自从年曲妥珠单抗获批以来，HER2阳性晚期乳腺癌患者的治疗选择已经明显增加。目前已有其他若干治疗方案，包括帕妥珠单抗＋曲妥珠单抗＋多西他赛、T-DM1、卡培他滨＋拉帕替尼、曲妥珠单抗＋拉帕替尼。
年12月2日，欧洲乳腺癌专科医师学会《乳腺》在线发表美国佛罗里达大学、佛罗里达农工大学、弗吉尼亚大学、迈阿密大学、中国台北医学大学的研究报告，根据中国台湾全民健康保险数据库对HER2阳性晚期乳腺癌四种治疗顺序的成本效益进行了评定。
该研究利用马尔可夫模型分析了HER2阳性晚期乳腺癌患者有生之年四种治疗顺序的成本（美元）和效益（质量校正寿命）。治疗顺序转换率、疾病进展、不良事件发生率、生存数据来自临床研究。根据中国台湾全民健康保险数据库、医院、文献，对成本和健康指数进行推算。通过确定、不确定因素敏感性分析和方案分析，对参数不确定性进行检验，剂量和成本计算时计入静脉注射药物消耗。
结果，四种治疗顺序的性价比从高到低依次为：
一线曲妥珠单抗＋多西他赛→二线T-DM1→三线曲妥珠单抗＋拉帕替尼
一线帕妥珠单抗＋曲妥珠单抗＋多西他赛→二线T-DM1→三线卡培他滨＋拉帕替尼
一线曲妥珠单抗＋多西他赛→二线曲妥珠单抗＋拉帕替尼→三线曲妥珠单抗＋卡培他滨
一线帕妥珠单抗＋曲妥珠单抗＋多西他赛→二线曲妥珠单抗＋拉帕替尼→三线曲妥珠单抗＋卡培他滨
该模型对成本和治疗顺序转换敏感，但是对静脉注射药物消耗并不特别敏感。
因此，该研究结果表明，根据中国台湾全民健康保险报销标准，对于HER2阳性晚期乳腺癌患者的四种治疗顺序，一线曲妥珠单抗＋多西他赛→二线T-DM1→三线曲妥珠单抗＋拉帕替尼的性价比最高，这些分析结果有助于医疗卫生决策者决定昂贵的抗癌新药治疗覆盖范围。
Breast.Dec2;49:-.[Epubaheadofprint]
Acost-effectivenessanalysisoftrastuzumab-containingtreatmentsequencesforHER-2positivemetastaticbreastcancerpatientsinTaiwan.
VakaramokoDiaby,HussainAlqhtani,SaschavanBoemmel-Wegmann,Ching-YuWang,AskalAyalewAli,RajeshBalkrishnan,YuKo,SofiaPalacio,GilbertodeLimaLopes.
UniversityofFlorida,Gainesville,FL,USA;FloridaAMUniversity,Tallahassee,FL,USA;UniversityofVirginia,Charlottesville,VA,USA;TaipeiMedicalUniversity,Taipei,Taiwan;UniversityofMiami,Miami,FL,USA.
HIGHLIGHTS
Inhealthsystemsinwhichresourcesarescarce,treatmentselectionshouldbecarefullyconsideredtopreserveefficiency.
WeconductedaCEAoffourtreatmentsequencesforHER-2-positivemBCinTaiwan,accountingforintravenousdrugwastage.
Resultsofsuchanalysescanbeusefultopolicymakersastheydecideoncoverageofexpensivenewanticancertreatments.
OBJECTIVE:TreatmentoptionsforHER-2-positivemetastaticbreastcancer(mBC)patientshaveexpandedmarkedlysincetrastuzumabapprovalin.Severalotherregimensarenowavailable,includingpertuzumabplustrastuzumabplusdocetaxel,T-DM1,capecitabinepluslapatinib,andtrastuzumabpluslapatinib.Thisstudyassessesthecost-effectivenessoffourtreatmentsequencesforHER-2-positivemBCaccordingtotheTaiwaneseNationalHealthInsuranceAdministration(TNHIA).
METHODS:Costs(U.S.Dollars)andeffectiveness(quality-adjustedlifeyears)offourtreatmentsequencesforHER-2-positivemBCpatientswereexaminedusingaMarkovmodeloveralifetimehorizon.Transitionprobabilities,diseaseprogression,andprobabilityofadverseeventsandsurvivalwerederivedfromclinicaltrialdata.CostsandhealthutilitieswereestimatedfromTNHIA,TaipeiMedicalUniversityHospital,andtheliterature.Deterministic,probabilisticsensitivityanalysesandascenarioanalysisexaminedparameteruncertaintyandaccountedfordrugwastageindosageandcostcalculations.
RESULTS:Sequence3(1stline:trastuzumabplusdocetaxel;2ndline:T-DM1;3rdline:trastuzumabpluslapatinib)wasthemostcost-effectivesequencefollowedbysequence1(1stline:pertuzumabplustrastuzumabplusdocetaxel;2ndline:T-DM1;3rdline:capecitabinepluslapatinib),andsequence4(1stline:trastuzumabplusdocetaxel;2ndline:trastuzumabpluslapatinib;3rdline:trastuzumabpluscapecitabine),respectively.Themodelwassensitivetocostsandtransitionprobabilities,butnotparticularlysensitivetothewastageassumption.
CONCLUSIONS:FromtheperspectiveoftheTNHIA,trastuzumabplusdocetaxelas1stlinefollowedbyT-DM1andtrastuzumabpluslapatinibas2ndand3rdlinerepresentsthemostcost-effectivestrategyamongthefoursequencesconsideredfortreatingHER-2-positivemBCpatients.
KEYWORDS:Breastcancer;Neoplasmmetastasis;Cost-effectivenessanalysis;Markovchains;Taiwan
DOI:10./j.breast..11.
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