1. Advancing Health Economics, Services, Policy and Ethics Stuart Peacock Cancer Control Research, BC Cancer Agency Canadian Centre for Applied Research in Cancer Control (ARCC) Simon Fraser University

2. I have no conflicts of interest

3. Single shot policy questions Ongoing priority setting frameworks Some points for discussion Real world evidence and priority setting

4. Prostate Cancer Screening policy: funded and led by ARCC Collaboration with ARCC, BCCA, Vancouver Prostate Centre (VPC), and the Fred Hutchinson Cancer Research Centre We found that regular screening resulted in a loss of quality- adjusted life years, regardless of screening intensity, when quality of life was factored into the model BCCA/VPC updated their 2012 provincial recommendation on PSA screening to explicitly state that they did not support unselected, population-based screening Prostate Cancer Screening

5. “The incremental cost-effectiveness of regular screening ranged from $36,300/LYG, for screening every four years from ages 55 to 69 years, to $588,300/LYG, for screening every two years from ages 40 to 74 years. After utility adjustment, all screening strategies resulted in a loss of quality- adjusted life years (QALYs)”

6. PBMA is a practical framework to aid decision- makers seeking to maximize benefits from scarce resources Limitations of PBMA –reliance on simple models –perceived dependence on content expert’s subjective estimates of effectiveness and/or benefits –lack of comparability between measures of effectiveness Program Budgeting and Marginal Analysis (PBMA) 6

7. Real World Evidence and PBMA Define aim and scope Form Steering Committee Determine current program budget Establish decision- making criteria Identify areas for resource release Identify areas for new resource use Make allocation recommendations Validity check and final decisions For each area identified: Form Advisory Panel Collect local costs/outcomes Build Markov model - CUA MCDA Models 5 areas identified: Adjuvant trastuzumab in breast cancer Bevacizumab in metastatic colorectal cancer Mammography for women with dense breast tissue PET for lung cancer staging MRI for breast cancer screening 7

8. Objective: – Examine the cost effectiveness of MRI and mammography for breast cancer screening in BRCA1/2 mutation carriers Current practice: – 6 mo. alternating MRI and mammography for confirmed BRCA1/2 carriers (& family) – Annual mammography for others at high hereditary risk Rationale: – MRI is more sensitive than mammography (75% vs. 32%) but less specific (96.1% vs. 98.5%) and more expensive

9. Markov Model Design 9

10. Study Sample – from HCP data 871 women with BRCA1/2 test results in 2002-2007 203 confirmed BRCA1/2 mutation positive 99 with no cancer (or no CAIS record of cancer) 105 BRCA1/2 positive cancer cases 87 patients with first cancer 668 mutation negative or uninformative 18 with other cancer or missing stage information 68 patients with complete records 19 patients diagnosed before 1995 10

11. Data Sources for Model Model InputSources Cancer IncidenceLiterature (meta-analysis) Screening Sensitivity and Specificity Literature (meta-analysis) Cancer SurvivalBCCA Surveillance and Outcomes data Treatment proceduresBCCA records for BRCA1/2 population Treatment CostsBCCA Pharmacy, Radiation Therapy and Administration; BC Medical Services Commission UtilitiesLiterature 11

12. Costs: –MRI screen: $277 (IH, BCCA and VIHA) –Bilateral mammography: $95 (2008 MSP) –Average diagnostic work-up: $187 (2008 MSP) Screening and Diagnostics SensitivitySpecificity MRI0.770.86 Mammography (in MRI arm)0.390.95 MRI & Mammo (pooled)0.940.77 Mammography (Mammography alone arm) < 50 yrs0.670.88 > 50 yrs0.830.88 from meta-analysis by Warner 2008; Kerlikowske 2000 12

13. Treatment Costs In SituLocalRegionalDistant Surgery 3,3943,3653,5953,057 Chemo 333,6259,1085,753 Radiation 03,78510,9096,835 TOTAL 3,42710,94023,61215,645 MR Chemo 11,082 Radiation 2,152 Hospitalization 12,714 TOTAL 26,704 13

14. 14 Utilities Derived from published quality of life studies Screening has ‘full health’ utility (1.00) State Utility Diagnostics0.987 In situ0.965 Local0.860 Regional0.675 Distant0.380 Remission0.965 MR0.380

15. Results

16. Other ICER Results Screening Mammography  annual screening mammography for women with greater than 75% mammographic breast density had an ICER range of $565,912/QALY PET/CT  PET for NSCLC staging: $10,932/LYG  PET for SPN diagnosis: $64,062/LYG Adjuvant Trastuzumab for breast cancer  use of adjuvant trastuzumab saves approximately $1,200,000 from the Systemic Therapy budget annually  projecting survival scenarios forward 28-years produced an ICER of $13,095/QALY Bevacizumab for metastatic colorectal cancer  Introduction of bevacizumab associated with an ICER of $43,058/QALY

20. Cost-effectiveness of Personalized Medicine Treatment decision Diagnostic test FLT3-ITD and NPM1 mutational testing ICER=$65,186/LYG 20

21. Sustainability Investments and disinvestments Personalized medicine – drugs Personalized medicine - tests Points for discussion

22. Advancing Health Economics, Services, Policy and Ethics www.cc-arcc.ca