Advancing Health Economics, Services, Policy and Ethics
Sonya Cressman, PhD, MBA
CADTH 2012, Ottawa
1. Simulating Lung Cancer Control: Screening Comparators
2. CRMM’s Lung Cancer Module
– Outcome simulation
3. Simulating a Canadian Screening Index trial
– CRMM’s new screening module
Contents
• 2010: National Lung Screening Trial (NLST) shows a 20% lung cancer mortality reduction for CT-screening of smokers over chest X-ray screening1
• Little evidence exists to inform estimates of cost-effectiveness, smoking cessation has a role in screening2
Lung Cancer Screening: 2012
1. Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic
Screening. N Engl J Med. 2011 Jun. 29.
2. Mcmahon PM, Kong CY, Bouzan C, Weinstein MC, Cipriano LE, Tramontano
AC, et al. Cost-effectiveness of computed tomography screening for lung
cancer in the United States. J Thorac Oncol. 2011 Nov.;6(11):1841–1848.
Framing the Decision Problem
Framing the Decision Problem
CRMM vs. CCS projections of Lung Cancer Deaths in Canada
The pan-Canadian Early Detection Study, 2.3 years in
Scenario Non-Small Cell Lung Cancer Stage
I II III IV
CT arm 0.564 0.0730 0.1976 0.166
CXR arm 0.297 0.0726 0.205 0.2791
CRMM base case
values 0.202 0.0510 0.260 0.489
NLST Stage Distribution Inputs
Simulated 12.9% Mortality Reduction With NLST Stage Shift)
Inputs to CRMM: screening stage distribution and smoking history
CRMM’s New Screening Module Cumulative lung cancer deaths
16
049
124
202
289
410
563
056
156
275
406
546
696
0
100
200
300
400
500
600
700
800
0 1 2 3 4 5 6
Years since "randomization"
CT scan
No screen
Cumulative lung cancer deaths at 6 yearsCT scan Reference
NLST : 350 443 -21%CRMM*: 563 696 -19%
*CRMM counts have been scaled to CT Scan arm of NLST for comparability based on number eligible
Parameter NLST pan-Canadian Study Other
Screening protocol
3 annual CT scans 2 or 3 annual CT scans with follow-up
LC working group: annual
Follow-up protocol
none Follow-up based on nodule size distribution, patient-level data
NCCN guidelines 2012
Sensitivity/specificity
0.93/0.74 Comparable sensitivity/ Higher specificity**
Enrollment/time, participation rates
1.67 years, 95% participation rates
2.3 years Colorectal, mammography screening
Individuals Age: 57-65 years Smoking history: 48 PY
Age: 57-66 Smoking history: 50 PY
Costs Forthcoming US manuscript
Patient-level screening resource utilization and costs
CRMM’s built-in costs, PSA
Simulating a Screening Index Trial
One-way Discrete Variation of Participation Rates
Simulating a Smoking Cessation Comparator
Opportunistic Private Screening
• CRMM can simulate costs and outcomes for lung cancer control comparators
• PSA an important, complicated and pending complement for CRMM
– CPAC’s PSA working group
• The information from CRMM comes in good time
– 3 pilots are currently being planned in Canada
– Private Opportunistic screening
Conclusions
A d v a n c i n g H e a l t h E c o n o m i c s , S e r v i c e s , Po l i c y a n d E t h i c s
Acknowledgements
• ARCC – Stuart Peacock, Jeffrey Hoch, Ian Cromwell, Dean Regier
• Pan-Canadian Investigators and Study Coordinators
• Canadian Partnership Against Cancer
• CRMM Developers, Statistics Canada
– Bill Flanagan, Micheal Wolfson, Bill Evans, John Goffin
• Thank You: [email protected]
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