|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
© 2002 American Society for Clinical Oncology
Cost-Effectiveness of Chemotherapy in Non–Small-Cell Lung CancerBaskent University, Ankara, Turkey To the Editor:In the March 1, 2002, issue of the Journal of Clinical Oncology, Leighl et al1 determined the cost-effectiveness of chemotherapy in non–small-cell lung cancer (NSCLC). In Turkey, chemotherapy expenses are generally paid by state insurance organizations, but the costs remain a major issue, especially in light of our current economic crisis. This letter expresses our point of view with respect to second-line treatment of NSCLC. The World Health Organization recently declared that, by the year 2005, 60% of cancer cases will be in global regions that have only 5% of the world economic resources to fight the disease.2 These areas include developing nations. In 2001, our economy experienced the sharpest recession in the history of the Turkish Republic, and annual per capita income fell from US $3,095 to US $2,160. The country’s gross national product also decreased in 2001, from US $201 billion to US $147 billion.3 Poor economic conditions and lack of financial resources are forcing the developing world to carefully analyze the cost-effectiveness of cancer treatments. In Turkey and throughout the world, lung cancer represents the largest proportion of cancer cases in both sexes.4 In NSCLC, a disease the world has labeled "the big killer," second- and third-line chemotherapies are the most expensive steps of maintenance treatment.2 Leighl et al1 used docetaxel as a second-line chemotherapy drug in their trial on NSCLC patients and reported that the cost per year of life gained was US $57,749. The incremental survival benefit in the docetaxel arm over the trial arm that received optimum supportive care was only 2 months.1 Should we not be administering the most cost-effective treatment to these patients? At such high cost, just 2 months of life gain may not be of significant value. We agree that, ideally, medical treatment should not be governed by a country’s economic situation or an individual’s personal wealth. However, budgets for cancer treatment are extremely limited in developing countries, and efficacious second- or even third-line therapy for malignancy further increases the cost burden. Finally, in our opinion, it is more economical and effective for developing nations to focus on preventive measures, such as educating the public about the consequences of smoking, than to administer second- and third-line treatment for lung cancer. REFERENCES 1. Leighl NB, Shepherd FA, Kwong R, et al: Economic analysis of the TAX 317 trial: Docetaxel versus best supportive care as second-line therapy of advanced non–small-cell lung cancer. J Clin Oncol 21: 1344-1352, 2002 2. Costa A: Will our planet be able to cope with the cancer burden in the next decade? Semin Oncol 28: 140-142, 2001[Medline] 3. International Monetary Fund public information notice (PIN) no. 02/46: IMF concludes 2002 article IV consultation with Turkey. Http://www.imf.org/external/np/sec/pn/2002/pn0246.htm 4. Comparison of cancer statistics in Turkey with international statistics, in Firat D, Celik I (eds): Cancer Statistics in Turkey and in the World 1993-1995. Ankara, Turkey, Turkish Association for Cancer Research and Control, 1998, p 55
ResponsePrincess Margaret Hospital/University Health Network and, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada In Reply:We agree with Drs Saglam et al and would certainly prefer to prevent or cure lung cancer rather than palliate our patients who have this disease. There is no argument that the eradication of tobacco use would bring us closer to decreasing the incidence of lung cancer and other tobacco-related diseases around the world. When given as second-line palliative chemotherapy to fit patients with advanced non–small-cell lung cancer, docetaxel at the recommended dose of 75 mg/m2 every 3 weeks yields a modest median survival improvement of 2.9 months over best supportive care (7.5 v 4.6 months, P = .01).1 One-year survival in chemotherapy-treated patients in the TAX 317 randomized trial was 37% with the recommended dose of docetaxel, compared with 11% for those patients randomized to best supportive care alone. Palliative treatment with docetaxel was also associated with greater clinical benefit and with less need for pain medications and palliative radiotherapy. This improvement in palliative care for lung cancer yields modest benefits, similar to those achieved with first-line palliative chemotherapy in lung cancer. The intervention is suitable for a select, small population of fit, interested patients with advanced lung cancer who have received prior chemotherapy. Our analysis estimates that the cost per year of life gained from this treatment is $31,776 (1999 Canadian dollars), at the recommended dose of 75 mg/m2 every 3 weeks.2 This is in the range of cost-effectiveness for other health care expenditures, palliative or otherwise. Best supportive care is less expensive in the second-line setting, but it is inferior with respect to survival and clinical benefit. Improvements in palliative treatment should not lead to complacency in our efforts to prevent and/or cure lung cancer. Smoking-related illness results in billions of dollars of health care expenditure and lost productivity.3 Smoking cessation campaigns, although expected to yield cessation in only 1% to 2% of the smoking population,4 are important and must not be neglected as a component of primary prevention of cancer and other diseases. Smoking cessation strategies are also cost effective. In one study, physician counseling cost as little as $705 to $988 per year of life saved in men and $1,204 to $2,058 in women (1984 US dollars).5 Another study estimated the incremental cost-effectiveness of adding nicotine gum to counseling at $4,113 to $6,465 per year of life saved for men and $6,880 to $9,473 for women (1984 US dollars).6 Thus we agree that global eradication of tobacco use and smoking-related illnesses has the potential to yield substantial health benefits to many, as opposed to docetaxel’s modest palliative benefit to a few. The rational allocation of health care resources to maximize society’s health benefits is a complex undertaking. Use of cost-effectiveness ratios alone to determine what interventions will be funded in a health system can lead to unsatisfactory results, as seen in the state of Oregon in the late 1980s. Interventions need to be evaluated against their alternatives, and their health effects need to be valued not just from the patient’s perspective but also from the community’s perspective. For example, a "life-year" gained in an older individual through palliative chemotherapy may not be as valuable to society as a life-year gained from a renal transplant in a younger individual, who is more likely to return to the workforce. Concepts of equity, community compassion, and the societal impact of adopting an intervention must also be considered. In the grading system put forth by Laupacis et al7 for the adoption and appropriate utilization of new technologies, palliative docetaxel would be graded as having moderate evidence for adoption, as it is more effective than supportive care alone but likely costs between US $20,000 to US $100,000 per quality of life-years gained. This may be compelling enough to adopt second-line docetaxel therapy in some countries, but not in others. The decision to adopt this therapy or not, after reviewing the proven palliative benefit over supportive care, will rest on each country’s assessment of available funding, the patient and community perspectives, and competing programs. REFERENCES
1. Shepherd FA, Dancey J, Ramlau R, et al: Prospective randomized trial of docetaxel versus best supportive care in patients with non-small-cell lung cancer previously treated with platinum-based chemotherapy. J Clin Oncol 18: 2095-2103, 2000 2. Leighl NB, Shepherd FA, Kwong R, et al: Economic analysis of the TAX 317 trial: Docetaxel versus best supportive care as second-line therapy of advanced non–small-cell lung cancer. J Clin Oncol 21: 1344-1352, 2002 3. Rice DP, Hodgson TA, Sinsheimer P, et al: The economic costs of the health effects of smoking. Milbank Q 64: 489-547, 1986[CrossRef][Medline] 4. Bains N, Pickett W, Hoey J: The use and impact of incentives in population-based smoking cessation programs: A review. Am J Health Promotion 12: 307-320, 1998[Medline]
5. Cummings SR, Rubin SM, Oster G: The cost-effectiveness of counseling smokers to quit. JAMA 261: 75-79, 1989
6. Oster G, Huse DM, Delea TE, et al: Cost-effectiveness of nicotine gum as an adjunct to physician’s advice against cigarette smoking. JAMA 256: 1315-1318, 1986 7. Laupacis A, Feeny D, Detsky AS, et al: How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J 146: 473-481, 1992[Abstract]
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
