Scaling up breast, cervical and oral cancer screening in the limited - - PowerPoint PPT Presentation

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Scaling up breast, cervical and oral cancer screening in the limited resource setting: Lessons from economic evaluations in India

Sujha Subramanian, Ph.D. Fellow, Health Economics & Policy, RTI International Senior Visiting Scientist, WHO-IARC December 5, 2017

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Efficiency in Integrated Screening

Cost Effectiveness Ratio = Cost of Screening Delivery Effectiveness of Screening

• Cost of screening can be decreased through synergies related to providing

integrated screening

• Screening effectiveness can be increased by higher levels of patient

compliance or improvement in quality

• In the real world, this is not static but instead should result in continuous

efficiency improvement processes

Decrease in Cost per Screen or Cost per QALYs

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Scaling-up Screening: Multi-level Perspective

Access to care Quality of care Adherence to care Health System / Provider Screening Program Patient / Community Geographic distribution; Patient education; provider Lack of trust; convenience; capacity; referral process; training; guidelines; data knowledge of screening supply of disposables etc. collection; quality metrics

• ptions; community support

Successful Scale Up of Screening Program (early detection and prevention to reduce mortality from cervical cancer)

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Complex Interactions between Cost and Effectiveness

Key activities Scale-up versus clinical trial (cost) Effectiveness impact Potential impact of inadequate resources for activity or component Provider Training  or  Quality Cost (over diagnosis) Harms (over treatment) Outcomes (under diagnosis) Patient education  Adherence Compliance with screening Outcomes Cost (treatment & patient time) Quality Monitoring & Program Evaluation  Access Quality Adherence Program Effectiveness Program Cost-Effectiveness

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Clinical Trial to Implementation: Cervical Cancer Screening Adherence Measures

Pilot Study Dindigul Osmanabad Mumbai TNHSP VIA VIA VIA VIA/VILI 49,311 34,074 75 360 660,917 Screening 63.6% 78.5% 71.5% 73.9% Diagnosis (colposcopy) 98.8% 98.7% 79.4% 56.5% Treatment 72.0% 85.0%* 85.0%* 13.0% * Approximate estimates based on treatment for precancer and cancers Randomized Screening Trials

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Evidence Base for Screening: Clinical Trials in India

Cervical cancer prevention/screening:

• Visual inspection and HPV DNA testing shown to be cost-effective;
• Cost per cancer/pre-cancer detected: $235-$314;
• Programmatic:$4-$6; Screening delivery:$8-$10.

Oral cancer screening:

• Visual screening randomized trial;
• Incremental cost per life-year saved of $156 for the high-risk population;
• Screening for under $6 per person.

Breast cancer early detection:

• Randomized clinical trial of clinical breast exams (CBEs) is ongoing;
• Modeling studies report CBEs to be cost-effective: $450-$794 per life year saved.

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Intervention % (95% CI) Control % (95% CI) P value

Advanced stage (IIB-IV) cancer 45.0 (34.1 to 55.9) 68.3 (56.8 to 79.7) .005 Breast Cancer Incidence for Women 30-69 years, 2006-2009

Trivandrum Breast Cancer Screening Study (TBCS)

Sankaranarayanan et al., 2011, JNCI

A cluster randomized controlled trial was initiated in the Trivandrum district (India) on January 1, 2006, to evaluate whether three rounds of triennial CBE Statistically significant difference in stage at diagnosis between intervention and control groups; earlier diagnosis among the screened group Cost-effectiveness assessment ongoing

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Cost per Women Screened – Cervical Cancer Screening Trial

Integrated delivery of services possible for most activities Site or disease specific triage

INR US $* % Total Cost Programmatic Cost Provider Training 44.62 0.74 5.7% Patient Education/Recruitmen 7.24 0.12 0.9% Research & Data Collection 96.50 1.61 12.3% Management & Administration81.52 1.79 13.7% Screening Delivery VIA Screening Labor 46.50 0.77 5.9% Consumables/Equipment 50.66 0.84 6.5% Screening Clinics 48.53 0.81 6.2% Diagnosis and Treatment 383.43 6.40 48.9%

VIA = Visual Inspection with Acetic Acid; INR = Indian Rupees; *2014 exchange rate

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Cost per Person Screened – Oral Cancer Screening Trial

Integrated delivery

• f services possible

Site or disease specific triage One-stop services decreases time cost to patient for screening US $* % Total Cost Programmatic Cost $2.10 42.0% Screening delivery $0.61 12.3% Diagnsosis and Treatment $1.69 33.7% Patient time** $0.60 12.1%

* 2004 conversion rate ** Based on dialy wage rate of 200 rupees or about $5

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Integration Cost Savings

Patient recruitment and education Program management and administration Shared infrastructure Provider Training Data Collection and Monitoring Potential savings with integrated delivery Savings will depend

• n type of approach

used for these program activities

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Opportunities and Challenges – India Experience

Opportunities………

 One-stop delivery of screening services can increase patient compliance;  Shared infrastructure and management processes can lead to lower cost  Potential innovations and efficiencies in patient follow-up, repeat

screening, tracking and data management

 Ability to introduce new approaches to training that can increase synergies

Challenges……….

 Compliance with diagnostic follow-up will need to be addressed  At the clinic level, there will be more complicated triage processes and

wait times may increase

 Significant funding or resources will still be required as a large proportion

• f the cost are related to diagnosis and treatment