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Journal of Clinical Oncology, Vol 25, No 22 (August 1), 2007: pp. 3382-3383 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.12.3760
Health Economics in the Journal of Clinical Oncology and an Evaluation of the Indirect Costs and Benefits Associated With Adjuvant TrastuzumabJohns Hopkins Singapore International Medical Centre, Johns Hopkins University, Republic of Singapore
Division of Hematology/Oncology, Braman Family Breast Cancer Institute, Sylvester Cancer Center, University of Miami Miller School of Medicine, Miami, FL To the Editor: We would like to commend the Journal of Clinical Oncology for encouraging article submission on health economics topics and the editors and authors who have contributed articles in the special edition and recent issues. It is refreshing and inspiring to see such important aspects comprehensively presented for education and discussion within the medical oncology community and society at large.1 Liberato et al2 and Kurian et al3 recently published two studies evaluating the cost-effectiveness of trastuzumab in the adjuvant treatment of women with early human epidermal growth factor receptor 2 (HER-2)/neu–positive breast cancer. These were well designed and thoughtfully presented articles, clearly complying with the current reporting guidelines and using the best available data from randomized trials and utility studies. However, the authors did not include an assessment of indirect costs and benefits (although Kurian et al did include indirect costs), and therefore, a societal perspective was lacking in their analyses as noted in the accompanying editorial.4 Aiming to complement their data and to contribute to the increased discussion on the clinical and economic benefits of adjuvant trastuzumab, we performed an assessment of its indirect costs and benefits and estimated its societal costs.
We used the data from the authors' models as well as their main assumptions. Gross national income per capita (GNI/capita) was the measure of individual productivity used to calculate the indirect benefits and costs of treatment, though this can be criticized, as many authors suggest the use of age- and gender-specific income measurements for this purpose.5 We used the GNI/capita estimates from the International Monetary Fund for 2005 values at purchasing power parity.6 Euros were converted to US dollars (USD) at the median exchange rate in 2005: USD1.2289 per Based on the data from Liberato et al, incremental indirect costs for trastuzumab were $5,976.44 in the United States and $4,108.71 in Italy. Indirect benefits were $304,303.84 in the United States and $209,204.36 in Italy for the patients who did not receive trastuzumab, and $343,499.35 in the United States and $236,150.68 in Italy for patients who did receive trastuzumab. Total calculated societal costs (benefits) in the United States were $248,741.84 for chemotherapy alone and $259,575.91 for chemotherapy plus trastuzumab, resulting in an incremental benefit of $10,834.07, for which the 95% CI ranging from a cost of $12,797.05 to a benefit of $33,982.92. The corresponding values for Italy were $165,610.10 and $164,322.47, leading to a more modest benefit of $1,287.63, with a 95% CI ranging from a cost of $14,958.42 to a benefit of $17,116.39. The results based on the study by Kurian et al were slightly different, but not unexpected as their estimated costs were higher. Indirect benefits were $347,679.00 and $392,612.62 in the chemotherapy alone and in the trastuzumab groups, and societal costs (benefits) were $214,250.00 and $202,520.62, respectively. The incremental cost with trastuzumab was $11,729.38 (95% CI, $7,038.57 to $14,901.69). Our data support both authors' conclusions that therapy with trastuzumab in the adjuvant setting is cost-effective in developed countries, though it might lead to greater societal costs than benefits. Longer follow-up in the adjuvant trastuzumab studies will help shed light on many of the uncertainties seen in the data presented. Our greatest challenge, however, is to broaden the reach of these technological improvements both in underserved populations in developed countries and in less affluent nations. It is important that the medical oncology community continues to promote societal discussion on health economics topics, especially on the issue of treatment access and affordability. Although there should clearly be incentives to develop new therapies, the current system is neither economically efficient nor socially just. Possible alternatives range from government intervention, such as in Brazil's aggressive negotiations with antiretroviral makers, which include threats of compulsory licensing, to more market-oriented approaches, such as broader use of price discrimination or a monetary award for drug discovery. Price discrimination, which consists of charging different prices for the same product in different markets or segments, usually based on ability to pay and on elasticity of demand, is already done in most industries, where discounts and rebates are commonplace. A one-time prize to a drug discoverer, with procedures collected through an auction for manufacturing licenses (instead of from a government or private foundation fund as proposed by Nobel Laureate Joseph Stiglitz8), could be a highly successful way of inducing competition while still rewarding innovation, as the winning bidders would price drugs closer to their marginal cost. Such a process would allow for other companies to share both the risk of developing new treatments and their monetary benefits. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES
1. Meropol NJ, Schulman KA: Perspectives on the cost of cancer care. J Clin Oncol 25:169-170, 2007 2. Liberato NL, Marchetti M, Liberato GB: Cost-effectiveness of adjuvant trastuzumab in human epidermal growth factor receptor 2–positive breast cancer. J Clin Oncol 25:625-633, 2007 3. Kurian AW, Thompson RN, Gaw AF, et al: A cost-effectiveness analysis of adjuvant trastuzumab regimens in early HER2/neu–positive breast cancer. J Clin Oncol 25:634-641, 2007 4. Hillner BE, Smith TJ: Do the large benefits justify the large costs of adjuvant breast cancer trastuzumab? J Clin Oncol 25:611-613, 2007 5. Glied S: Estimating the indirect cost of illness: An assessment of the forgone earnings approach. Am J Public Health 86:1723-1728, 1996 6. World Bank: GNI per capita 2005, atlas method, and PPP. http://siteresources.worldbank.org/DATASTATISTICS/Resources/GNIPC.pdf 7. European Central Bank: Statistical data warehouse: Interactive data access. http://www.ecb.int/stats/exchange/eurofxref/html/index.en.html#info 8. Stiglitz J: Making Globalization Work. New York, NY, W.W. Norton, 2006, pp 1-385
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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