Treatment pathways, resource use and costs in the management of small cell lung cancer

End-of-life cost for lung cancer patients in Greece: a hospital-based retrospective study

Objective: The aim of the present study was to estimate the cost of treating patients with lung cancer at their end-of-life (EOL) phase of care in Greece. Materials & methods: A hospital-based retrospective study was conducted in the Oncology Unit of 'Sotiria' Hospital, in Athens, Greece. All lung cancer patients who died between 1 January 2015 and 31 December 2018 with at least 6 months follow-up were enrolled in the study. Healthcare resource utilization data, including inpatient and outpatient ones, during the last 6 months before death was extracted from a registry kept in the unit. This data were combined with the corresponding local unit costs to calculate the 6, 3 and 1-month EOL cost in €2019 values. Results: A total of 122 patients met the inclusion criteria. The mean (standard deviation) age at diagnosis was 67.8 (8.9) years with 78.7% of patients being male and 55.0% diagnosed at stage IV. About 52.5% of patients had been diagnosed with adenocarcinoma, 28.7% with squamous non-small-cell lung cancer types and 18.9% with small-cell-lung cancer. The median overall survival of these patients was 10.8 months. During the EOL periods, the mean cost/patient in the last 6, 3 and 1 month were €7665, €3351 and €1009, respectively. Pharmaceutical cost was the key driver of the total cost (75% of the total 6-month) followed by radiation therapy (16.2%). The median EOL 6-month cost was marginally statistically significantly higher among patients with adenocarcinoma (€9031) compared with squamous (€6606) and to small-cell-lung cancer (€5474). Conclusion: The findings of the present study indicate that lung cancer treatment incurs high costs in Greece, mainly attributed to pharmaceutical expenses, even at the EOL phase.

[Evolution of the costs and management of lung cancer between 2004 and 2014]

BACKGROUND

Given its morbidity and mortality, lung cancer is a major public health issue. In recent years, it has benefited from several therapeutic innovations. The objective of this study was to compare, over two distinct periods of ten years, the impact on survival and the costs of lung cancer management.

METHODS

The monocentric study assessed survival and the direct costs of lung cancer management of patients diagnosed in Brest University hospital in 2004 and in 2014.

RESULTS

The analysis included 142 patients in 2004 and 156 in 2014. Most patients were smokers (72%), metastatic at diagnosis (60%) both in 2004 and in 2014. Median survival was not significantly improved between the 2 periods (9.7 versus 10.9 months), but there was a significant increase in the average cost of care per patient (€ 17,063 vs. € 29,264, P=<0.0001) between 2004 and 2014.

CONCLUSION

The significant increase in treatment costs did not translate into an improvement in the survival of patients with lung cancer between 2004 and 2014.

End-of-Life Health-Care Cost of Patients With Lung Cancer: A Retrospective Study

Introduction:

Lung cancer exerts a significant societal and health-care–related economic burden and chemotherapy drugs constitute a major factor of total direct cost. The aim of the present study was to assess the direct health-care cost of lung cancer in Greece by conducting a retrospective analysis on the last 6 months of life.

Methods:

The present study was based on both the medical data and costs of treatment of deceased adult patients who suffered from terminal stage IIIB/IV lung cancer (non-small cell lung cancer and small cell lung cancer) during the last 6 months of their life. The study’s protocol was approved by the Hospital’s Research Ethics Committee. Costs included outpatient (outpatient services) and inpatient (inpatient services) costs. Descriptive statistics were mainly used for statistical analysis.

Results:

The files of 144 patients were analyzed. The total cost of health-care services for the study population during the last 6 months of life was attributed by 57% to inpatient services, whereas chemotherapy costs (74%) comprised the largest proportion of the total inpatient cost. The highest expenditure for outpatient services was attributed to concomitant medication (59%), followed by the cost of tests (21%) and radiotherapy (20%).

Conclusions:

The results of our study indicate that both inpatient and outpatient costs were substantial. The main inpatient and outpatient cost drivers were chemotherapy and concomitant medication, respectively. A more comprehensive nationwide study would be useful to validate our results and to include also indirect costs of cancer care in Greece.

Survival changes in patients with small cell lung cancer and disparities between different sexes, socioeconomic statuses and ages

Small cell lung cancer (SCLC), as a proportion, makes up only 15–17% of lung cancer cases. The development of treatments for SCLC has remained stagnant for decades, and SCLC is expected to persist as a threat to human health. To date, no publications based on large populations have been reported. We calculated survival changes in patients with SCLC during each decade between 1983 and 2012 to determine the roles of race, sex, age, and socioeconomic status (SES) on survival rates based on the Surveillance, Epidemiology, and End Results (SEER) registries. In total, 106,296 patients with SCLC were identified, with the overall incidence per 100,000 decreasing each decade from 9.6 to 7.8 to 5.8. The median survival for SCLC remained 7 months, and the 12-month relative survival rates (RSRs) remained relatively stable at 32.9%, 33.2% and 33.2% during each decade. The 5-year RSRs significantly improved from 4.9% to 5.9% to 6.4% during each decade, but remained extremely low. In addition, a narrowing of the survival gaps among SES groups and stable survival gaps between sexes were observed. Although the incidence of SCLC decreased during each decade, the overall survival remained relatively stable, highlighting the urgency of developing novel treatments and the importance of prevention and early detection.

Estimating the direct and indirect costs of lung cancer: a prospective analysis in a Greek University Pulmonary Department

BACKGROUND

Lung cancer (LC) is a disease with high morbidity and mortality while the prevention and treatment constitutes a significant financial burden. This economic burden has an increasing trend, with hospitalization being the highest cost factor in most studies, while the patients' quality of life (QoL) and response to treatment is not proven to be positively affected.

OBJECTIVE

To evaluate the direct and indirect cost of managing patients with LC in Greece according to stage and histological type of cancer, total chemotherapy cycles, age, gender, smoking habit, overall survival (OS), treatment outcome (TO) and QoL.

METHODS

One hundred thirteen of 128 consecutive patients met the inclusion criteria and were included in this prospective study. Patient enrolment started in August 2011 and ended in November 2011. The duration of the patient follow up was 32 months after diagnosis until end of registry. Total direct cost included diagnosis and treatment cost. Indirect cost constituted of patient's and family caregivers lost days of productivity. QoL was assessed with EORTC-QLQ-30 and Lung Cancer Symptom Scale (LCSS) questionnaires before treatment and every three months.

RESULTS

Total direct cost was €1,853,984 and chemotherapy drugs was the highest cost factor (€1,216,421). Total indirect cost was 28,774 days of which 27,293 were related to patients. Total direct cost was significantly related to the increased number of total chemotherapy cycles, longer OS, histological type of adenocarcinoma, female gender and younger patients. No relation was found between total indirect cost and the above factors. When the association between total direct/indirect cost and QoL was examined no significant results were drawn.

CONCLUSIONS

The burden of LC on health care systems remains very high and was associated with the increased number of total chemotherapy cycles, longer OS, adenocarcinoma histological type of cancer, female gender and younger patients. Chemotherapy drugs constituted the higher factor of total direct cost. Indirect cost was considerably higher for patients than family caregivers and did not significantly differ in relation to the above factors. No significant conclusion was drawn regarding QoL and total direct/indirect cost.

Cost-effectiveness of chemotherapy combined with thoracic radiotherapy versus chemotherapy alone for limited stage small cell lung cancer: A population-based propensity-score matched analysis

BACKGROUND

The addition of thoracic radiotherapy improves the outcome of limited stage small cell lung cancer (LS-SCLC), however, the cost-effectiveness of this process has never been reported. We aimed to estimate the short-term cost-effectiveness of chemotherapy combined with thoracic radiotherapy (C-TRT) versus chemotherapy alone (C/T) for LS-SCLC patients from the payer's perspective (Taiwan National Health Insurance).

METHODS

We identified LS-SCLC patients diagnosed within 2007-2009 through a comprehensive population-based database containing cancer and death registries, and reimbursement data. The duration of interest was one year within diagnosis. We included potential confounding covariables through literature searching and our own experience, and used a propensity score to construct a 1:1 population for adjustment. We used a net benefit (NB) approach to evaluate the cost-effectiveness at various willingness-to-pay (WTP) levels. Sensitivity analysis regarding potential unmeasured confounder(s) was performed.

RESULTS

Our study population constituted 74 patients. The mean cost (2013 USD) and survival (year) was higher for C-TRT (42 439 vs. 28 357; 0.94 vs. 0.88). At the common WTP level (50 000 USD/life-year), C-TRT was not cost effective (incremental NB - 11 082) and the probability for C-TRT to be cost effective (i.e. positive net benefit) was 0.005. The result was moderately sensitive to potential unmeasured confounder(s) in sensitivity analysis.

CONCLUSIONS

We provide evidence that when compared to C/T, C-TRT is effective in improving survival, but is not cost-effective in the short-term at a common WTP level from a payer's perspective. This information should be considered by clinicians when discussing thoracic radiotherapy with their LS-SCLC patients.

The magnitude, share and determinants of unpaid care costs for home-based palliative care service provision in Toronto, Canada

With increasing emphasis on the provision of home-based palliative care in Canada, economic evaluation is warranted, given its tremendous demands on family caregivers. Despite this, very little is known about the economic outcomes associated with home-based unpaid care-giving at the end of life. The aims of this study were to (i) assess the magnitude and share of unpaid care costs in total healthcare costs for home-based palliative care patients, from a societal perspective and (ii) examine the sociodemographic and clinical factors that account for variations in this share. One hundred and sixty-nine caregivers of patients with a malignant neoplasm were interviewed from time of referral to a home-based palliative care programme provided by the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital, Toronto, Canada, until death. Information regarding palliative care resource utilisation and costs, time devoted to care-giving and sociodemographic and clinical characteristics was collected between July 2005 and September 2007. Over the last 12 months of life, the average monthly cost was $14 924 (2011 CDN$) per patient. Unpaid care-giving costs were the largest component - $11 334, accounting for 77% of total palliative care expenses, followed by public costs ($3211; 21%) and out-of-pocket expenditures ($379; 2%). In all cost categories, monthly costs increased exponentially with proximity to death. Seemingly unrelated regression estimation suggested that the share of unpaid care costs of total costs was driven by patients' and caregivers' sociodemographic characteristics. Results suggest that overwhelming the proportion of palliative care costs is unpaid care-giving. This share of costs requires urgent attention to identify interventions aimed at alleviating the heavy financial burden and to ultimately ensure the viability of home-based palliative care in future.

First data on direct costs of lung cancer management in Morocco

BACKGROUND

Lung cancer is the leading cause of cancer morbidity and mortality. Its management has a significant economic impact on society. Despite a high incidence of cancer, so far, there is no national register for this disease in Morocco. The main goal of this report was to estimate the medical costs of lung cancer in our country.

METHODS

We first estimated the number of annual new cases according to stage of the disease on the basis of the Grand-Casablanca-Region Cancer Registry data. For each sub-group, the protocol of treatment was described taking into account the international guidelines, and an evaluation of individual costs during the first year following diagnosis was made. Extrapolation of the results to the whole country was used to calculate the total annual cost of treatments for lung cancer in Morocco.

RESULTS

Overall approximately 3,500 new cases of lung cancer occur each year in the country. Stages I and II account for only 4% of cases, while 96% are diagnosed at locally advanced or metastatic stages III and IV. The total medical cost of lung cancer in Morocco is estimated to be around USD 12 million. This cost represents approximately 1% of the global budget of the Health Department. According to AROME Guidelines, about 86% of the newly diagnosed lung cancer cases needed palliative treatment while 14% required curative intent therapy. The total cost of early and advanced stages lung cancer management during the first year were estimated to be 4,600 and 3,420 USD, respectively.

CONCLUSION

This study provides health decision-makers with a first estimate of costs and the opportunity to achieve the optimal use of available data to estimate the needs of health facilities in Morocco. A substantial proportion of the burden of lung cancer could be prevented through the application of existing cancer control knowledge and by implementing tobacco control programs.

Cost analysis of lung cancer management in South Western Sydney

INTRODUCTION

Lung cancer is the leading cause of cancer mortality in Western nations, and associated health-care costs are escalating. The aim of this study was to describe the current pattern of resource use and direct medical costs associated in managing lung cancer in South Western Sydney, Australia.

METHODS

All new cases of primary lung carcinoma discussed at the Liverpool and Macarthur Cancer Therapy Centre (CTC) Lung Cancer Multidisciplinary Team meeting or seen at CTC between 1 December 2005 and 21 December 2006 were reviewed. Staging investigations, hospitalisation, treatment and follow-up investigations were documented from first consultation to last follow-up (31 October 2008 or death). Cost estimates were based on the Australian Medicare Benefits Schedule and reported in Australian dollars. Infrastructure, staff and non-medical costs were excluded.

RESULTS

There were 210 patients, median age 68.2 years (range 39-90) with median follow-up of 16.6 months. The pathology and stage distribution were: 3.8% limited stage small cell lung cancer (SCLC), 10.0% extensive stage SCLC, 13.4% stage I and II non-small cell lung cancer (NSCLC), 28.5% stage III NSCLC and 44.3% stage IV NSCLC. The estimated total cost for managing this patient cohort was A$2.91 million. The cost components were: staging investigations (10.1%), treatment 41.2% (2.8% surgery, 15.8% radiotherapy and 22.6% chemotherapy), hospitalisation (43.7%) and follow-up investigations (5%). The median costs for managing NSCLC and SCLC subgroups were A$10,675 (range A$669-612,789) and A$14,799 (range A$908-31,057), respectively.

CONCLUSION

Hospitalisation and cancer treatment, particularly chemotherapy, accounted for the major components of direct medical costs in the management of lung cancer.

Impact of initial pattern of care on hospital costs in a cohort of incident lung cancer cases

RATIONALE, AIMS AND OBJECTIVES

Lung cancer is a disease with high consumption of health care resources. The aim of this study was to describe hospital costs due to lung cancer care from diagnosis until death or end of the study follow-up, in a cohort of incident cases, by using administrative data.

METHODS

Particular attention was given to the determinants of total costs and the impact of the initial treatment approach on the process of costs accumulation. Incident cases were identified by the local Cancer Registry (January 2000-December 2003) among the residents of Turin (Italy). Per patient hospital care has been determined from administrative databases (outpatient radiotherapy records and hospital discharge records). Costs determinants were identified via a multivariable generalized linear model (GLM), with a Gamma cost distribution and a logarithmic link function. To assess the time effect over the cost accumulation process for non-small-cell lung cancer cases, the same GLM Gamma model was repeated at different follow-up periods. Analyses were stratified by cancer histotype.

RESULTS

Results evidenced the relevant role of initial patterns of care on the cost accumulation process, with increased midterm costs associated with curative patterns of care.

CONCLUSION

The use of administrative data enabled hospital lung cancer care to be described, and related costs to be estimated.

The Ambulatory and Home Care Record: A Methodological Framework for Economic Analyses in End-of-Life Care

Provision of end-of-life care in North America takes place across a multitude of settings, including hospitals, ambulatory clinics and home settings. As a result, family caregiving is characteristically a major component of care within the home. Accordingly, economic evaluation of the end-of-life care environment must devote equal consideration to resources provided by the public health system as well as privately financed resources, such as time and money provided by family caregivers. This paper addresses the methods used to measure end-of-life care costs. The existing empirical literature will be reviewed in order to assess care costs with areas neglected in this body of literature to be identified. The Ambulatory and Home Care Record, a framework and tool for comprehensively measuring costs related to the provision and receipt of end-of-life care across all health care settings, will be described and proposed. Finally, areas for future work will be identified, along with their potential contribution to this body of knowledge.

[Costs of initial cancer care and its affecting factors]

OBJECTIVES

The purposes of this study is to estimate the cost of cancer care after its diagnosis and to identify factors that can influence the cost of cancer care.

METHODS

The study subjects were patients with an initial diagnosis one of four selected tumors and had their first two-years of cancer care at a national cancer center. The data were obtained from medical records and patient surveys. We classified cancer care costs into medical and nonmedical costs, and each cost was analyzed for burden type, medical service, and cancer stage according to cancer types. Factors affecting cancer care costs for the initial phase included demographic variables, socioeconomic status and clinical variables.

RESULTS

Cancer care costs for the initial year following diagnosis were higher than the costs for the following successive year after diagnosis. Lung cancer (25,648,000 won) had higher costs than the other three cancer types. Of the total costs, patent burden was more than 50% and medical costs accounted for more than 60%. Inpatient costs accounted for more than 60% of the medical costs for stomach and liver cancer in the initial phase. Care for late-stage cancer was more expensive than care for early-stage cancer. Nonmedical costs were estimated to be between 4,500,000 to 6,000,000 won with expenses for the caregiver being the highest. The factors affecting cancer care costs were treatment type and cancer stage.

CONCLUSIONS

The cancer care costs after diagnosis are substantial and vary by cancer site, cancer stage and treatment type. It is useful for policy makers and researchers to identify tumor-specific medical and nonmedical costs. The effort to reduce cancer costs and early detection for cancer can reduce the burden to society and improve quality of life for the cancer patients.

Hospitalisation days in patients with lung cancer in a general population

BACKGROUND

Little is known concerning the hospitalisation of all lung cancer patients in a geographically defined population.

METHOD

All incident lung cancer patients in the Haugalandet area in South-west Norway from 1990 through 1996 were followed from diagnosis till either death or end of follow-up 1 December 2003. Initial symptoms, anatomical stage, functional performance status, histology, initial treatment, terminal care, number of admissions as well as days of hospitalisation were recorded.

RESULTS

Of a total of 271 patients (57 women) only 16 were still alive at end of follow-up. Median survival time was 170 days. Mean age at the first admission was 67.4 years (range 21-89 years). Median number (inter quartile range) of admissions was 3 (2, 5) and total hospitalisation days 35 (18, 58). Altogether 26% of the days in institutional care were spent in nursing homes. The 31 patients surgically treated had the highest number of hospitalisation days: 75 (56, 96). Young age, low anatomical stage and good performance status at time of diagnosis were associated with increased use of hospitalisation days. Cox regression analysis showed that treatment interventions and dyspnoea were significant predictors when adjusting for age, tumour stage and performance status.

CONCLUSION

In a population-based cohort of incident lung cancer patients, days in health care institutions involved a large part (19%) of all survival time for those who died. However, the absolute number was greater for those with small tumours and high functional performance status which initiated other interventions than palliative treatment.

Cost and outcomes of patients with solitary pulmonary nodules managed with PET scans

BACKGROUND

No prior study to our knowledge has observed the cost of managing solitary pulmonary nodules of patient groups defined by PET scan results.

METHODS

We combined study and administrative data over 2 years of follow-up.

RESULTS

Of 375 individuals with a definitive diagnosis, 54.4% had a malignant nodule and 62.1% had positive PET scan results. Mortality risk was 5.0 times higher (CI, 3.1-8.2) and cost was greater (50,233 dollars vs 22,461 dollars, P<.0001) among patients with malignant nodule. Mortality risk was 4.1 times higher (CI, 2.4-7.0) and cost was greater (47,823 dollars vs 20,744 dollars, P<.0001) among patients with a positive PET scan result. Among patients with a malignant nodule, 4.9% had a false-negative PET scan, but cost and survival were not different from true positives. Among patients with a benign nodule, 22.8% had a false-positive PET scan. These patients had greater cost (33,783 dollars vs 19,115 dollars, P<.01), more surgeries and biopsies, and 3.8 times the mortality risk (CI, 1.6-9.2) of true negatives. Just over one-half (54.5%) of individuals with positive PET scans received surgery. Most individuals with negative PET scans (85.2%) were managed by watchful waiting. They incurred fewer costs than patients with negative PET scans who were managed more aggressively (19,378 dollars vs 28,611 dollars, P<.01).

CONCLUSIONS

Management of solitary pulmonary nodules is expensive, especially if the nodule is malignant or if the PET scan result is false positive. Among patients with malignant nodules, 2-year survival is poor. Compared with true-positive PET scan results, false-negative results are not associated with lower costs or better outcomes.

Could CT screening for lung cancer ever be cost effective in the United Kingdom?

Background

The absence of trial evidence makes it impossible to determine whether or not mass screening for lung cancer would be cost effective and, indeed, whether a clinical trial to investigate the problem would be justified. Attempts have been made to resolve this issue by modelling, although the complex models developed to date have required more real-world data than are currently available. Being founded on unsubstantiated assumptions, they have produced estimates with wide confidence intervals and of uncertain relevance to the United Kingdom.

Method

I develop a simple, deterministic, model of a screening regimen potentially applicable to the UK. The model includes only a limited number of parameters, for the majority of which, values have already been established in non-trial settings. The component costs of screening are derived from government guidance and from published audits, whilst the values for test parameters are derived from clinical studies. The expected health gains as a result of screening are calculated by combining published survival data for screened and unscreened cohorts with data from Life Tables. When a degree of uncertainty over a parameter value exists, I use a conservative estimate, i.e. one likely to make screening appear less, rather than more, cost effective.

Results

The incremental cost effectiveness ratio of a single screen amongst a high-risk male population is calculated to be around £14,000 per quality-adjusted life year gained. The average cost of this screening regimen per person screened is around £200. It is possible that, when obtained experimentally in any future trial, parameter values will be found to differ from those previously obtained in non-trial settings. On the basis both of differing assumptions about evaluation conventions and of reasoned speculations as to how test parameters and costs might behave under screening, the model generates cost effectiveness ratios as high as around £20,000 and as low as around £7,000.

Conclusion

It is evident that eventually being able to identify a cost effective regimen of CT screening for lung cancer in the UK is by no means an unreasonable expectation.

Factors influencing hospital costs of lung cancer patients in Northern Ireland

Lung cancer is a major cause of morbidity and mortality. In this paper, the hospital costs incurred by 724 lung cancer patients diagnosed in 2001 were determined by review of case notes. These represented all patients diagnosed with lung cancer in Northern Ireland on whom data existed in that year. Total hospital costs in the 12 months from presentation for the 724 patients were 3.99 million pounds. Average patient costs were 5,956 pounds for patients diagnosed with non-small cell lung cancer and 5,876 pounds for those with small cell lung cancer. The main component of cost was inpatient stay, representing between 62 and 84% of costs depending on cell type. Multivariate analyses revealed significant differences in cost related to staging, co-morbidities, age, and deprivation. Total annual hospital costs were 13 times as high as the estimated enforcement cost of the smoke-free legislation in Northern Ireland.

The cost of lung cancer in Alberta

BACKGROUND

Lung cancer is the leading cause of cancer morbidity and mortality. In addition, lung cancer has a significant economic impact on society.

OBJECTIVE

To present an economic analysis of the actual care costs of lung cancer which will allow comparison with, and verification of, cost estimates that were developed through modelling and opinion.

METHODS

A chart review was conducted of incident cases (circa 1998) of primary bronchogenic lung cancer. Cases were censored at two years from the date of diagnosis. Relevant clinical and health utilization data were collected. Health utilization data included hospital and institutional outpatient (ie, ambulatory clinic) costs. Cost estimates were derived for over 200 specific health services. The present analysis was performed from the economic perspective of the health care institution.

RESULTS

A total of 13,389 health service events were captured with an estimated total cost of $8.4 million. Laboratory tests, diagnostic imaging and ambulatory visits constituted 86% of the service events while patient admissions and therapy constituted 76% of the costs. The vast majority of overall costs occurred just before, or within, three months of diagnosis. The median nonsmall cell lung cancer and small cell lung cancer case costs were $10,928 (range $9,234 to $11,047) and $15,350 (range $13,033 to $21,436), respectively.

CONCLUSION

The results agree with the literature that the majority of lung cancer case costs are realized around the date of diagnosis (ie, early phase). The present study illustrates Canadian health care system lung cancer case costs based on actual care received versus hypothetical care algorithms.

The Quit Benefits Model: a Markov model for assessing the health benefits and health care cost savings of quitting smoking

Background

In response to the lack of comprehensive information about the health and economic benefits of quitting smoking for Australians, we developed the Quit Benefits Model (QBM).

Methods

The QBM is a Markov model, programmed in TreeAge, that assesses the consequences of quitting in terms of cases avoided of the four most common smoking-associated diseases, deaths avoided, and quality-adjusted life-years (QALYs) and health care costs saved (in Australian dollars, A$). Quitting outcomes can be assessed for males and females in 14 five year age-groups from 15–19 to 80–84 years.

Exponential models, based on data from large case-control and cohort studies, were developed to estimate the decline over time after quitting in the risk of acute myocardial infarction (AMI), stroke, lung cancer, chronic obstructive pulmonary disease (COPD), and death. Australian data for the year 2001 were sourced for disease incidence and mortality and health care costs. Utility of life estimates were sourced from an international registry and a meta analysis.

In this paper, outcomes are reported for simulated subjects followed up for ten years after quitting smoking. Life-years, QALYs and costs were estimated with 0%, 3% and 5% per annum discount rates. Summary results are presented for a group of 1,000 simulated quitters chosen at random from the Australian population of smokers aged between 15 and 74.

Results

For every 1,000 males chosen at random from the reference population who quit smoking, there is a an average saving in the first ten years following quitting of A$408,000 in health care costs associated with AMI, COPD, lung cancer and stroke, and a corresponding saving of A$328,000 for every 1,000 female quitters. The average saving per 1,000 random quitters is A$373,000. Overall 40 of these quitters will be spared a diagnosis of AMI, COPD, lung cancer and stroke in the first ten years following quitting, with an estimated saving of 47 life-years and 75 QALYs. Sensitivity analyses indicated that QBM predictions were robust to variations of ± 10% in parameter estimates.

Conclusion

The QBM can answer many of the questions posed by Australian policy-makers and health program funders about the benefits of quitting, and is a useful tool to evaluate tobacco control programs. It can easily be re-programmed with updated information or a set of epidemiologic data from another country.

Cost-effectiveness of hypothetical new cancer drugs in patients with advanced small-cell lung cancer: results of a markov chain model

BACKGROUND

In the last decade, a number of new treatment modalities have been developed for patients with small cell lung cancer (SCLC). The clinical effects are encouraging, but little is known about the costs and cost-effectiveness of new drugs.

METHODS

A Markov chain model has been developed to project patient outcomes and costs for patients with advanced SCLC. All patients in the control group were treated with etoposide-cisplatin chemotherapy. Patients in the study group received a hypothetical new drug. The model consisted of four states: response, stable disease, progressive disease, and death. Estimates of transition probabilities were calculated using published data on survival and recurrence-free survival. For the cost analysis and utility calculation, published data and expert opinion were used as sources. The duration of the follow-up was maximal 2 years.

RESULTS

The total treatment costs in the etoposide-cisplatin group amounted to euro16 038 and in the alternative treatment groups between euro16 644 and euro18 171. The number of life years and quality adjusted life years (QALYs) gained were very small, around 16 days. The cost-effectiveness ratio varied between euro22 208 and euro81 443 and the cost-utility ratio varied accordingly. Results of the sensitivity analysis showed that the results were robust in favor of etoposide-cisplatin treatment.

CONCLUSION

SCLC is an illness with a poor prognosis which needed substantial healthcare resources to optimise patient survival and overall quality of life. New treatment modalities with better outcome and favourable cost-effective profiles can hopefully be developed.

The economic burden of lung cancer and the associated costs of treatment failure in the United States

The economic burden of lung cancer was examined with a retrospective case-control cohort study on a database containing inpatient, outpatient and drug claims for employees, dependents and retirees of multiple large US employers with wide geographic distribution. Patients were followed for maximum of 2 years from first cancer diagnosis until death, health benefits dis-enrollment or study end (31 December 2000). Compared with controls (subjects without any cancer), patients with lung cancer (n = 2040) had greater health care service utilization and costs for hospitalization, emergency room visits, outpatient office visits, radiology procedures, laboratory procedures and pharmacy-dispensed drugs (all P < 0.05). Regression-adjusted mean monthly total costs were US dollar 6520 for patients versus US dollar 339 for controls (P < 0.0001), and overall costs across the study period (from diagnosis to death or maximum of 2 years) were US dollar 45,897 for patients and US dollar 2907 for controls (P < 0.0001). The main cost drivers were hospitalization (49.0% of costs) and outpatient office visits (35.2% of costs). Monthly initial treatment phase costs (US dollar 11,496 per patient) were higher than costs during the secondary treatment phase (US dollar 3733) or terminal care phase (US dollar 9399). Failure of initial treatment was associated with markedly increased costs. Compared with patients requiring only initial treatment, patients experiencing treatment failure accrued an additional US dollar 10,370 per month in initial treatment phase costs and US dollar 8779 more per month after starting the secondary and/or terminal care phase. Over the course of the study period, these patients had total costs of US dollar 120,650, compared with US dollar 45,953 for those receiving initial treatment only. Thus, the incremental costs associated with treatment failure were US dollar 19,149 per month and US dollar 74,697 across the study period. Other types of clinical and epidemiological analysis are needed to identify risks for treatment failure. The economic burden of lung cancer on the US health care system is significant and increased prevention, new therapies or adjuvant chemotherapy may reduce both resource use and healthcare costs. New strategies for lung cancer that reduce hospitalizations and/or prevent or delay treatment failure could offset some of the economic burden associated with the disease.

Les composantes du coût des stratégies de prise en charge du cancer du poumon en France

INTRODUCTION

To evaluate the average cost of therapeutic strategies for the management of lung cancer in relation to histological type and diagnostic staging and of the individual components of the management strategy.

METHODS

Samples were taken between 1 September 1998 and 30 June 1999 from centres with sufficient numbers of lung cancer (LC) cases. All events over an 18 Month period were collected from a retrospective analysis of the records. A Markov model was constructed based on decision branches for localised and diffuse small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Several components of management were identified: first line treatment, second line treatment, observation, terminal care and death.

RESULTS

The average cost of LC was 22,006 Euro (10,631-36,296) for one year and 25,643 Euro (10,631-46,191) for two years. For SCLC the average annual costs were 22,420 Euro for diffuse disease and 27,098 for localised disease. For NSCLC the totals ranged from 19,543 Euro for inoperable stage I and II tumours to 39,424 for operable tumours. The cost for stage IV tumours was 24,383 Euro. The cost components over two Years varied according to the tumour type. The cost of diagnosis ranged from 6-14%, the cost of management and of terminal care from 33-45% of the total. Analyses of sensitivity confirmed that whatever the histological type or diagnostic staging the percentage of patients initially treated actively (that is to say not by palliative care) had the greatest effect on the total cost, greater than the costs of terminal care and of two courses of chemotherapy.

CONCLUSIONS

This model has allowed for the first time the calculation of the contributions of the different therapeutic components to the total cost of the management of lung cancer in France. In the future it will allow analysis of the economic impact of new methods of treatment.

Economics of the clinical management of lung cancer in France: an analysis using a Markov model

To evaluate, according to the histologic type and initial stage, the mean cost (MC) of managing patients with lung cancer and the costs of the different management phases. A Markov approach was used to model these costs, based on the management of a representative nation-wide sample of 428 patients with newly diagnosed lung cancer. The 18-month MC ranged from US$ 20 691 (95% CI: 5777–50 380 for diffuse non-small-cell lung cancer (NSCLC) to US$ 31 833 (95% CI: 15 866–64 455) for localised small-cell lung cancer (SCLC); first-line treatment costs ranged from 33.8% of MC for medically inoperable localised NSCLC to 74.6% for diffuse SCLC; second- or third-line treatment costs ranged from 7.8% of MC for surgically treated localised NSCLC to 32% for locally advanced NSCLC; and the cost of palliative care ranged from 9.1% of MC for locally advanced NSCLC to 39.9% for medically inoperable localised NSCLC. The cost of first-line chemotherapy and the percentage of actively treated patients impacted more on MC than did the cost of second- or third-line chemotherapy regimens or the cost of palliative care. In conclusion, this model provides a robust economic analysis of the cost of lung cancer management, and will be useful for assessing the economic consequences of future changes in patient management.

Management and costs of treating lung cancer patients in a university hospital

BACKGROUND

New diagnostic tools and emerging medications have significantly changed the existing medical treatment options for lung cancer over the last 5 years. However, the increase in healthcare costs in all developed societies has put the more economical treatments on centre stage.

OBJECTIVE

To examine the patterns and costs of lung cancer management at a Swiss University hospital at which there is a focus on interdisciplinary treatment.

PATIENTS AND METHODS

All patients encountered during 1998 at the University Hospital of Zurich (USZ) with any diagnosis of lung cancer were selected for this retrospective study. Medical and sociodemographic data were collected by medical chart review for a period beginning with the first contact and ending with the last follow-up examination up to 30 months afterwards. Costs were calculated by assessing all resources used by each patient, multiplied by a uniform average cost factor. Results are in euros at 1999 prices.

RESULTS

The sample included 118 patients (72% male) with a mean age of 64.2 years (SD 9.8, range 34-85 years) and a mean smoking history of 45 pack-years (SD 31.8, range 0-13 pack-years). Eighty-nine percent of all patients showed histology of non-small cell lung cancer (NSCLC), whereas 11% showed small cell lung cancer (SCLC). Of the NSCLC patients, 27% were classified as stage I, 14% as stage II, 19% as stage IIIA, 11% as stage IIIB and 26% as stage IV disease. The overall survival rate after 1 year was 55% and after 2 years was 29%. Gender and health insurance status were not associated with overall survival. The median length of hospitalisation during the first year of treatment was 14 days (range 0-112 days). For the entire patient sample, the mean cost per patient was 19,408 euros (median 14,691 euros, range 1821-80,020 euros), 71% of which was due to the hospitalisation costs. The mean cost per NSCLC patient was 19,212 euros (median 14,511 euros, range 1821-80,020 euros) and for SCLC patients it was 20,992 euros (median 15,367 euros, range 5282-51,840 euros).

CONCLUSION

This is the first study attempting to estimate the hospital cost of treatment for lung cancer patients in Switzerland and central Europe. The major part of the total cost was due to hospitalisation costs. Patients with advanced stages of lung cancer show the highest cost, mainly due to the costs of chemotherapy. We found that the distribution of total cost is asymmetric: a small number of patients with an excessively long hospital stay cause very high costs.

Is there standard chemotherapy for metastatic bladder cancer? Quality of life and medical resources utilization based on largest to date randomized trial

A large multinational phase III trial performed during the late 1990s compared two systemic chemotherapy regimens gemcitabine plus cisplatin and methotrexate, vinblastine, doxorubicin, cisplatin (M-VAC) in more than 400 patients with advanced or metastatic urothelial cancer. This trial has been discussed to landmark the beginning of a new era following M-VAC polychemotherapy which has dominated treatment of advanced urothelial cancer throughout the previous decade. Despite the fact that gemcitabine/cisplatin combination therapy did not surpass M-VAC therapy in regard to patient survival as initially intended, this combination demonstrated a more favourable toxicity profile with improved tolerability and superior cost effectiveness, rendering this combination an attractive alternative to M-VAC. This review on the largest to date phase III trial for advanced or metastatic urothelial cancer will focus on issues of quality of life including indicators such as performance status and changes in body weight. Furthermore, data on medical resources utilization as accounted during systemic polychemotherapy and related toxic events will be reconsidered, particularly under the impression of decreasing health care resources worldwide.

Direct treatment costs for patients with lung cancer from first recurrence to death in france

OBJECTIVE

To determine the direct treatment cost of lung cancer management from progression to death from the viewpoint of the hospital.

METHODS

A retrospective descriptive study was performed. Data from 100 patients who died of lung cancer and who had received treatment from four different types of hospital were used; the hospitals were public hospitals (teaching and non-teaching), private not-for-profit cancer centres, and private hospitals. Resource utilisation/cost data collected included the cost of diagnosis of the recurrence, the cost of hospitalisations or day care treatments and ambulatory surgery. All resources were valued in 2001 euros.

RESULTS

In France, the average cost per patient was euro12 518 for the whole group (78% with non-small cell lung cancer [NSCLC], and 22% with small cell lung cancer [SCLC]), euro13 969 for patients with NSCLC and euro7369 for patients with SCLC. The higher cost of treatment in patients with NSCLC is explained by longer survival and duration of chemotherapy. In patients with NSCLC, 51% of the total cost corresponded to terminal care, with up to seven lines of chemotherapy. In patients with SCLC, the costs of diagnosis and terminal care each represented 41% of the total cost.

CONCLUSIONS

The cost of treatment of recurrence of lung carcinoma is high, and is related to the number of lines of chemotherapy and the use of radiotherapy and surgery.