论文标题

晚期癌症治疗序列的成本效益分析:一种用于转移性前列腺癌的微仿真方法

Cost-effectiveness analysis for therapy sequence in advanced cancer: A microsimulation approach with application to metastatic prostate cancer

论文作者

Handorf, Elizabeth A., Beck, J. Robert, Correa, Andres, Ramamurthy, Chethan, Geynisman, Daniel M.

论文摘要

目的。晚期癌症患者可能会接受多种治疗,随着疾病的进展,切换疗法。通过对转移性前列腺癌的研究,我们开发了一个微仿真框架来研究治疗序列。方法。我们提出了一个离散的状态过渡模型,以研究两条抗癌治疗线。基于数字化已发表的无进展生存期(PFS)和总生存曲线(OS)曲线,我们推断事件类型(进展或死亡),并使用具有竞争风险的累积发生率功能估算过渡概率。我们的模型纳入了随着时间的时间内依赖性,因此对一线治疗的反应可为随后的事件概率提供信息。管理内科住院依赖程度的参数可用于将基于模型的结果校准为目标试验的结果。我们在对转移性前列腺癌的两种治疗序列的研究中证明了这些方法,其中多西他赛(DCT)和乙酸阿比罗酮(AA)都适合在第一线或第二线治疗中使用。我们评估成本,质量调整后的寿命(QALY)和增量成本效益比(ICER)的两种治疗策略:DCT,然后是AA vs aa,然后是DCT。结果。使用来自相关临床试验的数字化生存曲线,我们确定了应将其分类为死亡的PFS时间中的8.6-13.9%,从而估算了累积发生率功能。假设患者内独立性高估了OS时间的模型,并通过我们的校准方法进行了纠正。校正导致了治疗策略(0.07 vs 0.15)和ICER( - \ $ 76,836/QALY vs -\ $ 21,030/QALY)之间QALY的差异的有意义变化。结论。微观仿真模型可以成功地用于研究治疗序列的成本效益,并注意正确地考虑了患者的依赖性。

Purpose. Patients with advanced cancer may undergo multiple lines of treatment, switching therapies as their disease progresses. Motivated by a study of metastatic prostate cancer, we develop a microsimulation framework to study therapy sequence. Methods. We propose a discrete-time state transition model to study two lines of anti-cancer therapy. Based on digitized published progression-free survival (PFS) and overall survival (OS) curves, we infer event types (progression or death), and estimate transition probabilities using cumulative incidence functions with competing risks. Our model incorporates within-patient dependence over time, such that response to first-line therapy informs subsequent event probabilities. Parameters governing the degree of within-patient dependence can be used to calibrate the model-based results to those of a target trial. We demonstrate these methods in a study of two therapy sequences for metastatic prostate cancer, where Docetaxel (DCT) and Abiraterone Acetate (AA) are both appropriate for use in either first or second line treatment. We assess costs, Quality-Adjusted Life Years (QALYs) and Incremental Cost Effectiveness Ratio (ICER) for two treatment strategies: DCT then AA vs AA then DCT. Results. Using digitized survival curves from relevant clinical trials, we identified 8.6-13.9% of PFS times that should be categorized as deaths, allowing for estimation of cumulative incidence functions. Models assuming within-patient independence overestimated OS time, corrected with our calibration approach. Correction resulted in meaningful changes in the difference in QALYs between treatment strategies (0.07 vs 0.15) and the ICER (-\$76,836/QALY vs -\$21,030/QALY). Conclusions. Microsimulation models can be successfully used to study cost-effectiveness of therapy sequences, taking care to account correctly for within-patient dependence.

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