JAMA special issue focuses on comparative effectiveness research
Research Activities, August 2012, No. 384
The April 2012 issue of the Journal of the American Medical Association (JAMA) focused on comparative effectiveness research (CER), including the key role played by the Agency for Healthcare Research and Quality (AHRQ) in supporting this research. CER is designed to inform health care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.
Of the $1.1 billion that the Department of Health and Human Services received to fund such work under the American Recovery and Reinvestment Act, $473 million was channeled through AHRQ to fund CER research. The Affordable Care Act, passed in 2010, provides additional funding for this type of research, including efforts by AHRQ, Agency Director Carolyn M. Clancy, M.D., noted in a two-page interview with JAMA.
In the interview, she gave some of the history of the CER initiative and noted that AHRQ has been active in disseminating the results of Agency-funded CER in forms usable by clinicians, patients (both in English and in Spanish translations), and policymakers. AHRQ is focusing, Dr. Clancy said, on rapidly disseminating information on CER to health care providers and making simple explanations of the findings more available to patients.
Among the original papers published in the special issue of JAMA are two funded by AHRQ's Effective Health Care Program. One of the papers compares two drug regimens for lung cancer (AHRQ Contract No. 290-10-0006) and another compares the different approaches to radiation therapy in treating prostate cancer (AHRQ Contract No. 290-05-0040). Both studies are briefly discussed here.
Zhu, J., Sharma, D.B., Gray, S.W., and others (2012, April). "Carboplatin and paclitaxel with vs without bevacizumab in older patients with advanced non-small cell lung cancer." Journal of the American Medical Association 307(15), pp. 1593-1601.
This study did not find a survival benefit when the biological agent bevacizumab was added to combination chemotherapy using carboplatin and paclitaxel for elderly patients with advanced non-small cell lung cancer.
An earlier randomized clinical trial involving 878 patients with this form of lung cancer found that adding bevacizumab to the combination chemotherapy increased survival time significantly—though not for the 366 patients aged 65 years or older. In a retrospective cohort study, the researchers found that 1-year survival probability for patients receiving all three drugs was 39.6 percent versus 40.1 percent for those receiving carboplatin-paclitaxel (and 35.6 percent for those treated with carboplatin-paclitaxel).
Sheets, N.C., Goldin, G.H., Meyer A.-M., and others (2012, April). "Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer." Journal of the American Medical Association 307(15), pp. 1611-1620.
The researchers compared newer radiation treatments for localized prostate cancer (intensity-modulated radiation therapy [IMRT] and proton therapy) against an older treatment (conformal radiation therapy [conformal RT]). Prostate cancer is the most common malignancy in men. More than 200,000 men are diagnosed with the disease annually and 30,000 men die from it each year.
Adoption of the newer radiation therapies is estimated to have increased health expenditures in the United States by $350 million in 2005 alone, as the more-expensive IMRT replaced conformal RT. A further rise in health care costs is expected as the use of proton therapy increases. In a population-based study using Surveillance, Epidemiology and End Results-Medicare-linked data on nonmetastatic prostate cancer for 2000-2009, the researchers compared the rates of side-effects (gastrointestinal or urinary morbidity, erectile dysfunction, hip fractures, additional cancer therapy) among the three radiation therapies.
They found that use of IMRT versus conformal RT increased from 0.15 percent in 2000 to 95.9 percent in 2008. Men undergoing IMRT were relatively 9 percent less likely than those receiving conformal RT to develop gastrointestinal morbidities, 22 percent less likely to experience hip fractures, and 19 percent less likely to require additional cancer treatment. However, IMRT patients were 12 percent more likely to experience erectile dysfunction than conformal RT patients. Comparing patients undergoing IMRT versus proton therapy, IMRT patients had a relative 34 percent lower risk of gastrointestinal morbidities; no other significant differences were noted.