ROUTINE USE OF GRANULOCYTE-COLONY-STIMULATING FACTOR IS NOT COST-EFFECTIVE AND DOES NOT INCREASE PATIENT COMFORT IN THE TREATMENT OF SMALL-CELL LUNG-CANCER - AN ANALYSIS USING A MARKOV MODEL

Purpose: The clinical indications and economic consequences of human g ranulocyte colony-stimulating factar (G-CSF) prescription during small -cell lung cancer (SCLC) chemotherapy remain controversial. The aim of this study, based on a Markov model, was to assess the impact of rout ine G-CSF use in the treatment of SCLC on costs and patient comfort. M arkov models allow the modeling SCLC chemotherapy, in which the risk o f febrile neutropenia (FN) is continuous over time and may occur more than once. Patients and Methods: We used a Markov model to compare thr ee strategies: a chemotherapy dose reduction after FN and nonuse of G- CSF (''never'' strategy), secondary use of G-CSF (''CSF if FN'' strate gy) and primary use of G-CSF (''systematic CSF'' strategy). Model base line probabilities were based on a review of medical records for all p atients (n = 39) treated for SCLC in our unit during 1993 (when G-CSF was not used) and on published reductions in the incidence of FN obtai ned by using G-CSF. Two different types of rewards were used: a cast-u tility scale that took into account the costs of FN (CFN) episodes and G-CSF (CCSF) courses; and a comfort-utility scale that took into acco unt the discomfort of FN and G-CSF therapy. Costs were analyzed from t he health care payer's perspective and utilities were assessed prospec tively in standardized interviews with treated SCLC patients. Results: The never strategy was the least costly ($4,875 [United States] versu s $5,816 and $7,690 for CSF if FN and systematic CSF) and gave the hig hest comfort value (378 U v 365 and 327 for CSF if FN and systematic C SF). Sensitivity analyses showed that the never strategy remains the l ess costly when the probability of a first FN episode was less than 49 %, the probability of FN recurrence was less than 60%, or the CFN was less than $6,077, or the CCSF was greater than $863. In terms of patie nt comfort, the never strategy was the best choice, except for patient s who considered that a course of G-CSF caused little or no discomfort whether or not it prevented FN. Conclusion: Routine use of G-CSF duri ng SCLC chemotherapy is not justified by clinical benefits, improved p atient comfort, or economic considerations. J Clin Oncol 16: 2700-2707 . (C) 1998 by American Society of Clinical Oncology.