Asia-Pacific Journal of Clinical Oncology 2016; 12: 33–40
doi: 10.1111/ajco.12350
ORIGINAL ARTICLE
The rapidly escalating cost of treating colorectal cancer in Australia Sumitra ANANDA,1,2,3 Suzanne KOSMIDER,2,3 Ben TRAN,1,2 Kathryn FIELD,1,3 Ian JONES,1 Iain SKINNER,2 Mario GUERRIERI,4 Michael CHAPMAN1 and Peter GIBBS1,2,3 1
Royal Melbourne Hospital and 3BioGrid Australia, Parkville, and 2Western Hospital and 4Radiation Oncology Victoria, Footscray, Victoria, Australia
Abstract Aims: Considerable progress in cancer treatment is leading to better outcomes, but the cost of therapy is placing increasing pressure on the health system. Understanding the real-world cost of therapies for each stage will become increasingly important in informing treatment selection and health policy. Methods: To explore the cost of treating colorectal cancer in the modern era, data were entered onto a prospective database at four hospitals. We estimated the impact of bevacizumab by using data from July 2009, and projected the likely impact of the recent listing of cetuximab. The utility of these data for estimating the cost-effectiveness of treatment was explored. Results: Cancer stage and age at diagnosis were major determinants of treatment received and the associated cost. The cost of early stage disease has not substantially changed whereas therapies such as oxaliplatin and irinotecan were significant contributors to substantial increases in stage IV disease, now $71 156 per patient. Bevacizumab has added at least $10 247 per patient and we estimate that cetuximab will add a further $12 022. An exploratory analysis of the cost-effectiveness of oxaliplatin for adjuvant therapy of stage III colon cancer suggests that this is well within the accepted range. Conclusion: These data suggest that recent progress in the treatment of later stages of colorectal cancer is being achieved at significant financial cost. The increased costs of managing later stages of disease make an investment in prevention and early detection ever more attractive. Key words: colorectal cancer, cost, economic evaluation, prevention, stage.
INTRODUCTION Australia has one of the highest rates of colorectal cancer (CRC) in the world, with a 1:20 lifetime incidence.1,2 The projected incidence in 2014 is 16 980 new cases, more than a doubling in less than a decade.3 The financial cost of care is the combined sum of expenses
Correspondence: Dr Sumitra Ananda MBBS, FRACP, Department of Medical Oncology, Royal Melbourne Hospital, Grattan Street, Parkville, Vic. 3050, Australia. Email: [email protected] Conflict of interest: The author(s) declare that they have no competing interests Accepted for publication 30 December 2014.
© 2015 Wiley Asia12: Pty33–40 Ltd Asia-Pac J ClinPublishing Oncol 2016;
incurred during diagnosis, treatment and follow-up, with the stage of disease at diagnosis the major determinant of treatment and therefore cost. With much of the recent progress in treating CRC being achieved in later stage disease, where the median survival in clinical trials now regularly exceeds 20 months,4,5 the cost of agents used in this setting would be expected to have added substantially to the overall cost of care. Understanding the cost of treatment is critical for planning of health service delivery, with the cost of a new intervention needing to be traded off against the potential savings from avoiding later expenses. For example, an investment in a new adjuvant therapy ultimately may prove cost-effective if the cost of this therapy is less than what would have been spent on
34
S. Ananda et al.
managing the later cases of advanced disease that have now been avoided. To date, there are very little data available on the true cost of treatment for CRC. While the cost of an individual intervention can be determined, such as the price of a specific chemotherapy ampoule, in the absence of comprehensive data on what treatment is delivered in routine clinical practice, the true stage-based cost of treating patients cannot be determined. Here, using a comprehensive, prospective dataset, we have attempted to calculate the stage-specific costs of treating patients with CRC in routine clinical practice.
METHODS Patients BioGrid Australia is a novel concept in biomedical research that has successfully implemented prospective and standardized data capture (http://www. biogrid.org.au). A search of a prospective, comprehensive CRC database was undertaken, using data from four participating sites, to determine the treatment of individual stages of disease and the specific costs associated. Patients initially diagnosed from January 2003 (when data collection began) were included for stage I and II CRC. For stage III CRC, only those treated since
Table 1
the Pharmaceutical Benefit Scheme (PBS) availability of both oxaliplatin and capecitabine (April 2006) were analyzed. For patients with stage IV disease, those treated since the PBS availability of oxaliplatin and irinotecan (September 2005) were included. As bevacizumab is PBS restricted to the first-line setting, we analyzed patients initiating treatment after July 2009 (date of PBS listing) until December 2010 to determine the frequency of initial prescribing. Projections of the impact of cetuximab, only recently listed on the PBS, were made by combining data on current treatment practices with clinical trial outcome data. All costs routinely incurred at diagnosis, treatment and follow-up were considered. Stage-specific treatment of colon and rectal cancer was determined. Patients with locally advanced rectal cancer stage II or III were considered together due to the similar approach to management. Rectal cancer-specific costs including radiation therapy and reversal of temporary ileostomy were included. Stage-specific risk of recurrence for stages I–III, using our own data, was also determined. Cost estimates included the costs of treating any recurrence. Investigations are summarized in Table 1. We assumed all patients underwent a colonoscopy and computerized tomography staging at diagnosis. Routine blood tests (FBE, U&E, LFT, CEA, coagulation studies)
Interventions undertaken for each patient are determined by tumor stage and location
Stage Clinic (new) Clinic (review) Colonoscopy Biochemistry CEA CT CAP MRI pelvis ULAR (rectal surgery) Hemicolectomy Day oncology Chemo/CADD Chemo complications Portacath insertion Port complications Rectal RT PET Liver surgery (complicated) Liver surgery (uncomplicated) Lung surgery (complicated) Lung surgery (uncomplicated)
CCI
CCII
CCIII
RCI
RCII/III
Metastatic
x x x x x x
x x x x x x
x x x x x x
x x x x x x x x
x x x x x x x x
x
x x x x x x
x x x x x x
x x x x x x x x x x x x x x x x x x x x
x x x x x x
CADD, ambulatory infusion pump; CC, colon cancer; CEA, carcinoembryonic antigen; CT, computerized tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; RC, rectal cancer; ULAR, ultralow anterior resection.
© 2015 Wiley Publishing Asia Pty Ltd
Asia-Pac J Clin Oncol 2016; 12: 33–40
35
Rising cost of colorectal cancer
Table 2
Breakdown according to stage. Stage II and III rectal cancers are combined into a locally advanced category Colon cancer
Stage I Stage II Stage III Locally advanced Stage IV
Rectal cancer
Male (%)
Female (%)
doi: 10.1111/ajco.12350
ORIGINAL ARTICLE
The rapidly escalating cost of treating colorectal cancer in Australia Sumitra ANANDA,1,2,3 Suzanne KOSMIDER,2,3 Ben TRAN,1,2 Kathryn FIELD,1,3 Ian JONES,1 Iain SKINNER,2 Mario GUERRIERI,4 Michael CHAPMAN1 and Peter GIBBS1,2,3 1
Royal Melbourne Hospital and 3BioGrid Australia, Parkville, and 2Western Hospital and 4Radiation Oncology Victoria, Footscray, Victoria, Australia
Abstract Aims: Considerable progress in cancer treatment is leading to better outcomes, but the cost of therapy is placing increasing pressure on the health system. Understanding the real-world cost of therapies for each stage will become increasingly important in informing treatment selection and health policy. Methods: To explore the cost of treating colorectal cancer in the modern era, data were entered onto a prospective database at four hospitals. We estimated the impact of bevacizumab by using data from July 2009, and projected the likely impact of the recent listing of cetuximab. The utility of these data for estimating the cost-effectiveness of treatment was explored. Results: Cancer stage and age at diagnosis were major determinants of treatment received and the associated cost. The cost of early stage disease has not substantially changed whereas therapies such as oxaliplatin and irinotecan were significant contributors to substantial increases in stage IV disease, now $71 156 per patient. Bevacizumab has added at least $10 247 per patient and we estimate that cetuximab will add a further $12 022. An exploratory analysis of the cost-effectiveness of oxaliplatin for adjuvant therapy of stage III colon cancer suggests that this is well within the accepted range. Conclusion: These data suggest that recent progress in the treatment of later stages of colorectal cancer is being achieved at significant financial cost. The increased costs of managing later stages of disease make an investment in prevention and early detection ever more attractive. Key words: colorectal cancer, cost, economic evaluation, prevention, stage.
INTRODUCTION Australia has one of the highest rates of colorectal cancer (CRC) in the world, with a 1:20 lifetime incidence.1,2 The projected incidence in 2014 is 16 980 new cases, more than a doubling in less than a decade.3 The financial cost of care is the combined sum of expenses
Correspondence: Dr Sumitra Ananda MBBS, FRACP, Department of Medical Oncology, Royal Melbourne Hospital, Grattan Street, Parkville, Vic. 3050, Australia. Email: [email protected] Conflict of interest: The author(s) declare that they have no competing interests Accepted for publication 30 December 2014.
© 2015 Wiley Asia12: Pty33–40 Ltd Asia-Pac J ClinPublishing Oncol 2016;
incurred during diagnosis, treatment and follow-up, with the stage of disease at diagnosis the major determinant of treatment and therefore cost. With much of the recent progress in treating CRC being achieved in later stage disease, where the median survival in clinical trials now regularly exceeds 20 months,4,5 the cost of agents used in this setting would be expected to have added substantially to the overall cost of care. Understanding the cost of treatment is critical for planning of health service delivery, with the cost of a new intervention needing to be traded off against the potential savings from avoiding later expenses. For example, an investment in a new adjuvant therapy ultimately may prove cost-effective if the cost of this therapy is less than what would have been spent on
34
S. Ananda et al.
managing the later cases of advanced disease that have now been avoided. To date, there are very little data available on the true cost of treatment for CRC. While the cost of an individual intervention can be determined, such as the price of a specific chemotherapy ampoule, in the absence of comprehensive data on what treatment is delivered in routine clinical practice, the true stage-based cost of treating patients cannot be determined. Here, using a comprehensive, prospective dataset, we have attempted to calculate the stage-specific costs of treating patients with CRC in routine clinical practice.
METHODS Patients BioGrid Australia is a novel concept in biomedical research that has successfully implemented prospective and standardized data capture (http://www. biogrid.org.au). A search of a prospective, comprehensive CRC database was undertaken, using data from four participating sites, to determine the treatment of individual stages of disease and the specific costs associated. Patients initially diagnosed from January 2003 (when data collection began) were included for stage I and II CRC. For stage III CRC, only those treated since
Table 1
the Pharmaceutical Benefit Scheme (PBS) availability of both oxaliplatin and capecitabine (April 2006) were analyzed. For patients with stage IV disease, those treated since the PBS availability of oxaliplatin and irinotecan (September 2005) were included. As bevacizumab is PBS restricted to the first-line setting, we analyzed patients initiating treatment after July 2009 (date of PBS listing) until December 2010 to determine the frequency of initial prescribing. Projections of the impact of cetuximab, only recently listed on the PBS, were made by combining data on current treatment practices with clinical trial outcome data. All costs routinely incurred at diagnosis, treatment and follow-up were considered. Stage-specific treatment of colon and rectal cancer was determined. Patients with locally advanced rectal cancer stage II or III were considered together due to the similar approach to management. Rectal cancer-specific costs including radiation therapy and reversal of temporary ileostomy were included. Stage-specific risk of recurrence for stages I–III, using our own data, was also determined. Cost estimates included the costs of treating any recurrence. Investigations are summarized in Table 1. We assumed all patients underwent a colonoscopy and computerized tomography staging at diagnosis. Routine blood tests (FBE, U&E, LFT, CEA, coagulation studies)
Interventions undertaken for each patient are determined by tumor stage and location
Stage Clinic (new) Clinic (review) Colonoscopy Biochemistry CEA CT CAP MRI pelvis ULAR (rectal surgery) Hemicolectomy Day oncology Chemo/CADD Chemo complications Portacath insertion Port complications Rectal RT PET Liver surgery (complicated) Liver surgery (uncomplicated) Lung surgery (complicated) Lung surgery (uncomplicated)
CCI
CCII
CCIII
RCI
RCII/III
Metastatic
x x x x x x
x x x x x x
x x x x x x
x x x x x x x x
x x x x x x x x
x
x x x x x x
x x x x x x
x x x x x x x x x x x x x x x x x x x x
x x x x x x
CADD, ambulatory infusion pump; CC, colon cancer; CEA, carcinoembryonic antigen; CT, computerized tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; RC, rectal cancer; ULAR, ultralow anterior resection.
© 2015 Wiley Publishing Asia Pty Ltd
Asia-Pac J Clin Oncol 2016; 12: 33–40
35
Rising cost of colorectal cancer
Table 2
Breakdown according to stage. Stage II and III rectal cancers are combined into a locally advanced category Colon cancer
Stage I Stage II Stage III Locally advanced Stage IV
Rectal cancer
Male (%)
Female (%)
