What is the Clinical and Cost Effectiveness of Erythropoietin-Stimulating Agents for the Treatment of Patients with Cancer-Treatment Induced Anaemia? Insights from Cumulative Meta-Analyses (Cma) and Lessons for Cost-Effectiveness Analyses

Abstract

ABSTRACT Aim: A health technology assessment (HTA) informing the recent NICE guidance use of erythropoiesis-stimulating agents (ESA) in cancer-treatment induced anaemia (CIA) identified uncertainty around precision and the direction of overall survival hazard ratio (OSHR). It also found that cost-effectiveness results were extremely sensitive to changes in OSHR. We investigate how the understanding of OS in CIA patients treated with ESAs has shaped over time and the effects of accumulating OS evidence on cost-effectiveness. Methods: CMA was applied to the HTA review OS data to identify patterns in results; study results were accumulated by the year of publication. As with the HTA review a random effects model was assumed. The annual OSHR results from the CMA were applied to an economic model developed in the HTA to calculate long term quality-adjusted life year (QALY) gains and the corresponding incremental cost-effectiveness ratios. Results: Although the precision of the OSHR estimate appeared to be improving with additional evidence, the true location of the estimate remained uncertain and the best estimate varied over time; no conclusive patterns were identified. Using the CMA, results from 2001 and 2002 suggested survival benefits to using ESAs (0.77, 95% CI 0.60–0.98 and 0.78, 95% CI 0.65–0.93 respectively), with ESAs being cost-effective at a willingness to pay threshold of £30,000 per QALY, even at the upper limit of the OSHR 95% confidence interval. Apart from the 2001 and 2002 results, the CMA for other years, including the most recent estimates and including the overall estimate, did not suggest any significant effects of ESAs on OS. Conclusions: CMA results confirm the lack of stability of OSHR. The possibility that there is no difference in OS for patients receiving ESAs compared to those who do not cannot be rejected, nor is there sufficient evidence to support this conclusion. This analysis also highlights the additional uncertainty of the current evidence base on cost-effectiveness analyses, which cannot be captured in standard sensitivity analyses. Disclosure: All authors have declared no conflicts of interest.