Economic evaluation of FLOT and ECF/ECX perioperative chemotherapy in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma

Hanqing Zeng, Chunjiang Wang, Li-Ying Song, Su-Jie Jia, Xiaohui Zeng, Qiao Liu, Hanqing Zeng, Chunjiang Wang, Li-Ying Song, Su-Jie Jia, Xiaohui Zeng, Qiao Liu

Abstract

Objective: The perioperative chemotherapy with fluorouracil, leucovorin, oxaliplatin plus docetaxel (FLOT) was recommended by the Chinese Society of Clinical Oncology Guidelines for gastric cancer (2018 edition) for patients with resectable gastric or gastro-oesophageal junction adenocarcinoma (class IIA). However, the economic impact of FLOT chemotherapy in China remains unclear. The analysis aimed to compare the cost-effectiveness of FLOT versus epirubicin, cisplatin plus fluorouracil or capecitabine (ECF/ECX) in patients with locally advanced resectable tumours.

Design: We developed a Markov model to compare the healthcare and economic outcomes of FLOT and ECF/ECX in patients with resectable gastric or gastro-oesophageal junction adenocarcinoma. Costs were estimated from the perspective of Chinese healthcare system. Clinical and utility inputs were derived from the FLOT4 phase II/III clinical trial and published literature. Sensitivity analyses were employed to assess the robustness of our result. The annual discount rate for costs and health outcomes was set at 5%.

Outcome measures: The primary outcome of incremental cost-effectiveness ratios (ICERs) was calculated as the cost per quality-adjusted life years (QALYs).

Results: The base-case analysis found that compared with ECF/ECX, the use of FLOT chemotherapy was associated with an additional 1.08 QALYs, resulting in an ICER of US$851/QALY. One-way sensitivity analysis results suggested that the HR of overall survival and progression-free survival had the greatest impact on the ICER. Probabilistic sensitivity analysis demonstrated that FLOT was more likely to be cost-effective compared with ECF/ECX at a willingness-to-pay threshold of US$31 513/QALY.

Conclusions: For patients with locally advanced resectable tumours, the FLOT chemotherapy is a cost-effective treatment option compared with ECF/ECX in China.

Trial registration number: NCT01216644.

Keywords: gastroenterology; gastrointestinal tumours; health economics.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Markov model structure of fluorouracil, leucovorin, oxaliplatin plus docetaxel (FLOT) and epirubicin, cisplatin plus fluorouracil or capecitabine (ECF/ECX) strategies for the treatment of patients with locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma.
Figure 2
Figure 2
The log-logistic curves of (A) disease-free survival and (B) overall survival. ECF/ECX, epirubicin, cisplatin plus fluorouracil or capecitabine; FLOT, fluorouracil, leucovorin, oxaliplatin plus docetaxel; OS, overall survival; PFS, progression-free survival.
Figure 3
Figure 3
Tornado diagram for univariable sensitivity analyses. The grey dotted line represents the incremental cost-effectiveness ratio of US$850.6842 per quality-adjusted life year from the base-case results. ECF/ECX, epirubicin, cisplatin plus fluorouracil or capecitabine; FLOT, fluorouracil, leucovorin, oxaliplatin plus docetaxel; OS, overall survival; PFS, progression-free survival.
Figure 4
Figure 4
The results of Monte Carlo probabilistic sensitivity analysis for the strategies of fluorouracil, leucovorin, oxaliplatin plus docetaxel (FLOT) versus epirubicin, cisplatin plus fluorouracil or capecitabine (ECF/ECX) in scatter plots. The solid lines indicate the US$31 513 threshold. The estimates of 95% were surrounded in the ellipses. WTP, willingness to pay.
Figure 5
Figure 5
Acceptability curves for the two strategies at willingness-to-pay (WTP) thresholds in locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma patients. The vertical dashed line represents the threshold that the cost-effectiveness probability of fluorouracil, leucovorin, oxaliplatin plus docetaxel (FLOT) chemotherapy reached 99%, and the solid line represents the WTP threshold of US$10 504 (the per capita gross domestic product in China). ECF/ECX, epirubicin, cisplatin plus fluorouracil or capecitabine; FLOT, fluorouracil, leucovorin, oxaliplatin plus docetaxel.

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