Cost-effectiveness Analysis of FOLFOX followed by FOLFIRI versus 5-FU/LV followed by Irinotecan for metastatic colorectal cancer in the Brazilian Public Health Care System

Abstract

Background: The increasing costs related to cancer treatment are becoming unsustainable to all major economies of the world. The Brazilian government recently reviewed reimbursement values in an attempt to incorporate modern chemotherapy regimens for cancer care in the public health system. Our objective was to evaluate the cost-effectiveness of first-line regimens available for colorectal cancer treatment before and after the review process. Methods: A Markov model was developed to quantify disease progression, mortality, and the costs of two advanced colorectal cancer treatment strategies from Brazilian public health care system perspective. The initial strategy included 5-fluorouracil and leucovorin (FU/LV regimen) as first-line treatment followed by irinotecan monotherapy. The updated strategy included oxaliplatin, 5-fluorouracil and leucovorin (FOLFOX regimen) as first-line therapy followed by irinotecan, 5-fluorouracil and leucovorin (FOLFIRI regimen). The incremental cost-effectiveness ratio (ICER) per life-year (LY) gained was calculated comparing both strategies to best supportive care (BSC). Results: The initial strategy showed an estimate of 0.17 LY gained with chemotherapy compared to the BSC only, with an ICER of R$50,504/LY gained. The updated strategy showed an estimate of 0.91 LY gained, compared to BSC only, with an ICER of R$73,626/LY. Compared to the initial strategy, the updated strategy led to 0.74LY gained, with an ICER of R$78,188/LY gained. Conclusions: From the Brazilian public health care perspective, the reimbursement review does not allow the incorporation of the FOLFOX and FOLFIRI regimens in a cost-effective way. Reimbursement of infusion pumps, oral options, and targeted therapies must be taken into account.