Value of Money in Cancer - IMRT as a case study

Jean H.E. Yong, MASc Pharmacoeconomics Research Unit, Cancer Care Ontario Canadian Centre for Applied Research in Cancer Control Applied Health Research Centre, St. Michael’s Hospital

Key messages

 It is important to consider Value for Money when planning and coordinating cancer care  Assessing value for money is not difficult, but needs to be relevant to the context  Let’s try to provide value for money every step along the cancer journey

Value for money

 We want to buy as much health as possible  But, we have limited resources  Economics:   How much does something cost?

What do we get for what we pay?

 Cost-effectiveness analysis A costs $1 million B costs $1 million

Value for money in Cancer

70 60 50 40 30 20 10 0 2004 2005 2006 2007 2008 2009 2010 Others Asia Pacific Europe North America 350 publications in all disease areas in 2010 Data: The Center for Evaluation of Value and Risk in Health, CEA Registry

Intensity-Modulated Radiation Therapy (IMRT)

 Introducing IMRT across Ontario  Which disease sites?

 Is IMRT good value for money?

 Can we afford it?

Picture: Radiation Medical Group

Systematic review for clinical guidelines Activity-based costing Survey of radiation oncologists, physicists, therapists

2 models

Literature review to populate models Claims data analysis

Localized prostate cancer Clinically localized disease Biochemical failure Metastasis Dead

Grade 2 GI toxicity No toxicity Grade 3 GI toxicity Biochemical failure Metastasis Dead

IMRT vs. 3D-CRT in prostate cancer

Radiation treatment cost Radiotherapy toxicity cost Total cost (discounted at 5%) Life-years gained (discounted at 5%) QALYs gained (discounted at 5%) Incremental cost per QALY gained IMRT

$14,520 $106 $60,138 8.257

6.085

CRT

$13,501 $508 $59,518 8.257

6.062

Incremental

$1,019 $(402) $621 0.000

0.023

$26,768

Sensitivity analysis

 Results were sensitive to the disease control assumption and treatment cost difference  When IMRT is delivered at a higher dose than CRT, it is cost saving and is more effective  When we add Volumetric Modulated Arc Therapy to IMRT, IMRT has shorter treatment time than CRT and becomes cost saving  We estimated cost of IMRT for a mature program. In a start-up program scenario, IMRT costs $279,850 per QALY.

IMRT vs. 2D-RT in head and neck cancers

 Compared with 2D-RT, IMRT reduces xerostomia and improves quality of life  IMRT is less expensive than CRT  saves $1100 per patient  IMRT takes longer to plan but less time to deliver  Results are most sensitive to the cost difference between treatment  In a start up program scenario: $162,000 per QALY

Discussion

 Results are specific to the research questions  Not generalizable to other indications  Specific to the comparator  Radiotherapy costs vary across countries  Validate model  Literature review and sensitivity analysis

Success Factors

 An in house health economics unit  Effective partnerships with many stakeholders   Academics Community providers  Evaluation part of an implementation strategy

Cancer journey

Prevention Screening Diagnosis Treatment Recovery and palliative

Prevention Screening Diagnosis Treatment Recovery and palliative

Value for money in Cancer

313 studies (2004-2010) Data: The Center for Evaluation of Value and Risk in Health, CEA Registry

Key messages

 It is important to consider Value for Money when planning and coordinating cancer care  Assessing value for money is not difficult, but needs to be relevant to the context  Let’s try to provide value for money every step along the cancer journey

Acknowledgements

   Dr. Jeffrey Hoch & Jaclyn Beca Cancer Care Ontario Community practitioners  Radiation oncologists, physicists, therapists  Academic collaborators  Drs. Tom McGowan and Murray Krahn  IMRT Indications Expert Panel  Drs. Brian O’Sullivan and Glenn Bauman Ontario Ministry of Health and Long-Term Care

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Thank you.

Cancer Care in Canada

 Universal health care  Limited access to interventions that are not covered by public payers  Public health agency  Provincial cancer agencies  Provincial drug plans  Hospitals

Activity-based costing

Consultation CT simulation Planning Physics QA Treatment delivery & review visits