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