Pharmacoeconomics is becoming increasingly important in assessing the benefits of new (combinations of) cytotoxic drugs. In fact, in several countries, manufacturers are required to deliver a pharmacoeconomic evaluation in order to obtain reimbursement or to have their product situated in clinical guidelines, for example in the Netherlands (http://www.cvz.nl) and the UK (www.nice.org.uk). In this issue, Antonanzas et al. present an economic evaluation of the standard versus simplified De Gramont dose regimen in the treatment of patients with metastatic colorectal cancer. In particular, a cost-minimisation study design was chosen (assuming similar effectiveness for standard and simplified so-called FOLFOX and FOLFIRI regimens). For chemotherapy in particular, economic considerations are of major significance because of high treatment costs, substantial toxicity and relatively limited efficacy. For over 40 years, 5-fluorouracil, frequently combined with folinic acid, has been the main cytotoxic drug for the treatment of colorectal cancer. Over the last decade, however, new cytotoxic agents have been introduced: raltitrexed, irinotecan, oxaliplatin, and oral analogues of 5-fluorouracil, i.e. tegafur in combination with uracil (UFT) and capecitabine. In addition, novel biologically targeted therapeutics, i.e. angiogenesis inhibitors (e.g., bevacizumab), epidermal growth factor receptor (EGRF)-inhibitors (e.g., cetuximab), farnesyl transferase inhibitors, cellcycle interacting agents, non-steroid anti-inflammatory drugs, immunotherapy, and gene therapy are being clinically evaluated for both single-agent and combination strategies [1]. At present, mainly 5-fluorouracil combined with folinic acid, or capacitating, with or without irinotecan and/or oxaliplatin are chosen for the treatment of colorectal cancer in clinical practice. The use of these agents is increasing due to the addition of second and even third line chemotherapy for metastatic colorectal cancer in the case of disease progression under first line and second line treatment, respectively. In addition, adjuvant chemotherapy may be applied for the treatment of Dukes’ B or stage II colon cancer, as well as Dukes’ C or stage III colon cancer [2, 3]. Finally, elderly patients with colorectal cancer should no longer be excluded from chemotherapy, since they benefit to the same extent as younger patients from treatment with cytotoxic agents [4]. Better systemic chemotherapy has considerably improved prognosis. The median duration of survival among patients with metastatic colorectal cancer was increased from 8 months without chemotherapy to 12 months with 5-fluorouracil. The availability of irinotecan and oxaliplatin, in addition to 5-fluorouracil, further extended median survival to 21 months [5]. However, treatment with combinations of these agents is still associated with substantial toxicity. In terms of pharmacoeconomics, a comparison of different dose regimens for the treatment of colorectal cancer is complicated by several factors. First, the types of direct and indirect costs that are included in a pharmacoeconomic evaluation have to be considered carefully. Examples of direct costs are drug acquisition cost, cost for outpatient visits, for the administration of cytotoxic drugs, costs for health care use and medication to manage adverse effects, and costs for travelling to and from the hospital. Indirect costs are harder to assess, e.g. loss of productivity of the patients. For comparative purposes, dose regimens with equal efficacy are usually chosen. The main differences in costs most often refer to the incidence and severity of toxicity symptoms and the administration of the cytotoxic drugs. One should also be on the alert for the duration of the treatment courses or the number of cycles of chemotherapy being investigated. For instance, Antonanzas et al. excluded patients who have received less than three cycles of chemotherapy and subsequently may have missed patients with relatively high treatment costs because of early major toxicity. Another factor involved is the difference in health care systems between countries, leading to discrepancies in cost comparisons and actual utilization. In particular, the new chemotherapeutics are subject to varying regulations in diffe-
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