Cost-effectiveness analysis of cetuximab/irinotecan vs active/best supportive care for the treatment of metastatic colorectal cancer patients who have failed previous chemotherapy treatment.

Cost-effectiveness analysis of cetuximab/irinotecan vs active/best supportive care for the treatment of metastatic colorectal cancer patients who have failed previous chemotherapy treatment N Starling, D Tilden, J White and D Cunningham British Journal of Cancer, 2007, 96, 206-212

The advent of the integration of new biological agents with cytotoxic drugs, such as irinotecan and oxaliplatin, represents an important scientific and clinical advance in the management of metastatic colorectal cancer and heralds a new therapeutic era for the disease. Given the high costs of these novel agents, the question arises as to whether these drugs should be made available without restriction. It is important that physicians, insurers, patients and policymakers understand the relationship between cost and outcome of new cancer treatments.

The purpose of this analysis was to compare cost-effectiveness of cetuximab/irinotecan versus the active/best supportive care (ASC/BSC), where ASC is defined as the best care available and may include chemotherapy, and the BSC includes different types of supportive interventions but excludes chemotherapy.

The economic evaluation presented is an indirect comparison because of the absence of a direct trial of cetuximab versus ASC/BSC: data from the trial reported by Cunningham et al. in 2004 [1], which compared cetuximab/irinotecan versus cetuximab monotherapy, and the trial reported by Cunningham et al. in 1998 [2], which compared irinotecan monotherapy with supportive care, are used for the effectiveness estimates. Cetuximab/irinotecan was associated with an increase in survival of 0.44 discounted life-years per patient: life-expectancy was 11.01 months with cetuximab/irinotecan versus 9.64 months with cetuximab monotherapy versus 5.64 months with ASC/BSC. Both the incremental cost per life-year gained and the incremental cost per quality-adjusted life-year were very high; but perhaps we would have expected this because cetuximab (together with bevacizumab) is the most expensive biological agent.

In conclusion, we would need a direct comparison between cetuximab/irinotecan and ASC/BSC in order to define the 'rule of rescue' of such an expensive, but promising treatment for patients with low life expectancy. Cost-containment in oncology is a moral issue: treatments have a price but this does not logically imply that patients have a price.

References

[1.] Cunningham D, Pyrhonen S, Jones RD et al. Randomised trial of irinotecan plus supportive care versus supportive care alone after fluorouracil failure for patients with metastatic colorectal cancer. Lancet, 1998, 352, 1413-1418.

[2.] Cunningham D, Humblet Y, Siena S et al. Cetuximab monotherapy and cetuximab plus irinotecan in irinotecanrefrectory metastatic colorectal cancer. N Engl J Med, 2004, 351, 337-345.