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Eng L, Brual J, Nagee A, Mok S, Fazelzad R, Chaiton M, Saunders D, Mittmann N, Truscott R, Liu G, Bradbury P, Evans W, Papadakos J, Giuliani M. Reporting of tobacco use and tobacco-related analyses in cancer cooperative group clinical trials: a systematic scoping review. ESMO Open 2022; 7:100605. [PMID: 36356412 PMCID: PMC9646674 DOI: 10.1016/j.esmoop.2022.100605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Continued smoking after a diagnosis of cancer negatively impacts cancer outcomes, but the impact of tobacco on newer treatments options is not well established. Collecting and evaluating tobacco use in clinical trials may advance understanding of the consequences of tobacco use on treatment modalities, but little is known about the frequency of reporting and analysis of tobacco use in cancer cooperative clinical trial groups. PATIENTS AND METHODS A comprehensive literature search was conducted to identify cancer cooperative group clinical trials published from January 2017-October 2019. Eligible studies evaluated either systemic and/or radiation therapies, included ≥100 adult patients, and reported on at least one of: overall survival, disease/progression-free survival, response rates, toxicities/adverse events, or quality-of-life. RESULTS A total of 91 studies representing 90 trials met inclusion criteria with trial start dates ranging from 1995 to 2015 with 14% involving lung and 5% head and neck cancer patients. A total of 19 studies reported baseline tobacco use; 2 reported collecting follow-up tobacco use. Seven studies reported analysis of the impact of baseline tobacco use on clinical outcomes. There was significant heterogeneity in the reporting of baseline tobacco use: 7 reported never/ever status, 10 reported never/ex-smoker/current smoker status, and 4 reported measuring smoking intensity. None reported verifying smoking status or second-hand smoke exposure. Trials of lung and head and neck cancers were more likely to report baseline tobacco use than other disease sites (83% versus 6%, P < 0.001). CONCLUSIONS Few cancer cooperative group clinical trials report and analyze trial participants' tobacco use. Significant heterogeneity exists in reporting tobacco use. Routine standardized collection and reporting of tobacco use at baseline and follow-up in clinical trials should be implemented to enable investigators to evaluate the impact of tobacco use on new cancer therapies.
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Affiliation(s)
- L. Eng
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada,Prof L. Eng, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Tel: +1-416-946-2953; Fax: +1-416-946-6546 @Lawson_Eng@MeredithGiulia1@PMcancercentre
| | - J. Brual
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - A. Nagee
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - S. Mok
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - R. Fazelzad
- Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - M. Chaiton
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - D.P. Saunders
- Northeast Cancer Centre of Health Sciences North, Northern Ontario School of Medicine, Sudbury, Canada
| | - N. Mittmann
- Canadian Agency for Drugs and Technologies in Health, Toronto, Canada
| | - R. Truscott
- Division of Prevention Policy and Stakeholder Engagement, Ontario Health (Cancer Care Ontario), Toronto, Canada
| | - G. Liu
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada
| | - P.A. Bradbury
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada
| | - W.K. Evans
- Department of Oncology, McMaster University, Hamilton, Canada
| | - J. Papadakos
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada,Patient Education, Ontario Health (Cancer Care Ontario), Toronto, Canada
| | - M.E. Giuliani
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada,Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada,Correspondence to: Prof M. Giuliani, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Tel: +1-416-946-2983; Fax: +1-416-946-6546
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Yan M, Tjong M, Chan W, Darling G, Delibasic V, Davis L, Doherty M, Hallet J, Kidane B, Mahar A, Mittmann N, Parmar A, Tan V, Tan H, Wright F, Coburn N, Louie A. Dyspnea in Patients with Stage IV Non-Small Cell Lung Cancer: A Population-Based Analysis of Disease Burden and Patterns of Care. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tan V, Tjong M, Chan W, Yan M, Delibasic V, Darling G, Davis L, Doherty M, Hallet J, Kidane B, Mahar A, Mittmann N, Parmar A, Tan H, Wright F, Coburn N, Louie A. EP04.01-027 Pain and Interventions in Stage IV Non-Small Cell Lung Cancer: A Province-Wide Analysis. J Thorac Oncol 2022. [DOI: 10.1016/j.jtho.2022.07.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Li YYR, Mai H, Trudeau ME, Mittmann N, Chiasson K, Chan KKW, Cheung MC. Reimbursement recommendations for cancer drugs supported by phase II evidence in Canada. Curr Oncol 2020; 27:e495-e500. [PMID: 33173389 PMCID: PMC7606040 DOI: 10.3747/co.27.6489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Phase ii data are increasingly being used as primary evidence for public reimbursement for oncologic drugs. We compared the frequency of reimbursement recommendations for phase ii and phase iii submissions and assessed for variables associated with a positive or conditional recommendation. Methods We identified submissions made to the pan-Canadian Oncology Drug Review's Expert Review Committee (perc), of the Canadian Agency for Drugs and Technologies in Health, July 2011 to July 2019, that were supported only by phase ii data. We identified variables within the perc's deliberative framework, including clinical and economic factors, associated with the final reimbursement recommendation. We conducted a multivariable analysis with logistic regression for these variables: feasibility of phase iii study, hematologic indication, and unmet need. Results We identified 139 submissions with a perc final recommendation. In 27 instances (19%), the submission had only phase ii evidence, and a positive recommendation was issued for 63% of them (the positive recommendation rate was 82% for submissions with phase iii evidence). Clinical benefit (p < 0.001), unmet need (p = 0.047), and patient alignment (p = 0.015) were associated with a positive recommendation. If a future phase iii study was deemed feasible for submissions with only phase ii evidence, then in univariable (p = 0.040) and multivariable analysis (p = 0.024), the perc was less likely to recommend reimbursement (odds ratio: 0.132). Conclusions Although more than half the oncologic submissions with phase ii data were recommended for public reimbursement, compared with submissions having phase iii data, they were less likely to be recommended. A positive or conditional recommendation was more likely if clinical benefit and alignment with patient values was demonstrated. The perc was less likely to recommend reimbursement for submissions with phase ii evidence if a phase iii trial was deemed possible.
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Affiliation(s)
- Y Y R Li
- Department of Medicine, University of Toronto, Toronto
| | - H Mai
- Canadian Agency for Drugs and Technologies in Health, Ottawa
| | - M E Trudeau
- Canadian Agency for Drugs and Technologies in Health, Ottawa
- Division of Medical Oncology, Sunnybrook Odette Cancer Centre, Toronto
| | - N Mittmann
- Canadian Agency for Drugs and Technologies in Health, Ottawa
- Department of Pharmacology and Toxicology, Institute for Health Policy Management and Evaluation, and Sunnybrook Research Institute, Toronto, ON
| | - K Chiasson
- Canadian Agency for Drugs and Technologies in Health, Ottawa
| | - K K W Chan
- Canadian Agency for Drugs and Technologies in Health, Ottawa
- Division of Medical Oncology, Sunnybrook Odette Cancer Centre, Toronto
| | - M C Cheung
- Canadian Agency for Drugs and Technologies in Health, Ottawa
- Division of Medical Oncology, Sunnybrook Odette Cancer Centre, Toronto
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5
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Hassan S, Seung SJ, Clark RE, Gibbs JC, McArthur C, Mittmann N, Thabane L, Kendler D, Papaioannou A, Wark JD, Ashe MC, Adachi JD, Templeton JA, Giangregorio LM. Describing the resource utilisation and costs associated withvertebral fractures: the Build Better Bones with Exercise (B3E) Pilot Trial. Osteoporos Int 2020; 31:1115-1123. [PMID: 32219499 DOI: 10.1007/s00198-020-05387-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/10/2020] [Indexed: 11/26/2022]
Abstract
UNLABELLED This analysis examined costs/resources of 141 women with vertebral fractures, randomised to a home exercise programme or control group. Total, mean costs and the incremental cost-effectiveness ratio (ICER) were calculated. Quality of life was collected. Cost drivers were caregiver time, medications and adverse events (AEs). Results show adding an exercise programme may reduce the risk of AEs. INTRODUCTION This exploratory economic analysis examined the health resource utilisation and costs experienced by women with vertebral fractures, and explored the effects of home exercise on those costs. METHODS Women ≥ 65 years with one or more X-ray-confirmed vertebral fractures were randomised 1:1 to a 12-month home exercise programme or equal attention control group. Clinical and health system resources were collected during monthly phone calls and daily diaries completed by participants. Intervention costs were included. Unit costs were applied to health system resources. Quality of life (QoL) information was collected via EQ-5D-5L at baseline, 6 and 12 months. RESULTS One hundred and forty-one women were randomised. Overall total costs (CAD 2018) were $664,923 (intervention) and $614,033 (control), respectively. The top three cost drivers were caregiver time ($250,269 and $240,811), medications ($151,000 and $122,145) and AEs ($58,807 and $71,981). The mean cost per intervention participant of $9365 ± $9988 was higher compared with the mean cost per control participant of $8772 ± $9718. The mean EQ-5D index score was higher for the intervention participants (0.81 ± 0.11) compared with that of controls (0.79 ± 0.13). The differences in quality-adjusted life year (QALY) (0.02) and mean cost ($593) were used to calculate the ICER of $29,650. CONCLUSIONS Women with osteoporosis with a previous fracture experience a number of resources and associated costs that impact their care and quality of life. Caregiver time, medications and AEs are the biggest cost drivers for this population. The next steps would be to expand this feasibility study with more participants, longer-term follow-up and more regional variability.
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Affiliation(s)
- S Hassan
- HOPE Research Centre, Sunnybrook Research Institute, Toronto, Ontario, M4N 3M5, Canada.
| | - S J Seung
- HOPE Research Centre, Sunnybrook Research Institute, Toronto, Ontario, M4N 3M5, Canada
| | - R E Clark
- University of Waterloo, Waterloo, Canada
| | - J C Gibbs
- McGill University, Montreal, Quebec, Canada
| | | | | | - L Thabane
- McMaster University, Hamilton, Canada
| | - D Kendler
- University of British Columbia, Vancouver, Canada
| | | | - J D Wark
- University of Melbourne, Melbourne, Australia
| | - M C Ashe
- University of British Columbia, Vancouver, Canada
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6
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Giuliani M, Brual J, Cameron E, Chaiton M, Eng L, Haque M, Liu G, Mittmann N, Papadakos J, Saunders D, Truscott R, Evans W. Smoking Cessation in Cancer Care: Myths, Presumptions and Implications for Practice. Clin Oncol (R Coll Radiol) 2020; 32:400-406. [PMID: 32029357 DOI: 10.1016/j.clon.2020.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
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7
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Moskovitz M, Jao K, Su J, Brown MC, Naik H, Eng L, Wang T, Kuo J, Leung Y, Xu W, Mittmann N, Moody L, Barbera L, Devins G, Li M, Howell D, Liu G. Combined cancer patient-reported symptom and health utility tool for routine clinical implementation: a real-world comparison of the ESAS and EQ-5D in multiple cancer sites. ACTA ACUST UNITED AC 2020; 26:e733-e741. [PMID: 31896943 DOI: 10.3747/co.26.5297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background We assessed whether the presence and severity of common cancer symptoms are associated with the health utility score (hus) generated from the EQ-5D (EuroQol Research Foundation, Rotterdam, Netherlands) in patients with cancer and evaluated whether it is possible pragmatically to integrate routine hus and symptom evaluation in our cancer population. Methods Adult outpatients at Princess Margaret Cancer Centre with any cancer were surveyed cross-sectionally using the Edmonton Symptom Assessment System (esas) and the EQ-5D-3L, and results were compared using Spearman correlation coefficients and regression analyses. Results Of 764 patients analyzed, 27% had incurable disease. We observed mild-to-moderate correlations between each esas symptom score and the hus (Spearman coefficients: -0.204 to -0.416; p < 0.0001 for each comparison), with the strongest associations being those for pain (R = -0.416), tiredness (R = -0.387), and depression (R =-0.354). Multivariable analyses identified pain and depression as highly associated (both p < 0.0001) and tiredness as associated (p = 0.03) with the hus. The ability of the esas to predict the hus was low, at 0.25. However, by mapping esas pain, anxiety, and depression scores to the corresponding EQ-5D questions, we could derive the hus using partial esas data, with Spearman correlations of 0.83-0.91 in comparisons with direct EQ-5D measurement of the hus. Conclusions The hus derived from the EQ-5D-3L is associated with all major cancer symptoms as captured by the esas. The esas scores alone could not predict EQ-5D scores with high accuracy. However, esas-derived questions assessing the same domains as the EQ-5D-3L questions could be mapped to their corresponding EQ-5D questions to generate the hus, with high correlation to the directly measured hus. That finding suggests a potential approach to integrating routine symptom and hus evaluations after confirmatory studies.
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Affiliation(s)
- M Moskovitz
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON
| | - K Jao
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON.,Hôpital du Sacré-Coeur, McGill University, Montreal, QC
| | - J Su
- Department of Biostatistics, Ontario Cancer Institute, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - M C Brown
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON
| | - H Naik
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON.,Department of Medicine, University of British Columbia, Vancouver, BC
| | - L Eng
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON
| | - T Wang
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON.,Faculty of Pharmacy, University of Toronto, Toronto, ON
| | - J Kuo
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON
| | - Y Leung
- Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - W Xu
- Department of Biostatistics, Ontario Cancer Institute, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - N Mittmann
- Cancer Care Ontario, Toronto, ON.,Odette Cancer Centre, University of Toronto, Toronto, ON
| | - L Moody
- Cancer Care Ontario, Toronto, ON
| | - L Barbera
- Cancer Care Ontario, Toronto, ON.,Odette Cancer Centre, University of Toronto, Toronto, ON
| | - G Devins
- Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON.,Department of Psychiatry, University of Toronto, Toronto, ON
| | - M Li
- Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON
| | - D Howell
- Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON.,Lawrence Bloomberg School of Nursing, University of Toronto, Toronto, ON
| | - G Liu
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, and Department of Medicine, University of Toronto, Toronto, ON.,Department of Epidemiology, Dalla Lana School of Public Health, Department of Medical Biophysics, and Institute of Medical Science, University of Toronto, Toronto, ON
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8
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Mittmann N, Cheng SY, Liu N, Seung SJ, Saxena FE, DeAngelis C, Hong NJL, Earle CC, Cheung MC, Leighl N, Coburn N, Evans WK. The generation of two specific cancer costing algorithms using Ontario administrative databases. ACTA ACUST UNITED AC 2019; 26:e682-e692. [PMID: 31708661 DOI: 10.3747/co.26.5279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cancer treatment and management have become increasingly economically burdensome. Consequently, to help with planning health service delivery, it is vital to understand the associated costs. Administrative databases can be used to help understand and generate real-world system-level costs. Using databases to generate costs can take one of two approaches: top-down or bottom-up. Top-down approaches disaggregate the total health care spending from a global health care budget by sector and provider. A bottom-up approach begins with individual-level health care use and its costs, which are then aggregated.
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Affiliation(s)
- N Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto.,Cancer Care Ontario, Toronto
| | | | | | - S J Seung
- Health Outcomes and PharmacoEconomic (hope) Research Centre, Toronto
| | | | - C DeAngelis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - N J Look Hong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - C C Earle
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto.,ices, Toronto.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - M C Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
| | - N Leighl
- University Health Network, Toronto
| | - N Coburn
- ices, Toronto.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto
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9
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Abstract
OBJECTIVE To systematically review the published academic literature on the cost of chronic ulcers. METHODS A literature search was conducted in MEDLINE, EMBASE, HealthSTAR, Econlit and CINAHL up to 12 May 2016 to identify potential studies for review. Cost search terms were based on validated algorithms. Clinical search terms were based on recent Cochrane reviews of interventions for chronic ulcers. Titles and abstracts were screened by two reviewers to determine eligibility for full text review. Study characteristics were summarised. The quality of reporting was evaluated using a modified cost-of-illness checklist. Mean costs were adjusted and inflated to 2015 $US and presented for different durations and perspectives. RESULTS Of 2267 studies identified, 36 were eligible and included in the systematic review. Most studies presented results from the health-care public payer or hospital perspective. Many studies included hospital costs in the analysis and only reported total costs without presenting condition-specific attributable costs. The mean cost of chronic ulcers ranged from $1000 per year for patient out of pocket costs to $30,000 per episode from the health-care public payer perspective. Mean one year cost from a health-care public payer perspective was $44,200 for diabetic foot ulcer (DFU), $15,400 for pressure ulcer (PU) and $11,000 for leg ulcer (LU). CONCLUSIONS There was large variability in study methods, perspectives, cost components and jurisdictions, making interpretation of costs difficult. Nevertheless, it appears that the cost for the treatment of chronic ulcers is substantial and greater attention needs to be made for preventive measures.
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Affiliation(s)
- B Chan
- Leslie Dan Faculty of Pharmacy, University of Toronto, Canada
| | - S Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Canada
| | - W Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - J Wong
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Canada
| | - N Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada
| | - M Krahn
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Canada
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Mittmann N. Why are we organizing another costing supplement in Current Oncology? Curr Oncol 2019; 26:87-88. [PMID: 31043807 PMCID: PMC6476462 DOI: 10.3747/co.26.4975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Why are we publishing another costing supplement in Current Oncology? [...]
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Affiliation(s)
- N Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON
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11
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Cheung WY, Kornelsen EA, Mittmann N, Leighl NB, Cheung M, Chan KK, Bradbury PA, Ng RCH, Chen BE, Ding K, Pater JL, Tu D, Hay AE. The economic impact of the transition from branded to generic oncology drugs. ACTA ACUST UNITED AC 2019; 26:89-93. [PMID: 31043808 DOI: 10.3747/co.26.4395] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Economic evaluations are an integral component of many clinical trials. Costs used in those analyses are based on the prices of branded drugs when they first enter the market. The effect of genericization on the cost-effectiveness (ce) or cost-utility (cu) of an intervention is unknown because economic analyses are rarely updated using the costs of generic drugs. Methods We re-examined the ce or cu of regimens previously evaluated in Canadian Cancer Trials Group (cctg) studies that included prospective economic evaluations and where genericization has occurred or is anticipated in Canada. We incorporated the new costs of generic drugs to characterize changes in ce or cu. We also determined acceptable cost levels of generic drugs that would make regimens reimbursable in a publicly funded health care system. Results The four randomized controlled trials included (representing 1979 patients) were cctg br.10 (early lung cancer, adjuvant vinorelbine-cisplatin vs. observation, n = 172), cctg br.21 (metastatic lung cancer, erlotinib vs. placebo, n = 731), cctg co.17 (metastatic colon cancer, cetuximab vs. best supportive care, n = 557), and cctg ly.12 (relapsed or refractory lymphoma, gemcitabine-dexamethasone-cisplatin vs. cytarabine-dexamethasone-cisplatin, n = 619). Since the initial publication of those trials, the genericization of vinorelbine, erlotinib, cetuximab, and cisplatin has taken place or is expected in Canada. Costs of generics improved the ces and cus of treatment significantly. For example, genericization of erlotinib ($1460.25 per 30 days) resulted in an incremental cost-effectiveness ratio (icer) of $45,746 per life-year gained compared with $94,638 for branded erlotinib. Likewise, genericization of cetuximab ($275.80 per 100 mg) produced an icer of $261,126 per quality-adjusted life-year (qaly) gained compared with $299,613 for branded cetuximab. Decreases in the cost of generic cetuximab to $129.39 and $63.51 would further improve the icer to $150,000 and $100,000 per QALY respectively. Conclusions Genericization of a costly oncology drug can modify the ce and cu of a regimen significantly. Failure to revisit economic analyses with the costs of generics could be a missed opportunity for funding bodies to optimize value-based allocation of health care resources. At current levels, the costs of generics might not be sufficiently low to sustain publicly funded health care systems.
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Affiliation(s)
| | | | | | | | - M Cheung
- University of Toronto, Toronto, ON
| | - K K Chan
- University of Toronto, Toronto, ON
| | | | - R C H Ng
- University of Toronto, Toronto, ON
| | - B E Chen
- Queen's University, Kingston, ON
| | - K Ding
- Queen's University, Kingston, ON
| | | | - D Tu
- Queen's University, Kingston, ON
| | - A E Hay
- Queen's University, Kingston, ON
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12
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Doherty MK, Leung Y, Su J, Naik H, Patel D, Eng L, Kong QQ, Mohsin F, Brown MC, Espin-Garcia O, Vennettilli A, Renouf DJ, Faluyi OO, Knox JJ, MacKay H, Wong R, Howell D, Mittmann N, Darling GE, Cella D, Xu W, Liu G. Health utility scores from EQ-5D and health-related quality of life in patients with esophageal cancer: a real-world cross-sectional study. Dis Esophagus 2018; 31:5037798. [PMID: 29905764 DOI: 10.1093/dote/doy058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal cancer and its treatment can cause serious morbidity/toxicity. These effects on health-related quality of life (HRQOL) can be measured using disease-specific scales such as FACT-E, generic scales such as EQ-5D-3L, or through symptoms. In a two-year cross-sectional study, we compared HRQOL across esophageal cancer patients treated in an ambulatory clinic and across multiple disease states, among patients with all stages of esophageal cancer. Consenting patients completed FACT-E, EQ-5D, a visual analog scale, and patient reported (PR)-ECOG. Symptom complexes were constructed from FACT-E domains. Responses were categorized by disease state: pre-, during, and post-treatment, surveillance, progression, and palliative chemotherapy. Spearman correlation and multivariable linear regression characterized these associations. In total, 199 patients completed 317 questionnaires. Mean FACT-E and subscale scores dropped from baseline through treatment and recovered during post-treatment surveillance (P < 0.001); EQ-5D health utility scores (HUS) displayed a similar pattern but with smaller differences (P = 0.07), and with evidence of ceiling effect. Among patients with stage II/III esophageal cancer, mean EQ-5D HUS varied across disease states (P < 0.001), along with FACT-E and subscales (P < 0.001). Among patients with advanced disease, there was no significant difference between baseline and on-treatment total scores, but improved esophageal cancer-specific scales were noted (P = 0.003). Strong correlation was observed between EQ-5D and FACT-E (R = 0.73), along with physical and functional subscales. In addition, the association between FACT-E and EQ-5D HUS was maintained in a multivariable model (P < 0.001). We interpret these results to suggest that in a real-world clinic setting, FACT-E, EQ-5D HUS, and symptoms were strongly correlated. Most HRQOL and symptom parameters suggested that patients had worse HRQOL and symptoms during curative therapy, but recovered well afterwards. In contrast, palliative chemotherapy had a neutral to positive impact on HRQOL/symptoms when compared to their baseline pre-treatment state.
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Affiliation(s)
- M K Doherty
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Y Leung
- Department of Psychosocial Oncology, Princess Margaret Cancer Centre, British Colombia, Canada
| | - J Su
- Department of Biostatistics, Princess Margaret Cancer Centre, British Colombia, Canada
| | - H Naik
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - D Patel
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - L Eng
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Q Q Kong
- Department of Biostatistics, Princess Margaret Cancer Centre, British Colombia, Canada
| | - F Mohsin
- Department of Biostatistics, Princess Margaret Cancer Centre, British Colombia, Canada
| | - M C Brown
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - O Espin-Garcia
- Department of Biostatistics, Princess Margaret Cancer Centre, British Colombia, Canada
| | - A Vennettilli
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - D J Renouf
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,BC Cancer Agency, University of British Columbia, Vancouver, British Colombia, Canada
| | - O O Faluyi
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Department of Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, UK
| | - J J Knox
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - H MacKay
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - R Wong
- Radiation Medicine Program, University of Toronto, Toronto, Ontario
| | - D Howell
- Department of Psychosocial Oncology, Princess Margaret Cancer Centre, British Colombia, Canada
| | - N Mittmann
- Cancer Care Ontario, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario
| | - G E Darling
- Department of Surgery, Princess Margaret Cancer Centre, Chicago, Illinois, USA
| | - D Cella
- Department of Medical Social Sciences, Northwestern University, Chicago, Illinois, USA
| | - W Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, British Colombia, Canada
| | - G Liu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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13
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Giangregorio LM, Gibbs JC, Templeton JA, Adachi JD, Ashe MC, Bleakney RR, Cheung AM, Hill KD, Kendler DL, Khan AA, Kim S, McArthur C, Mittmann N, Papaioannou A, Prasad S, Scherer SC, Thabane L, Wark JD. Build better bones with exercise (B3E pilot trial): results of a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in older women with vertebral fracture. Osteoporos Int 2018; 29:2545-2556. [PMID: 30091064 DOI: 10.1007/s00198-018-4652-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
UNLABELLED We pilot-tested a trial of home exercise on individuals with osteoporosis and spine fracture. Our target enrollment was met, though it took longer than expected. Participants stayed in the study and completed the exercise program with no safety concerns. Future trials should expand the inclusion criteria and consider other changes. PURPOSE Osteoporotic fragility fractures create a substantial human and economic burden. There have been calls for a large randomized controlled trial examining the effect of exercise on fracture incidence. The B3E pilot trial was designed to evaluate the feasibility of a large trial examining the effects of home exercise on individuals at high risk of fracture. METHODS Community-dwelling women ≥ 65 years with radiographically confirmed vertebral compression fractures were recruited at seven sites in Canada and Australia. We randomized participants in a 1:1 ratio to a 12-month home exercise program or equal attention control group, both delivered by a physiotherapist (PT). Participants received six PT home visits in addition to monthly phone calls from the PT and a blinded research assistant. The primary feasibility outcomes of the study were recruitment rate (20 per site in 1 year), retention rate (75% completion), and intervention adherence rate (60% of weeks meeting exercise goals). Secondary outcomes included falls, fractures and adverse events. RESULTS One hundred forty-one participants were recruited; an average of 20 per site, though most sites took longer than anticipated. Retention and adherence met the criteria for success: 92% of participants completed the study; average adherence was 66%. The intervention group did not differ significantly in the number of falls (IRR 0.97, 95% CI 0.58 to 1.63) or fragility fractures (OR 1.11, 95% CI 0.60 to 2.05) compared to the control group. There were 18 serious adverse events in the intervention group and 12 in the control group. CONCLUSION An RCT of home exercise in women with vertebral fractures is feasible but recruitment was a challenge. Suggestions are made for the conduct of future trials.
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Affiliation(s)
- L M Giangregorio
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada.
| | - J C Gibbs
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - J A Templeton
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - J D Adachi
- McMaster University, Hamilton, Ontario, Canada
- St Joseph's Healthcare-Hamilton, Hamilton, Ontario, Canada
| | - M C Ashe
- University of British Columbia, Vancouver, Canada
- Centre for Hip Health and Mobility, Vancouver, Canada
| | | | - A M Cheung
- University of Toronto, Toronto, Ontario, Canada
| | - K D Hill
- School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - D L Kendler
- University of British Columbia, Vancouver, Canada
| | - A A Khan
- McMaster University, Hamilton, Ontario, Canada
| | - S Kim
- University of Toronto, Toronto, Ontario, Canada
- Women's College Hospital, Toronto, Ontario, Canada
| | - C McArthur
- Department of Kinesiology, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
- McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton, Ontario, Canada
| | - N Mittmann
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A Papaioannou
- McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton, Ontario, Canada
| | - S Prasad
- McMaster University, Hamilton, Ontario, Canada
| | - S C Scherer
- Broadmeadows Health Service, Broadmeadows, Australia
- University of Melbourne, Melbourne, Australia
| | - L Thabane
- McMaster University, Hamilton, Ontario, Canada
- St Joseph's Healthcare-Hamilton, Hamilton, Ontario, Canada
| | - J D Wark
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Parkville, Australia
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14
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Kagedan DJ, Mosko JD, Dixon ME, Karanicolas PJ, Wei AC, Goyert N, Li Q, Mittmann N, Coburn NG. Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial. ACTA ACUST UNITED AC 2018; 25:e430-e435. [PMID: 30464694 DOI: 10.3747/co.25.4007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level. Methods This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd. Results Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Conclusions Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.
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Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - J D Mosko
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON
| | - M E Dixon
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - P J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON
| | - A C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - N Goyert
- Sunnybrook Health Sciences Centre, Toronto, ON
| | - Q Li
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - N Mittmann
- Health Outcomes and PharmacoEconomic Research Centre, Toronto, ON
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON
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15
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Albaba H, Brown M, Shakik S, Su S, Naik H, Wang T, Liang M, Perez-Cosio A, Eng L, Mittmann N, Xu W, Liu G, Howell D, Barnes T. Acceptability in cancer outpatients of completing routine assessments of patient reported outcomes of common terminology criteria for adverse events (PRO-CTCAE) versus other patient reported symptom outcome tools. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy300.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Evans W, Flanagan W, Gauvreau C, Manivong P, Memon S, Fitzgerald N, Goffin J, Garner R, Khoo E, Mittmann N. MA18.03 How in the Real World Are Lung Cancer Patients Treated? The Ontario, Canada Experience. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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17
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Evans W, Flanagan W, Gauvreau C, Manivong P, Memon S, Fitzgerald N, Goffin J, Garner R, Khoo E, Mittmann N. How advanced lung cancer patients are really treated at the population level? The Ontario, Canada experience. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy297.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Hallet J, Law CHL, Cheung M, Mittmann N, Liu N, Fischer HD, Singh S. Patterns and Drivers of Costs for Neuroendocrine Tumor Care: A Comparative Population-Based Analysis. Ann Surg Oncol 2017; 24:3312-3323. [DOI: 10.1245/s10434-017-5986-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 12/19/2022]
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19
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Gwadry-Sridhar F, Nikan S, Hamou A, Seung SJ, Petrella T, Joshua AM, Ernst S, Mittmann N. Resource utilization and costs of managing patients with advanced melanoma: a Canadian population-based study. ACTA ACUST UNITED AC 2017; 24:168-175. [PMID: 28680276 DOI: 10.3747/co.24.3432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use and detailed costs of services provided for people with advanced melanoma (amel) are not well known. We conducted an analysis to determine the use of health care services and the associated costs delineated by relevant attributable costs, which we defined for subjects in the province of Ontario. METHODS Through the Ontario Cancer Data Linkage Project, a cohort of amel patients with diagnoses between 31 August 2005 and 2012 (follow-up to 2013) and with valid International Classification of Diseases (9th revision, Clinical Modification) 172 codes and histology codes was identified. A cohort of individuals with amel having a combination of at least 1 palliative, 1 medical oncology, and 1 hospitalization code was generated. The health system services used by this population were clustered into hospitalization, palliation, physician medical visits, medication, homecare, laboratory, diagnostics, and other resources. Overall rates of use and disaggregated costs were determined by phase of care for the entire cohort. RESULTS The mean age for the 2748 individuals in the cohort was 67 years. The greater proportion of the patients were men (65.6%) and were more than 65 years of age (>50%). In this advanced cohort, fewer than 45% of patients were alive 3 years after the malignant melanoma diagnosis. The average annual cost per patient over the time horizon was $6,551. At $15,830, year 1 after diagnosis was the most expensive, followed by year 2, at $8,166. CONCLUSIONS Our data provide a baseline for the costs associated with amel treatment. Future studies will include newer agents and comparative effectiveness research for personalized therapies.
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Affiliation(s)
| | | | | | - S J Seung
- Health Outcomes and PharmacoEconomics (hope) Research Centre, Sunnybrook Research Institute, Toronto
| | - T Petrella
- Sunnybrook Health Sciences Centre, Toronto
| | - A M Joshua
- Princess Margaret Hospital, Toronto; and
| | - S Ernst
- London Regional Cancer Program, London, ON
| | - N Mittmann
- Sunnybrook Health Sciences Centre, Toronto
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20
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Hassan S, Seung SJ, Cheung MC, Fraser G, Kuriakose B, Trambitas C, Mittmann N. Examining the medical resource utilization and costs of relapsed and refractory chronic lymphocytic leukemia in Ontario. ACTA ACUST UNITED AC 2017; 24:e50-e54. [PMID: 28270732 DOI: 10.3747/co.24.3182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of the present study was to collect medical resource utilization data and costs in Ontario for the management of patients with relapsed or refractory chronic lymphocytic lymphoma (cll) who have undergone at least 1 treatment course and have been stratified by Rai staging. METHODS This retrospective longitudinal cohort study, conducted by chart review, analyzed anonymized patient records from two cancer centres in Ontario. Comprehensive records of 86 patients meeting the inclusion criteria were used to obtain resource utilization, which, multiplied by unit costs, were used to determine overall and mean costs. Descriptive statistics are presented for patient demographics, medical resource utilization, and costing data. RESULTS The total cost for the cohort was $2.2 million over a mean follow-up period of 4.7 years. The mean total cost per patient (regardless of follow-up) was $25,736. In terms of Rai staging, overall mean costs were highest for stage iv patients. Almost 50% of the total cost was attributable to cll treatments, among which fludarabine-based treatments had the highest utilization. CONCLUSIONS For this Canadian cll cohort, medical resource utilization and costs were determined to be $2.2 million, with cll treatments accounting for about half the cost. Costs generally increased with Rai stage.
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Affiliation(s)
- S Hassan
- Health Outcomes and PharmacoEconomics ( hope ) Research Centre, Sunnybrook Research Institute, Toronto
| | - S J Seung
- Health Outcomes and PharmacoEconomics ( hope ) Research Centre, Sunnybrook Research Institute, Toronto
| | - M C Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto;; Department of Medicine, Division of Hematology, University of Toronto, Toronto
| | - G Fraser
- Juravinski Cancer Centre, Hamilton Health Sciences Centre, Hamilton;; Department of Oncology, Division of Malignant Hematology, McMaster University, Hamilton
| | | | | | - N Mittmann
- Health Outcomes and PharmacoEconomics (hope) Research Centre, Sunnybrook Research Institute, Toronto;; Department of Pharmacology, University of Toronto, Toronto, ON
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21
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Kagedan DJ, Dixon ME, Raju RS, Li Q, Elmi M, Shin E, Liu N, El-Sedfy A, Paszat L, Kiss A, Earle CC, Mittmann N, Coburn NG. Predictors of adjuvant treatment for pancreatic adenocarcinoma at the population level. ACTA ACUST UNITED AC 2016; 23:334-342. [PMID: 27803598 DOI: 10.3747/co.23.3205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the present study, we aimed to describe, at the population level, patterns of adjuvant treatment use after curative-intent resection for pancreatic adenocarcinoma (pcc) and to identify independent predictors of adjuvant treatment use. METHODS In this observational cohort study, patients undergoing pcc resection in the province of Ontario (population 13 million) during 2005-2010 were identified using the provincial cancer registry and were linked to administrative databases that include all treatments received and outcomes experienced in the province. Patients were defined as having received chemotherapy (ctx), chemoradiation (crt), or observation (obs). Clinicopathologic factors associated with the use of ctx, crt, or obs were identified by chi-square test. Logistic regression analyses were used to identify independent predictors of adjuvant treatment versus obs, and ctx versus crt. RESULTS Of the 397 patients included, 75.3% received adjuvant treatment (27.2% crt, 48.1% ctx) and 24.7% received obs. Within a single-payer health care system with universal coverage of costs for ctx and crt, substantial variation by geographic region was observed. Although the likelihood of receiving adjuvant treatment increased from 2005 to 2010 (p = 0.002), multivariate analysis revealed widespread variation between the treating hospitals (p = 0.001), and even between high-volume hepatopancreatobiliary hospitals (p = 0.0006). Younger age, positive lymph nodes, and positive surgical resection margins predicted an increased likelihood of receiving adjuvant treatment. Among patients receiving adjuvant treatment, positive margins and a low comorbidity burden were associated with crt compared with ctx. CONCLUSIONS Interinstitutional medical practice variation contributes significantly to differential patterns in the rate of adjuvant treatment for pcc. Whether such variation is warranted or unwarranted requires further investigation.
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Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - M E Dixon
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, U.S.A
| | - R S Raju
- Sunnybrook Health Sciences Centre
| | - Q Li
- Institute for Clinical Evaluative Sciences and
| | - M Elmi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - E Shin
- Faculty of Medicine, University of Toronto, Toronto, ON
| | - N Liu
- Institute for Clinical Evaluative Sciences and
| | - A El-Sedfy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, U.S.A
| | - L Paszat
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON
| | - A Kiss
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Institute of Health Policy, Management and Evaluation, University of Toronto and
| | - C C Earle
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON
| | | | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON;; Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON;; Institute of Health Policy, Management and Evaluation, University of Toronto and
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22
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Abstract
OBJECTIVE Costs for radiation therapy (rt) and the methods used to cost rt are highly diverse across the literature. To date, no study has compared various costing methods in detail. Our objective was to perform a thorough review of the radiation costing literature to identify sources of costs and methods used. METHODS A systematic review of Ovid medline, Ovid oldmedline, embase, Ovid HealthStar, and EconLit from 2005 to 23 March 2015 used search terms such as "radiation," "radiotherapy," "neoplasm," "cost," " cost analysis," and "cost benefit analysis" to locate relevant articles. Original papers were reviewed for detailed costing methods. Cost sources and methods were extracted for papers investigating rt modalities, including three-dimensional conformal rt (3D-crt), intensity-modulated rt (imrt), stereotactic body rt (sbrt), and brachytherapy (bt). All costs were translated into 2014 U.S. dollars. RESULTS Most of the studies (91%) reported in the 33 articles retrieved provided rt costs from the health system perspective. The cost of rt ranged from US$2,687.87 to US$111,900.60 per treatment for imrt, followed by US$5,583.28 to US$90,055 for 3D-crt, US$10,544.22 to US$78,667.40 for bt, and US$6,520.58 to US$19,602.68 for sbrt. Cost drivers were professional or personnel costs and the cost of rt treatment. Most studies did not address the cost of rt equipment (85%) and institutional or facility costs (66%). CONCLUSIONS Costing methods and sources were widely variable across studies, highlighting the need for consistency in the reporting of rt costs. More work to promote comparability and consistency across studies is needed.
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Affiliation(s)
- F Rahman
- Institute for Clinical Evaluative Sciences, ON
| | - S J Seung
- Health Outcomes and Pharmacoeconomics ( hope ) Research Centre, Sunnybrook Research Institute, ON
| | - S Y Cheng
- Institute for Clinical Evaluative Sciences, ON
| | - H Saherawala
- Health Outcomes and Pharmacoeconomics ( hope ) Research Centre, Sunnybrook Research Institute, ON
| | - C C Earle
- Institute for Clinical Evaluative Sciences, ON
| | - N Mittmann
- Cancer Care Ontario, ON.; University of Toronto, ON.; Sunnybrook Research Institute, Toronto, ON
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23
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Han K, Yap ML, Yong JHE, Mittmann N, Hoch JS, Fyles AW, Warde P, Gutierrez E, Lymberiou T, Foxcroft S, Liu FF. Omission of Breast Radiotherapy in Low-risk Luminal A Breast Cancer: Impact on Health Care Costs. Clin Oncol (R Coll Radiol) 2016; 28:587-93. [PMID: 27139262 DOI: 10.1016/j.clon.2016.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 01/08/2023]
Abstract
AIMS The economic burden of cancer care is substantial, including steep increases in costs for breast cancer management. There is mounting evidence that women age ≥ 60 years with grade I/II T1N0 luminal A (ER/PR+, HER2- and Ki67 ≤ 13%) breast cancer have such low local recurrence rates that adjuvant breast radiotherapy might offer limited value. We aimed to determine the total savings to a publicly funded health care system should omission of radiotherapy become standard of care for these patients. MATERIALS AND METHODS The number of women aged ≥ 60 years who received adjuvant radiotherapy for T1N0 ER+ HER2- breast cancer in Ontario was obtained from the provincial cancer agency. The cost of adjuvant breast radiotherapy was estimated through activity-based costing from a public payer perspective. The total saving was calculated by multiplying the estimated number of luminal A cases that received radiotherapy by the cost of radiotherapy minus Ki-67 testing. RESULTS In 2010, 748 women age ≥ 60 years underwent surgery for pT1N0 ER+ HER2- breast cancer; 539 (72%) underwent adjuvant radiotherapy, of whom 329 were estimated to be grade I/II luminal A subtype. The cost of adjuvant breast radiotherapy per case was estimated at $6135.85; the cost of Ki-67 at $114.71. This translated into an annual saving of about $2.0million if radiotherapy was omitted for all low-risk luminal A breast cancer patients in Ontario and $5.1million across Canada. CONCLUSION There will be significant savings to the health care system should omission of radiotherapy become standard practice for women with low-risk luminal A breast cancer.
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Affiliation(s)
- K Han
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - M L Yap
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - J H E Yong
- St. Michael's Hospital, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada
| | - N Mittmann
- HOPE Research Centre, Toronto, Ontario, Canada; Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
| | - J S Hoch
- St. Michael's Hospital, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute of Clinical Evaluative Studies, Toronto, Ontario, Canada
| | - A W Fyles
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - P Warde
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Cancer Care Ontario, Toronto, Ontario, Canada
| | - E Gutierrez
- Cancer Care Ontario, Toronto, Ontario, Canada
| | - T Lymberiou
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - S Foxcroft
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - F F Liu
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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24
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Tang PA, Hay AE, O'Callaghan CJ, Mittmann N, Chambers CR, Pater JL, Leighl NB. Estimation of drug cost avoidance and pathology cost avoidance through participation in NCIC Clinical Trials Group phase III clinical trials in Canada. ACTA ACUST UNITED AC 2016; 23:S7-S13. [PMID: 26985151 DOI: 10.3747/co.23.2861] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cost avoidance occurs when, because of provision of a drug therapy [drug cost avoidance (dca)] or a pathology test [pathology cost avoidance (pca)] during trial participation, health care payers need not pay for standard treatments or testing. The aim of our study was to estimate the total dca and pca for Canadian patients enrolled in relevant phase iii trials conducted by the ncic Clinical Trials Group. METHODS Phase iii trials that had completed accrual and resulted in dca or pca were identified. The pca was calculated based on the number of patients screened and the test cost. The dca was estimated based on patients randomized, the protocol dosing regimen, drug cost, median dose intensity, and median duration of therapy. Costs are presented in Canadian dollars. No adjustment was made for inflation. RESULTS From 1999 to 2011, 4 trials (1479 patients) resulted in pca and 17 trials (3195 patients) resulted in dca. The total pca was estimated at $4,194,849, which included testing for KRAS ($141,058), microsatellite instability ($18,600), and 21-gene recurrence score ($4,035,191). The total dca was estimated at $27,952,512, of which targeted therapy constituted 43% (five trials). The combined pca and dca was $32,147,361. CONCLUSIONS Over the study period, trials conducted by the ncic Clinical Trials Group resulted in total cost avoidance (pca and dca) of approximately $7,518 per patient. Although not all trials lead to cost avoidance, such savings should be taken account when the financial impact of conducting clinical research is being considered.
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Affiliation(s)
- P A Tang
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB
| | - A E Hay
- ncic Clinical Trials Group, Kingston, ON
| | | | - N Mittmann
- ncic Clinical Trials Group, Kingston, ON;; Health Outcomes and Pharmacoeconomic (hope) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - C R Chambers
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB
| | - J L Pater
- ncic Clinical Trials Group, Kingston, ON
| | - N B Leighl
- Princess Margaret Cancer Centre, Toronto, ON
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25
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Abstract
Canada has a distinctive health care system, [...]
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Affiliation(s)
- N Mittmann
- Cancer Care Ontario, Sunnybrook Health Sciences Centre, and Canadian Centre for Applied Research in Cancer Control, Toronto, ON
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26
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Lien K, Tam VC, Ko YJ, Mittmann N, Cheung MC, Chan KKW. Impact of country-specific EQ-5D-3L tariffs on the economic value of systemic therapies used in the treatment of metastatic pancreatic cancer. ACTA ACUST UNITED AC 2015; 22:e443-52. [PMID: 26715881 DOI: 10.3747/co.22.2592] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Previous Canadian cost-effectiveness analyses in cancer based on the EQ-5D-3L (EuroQoL, Rotterdam, Netherlands) have commonly used U.K. or U.S. tariffs because the Canadian equivalent only just recently became available. The implications of using non-Canadian tariffs to inform decision-making are unclear. We aimed to reevaluate an earlier cost-effectiveness analysis of therapies for metastatic pancreatic cancer (originally performed using U.S. tariffs) with tariffs from Canada and various other countries to determine the impact of using non-country-specific tariffs. METHODS We used tariffs from Canada, the United States, the United Kingdom, Denmark, France, Germany, Japan, the Netherlands, and Spain to derive EQ-5D-3L utilities for the 10 health states in the pancreatic cancer model. Quality-adjusted life years (qalys) and incremental cost-effectiveness ratios (icers) were generated, and probabilistic sensitivity analyses (psas) were performed. RESULTS Canadian utilities are generally lower than the corresponding U.S. utilities and higher than those for the United Kingdom. Compared with the Canadian-valued scenarios, U.S. and U.K. estimates were statistically different for 3 and 9 scenarios respectively. Overall, 35% of the non-Canadian utilities (28 of 80) were significantly different, clinically, from the Canadian values. Canadian qalys were 6% lower than those for the United States and 6% higher than those for the United Kingdom. When comparing the qalys of each treatment with those of gemcitabine alone, the average percent change was +6.8% for a U.S. scenario and -7.5% for a U.K. scenario compared with a Canadian scenario. Consequently, Canadian icers were approximately 5.4% greater than those for the United States and 8.6% lower than those for the United Kingdom. Based on the psas and compared with the Canadian threshold value, the minimum willingness-to-pay threshold at which the combination chemotherapy regimen of gemcitabine-capecitabine is the most cost-effective is $5,239 less than in the United States and $11,986 more than in the United Kingdom. CONCLUSIONS The use of non-country-specific tariffs leads to significant differences in the derived utilities, icers, and psa results. Past Canadian EQ-5D-3L-based cost-effectiveness analyses and related funding decisions might need to be re-visited using Canadian tariffs.
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Affiliation(s)
- K Lien
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - V C Tam
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - Y J Ko
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - N Mittmann
- Health Outcomes and Pharmacoeconomics Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - M C Cheung
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON
| | - K K W Chan
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON; ; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
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Raju RS, Coburn N, Liu N, Porter JM, Seung SJ, Cheung MC, Goyert N, Leighl NB, Hoch JS, Trudeau ME, Evans WK, Dainty KN, Earle CC, Mittmann N. A population-based study of the epidemiology of pancreatic cancer: a brief report. ACTA ACUST UNITED AC 2015; 22:e478-84. [PMID: 26715886 DOI: 10.3747/co.22.2653] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Administrative data are used to describe the pancreatic cancer (pcc) population. The analysis examines demographic details, incidence, site, survival, and factors influencing mortality in a cohort of individuals diagnosed with pcc. METHODS Incident cases of pcc diagnosed in Ontario between 1 January 2004 and 31 December 2011 were extracted from the Ontario Cancer Registry. They were linked by encrypted health card number to several administrative databases to obtain demographic and mortality information. Descriptive, bivariate, and survival analyses were conducted. RESULTS During the period of interest, 9221 new cases of pcc (4548 in men, 4673 in women) were diagnosed, for an age-adjusted standardized annual incidence in the range of 8.6-9.5 per 100,000 population. Mean age at diagnosis was 70.3 ± 12.5 years (standard deviation). Five-year survival was 7.2% (12.8% for those <60 years of age and 3.6% for those >80 years of age). Survival varied by sex, older age, rural residence, lower income, site of involvement in the pancreas, and presence of comorbidity. CONCLUSIONS The mortality rate in pcc is exceptionally high. With an increasing incidence and a mortality positively associated with age, additional support will be needed for this highly fatal disease as demographics in Ontario continue to trend toward a higher proportion of older individuals.
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Affiliation(s)
- R S Raju
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N Coburn
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N Liu
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - J M Porter
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - S J Seung
- Health Outcomes and PharmacoEconomics Research Centre, Sunnybrook Research Institute, Toronto, ON
| | - M C Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N Goyert
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N B Leighl
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - J S Hoch
- Applied Research in Cancer Control, Cancer Care Ontario, Toronto, ON
| | - M E Trudeau
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | | | - K N Dainty
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - C C Earle
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N Mittmann
- Health Outcomes and PharmacoEconomics Research Centre, Sunnybrook Research Institute, Toronto, ON; ; Department of Pharmacology, University of Toronto, Toronto, ON; ; International Centre for Health Innovation, Richard Ivey School of Business, Western University, London, ON
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Maslikowska JA, Walker SAN, Elligsen M, Mittmann N, Palmay L, Daneman N, Simor A. Impact of infection with extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella species on outcome and hospitalization costs. J Hosp Infect 2015; 92:33-41. [PMID: 26597637 DOI: 10.1016/j.jhin.2015.10.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/05/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Extended-spectrum β-lactamase (ESBL)-producing bacteria are important sources of infection; however, Canadian data evaluating the impact of ESBL-associated infection are lacking. AIM To determine whether patients infected with ESBL-producing Escherichia coli or Klebsiella species (ESBL-EcKs) exhibit differences in clinical outcome, microbiological outcome, mortality, and/or hospital resource use compared to patients infected with non-ESBL-producing strains. METHODS A retrospective case-control study of 75 case patients with ESBL-EcKs matched to controls infected with non-ESBL-EcKs who were hospitalized from June 2010 to April 2013 was conducted. Patient-level cost data were provided by the institution's business office. Clinical data were collected using the electronic databases and paper charts. FINDINGS Median infection-related hospitalization costs per patient were greater for cases than controls (C$10,507 vs C$7,882; median difference: C$3,416; P = 0.04). The primary driver of increased costs was prolonged infection-related hospital length of stay (8 vs 6 days; P = 0.02) with patient location (ward, ICU) and indirect care costs (including costs associated with infection prevention and control) as the leading cost categories. Cases were more likely to experience clinical failure (25% vs 11%; P = 0.03), with a higher all-cause mortality (17% vs 5%; P = 0.04). Less than half of case patients were prescribed appropriate empiric antimicrobial therapy, whereas controls received adequate initial treatment in nearly all circumstances (48% vs 96%; P < 0.01). CONCLUSION Patients with infection caused by ESBL-EcKs are at increased risk for clinical failure and mortality, with additional cost to the Canadian healthcare system of C$3,416 per patient.
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Affiliation(s)
- J A Maslikowska
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - S A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - M Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - N Mittmann
- HOPE Research Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
| | - L Palmay
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - N Daneman
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - A Simor
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Tseng E, Prica A, Zhang L, Mittmann N, Seung SJ, Callum J, Kim T, Wells RA, Buckstein R. Monthly blood transfusions decrease after four months of azacitidine. Vox Sang 2015; 109:163-7. [PMID: 25899763 DOI: 10.1111/vox.12266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/01/2015] [Accepted: 02/05/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Azacitidine (AZA) improves overall survival and transfusion independence in patients with myelodysplastic syndrome (MDS). We aimed to quantify the reduction in red blood cell (RBC) transfusions and to determine when this reduction occurs, in MDS patients treated with AZA. MATERIALS AND METHODS We performed a retrospective audit of changes in RBC transfusion burden in 51 patients with predominantly higher risk MDS (26.5% high risk, 51.0% intermediate-2) who received AZA. Transfusion requirements were audited 6 months prior to and up to 18 months after therapy initiation, and data were analysed using a generalized linear mixed model. RESULTS At baseline, 30 patients (58.8%) were transfusion dependent (TD). Seventeen patients (56.7%) achieved transfusion independence (TI) by 18 months, and 8 of these patients (47.1%) achieved this response by 4 months on therapy. Achievement of TI was not consistently durable in these 17 patients, as 11 patients reverted to TD while on therapy. Meanwhile, 6 of 21 patients who were TI at baseline became TD on therapy. The monthly average of RBC units transfused decreased significantly beginning at 4 months, with a reduction from 2.50 units per month at baseline to 1.00 units per month at month 4. This 60% reduction was significant (P = 0.002) and sustained beyond 12 months. CONCLUSION These results bolster the notion that AZA significantly reduces transfusion burden and resource utilization and illustrate the limitations of the current WHO erythroid response criteria which do not account for differing durability and fluctuations of response.
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Affiliation(s)
- E Tseng
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Prica
- Princess Margaret Hospital, Toronto, ON, Canada
| | - L Zhang
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - N Mittmann
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Pharmacology, University of Toronto, Toronto, ON, Canada.,International Centre for Health Innovation, Richard Ivey School of Business, Western University, London, ON, Canada
| | - S J Seung
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - J Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - T Kim
- Celgene Incorporated, Mississauga, ON, Canada
| | - R A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - R Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Heelan K, Hitzig SL, Knowles S, Drucker AM, Mittmann N, Walsh S, Shear NH. Loss of Work Productivity and Quality of Life in Patients With Autoimmune Bullous Dermatoses. J Cutan Med Surg 2015; 19:546-54. [DOI: 10.1177/1203475415582317] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Little is known about quality of life and work productivity in autoimmune bullous dermatoses (AIBDs). Objective: To determine the impact of AIBDs on quality of life and work productivity. Methods: An observational cross-sectional study took place between February and May 2013 at an AIBD tertiary referral centre. Ninety-four patients were included. All participants completed the Dermatology Life Quality Index and the Work Productivity and Activity Impairment–Specific Health Problem questionnaires. Results: Responders to treatment had less impairment ( P < .001) than nonresponders. Patients with severe AIBD had significantly more impairment that those with mild ( P < .001) and moderate ( P = .002) AIBD. Greater impairment was associated with higher percentage of work missed. Those with a higher Dermatology Life Quality Index score had greater work impairment and overall activity impairment ( P = .041, P = .024). Nonresponders had increased impairment while working ( P < .001), overall work impairment ( P < .001), and activity impairment ( P < .001). Severely affected patients had worse impairment in all Work Productivity and Activity Impairment Questionnaire domains. Conclusions: AIBD has the potential to be a large burden on ability to work and quality of life. Larger studies are needed to clarify how these domains change over time and whether or not they improve with treatment.
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Affiliation(s)
- K. Heelan
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S. L. Hitzig
- Institute for Life Course and Aging, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - S. Knowles
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | - A. M. Drucker
- Division of Dermatology, University Health Network, Toronto, ON, Canada
| | - N. Mittmann
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Health Outcomes and PharmacoEconomics (HOPE) Research Centre, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S. Walsh
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - N. H. Shear
- Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Mittmann N, Porter JM, Rangrej J, Seung SJ, Liu N, Saskin R, Cheung MC, Leighl NB, Hoch JS, Trudeau M, Evans WK, Dainty KN, DeAngelis C, Earle CC. Health system costs for stage-specific breast cancer: a population-based approach. ACTA ACUST UNITED AC 2014; 21:281-93. [PMID: 25489255 DOI: 10.3747/co.21.2143] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of the present analysis was to determine the publicly funded health care costs associated with the care of breast cancer (bca) patients by disease stage. METHODS Incident cases of female invasive bca (2005-2009) were extracted from the Ontario Cancer Registry and linked to administrative datasets from the publicly funded system. The type and use of health care services were stratified by disease stage over the first 2 years after diagnosis. Mean costs and costs by type of clinical resource used in the care of bca patients were compared with costs for a matched control group. The attributable cost for the 2-year time horizon was determined in 2008 Canadian dollars. RESULTS This cohort study involved 39,655 patients with bca and 190,520 control subjects. The average age in those groups was 61.1 and 60.9 years respectively. Most bca patients were classified as either stage i (34.4%) or stage ii (31.8%). Of the bca cohort, 8% died within the first 2 years after diagnosis. The overall mean cost per bca case from a public payer perspective in the first 2 years after diagnosis was $41,686. Over the 2-year time horizon, the mean cost increased by stage: i, $29,938; ii, $46,893; iii, $65,369; and iv, $66,627. The attributable cost of bca was $31,732. Cost drivers were cancer clinic visits, physician billings, and hospitalizations. CONCLUSIONS Costs of care increased by stage of bca. Cost drivers were cancer clinic visits, physician billings, and hospitalizations. These data will assist planning and decision-making for the use of limited health care resources.
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Affiliation(s)
- N Mittmann
- Health Outcomes and PharmacoEconomics ( hope ) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON. ; Department of Pharmacology, University of Toronto, Toronto, ON. ; International Centre for Health Innovation, Richard Ivey School of Business, Western University, London, ON. ; Applied Research in Cancer Control, Cancer Care Ontario, Toronto, ON
| | - J M Porter
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - J Rangrej
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - S J Seung
- Health Outcomes and PharmacoEconomics ( hope ) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N Liu
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - R Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - M C Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N B Leighl
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - J S Hoch
- Applied Research in Cancer Control, Cancer Care Ontario, Toronto, ON. ; Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - M Trudeau
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | | | - K N Dainty
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - C DeAngelis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - C C Earle
- Institute for Clinical Evaluative Sciences, Toronto, ON. ; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
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Kellar J, Mittmann N, von Heymann C, Zingaro J, Kuriakose B, Li A. Costs of Employees with Treatment-Resistant Depression Based on a Canadian Private Claims Database. Value Health 2014; 17:A456-A457. [PMID: 27201265 DOI: 10.1016/j.jval.2014.08.1252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- J Kellar
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - N Mittmann
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - J Zingaro
- Cubic Health Inc., Toronto, ON, Canada
| | | | - A Li
- Janssen Inc, Toronto, ON, Canada
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Mittmann N, Seung SJ, Liu N, Porter J, Saskin R, Hoch JS, Evans WK, Leighl NB, Trudeau M, Earle CC. Population-based utilization of radiation therapy by a Canadian breast cancer cohort. ACTA ACUST UNITED AC 2014; 21:e715-7. [PMID: 25302042 DOI: 10.3747/co.21.2162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We examined trends in radiation therapy (rt) utilization by a population-based breast cancer cohort in Ontario. The provincial cancer registry provided a breast cancer cohort based on diagnosis dates from April 1, 2005, to March 31, 2010. Staging information was also available. The cohort was then linked, by encrypted health card number, to linkable administrative datasets, including rt utilization. The average age in the identified female breast cancer cohort (n = 39,656) was 61.6 ± 14.0 years. Almost two thirds of the patients (n = 25,225) received rt, and staging information was available for 22,988 patients (9541 stage i, 8516 stage ii, 4050 stage iii, and 881 stage iv). The average number of rt courses received by the patients was 1.4 ± 0.7 for stage i, 1.8 ± 1.1 for stage ii, 2.5 ± 1.3 for stage iii, and 2.8 ± 2.4 for stage iv. The ratio of conventional rt to intensity-modulated rt was 70.9%:16.6% for stage i, 71.6%:11.3% for stage ii, 74.6%:4.6% for stage iii, and 89.6%:2.2% for stage iv. From 2005 to 2010, almost two thirds of a Canadian female breast cancer cohort received rt, and the average number of courses increased with disease severity. A similar trend was observed with the type of rt (use of conventional rt increased with disease severity). The next step is to apply unit costs to the number of fractions and to obtain rt planning and radiation therapist times.
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Affiliation(s)
- N Mittmann
- Applied Research in Cancer Control, Cancer Care Ontario, Toronto, ON. ; Health Outcomes and Pharmacoeconomics (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON. ; Department of Pharmacology, University of Toronto, Toronto, ON
| | - S J Seung
- Health Outcomes and Pharmacoeconomics (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N Liu
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - J Porter
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - R Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - J S Hoch
- Applied Research in Cancer Control, Cancer Care Ontario, Toronto, ON. ; Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | | | - N B Leighl
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - M Trudeau
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - C C Earle
- Institute for Clinical Evaluative Sciences, Toronto, ON. ; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
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Fine S, Koo M, Gill T, Marin M, Poulin-Costello M, Barron R, Mittmann N. The use of granulocyte colony-stimulating factors in a Canadian outpatient setting. Curr Oncol 2014; 21:e229-40. [PMID: 24764708 DOI: 10.3747/co.21.1575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Data on real-life utilization of granulocyte colony-stimulating factors (g-csfs) in Canada are limited. The objective of the present study was to describe the reasons for, and the patterns of, g-csf use in selected outpatient oncology clinics in Ontario and Quebec. METHODS In a retrospective longitudinal cohort study, a review of medical records from 9 Canadian oncology clinics identified patients being prescribed filgrastim (fil) and pegfilgrastim (peg). Patient characteristics, reasons for g-csf use, and treatment patterns were descriptively analyzed. RESULTS Medical records of 395 patients initiating g-csf therapy between January 2008 and January 2009 were included. Of this population, 80% were women, and breast cancer was the predominant diagnosis (59%). The most commonly prescribed g-csf was fil (56% in Ontario and 98% in Quebec). The most frequent reason for g-csf use was primary prophylaxis (42% for both fil and peg), followed by secondary prophylaxis (37% fil, 41% peg). Those proportions varied by tumour type and chemotherapy regimen. Delayed g-csf administration (more than 1 day after the end of chemotherapy) was frequently observed for fil, but rarely reported for peg, and that finding was consistent across tumours and concurrent chemotherapy regimens. CONCLUSIONS The use of g-csf varies with the malignancy type and the provincial health care setting. The most commonly prescribed g-csf agent was fil, and most first g-csf prescriptions were for primary prophylaxis. Delays were frequently observed for patients receiving fil, but were rarely reported for those receiving peg.
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Affiliation(s)
- S Fine
- Peel Regional Cancer Centre, Credit Valley Hospital, Mississauga, ON
| | - M Koo
- Health Outcomes and Pharmacoeconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto, ON
| | - T Gill
- OptumInsight, Burlington, ON
| | - M Marin
- OptumInsight, Burlington, ON
| | | | | | - N Mittmann
- Health Outcomes and Pharmacoeconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto, ON. ; Department of Pharmacology, University of Toronto, Toronto, ON
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Tam VC, Ko YJ, Mittmann N, Cheung MC, Kumar K, Hassan S, Chan KKW. Cost-effectiveness of systemic therapies for metastatic pancreatic cancer. ACTA ACUST UNITED AC 2013; 20:e90-e106. [PMID: 23559890 DOI: 10.3747/co.20.1223] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Gemcitabine and capecitabine (gem-cap), gemcitabine and erlotinib (gem-e), and folfirinox (5-fluorouracil-leucovorin-irinotecan-oxaliplatin) are new treatment options for metastatic pancreatic cancer, but they are also more expensive and potentially more toxic than gemcitabine alone (gem). We conducted a cost-effectiveness analysis of these treatment options compared with gem. METHODS A Markov model was constructed to examine costs and outcomes of gem-cap, gem-e, folfirinox, and gem in patients with metastatic pancreatic cancer from the perspective of a government health care plan. Ontario health economic and costing data (2010 Canadian dollars) were used. Efficacy data for the treatments were obtained from the published literature. Resource utilization data were derived from a chart review of consecutive metastatic patients treated for pancreatic cancer at Princess Margaret Hospital, Toronto, Ontario, 2008-2009, and supplemented with data from the literature. Utilities were obtained by surveying medical oncologists across Canada using the EQ-5D. Incremental cost-effectiveness ratios (icers) were calculated. RESULTS The icers for gem-cap, gem-e, and folfirinox compared with gem were, respectively, CA$84,299, CA$153,631, and CA$133,184 per quality-adjusted life year (qaly). The model was driven mostly by drug acquisition costs. Given a willingness-to-pay (wtp) threshold greater than CA$130,000/qaly, folfirinox was most cost-effective treatment. When the wtp threshold was less than CA$80,000/qaly, gem alone was most cost-effective. The gem-e option was dominated by the other treatments. CONCLUSIONS The most cost-effective treatment for metastatic pancreatic cancer depends on the societal wtp threshold. If the societal wtp threshold were to be relatively high or if drug costs were to be substantially reduced, folfirinox might be cost-effective.
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Affiliation(s)
- V C Tam
- Division of Medical Oncology and Hematology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON. ; Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB
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Mittmann N, Isogai PK, Saskin R, Liu N, Porter JM, Cheung MC, Leighl NB, Hoch JS, Trudeau ME, Evans WK, Dainty KN, Earle CC. Population-based home care services in breast cancer: utilization and costs. ACTA ACUST UNITED AC 2013; 19:e383-91. [PMID: 23300362 DOI: 10.3747/co.19.1078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine utilization and costs of home care services (hcs) for individuals with a diagnosis of breast cancer (bc). METHODS Incident cases of invasive bc in women were extracted from the Ontario Cancer Registry (2005-2009) and linked with other Ontario health care administrative databases. Control patients were selected from the population of women never diagnosed with any type of cancer. The types and proportions of hcs used were determined and stratified by disease stage. Attributable home care utilization and costs for bc patients were determined. Factors associated with hcs costs were assessed using regression analysis. RESULTS Among the 39,656 bc and 198,280 control patients identified (median age: 61.6 years for both), 75.4% of bc patients used hcs (62.1% stage i; 85.7% stage ii; 94.6% stage iii; 79.1% stage iv) compared with 14.6% of control patients. The number of hcs used per patient-year were significantly higher for the bc patients than for the control patients (14.97 vs. 6.13, p < 0.01), resulting in higher costs per patient-year ($1,210 vs. $325; $885 attributable cost to bc, p < 0.01). The number of hcs utilized and the associated costs increased as the bc stage increased. In contrast, hcs costs decreased as income increased and as previous health care exposure decreased. INTERPRETATION Patients with bc used twice as many hcs, resulting in costs that were almost 4 times those observed in a matched control group. Less than an additional $1000 per bc patient per year were spent on hcs utilization in the study population.
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Affiliation(s)
- N Mittmann
- Health Outcomes and PharmacoEconomic ( hope ) Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON. ; Department of Pharmacology, University of Toronto, Toronto, ON. ; International Centre for Health Innovation ( ichi ), Richard Ivey School of Business, Western University, London, ON
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Abstract
INTRODUCTION Currently marketed epidermal growth factor receptor inhibitors (egfris) have been associated with high rates of dermatologic toxicity. METHODS We formally reviewed the literature at medline and embase. Additional searches were conducted using Internet search engines. Studies were eligible if they were randomized controlled clinical trials of egfris, specifically cetuximab and panitumumab, in which at least one arm consisted of a non-egfri treatment and rash safety data were reported. The random effects method was used to pool differences in incident rash rates. Results are summarized as differences in incident rash (egfri therapy rate minus the non-egfri therapy rate) with corresponding 95% confidence intervals (cis) for all severity grades of rash and for grades 3 and 4 rash. RESULTS Sixteen studies met the initial inclusion criteria of randomized controlled trials comparing egfri with non-egfri therapy. Seven publications that provided information on all severity grades of rash were found to have an overall difference in incident rash rate of 0.74 (95% ci: 0.68 to 0.81; p < 0.01). Thirteen studies that reported the incidence of grades 3 and 4 rash showed an overall difference in the incident rash rate of 0.12 (95% ci: 0.09 to 0.14; p < 0.01) between egfri and non-egfri therapy. Sensitivity analyses showed that the results were generally robust, but sensitive to small samples. CONCLUSIONS Results quantify the difference in rash rates between egfri and non-egfri therapy.
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Affiliation(s)
- N Mittmann
- HOPE Research Centre, Division of Clinical Pharmacology, Sunnybrook Health Sciences Centre, Toronto, ON
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Abstract
Background This economic analysis aimed to determine, from the perspective of a Canadian provincial government payer, the cost-effectiveness of docetaxel (Taxotere: Sanofi–Aventis, Laval, QC) in combination with doxorubicin and cyclophosphamide (tac) compared with 5-fluorouracil, doxorubicin, and cyclophosphamide (fac) following primary surgery for breast cancer in women with operable, axillary lymph node–positive breast cancer. Methods A Markov model looking at two time phases—5-year treatment and long-term follow-up—was constructed. Clinical events included clinical response (based on disease-free survival and overall survival) and rates of febrile neutropenia, stomatitis, diarrhea, and infections. Health states were “no recurrence,” “locoregional recurrence,” “distant recurrence,” and “death.” Costs were based on published sources and are presented in 2006 Canadian dollars. Model inputs included chemotherapy drug acquisition costs, chemotherapy administration costs, relapse and follow-up costs, costs for management of adverse events, and costs for granulocyte colony-stimulating factor (g-csf) prophylaxis. A 5% discount rate was applied to costs and outcomes alike. Health utilities were obtained from published sources. Results For tac as compared with fac, the incremental cost was $6921 per life-year (ly) gained and $6,848 per quality-adjusted life-year (qaly) gained. The model was robust to changes in input variables (for example, febrile neutropenia rate, utility). When g-csf and antibiotics were given prophylactically before every cycle, the incremental ratios increased to $13,183 and $13,044 respectively. Conclusions Compared with fac, tac offered improved response at a higher cost. The cost-effectiveness ratios were low, indicating good economic value in the adjuvant setting of node-positive breast cancer patients.
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Affiliation(s)
- N Mittmann
- HOPE Research Centre, Division of Clinical Pharmacology, Sunnybrook Health Sciences Centre, Toronto, ON
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Goffin JR, Flanagan W, Earle C, Hoch J, Asakawa K, Mittmann N, Wolfson M, Evans WK. Impact of increased use of adjuvant chemotherapy in non-small cell lung cancer: A population and economic assessment. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e16630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Tam VC, Ko Y, Mittmann N, Kumar K, Hassan S, Cheung MC, Chan KK. Cost-effectiveness of systemic therapies for metastatic pancreatic cancer. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.6114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mittmann N, Isogai PK, Saskin R, Liu N, Hoch J, Leighl NB, Cheung MC, Trudeau ME, Evans WK, Dainty K, Earle C. Population-based health care cost estimates related to breast cancer by staging. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.6108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Shapiro JD, Siu LL, Zalcberg JR, Moore MJ, Ringash J, Mittmann N, Simes J, O'Callaghan CJ, Tu D, Walters IB, Magoski N, Smith P, Nomikos D, Zhu L, Savoie M, Virk S, El-Tahche F, Gill R, Price TJ, Jonker DJ. A phase III study of cetuximab (CET) plus either brivanib alaninate (BRIV) versus placebo in patients with chemotherapy-refractory KRAS wild-type (WT) advanced colorectal cancer (aCRC): The NCIC CTG/AGITG CO.20 trial. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.tps163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lathia N, Isogai PK, De Angelis C, Walker S, Cheung MC, Mittmann N. Factors influencing patient preferences for outpatient treatment of febrile neutropenia. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.6041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
OBJECTIVES Recent results of the U.S. Oncology Adjuvant Trial 9735 demonstrated significant disease-free survival and overall survival benefits for docetaxel and cyclophosphamide (tc) compared with doxorubicin and cyclophosphamide (ac) in the adjuvant treatment of operable invasive breast cancer. Based on clinical data from the 9735 study, we evaluated the lifetime cost-effectiveness of tc compared with ac from the perspective of the Canadian publicly funded health care system. METHODS A Markov model was developed to estimate the incremental cost per quality-adjusted life-year gained and per life-year gained. Monthly survival and risk of disease recurrence up to 7 years were obtained directly from the overall survival and disease-free survival curves in the 9735 study; life-years beyond 7 years were estimated using the average life expectancy of age-matched women in the general Canadian population. Canadian-specific resource utilization and unit costs (in 2008 Canadian dollars) were applied to estimate costs for chemotherapy administration, chemotherapy-related toxicities, recurrence, and adverse events. Health-utility scores and decrements used in the calculation of quality-adjusted life-years were derived from the literature. RESULTS The lifetime cost per quality-adjusted life-year gained was $8,251 for tc compared with ac, and the cost per life-year gained was $6,842. The results were robust across a range of sensitivity analyses. CONCLUSIONS Cost-effectiveness, combined with efficacy and an acceptable safety profile, support the adoption of tc as an alternative to ac in Canadian clinical practice for the adjuvant treatment of operable early breast cancer.
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Affiliation(s)
| | - S. Verma
- The Ottawa Hospital Cancer Centre, Ottawa, ON
| | | | - B.C.F. Chan
- HOPE Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - N. Mittmann
- HOPE Research Centre, Sunnybrook Health Sciences Centre, Toronto, ON
- Department of Pharmacology, University of Toronto, Toronto, ON
| | - L. Asma
- U.S. Oncology Research, Houston, TX, U.S.A
| | - S.E. Jones
- U.S. Oncology Research, Houston, TX, U.S.A
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Mittmann N, Evans WK, Rocchi A, Longo CJ, Au HJ, Husereau D, Isogai PK, Krahn M, Coyle D. Economic guidelines for oncology products: Adaptation of the Canadian Agency for Drugs and Technologies in Health (CADTH) technology assessment guidance document. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e17572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17572 Background: Economic evaluations (EE) are routinely used by decision-makers in Canada. CADTH's “Guidelines for the Economic Evaluation of Health Technologies: Canada” Third edition, 2006, provide guidance on the conduct of EEs for all therapeutic products. The consistency and quality of oncology EEs are variable and therapeutics in the cancer care environment presented unique challenges in decision making. Several chapters of the CADTH document adequately defined methods for the conduct of an oncology EE. However, some chapters required more specific guidance to improve the quality of oncology EEs. The goal was to provide direction on methods for the conduct of high quality EEs in oncology. Methods: The Working Group on Economic Analysis, NCIC CTG and CADTH jointly initiated this project and formed a working group (WG) of oncologists, health economists, decision makers and economic analysts. The WG identified CADTH chapters where oncology-specific guidance would be required. In-person and teleconference meetings provided content and structure for the document. Formal reviews by external academic experts, cancer agencies, patient groups and the pharmaceutical industry were conducted. Feedback was reviewed by the WG and incorporated as appropriate. Results: Chapters requiring guidance included: target population, comparators, perspective, effectiveness, modeling, type of evaluation, valuing health, time horizon, costs and resources, sensitivity analysis and equity. Guidance included clarity around CADTH methodology and recommendations for oncology products. For example for the effectiveness chapter, there was guidance around the use of intermediate outcomes (progression free survival vs. overall survival) and type of evidence (phase II vs. phase III). Overall recommendations for chapters will be presented. Conclusions: The oncology adapted economic guidelines provide specific guidance on the conduct of EEs for oncology products and will be published as an addendum to CADTH's third edition document. Their use should lead to more consistent application of EE methodologies for anti-cancer drugs and higher quality information for decision-makers at a national and perhaps international level. No significant financial relationships to disclose.
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Affiliation(s)
- N. Mittmann
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - W. K. Evans
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - A. Rocchi
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - C. J. Longo
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - H. J. Au
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - D. Husereau
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - P. K. Isogai
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - M. Krahn
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
| | - D. Coyle
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Juravinski Cancer Centre, Hamilton, ON, Canada; Axia Research, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada; Cross Cancer Institute, Edmonton, AB, Canada; Canadian Agency for Drugs and Technologies Health, Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment, Toronto, ON, Canada; University of Ottawa, Ottawa, ON, Canada; Working Group on Standardized Pharmacoeconomic Guidelines in Oncology
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Verma S, Mittmann N, Bernard L, Thompson M, Chan B, Asmar L, Jones S. Docetaxel plus cyclophosphamide is cost-effective compared to doxorubicin plus cyclophosphamide, based on an economic analysis of US oncology trial 9735: additional rationale to avoid anthracyclines in the adjuvant treatment of operable breast cancer? Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-6105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #6105
Background: Extended 7-year follow-up of the US Oncology Adjuvant Trial 9735 demonstrated that docetaxel plus cyclophosphamide (TC) as adjuvant treatment of operable invasive breast cancer significantly improves disease-free survival (DFS) and overall survival (OS) compared to doxorubicin plus cyclophosphamide (AC). DFS was 81% vs. 75%, respectively (p = 0.033) and OS was 87% vs. 82%, respectively (p = 0.032). A lifetime cost-effectiveness analysis of TC versus AC was conducted from a Canadian (province of Ontario) government payer perspective, based on head-to-head clinical data from Trial 9735. Methods: Survival and monthly risk of disease recurrence of women with early stage breast cancer (base case typifying those entered into the trial) was estimated up to 7 years using OS and DFS data from Trial 9735. Survival was extrapolated to lifetime using life expectancy estimates from the Canadian general population. Canadian resource utilization and unit costs were applied to estimate the costs of chemotherapy (including drug and administration costs), chemotherapy-related toxicities and disease recurrence. Quality of life (utility) weights for health states and events, used in the calculation of quality-adjusted life years (QALYs), were derived from the literature. Total costs, life years and QALYs were calculated for a lifetime horizon. Results: Life years and QALYs were higher for TC patients compared to AC patients, due primarily to longer survival and fewer recurrences for patients receiving TC. The predicted life expectancy of patients receiving TC and AC was 14.64 and 14.02 years, respectively. Mean total lifetime disease-related costs were $12,840 with TC and $8,579 with AC; the difference in costs was driven by higher drug acquisition costs for TC. Cost per life year gained (TC vs. AC) was $6,842 and cost per QALY gained was $8,251, discounting costs and outcomes at 5% per year. Base case results were most sensitive to assumptions regarding time horizon. In a sensitivity analysis conducted with a 7-year time horizon (the time frame of the clinical trial), cost per life year gained was $36,120 and cost per QALY gained was $43,248. In additional one-way sensitivity analyses conducted with a lifetime horizon and alternative assumptions regarding survival extrapolation, utility estimates, costs and discount rate, cost per life year gained remained between $2,982 and $7,538 and cost per QALY gained remained between $3,600 and $9,090. Conclusion: In patients with early stage, operable, invasive breast cancer, adjuvant treatment with TC provides gains in terms of life years and QALYs compared to AC and results in favourable cost-effectiveness ratios that should be acceptable in most jurisdictions.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6105.
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Affiliation(s)
- S Verma
- 1 Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - N Mittmann
- 2 Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - L Bernard
- 3 Cornerstone Research Group Inc., Burlington, ON, Canada
| | - M Thompson
- 3 Cornerstone Research Group Inc., Burlington, ON, Canada
| | - B Chan
- 2 Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - L Asmar
- 4 US Oncology Research, Houston, TX
| | - S Jones
- 4 US Oncology Research, Houston, TX
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Mittmann N, Au HJ, Tu D, O'Callaghan CJ, Karapetis CS, Moore MJ, Zalcberg J, Simes J, Evans WK, Jonker DJ. A prospective economic analysis of cost-effectiveness of cetuximab for metastatic colorectal cancer patients from the NCIC CTG and AGITG CO.17 trial. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Bradbury PA, Tu D, Seymour L, Ng R, Zhu L, Isogai PK, Mittmann N, Evans WK, Shepherd FA, Leighl NB. Impact of clinical and molecular predictors of benefit from erlotinib in advanced non-small cell lung cancer on cost-effectiveness. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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