COST EFFECTIVENESS OF FIRST LINE CHEMOTHERAPY FOR PATIENTS WITH ADVANCED OR METASTATIC NON SMALL CELL LUNG CANCER

Purpose: 1) To develop a comprehensive cost-effectiveness model of first-line chemotherapy treatments to guide choice of treatment for patients with advanced or metastatic non-small cell lung cancer (NSCLC). 2) To investigate the effect of using different price bases on relative cost-effectiveness.   

Method: We developed an economic model to capture contrasting patterns of patient outcomes and costs over time (maximum 10 years) between 12 available treatment options. Outcome data from our own systematic review of the clinical-effectiveness literature was used to populate the model. The decision model was implemented as a Microsoft Excel workbook, involving three health states prior to death, and up to two lines of chemotherapy. We considered patients with squamous disease, non-squamous disease, and also epidermal growth factor receptor (EGFR) mutation-positive patients. A UK NHS perspective was adopted. Costs and outcomes were discounted at 3.5%. We explored two price base scenarios: (i) British National Formulary (BNF) prices and (ii) Electronic Market Information Tool (eMIT) prices (eMIT prices are based on mean product prices for generic medicines drawn from information from about 95% of NHS Trusts). Incremental cost-effectiveness ratios (ICERs) in terms of cost per quality adjusted life years gained (QALYs) were calculated. 

Result: Using BNF prices, cisplatin doublets are preferred to carboplatin doublets. For patients with squamous disease, moving from low to moderate willingness to pay thresholds, preferred drugs are: paclitaxel→ gemcitabine→ docetaxel. For patients with non-squamous disease, a similar pattern of ranking applies: paclitaxel→ gemcitabine→ docetaxel. However, pemetrexed/cisplatin has improved overall survival compared with all other recommended treatments in patients with non-squamous disease, but pemetrexed/cisplatin is relatively expensive and a high threshold is required before pemetrexed can be considered cost effective, up to £35,000 (≈ $US 56,000) per QALY gained. For patients with EGFR mutation-positive tumours, comparing gefitinib to paclitaxel and docetaxel yields very high ICERs. For all populations, using eMIT prices means that carboplatin doublets are generally preferred to cisplatin doublets and drug administration costs become more important than drug acquisition costs.

Conclusion: Cost-effectiveness of first-line chemotherapy varies according to histology. Use of two different price bases shows that the cost-effective choice of platinum compound in a competitive market can be determined more by the cost of drug administration than by differences in the price of drugs.