Systematic Review and Meta-Analysis of Community- and Choice-Based Health State Utility Values for Lung Cancer

The impact of KRAS mutational status on patient-reported outcomes in advanced non-small-cell lung cancer: a cross sectional study in France and Germany

OBJECTIVES

Health-related quality of life (HRQoL) studies in patients with advanced non-small-cell lung cancer (NSCLC) according to KRAS mutational status are limited. This study aimed to report real-world evidence on HRQoL outcomes based on KRAS mutational status in patients with advanced NSCLC tumors receiving second-line or later (2L+) treatment in France and Germany.

METHODS

In this real-world, non-interventional, cross-sectional, multicenter, patient-reported outcome (PRO) study conducted in France (15 contributing sites) and Germany (8 contributing sites), physicians enrolled adult patients with locally advanced and unresectable or metastatic NSCLC with known KRAS mutation status (KRAS G12C, KRAS non-G12C, or KRAS wildtype [WT]), who received a 2L + treatment. Study outcomes included sociodemographic characteristics; HRQoL evaluations based on EORTC Global Health Status QoL scores (QLQ-C30) and EQ-5D-5L scores. Data were analyzed descriptively.

RESULTS

Of 156 enrolled patients, data from 149 patients were included in the final analysis (France, n = 103; Germany, n = 46). Median (quartile [Q]1, Q3) age was 67.0 (61.0, 71.0) years; 56.4% of patients were male. In total, 38.9% (n = 58), 26.2% (n = 39), and 34.9% (n = 52) of patients had tumors with KRAS G12C mutation, KRAS non-G12C mutation and WT KRAS, respectively. Mean (±SD) QLQ-C30 Global Health Status QoL scores were 56.99 (20.30) for the overall population, and 56.03 (22.55), 58.97 (18.67) and 56.57 (19.05) for KRAS G12C, non-G12C, and WT subpopulations. In the overall population, moderate-to-extreme problems were reported in all EQ-5D-5L dimensions (range: overall population, 15.5%-39.6%; KRAS G12C, 15.6%-46.6%; non-G12C, 7.8%-23.1%; WT, 21.1%-44.2%).

CONCLUSION

HRQoL was broadly similar across KRAS G12C, non-G12C, and WT subpopulations.

Cost-effectiveness of low-dose CT screening for non-smokers with a first-degree relative history of lung cancer

BACKGROUND

Lung cancer is the leading cause of cancer-related deaths worldwide, with non-smokers in China accounting for over 40% of cases. Despite the proven efficacy of low-dose computed tomography (LDCT) in early detection and reduction of lung cancer mortality, the current paradigm of lung cancer screening, heavily focused on smoking status and age, may inadequately address the unique risk factors associated with non-smokers, particularly those with a family history of the disease. This study evaluates the cost-effectiveness of LDCT screening for non-smokers with a first-degree relative (FDR) history of lung cancer, a group at particularly high-risk.

METHODS

We developed a state-transition Markov model to evaluate the incremental cost-effectiveness ratios (ICERs) of 16 screening strategies for a hypothetical cohort of 100,000 non-smoking individuals aged 50 with a FDR history of lung cancer, considering various starting ages (50, 55, 60, 65 years) and intervals (one-off, annual, biennial, triennial). The willingness-to-pay (WTP) threshold was set at three times China's 2022 per-capita GDP. Sensitivity analyses, scenario analyses and subgroup analysis by sex, were conducted.

RESULTS

Compared to no screening, all strategies except one-off screening at age 50, were cost-effective for both sexes. Biennial LDCT starting at age 55 was found to be most effective, with an ICER of CNY 68,932/QALY for males, and CNY 80,056/QALY for females. This cost-effectiveness probability for this strategy was approximately 90% for both sexes. Sensitivity analyses indicated that annual screening at age 55 was optimal without discounting. For males, biennial at age 60 was optimal if the FDR-related odds ratio for lung cancer incidence was below 1.492. Triennial screening at age 55 was optimal for females at full adherence. Ignoring disutility from false-positive results, annual at age 55 was optimal for both sexes.

CONCLUSIONS

LDCT screening for non-smokers with a FDR history of lung cancer is cost-effective, especially biennial screening at 55. These findings support the development of more inclusive screening guidelines, which could enhance early detection and reduce mortality rates.

Targeted lung cancer screening in the age of immunotherapies and targeted therapies - an economic evaluation for Australia

Background

The cost-effectiveness of different lung cancer screening strategies has been evaluated from an Australian public health system perspective using static models. In addition, the impact of novel therapies, including immunotherapies and targeted therapies, on the cost-effectiveness of lung cancer screening has not yet been evaluated comprehensively. We evaluated the benefits, harms and cost-effectiveness of a targeted national lung screening program in Australia, accounting for the increasing uptake of novel therapies, which informed the lung cancer screening recommendations of the Australian Medical Services Advisory Committee (MSAC).

Methods

Australia-specific data on lung cancer epidemiology, smoking behaviour and care costs were used to adapt the MIcrosimulation SCreening ANalysis (MISCAN)-Lung model. Benefits, harms and cost-effectiveness of different targeted lung cancer screening scenarios were evaluated for individuals born between 1945 and 1969. The scenarios considered various screening age ranges, intervals and eligibility criteria (minimum accumulated smoking history and PLCOm2012 risk thresholds).

Findings

The MSAC-recommended scenario was cost-effective at AUD62,754 per quality-adjusted life-year compared to no screening. This scenario biennially screens current and former smokers (quit ≤10 years ago) who smoked ≥30 pack-years between ages 50 and 70, preventing 62 lung cancer deaths per 100,000 and yielding 8.4 quality-adjusted life-years per prevented lung cancer death. Using novel therapies reduced the incremental costs of screening compared to no-screening by 14.8% but yielded 11.3% fewer incremental quality-adjusted life-years compared to traditional anti-cancer therapies, due to the improved survival yielded by novel therapies. Overall, the cost-effectiveness of screening was better when costs and effects of novel therapies were applied (AUD62,754 vs AUD65,340 per quality-adjusted life-year gained; 4% difference).

Interpretation

Targeted lung cancer screening is more cost-effective when costs and effects of novel therapies are applied, although impacts on cost-effectiveness are likely to be marginal.

Funding

Cancer Australia.

Cost-effectiveness of lung cancer screening with volume computed tomography in Portugal

Aim: Lung cancer is the most common cause of cancer death in Portugal. The Dutch-Belgian lung cancer screening (LCS) study (NELSON), the biggest European LCS study, showed a lung cancer mortality reduction in a high-risk population when being screened. In this study, the cost-effectiveness of LCS, based on the NELSON study protocol and outcomes, was evaluated compared with no screening in Portugal. Methods: The present study modified an established decision tree by incorporating a state-transition Markov model to evaluate the health-related advantages and economic implications of low-dose computed tomography (LDCT) LCS from the healthcare standpoint in Portugal. The analysis compared screening versus no screening for a high-risk population aged 50-75 with a smoking history. Various metrics, including clinical outcomes, costs, quality-adjusted life years (QALYs), life-years (LYs) and the incremental cost-effectiveness ratio (ICER), were calculated to measure the impact of LDCT LCS. Furthermore, scenario and sensitivity analyses were executed to assess the robustness of the obtained results. Results: Annual LCS with volume-based LDCT resulted in €558 million additional costs and 86,678 additional QALYs resulting in an ICER of €6440 per QALY for one screening group and a lifetime horizon. In total, 13,217 premature lung cancer deaths could be averted, leading to 1.41 additional QALYs gained per individual diagnosed with lung cancer. Results are robust based on the sensitivity analyses. Conclusion: This study showed that annual LDCT LCS for a high-risk population could be cost-effective in Portugal based on a willingness to pay a threshold of one-time the GDP (€19,290 per QALY gained).

Shall We Screen Lung Cancer with Volume Computed Tomography in Austria? A Cost-Effectiveness Modelling Study

This study assessed the cost-effectiveness of a lung cancer screening (LCS) program using low-dose computed tomography (LDCT) in Austria. An existing decision tree with an integrated Markov model was used to analyze the cost-effectiveness of LCS versus no screening from a healthcare payer perspective over a lifetime horizon. A simulation was conducted to model annual LCS for an asymptomatic high-risk population cohort aged 50-74 with a smoking history using the Dutch-Belgian Lung Cancer Screening Study (NEderlands-Leuvens Longkanker ScreeningsONderzoek, NELSON) screening outcomes. The principal measure utilized to assess cost-effectiveness was the incremental cost-effectiveness ratio (ICER). Sensitivity and scenario analyses were employed to determine uncertainties surrounding the key model inputs. At an uptake rate of 50%, 300,277 eligible individuals would participate in the LCS program, yielding 56,122 incremental quality-adjusted life years (QALYs) and 84,049 life years gained compared to no screening, with an ICER of EUR 24,627 per QALY gained or EUR 16,444 per life-year saved. Additionally, LCS led to the detection of 25,893 additional early-stage lung cancers and averted 11,906 premature lung cancer deaths. It was estimated that LCS would incur EUR 945 million additional screening costs and EUR 386 million additional treatment costs. These estimates were robust in sensitivity analyses. Implementation of annual LCS with LDCT for a high-risk population, using the NELSON screening outcomes, is cost-effective in Austria, at a threshold of EUR 50,000 per QALY.

Quality Appraisal in Systematic Literature Reviews of Studies Eliciting Health State Utility Values: Conceptual Considerations

BACKGROUND

The increasing number of studies that generate health state utility values (HSUVs) and the impact of HSUVs on cost-utility analyses make a robust tailored quality appraisal (QA) tool for systematic reviews of these studies necessary.

OBJECTIVE

This study aimed to address conceptual issues regarding QA in systematic reviews of studies eliciting HSUVs by establishing a consensus on the definitions, dimensions and scope of a QA tool specific to this context.

METHODS

A modified Delphi method was used in this study. An international multidisciplinary panel of seven experts was purposively assembled. The experts engaged in two anonymous online survey rounds. After each round, the experts received structured and controlled feedback on the previous phase. Controlled feedback allowed the experts to re-evaluate and adjust their positions based on collective insights. Following these surveys, a virtual face-to-face meeting was held to resolve outstanding issues. Consensus was defined a priori at all stages of the modified Delphi process.

RESULTS

The response rates to the first-round and second-round questionnaires and the virtual consensus meeting were 100%, 86% and 71%, respectively. The entire process culminated in a consensus on the definitions of scientific quality, QA, the three QA dimensions-reporting, relevance and  methodological quality-and the scope of a QA tool specific to studies that elicit HSUVs.

CONCLUSIONS

Achieving this consensus marks a pivotal step towards developing a QA tool specific to systematic reviews of studies eliciting HSUVs. Future research will build on this foundation, identify QA items, signalling questions and response options, and develop a QA tool specific to studies eliciting HSUVs.

Screening for lung cancer with computed tomography: protocol for systematic reviews for the Canadian Task Force on Preventive Health Care

PURPOSE

Lung cancer is the leading cause of cancer deaths in Canada, and because early cancers are often asymptomatic screening aims to prevent mortality by detecting cancer earlier when treatment is more likely to be curative. These reviews will inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening for lung cancer.

METHODS

We will update the review on the benefits and harms of screening with CT conducted for the task force in 2015 and perform de novo reviews on the comparative effects between (i) trial-based selection criteria and use of risk prediction models and (ii) trial-based nodule classification and different nodule classification systems and on patients' values and preferences. We will search Medline, Embase, and Cochrane Central (for questions on benefits and harms from 2015; comparative effects from 2012) and Medline, Scopus, and EconLit (for values and preferences from 2012) via peer-reviewed search strategies, clinical trial registries, and the reference lists of included studies and reviews. Two reviewers will screen all citations (including those in the previous review) and base inclusion decisions on consensus or arbitration by another reviewer. For benefits (i.e., all-cause and cancer-specific mortality and health-related quality of life) and harms (i.e., overdiagnosis, false positives, incidental findings, psychosocial harms from screening, and major complications and mortality from invasive procedures as a result of screening), we will include studies of adults in whom lung cancer is not suspected. We will include randomized controlled trials comparing CT screening with no screening or alternative screening modalities (e.g., chest radiography) or strategies (e.g., CT using different screening intervals, classification systems, and/or patient selection via risk models or biomarkers); non-randomized studies, including modeling studies, will be included for the comparative effects between trial-based and other selection criteria or nodule classification methods. For harms (except overdiagnosis) we will also include non-randomized and uncontrolled studies. For values and preferences, the study design may be any quantitative design that either directly or indirectly measures outcome preferences on outcomes pertaining to lung cancer screening. We will only include studies conducted in Very High Human Development Countries and having full texts in English or French. Data will be extracted by one reviewer with verification by another, with the exception of result data on mortality and cancer incidence (for calculating overdiagnosis) where duplicate extraction will occur. If two or more studies report on the same comparison and it is deemed suitable, we will pool continuous data using a mean difference or standardized mean difference, as applicable, and binary data using relative risks and a DerSimonian and Laird model unless events are rare (< 1%) where we will pool odds ratios using Peto's method or (if zero events) the reciprocal of the opposite treatment arm size correction. For pooling proportions, we will apply suitable transformation (logit or arcsine) depending on the proportions of events. If meta-analysis is not undertaken we will synthesize the data descriptively, considering clinical and methodological differences. For each outcome, two reviewers will independently assess within- and across-study risk of bias and rate the certainty of the evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation), and reach consensus.

DISCUSSION

Since 2015, additional trials and longer follow-ups or additional data (e.g., harms, specific patient populations) from previously published trials have been published that will improve our understanding of the benefits and harms of screening. The systematic review of values and preferences will allow fulsome insights that will inform the balance of benefits and harms.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022378858.

Risk-based lung cancer screening in heavy smokers: a benefit-harm and cost-effectiveness modeling study

BACKGROUND

Annual screening through low-dose computed tomography (LDCT) is recommended for heavy smokers. However, it is questionable whether all individuals require annual screening given the potential harms of LDCT screening. This study examines the benefit-harm and cost-effectiveness of risk-based screening in heavy smokers and determines the optimal risk threshold for screening and risk-stratified screening intervals.

METHODS

We conducted a comparative cost-effectiveness analysis in China, using a cohort-based Markov model which simulated a lung cancer screening cohort of 19,146 heavy smokers aged 50 ~ 74 years old, who had a smoking history of at least 30 pack-years and were either current smokers or had quit for < 15 years. A total of 34 risk-based screening strategies, varying by different risk groups for screening eligibility and screening intervals (1-year, 2-year, 3-year, one-off, non-screening), were evaluated and were compared with annual screening for all heavy smokers (the status quo strategy). The analysis was undertaken from the health service perspective with a 30-year time horizon. The willingness-to-pay (WTP) threshold was adopted as three times the gross domestic product (GDP) of China in 2021 (CNY 242,928) per quality-adjusted life year (QALY) gained.

RESULTS

Compared with the status quo strategy, nine risk-based screening strategies were found to be cost-effective, with two of them even resulting in cost-saving. The most cost-effective strategy was the risk-based approach of annual screening for individuals with a 5-year risk threshold of ≥ 1.70%, biennial screening for individuals with a 5-year risk threshold of 1.03 ~ 1.69%, and triennial screening for individuals with a 5-year risk threshold of < 1.03%. This strategy had the highest incremental net monetary benefit (iNMB) of CNY 1032. All risk-based screening strategies were more efficient than the status quo strategy, requiring 129 ~ 656 fewer screenings per lung cancer death avoided, and 0.5 ~ 28 fewer screenings per life-year gained. The cost-effectiveness of risk-based screening was further improved when individual adherence to screening improved and individuals quit smoking after being screened.

CONCLUSIONS

Risk-based screening strategies are more efficient in reducing lung cancer deaths and gaining life years compared to the status quo strategy. Risk-stratified screening intervals can potentially balance long-term benefit-harm trade-offs and improve the cost-effectiveness of lung cancer screenings.

Cost-effectiveness of risk-based low-dose computed tomography screening for lung cancer in Switzerland

Throughout Europe, computed tomography (CT) screening for lung cancer is in a phase of clinical implementation or reimbursement evaluation. To efficiently select individuals for screening, the use of lung cancer risk models has been suggested, but their incremental (cost-)effectiveness relative to eligibility based on pack-year criteria has not been thoroughly evaluated for a European setting. We evaluate the cost-effectiveness of pack-year and risk-based screening (PLCOm2012 model-based) strategies for Switzerland, which aided in informing the recommendations of the Swiss Cancer Screening Committee (CSC). We use the MISCAN (MIcrosimulation SCreening ANalysis)-Lung model to estimate benefits and harms of screening among individuals born 1940 to 1979 in Switzerland. We evaluate 1512 strategies, differing in the age ranges employed for screening, the screening interval and the strictness of the smoking requirements. We estimate risk-based strategies to be more cost-effective than pack-year-based screening strategies. The most efficient strategy compliant with CSC recommendations is biennial screening for ever-smokers aged 55 to 80 with a 1.6% PLCOm2012 risk. Relative to no screening this strategy is estimated to reduce lung cancer mortality by 11.0%, with estimated costs per Quality-Adjusted Life-Year (QALY) gained of €19 341, and a €1.990 billion 15-year budget impact. Biennial screening ages 55 to 80 for those with 20 pack-years shows a lower mortality reduction (10.5%) and higher cost per QALY gained (€20 869). Despite model uncertainties, our estimates suggest there may be cost-effective screening policies for Switzerland. Risk-based biennial screening ages 55 to 80 for those with ≥1.6% PLCOm2012 risk conforms to CSC recommendations and is estimated to be more efficient than pack-year-based alternatives.

Effects of medical interventions on health-related quality of life in chronic disease - systematic review and meta-analysis of the 19 most common diagnoses

Introduction

The demographic shift leads to a tremendous increase in age-related diseases, which are often chronic. Therefore, a focus of chronic disease management should be set on the maintenance or even improvement of the patients' quality of life (QoL). One indicator to objectively measure QoL is the EQ-5D questionnaire, which was validated in a disease- and world region-specific manner. The aim of this study was to conduct a systematic literature review and meta-analysis on the QoL across the most frequent chronic diseases that utilized the EQ-5D and performed a disease-specific meta-analysis for treatment-dependent QoL improvement.

Materials and methods

The most common chronic disease in Germany were identified by their ICD-10 codes, followed by a systematic literature review of these ICD-10 codes and the EQ-5D index values. Finally, out of 10,016 independently -screened studies by two persons, 538 studies were included in the systematic review and 216 studies in the meta-analysis, respectively.

Results

We found significant medium to large effect sizes of treatment effects, i.e., effect size >0.5, in musculoskeletal conditions with the exception of fractures, for chronic depression and for stroke. The effect size did not differ significantly from zero for breast and lung cancer and were significantly negative for fractures.

Conclusion

Our analysis showed a large variation between baseline and post-treatment scores on the EQ-5D health index, depending on the health condition. We found large gains in health-related quality of life mainly for interventions for musculoskeletal disease.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020150936, PROSPERO identifier CRD42020150936.

Cost-effectiveness analysis of a lung cancer screening program in the netherlands: a simulation based on NELSON and NLST study outcomes

BACKGROUND

In the Netherlands, lung cancer is the leading cause of cancer-related death, accounting for more than 10,000 annual deaths. Lung cancer screening (LCS) studies using low-dose computed tomography (LDCT) have demonstrated that early detection reduces lung cancer mortality. However, no LCS program has been implemented yet in the Netherlands. A national LCS program has the potential to enhance the health outcomes for lung cancer patients in the Netherlands.

OBJECTIVE AND METHODS

This study evaluates the cost-effectiveness of LCS compared to no-screening in the Netherlands, by simulating the screening outcomes based on data from NEderlands-Leuvens Longkanker Screenings ONderzoek (NELSON) and National Lung Screening Trial (NLST). We simulated annual screening up to 74 years of age, using inclusion criteria from the respective studies. A decision tree and Markov model was used to predict the incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICERs) for the screening population. The analysis used a lifetime horizon and a societal perspective.

RESULTS

Compared to no-screening, LCS resulted in an ICER of €5,169 per QALY for the NELSON simulation, and an ICER of €17,119 per QALY for the NLST simulation. The screening costs were highly impactful for the cost-effectiveness. The most influential parameter was the CT scan cost. Cost reduction for CT from €201 to €101 per scan would reduce the ICER to €2,335 using NELSON criteria. Additionally, LCS could prevent 15,115 and 12,611 premature lung cancer deaths, accompanied by 1.66 and 1.31 QALYs gained per lung cancer case for the NELSON and NLST simulations, respectively.

CONCLUSION

LCS was estimated to be cost-effective in the Netherlands for both simulations at a willingness-to-pay threshold of €20,000 per QALY. Using the NELSON criteria, less than €5,500 per QALY had to be spent. Lowering the cost per CT exam would lead to a further reduction of this amount.

Economic evaluation of adjuvant therapy with osimertinib in patients with early-stage non-small cell lung cancer and mutated EGFR

PURPOSE

The ADAURA trial demonstrated the superiority of osimertinib over a placebo with regard to disease-free survival, showing it to be indicated as an adjuvant therapy for treatment of non-small cell lung cancer with mutated epidermal growth factor receptor (EGFR). The aim of the present study was to conduct a cost-utility analysis and an analysis of the budgetary impact of adjuvant therapy with osimertinib in patients with non-small cell lung cancer with mutated EGFR who had undergone resection surgery with curative intent.

METHODS

Analyses were based on the outcomes of the ADAURA clinical trial and were conducted through a Spanish National Health Service perspective. The outcome measures used were quality-adjusted life years (QALY).

RESULTS

The average overall cost of adjuvant treatment with osimertinib over a period of 100 months in the overall sample of trial patients (stages IB-IIIA) was 220,961 €, compared with 197,849 € in the placebo group. Effectiveness, estimated according to QALY, was 6.26 years in the osimertinib group and 5.96 years in the placebo group, with the incremental cost-utility ratio being 77,040 €/QALY. With regard to the budgetary impact, it was estimated that, in 2021, approximately 1130 patients would be subsidiaries to receive osimertinib. This pertains to a difference of 17,375,330 € over 100 months to fund this treatment relative to no treatment.

CONCLUSION

Taking into account a Spanish threshold of 24,000 €/QALY, the reduction in the acquisition cost of osimertinib will have to be greater than 10%, to obtain a cost-effective alternative.

Health State Utility Values in Early-Stage Non-small Cell Lung Cancer: A Systematic Literature Review

BACKGROUND

Non-small cell lung cancer (NSCLC) is the predominant histological subtype of lung cancer and is the leading cause of cancer-related deaths globally. Quality of life is an important consideration for patients and current treatments can adversely affect health-related quality of life (HRQoL).

OBJECTIVE

The objectives of this systematic literature review (SLR) were to identify and provide a comprehensive catalogue of published health state utility values (HSUVs) in patients with early-stage NSCLC and to understand the factors impacting on HSUVs in this indication.

METHODS

Electronic searches of Embase, MEDLINE and Evidence-Based Medicine Reviews were conducted via the Ovid platform in March 2021 and June 2022 and were supplemented by grey literature searches of conference proceedings, reference lists, health technology assessment bodies, and other relevant sources. Eligibility criteria were based on patients with early-stage (stage I-III) resectable NSCLC receiving treatment in the adjuvant or neoadjuvant setting. No restriction was placed on interventions or comparators, geography, or publication date. English language publications or non-English language publications with an English abstract were of primary interest. A validated checklist was applied to conduct quality assessment of the full publications.

RESULTS

Twenty-nine publications (27 full publications and two conference abstracts) met all eligibility criteria and reported 217 HSUVs and seven disutilities associated with patients with early NSCLC. The data showed that increasing disease stage is associated with decreasing HRQoL. It was also indicated that utility values vary by treatment approach; however, the choice of treatment may be influenced by the patients' disease stage at presentation. Few studies aligned with the requirements of health technology assessment (HTA) bodies, indicating a need for future studies to conform to these preferences, making them suitable for use in economic evaluations.

CONCLUSIONS

This SLR found that disease stage and treatment approach were two of several factors that can impact patient-reported HRQoL. Additional studies are warranted to confirm these findings and to investigate emerging therapies for early NSCLC. In collecting a catalogue of HSUV data, this SLR has begun to identify the challenges associated with identifying reliable utility value estimates suitable for use in economic evaluations of early NSCLC.

Incorporating Prior Beliefs Into Meta-Analyses of Health-State Utility Values Using the Bayesian Power Prior

OBJECTIVES

Health-state utility values (HSUVs) directly affect estimates of Quality-Adjusted Life-Years and thus the cost-utility estimates. In practice a single preferred value (SPV) is often selected for HSUVs, despite meta-analysis being an option when multiple (credible) HSUVs are available. Nevertheless, the SPV approach is often reasonable because meta-analysis implicitly considers all HSUVs as equally relevant. This article presents a method for the incorporation of weights to HSUV synthesis, allowing more relevant studies to have greater influence.

METHODS

Using 4 case studies in lung cancer, hemodialysis, compensated liver cirrhosis, and diabetic retinopathy blindness, a Bayesian Power Prior (BPP) approach is used to incorporate beliefs on study applicability, reflecting the authors' perceived suitability for UK decision making. Older studies, non-UK value sets, and vignette studies are thus downweighted (but not disregarded). BPP HSUV estimates were compared with a SPV, random effects meta-analysis, and fixed effects meta-analysis. Sensitivity analyses were conducted iteratively updating the case studies, using alternative weighting methods, and simulated data.

RESULTS

Across all case studies, SPVs did not accord with meta-analyzed values, and fixed effects meta-analysis produced unrealistically narrow CIs. Point estimates from random effects meta-analysis and BPP models were similar in the final models, although BPP reflected additional uncertainty as wider credible intervals, particularly when fewer studies were available. Differences in point estimates were seen in iterative updating, weighting approaches, and simulated data.

CONCLUSIONS

The concept of the BPP can be adapted for synthesizing HSUVs, incorporating expert opinion on relevance. Because of the downweighting of studies, the BPP reflected structural uncertainty as wider credible intervals, with all forms of synthesis showing meaningful differences compared with SPVs. These differences would have implications for both cost-utility point estimates and probabilistic analyses.

Quality appraisal for systematic literature reviews of health state utility values: a descriptive analysis

BACKGROUND

Health state utility values (HSUVs) are an essential input parameter to cost-utility analysis (CUA). Systematic literature reviews (SLRs) provide summarized information for selecting utility values from an increasing number of primary studies eliciting HSUVs. Quality appraisal (QA) of such SLRs is an important process towards the credibility of HSUVs estimates; yet, authors often overlook this crucial process. A scientifically developed and widely accepted QA tool for this purpose is lacking and warranted.

OBJECTIVES

To comprehensively describe the nature of QA in published SRLs of studies eliciting HSUVs and generate a list of commonly used items.

METHODS

A comprehensive literature search was conducted in PubMed and Embase from 01.01.2015 to 15.05.2021. SLRs of empirical studies eliciting HSUVs that were published in English were included. We extracted descriptive data, which included QA tools checklists or good practice recommendations used or cited, items used, and the methods of incorporating QA results into study findings. Descriptive statistics (frequencies of use and occurrences of items, acceptance and counterfactual acceptance rates) were computed and a comprehensive list of QA items was generated.

RESULTS

A total of 73 SLRs were included, comprising 93 items and 35 QA tools and good recommendation practices. The prevalence of QA was 55% (40/73). Recommendations by NICE and ISPOR guidelines appeared in 42% (16/40) of the SLRs that appraised quality. The most commonly used QA items in SLRs were response rates (27/40), statistical analysis (22/40), sample size (21/40) and loss of follow up (21/40). Yet, the most commonly featured items in QA tools and GPRs were statistical analysis (23/35), confounding or baseline equivalency (20/35), and blinding (14/35). Only 5% of the SLRS used QA to inform the data analysis, with acceptance rates of 100% (in two studies) 67%, 53% and 33%. The mean counterfactual acceptance rate was 55% (median 53% and IQR 56%).

CONCLUSIONS

There is a considerably low prevalence of QA in the SLRs of HSUVs. Also, there is a wide variation in the QA dimensions and items included in both SLRs and extracted tools. This underscores the need for a scientifically developed QA tool for multi-variable primary studies of HSUVs.

Large-Scale Population-Based Surveys Linked to Administrative Health Databases as a Source of Data on Health Utilities in Australia

OBJECTIVES

Large-scale health surveys that contain quality-of-life instruments are a rich source of health utility data for health economic evaluations, especially when linked to routinely collected, administrative health databases. We derived health utility values for a wide range of health conditions using a large Australian cohort study linked to population-wide health databases.

METHODS

Short-Form 6-Dimension utility values were calculated for 56 094 adults, aged 47+ years, in the New South Wales 45 and Up Study who completed the Social, Economic, and Environmental Factors survey (2010-2011). Mean utilities were summarized for major health conditions identified through self-report, hospital records, primary cancer notifications, and claims for government-subsidized prescription medicines and medical services. To identify unique associations between health conditions and utilities, beta regression was performed. Utility values were analyzed by time to death using linked death records.

RESULTS

Mean Short-Form 6-Dimension utility was 0.810 (95% confidence interval [CI] 0.809-0.811), was age dependent, and was higher in men than women. Utilities for serious health conditions ranged from 0.685 (95% CI 0.652-0.718) for lung cancer to 0.800 (95% CI 0.787-0.812) for melanoma whereas disease-free respondents had a mean of 0.859 (95% CI 0.858-0.861). Most health conditions were independently associated with poorer quality of life. Utility values also declined by proximity to death where participants sampled 6 months before death had a mean score of 0.637 (95% CI 0.613-0.662).

CONCLUSIONS

Our data offer a snapshot of the health status of an older Australian population and show that record linkage can enable comprehensive ascertainment of utility values for use in health economic modeling.

Cost Effectiveness of Lung Cancer Screening With Low-Dose CT in Heavy Smokers in China

Although lung cancer screening with low-dose CT (LDCT) can reduce lung cancer mortality by 20%, without an appropriate eligibility criteria, it may result in a waste of medical resources and a degree of unnecessary damage to participants' health. This study aims to give the optimal screening strategy in China based on cost-effectiveness analysis on pros and cons of different situations. From the perspective of primary healthcare system, a Markov model was built to simulate LDCT screening of 100,000 heavy smokers (>30 pack years) aged 40 in different situations. Model parameters mainly came from screening programs conducted in China and other countries, official public data, and published literature. Two indicators of primary outcome, incremental cost-effectiveness ratio (ICER) and net health benefits (NHB), were compared with those of no screening. Sensitivity analysis was conducted to evaluate model uncertainties. We defined the optimal strategy as the one with both acceptable cost effectiveness and maximal NHB. Base-case analysis results showed that for all screening strategies, ICERs were less than three times of GDP per capita. As for NHB results, it showed that when the willingness to pay for screening was less than three times of GPD per capita, the largest NHB was obtained in the strategy which started screening at 50 years old and this strategy showed stable performance in univariate and probabilistic sensitivity as well. PREVENTION RELEVANCE: LDCT screening is cost effective in heavy smokers in China, and the optimal age to start screening is suggested to be 50 years old.

The Cost-Effectiveness of Lorlatinib Versus Chemotherapy as a Second- or Third-Line Treatment in Anaplastic Lymphoma Kinase (ALK)-Positive Non-small-cell Lung Cancer in Sweden

BACKGROUND

Lorlatinib is a third-generation anaplastic lymphoma kinase (ALK)/c-ros oncogene 1 (ROS1) tyrosine kinase inhibitor (TKI) with efficacy in patients with ALK-rearranged non-small-cell lung cancer (NSCLC) previously treated with a second-generation ALK inhibitor or with first- and second-generation ALK inhibitors. We examined the cost-effectiveness of second- or third-line+ (2L+ or 3L+) lorlatinib in Sweden, versus chemotherapy.

METHODS

A partitioned survival model with three health states (progression free, progressed, or death) was used. Lorlatinib relative efficacy versus chemotherapy was derived using unanchored matching adjusted indirect treatment comparisons from a phase 2 clinical trial. Utility data were derived from the same trial and published studies. Costs (year 2019) were obtained from Swedish national data. Costs and benefits were discounted at 3% per annum using a societal perspective (base case). Model robustness was evaluated with deterministic and probabilistic sensitivity analyses.

RESULTS

For 2L+, the average discounted total quality-adjusted life year (QALY) gain was 1.29 years. Total incremental costs were Swedish krona (SEK) 731,791, resulting in an incremental cost-effectiveness ratio (ICER) of SEK 566,278 per QALY gained. Non-discounted survival gain amounted to 1.94 years. For 3L+, the average discounted total QALY gain was 1.25 years. Total incremental costs were SEK 754,801, resulting in an ICER of SEK 603,934 per QALY gained. Non-discounted survival gain was 1.88 years. Sensitivity analyses were consistent.

CONCLUSIONS

ICERs ranged from SEK 421,000 to SEK 384,066 less than the boundary for a cost-effective treatment for a high-severity disease in Sweden (SEK 988,000), suggesting 2L+ or 3L+ lorlatinib is a cost-effective treatment for ALK-positive NSCLC versus chemotherapy.

Preliminary assessment of viral metagenome from cancer tissue and blood from patients with lung adenocarcinoma

In this study, using a viral metagenomic method, we investigated the composition of virome in blood and cancer tissue samples that were collected from 25 patients with lung adenocarcinoma. Results indicated that virus sequences showing similarity to human pegivirus (HPgV), anellovirus, human endogenous retrovirus (HERV), and polyomavirus were recovered from this cohort. Three different complete genomes of HPgV were acquired from the blood samples and one complete genome of polyomavirus was determined from the cancer tissue sample. Phylogenetic analysis indicated that the three HPgV strains belonged to genotype 3 and the polyomavirus showed the highest sequence identity (99.73%) to trichodysplasia spinulosa-associated polyomavirus. PCR screening results indicated that the three HPgVs were present in 5 out of the 25 blood samples and the polyomavirus only existed in a cancer tissue sample pool. Whether infections with viruses have an association with lung cancer needs further study with a larger size of sampling.