ICARO 2009 Round Table Discussion Cost & Economic Analyses in - - PowerPoint PPT Presentation

ICARO 2009

Round Table Discussion

Cost & Economic Analyses in Radiation Oncology

• Prof. Rajiv

Sarin, MD, FRCR Director Advanced Centre for Treatment, Research & Education in Cancer (ACTREC) TATA MEMORIAL CENTRE MUMBAI INDIA rsarin@actrec.gov.in

Criteria for deciding cost effectiveness for expensive new anti‐cancer agents

Sarin R (Editorial), Jr. Cancer Res. Ther. 4(1) 2008.

• New Radiation Technologies should be subjected to same analyses

and same cut offs as for other health interventions including the new molecular targeted therapies

• WHO recommends using per capita GDP (adjusted for Purchase

Power Parity) of a country for deciding the cut off for cost effectiveness of health interventions IF additional cost incurred to gain 1 quality adjusted life year is

< 1 times the GDP: COST EFFECTIVE INTERVENTION 1 – 3 times the GDP: PROBABLY COST EFFECTIVE INTERVENTION > 3 times the GDP: NOT COST EFFECTIVE INTERVENTION INDIA: Per capita GDP adjusted for Purchase Power Parity: 3800 US$

Radiotherapy is one of the most cost effective modality for cancer management

Cost effectiveness analyses for radiotherapy is complicated by major global differences in

• Type and stages of cancers to be treated
• Throughput ‘required’

per unit & handicaps in expertise

• Work practices (Monday – Friday: 9am – 5pm or weekends also)
• Initial Capital Cost of Equipment
• Interest rates
• Cost of maintenance
• Downtime of the machine
• Replacement cycle or life of machine

UNIVERSAL PROBLEM Integration of New Technology in ‘Routine Care’ without proper analysis of ‘Clinical Benefit’ complicates Cost effectiveness analyses

How New Technology is being Integrated in How New Technology is being Integrated in Radiation Oncology in Radiation Oncology in ‘ ‘most parts most parts’ ’ of the world

• f the world

We start with & often get lost in discussing the technical capabilities, finesse, & precision of new technology & how good it would be for our patients. Soon we say that patients want this new technology & it becomes ‘standard of care’

Evidence Based Assessment & Integration of Evidence Based Assessment & Integration of Technology in Radiation Oncology Technology in Radiation Oncology

Societal Costs

Technical Capabilities & Precision

Clinical Benefit

Research (Clinical and Health Economic Evaluation) in Emerging Technology becomes a necessity in Emerging economies to provide a solid foundation

Could be the starting point

BUT not the Centre point

How should we integrate New Technology in How should we integrate New Technology in ‘ ‘Routine Clinical Practice Routine Clinical Practice’ ’

• Overwhelming superiority in the clinical
• utcome with new technology OR
• Modest but definite benefit
• Results are generally reproducible
• Possible to integrate the new technology in a

particular health care system

Emerging Technology Promises Emerging Technology Promises

• Lower toxicity
• Improved Patient and Personnel Safety
• Better documentation and validation

<< Improved cure rates >>

May be Higher Throughput & Cost effectiveness in certain clinical contexts

Emerging Technology Generally Entails Emerging Technology Generally Entails

• Higher initial and maintenance Cost
• Uncertainty of clinical benefits
• Uncertainty of sturdy performance
• Human resource implications
• Skepticism of the critics & health economists

May prove to be expensive experimental tool, especially in emerging economies

Cost – effectiveness of RT can be improved by

• Optimal utilization of the conventional

technologies and better work practices

– Indications and prioritization – Fractionation – Audits, QA and QC programme

• New Technologies

– For better case selection (e.g. PET imaging) – Hypo‐fractionation in select indications

• Indigenous Technology

– May have lower initial / maintenance cost – Better suited for local conditions

α/β ratio of tumour (7-10Gy) much higher than late responding normal tissues (2-4Gy); e.g. Squamous Ca H&N, Lung, Cervix α/β ratio of Tumour (1.5 - 2Gy) < late responding normal tissue (2-4Gy); e.g. Prostate Cancer

HYPERRACTIONATED / ACCELERATED RT HYPERRACTIONATED / ACCELERATED RT

Improve tumour control without increasing late toxicity (possibly more acute toxicity) HYPOFRACTIONATED RT HYPOFRACTIONATED RT Better utilisation of health resources Tumour control &late toxicity comparable α/β ratio of Tumour (3 – 5Gy) similar

• r slightly higher than late

responding normal tissue (2-4Gy); e.g.

B r e a s t C a n c e r

H Y P O F R A C T I O N A T E D R T H Y P O F R A C T I O N A T E D R T

Improve tumour control with similar or reduced late & acute toxicity

Evidence Based Clinico-Radiobiological Fractionation Pyramid New Technology generally permits greater normal tissue sparing, thereby facilitating hypo-fractionation in ‘certain clinical contexts’ with similar / better Therapeutic Ratio

Sarin Sarin R, Lancet R, Lancet Oncol

• Oncol. 2006 (7); 445

. 2006 (7); 445-

• 47

47 Higher initial cost of new technology may be partly offset if it provides clinical benefit to sufficient number of patients with suitable tumours types

Use of fewer fractions, if safe would be to great advantage for patients and ‘professionals’ alike

BHABHATRON BHABHATRON -

• TELECOBALT

TELECOBALT Developed by BARC, Dept.

• f Atomic Energy in 2004

Technology Transferred to Panacea Tech. Ltd. Bangalore Dosimetric & Clinical evaluation of Prototype unit at ACTREC in 2005 - 06 Refined version Bhabhatron-II in use at ACTREC and in almost dozen Indian centres Integrated in Indian National Cancer Control Programme in the 11th Five Year Plan in 2008

VISION VISION

• Dept. of Atomic Energy of India set up a special Apex committee in 2003 to develop

high quality & cost effective indigenous equipment with initial emphasis on Telecobalt

Indian Indigenous Cancer Technology Development Programme

MISSION MODE Academia – Industry partnership can facilitate development of high quality and cost effective indigenous technology in developing countries with some pre- existent technological base.

Indian Indigenous Cancer Technology Development Programme

The Dept. of Atomic Energy & Tata Memorial Centre are continuing with coordinated efforts to develop and validate Indigenous Equipment for Cancer (LINAC, PACS, SIMULATOR etc.)

Bhabhatron II

India is donating India is donating Bhabhatron Bhabhatron Telecobalt Telecobalt to Vietnam under the to Vietnam under the IAEA IAEA ‐ ‐ PACT (Programme Action for Cancer Therapy) PACT (Programme Action for Cancer Therapy)

Building Sustainable Building Sustainable Cancer Control Capacity and Infrastructure Cancer Control Capacity and Infrastructure in Developing Countries in Developing Countries

Chairman, Atomic Energy Commission of India handing over a model of Bhabhatron to IAEA Director General, Dr El-Baradei at ACTREC, Mumbai (2007)

Emerging economies have TWIN REALITIES which pose Special Challenges of Optimizing limited resources through Indigenous R&D; Evaluation of new technology & Cost effectiveness studies

Two localities in Mumbai few miles apart Two bunkers in ACTREC sharing a wall Indigenous Indigenous Telecobalt Telecobalt Tomotherapy Tomotherapy