Elsevier

Lung Cancer

Volume 86, Issue 2, November 2014, Pages 281-287
Lung Cancer

A population-based study of the resource utilization and costs of managing resectable non-small cell lung cancer

https://doi.org/10.1016/j.lungcan.2014.09.013Get rights and content

Highlights

  • We investigate the costs of adjuvant chemotherapy in resectable non-small cell lung cancer patients.

  • We compare the costs to randomized controlled trial results in a phase IV study.

  • The average cost per patient treated with surgery and adjuvant chemotherapy was $37,860.88 (2012 US).

  • The average per patient costs closely reflects the costs of treatment estimated in the randomized controlled trial.

  • Geographic variation in per patient resource utilization and costs exists and may be a target to reduce system inefficiencies.

Abstract

Objectives

Surgical resection and adjuvant chemotherapy have become standard of care for treating resectable early stage non-small cell lung cancer (NSCLC). The purpose was to describe and compare the overall and regional resource utilization and costs of resected NSCLC treated with and without adjuvant chemotherapy.

Materials & Methods

A population-based retrospective cohort study of resected NSCLC patients, diagnosed between 2004 and 2006 (representing the cohort immediately affected by the change in clinical practice) was performed using administrative data. Patients were followed for four years from the date of surgery. The healthcare system perspective was used, and cost estimates (2012 US$) were derived from administrative data and the literature.

Results

3354 patients were included. The average cost per patient treated with surgery and adjuvant chemotherapy was $37,860.88 and was significantly higher than the average cost per patient treated with surgery alone $32,221.45 (p < 0.0001). Among regions, the costs of patients treated with surgery and chemotherapy ($32,672–$45,453) and the costs of those treated with surgery alone ($28,679–$36,845) varied significantly (p < 0.0001). Rates of chemotherapy, the proportion of patients who received any imaging scans, hospitalizations, specialist visits, emergency room visits, mean number of imaging scans, general physician visits, and blood transfusions all varied significantly among geographic regions.

Conclusions

This population-based study demonstrates an average cost per patient similar to that shown in randomized controlled trials; however, costs for either treatment approach varied by geographic region. Understanding the regional variation in costs and resource utilization is important with respect to delivering optimal treatment in a cost-effective strategy.

Introduction

Lung cancer is the leading cancer diagnosis, responsible for almost 13% of all cancer diagnoses world-wide. Five-year survival ranges widely from 25 to 70% for surgically resectable patients [1], [2]. Results from seminal randomized controlled trials published in 2004 demonstrated a significant benefit of adjuvant vinorelbine-cisplatin chemotherapy for resectable, early stage NSCLC patients [3], [4], [5]. The trials reported an increased survival benefit of approximately 5% between patients treated with surgical resection alone and those managed with additional chemotherapy. Adjuvant chemotherapy following surgical resection of the primary tumour is now considered a standard treatment pathway for early-stage NSCLC patients across the world [6], [7], [8]. Following the publication of the trials, a 24% increase in the adoption of adjuvant chemotherapy was reported and a 4% 4-year survival benefit documented in a phase IV population-based outcomes study comparing the uptake of adjuvant chemotherapy into clinical practice, with historical practice [9]. The impact of timing of adjuvant chemotherapy on survival [10], a description of practice patterns (dosage, regimens) [11] and effectiveness in the elderly [12] have also been reported using population-based approaches.

However, our understanding of the economic burden of this treatment regimen at the population-level, and the overall cost of managing surgically resected early stage patients, is less clear than our clinical knowledge. Ng et al. performed a cost-effectiveness evaluation of surgery alone compared to surgery and adjuvant cisplatin vinorelbine based on the NCI JBR.10 randomized controlled trial [13]. They reported an incremental cost effectiveness ratio of $7175/life year gained for adjuvant chemotherapy, with the largest contributor to costs being hospitalizations [13]. The costs of adjuvant chemotherapy in the real-world setting have yet to be studied. We estimated resources utilized and direct lung cancer costs in a subset of patients diagnosed with non-small-cell lung cancer (NSCLC) from 01/04/2004 to 31/03/2006 who underwent surgical resection, within the province of Ontario, Canada and report on the influence of adjuvant chemotherapy usage on total costs for treating surgically resectable lung cancer, while exploring regional variation.

Section snippets

Study design

This report represents a substudy of a larger, population-based, retrospective cohort study that compared the management and clinical outcomes of surgically resected NSCLC in Ontario [9]. This complementary study estimates the direct costs and resource utilization by linking administrative data holdings. Canada operates under a single payer healthcare system, with the majority of healthcare provided to residents through a public system managed by the provincial government. This study was

Results

The study population consisted of 3354 patients. According to the study definition of initiation in the 16 weeks following surgery, less than half of patients were treated with adjuvant chemotherapy (1032). Demographic characteristics of the patients are provided in Table 2. The mean age of the cohort was 67 years old (standard deviation 9.9 years). Approximately 23% of patients were recorded in the administrative data (using emergency room or hospitalization diagnostic codes) to have a

Discussion

Patients who received adjuvant chemotherapy and surgical resection of the primary tumour (n = 1032) for NSCLC were younger and had a greater burden of metastatic disease in the 90 days following surgery than those who received surgery alone (n = 2322). These differences in case-mix may explain the demonstrated geographic variation in uptake. The four-year costs of treating a patient with adjuvant chemotherapy and surgical resection of the primary was significantly higher than treating a patient

Conflict of interest

None declared.

Acknowledgements

Funding Sources: This research was undertaken, in part, thanks to funding from the Canada Research Chairs Program for Dr. Ana Johnson and through funding from a grant from the Canadian Institutes of Health Research. Dr. Coburn (Career Scientist Award) has received funding through the Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was additionally supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the MOHLTC. The

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