Cost of NSAID adverse effects to the UK National Health Service

Summary

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal problems, notably dyspepsia and bleeding. These adverse effects are costly both in terms of acute hospital admissions and in co-prescribing of gastroprotective agents. The costs of these interventions has been estimated for the National Health Service (NHS) in the UK on the basis of a typical Primary Care Group (PCG) of 100,000 people, the whole population, and for the average patient prescribed an NSAID. The annual burden of NSAID-related gastrointestinal adverse effects to the NHS is large. The middle estimate for an average PCG was £435,000 (range £290,000 to £633,000). The middle estimate for the UK was £251 million (range £166 million to £367 million). The middle cost per patient prescribed an NSAID was £48 (range £32 to £70). As much as half of all acid-suppressing prescribing in the UK may be for NSAID-related gastrointestinal effects.     

Cost of illness associated with Niemann-Pick disease type C in the UK

Abstract

Objective: Niemann-Pick disease type C (NP-C) is a rare and devastating genetic disorder characterised by a range of progressive neurological symptoms, which imposes a burden on patients, family members, the healthcare system and society overall. The objective of this study was to assess direct and indirect costs associated with NP-C in the UK.

Methods: This was a non-interventional, retrospective, cross-sectional cohort study based on responses from patients and/or their carers/guardians recruited from a UK NP-C database. Resource use and direct medical, direct non-medical and indirect costs were evaluated using data collected via postal survey in October 2007, which included a Medical Resource Use questionnaire. Total annual costs per patient were estimated.

Results: In total, 18 Medical Resource Use questionnaires (29% response rate) were received and analysed. The mean total annual cost (SD) of NP-C per patient was £39,168 (£50,315); 46% were direct medical costs, to which home visits and residential care contributed 68% and 15%, respectively. Direct non-medical costs accounted for 24% of the average annual cost per patient, mainly due to specialist education, and indirect costs 30%. If only direct medical costs were considered, the mean annual cost (SD) per patient was reduced to £18,012 (£46,536).

Conclusions: The direct annual per-patient cost of NP-C illness in 2007 appears moderate when compared with other rare and severely disabling diseases. However, cost estimates may be conservative, since findings are limited by a small sample size, low survey response rate and potential recall bias. As demonstrated by this study, a substantial proportion of the cost is shifted from the healthcare system to the patient, family and non-medical providers. These findings highlight the need for treatments that can slow or stop disease progression in NP-C.     

Use of opioid substitution therapies in the treatment of opioid use disorder: results of a UK cost-effectiveness modelling study

Aims: This study investigated the cost-effectiveness of buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) vs no opioid substitution therapy (OST) for the treatment of opioid use disorder, from the UK National Health Service (NHS)/personal social services (PSS) and societal perspectives over 1 year.

Methods: Cost-effectiveness of OST vs no OST was evaluated by first replicating and then expanding an existing UK health technology assessment model. The expanded model included the impact of OST on infection rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection.

Results: Versus no OST, incremental cost-effectiveness ratios (ICERs) for BMT and MMT were £13,923 and £14,206 per quality-adjusted life year (QALY), respectively, from a NHS/PSS perspective. When total costs (NHS/PSS and societal) are considered, there are substantial savings associated with adopting OST; these savings are in excess of £14,032 for BMT vs no OST and £17,174 for MMT vs no OST over 1 year. This is primarily driven by a reduction in victim costs. OST treatment also impacted other aspects of criminality and healthcare resource use.

Limitations: The model’s 1-year timeframe means long-term costs and benefits, and the influence of changes over time are not captured.

Conclusions: OST can be considered cost-effective vs no OST from the UK NHS/PSS perspective, with a cost per QALY well below the UK’s willingness-to-pay threshold. There were only small differences between BMT and MMT. The availability of two or more cost-effective options is beneficial to retaining patients in OST programs. From a societal perspective, OST is estimated to save over £14,032 and £17,174 per year for BMT and MMT vs no OST, respectively, due to savings in victim costs. Further work is required to fully quantify the clinical and health economic impacts of different OST formulations and their societal impact over the long-term.     

The Cost of Obesity in the United Kingdom

Summary

This study provides economic information on the costs of obesity in the UK using a modified method of attributable risk to establish the full resource implications of treating obesity and associated diseases. Prevalence estimates of obesity, defined as a Body Mass Index (BMI) greater than 30 kg/m², together with estimates of the risk of obesity-related diseases relative to a BMI range close to ideal, are used as the basis of the costing. The total costs of treating obesity and its related diseases are estimated at £355 million (in 1995 prices). The total costs of treating obesity directly, estimated at £3.8 million, are dominated by the costs arising from the treatment of attributable diseases, estimated at £351 million.     

TRADE BARRIERS IN THE PACIFIC FOREST SECTOR: WHO WINS AND WHO LOSES

This study uses a global model of the forest sector to examine changes in log production, consumption, prices, and trade and discusses the impacts of changes on economic wealth transfers for log export ban and log export tax scenarios. The results indicate that trade barriers are inefficient in allocating logs to domestic processors when a supply shortage exists. The trade barrier produces economic losses that exceed the benefits to the processors. A log export ban reduces log prices in the Pacc North-west by 8.5% and reduces timber harvests by 6.7%. The logs diverted to domestic mills save 1,208 more jobs than log export job losses but at an average annual cost of £230,463 per job saved. Economic transfers benefit lumber producers in the region under the ban. However, the benefits amount to 61% of regional timber producer losses including losses in the log export price premium, 39% of the loss to Asian processors, and 55% of the global consumer losses. Globally, lumber consumers lose £733 million. A log export tax scenario produces smaller impacts on prices and harvests since it does not eliminate total log exports. The tax scenario saves no jobs, and the average economic gain per job lost is £24,251 or about two-thirds of the current average salary in the forest products sector in the region. A log tax has the ability to retain £78 million in tax revenues.     

Cost-effectiveness of amisulpride compared with risperidone in patients with schizophrenia

SUMMARY

Amisulpride is an atypical antipsychotic, which has demonstrated efficacy across the range of symptoms of schizophrenia. This study compares the treatment costs of amisulpride (including drug costs, hospital costs, and costs of clinician and nurse visits) with those of risperidone over a 6-month treatment period, from the perspective of the UK National Health Service. Resource utilisation data were collected alongside an international, multicentre clinical trial comparing amisulpride (400-1000 mg/day) with risperidone (4-10 mg/day) in 198 patients with schizophrenia. As this trial demonstrated that amisulpride had at least equivalent efficacy to risperidone, the present study was a cost-minimisation analysis. Unit cost data for the UK were obtained from published sources and applied to the clinical data to calculate direct treatment costs. Amisulpride was associated with lower drug acquisition costs and lower resource utilisation costs than risperidone, although the differences did not reach statistical significance. Overall, the average total cost per patient for 6 months of treatment with amisulpride (£12,673; 95% CI: 10,628,14,717) was £2,145 less than for risperidone (£14,818; 95% CI: 12,323,17,312). These findings are similar to those of a previous study that compared the treatment costs of amisulpride with those of haloperidol, and found that

amisulpride was associated with significantly lower direct treatment costs than haloperidol. Amisulpride is a valuable treatment option in patients with schizophrenia.     

Cost effectiveness of rimonabant use in patients at increased cardiometabolic risk: estimates from a Markov model

Summary

Rimonabant, the first selective CB-1 receptor blocker, is expected to reduce cardiometabolic risk substantially. This study assesses the economics of such treatment in patients at elevated cardiometabolic risk.

A Markov model was developed using data from the Rimonabant in Obesity (RIO) trial, published risk equations, and UK cost and utility data. Patients begin either in a diabetic or a non-diabetic state and can transition to cardiovascular disease or to death (based on UK life tables). Transitions to diabetes and subsequent cardiovascular events are also counted. Resource use due to events and long-term management were translated to UK costs (2005 GBP). Tariffs for events and states were applied to age-dependent utilities. Extensive univariate and multivariate probabilistic sensitivity analyses were carried out.

Over 10 years, 8% will suffer a cardiovascular event with a loss of more than 1,000 quality-adjusted life years (QALYs) and a cost of more than £500,000 per 1,000 patients. Projecting risk for a lifetime, 1 year of rimonabant use is estimated to gain >65 QALYs at £8,574/QALY. In probabilistic sensitivity analysis, incremental cost-effectiveness ratios varied from £2,657 to £22,141/QALY.

Based on the metabolic effects seen in clinical trials, rimonabant should reduce cardiovascular risk in obese or overweight people at reasonable cost.     

Economic evaluation of the use of Innohep® in the treatment of acute pulmonary embolism

Summary

This article reports the cost implications of using Innohep® (tinzaparin), a low-molecular-weight heparin (LMWH), instead of intravenous (iv) unfractionated heparin (UFH) in the treatment of acute pulmonary embolism (PE). The expected cost per patient, including initial treatment costs and the cost of managing adverse outcomes (but excluding costs common to both regimes) was found to be £191.81 for patients treated with UFH and £186.64 for patients treated with Innohep® (costs estimated as of end 1997). Therefore, the use of Innohep® reduces the expected cost per patient by £5.17 or 3%. When the costs of managing adverse outcomes occurring after cessation of UFH/Innohep® therapy are excluded, expected costs per patient for UFH and Innohep® treatment are £136.70 and £120.22, respectively. Therefore, when outcomes not directly attributable to the choice between UFH and Innohep® treatment are reduced, the use of Innohep® reduces the expected cost per patient by £16.48 or 12%.

Innohep® reduces costs through greater ease of administration, by removing the need for extensive laboratory monitoring and by saving staff time. These results are generally robust to variations in key assumptions. Sensitivity analysis demonstrates that if patients treated with Innohep® can be discharged from hospital earlier, with their treatment continuing at home, substantial cost savings may result.     

The Unequal Distribution of Job Insecurity, 1966-86

In the first half of this paper the evidence concerning the costs of job insecurity is presented. There is now sufficient good research data to conclude that job insecurity is damaging to psychological health, marriages and employee motivation, and contributes to 'cycles of disadvantage'. In the second half of this paper, flows out of secure and insecure jobs are analysed using a work-histories dataset. Not only is it the case that flows from secure to insecure jobs were more common in the 1980s than in the 1970s and 1960s, but it is also apparent that the risk of a transition from a secure job into an insecure job is much greater for those in less advantaged jobs. The negative consequences of this further polarisation of the UK labour market are discussed.     

Economic evaluation of sevelamer for the treatment of hyperphosphatemia in chronic kidney disease patients not on dialysis in the United Kingdom

Abstract

Objectives:

To determine the cost effectiveness of sevelamer vs calcium carbonate in patients with chronic kidney disease and not on dialysis (CKD-ND) from the perspective of the National Health Service (NHS) in the UK.

Methods:

A Markov decision analytic model was developed to estimate (1) total life years (LYs), quality-adjusted life years (QALYs), and costs for patients treated with sevelamer or calcium carbonate; and (2) incremental costs per LY gained (LYG) and per QALY gained for sevelamer vs calcium carbonate. Data informing probability transitions to all-cause death and dialysis inception in CKD-ND patients were taken directly from the INDEPENDENT-CKD study and were extrapolated beyond the 3-year clinical trial using Weibull regression analysis. Estimates of health utility and costs (in £2011) were derived from the published literature.

Results:

Over a lifetime horizon, sevelamer treatment resulted in a gain of 2.05 LYs and 1.56 QALYs per patient, an increase of £37,282 in total costs per patient vs calcium carbonate (3.5% discount), and a per-patient cost of £18,193/LYG and £23,878/QALY gained. Results were robust to alternative assumptions in key parameters; results were most sensitive to alternative assumptions regarding the mean daily dose of sevelamer, impact of sevelamer on dialysis initiation, cost of dialysis, and health utility estimates. The probabilistic sensitivity analysis showed that sevelamer was cost-effective vs calcium carbonate in 93% of simulations at a willingness-to-pay threshold of £30,000/QALY gained.

Limitations:

While the model simulated a real-world clinical setting, this analysis was subject to limitations common to all decision analytic models, in that it used a mix of data sources and relied on several assumptions. Not all variables that impact real-world outcomes and costs were included in this model.

Conclusions:

Sevelamer is a cost-effective option compared to calcium carbonate for the first-line treatment of hyperphosphatemia in CKD-ND patients in the UK.     

Reduction in costs of inpatient stay associated with clozapine treatment: A retrospective study

Summary

Clozapine is an atypical antipsychotic drug used to treat the 10-25% of patients who suffer from schizophrenia who are treatment resistant or intolerant to standard antipsychotic drug treatment. A major issue associated with treatment is the high cost of the drug compared to standard antipsychotic drug treatment. Research carried out to date has suggested that despite the high cost of clozapine, it is overall a cost-effective treatment. This contention is based on the findings described elsewhere that clozapine treatment is associated with a dramatic decrease in psychiatric inpatient stay.

There are many ethical difficulties associated with a prospective double-blind controlled trial of clozapine treatment. We have therefore reported on a retrospective audit. A retrospective analysis was carried out by the examination of computerised patient records to determine if clozapine treatment had been associated with a reduction in psychiatric inpatient stay. Also examined was whether clozapine treatment had been associated with an overall shift from intensive therapeutic ward usage.

For example, patients are moved from intensive care and acute wards to wards with less intensive therapeutic input such as continuing care and rehabilitation wards. The inpatient stay details for 76 patients prescribed clozapine since early 1991 were examined before and after clozapine treatment commenced. The main problem with this retrospective analysis is that without any control group observed over the same time period, it is very difficult to assess how much of the decrease in bed usage is related to either the natural history of the disease and/or to changes in bed use over time associated with changes in mental health service provision and the development of community facilities.

Psychiatric inpatient stay decreased by a statistically non-significant average of 13.2 days (6%) in the first year of treatment (p=0.7692), a non-significant average of 34 days (15%) in the second year of treatment (p=0.0669), a significant average of 38.4 days (17%) in the third year of treatment (p=0.0007) and again by a significant average of 51.2 days (22%) in the fourth year of treatment (p=0.0011).

The average cost per inpatient bed-day for the main psychiatric hospital in the Health Board's area is £90.86 (based on 100% occupancy rate, 1994/95 prices). The reduction in bed days identified was equivalent to a saving of £1,200 per patient in the first year of treatment, £3,090 per patient in the second year, £3,490 per patient in the third year and £4,652 per patient in the fourth year. The average annual cost of clozapine per patient is approximately £2,500.

Clozapine treatment was also associated with a shift from intensive care and acute ward inpatient usage to continuing care and rehabilitative ward usage. In the year prior to clozapine treatment intensive care and acute ward stay accounted for 72.7% of total inpatient stay. In the first year of treatment this proportion decreased to 63.7%, in the second year to 39.5%, in the third year to 31.8% and in the fourth year to 24.6%. This represented potential savings of £500,000 per annum.

Overall, the data generated from this study indicated that clozapine treatment is associated with both a reduction in psychiatric bed usage and a shift to less therapeutically intensive care wards. However, the decrease identified is not as dramatic as the reduction quoted elsewhere in the literature. These findings provide useful costing information to support the view that clozapine is a cost-saving or cost-neutral treatment in terms of the provision of psychiatric services in the UK. However, the costs associated with the increased use of community services by the study group were not identified in this review. In order to establish whether or not clozapine is cost saving overall compared to standard antipsychotic treatment it would have been necessary to identify all costs, including the whole range of community costs, before and after treatment commenced.     

Addressing shortfalls in TIA care in the UK: an economic perspective

Abstract

Objective: To estimate the clinical outcomes and costs associated with reconfiguring the management of TIA in the UK to offer patients rapid access to outpatient clinics for specialist assessment and treatment.

Methods: An economic deterministic model was run comparing two pathways – one arm representing current clinical care based on national guidelines and clinical practice and patient referral to a weekly outpatient clinic, and a revised care pathway replicating phase 2 of the EXPRESS study with patient referral to a daily outpatient clinic. The outcomes of the model were measured in terms of recurrent strokes avoided and net budget impact to secondary care.

Results: Reconfiguring TIA care pathways in the UK could result in the avoidance of 8,164 recurrent stroke events. The model predicts savings of £25,573,279 for the UK healthcare system over 12 months. Annual net savings are predicted in England (£24,916,011), Scotland (£80,554) and Northern Ireland (£1,041,817). In Wales, increased costs of £450,435 are estimated.

Limitations: Using the data published from the EXPRESS study, it is not possible to model a stepwise approach to implementing the revised TIA care pathway. It is therefore assumed that it would be possible to implement the revised TIA care pathway as detailed in the EXPRESS study across the UK and achieve the reduction in recurrent stroke risk that was reported.

Conclusions: The model suggests that the reconfiguration of TIA care pathways in the UK to offer rapid access to treatment and assessment could prevent TIA-related future stroke events and potentially result in cost savings to the healthcare system.     

The cost-effectiveness of onabotulinumtoxinA for the prophylaxis of headache in adults with chronic migraine in the UK

Abstract

Background:

Although chronic migraine is associated with substantial disability and costs, few treatments have been shown to be effective. OnabotulinumtoxinA (Botox, Allergan Inc., Irvine, CA) is the first treatment to be licensed in the UK for the prophylaxis of headaches in adults with chronic migraine. This study aims to evaluate the cost-effectiveness of onabotulinumtoxinA in this indication in the UK.

Methods:

A state-transition (Markov) model was developed comparing onabotulinumtoxinA to placebo. Efficacy data and utility values were taken from the pooled Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical trials program (n?=?1384). Estimates of resource utilisation were taken from the International Burden of Migraine Study (IBMS), and stopping rules were informed by published medical guidelines and clinical data. This study estimated 2-year discounted costs and quality-adjusted life years (QALYs) from the UK National Health Service perspective.

Results:

At 2 years, treatment with onabotulinumtoxinA was associated with an increase in costs of £1367 and an increase in QALYs of 0.1 compared to placebo, resulting in an incremental cost-effectiveness ratio (ICER) of £15,028. Treatment with onabotulinumtoxinA reduced headache days by an estimated 38 days per year at a cost of £18 per headache day avoided. Sensitivity analysis showed that utility values had the greatest influence on model results. The ICER remained cost-effective at a willingness to pay threshold of £20,000–£30,000/QALY in the majority of scenario analyses as well as in probabilistic sensitivity analysis, where onabotulinumtoxinA was cost-effective on 96% of occasions at a threshold of £20,000/QALY and 98% of occasions at £30,000/QALY.

Conclusion:

OnabotulinumtoxinA has been shown to reduce the frequency of headaches in patients with chronic migraine and can be considered a cost-effective use of resources in the UK National Health Service. The uncertainties in the model relate to the extrapolation of clinical data beyond the 56-week trial.     

Retrospective database study to assess the economic impact of hip fracture in the United Kingdom

Objective:

Publications containing recent, real-world data on the economic impact of hip fractures in the UK are lacking. This retrospective electronic medical records database analysis assessed medication and healthcare resource use, direct healthcare costs, and factors predicting increased resource use and costs in adult UK hip fracture patients.

Methods:

Data were obtained from the Clinical Practice Research Datalink linked to the Hospital Episode Statistics for adult patients hospitalized for their first hip fracture between January 1, 2006 and March 31, 2011 (index event); healthcare costs were calculated from the National Health Service perspective using 2011–2012 cost data.

Results:

Data from 8028 patients were analyzed. Resource use and costs were statistically significantly higher in the year following fracture (mean total [standard deviation (SD)] cost £7359 [£14,937]) compared with the year before fracture (mean total [SD] cost £3122 [£9435]; p?Conclusions:

Although we did not capture all pre- and post-index costs and healthcare utilization, this study provides important insights regarding the characteristics of patients with hip fracture, and information that will be useful in burden-of-illness and economic analyses.     

Cost-effectiveness of continuous subcutaneous apomorphine in the treatment of Parkinson’s disease in the UK and Germany

Abstract

Background:

Parkinson’s disease (PD) is the second most common neurodegenerative disease, affecting ～5.2 million people worldwide. Continuous subcutaneous apomorphine (CSAI) represents an alternative treatment option for advanced PD with motor fluctuation. The purpose of this analysis was to estimate the cost-effectiveness of CSAI compared with Levodopa/carbidopa intestinal gel (LCIG), Deep-Brain-Stimulation (DBS) and Standard-of-care (SOC).

Methods:

A multi-country Markov-Model to simulate the long-term consequences, disease progression (Hoehn & Yahr stages 3–5, percentage of waking-time in the OFF-state), complications, and adverse events was developed. Monte-Carlo simulation accounted for uncertainty. Probabilities were derived from RCT and open-label studies. Costs were estimated from the UK and German healthcare provider’s perspective. QALYs, life-years (LYs), and costs were projected over a life-time horizon.

Results:

UK lifetime costs associated with CSAI amounts to £78,251.49 and generates 2.85 QALYs and 6.28 LYs (€104,500.08, 2.92 QALYs and 6.49 LYs for Germany). Costs associated with LCIG are £130,011.34, achieves 3.06 QALYs and 6.93 LYs (€175,004.43, 3.18 QALYs and 7.18 LYs for Germany). The incremental-cost per QALY gained (ICER) was £244,684.69 (€272,914.58). Costs for DBS are £87,730.22, associated with 2.75 QALYs and 6.38 LYs (€105,737.08, 2.85 QALYs and 6.61 LYs for Germany). CSAI dominates DBS. SOC associated UK costs are £76,793.49; 2.62 QALYs and 5.76 LYs were reached (€90,011.91, 2.73 QALYs and 6 LYs for Germany).

Conclusions:

From a health economic perspective, CSAI is a cost-effective therapy and could be seen as an alternative treatment to LCIG or DBS for patients with advanced PD.     

Cost-effectiveness analysis of glatiramer acetate in the treatment of relapsing-remitting multiple sclerosis

SUMMARY

We have developed an economic model around the patient level data from the pivotal clinical trial for Copaxone® (glatiramer acetate), combined with published cost and natural history data, to demonstrate cost-effectiveness in relapsing-remitting multiple sclerosis (RRMS). Based upon analysis over 8 years, the cost per relapse avoided and cost per disability unit avoided was £11,000 and £8,862 respectively. To facilitate comparison with other therapies and across other disease areas we also calculated the cost per quality adjusted life year (QALY). Dependent upon the assumed utility loss associated with duration of relapse, the cost per QALY ranged between £22,586 and £64,636 over 8 years analysis. Given the nature of the disease and compared to accepted standards of cost-effectiveness in the UK, this analysis shows that glatiramer acetate is demonstrably cost-effective versus best supportive care alone.

Copaxone is a registered trademark of Teva Pharmaceutical Industries, Israel     

An economic evaluation of ramipril in the treatment of patients at high risk for cardiovascular events due to diabetes mellitus

SUMMARY

Cardiovascular disease (CVD) is a major cause of death and morbidity in the United Kingdom (UK) and carries with it a significant financial cost through health care resource use. More than one in three people die from CVD events, and the cost to the UK National Health Service (NHS) was £1.6 billion in 1996¹. The recently published MICRO-HOPE study evaluated the treatment of 3,577 patients at high risk for cardiovascular events from diabetes mellitus and demonstrated significant survival and morbidity benefits associated with ramipril.

The purpose of this paper is to assess whether the significant clinical benefits offered by ramipril can be translated into economic benefits, and to what extent it can reduce the economic burden of CVD to the UK NHS.

Applying the same analytical framework used in a previous economic analysis of the HOPE study, our base case estimate of cost-effectiveness for ramipril in the MICRO HOPE study is £2,396 per life-year saved (undiscounted) and £2,971 per life-year saved (discounted). A sensitivity analysis was performed which ranged from a best case of £1,954 per life-year saved (undiscounted) to a worst case of £2,964 per life-year saved (undiscounted). Our base case estimate of cost-effectiveness suggests that treating patients at high risk for CVD events with ramipril is likely to be a good investment of NHS resources.     

Cost-effectiveness implications of increased survival with anastrozole in the treatment of advanced breast cancer

Summary

Anastrozole (Arimidex*) has a survival benefit compared with megestrol acetate in postmenopausal women with advanced breast cancer who have failed on tamoxifen. It was felt appropriate that such a clinical finding should be subjected to economic evaluation.

A cost-effectiveness analysis was undertaken from the viewpoint of a third-party payer, of the data from a combined analysis of two clinical studies. The outcome measures were duration of drug treatment and life years gained. The incremental cost effectiveness ratio (ICER) of anastrozole was £1,608 per life year gained based on UK NHS drug prices in April 1998. Sensitivity analysis showed that the ICER could vary between £5 and £1,643, depending on relative drug costs in a number of countries, between £1,056 and £1,761, depending on the method used to calculate duration of treatment and survival, and could increase to £3,730, based on treatment provided during the extra period of survival.

Anastrozole is a highly cost-effective alternative to megestrol acetate for postmenopausal women with advanced breast cancer.