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Cost-Effectiveness of Chemotherapy Sequences in Metastatic Breast Cancer According to Prior Therapy Exposure


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In a modeling study reported in the Journal of Clinical Oncology, Stephanie B. Wheeler, PhD, MPH, and colleagues identified the most cost-effective sequences of single-agent chemotherapy regimens among patients with endocrine-refractory or triple-negative metastatic breast cancer according to prior taxane and anthracycline exposure.

As stated by the investigators, “Treatments for endocrine-refractory or triple-negative metastatic breast cancer are modestly effective at prolonging life and improving quality of life but can be extremely expensive. Given these tradeoffs in quality of life and cost, the optimal choice of treatment sequencing is unclear. Cost-effectiveness analysis can explicitly quantify such tradeoffs, enabling more informed decision-making. Our objective was to estimate the societal cost-effectiveness of different therapeutic alternatives in the first- to third-line sequences of single-agent chemotherapy regimens….”


In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.
— Stephanie B. Wheeler, PhD, MPH, and colleagues

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Study Details

In the analysis, with use of three dynamic microsimulation models of 10,000 patients, three cohorts were simulated based on prior chemotherapy exposure: taxane- and anthracycline-naive, taxane- and anthracycline-exposed, and taxane-exposed/anthracycline-naive. Cost-effective analysis was performed for sequences of single-agent chemotherapy regimens consider to be reasonable and commonly used options in the first three lines of therapy for each cohort based on information from oncologists treating endocrine-refractory or triple-negative metastatic breast cancer.

Key Findings

Overall, accumulated quality-adjusted life-years (QALYs) were similar between regimens in each cohort, but total societal costs showed considerable variation.

For the taxane- and anthracycline-naive cohort, chemotherapy options were paclitaxel, capecitabine, or pegylated liposomal doxorubicin. Modeling indicated that the sequences paclitaxel, capecitabine, pegylated liposomal doxorubicin, and paclitaxel, pegylated liposomal doxorubicin, capecitabine dominated in cost-effectiveness (higher expected QALYs and lower costs) compared to all other sequences leading with capecitabine or pegylated liposomal doxorubicin in the first line.

For the taxane- and anthracycline-exposed cohort, chemotherapy options were eribulin, capecitabine, and carboplatin. Modeling indicated that sequences starting with carboplatin dominated all others.

For the taxane-exposed/anthracycline-naive cohort, chemotherapy options were pegylated liposomal doxorubicin, capecitabine, and eribulin. Modeling indicated that sequences beginning with capecitabine and pegylated liposomal doxorubicin produced the highest number of QALYs and dominated sequences starting with eribulin. It was found that following capecitabine with eribulin would unlikely be of higher value than following capecitabine with pegylated liposomal doxorubicin due to the lower cost of pegylated liposomal doxorubicin vs eribulin.

The investigators concluded: “Sequences beginning first-line treatment with paclitaxel, carboplatin, and capecitabine in the three respective cohorts had lower costs and similar or slightly better outcomes compared with alternative options…. In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.”

Dr. Wheeler, of UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, is the corresponding author for the Journal of Clinical Oncology article.

Disclosure: The study was supported by the Centers for Disease Control and Prevention through the Prevention Research Centers Program. For full disclosures of the study authors, visit ascopubs.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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