Bruce E. Hillner, MD

In this issue, Ramaswamy and Shapiroprovide another excellent reviewof the recent literature on therole of bisphosphonates in the managementof bone metastases frombreast cancer and selected other cancers.Bisphosphonates and bone metastaseshave been the subject ofnumerous similar publications. In aquick Medline search of papers publishedsince January 2002, I found 12different review articles including asimilar manuscript in this journal.[1]

Financial costs to individuals andsociety represent one measureof the burden of disease. Accurateand complete estimates of thefinancial burden associated with cancerare a necessary component forreaching a variety of goals. Thesegoals might include the costs andbenefits of cancer control interventions,assessing the performance ofhealth systems, and the allocation ofhealth-care and research resourcesacross disease categories.[1]

The costs and relative cost-effectiveness of different treatments for common illnesses are an increasing concern. New treatments for advanced non-small-cell lung cancer are having an impact. However, these treatments vary markedly in their direct financial costs, toxicity, and quality-of-life profiles. Direct comparisons between most combination regimens are not yet completed. Vinorelbine (Navelbine) is the first new agent approved in the United States for the treatment of metastatic non-small-cell lung cancer in more than a decade. We previously reported results of a post-hoc economic analysis that compared the anticipated cost-effectiveness of three regimens used to treat non-small-cell lung cancer (vinorelbine alone versus vinorelbine plus cisplatin [Platinol] versus vindesine plus cisplatin, the assumed standard treatment in Europe). Results showed that vinorelbine plus cisplatin was the most effective regimen. Using vinorelbine alone as a baseline, vinorelbine plus cisplatin added 56 days of life at an additional cost of $2,700, resulting in a cost-effectiveness ratio of $17,700 per year of life gained. Similarly, vindesine plus cisplatin added 19 days of life at a cost of $1,150, or $22,100 per year of life gained. Compared to vindesine plus cisplatin, vinorelbine plus cisplatin added 37 days of life at a cost of $1,570, or $15,500 per year of life gained. We conclude that the incremental cost-effectiveness of the vinorelbine plus cisplatin regimen was less than most commonly accepted medical interventions. If vinorelbine is preferred because of its favorable toxicity profile, the additional effectiveness of cisplatin added substantial efficacy at an acceptable cost.[ONCOLOGY(Suppl 4):14-17, 1998]

The 1992 metaanalysis of adjuvant therapies after surgery in early breast cancer summarizes the most extensively studied of all cancer treatments via randomized controlled trials. This study found overall benefits with use of adjuvant therapies, and their expanded use outside the clinical trial setting was assumed to be effective and implied to be cost effective. Thus, the primary remaining questions are which form of adjuvant therapy to use and how to identify which patients are unlikely to benefit. In British Columbia, the effectiveness of adjuvant therapy outside the clinical trial setting was reassuringly similar to the metaanalysis efficacy. Our decision analysis model of hypothetical cohorts of women with early breast cancer confirmed that the efficacy of adjuvant treatment is the primary determinate of its incremental cost effectiveness. Future cost-effectiveness and quality of life assessments should move from hypothetical cohorts assessed via models to prospective data collected within clinical trials or integrated health delivery system. [ONCOLOGY 9(Suppl):129-134, 1995]