Institute for Medical Technology Assessment, Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR, Rotterdam, The Netherlands.
Pharmacoeconomics. 2018 Jan;36(1):91-103. doi: 10.1007/s40273-017-0557-6.
Clinical guidelines have recommended a 1-year trastuzumab regimen as standard care for early human epidermal growth factor receptor 2 (HER2)-positive breast cancer; however, this recommendation can have a dramatic impact on total drug expenditures in middle-income countries (MICs). We performed a cost-effectiveness analysis from the Iranian healthcare perspective to find an optimum duration of trastuzumab use in Iran.
We compared four treatment strategies comprising chemotherapy and varying durations of trastuzumab use (no trastuzumab, 6, 9 months, and 1 year), and a Markov model and probabilistic sensitivity analysis were used to estimate the costs and effects of the strategies. We then examined the cost effectiveness of the strategies at different willingness-to-pay (WTP) thresholds and ages at onset of treatment.
Incremental costs (versus no trastuzumab) were €8826 (6 months), €13,808 (9 months) and €18,588 (12 months), while incremental quality-adjusted life-years (QALYs) were 0.65 (6 months), 0.87 (9 months) and 1.14 (12 months). At a threshold of 3 × gross domestic product (GDP)/capita (€21,000/QALY) and for patients younger than 59 years, the 6-month protocol was most likely to be cost effective (probability of 42%). At a threshold of 4 × GDP/capita (€28,000/QALY), the 6-month and 1-year regimens were essentially equal in cost effectiveness (37 and 35%, respectively). At this WTP threshold, the 6-month and 1-year regimens were optimal strategies only for patients up to 66 and 44 years of age, respectively.
In contrast to clinical guidelines, 6 months of trastuzumab may be the most cost-effective option for Iran. The lower absolute WTP threshold and lower life expectancy compared with high-income countries are two crucial parameters in the cost effectiveness of interventions in MICs. It is therefore necessary to strike a balance between maximum population health and maintaining affordability in these countries.
临床指南推荐曲妥珠单抗治疗方案作为早期人表皮生长因子受体 2（HER2）阳性乳腺癌的标准治疗方法；然而，这一建议会对中低收入国家（MIC）的总药物支出产生重大影响。我们从伊朗医疗保健的角度进行了一项成本效益分析，以确定在伊朗使用曲妥珠单抗的最佳时间。
我们比较了四种治疗策略，包括化疗和不同时间的曲妥珠单抗使用（无曲妥珠单抗、6 个月、9 个月和 1 年），并使用马尔可夫模型和概率敏感性分析来估计策略的成本和效果。然后，我们在不同的意愿支付（WTP）阈值和治疗开始年龄下检查了策略的成本效益。
与无曲妥珠单抗相比，增量成本分别为 8826 欧元（6 个月）、13808 欧元（9 个月）和 18588 欧元（12 个月），而增量质量调整生命年（QALY）分别为 0.65（6 个月）、0.87（9 个月）和 1.14（12 个月）。在 3 倍国内生产总值（GDP）/人均（21000 欧元/QALY）的阈值下，对于年龄小于 59 岁的患者，6 个月的方案最有可能具有成本效益（概率为 42%）。在 4 倍 GDP/人均（28000 欧元/QALY）的阈值下，6 个月和 1 年的方案在成本效益方面基本相同（分别为 37%和 35%）。在这个 WTP 阈值下，6 个月和 1 年的方案仅对年龄分别不超过 66 岁和 44 岁的患者是最佳选择。
与临床指南相反，6 个月的曲妥珠单抗可能是伊朗最具成本效益的选择。与高收入国家相比，较低的绝对 WTP 阈值和较低的预期寿命是 MIC 中干预措施成本效益的两个关键参数。因此，在这些国家，有必要在最大限度地提高人口健康和保持可负担性之间取得平衡。
