Phase-specific and lifetime costs of cancer care in Ontario, Canada

BACKGROUND: Cancer is a major public health issue and represents a significant economic burden to health care systems worldwide. The objective of this analysis was to estimate phase-specific, 5-year and lifetime net costs for the 21 most prevalent cancer sites, and remaining tumour sites combined, in Ontario, Canada. METHODS: We selected all adult patients diagnosed with a primary cancer between 1997 and 2007, with valid ICD-O site and histology codes, and who survived 30 days or more after diagnosis, from the Ontario Cancer Registry (N = 394,092). Patients were linked to treatment data from Cancer Care Ontario and administrative health care databases at the Institute for Clinical and Evaluative Sciences. Net costs (i.e., cost difference between patients and matched non-cancer control subjects) were estimated by phase of care and sex, and used to estimate 5-year and lifetime costs. RESULTS: Mean net costs of care (2009 CAD) were highest in the initial (6 months post-diagnosis) and terminal (12 months pre-death) phases, and lowest in the (3 months) pre-diagnosis and continuing phases of care. Phase-specific net costs were generally lowest for melanoma and highest for brain cancer. Mean 5-year net costs varied from less than $25,000 for melanoma, thyroid and testicular cancers to more than$60,000 for multiple myeloma and leukemia. Lifetime costs ranged from less than $55,000 for lung and liver cancers to over$110,000 for leukemia, multiple myeloma, lymphoma and breast cancer. CONCLUSIONS: Costs of cancer care are substantial and vary by cancer site, phase of care and time horizon analyzed. These cost estimates are valuable to decision makers to understand the economic burden of cancer care and may be useful inputs to researchers undertaking cancer-related economic evaluations

Methods for the economic evaluation of personalized medicine : a case study in advanced colorectal cancer

With the use of precision medicine in oncology, where choice of treatment is informed by the molecular characteristics of the disease, we expect to see heterogeneity in the effectiveness and costs of interventions. New precision medicine interventions are often costly and evidence from randomized controlled trials may not be available, yet decision-makers must be able to evaluate these interventions appropriately to inform efficient health resource allocation. The goal of my thesis is to explore methods to quantify the value and impact of identifying heterogeneity, using real-world observational data. The use of third-line anti-EGFR therapy (cetuximab and panitumumab) informed by RAS mutation status for patients with metastatic colorectal cancer is used as the example throughout the work. The analysis uses linked administrative data for a historical cohort of patients with metastatic colorectal cancer who were potentially-eligible for third-line systemic therapy. Using these data I conducted a cost-effectiveness analysis of anti-EGFR therapy informed by KRAS testing, and a cost-effectiveness analysis of panel-based expanded RAS testing vs. simple KRAS testing. I also conducted a literature review to identify and compare alternative frameworks for valuing heterogeneity-informed treatment decisions in the context of precision medicine. Based on this review, I selected the value of heterogeneity framework to evaluate alternative RAS-based subgrouping strategies to inform anti-EGFR therapy. The results of the analysis indicate that at the lower range of cost-effectiveness thresholds, anti-EGFR therapy would not be considered cost-effective regardless of subgrouping strategy. Value of heterogeneity analysis indicates that at a threshold of $100,000/LYG the value gained from subgroup-based decisions exceeds the costs of the genomic testing required to define the subgroups. Resolving uncertainty, or reducing the costs of testing and treatment, could provide considerable additional value. The value of heterogeneity framework can complement conventional methods for economic evaluation by describing and valuing the heterogeneity that arises with the use of precision medicine in a more comprehensive way. This research also demonstrates the strengths of using real-world data to conduct value of heterogeneity analysis. The precision medicine landscape is continuously evolving, and embracing new methods and sources of evidence will help decision-makers keep pace with these changes.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Persistence and adherence with cardiovascular and lipid-lowering drugs following acute myocardial infarction in British Columbia

BACKGROUND – Pharmaceutical use for the secondary prevention of cardiac events after acute myocardial infarction (AMI) is widespread, but there is uncertainty as to how (or if) patients use their medicines over long periods of time. Accordingly, the purpose of this thesis is 1) to measure persistence with and adherence to ACE inhibitors, beta blockers and statins, following AMI in BC, 2) to construct a conceptually-driven model of adherence and persistence, with patient demographic, socioeconomic, health status and pharmaceutical use variables, and 3) to determine whether regional variation in adherence and persistence rates exist. METHODS – Using administrative data from the BC Linked Health Database and PharmaNet, I studied a cohort of BC patients who were hospitalized for their first AMI between 2001 and 2005. I measured persistence as days to first 90-day gap in medication, and I measured adherence in two ways: the proportion of days covered (PDC) between first prescription and first 90-day gap, and PDC in the first year post-discharge (1-year PDC). Rates of persistence and adherence were analyzed using Cox proportional hazards models and multivariate logistic regression respectively. RESULTS – Patient persistence and adherence with medication was generally high, with 70% of ACE inhibitor users, 73% of beta blocker users and 78% of statin users persisting at one year. Nearly 89% of users of any class were persistent at 1 year, as opposed to 52% of users of all three concurrently. Factors consistently associated with high adherence and persistence were high income, private insurance, the use of more drug classes (both before and after AMI), and being in the mid-range of age (60-69 years). Sex had mixed effects between classes, with women having higher persistence and adherence with beta blockers and lower with ACE inhibitors. Some regional variation existed, but effects were small and inconsistent. CONCLUSION – Most AMI patients in BC use at least one drug for several years after AMI, but few persist with all three recommended classes. Important next steps include determining the clinical outcomes of adherence and persistence, especially with drug combinations, to more clearly define optimal secondary prevention practices following AMI.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Understanding the costs of cancer care before and after diagnosis for the 21 most common cancers in Ontario: a population-based descriptive study

Background: The first year after cancer diagnosis is a period of intensive treatment and high cost. We sought to estimate costs for the 21 most common cancers in Ontario in the 3-month period before and the first year after diagnosis. Methods: We used the Ontario Cancer Registry to select patients who received diagnoses between 1997 and 2007 at 19 years of age or older, with valid International Classification of Diseases for Oncology (ICD-O) and histology codes, who survived 30 days or longer after diagnosis and had no second cancer within 90 days of the initial cancer (n = 402 399). We used linked administrative data to calculate mean costs for each cancer during the pre- and postdiagnosis periods for patients who died within 1 year after diagnosis and patients who survived beyond 1 year after diagnosis. Results: Mean prediagnosis costs were $2060 (95$2023–$2098) for all patients with cancer. Costs ranged from$890 (95% CI $795–$985) for melanoma to $4128 (95$3591–$4664) for liver cancer among patients who survived beyond 1 year after diagnosis, and ranged from$2188 (95% CI $2040–$2336) for esophageal cancer to $5142 (95$4664–$5620) for multiple myeloma among patients who died within 1 year. The mean postdiagnosis cost for our cohort was$25 914 (95% CI $25 782–$26 046). Mean costs were lowest for melanoma ($8611 [95$8221–$9001]) and highest for esophageal cancer ($50 620 [95% CI $47 677–$53 562] among patients who survived beyond 1 year after diagnosis, and ranged from $27 560 (95$25 747–$29 373) for liver cancer to$81 655 (95% CI $58 361–$104 949) for testicular cancer among patients who died within 1 year. Interpretation Our research provides cancer-related cost estimates for the pre- and postdiagnosis phases and offers insight into the economic burden incurred by the Ontario health care system. These estimates can help inform policy-makers’ decisions regarding resource allocation for cancer prevention and control, and can serve as important input for economic evaluations

Societal preferences for the return of incidental findings from clinical genomic sequencing: a discrete-choice experiment

BACKGROUND: An important challenge with the application of next-generation sequencing technology is the possibility of uncovering incidental genomic findings. A paucity of evidence on personal utility for incidental findings has hindered clinical guidelines. Our objective was to estimate personal utility for complex information derived from incidental genomic findings. METHODS: We used a discrete-choice experiment to evaluate participants’ personal utility for the following attributes: disease penetrance, disease treatability, disease severity, carrier status and cost. Study participants were drawn from the Canadian public. We analyzed the data with a mixed logit model. RESULTS: In total, 1200 participants completed our questionnaire (available in English and French). Participants valued receiving information about high-penetrance disorders but expressed disutility for receiving information on low-penetrance disorders. The average willingness to pay was $445 (95$322–$567) to receive incidental findings in a scenario where clinicians returned information about high-penetrance, medically treatable disorders, but only 66$725, 95% CI $600–$850) on having a choice about what type of findings they would receive, including receipt of information about high-penetrance, treatable disorders or receipt of information about high-penetrance disorders with or without available treatment. The predicted uptake of that scenario was 76% (95% CI 72%–79%). INTERPRETATION: Most participants valued receiving incidental findings, but personal utility depended on the type of finding, and not all participants wanted to receive incidental results, regardless of the potential health implications. These results indicate that to maximize benefit, participant-level preferences should inform the decision about whether to return incidental findings

Societal preferences for the return of incidental findings from clinical genomic sequencing: a discrete-choice experiment

BackgroundAn important challenge with the application of next-generation sequencing technology is the possibility of uncovering incidental genomic findings. A paucity of evidence on personal utility for incidental findings has hindered clinical guidelines. Our objective was to estimate personal utility for complex information derived from incidental genomic findings.MethodsWe used a discrete-choice experiment to evaluate participants' personal utility for the following attributes: disease penetrance, disease treatability, disease severity, carrier status and cost. Study participants were drawn from the Canadian public. We analyzed the data with a mixed logit model.ResultsIn total, 1200 participants completed our questionnaire (available in English and French). Participants valued receiving information about high-penetrance disorders but expressed disutility for receiving information on low-penetrance disorders. The average willingness to pay was $445 (95$322-$567) to receive incidental findings in a scenario where clinicians returned information about high-penetrance, medically treatable disorders, but only 66$725, 95% CI $600-$850) on having a choice about what type of findings they would receive, including receipt of information about high-penetrance, treatable disorders or receipt of information about high-penetrance disorders with or without available treatment. The predicted uptake of that scenario was 76% (95% CI 72%-79%).InterpretationMost participants valued receiving incidental findings, but personal utility depended on the type of finding, and not all participants wanted to receive incidental results, regardless of the potential health implications. These results indicate that to maximize benefit, participant-level preferences should inform the decision about whether to return incidental findings

Estimating the Cost of Cancer Care in British Columbia and Ontario: A Canadian Inter-Provincial Comparison.

BackgroundCosting studies are useful to measure the economic burden of cancer. Comparing costs between healthcare systems can inform evaluation, development or modification of cancer care policies.ObjectivesTo estimate and compare cancer costs in British Columbia and Ontario from the payers' perspectives.MethodsUsing linked cancer registry and administrative data, and standardized costing methodology and analyses, we estimated costs for 21 cancer sites by phase of care to determine potential differences between provinces.ResultsOverall, costs were higher in Ontario. Costs were highest in the initial post-diagnosis and pre-death phases and lowest in the pre-diagnosis and continuing phases, and generally higher for brain cancer and multiple myeloma, and lower for melanoma. Hospitalization was the major cost category. Costs for physician services and diagnostic tests differed the most between provinces.ConclusionsThe standardization of data and costing methodology is challenging, but it enables interprovincial and international comparative costing analyses