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Cost-utility analysis for advanced breast cancer therapy in Germany: results of the fulvestrant sequencing model

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Abstract

Therapy decisions in advanced breast cancer (ABC) increasingly require assessment not only of treatment efficacy but also of cost-effectiveness. To this end, we performed a cost-utility analysis by comparing treatment sequences including/omitting fulvestrant in a hypothetical population of hormone receptor-positive (HR+) postmenopausal women with ABC. The analysis was performed from the German health care perspective. Using a first-order sequential Markov model, expected costs and utilities were calculated over a time horizon of 10 years for cohorts of patients with HR+ ABC, previously treated for at least 5 years using adjuvant endocrine therapies. Utilities were primarily quantified in terms of quality adjusted life years (QALY). “Base-case” estimates of state transition rates, resource utilization, and other model parameters were derived from published evidence and expert assessment. The impacts of uncertainties in all key model parameters were evaluated by sensitivity analysis. Costs and benefits were discounted at 3% annually. Including second-line fulvestrant in the treatment sequence led to greater estimated health gains (0.021 QALY) and cost savings of €564 ($745, £380) per patient, i.e. the fulvestrant-containing sequence was “dominant”. The prediction of a cost savings was robust with respect to variations in all key parameters. The probability of acceptable cost-effectiveness for the fulvestrant sequence was 72% at a willingness to pay (WTP) of €30,000/QALY ($39,621/QALY, £20,198/QALY); the probability was even higher at lower WTP and substantially exceeded 50% for any realistic WTP. In a representative population of women with HR+ advanced breast cancer, inclusion of fulvestrant in the treatment sequence provides a cost-effective alternative from the German health care perspective. A high probability of cost-effectiveness is maintained under variations in all key parameters. The results reflect a tendency for patients receiving fulvestrant at an early stage to maintain high quality of life for a longer interval.

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Notes

  1. Data on file. Utilities from Belgian clinicians were obtained from a panel of five Belgian clinicians as part of a health economic analysis for fulvestrant in the Belgian health care system. The analysis was part of an official application for reimbursement of fulvestrant by AstraZeneca Belgium to the Belgian reimbursement authority (CTG = Commissie Tegemoetkoming Geneesmiddelen, CRM = Commission de Remboursement des Médicaments The application was submitted on March 12, 2007) 2007.

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Acknowledgements

The authors would like to thank Dr. Ronald Kates for his professional editing, helpful comments and perceptive criticisms of the manuscript. This work was supported by an unrestricted grant from AstraZeneca Germany.

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Authors and Affiliations

  1. Universitäts-Brustzentrum Franken (UBF), Frauenklinik, Universitätsklinikum Erlangen, Universitätsstrasse 21-23, 91054, Erlangen, Germany

    Michael Patrick Lux

  2. Apotheke, Universitätsklinikum Jena, Jena, Germany

    M. Hartmann

  3. Klinik für Gynäkologie und Geburtshilfe, Klinikum Offenbach GmbH, Offenbach, Germany

    C. Jackisch

  4. Frauenarztpaxis mit Schwerpunkt Gynäkologische Operationen und Brustkrebschirurgie, Munich, Germany

    G. Raab

  5. Klinik für Allgemeine Frauenheilkunde und Geburtshilfe mit Poliklinik, Universitätsklinikum Heidelberg, Heidelberg, Germany

    A. Schneeweiß

  6. Medizinische Klinik mit Schwerpunkt Hämatologie und Onkologie (CCM), Freie Universität Berlin, Berlin, Germany

    K. Possinger

  7. Mapi Values, Bollington, UK

    J. Oyee

  8. Frauenklinik und Poliklinik, Technische Universität München, Munich, Germany

    N. Harbeck

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Lux, M.P., Hartmann, M., Jackisch, C. et al. Cost-utility analysis for advanced breast cancer therapy in Germany: results of the fulvestrant sequencing model. Breast Cancer Res Treat 117, 305–317 (2009). https://doi.org/10.1007/s10549-008-0294-9

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