title: Economic evaluations of trastuzumab in HER2-positive metastatic breast cancer: a systematic review and critique.
abstract: BACKGROUND
  Published economic evaluations of trastuzumab for the treatment of HER2-positive metastatic breast cancer have arrived at different conclusions regarding the cost-effectiveness of trastuzumab, despite comparative efficacy being demonstrated by a small set of randomised controlled trials (RCTs).
  
  
  OBJECTIVE
  This article aims to provide insight into the quality of the evaluations and explore the possible drivers of the conflicting conclusions.
  
  
  METHODS
  A systematic literature review was conducted to identify all published economic evaluations that compared the incremental costs and outcomes of trastuzumab versus a comparator.
  
  
  RESULTS
  Fifteen economic evaluations were identified. In the evaluations that estimated efficacy using an RCT, the key drivers of the conclusions regarding cost-effectiveness were: the approach used to estimate overall survival in the control group given crossover to trastuzumab following progression in the trials; the inclusion of treatment beyond progression; inclusion of wastage due to unused vial portions, adverse events, and the cost of HER2 testing. Four evaluations used non-randomised approaches to estimate efficacy, thus introducing the potential for confounding. As a result these evaluations reported relatively optimistic estimates of comparative effectiveness. Finally the evaluations used different thresholds to determine whether treatment with trastuzumab was cost-effective.
  
  
  CONCLUSIONS
  There were numerous drivers of the different conclusions regarding the cost-effectiveness of trastuzumab, many of which are due to judgements made by the authors when translating data from RCTs. Many of the potential drivers were not identified by the published systematic reviews of economic evaluations and perhaps more remain unidentified because of inconsistent and limited reporting.
authors: Centre for Health Economics Research and Evaluation (CHERE), University of Technology, Sydney, Broadway, PO Box 123, Sydney, NSW, 2007, Australia, Bonny.parkinson@chere.uts.edu.au.
authors: Bonny
authors: B
authors: Parkinson
authors: Sallie-Anne
authors: SA
authors: Pearson
authors: Rosalie
authors: R
authors: Viney
mesh_terms: D061067:Antibodies, Monoclonal, Humanized / Q000191:economics* / Q000627:therapeutic use*; D000970:Antineoplastic Agents / Q000191:economics* / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000473:pathology*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D009362:Neoplasm Metastasis; D016032:Randomized Controlled Trials as Topic; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000037:antagonists & inhibitors; D000068878:Trastuzumab
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D000970:Antineoplastic Agents; D018719:Erb-b2 Receptor Tyrosine Kinases; D000068878:Trastuzumab