Estimation of lung cancer diagnosis and treatment costs based on a patient-level analysis in Catalonia (Spain)

Cost-Effectiveness of a Multi-faceted Workplace Intervention to Reduce Musculoskeletal Pain in Nursing Staff: A Cluster-Randomized Controlled Trial (INTEVAL_Spain)

PURPOSE

To evaluate the cost-effectiveness of a multifaceted workplace intervention to reduce musculoskeletal pain (MSP) in nursing staff.

METHODS

The study was a 1-year cluster-randomized controlled trial. The intervention combined participatory ergonomics, health promotion, and case management. The control group received usual care. Societal and health system perspectives were used. Costs included direct health and indirect costs. The effects were MSP and quality-adjusted life years (QALYs). MSP was measured using the Standardized Nordic Questionnaire at baseline and 6- and 12-month follow-up. QALYs were measured using the EuroQol-5D-3L at 6- and 12-month follow-up. Incremental costs and QALYs were modelled using generalized linear models. MSP was analysed through generalized logistic models. Incremental cost-effectiveness ratios (ICERs) were calculated, and cost-effectiveness planes and acceptability curves were constructed.

RESULTS

Total mean costs per person were €614 and €216 for the intervention and control group, respectively, with a societal perspective. The intervention mean cost was €38/person. From the societal perspective, the ICER showed that overall additional €68 (€9 from a health system perspective) were required to achieve 1-extra-percentage-point reduction of MSP. ICERs were €34 from the societal and €4 from the health system perspectives for neck, shoulders and upper back pain; €53 and €7 for low back; €179 and €23 for hands; €39 and €5 for legs; €115 and €14 for the knees; €36 and €5 for feet For MSP in the elbows. For participants with pain in the elbow, and for QALYs, the ICER showed that the intervention group was dominated by the control group.

CONCLUSION

This intervention was not cost-effective in terms of QALYs. However, in terms of MSP, with a willingness to pay of €100, the probability of the intervention being cost-effective was around 90%. Further studies incorporating our recommendations are needed to confirm these findings.

STUDY REGISTRATION

ISRCTN15780649, retrospectively registered.

Evolution of Diagnoses, Survival, and Costs of Oncological Medical Treatment for Non-Small-Cell Lung Cancer over 20 Years in Osona, Catalonia

Non-small-cell lung cancer (NSCLC) has experienced several diagnostic and therapeutic changes over the past two decades. However, there are few studies conducted with real-world data regarding the evolution of the cost of these new drugs and the corresponding changes in the survival of these patients. We collected data on patients diagnosed with NSCLC from the tumor registry of the University Hospital of Vic from 2002 to 2021. We analyzed the epidemiological and pathological characteristics of these patients, the diverse oncological treatments administered, and the survival outcomes extending at least 18 months post-diagnosis. We also collected data on pharmacological costs, aligning them with the treatments received by each patient to determine the cost associated with individualized treatments. Our study included 905 patients diagnosed with NSCLC. We observed a dynamic shift in histopathological subtypes from squamous carcinoma in the initial years to adenocarcinoma. Regarding the treatment approach, the use of chemotherapy declined over time, replaced by immunotherapy, while molecular therapy showed relative stability. An increase in survival at 18 months after diagnosis was observed in patients with advanced stages over the most recent years of this study, along with the advent of immunotherapy. Mean treatment costs per patient ranged from EUR 1413.16 to EUR 22,029.87 and reached a peak of EUR 48,283.80 in 2017 after the advent of immunotherapy. This retrospective study, based on real-world data, documents the evolution of pathological characteristics, survival rates, and medical treatment costs for NSCLC over the last two decades. After the introduction of immunotherapy, patients in advanced stages showed an improvement in survival at 18 months, coupled with an increase in treatment costs.

New systemic treatment paradigms in resectable non-small cell lung cancer and variations in patient access across Europe

The treatment landscape of resectable early-stage non-small cell lung cancer (NSCLC) is set to change significantly due to encouraging results from randomized trials evaluating neoadjuvant and adjuvant immunotherapy, as well as adjuvant targeted therapy. As of January 2024, marketing authorization has been granted for four new indications in Europe, and regulatory approvals for other study regimens are expected. Because cost-effectiveness and reimbursement criteria for novel treatments often differ between European countries, access to emerging developments may lead to inequalities due to variations in recommended and available lung cancer care throughout Europe. This Series paper (i) highlights the clinical studies reshaping the treatment landscape in resectable early-stage NSCLC, (ii) compares and contrasts approaches taken by the European Medicines Agency (EMA) for drug approval to that taken by the United States Food and Drug Administration (FDA), and (iii) evaluates the differences in access to emerging treatments from an availability perspective across European countries.

Systematic Literature Review to Identify Cost and Resource Use Data in Patients with Early-Stage Non-small Cell Lung Cancer (NSCLC)

BACKGROUND

Approximately 2 million new cases and 1.76 million deaths occur annually due to lung cancer, with the main histological subtype being non-small cell lung cancer (NSCLC). The costs and resource use associated with NSCLC are important considerations to understand the economic impact imposed by the disease on patients, caregivers and healthcare services.

OBJECTIVE

The objective of this systematic literature review (SLR) is to provide a comprehensive overview of the available direct medical costs, direct non-medical costs, indirect costs, cost drivers and resource use data available for patients with early-stage NSCLC.

METHODS

Electronic searches were conducted via the Ovid platform in March 2021 and June 2022 and were supplemented by grey literature searches. Eligible patients had early-stage (stage I-III) resectable NSCLC and received treatment in the neoadjuvant or adjuvant setting. There was no restriction on intervention or comparators. Publication date was restricted to 2011 onwards, and English language publications or non-English language publications with an English abstract were of primary interest. Due to the anticipation of many studies meeting the inclusion criteria, analyses were restricted to full publications from countries of primary interest (Australia, Brazil, Canada, China, France, Germany, Italy, Japan, South Korea, Spain, UK and the US) and those with > 200 patients. The Molinier checklist was applied to conduct quality assessment.

RESULTS

Forty-two full publications met the eligibility criteria and were included in this SLR. Early-stage NSCLC was associated with significant direct medical costs and healthcare utilisation, and the economic burden of the disease increased with its progression. Surgery was the primary cost driver in stage I patients, but as patients progressed to stage II and III, treatments such as chemotherapy and radiotherapy, and inpatient care became the main cost drivers. There was no significant difference in resource use between patients with early-stage disease. However, these data were heavily US-centric and there was a paucity of data relating to direct non-medical and indirect costs associated with early-stage NSCLC.

CONCLUSIONS

Preventing disease progression for patients with NSCLC could reduce the economic burden of NSCLC on patients, caregivers and healthcare systems. This review provides a comprehensive overview of the available cost and resource use data in this indication, which is important in guiding the decisions of policy makers regarding the allocation of resources. However, it also indicates a need for more studies comparing the economic impact of NSCLC in markets in addition to the US.

Economic burden of lung cancer in Morocco: A cost of illness study

INTRODUCTION

Lung cancer is the most common cancer in men and the second most common cancer in women. It is associated with substantial economic impact in terms of direct and indirect costs. The main objective of this study is to estimate the direct medical cost of lung cancer management in Morocco MATERIALS AND METHODS: A cost-of-illness study was conducted among patients treated at the Mohammed VI Center of Cancer (Casablanca) in 2019. The costs were estimated from the societal perspective using a bottom-up approach. The materials and procedures used were identified and quantified retrospectively from the information system and files. Their monetary value was calculated according to official prices published by the national health insurance agency. The horizon time adopted was 12 months.

RESULTS

The study included 271 patients, with an average age of 62.5 ± 9.5 years. Of these, 93.4 % were men and 92.1 % were former smokers. In terms of cancer staging, 68.3 % of patients were in stage IV while 28.8 % were in stage III. Adenocarcinoma was present in 43.5 % of cases. Patients underwent an average of 10.6 ± 5.1 radiological investigations, 56.1 ± 30.9 biological tests, and 24.1 ± 11.7 consultations. The average direct medical cost was 4455.3 USD (95 % CI: 4037.4-4873.2). Chemotherapy accounted for 19.9 % of the total cost, while radiological investigations and drugs accounted for 18.7 % and 17.6 %, respectively. Diagnostic tests and radiotherapy each accounted for 7.6 % of the total cost, while biological tests accounted for 7.5 % and hospitalizations accounted for 7.1 %. The cost was statistically higher in young patients (p = 0.017), in patients with adenocarcinoma (p < 0.0001), in patients with stage II tumor (< 0.00001), in patients who have undergone surgery (p = 0.002), chemotherapy (p < 0.0001), radiotherapy (p < 0.001) and in those without metastases (p < 0.0001).

CONCLUSION

These results provide evidence to support the ratification of the Framework Convention on Tobacco Control and the full adherence of the Kingdom of Morocco to the MPOWER measures.

Economic burden of locoregional and metastatic relapses in resectable early-stage non-small cell lung cancer in Spain

BACKGROUND

There are scarce data of the costs of non-small cell lung cancer (NSCLC) recurrence in Spain. The objective of this study is to assess the economic burden of disease recurrence, for both locoregional and/or metastatic relapses, after appropriate early-stage NSCLC treatment in Spain.

MATERIALS AND METHODS

A two-round consensus panel of Spanish oncologists and hospital pharmacists was conducted to collect information on patient's flow, treatments, use of healthcare resources and sick leaves in patients with relapsed NSCLC. A decision-tree model was developed to calculate the economic burden of disease recurrence after appropriate early-stage NSCLC. Both direct and indirect costs were considered. Direct costs included drug acquisition and healthcare resources costs. Indirect costs were estimated using the human-capital approach. Unit costs were obtained from national databases (euros of 2022). A multi-way sensitivity analysis was performed to provide a range to the mean values.

RESULTS

Among a cohort of 100 patients with relapsed NSCLC, 45 patients would have locoregional relapse (36.3 would eventually progress to metastasis and 8.7 would be considered in remission) and 55 patients would have metastatic relapse. Over time, 91.3 patients would experience a metastatic relapse (55 as first relapse and 36.6 after previous locoregional relapse). The overall cost incurred by the 100-patients cohort is €10,095,846 (€9,336,782 direct costs, €795,064 indirect costs). The average cost of a locoregional relapse is €25,194 (€19,658 direct costs, €5536 indirect costs), while the average cost a patient with metastasis who receives up to 4 lines of treatment is €127,167 (€117,328 direct, €9839 indirect).

CONCLUSIONS

To our knowledge, this is the first study that specifically quantifies the cost of relapse in NSCLC in Spain. Our findings shown that the overall cost of a relapse after appropriate treatment of early-stage NSCLC patients is substantial, and it increases considerably in the metastatic relapse setting, mainly due to the high cost and long duration of first-line treatments.

Estimating ambient air pollution mortality and disease burden and its economic cost in Barcelona

BACKGROUND

The new WHO air quality guidelines indicate that the air pollution disease burden is greater than previously reported. We aimed to estimate the air pollution disease burden and its economic cost in Barcelona to inform local action.

METHODS

We used a quantitative health impact assessment to estimate the non-accidental mortality and incidence of childhood asthma and lung cancer attributable to long-term air pollution exposure in the city of Barcelona (Spain) in 2018-2019. We used the population weighted mean of PM_2.5 and NO₂ assigned at the geocoded address during the study period and the 2021 WHO air quality guidelines as counterfactual scenario to estimate new annual cases attributable to each pollutant separately and combined. We estimated the social cost of attributable deaths and the health care cost of childhood asthma and lung cancer attributable cases. We also estimated attributable mortality by city district and the mortality avoidable by achieving the WHO air quality interim targets.

RESULTS

Mean exposure was 17 μg/m³ for PM_2.5 and 39 μg/m³ for NO₂. Total combined air pollution attributable mortality was 13% (95%CI = 9%-17%), corresponding to 1,886 deaths (95%CI = 1,296-2,571) and a social cost of €1,292 million (95%CI = 888-1,762) annually. Fifty-one percent (95%CI = 21%-71%) and 17% (95%CI = 7%-29%) of new cases of childhood asthma and lung cancer were attributable to air pollution with a health care cost of €4.3 and €2.7 million, respectively. Achieving the first unmet WHO air quality interim targets for PM_2.5 and for NO₂ would avoid 410 deaths and €281 million annually.

CONCLUSION

Air pollution in Barcelona represents a huge disease and economic burden, which is greater than previous estimates. Much stronger measures to reduce PM_2.5 and NO₂ levels are urgently needed. Until the WHO air quality guidelines are met in the city, achieving each WHO air quality interim targets would avoid hundreds of deaths each year.

Changes in Treatment Patterns and Costs for Lung Cancer Have Not Resulted in Relevant Improvements in Survival: A Population-Based Observational Study in Catalonia

OBJECTIVE

Few published studies have described multidisciplinary therapeutic strategies for lung cancer. This study aims to describe the different approaches used for treating lung cancer in Catalonia in 2014 and 2018 and to assess the associated cost and impact on patient survival.

METHODS

A retrospective observational cohort study using data of patients with lung cancer from health care registries in Catalonia was carried out. We analyzed change in treatment patterns, costs and survival according to the year of treatment initiation (2014 vs. 2018). The Kaplan-Meier method was used to estimate survival, with the follow-up until 2021.

RESULTS

From 2014 to 2018, the proportion of patients undergoing surgery increased and treatments for unresectable tumors decreased, mainly in younger patients. Immunotherapy increased by up to 9% by 2018. No differences in patient survival were observed within treatment patterns. The mean cost per patient in the first year of treatment increased from EUR 14,123 (standard deviation [SD] 4327) to EUR 14,550 (SD 3880) in surgical patients, from EUR 4655 (SD 3540) to EUR 5873 (SD 6455) in patients receiving curative radiotherapy and from EUR 4723 (SD 7003) to EUR 6458 (SD 10,116) in those treated for unresectable disease.

CONCLUSIONS

From 2014 to 2018, surgical approaches increased in younger patients. The mean cost of treating patients increased, especially in pharmaceutical expenditure, mainly related to the use of several biomarker-targeted treatments. While no differences in overall patient survival were observed, it seems reasonable to expect improvements in this outcome in upcoming years as more patients receive innovative treatments.

Expected Cost Savings from Low Dose Computed Tomography Scan Screening for Lung Cancer in Alberta, Canada

Introduction

The expensive modern therapeutic regimens for advanced lung cancer (LC) stages have been recently approved. We evaluated whether low-dose computed tomography (LDCT) LC screening of high-risk Albertans is cost saving.

Methods

We used a decision analytical modeling technique with a health system perspective and a time horizon of 3 years to compare benefits associated with reduced health service utilization (HSU) from earlier diagnosis to the costs of screening. Using patient-level data, HSU costs by stage of disease were estimated for patients with LC, including inpatient, outpatient, and physician services, and costs for prescription drugs and cancer treatments.

Results

Of 101,000 people aged 55 to 74 years eligible for screening, an estimated 88,476 scans would be performed in Alberta in 3 years. Given LDCT sensitivity and specificity of 90.5% and 93.1%, respectively, we estimated that a stage shift toward earlier diagnosis would be expected whereby 43% more patients would be identified at stage 1 or 2 as compared with without screening. The estimated cost of screening is $35.6 million (M), whereas the stage shift associated with screening would avoid $42M in HSU costs. The net cost avoidance associated with screening is therefore $6.65M. The probability for the screening to be cost saving is estimated at 72%.

Conclusions

This study has revealed that LDCT LC screening is likely to be cost saving in Alberta. Adoption of this program into the provincial health care system is worth considering provided constraints in the system related to surgical capacity and CT wait times could be addressed.

Cost-effectiveness analysis of a lung cancer screening programme in Spain

OBJECTIVE

To evaluate the cost-effectiveness of the implementation of national lung cancer (LC) screening programme (SP) in a high-risk population from the perspective of the Spanish National Health System (NHS).

METHODS

A cost-effectiveness analysis for a LC SP was carried out on a lifetime horizon. A Markov model was designed that assumed two scenarios, one with the implementation of the SP and another one without it. Effectiveness and cost of LC management, diagnosis and screening were included in the different health states. Deterministic and probabilistic sensitivity analyses were conducted to evaluate its robustness. A discount rate was set at 3% both for effectiveness and cost.

RESULTS

In the base-case, an increase of 4.80 quality-adjusted life years (QALY) per patient was obtained, resulting in an incremental cost-effectiveness ratio of €2345/QALY. Probabilistic sensitivity analysis showed the national LC SP to be cost-effective in 80% of cases (probability=0.8) for a willingness-to-pay threshold equivalent to the gross domestic product per capita in Spain, which was set at €25 854/QALY in 2018 based on the per capita income of Spain. The sensitivity analysis indicates that the obtained results are robust in terms of changes in the presentation rates and costs, and the cost-effectiveness thresholds.

CONCLUSIONS

This analysis suggests that the implementation of a LC SP in the high-risk Spanish population would be a cost-effective strategy for the Spanish NHS.

Cost-effectiveness analysis of the first-line EGFR-TKIs in patients with advanced EGFR-mutated non-small-cell lung cancer

AIM

To evaluate the cost-effectiveness of first-line treatments, such as erlotinib, gefitinib, afatinib, dacomitinib, and osimertinib, for patients diagnosed with stage IIIB/IV NSCLC harboring EGFR mutations.

MATERIALS & METHODS

A partitioned survival model was developed to estimate quality-adjusted life-year (QALY) and incremental cost-effectiveness ratio (ICER) from the perspective of the Spanish National Health System. Two Bayesian NMAs were performed independently, by using the polynomial fraction method to fit Kaplan-Meier curves for overall survival and progression-free survival. Deterministic and probabilistic sensitivity analyses were performed to evaluate the uncertainty.

RESULTS

The ICER was calculated for the four first-line treatments by comparing them with gefitinib, and the ratios obtained were as follows: €166,416/QALY for osimertinib, €183,682/QALY for dacomitinib, €167,554/QALY for afatinib, €36,196/QALY for erlotinib. It was seen that patients who received osimertinib presented higher QALYs (0.49), followed by dacomitinib (0.33), afatinib (0.32), erlotinib (0.31), and gefitinib (0.28).

CONCLUSIONS

Gefitinib is the most cost-effective treatment. In terms of QALYs gained, Osimertinib was more effective than all other TKIs. Nevertheless, with a Spanish threshold of €24,000/QALY, the reduction in the acquisition cost of osimertinib will have to be greater than 70%, to obtain a cost-effectiveness alternative.

Health and economic impact at a population level of both primary and secondary preventive lung cancer interventions: A model-based cost-effectiveness analysis

OBJECTIVES

Robust economic evaluations are needed to identify efficient strategies for lung cancer prevention that combine brief and intensive smoking cessation intervention programmes with screening using low-dose computed tomography (LDCT) at different ages, frequencies, and coverages. We aimed to assess the cost-effectiveness of smoking cessation approaches combined with lung cancer screening in the European context at a population level from a societal perspective.

MATERIALS AND METHODS

A microsimulation model that describes the natural history of lung cancer and incorporates several prevention strategies was developed. Discounted lifetime QALYs and costs at a rate of 3% were used to calculate incremental cost-effectiveness ratios, defined as additional costs in 2017 Euros per QALY gained.

RESULTS

Smoking cessation interventions reduce the incidence of lung cancer by 8%-46% and are consistently more effective and cost-effective when starting at younger ages. Screening reduces lung cancer mortality by 1%-24% and is generally less effective and more costly than smoking cessation interventions. The most cost-effective strategy would be to implement intensive smoking cessation interventions at ages 35, 40 and 45, combined with screening every three years between the ages of 55 and 65.

CONCLUSIONS

Combining smoking cessation interventions with LDCT screening is a very attractive prevention strategy that substantially diminishes the burden of lung cancer. These combined prevention strategies, especially when providing several intensive interventions for smoking cessation at early ages, are more cost-effective than both approaches separately and allow for a more intensified LDCT without losing efficiency.

Economic burden of lung cancer in Turkey: a cost of illness study from payer perspective

BACKGROUND

This study was designed to estimate economic burden of lung cancer in Turkey from payer perspective based on expert panel opinion on practice patterns in clinical practice.

METHODS

In this cost of illness study, direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations/interventions, drug treatment, adverse events and metastasis. Indirect cost was calculated based on lost productivity due to early retirement, morbidity and premature death resulting from the illness, the value of lost productivity due to time spent by family caregivers and cost of formal caregivers.

RESULTS

Cost analysis revealed the total per patient annual direct medical cost for small cell lung cancer to be €8772), for non-small-cell lung cancer to be €10,167. Total annual direct medical cost was €497.9 million, total annual indirect medical cost was €1.1 billion and total economic burden of lung cancer was €1.6 billion. Hospitalization/interventions (41%) and indirect costs (68.6%) were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively.

CONCLUSIONS

Our findings indicate per patient direct medical costs of small cell lung cancer and non-small-cell lung cancer to be substantial and comparable, indicating the substantial economic burden of lung cancer in terms of both direct and indirect costs. Our findings indicate that hospitalization/interventions cost item and indirect costs were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively. Our findings emphasize the potential role of improved cancer prevention and early diagnosis strategies, by enabling cost savings related to drug treatment and metastasis management cost items, in sustainability of cancer treatments.

Non-Small-Cell Lung Cancer: Real-World Cost Consequence Analysis

PURPOSE

The present work aimed at conducting a real-world data analysis on the management costs and survival analysis comparing data from non-small-cell lung cancer (NSCLC) cases diagnosed in the Veneto region before (2015) and after (2017) the implementation of a regional diagnostic and therapeutic pathway including all new diagnostic and therapeutic strategies.

METHOD

This study considered 254 incidental cases of NSCLC in 2015 and 228 in 2017 within the territory of the Padua province (Italy), as recorded by the Veneto Cancer Registry. Tobit regression analysis was performed to verify if total and each item costs (2 years after NSCLC diagnosis) are associated with index year, adjusting by year of diagnosis, sex, age, and stage at diagnosis. Logistic regression models were run to study overall mortality at 2 years, adjusting by the same covariates.

RESULTS

The 2017 cohort had a lower mortality odd (odds ratio, 0.93; P = .02) and a significant increase in the average overall costs (P = .009) than the 2015 cohort. The Tobit regression analysis by cost item showed a very significant increase in the average cost of drugs (coefficient = 5,953, P = .008) for the 2017 cohort, as well as a decrease in the average cost of hospice care (coefficient = -1,822.6, P = .022).

CONCLUSION

Our study showed a survival improvement for patients with NSCLC as well as an economic burden growth. Physicians should therefore be encouraged to follow new clinical care pathways, while the steadily rising related costs underscore the need for policymakers and health professionals to pursue.

Health care costs of breast, prostate, colorectal and lung cancer care by clinical stage and cost component

OBJECTIVE

To measure 3-year care costs of breast, prostate, colorectal and lung cancers disaggregated by site and clinical stage.

METHOD

A retrospective observational design was employed to investigate care costs of cases recorded in the Registry of the Basque Country between 2010 and 2015. Data gathered included TNM stage and demographic, clinical and resource use variables. Total costs per patient with stage IV disease were calculated by combining generalized linear models with parametric survival analysis. Unit costs were obtained from the analytical accounting system of the Basque Health Service.

RESULTS

The sample comprised 23,782 cancer cases (7801 colorectal, 5530 breast, 4802 prostate and 5649 lung cancer). The mean 3-year costs per patient with stage I to III disease were €11,323, €13,727, €8,651 and €12,023 for colorectal, breast, prostate and lung cancer, respectively. The most important cost components were surgery and chemotherapy. Total survival-adjusted costs until death for patients with stage IV disease (€27,568, €26,296, €16,151 and €15,931 for breast, colorectal, lung and prostate cancer, respectively) were higher than the 3-year costs for those with earlier-stage disease.

CONCLUSIONS

This study quantitatively shows the pattern of changes in the economic burden of cancer throughout its natural history and the great magnitude of this burden for the health system. The use of indicators based on real-world data from each regional health service would allow cancer care in each region to be tailored to local population needs.

Estimated direct costs of non-small cell lung cancer by stage at diagnosis and disease management phase: A whole-disease model

Background

Non‐small cell lung cancer (NSCLC) is the first cause of cancer‐related death among men and the second among women worldwide. It also poses an economic threat to the sustainability of healthcare services. This study estimated the direct costs of care for patients with NSCLC by stage at diagnosis, and management phase of pathway recommended in local and international guidelines.

Methods

Based on the most up‐to‐date guidelines, we developed a very detailed “whole‐disease” model listing the probabilities of all potentially necessary diagnostic and therapeutic actions involved in the management of each stage of NSCLC. We assigned a cost to each procedure, and obtained an estimate of the total and average per‐patient costs of each stage of the disease and phase of its management.

Results

The mean expected cost of a patient with NSCLC is 21,328 € (95% C.I. −20 897−22 322). This cost is 16 291 € in stage I, 19530 € in stage II, 21938 € in stage III, 22175 € in stage IV, and 28 711 € for a Pancoast tumor. In the early stages of the disease, the main cost is incurred by surgery, whereas in the more advanced stages radiotherapy, medical therapy, treatment for progressions, and supportive care become variously more important.

Conclusions

An estimation of the direct costs of care for NSCLC is fundamental in order to predict the burden of new oncological therapies and treatments on healthcare services, and thus orient the decisions of policy‐makers regarding the allocation of resources.

Key points

Significant findings of the study

The high costs of surgery make the early stages of the disease no less expensive than the advanced stages.

What this study adds

An estimation of the direct costs of care is fundamental in order to orient the decisions of policy‐makers regarding the allocation of resources.

Cost analysis of the management of brain metastases in patients with advanced ALK+ NSCLC: alectinib versus crizotinib

Aim

To estimate management cost of NSCLC ALK+ patients with and without brain metastasis (BM), and to compare annual costs in patients treated with alectinib or crizotinib.

Methods

Management cost/year (€ 2018) in patients with and without BM was estimated with disaggregated resource consumption provided by local oncologists, including medical visits, hospitalizations, diagnostic/laboratory tests, imaging techniques and surgical procedures. The comparison of costs/year with alectinib and crizotinib, considered the cumulative 12-month incidence of BM in ALEX trial (9.4 and 41.4%, respectively).

Results

Management cost was €6173.42/patient-year without BM and €21,637.50/patient-year with BM. With alectinib, average cost/patient was lower than crizotinib (€4948.51/patient-year).

Conclusion

Prevention of BM with alectinib may result in reductions of cost/year in the management of advanced ALK+ NSCLC.

Survivability Prognosis for Lung Cancer Patients at Different Severity Stages by a Risk Factor-Based Bayesian Network Modeling

Lung cancer is a major reason of mortalities. Estimating the survivability for this disease has become a key issue to families, hospitals, and countries. A conditional Gaussian Bayesian network model was presented in this study. This model considered 15 risk factors to predict the survivability of a lung cancer patient at 4 severity stages. We surveyed 1075 patients. The presented model is constructed by using the demographic, diagnosed-based, and prior-utilization variables. The proposed model for the survivability prognosis at different four stages performed R² of 93.57%, 86.83%, 67.22%, and 52.94%, respectively. The model predicted the lung cancer survivability with high accuracy compared with the reported models. Our model also shows that it reached the ceiling of an ideal Bayesian network.

Research on Current Curative Expenditure among Lung Cancer Patients Based on the "System of Health Accounts 2011": Insights into Influencing Factors

PURPOSE

To investigate the total current curative expenditure (CCE) of lung cancer in Hunan Province, China under the framework of the System of Health Accounts 2011 (SHA 2011) and explore the effect of insurance status, surgery and length of stay on the hospitalization expenses of patients with lung cancer.

METHODS

Through multistage stratified cluster random sampling, a total of 46,214 patients with lung cancer were enrolled from 1,072 medical institutions in Hunan Province in 2016. Under the SHA 2011 framework, the lung cancer CCE was analyzed. The relationships between hospitalization expenditure and the following factors (surgery, type of hospital, insurance status, length of stay, institution level, age and sex) were analyzed using Spearman's correlation analyses, and how these factors influenced hospital expenditure was explored through multiple stepwise regression analysis and structural equation modelling.

RESULTS

The CCE for lung cancer patients was 8063.75 million CNY. In total, 96.03% of the CCE for lung cancer occurred in hospitals and 58.88% of the expenditure flowed to general hospitals. The highest expenditures were incurred in the group aged 55-74 y, which accounted for 61.58% of the CCE. Drugs accounted for the greatest share expenditure to lung cancer patients at 34.31% of the CCE. Surgery, insurance status, institution level, sex and hospital type explained 57.5% of the variance in hospital expenses. The hospitalization expenses were related to surgery, insurance status, institution level and sex (rs = 0.033-0.688, p < 0.001). Surgery, insurance status and length of stay had direct effects on hospitalization expenses. Length of stay mediated the relationship between surgery and hospitalization expenses for lung cancer patients. Surgery mediated the relationship between insurance status and hospitalization expenses. All of these variables can explain 45% of the variance in hospitalization expenses.

CONCLUSIONS

The CCE of lung cancer is extremely high. The problems related to treatment efficiency and equity are serious for lung cancer patients in China. It is essential to expand health insurance coverage and reduce the curative expenditure of lung cancer.

Economic and epidemiologic impact of guidelines for early ART initiation irrespective of CD4 count in Spain

INTRODUCTION

Emerging data suggest that early antiretroviral therapy (ART) could reduce serious AIDS and non-AIDS events and deaths but could also increase costs. In January 2016, the Spanish guidelines were updated to recommend ART at any CD4 count. However, the epidemiologic and economic impacts of early ART initiation in Spain remain unclear.

METHODS

The Johns Hopkins HIV Economic-Epidemiologic Mathematical Model (JHEEM) was utilized to estimate costs, transmissions, and outcomes in Spain over 20 years. We compared implementation of guidelines for early ART initiation to a counterfactual scenario deferring ART until CD4-counts fall below 350 cells/mm3. We additionally studied the impact of early ART initiation in combination with improvements to HIV screening, care linkage and engagement.

RESULTS

Early ART initiation (irrespective of CD4-count) is expected to avert 20,100 [95% Uncertainty Range (UR) 11,100-83,000] new HIV cases over the next two decades compared to delayed ART (28% reduction), at an incremental health system cost of €1.05 billion [€0.66 - €1.63] billion, and an incremental cost-effectiveness ratio (ICER) of €29,700 [€13,700 - €41,200] per QALY gained. Projected ICERs declined further over longer time horizon; e.g., an ICER of €12,691 over 30 years. Furthermore, the impact of early ART initiation was potentiated by improved HIV screening among high-risk individuals, averting an estimated 41,600 [23,200-172,200] HIV infections (a 58% decline) compared to delayed ART.

CONCLUSIONS

Recommendations for ART initiation irrespective of CD4-counts are cost-effective and could avert > 30% of new cases in Spain. Improving HIV diagnosis can amplify this impact.

The cost of hospital treatment of advanced stage lung cancer patients in a developing South East European country

Assessing the lung cancer treatment costs is necessary in order to estimate the budget impact of new interventions and therapeutic innovations. However, there are few studies regarding the use of resources and costs associated with treatment of lung cancer patients, not only in Serbia, but internationally. The aim of this paper was to assess the hospital costs of diagnosing and treating patients with stage IIIB and IV non-small cell lung cancer. Analysis of costs of care, services, medications and medical supplies, as well as of total hospital costs, was performed. Patients diagnosed with stage IIIB or IV NSCLC in the Institute during the year 2013 were enrolled in the study. A total of 187 patients with stage IIIB or IV NSCLC were analyzed. Total hospital costs were 506.970€, of which nearly two thirds was accounted to costs of services and medications. The mean cost per patient with adenocarcinoma was 3.075€, and for squamous cell lung carcinoma patient 1.943€. Statistically significant difference was shown when comparing mean hospital costs between patients in stage IIIB and stage IV adenocarcinoma, where this cost is higher in patients with stage IIIB. Mean hospital cost per female patient was nearly double as high that of the male patients, although without statistically significant difference. The mean cost for all adenocarcinoma patients was 1.317€, and for only four patients treated with TKI therapy 21.233€. This cost analysis could provide useful information in terms of budget impact of different lung cancer treatments and innovations in Serbia and corresponding developing countries.

Estimates of costs for modelling return on investment from smoking cessation interventions

BACKGROUND AND AIMS

Modelling return on investment (ROI) from smoking cessation interventions requires estimates of their costs and benefits. This paper describes a standardized method developed to source both economic costs of tobacco smoking and costs of implementing cessation interventions for a Europe-wide ROI model [European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD)].

DESIGN

Focused search of administrative and published data. A standardized checklist was developed in order to ensure consistency in methods of data collection.

SETTING AND PARTICIPANTS

Adult population (15+ years) in Hungary, Netherlands, Germany, Spain and England. For passive smoking-related costs, child population (0-15 years) was also included.

MEASUREMENTS

Costs of treating smoking-attributable diseases; productivity losses due to smoking-attributable absenteeism; and costs of implementing smoking cessation interventions.

FINDINGS

Annual costs (per case) of treating smoking attributable lung cancer were between €5074 (Hungary) and €52 106 (Germany); coronary heart disease between €1521 (Spain) and €3955 (Netherlands); chronic obstructive pulmonary disease between €1280 (England) and €4199 (Spain); stroke between €1829 (Hungary) and €14 880 (Netherlands). Costs (per recipient) of smoking cessation medications were estimated to be: for standard duration of varenicline between €225 (England) and €465 (Hungary); for bupropion between €25 (Hungary) and €220 (Germany). Costs (per recipient) of providing behavioural support were also wide-ranging: one-to-one behavioural support between €34 (Hungary) and €474 (Netherlands); and group-based behavioural support between €12 (Hungary) and €257 (Germany). The costs (per recipient) of delivering brief physician advice were: €24 (England); €9 (Germany); €4 (Hungary); €33 (Netherlands); and €27 (Spain).

CONCLUSIONS

Costs of treating smoking-attributable diseases as well as the costs of implementing smoking cessation interventions vary substantially across Hungary, Netherlands, Germany, Spain and England. Estimates for the costs of these diseases and interventions can contribute to return on investment estimates in support of national or regional policy decisions.

Development and application of an economic model (EQUIPTMOD) to assess the impact of smoking cessation

BACKGROUND AND AIMS

Although clear benefits are associated with reducing smoking, there is increasing pressure on public health providers to justify investment in tobacco control measures. Decision-makers need tools to assess the Return on Investment (ROI)/cost-effectiveness of programmes. The EQUIPT project adapted an ROI tool for England to four European countries (Germany, the Netherlands, Spain and Hungary). EQUIPTMOD, the economic model at the core of the ROI tool, is designed to assess the efficiency of packages of smoking cessation interventions. The objective of this paper is to describe the methods for EQUIPTMOD and identify key outcomes associated with continued and cessation of smoking.

METHODS

EQUIPTMOD uses a Markov model to estimate life-time costs, quality-adjusted life years (QALYs) and life years associated with a current and former smoker. It uses population data on smoking prevalence, disease prevalence, mortality and the impact of smoking combined with associated costs and utility effects of disease. To illustrate the tool's potential, costs, QALYs and life expectancy were estimated for the average current smoker for five countries based on the assumptions that they continue and that they cease smoking over the next 12 months. Costs and effects were discounted at country-specific rates.

RESULTS

For illustration, over a life-time horizon, not quitting smoking within the next 12 months in England will reduce life expectancy by 0.66, reduce QALYs by 1.09 and result in £4961 higher disease-related health care costs than if the smoker ceased smoking in the next 12 months. For all age-sex categories, costs were lower and QALYs higher for those who quit smoking in the 12 months than those who continued.

CONCLUSIONS

EQUIPTMOD facilitates assessment of the cost effectiveness of smoking cessation strategies. The demonstrated results indicate large potential benefits from smoking cessation at both an individual and population level.

Cost-effectiveness of alternative smoking cessation scenarios in Spain: results from the EQUIPTMOD

AIMS

To assess the cost-effectiveness of alternative smoking cessation scenarios from the perspective of the Spanish National Health Service (NHS).

DESIGN

We used the European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD), a Markov-based state transition economic model, to estimate the return on investment (ROI) of: (a) the current provision of smoking cessation services (brief physician advice and printed self-helped material + smoking ban and tobacco duty at current levels); and (b) four alternative scenarios to complement the current provision: coverage of proactive telephone calls; nicotine replacement therapy (mono and combo) [prescription nicotine replacement therapy (Rx NRT)]; varenicline (standard duration); or bupropion. A rate of 3% was used to discount life-time costs and benefits.

SETTING

Spain.

PARTICIPANTS

Adult smoking population (16+ years).

MEASUREMENTS

Health-care costs associated with treatment of smoking attributable diseases (lung cancer, coronary heart disease, chronic obstructive pulmonary infection and stroke); intervention costs; quality-adjusted life years (QALYs). Costs and outcomes were summarized using various ROI estimates.

FINDINGS

The cost of implementing the current provision of smoking cessation services is approximately €61 million in the current year. This translates to 18 quitters per 1000 smokers and a life-time benefit-cost ratio of 5, compared with no such provision. All alternative scenarios were dominant (cost-saving: less expensive to run and generated more QALYs) from the life-time perspective, compared with the current provision. The life-time benefit-cost ratios were: 1.87 (proactive telephone calls); 1.17 (Rx NRT); 2.40 (varenicline-standard duration); and bupropion (2.18). The results remained robust in the sensitivity analysis.

CONCLUSIONS

According to the EQUIPTMOD modelling tool it would be cost-effective for the Spanish authorities to expand the reach of existing GP brief interventions for smoking cessation, provide pro-active telephone support, and reimburse smoking cessation medication to smokers trying to stop. Such policies would more than pay for themselves in the long run.

"Factors associated with non-small cell lung cancer treatment costs in a Brazilian public hospital"

BACKGROUND

The present study estimated the cost of advanced non-small cell lung cancer care for a cohort of 251 patients enrolled in a Brazilian public hospital and identified factors associated with the cost of treating the disease, considering sociodemographic, clinical and behavioral characteristics of patients, service utilization patterns and survival time.

METHODS

Estimates were obtained from the survey of direct medical cost per patient from the hospital's perspective. Data was collected from medical records and available hospital information systems. The ordinary least squares (OLS) method with logarithmic transformation of the dependent variable for the analysis of cost predictors was used to take into account the positive skewness of the costs distribution.

RESULTS

The average cost of NSCLC was US$ 5647 for patients, with 71% of costs being associated to outpatient care. The main components of cost were daily hospital bed stay (22.6%), radiotherapy (15.5%) and chemotherapy (38.5%). The OLS model reported that, with 5% significance level, patients with higher levels of education, with better physical performance and less advanced disease have higher treatment costs. After controlling for the patient's survival time, only education and service utilization patterns were statistically significant. Individuals who were hospitalized or made use of radiotherapy or chemotherapy had higher costs. The use of these outpatient and hospital services explained most of the treatment cost variation, with a significant increase of the adjusted R2 of 0.111 to 0.449 after incorporation of these variables in the model. The explanatory power of the complete model reached 62%.

CONCLUSIONS

Inequities in disease treatment costs were observed, pointing to the need for strategies that reduce lower socioeconomic status and population's hurdles to accessing cancer care services.

Changing costs of metastatic non small cell lung cancer in the Netherlands

OBJECTIVES

The primary objective of this study was to identify the total intramural cost of illness of metastatic non-small cell lung cancer (NSCLC) in the Netherlands between 2006-2012. Secondary objective was to identify whether changes in cost patterns of metastatic NSCLC have occurred over the last years.

METHODS

Patients diagnosed with metastatic NSCLC between 1-1-2006 and 31-12-2012, who had follow-up to death or the date of data cut-off and no trial participation were included. A structured chart review was performed using a case report form. Data collection started after diagnosis of metastatic NSCLC and ended at death or April first, 2015. Data regarding outpatient visits, clinical attendance, oncolytic drug use, imaging, lab tests, radiotherapy and surgery were collected.

RESULTS

Sixty-seven patients were included with a median age of 67 years. The median follow-up was 234days. On average patients had 28 outpatient visits and 11 inpatient days. Oncolytic drugs were administered to 76% of the patients. Mean per patient expenditures amounted up to €17,463, with oncolytic drugs (€6,390) as the main cost driver. In comparison with the time-period of 2003-2005 total per patient per year expenses decreased by 44%. The contribution to total yearly costs of oncolytic drugs increased from 18% to 35%, while costs for inpatient stay decreased from 52% to 28% of total expenditures.

CONCLUSION

Outcomes in this study demonstrate that average treatment costs for metastatic NSCLC in the Netherlands Cancer Institute amount to €17,463. Compared to a prior study the average cost for metastatic NSCLC over time in the Netherlands has decreased. A shift of main cost drivers seems to have occurred from inpatient stay, to oncolytic drugs as main contributor. The shift towards treatment cost might become more visible with the introduction of immunotherapy. These results mark the importance of up-to-date cost of illness studies.

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.

Factors affecting hospital costs in lung cancer patients in the United Kingdom

INTRODUCTION

Rising healthcare costs and financial constraints are increasing pressure on healthcare budgets. There is little published data on the healthcare costs of lung cancer in the UK, with international studies mostly small and limited by data collection methods. Accurate assessment of healthcare costs is essential for effective service planning.

METHODS

We conducted a retrospective, descriptive cohort study linking clinical data from a local electronic database of lung cancer patients at a large UK teaching hospital with recorded hospital income. Costs were adjusted to 2013-2014 prices.

RESULTS

The study analysed secondary care costs of 3274 patients. Mean cumulative costs were £5852 (95% CI, £5694 to £6027) at 90 days and £10,009 (95% CI, £9717 to £10,278) at one year. The majority of costs (58.5%) were accumulated within the first 90 days, with acute inpatient costs the largest contributor at one year (42.1%). The strongest predictor of costs was active treatment, especially surgery. Costs were also affected by age, route to diagnosis, clinical stage and cell type.

DISCUSSION

Successful early diagnosis initiatives that increase radical treatment rates and improve outcomes may significantly increase the secondary care costs of lung cancer management. The use of routine NHS clinical and financial data can enable efficient and effective analyses of large cohort health economic data.

Optimal sequence of tests for the mediastinal staging of non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) is the most prevalent type of lung cancer and the most difficult to predict. When there are no distant metastases, the optimal therapy depends mainly on whether there are malignant lymph nodes in the mediastinum. Given the vigorous debate among specialists about which tests should be used, our goal was to determine the optimal sequence of tests for each patient.

METHODS

We have built an influence diagram (ID) that represents the possible tests, their costs, and their outcomes. This model is equivalent to a decision tree containing millions of branches. In the first evaluation, we only took into account the clinical outcomes (effectiveness). In the second, we used a willingness-to-pay of € 30,000 per quality adjusted life year (QALY) to convert economic costs into effectiveness. We assigned a second-order probability distribution to each parameter in order to conduct several types of sensitivity analysis.

RESULTS

Two strategies were obtained using two different criteria. When considering only effectiveness, a positive computed tomography (CT) scan must be followed by a transbronchial needle aspiration (TBNA), an endobronchial ultrasound (EBUS), and an endoscopic ultrasound (EUS). When the CT scan is negative, a positron emission tomography (PET), EBUS, and EUS are performed. If the TBNA or the PET is positive, then a mediastinoscopy is performed only if the EBUS and EUS are negative. If the TBNA or the PET is negative, then a mediastinoscopy is performed only if the EBUS and the EUS give contradictory results. When taking into account economic costs, a positive CT scan is followed by a TBNA; an EBUS is done only when the CT scan or the TBNA is negative. This recommendation of performing a TBNA in certain cases should be discussed by the pneumology community because TBNA is a cheap technique that could avoid an EBUS, an expensive test, for many patients.

CONCLUSIONS

We have determined the optimal sequence of tests for the mediastinal staging of NSCLC by considering sensitivity, specificity, and the economic cost of each test. The main novelty of our study is the recommendation of performing TBNA whenever the CT scan is positive. Our model is publicly available so that different experts can populate it with their own parameters and re-examine its conclusions. It is therefore proposed as an evidence-based instrument for reaching a consensus.

Cost-components of lung cancer care within the first three years after initial diagnosis in context of different treatment regimens

OBJECTIVES

Although lung cancer is of high epidemiological relevance in Germany, evidence on its economic implications is scarce. Sound understanding of current care structures and associated expenditures is required to comprehensively judge the additional benefit of novel interventions in lung cancer care. Adopting a payer perspective, our study aims to analyze expenditures for individuals with incident lung cancer.

MATERIAL AND METHODS

Patients with an initial diagnosis of lung cancer (ICD-10 code C34) in 2009 were searched in a large, nationwide base of health insurance claims data and grouped according to initial treatment (Surgery, Chemotherapy/Radiotherapy, No specific treatment). All-cause SHI and lung cancer-related spending was assessed for a patient-individual three-year time frame after initial diagnosis. Expenditures per case and expenditures per year survived were calculated via Generalized Linear Gamma Models adjusted for age, gender, living region, baseline metastases, multiple tumors and initial treatment regimen using time under observation as a weighting factor.

RESULTS

17,478 individuals were identified. Lung cancer-related expenditures peaked within the first six months after initial diagnosis. Following, they declined subsequently and so did their share in all-cause SHI spending. Lung cancer-related expenditures per case were estimated at €20,400 (53% of all-cause expenditures) with a huge variance according to initial treatment regimen [

SURGERY

€20,400, Chemotherapy/Radiotherapy: €26,300, No specific treatment: €4200]. Cost per year survived amounted to €15,500 (55% of all cause expenditures) [

SURGERY

€11,600, Chemotherapy/Radiotherapy: €20,200, No specific treatment: €7600].

CONCLUSION

Analyses of lung cancer-related expenditures need to take into account treatment strategies and survival. Our study is representative for a large share of the population and provides detailed, patient-level information on costs of care and their compilation. Results render estimates available for the cost of lung cancer e.g. for budget impact analyses, cost-effectiveness analyses of screening and prevention schemes, or prognostic models of life-time expenditures per lung cancer case.