化學治療於轉移性乳癌之利用及其成本效益分析

Utilization and Cost-Effectiveness Analysis of Chemotherapy for Patients with Metastatic Breast Cancer

蔡謹如(Chin-Ju Tsai)

指導教授 ： 謝坤屏

高雄醫學大學/藥學院/藥學系臨床藥學碩士班/碩士(2018年)

摘要

背景
近年來昂貴的新藥不斷的上市，導致整體醫療負擔上升。在台灣，乳癌總醫療花費為8510436 (仟NTD) (2016年)。2015年統計資料顯示，第四期的乳癌病人占6.68%並且其中有51.16% 接受化療。因此，對於第四期接受化療的乳癌婦女的成本效益議題須被重視。
目的
本研究目的為利用具台灣社區代表性為基礎的資料庫來研究轉移性乳癌女性的藥物利用率和評估接受化療的臨床結果和經濟學結果。
方法
本研究利用台灣健保資料庫、癌症登記資料及死亡登記檔，進行世代追蹤研究。納入的族群為2010~2013年之間被診斷出為轉移性乳癌且接受化療婦女。治療組別分為化療、化療合併手術、化療合併賀爾蒙治療及化療合併賀爾蒙治療合併手術4組，並進行不同治療組別的藥物治療成本與存活分析。後續選擇化療合併賀爾蒙治療組進行經濟學評估，分析taxane-based (TB) 和anthracycline-based (AB) 有無並用標靶藥物的成本效益。使用Kaplan-Meier和log-rank test進行存活分析，使用Incremental cost-effectiveness ratio (ICER)進行成本效益分析。
結果
本研究中共有1515位接受化療的轉移性乳癌婦女，並且研究結果發現在化療合併手術組具有最高的平均總藥物花費(941(仟 NTD/人))及化療費用(341(仟 NTD/人))。然而，化療組與其他三組相比其平均月總藥物花費(46 (仟 NTD/人/月))及化療的月平均費用(17 (仟 NTD/人/月))排名第一且具有最差的整體存活率(存活時間之中位數為 1.33年)。Docetaxel所花的費用是所有化療藥物中最高的。ICER值於TB合併標靶藥物治療組相對AB合併標靶藥物治療組為273442.04 NTD/生命年。
結論
在轉移性乳癌婦女，化療合併手術組每個病人於追蹤期間藥物總支出最高，然而，化療組具有最高的藥物月支出。於化療合併賀爾蒙治療組，AB治療組(病人無使用標靶藥物)具有經濟效益優勢的治療方案。如果病人需使用標靶藥物的情況下，TB合併標靶藥物治療組是具有成本效益。

關鍵字

轉移性乳癌 ； 成本效益 ； 醫療利用 ； 化療

並列摘要

Background
In recent years, many costly medications for cancers were launched onto the market, which leads to total economic burden increase. In Taiwan, the total healthcare cost of breast cancer was 8510436 (thousand New Taiwan Dollars (NTD)) in 2016. In 2015, there were 6.68% stage IV breast cancer patients and 51.16% of them treated with chemotherapy (CT). Therefore, the cost-effectiveness issue on stage IV breast cancer women treating with CT need to be addressed.
Aim
This study aims to investigate the medication utilizations and to evaluate the clinical and economic outcomes of metastatic breast cancer women treated with CT by using Taiwanese population-based database.
Methods
This retrospective cohort study was conducted using the National Health Insurance Database, the Taiwan Cancer Registry Database and the Death Registry Database. Women diagnosed with metastatic breast cancer during 2010-2013 and treated with CT were included. Treatment patterns were classified into four groups: CT, CT plus operation (OP), CT plus hormone therapy (HT) and CT plus HT plus OP (cohort 1). The expenditure of medicines and overall survival rate among different treatment patterns were estimated. Cost effectiveness analysis was conducted in taxane-based and anthracycline-based with or without target therapy (TT) in CT+HT group (cohort 2). Overall survival rate was analyzed using Kaplan-Meier survival analysis and log-rank test. Cost effectiveness was analyzed using incremental cost-effectiveness ratio (ICER).
Results
There were 1515 metastatic breast cancer women treated with CT. The CT+OP group had the highest total medication cost (mean = 941 (thousand (NTD) /patient)) and CT cost (mean = 341 (thousand NTD /patient)). However, CT group was the rank one in monthly total and CT cost (46 (thousand NTD/patient /month)) and (17 (thousand NTD/patient /month)) and the worst survival outcome (median survival time=1.33 years) while compared to other three groups. The result indicated that docetaxel was the most costly chemotherapy. The ICER of taxane-based plus TT compared to anthracycline-based plus TT was NTD 273442.04 per life year.
Conclusions
In metastatic breast cancer women, CT+OP group had the highest expenditure during follow-up period and CT group had the highest expenditure per month. In CT+HT group, the anthracycline-based without TT regimen was an economically dominant regimen. If patient received TT, then the taxane-based plus TT regimen is likely to be cost effective.

並列關鍵字

Metastatic breast cancer ； cost-effectiveness ； utilization ； chemotherapy

參考文獻

1. World Health Organization, Breast cancer: prevention and control, http://www.who.int/cancer/detection/breastcancer/en/. Accessed 15 Mar 2018.

2. Siegel, R.L., K.D. Miller and A. Jemal, Cancer statistics, 2018. CA Cancer J Clin, 2018. 68(1): p. 7-30.

3. Taiwan cancer registry annual report, 2015. 2015.

4. Luengo-Fernandez, R., J. Leal, A. Gray, et al., Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol, 2013. 14(12): p. 1165-74.

5. Kim, Y.A., I.H. Oh, S.J. Yoon, et al., The Economic Burden of Breast Cancer in Korea from 2007-2010. Cancer Res Treat, 2015. 47(4): p. 583-90.