Advanced Breast Cancer

Recent preliminary reports from several large trials show that the rigorous and costly regimen of high-dose chemotherapy with autologous stem cell rescue for metastatic breast cancer probably offers no survival advantage over standard chemotherapy (Peters et al., 2000). Given the lack of a clear, definitive answer to the question, a number of different chemotherapeutic regimens and doses, as well as the timing of these agents, are continuing to be investigated. Eight years prior to these reports, Hillner and colleagues had shown that autologous bone marrow transplant versus standard chemotherapy in a hypothetical cohort of 45-year old women with metastatic (Stage IV) breast cancer increased life expectancy by six months, using a five-year horizon. However, it came at a considerable cost of $115,800 per year of life gained. They also demonstrated that if the cost of the transplant procedure could be reduced, the cost per life-year gained could be improved to $70,000 (Hillner et al., 2000).

One of the most common metastatic sites in breast cancer is bone, resulting in additional treatment costs for pain management, such as narcotic analgesics or radiation, and surgery to treat bone fractures. On the other hand, many bony lesions are asymptomatic, often found on routine follow-up. Consequently, a balance must be achieved between expending undue resources to find asymptomatic lesions and necessary efforts to prevent or reduce complications. One approach to reducing the risk of complications has focused on the role of bisphosphonates, specifically pamidronate. A post hoc evaluation of the cost-effectiveness of pamidronate revealed that although it was effective in preventing skeletal related events (SREs), the total costs of administering pamidronate far exceeded the cost savings from avoided SREs, which included pathologic fractures, spinal cord compression or collapse, radiation for pain relief, and hypercalcemia. In addition, 80 percent of the projected costs of pamidronate per treatment were due to the drug’s costs. The 1998 monthly estimated cost of pamidronate therapy was $775 (Hillner et al., 2000).

Hospital charges for breast cancer patients who died in 1992 in a Connecticut hospital averaged $42,000, while the costs for those who died at home or in hospice care averaged $20,000 (Polednak and Shevchenko, 1998).

Advanced Prostate Cancer

Finding the most effective therapy, both medically and financially, for relieving pain related to metastatic prostate cancer has been a major focus of recent research (Beemstrober et al., 1999; Bennett et al., 1996; McEwan et al., 1994; Shah et al., 1999). Medicare reimbursement policies play a



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