Special Supplement on Canadian Cancer Costing Research

As we approach the 10th anniversary of the Canadian Centre for Applied Research in Cancer Control (arcc) [...

Metastatic Colorectal Cancer: Therapeutic Options for Treating Refractory Disease

Therapeutic options for chemorefractory metastatic colorectal cancer (mcrc) have significantly expanded since 2009. The oral targeted therapies regorafenib and trifluridine/tipiracil have been established to be efficacious and safe in patients with mcrc who have progressed beyond 2 or more lines of chemotherapy. Evidence for the use of immunotherapy in a subgroup of this patient population is also encouraging, particularly in patients with mcrc that exhibits high microsatellite instability or deficient mismatch repair. Those significant advances have led to Health Canada approval of 3 novel therapeutic options for the treatment of patients with chemorefractory mcrc. However, the limited clinical efficacy of those treatments underscores the need for ongoing development of systemic therapy options for this unique cohort of patients. Here, we review the current and emerging treatment landscape for chemorefractory mcrc

Understanding the Reasons for Provincial Discordance in Cancer drug Funding—A Survey of Policymakers

Background: Cancer drug-funding decisions between provinces shows discordance. The pan-Canadian Oncology Drug Review (PCODR) was implemented in 2011 partly to address uneven drug coverage and lack of transparency in the various provincial cancer drug review processes in Canada. We evaluated the underlying reasons for ongoing provincial discordance since the implementation of PCODR. Methods: Participation in an online survey was solicited from participating provincial ministries of health (MOHS) and cancer agencies (CAS). The 4-question survey (with both multiple-choice and free-text responses) was administered between 4 March 2015 and 1 April 2015, inclusive. Anonymity was ensured. Descriptive statistics were used to evaluate responses. Results: Data were available from 9 provinces (all Canadian provinces except Quebec), with a response rate of 100%. The 12 responses received each came from a senior policymaker with more than 5 years’ experience in cancer drug funding decision-making (5 from MOHS, 7 from CAS). Responses for 3 provinces came from both a moh representative and a ca representative. The most common reason for funding a drug not recommended by PCODR was political pressure (64%). The most common reason not to fund a drug recommended by PCODR was budget constraints (91%). The most common reason for a province to fund a drug before completion of the PCODR review was also political pressure (57%). Conclusions: Political pressure and budgetary constraints continue to affect equity of access to cancer drugs for patients throughout Canada

Systemic Therapy in the Curative Treatment of Head-and-Neck Squamous Cell Cancer: Cancer Care Ontario Clinical Practice Guideline

Objective: The aim of the present work was to make recommendations about the use of systemically administered drugs in combination or in sequence with radiation (rt) or surgery, or both, for cure or organ preservation, or both, in patients with locally advanced nonmetastatic (stages iii–ivb) squamous cell carcinoma of the head and neck (lascchn). Methods: The Meta-analysis of Chemotherapy in Head and Neck Cancer (mach-nc) reports have, de facto, guided practice since 2000, and so we searched the literature for systematic reviews published from January 2000 to February 2015 in reference to five research questions. A search was also conducted up to February 2015 for randomized trials (rcts) not included in the meta-analyses. Recommendations were constructed using the Cancer Care Ontario Program in Evidence-Based Care practice guidelines development cycle. Results: In addition to updated mach-nc reports, five additional meta-analyses and thirty rcts were identified. Five recommendations for lascchn treatment were generated based on those data. Concurrent chemoradiation (ccrt) is recommended to maximize the chance of cure in patients less than 71 years of age when rt is used as definitive treatment. The same recommendation also applies to patients with resected lascchn considered to be at high risk for locoregional recurrence. For lascchn patients who are candidates for organ preservation strategies and would otherwise require total laryngectomy, either ccrt or induction chemotherapy, followed by rt or surgery based on tumour response is recommended. The addition of cetuximab to intensified rt (concomitant boost or hyperfractionated schedule) is an alternative to ccrt. Routine use of induction chemotherapy to improve overall survival is not recommended. Conclusions: We were able to use high-level evidence from patients receiving rt as definitive or postoperative treatment to generate recommendations for the use of systemic therapy in the treatment of lascchn. A limitation is a lack of stratification for human papillomavirus–related cancers of the oropharynx. One rct provided evidence for the use of cetuximab as an alternative to chemotherapy in the definitive rt setting. Concurrent chemoradiation provides one strategy for larynx preservation, but the best strategy is unclear. Use of induction chemotherapy does not improve overall survival, and its use should be limited to patients requiring immediate tumour downsizing before local therapy

A Cost–Utility Analysis of Atezolizumab in the Second-Line Treatment of Patients with Metastatic Bladder Cancer

Background: Despite initial promising results, the IMvigor211 clinical trial failed to demonstrate an overall survival (OS) benefit for atezolizumab compared with chemotherapy as second-line treatment for metastatic bladder cancer (mBC). However, given lessened adverse events (AES) and preserved quality of life (QOL) with atezolizumab, there might still be investment value. To evaluate that potential value, we conducted a cost–utility analysis (CUA) of atezolizumab compared with chemotherapy from the perspective of the Canadian health care payer. Methods: A partitioned survival model was used to evaluate atezolizumab compared with chemotherapy over a lifetime horizon (5 years). The base-case analysis was conducted for the intention-to-treat (ITT) population, with additional scenario analyses for subgroups by IMvigor-defined PD-L1 status. Health outcomes were evaluated through life–year gains and quality-adjusted life–years (QALYS). Cost estimates in 2018 Canadian dollars for systemic treatment, AES, and end-of-life care were incorporated. The incremental cost-effectiveness ratio (ICER) was used to compare treatment strategies. Parameter and model uncertainty were assessed through sensitivity and scenario analyses. Per Canadian guidelines, cost and effectiveness were discounted at 1.5%. Results: For the ITT population, the expected qalys for atezolizumab and chemotherapy were 0.75 and 0.56, with expected costs of $90,290 and$8,466 respectively. The resultant ICER for atezolizumab compared with chemotherapy was $430,652 per QALY. Scenario analysis of patients with PD-L1 expression levels of 5$334,387 per QALY). Scenario analysis of observed compared with expected benefits demonstrated a higher icer, with a shorter time horizon ($928,950 per QALY). Conclusions: Despite lessened aes and preserved QOL, atezolizumab is not considered cost-effective for the second-line treatment of mbc

Cost-Effectiveness Analysis of Selective First-Line Use of Biologics for Unresectable RAS Wild-Type Left-Sided Metastatic Colorectal Cancer

Background: Evidence from a retrospective analysis of multiple large phase iii trials suggested that primary tumour location (ptl) in RAS wild-type metastatic colorectal cancer (wtRAS mcrc) might have predictive value with respect to response to drug therapies. Recent studies also show a potential preferential benefit for epidermal growth factor inhibitors (egfris) for left-sided tumours. In the present study, we aimed to determine the incremental cost-effectiveness ratio (icer) for the first-line use of an egfri for patients with left-sided wtRAS mcrc. Methods: We developed a state-transition model to determine the cost effectiveness of alternative treatment strategies in patients with left-sided mcrc: 1. Standard of care; 2. Use of an egfri in first-line therapy. The cohort for the study consisted of patients diagnosed with unresectable wtRAS mcrc with an indication for chemotherapy and previously documented ptl. Model parameters were obtained from the published literature and calibration. The perspective was that of a provincial ministry of health in Canada. We used a 5-year time horizon and an annual discount rate of 1.5%. Results: Selecting patients for first-line egfri treatment based on left-sided location of their colorectal primary tumour was more effective than the standard of care, resulting in an increase in quality-adjusted life-years (qalys) of 0.226 (or 0.644 life-years gained). However, the strategy was also more expensive, costing an average of $60,639 more per patient treated. The resulting icer was$268,094 per qaly. A 35% price reduction in the cost of egfri would be needed to make this strategy cost-effective at a willingness-to-pay threshold (wtp) of $100,000 per qaly. Conclusions: Selective use of an egfri based on ptl was more cost-effective than unselected use of those agents; however, based on traditional wtp thresholds, it was still not cost-effective. While awaiting the elucidation of more precise predictive biomarkers that might improve cost-effectiveness, the price of egfris could be reduced to meet the wtp threshold