evidence-based screening policies. METHODS: For the current study, a state-transition Markov model was developed to simulate mammography screening, breast cancer diagnosis, and treatment in a hypothetical cohort of Chinese women. The benefit of mammography was modeled by assuming a stage shift, in which cancers in screened women were more likely to be diagnosed at an earlier disease stage. The authors compared costs, quality-adjusted life years (QALYs) saved, and life years saved (LYS) for 5 screening strategies. RESULTS: Biennial screening resulted in a gain in life expectancy ranging from 4.3 days to 9.4 days compared with no screening at an incremental cost of from US $1,166 to US $2,425 per woman. The least costly, nondominated screening option was screening from ages 40 years to 69 years, with an incremental cost-effectiveness ratio (ICER) of US $61,600 per QALY saved or US $64,400 per LYS compared with no screening. In probabilistic sensitivity analyses, the probability of the ICER being below a threshold of US $50,000 per QALY (LYS) was 15.3% (14.6%). CONCLUSIONS: The current results suggested that mammography for Hong Kong Chinese women currently may not be cost effective based on the arbitrary threshold of US $50,000 per QALY. However, clinicians must remain vigilant and periodically should revisit the question of population screening: Disease rates in China have been increasing because of westernization and socioeconomic development.     

Cost-effectiveness analysis of trastuzumab to treat HER2-positive advanced gastric cancer based on the randomised ToGA trial

Background:

We performed a cost-effectiveness analysis of trastuzumab plus chemotherapy for human epidermal growth factor type-2 (HER2)-positive advanced gastric cancer (GC) based on data obtained from the Trastuzumab for Gastric Cancer (ToGA) trial from a Japanese perspective.

Methods:

The following Japanese and Korean populations of the ToGA trial were analysed to obtain mean overall and progression-free survival times: (1) all HER2-positive populations, (2) immunohistochemical (IHC) 2+/fluorescence in situ hybridisation (FISH)+ or IHC 3+ populations, and (3) IHC 3+ only population. The effect of trastuzumab treatment on mean survival time was estimated by fitting a Weibull parametric function. Costs were calculated from the perspective of health-care payer. Neither costs nor outcomes were discounted because of short life expectancy.

Results:

In the base-case analysis, the incremental cost-effectiveness ratio was (1) JPY 12 million (€110 000) per quality-adjusted life year (QALY) gained and JPY 8.9 million (€81 000) per life-year gained (LYG) for all HER2-positive populations, (2) JPY 9.1 million (€83 000) per QALY gained and JPY 6.6 million (€60 000) per LYG for the IHC 2+/FISH+ or IHC 3+ population, and (3) JPY 6.1 million (€55 000) per QALY gained and JPY 4.3 million (€39 000) per LYG for the IHC 3+ population.

Conclusion:

Trastuzumab treatment for IHC 3+ populations is cost effective. Our analysis can find a cost-effective subgroup when advanced GC is treated by trastuzumab.     

Proton therapy of cancer: potential clinical advantages and cost-effectiveness

Proton therapy may offer potential clinical advantages compared with conventional radiation therapy for many cancer patients. Due to the large investment costs for building a proton therapy facility, however, the treatment cost with proton radiation is higher than with conventional radiation. It is therefore important to evaluate whether the medical benefits of proton therapy are large enough to motivate the higher costs. We assessed the cost-effectiveness of proton therapy in the treatment of four different cancers: left-sided breast cancer, prostate cancer, head and neck cancer, and childhood medulloblastoma. A Markov cohort simulation model was created for each cancer type and used to simulate the life of patients treated with radiation. Cost and quality adjusted life years (QALYs) were used as primary outcome measures. The results indicated that proton therapy was cost-effective if appropriate risk groups were chosen. The average cost per QALY gained for the four types of cancer assessed was about €10 130. If the value of a QALY was set to €55 000, the total yearly net benefit of treating 925 cancer patients with the four types of cancer was about €20.8 million. Investment in a proton facility may thus be cost-effective. The results must be interpreted with caution, since there is a lack of data, and consequently large uncertainties in the assumptions used.     

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

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 £301 359. This equated to £6500 per life years gained and £7500 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 £430 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.     

Colorectal cancer screening comparing no screening,immunochemical and guaiac fecal occult blood tests: A cost‐effectiveness analysis

Comparability of cost‐effectiveness of colorectal cancer (CRC) screening strategies is limited if heterogeneous study data are combined. We analyzed prospective empirical data from a randomized‐controlled trial to compare cost‐effectiveness of screening with either one round of immunochemical fecal occult blood testing (I‐FOBT; OC‐Sensor®), one round of guaiac FOBT (G‐FOBT; Hemoccult‐II®) or no screening in Dutch aged 50 to 75 years, completed with cancer registry and literature data, from a third‐party payer perspective in a Markov model with first‐ and second‐order Monte Carlo simulation. Costs were measured in Euros (€), effects in life‐years gained, and both were discounted with 3%. Uncertainty surrounding important parameters was analyzed. I‐FOBT dominated the alternatives: after one round of I‐FOBT screening, a hypothetical person would on average gain 0.003 life‐years and save the health care system €27 compared with G‐FOBT and 0.003 life years and €72 compared with no screening. Overall, in 4,460,265 Dutch aged 50–75 years, after one round I‐FOBT screening, 13,400 life‐years and €320 million would have been saved compared with no screening. I‐FOBT also dominated in sensitivity analyses, varying uncertainty surrounding important effect and cost parameters. CRC screening with I‐FOBT dominated G‐FOBT and no screening with or without accounting for uncertainty.     

The cost-effectiveness of screening lung cancer patients for targeted drug sensitivity markers

Background:

New oncology drugs are being developed in conjunction with companion diagnostics with approval restricting their use to certain biomarker-positive subgroups. We examined the impact of different predictive biomarker screening techniques and population enrichment criteria on the cost-effectiveness of targeted drugs in lung cancer, using ALK and crizotinib to build the initial model.

Methods:

Health economic modeling of cost per Quality Adjusted Life Year was based on literature review and expert opinion. The modeled population represented advanced non-small cell lung cancer (NSCLC), eligible for predictive biomarker screening with prescribing restricted to biomarker-positive patients.

Results:

For assays costing $1400 per person, cost per quality-adjusted life year (QALY) gained for ALK screening all advanced NSCLC, excluding treatment cost, is $106 707. This falls to $4756 when only a highly enriched population is screened (increasing biomarker frequency from 1.6 to 35.9%). However, the same enrichment involves missing 56% patients who segregate within the unscreened group. Cheaper screening tests that miss some true positives can be more cost-effective if proportional reductions in cost exceed proportion of subjects missed. Generic modeling of idealised screening assays, including treatment cost, reveals a dominant effect of screening cost per person at low biomarker frequencies. Cost-effectiveness of <$100 000 per QALY gained is not achievable at biomarker frequencies <5% (with drug costs $1–5000 per month and screening costs $600–1400 per person).

Interpretation:

Cost-effectiveness of oncology drugs whose prescribing is restricted to biomarker-positive subgroups should address the cost of detecting marker-positive patients. The cost of screening dominates at low frequencies and strategies to improve cost-effectiveness based on the assay cost, drug cost and the group screened should be considered in these scenarios.     

Cost-effectiveness analysis of screening modalities for breast cancer in Japan with special reference to women aged 40-49 years

Although the introduction of screening mammography in Japan would be expected to reduce mortality from breast cancer, the optimal screening modality in terms of cost-effectiveness remains unclear. We compared the cost-effectiveness ratio, defined as the cost required for a life-year saved, among the following three strategies: (1) annual clinical breast examination; (2) annual clinical breast examination combined with mammography; and (3) biennial clinical breast examination combined with mammography for women aged 30-79 years using a hypothetical cohort of 100 000. The sensitivity, specificity and early breast cancer rates were derived from studies conducted from 1995 to 2000 in Miyagi Prefecture. The treatment costs were based on a questionnaire survey conducted at 13 institutions in Japan. We used updated parameters that were needed in the analysis. Although the effectiveness of treatment in terms of the number of expected survival years was highest for annual combined modality, biennial combined modality had a higher cost-effectiveness ratio, followed by annual combined modality and annual clinical breast examination in all age groups. In women aged 40-49 years, annual combined modality saved 852.9 lives and the cost/survival duration was 3 394 300 yen/year, whereas for biennial combined modality the corresponding figures were 833.8 and 2 025 100 yen/year, respectively. Annual clinical breast examination did not confer any advantages in terms of effectiveness (815.5 lives saved) or cost-effectiveness (3 669 900 yen/year). While the annual combined modality was the most effective with respect to life-years saved among women aged 40-49 years, biennial combined modality was found to provide the highest cost-effectiveness.     

Cost-effectiveness of primary cytology and HPV DNA cervical screening

Because cost-effectiveness of different cervical cytology screening strategies with and without human papillomavirus (HPV) DNA testing is unclear, we used a Markov model to estimate life expectancy and health care cost per woman during the remaining lifetime for 4 screening strategies: (i) cervical cytology screening at age 32, 35, 38, 41, 44, 47, 50, 55 and 60, (ii) same strategy with addition of testing for HPV DNA persistence at age 32, (iii) screening with combined cytology and testing for HPV DNA persistence at age 32, 41 and 50, iv) no screening. Input data were derived from population-based screening registries, health-service costs and from a population-based HPV screening trial. Impact of parameter uncertainty was addressed using probabilistic multivariate sensitivity analysis. Cytology screening between 32 and 60 years of age in 3-5 year intervals increased life expectancy and life-time costs were reduced from 533 to 248 US Dollars per woman compared to no screening. Addition of HPV DNA testing, at age 32 increased costs from 248 to 284 US Dollars without benefit on life expectancy. Screening with both cytology and HPV DNA testing, at ages 32, 41 and 50 reduced costs from 248 to 210 US Dollars with slightly increased life expectancy. In conclusion, population-based, organized cervical cytology screening between ages 32 to 60 is highly cost-efficient for cervical cancer prevention. If screening intervals are increased to at least 9 years, combined cytology and HPV DNA screening appeared to be still more effective and less costly.     

The cost-effectiveness of nationwide breast carcinoma screening in Finland, 1987-1992.

BACKGROUND: The aim of this study was to evaluate the cost-effectiveness, from a societal perspective, of the Finnish nationwide breast carcinoma screening program. METHODS: The effects were measured in life-years saved from 1987 to 2020, using data from the nationwide program to the end of 1992. A total of 90,000 women ages 50-59 were invited for screening during the years 1987-89. The total number of participants screened was 76,000. The screening interval was 24 months, with follow-up to the end of 1992. From the beginning of 1993, the estimation model used parameters based on published studies and national cancer statistics. Data on health care and non-health care costs and time costs were obtained from internal accounts of screening units, published studies, national statistics, health market sources, and a questionnaire completed by a sample of 1400 screening attendees. The discount rate, the annual rate of time preference over future costs and life-years saved, was 3%. The main outcome measure was the cost per life-year saved. RESULTS: The estimated number of life-years of life saved was 578, of which 8% occurred 1987-1992. The estimated life-years saved per 1000 screenings was 3.2. The total costs were $11 million in U.S. dollars, i.e., $14.3 million per 100,000 participants. CONCLUSIONS: The cost of breast carcinoma mammographic screening per life-year saved was $18,955 in the base case, ranging from $15,502 to $40,308 according to the different models used in analysis.     

Building a model to determine the cost-effectiveness of breast cancer screening in France

This paper describes the methods and initial validation of a cost-effectiveness model developed to simulate the breast cancer screening situation in France. The first screening pilot programmes were set up in France in 1989 to test the feasibility of a decentralized screening model based in a large number of existing non-dedicated radiology centres. The present cost-effectiveness model was built as a tool to help guide current policy discussions on the future of screening in France. This Markov model compares the costs and effects expected when a screening programme is offered to a given cohort of women to those expected in the absence of screening. The model was initially validated using current results from the Bas-Rhin screening programme and local cancer registry epidemiological data. Over a 20-year period, 315 274 women would attend for screening, of whom 12 491 would be recalled for further assessment. 4423 cancers would be detected, resulting in 637 deaths. Screening allows the detection of 106 additional cancer cases, thereby preventing 92 deaths, and saves 1522 life-years compared with a situation without screening. Breast cancer mortality is reduced by 12.6%, yielding a cost-effectiveness ratio of 137 000 FF per life-year saved. The results of initial analyses suggest that the model is capable of suitably assessing the impact of breast cancer screening in terms of costs and effects. Further scenario analyses are needed to understand the impact of screening policy changes on the costs and effectiveness of future screening programmes.     

Cost-Effectiveness of HPV Vaccination in the Prevention of Cervical Cancer in Malaysia

Introduction: Cervical cancers (CC) demonstrate the second highest incidence of female cancers in Malaysia.The costs of chronic management have a high impact on nation’s health cost and patient’s quality of life that canbe avoided by better screening and HPV vaccination. Methodology: Respondents were interviewed from sixpublic Gynecology-Oncology hospitals. Methods include experts’ panel discussions to estimate treatment costsby severity and direct interviews with respondents using costing and SF-36 quality of life (QOL) questionnaires.Three options were compared i.e. screening via Pap smear; quadrivalent HPV Vaccination and combined strategy(screening plus vaccination). Scenario based sensitivity analysis using screening population coverage (40-80%)and costs of vaccine (RM 300-400/dose) were calculated. Results: 502 cervical pre invasive and invasive cervicalcancer (ICC) patients participated in the study. Mean age was 53.3 ± 11.21 years, educated till secondary level(39.39%), Malays (44.19%) and married for 27.73 ± 12.12 years. Life expectancy gained from vaccination is13.04 years and average Quality Adjusted Life Years saved (QALYs) is 24.4 in vaccinated vs 6.29 in unvaccinated.Cost/QALYs for Pap smear at base case is RM 1,214.96/QALYs and RM 1,100.01 at increased screening coverage;for HPV Vaccination base case is at RM 35,346.79 and RM 46,530.08 when vaccination price is higher. Incombined strategy, base case is RM 11,289.58; RM 7,712.74 at best case and RM 14,590.37 at worst case scenario.Incremental cost-effectiveness ratio (ICER) showed that screening at 70% coverage or higher is highly costeffective at RM 946.74 per QALYs saved and this is followed by combined strategy at RM 35,346.67 per QALYssaved. Conclusion: Vaccination increase life expectancy with better QOL of women when cancer can be avoided.Cost effective strategies will include increasing the Pap smear coverage to 70% or higher. Since feasibility andlong term screening adherence is doubtful among Malaysian women, vaccination of young women is a more costeffective strategy against cervical cancers.     

A new method for expressing survival and life expectancy in lifetime cost-effectiveness studies that evaluate cancer patients (review).

The methodology of cost-effectiveness studies that use a lifetime perspective is based on the extrapolation to infinity of the survival curves. However, the research in this methodological area is at an initial phase. Hence, adequate techniques for survival curve extrapolation still need to be devised for handling the different clinical settings that can be analysed by cost-effectiveness survival studies. After a brief overview of the two most commonly used extrapolation methods (Markov decision-tree model and Gompertz technique), we describe a new method for expressing lifetime survival in cost-effectiveness studies that evaluate cancer patients. Our method extrapolates to infinity a traditional survival curve by assigning a normal life expectancy to patients (or long-term survivors). In this way, the value of mean lifetime survival (MLS) for the patient cohort under study can be determined using a lifetime perspective. This value can be employed in lifetime cost-effectiveness analyses that compare different forms of intervention for that disease condition. A separate section of our method compares the overall survival pattern of cured and not cured patients with that of a reference healthy population to assess the impact of the disease on life expectancy. As an example of the application of our method, we reanalysed a survival data set reported by Spinolo et al in 1992, that refers to patients with acute leukaemia who relapsed after their first allogeneic bone marrow transplantation and who received a second transplant (n=17, mean age at relapse = 26 years). The use of our extrapolation method provided the following results: MLS for leukaemia patients = 105.9 months per patient or 8.8 years per patient; MLS for the reference cohort of healthy subjects = 583.8 months per patient or 48.6 years per patient. We conclude that the extrapolation technique described herein can be useful to handle lifetime survival data in cost-effectiveness analysis.     

Cost-effectiveness analysis of mass screening for breast cancer in Japan

The official Japanese recommendation for breast cancer screening is physical examination by a physician, in contrast to US recommendations of mammography. In this analysis of breast cancer screening, the authors used Japanese data in a cost-effectiveness model to compare the following five strategies: (1) no screening (N); (2) physical examination alone (PE); (3) mammography (MG); (4) PE followed by MG if PE findings were abnormal (PE----MG); and (5) PE combined with MG for all screened women (PE + MG). None of these programs would save medical expenditures. The total discounted net costs per patient (in US dollars) were as follows: N, +54; PE, +412; MG, +517; PE----MG, +340; and PE + MG, +731. The number of years of life saved per cohort of 100,000 asymptomatic Japanese women would range from 708 (PE----MG) to 3724 (PG + MG). The additional cost of each strategy (compared with N) per additional year of life would be +49,700 for PE, +40,400 for PE----MG, +14,300 for MG, and +18,000 for PE + MG. The least costly screening option (PE----MG) does not have the lowest cost per additional year of life saved (MG does). MG would be preferable to the current Japanese recommendation of PE alone.     

Simulation Models in Gastric Cancer Screening: A Systematic Review

Background: Together with such high-quality approaches as randomized controlled trials and large-scale cohortstudies, simulation models are often employed to evaluate the effect of cancer screening methods and decide ontheir appropriateness. This study aimed to evaluate all effects of gastric cancer screening that have been assessedusing simulation models, including cost-effectiveness, mortality reduction, and early-stage detection. Methods: Weperformed a systematic review using PubMed and Web of Science. We evaluated the effect of screening related tocost, such as incremental cost-effectiveness and incremental cost-effectiveness ratios; we also separately assessedeffects other than cost, such as quality-adjusted life-years, number of deaths prevented, life-years saved, relative riskof mortality from gastric cancer, life expectancy, and incidence reduction. The methods targeted for evaluation wereHelicobacter pylori testing or endoscopy. Results: We identified 19 studies dealing with simulation models in gastriccancer screenings: 14 examined H. pylori screening and 7 focused on endoscopy. Among those studies, two assessedboth H. pylori and endoscopy screening. Most of the studies adopted a Markov model, and all the studies evaluatedcost-effectiveness. Of the 14 H. pylori screening studies, 13 demonstrated cost-effectiveness and 11 also showed goodresults other than cost-effectiveness, such as extension of life-years and increase in early-stage detection. In three of thefive endoscopy studies, the target population was patients; all five studies obtained good results for cost-effectivenessand four observed good results other than for cost-effectiveness. Conclusions: In this study, we showed that the H.pylori screening test was cost-effective in terms of simulation model investigations. However, the H. pylori screeningtest should not ordinarily be recommended since there is insufficient evidence that it reduces gastric cancer mortality.In Japan, simulation modeling should be employed to plan for cancer control, and the appropriate use of simulationmodels should be examined for future use.     

Potential cost-effectiveness of one-time screening for lung cancer (LC) in a high risk cohort

The development of low-dose helical computed-tomography (CT) scanning to detect nodules as small as a few mm has sparked renewed interest in lung cancer (LC) screening. The objective of this study was to assess the potential health effects and cost-effectiveness of a one-time low-dose helical CT scan to screen for LC. We created a decision analysis model using baseline results from the Early Lung Cancer Action Project (ELCAP); Surveillance, Epidemiology and End Results (SEER) registry public-use database; screening program costs estimated from 1999 Medicare reimbursement rates; and annual costs of managing cancer and non-cancer patients from Riley et al. (1995) [Med Care 1995;33(8):828-841] and Taplin et al. (1995) [J Natl Cancer Inst 1995;87(6):417-26]. The main outcome measures included years of life, cost estimates of baseline diagnostic screening and follow up, and cost-effectiveness of screening. We found that in a very high-risk cohort (LC prevalence of 2.7%) of patients between 60 and 74 years of age, a one-time screen appears to be cost-effective at $5940 per life year saved. In a lower risk general population of smokers (LC prevalence of 0.7%), a one-time screen appears to be cost-effective at $23100 per life year. Even when a lead-time bias of 1 year is incorporated into the model for a low risk population, the cost-effectiveness is estimated at $58183 per life year. Based on the assumptions embedded in this model, one-time screening of elderly high-risk patients for LC appears to be cost-effective.     

Cost-effectiveness analysis for breast cancer screening: double reading versus single + CAD reading

Background

Computer-aided detection (CAD) increases breast cancer detection, but its cost-effectiveness is unknown for breast cancer screening in Japan. We aimed to determine whether screening mammography diagnosed by one physician using CAD is cost-effective when compared with the standard double reading by two physicians.

Methods

We established our model with a decision tree and Markov model concept based on feasible screening and clinical pathways, combined with prognosis of the health state transition of breast cancer. Cost-effectiveness analysis between double reading by two readers and single reading with CAD by one reader was performed from a social perspective in terms of the expected cost, life expectancy and incremental cost-effectiveness ratio (ICER). The hypothetical population comprised 50-year-old female breast cancer screening examinees. Only direct medical costs related to breast cancer screening and treatment were considered. One simulation cycle was 2 years, and the annual discount rate was 3 %. Sensitivity analysis was performed to evaluate the robustness of the model and input data.

Results

Single reading with CAD increased expected costs by 2,704 yen and extended life expectancy by 0.0087 years compared with double reading. The ICER was 310,805 yen per life year gained, which is below the threshold. Sensitivity analysis showed that the sensitivity and specificity of CAD and the number of breast cancer screening examinees greatly affected the results.

Conclusions

Single reading using CAD in mammography screening is more cost-effective than double reading, although the results are highly sensitive to the sensitivity and specificity of CAD and the numbers of examinees.     

Screening of colorectal cancer

Cost-effectiveness analyses have shown that the cost per year of life saved by screening with any of the tests recommended is reasonable by US standards. Although the specific results vary among analyses, in general the marginal cost-effectiveness of this screening is less than $25,000 per year of life saved. Screening for CRC was among the highest ranked services in an analysis of the value of preventive services based on the burden of disease prevented and cost-effectiveness. Although the up-front costs vary by screening modality, the long-term cost-effectiveness is similar across screening tests, so that decisions about which options to include--in the long run and from the perspective of society--do not need to be affected heavily by costs. Costs increase out of proportion to benefits with shorter intervals between screening examinations. Screening has provided great opportunities. Screening can prevent CRC by polypectomy and find early-stage cancers for treatment with less morbidity. Screening can reduce the burden of treating advanced cancers and can identify families at increased risk. Screening also has provided a better understanding of the biology of CRC. Screening for CRC should be part of a complete prevention program that includes a healthy lifestyle and familial risk assessment. Individuals with increased familial risk require special screening approaches, whereas individuals with average risk can have more standard screening. The average-risk individuals can be stratified further into persons who require intensive follow-up and persons who require less intensive or no follow-up at all. We are beginning to learn how to apply screening and surveillance approaches based on risk stratification for a more cost-effective approach to conserve resources and reduce complications and costs. Chemoprevention can be added to the program when substantial benefit of agents has been demonstrated. We have a better understanding of the biology of CRC and the technology to intervene in that biology to make a difference in the lives of many people. We have the concepts and technology to reduce substantially the mortality for CRC and even prevent it entirely. Newer screening tests or others yet to be developed may, with time, replace the modern options. Screening should take place with the tests currently available and not wait until something better comes along. In this way, needless suffering and loss of life can be avoided for this leading cause of cancer death. Screening may become even more successful if the promise of new technologies is confirmed and they enter clinical practice. In the last analysis, the best test is the one that gets done and gets done immediately.     

Cost-utility analysis of preoperative radiotherapy in patients with rectal cancer undergoing total mesorectal excision: a study of the Dutch Colorectal Cancer Group.

PURPOSE: To compare the societal costs and the (quality-adjusted) life expectancy of patients with rectal cancer undergoing total mesorectal excision (TME) with or without short-term preoperative radiotherapy (5 x 5 Gy). PATIENTS AND METHODS: We used a Markov model to project the clinical and economic outcomes of preoperative radiotherapy. Data on local recurrence rates, quality of life, and costs were obtained from the patients of a multicenter randomized clinical trial. In this trial, 1,861 patients with resectable rectal cancer from 108 hospitals were randomly assigned for TME surgery with or without preoperative radiotherapy. Outcome measures of the model were life expectancy, quality-adjusted life expectancy, lifetime costs per patient, and the incremental cost-effectiveness ratio. RESULTS: The base case model estimates that the loss of quality of life due to preoperative radiotherapy is outweighed by the gain in life expectancy. Life expectancy increases by 0.67 years; quality-adjusted life expectancy, by 0.39 years; and costs, by $9,800 per patient. The corresponding cost-effectiveness ratio is $25,100 per quality-adjusted life year. Sensitivity analyses indicate that the cost-effectiveness ratio remains acceptable under a wide range of assumptions. CONCLUSION: Assuming that the reduced local recurrence rate does lead to a survival advantage, the cost-utility analysis estimates that the improved survival outweighs the impaired quality of life and the increased costs. We conclude that short-term preoperative radiotherapy in patients with rectal cancer undergoing TME is both effective and cost-effective.     

Effectiveness and cost-effectiveness of an awareness campaign for colorectal cancer: a mathematical modeling study

Background

A campaign to increase the awareness of the signs and symptoms of colorectal cancer (CRC) and encourage self-presentation to a GP was piloted in two regions of England in 2011. Short-term data from the pilot evaluation on campaign cost and changes in GP attendances/referrals, CRC incidence, and CRC screening uptake were available. The objective was to estimate the effectiveness and cost-effectiveness of a CRC awareness campaign by using a mathematical model which extrapolates short-term outcomes to predict long-term impacts on cancer mortality, quality-adjusted life-years (QALYs), and costs.

Methods

A mathematical model representing England (aged 30+) for a lifetime horizon was developed. Long-term changes to cancer incidence, cancer stage distribution, cancer mortality, and QALYs were estimated. Costs were estimated incorporating costs associated with delivering the campaign, additional GP attendances, and changes in CRC treatment.

Results

Data from the pilot campaign suggested that the awareness campaign caused a 1-month 10 % increase in presentation rates. Based on this, the model predicted the campaign to cost £5.5 million, prevent 66 CRC deaths and gain 404 QALYs. The incremental cost-effectiveness ratio compared to “no campaign” was £13,496 per QALY. Results were sensitive to the magnitude and duration of the increase in presentation rates and to disease stage.

Conclusions

The effectiveness and cost-effectiveness of a cancer awareness campaign can be estimated based on short-term data. Such predictions will aid policy makers in prioritizing between cancer control strategies. Future cost-effectiveness studies would benefit from campaign evaluations reporting as follows: data completeness, duration of impact, impact on emergency presentations, and comparison with non-intervention regions.     

Cost-effectiveness of prostate cancer chemoprevention: a quality of life-years analysis

BACKGROUND: The Prostate Cancer Prevention Trial (PCPT) demonstrated that finasteride reduces the prevalence of prostate cancer by 24.8% (risk reduction) but questions remain regarding the cost-effectiveness of widespread utilization. The purpose of the current analysis was to evaluate the cost-effectiveness of chemoprevention utilizing a quality-of-life adjustment. METHODS: A Markov decision analysis model with probabilistic sensitivity analysis was designed to determine the lifetime prostate health-related costs, beginning at age 50 years, for men treated with finasteride compared with placebo. Model assumptions were based on data from the PCPT; Surveillance, Epidemiology, and End-Results program; literature review of costs, utilities, and transition rates among various prostate cancer health states; and local institutional cost data. RESULTS: The quality-adjusted cost-effectiveness ratio for finasteride compared with men not receiving chemoprevention was $122,747 (in U.S.$) per quality-adjusted life-years saved (QALYs). If finasteride is assumed to not increase the incidence of high-grade tumors, the quality-adjusted cost-effectiveness ratio was $112,062 per QALYs. Sensitivity analysis found that chemoprevention of prostate cancer with an agent that has no effect on the prevalence of benign prostatic hyperplasia can render a cost-effectiveness ratio of <$50,000 per QALYs saved when applied to a high-risk population associated with a 25% risk reduction, and a cost of $30 per month. CONCLUSIONS: Finasteride is unlikely to be cost-effective when considering the impact on survival differences among treated versus untreated groups. However, chemoprevention may be cost-effective in high-risk populations when taking into consideration adjustments for the impact on quality of life.