Cost-effectiveness of implementing computed tomography screening for lung cancer in Taiwan

Losses of lifetime employment duration and productivity for patients with different subtypes and stages of lung cancer

BACKGROUND

How different subtypes and stages of lung cancer affect morbidity- and mortality-associated productivity have not been investigated. This study quantified the losses of lifetime employment duration and productivity among patients with various subtypes and stages of lung cancer.

METHODS

We identified nationwide lung cancer patients diagnosed at the ages of 50-64 between 2011 and 2019. Monthly survival probabilities were weighted by monthly employed-to-population ratios and working salaries to estimate lifetime employment duration and productivity. We compared lifetime employment duration and productivity of patients with those of the age-, sex-, calendar year-matched general population for losses of lifetime employment duration and productivity, which were multiplied by pathology and stage shifts based on the first-round screening of Taiwan Lung Cancer Screening in Never Smoker Trial (TALENT) to calculate the savings of lifetime employment duration and productivity.

RESULTS

Lung cancer patients had shorter survival and employment duration than the referents. Patients with lung cancers other than adenocarcinoma experienced greater losses of lifetime employment duration and productivity as compared to adenocarcinoma patients. Applying the estimations of never-smoking patients to 100 lung cancer patients with pathology and stage shifts based on the TALENT, the savings of lifetime employment duration and productivity were 132.2 (95% prediction interval: 116.2-147.4) years and 3353 (95% prediction interval: 2914-3802) thousand US dollars, respectively.

CONCLUSIONS

Early diagnosis of lung cancer would save the losses of employment duration and lifetime productivity. Future evaluation of the cost-effectiveness of lung cancer screening could consider incorporating these societal impacts.

The survival and cost-effectiveness analysis of adjunctive Chinese medicine therapy for patients with non-small cell lung cancer: a nationwide cohort study in Taiwan

Introduction: Cancer, particularly lung cancer, is a significant global healthcare challenge. Non-Small Cell Lung Cancer (NSCLC) constitutes 85% of cases. Patients often seek alternative therapies like Chinese medicine alongside Western treatments. This study investigates the survival outcomes and cost-effectiveness of adjunctive Chinese medicine therapy for NSCLC patients in Taiwan. Methods: We utilized the National Health Insurance Research Database in a retrospective cohort study from 2000 to 2018, focusing on NSCLC patients diagnosed between 2007 and 2013. After propensity score matching 1:5 ratio, then compared patients with and without adjunctive Chinese medicine therapy. Survival outcomes, cost-effectiveness, and sensitivity analyses were conducted. Results: The study involved 43,122 NSCLC patients with 5.76% receiving adjunctive Chinese medicine. There is no significant associated between the risk of death and adjuvant Chinese medicine therapy until 181-365 days of adjuvant treatment could reduce the risk of death (HR = 0.88, 95% CI: 0.80-0.98). Cost-effectiveness analysis showed an incremental cost-effectiveness ratio of 880,908 NT$/year. Conclusion: Adjunctive Chinese medicine therapy, particularly when administered for 181-365 days, significantly reduced the mortality risk among stage IV NSCLC patients. The cost-effectiveness aligns with willingness-to-pay thresholds, indicating economic benefit.

Estimating Taiwan's QALY league table for catastrophic illnesses: Providing real-world evidence to integrate prevention with treatment for resources allocation

BACKGROUND/PURPOSE

Curative technologies improve patient's survival and/or quality of life but increase financial burdens. Effective prevention benefits all three. We summarize estimation methods and provide examples of how much money is spent per quality-adjusted life year (QALY) or life year (LY) on treating a catastrophic illness under a lifetime horizon and how many QALYs/LYs and lifetime medical costs (LMC) could be potentially saved by prevention.

METHODS

We established cohorts by interlinkages of Taiwan's nation-wide databases including National Health Insurance. We developed methods to estimate lifetime survival functions, which were multiplied with the medical costs and/or quality of life and summed up to estimate LMC, quality-adjusted life expectancy (QALE) and lifetime average cost per QALY/LY for catastrophic illnesses. By comparing with the age-, sex-, and calendar year-matched referents simulated from vital statistics, we obtained the loss-of-QALE and loss-of-life expectancy (LE).

RESULTS

The lifetime cost-effectiveness ratios of ventilator-dependent comatose patients, dialysis, spinal cord injury, major trauma, and cancers were US$ 96,800, 16,200-20,000, 5500-5,900, 3400-3,600, and 2900-11,900 per QALY or LY, respectively. The successful prevention of lung, liver, oral, esophagus, stomach, nasopharynx, or ovary cancer would potentially save US$ 28,000-97,000 and > 10 QALYs; whereas those for end-stage kidney disease, stroke, spinal injury, or major trauma would be US$ 55,000-300,000 and 10-14 QALYs. Loss-of-QALE and loss-of-LE were less confounded indicators for comparing the lifetime health benefits of different technologies estimated from real-world data.

CONCLUSIONS

Integration of prevention with treatment for resources allocation seems feasible and would improve equity and efficiency.

Possible overdiagnosis of early-stage lung adenocarcinoma among never-smokers in Taiwan

10-year survival for never-smokers with >1 cm but ≤3 cm AIS/BAC/MIA was not inferior to that of the matched referents, pointing to possible overdiagnosis. Clinicians might consider adhering to Lung-RADS and watchful waiting for these non-solid nodules. https://bit.ly/41U6kxs.

Early HIV diagnosis enhances quality-adjusted life expectancy of men who have sex with men living with HIV: A population-based cohort study in Taiwan

BACKGROUND

Whether early HIV diagnosis is beneficial for HIV patients themselves remains uncertain, given the stigma and social discrimination associated with an HIV diagnosis. This study aimed to measure the impact of early HIV diagnosis on quality-adjusted life expectancy (QALE) in comparison with late HIV diagnosis, from real-world data in Taiwan under universal access to antiretroviral therapy (ART).

METHODS

This population-based cohort study included 14,570 men who have sex with men (MSM) in the national HIV registry and a quasi-random sample (n = 127) of MSM patients to measure quality of life using the EQ-5D health utility instrument. We integrated quality of life data into the extrapolated cohort survival curve to estimate the QALE in patients with early versus late HIV diagnosis (≤30 days before AIDS diagnosis). Loss-of-QALE were estimated by comparing the cohort with age-, sex-, and calendar-year-matched referents simulated from vital statistics. Difference-in-differences was estimated to quantify the effect of early HIV diagnosis.

RESULTS

Early HIV diagnosis is associated with a loss-of-life expectancy of 3.11 years, with an average health utility of 0.95, in contrast to those diagnosed late (loss-of-life expectancy 8.47 years, with an average health utility of 0.86). After integration of survival and life quality, early HIV diagnosis results in a reduction of loss-of-QALE by 8.28 quality-adjusted life years among MSM living with HIV.

CONCLUSIONS

Under universal access to ART, early HIV diagnosis is highly beneficial for people living with HIV themselves, with a net gain of 8.28 healthy life years compared with those diagnosed late.

Cost-Effectiveness Analysis of Risk Factor-Based Lung Cancer Screening Program by Low-Dose Computer Tomography in Current Smokers in China

Although the effectiveness of lung cancer screening by low-dose computed tomography (LDCT) could be shown in China, there could be variation in the evidence concerning the economic impact. Our study explores the cost-effectiveness of lung cancer screening and optimizes the best definition of a high-risk population. A Markov model consisting of the natural history and post-diagnosis states was constructed to estimate the costs and quality-adjusted life years (QALYs) of LDCT screening compared with no screening. A total of 36 distinct risk factor-based screening strategies were assessed by incorporating starting ages of 40, 45, 50, 55, 60 and 65 years, stopping ages of 69, 74 and 79 years as well as smoking eligibility criteria. Screening data came from community-based mass screening with LDCT for lung cancer in Guangzhou. Compared with no screening, all screening scenarios led to incremental costs and QALYs. When the willingness-to-pay (WTP) threshold was USD37,653, three times the gross domestic product (GDP) per capita in China, six of nine strategies on the efficiency frontier may be cost-effective. Annual screening between 55 and 79 years of age for those who smoked more than 20 pack-years, which yielded an incremental cost-effectiveness ratio (ICER) of USD35,000.00 per QALY gained, was considered optimal. In sensitivity analyses, the result was stable in most cases. The trends of the results are roughly the same in scenario analyses. According to the WTP threshold of different regions, the optimal screening strategies were annual screening for those who smoked more than 20 pack-years, between 50 and 79 years of age in Zhejiang province, 55-79 years in Guangdong province and 65-74 years in Yunnan province. However, annual screening was unlikely to be cost-effective in Heilongjiang province under our modelling assumptions, indicating that tailored screening policies should be made regionally according to the local epidemiological and economic situation.

Is long-term screening for lung cancer justified in patients with head and neck carcinoma?

OBJECTIVE

Patients with head and neck squamous cell carcinoma (HNSCC) have a higher risk of second lung neoplasms than the general population. The aim of the present study is to evaluate the long-term incidence of second lung malignancies after the diagnosis of a HNSCC and to consider the convenience of the screening for lung cancer in these patients.

MATERIAL AND METHODS

We conducted a retrospective study performed on 4954 patients with an index tumor located in the oral cavity, oropharynx, hypopharynx, or larynx during the period 1985-2017.

RESULTS

During the follow-up period 469 patients (9.5%) presented a second pulmonary neoplasm. The incidence of second lung neoplasm was 1.26% per year and remained practically constant throughout the 25-year follow-up period analyzed. According to the results of a multivariate study, male patients, aged between 50 and 80 years, with a history of tobacco use, and with tumors located in the oropharynx or the supraglottis were those with the highest risk of second lung neoplasms.

CONCLUSION

Patients with a HNSCC index tumor have a high risk of second neoplasms located in the lung. In order to achieve an early diagnosis of these second neoplasms, it would be advisable to establish screening protocols based on the use of low-dose lung CT, which should be maintained indefinitely during the follow-up period.

Estimation of disability free life expectancy in non small cell lung cancer based on real world data

To quantify the societal impact of disability in patients with non-small cell lung cancer (NSCLC), this study estimated the disability-free life expectancy (DFLE), loss-of-DFLE and explored their associations with quality-adjusted life expectancy (QALE) and loss-of-QALE. We interlinked national databases and applied a rolling-over algorithm to estimate the lifetime survival function for patients with NSCLC. Using the EuroQOL-5 Dimension (EQ-5D) and Barthel index (BI), we repeatedly measured the quality-of-life and disability functions of NSCLC patients who visited our hospital from 2011 to 2020. Age-, sex-matched referents were simulated from lifetables of the same calendar year of diagnosis. We categorized BI scores ≤ 70 as in need of long-term care and constructed linear mixed models to estimate the utility values and disability scores. We collected 960 cases and 3088 measurements. The proportions of measurements without disability at age 50-64 and in stage I-IIIa, 50-64 and stage IIIb-IV, 65-89 and stage I-IIIa and 65-89 and stage IIIb-IV were 97.3%, 89.3%, 94.8%,78.3%, corresponding to DFLEs of 15.3, 2.4, 6.8, 1.2 years and losses-of-DFLE of 8.1, 20.7, 4.0, 8.6 years, respectively, indicating that advanced stage had a stronger effect than old age. Survivors in advanced stages showed increased demands for assistance in almost all subitems. The DFLEs seemed to be approximate to the QALEs and the latter were shorter than the former due to discomfort and depression. From a societal perspective, future health technology assessment should consider the impact of lifetime duration of functional disability. Early diagnosis of NSCLC may decrease the burden of long-term care.

Diagnosis and Treatment of Tubercular Uveitis in Taiwan - Consensus of Expert Panels

There is currently a lack of guidelines with regard to tubercular uveitis (TBU) management in Taiwan. We therefore propose an evidence-based consensus on the management for TBU. The Taiwan Ocular Inflammation Society conducted a meeting that included nine ophthalmologist and one infection disease expert that focused on three broad areas of (1) nomenclature for TBU, (2) assessment and diagnosis for TBU, and (3) treatment of TBU. Brief literature review on TBU diagnosis and management was conducted that informed this panel meeting in order to make decisions on each consensus statements. In terms of our results, a consensus statements and recommendations for the diagnosis and management of TBU were developed. This consensus statement provides an algorithmic approach toward diagnosing and managing TBU. These statements are meant to enhance but not replace individual clinician-patient interactions and to facilitate real-world clinical practice improvement in terms of TBU patients care.

Sybil: A Validated Deep Learning Model to Predict Future Lung Cancer Risk From a Single Low-Dose Chest Computed Tomography

PURPOSE

Low-dose computed tomography (LDCT) for lung cancer screening is effective, although most eligible people are not being screened. Tools that provide personalized future cancer risk assessment could focus approaches toward those most likely to benefit. We hypothesized that a deep learning model assessing the entire volumetric LDCT data could be built to predict individual risk without requiring additional demographic or clinical data.

METHODS

We developed a model called Sybil using LDCTs from the National Lung Screening Trial (NLST). Sybil requires only one LDCT and does not require clinical data or radiologist annotations; it can run in real time in the background on a radiology reading station. Sybil was validated on three independent data sets: a heldout set of 6,282 LDCTs from NLST participants, 8,821 LDCTs from Massachusetts General Hospital (MGH), and 12,280 LDCTs from Chang Gung Memorial Hospital (CGMH, which included people with a range of smoking history including nonsmokers).

RESULTS

Sybil achieved area under the receiver-operator curves for lung cancer prediction at 1 year of 0.92 (95% CI, 0.88 to 0.95) on NLST, 0.86 (95% CI, 0.82 to 0.90) on MGH, and 0.94 (95% CI, 0.91 to 1.00) on CGMH external validation sets. Concordance indices over 6 years were 0.75 (95% CI, 0.72 to 0.78), 0.81 (95% CI, 0.77 to 0.85), and 0.80 (95% CI, 0.75 to 0.86) for NLST, MGH, and CGMH, respectively.

CONCLUSION

Sybil can accurately predict an individual's future lung cancer risk from a single LDCT scan to further enable personalized screening. Future study is required to understand Sybil's clinical applications. Our model and annotations are publicly available.

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Population-Based Screening Using Low-Dose Chest Computed Tomography: A Systematic Review of Health Economic Evaluations

BACKGROUND

Chest low-dose computed tomography (LDCT) is a promising technology for population-based screening because it is non-invasive, relatively inexpensive, associated with low radiation and highly sensitive to lung cancer. To improve the cost-effectiveness of lung cancer screening, simultaneous screening for other diseases could be considered. This systematic review was conducted to analyse studies that published evidence on the cost-effectiveness of chest LDCT screening programs for different diseases.

METHODS

Scopus and PubMed were searched for English publications (1 January 2011-22 July 2022) using search terms related to screening, computed tomography and cost-effectiveness. An additional search specifically searched for the cost-effectiveness of screening for lung cancer, chronic obstructive pulmonary disease or cardiovascular disease. Included publications should present a full health economic evaluation of population screening with chest LDCT. The extracted data included the disease screened for, model type, country context of screening, inclusion of comorbidities or incidental findings, incremental costs, incremental effects and the resulting cost-effectiveness ratio amongst others. Reporting quality was assessed using the 2022 Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

The search yielded 1799 unique papers, of which 43 were included. Most papers focused on lung cancer screening (n = 40), and three were on coronary calcium scoring. Microsimulation was the most commonly applied modelling type (n = 16), followed by life table analysis (n = 10) and Markov cohort models (n = 10). Studies reflected the healthcare context of the US (n = 15), Canada (n = 4), the UK (n = 3) and 13 other countries. The reported incremental cost-effectiveness ratio ranged from US$10,000 to US$90,000/quality-adjusted life year (QALY) for lung cancer screening compared to no screening and was US$15,900/QALY-US$45,300/QALY for coronary calcium scoring compared to no screening.

DISCUSSION

Almost all health economic evaluations of LDCT screening focused on lung cancer. Literature regarding the health economic benefits of simultaneous LDCT screening for multiple diseases is absent. Most studies suggest LDCT screening is cost-effective for current and former smokers aged 55-74 with a minimum of 30 pack-years of smoking history. Consequently, more evidence on LDCT is needed to support further cost-effectiveness analyses. Preferably evidence on simultaneous screening for multiple diseases is needed, but alternatively, on single-disease screening.

REGISTRATION OF SYSTEMATIC REVIEW

Prospective Register of Ongoing Systematic Reviews registration CRD42021290228 can be accessed https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=290228 .

Lung cancer screening

Randomised controlled trials, including the National Lung Screening Trial (NLST) and the NELSON trial, have shown reduced mortality with lung cancer screening with low-dose CT compared with chest radiography or no screening. Although research has provided clarity on key issues of lung cancer screening, uncertainty remains about aspects that might be critical to optimise clinical effectiveness and cost-effectiveness. This Review brings together current evidence on lung cancer screening, including an overview of clinical trials, considerations regarding the identification of individuals who benefit from lung cancer screening, management of screen-detected findings, smoking cessation interventions, cost-effectiveness, the role of artificial intelligence and biomarkers, and current challenges, solutions, and opportunities surrounding the implementation of lung cancer screening programmes from an international perspective. Further research into risk models for patient selection, personalised screening intervals, novel biomarkers, integrated cardiovascular disease and chronic obstructive pulmonary disease assessments, smoking cessation interventions, and artificial intelligence for lung nodule detection and risk stratification are key opportunities to increase the efficiency of lung cancer screening and ensure equity of access.

EarlyCDT Lung blood test for risk classification of solid pulmonary nodules: systematic review and economic evaluation

BACKGROUND

EarlyCDT Lung (Oncimmune Holdings plc, Nottingham, UK) is a blood test to assess malignancy risk in people with solid pulmonary nodules. It measures the presence of seven lung cancer-associated autoantibodies. Elevated levels of these autoantibodies may indicate malignant disease. The results of the test might be used to modify the risk of malignancy estimated by existing risk calculators, including the Brock and Herder models.

OBJECTIVES

The objectives were to determine the diagnostic accuracy, clinical effectiveness and cost-effectiveness of EarlyCDT Lung; and to develop a conceptual model and identify evidence requirements for a robust cost-effectiveness analysis.

DATA SOURCES

MEDLINE (including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE), EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, EconLit, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database ( NHS EED ) and the international Health Technology Assessment database were searched on 8 March 2021.

REVIEW METHODS

A systematic review was performed of evidence on EarlyCDT Lung, including diagnostic accuracy, clinical effectiveness and cost-effectiveness. Study quality was assessed with the quality assessment of diagnostic accuracy studies-2 tool. Evidence on other components of the pulmonary nodule diagnostic pathway (computerised tomography surveillance, Brock risk, Herder risk, positron emission tomography-computerised tomography and biopsy) was also reviewed. When feasible, bivariate meta-analyses of diagnostic accuracy were performed. Clinical outcomes were synthesised narratively. A simulation study investigated the clinical impact of using EarlyCDT Lung. Additional reviews of cost-effectiveness studies evaluated (1) other diagnostic strategies for lung cancer and (2) screening approaches for lung cancer. A conceptual model was developed.

RESULTS

A total of 47 clinical publications on EarlyCDT Lung were identified, but only five cohorts (695 patients) reported diagnostic accuracy data on patients with pulmonary nodules. All cohorts were small or at high risk of bias. EarlyCDT Lung on its own was found to have poor diagnostic accuracy, with a summary sensitivity of 20.2% (95% confidence interval 10.5% to 35.5%) and specificity of 92.2% (95% confidence interval 86.2% to 95.8%). This sensitivity was substantially lower than that estimated by the manufacturer (41.3%). No evidence on the clinical impact of EarlyCDT Lung was identified. The simulation study suggested that EarlyCDT Lung might potentially have some benefit when considering intermediate risk nodules (10-70% risk) after Herder risk analysis. Two cost-effectiveness studies on EarlyCDT Lung for pulmonary nodules were identified; none was considered suitable to inform the current decision problem. The conceptualisation process identified three core components for a future cost-effectiveness assessment of EarlyCDT Lung: (1) the features of the subpopulations and relevant heterogeneity, (2) the way EarlyCDT Lung test results affect subsequent clinical management decisions and (3) how changes in these decisions can affect outcomes. All reviewed studies linked earlier diagnosis to stage progression and stage shift to final outcomes, but evidence on these components was sparse.

LIMITATIONS

The evidence on EarlyCDT Lung among patients with pulmonary nodules was very limited, preventing meta-analyses and economic analyses.

CONCLUSIONS

The evidence on EarlyCDT Lung among patients with pulmonary nodules is insufficient to draw any firm conclusions as to its diagnostic accuracy or clinical or economic value.

FUTURE WORK

Prospective cohort studies, in which EarlyCDT Lung is used among patients with identified pulmonary nodules, are required to support a future assessment of the clinical and economic value of this test. Studies should investigate the diagnostic accuracy and clinical impact of EarlyCDT Lung in combination with Brock and Herder risk assessments. A well-designed cost-effectiveness study is also required, integrating emerging relevant evidence with the recommendations in this report.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42021242248.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 49. See the NIHR Journals Library website for further project information.

Detection and treatment of lung adenocarcinoma at pre-/minimally invasive stage: is it lead-time bias?

OBJECTIVES

This study investigates whether lead-time bias contributes to the excellent survival of AIS and MIA.

METHODS

We enrolled patients with resected adenocarcinoma from 2008 to 2012. Age, sex, smoke history, surgical approach, radiological features, invasive stage and postoperative follow-up data were documented. 1:1 PSM was performed to balance the influence of sex and smoking status on survival. After matching, the average age of the two groups was compared to calculate the lead time of diagnosis. The gain in life years for adenocarcinoma diagnosed at pre-/minimally invasive stage was estimated by subtracting the "lead time" and "median survival year of IAC" from "the life expectancy of AIS/MIA patients" referring to the Centre for Health and Information.

RESULTS

There were 124 AIS/MIA patients and 1148 IAC patients. The frequency of female and never-smoking patients in AIS/MIA group was much higher than that in IAC group. PSM analysis identified 124 patient pairs. No cancer-related death and recurrence were observed among AIS/MIA patients 5 years after surgery. For IAC patients, the 5-year disease-specific survival rate was 73.5% and the median survival is 13.5 years. The average age of AIS/MIA group and IAC group are 53.6 years and 58.2 years, respectively. The lead time between diagnosis of AIS/MIA and IAC is 4.6 years. Referring to the Centre for Health and Information, the life expectancy of patients with AIS/MIA diagnosed at 53.6 years old is 28.9 years. With adjustment for the lead time, the gain in life years for adenocarcinoma diagnosed at pre-/minimally invasive stage is 10.8 years.

CONCLUSIONS

With adjustment for the lead time between diagnosis of AIS/MIA and IAC, resecting lung adenocarcinoma at pre-/minimally invasive stage can improve life expectancy. The excellent survival of AIS/MIA is not lead-time bias.

Variation in Model-Based Economic Evaluations of Low-Dose Computed Tomography Screening for Lung Cancer: A Methodological Review

OBJECTIVES

There is significant heterogeneity in the results of published model-based economic evaluations of low-dose computed tomography (LDCT) screening for lung cancer. We sought to understand and demonstrate how these models differ.

METHODS

An expansion and update of a previous systematic review (N = 19). Databases (including MEDLINE and Embase) were searched. Studies were included if strategies involving (single or multiple) LDCT screening were compared with no screening or other imaging modalities, in a population at risk of lung cancer. More detailed data extraction of studies from the previous review was conducted. Studies were critically appraised using the Consensus Health Economic Criteria list.

RESULTS

A total of 16 new studies met the inclusion criteria, giving a total of 35 studies. There are geographic and temporal differences and differences in screening intervals and eligible populations. Studies varied in the types of models used, for example, decision tree, Markov, and microsimulation models. Most conducted a cost-effectiveness analysis (using life-years gained) or cost-utility analysis. The potential for overdiagnosis was considered in many models, unlike with other potential consequences of screening. Some studies report considering lead-time bias, but fewer mention length bias. Generally, the more recent studies, involving more complex modeling, tended to meet more of the critical appraisal criteria, with notable exceptions.

CONCLUSIONS

There are many differences across the economic evaluations contributing to variation in estimates of the cost-effectiveness of LDCT screening for lung cancer. Several methodological factors and evidence needs have been highlighted that will require consideration in future economic evaluations to achieve better agreement.

Combined quality of life and survival for estimation of long-term health outcome of patients with stroke

Background

Advanced medical technologies can prolong life of stroke survivors. Dynamic change of health outcomes provides essential information to manage stroke. Mathematical models, to extrapolate health status over a lifetime from cross-sectional data, can be used to investigate long term health outcomes among stroke survivors. This study aimed to estimate the health outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) at each survival time point.

Methods

The cohort of 5391 patients with IS and ICH stroke, registered at Ramathibodi Hospital from 2005 to 2013, were followed up regarding survival status until 2016 with the National Mortality Registry. Survival functions were extrapolated over 50 years to age- and sex-matched referents simulated from the national data of the Thailand National Health Statistic Office. From July to December 2016, the EuroQoL 5-dimension questionnaire was used to measure quality of life (QoL) among 400 consecutive, cross-sectional subsamples. The survival functions were then adjusted by the utility values of QoL for the stroke cohort to estimate quality adjusted life expectancy (QALE).

Results

The average health utility values were lower in the initial months, then slowly increased to stable levels. However, male stroke survivors presented higher health utility than females. Throughout lifetime estimation, patients with IS stroke exhibit better health outcomes than those with ICH [10.2 vs. 7.5 quality-adjusted life years (QALYs)]. Patients with ICH presented a significantly decreased QoL than patients with IS (16.3 and 8.5 QALYs).

Conclusion

Preventing stroke can save people from reduced years and QoL, which can be quantified by loss-of-QALE in QALY units to compare health benefits from prevention, clinical diagnosis and direct treatment.

Cost Effectiveness of Lung Cancer Screening With Low-Dose CT in Heavy Smokers in China

Although lung cancer screening with low-dose CT (LDCT) can reduce lung cancer mortality by 20%, without an appropriate eligibility criteria, it may result in a waste of medical resources and a degree of unnecessary damage to participants' health. This study aims to give the optimal screening strategy in China based on cost-effectiveness analysis on pros and cons of different situations. From the perspective of primary healthcare system, a Markov model was built to simulate LDCT screening of 100,000 heavy smokers (>30 pack years) aged 40 in different situations. Model parameters mainly came from screening programs conducted in China and other countries, official public data, and published literature. Two indicators of primary outcome, incremental cost-effectiveness ratio (ICER) and net health benefits (NHB), were compared with those of no screening. Sensitivity analysis was conducted to evaluate model uncertainties. We defined the optimal strategy as the one with both acceptable cost effectiveness and maximal NHB. Base-case analysis results showed that for all screening strategies, ICERs were less than three times of GDP per capita. As for NHB results, it showed that when the willingness to pay for screening was less than three times of GPD per capita, the largest NHB was obtained in the strategy which started screening at 50 years old and this strategy showed stable performance in univariate and probabilistic sensitivity as well. PREVENTION RELEVANCE: LDCT screening is cost effective in heavy smokers in China, and the optimal age to start screening is suggested to be 50 years old.

Cost-effectiveness evaluation of mammography screening program in Taiwan: Adjusting different distributions of age and calendar year for real world data

BACKGROUND/PURPOSE

We estimated loss-of-life expectancy (LE) and lifetime medical expenditures (LME) stratified by stages to evaluate the cost-effectiveness of breast cancer (BC) screening in Taiwan.

METHODS

We interlinked four national databases- Cancer Registry, Mortality Registry, National Health Insurance Claim, and Mammography Screening. A cohort of 123,221 BC was identified during 2002-2015 and followed until December 31, 2017. We estimated LE and loss-of-LE by rolling extrapolation algorithm using age-, sex-, and calendar-year-matched referents simulated from vital statistics. LME was estimated by multiplying monthly cost with survival probability and adjusted for annual discount rate. We calculated incremental cost-effectiveness ratio (ICER) by comparing the loss-of-LE of those detected by screening versus non-screening after accounting for administration fees and radiation-related excess BC.

RESULTS

The LEs of stages I, II, III, and IV were 31.4, 27.2, 20.0, and 5.2 years, respectively, while the loss-of-LEs were 1.2, 4.9, 11.7, and 25.0 years with corresponding LMEs of US$ 73,791, 79,496, 89,962, and 66,981, respectively. The difference in LE between stages I and IV was 26.2 years while that of loss-of-LE was 23.8 years, which implies that a potential lead time bias may exist if diagnosis at younger ages for earlier stages were not adjusted for. The ICER of mammography seemed cost-saving after the coverage exceeded half a million.

CONCLUSION

Mammography could detect BC early and be cost-saving after adjustment for different distributions of age and calendar year of diagnosis. Future studies exploring healthcare expenditure and impaired quality of life for false-positive cases are warranted.

Considering lead-time bias in evaluating the effectiveness of lung cancer screening with real-world data

Low-dose computed tomography screening can be used to diagnose lung cancer at a younger age compared to no screening. Real-world studies observing mortality after lung cancer diagnosis are subject to lead-time bias. This study developed a method using a nationwide cancer registry and stage shift from trial for the adjustment of lead-time bias. 78,897 Taiwanese nationwide lung cancer patients aged 55–82 were matched with 788,820 referents randomly selected from the general population at a ratio of 1:10 by age, sex, calendar year, and comorbidities, to estimate the pathology- and stage-specific life expectancy (LE). Loss-of-LE is the difference between the LE of cancer patients and that of referents. By multiplying LE and loss-of-LE by the pathology and stage shift in the National Lung Screening Trial (NLST), we compared the effectiveness of cancer screening measured by LE gained and loss-of-LE saved. The mean LEs of stage IA and IV adenocarcinoma were 14.5 and 1.9 years, respectively, indicating a LE gain of 12.6 years. However, the mean loss-of-LEs of stage IA and IV adenocarcinoma were 3.7 and 15.1 years, respectively, with a saving of only 11.4 years, implying an adjustment of different distributions of age, sex, and calendar year of diagnosis from stage shift and a reduction in lead-time bias. Applying such estimations on the results of 10,000 participants with the same pathology and stage shift in the NLST, the benefit of screening using LE gained would be 410.3 (95% prediction interval: 328.4 to 503.3) years. It became 297.1 (95% prediction interval: 187.8 to 396.4) years when using loss-of-LE saved, indicating the former approach would overestimate the effectiveness by 38%. Our approach of multiplying loss-of-LE by pathology and stage shift to estimate loss-of-LE saved could adjust for different distributions of age, sex, and calendar year at early diagnosis and reduce lead-time bias.

Investing preventive care and economic development in ageing societies: empirical evidences from OECD countries

BACKGROUND

The proportion of the elderly aged 65 years old or above will reach 16% in 2050 worldwide. Early investment in effective prevention would generally reduce the morbidity, complication, functional disability, and mortality of most chronic illnesses and save resources in both healthcare and social services. This research aims to investigate how the optimal allocation of medical resources between prevention and treatment adds value to the population's health as well as examine the interaction between ageing, health, and economic performance.

METHODS

This research undertakes ageing-health analyses by developing an economic growth model. Based on the Organization for Economic Co-Operation and Development (OECD) countries' experiences over the period from 2000 to 2017, this research further examines the hypothesis that an ageing society could increase demand for preventive and curative healthcare.

RESULTS

Theoretical analysis found that the prevention share for maximizing growth is the same as that for minimizing ill health and maximizing welfare; this share increases with treatment share and ageing ratios. Estimation results from OECD countries' experiences indicate that when treatment share increases by 1%, the prevention demand increases by 0.036%. A one-percent increase in the ageing ratio yields a change in prevention share of 0.0368%. The optimal share of prevention health expenditure to GDP would be 1.175% when the prevalence rate of ill health isat 6.13%; a higher or lower share of prevention would be accompanied with a higher prevalence of ill health. For example, a zero and 1.358% preventive health expenditure would be associated with an 18.01% prevalence of ill health, while the current share of prevention of 0.237% is associated with a 10.26% prevalence of ill health.

CONCLUSION

This study shows that appropriate prevention is associated with decreases in the prevalence rates of ill health, which in turn attains sustainable growth in productivity. Too much prevention, however, could lead to higher detection of new chronic diseases with mild severity, which would result in longer illness duration, and higher prevalence rates of ill health. With suitable allocation of medical resources, the economic growth rate will help to cancel out increases in healthcare spending for the elderly and for expenses needed for the improvement of the population's health as a whole.

QALYs and medical costs saved from prevention of a cancer: Analysis of nation-wide real-world data of Taiwan with lifetime horizon

BACKGROUND/PURPOSE

To quantify savings of loss-of-QALE (quality-adjusted life expectancy) and lifetime medical costs from prevention of different cancers.

METHODS

We collected nation-wide data on 808,700 new cancer cases of 14 different organ systems and followed them from 1998 to 2014 in Taiwan. We also collected 13,005 cancer patients from a medical center and 47,320 repeated measurements of quality of life (QoL) of EQ-5D to obtain utility values and multiplied them with the corresponding survival rates to calculate QALE. With Kaplan-Meier estimation to survival function to the end of follow-up, we extrapolated to lifetime through a rolling over algorithm on the logit transform of the survival ratio between the index cohort and age-, sex, and calendar year matched referents simulated from vital statistics. Lifetime costs for each cancer were estimated by multiplying survival with average monthly costs after adjustment with annual discount rate. The loss-of-QALE was estimated by the difference in QALE between the index cancer cohort and corresponding referents.

RESULTS

The dynamic changes and weighted averages of the QoL utility values of 14 different cancers ranged from 0.82 to 0.95. Successful prevention of liver, lung, esophagus, or nasopharynx cancer would save more than 10 quality-adjusted life years and more than 21,000 USD per case for both genders. Since the saving of loss-of-QALE was adjusted for different age, sex, and calendar-year distributions, it could be used in cost effectiveness evaluation.

CONCLUSION

Savings of loss-of-QALE and lifetime costs could be used for comparison of prevention, diagnosis, treatment and rehabilitation from a lifetime horizon.

Downstream Complications and Healthcare Expenditure after Invasive Procedures for Lung Lesions in Taiwan

This study aimed to estimate the downstream complications and healthcare expenditure after invasive procedures for lung lesions, which in turn could be used for future cost-effectiveness analyses of lung cancer screening in Taiwan. We interlinked the Taiwan National Beneficiary Registry with the National Health Insurance Reimbursement databases to identify non-lung cancer individuals aged 50–80 years who underwent invasive lung procedures within one month after non-contrast chest computed tomography between 2014 and 2016. We directly matched one individual with 10 controls by age, gender, calendar year, residence area, comorbidities, and the past one-year healthcare expenditure to calculate incremental one-month complication rates and attributable costs. A total of 5805 individuals who underwent invasive lung procedures were identified and matched with 58,050 controls. The incremental one-month complication rates were 13.4% (95% CI: 10.9% to 15.8%), 10.7% (95% CI: 9.2% to 12.1%), and 4.4% (95% CI: 2.0% to 6.7%) for thoracic surgery, bronchoscopy, and needle biopsy, respectively. The incremental one-month healthcare expenditure for minor, intermediate, and major complications were NT$1493 (95% CI: NT$-3107 to NT$6092), NT$18,422 (95% CI: NT$13,755 to NT$23,089), and NT$58,021 (95% CI: NT$46,114 to NT$69,929), respectively. Individuals aged 60–64 years incurred the highest incremental costs. Downstream complications and the healthcare expenditure after invasive procedures for lung lesions would be substantial for non-lung cancer individuals 50–80 years of age. These estimates could be used in modeling the cost-effectiveness of the national lung screening program in Taiwan.

The challenges of implementing low-dose computed tomography for lung cancer screening in low- and middle-income countries

Lung cancer accounts for an alarming human and economic burden in low- and middle-income countries (LMICs). Recent landmark trials from high-income countries (HICs) by demonstrating that low-dose computed tomography (LDCT) screening effectively reduces lung cancer mortality have engendered enthusiasm for this approach. Here we examine the effectiveness and affordability of LDCT screening from the viewpoint of LMICs. We consider resource-restricted perspectives and discuss implementation challenges and strategies to enhance the feasibility and cost-effectiveness of LDCT screening in LMICs.

[Progress of Lung Cancer Screening with Low Dose Helical Computed Tomography]

Lung cancer which represents characteristics of a heavy disease burden, a large proportion of advanced lung cancer and a low five-year survival rate is a threat to human health. It is essential to implement population-based lung cancer screening to improve early detection and early treatment. The National Lung Screening Trial (NLST) demonstrated that screening with low dose helical computed tomography (LDCT) may decrease lung cancer mortality, which brings hope for the early diagnosis and treatment of lung cancer. In recent years, great progresses have been made on research of lung cancer screening with LDCT. However, whether LDCT could be applied to large population-based lung cancer screening projects is still under debate. In this paper, we review the recent progresses on history of lung cancer screening with LDCT, selection of high-risk individuals, management of pulmonary nodules, performance of screening, acceptance of LDCT and cost-effectiveness.
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Lifetime risks and health impacts of hemorrhagic and ischemic stroke in South Korea

This study is aimed toward estimating the lifetime risks, life expectancy, expected years of life lost (EYLL), and lifetime costs related to different subtypes of stroke in South Korea. We included 13,994 patients diagnosed with stroke (ICD-10, I60-I63) in the National Health Insurance Service-National Sample Cohort of Korea between 2006 and 2015. Lifetime risks were calculated using the cumulative incidence rate for patients aged 18–84. Lifetime survival data were obtained through the Kaplan–Meier method and extrapolated with a rolling-over extrapolation algorithm. The lifetime costs were estimated by multiplying the average monthly expenditures with the survival probabilities and adding the values over lifetime. The lifetime risks of stroke in Korea have been decreasing consistently over the last decade with the exception of subarachnoid hemorrhage in females, which appears to have slightly increased. The EYLL is higher in hemorrhagic stroke than in ischemic stroke (6–9.7 vs. 4.7). Expected lifetime costs reimbursed by the NHIS would amount to about $71,406 accompanied with $14,921 copayment from the patients for hemorrhagic stroke, and $50,551 and $11,666, respectively, for ischemic stroke. Further studies are warranted to combine survival with quality of life and functional disability to obtain a more detailed outcome assessment of the potential impact of the prevention of stroke.

Development and outcomes of a comprehensive multidisciplinary incidental lung nodule and lung cancer screening program

BACKGROUND

Appropriate management of lung nodules detected incidentally or through lung cancer screening can increase the rate of early-stage diagnoses and potentially improve treatment outcomes. However, the implementation and management of comprehensive lung nodule programs is challenging.

METHODS

This single-center, retrospective report describes the development and outcomes of a comprehensive lung nodule program at a community practice in Tennessee. Computed tomography (CT) scans potentially revealing incidental lung nodules were identified by a computerized search. Incidental or screening-identified lung nodules that were enlarging or not seen in prior scans were entered into a nodule database and guideline-based review determined whether to conduct a diagnostic intervention or radiologic follow-up. Referral rates, diagnosis methods, stage distribution, treatment modalities, and days to treatment are reported.

RESULTS

The number of patients with lung nodules referred to the program increased over 2 years, from 665 patients in Year 1 to 745 patients in Year 2. Most nodules were incidental (62-65%). Nodules identified with symptoms (15.2% in Year 1) or through screening (12.6% in Year 1) were less common. In Year 1, 27% (182/665) of nodules required a diagnostic intervention and 18% (121/665) were malignant. Most diagnostic interventions were image-guided bronchoscopy (88%) or percutaneous biopsy (9%). The proportion of Stage I-II cancer diagnoses increased from 23% prior to program implementation to 36% in Year 1 and 38% in Year 2. In screening cases, 71% of patients completed follow-up scans within 18 months. Only 2% of Year 1 patients under watchful waiting required a diagnostic intervention, of which 1% received a cancer diagnosis.

CONCLUSIONS

The current study reports outcomes over the first 2 years of a lung cancer screening and incidental nodule program. The results show that the program was successful, given the appropriate level of data management and oversight. Comprehensive lung nodule programs have the potential to benefit the patient, physician, and hospital system.

Comparative effectiveness and cost-effectiveness of three first-line EGFR-tyrosine kinase inhibitors: Analysis of real-world data in a tertiary hospital in Taiwan

Introduction

Comparison of the effectiveness and cost-effectiveness of three first-line EGFR-tyrosine kinase inhibitors (TKIs) would improve patients’ clinical benefits and save costs. Using real-world data, this study attempted to directly compare the effectiveness and cost-effectiveness of first-line afatinib, erlotinib, and gefitinib.

Methods

During May 2011-December 2017, all patients with non-small cell lung cancer (NSCLC) visiting a tertiary center were invited to fill out the EuroQol five-dimension (EQ-5D) questionnaires and World Health Organization Quality of Life, brief version (WHOQOL-BREF), and received follow-ups for survival and direct medical costs. A total of 379 patients with EGFR mutation-positive advanced NSCLC under first-line TKIs were enrolled for analysis. After propensity score matching for the patients receiving afatinib (n = 48), erlotinib (n = 48), and gefitinib (n = 96), we conducted the study from the payers’ perspective with a lifelong time horizon.

Results

Patients receiving afatinib had the worst lifetime psychometric scores, whereas the differences in quality-adjusted life expectancy (QALE) were modest. Considering 3 treatments together, afatinib was dominated by erlotinib. Erlotinib had an incremental cost-effectiveness of US$17,960/life year and US$12,782/QALY compared with gefitinib. Acceptability curves showed that erlotinib had 58.6% and 78.9% probabilities of being cost-effective given a threshold of 1 Taiwanese per capita GDP per life year and QALY, respectively.

Conclusion

Erlotinib appeared to be cost-effective. Lifetime psychometric scores may provide additional information for effectiveness evaluation.

Epidemiology and Survival Outcomes of Lung Cancer: A Population-Based Study

Purpose

Lung cancer has been the top-ranking cause of cancer deaths in Taiwan for decades. Limited data were available in global cancer surveillance regarding lung cancer epidemiology in Taiwan, and previous reports are outdated.

Patients and Methods

This population-based cohort study extracted data of patients with lung cancer from the Taiwan National Health Insurance database and determined the lung cancer incidence and prevalence during 2002–2014. Histological subtypes were retrieved from the Taiwan Cancer Registry database; survival rates were gathered from the National Death Registry. Average annual percentage changes (APCs) of prevalence, incidence, and overall survival were estimated by joinpoint regression analysis.

Results

Age-standardized incidence of lung cancer increased from 45.04 per 100,000 person-years in 2002 to 49.86 per 100,000 person-years in 2014, with an average APC of 0.7 (95% CI = 0.3–1.1; 0.2 in males, 2.0 in females). Lung cancer was more prevalent in male patients, but this increase gradually slowed down. Socioeconomic analysis showed that lung cancer has higher prevalence in patients with higher income level and urban residency. Adenocarcinoma was the most abundant histological subtype in Taiwan (adenocarcinoma-to-squamous cell carcinoma ratio = 4.16 in 2014), with a 2.4-fold increase of incident cases during 2002–2014 (from 43.47% to 64.89% of all lung cancer cases). The 5-year survival rate of lung cancer patients in 2010 was 17.34% (12.60% in male, 25.40% in female), with an average APC of 9.3 (6.3 in male, 11.8 in female) during 2002–2010.

Conclusion

Average APCs of prevalence and incidence of lung cancer were 3.1 and 0.7, respectively, during 2002–2014 in Taiwan. The number of female patients and number of patients with adenocarcinoma have increased the most, with incident cases doubling in these years. Facing this fatal malignancy, it is imperative to improve risk stratification, encourage early surveillance, and develop effective therapeutics for lung cancer patients in Taiwan.

Cost-Effectiveness Analysis of Lung Cancer Screening in the United States: A Comparative Modeling Study

BACKGROUND

Recommendations vary regarding the maximum age at which to stop lung cancer screening: 80 years according to the U.S. Preventive Services Task Force (USPSTF), 77 years according to the Centers for Medicare & Medicaid Services (CMS), and 74 years according to the National Lung Screening Trial (NLST).

OBJECTIVE

To compare the cost-effectiveness of different stopping ages for lung cancer screening.

DESIGN

By using shared inputs for smoking behavior, costs, and quality of life, 4 independently developed microsimulation models evaluated the health and cost outcomes of annual lung cancer screening with low-dose computed tomography (LDCT).

DATA SOURCES

The NLST; Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; SEER (Surveillance, Epidemiology, and End Results) program; Nurses' Health Study and Health Professionals Follow-up Study; and U.S. Smoking History Generator.

TARGET POPULATION

Current, former, and never-smokers aged 45 years from the 1960 U.S. birth cohort.

TIME HORIZON

45 years.

PERSPECTIVE

Health care sector.

INTERVENTION

Annual LDCT according to NLST, CMS, and USPSTF criteria.

OUTCOME MEASURES

Incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY).

RESULTS OF BASE-CASE ANALYSIS

The 4 models showed that the NLST, CMS, and USPSTF screening strategies were cost-effective, with ICERs averaging $49 200, $68 600, and $96 700 per QALY, respectively. Increasing the age at which to stop screening resulted in a greater reduction in mortality but also led to higher costs and overdiagnosis rates.

RESULTS OF SENSITIVITY ANALYSIS

Probabilistic sensitivity analysis showed that the NLST and CMS strategies had higher probabilities of being cost-effective (98% and 77%, respectively) than the USPSTF strategy (52%).

LIMITATION

Scenarios assumed 100% screening adherence, and models extrapolated beyond clinical trial data.

CONCLUSION

All 3 sets of lung cancer screening criteria represent cost-effective programs. Despite underlying uncertainty, the NLST and CMS screening strategies have high probabilities of being cost-effective.

PRIMARY FUNDING SOURCE

CISNET (Cancer Intervention and Surveillance Modeling Network) Lung Group, National Cancer Institute.

Thoracoscopic segmentectomy assisted by three-dimensional computed tomography bronchography and angiography for lung cancer in a patient living with situs inversus totalis: A case report

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital condition that is characterized by a complete mirror image of the typical arrangement of the thoracic and abdominal viscera. Performing thoracoscopic segmentectomy for a patient with lung cancer and SIT is an extremely skilled and challenging surgical procedure.

CASE SUMMARY

A 41-year old woman with a medical history of dextrocardia since childhood was admitted to our hospital with a mixed ground-glass opacity (mGGO) in her left lung field, discovered by computed tomography during her health checkup. In order to facilitate surgical orientation, three-dimensional computed tomography bronchography and angiography (3D-CTBA) was preoperatively carried out. The result of 3D-CTBA was consistent with the diagnosis of SIT and an mGGO in the posterior segment of the left upper lobe (LS²). Surgery was conducted in accordance with preoperative 3D-CTBA and designed surgical procedure, combined with intraoperative navigation. Final pathological examination revealed in situ adenocarcinoma. The patient’s postoperative condition was uneventful and no complications were observed.

CONCLUSION

We present the first case of lung cancer in a patient with SIT who successfully underwent thoracoscopic segmentectomy assisted by 3D-CTBA. This is a new technique that covers precise confirmation and dissection of targeted structures and intersegmental demarcation, and can help achieve a meticulous anatomical segmentectomy.

Lead Time Bias May Contribute to the Shorter Life Expectancy in Post-colonoscopy Colorectal Cancer

BACKGROUND

The long-term outcomes of post-colonoscopy colorectal cancer have varied in previous studies. Our nationwide cohort analysis estimated expected years of life lost to adjust for lead time bias.

AIM

We recalculated the long-term outcomes for post-colonoscopy and detected colorectal cancer.

METHODS

Patients with colorectal cancer registered in the Taiwan Cancer Registry between 2002 and 2009 were enrolled. The detected group included 22,169 cases of colorectal cancer confirmed within 6 months after a colonoscopy. The post-colonoscopy group included 1653 cancer patients who received a colonoscopy 6-60 months before diagnosis. Patients were followed up until 2011. We simulated age-, sex-, and calendar year-matched referents from life tables in the Taiwan National Vital Statistics using a Monte Carlo method. The life expectancy and expected years of life lost of the cancer patients were obtained from extrapolation of the logit transformation of the survival ratio between the cancer cohorts and the referent groups.

RESULTS

Post-colonoscopy colorectal cancer had shorter life expectancies than detected cancer (stages 2-4: 13.6 vs. 16.1 years; 8.7 vs. 12.6 years; 2.1 vs. 4.1 years, p < 0.001). The loss-of-life expectancy did not show this trend after adjusting for lead time bias. Post-colonoscopy colorectal cancer was found at an older age, more often proximal, and was associated with previous endoscopic polypectomy procedures (p < 0.001).

CONCLUSIONS

Post-colonoscopy colorectal cancer leads to a shorter life expectancy, which appears partially explained by the presence of lead time bias. Quality assurance for colonoscopy and close surveillance for high risk groups would reduce post-colonoscopy colorectal cancer.

Opioid agonist treatment reduces losses in quality of life and quality-adjusted life expectancy in heroin users: Evidence from real world data

BACKGROUND

This study estimated the long-term changes of opioid agonist treatment (OAT) in quality of life (QOL) and quantified the quality-adjusted life years (QALY) from the loss of quality-adjusted life expectancy (QALE) in heroin users.

METHODS

A total of 1283 heroin users stratified by OAT were linked to the National Mortality Registry for 8 years (2006-2014) to obtain survival functions, which were extrapolated to lifetime by applying a rolling extrapolation algorithm to survival ratio between the sub-cohorts and age- and sex-matched referents simulated from vital statistics of Taiwan. We performed cross-sectional measurement of EQ-5D on 349 participants, including those with a valid state of OAT or non-OAT plus newly recruited consecutive patients, during 2015-2017 for utility values, while the QOL of referents were abstracted from the 2009 National Health Interview Survey. The QALE was calculated by summing the products of the mean QOL and survival rate throughout life. The QALE difference between the cohort and corresponding referents was the loss-of-QALE.

RESULTS

QOL of the OAT group was significantly better than that of the non-OAT group in every domain of the EQ-5D, which was quantified to be 0.23 for utility after controlling for other variables. After extrapolation to 70 years, the estimated QALE and loss-of-QALE were 17.8 and 18.2 QALY for OAT subjects, respectively, while those of the non-OAT group were 9.2 and 27.9 QALY.

CONCLUSIONS

Receiving OAT could reduce QALE lost by 9.7 QALYs compared with non-OAT after accounting for QOL differences along time and different age and sex distributions.

Dynamic Changes of Health Utility in Lung Cancer Patients Receiving Different Treatments: A 7-Year Follow-up

INTRODUCTION

This study aimed to estimate the utility values of all subtypes of lung cancer. The trajectories after different kinds of treatments and their major determinants were explored on the basis of real-world data and repeated measurements.

METHODS

From 2011 to 2017, all patients with lung cancer who visited a medical center were invited to fill out the EuroQol Five-Dimension and WHO Quality of Life-Brief questionnaires at each visit. Utility values of quality of life (QoL) after diagnosis and treatments were depicted using a kernel smoothing method. We constructed linear mixed models to predict health utility in each time period and cross-validated them with domain scores of the WHO Quality of Life-Brief.

RESULTS

A total of 1715 patients were enrolled, with 6762 QoL measurements. Utility values were lower in patients with advanced-stage disease and older patients. Patients receiving second-line targeted therapy showed higher utility values at 0 to 3 months, 3 to 6 months, and 6 months and beyond (0.89, 0.90, and 0.88, respectively) than did those undergoing chemotherapy (0.81, 0.85, and 0.80, respectively). After using mixed models to control confounders, including poor performance status and disease progression, patients receiving second-line chemotherapy showed health utility similar to that at quasi-baseline, whereas utility values related to second-line targeted therapy were higher at 3 to 6 months and 6 months and beyond (β = 0.07, p = 0.010 and β = 0.07, p < 0.001, respectively). There was convergent validity between the utility values and scores of the physical and psychological domains.

CONCLUSION

Targeted therapy provided treated patients with a higher health utility value than was provided to those treated with chemotherapy. Development of the longitudinal trajectory may help predict changes in QoL and improve the care of lung cancer survivors.

Clustering of malignant pleural mesothelioma in asbestos factories: a subgroup analysis in a 29-year follow-up study to identify high-risk industries in Taiwan

OBJECTIVE

Exposure to asbestos is the major cause for malignant pleural mesothelioma (MPM), but the causal link of individual cases is difficult to establish for lack of exposure information and long disease latency.

METHODS

We established a retrospective cohort of workers employed in asbestos industries during the period of 1950-1989 and the occurrence of MPM during the period of 1980-2009 was examined with the Taiwan Cancer Registry. Estimated rate ratios (eRRs) were computed for each factory where any case of MPM was diagnosed by assuming Poisson distribution with a minimal latency of 20 years.

RESULTS

A total of 18 MPM (17 males, 1 female) in eight factories were found. The incidence rate of MPM for the eight factories was 18.0 per million, ranging from 6.2 per million (military factory) to 268.2 per million (asbestos cement). We observed significantly increased risks for MPM in asbestos cement, thermal insulation and shipbuilding industries, with eRR (genders combined) of 113.6, 87.5 and 15.8, respectively. The sensitivity analyses considering latency showed similar findings in latency ≥30 years, and the shipbuilding industry presented a significant eRR given a latency ≥40 years. The gender-specific eRR showed similar results in men, but high eRR of 729.6 was observed in an asbestos cement factory where a female MPM was diagnosed.

CONCLUSIONS

This nationwide study in Taiwan comprehensively shows that different asbestos manufacturing processes, including asbestos cement, thermal insulation and shipbuilding industries, were at significantly increased risks for MPM. We recommend to establish a medical screening programme for workers previously exposed to asbestos to identify MPM and other asbestos-related diseases at an earlier stage.

Universal health insurance, health inequality and oral cancer in Taiwan

INTRODUCTION

The introduction of universal health insurance coverage aims to provide equal accessibility and affordability of health care, but whether such a policy eliminates health inequalities has not been conclusively determined. This research aims to examine the healthcare outcomes of oral cancer and determine whether the universal coverage system in Taiwan has reduced health inequality.

METHODS

Linking the databases of the National Cancer Registry with the National Mortality Registry in Taiwan, we stratified patients with oral squamous cell carcinoma by gender and income to estimate the incidence rate, cumulative incidence rate aged from 20 to 79 (CIR20-79), life expectancy, and expected years of life lost (EYLL). The difficulties with asymmetries and short follow-up periods were resolved through applying survival analysis extrapolation methods.

RESULTS

While all people showed a general improvement in life expectancy after the introduction of the NHI, the estimated change in EYLL's of the high-, middle-, and low-income female patients were found to have +0.3, -0.5 and -7 years of EYLL, respectively, indicating a reduction in health inequality. Improvements for the male patients were unremarkable. There was no drop in the CIR20-79 of oral cancer in disadvantaged groups as in those with higher incomes.

CONCLUSIONS

Universal coverage alone may not reduce health inequality across different income groups for oral cancer unless effective preventive measures are implemented for economically disadvantaged regions.

Hyperthyroidism is not a significant risk of benign prostatic hyperplasia: A nationwide population-based study

Benign prostatic hyperplasia (BPH) is a common disorder in the aging male population. Despite evidence that thyroid status impacts the prostate, the objective of this study was to examine whether patients with hyperthyroidism were at a greater risk for BPH.This study is a retrospective nationwide population-based cohort study of the Chinese population. Data for this study were retrieved from the Taiwan National Health Insurance Research Database (NHIRD). Overall, 1032 male patients aged 40 years or older with hyperthyroidism diagnosed between 2000 and 2006 were included in the hyperthyroidism group, and 4128 matched controls without hyperthyroidism were included in the non-hyperthyroidism group. Both groups were monitored until the end of 2011. A Cox proportional hazards regression model was used to compute and compare the risk of BPH between study participants with and those without hyperthyroidism.Patients with hyperthyroidism exhibited a greater incidence of BPH (18.51% vs 15.53%) than did the controls. Furthermore, the hazard ratio (HR) of the hyperthyroidism group was 1.24 times that of the control group [95% confidence interval (95% CI 1.05-1.46)] signifying that there is a significant 24% increase in the risk of BPH with the presence of hyperthyroidism. This increased risk of BPH with hyperthyroidism, however, failed to remain significant (adjusted HR = 1.11, 95% CI = 0.94-1.3) after adjusting for covariates of age (adjusted HR = 2.72, 95% CI = 2.32-3.2), diabetes (adjusted HR = 1.4, 95% CI = 1.17-1.68), hypertension (adjusted HR = 1.74, 95% CI = 1.49-2.03), hyperlipidemia (adjusted HR = 1.25, 95% CI = 1.03-1.53), neurogenic bladder, cystitis (adjusted HR = 1.23, 95% CI = 0.58-2.59), urethral stricture (adjusted HR = 2.01, 95% CI = 0.28-14.47), urethritis (adjusted HR = 1.52, 95% CI = 0.72-3.21), and urinary tract infection (adjusted HR = 1.77, 95% CI = 1.31-2.39).After adjustment for comorbidities and covariates, hyperthyroidism was not found to be a significant risk factor of BPH in our male study subjects. Further research is warranted to validate our results and elucidate the association of the pathophysiology of these 2 diseases.

Estimate dynamic changes of dysfunction and lifelong spent for psychiatric care needs in patients with schizophrenia

BACKGROUND

Disturbance of functionality is one of the core features of schizophrenia, and has deleterious effects on a patient's employment, increased healthcare costs, and a large societal burden. Thus, if a patient's disability status could be predicted, and interventions needed identified in advance, poor outcomes could be prevented. To achieve this aim, we developed a method by which to assess dynamic changes of dysfunction and estimate the lifetime duration of disability in patients with schizophrenia, as a proxy for assessing their specialized healthcare needs.

METHODS

The proposed method was developed based on a nationwide database and a cross-sectional survey. The primary analysis investigated the dynamic change in the proportion of patients with manifested disability over time, while the secondary analysis estimated the lifetime duration of disability, obtained as the proportion of patients with manifested disability multiplied by the survival probability throughout the life of patients.

RESULTS

The average lifetime duration of manifested disability of global functioning was estimated to be 20.9 years, which represents approximately 73% of the whole lifetime of patients. The duration of disability in socially-useful activities was estimated to be 15.6 years, while that in personal and social relationships was 17.5 years. The female patients had a longer duration of manifested disability (22.9 years) than the male patients (19.5 years).

CONCLUSIONS

The developed method of analysis indicated that the longest lifetime durations of manifest disability were observed in the areas of socially-useful activities and personal and social relationships, and the proportions of patients with these disabilities rapidly increased at 200 months after diagnosis.

Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

Background

Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools.

Objective

This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them.

Methods

A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized.

Results

Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early.

Conclusions

To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.

Validation of EGFL6 expression as a prognostic marker in patients with lung adenocarcinoma in Taiwan: a retrospective study

OBJECTIVE

Lung adenocarcinoma is a non-small cell lung cancer, a common cancer in both genders, and has poor clinical outcome. Our aim was to evaluate the role of epidermal growth factor (EGF)-like domain multiple 6 (EGFL6) and its prognostic significance in lung adenocarcinoma.

METHODS

EGFL6 expression was studied by immunohistochemical staining of specimens from 150 patients with lung adenocarcinoma. The correlation between clinicopathological features and EGFL6 expression was quantitatively analysed. We used Kaplan-Meier analysis and Cox proportional hazard models to examine the prognostic value of EGFL6 in terms of overall survival.

RESULTS

No significant correlation was found between EGFL6 expression and clinical parameters. However, patients with high levels of EGFL6 expression showed a tendency towards poor prognosis, with borderline statistical significance. Grouping the patients according to a medium age value revealed a significant association between high EGFL6 expression and poor clinical outcome in young patients. This finding was further confirmed by grouping the patients into three groups according to age. HR in patients with high EGFL6 expression was higher in younger patients than in older patients.

CONCLUSION

High EGFL6 expression may serve as a marker for poor prognosis of lung adenocarcinoma, especially in younger patients.

Lifetime risks, loss of life expectancy, and health care expenditures for 19 types of cancer in Taiwan

Background

The mortality rates for different cancers are no longer an efficient tool for making national policy. The purpose of this study were to quantify the lifetime risks, life expectancies (LEs) after diagnosis, expected years of life lost (EYLL), and lifetime health care expenditures for 19 major cancers in Taiwan.

Methods

A total of 831,314 patients with 19 pathologically proven cancers were abstracted from the Taiwan Cancer Registry from 1998 to 2012. They were linked to the National Mortality Registry (1998–2014) and National Health Insurance reimbursement database (1998–2013) for survival and health care costs. We estimated the cumulative incidence rate for ages 0–79 years and the lifetime survival function for patients with different cancer sites. The EYLL was calculated by subtracting the LE of each cancer cohort from that of the age- and sex-matched referents simulated from national life tables. The estimated lifetime cost was calculated by adding up the product of survival probability and mean cost at the corresponding duration-to-date after adjustment for the inflation to the year of 2013.

Results

There were 5 cancers with a lifetime risk exceeding 4%: colorectal, liver, lung, and prostate in males, and breast and colorectal in females. Cancers with EYLL of >10 years were: esophageal, intrahepatic bile ducts, liver, pancreas, oral, nasopharyngeal, leukemia, lung, and gallbladder, extrahepatic bile ducts and biliary tract in males, and intrahepatic bile ducts, pancreas, nasopharyngeal, lung, esophageal, leukemia, liver, gallbladder, extrahepatic bile ducts and biliary tract, ovary, and stomach in females. Cancers with lifetime health care expenditures exceeding US$50,000 to the National Health Insurance were as follows: leukemia, kidney, testis, renal pelvis and ureter in males, and renal pelvis and ureter, leukemia, breast, urinary bladder, kidney, ovary, and nasopharyngeal in females. All these impacts should be considered in health policy decisions.

Conclusion

The impacts of cancer in Taiwan are very large. Future studies must consider both quality of life and the entire impact from societal perspectives.

Progress in the Management of Early-Stage Non-Small Cell Lung Cancer in 2017

The landscape of care for early-stage non-small cell lung cancer continues to evolve. While some of the developments do not seem as dramatic as what has occurred in advanced disease in recent years, there is a continuous improvement in our ability to diagnose disease earlier and more accurately. We have an increased understanding of the diversity of early-stage disease and how to better tailor treatments to make them more tolerable without impacting efficacy. The International Association for the Study of Lung Cancer and the Journal of Thoracic Oncology publish this annual update to help readers keep pace with these important developments. Experts in the care of early-stage lung cancer patients have provided focused updates across multiple areas including screening, pathology, staging, surgical techniques and novel technologies, adjuvant therapy, radiotherapy, surveillance, disparities, and quality of life. The source for information includes large academic meetings, the published literature, or novel unpublished data from other international oncology assemblies.