Economics and Quality of Life in Oncology Clinical Practice

Pharmacoeconomics and outcomes research are two new sciences that are beginning to affect the practice of oncology. As cost awareness in cancer care becomes acute, practicing oncologists must understand how to apply these sciences to their practices. This publication represents the proceedings of the symposium, Economics and Quality of Life in Oncology Clinical Practice, which was held on November 19, 1997, on the occasion of the EORTC meeting during The First European Conference on the Economics of Cancer. The presentations at the symposium provided an overview of some studies that have begun to explore the variety of activities comprising outcomes assessment, and how such data can be used to help deliver high quality patient care in a cost-conscious environment.

Bruce E. Hillner, MD, from the Medical College of Virginia in Richmond, Virginia, presented results of a post hoc economic analysis of treatment of advanced non-small-cell lung cancer. His analysis used findings from a previous randomized trial, conducted by Le Chevalier and colleagues, of 612 patients who received vinorelbine alone, vinorelbine plus cisplatin, or vindesine plus cisplatin. Results showed that the vinorelbine/cisplatin regimen was most effective in terms of mean survival and at an acceptable cost-effectiveness; and vinorelbine monotherapy had the lowest costs due to fewer required antiemetic agents and laboratory tests.

Another economic analysis of non-small-cell lung cancer treatment was reported by William K. Evans, MD, FRCPC from the Ottawa Regional Cancer Centre in Ottawa, Ontario, Canada. This analysis used Statistics Canada’s Population Health Model to determine the costs of managing stage IV non-small-cell lung cancer patients with any of the three regimens assessed in the study by Le Chevalier et al, as well as other standard regimens (ie, vinblastine/cisplatin and etoposide/cisplatin), against best supportive care. They found that the cost-effectiveness of each of the regimens was within an acceptable range for health care interventions in Canada. These data, along with results from meta-analyses demonstrating a survival advantage in non-small-cell lung cancer patients who receive treatment, show that the perceived high costs of treatment should not deter physicians from prescribing chemotherapy for such patients.

Quality of life issues regarding treatment of metastatic breast cancer were presented by Robert W. Carlson, MD, from Stanford University Medical Center in Palo Alto, California. He emphasized that consideration of quality of life is critical in this setting because the toxicity of treatment must be weighed against the often modest gains in survival it produces, and because the primary goal of therapy is often palliation. He pointed out that several trials have shown that response to treatment is associated with an improved quality of life. Furthermore, new hormonal and cytotoxic agents active against breast cancer, including the taxanes and vinorelbine, have become available, some of which may offer quality of life advantages, such as decreased toxicity and increased ease of administration.

Gary R. Morrow, PhD, MS, from the University of Rochester Cancer Center in Rochester, New York, discussed prevention of nausea and vomiting to improve quality of life of cancer patients. His report of a multicenter study of 1,413 cancer patients showed that occurrence of nausea and vomiting after the first chemotherapy treatment predicted occurrence of nausea and vomiting as well as anticipatory nausea in subsequent courses. While these findings argue for aggressive antiemetic control at the time of initial treatment, supportive care costs (including costs of antiemetic therapy) are a current focus of pharmacoeconomic analyses of cancer care. Steven M. Grunberg, MD, from the University of Vermont College of Medicine in Burlington, Vermont, stated that a full accounting of the costs of antiemetic therapy should include, in addition to drug acquisition costs, the potential cost savings that could result from avoiding the complications of poorly controlled nausea and vomiting. Furthermore, one needs to consider the substantial quality-of-life benefits patients may experience with effective antiemetic therapy. The most appropriate pharmacoeconomic assessment method for oncologic supportive care is cost-utility analysis, which takes patients’ quality of life into account in assessing whether the benefits of therapy justify its costs. Dr. Grunberg and colleagues are conducting pilot studies to determine the utility scores needed for such an analysis.

The increasing use of oral chemotherapy may also reduce overall oncologic treatment costs while improving quality of life through more convenient therapy for patients. F. Anthony Greco, MD, from the Sarah Cannon—Minnie Pearl Cancer Center, in Nashville, Tennessee, reviewed several oral agents commonly used for the treatment of cancer, such as oral etoposide and cyclophosphamide, and other agents being studied or under development. One such agent is GW776C85, a new dihydropyrimidine dehydrogenase (DPD) inactivator. As reported by Robert B. Diasio, MD, from the University of Alabama in Birmingham, Alabama, this agent coadministered with 5-fluorouracil in the preclinical setting resulted in desirable pharmacologic effects; and initial clinical studies suggest increased antitumor efficacy in some malignancies when GW776C85 and 5-fluorouracil were coadministered orally. In addition, GW776C85 offers the possibility of giving oral 5-fluorouracil with more predictable pharmacokinetics relative to other approaches due to inactivation of DPD. Clinical studies are under way or planned to confirm these findings and to determine whether toxicities are reduced in patients receiving GW776C85 with 5-FU compared with those receiving continuous infusion 5-FU.