Cost-effectiveness of adding cetuximab to platinum-based chemotherapy for first-line treatment of recurrent or metastatic head and neck cancer.

Malek B Hannouf,Chander Sehgal,Gregory S Zaric,Joseph D Mocanu,Jeffrey Q Cao,Eric Winquist,Yoel Lubell

doi:10.1371/journal.pone.0038557

Abstract

PurposeTo assess the cost effectiveness of adding cetuximab to platinum-based chemotherapy in first-line treatment of patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) from the perspective of the Canadian public healthcare system.MethodsWe developed a Markov state transition model to project the lifetime clinical and economic consequences of recurrent or metastatic HNSCC. Transition probabilities were derived from a phase III trial of cetuximab in patients with recurrent or metastatic HNSCC. Cost estimates were obtained from London Health Sciences Centre and the Ontario Case Costing Initiative, and expressed in 2011 CAD. A three year time horizon was used. Future costs and health benefits were discounted at 5%.ResultsIn the base case, cetuximab plus platinum-based chemotherapy compared to platinum-based chemotherapy alone led to an increase of 0.093 QALY and an increase in cost of $36,000 per person, resulting in an incremental cost effectiveness ratio (ICER) of $386,000 per QALY gained. The cost effectiveness ratio was most sensitive to the cost per mg of cetuximab and the absolute risk of progression among patients receiving cetuximab.ConclusionThe addition of cetuximab to standard platinum-based chemotherapy in first-line treatment of patients with recurrent or metastatic HNSCC has an ICER that exceeds $100,000 per QALY gained. Cetuximab can only be economically attractive in this patient population if the cost of cetuximab is substantially reduced or if future research can identify predictive markers to select patients most likely to benefit from the addition of cetuximab to chemotherapy.

Highlights

There were approximately 4550 new cases of head and neck cancers diagnosed in Canada in 2010 [1]
Cetuximab plus platinum-based chemotherapy compared to platinum-based chemotherapy alone led to an increase of 0.093 QALY per person and an increase in cost of $36,000 per person, resulting in an incremental cost effectiveness ratio (ICER) of $386,000 per QALY gained
The ICER remains above $200,000 per QALY when we changed these variables in one way, two way and three way sensitivity analyses

Summary

Introduction

There were approximately 4550 new cases of head and neck cancers (excluding thyroid cancer and melanoma) diagnosed in Canada in 2010 [1]. Treatment may include surgery and definitive radiation therapy, with or without concurrent chemotherapy. The main manifestations of treatment failure are loco-regional recurrences and distant metastatic disease. Management of recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) that is inoperable and not amenable to re-irradiation usually involves systemic chemotherapy, with platinum-based combinations being the most commonly used regimens [2]. Regardless of the choice of chemotherapy, this patient population has a poor prognosis with a median survival of six to eight months [3]. Cetuximab (Erbitux) is a chimeric IgG1 monoclonal antibody that competitively inhibits transforming growth factor-a (TGF-a) ligand from binding to epidermal growth factor receptor (EGFR), resulting in inhibition of tumour growth, invasion and metastasis, DNA damage repair and angiogenesis [4,5,6]

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