Jm. Berthelot et al., Decision framework for chemotherapeutic interventions for metastatic non-small-cell lung cancer, J NAT CANC, 92(16), 2000, pp. 1321-1329
Best supportive care has long been considered to be the standard therapy fo
r metastatic non-small-cell lung cancer (NSCLC), There is now evidence from
randomized trials that a number of chemotherapy regimens can palliate canc
er-related symptoms and modestly improve survival. We show how cost-effecti
veness analyses can be used to make choices between different (ambulatory)
chemotherapy regimens. Methods: Clinical algorithms describing the diagnosi
s, staging, and treatment of metastatic NSCLC were incorporated into Statis
tics Canada's Population Health Model. Using consistent methodology, we ass
essed the cost-effectiveness of several chemotherapeutic interventions: a c
ombination of vindesine (VDS) plus cisplatin, etoposide (VP-16) plus cispla
tin, vinblastine (VLB) plus cisplatin, vinorelbine (Navelbine; NVB) plus ci
splatin, paclitaxel (Taxol) plus cisplatin, and gemcitabine (GEM) and NVB a
lone. We calculated the total chemotherapy costs in 1995 Canadian dollars,
the cost per case, the average life-years saved, and the cost per life-year
saved. Using the Population Health Model, we then constructed an advanced
decision framework that rank-ordered the various treatment regimens so as t
o optimize benefit below various cost-effectiveness thresholds, Results: On
e regimen (VLB plus cisplatin) appears to result in better survival and low
er health care expenditures than best supportive care. By use of cost-effec
tiveness thresholds of $25 000 and $50 000 per life-year gained, NVB plus c
isplatin is the preferred regimen. When quality of life is considered, howe
ver, GEM is preferred to NVB plus cisplatin at a threshold value of $50 000
. At thresholds of $75 000 and $100 000, paclitaxel plus cisplatin at a dos
e of 135 mg/m(2) is the preferred regimen. At thresholds of $50 000 and abo
ve, best supportive care is the least preferred regimen. Conclusions: This
decision framework allows the comparison of different treatment regimens ba
sed on various cost-effectiveness thresholds. Our analysis also supports th
e use of chemotherapy regimens and the abandonment of best supportive care
as the standard of care for patients with advanced NSCLC.