Authors' objectives:

"The objectives of this review were to establish the clinical and cost-effectiveness of aromatase inhibitors (AIs) anastrozole, letrozole and exemestane compared with tamoxifen in the adjuvant treatment of early oestrogen receptor-positive breast cancer in postmenopausal women with oestrogen receptor-positive early-stage breast cancer."

(from executive summary)

Authors' recommendations: Clinical effectiveness No individual study reported a difference in overall survival between any AI and tamoxifen (or placebo in the extended adjuvant setting). An unpublished meta-analysis of individual patient data from three trials did find a significant difference in overall survival when unplanned anastrozole switching strategy was compared with 5 years' tamoxifen. Compared with 5 years' tamoxifen, DFS (absence of disease recurrence or death from any cause) was significantly increased in the primary adjuvant setting (using anastrozole or letrozole) and the unplanned switching strategy (using anastrozole or exemestane). Breast cancer recurrence (censoring death as an event) was significantly improved with primary adjuvant anastrozole or letrozole, an anastrozole or exemestane unplanned switching strategy and an extended adjuvant anastrozole or letrozole strategy. There is no evidence that AIs confer any advantage in overall health-related quality of life. On the basis of the current data and within their licensed indications, AIs can be considered clinically effective compared with standard tamoxifen treatment. However, their long-term effects, in terms of both benefits and harms, remain unclear. Cost-effectiveness Three treatment strategies for AIs ; primary adjuvant therapy, unplanned switch therapy and extended adjuvant therapy ; were considered separately within the economic analysis. Under the conservative assumption that benefits gained by AIs during the treatment period are gradually lost over the following 10 years, the cost per QALY for AIs compared with tamoxifen is estimated to be between 21,000 and 32,000 in the primary adjuvant setting and around 20,000 in the unplanned switch setting. The cost per QALY for AIs compared with placebo in the extended adjuvant setting is estimated to be around 10,000. Under the less conservative assumption that rates of recurrence are the same in both arms after the therapy period is complete, the incremental cost-effectiveness ratios are typically at least 50% lower, suggesting that AIs are likely to be considered cost-effective in all three settings. However, understanding of the long-term treatment effects oncost-effectiveness is incomplete.

Authors' methods: Review

Project Status: Completed

URL for project: http://www.hta.ac.uk/1485

Year Published: 2007

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk

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