Are different methotrexate regimens as first line therapy for low risk gestational trophoblastic neoplasia more cost effective than the dactinomycin regimen used in GOG 0174?
Are different methotrexate regimens as first line therapy for low risk gestational trophoblastic neoplasia more cost effective than the dactinomycin regimen used in GOG 0174?
复制标题
与GOG 0174中使用的Dactinomycin方案相比，不同的甲氨蝶呤方案作为低风险妊娠滋养细胞肿瘤的第一线治疗更具成本效益吗？
DOI：
10.1016/j.ygyno.2016.10.038
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发表时间：
2017-01
影响因子：
4.7
通讯作者：
Barnett JC
中科院分区：
文献类型：
--
作者：
Miller CR;Chappell NP;Sledge C;Leath CA 3rd;Phippen NT;Havrilesky LJ;Barnett JC
妇科肿瘤组（GOG）0174比较了每周一次肌内注射甲氨蝶呤（MTX）与每两周一次脉冲静脉注射更生霉素（Act-D）作为低风险妊娠滋养细胞肿瘤（GTN）的单药化疗。Act-D的初始完全缓解率（CR）较高（70% vs. 53%，p = 0.01），但MTX多日方案的历史成功率较高。我们根据GOG 0174评估了Act-D与MTX的成本-效果，并探索了多日MTX方案。利用GOG 0174的数据构建了成本效益决策模型。结果是每一线治疗成功的成本，以增量成本效果比（ICER）表示。假设一线治疗失败者接受交叉单药治疗，二线治疗失败者接受多药化疗。GOG 0174没有生活质量（QOL）评价，因此假设QOL相等（效用1.0），但在敏感性分析中存在差异。第二个探索性模型包括5天和8天MTX方案。Act-D（18,505美元）比每周MTX（8950美元）更昂贵，与每周MTX相比，一线治疗成功的ICER为56,215美元。在敏感性分析中，QOL的小幅下降显著增加了ICER。多天MTX方案的模型也比Act-D更具成本效益。如果有效性被重新定义为避免多药化疗，每周MTX更有效。由于低风险GTN的完全治愈率与初始药物无关，我们的模型支持提供者对低风险GTN的一线Act-D犹豫不决。虽然Act-D对于一线治疗成功更有效，但它更昂贵，并且不会降低多药化疗的使用率。
Gynecologic Oncology Group (GOG) 0174 compared weekly intramuscular methotrexate (MTX) with biweekly pulsed intravenous dactinomycin (Act-D) as single-agent chemotherapy for low-risk gestational trophoblastic neoplasia (GTN). Act-D had a higher rate of initial complete response (CR) (70% vs. 53%, p = 0.01), but multi-day regimens of MTX have higher historic success rates. We assessed the cost-effectiveness of Act-D vs. MTX per GOG 0174 and explored multi-day MTX regimens. A cost effectiveness decision model was constructed with data from GOG 0174. Outcome was cost per first-line treatment success expressed in terms of incremental cost-effectiveness ratio (ICER). Front-line failures were assumed to receive cross-over single agent therapy, second line failures; multi-agent chemotherapy. GOG 0174 had no quality of life (QOL) evaluation, so equal QOL (utility 1.0) was assumed but varied in sensitivity analysis. A second exploratory model included 5-day and 8-day MTX regimens. Act-D ($18,505) was more expensive compared to weekly MTX ($8950) with an ICER of $56,215 per first-line treatment success compared to weekly MTX. Small decreases in QOL dramatically increased the ICER during sensitivity analysis. Models with multi-day MTX regimens were also more cost-effective than Act-D. If effectiveness was redefined as avoidance of multi-agent chemotherapy, weekly MTX was more effective. With a complete cure rate for low-risk GTN regardless of initial agent, our model supports provider hesitation toward first line Act-D for low risk GTN. While Act-D is more effective for first line treatment success, it is more costly, and does not decrease rate of multi-agent chemotherapy use.