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Management Costs and Cost Effectiveness Analysis of Gefitinib or Combination Chemotherapy in Patients with Stage IIIB or IV Non-Small Cell Lung Cancer
Medical-economic analysis,Pharmacoeconomic analysis,Non-small cell lung cancer,Target therapy,first line gefitinib therapy,
|Publication Year :||2008|
The objective of this study was to evaluate the clinical outcome and mean medical cost for patients treated with gefitinib or combination chemotherapy for advanced non-small-cell lung cancer（NSCLC）. Economic analysis was carried out based on the perspective of the Bureau of National Health Insurance（BNHI）in Taiwan to evaluate the cost and benefit of the treatments in order to provide references for health policy or guidelines for drugs price adjustment in the future.
This study consisted of a prospective clinical trial in conjunction with a retrospective chart-review using data from a single medical center.
Data for this study was obtained from the National Taiwan University Hospital（NTUH）.
Adult patients who had an initial diagnosis of advanced NSCLC between January 1, 2001 and June 30, 2007 were included in the study. The clinical trial group consisted of first line gefitinib treatment or combination chemotherapy patients. The rear use gefitinib group patients were categorized into second line or third line treatment according to their individual health states.
The study spanned the period from the patients’ first drug-taking date to the censored date of the study, and all activities were assumed to be related to the treatment for NSCLC that will be absorbed into the medical management expense. The management costs represented costs reimbursed to NTUH from BNHI, and only direct costs were accounted. The survival time, death event, overall survival rate, time to progression, and treatment regimens were included in patients’ clinical assessment. Cox proportional hazard analysis was used to identify predictors for the management costs. The identified predictors were then utilized in the analyses of cost minimization and cost effectiveness.
During the study period, 106 patients were involved in the first line gefitinib therapy for the NSCLC trial. The median survival time was 22.4 months, and the mean lifetime total management cost was 850,231 NTD. One-year and two-year cumulative total costs were 752,374 NTD and 1,236,669 NTD, respectively. The cost for the first line gefitinib treatment period was 72,434 NTD per month, while that for the second line, third line, and palliative treatment periods were 54,937 NTD, 112,271 NTD, and 66,226 NTD, respectively. Forty-eight patients（45.3％）had deceased during our study period. Their 1-year survival rate was 31.3％, and their median survival time was 9.6 months. Their highest count in the number of patients for lifetime NSCLC treatment cost fell into the 100- 200 thousand NTD stratification—there was seven（14.6％）.
There were 182 patients involved in the first line combination chemotherapy for the NSCLC trial. The median survival time was 16.7 months, and the mean lifetime total management cost was 928,041 NTD. One-year and two-year cumulative total costs respectively were 624,299 NTD and 832,938 NTD. The cost of the first line treatment period was 81,839 NTD per month, while that of the second line, third line, and palliative treatment periods were 63,767 NTD, 63,854 NTD, and 51,492 NTD, respectively. There were 157 patients（86.3％）who had deceased within our study period. Their median survival time was 14.4 months, and the highest count for lifetime cost was 17 patients （10.8％）who fell into the 800- 900 thousand NTD stratification.
There were 33 end-stage NSCLC patients treated with second line gefitinib therapy. The median survival time was 36.7 months, the mean lifetime total treatment cost was 1,271,733 NTD, the average gefitinib duration was 6.6 months, the survival time after starting gefitinib was 27.6 months, the total cost of gefitinib period was 571,401 NTD, and the monthly cost was 167,063 NTD. There were 70 patients treated with the third line gefitinib therapy for compassionate use. Their median survival time was 28.6 months; mean lifetime total treatment cost, 1,328,475 NTD; average gefitinib duration, 7.1 months; survival time after starting gefitinib, 11.4 months; total cost of gefitinib period, 455,200 NTD; and monthly cost, 114,816 NTD.
Cox proportional hazard analysis showed that first line drug treatment option, age, gender and the status of adenocarcinoma were significant predictors for the first time to progression cost and the lifetime cumulative cost. Among the clinical trial study, for female patients with adenocarcinoma under the age of 65, the incremental cost effectiveness ratio （ICER） of first line gefitinib therapy in comparison with first line chemotherapy was 26,859 NTD per month.
Our study showed that end-stage NSCLC patients’ management cost was associated with first line drug treatment option, age, gender and the presence or absence of adenocarcinoma. For patients who were female, under 65 years old and had adenocarcinoma, the difference between the ICER of first line gefitinib therapy and that of first line chemotherapy was smaller than Gross Domestic Product（GDP）per capital. This result appeared to be acceptable in terms of medical economics, but chiefly for the advantage of patients and societies should be the prior consideration.
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