title: Is the progression free survival advantage of concurrent gemcitabine plus cisplatin and radiation followed by adjuvant gemcitabine and cisplatin in patients with advanced cervical cancer worth the additional cost? A cost-effectiveness analysis.
abstract: OBJECTIVE
  The objective of this study is to determine whether concurrent and adjuvant chemoradiation with gemcitabine/cisplatin is cost-effective in patients with stage IIB to IVA cervical cancer.
  
  
  METHODS
  A cost-effectiveness model compared two arms of the trial performed by Duenas-Gonzalez et al. [1]: concurrent and adjuvant chemoradiation with gemcitabine/cisplatin (RT/GC+GC) versus concurrent radiation with cisplatin (RT/C). Major adverse events (AEs) and progression free survival (PFS) rates of each arm were incorporated in the model. AEs were defined as any hospitalization including grade 4 anemia, grade 4 neutropenia, and death. Medicare data and literature review were used to estimate costs. Incremental cost-effectiveness ratios (ICERs) per progression-free life-year saved (PF-LYS) were calculated. Sensitivity analyses were performed for pertinent uncertainties.
  
  
  RESULTS
  For 10,000 women with locally advanced cervical cancer, the cost of therapy and AEs was $173.9 million (M) for RT/C versus $259.8M for RT/GC+GC. There were 879 additional 3-year progression-free survivors in the RT/GC+GC arm. The ICER for RT/GC+GC was $97,799 per PF-LYS. When the rate of hospitalization was equalized to 4.3%, the ICER for RT/GC+GC exceeded $80,000. The resultant ICER when increasing PFS in the RT/GC+GC arm by 5% was $62,605 per PF-LYS. When the cost of chemotherapy was decreased by 50%, the ICER was below $50,000 at $41,774 per PF-LYS.
  
  
  CONCLUSIONS
  Radiation and gemcitabine/cisplatin for patients with stage IIB to IVA cervical cancer are not cost-effective. The increased financial burden of radiation with gemcitabine/cisplatin and associated toxicities appears to outweigh the benefit of increased 3-year PFS and is primarily dependent on chemotherapy drug costs.
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, USA. Blair.Smith@osumc.edu
authors.forename: B
authors.initials: B
authors.lastname: Smith
authors.forename: D E
authors.initials: DE
authors.lastname: Cohn
authors.forename: A
authors.initials: A
authors.lastname: Clements
authors.forename: B J
authors.initials: BJ
authors.lastname: Tierney
authors.forename: J M
authors.initials: JM
authors.lastname: Straughn
mesh_terms: D000740:Anemia / Q000191:economics / Q000209:etiology; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000191:economics* / Q000627:therapeutic use; D002277:Carcinoma / Q000191:economics* / Q000628:therapy; D059248:Chemoradiotherapy / Q000009:adverse effects / Q000191:economics*; D017024:Chemotherapy, Adjuvant / Q000009:adverse effects / Q000191:economics; D002945:Cisplatin / Q000008:administration & dosage / Q000191:economics; D003362:Cost-Benefit Analysis; D003841:Deoxycytidine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000191:economics; D018572:Disease-Free Survival; D005260:Female; D006760:Hospitalization / Q000191:economics; D006801:Humans; D017059:Models, Econometric; D009503:Neutropenia / Q000191:economics / Q000209:etiology; D002583:Uterine Cervical Neoplasms / Q000191:economics* / Q000628:therapy; D000093542:Gemcitabine
chemical_list: D003841:Deoxycytidine; D002945:Cisplatin; D000093542:Gemcitabine
keywords: Adjuvant chemotherapy; Cervical cancer; Cost-effectiveness analysis