title: Mifamurtide for high-grade, resectable, nonmetastatic osteosarcoma following surgical resection: a cost-effectiveness analysis.
abstract: OBJECTIVE
  Mifamurtide is an immune macrophage stimulant that when added to standard chemotherapy has demonstrated survival benefit for newly diagnosed osteosarcoma. The objectives of this study were to investigate the cost-effectiveness of adding mifamurtide to standard three- or four-agent chemotherapy for high-grade, resectable, nonmetastatic osteosarcoma following surgical resection and the issues of obtaining robust cost-effectiveness estimates for ultra-orphan drugs, given the shortage of data.
  
  
  METHODS
  An economic evaluation was conducted from the perspective of the UK's National Health Service as part of the manufacturer's submission to the National Institute for Health and Care Excellence. The disease process was simplified to a transition through a series of health states, modeled by using a Markov approach. Data to inform the model were derived from patient-level data of Study INT-0133, published literature, and expert opinion. The final efficacy measure was life-years gained (LYG), and utilities were used to obtain quality-adjusted life-years (QALYs).
  
  
  RESULTS
  For a 60-year time frame and a discount rate of 3.5% for outcomes, patients receiving mifamurtide benefited from an average additional 1.57 years of life and 1.34 QALYs, compared with patients receiving chemotherapy alone, giving an incremental cost-effectiveness ratio (ICER) of £58,737 per LYG and £68,734 per QALY. Because treatment effects were both substantial in restoring health and sustained over a very long period, the National Institute for Health and Care Excellence changed its guidance to allow a discount of 1.5% for outcomes to be applied in these special circumstances. By using this discount factor, it was found that patients receiving mifamurtide had an average additional 2.58 years of life and 2.20 QALYs compared with patients receiving chemotherapy alone, resulting in an ICER of £35,765 per LYG and £41,933 per QALY.
  
  
  CONCLUSIONS
  Mifamurtide's ICER is cost-effective compared with that of other orphan and ultra-orphan drugs, for which prices and corresponding cost-effectiveness estimates are high.
authors: RTI Health Solutions, Velocity House - Business and Conference Centre, Sheffield, UK.
authors: Sukhvinder
authors: S
authors: Johal
authors: Stephen
authors: S
authors: Ralston
authors: Christopher
authors: C
authors: Knight
mesh_terms: D000119:Acetylmuramyl-Alanyl-Isoglutamine / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D000276:Adjuvants, Immunologic / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D000971:Antineoplastic Combined Chemotherapy Protocols; D001859:Bone Neoplasms / Q000188:drug therapy*; D003362:Cost-Benefit Analysis; D006801:Humans; D008390:Markov Chains; D012516:Osteosarcoma / Q000188:drug therapy*; D010714:Phosphatidylethanolamines / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D019057:Quality-Adjusted Life Years
chemical_list: D000276:Adjuvants, Immunologic; D010714:Phosphatidylethanolamines; C037144:mifamurtide; D000119:Acetylmuramyl-Alanyl-Isoglutamine
keywords: NICE appraisal; cost-effectiveness analysis; discount rate; osteosarcoma; ultra-orphan