The Cost Effectiveness of Docetaxel and Active Symptom Control versus Active Symptom Control Alone for Refractory Oesophagogastric Adenocarcinoma: Economic Analysis of the COUGAR-02 Trial
The COUGAR-02 trial recently showed survival and quality-of-life benefits of docetaxel and active symptom control (DXL + ASC) over active symptom control (ASC) alone in patients with refractory oesophagogastric adenocarcinoma.
The aim of this study was to conduct an economic evaluation conforming to National Institute for Health and Care Excellence (NICE) technology appraisal guidance to evaluate the cost effectiveness of DXL + ASC versus ASC from the perspective of the English National Health Service (NHS).
Cost-utility analyses were conducted using trial data. Utility values were captured using the EQ-5D completed by patients at 3- and 6-weekly intervals, while resource use was captured using nurse-completed report forms and patient reports. Incremental cost-effectiveness ratios (ICERs) were calculated and the main outcome was cost per incremental quality-adjusted life-year (QALY). Nonparametric bootstrapping was conducted to capture sampling uncertainty and to generate a cost-effectiveness acceptability curve (CEAC). The analysis horizon was the trial period (median follow-up 12 months) and no modelling or discounting of future costs and benefits was conducted.
Average costs were £9352 and £6218 for DXL + ASC and ASC, respectively, and average QALYs were 0.302 and 0.186, respectively. This yielded an ICER of £27,180 for DXL + ASC. DXL + ASC had a 24 % chance of being cost effective at a £20,000 QALY threshold (lambda) and a mean net monetary benefit of −£821; this rose to 59 % and £332 when the threshold was raised to £30,000. If NICE end-of-life criteria are applied, the probability of cost effectiveness increases to 90 % (at lambda = £50,000). Results were robust to sensitivity analyses.
DXL + ASC is likely to be cost effective if an end-of-life premium is applied. Further research should determine the impact of different utility measurement strategies and different chemotherapy delivery modes on estimates of cost effectiveness.
KeywordsDocetaxel National Health Service Evidence Review Group Appraisal Committee Electronic Supplementary Table
The COUGAR-02 trial was an academic, investigator-led study. The trial was sponsored by the Cambridge University Hospitals NHS Foundation Trust (Cambridge, UK), supported by the Cambridge Clinical Trials Unit (CCTU) and funded by Cancer Research UK (grant number C21276/A12372), clinical trial number CRUK/07/013; however, no funding was received for this analysis. Hugo E. R. Ford was part-funded by the National Institute for Health Research Cambridge Biomedical Research Centre. The authors would like to thank Yemi Oluboyede for help in identifying unit costs. We thank all the patients, investigators and their research teams who participated in the COUGAR-02 trial, as well as the COUGAR-02 trial management and coordination teams.
Compliance with Ethical Standards
Role of the funding source
No funding was received for this analysis. However, the trial was funded by Cancer Research UK. Neither the funders nor sponsors of the COUGAR-02 trial participated in study design, data accrual or analysis, or in the preparation of this paper. Access to the raw data was available to the health economist (David M. Meads) and statistician (Andrea Marshall). The corresponding author had full access to all of the data and had final responsibility to submit for publication.
David M. Meads conducted the health economic analysis and wrote the manuscript. Hugo E. R. Ford was the chief investigator for the COUGAR-O2 trial. Andrea Marshall, Claire T. Hulme, Janet A. Dunn, and Hugo E. R. Ford had input into the design of the study and the data analysis, and contributed to the writing of the manuscript.
Conflict of interest
Hugo E. R. Ford received research funding from Sanofi. David M. Meads, Andrea Marshall, Claire T. Hulme and Janet A. Dunn declare that they have no conflicts of interest.
- 1.The Royal College of Surgeons of England. National Oesophago-Gastric Cancer Audit. 2012. http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2012-13/Oesophago-Gastric-Cancer-National-Audit-INTERACTIVE-pub-2012.pdf.
- 3.Vergnenegre A, Corre R, Berard H, Paillotin D, Dujon C, Robinet G, et al. Cost-effectiveness of second-line chemotherapy for non-small cell lung cancer: an economic, randomized, prospective, multicenter phase III trial comparing docetaxel and pemetrexed: the GFPC 05-06 study. J Thorac Oncol. 2011;6(1):161–8.PubMedCrossRefGoogle Scholar
- 7.National Institute for Health and Care Excellence. Guide to the methods of technology appraisal. 2013. https://www.nice.org.uk/article/pmg9/chapter/Foreword.
- 11.Curtis L. Unit costs of health and social care 2012. Personal Social Services Research Unit. 2012. http://www.pssru.ac.uk/project-pages/unit-costs/2012/.
- 12.Department of Health. NHS reference costs: financial year 2011–2012. https://www.gov.uk/government/publications/nhs-reference-costs-financial-year-2011-to-2012. Accessed 2 Sep 2014.
- 13.Joint Formulary Committee. British national formulary (online). London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com. Accessed 2 Sep 2014.
- 14.Department of Health. Drugs and pharmaceutical electronic market information (eMit). http://cmu.dh.gov.uk/electronic-market-information-tool-emit/. Accessed 2 Sep 2014.
- 15.Cornell University, Joan and Sanford I. Weill Medical College. Body surface area. http://www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm. Accessed 2 Sep 2014.
- 17.CCEMG—EPPI-Centre cost converter. http://eppi.ioe.ac.uk/costconversion/default.aspx. Accessed 2 Sep 14.
- 18.Drummond MF, Sculpher M, Torrance G, O’Brien B, Stoddart G. Methods for the economic evaluation of health care programmes. New York: Oxford University Press; 2005.Google Scholar
- 22.Van Buuren S, Oudshoorn K. Flexible multivariate imputation by MICE. Leiden: TNO Prevention Center; 1999.Google Scholar
- 28.Fuchs CS, Tomasek J, Yong CJ, Dumitru F, Passalacqua R, Goswami C, et al. Ramucirumab monotherapy for previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (REGARD): an international, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet. 2014;383(9911):31–9.PubMedCrossRefGoogle Scholar
- 30.Teckle P, Peacock S, McTaggart-Cowan H, van der Hoek K, Chia S, Melosky B, et al. The ability of cancer-specific and generic preference-based instruments to discriminate across clinical and self-reported measures of cancer severities. Health Qual Life Outcomes. 2011;9(1):106.PubMedPubMedCentralCrossRefGoogle Scholar
- 33.Corrie PG, Moody M, Wood V, Bavister L, Prevost T, Parker RA, et al. Protocol for the OUTREACH trial: a randomised trial comparing delivery of cancer systemic therapy in three different settings: patient’s home, GP surgery and hospital day unit. BMC Cancer. 2011;11(1):467.PubMedPubMedCentralCrossRefGoogle Scholar
- 34.Molassiotis A, Brearley S, Saunders M, Craven O, Wardley A, Farrell C, et al. Effectiveness of a home care nursing program in the symptom management of patients with colorectal and breast cancer receiving oral chemotherapy: a randomized, controlled trial. J Clin Oncol. 2009;27(36):6191–8.PubMedCrossRefGoogle Scholar