Chemoprevention

Drug pricing and mortality - The case of tamoxifen

Joy Melnikow, Christina Kuenneth, L. Jay Helms, Amber Barnato, Miriam Kuppermann, Stephen Birch, James Nuovo

Research output: Contribution to journalArticle

22 Citations (Scopus)

Abstract

BACKGROUND. Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost-effectiveness. METHODS. A state-transition Markov model for a hypothetical cohort of women age 50 years was used to evaluate the effects of tamoxifen on mortality and tamoxifen price on cost-effectiveness. Incidence and mortality rates for breast and endometrial cancers were derived from Surveillance, Epidemiology and End Results statistics, and noncancer outcomes were obtained from published studies. Relative risks of outcomes were derived from the National Surgical Adjuvant Breast and Bowel Project P-1 trial. Costs were based on Medicare reimbursements. RESULTS. Projected overall mortality for women at 1.67% 5-year breast cancer risk showed little difference with or without tamoxifen, resulting in a cost-effectiveness ratio of $1,335,690 per life-year saved as a result of tamoxifen use. Adjusting for the differential impact of estrogen receptor-negative cancers, tamoxifen increased mortality for women with a uterus until the 5-year breast cancer risk reached >2.1%. Assigning the Canadian price for tamoxifen dramatically reduced the incremental cost (to $123,780 per life-year saved). At that price, the use of tamoxifen was less costly and more effective for women with 5-year breast cancer risks >4%. CONCLUSIONS. Tamoxifen may increase mortality in women at the lower end of the "high-risk" range for breast cancer. If prices in the U.S. approximated Canadian prices, then tamoxifen use for breast cancer risk reduction in women with a 5-year risk >3% could be a reasonable strategy to reduce the incidence of breast cancer. Because they are used by many unaffected individuals, the price of chemopreventive agents has a major influence on their cost-effectiveness.

Original languageEnglish (US)
Pages (from-to)950-958
Number of pages9
JournalCancer
Volume107
Issue number5
DOIs
StatePublished - Sep 1 2006

Fingerprint

Chemoprevention
Tamoxifen
Costs and Cost Analysis
Mortality
Breast Neoplasms
Pharmaceutical Preparations
Cost-Benefit Analysis
Incidence
Risk Reduction Behavior
Endometrial Neoplasms
Medicare
Estrogen Receptors
Uterus
Neoplasms
Epidemiology
Breast
Clinical Trials

Keywords

  • Breast cancer
  • Cost effectiveness
  • Prevention
  • Tamoxifen

ASJC Scopus subject areas

  • Cancer Research
  • Oncology

Cite this

Melnikow, J., Kuenneth, C., Helms, L. J., Barnato, A., Kuppermann, M., Birch, S., & Nuovo, J. (2006). Chemoprevention: Drug pricing and mortality - The case of tamoxifen. Cancer, 107(5), 950-958. https://doi.org/10.1002/cncr.22075

Chemoprevention : Drug pricing and mortality - The case of tamoxifen. / Melnikow, Joy; Kuenneth, Christina; Helms, L. Jay; Barnato, Amber; Kuppermann, Miriam; Birch, Stephen; Nuovo, James.

In: Cancer, Vol. 107, No. 5, 01.09.2006, p. 950-958.

Research output: Contribution to journalArticle

Melnikow, J, Kuenneth, C, Helms, LJ, Barnato, A, Kuppermann, M, Birch, S & Nuovo, J 2006, 'Chemoprevention: Drug pricing and mortality - The case of tamoxifen', Cancer, vol. 107, no. 5, pp. 950-958. https://doi.org/10.1002/cncr.22075
Melnikow J, Kuenneth C, Helms LJ, Barnato A, Kuppermann M, Birch S et al. Chemoprevention: Drug pricing and mortality - The case of tamoxifen. Cancer. 2006 Sep 1;107(5):950-958. https://doi.org/10.1002/cncr.22075
Melnikow, Joy ; Kuenneth, Christina ; Helms, L. Jay ; Barnato, Amber ; Kuppermann, Miriam ; Birch, Stephen ; Nuovo, James. / Chemoprevention : Drug pricing and mortality - The case of tamoxifen. In: Cancer. 2006 ; Vol. 107, No. 5. pp. 950-958.
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AB - BACKGROUND. Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost-effectiveness. METHODS. A state-transition Markov model for a hypothetical cohort of women age 50 years was used to evaluate the effects of tamoxifen on mortality and tamoxifen price on cost-effectiveness. Incidence and mortality rates for breast and endometrial cancers were derived from Surveillance, Epidemiology and End Results statistics, and noncancer outcomes were obtained from published studies. Relative risks of outcomes were derived from the National Surgical Adjuvant Breast and Bowel Project P-1 trial. Costs were based on Medicare reimbursements. RESULTS. Projected overall mortality for women at 1.67% 5-year breast cancer risk showed little difference with or without tamoxifen, resulting in a cost-effectiveness ratio of $1,335,690 per life-year saved as a result of tamoxifen use. Adjusting for the differential impact of estrogen receptor-negative cancers, tamoxifen increased mortality for women with a uterus until the 5-year breast cancer risk reached >2.1%. Assigning the Canadian price for tamoxifen dramatically reduced the incremental cost (to $123,780 per life-year saved). At that price, the use of tamoxifen was less costly and more effective for women with 5-year breast cancer risks >4%. CONCLUSIONS. Tamoxifen may increase mortality in women at the lower end of the "high-risk" range for breast cancer. If prices in the U.S. approximated Canadian prices, then tamoxifen use for breast cancer risk reduction in women with a 5-year risk >3% could be a reasonable strategy to reduce the incidence of breast cancer. Because they are used by many unaffected individuals, the price of chemopreventive agents has a major influence on their cost-effectiveness.

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