Academic journal article Applied Health Economics and Health Policy

Cost Effectiveness of Pegfilgrastim versus Filgrastim after High-Dose Chemotherapy and Autologous Stem Cell Transplantation in Patients with Lymphoma and Myeloma: An Economic Evaluation of the PALM Trial

Academic journal article Applied Health Economics and Health Policy

Cost Effectiveness of Pegfilgrastim versus Filgrastim after High-Dose Chemotherapy and Autologous Stem Cell Transplantation in Patients with Lymphoma and Myeloma: An Economic Evaluation of the PALM Trial

Article excerpt

Published online: 23 February 2013

© Springer International Publishing Switzerland 2013

Abstract

Background Use of the recombinant human granulocyte colony-stimulating factor (rhG-CSF) filgrastim accelerates neutrophil recovery following myelosuppressive chemo- therapy. Since filgrastim requires multiple daily administrations, forms of rhG-CSF with a longer half life, including pegfilgrastim, have been developed. Pegfilgrastim is safe and effective in supporting neutrophil recovery and reducing febrile neutropenia after conventional chemotherapy. Peg- filgrastim has also been successfully used to support patients undergoing peripheral blood stem cell (PBSC) transplanta- tion for haematological malignancies. To our knowledge, no cost-effectiveness analysis (CEA) of pegfilgrastim in this setting has been published yet.

Objective We undertook a CEA to compare a single injection of pegfilgrastim versus repeated administrations of filgrastim in patients who had undergone PBSC transplanta- tion for lymphoma or myeloma. The CEA was set in France and covered a period of 100 ± 10 days from transplant.

Methods The CEA was designed as part of an open-label, multicentre, randomized phase II trial. Costs were assessed from the hospital's point of view and are expressed in 2009 euros. Costs computation focused on inpatient, outpatient, and home care. Costs in the two arms of the study were compared using the Mann-Whitney test. When dif- ferences were statistically significant, multiple regression analyses were performed in order to identify cost drivers. Incremental cost-effectiveness ratios (ICER) were calcu- lated for the major endpoints of the trial; i.e., duration of febrile neutropenia (absolute neutrophil count [ANC] <0.5 x 10^sup 9^/L and temperature ≥38 °C), duration of neutropenia (ANC <1.0 × 10^sup 9^/L and ANC <0.5 × 10^sup 9^/L), duration of thrombopenia (platelets <50 × 10^sup 9^/L and <20 × 10^sup 9^/L), and days with a temperature ≥38 °C). Uncertainty around the ICER was captured by a probabi- listic analysis using a non-parametric bootstrap method.

Results 151 patients were enrolled at ten French centres from October 2008 to September 2009. The mean total cost in the pegfilgrastim arm of the study (n = 74) was euro25,024 (SD 9,945). That in the filgrastim arm (n = 76) was euro28,700 (SD 20,597). Pegfilgrastim strictly dominated filgrastim for days of febrile neutropenia avoided, days of neutropenia (ANC <1.0 × 10^sup 9^/L) avoided, days of thrombopenia (platelets <20 × 10^sup 9^/L) avoided, and days with temperature ≥38 °C) avoided. Pegfilgrastim was less costly and less effective than filgrastim for the number of days with ANC <0.5 × 10^sup 9^/L avoided and the number of days with platelets <50.0 × 10^sup 9^/L avoided. Taking uncertainty into account, the probabilities that pegfilgrastim strictly dominated filgrastim were 67 % for febrile neutropenia, 86 % for neutropenia (ANC <1.0 x 10^sup 9^/L), 59 % for thrombopenia (platelets <20 × 10^sup 9^/L), 86 % for temperature ≥38 °C, 32 % for neutropenia (ANC <0.5 × 10^sup 9^/L), and 43 % for thrombopenia (platelets <50 × 10^sup 9^/L). Conversely, the probability that filgrastim strictly dominated pegfilgrastim for neutropenia (ANC <0.5 × 10^sup 9^/L) is 5 %.

Conclusion This study found no evidence that the use of pegfilgrastim is associated with greater cost in lymphoma and myeloma patients after high-dose chemotherapy and PBSC transplantation.

1 Introduction

The lymphoproliferative disorders represent a heteroge- neous group of malignancies arising from neoplastic transformation of lymphoid cells with different pheno- types, function and location. Their incidence is increasing in developed countries. Within this group of diseases, lymphoma and myeloma are the most common. Despite the introduction of targeted therapies such as rituximab for lymphoma and bortezomib in myeloma, intensive chemo- therapy followed by transplantation using autologous hae- matopoietic progenitor cells remains the cornerstone of treatment. …

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