Background
Methods
Literature search
Study selection
Data extraction
Quality assessment
Structural uncertainty
Methodological uncertainty
Parameter uncertainty
Results
Literature search
Characteristics of studies included in the review
Study Country | Perspective/ Time Horizon | Type of Model/ economic evaluation | Aromatase Inhibitor | Population Studied (Age at entry) |
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Ye, M. et al[11] (2018) China | Chinese Healthcare system/ Lifetime | Markov CEA | Letrozole | Postmenopausal women with newly diagnosed early ER + ve BC after lumpectomy, 57 yrs (27–79 yrs) |
Djalalov, S. et al[12] (2015) Canada | Canadian health system/ Lifetime | Markov CEA | Treated the AI drug class as a group without reference to a specific drug | Postmenopausal women with ER + ve early BC, 65 yrs |
Shih, V.et al[13] (2012) Singapore | Societal/ Lifetime | Markov CEA and CUA | Anastrozole | Postmenopausal women with HR + ve early-stage BC who had completed primary therapy, 64 yrs |
Mould-Quevedo[10] et al. (2011) Mexico | Healthcare payers/ 10 years | Markov CEA | Anastrozole Letrozole Exemestane | Postmenopausal HR + BC females. The cohort was divided into two groups. One for females with positive lymph nodes (LN+) and one for females with negative lymph nodes (LN-) NR |
Lux, M. et al.[15] (2011) Germany | Healthcare system/ 20 years | Hybrid and Markov CBA* | Anastrozole Letrozole | Postmenopausal women with HR + ve BC, 76–80 yrs |
Gamboa et al[17] (2010) Colombia | Colombian health care system/ 30 years | Markov CEA | Anastrozole | Postmenopausal women with ER + ve early BC, 50 yrs |
Lee, et al[16] (2010) Korea | Societal/ 35 years | Markov CEA | Anastrozole Letrozole | Postmenopausal women with HR + ve early BC, 50 yrs |
Lux, M. et al.[14] (2010) Germany | German healthcare system/ 25 years | Markov CEA | Anastrozole | Postmenopausal women with HR + ve early BC, 64 yrs |
Author | Source of Data | Outcomes | Type of sensitivity analysis | ICER conversion to I$ 2021 | Findings |
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Ye, M. et al. [11] | Effectiveness: published randomized clinical trials meta-analyses (EBCTCG). Costs: from published Chinese studies. | - Progression-free LY’s - Overall LY’s - QALYs | - PSA (second-order Monte Carlo technique) - One-way sensitivity analyses | 11,510/QALY | Adjuvant endocrine therapy with Letrozole is a cost-effective strategy compared to tamoxifen in women with early BC |
Djalalov, S.et al [12] | Effectiveness: Medical literature, meta-analysis (BIG 1–98 trial and ATAC trial) Costs: Ontario Ministry of Health and Long-Term Care, Ontario Drug Benefit Formulary Costs, published Canadian studies. | QALY’s (Utility weights) | - PSA (Monte Carlo simulation) - Deterministic sensitivity analysis | NR | In postmenopausal women with ER + ve early BC, strategies using AIs appear to provide more benefit than strategies using TAM alone. Sequential strategies using TAM and an AI appear to provide benefits similar to those provided by upfront AI but at lower cost |
Shih, et al [13] | Effectiveness: ATAC trial, interviews with oncology nurses, local financial electronic databases, published literature Costs: were obtained via financial electronic databases of the NCCS and the Singapore General Hospital | - Cost per LY survival - Cost per QALY gained | Multiple one-way sensetivity analyses | ICER of anastrozole was: − 242,815/ LY − 133,536 / QALY gained | If the WHO recommendation of 1 to 3x GDP range is an acceptable threshold, anastrozole is deemed cost-effective compared with tamoxifen in the treatment of early-stage BC |
Mould-Quevedo,et al [10] | Effectiveness: Probabilities derived from published data. Costs: obtained from the Mexican Social Security Institute | - Non- recurrence rate - Time to recurrence | PSA (2nd order Monte Carlo simulation) | NR | Sequential treatment with tamoxifen/ exemestane appeared to be a cost-effective alternative among the therapies, which includes an aromatase inhibitor for women with BC in Mexico |
Lux, M. et al. [15] | Effectiveness: BIG 1–98 study, ATAC study, and EBCTG study Costs: generic prices | - Recurrence rate - Overall survival - QALY (Utility weights) | PSA (Monte Carlo simulation with 2000 scenarios). | - ICER for anastrozole is 206,256 /QALY - ICER for letrozole is 45,019/QALY | The present model, including the inverse probability of censoring weighted analysis (IPWC) for letrozole and generic prices for both AIs shows that letrozole is cost-effective. |
Gamboa, et al [17] | Effectiveness: Literature Costs: Treatment and adverse events costs derived from information provided by several health service providers over a period of 12 months. Relapse costs based on the individual costs for 23 women provided by the National Institute of Cancer | - Survival - Time free from disease | - PSA - One- way sensitivity analysis | - Non-discounted ICER = 29.51 /LY - Discounted ICER = 40.35/ LY | Compared to tamoxifen, adjuvant therapy with anastrozole yields an additional 0.49 disease-free years. The additional cost per disease-free year gained is 37,071 Colombian pesos. Tamoxifen has a higher probability of being cost-effective at all WTP points considered in the analysis |
Lee, et al [16] | Effectiveness: published studies (EBCTCG meta-analysis, the ATAC trial, and the BIG 1–98 trial) Costs: Drug costs were based on the 2009 pharmaceutical prices that were weighted by the prescription volume, which was issued by the Korean Health Insurance Review and Assessment Service (HIRA) in the first half year of 2009 | - QALY’s - LY | Deterministic sensitivity analysis | - for anastrozole 31,858 - for letrozole 29,791 | Anastrozole and letrozole were both cost-effective treatments compared to tamoxifen. When anastrozole and letrozole were compared indirectly in the overall population, their cost-effectiveness ratios were too similar to decide which treatment was superior to the other When the population was divided by nodal status, anastrozole was more cost-effective than letrozole in the node-negative group, and letrozole was more effective in the node-positive group |
Lux, M. P. et al. [14] | Effectiveness: published literature and expert opinion (ATAC trial) Costs: costs were derived from standard sources. | - QALY - Overall survival | - Scenario analyses - Deterministic sensitivity analysis - PSA | for anastrozole compared to tamoxifen was 32,616/QALY gained | Adjuvant treatment with anastrozole for postmenopausal women with HR + EBC is a cost-effective alternative to tamoxifen |
Quality assessment
Ye, M.et al [11] | Djalalov, S.et al [12] | Shih, et al. [13] | Mould-Quevedo,et al. [10] | Lux, M.et al [15] | Gamboa,et al. [17] | Lee, et al. [16] | Lux, M.et al [15] | |||||||||||
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Title | ||||||||||||||||||
1 | Title | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
Abstract | ||||||||||||||||||
2 | Abstract | √ | √ | √ | √ | √ | √ | x | √ | |||||||||
Introduction | ||||||||||||||||||
3 | Background and objectives | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
Methods | ||||||||||||||||||
4 | Health economic analysis plan | x | x | x | x | x | x | x | x | |||||||||
5 | Study population | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
6 | Setting and location | √ | √ | √ | √ | √ | x | √ | √ | |||||||||
7 | Comparators | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
8 | Perspective | √ | x | √ | √ | √ | √ | √ | √ | |||||||||
9 | Time horizon | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
10 | Discount rate | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
11 | Selection of outcomes | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
12 | Measurement of outcomes | √ | √ | √ | x | √ | √ | √ | √ | |||||||||
13 | valuation of outcomes | √ | √ | √ | x | √ | x | √ | √ | |||||||||
14 | Measurement and valuation of resources and costs | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
15 | Currency, price date, and conversion | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
16 |
Rationale and description of model
| √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
17 | Analytics and assumptions | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
18 | Characterizing heterogeneity | √ | x | √ | x | x | √ | √ | x | |||||||||
19 | Characterizing distributional effects | x | x | x | x | x | x | x | x | |||||||||
20 | Characterizing uncertainty | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
21 | Approach to engagement with patients and others affected by the study | x | x | x | x | x | x | x | x | |||||||||
Results | ||||||||||||||||||
22 | Study parameters | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
23 | Summary of main results | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
24 | Effect of uncertainty | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
25 | Effect of engagement with patients and others affected by the study | √ | x | x | x | x | x | x | x | |||||||||
Discussion | ||||||||||||||||||
26 | Study findings, limitations, generalizability, and current knowledge | √ | √ | √ | √ | √ | √ | √ | √ | |||||||||
Other Relevant Information | ||||||||||||||||||
27 | Source of funding | √ | √ | √ | √ | √ | √ | x | √ | |||||||||
28 | Conflicts of interest | √ | √ | √ | √ | x | √ | x | x |