BACKGROUND: Adjuvant chemotherapy (5-fluorouracil, levamisole) is now standard practice in the treatment of Dukes' B and C coloretal carcinoma (CRC), and this has increased the financial burden on health care systems world-wide. PATIENTS AND METHODS: Between 1993 and 1996, 95 patients in northern Norway were included in a national randomised CRC study, and assigned to surgery plus adjuvant chemotherapy or surgery alone. In April 1996, 94 of the patients were evaluable and 82 were still alive. The total treatment costs (hospital stay, surgery, chemotherapy, administrative and travelling costs) were calculated. A questionnaire was mailed to all survivors for assessment of the quality of their lives (QoL) (EuroQol questionnaire, a simple QoL-scale, global QoL-measure of the EORTC QLQ-C30), and 62 of them (76%) responded. RESULTS: Adjuvant chemotherapy in Dukes' B and C CRC raised the total treatment costs by 3,369 pounds. The median QoL was 0.83 (0-1 scale) in both arms. Employing a 5% discount rate and an improved survival of adjuvant therapy ranging from 5% to 15%, we calculated the cost of one gained quality-adjusted life-year (QALY) to be between 4,800 pounds and 16,800 pounds. CONCLUSION: Using a cut-off point level of 20,000 pounds per QALY, adjuvant chemotherapy in CRC appears to be cost-effective only when the improvement in 5-year survival is > or = 5%. Adjuvant chemotherapy does not affect short-term QoL.
Adjuvant chemotherapy (ACT) may expose patients to morbidity, with little gain in outcome. Treatment with CMF (cyclophosphamide, methotrexate, fluorouracil) has been the standard ACT in several countries for decades. In this model, efficacy, tolerability and quality of life data from the English-language literature were incorporated with Norwegian standard ACT practice and cost data in a cost-effectiveness/cost-utility approach. The CMF efficacy was calculated as 2.45 years saved per patient treated. The quality of life was assumed diminished by 0.33 (0-1 scale) for 6 months and the life years gained were valued Q = 0.86. An 85% dose intensity was employed, one British pound ( 1) was calculated as 12 NOK and a 5% discount rate was used. The total cost of adjuvant CMF, including amounts spent on drugs, administration, travelling and production loss, was calculated to 2365- 6253, depending on the method chosen. Money spent on drugs alone constituted 13-34%. The cost per life year saved was measured as 2170- 5737. A cost-utility approach revealed a cost per quality-adjusted life year (QALY) of 2973- 7860. Adjuvant CMF in breast cancer is cost-effective in Norway.
BACKGROUND: Mammography screening is a promising method for improving prognosis in breast cancer. PATIENTS AND METHODS: In this economic analysis, data from the Norwegian Mammography Project (NMP), the National Health Administration (NMA) and the Norwegian Medical Association (NMA) were employed in a model for cost-effectiveness analysis. According to the annual report of the NMP for 1996, 60,147 women aged 50-69 years had been invited to a two-yearly mammographic screening programme 46,329 (77%) had been screened and 337 (0.7%) breast cancers had been revealed. The use of breast conserving surgery (BCS) was in this study estimated raised by 17% due to screening, the breast cancer mortality decreased by 30% and the number of life years saved per prevented breast cancer death was calculated 15 years. RESULTS: The cost per woman screened was calculated 75.4 Pounds, the cost per cancer detected 10.365 Pounds and the cost per life year (LY) saved 8.561 Pounds. A raised frequency of BCS, diagnosis and adjuvant chemotherapy brought two years forward, follow-up costs and costs/savings due to prevented breast cancer deaths were all included in the analysis. A sensitivity analysis documented mammography screening cost-effective in Norway when four to nine years are gained per prevented breast cancer death. CONCLUSION: Mammography screening in Norway looks cost-effective. Time has come to encourage national screening programmes.
In the period 1986 to 94, 173 women who had had a lumpectomy or a mastectomy were treated with radiotherapy at the University Hospital of TromsÃ¸. The median diagnostic delay was 2.4 months (range 0-98.6 months). Three out of four patients were operated on within two weeks of the diagnosis being made. About two thirds experienced a delay of more than six weeks from the operation to the start of radiotherapy treatment. The five-year overall survival rate in the mastectomy and postoperative radiotherapy group was 67%. Patients with estrogen receptor positive tumours had a better prognosis. Only 5% and 7% of all patients in our region in stages I and II had breast conserving surgery (BCS) during the study period (66 patients). The five-year overall survival rate in the BCS group was 77%. BCS raised the cost per patient by about 3,000 GBP compared to modified radical mastectomy (MRM). The cost per QALY using BCS as against MRM was about 12,000 GBP. We conclude that MRM should not be used instead of BCS merely for economical reasons.
The prognosis in gastric cancer has been almost unchanged for the last 20 years. At the time of diagnosis the majority of patients have disseminated disease. The 5-year survival is only about 15%. Several efforts with numerous antineoplastic regimens have been studied. The most widely used regimen has been the FAM (5-fluorouracil, adriamycin, mitomycin C) regimen. Because of the cardiotoxicity and dose intensity of the FAM regimen, a low toxicity regimen, the ELF (etoposide, leucovorin, 5-fluorouracil) regimen, has been introduced. We present the data from the treatment of 26 patients (17 FAM, 9 ELF) with advanced gastric cancer at the University Hospital of Tromsø. The monthly costs of FAM and ELF treatment were calculated to a price of 553 pounds and 2976 pounds (British pounds). The median survival of 5 months (FAM) and 6 months (ELF) is in accordance with other studies. Assuming that the median survival in our study is correct, the cost of one year saved was 123,834 pounds, while the cost of one QALY (quality adjusted life year) employing the ELF compared to the FAM regimen was 104,334 pounds. We conclude that the standard ELF regimen too expensive in the treatment of gastric cancer.
BACKGROUND: Today, continued periodic follow-up of patients treated for colorectal cancer (CRC) seems often to be routine because of tradition, rather than its demonstrated value. Recently, the Norwegian Gastrointestinal Cancer Group (NGICG) has recommended a standard surveillance programme in this malignancy. In this protocol patients are suggested followed for four years with CEA monitoring, ultrasound of the liver, chest radiograph and colonoscopy at regular intervals. MATERIALS AND METHODS: In this study, the cost-effectiveness of this programme was addressed employing Norwegian cost data and data from the Cancer Registry of Norway. Clinical data from the existing English language literature was used in the analysis. RESULTS: The basic cost of the NGICG recommended programme was 1,232 Pounds per patient. Including extended investigation due to suspected relapse in 45% of cases, the figure raised to 1,943 Pounds per patient. The cost per life year saved was indicated to 9,525 Pounds-16,192 Pounds. The corresponding cost per quality adjusted life year (QALY) was indicated to 11,476 Pounds-19,508 Pounds. CONCLUSION: We conclude the NGICG recommended follow-up programme in CRC cost-effective. Excluding CEA monitoring may improve the cost-effectiveness.
BACKGROUND: We have today two treatment alternatives (orchiectomy or LHRH-analogue) in metastatic prostate cancer offering the same expectations of survival. This study documents the quality of life (QoL) and cost-effectiveness of these alternatives. PATIENTS AND METHODS: 65 consecutive patients treated at the University Hospital of TromsÃ¸ (UHT), Norway, between 1994 and 1999 were registered. At evaluation, 45 patients (LHRH-analogue--15 patients, orchiectomy--30 patients) were alive and included in the QoL-study (EORTC QLQ C-30, QoL 15D). 45 patients were followed-up at the UHT and included in the cost-analysis. Costs were calculated for a 36-month interval and converted to British pounds (1 Pound = 13 NOK). A 5% d.r. was employed. RESULTS: The mean QoL (15D) was 76.4 (orchiectomy) and 72 (LHRH) (0-100 scale). Constipation, urinating problems, fatigue, pain and loss of sexual functioning were the dominant symptoms. The treatment costs per patient treated were 8,895 Pounds (orchiectomy) and 10,937 Pounds (LHRH-analogue). The crossover in cost was located at 25 months. A sensitivity analysis varying discount rate (0-10%), drug charges (25-50% off) and treatment time (12-18 months) did not alter the conclusion. CONCLUSION: Orchiectomy is the treatment of choice when life expectancy is more than two years.
In the last decade, breast cancer patients have enjoyed an increase in breast conserving surgery (BCS). At present, modified radical mastectomy (MRM) and BCS offers equal expectations of survival. During the last few years, however, a drop in the frequency of BCS has been reported by several authors. Is this new trend due to economic concerns? To clarify the costs of breast cancer therapy (stage I and II), we review the literature and include a cost-utility and a cost-minimisation analysis comparing MRM and BCS. The treatment cost (per patient) of BCS and MRM in Norway was calculated at $9,564 and $5,596, respectively. Employing a quality of life gain in BCS of 0.03 (0-1 scale) and a 5% discount rate, the cost per QALY in BCS compared to MRM was $20,508. In cost-minimising analysis, BCS and mastectomy followed by reconstructive surgery had a cost of $10,748 and $8,538, respectively. This indicates that BCS remains within reasonable cost and should not be displaced by mastectomy on economic grounds.
561 chemotherapy-cycles administered to 191 patients during the period 1990-92 at the University Hospital, Tromsø, were retrospectively analysed for combination with ondansetron. 65% of the cycles were combined with ondansetron. The frequency increased from 1991 (50%) to 1992 (69%). Among moderate emetogenic regimens (MIME, MMM, High-dose MTX, EBVP, ELF) the frequency had changed from 44% to 91%. The increased ondansetron-treatment in moderate emetogenic regimens raised the total cost of treatment. Better cost-effectiveness can possibly be achieved by "low dose-ondansetron" (4 mg x 2) and more frequent supplementary use of diazepam, corticosteroids or haloperidol. Use of ondansetron regimens extending beyond 24 hours is not cost-effective. Peroral treatment is less expensive and usually adequate to control acute emesis.
Comment In: Tidsskr Nor Laegeforen. 1993 Aug 30;113(20):26027639831
BACKGROUND: Today, only carcinoma of the bronchus kills more people than colorectal cancer (CRC). However, CRC is both preventable and curable. In Norway, projects aiming to detect adenomas and early cancers by the screening of a population aged about 60 years employing sigmoidoscopy have been discussed. MATERIALS AND METHODS: In this study, a mathematical model was used to estimate the cost-effectiveness of a screening programme for colorectal polyps followed by polypectomy. A once-only sigmoidoscopy at age 60 followed by coloscopy in selected risk groups was suggested. Data from the English-language literature, the National Cancer Registry of Norway, and Statistics Norway were included. Norwegian cost data from the National Health Administration were also used. Costs of screening and those related to earlier diagnosis, and savings on health care and averted loss in production due to prevented CRCs were calculated. RESULTS: The basic cost per patient invited and screened (70% compliance) in the suggested programme was estimated at 81.7 Pounds and 116.7 Pounds, respectively. When gains due to prevented CRCs were included, the figures became 34.5 Pounds and 49.2 Pounds. The cost per life-year saved was calculated as 2,889 Pounds. This strongly indicates that screening for the early detection and prevention of CRC is one of the most cost-effective programmes in cancer. CONCLUSIONS: CRC screening according to the suggested programme appears to be cost-effective. Clear evidence that screening can reduce mortality from CRC should convince health-care policy makers that the time has come to encourage screening for colorectal cancer.