Comparison of Parametric Survival Extrapolation Approaches Incorporating General Population Mortality for Adequate Health Technology Assessment of New Oncology Drugs

Ilse van Oostrum*, Mario Ouwens, Antonio Remiro-Azocar, Gianluca Baio, Maarten J. Postma, Erik Buskens, Bart Heeg

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

5 Citations (Scopus)
73 Downloads (Pure)


Objectives: Survival extrapolation of trial outcomes is required for health economic evaluation. Generally, all-cause mortality (ACM) is modeled using standard parametric distributions, often without distinguishing disease-specific/excess mortality and general population background mortality (GPM). Recent National Institute for Health and Care Excellence guidance (Technical Support Document 21) recommends adding GPM hazards to disease-specific/excess mortality hazards in the log-likelihood function ("internal additive hazards"). This article compares alternative extrapolation approaches with and without GPM adjustment. Methods: Survival extrapolations using the internal additive hazards approach (1) are compared to no GPM adjustment (2), applying GPM hazards once ACM hazards drop below GPM hazards (3), adding GPM hazards to ACM hazards (4), and pro-portional hazards for ACM versus GPM hazards (5). The fit, face validity, mean predicted life-years, and corresponding uncertainty measures are assessed for the active versus control arms of immature and mature (30-and 75-month follow-up) multiple myeloma data and mature (64-month follow-up) breast cancer data. Results: The 5 approaches yielded considerably different outcomes. Incremental mean predicted life-years vary most in the immature multiple myeloma data set. The lognormal distribution (best statistical fit for approaches 1-4) produces survival increments of 3.5 (95% credible interval: 1.4-5.3), 8.5 (3.1-13.0), 3.5 (1.3-5.4), 2.9 (1.1-4.5), and 1.6 (0.4-2.8) years for approaches 1 to 5, respectively. Approach 1 had the highest face validity for all data sets. Uncertainty over parametric distributions was comparable for GPM-adjusted approaches 1, 3, and 4, and much larger for approach 2. Conclusion: This study highlights the importance of GPM adjustment, and particularly of incorporating GPM hazards in the log-likelihood function of standard parametric distributions.

Original languageEnglish
Pages (from-to)1294-1301
Number of pages8
JournalValue in Health
Issue number9
Publication statusPublished - Sept-2021


  • additive hazards
  • general population mortality
  • incremental life-years
  • parametric modeling

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