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W.K. Evans
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MS 23 - Risk Factors: Beyond the Cigarette (ID 41)
- Event: WCLC 2015
- Type: Mini Symposium
- Track: Prevention and Tobacco Control
- Presentations: 1
- Moderators:N. Yamaguchi
- Coordinates: 9/09/2015, 14:15 - 15:45, 605+607
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MS23.05 - Cost Efficacy of Tobacco Cessation Versus Treatment of Lung Cancer (ID 1953)
15:20 - 15:35 | Author(s): W.K. Evans
- Abstract
- Presentation
Abstract:
The global burden of lung cancer is significant and growing. In 2015, WHO reported that there were almost 1.7 million deaths from lung cancer and this number could increase 1.5 times by 2030 (1).The cost associated with the management of lung cancer is significant and can be expected to increase dramatically. It has been estimated that the costs to manage lung cancer will increase in Canada by 80% from 2010 to 2030 but this may prove to be a gross underestimate because of new targeted and immuno-therapies (2). As smoking is the main cause of lung cancer, smoking cessation programs could improve not only the health of nations but also help to contain rising health care costs. In the face of the increasing global burden of lung cancer, it is instructive to consider the cost-effectiveness of lung cancer treatment in relation to smoking cessation programs. Cost effectiveness of lung cancer treatment options Treatment options for lung cancer depend on the stage and type of cancer. Recent advances in the treatment of metastatic non-small-cell lung cancer (NSCLC) have markedly increased the cost to health care systems and to patients themselves. When considering the implementation of new health care technologies, decision-makers consider the incremental cost of the new therapy (∆C) compared to the current standard in relation to the incremental benefit (∆E), usually expressed in life-years gained, to determine the incremental cost-effectiveness ratio or ICER. The life-years gained may be adjusted for the quality of the life lived with the disease and its treatment producing an estimate of cost per quality-adjusted life year or QALY. The ICER is influenced by many factors including the choice of comparator (best supportive care vs a chemotherapy regimen), the time horizon of the analysis, the inclusion of the cost of managing early and late adverse events, amongst other factors. Not surprisingly, the major determinant of the ICER for most new drugs is the price of the drug and the magnitude of the clinical benefit. A review of economic evaluations of drugs used for advanced non-squamous NSCLC suggests that ICERs are progressively rising: the ICER for erlotinib as a 3[rd] line therapy was only $39,000/LY when compared to BSC (3). However, the ICER for pemetrexed used as a 1[st ]line treatment in tumours with no known mutations was $142,500 US dollars (2013) per QALY when compare to best supportive care (BSC) and $164,000 per life year (LY) gained when compared to erlotinib (4).Estimates of the ICER for afatinib based on the pan-Canadian Oncology Drug Review (pCODR) ranged from $39,000 to 211,000/QALY when compared to gefitinb reflecting the uncertainty in the clinical benefit in the absence of a head-to-head comparative trial (5). The ICER for crizotinib as first-line therapy in ALK +ve patients ranged from $173,570 (CDN) to $285,299, reflecting uncertainty in economic model assumptions related to the incremental benefit and the time horizon selected (5). ICERs above $100,000 per QALY are generally not considered “cost-effective” in Canada. The trend to higher ICERs could reverse with immune check point inhibitors given the potential for long term survival (much greater ∆E) in some patients, although the incremental cost may be unacceptably high (6). However, it must be remembered that dollars spent on lung cancer treatments cannot be spent on something else and represent a lost opportunity cost no matter how cost-effective the treatment appears. Value of smoking cessation programs Although some countries and American states have invested in public health programs to reduce smoking, globally there has been a low level of investment suggesting that there is resistance to investing in smoking cessation. This may be due to the perception that cessation interventions are ineffective, that smokers do not want to quit or that smoking cessation interventions are not cost effective (7). These commonly held perceptions are wrong. Smoking cessation (e.g., telephone counseling and pharmacological interventions) has been shown to improve health outcomes and survival. Most smokers in the general population, at least in North America, have made multiple quit attempts and express the desire to quit and cost-effectiveness estimates range from about $330 to $1500 US per life-year gained (7). A review of economic evaluations of smoking cessations programs shows that these programs are economically attractive and can even be cost-saving. For example, the American Cancer Society’s telephone counseling service nearly doubled a smoker’s odds of quitting and staying stopped for one year at a cost of approximately $1,500 per smoker (8).Nicotine Replacement Therapies (NRT) compared to self-help have an ICER of $1,500/QALY while varenicline was a dominant option compared to NRT. Also generally unrecognized are the health benefits to cancer patients, although these benefits have been well outlined in the 2014 U.S. Surgeon General’s Report on Smoking (9). Nonetheless, smoking cessation programs are rare in the oncology setting and information on the cost-effectiveness of smoking cessation in the oncology setting is limited. One study examined the cost-effectiveness of a pre-operative smoking cessation program for patients with early-stage NSCLC in the United States (10), and reported an ICER of $2,609/QALY and $2,703/LY at 5-years post-surgery. The cost-effectiveness of smoking cessation programs could be more dramatic over longer time horizons. Even though the benefits of smoking cessation programs on clinical outcomes have been reported, including the value for money of these programs, more evidence on the impact of smoking on outcomes for lung cancer patients receiving radiotherapy and systemic therapy is clearly needed. Discussion Faced with a global epidemic of lung cancer and a growing number of new but expensive drugs, recognition that smoking cessation programs are both effective and cost-effective should drive public policy. References 1. World Health Organization. Projections of mortality and burden of disease, 2002-2030. World Health Organization,; 2002 [cited 2015]; Available at:http:www.who.int/healthinfo/global_burden_disease/projections2002/en/. 2. Hermus G, Stonebridge C, Goldfarb D, et al. Cost risk analysis for chronic lung disease in Canada: The Conference Board of Canada 3. Cromwell I, van der Hoek K, Taylor SCM, et al. Erlotinib or best supportive care for third-line treatment of advanced non-small-cell lung cancer: a real-world cost-effectiveness analysis. Lung Cancer 2012;76(3):472-7 4. Matter-Walstra K, Joerger M, Kuhnel U, et al. Cost-effectiveness of maintenance pemetrexed in patients with advanced nonsquamous-cell lung cancer from the perspective of the Swiss health care system. Value in health. 2012;15165-71 5. Available at pcodr website . 6. Available at am.asco.org/aso-plenary-nivolumab-ipilimumab-combination-effective-advanced-melanoma. 7. Parrott S, Godfrey C, Raw M, et al. Guidance for Commissioners on the cost-effectiveness of smoking cessation interventions. Thorax 1998; 53 (Suppl 5, Part 2): S2-S3 8. McAlister A, Rabius V, Geiger A, et al. Telephone assistance for smoking cessation: one year cost effectiveness estimations. Tobacco control. 2004;13(1):85-6. 9. The Health Consequences of Smoking - 50 Years of Progress. A report of the Surgeon General, 2014. U.S Department of Health and Human Services, Office of the Surgeon General, Rockville, MD 10. Slatore CG, Au DH, Hollingworth W. Cost-effectiveness of a smoking cessation program implemented at the time of surgery for lung cancer. Journal of Thoracic Oncology. 2009;4(4):499-504.
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ORAL 08 - Smoking Cessation, Tobacco Control and Lung Cancer (ID 94)
- Event: WCLC 2015
- Type: Oral Session
- Track: Prevention and Tobacco Control
- Presentations: 1
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ORAL08.06 - Introducing Smoking Cessation Across Ontario's Cancer Treatment System: Early Successes and Continuing Challenges (ID 537)
11:28 - 11:39 | Author(s): W.K. Evans
- Abstract
- Presentation
Background:
Smoking cessation (SC) has rarely been recommended by oncologists in Ontario’s cancer centres. Many believe it is too late to matter or perceive that patients will not be receptive to SC. However, a growing body of literature has identified substantial health benefits from SC in cancer patients including improved general health, improved all-cause and cancer-specific mortality, reduced toxicity, greater response to treatment and decreased risk of disease recurrence and second primaries. Based on this evidence, Cancer Care Ontario (CCO) undertook an initiative to support SC for new ambulatory cancer patients in its Regional Cancer Programs (RCPs) in 2013.
Methods:
A steering committee of experts recommended a framework for SC in 2012 based on the Ottawa Model for Smoking Cessation. The CCO executive leadership and Regional Vice-Presidents supported the initiative which was then piloted in all 14 health regions in Ontario in 2014. Regional SC “champions” participated in monthly web meetings, data calls and in-person meetings led by a secretariat at CCO. Presentations on the health benefits of SC were made to physicians and other health care providers (HCPs) at regional cancer treatment centres and through the Ontario Telehealth Network. Presentations emphasized short, repeated oncologist scripts on the benefits of SC with referral to other HCPs for in-depth SC advice. New ambulatory cancer patients are screened, advised and referred to internal or external SC services dependent on regional resources. A minimum data set of standardized performance metrics is captured by CCO with patient-level data aggregated at the RCP level, presented as a provincial average, and reviewed with the RCPs in quarterly performance management sessions.
Results:
During Q1-Q3 of the 2014/15 fiscal year, 52.9% of all new ambulatory cancer cases were screened for smoking status. Of those screened, 21.3% were current or recent (within the last 6 months) tobacco users. Approximately three-quarters of these individuals were advised of the benefits of SC; a referral for cessation services was recommended in nearly 50%; of these patients, 66.7% accepted the referral to SC services. Of those accepting a referral, 50.4% chose referrals internal to the cancer treatment facility, 32.3% chose external referrals and the remainder (17.2%) used a combination of both referral resources. As part of this initiative a standardized cancer patient resource on SC in a print-ready format has been recently developed in both French and English and will be adapted for Ontario’s Aboriginal population.
Conclusion:
CCO’s centralized yet collaborative approach has led to province-wide implementation of a standardized intervention in a relatively short timeframe with limited financial resources. Ongoing barriers to implementation and sustainability experienced by RCPs include financial constraint, limited SC training resources, reluctant physician buy-in, strained staff and system capacity, and suboptimal inter-departmental communication. Nonetheless, there has been substantial progress. Framing SC as a quality of care issue has been critical to the success to date. Sustainability of the initiative will be dependent on continued committed leadership, buy-in from front-line staff, funding for dedicated SC counselors and other resources, and evidence of program cost-effectiveness.
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ORAL 09 - CT Screening - New Data and Risk Assessment (ID 95)
- Event: WCLC 2015
- Type: Oral Session
- Track: Screening and Early Detection
- Presentations: 1
- Moderators:J. Mulshine, J.K. Field
- Coordinates: 9/07/2015, 10:45 - 12:15, Mile High Ballroom 2a-3b
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ORAL09.06 - The Cancer Risk Management Model: A Tool to Inform Canadian Policymakers Implementing Low-Dose CT Screening for Lung Cancer (ID 968)
11:50 - 12:01 | Author(s): W.K. Evans
- Abstract
- Presentation
Background:
Although the National Lung Screening Trial (NLST) demonstrated that 3 annual low-dose CT (LDCT) screens reduced lung cancer specific and overall mortality at 6 years in a defined population of smokers, the decision to implement population-based screening is difficult in the absence of information on factors not evaluated in the NLST including frequency and duration of screening, characteristics of the “at risk” population, program cost and cost-effectiveness. The Canadian Partnership Against Cancer has developed a Cancer Risk Management Model for lung cancer (CRMM-LC) with a screening module informed by data from NLST that can evaluate these factors.
Methods:
CRMM-LC uses longitudinal microsimulation techniques that incorporate Canadian demographic characteristics, risk factors, cancer management approaches and outcomes, resource utilization and other economic factors to assess impacts on population health and costs to the Canadian healthcare system. Data sources include large national population surveys, cancer registries and census data. The diagnostic and therapeutic approaches and outcomes in CRMM-LC are based on input from Canadian lung cancer experts and survival information from medical literature. The simulated mortality reduction from LDCT screening using CRMM-LC is comparable to NLST. The model can projected incident cases, life years and quality adjusted life years over different time periods for populations defined by different age ranges and smoking histories and by screening duration and frequency (annual vs biennial). It can also inform individual provinces of the incremental resources (CT scans, invasive procedures) required for program implementation and project budget impact.
Results:
Based on NLST at risk criteria (55-74 yr old smokers of 30+ pack-years, the base case scenario), 1.4 million or 4% of Canadians would be candidates for LDCT screening in 2014. Annual screening over a 10 year period with a participation rate of 60% and 70% adherence would identify an additional 12,500 (4.7%) incident cases and result in 11,320 life-years saved (undiscounted). Biennial screening would identify 4,620 (1.6%) fewer cases and save 1,454 (12.8%) fewer life-years, but may be more cost-effective than annual screening. Scenarios modeling participation rates of 20, 40 and 80% (linear uptake over 10 years) yield incident cases that vary from 8,380 fewer for the lowest rate to 3,950 more for the highest with life years saved over 10 years ranging from 7,540 fewer to 3,310 more, respectively. The model projects 3,560 more cases would be detected if LDCT was introduced for younger (50 to 69 yr old), 30 pack-year smokers compared to the base case scenario and 1,760 more cases if the threshold number of pack years was decreased to 20 pack-years. The 10 year cumulative incremental cost in Canada of annual and biennial screening would be $1,107 and $709 million, respectively
Conclusion:
CRMM-LC, available at cancerview.ca/cancerriskmanagement, can be used by provincial analysts to estimate the impact of various scenarios on the impact of policy decisions concerning the scope of the LDCT screening program. In the current fiscally constrained healthcare environment, models that can assimilate diverse sources of information and extrapolate beyond clinical trial results can help inform decisions that healthcare administrators confront.
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