Cost-Effectiveness of Chemotherapy in Non–Small-Cell Lung Cancer
Authors: Selin Saglam, Begüm Yetis, Ozgür Ozyilkan, Zafer Akçali, Natasha B. Leighl, Frances A. Shepherd, Pamela J. Goodwin
Journal: Journal of Clinical Oncology (2002)

Article Tools SPECIAL DEPARTMENTS Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/JCO.2002.99.136 Journal of Clinical Oncology - published online before print September 21, 2016 PMID: 12202680 Cost-Effectiveness of Chemotherapy in Non–Small-Cell Lung Cancer Selin SaglamxSelin SaglamSearch for articles by this author , Begüm YetisxBegüm YetisSearch for articles by this author , Ozgür OzyilkanxOzgür OzyilkanSearch for articles by this author , Zafer AkçalixZafer AkçaliSearch for articles by this author Natasha B. LeighlxNatasha B. LeighlSearch for articles by this author , Frances A. ShepherdxFrances A. ShepherdSearch for articles by this author , Pamela J. GoodwinxPamela J. GoodwinSearch for articles by this author Show More Baskent University, Ankara, TurkeyPrincess Margaret Hospital/University Health Network and, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada https://doi.org/10.1200/JCO.2002.99.136 First Page Full Text PDF Figures and Tables © 2002 by American Society of Clinical OncologyjcoJ Clin OncolJournal of Clinical OncologyJCO0732-183X1527-7755American Society of Clinical OncologyResponse01092002In Reply:We agree with Drs Saglam et al and would certainly prefer to prevent or cure lung cancer rather than palliate our patients who have this disease. There is no argument that the eradication of tobacco use would bring us closer to decreasing the incidence of lung cancer and other tobacco-related diseases around the world.When given as second-line palliative chemotherapy to fit patients with advanced non–small-cell lung cancer, docetaxel at the recommended dose of 75 mg/m2 every 3 weeks yields a modest median survival improvement of 2.9 months over best supportive care (7.5 v 4.6 months, P = .01).1 One-year survival in chemotherapy-treated patients in the TAX 317 randomized trial was 37% with the recommended dose of docetaxel, compared with 11% for those patients randomized to best supportive care alone. Palliative treatment with docetaxel was also associated with greater clinical benefit and with less need for pain medications and palliative radiotherapy. This improvement in palliative care for lung cancer yields modest benefits, similar to those achieved with first-line palliative chemotherapy in lung cancer. The intervention is suitable for a select, small population of fit, interested patients with advanced lung cancer who have received prior chemotherapy.Our analysis estimates that the cost per year of life gained from this treatment is $31,776 (1999 Canadian dollars), at the recommended dose of 75 mg/m2 every 3 weeks.2 This is in the range of cost-effectiveness for other health care expenditures, palliative or otherwise. Best supportive care is less expensive in the second-line setting, but it is inferior with respect to survival and clinical benefit.Improvements in palliative treatment should not lead to complacency in our efforts to prevent and/or cure lung cancer. Smoking-related illness results in billions of dollars of health care expenditure and lost productivity.3 Smoking cessation campaigns, although expected to yield cessation in only 1% to 2% of the smoking population,4 are important and must not be neglected as a component of primary prevention of cancer and other diseases. Smoking cessation strategies are also cost effective. In one study, physician counseling cost as little as $705 to $988 per year of life saved in men and $1,204 to $2,058 in women (1984 US dollars).5 Another study estimated the incremental cost-effectiveness of adding nicotine gum to counseling at $4,113 to $6,465 per year of life saved for men and $6,880 to $9,473 for women (1984 US dollars).6 Thus we agree that global eradication of tobacco use and smoking-related illnesses has the potential to yield substantial health benefits to many, as opposed to docetaxel’s modest palliative benefit to a few.The rational allocation of health care resources to maximize society’s health benefits is a complex undertaking. Use of cost-effectiveness ratios alone to determine what interventions will be funded in a health system can lead to unsatisfactory results, as seen in the state of Oregon in the late 1980s. Interventions need to be evaluated against their alternatives, and their health effects need to be valued not just from the patient’s perspective but also from the community’s perspective. For example, a “life-year” gained in an older individual through palliative chemotherapy may not be as valuable to society as a life-year gained from a renal transplant in a younger individual, who is more likely to return to the workforce. Concepts of equity, community compassion, and the societal impact of adopting an intervention must also be considered. In the grading system put forth by Laupacis et al7 for the adoption and appropriate utilization of new technologies, palliative docetaxel would be graded as having moderate evidence for adoption, as it is more effective than supportive care alone but likely costs between US $20,000 to US $100,000 per quality of life-years gained. This may be compelling enough to adopt second-line docetaxel therapy in some countries, but not in others. The decision to adopt this therapy or not, after reviewing the proven palliative benefit over supportive care, will rest on each country’s assessment of available funding, the patient and community perspectives, and competing programs.1. Shepherd FA, Dancey J, Ramlau R, et al: Prospective randomized trial of docetaxel versus best supportive care in patients with non-small-cell lung cancer previously treated with platinum-based chemotherapy. J Clin Oncol 18:: 2095,2000-2103, Link, Google Scholar2. Leighl NB, Shepherd FA, Kwong R, et al: Economic analysis of the TAX 317 trial: Docetaxel versus best supportive care as second-line therapy of advanced non–small-cell lung cancer. J Clin Oncol 21:: 1344,2002-1352, Google Scholar3. Rice DP, Hodgson TA, Sinsheimer P, et al: The economic costs of the health effects of smoking. Milbank Q 64:: 489,1986-547, Crossref, Medline, Google Scholar4. Bains N, Pickett W, Hoey J: The use and impact of incentives in population-based smoking cessation programs: A review. Am J Health Promotion 12:: 307,1998-320, Crossref, Medline, Google Scholar5. Cummings SR, Rubin SM, Oster G: The cost-effectiveness of counseling smokers to quit. JAMA 261:: 75,1989-79, Crossref, Medline, Google Scholar6. Oster G, Huse DM, Delea TE, et al: Cost-effectiveness of nicotine gum as an adjunct to physician’s advice against cigarette smoking. JAMA 256:: 1315,1986-1318, Crossref, Medline, Google Scholar7. Laupacis A, Feeny D, Detsky AS, et al: How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J 146:: 473,1992-481, Medline, Google Scholar