Canadian Cancer Risk Management Model: A new health policy tool useful in policy decisions related to lung cancer WK Evans, M Wolfson, WM Flanagan, J Oderkirk, J Goffin, J Shin, G Lockwood Department of Oncology, McMaster University, Hamilton, Ontario; Statistics Canada, Ottawa, Ontario and the Canadian Partnership Against Cancer, Toronto, Ontario

Canadian Cancer Risk Management Model (CRMM) A web-based modeling platform that projects the future burden of cancer and its macroeconomic impacts Simulate current and future cancer control interventions on both the population and the economy Developed to inform policymakers in government and cancer agencies in Canada about future investments in cancer control

Cancer Risk Conceptual Model

Data Sources SOURCEDATA TYPE Vital Statistics, CensusMortality, Births, Population projections Canadian Cancer RegistryIncidence, Staging Canadian Community Health Survey; National Population Health Survey Smoking rates, Population health utilities General Social SurveyTime use data Census, T1-Family File, SPSD/MEarnings, Transfers and Taxes Canadian Institute for Health InformationTotal health care expenditures Ontario Case Costing Initiative; Provincial Formulary; Provincial Ministries of Health Health care costs of diagnosis, treatment, follow-up, palliative and terminal care Expert OpinionCurrent treatment practice Literature Lung cancer risk equation, Screening parameters, Radon mitigation options, Radon exposure Chart Review, SEER, LiteratureCancer survival Population Health Impact of Disease in Canada Study Health-related quality of life associated with living with cancers

5 Family Diagnosis of lung cancer (all cases) Stage I NSCLC Stage III NSCLC Stage IV NSCLC Stage II NSCLC Surgery Surveillance post-resection 2nd Line Chemo* 1st Line Chemo* Progression (Relapse) Concurrent Adjuvant Chemo &Radio Surveillance Adjuvant Chemo New Lung Primary (re-enter on the left – empty for phase I) Limited SCLC Extensive SCLC 3rd Line Chemo* 2nd Line Chemo 1st Line Chemo Concurrent Adjuvant Chemo & Chest Radio Terminal Care Specialist Diagnostic Workup Surgery Palliative Radio PCI Specialist Diagnostic Workup BSC Medically inoperable Radio 1st Line Chemo** Radio Surveillance P P Best Supportive Care only* BSC P *Palliative Radio given to a % of Stage IV patients after chemotherapy, and a % of patients receiving best supportive care ** Some may get 2nd line chemo and palliative radio at recurrence Details of costs, transition probabilities, durations and health utilities found in Lung Cancer Management Data xls Lung Cancer Management Algorithm

Life-years gainedDirect HC costs Cigarette Taxes Base case: Constant smoking rate of 22% savings (reduced revenue) 50% relative reduction reached over 3 years ( )646,800 $84 B 50% relative reduction reached over 5 years ( )587,000$656 M $81 B 50% relative reduction reached over 10 years ( ) 469,100 $74 B Impact of Smoking Cessation on Total Direct Healthcare Costs Base case Smoking cessation (3 yrs) Smoking cessation (5 yrs) Smoking cessation (10 yrs)

Impact of Smoking Reduction 50% reduction achieved over 5 years: Over 20 years, would result in: Decrease in lung cancer cases by 40,200 Decrease in prevalence of lung cancer by 72,400 Reduce deaths from lung cancer by 25,300

Report date: March, 2010 Data source: Cancer Care Ontario, ALR, OCR Notes: 1. Many patients in the "No Treatment" category may not be medically fit for the guideline treatment due to factors we are not currently able to adjust for. Patients may also decline treatment for personal reasons. Others may have been treated outside Ontario. 2. Alternate Treatment: cases receiving a therapy different from that recommended in the guidelines. This may include non-platinum-based chemotherapy or radiation therapy only. 3. Treated Non RCC: patients receiving chemotherapy outside of a cancer centre where the drug regimen is not reported to CCO. 4. Data represents patients diagnosed Between Jan 2007 and Dec 2007, and and resected within 270 days of diagnosis)

Impact of Increasing Adjuvant Chemotherapy Uptake on Health Care Costs and Life Years Gained ( Stage II and IIIa, N = 1033) Uptake RateHealth Care CostLife Years Gained 20%35,793,6117,802 70%35,922,6879,072 $ 129,0761,270 Incremental cost-effectiveness ratio (ICER) = $102 per life year gained Increasing adjuvant chemotherapy uptake rates from 20% to 70% could extend life years by an average of 1.3 years per patient Savings in 2 nd -line chemotherapy $1.1M, supportive $394,555 and end of life care $344,434

Lung Cancer Screening Eligibility Criteria Minimum pack - years smoked Screening age range – 743,341,8682,620,0722,060, – 742,703,2522,184,7351,732, – 741,944,3131,613,0261,312, – 702,827,8852,193,2511,692, – 702,189,2691,757,9141,364, – 701,430,3301,186,205944,143 Number eligible in Canada in 2011 using NLST eligibility criteria would be 2,184,735

Describes the total annual direct healthcare treatment cost for cases who are initially diagnosed as Stage IV NSCLC between 2011 and 2015 and receive the 1 st line chemotherapy (followed by subsequent lines of chemotherapies and/or receive supportive care) Five-year cumulative budgetary impact of introducing TC-beva regimen to the Stage IV 1 st line chemotherapy would be $185 million.

Potential Policy Questions that CRMM can Address Impact of changes in smoking rates by province on the number of lung cancer cases by age, gender, cell type and stage and by province over next 20 years Impacts (health outcomes and costs) of the introduction of a population-based screening program at the provincial or national level Likely effect of any new intervention on disease progression, life expectancy, years lived in health, budget impact, cost- effectiveness – Adjuvant therapy for surgically resected lung cancer – New systemic therapy for advanced disease