Analysis of economic evaluations of pharmacological cancer treatments in Spain between 1990 and 2010


Economic evaluation of pharmacological cancer treatment is a critical clinical problem currently under consideration worldwide. We have analysed their main characteristics in Spain between 1990 and 2010 following a systematic review of the 29 complete economic analyses published. The pathology most frequently evaluated was non-small cell lung cancer (31 %). Cost-effectiveness analyses (69 %) were the most frequent analyses. A wide range of incremental cost-effectiveness values (295–160,667 €/QALY) has been reported, and mostly are developed from the perspective of the National Health System (65.5 %). However, none of the studies estimated the indirect costs. The major conclusion is that the absence of regulations concerning the application of the efficiency criterion in decision-making on the subject of price and financing and, most importantly, the fact that these are not included in Spanish hospitals forms make it difficult to analyse the real impact of economic evaluations of cancer treatments on such decisions.

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The authors thank Lilly S.A. Spain, for the help provided in the performance of the study.

Conflict of interest

ASG, AH, JDL and JR have received an investigator-led research from Lilly.

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Corresponding author

Correspondence to Álvaro Hidalgo.

Appendix 1: Articles of selected complete economic evaluations

Appendix 1: Articles of selected complete economic evaluations

References Analysis Alternatives Pathology Result Recommendation
Soto [13] MC Interferon alpha (different presentations: 18, 10 and 25 vials) LMC −201,689,425 pta (18 vials presentation) It is the cheapest option
Berger et al. [14] CE Paclitaxel + cisplatin vs. cyclophosphamide + cisplatin CO 6,395 $/LYG  
Ferriols and Ferriols [15] CE 5-Fluorouracil + folinic vs. 5-fluorouracilo CCR 922,570 pta/LYG The option should be considered for having RCEI similar to others. The addition of folinic assumes RCEI
Ferriols and Ferriols [16] CE Gemcitabine + cisplatin vs. cisplatin + iphosphamide + mesna CPCNP 354,047 pta/objective response; 236,031 pta/1 % survival The scheme constituted by gemcitabine plus cisplatin is an efficient option
Gallego et al. [17] CE All first and second line treatments CPCNP Stage IIIB: Cost: 3,867 € (643,403 pta) per patient; average survival: 9 months.
Stage IV: 2,818 € (468,850 pta) per patient; average survival: 4.3 months
The standard patterns obtain acceptable results with reasonable costs
Annemans [18] CE Paclitaxel + cisplatin vs. teniposide + cisplatin CPCNP 20,394 $ per response It does not improve survival but improves response significantly; it may be considered as efficient intervention
Sacristan et al. [19] CE Gemcitabine + cisplatin vs. etoposide + cisplatin CPCNP −27,310 pta per response; −3,405 pta per progression-free month A potential gemcitabine plus cisplatin efficiency is observed in advanced non-small cell lung cancer
Ferriols et al. [20] CE Docetaxel vs. paclitaxel CM 6,513,075 pta per 1 % complete response with paclitaxel in 1st line poly-therapy respect to docetaxel in first line poly-therapy Docetaxel, in first line poly chemotherapy is more cost-effective and it is presented as the reference option; in the other options, it is dominant
González et al. [21] CE Interferon alpha 2b vs. not giving ML 9,015 € per LYG It should be accepted as it presents a lower RCEI than that of other medical practices
Rubio-Terres [22] MC Docetaxel + cisplatin vs. paclitaxel plus cisplatin o carboplatin CPCNP −1,788 and −2,104 € respect to paclitaxel + cisplatin or carboplatin Docetaxel + cisplatin produce cost saving
Lindgren et al. [23] CE Exemestane vs. megestrol acetate CM 7,806 €/LYG Exemestane is an efficient option respect to megestrol
Ojeda B et al. [24] MC Pegylated liposomal doxorubicin vs. topotecan COE −2,210 € It is an efficient election respect to topotecan and it can be used to reduce costs
Díaz-Rubio et al. [25] CE Irinotecan + 5-fluorouracil and folinic vs. 5-fluorouracil and folinic CCR 35,416 € per LYG The combination with Irinotecan may be considered efficient in the 1st line treatment of advanced colorectal cancer
Rubio-Terres et al. [26] MC/CU Erlotinib vs. docetaxel, pemetrexed or supportive treatment CPCNP −2,554 and −9,479 € respect to docetaxel and pemetrexed; 160,667 €/QALY respect to support care Erlotinib would provide more QALY than docetaxel and pemetrexed at a lower cost, being this treatment more effective
Gil et al. [27] CU Exemestane or anastrozole vs. tamoxifene or letrozol vs. placebo CM Exemestane vs. tamoxifene: 50,801–62,522 €/QALY; anastrozole vs. tamoxifene: 104,272 €/QALY; letrozol vs. placebo: 91,210 €/QALY Compared to tamoxifene, exemestane offers more efficiency than anastrozole and letrozol respect to tamoxifene
Ballester et al. [28] CE Letrozol or anastrozol vs. tamoxifene CM Letrozol and anastrozol: metastatic cancer: 197,926 and 56,525 €/progression-free month; neoadjuvant therapy: 2,548 and 969 €/objective response; 4,842 and 779 €/conservative surgery More efficiency is observed with aromatase inhibitors, being cost effective for presenting a ratio less than 1,000 € with anastrozole per unit of extra effectiveness
Ferriols et al. [29] CE Taxanes (docetaxel and paclitaxel) vs. not giving taxanes CPCNP Taxane-free schemes dominate paclitaxel (similar effectiveness, objective response and 1 year survival) and lower cost; with 2-year survival, the ratio is 1,601,312 € per LYG. Respect to docetaxel: 96,527 € per objective response; 27,203 and 26,559 € per LYG, with 1 and 2-year survival The taxanes are valid alternatives as they show an effectiveness which is similar or slightly superior to taxane-free schemes but with a very high cost
Casado et al. [30] CE IFL (Irinotecan, fluorouracil, leucovorin) + bevacizumab vs. FOLFOX4 (oxaliplatine, fluorouracil, leucovorin) CCR 62,790 €/progression-free year; 149,126 €/LYG Each therapeutic regime associated to monoclonal antibodies should be evaluated individually to determine if the increase of efficiency compensates for the cost associated to its use and determine the type of patient to whom the monoclonal antibody was efficient
Alberola et al. [31] MC Vinorelbine (po e iv), gemcitabine, Docetaxel and paclitaxel CPCNP Average annual cost/patient: vinorelbine iv: 2,937–3,075 €; vinorelbine po: 3,571 €; gemcitabine iv: 4,240–4,356 €; docetaxel iv: 6,494 €; paclitaxel: 7,493–11,752 € The use of vinorelbine in the management of lung cancer is a new alternative which allows to make savings with respect to traditional treatments with taxanes and gemcitabine
Grupo de Farmacoeconomía del Linfoma Folicular [32] CE/CU Rituximab vs. not doing anything LF RCEI: 8,493 €/LYG; 9,358 €/QALY; 5,485 €/progression-free year In comparison with the option of waiting and see, the maintenance treatment with rituximab provides more QALY at a cost per QALY of 9,358 € in patients with resistant advanced follicular lymphoma or in relapses who have responded to CHOP or R-CHOP before
Maroto et al. [33] CE Sorafenib + best supportive care vs. better medical treatment CCRe RCEI at 1 year: 153,083 €/LYG; throughout life: 21,058 €/LYG The addition of sorafenib to a better medical treatment is cost-effective respect to the medical treatment alone
Paz-Ares et al. [34] CE/CU Sunitinib better supportive treatment vs. better supportive treatment TEGI 4,090 €/progression-free month; 30,242 €/LYG; 49,090 €/QALY Depending on the efficiency thresholds in oncology in developing countries, sunitinib is considered cost effective with respect to the best supportive care
Martín-Jimenez et al. [35] CE/CU Docetaxel + doxorubicin and cyclophosphamide vs. fluorouracil + doxorubicin and cyclophosphamide CM 2,631 €/QALY; 2,345 €/LYG The docetaxel scheme is cost-effective compared to that of fluorouracil and it is positioned below the threshold used in Spain
Arocho et al. [36] MC Panitumumab vs. cetuximab CCR Without reutilization of vials: −5,285 €; with reutilization: −2,864 € per patient Biological therapy of metastatic colorectal cancer with panitumumab in third line can generate savings for the NHS hospitals compared to treatment with cetuximab
Delgado et al. [37] MC Oral fludarabine (alone or with cyclophosphamide) vs. fludarabine iv LLC Mono therapy: −1,908 €/patient; with cyclophosphamide: −1,292 €/patient Oral Fludarabine is associated to economic saving in the treatment of B cell chronic lymphocytic leukemia
Asukai et al. [38] CE/CU Pemetrexed vs. docetaxel CPCNP 23,967 €/QALY; 17,225 €/LYG Pemetrexed is a cost effective option for docetaxel in the treatment of advanced non-small cell lung cancer with predominant non-squamous histology, being below the threshold of 30,000 €/additional QALY, accepted in Spain
Paz-Ares et al. [39] CU Sunitinib vs. better supportive care CCRe 6,073 €/progression-free month; 25,199 €/LYG; 34,196 €/QALY Sunitinib has a good profile of efficiency in metastatic renal cell cancer; the cost per additional QALY is affordable according to thresholds in developed countries (50,000 €/QALY)
Frías et al. [40] CE/CU Docetaxel vs. paclitaxel CM 190 €/LYG; 295 €/QALY Docetaxel is a cost-effective treatment compared to paclitaxel in the treatment of metastatic breast cancer previously treated with anthracycline
Gómez et al. [41] CE/CU Rituximab + CVP, MCP, CHOP, CHVP + I LF R + CVP vs. CVP: 10,158 €/LYG; 10,171 €/QALY; R + MCP vs. MCP: 6,330 €/LYG; 6,083 €/QALY; R + CHOP vs. CHOP: 8,165 €/LYG; 7,837 €/QALY; R + CHVP + 1 vs. CHVP + I: 8,453 €/LYG; 8,026 €/QALY The addition of rituximab to any of the usual first line advanced follicular lymphoma chemotherapy treatment schemes is an efficient option
  1. Spanish acronyms and their English equivalents: MC, minimización de costes (CM: cost minimization); CPCNP, Cáncer de pulmón de células no pequeñas (NSCLC: non-small cell lung cancer); LMC, Leucemia mieloide crónica (CML: chronic myeloid leukemia); CO, cáncer de ovario (OC: ovarian cancer); LYG, años de vida ganados (LYG: Life-years gained); RCEI, ratio coste efectividad incremental (ICER: Incremental cost-effectiveness ratio); CCR, cáncer colorrectal (CRC: Colorectal cáncer); CM, cáncer de mama (BC: Breast cancer); ML, melanoma; COE, cáncer de ovario epitelial (EOC: epithelial ovarian cancer); LF, linfoma folicular (FL: Folicular lymphoma); CCRe, cáncer de células renales (RCC: Renal cell cancer); TEGI, tumor de estroma gastrointestinal (GST: gastrointestinal stromal tumor); LLC, leucemia linfocítica crónica (CLL: chronic lymphocytic leukemia); R, rituximab; CVP, ciclofosfamida + vincristina + prednisone (CVP: cyclophosphamide + vincristine + prednisone); MCP, mitoxantrona + clorambucilo + prednisolona (MCP: mitoxantrone + chlorambucil + prednisolone); CHOP, ciclofosfamida + doxorrubicina + vincristina + prednisona (CHOP: cyclophosphamide + doxorubicin + vincristine + prednisone); CHVP + I, ciclofosfamida + doxorrubicina + etopósido + prednisona + interferón (CHVP + I: cyclophosphamide + doxorubicin + etoposide + prednisone + interferon)

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Sanz-Granda, Á., Hidalgo, Á., del Llano, J.E. et al. Analysis of economic evaluations of pharmacological cancer treatments in Spain between 1990 and 2010. Clin Transl Oncol 15, 9–19 (2013).

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  • Economic evaluation
  • Cost-effectiveness
  • Medications
  • Drugs
  • Cancer/oncology
  • Spain