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W.K. Evans
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OA17 - Aspects of Health Policies and Public Health (ID 397)
- Event: WCLC 2016
- Type: Oral Session
- Track: Regional Aspects/Health Policy/Public Health
- Presentations: 1
- Moderators:M. Kneussl
- Coordinates: 12/06/2016, 16:00 - 17:30, Schubert 1
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OA17.02 - Potential Health and Economic Consequences of Organized vs Opportunistic Lung Cancer Screening in Canada (ID 6033)
16:10 - 16:20 | Author(s): W.K. Evans
- Abstract
- Presentation
Background:
Annual LDCT screening for individuals 55-74 yrs with >30 pack-year smoking history is supported by evidence from the NLST but has led to questions of implementation. Compared to organized screening (ORG), opportunistic screening (OPP) may utilize broader entry criteria and not include smoking cessation.
Methods:
Health and economic impacts of ORG using NLST entry criteria were modelled using population microsimulation (OncSim – formerly Canadian Risk Management Model v 2.3) and compared to OPP scenarios. We modeled ORG at a participation rate of 30 and 60%, with and without smoking cessation, compared to various plausible OPP scenarios: younger individuals (40-74 yrs); lesser smoking histories (10 or 20 pack-yrs). Outcomes projected to 20 years included incidence, mortality, number of scans, invasive diagnostics for false positives, and screening and treatment costs. A lifetime horizon and 3% discounting were used to estimate the incremental cost-effectiveness ratio (ICER) from a health system perspective. All costs are in 2016 CAD.
Results:
A large number of outputs can be presented. At a participation rate of 30%, average annual incremental incident cases of lung cancer with OPP for 40-74 yr-olds with 10 pack-yr histories are higher by 254 over ORG without cessation, and there would be an average 135 fewer deaths annually. However, the annual number of CT scans would increase by 433,000 on average and diagnostic tests for false positive results would increase by 1540. Average annual costs would increase by $141 M compared with ORG without cessation, resulting in an ICER of $133,000/QALY. OPP with 40-74 yr-olds having 20 and 30 pk-yr histories result in $92,147 and 74,978/QALY respectively. In all cases of OPP compared to ORG with cessation there are net losses of QALY. Notably, ORG with smoking cessation compared to ORG without yields an ICER of $2800/QALY.
Conclusion:
OPP screening results in more incident cases and fewer deaths but more cost from over-diagnosis and false positives. In Canada, an annual screening program with strict adherence to NLST entry criteria could be highly cost-effective. Jurisdictions will have to weigh the benefits and risks of LDCT scanning beyond the currently available evidence.
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P1.05 - Poster Session with Presenters Present (ID 457)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Early Stage NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 12/05/2016, 14:30 - 15:45, Hall B (Poster Area)
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P1.05-068 - Elderly Patients with Resected Stage II Nonsmall Cell Lung Cancer Are Less Likely to Have a Consultation with a Medical Oncologist (ID 4814)
14:30 - 14:30 | Author(s): W.K. Evans
- Abstract
Background:
Adjuvant chemotherapy (AC) is guideline recommended standard of care for resected Stage II NSCLC patients in Ontario. Despite evidence of a significant survival benefit, uptake of AC has been lower than expected and has remained unchanged since 2008 at 50-55%. Factors that may preclude use of chemotherapy include comorbid medical conditions, socioeconomic and demographic factors and the opportunity for consultation with a medical oncologist (MO). This study evaluated: 1) patient opportunity for a consultation with a MO, and 2) differences between patients who had a consultation and those who did not
Methods:
Stage II NSCLC adult patients diagnosed between 2010 and 2013 were identified using the Ontario Cancer Registry. Complete surgical resections and consultation with a MO were identified using multiple administrative databases. Receipt of guideline-recommended AC within 120 days after resection, and consultation with MO within 30 days prior and 90 days after resection were determined. Guideline-recommended AC includes platinum based regimens, including receipt outside a Regional Cancer Center (RCC). Alternative treatments were defined as non-platinum based chemotherapy or radiotherapy. Socioeconomic and demographic characteristics were compared between patients who received a consultation and those who did not. Characteristics associated with receiving a consultation were assessed using univariable analysis and multivariable logistic regression.
Results:
Of 778 Stage II resected NSCLC patients who survived at least 120 days, 40.9% (n=318, CI: 37.40–44.42) received guideline-recommended AC, 3.0% (n=23, CI: 1.70-4.40) received alternative treatment in an RCC, 11.2% (n=87, CI:8.95-13.50) received chemotherapy outside of an RCC hospital, and 45.0% (n=350, CI:41.45-48.56) of patients did not have systemic treatment after surgery. Overall, 72.9% (n=567) of patients had a consultation with a MO within 30 days prior or 90 days after resection. Of 350 patients who did not receive AC, 219 (62.6%) had a MO consultation. Median time from resection to consultation was 29 days, and did not differ between treatment groups (p=0.35). Age was a significant determinant for MO consultation. Adjusting for sex, patients aged 41-60yrs (OR 2.38, CI:1.25-4.56) and 61-70yrs (OR 2.46, CI:1.35-4.49) were significantly more likely to have a consultation versus patients >80 yrs. Other characteristics were not significantly associated with having a consultation.
Conclusion:
Although uptake of guideline-recommended AC is lower than expected (52.1%, CI:48.48-55.62), the majority of patients had an opportunity to discuss this treatment option with a MO. Patients over 80yrs were significantly less likely to have this consultation.
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P3.07 - Poster Session with Presenters Present (ID 493)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Regional Aspects/Health Policy/Public Health
- Presentations: 1
- Moderators:
- Coordinates: 12/07/2016, 14:30 - 15:45, Hall B (Poster Area)
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P3.07-016 - Ontario's Episode-Based Funding Model Reveals Practice Variation in Adjuvant NSCLC Chemotherapy (ID 5688)
14:30 - 14:30 | Author(s): W.K. Evans
- Abstract
Background:
A new episode-based funding model (FM) for ambulatory systemic therapy was implemented in Ontario, Canada in April 2014. The FM bundled reimbursement for components of care, including initial consultation, treatment episodes delivered with adjuvant/curative (AC) or palliative intent and supportive care. Options for evidence-informed AC regimens and their optimal number of treatment cycles and chemotherapy suite visits were informed by the provincial lung Disease Site Group (DSG) based on published literature or group concensus. It was expected that cisplatin-vinorelbine (CISPVINO) would be the most commonly used regimen as CISPVINO was used in the clinical trial conducted in Canada that established CISPVINO as a standard of care and is recommended in Ontario’s adjuvant chemotherapy practice guideline.
Methods:
The utilization of AC was analyzed for 35 systemic treatment facilities in Ontario comparing actual practice (AP) with “best practice” (BP) (cycle number). For this analysis, cases were included if they started a new course of AC after January 1, 2014 and completed the treatment before July 30, 2015.
Results:
The percentage of patients with stage II/IIIa NSCLC receiving AC has been stable at 50-55% for over five years. In this analysis 1,531 cases received some form of AC. 506 cases received chemotherapy with XRT (usually etoposide-cisplatin) and these cases were assumed to be Pancoast tumours or stage IIIa disease on neoadjuvant therapy. The most common regimens prescribed without XRT were cisplatin-vinorelbine (CISPVINO) (331 cases) cisplatin-etoposide (222), carboplatin-etoposide (154) and carboplatin + vinorelbine (74 cases). For all adjuvant chemotherapy excluding XRT (1,025 cases), AP was equal to BP in only 24 % of cases, APBP in 4%. For CISPVINO, AP=BP was achieved in only 36%, AP< BP in 55% and AP > BP in 9%. For the top 5 hospitals by volume administering AC, BP=AP ranged from 8-45%; AP< BP ranged from 41-73%; AP > BP occurred in 20 cases in 3 facilities.
Conclusion:
This analysis of first-year funding data provided insights on how adjuvant chemotherapy is administered in Ontario. As expected, CISPVINO was the most commonly used AC regimen (32%) when AC was used alone. However, etoposide-cisplatin was also commonly used alone and in combination with XRT and carboplatin was frequently substituted. BP is only achieved in the minority of cases and there is wide institutional variance. Reasons for this variation need to be better understood and opportunities identified to drive efficiency and standardization.
