Patterns, costs and cost-effectiveness of care in a trial of chemotherapy for advanced non-small cell lung cancer
Introduction
The recently published trials investigating the effect of mitomycin, ifosfamide and cisplatin chemotherapy (MIC) in non-small cell lung cancer (NSCLC) show that chemotherapy prolongs survival, without compromising quality of life [1]. In particular, the trial in advanced disease (the MIC2 trial) showed a statistically significant survival benefit (P=0.03) with an increased median survival on chemotherapy of almost 2 months. The meta-analysis of smaller trials also showed that cisplatin-based chemotherapy confers a small survival benefit, with the greatest effect in patients with advanced disease [2].
Given the unavoidable reality of resource constraints in all health care systems, purchasing decisions in cancer care are based not only on evidence describing the impact of treatment on survival and quality of life, but also on cost. There has been some research into the cost of treating lung cancer in the UK [3] but not within a randomised trial setting. The majority of studies addressing the cost of chemotherapy in advanced NSCLC are Canadian-based, and these in general have adopted a decision-analytic approach [4], [5], although one influential Canadian study directly collected and reported data from patients within a randomised trial [6]. Intuitively, one would expect the costs of chemotherapy to be higher but this latter study suggested that chemotherapy use may be associated with lower costs than ‘best supportive care’. They showed that chemotherapy drug costs are a relatively small proportion of the overall costs of care in advanced lung cancer, and may be more than counterbalanced by the extra cost of palliation in patients not having chemotherapy.
Having established the effect of MIC chemotherapy on duration and quality of life in advanced NSCLC via the MIC2 trial, the study reported here was designed to provide the final necessary component of information, namely cost. The study was a retrospective examination aimed at identifying patterns of care and their associated costs in the UK, in a subgroup of patients within the two arms of the MIC2 trial, to allow an estimate of the cost differences attributable to chemotherapy.
The difference in cost can be compared to the survival benefit observed in all trial patients, allowing the estimation of the incremental cost-effectiveness of chemotherapy versus palliative care.
Section snippets
Patients
Details of the design of the MIC2 trial are given elsewhere [1]. In summary, ambulatory (WHO performance status 0, 1 or 2) patients, aged 75 or less, with inoperable extensive stage NSCLC were prospectively randomised to receive MIC chemotherapy plus standard palliative care (MIC+PC) versus standard palliative care alone (PC). The trial recruited 351 eligible patients between March 1988 and March 1996.
A detailed retrospective study of patterns and costs of care between entry to trial and death
Patients
The baseline characteristics of all trial patients are described in Table 2. The study presented here consists of a representative subset of 116 of these patients, 58 on each treatment arm. The study patients on each arm are reasonably well balanced with respect to these characteristics (Table 2).
Survival
Details of the survival times on the two arms of the trial are given elsewhere [1]. In summary, the hazard ratio of chemotherapy against palliative care was 0.79 (95% confidence interval (CI):
Discussion
The MIC2 trial showed that MIC chemotherapy significantly prolongs survival without compromising quality of life. Ideally, a study of costs within the trial would have been carried out on all randomised patients, but limited resources meant that this was not a viable option and so a representative subset of patients was used. The choice of patients was based purely on geographical criteria and the treatment comparison should therefore be unbiased. Restricting the study to a single geographical
Acknowledgements
We would like to thank the National Health Service Research & Development Programme for funding this study. We are grateful to Charlotte Woodroffe, Julia Mason, Christine Faul, Sue Whitmarsh, Mandy Smith, David Parry, Andreas Abrousalis and Gulnaz Begum for their input to the study and to Julie Barber for her advice on bootstrapping.
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