title: Are supportive care-based treatment strategies preferable to standard chemotherapy in recurrent cervical cancer?
abstract: OBJECTIVE
  Recurrent cervical cancer has a poor prognosis despite aggressive treatment. We evaluate the comparative-effectiveness of four management strategies in recurrent cervix cancer incorporating risk prognostication categories derived from pooled collaborative group trials: 1) standard doublet chemotherapy; 2) selective chemotherapy (home hospice with no chemotherapy for poorest prognosis patients with remainder receiving standard doublet chemotherapy); 3) single-agent chemotherapy with home hospice; and 4) home hospice.
  
  
  METHODS
  A cost-effectiveness decision model was constructed. Survival reduction of 24% was assumed for single-agent chemotherapy and 40% for hospice only compared to standard doublet chemotherapy. Overall survival and strategy cost for each arm were modeled as follows: standard doublet chemotherapy 8.9 months ($33K); selective chemotherapy 8.7 months ($29K); single-agent chemotherapy with home hospice 6.7 months ($16K); and home hospice alone 5.3 months ($11K). Base case analysis assumed equal quality of life (QOL). Sensitivity analyses assessed model uncertainties.
  
  
  RESULTS
  Standard doublet chemotherapy for all is not cost-effective compared to selective chemotherapy with an incremental cost-effectiveness ratio (ICER) of $276K per quality-adjusted life-year (QALY). Sensitivity analysis predicted that a 90% improvement in survival is required before standard doublet chemotherapy is cost-effective in the poorest prognosis patients. Selective chemotherapy is the most cost-effective strategy compared to single-agent chemotherapy with home hospice with an ICER of $78K/QALY. Chemotherapy containing regimens become cost-prohibitive with small decreases in QOL.
  
  
  CONCLUSIONS
  Supportive care based treatment strategies are potentially more cost-effective than the current standard of doublet chemotherapy for all patients with recurrent cervical cancer and warrant prospective evaluation.
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA.
authors.forename: Neil T
authors.initials: NT
authors.lastname: Phippen
authors.forename: Charles A
authors.initials: CA
authors.lastname: Leath
authors.forename: Caela R
authors.initials: CR
authors.lastname: Miller
authors.forename: William J
authors.initials: WJ
authors.lastname: Lowery
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Havrilesky
authors.forename: Jason C
authors.initials: JC
authors.lastname: Barnett
mesh_terms: D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D017051:Hospice Care; D006801:Humans; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy* / Q000401:mortality; D011788:Quality of Life; D002583:Uterine Cervical Neoplasms / Q000188:drug therapy* / Q000401:mortality
keywords: Cost-effectiveness; Decision analysis; Recurrent cervix cancer; Selective chemotherapy; Supportive care