Risk-based lung cancer screening performance in a universal healthcare setting

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Evaluating the economic burden of acute myeloid leukemia in Canada

Background Acute myeloid leukemia (AML) represents a significant burden for patients and their families, and to the healthcare system. This study estimated the total cost of illness associated with newly diagnosed AML patients in Canada. Methods The economic burden of AML was estimated using an incidence-based model, analyzing different types of AML cases in Canada. Direct and indirect costs were calculated using scientific literature and Canadian clinical experts' inputs. Patients were categorized depending on their eligibility for intensive chemotherapy (fit and unfit patients) as well as according to age and cytogenetic markers. Results The total average cost of AML per patient is estimated to be $178,073 with a cost of $210,983 and $145,163 for fit and unfit patients, respectively. The costs related to treatment represent half of the total average cost (52%), followed by hematopoietic stem cell transplant (23%), best supportive care (16%), productivity loss (6%) and wastage (4%) Conclusions For patients with AML, the costs associated with fit patients are higher than unfit patients. Hospitalization and best supportive care costs are key cost drivers for the total costs of fit and unfit patients, respectively. This study highlights that AML is associated with a significant economic burden in Canada.

Physician-brief advice for promoting smoking cessation among cancer patients on treatment in low and middle-income countries: a scoping review

INTRODUCTION

Physician-brief advice has been utilized in high-income countries to promote smoking cessation among cancer patients. Empirical evidence on its effectiveness among cancer patients in low and middle-income countries (LMICs) is lacking. The gap could be due to inadequate training, and competing healthcare priorities, leading to insufficient implementation of targeted smoking cessation interventions in oncology settings. We undertook this scoping review to determine if physician-brief advice is effective in promoting smoking cessation among cancer patients in LMICs.

METHODS

We conducted a literature search of all relevant articles across five databases: Cochrane Central Register of Controlled Trials, Cochrane Library (Tobacco Addiction Group trials), World Conference on Lung Cancer proceedings, PubMed, and Google Scholar up to November 2023, using pre-defined inclusion criteria and keywords. The study population was cancer survivors in LMICs, the intervention was smoking cessation advice by a physician in a clinic or oncology center during a consultation, and the outcome was the effect of smoking cessation programs in discontinuing smoking among cancer survivors in LMICs.

RESULTS

Overall, out of every 10 cancer patients in LMICs, about seven were smokers, and one-half had received physician-brief advice for smoking cessation. Physician-brief advice was more likely to be delivered to patients with smoking-related cancer (Cohen's d = 0.396). This means that there is a noticeable difference between patients with smoking-related cancer compared to those with cancer unrelated to smoking. Smoking cessation failure was due to the inability to cope with the symptoms of withdrawal, missed smoking cessation clinic visits, mental health disorders, limited time and resources, and minimal patient-physician contact.

CONCLUSION

There is very little literature on the frequency of use or the efficacy of physician-brief advice on smoking cessation in LMICs. The literature suggests that cancer patients in LMICs have low self-efficacy to quit smoking, and smoking cessation is rarely part of cancer care in LMICs. Physicians in LMICs should be trained to use motivational messages and good counseling techniques to improve smoking cessation among cancer patients. Policymakers should allocate the resources to implement physician-brief advice and design training programs for physicians focusing on physician-brief advice tailored to cancer patients.

Integrating Smoking Cessation Into Low-Dose Computed Tomography Lung Cancer Screening: Results of the Ontario, Canada Pilot

INTRODUCTION

Low-dose computed tomography screening in high-risk individuals reduces lung cancer mortality. To inform the implementation of a provincial lung cancer screening program, Ontario Health undertook a Pilot study, which integrated smoking cessation (SC).

METHODS

The impact of integrating SC into the Pilot was assessed by the following: rate of acceptance of a SC referral; proportion of individuals who were currently smoking cigarettes and attended a SC session; the quit rate at 1 year; change in the number of quit attempts; change in Heaviness of Smoking Index; and relapse rate in those who previously smoked.

RESULTS

A total of 7768 individuals were recruited predominantly through primary care physician referral. Of these, 4463 were currently smoking and were risk assessed and referred to SC services, irrespective of screening eligibility: 3114 (69.8%) accepted referral to an in-hospital SC program, 431 (9.7%) to telephone quit lines, and 50 (1.1%) to other programs. In addition, 4.4% reported no intention to quit and 8.5% were not interested in participating in a SC program. Of the 3063 screen-eligible individuals who were smoking at baseline low-dose computed tomography scan, 2736 (89.3%) attended in-hospital SC counseling. The quit rate at 1 year was 15.5% (95% confidence interval: 13.4%-17.7%; range: 10.5%-20.0%). Improvements were also observed in Heaviness of Smoking Index (p < 0.0001), number of cigarettes smoked per day (p < 0.0001), time to first cigarette (p < 0.0001), and number of quit attempts (p < 0.001). Of those who reported having quit within the previous 6 months, 6.3% had resumed smoking at 1 year. Furthermore, 92.7% of the respondents reported satisfaction with the hospital-based SC program.

CONCLUSIONS

On the basis of these observations, the Ontario Lung Screening Program continues to recruit through primary care providers, to assess risk for eligibility using trained navigators, and to use an opt-out approach to referral for cessation services. In addition, initial in-hospital SC support and intensive follow-on cessation interventions will be provided to the extent possible.

Building a National Reassessment Process for Oncology Drugs: Lessons Learned by the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration through a Simulated Reassessment Exercise

The CanREValue Collaboration established the Reassessment & Uptake Working Group to develop a preliminary process to reassess funded cancer drugs in Canada. A simulated exercise was conducted to evaluate the proposed reassessment process using a real-world case. We invited 32 attendees including representatives from Health Canada and Health Technology Assessment (HTA) agencies, along with payers, clinicians, academics, and patient representatives. A case was developed using a real-world study on a publicly funded cancer drug. In facilitated group sessions, participants were asked to deliberate upon the evidence presented in the case to issue reassessment recommendations. Several themes were identified through the deliberation discussions. While the generalizability of real-world evidence (RWE) is perceived as a strength, trust in the RWE depends largely on the source of the real-world data. The attendees suggested several improvements to the proposed reassessment process including evidence requirement for reassessment, recommendation categories, and a priori study protocols. This exercise generated important insights on the evidence required for conducting reassessment and considerations for improvements of the proposed reassessment process. Building upon lessons from this exercise, future work would continue to refine the reassessment process as part of the overall CanREValue framework.

Reporting of tobacco use and impact on outcomes in cancer cooperative group clinical trials: A systematic scoping review

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Background: Continued smoking after a diagnosis of cancer negatively impacts cancer outcomes but the impact of tobacco on many innovative treatments has not yet been well established. Collecting and evaluating tobacco use in cancer clinical trials may advance understanding of the consequences of tobacco use on specific treatment modalities. We performed a systematic scoping review of the frequency of reporting and analysis of tobacco use in clinical trials run by cancer cooperative clinical trial groups. Methods: A comprehensive literature search was conducted to identify cancer cooperative group clinical trials published from January 2017 to October 2019 using Medline, Epub Ahead of Print and In-Process & Other Non-Indexed Citations, Embase, Cochrane Central Register of Controlled Trials using OvidSP. Eligible studies evaluated either systemic and/or radiation therapies, involved at least one cancer cooperative group, included > 100 adult patients and reported on at least one primary or secondary endpoint, which included overall survival (OS), disease/progression-free survival (DFS/PFS), response rates, toxicities/adverse events, or quality of life (QoL). Secondary analyses of previously published trials were excluded. Results: Among 14843 identified studies, 91 studies representing 90 trials met inclusion criteria. 24% were phase II trials, 2% phase II/III and 74% phase III. Trial start dates ranged from 1995-2015 with most (29%) between 2007-2008; median trial sample size was 406 (range: 100-4994); 86% involved systematic therapy, 35% involved radiation; 14% were lung and 5% were head and neck trials. 51% of trials had a curative intent, 33% were palliative and 16% involved hematologic cancers. 74 studies reported on OS, 73 DFS/PFS, and 88 toxicity/QoL. 19 studies reported baseline tobacco use information, while two reported collecting follow-up tobacco use. Of those collecting baseline tobacco use, only 7 reported any analysis of the impact of tobacco on clinical outcomes. There was significant heterogeneity in the reporting of baseline tobacco use: 5 reported never/ever status, 10 reported never/ex-smoker/current smoker status; 4 reported some measure of smoking intensity; none reported on verifying smoking status or second hand smoke exposure. Trials of tobacco related (lung and head and neck) cancers were more likely to report baseline tobacco use compared to non-tobacco related cancers (83% vs 6% p < 0.001). Conclusions: Few cancer cooperative group clinical trials report and analyze trial participants’ baseline tobacco use, and even fewer collect follow up information. Significant heterogeneity exists in reporting tobacco use. Routine standardized collection and reporting of tobacco use, both at baseline and follow up in clinical trials, should be implemented to enable investigators to evaluate the clinical impact of tobacco use on new cancer therapies.

Real-world treatment patterns and survival in stage IV non-small-cell lung cancer in Canada

Background

Almost half of all patients with non-small-cell lung cancer (nsclc) present with stage iv disease. The objective of the present study was to characterize treatment patterns and survival outcomes in patients with advanced nsclc.

Methods

We conducted a longitudinal population-level study in patients diagnosed with stage iv nsclc in Ontario between 1 April 2010 and 31 March 2015, with follow-up to 31 March 2017 for overall survival and treatment sequence. Patients were stratified as nonsquamous or squamous histology. A sub-analysis was conducted for patients with nonsquamous histology who received targeted therapies, on the assumption that their tumours were EGFR mutation-positive (EGFRm+). Treatment patterns were determined, and survival was calculated from date of diagnosis to death or censoring.

Results

Of 24,729 nsclc cases identified, stage iv disease was diagnosed in 49.2%, histology was nonsquamous in 10,103, and EGFRm+ was assumed in 508. Median patient age ranged from 69 to 72 years for the three cohorts. For patients with nonsquamous histology, palliative radiotherapy was the most frequently used first-line treatment (44.4%), followed by no treatment (26.7%) and chemotherapy (14.9%). In the EGFRm+ cohort, 75.6% received gefitinib as first- or second-line therapy, and almost half (47.4%) the 473 patients with squamous histology treated with first-line chemotherapy received cisplatin or carboplatin with gemcitabine. Median overall survival in the nonsquamous and squamous cohorts was 4.9 and 4.6 months respectively; it was 17.6 months for patients who were EGFRm+.

Conclusions

Survival of patients with stage iv nsclc remains poor, with the exception of patients who are EGFRm+. Only 14.9% of patients received first-line chemotherapy; the mainstay of treatment was palliative radiotherapy.

Retrospective cohort study of unresectable stage III non-small-cell lung cancer in Canada

Background

The management of unresectable stage iii non-small-cell lung cancer (nsclc) is complex and best determined through multidisciplinary consultation. A longitudinal, population-level study was carried out to describe the management approach and outcomes of treatment in the real-world setting in Ontario.

Methods

Individuals diagnosed with nsclc between 1 April 2010 and 31 March 2015 were identified in the Ontario Cancer Registry. Unresectable disease was defined as no surgery reported within 3 months of diagnosis. Initial treatments included radiotherapy (rt, curative or palliative), chemotherapy, targeted therapy, and chemoradiation [crt, concurrent (ccrt) or sequential (scrt)]. Survival was calculated from diagnosis with stage iii disease to death or last follow-up.

Results

Of the 24,729 individuals diagnosed with nsclc, 5243 (21.2%) had stage iii disease, with most of the latter group (4542, 86.6%) having unresectable disease. Median age was 70 years, and 54.2% were men. The frequency of first-line treatment was ccrt, 22.1%; palliative rt, 21.0%; curative rt, 19.6%; no treatment, 19.6%; chemotherapy alone, 11.6%; scrt, 5.4%; and targeted therapy, 0.7%. Median overall survival (mos) was 14.2 months [95% confidence interval (ci): 13.6 months to 14.7 months], with the longest survival observed in patients who received targeted therapy (mos: 34.7 months; 95% ci: 21.4 months to 51.2 months), and the poorest, in those receiving no cancer treatment (mos: 5.9 months; 95% ci: 5.0 months to 6.4 months). The mos in patients receiving ccrt was 23.6 months (95% ci: 21.4 months to 25.6 months).

Conclusions

Guideline-recommended ccrt is undertaken in only a small proportion of patients with unresectable nsclc in Ontario. The reasons for low uptake of that recommendation are only partly understood.

Clinical impact and cost-effectiveness of integrating smoking cessation into lung cancer screening: a microsimulation model

BACKGROUND

Low-dose computed tomography (CT) screening can reduce lung cancer mortality in people at high risk; adding a smoking cessation intervention to screening could further improve screening program outcomes. This study aimed to assess the impact of adding a smoking cessation intervention to lung cancer screening on clinical outcomes, costs and cost-effectiveness.

METHODS

Using the OncoSim-Lung mathematical microsimulation model, we compared the projected lifetime impact of a smoking cessation intervention (nicotine replacement therapy, varenicline and 12 wk of counselling) in the context of annual low-dose CT screening for lung cancer in people at high risk to lung cancer screening without a cessation intervention in Canada. The simulated population consisted of Canadians born in 1940-1974; lung cancer screening was offered to eligible people in 2020. In the base-case scenario, we assumed that the intervention would be offered to smokers up to 10 times; each intervention would achieve a 2.5% permanent quit rate. Sensitivity analyses varied key model inputs. We calculated incremental cost-effectiveness ratios with a lifetime horizon from the health system's perspective, discounted at 1.5% per year. Costs are in 2019 Canadian dollars.

RESULTS

Offering a smoking cessation intervention in the context of lung cancer screening could lead to an additional 13% of smokers quitting smoking. It could potentially prevent 12 more lung cancers and save 200 more life-years for every 1000 smokers screened, at a cost of $22 000 per quality-adjusted life-year (QALY) gained. The results were most sensitive to quit rate. The intervention would cost over $50 000 per QALY gained with a permanent quit rate of less than 1.25% per attempt.

INTERPRETATION

Adding a smoking cessation intervention to lung cancer screening is likely cost-effective. To optimize the benefits of lung cancer screening, health care providers should encourage participants who still smoke to quit smoking.

The impact of tobacco retail density on overall survival (OS) in lung cancer survivors

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Background: Continued smoking after a cancer diagnosis is associated with poorer outcomes. We previously identified that tobacco retail outlet density is negatively associated with cessation in lung cancer survivors (ASCO 2019). However, the impact of tobacco retail density on survival has not been evaluated. We evaluated the impact of tobacco retail density on OS in lung cancer patients (pts). Methods: Lung cancer pts diagnosed from 2009-2012 were recruited at diagnosis and completed a baseline questionnaire on their socio-demographics, ECOG and smoking history. Clinicopathologic data including stage, histology and OS data were collected. Validated tobacco retail location data obtained from Ministry of Health and pt home addresses were geocoded using ArcGIS 10.6.1, which calculated tobacco outlet density within 250 meters (m) and 500m from pts. Multivariable Cox proportional hazard models evaluated the impact of tobacco outlet density on OS adjusted for significant clinicodemographic covariates. Results: Among 1411 pts, median age 66, 53% female, 8% small cell/56% adenocarcinoma/17% squamous/19% other, 28% stage 1/9% stage 2/20% stage 3/35% stage 4, 38% were current smokers at diagnosis and 40% were ex-smokers; median OS was 24 months. On average, there was one vendor (range 0-23) within 250m and four vendors (range 0-44) within 500m from pts; 33% and 60% of pts lived within 250m and 500m from at least one vendor respectively. The final baseline multivariable model consisted of age, gender, stage, smoking status, ECOG and neighbourhood marginalization index ( P< 0.05). Among all pts, not living within 250m to an outlet improved OS (aHR 0.84 [0.72-0.97] P= 0.02). Living near more outlets within 250 m (aHR 1.03 per outlet [1.00-1.05] P= 0.03) or 500 m (aHR 1.01 per outlet [1.00-1.02] P= 0.04) worsened OS. Subgroup analysis based on smoking status at diagnosis, identified that among current smokers, not living within 250m to an outlet improved OS (aHR 0.76 [0.60-0.97] P= 0.03), and among ex-smokers, living near more outlets within 500 m worsened OS (aHR 1.02 per outlet [0.99-1.03] P= 0.07); other associations showed similar directionality. Among 135 current smokers at diagnosis with follow-up smoking status, not living within 250m to an outlet continued to show a trend towards improved OS (aHR 0.57 [0.31-1.03] P= 0.06), after also adjusting for follow-up smoking status. Conclusions: Living near a greater density of tobacco outlets is associated with poorer OS among lung cancer pts. Reducing the density of tobacco outlets may be a strategy that can help improve lung cancer pt outcomes.

Health system costs for cancer medications and radiation treatment in Ontario for the 4 most common cancers: a retrospective cohort study

BACKGROUND

Previous costing and resource estimates for cancer have not been complete owing to lack of comprehensive data on cancer-related medication and radiation treatment. Our objective was to calculate the mean overall costs per patient of cancer-related medications and radiation, as well as by disease subtype and stage, in the first year after diagnosis for the 4 most prevalent cancers in Ontario.

METHODS

We conducted a retrospective cohort study using provincial health administrative databases to identify population health system resources and costs for all patients diagnosed with breast, colorectal, lung or prostate cancer between Jan. 1, 2010, and Dec. 31, 2015 in Ontario. The primary outcome measure was the overall average cost per patient in the 365 days after diagnosis for cancer-related medications and radiation treatment, calculated with the use of 2 novel costing algorithms. We determined the cost by disease, disease subtype and stage as secondary outcomes.

RESULTS

There were 168 316 Ontarians diagnosed with cancer during the study period, 50 141 with breast cancer, 38 108 with colorectal cancer, 34 809 with lung cancer and 45 258 with prostate cancer. The mean per-patient cost for cancer-related medications was $8167 (95% confidence interval [CI] $8023-$8311), $6568 (95% CI $6446-$6691), $2900 (95% CI $2816-$2984) and $1211 (95% CI $1175-$1247) for breast, colorectal, lung and prostate cancer, respectively. The corresponding mean radiation treatment costs were $18 529 (95% CI $18 415-$18 643), $15 177 (95% CI $14 899-$15 456), $10 818 (95% CI $10 669-$10 966) and $16 887 (95% CI $16 648-$17 125). In general, stage III and IV cancers were the most expensive stages for both medications and radiation across all 4 disease sites.

INTERPRETATION

Our work updates previous costing estimates to help understand costs and resources critical to health care system planning in a single-payer system. More refined costing estimates are useful as inputs to allow for more robust health economic modelling and health care system planning.

Development, validation and results from the impact of treatment evolution in non-small cell lung cancer (iTEN) model

OBJECTIVES

Treatment of advanced NSCLC (aNSCLC) is rapidly evolving, as new targeted and immuno-oncology (I-O) treatments become available. The iTEN model was developed to predict the cost and survival benefits of changing aNSCLC treatment patterns from a Canadian healthcare system perspective. This report describes iTEN model development and validation.

MATERIALS & METHODS

A discrete event patient simulation of aNSCLC was developed. A modified Delphi process using Canadian clinical experts informed the development of treatment sequences that included commonly used, Health Canada approved treatments of aNSCLC. Treatment efficacy and the timing of progression and death were estimated from published Kaplan-Meier progression free and overall survival data. Costs (2018 CDN$) included were: drug acquisition and administration, imaging, monitoring, adverse events, physician visits, best supportive care, and end-of-life.

RESULTS AND CONCLUSION

Clinical validity of the iTEN model was assessed by comparing model survival predictions to published real-world evidence (RWE). Four RWE studies that reported the overall survival of patients treated with a broad sampling of common aNSCLC treatment patterns were used for validation. The validation coefficient of determination was R² = 0.95, with the model generally producing estimates that were neither optimistic nor conservative. The model estimated that current Canadian practice patterns yield a median survival of almost 13 months, a five-year survival rate of 3% and a life-time per-treated-patient cost of $110,806. Cost and survival estimates are presented and were found to vary by aNSCLC subtype. In conclusion, the iTEN model is a reliable tool for forecasting the impact on cost and survival of new treatments for aNSCLC.

The generation of two specific cancer costing algorithms using Ontario administrative databases

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.

Tobacco retail availability and tobacco cessation in lung and head and neck (HN) cancer survivors

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Background: Continued smoking after a cancer diagnosis is associated with poorer outcomes. Tobacco retail availability is negatively associated with cessation in non-cancer patients (pts), but has not been explored in cancer survivors. We evaluated the impact of tobacco retail availability on cessation in lung and HN cancer pts. Methods: Lung and HN cancer pts (Princess Margaret Cancer Centre, Toronto) completed questionnaires evaluating changes in tobacco use with a median of 26 months apart. Validated tobacco retail location data were obtained from Ministry of Health and pt home addresses were geocoded using ArcGIS 10.6.1, which calculated walking time/distance to nearest vendor, and vendor density within 250 meters (m) and 500m from pts. Multivariable logistic regression and Cox proportional hazard models evaluated the impact of vendor availability on cessation and time to quitting after diagnosis respectively, adjusting for significant clinico-demographic and tobacco covariates. Results: 242/721 lung and 149/445 HN pts smoked at diagnosis; subsequent overall quit rates were 66% and 49% respectively. Mean distance and walking time to a vendor was 1 km (range 0-13) and 11 min (range 0-156). On average, there was one vendor (range 0-19) within 250m and four vendors (range 0-40) within 500m from pts; 37% and 61% of pts lived within 250m and 500m from at least one vendor respectively. Greater distance (aOR 1.18 per 1000m [95% CI 1.00-1.38] p = 0.05) and increased walking time (aOR 1.01 per minute [1.00-1.02] p = 0.05) were associated with quitting at one year. Living within 250m (aOR 0.52 [0.32-0.84] p = 0.008) or 500m (aOR 0.57 [0.35-0.92] p = 0.02) to at least one vendor reduced quitting at one year. Living near more vendors within 500m had an increasing dose effect on reducing cessation rates at one year (aOR 0.96 per vendor [0.93-1.00] p = 0.05). Living within 500m to a vendor reduced chance of quitting at any time (aHR 0.66 [0.48-0.91] p = 0.01). HN and lung subgroups revealed similar associations. Conclusions: Close access to tobacco retail outlets is associated with reduced cessation rates for lung and HN cancer survivors. Reducing density of tobacco vendors is a cessation strategy that can positively impact cancer pt outcomes.

Implementing smoking cessation within cancer treatment centres and potential economic impacts

Background

Although the health benefits of smoking cessation in newly diagnosed cancer patients are well established, systematic efforts to help cancer patients stop smoking have rarely been implemented in cancer centres.

Methods

Starting in 2012, the 14 regional cancer centres overseen by Cancer Care Ontario in the province of Ontario, Canada began to screen ambulatory cancer patients for their smoking status, to provide smokers with advice on the health benefits of quitting and to offer referral to smoking cessation services. Multiple initiatives were undertaken to educate healthcare providers and patients on the health benefits of cessation. Critical to the success of the initiative was strong leadership from Cancer Care Ontario executives and regional vice presidents, advice from an advisory committee of smoking cessation experts, engagement of regional champions and support from a provincial secretariat. The quarterly review of performance metrics was an important driver of change.

Results

Most cancer centres now screen in excess of 75% of ambulatory patients but rates for the acceptance of a referral to smoking cessation services remain low (less than 25%). Introduction of an opt-out referral process appears to increase referral acceptance. Economic analyses suggest that smoking cessation is cost-effective in a cancer centre environment.

Conclusions

Although there are barriers to the implementation of smoking cessation in cancer centres, it is possible to change the culture to one in which smoking cessation is considered part of high-quality treatment.

Cost-of-illness study for non-small-cell lung cancer using real-world data

Background

With recent advances in the treatment of non-small-cell lung cancer (nsclc) and current fiscal constraints within publicly funded health care systems, understanding the real-world economic effect of lung cancer management has become important. The objective of the present study was to determine the costs and resources used in the management of nsclc cohorts in Ontario.

Methods

Patients diagnosed between 1 April 2010 and 31 March 2015 were identified in the Ontario Cancer Registry and linked to provincial administrative databases, capturing resources such as hospitalizations, cancer clinic visits, physician services, and systemic therapies or radiotherapy. A cost-of-illness analysis using a bottom-up approach and the GETCOST macro available at ices determined the overall total and mean costs in 2017 Canadian dollars. Resource utilization results were analyzed according to the total number of encounters per resource, the number of patients using each resource, and the number of encounters per patient. A separate cost-and-resource analysis was conducted for radiotherapy.

Results

The 24,729 nsclc patients identified included 4542 with stage iii unresectable disease and 10,103 with stage iv nonsquamous disease. The overall total cost for all nsclc patients was $1.9 billion, with inpatient hospitalizations ($635.2 million), cancer clinic visits ($323.7 million), and physician services ($301.4 million) being the top cost contributors. The mean cost per patient was $76,816. The total cost of radiotherapy was $38.5 million.

Conclusions

Real-world costs for the management of nsclc during the 5-year period examined were substantial, despite the fact that median survival was poor and treatment information was limited.

Cancer patient (pt) attitudes and preferences towards smoking status assessment

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Background: Continued smoking after a cancer diagnosis is associated with poorer outcomes. Understanding pt attitudes towards smoking status assessment will help with integrating smoking cessation programs into survivorship care. Methods: Cancer pts were surveyed on their smoking history, assessment rates and attitudes/preferences towards smoking status assessment. Multivariate logistic regression models assessed for factors associated with screening preferences. Results: Among 501 pts, 115 smoked at diagnosis, 60% quit after; 53% had a tobacco related (lung/head and neck) cancer (TRC); 40% reported that their smoking status was assessed only on their first clinic visit, while 12% were assessed at all visits. Most felt smoking status should be assessed at the first visit (95%), while half (58%) felt it should be assessed each visit. Most felt comfortable with being assessed (96%), felt it was important for clinicians to be aware of tobacco use (98%) and that smoking cessation discussions should occur at the first visit (87%). Most preferred being assessed by their oncologist (88%); less preferred being asked by another healthcare provider (44%), on paper (29%) or e-surveys (32%). Compared to ex/never smokers, current smokers were assessed more often at most/every visit (36% vs 20%) and were less comfortable being assessed (88% vs 98%). Among current smokers, lung cancer pts were more agreeable being assessed each visit compared to head/neck (aOR 2.48 95% CI [0.9-6.5] P = 0.06) and non TRCs (aOR 2.63 [1.0-6.8] P = 0.05). Among all, pts who are older (aOR 1.03 [1.0-1.1]), curative (aOR 1.92 [1.1-3.2]) and smoked less (aOR 0.98 per pkyr [0.97-0.99]) were more agreeable to routine assessment. Most pts also felt oncologists should screen for second hand smoke exposure (92%), felt its assessment was important (93%) and should help others who smoke to quit (68%). Many felt that tobacco cessation programs for both pts (75%) and others who around them who smoke (65%) should be routine cancer care. Conclusions: Most cancer pts felt that assessment of smoking status was important, were comfortable being assessed and preferred direct assessment by their oncologist. Routine screening of those currently smoking is recommended to help with cessation.

Sociodemographic characteristics associated with thyroid cancer risk in Canada

BACKGROUND

Thyroid cancer incidence in Canada has increased rapidly over the past 25 years. This study examines thyroid cancer incidence and relative risk according to individual-level sociodemographic characteristics in two population-based cohorts.

DATA AND METHODS

The analysis uses data from the 1991 and 2001 Canadian Census Health and Environment Cohorts (CanCHECs). Using nine years of cancer follow-up for both time periods, age-standardized incidence rates of thyroid cancer were estimated by sex-with sex-specific estimates produced by immigrant status, ethnicity, educational attainment and family income-and by histology type. All characteristics were included in sex-specific standard Cox proportional hazard models to examine the relative risk of thyroid cancer and the relative risk of papillary versus non-papillary thyroid cancer.

RESULTS

A significant increase over time in thyroid cancer incidence was observed for both sexes, and across all characteristics. Immigrant status and ethnicity were each independently associated with the risk of thyroid cancer, with immigrant men and women and East and Southeast Asian women at higher risk. Men and women who had a postsecondary diploma or higher or who were in the highest income quintile were at increased risk of being diagnosed with papillary thyroid cancer, but not with non-papillary thyroid cancer.

DISCUSSION

While increased detection has played a role in the rising incidence of thyroid cancer in Canada, it does not fully account for the greater relative risk among the immigrant population and certain ethnic groups. More research is needed to better understand the determinants of the increased risk in these populations.

Cancer patient attitudes and preferences towards smoking status assessment

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Background: Continued smoking after a cancer diagnosis is associated with poorer outcomes. As smoking cessation is an important part of cancer care, understanding pt attitudes towards smoking status assessment will help with integrating smoking cessation programs into survivorship care. Methods: Cancer pts were surveyed on their smoking history, assessment rates and attitudes/preferences towards smoking status assessment. Multivariate logistic regression models assessed for factors associated with screening preferences. Results: Among 501 pts, 115 smoked at diagnosis, 60% quit after; 53% had a tobacco related (lung/head and neck) cancer (TRC); 40% reported that their smoking status was assessed only on their first clinic visit, while 32% were assessed at a few visits and 12% all visits. Most felt smoking status should be assessed at the first visit (95%), while half (58%) felt it should be assessed each visit. Most felt comfortable with being assessed (96%), felt it was important for clinicians to be aware of smoking status (98%) and that smoking cessation discussions should occur at the first visit (87%). Most preferred being assessed by their oncologist (88%); less than half preferred being asked by another healthcare provider (44%), on paper (29%) or e-surveys (32%). Compared to ex/never smokers, current smokers were assessed more often at every/most visits (36% vs 20% P= 0.001) and were less comfortable with being assessed (88% vs 98% P< 0.001). Among current smokers, lung cancer pts were more agreeable (58%) to being assessed each visit compared to head/neck (aOR 2.48 95% CI [0.9-6.5] P= 0.06) and non TRCs (aOR 2.63 [1.0-6.8] P= 0.05). Among all, pts who are older (aOR 1.03 [1.0-1.1]), curative (aOR 1.92 [1.1-3.2]) and smoked less (aOR 0.98 per pkyr [0.97-0.99]) were more agreeable to assessment at each visit. Most pts also felt oncologists should screen for second hand smoke exposure (92%), felt its assessment was important (93%) and should help others who smoke to quit (68%). Conclusions: Most cancer pts felt that assessment of smoking status was important, were comfortable being assessed and preferred being assessed directly by their oncologist. Routine screening of those currently smoking is recommended to help with cessation.

The OncoSim model: development and use for better decision-making in Canadian cancer control

The Canadian Partnership Against Cancer was created in 2007 by the federal government to accelerate cancer control across Canada. Its OncoSim microsimulation model platform, which consists of a suite of specific cancer models, was conceived as a tool to augment conventional resources for population-level policy- and decision-making. The Canadian Partnership Against Cancer manages the OncoSim program, with funding from Health Canada and model development by Statistics Canada. Microsimulation modelling allows for the detailed capture of population heterogeneity and health and demographic history over time. Extensive data from multiple Canadian sources were used as inputs or to validate the model. OncoSim has been validated through expert consultation; assessments of face validity, internal validity, and external validity; and model fit against observed data. The platform comprises three in-depth cancer models (lung, colorectal, cervical), with another in-depth model (breast) and a generalized model (25 cancers) being in development. Unique among models of its class, OncoSim is available online for public sector use free of charge. Users can customize input values and output display, and extensive user support is provided. OncoSim has been used to support decision-making at the national and jurisdictional levels. Although simulation studies are generally not included in hierarchies of evidence, they are integral to informing cancer control policy when clinical studies are not feasible. OncoSim can evaluate complex intervention scenarios for multiple cancers. Canadian decision-makers thus have a powerful tool to assess the costs, benefits, cost-effectiveness, and budgetary effects of cancer control interventions when faced with difficult choices for improvements in population health and resource allocation.

How equitable is access to treatment for lung cancer patients? A population-based review of treatment practices in Ontario

Aim:

Guideline concordance is one of the metrics used by the Cancer Quality Council of Ontario and Cancer Care Ontario to assess the quality of cancer care and to drive quality improvement.

Materials & Methods:

The rates for lung cancer surgical resection and concordance with the Cancer Care Ontario postoperative adjuvant chemotherapy (AC) guideline were assessed by health region during two time periods (2010–2011 and 2012–2013) according to five equity measures (age, sex, neighborhood income, location of residence and size of immigrant population).

Results:

Of the patients with stage I/II NSCLC, 52.2% to 63.0% underwent surgical resection in the province of Ontario, Canada; for patients with stage IIIA disease, the rate was 26.4%. The probability of a surgical resection decreased substantially with age; only 26.9% of those with potentially resectable (stage I–IIIA) disease over 80 years underwent surgery. The use of postoperative AC increased modestly over the time of the study but the rate of use varied widely by health region (34.6 to 84.6%). Patients in rural areas were as likely to receive AC as urban dwellers; however, older aged patients (≥65 years) and those from the lowest income neighborhoods were significantly less likely to receive AC.

Conclusion:

Surgical rates and the use of AC vary by health region in Ontario and by age and level of neighborhood income despite universal access in a publicly funded health care system. The reasons for this variance are unclear but warrant further study.

Presented in part at the 15th World Conference on Lung Cancer, Sydney, Australia, 27–30 October 2013

Participant selection for lung cancer screening by risk modelling (the Pan-Canadian Early Detection of Lung Cancer [PanCan] study): a single-arm, prospective study

BACKGROUND

Results from retrospective studies indicate that selecting individuals for low-dose CT lung cancer screening on the basis of a highly predictive risk model is superior to using criteria similar to those used in the National Lung Screening Trial (NLST; age, pack-year, and smoking quit-time). We designed the Pan-Canadian Early Detection of Lung Cancer (PanCan) study to assess the efficacy of a risk prediction model to select candidates for lung cancer screening, with the aim of determining whether this approach could better detect patients with early, potentially curable, lung cancer.

METHODS

We did this single-arm, prospective study in eight centres across Canada. We recruited participants aged 50-75 years, who had smoked at some point in their life (ever-smokers), and who did not have a self-reported history of lung cancer. Participants had at least a 2% 6-year risk of lung cancer as estimated by the PanCan model, a precursor to the validated PLCOm2012 model. Risk variables in the model were age, smoking duration, pack-years, family history of lung cancer, education level, body-mass index, chest x-ray in the past 3 years, and history of chronic obstructive pulmonary disease. Individuals were screened with low-dose CT at baseline (T0), and at 1 (T1) and 4 (T4) years post-baseline. The primary outcome of the study was incidence of lung cancer. This study is registered with ClinicalTrials.gov, number NCT00751660.

FINDINGS

7059 queries came into the study coordinating centre and were screened for PanCan risk. 15 were duplicates, so 7044 participants were considered for enrolment. Between Sept 24, 2008, and Dec 17, 2010, we recruited and enrolled 2537 eligible ever-smokers. After a median follow-up of 5·5 years (IQR 3·2-6·1), 172 lung cancers were diagnosed in 164 individuals (cumulative incidence 0·065 [95% CI 0·055-0·075], incidence rate 138·1 per 10 000 person-years [117·8-160·9]). There were ten interval lung cancers (6% of lung cancers and 6% of individuals with cancer): one diagnosed between T0 and T1, and nine between T1 and T4. Cumulative incidence was significantly higher than that observed in NLST (4·0%; p<0·0001). Compared with 593 (57%) of 1040 lung cancers observed in NLST, 133 (77%) of 172 lung cancers in the PanCan Study were early stage (I or II; p<0·0001).

INTERPRETATION

The PanCan model was effective in identifying individuals who were subsequently diagnosed with early, potentially curable, lung cancer. The incidence of cancers detected and the proportion of early stage cancers in the screened population was higher than observed in previous studies. This approach should be considered for adoption in lung cancer screening programmes.

FUNDING

Terry Fox Research Institute and Canadian Partnership Against Cancer.

Lessons learned implementing a province-wide smoking cessation initiative in Ontario's cancer centres

PURPOSE

A large body of evidence clearly shows that cancer patients experience significant health benefits with smoking cessation. Cancer Care Ontario, the provincial agency responsible for the quality of cancer services in Ontario, has undertaken a province-wide smoking cessation initiative. The strategies used, the results achieved, and the lessons learned are the subject of the present article.

METHODS

Evidence related to the health benefits of smoking cessation in cancer patients was reviewed. A steering committee developed a vision statement for the initiative, created a framework for implementation, and made recommendations for the key elements of the initiative and for smoking cessation best practices.

RESULTS

New ambulatory cancer patients are being screened for their smoking status in each of Ontario's 14 regional cancer centres. Current or recent smokers are advised of the benefits of cessation and are directed to smoking cessation resources as appropriate. Performance metrics are captured and used to drive improvement through quarterly performance reviews and provincial rankings of the regional cancer centres.

CONCLUSIONS

Regional smoking cessation champions, commitment from Cancer Care Ontario senior leadership, a provincial secretariat, and guidance from smoking cessation experts have been important enablers of early success. Data capture has been difficult because of the variety of information systems in use and non-standardized administrative and clinical processes. Numerous challenges remain, including increasing physician engagement; obtaining funding for key program elements, including in-house resources to support smoking cessation; and overcoming financial barriers to access nicotine replacement therapy. Future efforts will focus on standardizing processes to the extent possible, while tailoring the approaches to the populations served and the resources available within the individual regional cancer programs.

The Cost-Effectiveness of High-Risk Lung Cancer Screening and Drivers of Program Efficiency

INTRODUCTION

Lung cancer risk prediction models have the potential to make programs more affordable; however, the economic evidence is limited.

METHODS

Participants in the National Lung Cancer Screening Trial (NLST) were retrospectively identified with the risk prediction tool developed from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. The high-risk subgroup was assessed for lung cancer incidence and demographic characteristics compared with those in the low-risk subgroup and the Pan-Canadian Early Detection of Lung Cancer Study (PanCan), which is an observational study that was high-risk-selected in Canada. A comparison of high-risk screening versus standard care was made with a decision-analytic model using data from the NLST with Canadian cost data from screening and treatment in the PanCan study. Probabilistic and deterministic sensitivity analyses were undertaken to assess uncertainty and identify drivers of program efficiency.

RESULTS

Use of the risk prediction tool developed from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial with a threshold set at 2% over 6 years would have reduced the number of individuals who needed to be screened in the NLST by 81%. High-risk screening participants in the NLST had more adverse demographic characteristics than their counterparts in the PanCan study. High-risk screening would cost $20,724 (in 2015 Canadian dollars) per quality-adjusted life-year gained and would be considered cost-effective at a willingness-to-pay threshold of $100,000 in Canadian dollars per quality-adjusted life-year gained with a probability of 0.62. Cost-effectiveness was driven primarily by non-lung cancer outcomes. Higher noncurative drug costs or current costs for immunotherapy and targeted therapies in the United States would render lung cancer screening a cost-saving intervention.

CONCLUSIONS

Non-lung cancer outcomes drive screening efficiency in diverse, tobacco-exposed populations. Use of risk selection can reduce the budget impact, and screening may even offer cost savings if noncurative treatment costs continue to rise.

Clinical trials in Ontario’s quality-based funding model

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Background: Clinical trials (CTs) are a key component of a quality cancer care system. When funding for systemic therapy services in Ontario transitioned in 2014 from a one-time payment for new cases to bundled payments for specific care activities (consultation, therapy, well follow-up, supportive care), a policy was developed to address public funding for systemic therapy in CTs. Methods: Treatment facilities receive funding from the Systemic Treatment-Quality Based Program (ST-QBP) for treatment with evidence-informed regimens inclusive of inexpensive drug, preparation and delivery costs. Under the new CT policy, randomized CTs with a standard of care comparator arm receive funding for all arms of the trial from the ST-QBP for older inexpensive drugs and all treatment administration costs at the band level for the disease type and stage. Non-randomized CTs are funded at the level of best supportive care or other appropriate band level. CT costs over and above the standard of care must be negotiated with industry sponsors. New and expensive drugs in CTs may be funded through separate provincial drug reimbursement programs if used according to publicly approved funding indications. Weekly joint reviews of new CT submissions by staff of the ST-QBP and drug reimbursement programs ensures timely communication to investigators concerning policy alignment and public funding and addresses potential concerns with regard to downstream access to expensive drugs. Results: As of January 29, 2016, 121 CT applications have been assessed (Phase 0 = 1, Phase I = 26, Phase II = 31, Phase III = 39, Phase IV = 1 and Multi-Phase = 23). Almost all CTs are aligned with the new policy and were assessed in a timely fashion. Assessments are posted on Cancer Care Ontario’s website within 1 week of review to allow all Ontario investigators access to this information. Conclusions: A clear CT funding policy and timely reviews support patient and investigator access to new and innovative therapies within an evidence-informed public funding model in Ontario, Canada. [Table: see text]

Comparing assessment frameworks for cancer drugs between Canada and Europe: What can we learn from the differences?

The increasing burden of costs associated with novel cancer therapies is becoming untenable. In Europe and Canada, assessment frameworks have been developed to attribute value to novel therapies and ultimately facilitate access to cancer drug funding. A review of the two frameworks has not previously been undertaken. This review provides insight into the relative strengths and benefits of each approach, the various perspectives of value (patient, physician and societal) and how the frameworks relate to their unique context and core principles. Both frameworks assess the clinical benefit of a new cancer therapy. The European framework considers effectiveness, quality of life, and toxicity in its determination of benefit and has the advantage of providing a simple summary score to facilitate priority setting. The Canadian framework considers other elements including cost-effectiveness, patient preferences and adoption feasibility; its deliberative framework precludes a simple summative presentation of value but can address complex and nuanced drug funding considerations with flexibility. Both frameworks have evolved to meet the needs unique to their jurisdictions and offer potentially complementary tools in the assessment of new cancer drugs. Lessons learnt in both systems can be applied to future iterations of the frameworks, which remain works in progress.

Towards Integrating Primary Care with Cancer Care: A Regional Study of Current Gaps and Opportunities in Canada

BACKGROUND AND OBJECTIVES

Better integration between cancer care systems and primary care physicians (PCPs) is a goal of most healthcare systems, but little direction exists on how this can be achieved. This study systematically examined the extent of integration between PCPs and a regional cancer program (RCP) to identify opportunities for improvement.

METHOD

Cross-sectional survey of all practising PCPs in the region of interest using a study-specific instrument based on a three-tier conceptualization of integration.

RESULTS

Among the 473 PCPs who responded (63% response rate), perceived role clarity and the desire for greater involvement in patient care varied across the care trajectory. Specific gaps were identified in PCPs' understanding of the referral process and patient follow-up after treatment.

CONCLUSION

Our novel survey of PCPs explicated the strategies that could improve their integration in cancer care, including mechanisms to support PCPs in the initial diagnosis of their patients and standardized post-treatment transition plans outlining care roles and responsibilities.

Using Data From Ontario's Episode-Based Funding Model to Assess Quality of Chemotherapy

INTRODUCTION

A new episode-based funding model for ambulatory systemic therapy was implemented in Ontario, Canada on April 1, 2014, after a comprehensive knowledge transfer and exchange strategy with providers and administrators. An analysis of the data from the first year of the new funding model provided an opportunity to assess the quality of chemotherapy, which was not possible under the old funding model.

MATERIALS AND METHODS

Options for chemotherapy regimens given with adjuvant/curative intent or palliative intent were informed by input from disease site groups. Bundles were developed and priced to enable evidence-informed best practice. Analysis of systemic therapy utilization after model implementation was performed to assess the concordance rate of the treatments chosen with recommended practice. The actual number of cycles of treatment delivered was also compared with expert recommendations.

RESULTS

Significant improvement compared with baseline was seen in the proportion of adjuvant/curative regimens that aligned with disease site group-recommended options (98% v 90%). Similar improvement was seen for palliative regimens (94% v 89%). However, overall, the number of cycles of adjuvant/curative therapy delivered was lower than recommended best practice in 57.5% of patients. There was significant variation by disease site and between facilities.

CONCLUSION

Linking funding to quality, supported by knowledge transfer and exchange, resulted in a rapid improvement in the quality of systemic treatment in Ontario. This analysis has also identified further opportunities for improvement and the need for model refinement.

Biennial lung cancer screening in Canada with smoking cessation-outcomes and cost-effectiveness

BACKGROUND

Guidelines recommend low-dose CT (LDCT) screening to detect lung cancer among eligible at-risk individuals. We used the OncoSim model (formerly Cancer Risk Management Model) to compare outcomes and costs between annual and biennial LDCT screening.

METHODS

OncoSim incorporates vital statistics, cancer registry data, health survey and utility data, cost, and other data, and simulates individual lives, aggregating outcomes over millions of individuals. Using OncoSim and National Lung Screening Trial eligibility criteria (age 55-74, minimum 30 pack-year smoking history, smoking cessation less than 15 years from time of first screen) and data, we have modeled screening parameters, cancer stage distribution, and mortality shifts for screen diagnosed cancer. Costs (in 2008 Canadian dollars) and quality of life years gained are discounted at 3% annually.

RESULTS

Compared with annual LDCT screening, biennial screening used fewer resources, gained fewer life-years (61,000 vs. 77,000), but resulted in very similar quality-adjusted life-years (QALYs) (24,000 vs. 23,000) over 20 years. The incremental cost-effectiveness ratio (ICER) of annual compared with biennial screening was $54,000-$4.8 million/QALY gained. Average incremental CT scan use in biennial screening was 52% of that in annual screening. A smoking cessation intervention decreased the average cost-effectiveness ratio in most scenarios by half.

CONCLUSIONS

Over 20 years, biennial LDCT screening for lung cancer appears to provide similar benefit in terms of QALYs gained to annual screening and is more cost-effective. Further study of biennial screening should be undertaken in population screening programs. A smoking cessation program should be integrated into either screening strategy.

End-of-life home care utilization and costs in patients with advanced colorectal cancer

OBJECTIVE

To determine overall utilization and costs associated with home care services in Ontario, Canada by linking a home care database to a stage IV colorectal cancer cohort.

METHODS

The names of patients with stage IV colorectal cancer at time of diagnosis (diagnosed from 2005 through 2009) were extracted from the Ontario Cancer Registry. The study cohort comprised those who died before the end of the study. The terminal phase of care was the period of time between diagnosis and death, with a maximum value of 180 days (6 months). Patients were linked to home care services datasets. The type, frequency, and cost of home care services were determined. Regression analysis was used to examine factors associated with utilization and cost.

RESULTS

In all, 3,613 stage IV colorectal cancer patients (median age, 71 years) were diagnosed and died during the study's time horizon. During the terminal phase, 79.3% received at least 1 home care visit, and 58.0% had at least 1 palliative visit. Terminal metastatic colorectal cancer patients received an average of 8 home care visits at Canadian $800 within a 30-day time horizon. Home care costs were highest in the month before death. Male sex, a history of moderate or high utilization of health care services, and hospitalization were associated with lower home care costs.

LIMITATIONS

Administrative data do not reveal the purpose, efficiency, effectiveness/sufficiency, quality, or appropriateness of home care.

CONCLUSION

Patients with advanced colorectal cancer who were approaching death required a moderate level of home care support, resulting in costs of about $5,000 over the 6-month time horizon.

FUNDING

This study was conducted with the support of the Ontario Institute for Cancer Research and Cancer Care Ontario through funding provided by the government of Ontario. Data were provided by Cancer Care Ontario and the Institute for Clinical Evaluative Sciences. The ICES also provided funding for the study from an annual grant by the Ontario Ministry of Health and Long-term Care.

Implementing low-dose computed tomography screening for lung cancer in Canada: implications of alternative at-risk populations, screening frequency, and duration

BACKGROUND

Low-dose computed tomography (ldct) screening has been shown to reduce mortality from lung cancer; however, the optimal screening duration and "at risk" population are not known.

METHODS

The Cancer Risk Management Model developed by Statistics Canada for the Canadian Partnership Against Cancer includes a lung screening module based on data from the U.S. National Lung Screening Trial (nlst). The base-case scenario reproduces nlst outcomes with high fidelity. The impact in Canada of annual screening on the number of incident cases and life-years gained, with a wider range of age and smoking history eligibility criteria and varied participation rates, was modelled to show the magnitude of clinical benefit nationally and by province. Life-years gained, costs (discounted and undiscounted), and resource requirements were also estimated.

RESULTS

In 2014, 1.4 million Canadians were eligible for screening according to nlst criteria. Over 10 years, screening would detect 12,500 more lung cancers than the expected 268,300 and would gain 9200 life-years. The computed tomography imaging requirement of 24,000-30,000 at program initiation would rise to between 87,000 and 113,000 by the 5th year of an annual nlst-like screening program. Costs would increase from approximately $75 million to $128 million at 10 years, and the cumulative cost nationally over 10 years would approach $1 billion, partially offset by a reduction in the costs of managing advanced lung cancer.

CONCLUSIONS

Modelling various ways in which ldct might be implemented provides decision-makers with estimates of the effect on clinical benefit and on resource needs that clinical trial results are unable to provide.

Assessing the quality of chemotherapy in an episode-based funding model in Ontario

1

Background: On April 1, 2014, the delivery of systemic treatment in Ontario transitioned to an episode-based funding model, which provides bundled payments for a full course of therapy delivered with adjuvant/curative intent and a monthly bundled payment for palliative intent. Disease Site Teams have defined treatment options and “best practice” for each funded adjuvant/curative regimen. Methods: The utilization of treatment according to disease and intent was analyzed for 35 systemic treatment facilities in Ontario, comparing actual practice (AP) with “best practice” (BP) (dose/schedule/cycle number), for common adjuvant/curative regimens. Variation in the choice of chemotherapy regimen was also reviewed. Results: Cases were included if they started a new course of adjuvant/curative therapy after January 1, 2014, and completed their treatment before July 31, 2015 (17,341 cases). For all disease sites and facilities, AP was equal to BP in 34.6% of cases, AP < BP in 57.5%, and AP > BP in 7.8% (Table). There was significant variation by disease site and facility. As a specific example, 1,368 courses of adjuvant mFOLFOX were completed for colorectal cancer: AP = BP (12 cycles) in 34% (range 7-70%), AP < BP in 66% (range 30-93%), and AP > BP in 1% (range 0-4%). Variation in choice of adjuvant regimen for breast cancer was also observed. Provincially, 21.5% of patients received non-anthracycline containing therapy, but the range in the 20 largest volume centers was 0% to 39.8%. Conclusions: With the administration of potentially curative therapy, it might be assumed that BP would be administered in the majority of cases. However, initial results demonstrate significant variation in practice in an episode based funding model. There is a need to understand the reasons for this variation and to identify potential opportunities to drive efficiency and to increase standardization by engaging clinical experts and practitioners. [Table: see text]

A population-based study of the epidemiology of pancreatic cancer: a brief report

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.

Performance of the cancer risk management model lung cancer screening module

BACKGROUND

The National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening reduces lung cancer mortality in a high-risk U.S. population. A microsimulation model of LDCT screening was developed to estimate the impact of introducing population-based screening in Canada.

DATA AND METHODS

LDCT screening was simulated using the lung cancer module of the Cancer Risk Management Model (CRMM-LC), which generates large, representative samples of the Canadian population from which a cohort with characteristics similar to NLST participants was selected. Screening parameters were estimated for stage shift, LDCT sensitivity and specificity, lead time, and survival to fit to NLST incidence and mortality results. The estimation process was a step-wise directed search.

RESULTS

Simulated mortality reduction from LDCT screening was 23% in the CRMM-LC, compared with 20% in the NLST. The difference in the number of lung cancer cases over six years varied by, at most, 2.3% in the screen arm. The difference in cumulative incidence at six years was less than 2% in both screen and control arms. The estimated percentage over-diagnosed was 24.8%, which was 6% higher than NLST results.

INTERPRETATION

Simulated screening reproduces NLST results. The CRMM-LC can evaluate a variety of population-based screening strategies. Sensitivity analyses are recommended to provide a range of projections to reflect model uncertainty.

Eligibility for low-dose computerized tomography screening among asbestos-exposed individuals

OBJECTIVES

The study aimed to incorporate an estimate of risk for asbestos exposure in the Canadian Cancer Risk Management Lung Cancer (CRMM-LC) microsimulation model.

METHODS

In CRMM-LC, a 3-year probability of developing lung cancer can be derived from different risk profiles. An asbestos-exposed cohort was simulated and different scenarios of low-dose computerized tomography (LDCT) screening were simulated.

RESULTS

As annual LDCT screening among non-asbestos-exposed individuals is less cost-effective than biennial screening, all the scenarios modeled for an asbestos-exposed cohort were biennial. For individuals with a two-fold risk of asbestos-induced lung cancer to be eligible for biennial LDCT screening, a smoking history of ≥15 pack-years would be necessary. For non-smokers with asbestos exposure resulting in a relative risk (RR) for lung cancer, it is not cost-effective to screen those with a RR of 5, but it is cost-effective to screen those with a RR of 10 (the heavily exposed).

CONCLUSION

Asbestos-exposed individuals with an estimated two-fold or more risk of lung cancer from asbestos-exposure are eligible for LDCT screening at all ages from 55-74 years if they have a cigarette smoking history of ≥15 pack-years. Asbestos-exposed individuals who are lifelong non-smokers are eligible for LDCT screening at all ages from 55-74 years if they have accumulated a degree of asbestos exposure resulting in an estimated risk of lung cancer of ≥10.

Health system costs for stage-specific breast cancer: a population-based approach

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.

Home care utilization and costs in stage IV lung cancer: a Canadian public payer experience

SUMMARY 

Background: Lung cancer (LC) is a leading cause of morbidity and mortality and there is limited information on the type, quantity and cost of home care services (HCS) for LC. Aim: The objectives of this study include: identifying a stage IV LC cohort; determining the utilization and costs of HCS for the stage IV LC cohort; and comparing HCS utilization and costs by phase of disease. Methods: New cases of stage IV LC were extracted from a provincial cancer registry and linked to administrative datasets. HCS utilization and costs (2009 Canadian dollars [CAD]) for stage IV cases were determined from a public payer perspective and by disease phase. Results: There are 4616 stage IV LC patients who used HCS.. The mean number of HCS visits per 30 days was 7.7 and the mean cost per 30 days was CAD$798 for terminal-phase patients. Conclusion: HCS costs for stage IV patients are less expensive than other health resources.

Measuring alignment with evidence-informed practice in Ontario’s systemic treatment funding model

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Background: A new systemic treatment funding model (STFM) was implemented in Ontario on April 1, 2014, transitioning from life-time per case funding to reimbursement based on evidence-informed episodes of care. The effectiveness of the model will be evaluated against key indicators including the percent of patients on evidence-informed regimens (PPEIR). Methods: Provincial Disease Site Group (DSG) experts reviewed all chemotherapy regimens administered in Ontario over the two years prior to implementation. Each DSG identified the treatment regimens to be STFM reimbursed, based on evidence of clinical benefit according to treatment intent (curative/adjuvant vs. palliative or both). A year of pre-implementation data will serve as a baseline to assess the impact of transition to the new funding model. Clinical and administrative stakeholders have received their baseline facility-level data and will receive monthly reports, including the PPEIR, to aid in identifying and resolving clinical practice and/or data quality issues post-implementation. Results: Of approximately 1,000 regimens reviewed by the DSGs, ~100 were deemed to be evidence informed for adjuvant/curative intent, ~325 for palliative intent, and ~90 for both intents. Overall, the 2013/14 baseline provincial PPEIR was 91.6% for 16,200 treatment courses given with adjuvant/curative intent while 93.2% of 56,800 patient-months of treatment with palliative intent were aligned with the proposed evidence informed definition. Significant variation in baseline PPEIR was seen for the 29 level 1-3 provincial treatment facilities (range = 71-99%) and for the 10 different disease sites. Conclusions: Knowledge of the PPEIR utilized increases understanding of practice at the system (provincial), regional, facility and disease site level and will provide opportunities for benchmarking and ongoing improvement in quality of care.

Population-based utilization of radiation therapy by a Canadian breast cancer cohort

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.

Implementing a regional oncology information system: approach and lessons learned

RATIONALE

Paper-based medical record systems are known to have major problems of inaccuracy, incomplete data, poor accessibility, and challenges to patient confidentiality. They are also an inefficient mechanism of record-sharing for interdisciplinary patient assessment and management, and represent a major problem for keeping current and monitoring quality control to facilitate improvement. To address those concerns, national, regional, and local health care authorities have increased the pressure on oncology practices to upgrade from paper-based systems to electronic health records.

OBJECTIVES

Here, we describe and discuss the challenges to implementing a region-wide oncology information system across four independent health care organizations, and we describe the lessons learned from the initial phases that are now being applied in subsequent activities of this complex project.

RESULTS

The need for change must be shared across centres to increase buy-in, adoption, and implementation. It is essential to establish physician leadership, commitment, and engagement in the process. Work processes had to be revised to optimize use of the new system. Culture change must be included in the change management strategy. Furthermore, training and resource requirements must be thoroughly planned, implemented, monitored, and modified as required for effective adoption of new work processes and technology. Interfaces must be established with multiple existing electronic systems across the region to ensure appropriate patient flow. Periodic assessment of the existing project structure is necessary, and adjustments are often required to ensure that the project meets its objectives.

CONCLUSIONS

The implementation of region-wide oncology information systems across different health practice locations has many challenges. Leadership is essential. A strong, collaborative information-sharing strategy across the region and with the supplier is essential to identify, discuss, and resolve implementation problems. A structure that supports project management and accountability contributes to success.

Raising the bar: using program evaluation for quality improvement

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