Cost-utility, cost-effectiveness, and budget impact of Internet-based cognitive behavioral therapy for breast cancer survivors with treatment-induced menopausal symptoms

Abstract

Purpose: Internet-based cognitive behavioral therapy (iCBT), with and without therapist support, is effective in reducing treatment-induced menopausal symptoms and perceived impact of hot flushes and night sweats (HF/NS) in breast cancer survivors. The aim of the current study was to evaluate the cost-utility, cost-effectiveness, and budget impact of both iCBT formats compared to a waiting list control group from the Dutch healthcare perspective.

Methods: A Markov model was constructed with a 5-year time horizon. Costs and health outcomes were measured alongside a randomized controlled clinical trial and included quality-adjusted life years (QALYs), overall levels of menopausal symptoms, and perceived impact of HF/NS. Uncertainty was examined using probabilistic and deterministic sensitivity analyses, together with a scenario analysis incorporating a different perspective.

Results: iCBT was slightly more expensive than the waiting list control, but also more effective, resulting in incremental cost-utility ratios of €23,331/QALY and €11,277/QALY for the guided and self-managed formats, respectively. A significant reduction in overall levels of menopausal symptoms or perceived impact of HF/NS resulted in incremental costs between €1460 and €1525 for the guided and €500-€753 for the self-managed format. The estimated annual budget impact for the Netherlands was €192,990 for the guided and €74,592 for the self-managed format.

Conclusion: Based on the current trial data, the results indicate that both guided and self-managed iCBT are cost-effective with a willingness-to-pay threshold of well below €30,000/QALY. Additionally, self-managed iCBT is the most cost-effective strategy and has a lower impact on healthcare budgets.

Keywords: Breast cancer; Budget impact; Cognitive behavioral therapy; Cost-effectiveness; Internet-based; Menopause.

Fig. 1

Cost-effectiveness Acceptability Curves (CEAC); presenting the probability of cost-effectiveness for a range of willingness-to-pay (WTP) thresholds of guided iCBT compared to waiting list control group (a), self-managed iCBT compared to waiting list control group (b), and self-managed versus guided versus waiting list control group (c). For a WTP threshold of 30,000 per QALY, guided and self-managed iCBT are superior over waiting list control group with a probability of 60.5% and 79.5%, respectively (a, b), and the self-managed variant is superior when comparing to both waiting list control group and guided iCBT simultaneously with a probability of 68.9% (c)

Fig. 2

Incremental cost-effectiveness planes of the quality-adjusted life years (QALYs) per costs of the self-managed and guided iCBT intervention groups compared to a waiting list control group. The scatter plots are showing the mean differences in costs and outcomes from the data using 5000 bootstrap replicates. Ninety-two and eighty-nine percent of the dots are in the North-East quadrant of the plane for the guided and self-managed iCBT interventions, respectively. This indicates that there is a high probability that both treatments are more effective and more expensive compared to a waiting list control group

Fig. 3

Tornado diagrams. This figure presents several univariate sensitivity analyses for both guided and self-managed iCBT. Parameters are ranked according to impact on incremental cost-utility ratio (ICUR). Results show that the utility attributed to the states ‘Reduction in Menopausal Symptoms (MS)’ and ‘Menopausal Symptoms’, the effect of the intervention lasting shmter/longer, transition probabilities, and the costs of states ‘Reduction in Menopausal Symptoms’ and ‘Menopausal Symptoms’ affect the ICUR the most. Moreover, self-managed iCBT seems to be more resistant to univariate differences in the model compared to guided iCBT