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J. Hoch

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    MS 23 - Risk Factors: Beyond the Cigarette (ID 41)

    • Event: WCLC 2015
    • Type: Mini Symposium
    • Track: Prevention and Tobacco Control
    • Presentations: 1
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      MS23.05 - Cost Efficacy of Tobacco Cessation Versus Treatment of Lung Cancer (ID 1953)

      14:15 - 15:45  |  Author(s): J. Hoch

      • Abstract
      • Presentation
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      The global burden of lung cancer is significant and growing. In 2015, WHO reported that there were almost 1.7 million deaths from lung cancer and this number could increase 1.5 times by 2030 (1).The cost associated with the management of lung cancer is significant and can be expected to increase dramatically. It has been estimated that the costs to manage lung cancer will increase in Canada by 80% from 2010 to 2030 but this may prove to be a gross underestimate because of new targeted and immuno-therapies (2). As smoking is the main cause of lung cancer, smoking cessation programs could improve not only the health of nations but also help to contain rising health care costs. In the face of the increasing global burden of lung cancer, it is instructive to consider the cost-effectiveness of lung cancer treatment in relation to smoking cessation programs. Cost effectiveness of lung cancer treatment options Treatment options for lung cancer depend on the stage and type of cancer. Recent advances in the treatment of metastatic non-small-cell lung cancer (NSCLC) have markedly increased the cost to health care systems and to patients themselves. When considering the implementation of new health care technologies, decision-makers consider the incremental cost of the new therapy (∆C) compared to the current standard in relation to the incremental benefit (∆E), usually expressed in life-years gained, to determine the incremental cost-effectiveness ratio or ICER. The life-years gained may be adjusted for the quality of the life lived with the disease and its treatment producing an estimate of cost per quality-adjusted life year or QALY. The ICER is influenced by many factors including the choice of comparator (best supportive care vs a chemotherapy regimen), the time horizon of the analysis, the inclusion of the cost of managing early and late adverse events, amongst other factors. Not surprisingly, the major determinant of the ICER for most new drugs is the price of the drug and the magnitude of the clinical benefit. A review of economic evaluations of drugs used for advanced non-squamous NSCLC suggests that ICERs are progressively rising: the ICER for erlotinib as a 3[rd] line therapy was only $39,000/LY when compared to BSC (3). However, the ICER for pemetrexed used as a 1[st ]line treatment in tumours with no known mutations was $142,500 US dollars (2013) per QALY when compare to best supportive care (BSC) and $164,000 per life year (LY) gained when compared to erlotinib (4).Estimates of the ICER for afatinib based on the pan-Canadian Oncology Drug Review (pCODR) ranged from $39,000 to 211,000/QALY when compared to gefitinb reflecting the uncertainty in the clinical benefit in the absence of a head-to-head comparative trial (5). The ICER for crizotinib as first-line therapy in ALK +ve patients ranged from $173,570 (CDN) to $285,299, reflecting uncertainty in economic model assumptions related to the incremental benefit and the time horizon selected (5). ICERs above $100,000 per QALY are generally not considered “cost-effective” in Canada. The trend to higher ICERs could reverse with immune check point inhibitors given the potential for long term survival (much greater ∆E) in some patients, although the incremental cost may be unacceptably high (6). However, it must be remembered that dollars spent on lung cancer treatments cannot be spent on something else and represent a lost opportunity cost no matter how cost-effective the treatment appears. Value of smoking cessation programs Although some countries and American states have invested in public health programs to reduce smoking, globally there has been a low level of investment suggesting that there is resistance to investing in smoking cessation. This may be due to the perception that cessation interventions are ineffective, that smokers do not want to quit or that smoking cessation interventions are not cost effective (7). These commonly held perceptions are wrong. Smoking cessation (e.g., telephone counseling and pharmacological interventions) has been shown to improve health outcomes and survival. Most smokers in the general population, at least in North America, have made multiple quit attempts and express the desire to quit and cost-effectiveness estimates range from about $330 to $1500 US per life-year gained (7). A review of economic evaluations of smoking cessations programs shows that these programs are economically attractive and can even be cost-saving. For example, the American Cancer Society’s telephone counseling service nearly doubled a smoker’s odds of quitting and staying stopped for one year at a cost of approximately $1,500 per smoker (8).Nicotine Replacement Therapies (NRT) compared to self-help have an ICER of $1,500/QALY while varenicline was a dominant option compared to NRT. Also generally unrecognized are the health benefits to cancer patients, although these benefits have been well outlined in the 2014 U.S. Surgeon General’s Report on Smoking (9). Nonetheless, smoking cessation programs are rare in the oncology setting and information on the cost-effectiveness of smoking cessation in the oncology setting is limited. One study examined the cost-effectiveness of a pre-operative smoking cessation program for patients with early-stage NSCLC in the United States (10), and reported an ICER of $2,609/QALY and $2,703/LY at 5-years post-surgery. The cost-effectiveness of smoking cessation programs could be more dramatic over longer time horizons. Even though the benefits of smoking cessation programs on clinical outcomes have been reported, including the value for money of these programs, more evidence on the impact of smoking on outcomes for lung cancer patients receiving radiotherapy and systemic therapy is clearly needed. Discussion Faced with a global epidemic of lung cancer and a growing number of new but expensive drugs, recognition that smoking cessation programs are both effective and cost-effective should drive public policy. References 1. World Health Organization. Projections of mortality and burden of disease, 2002-2030. World Health Organization,; 2002 [cited 2015]; Available 2. Hermus G, Stonebridge C, Goldfarb D, et al. Cost risk analysis for chronic lung disease in Canada: The Conference Board of Canada 3. Cromwell I, van der Hoek K, Taylor SCM, et al. Erlotinib or best supportive care for third-line treatment of advanced non-small-cell lung cancer: a real-world cost-effectiveness analysis. Lung Cancer 2012;76(3):472-7 4. Matter-Walstra K, Joerger M, Kuhnel U, et al. Cost-effectiveness of maintenance pemetrexed in patients with advanced nonsquamous-cell lung cancer from the perspective of the Swiss health care system. Value in health. 2012;15165-71 5. Available at pcodr website . 6. Available at 7. Parrott S, Godfrey C, Raw M, et al. Guidance for Commissioners on the cost-effectiveness of smoking cessation interventions. Thorax 1998; 53 (Suppl 5, Part 2): S2-S3 8. McAlister A, Rabius V, Geiger A, et al. Telephone assistance for smoking cessation: one year cost effectiveness estimations. Tobacco control. 2004;13(1):85-6. 9. The Health Consequences of Smoking - 50 Years of Progress. A report of the Surgeon General, 2014. U.S Department of Health and Human Services, Office of the Surgeon General, Rockville, MD 10. Slatore CG, Au DH, Hollingworth W. Cost-effectiveness of a smoking cessation program implemented at the time of surgery for lung cancer. Journal of Thoracic Oncology. 2009;4(4):499-504.

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