PharmacoEconomics Open (2018) 2:97–107 https://doi.org/10.1007/s41669-017-0040-5 REVIEW AR TICLE Does Methodological Guidance Produce Consistency? A Review of Methodological Consistency in Breast Cancer Utility Value Measurement in NICE Single Technology Appraisals 1 2 2 • • Micah Rose Stephen Rice Dawn Craig Published online: 5 July 2017 The Author(s) 2017. This article is an open access publication Abstract Since 2004, National Institute for Health and Care following NICE methodological guidance, historically STA Excellence (NICE) methodological guidance for technology guidance in breast cancer has generally not used NICE’s appraisals has emphasised a strong preference for using the preferred methods. Future STAs in breast cancer and reviews validated EuroQol 5-Dimensions (EQ-5D) quality-of-life of older guidance should ensure that utility measurement instrument, measuring patient health status from patients or methods are consistent with the NICE reference case to help carers, and using the general public’s preference-based valu- produce consistent, equitable decision making. ation of different health states when assessing health beneﬁts in economic evaluations. The aim of this study was to review all NICE single technology appraisals (STAs) for breast Key Points for Decision Makers cancer treatments to explore consistency in the use of utility scores in light of NICE methodological guidance. A review of A comprehensive review of all completed National all published breast cancer STAs was undertaken using all Institute for Health and Care Excellence (NICE) publicly available STA documents for each included assess- single technology appraisals (STAs) and their ment. Utility scores were assessed for consistency with NICE- supporting documents identiﬁed 12 STAs with utility preferred methods and original data sources. Furthermore, scores derived from 14 published utility sources and academic assessment group work undertaken during the STA 3 redacted unpublished sources. process was examined to evaluate the emphasis of NICE- STA guidance published prior to 2016 lacked preferred quality-of-life measurement methods. Twelve compliance or exhibited poor compliance with NICE breast cancer STAs were identiﬁed, and many STAs used preferred methods for measuring quality-of-life (utility evidence that did not follow NICE’s preferred utility score scores), which reduces the consistency of decision measurement methods. Recent STA submissions show com- panies using EQ-5D and mapping. Academic assessment making both within and between disease areas. groups rarely emphasized NICE-preferred methods, and There appears to be a pattern of improved queries about preferred methods were rare. While there compliance, beginning in 2016. When NICE appears to be a trend in recent STA submissions towards periodically updates guidance to reﬂect new evidence and treatments, it is important that quality- of-life data are concurrently updated to conform to & Micah Rose email@example.com NICE’s preferred methods. Southampton Health Technology Assessments Centre, University of Southampton, The University of Southampton 1 Background Science Park, Alpha House, Enterprise Road, Southampton SO16 7NS, UK The role of the National Institute for Health and Care Institute of Health and Society, Newcastle University, Excellence (NICE) is to improve health outcomes using the The Baddiley-Clark Building, Richardson Road, English National Health Service (NHS) and other public Newcastle upon Tyne NE2 4AX, UK 98 M. Rose et al. health and social care services. This is achieved through lead to inconsistent decision making, with potential adverse several research avenues, one of which will be explored in consequences for maximising population health. this study: producing evidence-based guidance and advice for health, public health and social care practitioners through the single technology appraisal (STA) process. 2 Objective STAs assess the clinical and cost effectiveness of health technologies to ensure that all NHS patients have This study assesses the consistency in utility measurement equitable access to the most clinically effective and cost- methods used in NICE STAs. Breast cancer was chosen as effective treatments available. STAs are designed to a case study for this review. Because the incidence of appraise a single health technology for a single indication breast cancer is consistently among the highest of any . cancer in England, with 15.4% of new cancer registrations The STA process consists of several stages designed to in 2015 from breast cancer , we deemed that there would create rigorous, transparent decision making with ample be a higher likelihood of attaining a good sample size of stakeholder input into decisions. The primary evidence published STAs. sources are company evidence submissions and work conducted by an independent Evidence Review Group (ERG) that assesses the validity and quality of the company 3 Methods submissions (CSs). The ERG requests and incorporates clariﬁcations from the company, and conducts additional 3.1 Evidence Selection analyses to address uncertainty and areas where the CS is lacking. All published guidance produced by the NICE STA and Cost-utility analyses (CUAs) are the primary type of multiple technology appraisal (MTA) programmes is avail- health economic analysis in NICE technology appraisals, a able on the NICE website . Title searches were conducted type of cost-effectiveness analysis where the primary among these guidance to identify all published breast cancer measure of beneﬁt is health-related quality-of-life STA guidance published between January 2006 and April (HRQoL), measured as quality-adjusted life-years 2017. The primary evidence documents for an STA are the (QALYs). In CUAs, HRQoL is generally measured CS and the ERG report. These documents, as well as the through preference-based utility scores and decrements following additional documents, were obtained and checked (utility values). for utility data: (1) company responses to requests for clar- In 2004, NICE established a reference case deﬁning the iﬁcation from the ERG and NICE; (2) errata and addenda; preferred methods for economic submissions; guidance on and (3) documents produced by the NICE committee for measuring utility scores were as follows: utility scores public consultation and guidance production. Only STAs should be measured from patients or carers with valuation with published ﬁnal funding decisions were included. Where of health states conducted by the general public using a any of the above documents referenced external sources, standardised and validated generic choice-based instrument these publications were obtained and reviewed for utility (time trade-off or standard gamble), with EuroQol 5-Di- data and additional sources. mensions (EQ-5D) as the preferred method of utility measurement . Alternative methods required justiﬁca- 3.2 Data Extraction tion. In 2008, NICE methods guidance recommended considering mapping to EQ-5D from other instruments Data were extracted using a form developed in Microsoft when EQ-5D was unavailable; this transforms other Excel (Microsoft Corporation, Redmond, WA, USA). The methods of measuring quality-of-life into EQ-5D data and extraction form was piloted on two STAs and further removed standard gamble from valuation methods . The reﬁned to ensure the capture of all relevant data. Data were latest guidance (2013) provides a checklist explicitly ask- extracted by one researcher (MJR) and checked by a sec- ing whether EQ-5D was used . ond researcher (SJCR). The logic behind recommending one validated instru- A streamlined process was used to extract utility data. ment is that different methods of measurement produce First, data were extracted from the CS, and, second, the different results [2–4]. A systematic review in breast cancer ERG report was examined. Utility scores and utility utilities by Peasgood et al. found that measurement method decrements were identiﬁed in the ERG report, but only substantially inﬂuenced utility score, as did whose prefer- extracted where they differed from the CS. NICE appraisal ences were measured and whose values were ascribed to documents other than CSs and ERG reports were checked those preferences . This measurement inconsistency can in the same way but none contained new utility data. A review of methodological consistency in breast cancer utility measurement in NICE STAs 99 Lastly, studies identiﬁed by STAs as utility value sources methodological guidance [2, 4]. Across the four EBC were extracted. STAs, there were 39 utility values (utility scores and utility Data on study and population characteristics, such as decrements). Three unpublished sources based on company year of publication, patient age, menopausal status, breast trials and ten published sources were used for utility values cancer stage, receptor status, treatments compared, and [15–24]. Among utility values, 21% (n = 8) were redacted previous treatments, were extracted. In addition, utility or not reported in the submission document, including all data were extracted for each health state and each adverse health-state utility scores in TA 107 (only utility decre- event. Health states were commonly represented by utility ments from Hillner and Smith were reported ) and scores, while adverse events and complications were health-state utility scores from TA 109 for remission commonly represented by utility decrements. Collectively, (disease-free survival [DFS]) and ﬁrst locoregional recur- we deﬁne these as utility values. Additional data were rence. Among the redacted or not reported scores, there extracted on measurement methods, additional utility data were six utility scores that did not have the methods references, and mapping techniques. reported and two that were derived by mapping to EQ-5D from European Organisation for Research and Treatment 3.3 Synthesis and Analysis of Cancer (EORTC) Quality-of-Life Questionnaire-Core 30 (QLQ-C30) data in the company primary effectiveness The STAs were ﬁrst divided into early breast cancer (EBC) trial (the Breast Cancer International Research Group 001 and metastatic breast cancer (MBC). The sources and Trial [BCIRG001]), both redacted [11, 25]. In summary, methods for the utility values were then compared with the there were 33 utility scores that had methods reported in relevant NICE reference case, which was deﬁned by the EBC. Table 1 shows the consistency of unredacted utility year of STA submission. Next, utility scores identiﬁed in value sources, with the relevant NICE reference case for STAs were analysed for value consistency with their each utility source used in EBC STAs. The ERG on TA source. Additionally, an analysis of clariﬁcation requests 424 listed Essers et al. as the source of alternative utility by the ERG and NICE was undertaken. Feasibility of values in their analyses, however they did not identify the mapping was assessed by checking the availability of four original source papers these utility values were mapping algorithms using the Health Economics Research derived from in the study by Essers et al., i.e. Tengs and Centre (HERC) database of mapping studies . Analyses Wallace, Carter et al., Hayman et al. and Van Hanswijck de included assessment of alternative utility values identiﬁed Jonge et al. [20, 21, 23, 24, 26]. Utility scores did not by ERGs and used in their exploratory analyses, where appear to be directly derived from the source papers as these differed from the CS. these papers were not cited by the ERG. We were unable to conﬁrm utilities by Van Hanswijck de Jonge et al. as the poster presentation was not available to us; therefore, these 4 Results values are not included in Table 1 or in the following totals. Values derived from the study by Hayman et al. Twelve breast cancer STAs were identiﬁed, four evaluating were identical to those derived from the case report by EBC and eight evaluating MBC. The following sections Carter et al., and were therefore also not included [20, 21]. analyse STA consistency with preferred methods in the All percentages in this section are based on the 33 utility NICE reference case, and then consistency with source data scores with clear methods reporting. Among the transpar- and methods. ently reported utility scores, 36% (n = 12) of utility values were derived from patients and 39% (n = 13) were valued 4.1 Early Breast Cancer Technology Appraisals by the general public. The most consistent application of the reference case in EBC was the use of standard gamble There were four STAs relating to EBC: TA 107, TA 108, or time trade-off methods, with 45% (n = 15) of utility TA 109, and TA 424 [9–12]. EBC STAs and their utility scores using appropriate methods. Only 21% (n = 7) of score sources had broadly similar populations, with some utility scores used EQ-5D values. EBC utilities were often differences in epidermal growth factor receptor, oestrogen inconsistent with NICE reference case preferences. receptor and axillary lymph node involvement status, Two ERG groups evaluated four CSs of EBC treat- which may affect prognosis but was considered unlikely to ments. Of the four EBC STAs, only two included questions affect quality-of-life measurement . No studies in the submitted to the company for clariﬁcation as the NICE meta-analysis by Peasgood et al. assessed quality-of-life STA process was still in its infancy in 2006. The clariﬁ- using the above factors . cation questions submitted to the company in TA 107 did Three EBC STAs were assessed against 2004 method- not contain any questions about the derivation of utility ological guidance, and one was assessed against 2013 scores, and TA 424 primarily used methodologically 100 M. Rose et al. Table 1 Consistency of EBC utility sources with the NICE reference case Utility source, year STAs that use NICE-preferred assumptions (all should be yes) the utility source Utilities measured Valuation by the EQ-5D Choice-based method by patients general public used (not rating scale), TTO after 2008 Hillner and Smith 1991  107, 109 No No No No Sorensen et al. 2004  108 No No No Yes Ossa et al. 2004  109 No Yes No Yes Brown and Hutton 1998  109 No No No Yes Launois et al. 1996  109 No No No No b c Lloyd et al. 2006  424 No Yes No No Lidgren et al. 2007  424 Yes Yes Yes Yes b,d Tengs and Wallace 2000  424 No Variable No No b,d Carter et al. 1998  424 No No No No EBC early breast cancer, EQ-5D EuroQoL-5 dimensions, NICE National Institute for Health and Care Excellence, STAs single technology appraisals, TTO time trade-off Assessed against 2004 NICE reference case Assessed against 2013 NICE reference case No mapping methods used to derive EQ-5D Referenced as Essers et al. , and used only in Evidence Review Group analyses, Essers et al. used multiple sources  appropriate scores, resulting in no questions about NICE- citedbythe ERG[20, 23, 24]. Tengs and Wallace preferred methods [27, 28]. While each of the ERG groups gathered together a large sample of utility scores derived commented on the methods of deriving utility scores in from a variety of studies using a variety of methods; their reports, no commentary indicated an NICE preference however, none that were cited in the study by Essers for EQ-5D data [29–32]. In fact, as Table 1 shows, one et al. complied with the 2013 NICE guidance [4, 23, 26]. ERG group that examined company utility values derived Carter et al. reported on a case study of a 74-year-old from EQ-5D explicitly chose to test alternative utility woman who used standard gamble elicitation derived values that consistently did not use NICE-preferred meth- from healthcare workers to assess her quality-of-life ods or comply with the 2013 NICE reference case [4, 32]. . The utility value reported by Essers et al. does not Utility scores used in EBC had utility values that were perfectly match the value reported by Carter et al. generally consistent with their cited sources, but sources [20, 26]. Thethird studywas aposter thatwecould not rarely used NICE-preferred methods. Among studies acquire . Mixing these different instruments could assessed against the 2004 NICE reference case, Hillner and provide inconsistent results as it is well-known that Smith used a rating scale , Sorensen et al. used a alternative methods of utility measurement produce dif- chained standard gamble method [33, 34], Brown and ferent results . Hutton used the standard gamble method , Ossa et al. used a bespoke time trade-off method based on the EQ-5D 4.2 Metastatic Breast Cancer Technology , and redacted scores in submissions used undisclosed Appraisals scales or EQ-5D. One STA was assessed against the 2013 NICE reference case, TA 424. Between the CS and the There were eight technology appraisals of MBC: TA 116, ERG report, there were ﬁve sources for utility scores TA 214, TA 239, TA 250, TA 263, TA 295, TA 371, and reported, i.e. Lidgren et al., Lloyd et al., Tengs and Wal- TA 423 [12, 35–41]. Some appraisals were for locally lace, Carter et al., and Van Hanswijck de Jonge et al. advanced breast cancer (LABC) or MBC. Similar to how [19, 20, 22–24]. The company used ﬁve utility scores from human epidermal growth factor receptor 2 (HER2) and Lidgren et al. and one score from Lloyd et al. All ﬁve oestrogen receptor status in EBC were handled, the same scores from Lidgren et al. were derived by mapping utility scores were used for LABC as those used for MBC. EORTC QLQ-C30 to EQ-5D. Lloyd et al. conducted a The populations for the STAs were broadly similar, with standard gamble with regression to derive scores. most technology appraisals using utility scores derived The ERG used alternative utility scores from Essers from one study, i.e. Lloyd et al. . No utility values were et al. , which were derived from three studies not redacted in MBC STAs. A review of methodological consistency in breast cancer utility measurement in NICE STAs 101 All STAs were assessed against the NICE reference case were utilised and how the utility scores were generated . relevant to the year of their production. Only TA 116 was As such, no STA conducted on breast cancer has produced assessed against the 2004 reference case , and six STAs cost-effectiveness results that can be compared like-for- were assessed against the 2008 reference case: TA 214, like with other disease areas. TA 239, TA 250, TA 263, TA 295 and TA 371 The eight MBC STAs included three ERG groups and [35–39, 46]. While TA 371 was published after the 2013 ﬁve companies [35–41, 46]. Only one ERG group explic- NICE reference case had been published, the STA began itly expressed NICE’s preference for EQ-5D data and before the 2013 methods guidance had been published, queried whether mapping algorithms to EQ-5D were con- therefore it has also been assessed against the 2008 refer- sidered . The company reply indicated that no search ence case. One MBC STA was assessed against the 2013 had been conducted but that a current trial was collecting NICE reference case, i.e. TA 423 . In total, 135 utility both EQ-5D and FACT-B data with a goal of producing values were reported. such an algorithm, with data expected in the next Six sources were used among the eight MBC STAs. 18–24 months (that submission was in 2010 ). The Evaluating the six sources for consistency with the NICE company has since had three NICE STA guidance pub- reference case is more parsimonious than evaluating each lished using the study by Lloyd et al. for utilities, with the of the 135 utility values. Table 2 presents the six MBC latest submission produced in 2013 [19, 36, 46, 55]. utility sources and assesses them against the NICE refer- In 2008, NICE ofﬁcially advocated mapping methods to ence case. Five of six sources used regression methods to convert other quality-of-life scales to EQ-5D . Only the derive utility scores [5, 19, 41–43]. Lloyd et al. built a last of the seven breast cancer STAs produced after the regression based on chained standard gamble results from 2008 NICE methods guidance used mapping to produce the general population , while Cooper et al.  used a EQ-5D values [35–39, 46]. Each of the six STAs that did meta-regression of utility scores for MBC, with most val- not use mapping algorithms used trial evidence with ues derived from three sources, all of which used the effectiveness measures that could be mapped to EQ-5D at standard gamble approach, with oncology nurses and the time of submission to NICE. oncologists providing responses and valuations Four clinical effectiveness studies used in STAs used the [15, 17, 44]. Peasgood et al. conducted a systematic review FACT-B disease-speciﬁc quality-of-life instrument. The with separate meta-regressions of utility scores in EBC and E2100 trial was used by TA 214 (submitted May 2010) and MBC, derived using a variety of measurement methods and TA 263 (submitted December 2011) for effectiveness a variety of different groups of individuals valuing health evidence [36, 54, 56], while the CONFIRM trial was used states; the meta-regressions included many covariates, for effectiveness evidence in TA 239 (submitted November including valuation methods . TA 423 used the mapping 2011) [38, 57]. The study referred to as Study 201 was used algorithm developed by Crott and Briggs to map EORTC- in the CS for TA 250 (submitted March 2011) [37, 58], and QLQC30 trial data to EQ-5D utility scores for both health the EMILIA trial was used for effectiveness evidence in states and for utility decrements due to adverse events TA 371 (submitted December 2013) [46, 59, 60]. FACT-B [41, 43, 45]. contains the FACT-G cancer questionnaire plus additional As Table 2 shows, most utility scores used in STAs of breast cancer-speciﬁc questions . Cheung et al. and MBC did not use the preferred methods of utility mea- Teckle et al. mapped FACT-G to EQ-5D in a breast cancer surement speciﬁed in the relevant NICE methods guidance. population [62, 63]. During TA 214, the company in From 2006 onwards, seven of eight CSs for MBC STAs TA 263 indicated that an in-process trial using FACT-B used Lloyd et al., a source that did not use NICE-preferred and EQ-5D data would produce a mapping algorithm , methods [35–41, 46]. All eight ERG reports for MBC and use of individual patient data in this algorithm could STAs used utility values derived from Lloyd et al. allow sophisticated control for adverse events and disease [32, 47–53]. As a consequence, many of the utility values states. Examining the latest version of the HERC database are out of line with NICE-preferred methods used in other of mapping studies identiﬁed no published algorithm based STAs in other disease areas, making the utility values in on that trial . breast cancer difﬁcult to compare with those in other The Bolero-2 trial was used for effectiveness evidence areas—the currency of comparison is not universal and in TA 295 (submitted February 2013); Bolero-2 used the there is no means of conversion . EORTC QLQ-C30 and the breast cancer-speciﬁc ques- Peasgood et al. found that measurement methodology tionnaire (QLQ-BR23) [2, 35, 64]. EORTC QLQ-C30 was (who measured, who valued, what instrument) was often mapped to EQ-5D by Kind , Crott and Briggs (breast highly inﬂuential on utility values . While the work of cancer population) , and Kim et al. (MBC population) Peasgood et al. was used for sensitivity analysis in TA 214, . Additionally, Kim et al. included the QLQ-BR23 in no explanation was given as to which regression variables mapping . In 2013, mapping was possible at the time of 102 M. Rose et al. Table 2 Comparison of MBC utility methods with NICE reference case Utility source, year STAs utilising NICE preferred assumptions (all should be yes) source Utilities Valuation by EQ-5D Choice-based Mapping measured the used method used? by patients general public (not rating scale); if after 2008, TTO Lloyd et al. 2006  116 No Yes No Yes Not relevant a b d Lloyd et al. 2006 214 , 239, 250, 263 , 295, 371 , 423 No Yes No No No g,h  (ERG) Cooper et al. 2003 214 No No No No No  Hutton et al., 1996 250 No No No No No  Peasgood et al. 2010 214 Partially Partially Partially Partially No  h e TA 423 CS  423 Yes Yes Yes Yes Yes Hudgens et al. 2014 423 Yes Yes Yes Yes Yes  MBC metastatic breast cancer, EQ-5D EuroQoL-5 dimensions, TTO time trade-off, CS company submission, ERG Evidence Review Group report, NICE National Institute for Health and Care Excellence, STAs single technology appraisals Used only in sensitivity analysis Cites Fleeman et al. , used the Lloyd et al. , regression but ﬁxed age at 47 years and weighted by treatment response Cited as Winstanley et al.  in the company submission but all utility values are derived from Cooper et al.  TA371 began in 2012, before the 2013 NICE Methods Guidance was released  Crott and Briggs  Assessed against 2004 NICE reference case Assessed against 2008 NICE reference case Assessed against 2013 NICE reference case submission for TA 295. No justiﬁcation was provided as to that did not use a mapping algorithm generated from that why mapping methods were not used by the company. trial [12, 36, 46, 55, 66]. In addition to nonreference Table 3 provides a checklist for assessing consistency methods being prevalent across breast cancer STAs, clin- with the NICE reference case with regard to utility mea- ical guideline (CG) 81 and an HTA of lapatinib plus tras- surement. The checklist is designed to force technology tuzumab with an aromatase inhibitor also used utility appraisal participants (whether the company or appraisal values that were not valued using EQ-5D or mapped to EQ- group) to fully examine consistency with the NICE refer- 5D [47, 67]. These guidance were produced with direct ence case, help formulate clariﬁcation requests and NICE oversight or by an NICE-contracted technology requests for additional analyses to be sent to the company, appraisal group. and encourage ERGs to ensure that they are knowledgeable The ﬁndings of this review relate to breast cancer STAs about available mapping algorithms for the disease area conducted by NICE for the English NHS. It is unclear being studied in a technology appraisal. whether the results are generalisable to other disease areas. We have not made, nor can we make, any conclusions about methodological consistency in utility score mea- 5 Discussion surement in NICE technology appraisals in general. The review did not formally assess other forms of NICE The results of this review show that NICE methodological guidance, such as MTAs, diagnostic guidance (DG), or CG. guidance has not led to consistent application of NICE- For completeness, we have conducted rapid informal preferred methods of utility measurement in breast cancer reviews of the utility scores used in other breast cancer STAs. While mapping algorithms were often available, guidance produced by and for NICE. We identiﬁed two they were rarely assessed, recommended, or used. In one NICE CGs related to breast cancer: CG 80 and CG 81 instance, a company stated that their trial data would allow [67, 68]. CG 80 did not use QALYs or utility scores , mapping , and subsequently submitted ﬁve submissions whereas CG81 used utility scores that were derived from A review of methodological consistency in breast cancer utility measurement in NICE STAs 103 Table 3 Reference case assessment checklist for technology appraisal submissions Was EQ-5D used to value health? Yes No Were utility scores derived from the relevant patient population? Were utility scores derived from the relevant patient population? Were values for these utility scores derived from the general Were values for these utility scores derived from the general population? population? Was EQ-5D measured directly, or mapped from another Was the preferred time trade-off utility score measurement method used? instrument? Were any mapping algorithms available and not used? Was sufﬁcient justiﬁcation provided for the choice of utility score measurement? EQ-5D EuroQoL-5 dimensions Cooper and colleagues and were thus inconsistent with In the study by Lloyd et al., EQ-5D was collected at NICE-preferred methods, as stated earlier [42, 67]. Four baseline in a nonclinical valuation population but not in a additional technology appraisals were identiﬁed through clinical study for the disease population . One ERG the NICE website (TA 34) and through CG 81, which stated that Lloyd et al. might have been the best available replaced TA 30, TA 54, and TA 62, all of which were not utility data; however, this ERG did not consider whether a available from the NICE website, and, although TA 34 was mapping algorithm could have been used to produce EQ- available, it did not use QALYs or utility scores . 5D utilities. Using utility scores derived by mapping as the CG 81 did not use methodologically appropriate HRQoL base case, and the values used in the study by Lloyd et al. data . Two DGs were identiﬁed: DG 8 and DG 10. utilities as a sensitivity analysis would have been in line DG 8 used health-state utility scores that were inconsistent with NICE guidance, would allow transparent discussion of with preferred methods, but did include utility decrements any limitations of mapping algorithms, and would allow that were consistent with NICE methodology; the majority decision makers to decide whether they prefer consistency of utility values used in DG 8 were inconsistent with NICE within breast cancer STAs or consistency with method- methods . The utility values in DG 10 used NICE- ological guidance [3, 19]. preferred methods . A limited amount of data were There are many mapping studies but support for map- available for TAs produced prior to 2002, but it is clear ping methods is not universal. Doble and Lorgelly assessed from other published guidance in breast cancer that the external validity of mapping algorithms from EORTC inconsistency with methodological guidance has histori- QLQ-C30 to EQ-5D and found that existing algorithms cally been a problem in these evidence streams, in a similar generally perform poorly, with seven of ten algorithms fashion to STAs. having statistically signiﬁcantly different observed and The ﬁndings of this study are similar to previous work predicted QALYs . The best performing algorithm was evaluating utility value measurement in STAs. Tosh et al. the most complicated and computationally intensive algo-  found that only 56% of values used in technology rithm, which limits its application [73, 74]. Pennington and appraisals were compliant with the 2004 NICE reference Davis found that choice of mapping algorithm could sig- case , and only 49% used EQ-5D . Technology niﬁcantly affect cost-effectiveness results . Introducing appraisal participants have shown a lack of awareness of mapping algorithms may add complexity to the technology the full speciﬁcation of NICE’s methodological prefer- appraisal process without producing better estimates of ences for utility measurement, and have not emphasised EQ-5D valuations. The impending transition from EQ-5D- mapping to EQ-5D. This can be remedied in future tech- 3L to EQ-5D-5L now that a UK scoring algorithm for EQ- nology appraisals by working from the full reference case 5D-5L is available adds further complications to the debate guidance and using the framework laid out in Table 3 for over the appropriateness of mapping as the greater sensi- assessing utilities. tivity of EQ-5D-5L may make it more amenable to map- The study by Lloyd et al. was used most across the 12 ping [76, 77]. published STAs, and was used in some form by all eight A search for STAs currently in development revealed MBC STAs and one EBC STA . Their study was eight STAs ; four were suspended, withdrawn, or dis- conducted by United BioSource Corporation, a consultancy continued before any evidence submissions were received company, and Eli Lilly, a pharmaceutical company and one from the company. In addition, one STA was suspended of the companies that made a submission to NICE [19, 40]. after evidence submission by the company and analysis by 104 M. Rose et al. the ERG; this STA used utility scores from the study by and analyses from the company clariﬁcation response into Lloyd et al., with no objection from the ERG and no ERG analysis, check an executable model, and produce a request for additional analyses using NICE-preferred report usually spanning more than 100 pages . It is methods . NICE currently has four guidance actively in important for ERGs to focus on the factors most likely to development for MBC , two of which do not have affect cost-effectiveness conclusions, and survival data publicly available submissions from the manufacturers frequently have the largest impact on cancer model [80, 81]. One STA began in 2013, and, in this STA, the CS outcomes. and ERG report used the study by Lloyd et al. for utility However, ERGs have frequently failed to comment on data [19, 46, 82]. The most recent STA (CS provided in the consistency of utility scores in breast cancer STAs with September 2016) to have CSs, clariﬁcation questions, and NICE-preferred methods. In fact, in TA 423, the ERG an ERG report conforms well to NICE-preferred methods advised using noncompliant data from the study by Lloyd [83, 84]. et al. , and, in TA 424, the ERG used utility scores Why EQ-5D values were so infrequently used in CSs is from sources that did not comply with the NICE reference an unanswered question. An in-progress systematic review, case for their alternative utility value analyses [32, 48]. We currently published only as a conference abstract, identiﬁed believe that failure to use NICE preferences may be pre- 17 studies that provided EQ-5D utility scores for breast vented through the use of Table 3. cancer . Only three published breast cancer STAs used In the current methodological guidance (2013), the EQ-5D values. Two EBC STAs used EQ-5D—one used section on valuing health effects for the reference cases has mapping (TA 109, scores redacted) and one used directly 12 subsections, with the use of EQ-5D being reiterated in measured EQ-5D scores (TA 424). The clinical evidence nine of these . The emphasis in the guidance is clearly sources used in the companies’ submissions for MBC all on consistency across different disease areas and between had data that could be mapped to EQ-5D at the time of NICE guidance. Unfortunately, the written emphasis has submission. Only one MBC STA used mapping from not, until very recently, been followed by consistent EORTC QLQ-C30 to derive appropriate EQ-5D utility actions. scores and received criticism for using these appropriate In breast cancer STAs, NICE and ERG groups have methods [41, 48]. We believe there are three potential often not requested analyses, and have frequently not explanations for why alternative utility values have not conducted supplemental analyses, using EQ-5D utilities. been used: (1) alternative values have been identiﬁed and The quantity of EQ-5D mapping algorithms for breast are unfavourable to companies; (2) there is a lack of belief cancer populations has increased, as evidenced in the in mapping methodology; (3) and/or the values from the HERC database of mapping studies . This database study by Lloyd et al. are viewed as accepted and further facilitates the use of mapping methods to transform clinical work viewed as unnecessary or inappropriate in spite of the effectiveness data into EQ-5D utility scores in current and dataset’s inconsistency with NICE-preferred methods. future breast cancer STAs. NICE needs to clarify whether None of these potential explanations helps foster informed the use of mapping methodologies is their preferred second consistent decision making across disease areas. option, and, if it is, they should cease to accept utility The last two published MBC guidance (TA 423 and values derived from noncompliant measurement methods TA 424) both used EQ-5D utility scores, with one STA in breast cancer STAs (and more broadly), and ensure that using mapping to derive these values [12, 41]. The most their preference for EQ-5D utility scores is adhered to, recent breast cancer STA guidance in development also otherwise NICE’s repeated emphasis of their preference for used EQ-5D . It appears probable that NICE, ERGs and EQ-5D has little meaning and they increase the risk of companies are improving compliance to NICE’s methods; inconsistent decision making. however, STA guidance issued prior to this improvement in compliance are still binding and still have the potential to cause inequitable decisions. The NICE should ensure 6 Conclusion that when these guidance are updated, the utility methods in these guidance are also made conformant with NICE- Historically, breast cancer STAs have shown a broad lack preferred methods. of compliance with preferred methods for measuring utility While some ERGs have criticised utility score usage in scores in the NICE reference case. However, the last two STAs, the primary focus in breast cancer STAs has been on guidance published in December 2016 adhere to the NICE survival rather than utilities, which is not inappropriate. reference case, and the latest STA guidance in develop- Time is limited in STAs. Only 8 weeks are available to ment also conforms to NICE-preferred methods evaluate a multi-hundred page document, formulate clari- [12, 41, 83]. It will be the continued responsibility of the ﬁcation questions to the company, incorporate new data ERG groups and NICE to ensure that future guidance and A review of methodological consistency in breast cancer utility measurement in NICE STAs 105 standardised incidence rates for all cancer sites by age and sex: reviews of guidance maintain this forming trend. It would Ofﬁce for National Statistics; 2017. be inappropriate to let noncompliant utilities used in past 7. National Institute for Health and Care Excellence (NICE). NICE guidance remain the preferred utilities in future guidance. published guidance and advice list. 2017. Available at: https:// To fail to update to methodologically appropriate utility www.nice.org.uk/guidance/published?type=ta. Accessed 3 Apr scores when updating guidance would be to grant these 8. Dakin H. Review of studies mapping from quality of life or guidance using methods that are inconsistent with the clinical measures to EQ-5D: an online database. Health Qual Life NICE reference case a durable precedent, which is a Outcomes. 2013;11:151. doi:10.1186/1477-7525-11-151. decision that should not stand. 9. Bristol-Myers Squibb Pharmaceuticals Ltd. Taxol (paclitaxel) for the adjuvant treatment of early breast cancer: submission to the National Institute for Health and Clinical Excellence (CS TA108); 2006. Author Contributions MR was responsible for revision of the 10. Roche. Herceptin (trastuzumab): NICE submission. Achieving research proposal, drafting the protocol, collaboratively designing the clinical excellence in the adjuvant treatment of her-2 positive data extraction form, piloting the extraction form, performing data breast cancer (CS TA107). 2006. extraction and checking, synthesising ﬁndings, and writing all drafts 11. Sanoﬁ-Aventis. 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