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Cost-Effectiveness of Hepatic
Artery Infusion Chemotherapy
Boris W. Kuvshinoff,
Division of Surgical Oncology, Ellis Fischel Cancer Center, University of Missouri,
Columbia, Missouri.
See referenced original article on pages 882– 8,
this issue.
Address for reprints: Boris W. Kuvshinoff, M.D.,
Division of Surgical Oncology, Ellis Fischel Cancer
Center, University of Missouri, 115 Business Loop,
70 West, Columbia, MO 65203.
Received March 31, 1998; accepted April 6, 1998.
© 1998 American Cancer Society
he issue of the cost-effective use of health care resources in oncology is an important one, yet there is relatively little written
regarding this topic. Consequently, health care administrators and
insurers currently are making decisions that influence cancer treatment without sufficient data regarding cost-effectiveness or outcome.
In this issue of Cancer, Durand-Zaleski et al. address these issues
through the detailed acquisition of hospital and societal treatment
costs, quality of life analysis, and survival data.1
The treatment of unresectable liver metastases from colorectal
carcinoma is a good example of the difficulties encountered when
comparing cancer treatments. Hepatic arterial infusion (HAI) chemotherapy is associated with higher response rates than systemic 5-fluorouracil-based therapy, yet there is conflicting evidence in prospective randomized studies regarding a benefit in survival.2,3 A recent
meta-analysis of these studies could not identify a survival advantage
for HAI compared with systemic chemotherapy, although there was a
survival benefit when studies that included untreated controls were
included in the analysis.4 Critics of HAI cite the lack of improved
survival together with the inconvenience and risk of an additional
laparotomy as reasons why HAI may not be justified. Proponents of
HAI argue that the studies conducted thus far lack the design and
power to resolve the issue sufficiently. Some of these problems include small sample sizes, treatment crossover, and heterogenous
control groups. Clearly, a well designed prospective randomized
study comparing HAI and systemic chemotherapy in untreated patients is necessary to settle this controversy.
Given the difficulties in showing a survival difference between
HAI and systemic chemotherapy, the issues of cost-effectiveness and
quality of life have taken on added significance. Durand-Zaleski et al.
address both health care and societal costs of HAI and systemic
chemotherapy as well as symptom control using data from two randomized trials within the same center.5 Despite the limitations inherent in comparing cost and outcome data from two separate trials, to
my knowledge this type of in-depth cost analysis in the treatment of
unresectable colorectal liver metastases has not been performed before and the authors should be commended for gathering this information.
When total health care costs per patient were analyzed in the
study by Durand-Zaleski et al., HAI was the most expensive (£18,762),
compared with systemic chemotherapy (£6089) or symptom control
CANCER September 1, 1998 / Volume 83 / Number 5
(£2136). The authors take the analysis one step further
by determining the cost-effectiveness of each therapy,
taking into consideration both survival and quality of
life. Comparing HAI with systemic chemotherapy, the
health care costs per life-year gained for HAI was
£24,604 and the health care costs per normal quality of
life-year gained was £24,218. It would appear that the
higher total cost of HAI was offset by improvements in
both overall and normal quality survival time for the
HAI.5 It is especially noteworthy that these treatment
costs are well within the range of those reported for
other advanced malignancies.6,7
When interpreting this cost analysis, it is important to realize that it was performed within a national
health care system, and caution should be taken in
applying these results to the U. S. fee-for-service system. Clearly, U. S. health care insurers would not
reimburse for a 12.5-day hospital stay for placement of
a hepatic artery pump nor the inpatient placement of
a venous access port under general anesthesia. The
authors recognize this difficulty and provide a sensitivity analysis using a relative value scale for nursing
and shorter hospital stays, but these adjustments
again should be viewed with a critical eye when extrapolating to other health care delivery systems.
Although health care costs can be calculated and
are reasonably definable, the interpretation of societal
costs for the various treatments is less clear. Societal
costs in the current study primarily were based on
workdays lost and disability living allowance. The societal cost of HAI was £12,897 per patient compared
with £9143 and £8090 for systemic chemotherapy and
symptom control, respectively. This difference was
present despite a tenfold increase in the median days
worked for patients receiving HAI compared with
those receiving systemic chemotherapy. Thus, although the majority of HAI patients continued to
work, the monetary cost to society still was greater due
to more lost workdays as a consequence of their prolonged survival. I agree with the authors that comparing societal cost is problematic, both from a monetary
and sociologic perspective. It remains unclear whether
the societal costs of various cancer treatments can
ever be adequately compared, especially when one
considers the complexity of social attitudes toward
terminal illness displayed among different cultures
and health care systems.
The current study would suggest that HAI and
systemic chemotherapy are equally cost-effective in
providing normal quality survival for health care resources expended. However, it also is evident that the
overall health care cost of HAI is considerably more
than systemic chemotherapy or supportive care.
Health care providers undoubtedly are concerned
about issues such as cost-effectiveness with regard to
survival and quality of life, but how will third-party
payers interpret these data? They may be more concerned with total costs rather than cost-effectiveness.
The treatments discussed in the article by DurandZaleski et al. appear to prolong survival but they ultimately are palliative, not curative. For example, from
the payor’s point of view HAI is three times more
expensive than systemic chemotherapy without a
proven significant benefit in survival. From the provider’s point of view, HAI would appear to provide a
modest improvement in survival time with acceptable
quality of life and reasonable cost-effectiveness.
The cost analysis presented by Durand-Zaleski et
al. is an important contribution to our understanding
of the treatment of unresectable colorectal liver metastases. The cost-effectiveness of both systemic chemotherapy and HAI therapy are well within the range
of other commonly utilized palliative cancer treatments. However, caution is needed in extrapolating
data from a national health care system to a fee-forservice system. Until survival, quality of life, and cost
data can be evaluated from a single prospective randomized study comparing HAI with systemic chemotherapy, the actual cost-effectiveness remains speculative.
Durand-Zaleski I, Earlam S, Fordy C, Davies M, Allen-Mersh
TG. Cost-effectiveness of systemic and regional chemotherapy for the treatment of patients with unresectable colorectal liver metastases. Cancer 1998;83:882– 8.
Kemeny N, Seiter K. Hepatic arterial chemotherapy. In: Cohen AM, Winawer SJ, Friedman MA, Gunderson LL, editors.
Cancer of the colon, rectum and anus. New York: McGrawHill, 1995:831– 43.
Venook AP. Update on hepatic intra-arterial chemotherapy.
Oncology 1997;11:947–70.
Meta-Analysis Group in Cancer. Reappraisal of hepatic arterial infusion in the treatment of non-resectable liver metastases from colorectal cancer. J Natl Cancer Inst 1996;88:
252– 8.
Allen-Mersh TG, Earlam S, Fordy C, Abrams K, Houghton J.
Quality of life and survival with continuous hepatic artery
floxuridine infusion for colorectal liver metastases. Lancet
1994;344:1255– 60.
Smith TJ, Hillner BE, Desch CE. Efficacy and cost-effectiveness of cancer treatment: rational allocation of resources
based on decision analysis. J Natl Cancer Inst 1993;85:1460 –
Glimelius B, Hoffman K, Graf W, Haglund U, Nyren O,
Pahlman L, et al. Cost-effectiveness of palliative chemotherapy in advanced gastrointestinal malignancies. Ann Oncol
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