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: scressman@bccrc.ca