Should we continue temozolomide beyond six cycles in the adjuvant treatment of glioblastoma without an evidence of clinical benefit? A cost analysis based on prescribing patterns in Spain
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The standard adjuvant treatment for glioblastoma is temozolomide concomitant with radiotherapy, followed by a further six cycles of temozolomide. However, due to the lack of empirical evidence and international consensus regarding the optimal duration of temozolomide treatment, it is often extended to 12 or more cycles, even in the absence of residual disease. No clinical trial has shown clear evidence of clinical benefit of this extended treatment. We have explored the economic impact of this practice in Spain.
Materials and methods
Spanish neuro-oncologists completed a questionnaire on the clinical management of glioblastomas in their centers. Based on their responses and on available clinical and demographic data, we estimated the number of patients who receive more than six cycles of temozolomide and calculated the cost of this extended treatment.
Temozolomide treatment is continued for more than six cycles by 80.5 % of neuro-oncologists: 44.4 % only if there is residual disease; 27.8 % for 12 cycles even in the absence of residual disease; and 8.3 % until progression. Thus, 292 patients annually will continue treatment beyond six cycles in spite of a lack of clear evidence of clinical benefit. Temozolomide is covered by the National Health Insurance System, and the additional economic burden to society of this extended treatment is nearly 1.5 million euros a year.
The optimal duration of adjuvant temozolomide treatment merits investigation in a clinical trial due to the economic consequences of prolonged treatment without evidence of greater patient benefit.
KeywordsExtended adjuvant treatment Glioblastoma Pharmacoeconomics Pseudoprogression Residual disease Temozolomide
The authors would like to thank the following neuro-oncologists who participated in the survey: V. Moreno (Hospital La Paz, Madrid), O. Gallego (Hospital Sant Pau, Barcelona), C. Sanchez (Hospital Virgen de las Nieves, Granada), I. Marquez (Hospital Gregorio Marañón, Madrid), I. Fernandez (Hospital Universitario, Vigo), P. Fuster (Hospital Son Espases, Palma de Mallorca), E. Pujol (Hospital Lozano Blesa, Zaragoza), M. Navarro (Hospital Universitario, Salamanca), C. Mesía (Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona), T. Quejereta (Hospital Infanta Cristina, Badajoz), S. Del Barco (Catalan Institute of Oncology, Hospital Trueta, Girona), C. Olier (Hospital de Alcorcón, Madrid), P. Ramirez (Hospital Puerta de Cádiz, Cádiz), E. Vicente (Hospital Insular de Gran Canaria, Las Palmas), R. Marsé (Hospital Son Espases, Palma de Mallorca), S. Peralta (Hospital Sant Joan, Reus), M. Santiesteban (Clinica de Navarra, Navarra), T. Quintanar (Hospital Universitario de Elche, Elche), A. Herrero (Hospital Miquel Servet, Zaragoza), M. Quindos (Hospital Teresa Herrera, Complejo Hospitalario La Coruña, La Coruña), B. Perez-Valderrama (Hospital Virgen del Rocio, Sevilla), R. Romero (Hospital Lucus Agusti, Lugo). The authors also thank Mercè Francisco and Anna del Prado from Marketing Farmacéutico & Investigación Clínica, S.L. (MFAR) for their expert technical assistance in conducting the survey and Renée O’Brate for her assistance in drafting the manuscript. This work has received no financial support.
Conflict of interest
The authors have declared no conflicts of interest.
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