1. 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

2. 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

3. Rapidly rising cost of cancer care often made it to the news because many are concerned that we will not be able to afford cancer care in the future. 37 experts from developed countries on managing cancer costs recently released a new report in the Lancet Oncology. The authors concluded that the cost of cancer care in wealthy countries is becoming unsustainable. In cancer, we overdiagnose, overtreat, and overpromise. It’s not just how much we pay for cancer care that is an issue, we are more concerned about the rapidly rising costs. On the list of urgent solutions the authors proposed was using a value-based approach to provide affordable and sustainable cancer care.

4. 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
Life
The goal of a health care system is to maximize health in its population. From a planner’s perspective, we want to buy as much health as we can afford within our limited budget because we are also accountable for not running a budget deficit. When we talk about economics of cancer care, we are concerned about how much does something cost? And also what do we get for what we pay.
For example, imagine if you are planning care, you have only $1 million, and have to decide which treatment to provide for patients. Both cost $1 million, but treatment A extends patient’s life by 1 year, and treatment B extends 4 years of life. Which one would you choose? Our unit is committed to providing high quality economic evidence to inform cancer planning decisions. We compare treatments and calculate how many lives a new treatment can save at what cost.

5. Value for money in Cancer
Data: The Center for Evaluation of Value and Risk in Health, CEA Registry

6. Intensity-Modulated Radiation Therapy (IMRT)
Introducing IMRT across Ontario
Which disease sites?
Is IMRT good value for money?
Can we afford it?
Intensity-Modulated Radiation Therapy or IMRT is an advanced radiation therapy that allows us to deliver higher dose of radiation to the target organ without affecting neighboring tissues. Although IMRT is a more effective treatment, it is also more expensive. Although the Ministry was convinced that IMRT is more effective, they wanted to know if IMRT is good value for money, and whether we can afford it. This is the first study in Canada to evaluate value for money of radiation therapy. This study started in 2009, when the Radiation Treatment Program at CCO received funding from the ministry to make IMRT available across Ontario.
Picture: Radiation Medical Group

7. 2 models Systematic review for clinical guidelines
Activity-based costing
Survey of radiation oncologists, physicists, therapists
Literature review to populate models
Claims data analysis
The Program for Evidence-based Care (PEBC) led the systematic review compiling clinical evidence comparing IMRT to the conventional treatment. It was a very rigorous process, where we were very lucky to have key experts leading the process. Many clinical studies have compared IMRT with the conventional treatment, conformal radiation therapy, and have demonstrated that patients who received IMRT live at least as long as those who received conformal radiation therapy, but have fewer side effects. From the review, we found that we only have very good clinical evidence for localized prostate cancer and locally advanced head and neck cancers. So, we built 2 economic models for these 2 diseases. Activity-based costing was the major component of this study because we did not have detailed enough cost data to compare the two radiation techniques.

8. Clinically localized disease
Localized prostate cancer
Clinically localized disease
Biochemical failure
Metastasis
Dead

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

10. IMRT vs. 3D-CRT in prostate cancer
IMRT
CRT
Incremental
Radiation treatment cost
$14,520
$13,501
$1,019
Radiotherapy toxicity cost
$106
$508
$(402)
Total cost (discounted at 5%)
$60,138
$59,518
$621
Life-years gained (discounted at 5%)
8.257
0.000
QALYs gained (discounted at 5%)
6.085
6.062
0.023
Incremental cost per QALY gained
$26,768

11. 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.

12. 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

13. 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

14. Success Factors An in house health economics unit
Effective partnerships with many stakeholders
Academics
Community providers
Evaluation part of an implementation strategy
This is our first experience working with our internal partner on a project. Overall, we felt that it was a success. Because we were housed within CCO, we were able to build on relationships formed over 4 years and had access to a lot of resources within CCO, such as financial data from Capital Planning, highly engaged clinical experts in the specific disease areas. The product was high quality because it had a lot of scientific input from different partners, and our stakeholders were very engaged throughout the process. We were lucky enough to have Dr. Tom McGowan, an external consultant, who was extremely engaged in our study to lead this costing initiative. Many parties were involved in the costing process. When a physicist found out about our costing project, he developed a detailed online questionnaire to survey other physicists in Ontario to get representative estimate. Because the project was funded by the Ministry and the study had really good input from experts, community providers and finance, we are confident that the results are more likely to be useful for decision makers at CCO and the Ministry.

15. Recovery and palliative
Cancer journey
Prevention
Screening
Diagnosis
Treatment
Recovery and palliative

16. Value for money in Cancer
Prevention
Screening
Diagnosis
Treatment
Recovery and palliative
Value for money in Cancer
313 studies ( )
Data: The Center for Evaluation of Value and Risk in Health, CEA Registry

17. 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

18. 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
This project was really a team effort. We worked very closely with the Radiation Treatment Program, with whom, we had access to Dr. Warde’s clinical expertise, and his network of radiation oncologists, physicists and PMH financial department. Also, the Program for Evidence-Based Care played a significant role in this project, synthesizing the clinical evidence of IMRT. This study had great scientific input from our academic collaborators, through the Canadian Center for Applied Research in Cancer Control (ARCC). When the Radiation Treatment Program received funding from the Ministry for implementing IMRT, it also received funding for us to assess the value for money of IMRT.
Ontario Ministry of Health and Long-Term Care

19.
Thank you.

20. 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
I will be presenting a study that took place in Ontario, the province with the largest population (>13 millions). In Ontario, cancer care planning is centralized, and most decisions are made at the provincial cancer agency, together with the provincial ministry of health.
Cost-effectiveness evidence has been used in cancer drug reimbursement decisions in Ontario since xxx. When a drug company wants to get the public payer to pay for a drug, it has to provide cost-effectiveness evidence. However, the use of cost-effectiveness evidence outside of pharmaceutical reimbursement is limited.

21. Activity-based costing
Consultation
CT simulation
Planning
Physics QA
Treatment delivery & review visits