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M. Kneussl

Moderator of

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    OA17 - Aspects of Health Policies and Public Health (ID 397)

    • Event: WCLC 2016
    • Type: Oral Session
    • Track: Regional Aspects/Health Policy/Public Health
    • Presentations: 8
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      OA17.01 - Estimate of Economic Impact of Immune Checkpoint Inhibitors for NSCLC Relative to PD-L1 Expression in the US (ID 4133)

      16:00 - 17:30  |  Author(s): P. Aguiar Jr, R. De Mello, H. Tadokoro, H. Babiker, B. Gutierres, G. Lopes

      • Abstract
      • Presentation
      • Slides

      Background:
      Delivering high-quality cancer care at an affordable cost is the main challenge for health care professionals and policy makers. Immunotherapy achieved encouraging results in NSCLC. PD-L1 expression is being studied as a predictive biomarker. The objective of our study is to assess the economical impact of NIVO and PEMBRO with and without the use of PD-L1 as a biomarker in the US.

      Methods:
      We developed a decision-analytic model to determine the cost-effectiveness of PD-L1 assessment and second-line treatment with NIVO or PEMBRO versus docetaxel. The model used outcomes data from RCTs and costs from the US. We included the costs of adverse events and post-progression therapies. Thereafter, we used American epidemiology data to estimate the impact of the treatment.

      Results:
      We included three RCTs (two with NIVO and one with PEMBRO). The estimated number of cases eligible was 37,638. Treating all patients with NIVOLUMAB would cost 1.6 billion dollars each year, increasing total oncology drug expenditure in the US by 4%. Treating only patients with PD-L1 > 1% with NIVOLUMAB would cost US$ 850 million each year and would increase total oncology drug expenditure by 2%. However, with such patient selection up to 46% of cases would not be treated and 2,509 fewer life-years would be saved. The cost of each year-of-life saved was improved by PD-L1 selection (from US$ 223,000 to US$ 186,000 thousand). Table 1 summarizes our findings. Results were similar with NIVOLUMAB and PEMBROLIZUMAB.

      Scenario QALY gain ICER U$ Life-Years Saved Years of life not saved Not Treated % Total Cost U$ Impact on Total Cancer Drug Expenditure Cost/LYS U$
      37,638 100
      NIVO ALL COMERS 0.148 124K 7,043 0 0 0 1.6 bi 4% 223K
      NIVO PD-L1 > 1% 0.201 91K 4,534 2,509 17,389 46 850 mi 2% 186K
      PEMBRO PD-L1 > 1% 0.138 116K 5,302 NA 12,685 34 971 mi 2% 183K
      NIVO ALL SQ/>1% NSQ 0.216 93K 5,868 1,175 13,303 35 1 bi 3% 178K
      PEMBRO PD-L1 > 50% 0.164 97K 2,270 NA 26,912 72 420 mi 1% 184K


      Conclusion:
      The use of PD-L1 expression as a biomarker for treatment with immunotherapy decreases the overall economic impact and the cost per life-year saved. Nevertheless, the number of life-years saved with this strategy would be significantly smaller than if we choose to treat all patients. Further study and societal discussion is warranted in order to find the optimal strategy for patient selection.

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      OA17.02 - Potential Health and Economic Consequences of Organized vs Opportunistic Lung Cancer Screening in Canada (ID 6033)

      16:00 - 17:30  |  Author(s): W.K. Evans, C. Gauvreau, S. Memon, J. Goffin, J. Lacombe, M. Wolfson, N. Fitzgerald, A. Miller

      • Abstract
      • Presentation
      • Slides

      Background:
      Annual LDCT screening for individuals 55-74 yrs with >30 pack-year smoking history is supported by evidence from the NLST but has led to questions of implementation. Compared to organized screening (ORG), opportunistic screening (OPP) may utilize broader entry criteria and not include smoking cessation.

      Methods:
      Health and economic impacts of ORG using NLST entry criteria were modelled using population microsimulation (OncSim – formerly Canadian Risk Management Model v 2.3) and compared to OPP scenarios. We modeled ORG at a participation rate of 30 and 60%, with and without smoking cessation, compared to various plausible OPP scenarios: younger individuals (40-74 yrs); lesser smoking histories (10 or 20 pack-yrs). Outcomes projected to 20 years included incidence, mortality, number of scans, invasive diagnostics for false positives, and screening and treatment costs. A lifetime horizon and 3% discounting were used to estimate the incremental cost-effectiveness ratio (ICER) from a health system perspective. All costs are in 2016 CAD.

      Results:
      A large number of outputs can be presented. At a participation rate of 30%, average annual incremental incident cases of lung cancer with OPP for 40-74 yr-olds with 10 pack-yr histories are higher by 254 over ORG without cessation, and there would be an average 135 fewer deaths annually. However, the annual number of CT scans would increase by 433,000 on average and diagnostic tests for false positive results would increase by 1540. Average annual costs would increase by $141 M compared with ORG without cessation, resulting in an ICER of $133,000/QALY. OPP with 40-74 yr-olds having 20 and 30 pk-yr histories result in $92,147 and 74,978/QALY respectively. In all cases of OPP compared to ORG with cessation there are net losses of QALY. Notably, ORG with smoking cessation compared to ORG without yields an ICER of $2800/QALY.

      Conclusion:
      OPP screening results in more incident cases and fewer deaths but more cost from over-diagnosis and false positives. In Canada, an annual screening program with strict adherence to NLST entry criteria could be highly cost-effective. Jurisdictions will have to weigh the benefits and risks of LDCT scanning beyond the currently available evidence.

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      OA17.03 - Insurance Type Influences Stage, Treatment, and Survival in Asian American Lung Cancer Patients (ID 5059)

      16:00 - 17:30  |  Author(s): A. Tantraworasin, E. Taioli, B. Liu, A.J. Kaufman, R. Flores

      • Abstract
      • Presentation
      • Slides

      Background:
      Effect of insurance type on lung cancer diagnosis, treatment and survival is still under debate in Asian patients living in United States.

      Methods:
      A total of 447,167 patients (18 to 113 years), diagnosed with lung cancer between 2004 and 2013 in the Surveillance, Epidemiology, and End Results database were analyzed. Patient demographics and clinical characteristics were compared between Asian and Non-Asian patients. In Asian patients, patient demographics and characteristics were compared among insurance types. Multivariable logistic regression analysis was performed to identify the effect of insurance types on stage at diagnosis and treatment modalities. Multivariable cox’s regression analysis was performed to identify the effect of insurance type on cancer-specific death.

      Results:
      Asian were significantly more frequently males (56.7% vs. 53.1%), married (62.2% vs. 50.2%), with Medicaid (17.4% vs. 8.7%), living in rural area (93.6% vs. 86.9%), in a low income county (26.3% vs. 13.4%), and stage 4 at time of diagnosis (51.1% vs. 48.0%) than non-Asian patients (all p-value < 0.001). Among 26,884 Asian lung cancer patients, uninsured were significant younger (61.1±10.8 years) than non-Medicaid (69.1±11.9 years) and Medicaid (70.7±11.7 years), p <0.001, more likely single (18.9 % vs. 8.8% vs. 13.0%); living in a high income county (41.8% vs. 30.5% vs. 38.6%); more likely to be stage IV (63.7% vs. 50.0% vs. 51.2%); and not undergo surgery (86.2% vs. 75.4% vs. 82.6%), [all p-value < 0.001). Localized disease was more frequent in non-Medicaid (21.2%) and Medicaid (17.3%) compared to uninsured (9.0), (p < 0.001).At multivariable analyses, insurance type was not associated with cancer-directed surgery and radiotherapy. Insurance was significantly associated with cancer-specific death (uninsured HR 1.37 95%CI 1.07-1.75; non-Medicaid HR 1.17 95% CI 1.07-1.28 vs Medicaid).Figure 1



      Conclusion:
      Insurance type affects stage at diagnosis and cancer-specific death but not surgical treatment and radiotherapy in Asian lung cancer patients.

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      OA17.04 - Discussant for OA17.01, OA17.02, OA17.03 (ID 7092)

      16:00 - 17:30  |  Author(s): D. Behera

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      OA17.05 - Survival in a Cohort of Patients with Lung Cancer: The Role of Age and Gender on Prognosis (ID 6310)

      16:00 - 17:30  |  Author(s): J.P. Franceschini, S. Jamnik, I. Santoro

      • Abstract
      • Presentation
      • Slides

      Background:
      Lung cancer has a high incidence in Brazil; approximately thirty-four thousand new cases are diagnosed each year. In Brazil, as in other countries, the majority of patients diagnosed with lung cancer are elderly. There are few studies that evaluate demographic and clinical characteristics, disease staging, treatment modalities and survival in young patients, mostly carried out in developed countries. This study aimed to describe these aspects in patients with non-small cell lung cancer (NSCLC) according to age.

      Methods:
      Retrospective cohort consisted of patients diagnosed with NSCLC followed in a referral hospital in São Paulo. During the monitoring the survival time was evaluated. Survival functions were calculated using the method of Kaplan-Meier. The survival stratified by age was also obtained, according to distribution of percentages (less than 55; between 55 and 72 years; older than 72 years). Differences between survival curves were determined using the log-rank test.

      Results:
      From January 2000 to July 2015 790 patients were followed, 165 aged less than 55 years, 423 between 55 and 72 years and 202 older than 72 years. Higher incidence of adenocarcinoma was seen at the groups up to 72 years. 575 (73%) patients with advanced disease (IIIB-IV stages) were observed. The median five-year survival was 12 months [46-4]. The survival of patients in different age groups was not different.

      <55 165 >55<72 423 >72 202 p
      Male n(%) 87 (53) 279 (66) 127 (63) 0.012*
      Smoke n(%) 136 (82) 363 (86) 165 (82) 0.34*
      Male 78 (90) 263 (94) 121 (95) 0.21*
      Female 58 (74) 100 (69) 44 (59) 0.10*
      Histological type n(%) 0.13*
      Adenocarcinoma 92 (56) 216 (51) 91 (45)
      Squamous Cell Carcinoma 52 (32) 170 (40) 91 (45)
      Staging n(%) 0.057*
      IA/IIIA 34 (21) 127 (30) 52 (26)
      IIIB/IV 131 (79) 294 (70) 150 (74)
      Deaths n (%) 83 (50) 232 (55) 105 (52) 0.56*
      Follow-up (months) Median[IIQ] 4.9 [1.3-13.2] 6.5 [2.0-16.3] 4.4 [1.4-12.9] 0.07†
      *Chi-square test; † Kruskal-Wallis (Duncan test); ‡oneway ANOVA (Bonferroni test).

      Conclusion:
      In the age group of younger patients (<55) women predominated, histological type adenocarcinoma was more frequent, and there were more patients with advanced stage at the diagnosis and a higher percentage of smokers in both genders.

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      OA17.06 - Make the World Beautiful and Healthy by Making Your Country Smoke Free: Case Study between Iceland and Thailand? (ID 5570)

      16:00 - 17:30  |  Author(s): M.M. Cho

      • Abstract
      • Presentation
      • Slides

      Background:
      Globally, 600,000 non-smokers die due to tobacco related diseases and health care cost for tobacco related diseases are soaring especially in developing countries.Cigarette smoke contains 69 known carcinogens out of 7000 chemicals causing various health problems in children and infants including ear infections, bronchitis, pneumonia, frequent and severe asthma attacks, sudden infant death syndrome and cancer. Secondhand smoke can cause coronary heart disease, stroke and various kinds of cancer including lung cancer in adult. 2006 U.S. Surgeon General Report clearly confirmed that there is no safe level of exposure to secondhand smoke. Therefore, there is a strong need for comprehensive smoke free law in reducing the burden of tobacco use in the world.

      Methods:
      "Section not applicable"

      Results:
      Iceland is a high income country with a long history of tobacco control. The comprehensive tobacco control law was passed in 1984 which included restriction on smoking in service areas of public and private buildings, premises of health care facilities, schools, workplaces, and in public transport whereas Thailand is an upper middle income country and once had a very high smoking rate (70 percent for male and around 5 percent for female) in early 1970. Smoking ban in movie theaters and buses ordinance was issued by Bangkok Metropolitan Administration I n 1976 followed by the comprehensive interventions including smoke-free areas by the royal Thai government in 1991. As a result, the smoking prevalence went down to 32 percent in Thailand but this still demonstrated that one in three adults in 1991. It was found that the role of government and different civil society organizations in implementing smoke free policies was significant in both countries in this review paper. Although both countries issued smoke free policies, there are still challenges on implementation. Iceland try to overcome the challenges by developing comprehensive system including investigation after complaint and allocating budget for enforcement. Thailand also implemented 100% Smoke-Free Hospitals with the compliance rate of 86.4 percent according to a research in 2010. Thailand established the Thai Health Promotion Foundation (ThaiHealth) in 2001 which allowed Thailand to implement comprehensive tobacco control measures in a sustainable way. ThaiHealth used knowledge generation, social mobilization and policy advocacy called tri-power strategy in achieving the success.

      Conclusion:
      This paper concluded that civil society initiative and continuing efforts on tobacco control which leads to adoption of comprehensive tobacco control law is the heart of the success of tobacco control in both countries.

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      OA17.07 - Time from the Identification of a Suspicious Pulmonary Lesion to the Treatment of Non-Small Cell Lung Cancer (ID 4069)

      16:00 - 17:30  |  Author(s): C. Hiles, P. Hiles, M. Osswald

      • Abstract
      • Presentation
      • Slides

      Background:
      Despite guideline recommendations on time intervals in the care of a lung cancer patient, delays are often experienced. The goal of this study was to quantify time intervals and identify delays in the workup to treatment of non-small cell lung cancer (NSCLC) at our institution.

      Methods:
      A retrospective review of all NSCLC cases in the Tumor Registry at a tertiary military medical center diagnosed and treated between July 2011 and July 2014 was performed. Dates of radiographic identification of a suspicious pulmonary lesion, tissue diagnosis, evaluation by the treating specialist, and initial treatment (whether surgery, radiation, chemotherapy, or best supportive care/palliative care) were recorded. Time intervals were calculated from these dates; if any interval was more than 60 days, reasons for delays were recorded.

      Results:
      The median time from the identification of a suspicious pulmonary lesion to the treatment of NSCLC was 74 days (range 5-557 days) and the median time from tissue diagnosis to first treatment was 33 days (range 1-252 days) for the 148 patients included in the analysis. Even after excluding outliers, the adjusted median time from the identification of a suspicious pulmonary lesion to the treatment was 71 days. The most common reasons for treatment delay were waiting for consultant evaluations, staging procedures, repeat biopsies, or additional studies (pre-operative risk stratification, molecular testing). Only 1 patient was upstaged from time of tissue diagnosis to first treatment (from IA to IIB following resection).

      Table 1: Critical time intervals
      Time interval Median Range
      Days from suspicious imaging study to first treatment 74 5-557
      Days from suspicious imaging study to tissue diagnosis 34 1-556
      Days from suspicious imaging study to evaluation by treating specialist 50 1-553
      Days from tissue diagnosis to first treatment 33 1-252
      Days from tissue diagnosis to evaluation by treating specialist Cardiothoracic surgery Radiation-oncology Medical-oncology Palliative care 20 21 21 18 15 1-157 10-56 1-157 1-64 4-48
      Days from evaluation by treating specialist to first treatment Surgery Radiation Chemotherapy Best supportive care 16 23 14 16 1 1-261 6-261 1-88 1-28 1-28


      Conclusion:
      Several time intervals identified in the workup to initial treatment of NSCLC patients at our institution exceeded recommendations from various guidelines. These delays could be addressed with process and quality improvement projects involving a standardized NSCLC clinical care pathway.

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      OA17.08 - Discussant for OA17.05, OA17.06, OA17.07 (ID 7013)

      16:00 - 17:30  |  Author(s): G. Babu

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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