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Making comparative effectiveness work in cancer care

Making comparative effectiveness work in cancer care

ABSTRACT: Patient preference needs to be weighed against overall societal benefits.

When pundits and politicos want to talk up the current healthcare reform plan in the U.S., they drop the term comparative effectiveness somewhere in the conversation. Given that more than $1.1 billion of the 2009 federal economic stimulus bill was allocated for comparative effectiveness research, it is one of the key elements driving the reform movement.

Comparative effectiveness is being used in cancer care in particular, as payers weigh the cost of treatment against its value to the patient. Two recent studies looked at comparative effectiveness in breast and ovarian cancer as well as in prostate cancer.

Prevention interventions

Victor Grann, MD, MPH, and colleagues at New York's Columbia University compared various prevention interventions in women at increased risk of ovarian or breast cancer. Dr. Grann's group used a Markov model with 25,000 Monte Carlo simulations to conduct a comparative effectiveness analysis of a simulated cohort of women with BRCA1/2 mutations. All women in the cohort were aged 30 to 65, had tested positive for a BRCA mutation, and had no cancer at baseline.

Using cost in dollars per life year saved and per quality-adjusted life year (QALY) saved, the investigators compared mammography with and without MRI, prophylactic oophorectomy or mastectomy or both, and chemoprevention with tamoxifen. Costs were based on the literature and expressed in 2009 dollars, and survival was based on SEER data and published studies of surgical, chemoprevention, and imaging interventions (ASCO 2010 abstract 6011).

The study found that prophylactic surgery was the most cost-effective intervention for women at increased risk of ovarian cancer (BRCA1 carriers) and breast cancer (BRCA1 and BRCA2 carriers). Of the preventive surgical options, prophylactic oophorectomy was the most cost-effective strategy for BRCA1 carriers: $1,741/QALY saved. For BRCA2, oophorectomy was $4,587 compared to both prophylactic oophorectomy and mastectomy procedures.

However, patients preferred screening modalities to surgical intervention. In breast cancer, MRI screening was associated with the longest quality-adjusted survival. For patients with the BRCA1 mutation, MRI and mammography provided 18.66 QALYs at a cost of $192,418 (at a discount rate of 3%). For patients with a BRCA2 mutation, MRI and mammography provided 19.12 QALYs at a cost of $177,934.

JULIA H. HAYES, MD
JULIA H. HAYES, MD

Based on their model, the investigators estimated that if the cost of MRI could be reduced by more than 50%, the use of MRI would be the most cost-effective of the studied interventions.

Emphasizing the importance of prevention to reverse the effects of having a mutation, Dr. Grann said that choosing an intervention requires that patients be informed of the harms and benefits of each strategy. "They should also appreciate the value of clinical trials to determine which prevention is better," he said.

"It is very important to do randomized trials of high-risk women who have mutations to determine whether the simulations we performed in our models offer the same real-world benefits," added Dr. Grann, who is a clinical professor of medicine and public health at the Herbert Irving Comprehensive Cancer Center and Joseph L. Mailman School of Public Health at Columbia.

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