title: Cost-effectiveness of pegfilgrastim versus 6-day filgrastim primary prophylaxis in patients with non-Hodgkin's lymphoma receiving CHOP-21 in United States.
abstract: OBJECTIVE
  Prophylaxis with granulocyte-colony stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. Randomized clinical trials have shown that pegfilgrastim, a 2nd-generation G-CSF, is at least as effective as the 1st-generation G-CSF filgrastim. In the meta-analysis of trials pegfilgrastim performed better than filgrastim with respect to FN risk. The incremental cost-effectiveness of primary prophylaxis (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) with pegfilgrastim versus filgrastim used for 6 days (as is often used in clinical practice) was estimated in patients with aggressive non-Hodgkin's lymphoma (NHL) receiving myelosuppressive chemotherapy in the United States.
  
  
  METHODS
  A decision-analytic model was constructed from a health insurer's perspective with a life-time study horizon. The model considered direct medical costs and outcomes related to reduced FN and potential survival benefits due to reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values.
  
  
  RESULTS
  The incremental cost-effectiveness (ICER) of pegfilgrastim versus 6-day filgrastim primary prophylaxis was $2167/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $5532/LY gained or $6190/QALY gained. When the potential benefit of optimized chemotherapy was included, the ICER was $1494/LY gained or $1677/QALY gained. The most influential factors included cost of pegfilgrastim, relative risk of FN between pegfilgrastim and filgrastim, FN case-fatality rate, cost of filgrastim and baseline FN risk.
  
  
  CONCLUSIONS
  Pegfilgrastim is cost-effective in primary prophylaxis of FN compared to 6 days per cycle of filgrastim, in patients with NHL receiving myelosuppressive chemotherapy (e.g., cyclophosphamide + doxorubicin + vincristine + prednisolone [CHOP-21]) chemotherapy. Study limitations included lack of direct evidence linking G-CSF use with a reduction in FN-related mortality and limited data that show a relationship between relative dose intensity (RDI) and cancer-specific patient survival.
authors.affiliation: Duke University School of Medicine and the Duke Comprehensive Cancer Center, Chapel Hill, NC, USA.
authors.forename: Gary
authors.initials: G
authors.lastname: Lyman
authors.forename: Anjana
authors.initials: A
authors.lastname: Lalla
authors.forename: Richard
authors.initials: R
authors.lastname: Barron
authors.forename: Robert W
authors.initials: RW
authors.lastname: Dubois
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects*; D003362:Cost-Benefit Analysis; D003520:Cyclophosphamide / Q000009:adverse effects; D003661:Decision Support Techniques; D004317:Doxorubicin / Q000009:adverse effects; D000069585:Filgrastim; D016179:Granulocyte Colony-Stimulating Factor / Q000191:economics / Q000627:therapeutic use*; D006801:Humans; D009503:Neutropenia / Q000139:chemically induced / Q000188:drug therapy*; D011092:Polyethylene Glycols; D011241:Prednisone / Q000009:adverse effects; D011336:Probability; D019057:Quality-Adjusted Life Years; D011994:Recombinant Proteins; D016896:Treatment Outcome; D014481:United States; D014750:Vincristine / Q000009:adverse effects
chemical_list: D011994:Recombinant Proteins; D016179:Granulocyte Colony-Stimulating Factor; C455861:pegfilgrastim; D011092:Polyethylene Glycols; D014750:Vincristine; D004317:Doxorubicin; D003520:Cyclophosphamide; D000069585:Filgrastim; D011241:Prednisone