title: Is febrile neutropenia prophylaxis with granulocyte-colony stimulating factors economically justified for adjuvant TC chemotherapy in breast cancer?
abstract: OBJECTIVE
  Febrile neutropenia (FN) during adjuvant chemotherapy is associated with morbidity, mortality risk, and substantial cost, and subsequent chemotherapy dose reductions may result in poorer outcomes. Patients at high risk of, or who develop FN, often receive prophylaxis with granulocyte colony-stimulating factors (G-CSF). We investigated whether different prophylaxis strategies with G-CSF offered favorable value-for-money.
  
  
  METHODS
  We developed a decision model to estimate the short- and long-term costs and outcomes of a hypothetical cohort of women with breast cancer receiving adjuvant taxotere + cyclophosphamide (TC) chemotherapy. The short-term phase estimated upfront costs and FN risks with adjuvant TC chemotherapy without G-CSF prophylaxis (i.e., chemotherapy dose reductions) as well as with secondary and primary G-CSF prophylaxis strategies. The long-term phase estimated the expected costs and quality-adjusted life years (QALYs) for patients who completed adjuvant TC chemotherapy with or without one or more episodes of FN.
  
  
  RESULTS
  Secondary G-CSF was associated with lower costs and greater QALY gains than a no G-CSF strategy. Primary G-CSF appears likely to be cost-effective relative to secondary G-CSF at FN rates greater than 28%, assuming some loss of chemotherapy efficacy at lower dose intensities. The cost-effectiveness of primary vs. secondary G-CSF was sensitive to FN risk and mortality, and loss of chemotherapy efficacy following FN.
  
  
  CONCLUSIONS
  Secondary G-CSF is more effective and less costly than a no G-CSF strategy. Primary G-CSF may be justified at higher willingness-to-pay thresholds and/or higher FN risks, but this threshold FN risk appears to be higher than the 20% rate recommended by current clinical guidelines.
authors.affiliation: Norwich Medical School, University of East Anglia, Bob Champion Building, Norwich, NR4 7UQ, UK. c.skedgel@uea.ac.uk.
authors.forename: Chris
authors.identifier: http://orcid.org/0000-0003-4989-8846
authors.initials: C
authors.lastname: Skedgel
authors.affiliation: Atlantic Clinical Cancer Research Unit, Capital Health, Halifax, NS, Canada.|Department of Medicine, Capital Health, Halifax, NS, Canada.
authors.forename: Daniel
authors.initials: D
authors.lastname: Rayson
authors.affiliation: Atlantic Clinical Cancer Research Unit, Capital Health, Halifax, NS, Canada.|Department of Medicine, Capital Health, Halifax, NS, Canada.
authors.forename: Tallal
authors.initials: T
authors.lastname: Younis
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000191:economics; D001943:Breast Neoplasms / Q000188:drug therapy / Q000191:economics*; D017024:Chemotherapy, Adjuvant / Q000009:adverse effects*; D064146:Chemotherapy-Induced Febrile Neutropenia / Q000191:economics / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D003520:Cyclophosphamide / Q000008:administration & dosage / Q000009:adverse effects / Q000191:economics; D003661:Decision Support Techniques; D000077143:Docetaxel; D005260:Female; D016179:Granulocyte Colony-Stimulating Factor / Q000191:economics* / Q000627:therapeutic use*; D006801:Humans; D008875:Middle Aged; D011322:Primary Prevention; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D043823:Taxoids / Q000008:administration & dosage / Q000009:adverse effects / Q000191:economics
chemical_list: D043823:Taxoids; D016179:Granulocyte Colony-Stimulating Factor; D000077143:Docetaxel; D003520:Cyclophosphamide
keywords: Breast cancer; Economic evaluation; Febrile neutropenia; Granulocyte colony-stimulating factors