Stuart Peacock Cancer Control Research, BC Cancer Agency Canadian Centre for Applied Research in Cancer Control (ARCC) Simon Fraser University Advancing Health Economics, Services, Policy and Ethics
I have no conflicts of interest
Real world evidence and priority setting Single shot policy questions Ongoing priority setting frameworks Some points for discussion
Prostate Cancer Screening Prostate Cancer Screening policy: funded and led by ARCC Collaboration with ARCC, BCCA, Vancouver Prostate Centre (VPC), and the Fred Hutchinson Cancer Research Centre We found that regular screening resulted in a loss of qualityadjusted life years, regardless of screening intensity, when quality of life was factored into the model BCCA/VPC updated their 2012 provincial recommendation on PSA screening to explicitly state that they did not support unselected, population-based screening
The incremental cost-effectiveness of regular screening ranged from $36,300/LYG, for screening every four years from ages 55 to 69 years, to $588,300/LYG, for screening every two years from ages 40 to 74 years. After utility adjustment, all screening strategies resulted in a loss of qualityadjusted life years (QALYs)
Program Budgeting and Marginal Analysis (PBMA) PBMA is a practical framework to aid decisionmakers seeking to maximize benefits from scarce resources Limitations of PBMA reliance on simple models perceived dependence on content expert s subjective estimates of effectiveness and/or benefits lack of comparability between measures of effectiveness 6
Real World Evidence and PBMA Define aim and scope Determine current program budget Form Steering Committee Identify areas for new resource use Establish decisionmaking criteria Make allocation recommendations Validity check and final decisions Identify areas for resource release For each area identified: Form Advisory Panel Collect local costs/outcomes Build Markov model - CUA MCDA Models 5 areas identified: Adjuvant trastuzumab in breast cancer Bevacizumab in metastatic colorectal cancer Mammography for women with dense breast tissue PET for lung cancer staging MRI for breast cancer screening 7
Objective: Examine the cost effectiveness of MRI and mammography for breast cancer screening in BRCA1/2 mutation carriers Current practice: 6 mo. alternating MRI and mammography for confirmed BRCA1/2 carriers (& family) Annual mammography for others at high hereditary risk Rationale: MRI is more sensitive than mammography (75% vs. 32%) but less specific (96.1% vs. 98.5%) and more expensive
Markov Model Design 9
Study Sample from HCP data 871 women with BRCA1/2 test results in 2002-2007 203 confirmed BRCA1/2 mutation positive 105 BRCA1/2 positive cancer cases 87 patients with first cancer 68 patients with complete records 668 mutation negative or uninformative 99 with no cancer (or no CAIS record of cancer) 18 with other cancer or missing stage information 19 patients diagnosed before 1995 10
Data Sources for Model Model Input Cancer Incidence Screening Sensitivity and Specificity Cancer Survival Treatment procedures Treatment Costs Utilities Sources Literature (meta-analysis) Literature (meta-analysis) BCCA Surveillance and Outcomes data BCCA records for BRCA1/2 population BCCA Pharmacy, Radiation Therapy and Administration; BC Medical Services Commission Literature 11
Screening and Diagnostics Sensitivity Specificity MRI 0.77 0.86 Mammography (in MRI arm) 0.39 0.95 MRI & Mammo (pooled) 0.94 0.77 Mammography (Mammography alone arm) < 50 yrs 0.67 0.88 > 50 yrs 0.83 0.88 from meta-analysis by Warner 2008; Kerlikowske 2000 Costs: MRI screen: $277 (IH, BCCA and VIHA) Bilateral mammography: $95 (2008 MSP) Average diagnostic work-up: $187 (2008 MSP) 12
Treatment Costs In Situ Local Regional Distant Surgery 3,394 3,365 3,595 3,057 Chemo 33 3,625 9,108 5,753 Radiation 0 3,785 10,909 6,835 TOTAL 3,427 10,940 23,612 15,645 MR Chemo 11,082 Radiation 2,152 Hospitalization 12,714 TOTAL 26,704 13
Utilities Derived from published quality of life studies Screening has full health utility (1.00) State Utility Diagnostics 0.987 In situ 0.965 Local 0.860 Regional 0.675 Distant 0.380 Remission 0.965 MR 0.380 14
Results
Other ICER Results Screening Mammography annual screening mammography for women with greater than 75% mammographic breast density had an ICER range of $565,912/QALY PET/CT PET for NSCLC staging: $10,932/LYG PET for SPN diagnosis: $64,062/LYG Adjuvant Trastuzumab for breast cancer use of adjuvant trastuzumab saves approximately $1,200,000 from the Systemic Therapy budget annually projecting survival scenarios forward 28-years produced an ICER of $13,095/QALY Bevacizumab for metastatic colorectal cancer Introduction of bevacizumab associated with an ICER of $43,058/QALY
Cost-effectiveness of Personalized Medicine FLT3-ITD and NPM1 mutational testing ICER=$65,186/LYG Treatment decision Diagnostic test 20
Points for discussion Sustainability Investments and disinvestments Personalized medicine drugs Personalized medicine - tests
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