How Much Is Too Much per QALY?
Incremental cost-effectiveness analysis is an increasingly popular tool for helping determine whether an intervention provides value for money spent, according to Elena B. Elkin, Ph.D., of the Health Outcomes Research Group at Memorial Sloan-Kettering Cancer Center, New York.
Dr. Elena B. Elkin
For example, breast cancer cost-effectiveness studies published in recent years have concluded that the use of raloxifene (Evista) to reduce breast cancer risk among white women starting at age 55 comes at a price tag of $22,000 per quality-adjusted life year (QALY) gained. Similarly, the use of adjuvant letrozole (Femara) instead of anastrozole (Arimidex) in patients with hormone receptor–positive breast cancer has a cost of $26,000 per QALY.
At the higher end of the spectrum, bevacizumab (Avastin) plus paclitaxel vs. paclitaxel alone in women with HER2-positive metastatic breast cancer has a cost-effectiveness of $280,000 per QALY; ixabepilone (Ixempra) plus capecitabine (Xeloda) vs. capecitabine alone in the setting of taxane- and anthracycline-resistant metastatic breast cancer has been calculated to carry a price tag of $360,000 per QALY; and digital screening mammography instead of film for all women aged 40 or older costs an estimated $930,000 per QALY gained, according to Dr. Elkin.
There is no "right" answer as to what constitutes good value for money spent on health care. A widespread view held since the early 1980s is that less than $50,000 per QALY is a favorably low incremental cost-effectiveness ratio and thus good value, whereas $50,000-$100,000 per QALY is a grey area and a judgment call. But those rules of thumb are "certainly outdated," said Dr. Elkin.
She noted that Dr. Smith and Dr. Bruce E. Hillner have calculated that by adjusting for health care inflation, an incremental cost-effectiveness ratio of $50,000 per QALY in 1982 equates to $197,000 per QALY in 2007 dollars. Moreover, using the World Health Organization definition of good value for health care money spent (that is, a figure not more than three times a nation’s per capita gross domestic product), then $140,100 per QALY in 2008 U.S. dollars would be a reasonable threshold (J. Clin. Oncol. 2009;27:2111-3).
Impact on Care Worries Oncologists
There are indications that many oncologists are concerned about the exponentially rising cost of cancer care but leery about the possible unintended consequences of efforts to control costs, such as jeopardizing quality or access.
<a href="http://polldaddy.com/poll/5872498/">Should oncologists consider cost when delivering cancer care?</a>A national survey of medical oncologists conducted by researchers at Tufts University showed that 84% said that patients’ out-of-pocket costs influence their treatment recommendations. Some 56% indicated the cost of new cancer drugs influences their treatment recommendations. Only 29% believe that more cost-sharing by patients for cancer drugs is needed. And 80% of those surveyed want to see more use of cost-effectiveness data in coverage and payment decisions (Health Aff. [Millwood] 2010;29:196-202).
When asked who should determine whether a drug provides good value, 60% of the medical oncologists responded that physicians should make this determination; 57% said nonprofit organizations, 37% said patients, 21% named the government, and 6% said insurance companies.
"I think that’s interesting, because in reality it’s probably the reverse of what actually happens," according to Dr. Hassett.
Earlier Adoption of Trial Results Urged
Dr. Laura J. Esserman suggested that one novel way to curb cancer care costs is through selective early adoption of persuasive clinical trial findings while ongoing definitive studies are still being completed. She cited intraoperative radiation therapy during breast-conserving surgery as a case in point.
Results of the international TARGIT-A (Targeted Intraoperative Radiotherapy) trial, in which 2,232 patients undergoing lumpectomy were randomized to intraoperative radiotherapy (IORT) or standard external-beam radiation, showed closely similar 4-year local recurrence rates in the conserved breast: 1.2% in the IORT group and 0.95% with external-beam radiation (Lancet 2010;376:91-102). Yet IORT costs $6,400 less and provides enormous quality of life advantages, as it replaces the conventional 6 weeks of near-daily radiation therapy with 30 minutes of intraoperative treatment.
"To wake up from your surgery and be done is a wonderful thing," commented Dr. Esserman, professor of surgery and radiology and director of the breast care center at the University of California, San Francisco.
More than 70,000 American women per year who have been diagnosed with breast cancer fit the profile of the TARGIT-A population, she said. Yet some authorities urge holding off on widespread adoption of IORT until results are in from ongoing, large, randomized trials of mastectomy vs. lumpectomy and various forms of radiation, which will take another decade or more.