PharmacoEconomics

, Volume 24, Issue 3, pp 237–250

Cost Effectiveness of Extended Adjuvant Letrozole in Postmenopausal Women after Adjuvant Tamoxifen Therapy

The UK Perspective
  • Jonathan Karnon
  • Thomas Delea
  • Stephen R. D. Johnston
  • Robert Smith
  • Jane Brandman
  • Jennifer Sung
  • Paul E. Goss
Original Research Article

Abstract

Background

MA17 was a randomised placebo-controlled trial of letrozole 2.5 mg/day in 5187 estrogen receptor-positive, 50% node-negative, postmenopausal women (median age 62 years at enrolment) with early breast cancer, post-5 years’ adjuvant tamoxifen therapy. The objective of this evaluation was to extrapolate the findings from the MA17 trial to estimate the lifetime cost effectiveness of letrozole in this setting.

Methods

A Markov model was used to estimate the incremental cost per QALY gained with extended adjuvant letrozole versus no therapy. Probabilities of disease progression and death were estimated using data from the MA17 study and other secondary sources. Costs of breast cancer care (letrozole therapy, surveillance, recurrences, terminal care) and treatment of osteoporosis and utilities were derived from literature. A full probabilistic sensitivity analysis was undertaken. The analysis was conducted from the perspective of the UK National Health Service (NHS) and cost estimates reflect 2004 values. All costs and outcomes were discounted at 3.5%.

Results

Extended adjuvant letrozole resulted in a gain of 0.36 QALYs per patient (13.66 vs 13.30 with no therapy). These benefits were obtained at an additional expected lifetime cost of £3732 per patient (£10 833 letrozole vs £7101 with no therapy). Cost effectiveness was estimated at £10 338 per QALY gained (95% CI 5276, 43 828). The results were robust to sensitivity analyses.

Conclusion

Five years of letrozole therapy appears to be cost effective from the NHS perspective and should be considered in women with early breast cancer, following tamoxifen adjuvant therapy.

References

  1. 1.
    Harris JR, Morrow M, Bonadonna G. Cancer of the breast. In: De Vita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia (PA): JB Lippencott Co., 1993Google Scholar
  2. 2.
    Glick JH. Adjuvant therapy for node-negative breast cancer. In: Fowble B, Goodman, RL, Glick JH, et al. Breast cancer treatment: a comprehensive guide to management. St Louis (MO): Mosby Year Book, 1991Google Scholar
  3. 3.
    Early Breast Cancer Trialists’ Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 1998; 351: 1451–1467CrossRefGoogle Scholar
  4. 4.
    Saphner T, Tormey DC, Gray R. Annual hazard rates of recurrence for breast cancer after primary therapy. J Clin Oncol 1996; 14 (10): 2738–2746PubMedGoogle Scholar
  5. 5.
    Goss P, Ingle J, Martino S, et al. A randomised trial of letrozole in postmenopausal women after five years of tamoxifen therapy for early-stage breast cancer. New Eng J Med 2003; 349 (19): 1793–1802PubMedCrossRefGoogle Scholar
  6. 6.
    Goss P, Ingle IN, Marino S, et al. Updated analysis of the NCIC CTG MA-17 randomized placebo controlled trial of letrozole after five years of tamoxifen in postmenopausal women with early stage breast cancer [abstract 847]. Proc Am Soc Clin Oncol; 2004 Jun 5–8; New OrleansGoogle Scholar
  7. 7.
    Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making 1993; 13: 322–338PubMedCrossRefGoogle Scholar
  8. 8.
    Karnon J, Brown J. Tamoxifen plus chemotherapy versus tamoxifen alone as adjuvant therapies for node positive postmenopausal women with early breast cancer. Phannacoeconomics 2002; 20 (2): 119–137CrossRefGoogle Scholar
  9. 9.
    Moran MS, Haffty BG. Local-regional breast cancer recurrence: prognostic groups based on patterns of failure. Breast J 2002; 8 (2), 81–87PubMedCrossRefGoogle Scholar
  10. 10.
    Haylock BJ, Coppin CML, Jackson J, et al. Locoregional first recurrence after mastectomy: prospective cohort studies with and without immediate chemotherapy. Int J Radiat Oncol Biol Phys 2000; 46 (2): 355–362PubMedCrossRefGoogle Scholar
  11. 11.
    Schmoor C, Sauerbrei W, Bastert G, et al. Role of isolated locoregional recurrence of breast cancer: results of four prospective studies. J Clin Oncol 2000; 18 (8): 1696–1708PubMedGoogle Scholar
  12. 12.
    Karmy C, Sengelov L. Pattern of dissemination and survival following isolated locoregional recurrence of breast cancer. Breast Cancer Res Treat 1997; 45: 181–192CrossRefGoogle Scholar
  13. 13.
    Borner M, Bacchi M, Goldhirsch A, et al. First isolated locoregional recurrence following mastectomy for breast cancer: results of a phase III multicenter study comparing systemic treatment with observation after excision and radiation. J Clin Oncol 1994; 12: 2071–2077PubMedGoogle Scholar
  14. 14.
    Toonkel LM, Fix I, Jacobsen LH, et al. The significance of local recurrence of carcinoma of the breast. Int J Radiat Oncol Biol Phys 1983; 9: 33–39PubMedCrossRefGoogle Scholar
  15. 15.
    Mouridsen H, Gershanovich M, Sun Y, et al. Superior efficacy of letrozole versus tamoxifen as first-line therapy for postmenopausal women with advanced breast cancer: results of a phase III study of the International Letrozole Breast Cancer Group. J Clin Oncol 2001; 19 (10): 2596–2606PubMedGoogle Scholar
  16. 16.
    Department of Health. Financial matters. Appendix 1: health service cost index. 2004 May [online]. Available from URL: http://www.info.doh.gov.uk/doh/finman.nsf [Accessed 2006 Feb 5]Google Scholar
  17. 17.
    British National Formulary. British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2004 Mar [online]. Available from URL: http://www.bnf.org [Accessed 2006 Feb 5]Google Scholar
  18. 18.
    NHS Executive. The new NHS 2002 reference costs. London: Department of Health, 2002Google Scholar
  19. 19.
    Netten A, Curtis L. Unit costs of health and social care, PSSRU. Kent: University of Kent, 2003Google Scholar
  20. 20.
    Kanis JA, Brazier JE, Stevenson M, et al. Treatment of established osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 2002; 6 (29): 1–146PubMedGoogle Scholar
  21. 21.
    Sorensen S, Brown R, Benedict A, et al. Patient-rated utilities in postmenopausal early breast cancer: a cross country comparison. ISPOR Seventh Annual European Congress; 2004 Oct 24–26; HamburgGoogle Scholar
  22. 22.
    Interim life tables for England and Wales 1999–2001. Actuary’ s Department. UK Government [online]. Available from URL: http://www.gad.gov.uk/Life_Tables/Historical_Interim_life_tables.htm [Accessed 2006 Feb 5]
  23. 23.
    Gabriel SE, Kneeland TS, Melton 3rd LJ, et al. Health-related quality of life in economic evaluations for osteoporosis: whose values should we use? Med Dec Making 1999; 19: 141–148CrossRefGoogle Scholar
  24. 24.
    National Institute for Clinical Excellence. Guide to the methods of technology appraisal. London: NICE, 2004 AprGoogle Scholar
  25. 25.
    Towse A, Pritchard C, Devlin N. Cost effectiveness thresholds: economic and ethical issues, 2002 [online]. Available from URL: http://www.ohe.org [Accessed 2006 Feb 10]Google Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  • Jonathan Karnon
    • 1
  • Thomas Delea
    • 2
  • Stephen R. D. Johnston
    • 3
  • Robert Smith
    • 4
  • Jane Brandman
    • 5
  • Jennifer Sung
    • 5
  • Paul E. Goss
    • 6
  1. 1.School of Health and Related Research, University of SheffieldSheffieldEngland
  2. 2.Policy Analysis Inc. (PAI)BrooklineUSA
  3. 3.Royal Marsden HospitalLondonEngland
  4. 4.South Carolina Oncology AssociatesColumbiaUSA
  5. 5.Novartis Pharmaceuticals Corp.East HanoverUSA
  6. 6.Massachusetts General Hospital Cancer CenterBostonUSA

Personalised recommendations