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W. Evans



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    MS19 - New Health Technology for Lung Cancer; Assessment and Implementation (ID 36)

    • Event: WCLC 2013
    • Type: Mini Symposia
    • Track: Radiation Oncology + Radiotherapy
    • Presentations: 1
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      MS19.4 - Resource Constraints as a Barrier to Lung Cancer Management: Developed Nations (ID 549)

      14:00 - 15:30  |  Author(s): W. Evans

      • Abstract
      • Presentation
      • Slides

      Abstract
      The chronic disease burden of developed countries is increasing as the postwar “baby boomers” enter their senior years. The cost of managing these chronic diseases is compounded by the increasing availability and use of expensive technologies. Cancer drug costs are a key driver of health care costs and the expenditure on cancer drugs is rising faster than spending in most other areas of healthcare. Because of this and the fiscal constraint most developed countries have put in place a rigorous drug review process. The United Kingdom’s National Institute for Health and Care Excellence (NICE), amongst others has led the way in establishing drug review processes. These reviews are generally viewed by the pharmaceutical industry, healthcare providers and the public itself as a barrier to access. The pan-Canadian Oncology Drug Review (pCODR) evaluates the clinical benefits and safety of new cancer drugs, as well as their cost-effectiveness and alignment with patient values using a standardized clinical and economic review process, an expert panel, a deliberative framework and broad public engagement (1). Commonly, recommendations are conditional on the drug price being lowered because the drug is not felt to be cost-effective. The determination of incremental cost-effectiveness or cost-utility is critical to drug funding approval in most jurisdictions except the United States. This is determined by assessing the incremental cost of the new drug or regimen over the standard treatment and dividing by the incremental benefit usually measured as years of life gained. In Canada, $50,000 per life year gained or less was generally accepted as cost-effective. As drug costs have increased, this "threshold" has crept higher and $100,000 per LYG is increasingly accepted as “reasonable”. To take account of morbidity from the disease and its treatment, the quantity of life gained is weighted by the quality of that life into a single multidimensional measure (i.e. the quantity adjusted life year or QALY). The availability of other resources, not related to the cost of drugs, can be a barrier to access. In 2008, Cancer Care Ontario began to measure concordance with guidelines developed through its Program in Evidence-based Care and to report this information through a Cancer System Quality Index (CSQI) (3). In 2010- 2011, it was noted that only 41% of resected stage II/IIIA patients received guideline recommended adjuvant chemotherapy (AC) at Ontario’s regional cancer centres. There was also substantial variation in guideline adherence between centers ranging from 42.9% to 72.1%. Men were significantly less likely to be treated with AC (38.2% compared to 52.7% for women) (p=0001), as were patients over age 65 (65% < 65 yrs. vs. 34% > 65 yrs.)(p=.0001). Patients from regions with the highest tercile of immigrants were significantly less likely to be treated: 14.3% for the highest, 46% for the middle and 51% for the lowest tercile. Similar variations were seen for the uptake of the guideline recommendation for the use of combined modality therapy in the treatment of stage III NSCLC. To better understand the reasons for these variances, a survey and key informant interviews were undertaken with clinicians and administrators. The perception of respondents was that the most common barriers to implementing practice guidelines were the slow referral process of patients to the treatment centers, lack of support from the organization’s leadership to implement the recommended regimens and the difficulties that patients had in getting to the treatment centers. These results suggested that greater efforts are required to communicate best practices to providers, (including primary care physicians), to improve the efficiency of clinic processes and to arrange patient transportation. For aboriginal and immigrant populations, culture and language are known barriers. Resources to lower language barriers, to assist patients in health system navigation and to educate health providers in the provision of culturally sensitive care may be necessary to ensure equitable access to appropriate care. Some developed countries have experienced resource constraints that have delayed access to cancer surgery and to radiation treatment. Excessive wait times result from inadequate capacity and/or inefficiencies in the health system. To resolve these issues first requires recognition of the problem, the development of a plan of action, appropriate funding to address capacity issues, process improvements to increase efficiency and incentives to providers to prioritize cancer treatments. In a recent review of access to cancer care services in Canada, Maddison et al. noted that inequity of access occurs across the continuum of care for different disease sites (4). The review suggested that access to cancer services is most inequitable at the beginning (i.e. screening) and at the end (i.e. end-of-life care). Income level appeared to have the most influence on screening while age and geography were most influential on access to end-of-life services. As the results of the NLST are implemented as population-based screening programs, low dose CT will compete for diagnostic service resources and other services. Smokers at risk from lower socioeconomic levels, in particular, may encounter barriers to access. At the other end of the cancer spectrum, access to palliative care resources varies widely in developed countries. Conclusions: Access to optimal lung cancer care across the continuum from screening and early detection through treatment and end-of-life care can encounter numerous resource barriers, which are not all monetary in nature. Although the cost of new drugs is the most significant potential resource barrier, numerous other barriers can exist in developed countries related to the resources available for screening or diagnosis, radiation and surgery, access to knowledge specialists, supportive care services and accessible end-of-life care in the home or community. References: 1. Pan-Canadian Oncology Drug Review (pCODR) (website). Toronto, Ontario. (Accessed August 1, 2013) Available at http://www.pCODR.org 2. Cancer System Quality Index (CSQI) (website). Toronto, Ontario: Cancer Quality Council of Ontario (accessed August 6, 2013). Available from: http://www.csqi.on.ca 3. Maddison AR, Asada Y, Urquhart R. Inequity in access to cancer care: a review of the Canadian literature. Cancer Causes Control 2011; 22:359-366

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    O05 - Cancer Control (ID 130)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Prevention & Epidemiology
    • Presentations: 1
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      O05.05 - Biennial lung cancer screening by low-dose CT scan - a simulation of cost effectiveness in Canada (ID 2313)

      10:30 - 12:00  |  Author(s): W. Evans

      • Abstract
      • Presentation
      • Slides

      Background
      Randomized data support annual screening for lung cancer among smokers using low-dose CT scans. To compare the resource implications of annual versus biennial screening, a cost-effectiveness analysis was undertaken using the Cancer Risk Management Model (CRMM version 2.0.1) in the context of the Canadian publicly funded healthcare system.

      Methods
      The CRMM performs simulations at an individual level and incorporates demographic data, cancer risk factors, cancer registry data, diagnostic and treatment algorithms and health utilities. Outputs are aggregated and costs (in 2008 Cdn dollars) and life-years are discounted at 3% annually. Simulations were performed with a cohort 55-74 years and a ≥30 pack-year (p-y) smoking history recruited from 2012-2032. CT scan sensitivity (Sens) and specificity (Spec) and cohort outcomes were based on NLST and Canadian data. It was assumed 60% of the eligible population participates by 10 years, 70% adhere to the screening regimen, and smoking cessation rates are unchanged. Sensitivity analysis was undertaken.

      Results
      An annual screening program incurs net costs of $2.97 billion and saves 55,000 quality-adjusted life-years (QALYs) at an incremental cost-effectiveness ratio (ICER) of $53,700 per QALY. Under default biennial screening assumptions (Table 1, scenario 3), biennial screening costs are $1.81 billion, saving 32,000 QALYs and producing an ICER of $56,200. In the least favourable stage shift scenario (1) tested, the ICER is $275,000, whereas the most favourable shift (4) results in $49,300. Using Sens/Spec 0.90/0.73 for all scans in scenario 3 produces an ICER of $61,400, whereas changing all incidence scan Sens/Spec to 0.87/0.73 gives an ICER of $60,900. Increasing age of eligibility to 55-79 cost $2.25 billion at an ICER of $58,700 per QALY while requiring a 40 p-y smoking history reduced cost to $1.3 billion at an ICER of $49,800 per QALY. Table 1.

      Year Stage Shift Scenario Sens/ Spec
      1 2 3 4 5
      0 T0 T0 T0 T0 T0 0.9/0.73
      1 CD PS PS PS CD -
      2 T0 T0 T0/T1 T1 T1 0.89/0.84
      3* CD PS PS PS CD -
      4** T0 T0 T0/T1 T1 T1 0.89/0.84
      ICER $275,000 $65,000 $56,200 $49,300 $104,00
      T0, T1 refer to the NLST stage shift at specified time, where T0 equals shift at time zero screen, T1 shift at 12 month screen. T0/T1 indicates an average. CD: the unscreened Canadian stage distribution. PS: NLST post-screening stage shift. *Represents 3[rd] year and all future odd years. **Represents 4[th] year and all future even years. Hyphens indicate years without screening.

      Conclusion
      Compared to annual lung cancer screening, biennial screening reduces net cost but may have a similar ICER. Stage shift assumptions have a significant impact on ICER values. Minor adjustments in Sens/Spec modestly change the ICER. Widening the age range increases but increasing the p-y requirement reduces system costs.

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    P2.09 - Poster Session 2 - Combined Modality (ID 213)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Combined Modality
    • Presentations: 1
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      P2.09-010 - Variation in the Uptake of the Combined Modality Practice Guideline for Surgically Unresectable Stage III NSCLC in Ontario (ID 1887)

      09:30 - 16:30  |  Author(s): W. Evans

      • Abstract

      Background
      Cancer Care Ontario’s (CCO) Program in Evidence-based Care has been developing lung cancer practice guidelines since 1997. Based on randomized clinical trials and published meta-analyses, a modest but clinically significant benefit for the use of concurrent chemo-radiotherapy treatment (CCRT) in selected inoperable stage III NSCLC (good performance status, limited weight loss), was recommended in a guideline published in 2005 and revised in 2006.

      Methods
      In 2008, CCO began to measure concordance with guidelines and to publically report regional results through the Cancer System Quality Index (CSQI),a web-based public reporting tool released annually by the Cancer Quality Council of Ontario (CQCO), Guideline concordance is a measure within the Effective quality domain of CSQI and is used to track the consistency of cancer treatment services across Ontario. This measure links data within Cancer Care Ontario’s Activity Level Reporting Enterprise Data Warehouse and the Ontario Cancer Registry with information from the Canadian Institute for Health Information’s Discharge Abstract Data and National Ambulatory Care Reporting System.

      Results
      Of 1312 patients with unresected stage III disease diagnosed in 2010 and 1259 in 2011, only 30.3% and 31.8% respectively received CCRT defined as radiation and chemotherapy given within 180 days of diagnosis. An additional 33.9% received an alternative form of treatment in 2011: 83.6% of these patients were treated only with radiation, 66% of whom had palliative radiotherapy while 33.4% had radical (curative) radiotherapy. In 2010, a similar pattern of treatment was observed with 33.5% of cases receiving alternate treatment: 81.3% of whom received only radiation; 70% of these patients received palliative treatment while 27.5% received radical radiotherapy. In 2011, 34.2% received no treatment, a decrease of 2% from 2010. Variation in guideline concordant practice was evident between the 14 health service regions of the province (range from 23.3% to 44.5%) but only one was significantly greater than the Ontario rate (95% Confidence Interval (CI); effect size (d =0.56). Six of 14 regions had a decline in the concordance rate between 2010 and 2011. There was no difference in the rate of CCRT use by gender (28.4%) but there was a sharp decline in CCRT after age 65 (45% < 65 yr vs. 25% > 65 yr), (95% CI, 21.5-28.5; p=0001). Less CCRT was given to the lowest income quintile (Q)(22.9% vs. 29.9% for Q4, 95% CI 23.9-35.9; p=0.0001), to urban vs. rural populations (22.9% vs. 34.8%; 95% CI, 28.6-40.9; p=0.0001) and in those areas of the province with higher populations of immigrants (lowest tercile 28.4% vs. 18.6% for middle and 19.0% for the highest tercile, p=0.0001).

      Conclusion
      Concordance with the CCO guideline on CCRT in Stage III unresectable NSCLC is particularly low in older, lower income, urban and immigrant populations. The absence of weight loss and performance status data makes interpretation of this data difficult. Further study of the reasons for these variations in practice will be necessary to inform appropriate strategies to reduce these inequities.

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    P2.24 - Poster Session 2 - Supportive Care (ID 157)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P2.24-022 - Implementing Dyspnea Management: A quality improvement project for patients with lung cancer in Ontario, Canada (ID 1439)

      09:30 - 16:30  |  Author(s): W. Evans

      • Abstract

      Background
      Dyspnea is a distressing symptom that occurs in up to 75% of patients with lung cancer as measured by the Edmonton Symptom Assessment System (ESAS). Appropriate dyspnea management (DM) can improve the patient’s quality of life, performance status and emotional well-being. However DM is not uniform or standard across Regional Cancer Centers (RCC). A quality improvement intiative on DM was implemented through the Disease Pathway Management (DPM) of Cancer Care Ontario (CCO). DPM is a unifying approach to quality improvement that integrates program activity across the cancer continuum in order to advance system-wide improvements. This initiative provided advice on various delivery models and strategies for DM.

      Methods
      Seven RCCs received funding from CCO to undertake one year pilot projects in DM. These projects had to have potential for significant impact, be innovative and be cost effective. Each RCC project was required to address the physical and psychological aspects of dyspnea that affect the patient, their families and/or caregivers. The precise methodology was left to each RCC to develop and initiate within the specified criteria. Approaches included educational sessions for patients and family members, individual counseling and treatment plans, and symptom management clinics. Four measures were tracked: ESAS for patient-reported symptom severity, Palliative Performance Status (PPS) for evaluation of functional status, European Organization for Research and Treatment Quality of Life Questionnaire (EORTC-QOL) to measure quality of life and a Patient Survey to evaluate the patient’s knowledge of dyspnea, preparedness for self-management and overall satisfaction with the DM initiative.

      Results
      188 patients were evaluable. 45% of patients with an initial severe dyspnea score on ESAS reported a shift to either a moderate or mild score by the last visit. 32% of patients with an initial moderate dyspnea score on ESAS reported a shift to a mild score. Patient satisfaction was high, with feelings of empowerment to carry on daily activities as a result of the interventions offered; caregivers reported a better understanding of dyspnea and better ability to support their loved ones; clinicians noted a difference in patients attending the dyspnea care initiative and valued the helpful resource for their patients. Challenges encountered during the project were lower than expected recruitment due to lack of clinical engagement from busy clinicians, multiple additional visits that sometimes conflicted with other scheduled patient visits to the RCC, and declining performance status of the patients precluding in-person attendance for training in DM techniques.

      Conclusion
      DM can be effectively implemented and tailored to local needs of a RCC or program. Key factors for success included a clinical champion and a multidisciplinary team approach in order to build the necessary knowledge and expertise for DM. The lessons learned as a result of these pilot projects have led to a new initiative to improve the quality and consistency of DM across the province of Ontario. This new initiative will incorporate novel approaches for knowledge transference with the possibility of engaging healthcare providers beyond the RCC.

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    P3.12 - Poster Session 3 - NSCLC Early Stage (ID 206)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P3.12-008 - Variations in the Uptake of Practice Guideline Recommendations on Adjuvant Chemotherapy Use Following Surgical Resection in Ontario (ID 1921)

      09:30 - 16:30  |  Author(s): W. Evans

      • Abstract

      Background
      Since 1997, lung cancer practice guidelines have been developed through Cancer Care Ontario’s Program in Evidence-based Care. A 2006 CCO guideline (EBS 7-1-2) recommends adjuvant chemotherapy (AC) in selected patients with resected lung cancer.

      Methods
      In 2008, CQCO began to measure concordance with guidelines and to publically report regional results through the Cancer System Quality Index (CSQI),a web-based public reporting tool released annually by the Cancer Quality Council of Ontario (CQCO). Guideline concordance is a measure within the Effective quality domain of CSQI and is used to track the consistency of cancer treatment services across Ontario. This measure links data within Cancer Care Ontario’s Activity Level Reporting Enterprise Data Warehouse and the Ontario Cancer Registry with information from the Canadian Institute for Health Information’s Discharge Abstract Data and National Ambulatory Care Reporting System. Two cohorts of patients who were diagnosed with Stage II or IIIa NSCLC between January and December 2008 to 2009 (cohort 1; n=685) and 2010 to 2011 (cohort 2; n=626) and resected within 270 days of diagnosis and who received cisplatin-based chemotherapy within 120 days of surgery are included in this analysis.

      Results
      In 2011, 60% of stage I, 64% of stage II and 15% of stage III NSCLC underwent surgical resection. On average, AC use increased in those resected from 54.3% in cohort 1 to 56.7% in cohort 2 but with significant variation amongst the 14 health service regions of the province (range 42.9 to 72.1%). 3 regions were moderately different from the Ontario rate based on Cohen’s d effect test at 95% CI, (d = 0.53-0.65). The variation between regions was greater in cohort 1 (31.4% to 66.9%; Δ 35.5%) than in cohort 2 (42.9% to 72.1%; Δ 29.2%) suggesting that public reporting may have driven some modest change. However, although the rate of use of AC increased for 10 regions, it actually decreased in 4. Men were significantly less likely to be treated with AC (38.2%) compared to women (52.7%) (95% CI, 44.6-60.8, p=.0001), as were patients over age 65 (65% < 65 yr vs. 34% % > 65 yr), (95% CI, 27.5-41.2; p=0001). Patients from areas with the highest tercile of immigrant population were also significantly less likely to be treated 14.3% (95% CI, p=.023) vs 46.0% for the middle; and 51.0% (p=.0001) for the lowest tercile. There were no differences based on quintiles (Q) of income (lowest Q 48.3% vs Q4, 48.3%; Q5, 40.8%) or rural versus urban residence.

      Conclusion
      Overall guideline uptake appears low for a therapy with the potential to improve long term survivorship and there is wide variance between regions only partially explained by factors such as age, gender and immigrant status. Further study is necessary to understand the factors driving this variation in practice and the best strategies to ensure that patients receive guideline recommended therapy.