, Volume 2, Issue 2, pp 111-124
Date: 10 Aug 2012

Cost-Effective Strategies in the Management of Advanced Colorectal Cancer

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Abstract

After many years of fluorouracil being a standard part of various treatment regimens for patients with advanced or metastatic colorectal cancer, new agents are now available. The purchase costs of these novel agents are higher than for fluorouracil, so the question is whether these options are cost-effective. This review focuses on cost-effectiveness, concentrating mainly on the drug costs that constitute only a small percentage of the overall cost of cancer care, but are a major focus in the planning of healthcare services.

Although new agents tend to have higher purchase costs than fluorouracil, they have other advantages that may render them more cost-effective. Capecitabine achieves higher response rates, equivalent progression-free and overall survival, with a substantially improved tolerability profile compared with fluorouracil. Patients prefer oral treatments and medical resource use is significantly lower with capecitabine than with the Mayo Clinic fluorouracil regimen. Capecitabine may replace single agent fluorouracil therapy as the standard single agent treatment for patients with colorectal cancer.

The administration of raltitrexed is also more convenient than fluorouracil. Patients prefer raltitrexed to fluorouracil regimens and the additional purchase cost of raltitrexed is offset by the decreased incidence of expensive adverse effects and ease of administration. However, since there is no survival benefit, raltitrexed is not cost-effective in terms of life-years gained. The use of raltitrexed may be largely limited to those patients not able to tolerate fluorouracil.

Irinotecan, as combination treatment in the first-line setting with fluorouracil and as a single agent second-line therapy, is associated with significant gains in progression-free and overall survival. There are additional toxicities associated with irinotecan, but they appear not to have an adverse effect on quality of life.

Oxaliplatin with fluorouracil in the first-line setting also extends median progression-free survival. The addition of oxaliplatin may also prolong survival, but this is less clear and it is not yet possible to define the cost per life-year gained compared with fluorouracil alone. The combination treatment allows more patients to undergo resection of liver metastases, improving prospects of long-term survival.

Cost-effectiveness evaluations are increasingly important as novel anticancer treatments emerge competing for limited resources. A single parameter by which to judge cost-effectiveness has not been defined. A standard methodology is needed but even then judgments may vary between countries, tumor types and treatments available, leading to differing priorities.