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Full Reference:

Overall Survival with Fulvestrant plus Anastrozole in Metastatic Breast Cancer, Rita S. Mehta, Et al, N Engl J Med 2019; 380:1226-1234, DOI: 10.1056/NEJMoa1811714

Web link to Paper

 This week’s blog is brought to you by: Dr Tim Wilson

Authors conclusion

In this trial, we found that combination therapy with anastrozole plus fulvestrant significantly prolonged, as compared with treatment with anastrozole alone, the primary and secondary end points of progression-free survival (P=0.007) and long-term overall survival (P=0.03) when used as first-line therapy for hormone-receptor–positive metastatic breast cancer in postmenopausal women.

3VH – Implications for value

Another promising treatment emerges for breast cancer. Not a cure, but one that prolongs survival from 42 to 49.8 months in women with metastatic breast cancer. As with all treatments whether this passes cost effective test, in terms of cost per QALYS gained, will depend entirely on the price the manufacturer charges for the treatment.

But it raises three important points from the perspective of value based healthcare:

  1. The trial showed a non statistically significant increase in side effects, with more women stopping the combined treatment opposed to the single therapy. As we get further information from multiple trials, it may be the increase in side effects proves to be significant. Importantly, women with metastatic breast cancer should be supported to make a decision- only they can make the trade off.
  2. All these women will die of their cancer, on average within four years. It is probably not too soon to start to discuss this with these women. They need to be prepared for what is to come and supported to be able to describe and achieve the outcomes that are important to them. This might not be longevity. There is a great deal of difference between:
    • “we have a new treatment that can help you” and
    • “as we have discussed, sadly women with breast cancer like yours will die in around 42 months. But we can extend that to 49.8 months with a new treatment”
  3. If this treatment is going to be used, and assuming there is no new money already allocated to its introduction, we need to free up resources. The diagram below shows the typical output from the Socio Technical Allocation of Resources approach. A series of cost benefit triangles, ordered to show a ranking of technical value. Choices are made on how to use finite resources for the population with a need, population value. In this approach, various stakeholders, including patients and patient groups make decisions one which interventions should receive what resources.[1] So, with evidence to show the ineffectiveness from breast cancer screening, for instance, is this now a time to reduce the frequency of mammography to find resources for innovations?[2]




[1] Airoldi, M., Morton, A., Smith, J. A. E., & Bevan, G. (2014). STAR—People-Powered Prioritization. Medical Decision Making, 34(8), 965–975.

[2] Autier, P., Boniol, M., Koechlin, A., Pizot, C., & Boniol, M. (2017). Effectiveness of and overdiagnosis from mammography screening in the Netherlands: population based study. BMJ (Clinical Research Ed.), 359, j5224.