When is Cancer Care Cost-Effective? A Systematic Overview of Cost–Utility Analyses in Oncology

Dan Greenberg 0 1 Craig Earle 0 1 Chi-Hui Fang 0 1 Adi Eldar-Lissai 0 1 Peter J. Neumann ) 0 1 0 No. 063, Boston, MA 02111 ( 1 Funding National Cancer Institute contract No. HHSN261200800748P to the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center , Boston, Massachusetts New cancer treatments pose a substantial financial burden on health-care systems, insurers, patients, and society. Cost-utility analyses (CUAs) of cancer-related interventions have received increased attention in the medical literature and are being used to inform reimbursement decisions in many health-care systems. We identified and reviewed 242 cancer-related CUAs published through 2007 and included in the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org). Leading cancer types studied were breast (36% of studies), colorectal (12%), and hematologic cancers (10%). Studies have examined interventions for tertiary prevention (73% of studies), secondary prevention (19%), and primary prevention (8%). We present league tables by disease categories that consist of a description of the intervention, its comparator, the target population, and the incremental cost-effectiveness ratio. The median reported incremental cost-effectiveness ratios (in 2008 US $) were $27 000 for breast cancer, $22 000 for colorectal cancer, $34 500 for prostate cancer, $32 000 for lung cancer, and $48 000 for hematologic cancers. The results highlight the many opportunities for efficient investment in cancer care across different cancer types and interventions and the many investments that are inefficient. Because we found only modest improvement in the quality of studies, we suggest that journals provide specific guidance for reporting CUA and assure that authors adhere to guidelines for conducting and reporting economic evaluations. - Innovative interventions in cancer prevention, diagnosis, and treatment may improve patients survival and quality of life, but such improvements may come at a substantial economic cost. The cost of cancer treatment has risen dramatically in recent years and has created financial burdens for both patients and third-party payers (17). In the United States, for example, the National Institutes of Health estimated that the overall cost of cancer care in 2007 was $219.2 billion: direct medical care costs accounted for $89.0 billion of this total, $18.2 billion was attributed to indirect morbidity costs (ie, costs of lost productivity because of illness), and the remainder to indirect mortality costs (ie, cost of lost productivity because of premature death) (8). Jnsson and Wilking (9) found that the direct cost for cancer care in 19 selected European countries in 2004 was approximately 57 billion (US $71 billion). Recently, a study by Yabroff et al. suggested that the value of life lost from all cancer deaths in the year 2000 was $960.6 billion, and this value is projected to be $1472.5 billion in 2020 (10). This projected increase is because of increasing life expectancy and to the expected growth and aging of the US population. The economic impact of cancer-related interventions has received increased attention in the medical literature and in the popular media because of the very high cost of many newer cancer drugs and treatment protocols (3,4,7,1113). The debate has focused not only on the costs of treatments but also on their relatively modest benefits. Many new interventions in oncology, such as those targeted at patients with metastatic disease, produce relatively small gains in life expectancy or quality of life in relation to existing treatments. Therefore, it has become crucial to understand the potential costs and benefits of each intervention to determine whether they provide good value. Economic evaluations of health-care interventions have become more common in the medical and health economics literature and are increasingly being used to inform reimbursement and coverage decisions in Australia, Canada, the United Kingdom, and other European countries (1417), although results from economic evaluations have not traditionally been used in the United States for these purposes (1820). Because reimbursement and coverage decisions influence patient care, it is important for both decision makers and medical practitioners to be able to adequately interpret the design, the results, and the conclusions of economic evaluations. Cost-effectiveness analysis (CEA) provides a standard wellaccepted methodological technique for judging whether a medical service provides good value for money. The approach has emerged as an important tool for evaluating the impact of a wide variety of health interventions. A costutility analysis (CUA) is a type of CEA in which benefits are measured in terms of qualityadjusted life-years (QALYs) to allow comparison of the relative efficiency of health-care interventions across a spectrum of conditions. The main elements of CUAs and their application and interpretation in oncology are described in greater detail elsewhere (21,22). Also, we briefly describe the main elements that should be addressed when designing, performing, and reporting findings from a CUA in an appendix (Supplementary Material, available online). CUAs have the potential to inform coverage decisions and patient care if they are of high quality and use standard recommended methods. Nearly a decade ago, we published an overview of costutility assessments in oncology, which examined the literature published before 1998 (23). In this article, we have described and synthesized published analyses of cancer-related care, examined the number and quality of such analyses over time and related factors, and summarized the resulting standardized costutility ratios. We analyzed data from the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), a database with detailed information on 1677 CEAs published in the peer-reviewed medical and economic literature through 2007. Our methodology for searching the literature and extracting information, which is described in more detail elsewhere (24), involved searching MEDLINE by the keywords, QALYs, quality-adjusted, and costutility analysis and then retrieving English-language publications that contained an original cost per QALY estimate. Our review included all studies that pertained to prevention, screening, and treatment of cancer. We excluded review, editorial, or methodological articles; CEAs that measured health effects in units other than QALYs; and articles in languages other than English. We used a standard data auditing form to review each CUA for clarity, completeness, and health economic methodological quality. The form was developed based on a variety of sources, including the checklist for reporting reference-case CUAs recommended by the Panel on Cost-Effectiveness in Health and Medicine as well as other published guidelines (25,26). Two readers with advanced training in d (...truncated)