Cost-Effectiveness Analysis of Prophylaxis Treatment Strategies to Reduce the Incidence of Febrile Neutropenia in Patients with Early-Stage Breast Cancer or Non-Hodgkin Lymphoma

Abstract

ObjectiveThe objective of this study was to evaluate the cost effectiveness of no prophylaxis, primary prophylaxis (PP), or secondary prophylaxis (SP) with granulocyte colony-stimulating factors (G-CSFs), i.e., pegfilgrastim, lipegfilgrastim, filgrastim (6- and 11-day), or lenograstim (6- and 11-day), to reduce the incidence of febrile neutropenia (FN) in patients with stage II breast cancer receiving TC (docetaxel, cyclophosphamide) and in patients with non-Hodgkin lymphoma (NHL) receiving R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) over a lifetime horizon from a Belgian payer perspective.MethodsA Markov cycle tree tracked FN events during chemotherapy (3-week cycles) and long-term survival (1-year cycles). Model inputs, including the efficacy of each strategy, risk of reduced relative dose intensity (RDI), and the impact of RDI on mortality, utilities, and costs (in €; 2014 values) were estimated from public sources and the published literature. Incremental cost-effectiveness ratios (ICERs) were assessed for each strategy for costs per FN event avoided, life-year (LY) saved, and quality-adjusted LY (QALY) saved. LYs and QALYs saved were discounted at 1.5% annually. Deterministic and probabilistic sensitivity analyses (DSAs and PSAs) were conducted.ResultsBase-case ICERs for PP with pegfilgrastim relative to SP with pegfilgrastim were €15,500 per QALY and €14,800 per LY saved for stage II breast cancer and €7800 per QALY and €6900 per LY saved for NHL; other comparators were either more expensive and less effective than PP or SP with pegfilgrastim or had lower costs but higher ICERs (relative to SP with pegfilgrastim) than PP with pegfilgrastim. Results of the DSA for breast cancer and NHL comparing PP and SP with pegfilgrastim indicate that the model results were most sensitive to the cycle 1 risk of FN, the proportion of FN events requiring hospitalization, the relative risk of FN in cycles ≥2 versus cycle 1, no history of FN, and the mortality hazard ratio for RDI (<90% vs ≥90% [for NHL]). In the PSAs for stage II breast cancer and NHL, the probabilities that PP with pegfilgrastim was cost effective or dominant versus all other prophylaxis strategies at a €30,000/QALY willingness-to-pay threshold were 52% (other strategies ≤24%) and 58% (other strategies ≤24%), respectively.ConclusionFrom a Belgian payer perspective, PP with pegfilgrastim appears cost effective compared to other prophylaxis strategies in patients with stage II breast cancer or NHL at a €30,000/QALY threshold.Electronic supplementary materialThe online version of this article (doi:10.1007/s40273-016-0474-0) contains supplementary material, which is available to authorized users.

Cost-Utility Analysis of Lipegfilgrastim Compared to Pegfilgrastim for the Prophylaxis of Chemotherapy-Induced Neutropenia in Patients with Stage II-IV Breast Cancer

“…The results of our study aligned with Kulikov et al ( 2016 ) but disagree with those obtained by Fust et al ( 2015 , 2016 ), who found pegfilgrastim to be dominant when compared to lipegfilgrastim. This difference in conclusion may arise from the study design.…”

“…There are very few studies assessing the cost-effectiveness of lipegfilgrastim compared to pegfilgrastim. Taking the Belgian payer perspective, Fust et al concluded that pegfilgrastim was cost-effective vs. lipegfilgrastim in patients with stage II breast cancer using Wang et al's risk estimate for FN of 1.39 (0.54–3.50) for lipegfilgrastim compared to pegfilgrastim (Fust et al, 2015 , 2016 ; Wang et al, 2015 ). Wang et al's risk estimate for FN was derived from a mixed treatment comparison (MTC) using a heterogeneous (i.e., non-breast cancer specific) cancer population and considering different studies designs.…”

Prophylaxis of febrile neutropenia with colony-stimulating factors: the first 25 years

“…Finally, from a Belgium perspective, Fust et al analyzed cost-effectiveness among patients with ESBC and NHL. The authors reported that secondary prevention dominated the no prophylaxis strategy, and primary prevention had highly favorable ICERs versus secondary prevention: e15,500 per QALY gained for breast cancer and e7800 for NHL 86 .…”

Treatment of HER2-positive early breast cancer: How to best balance efficacy and toxicity?

“…While the therapeutic value of PPG in EBC patients receiving docetaxel‐based regimens is well documented from several phase III trials; however, none were conducted on TCH‐treated patients. Economically, PPG has been considered both cost‐effective and cost‐reducing in patients with >20% high risk of FN, although some reports concluded no change in costs, because the reduction in hospitalization costs was offset by the cost of PPG administration . We strongly believe that in real life practice, the incidence of FN is patients receiving TCH is crossing the 20% boundary of cost‐effectiveness, and hence, we endorse Bayo et al.…”