ColonCancerCheck (CCC): Modelling FOBT screening in Ontario for colorectal cancer (CRC) using the Cancer Risk Management Model (CRMM)

Transcription

1 ColonCancerCheck (CCC): Modelling FOBT screening in Ontario for colorectal cancer (CRC) using the Cancer Risk Management Model (CRMM) CADTH Panel Presentation April 16, 2012 Toronto Health Economics and Technology Assessment Collaborative (THETA) Luciano Ieraci Murray Krahn Cancer Care Ontario (CCO) Loraine Marrett

2 Outline Examining FOBT uptake rates for CRC screening in Ontario: 1. ColonCancerCheck (CCC) CCC program start in 2008 and current program evaluation 2. Colorectal cancer (CRC) incidence, deaths, follow-up colonoscopies Comparing numbers: the Cancer Risk Management Model (CRMM) and Cancer Care Ontario (CCO) Differences between varying levels of gfobt uptake (30% to 50%) 3. Cost-effectiveness of FOBT screening in Ontario Cost-effectiveness of varying levels of gfobt uptake (30% to 50%) Cost-effectiveness of gfobt-to-ifobt (FIT) screening ratios 4. Summary, Limitations, Next steps

3 Background Ontario Colorectal Cancer (CRC) incidence in 2007 WOMEN = 41 per 100,000 (Canada = 40) MEN = 58 per 100,000 (Canada = 61) Total number of new cases = 7,600 (Canada = 20,700) Ontario Colorectal Cancer (CRC) mortality in 2006 WOMEN = 15 per 100,000 (Canada = 16) MEN = 25 per 100,000 (Canada = 25) Total number of deaths = 3,050 (Canada = 8,200) Recent projections in Ontario 2011: 8,376 new cases; 3,323 deaths Lifetime risk of developing CRC: 7.1% in men, 6.3% in women CRC risk increases for ages 50+ : 6.3% of cases occur < age 50

4 1. ColonCancerCheck (CCC) In FY2008, about 30% of Ontarians aged had an FOBT (gfobt) within the last 2 years Population (average risk of colorectal cancer) FY2008 uptake twice the rate in FY2003 (14.8%) Two example goals of the program Reduce mortality (deaths) from colorectal cancer Obtain a 40% uptake / participation rate in FOBT screening by 2011 Objectives of current study a) Provide additional information for the 2012 CCC evaluation and the impact of what if scenarios (i.e. varying degrees of FOBT uptake) b) Determine whether increased FOBT uptake (i.e. gfobt or FIT) is costeffective Compare varying gfobt uptake rates to 30% gfobt Compare varying gfobt-to-fit uptake ratios to 40% gfobt

5 2. CRC incidence, deaths, follow-up colonoscopies Comparison of gfobt uptake in Ontario 2005 to 2015 Historical and projected comparison of incidence, deaths and follow-up colonoscopies after positive gfobt CCO data: historical + projected data (age-period-cohort) 2005 to 2015 Focus on differences between CRMM and CCO; and gfobt uptake rates Parameters used in the CRMM model gfobt screening program parameters (i.e. a simulated CCC program ) Screening program start date = 2008 (3-year phase-in) gfobt uptake rate (participation rate) from 30% to 50% Colonoscopy compliance following positive gfobt ~ 71% (2011 estimate)

6 Incidence (new cases) 10,000 9,500 Ontario colorectal cancer incidence (new cases), by gfobt uptake and calendar year Short-term rise in incidence compared to no screening 9,000 8,500 8,000 7,500 7,000 6,500 6, Calendar year no screen CCO data 30% 35% 40% 45% 50%

7 Cancer deaths avoided 200 Ontario colorectal cancer deaths "avoided" by gfobt uptake, (i.e. difference in expected deaths) compared to 30% gfobt uptake Calendar year no screen 35% 40% 45% 50%

8 Follow-up colonoscopies 19,000 Ontario colorectal cancer follow-up colonoscopies (after positive FOBT), by gfobt uptake and calendar year 17,000 15,000 Average difference of ~ 1,700 colonoscopies 13,000 11,000 9,000 7,000 5, Calendar year CCO data 30% 35% 40% 45% 50%

9 2. CRC incidence, deaths, follow-up colonoscopies Comparison of gfobt-to-fit uptake ratio in Ontario 2011 to 2015 No historical comparison (i.e. impact of adopting FIT screening in 2011) Projected comparison of incidence, deaths and follow-up colonoscopies Focus on differences between gfobt-to-fit uptake ratios (i.e. 2 screening modalities) Parameters used in the CRMM model gfobt + FIT screening program parameters (i.e. a what if scenario) Screening program start date = 2011 (3-year phase-in) Combination uptake rates (participation rates) of FOBT screening gfobt-to-fit uptake ratios (i.e. uptake rate pairs) gfobt = 40%, 30%, 20%, 10%; with FIT = 0%, 10%, 20%, 30%, respectively Colonoscopy compliance following positive gfobt or FIT ~ 71%

10 Incidence rate (per 100,000 person years) 75 Ontario colorectal cancer incidence rates (unstandardized), by gfobt-to-fit uptake ratio and calendar year Short-term rise in incidence compared to no screening Lower incidence rates (compared to no screening) occur sooner with FIT than with gfobt Calendar year no screen CCO data 40% : 0% 30% : 10% 20% : 20% 10% : 30%

11 Cancer deaths avoided 100 Ontario colorectal cancer deaths "avoided" by gfobt-to-fit ratio, (i.e. difference in expected deaths) compared to 40% gfobt uptake Calendar year no screen 30% : 10% 20% : 20% 10% : 30%

12 Follow-up colonoscopies 40,000 Ontario colorectal cancer follow-up colonoscopies (after positive FOBT), by gfobt-to-fit uptake ratio and calendar year 35,000 30,000 25,000 Average difference of ~ 6,700 colonoscopies 20,000 15,000 10,000 5, Calendar year 40% : 0% 30% : 10% 20% : 20% 10% : 30%

13 3. Cost-effectiveness of FOBT screening in Ontario Comparison involving only gfobt screening Cost-effectiveness of program started in 2008 and reaching a range of 35% to 50% FOBT uptake rates in 3 years (i.e. CCC program in Ontario) Same parameters as Section 2 (i.e. colonoscopy compliance ~ 71%) Cohort: Average risk of CRC, ages 50-74, from Baseline strategy: 30% gfobt uptake rate Comparators (scenarios): Varying gfobt uptake rates from 35% to 50% Time horizon: Lifetime (cohort followed until death) Net monetary benefit (NMB) Incremental cost-effectiveness ratio (ICER) (cost per QALY) Undiscounted costs and effects

14 Total cost (direct costs) $500.0M Total cost of gfobt uptake in Ontario by calendar year (cohort starting in 2008) $450.0M $400.0M $350.0M $300.0M $250.0M $200.0M $150.0M $100.0M $50.0M $0.0M no screen 30% 40% 50% no screen 30% 40% 50% no screen 30% 40% 50% gfobt uptake by calendar year Screening costs Treatment costs

15 Net monetary benefit ($) $20,000.0M Ontario net monetary benefit (NMB) of gfobt uptake compared to 30% gfobt uptake (cohort starting in 2008) $15,000.0M $10,000.0M $5,000.0M $0.0M $0 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 -$5,000.0M -$10,000.0M -$15,000.0M -$20,000.0M Threshold; Ceiling ratio ($/QALY) no screen 35% 40% 45% 50%

16 Total cost ($) Cost-effectiveness of gfobt uptake in Ontario, compared to 30% FOBT uptake (cohort starting in 2008) $1,000.0M $750.0M $500.0M $250.0M $0.0M -400, , , , , , , ,000 -$250.0M -$500.0M -$750.0M -$1,000.0M Effect (QALYs) no screen 35% 40% 45% 50%

17 3. Cost-effectiveness of FOBT screening in Ontario Comparison involving FIT screening (i.e. using both gfobt and FIT) Cost-effectiveness of having a mix of gfobt and FIT screening modalities starting in 2011 (i.e. not a planned program, but suits future implementation) Same parameters as Section 2 (e.g. colonoscopy compliance ~ 71%) Cohort: Average risk of CRC, ages 50-74, from Baseline strategy: 40% gfobt uptake rate Comparators (scenarios): Varying gfobt-to-fit uptake ratios i.e. gfobt = 40%, 30%, 20%, 10%; with FIT = 0%, 10%, 20%, 30%, respectively Time horizon: Lifetime (cohort followed until death) Net monetary benefit (NMB) Incremental cost-effectiveness ratio (ICER) (cost per QALY) Undiscounted costs and effects

18 Total cost (direct costs) $500.0M Total cost of gfobt-to-fit uptake ratio in Ontario by calendar year (cohort starting in 2011) $450.0M $400.0M $350.0M $300.0M $250.0M $200.0M $150.0M $100.0M $50.0M $0.0M no screen 40% : 0% 30% : 10% 10% : 30% no screen 40% : 0% 30% : 10% 10% : 30% no screen 40% : 0% 30% : 10% 10% : 30% gfobt uptake by calendar year Screening costs Treatment costs

19 Net monetary benefit ($) $20,000.0M Ontario net monetary benefit (NMB) of gfobt-to-fit uptake ratio, compared to 40% gfobt uptake (cohort starting in 2011) $15,000.0M $10,000.0M $5,000.0M $0.0M $0 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 -$5,000.0M -$10,000.0M -$15,000.0M -$20,000.0M Threshold; Ceiling ratio ($/QALY) no screen 30% : 10% 20% : 20% 10% : 30%

20 Total cost ($) Cost-effectiveness of gfobt-to-fit uptake ratio in Ontario, compared to 40% FOBT uptake (cohort starting in 2011) $2,000.0M $1,500.0M $1,000.0M $500.0M $0.0M -400, , , , , , , ,000 -$500.0M -$1,000.0M -$1,500.0M -$2,000.0M Effect (QALYs) no screen 30% : 10% 20% : 20% 10% : 30%

21 4. Summary Epidemiology and cost-effectiveness results for CRC screening in Ontario As gfobt uptake rate increases Short-term CRC incidence increases, but long-term incidence decreases Fewer deaths with increasing FOBT uptake over time Can expect ~ 1,700 more follow-up colonoscopies annually for every 5% increase in gfobt As gfobt uptake increases, cost-effectiveness increases (i.e. higher costs for screening program, but also greater benefit for population)

22 4. Summary Epidemiology and cost-effectiveness results for CRC screening in Ontario (continued) As FIT uptake rate increases (i.e. as FIT is used more frequently) Same effect on CRC incidence, but more pronounced (effects occur more quickly) Same effect on CRC deaths, but more pronounced Can expect ~ 6,700 more follow-up colonoscopies annually for every 5% increase in FIT With given ratios: 30:10%, 20:20%, and 10:30% uptake rate ratios of gfobt-to-fit screening As FIT uptake increases, cost-effectiveness increases (i.e. higher costs for screening program, but also greater benefit; performs better than gfobt)

23 4. Limitations, Next steps Some limitations Opportunistic screening vs. program-specific screening No comparison of age-standardized rates (e.g Canadian population) Colonoscopies based on CCC-branded kit estimates (i.e. 88% of gfobts) Potential next steps Determination of follow-up colonoscopies from opportunistic vs. organized screening (and how to represent this using the CRMM) Determination of actual gfobt uptake in 2011 and re-parameterize CRMM with actual (observed) values Return on investment (ROI): comparing costs of the screening program with deaths avoided, lower incidence, additional colonoscopies, etc. Budget impact analysis (BIA): determining actual program costs and projected effects on spending over the next 5-10 years