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. 2015 Apr;22(2):84-96.
doi: 10.3747/co.22.2120.

Economic evaluation of hormonal therapies for postmenopausal women with estrogen receptor-positive early breast cancer in Canada

S Djalalov  1 , J Beca  2 , E Amir  3 , M Krahn  4 , M E Trudeau  5 , J S Hoch  6
Affiliations

Economic evaluation of hormonal therapies for postmenopausal women with estrogen receptor-positive early breast cancer in Canada

S Djalalov et al. Curr Oncol. 2015 Apr.

Abstract

Background: Aromatase inhibitor (ai) therapy has been subjected to numerous cost-effectiveness analyses. However, with most ais having reached the end of patent protection and with maturation of the clinical trials data, a re-analysis of ai cost-effectiveness and a consideration of ai use as part of sequential therapy is desirable. Our objective was to assess the cost-effectiveness of the 5-year upfront and sequential tamoxifen (tam) and ai hormonal strategies currently used for treating patients with estrogen receptor (er)-positive early breast cancer.

Methods: The cost-effectiveness analysis used a Markov model that took a Canadian health system perspective with a lifetime time horizon. The base case involved 65-year-old women with er-positive early breast cancer. Probabilistic sensitivity analyses were used to incorporate parameter uncertainties. An expected-value-of-perfect-information test was performed to identify future research directions. Outcomes were quality-adjusted life-years (qalys) and costs.

Results: The sequential tam-ai strategy was less costly than the other strategies, but less effective than upfront ai and more effective than upfront tam. Upfront ai was more effective and less costly than upfront tam because of less breast cancer recurrence and differences in adverse events. In an exploratory analysis that included a sequential ai-tam strategy, ai-tam dominated based on small numerical differences unlikely to be clinically significant; that strategy was thus not used in the base-case analysis.

Conclusions: In postmenopausal women with er-positive early breast cancer, strategies using ais appear to provide more benefit than strategies using tam alone. Among the ai-containing strategies, sequential strategies using tam and an ai appear to provide benefits similar to those provided by upfront ai, but at a lower cost.

Keywords: Breast cancer; aromatase inhibitors; cost-effectiveness; tamoxifen.

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Figures

Figure 1
Figure 1
Markov model used in the analysis. a Includes contralateral tumour. b Adverse events of two types, with separate health states, are considered in the model: short-term events (thromboembolism, fractures, arthralgia) and chronic events (stroke, cardiac events, endometrial cancer).
FIGURE 2
FIGURE 2
Base-case results on the cost-effectiveness plane for the breast cancer model. Includes the exploratory sequential strategy of aromatase inhibitor (ai) followed by tamoxifen (tam). Inset illustrates the costs and effects of the four strategies in detail. qaly = quality-adjusted life-years.
FIGURE 3
FIGURE 3
Cost-effectiveness acceptability curve for six treatment strategies in estrogen receptor–positive early breast cancer. Includes the exploratory sequential strategy of aromatase inhibitor (ai) followed by tamoxifen (tam). qaly = quality-adjusted life-years.
FIGURE 4
FIGURE 4
Plot of the expected value of perfect information (evpi) for the analyzed population.
FIGURE 5
FIGURE 5
Plot of the partial and total expected value of perfect information (evpi) per patient, by quality-adjusted life-year (qaly) cost threshold.
See this image and copyright information in PMC

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References

    1. Anderson WF, Chatterjee N, Ershler WB, Brawley OW. Estrogen receptor breast cancer phenotypes in the Surveillance, Epidemiology, and End Results database. Breast Cancer Res Treat. 2002;76:27–36. doi: 10.1023/A:1020299707510. - DOI - PubMed
    1. Canadian Cancer Society’s Steering Committee on Cancer Statistics . Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012.
    1. Mouridsen H, Giobbie–Hurder A, Goldhirsch A, et al. on behalf of the big 1–98 Collaborative Group Letrozole therapy alone or in sequence with tamoxifen in women with breast cancer. N Engl J Med. 2009;361:766–76. doi: 10.1056/NEJMoa0810818. - DOI - PMC - PubMed
    1. Forbes JF, Cuzick J, Buzdar A, Howell A, Tobias JS, Baum M, on behalf of the Arimidex, Tamoxifen, Alone or in Combination (atac) Trialists’ Group Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 100-month analysis of the atac trial. Lancet Oncol. 2008;9:45–53. doi: 10.1016/S1470-2045(07)70385-6. - DOI - PubMed
    1. Dowsett M, Cuzick J, Ingle J, et al. Meta-analysis of breast cancer outcomes in adjuvant trials of aromatase inhibitors versus tamoxifen. J Clin Oncol. 2010;28:509–18. doi: 10.1200/JCO.2009.23.1274. - DOI - PubMed