Cost-effectiveness of prophylactic granulocyte colony-stimulating factor for febrile neutropenia in breast cancer patients receiving FEC-D

Abstract

5-fluorouracil, epirubicin, cyclophosphamide → docetaxel (FEC-D) has been associated with higher-than-expected rates of febrile neutropenia (FN) that meet the current guideline threshold of 20 % for primary prophylaxis (PP) with granulocyte colony-stimulating factor (G-CSF). We examined the cost-effectiveness of FEC-D with varying strategies of G-CSF prophylaxis from the perspective of the public payer in Ontario, Canada. A state-transition model was developed to compare three strategies: FEC-D with secondary prophylaxis (SP) only, PP starting with the first cycle of D, and PP starting with the first cycle of FEC. Analysis was conducted for a hypothetical cohort of 50-year-old early-stage breast cancer patients undergoing adjuvant chemotherapy, at a 10-year horizon. Results were expressed in quality-adjusted life-years (QALYs) and 2013 Canadian dollars. Costs and benefits were discounted at 5 %. Event rates, costs, and utilities were derived from the literature. One-way and probabilistic sensitivity analyses were conducted. Using filgrastim, the incremental cost-effectiveness ratios (ICERs) for starting PP with the first cycle of D and starting PP with the first cycle of FEC, compared to using SP only, were $57,886/QALY and $116,186/QALY, respectively. With pegfilgrastim, the ICERs for the same strategies were $90,735/QALY and $149,483/QALY. Compared to using filgrastim SP only, starting PP with D had a 24 % chance of being cost-effective at a willingness-to-pay (WTP) threshold of $50,000/QALY, and a 99 % chance at a WTP threshold of $100,000/QALY. Results were sensitive to FN-related parameters, such as the risk of FN per cycle with D and the associated mortality, but were robust to uncertainty in parameters related to breast cancer, such as the utilities and hazard of relapse. FEC-D with PP starting with the first cycle of D is most likely to be cost-effective, especially with increased risk of FN and mortality from FN.

Cost-effectiveness of febrile neutropenia prevention with primary versus secondary G-CSF prophylaxis for adjuvant chemotherapy in breast cancer: a systematic review

“…Overall, the computed incremental cost per QALY gained was higher than commonly utilized CE thresholds except in the evaluation (25) that examined PP G-CSF only for the D cycles of FEC-D chemotherapy. In all other evaluations, (23,24,26,27) PP G-CSF was associated with a less than 50% (range 5 -42%) probability of being a cost-effective strategy when judged against commonly utilized CE thresholds in the various jurisdictions studied.…”

“…All evaluations incorporated PP G-CSF for all chemotherapy cycles, with one (25) also examining PP G-CSF for the D cycles only (FN risk 14.8%) of FEC-D. All studies incorporated lower FN-related costs and improved patient quality of life due to reductions in FN event rate following G-CSF prophylaxis, but incorporated varying survival benefits due to lower short-term FN-related mortality and/or improved long-term breast cancer survival (Table 2). A public payer perspective was considered by all evaluations, and none accounted for indirect costs or took a societal perspective.…”

“…Five studies met the predefined inclusion / exclusion criteria, and were included in this review (Table 1). (23,24,25,26,27) Backward search did not identify any other eligible studies. The included studies were conducted in different health care jurisdictions (USA = 1, UK = 1, Canada = 3), involved commonly utilized adjuvant taxane-based regimens (TAC = 2; FEC-D = 1; TC = 2), and all reported on incremental costs per QALY gained, albeit at different time horizons (range: 3-month to lifetime).…”

“…In all other evaluations, (23,24,26,27) PP G-CSF was associated with a less than 50% (range 5 -42%) probability of being a cost-effective strategy when judged against commonly utilized CE thresholds in the various jurisdictions studied. In sensitivity analyses, the value for money of PP G-CSF was primarily dependant on FN mortality rate assumptions, (23,25,26) baseline FN rate, (23,24,25,26) G-CSF costs, (23,24,25,26) and impact of PP on FN rate (23,26) . Conversely, FN utility (23,26) and chemotherapy characteristics, (26) including price and relative effectiveness, appeared to have relatively little impact on G-CSF value for money.…”

“…Conversely, FN utility (23,26) and chemotherapy characteristics, (26) including price and relative effectiveness, appeared to have relatively little impact on G-CSF value for money. Finally, FN management costs (23,25,26) had less significant [DR2]impact on G-CSF cost-effectiveness.…”