Hillner B E, McLeod D G, Crawford E D, Bennett C L
Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond, USA.
Urology. 1995 Apr;45(4):633-40. doi: 10.1016/S0090-4295(99)80055-7.
Although combined androgen blockade with flutamide plus medical or surgical castration is effective in metastatic prostate cancer, debate exists over whether it is cost effective.
Decision analysis model of hypothetical cohorts of 70-year-old men presenting with metastatic prostate cancer, using a societal perspective, calculated anticipated survival and incremental cost per life-year gained. Time to progression and survival rate were from the Intergroup 0036 trial. Costs were based on Medicare data and wholesale drug pricing. Flutamide was estimated to reduce the relative risk of progressive disease by 25% (range, 0 to 50%). Costs and survival benefits were discounted at a 5% annual rate.
In our model for minimal disease, median survival increased from 42.3 to 49.4 months with flutamide and average survival by 5.2 months at an incremental cost of $25,300 per life-year gained. If the efficacy were as high as 50%, the benefit would be 12 months at a cost of $13,700 per life-year gained. At a 10% efficacy, the benefit would be 1.9 months at a cost of $60,900 per life-year gained. For severe disease, the model estimated the median survival increased from 29.5 to 34.3 months with flutamide and average survival by 4.0 months at an incremental cost of $20,000 per life-year gained. At worst-case 10% efficacy, the benefit decreased to 1.5 months at an incremental cost of $47,500 per life-year gained. Total costs for patients treated with an orchiectomy and flutamide compared to leuprolide alone were similar if severe disease was present and actually lowered costs if there was minimal disease.
Flutamide has an incremental cost effectiveness more favorable than most accepted therapies. If drug costs are covered under health care reform, flutamide should be initiated and covered for all good performance status patients.
虽然氟他胺联合雄激素阻断疗法加药物或手术去势在转移性前列腺癌中有效，但对于其是否具有成本效益仍存在争议。
采用社会视角，对70岁转移性前列腺癌男性假设队列进行决策分析模型，计算预期生存期和每获得一个生命年的增量成本。疾病进展时间和生存率来自0036组间试验。成本基于医疗保险数据和药品批发价格。氟他胺估计可将疾病进展的相对风险降低25%（范围为0至50%）。成本和生存效益按每年5%的比率进行贴现。
在我们的轻度疾病模型中，使用氟他胺时中位生存期从42.3个月增加到49.4个月，平均生存期增加5.2个月，每获得一个生命年的增量成本为25300美元。如果疗效高达50%，获益将为12个月，每获得一个生命年的成本为13700美元。在10%的疗效下，获益将为1.9个月，每获得一个生命年的成本为60900美元。对于重度疾病，模型估计使用氟他胺时中位生存期从29.5个月增加到34.3个月，平均生存期增加4.0个月，每获得一个生命年的增量成本为20000美元。在最坏情况下10%的疗效下，获益降至1.5个月，每获得一个生命年的增量成本为47500美元。与单独使用亮丙瑞林相比，接受睾丸切除术和氟他胺治疗的患者的总成本在存在重度疾病时相似，而在存在轻度疾病时实际上降低了成本。
氟他胺的增量成本效益比大多数公认的疗法更有利。如果医疗保健改革涵盖药品成本，对于所有身体状况良好的患者都应开始使用并涵盖氟他胺。
