Clinical and Pharmacoeconomic Aspects Both Play an Important Role in the Treatment of Ovarian Cancer

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A Costly Disease

Ovarian cancer is associated with significant costs which impact on the affected individuals and their families, as well as society.[1] The costs of ovarian cancer include those which relate directly to medical care, such as the costs of drugs and physician services, and also indirect costs which include costs associated with loss of productivity (e.g. lost or decreased ability to work).[1] There are also intangible costs of ovarian cancer which are a monetary expression of the pain and suffering associated with the disease and its treatment. Although intangible costs are hard to quantify, these are often the most important costs for the patient.

Chemotherapy regimens which include cisplatin and an alkylating agent have high response rates in women with advanced ovarian cancer. Furthermore, cisplatin plus paclitaxel is superior to previous standard therapy with cisplatin plus cyclophosphamide. 73% of women with advanced ovarian cancer treated with cisplatin plus paclitaxel responded to this therapy compared with a response rate of 60% among women receiving cisplatin plus cyclophosphamide in the Gynecologic Oncology Group study 111 (GOG 111).[3]

Although paclitaxel combined with cisplatin offers advantages in terms of response rate and survival, it is an expensive therapy. The acquisition costs alone of paclitaxel are roughly 100 times greater than the costs of cyclophosphamide.[1] Furthermore, the higher incidence of adverse events requiring supportive inpatient care, such as febrile neutropenia, add to the cost.[1] To address these concerns, a number of investigations have examined the cost effectiveness of cisplatin plus paclitaxel versus cisplatin plus cyclophosphamide using data from GOG 111. From the perspective of the healthcare provider, the total drug costs for cisplatin plus paclitaxel are 4 times higher than those for cisplatin plus cyclophosphamide ($US9918 vs $US2527; year of costing not specified).[4] Compared with cisplatin plus cyclophosphamide, the incremental costs per year of life gained for cisplatin plus paclitaxel therapy are $US19 820 for inpatient treatment and $US21 222 for outpatient treatment. These incremental costs fall well within the generally accepted range of costs for new therapies.

From a provincial (Ontario, Canada) perspective, cisplatin plus paclitaxel is more expensive than cisplatin plus cyclophosphamide, with an incremental cost-effectiveness ratio in Canadian dollars ($Can) of $Can32 213 ($US24 751; 1993 costs for drug and hospital costs) per life-year gained.[5] The investigators concluded that adopting this therapy as first line for all advanced-stage ovarian cancer patients would cost the province of Ontario an additional $Can9 million a year.[5] Since Ontario has a fixed budget for cancer care, adopting this new therapy would mean fewer resources would be available for treating patients with recurring disease.

The cost effectiveness of cisplatin plus paclitaxel was also investigated in a European analysis.[6] From the perspective of the relevant country's national health service, the incremental cost of cisplatin plus paclitaxel per life-year saved were evaluated for Spain ($US6395), the UK ($US6403), France ($US6642), The Netherlands ($US7796), Germany ($US9362) and Italy ($US11 420).[6] Relative costs of alternative chemotherapy regimens are shown in table 1.

Since the majority of women with ovarian cancer will develop recurring disease, the costs associated with providing on-going palliative care for these patients are very important. A retrospective study estimated the costs of palliative care for 40 women with recurring ovarian cancer from the perspective of the provincial healthcare provider.[7] From the start of second- or third-line chemotherapy until the time of death, the mean cost per patient was calculated at $US53 000 (1994 costs). Approximately 62% of the total costs were due to inpatient admissions, with 58% of inpatient days attributed to symptomatic care.

The costs of chemotherapy drugs accounted for 21% of total costs, less than half of the 45% of total costs attributable to chemotherapy (e.g. inpatient days for chemotherapy, complications and outpatient visits). Roughly 33% of inpatient days and half of outpatient days were for chemotherapy. Thus, the overall costs of using chemotherapy drugs were far higher than the acquisition costs of the drugs.

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