Chemoprevention: drug pricing and mortality: the case of tamoxifen.
BACKGROUND
Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost-effectiveness.


METHODS
A state-transition Markov model for a hypothetical cohort of women age 50 years was used to evaluate the effects of tamoxifen on mortality and tamoxifen price on cost-effectiveness. Incidence and mortality rates for breast and endometrial cancers were derived from Surveillance, Epidemiology and End Results statistics, and noncancer outcomes were obtained from published studies. Relative risks of outcomes were derived from the National Surgical Adjuvant Breast and Bowel Project P-1 trial. Costs were based on Medicare reimbursements.


RESULTS
Projected overall mortality for women at 1.67% 5-year breast cancer risk showed little difference with or without tamoxifen, resulting in a cost-effectiveness ratio of $1,335,690 per life-year saved as a result of tamoxifen use. Adjusting for the differential impact of estrogen receptor-negative cancers, tamoxifen increased mortality for women with a uterus until the 5-year breast cancer risk reached > or =2.1%. Assigning the Canadian price for tamoxifen dramatically reduced the incremental cost (to $123,780 per life-year saved). At that price, the use of tamoxifen was less costly and more effective for women with 5-year breast cancer risks >4%.


CONCLUSIONS
Tamoxifen may increase mortality in women at the lower end of the "high-risk" range for breast cancer. If prices in the U.S. approximated Canadian prices, then tamoxifen use for breast cancer risk reduction in women with a 5-year risk >3% could be a reasonable strategy to reduce the incidence of breast cancer. Because they are used by many unaffected individuals, the price of chemopreventive agents has a major influence on their cost-effectiveness.
Melnikow
Joy
J
Department of Family and Community Medicine, University of California-Davis, Sacramento, California 95817, USA. jamelnikow@ucdavis.edu
Kuenneth
Christina
C
Helms
L Jay
LJ
Barnato
Amber
A
Kuppermann
Miriam
M
Birch
Stephen
S
Nuovo
James
J
D016588:Anticarcinogenic Agents / Q000191:economics / Q000627:therapeutic use*; D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy / Q000191:economics / Q000401:mortality* / Q000517:prevention & control*; D002170:Canada; D003362:Cost-Benefit Analysis; D016889:Endometrial Neoplasms / Q000139:chemically induced; D005260:Female; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D009010:Monte Carlo Method; D009376:Neoplasms, Hormone-Dependent / Q000191:economics; D012306:Risk; D013629:Tamoxifen / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use*; D013997:Time Factors; D014481:United States
D016588:Anticarcinogenic Agents; D018931:Antineoplastic Agents, Hormonal; D013629:Tamoxifen