What Is the Role of Maintenance Therapy in Cancer Care?

Beth Fand Incollingo @fandincollingo | May 01, 2013
In some cases, comparable medications can come at vastly different costs, Gerber and Schiller added. They pointed to a study that compared the costs of maintenance paclitaxel and maintenance bevacizumab in ovarian cancer—both of which have been shown to substantially improve PFS—following initial therapy with carboplatin and paclitaxel. The first-line regimen plus maintenance paclitaxel had an ICER of $13,402 per quality-adjusted life-year, while the first-line regimen followed by maintenance bevacizumab raised the ICER to $326,530 per quality-adjusted life-year, they wrote.

Berger agrees that the costs of maintenance pemetrexed and bevacizumab might be considered high by payers. In countries whose governments use equations such as ICERs to decide which health services to fund, she said, such price tags could be deal breakers.

“If the quality cost per life-year is over $50,000 or $100,000,” Berger said, “they don’t cover it.”

Limits tend to be similar among American payers, but should be increased, according to Klein et al.

“The base case cost per life year gained (LYG) for maintenance therapy with pemetrexed plus best supportive care (BSC) compared with observation plus BSC may not be considered cost-effective when compared with a commonly mentioned threshold of $100,000 per LYG in the United States,” they wrote. “However, this threshold is often criticized for being outdated and not taking into consideration the severity of the condition. In addition, this threshold is not well documented in the medical literature. Braithwaite et al19 have recently developed plausible lower and upper bounds for cost-effectiveness decision rules in the United States ranging from $95,000 per LYG to $264,000 per LYG. Based on these revised thresholds, in a population with advanced, nonsquamous NSCLC, maintenance therapy with pemetrexed is cost-effective compared with observation or erlotinib.”

To better determine which therapies deserve coverage, Berger suggested, clinical trial investigators should use patient registries—databases that follow the progress of patients over time.

“They answer questions about value, like what the side effects are, whether it’s hard for somebody to continue to take the medication, and whether patients experience depression,” she said.

In the meantime, Berger said, the costs and benefits of MT and other cancer treatments need to be part of “an active discussion,” even though they’re emotional topics.

“What a life is worth financially is a very philosophical and difficult societal conversation,” she said. “It’s a discussion we’re all afraid to have, but one we can no longer shy away from.”

References

  1. American Society of Clinical Oncology. Explaining Maintenance Therapy. Cancer.Net. Updated February 22, 2010. Accessed March 28, 2013.
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  3. Paz-Ares LG, DeMarinis F, Dediu M, et al. PARAMOUNT: phase III study of maintenance pemetrexed (pem) plus best supportive care (BSC) versus placebo plus BSC immediately following induction treatment with pem plus cisplatin for advanced nonsquamous non-small cell lung cancer (NSCLC). J Clin Oncol. 2011;29(suppl; abstr CRA7510).
  4. Patel J, Socinski MA, Garon EB, et al. A randomized, open- label, phase 3, superiority study of pemetrexed (Pem)+ carboplatin (Cb)+bevacizumab (B) followed by maintenance Pem+B versus paclitaxel (Pac)+Cb+B followed by maintenance B in patients (pts) with stage IIIB or IV non-squamous nonsmall cell lung cancer (NS-NSCLC). Presented at: 2012 Chicago Multidisciplinary Symposium in Thoracic Oncology; September 7, 2012; Chicago, IL. Abstract LBPL1.
  5. Ciuleanu T, Brodowicz T, Zielinski C, et al. Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small-cell lung cancer: a randomised, double-blind, phase 3 study. Lancet. 2009; 374(9699):1432-1440.
  6. Neal JW. The SATURN trial: the value of maintenance erlotinib in patients with non-small-cell lung cancer. Future Oncol. 2010;6(12):1827-1832.
  7. Fidias PM, Dakhil SR, Lyss AP, et al. Phase III study of immediate compared with delayed docetaxel after front-line therapy with gemcitabine plus carboplatin in advanced non-small-cell lung cancer. J Clin Oncol. 2009;27(4):591-598.
  8. Gerber DE, Schiller JH. Maintenance chemotherapy for advanced non-small-cell lung cancer: new life for an old idea. J Clin Oncol. 2013;31(8):1009-1018.
  9. Soon YY, Stockler MR, Askie, LM, Boyer MJ. Duration of chemotherapy for advanced non-small-cell lung cancer: a systematic review and meta-analysis of randomized trials. J Clin Oncol. 2009;27:3277-3283.
  10. da Silveira Nogueira Lima JP, dos Santos LV, Sasse EC, Sasse AD. Optimal duration of first-line chemotherapy for advanced non-small cell lung cancer: A systematic review with meta-analysis. EJC. 2009;45(4):601-607.
  11. Behera M, Owonikoko TK, Chen Z, et al. Single agent maintenance therapy for advanced stage non-small cell lung cancer: a meta-analysis. Lung Cancer. 2012;77(2):331-338.
  12. Zhang X, Zang J, Xu J, et al. Maintenance therapy with continuous or switch strategy in advanced non-small cell lung cancer: a systematic review and meta-analysis. Chest. 2011;140(1):117-126.
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  14. IM YH, Park YH, Jung KH, et al. A phase III, multicenter, randomized trial of maintenance versus observation after achieving clinical response in patients with metastatic breast cancer who received six cycles of gemcitabine plus paclitaxel as first-line chemotherapy (KCSG-BR 0702, NCT00561119). Ann Oncol. 2012;23(suppl 11):xi6-xi8.
  15. Gennari A, Stockler M, Puntoni M, et al. Duration of chemotherapy for metastatic breast cancer: a systematic review and meta-analysis of randomized clinical trials. J Clin Oncol. 2011;29(16):2144-2149.
  16. Markman M, Liu PY, Wilczynski S, et al. Phase III randomized trial of 12 versus 3 months of maintenance paclitaxel in patients with advanced ovarian cancer after complete response to platinum and paclitaxel-based chemotherapy: A Southwest Oncology Group and Gynecologic Oncology Group Trial. J Clin. Oncol. 2003;21[13]:2460-2465.
  17. Abaid LN, Goldstein BH, Micha JP, Rettenmaier MA, Brown, JV III, Markman M. Improved overall survival with 12 cycles of single-agent paclitaxel maintenance therapy following a complete response to induction chemotherapy in advanced ovarian carcinoma. Oncology. 2010;78(5-6):389-393.
  18. Klein R, Wielage R, Muehlenbein C, et al. Cost-effectiveness of pemetrexed as first-line maintenance therapy for advanced nonsquamous non-small cell lung cancer. J Thorac Oncol. 2010;5(8):1263-1272.
  19. Braithwaite RS, Meltzer DO, King JT Jr, et al. What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule? Med Care. 2008;46:349–356.



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