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O-063 Do decisions made at lung cancer multi-disciplinary team meetings get carried out
$24
Oral Sessions/Health services research
one SRE had estimated SRE related costs of $10.392 while these with two or more SREs had SRE-related costs of $14.276 Conclusions: In clinical practJco, more than half of all pafients with bone metastases of lung cancer e=pedence skeletal compiications More than a third of those with an SRE have one or more subsequent SREs. wftch increase treatment costs These findings suggest that in pafients who e0¢pedence SREs. it may be important to continue treatments such as intTavenous bisphosphonates to reduce the nsk of subsequent events and associated costs ~0~2T Economic assessment of first-line ctlemotherapy In symptomatic
advanced stage NSCLC In Belgium: A cost-utility analysis (CUA) C. Dooms. Y. Liovens. J. Vansteenkiste. Leuven L~"~g Cancer Group,
Un;vers~ty Hospttal, Leuven, Belg;um Background: The use of chemotherapy has an important impact on health economy and feeds the interest for economic analyses in medical oncology. In pafients with a short life expectancy subjective b-eatment outcomes can be rated as a utility to make them comparable to other conditions and to perform economic analyses For advanced NSCLC there are very few data assessing chemotherapy within a cost-utility analysis (CUA) We therefore present a CUA alongside a prospecfive randomised study in which we shewed superior clinical benefit for firstqine Gomcitabine monotherapy compared to CisplalJnVindesine combination therapy for symptomafic advanced NSCLC (Ann Oncol 12:1221 30. 2001) Methods: A weekly VAS score for global quality~oflife and all direct resource costs were collected prospoctiveiy denng 24 weeks from the start of first line chemotherapy. The VAS scores were b-ansformed to a corresponding utile. Multiplying the utility by the survlval time. QualltyAdJusted Life Years (QALY) were obtained and used in CUA. Results: An incremental cost of 1522~ per pafient was calculated Ibr Gemcitabine compared to Cisplatin Vlndeslne. mainly due to the cost of the drug A QALY per palJent of respectively 0 29 and 0 18. provided an incremental QALY of 0 11 b r Gemcitabine T;ts resulted in an incremental cost-utility ratio (CUR) for Gomcitabine of 13.836~ per QALY gained, which proved to be robust in sensifivity analysis (Table 1) Tal~a 1 Rasultsfrom satTsl1~tyanalysis Incramental cost (~, 2000)
Ll~hty 50% Ubllty 25% IncrematTtal LRJIIty+25% LRJhty*50% QALY 0 05 QALY0 08 u~l=~, QALY 0 13 QALY0 16 QALY 0 11
AJI costs 50% AJI costs 25% AJl costs A~I cosls +25% AJl cosls +50%
15,220 22,840 30,440 38,040
9513 14,275 19,O25 23,775
45,850
28,638
761 1142 1522 1g02 2283
6918 1O,382 13,836 17,291 20,755
5~54 87&5 11,708 14,531 17,682
4756 7138 9513 11,866 14,269
Numbers In =tahcsare Cos~Ll~hty Rab:}'s
Conclusions: The third generafion cytotoxic drug Gomcitabine ~ r symptomatic advanced NSCLC is a palliative treatment with a similar survival outcome compared to a second generafion Cisplafin-based doublet, and is associated with extTa health care costs However. the better clinical benefit response highly valued by patients with symptomatic advanced NSCLC - leads to an acceptable incremental CUR compared to other health care interventions [ ~ 6 3 ~ Do derisions made at Lung Carmer Multi-Disciplinary Team
Mestlngs get carded oUt
Conclusion: MDTM would appear to be effective at making decisions in a cisease as compie0¢ and heterogeneous as lung cancer The effectiveness of an MDTM depends very much on the quality of information available and there may be a need to introduce external quality control to measure this ~0~
Economic factors In the treatment of advanced non-small cell lung cancer (NSCLC) based on a US model: An analysis
of the Impact of regulatory findings and survival results on reimbursement for chemo~erapy P Grusenmayer I . R Gralla 2 1Christiaria Care Helen E Graham Cancer
Center, Newark, Delaware, USA. 2New York Lung Cancer A#iance, USA Background: Economic factors can have a major influence on the approach to treatment Costs of cancer care have risen dramatically, encouraging new inconfivas in prance Regulatory agencies have subscribed to ovidenoe~ased approval criteria, and recently insurers have voiced interest in coupling payment with evidence of benefit. We esamined whether changes in reimbursement by the leading US governmental insurer. CMS (Centers for Medicare and Medicaid Services) are consistent v~th regulatory (FDA) approval and ovidenoe~ased findings. Reimbursement changes are based on reduction in drug payments and increases in chemotherapy administration charges due to new leglsiation. Four clsplat]r, based regimens are the only FDA approved combinations ~r first-line treatment of NSCLC: three carboplafin-based regimens are also commonly used While survival results are relaf]vely similar among chemotherapy choices, modest differences have emerged Three recent metaanalyses (pooled study analyses) have demonstTated: 1) 2-agent regimens are supedor to 1 drug (and equal to 3-agents. Delbaldo. JAMA 2004). 2) cisplafin combinations with newer agents domonstT"ate 10%-20% survival improvements compared with carbeplafin regimens (Hotta. JCO 2004: Zojwalla. Proc ASCO 2004). We analyzed Medicare reimbursement lJ'ends following implementation of the Meclcare Prescnpfion Drug Act 2003. to see if finarx~al incont]ves were consistent with regulatory and ovidenco findings. Methods: Medicare 2003 reimbursement was calculated using CMS Drug Pricing File (October 2003. drugs reimbursed at 95% of Average Wholesale Price) and the Meclcare Physician Fee Schedule (PFS). Medicare 2005 reimbursement was calculated using CMS Drug Payment Table (January 2005. drugs reimbursed at ASP +6%) and Mecicare revisions to the PFS Reimbursement was calculated on six <>/(des (1,5 weeks) of treatment and patient BSA = 1.8 m2 Results: Medicare 2003/2005 reimbursements are compared in the table: 2003 2005 2003-200,5 Reimburse Reimburse Increase,t(Decrease)
FDA Approved Regimens Cisplatin/vinorelbine Cisplatin/gemcitabine Cisplatin/docotasel Cisplatin/paclitaxel Mean FDA approved
$15.340 $17.912 $19.308 $16.090 $17.138
$15.481 $19.540 $16.736 $5379 $14.034
$140 $729 ($2572) ($10.711) ($3104)
$25.75,4 $27.470 $29.474 $27.566
$14.469 $27.514 $25.710 $22.564
($11.28.5) $44 ($3765) ($5002)
Non-approved regimens Carbpplatin/paditaxel Carboplatin/gemcltabina Carboplatin/docotaxel Mean non-appreved regimens
D. Gilligan I . L. Goodrum ~. L. MageeI . S. Harris 2. IPapwor~ Hospital NHS
Foundation Trust, Cambridge, UI~ 2WACN, Cambridge, UK Background: Nafional Cancer Standards state that all patients with lung cancer have to have a management plan ciscussed and recorded at a mulfidisciplinary team meeting (MD]M). At our MDTM decisions are made with the best available inforroat]on, usually clinical details, radiology, pathology and assessment by lung cancer nurses. Treatment options for lung cancer are heavily dependent on the general condition and performance status of a patient as well as tumour stage, type and co morbJdlt]es. We have audited our well established MDTM to find out whether decisions made were actually camed out and If not why not. Methods: Between September and November 2003 all MDTM decisions were collected Actual management decisions were subsequently analysed from palJents hospital notes and the results compared Results: 24 MDTM took piace and 129 patients were discussed in 217 episodes (53 patients were discussed on two or more occasions) 173;'217 (Tg 7%) decisions were implemented 27 (12 4%) were not and no data is available in 17 (7 8%) of cases Of the 27 decisions which were not carried out 6 (3.7%) were declined by the patient. 6 (3.7%) were deemed unfit Ibr the proposed management. 5 (2.3%) had clad. 3 (1.4%) had comort~dfies which made the intended management clfficult and 3 (1.4%) had management different from the MDTM decision with no obvious reason. Out of 103 b'eatment decisions 72 (69.9%) were carried out.
Conclusions: 1) Average reimbursement by Medicare for all regimens decreased $4740 USD from 2003-2005; 2) Medicare continues to reimburse FDA approved combinafions at markedly lower rates than non approved regimens: the least costly non-approved regimen still escoeds the mean of all FDA approved regimens: 3) if the FDA approval process reflects a rigorous application of ovidenoe~ased mecicine, it is conous that Medicare incontJves remain as established: 4) additional analyses are needed to determine if other cost or quality of life advantages can counterbalance the more espensive regimens when compared to the least espensive, in the absence of survival benefit, and to determine if the new reimbursement rates / incenfives will affect fiJture utilization in the US and other countnes.
Oral Sessions/Health services research
one SRE had estimated SRE related costs of $10.392 while these with two or more SREs had SRE-related costs of $14.276 Conclusions: In clinical practJco, more than half of all pafients with bone metastases of lung cancer e=pedence skeletal compiications More than a third of those with an SRE have one or more subsequent SREs. wftch increase treatment costs These findings suggest that in pafients who e0¢pedence SREs. it may be important to continue treatments such as intTavenous bisphosphonates to reduce the nsk of subsequent events and associated costs ~0~2T Economic assessment of first-line ctlemotherapy In symptomatic
advanced stage NSCLC In Belgium: A cost-utility analysis (CUA) C. Dooms. Y. Liovens. J. Vansteenkiste. Leuven L~"~g Cancer Group,
Un;vers~ty Hospttal, Leuven, Belg;um Background: The use of chemotherapy has an important impact on health economy and feeds the interest for economic analyses in medical oncology. In pafients with a short life expectancy subjective b-eatment outcomes can be rated as a utility to make them comparable to other conditions and to perform economic analyses For advanced NSCLC there are very few data assessing chemotherapy within a cost-utility analysis (CUA) We therefore present a CUA alongside a prospecfive randomised study in which we shewed superior clinical benefit for firstqine Gomcitabine monotherapy compared to CisplalJnVindesine combination therapy for symptomafic advanced NSCLC (Ann Oncol 12:1221 30. 2001) Methods: A weekly VAS score for global quality~oflife and all direct resource costs were collected prospoctiveiy denng 24 weeks from the start of first line chemotherapy. The VAS scores were b-ansformed to a corresponding utile. Multiplying the utility by the survlval time. QualltyAdJusted Life Years (QALY) were obtained and used in CUA. Results: An incremental cost of 1522~ per pafient was calculated Ibr Gemcitabine compared to Cisplatin Vlndeslne. mainly due to the cost of the drug A QALY per palJent of respectively 0 29 and 0 18. provided an incremental QALY of 0 11 b r Gemcitabine T;ts resulted in an incremental cost-utility ratio (CUR) for Gomcitabine of 13.836~ per QALY gained, which proved to be robust in sensifivity analysis (Table 1) Tal~a 1 Rasultsfrom satTsl1~tyanalysis Incramental cost (~, 2000)
Ll~hty 50% Ubllty 25% IncrematTtal LRJIIty+25% LRJhty*50% QALY 0 05 QALY0 08 u~l=~, QALY 0 13 QALY0 16 QALY 0 11
AJI costs 50% AJI costs 25% AJl costs A~I cosls +25% AJl cosls +50%
15,220 22,840 30,440 38,040
9513 14,275 19,O25 23,775
45,850
28,638
761 1142 1522 1g02 2283
6918 1O,382 13,836 17,291 20,755
5~54 87&5 11,708 14,531 17,682
4756 7138 9513 11,866 14,269
Numbers In =tahcsare Cos~Ll~hty Rab:}'s
Conclusions: The third generafion cytotoxic drug Gomcitabine ~ r symptomatic advanced NSCLC is a palliative treatment with a similar survival outcome compared to a second generafion Cisplafin-based doublet, and is associated with extTa health care costs However. the better clinical benefit response highly valued by patients with symptomatic advanced NSCLC - leads to an acceptable incremental CUR compared to other health care interventions [ ~ 6 3 ~ Do derisions made at Lung Carmer Multi-Disciplinary Team
Mestlngs get carded oUt
Conclusion: MDTM would appear to be effective at making decisions in a cisease as compie0¢ and heterogeneous as lung cancer The effectiveness of an MDTM depends very much on the quality of information available and there may be a need to introduce external quality control to measure this ~0~
Economic factors In the treatment of advanced non-small cell lung cancer (NSCLC) based on a US model: An analysis
of the Impact of regulatory findings and survival results on reimbursement for chemo~erapy P Grusenmayer I . R Gralla 2 1Christiaria Care Helen E Graham Cancer
Center, Newark, Delaware, USA. 2New York Lung Cancer A#iance, USA Background: Economic factors can have a major influence on the approach to treatment Costs of cancer care have risen dramatically, encouraging new inconfivas in prance Regulatory agencies have subscribed to ovidenoe~ased approval criteria, and recently insurers have voiced interest in coupling payment with evidence of benefit. We esamined whether changes in reimbursement by the leading US governmental insurer. CMS (Centers for Medicare and Medicaid Services) are consistent v~th regulatory (FDA) approval and ovidenoe~ased findings. Reimbursement changes are based on reduction in drug payments and increases in chemotherapy administration charges due to new leglsiation. Four clsplat]r, based regimens are the only FDA approved combinations ~r first-line treatment of NSCLC: three carboplafin-based regimens are also commonly used While survival results are relaf]vely similar among chemotherapy choices, modest differences have emerged Three recent metaanalyses (pooled study analyses) have demonstTated: 1) 2-agent regimens are supedor to 1 drug (and equal to 3-agents. Delbaldo. JAMA 2004). 2) cisplafin combinations with newer agents domonstT"ate 10%-20% survival improvements compared with carbeplafin regimens (Hotta. JCO 2004: Zojwalla. Proc ASCO 2004). We analyzed Medicare reimbursement lJ'ends following implementation of the Meclcare Prescnpfion Drug Act 2003. to see if finarx~al incont]ves were consistent with regulatory and ovidenco findings. Methods: Medicare 2003 reimbursement was calculated using CMS Drug Pricing File (October 2003. drugs reimbursed at 95% of Average Wholesale Price) and the Meclcare Physician Fee Schedule (PFS). Medicare 2005 reimbursement was calculated using CMS Drug Payment Table (January 2005. drugs reimbursed at ASP +6%) and Mecicare revisions to the PFS Reimbursement was calculated on six <>/(des (1,5 weeks) of treatment and patient BSA = 1.8 m2 Results: Medicare 2003/2005 reimbursements are compared in the table: 2003 2005 2003-200,5 Reimburse Reimburse Increase,t(Decrease)
FDA Approved Regimens Cisplatin/vinorelbine Cisplatin/gemcitabine Cisplatin/docotasel Cisplatin/paclitaxel Mean FDA approved
$15.340 $17.912 $19.308 $16.090 $17.138
$15.481 $19.540 $16.736 $5379 $14.034
$140 $729 ($2572) ($10.711) ($3104)
$25.75,4 $27.470 $29.474 $27.566
$14.469 $27.514 $25.710 $22.564
($11.28.5) $44 ($3765) ($5002)
Non-approved regimens Carbpplatin/paditaxel Carboplatin/gemcltabina Carboplatin/docotaxel Mean non-appreved regimens
D. Gilligan I . L. Goodrum ~. L. MageeI . S. Harris 2. IPapwor~ Hospital NHS
Foundation Trust, Cambridge, UI~ 2WACN, Cambridge, UK Background: Nafional Cancer Standards state that all patients with lung cancer have to have a management plan ciscussed and recorded at a mulfidisciplinary team meeting (MD]M). At our MDTM decisions are made with the best available inforroat]on, usually clinical details, radiology, pathology and assessment by lung cancer nurses. Treatment options for lung cancer are heavily dependent on the general condition and performance status of a patient as well as tumour stage, type and co morbJdlt]es. We have audited our well established MDTM to find out whether decisions made were actually camed out and If not why not. Methods: Between September and November 2003 all MDTM decisions were collected Actual management decisions were subsequently analysed from palJents hospital notes and the results compared Results: 24 MDTM took piace and 129 patients were discussed in 217 episodes (53 patients were discussed on two or more occasions) 173;'217 (Tg 7%) decisions were implemented 27 (12 4%) were not and no data is available in 17 (7 8%) of cases Of the 27 decisions which were not carried out 6 (3.7%) were declined by the patient. 6 (3.7%) were deemed unfit Ibr the proposed management. 5 (2.3%) had clad. 3 (1.4%) had comort~dfies which made the intended management clfficult and 3 (1.4%) had management different from the MDTM decision with no obvious reason. Out of 103 b'eatment decisions 72 (69.9%) were carried out.
Conclusions: 1) Average reimbursement by Medicare for all regimens decreased $4740 USD from 2003-2005; 2) Medicare continues to reimburse FDA approved combinafions at markedly lower rates than non approved regimens: the least costly non-approved regimen still escoeds the mean of all FDA approved regimens: 3) if the FDA approval process reflects a rigorous application of ovidenoe~ased mecicine, it is conous that Medicare incontJves remain as established: 4) additional analyses are needed to determine if other cost or quality of life advantages can counterbalance the more espensive regimens when compared to the least espensive, in the absence of survival benefit, and to determine if the new reimbursement rates / incenfives will affect fiJture utilization in the US and other countnes.