CERGAS

The burden of cancer supportive care Rosanna Tarricone, PhD Director CERGAS Bocconi University Milano, 4.04.2014

Cancer. Epidemiology and economics burden of cancer supportive care

The Current evidence: an unexplored issue

The

way forward and conclusive remarks

The burden of Non Communicable Diseases (NCDs) In 2011,

55

million people died worldwide

NCDs were responsible for

87% 4 The

2/3

of all deaths globally

of all deaths were caused by NCDs in high-income countries

main NCDs are cardiovascular diseases, cancers, diabetes

and chronic lung diseases

Source: WHO, The top 10 leading causes of death, 2013

Cancer: epidemiological burden

14.1

million new cancer cases

8.2 32.6

million cancer deaths

million people living with cancer

Source: WHO, The top 10 leading causes of death, 2013

Cancer: epidemiological burden

U.S.A. EU-28

% 45 of all deaths in 2012

Lung Cancer Breast Cancer Colon Rectal Cancer Prostate Cancer

China Source: WHO, The top 10 leading causes of death, 2013

The economic burden of cancer in EU countries In 2009 the total economic cost of cancer in the EU was more than

€ 126

billion

Inpatient care costs were estimated to The health-care cost was

€ 51

billion that accounted for 4% of total EU health-care expenditure, of these:

be € 28,4 billion, accounting for 56% of cancer-related health-care costs Drug costs accounted for more than € 13,5 billion 27% of cancer-related health-care costs.

However,

60%

areas, with almost

of the economic burden of cancer was incurred in non-health-care

€ 43

billion incurred in lost productivity attributable to early death

Source: Luengo-Fernandez et al. Economic burden of cancer across the European Union: a population-based cost analysis. The Lancet Oncology 2013;14(12):1165-74.

The economic burden of cancer in EU countries The cost of lung, breast, colorectal, and prostate cancers was

44%

€ 55,3

of the total economic cost of cancer:

% 15 % 12

10% 7%

Lung cancer €18,8 billion Breast cancer €15,0 billion Colorectal cancer € 13,1 billion Prostate cancer € 8,43 billion

Source: Luengo-Fernandez et al. Economic burden of cancer across the European Union: a population-based cost analysis. The Lancet Oncology 2013;14(12):1165-74.

billion i.e,

The economic burden of cancer (USA) in 2008 In the USA, the cost of cancer was estimated at

US$ 202

billion (€ 157)

US$ 77

US$ 125

billion (€ 60) were direct medical costs

billion (€ 97) were mortality costs.

Source: Luengo-Fernandez et al. Economic burden of cancer across the European Union: a population-based cost analysis. The Lancet Oncology 2013;14(12):1165-74.

Too many patients still experience cancer care side effects

€  individual’s quality of life  dose delays, dose reductions, reduction in dose density and in some cases dose discontinuation

which reduce the effectiveness of chemotherapy that worsen health outcomes.



 increase in hospitalization  emergency room visits  adoption of a palliative treatment and increase the care giving burden

all of which raise the costs for healthcare systems, patients and care givers.



Chemotherapy-Induced Diarrhoea: a side effect whose incidence is 50 - 80% worldwide

% 54

59

%

Patients suffering from colon rectal cancer developed diarrhoea grade III or IV after the first cycle of chemotherapy

patients attended an unscheduled visit to the oncology centre

43

%

14% 5%

attended the emergency department for symptom control

patients died, 5% of which had uncontrolled diarrhoea

Sources: Benson et al., Recommended guidelines for the treatment of cancer treatment-induced diarrhea. J Clin Oncol 2004;22:2918-26. Gibson & Stringer Chemotherapy-induced diarrhea. Curr Opin Suppot Palliat Care 2009;3:31-5

Chemotherapy-Induced Diarrhoea: a side effect whose incidence is 50 - 80% worldwide

27

patients having to delay their chemotherapy for 14 days

33

patients had their chemotherapy reduced by 25%

16

patients had their chemotherapy changed

%

% 86

patients had a median hospitalisation length of 8 days

%

%

4%

patients had their chemotherapy discontinued

The total cost per hospitalisation per patient with diarrhoea grade III or IV was estimated to be on average US$ 8,230 Sources: Benson et al., Recommended guidelines for the treatment of cancer treatment-induced diarrhea. J Clin Oncol 2004;22:2918-26. Gibson & Stringer Chemotherapy-induced diarrhea. Curr Opin Suppot Palliat Care 2009;3:31-5

Chemotherapy-Induced Diarrhoea: an avoidable cost CID has shown to bear a relevant proportion of avoidable costs in terms of hospitalisations, unplanned visits, tests, drug consumptions, discontinuation or prolongation of chemotherapy

These cost components are likely to be complemented by informal care and productivity losses that have not been investigated in current literature but can further explain an important fraction of CID total burden

Furthermore, quality of life - the most important outcome in research in oncology - has not been extensively investigated when CID is at stake

Source: Tarricone et al. Chemotherapy induced diarrhea (CID) what do we know about its prevalence, incidence and the impact that it has on costs and quality of life: a systematic literature review. Preliminary findings

Cancer Cachexia-Anorexia Syndrome: a side effect that impacts till 80% of advanced cancer patients CACS imposes an additional burden on the prognosis, treatment and patients’ outcomes with a detrimental effect on their quality of life CACS reduces tolerance to therapy and increases postsurgical complications Overall, CACS accounts for up to 40% of all cancer-related deaths •

No evidence exists on the economic burden of CACS but cost-saving strategies of nutrition interventions for preventing CACS death Quality of life has been predominantly measured through the EORTC-QLQ-C30 and the FAACT

Source: Tarricone et al. Impact of cancer-cachexia on the health-related quality of life and resource utilisation: a systematic review. Preliminary findings

Chemotherapy induced nausea and vomiting (CINV): open room to debate CINV is amongst the most unpleasant and distressing aspects of chemotherapy experienced by up to 60% of patients Inadequate control of emesis cause patients to delay or refuse potentially curative therapy Even one or two emetic episodes is associated with a significant deterioration in the quality of life, impairing social, physical and emotional functioning Currently anti-emetic drugs can cure up to 75-90% acute emesis Despite this, about 40-75% of cancer patients still suffer from delayed CINV, and it still remains the significant cause for chemotherapy related morbidity

Source: Tarricone et al. Impact of chemotherapy-induced nausea and vomiting on costs and quality of life: a systematic review. Preliminary findings

Cancer Supportive Care: key to manage cancer care side effects Cancer supportive care (CSC) aims at improving patients and carers’ quality of life

CSC can massively help reducing unnecessary costs CSC aims at providing accurate information for helping patients and their carers understand the side effects of cancer treatment and giving patients and their family the opportunity to participate in the decision making of the pathway of care More insight is however needed to assess CSC strategies and delivering patterns of care

Conclusive remarks: the way forward

Compared to cancer, research in cancer care side effects is scant Side effects are too often mis-diagnosed, under-diagnosed, if not unrecognised till it is too late

Scarce clinical evidence on different therapeutic strategies leads to lack of consensus on treatment modalities thus leaving the patients, carers, healthcare systems and societies bearing the full avoidable costs In times of resource constraints robust research is urgently needed to assess clinical outcomes of current and prospective strategies to prevent, or reduce side effects and compare them against economic costs

Conclusive remarks: the way forward Comprehensive burden of illness analysis need to be performed aimed at measuring the economic costs of side effects and who bears them.

Comparative economic evaluation analysis (e.g. cost-effectiveness analysis) must be developed to estimate the differential costs and outcomes of several treatment modalities thus leading to universally agreed guidelines and patients’ access to cost-effective technologies: economic evidence in this area is worryingly scanty

Quality of life must be assessed and compared against costs:  Given the distress caused by side effects patient-reported outcomes need to be included in QoL evaluation 

Disease-specific QoL scales (e.g. EORTC-QLQ-C30, FAACT) must be compared to determine whether one is more sensitive to small changes in health-related quality of life (HRQoL) of cancer patients suffering from side effects

 Disease-specific HRQoL scales are however poorly informative if no utilities can be retrieved to make comparative assessment for policy-makers

Conclusive remarks: the way forward Cost-Effectiveness Analysis and Health Technology Assessment are common tools to decide the introduction in routine care of new technologies However to effectively support policy-makers in allocating scarce resources, health outcomes have to be measured and compared consistently across different disease areas The Quality-Adjusted-Life-Year (QALY) is the accepted health outcome by policymakers for comparative assessments and is estimated by deriving utilities from generic HRQoL tools such as the EuroQoL 5-Dimension (EQ-5D) and the Short Form 6Dimension (SF-6D) Unless utilities can be retrieved by specific HRQoL tools in cancer care (e.g. FAACT), no comparative assessments on QALYs can be performed across different treatment modalities

Conclusive remarks: the way forward

CERGAS and SDA Bocconi School of Management in collaboration with Helsinn Group are striving to fill the gaps in current evidence as to the economic burden of cancer treatment side effects; comparative economic evaluation analysis of different treatment modalities for sufferers of side effects; innovative clinical

management patterns Given the multifaceted nature of the problem, clinical management of cancer care side effects must adopt a multimodality and multi-stakeholder approach Together with health professionals (i.e. oncologists, nurses), patients and carers have a role in managing side effects and with adequate knowledge they can ask appropriate assessments and interventions

Mobile health has the great potential to connect patients, carers, and health professionals so to get early detection and intervention, less costs and higher quality of life

The future is here to come. Thank you.