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1.  Real world costs and cost-effectiveness of Rituximab for diffuse large B-cell lymphoma patients: a population-based analysis 
BMC Cancer  2014;14(1):586.
Current treatment of diffuse-large-B-cell lymphoma (DLBCL) includes rituximab, an expensive drug, combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. Economic models have predicted rituximab plus CHOP (RCHOP) to be a cost-effective alternative to CHOP alone as first-line treatment of DLBCL, but it remains unclear what its real-world costs and cost-effectiveness are in routine clinical practice.
We performed a population-based retrospective cohort study from 1997 to 2007, using linked administrative databases in Ontario, Canada, to evaluate the costs and cost-effectiveness of RCHOP compared to CHOP alone. A historical control cohort (n = 1,099) with DLBCL who received CHOP before rituximab approval was hard-matched on age and treatment intensity and then propensity-score matched on sex, comorbidity, and histology to 1,099 RCHOP patients. All costs and outcomes were adjusted for censoring using the inverse probability weighting method. The main outcome measure was incremental cost per life-year gained (LYG).
Rituximab was associated with a life expectancy increase of 3.2 months over 5 years at an additional cost of $16,298, corresponding to an incremental cost-effectiveness ratio of $61,984 (95% CI $34,087‒$135,890) per LYG. The probability of being cost-effective was 90% if the willingness-to-pay threshold was $100,000/LYG. The cost-effectiveness ratio was most favourable for patients less than 60 years old ($31,800/LYG) but increased to $80,600/LYG for patients 60–79 years old and $110,100/LYG for patients ≥80 years old. We found that post-market survival benefits of rituximab are similar to or lower than those reported in clinical trials, while the costs, incremental costs and cost-effectiveness ratios are higher than in published economic models and differ by age.
Our results showed that the addition of rituximab to standard CHOP chemotherapy was associated with improvement in survival but at a higher cost, and was potentially cost-effective by standard thresholds for patients <60 years old. However, cost-effectiveness decreased significantly with age, suggesting that rituximab may be not as economically attractive in the very elderly on average. This has important clinical implications regarding age-related use and funding decisions on this drug.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2407-14-586) contains supplementary material, which is available to authorized users.
PMCID: PMC4148552  PMID: 25117912
2.  Trends in use and cost of initial cancer treatment in Ontario: a population-based descriptive study 
CMAJ Open  2013;1(4):E151-E158.
Cancer incidence and treatment-related costs are rising in Canada. We estimated health care use and costs in the first year after diagnosis for patients with 7 common types of cancer in Ontario to examine temporal trends in patterns of care and costs.
We selected patients aged 19–44 years who had received a diagnosis of melanoma, breast cancer (female only), testicular cancer or thyroid cancer, in addition to patients aged 45 years and older who had received a diagnosis of breast (female only), prostate, lung or colorectal cancer, between 1997 and 2007. Patients were identified from the Ontario Cancer Registry. Using linked administrative databases, we determined use and costs of chemotherapy, radiotherapy, cancer-related surgery, other admissions to hospital and home care. We adjusted all costs to 2009 Canadian dollars.
We identified 20 821 patients aged 19–44 years and 178 797 patients aged 45 years and older. The greatest increases in costs during the study period were for melanoma, breast cancer, colorectal cancer, lung cancer and prostate cancer (p < 0.05). For prostate and lung cancers, mean costs increased 50% (from $11 490 and $22 037 to $15 170 and $34 473, respectively). Mean costs doubled for breast (from $15 460 and $12 909 to $35 977 and $29 362 for younger and older patients, respectively) and colorectal cancers (from $24 769 to $43 964), and nearly tripled for melanoma (from $3581 to $8934). Costs related to hospital admissions accounted for the largest portion of total costs. The use of chemotherapy, radiotherapy and home care generally increased for all cancers.
The significant increase in mean costs of initial cancer treatment among the patients included in this study was primarily due to more patients receiving adjuvant therapy and home care, and to the increasing expenditures for these services and cancer-related surgeries. Understanding trends in health care use and costs can help policy-makers to take the necessary measures to achieve a more accountable, high-performing health care system.
PMCID: PMC3986020  PMID: 25077117
3.  Understanding the costs of cancer care before and after diagnosis for the 21 most common cancers in Ontario: a population-based descriptive study 
CMAJ Open  2013;1(1):E1-E8.
The first year after cancer diagnosis is a period of intensive treatment and high cost. We sought to estimate costs for the 21 most common cancers in Ontario in the 3-month period before and the first year after diagnosis.
We used the Ontario Cancer Registry to select patients who received diagnoses between 1997 and 2007 at 19 years of age or older, with valid International Classification of Diseases for Oncology (ICD-O) and histology codes, who survived 30 days or longer after diagnosis and had no second cancer within 90 days of the initial cancer (n = 402 399). We used linked administrative data to calculate mean costs for each cancer during the pre- and postdiagnosis periods for patients who died within 1 year after diagnosis and patients who survived beyond 1 year after diagnosis.
Mean prediagnosis costs were $2060 (95% confidence interval [CI] $2023–$2098) for all patients with cancer. Costs ranged from $890 (95% CI $795–$985) for melanoma to $4128 (95% CI $3591–$4664) for liver cancer among patients who survived beyond 1 year after diagnosis, and ranged from $2188 (95% CI $2040–$2336) for esophageal cancer to $5142 (95% CI $4664–$5620) for multiple myeloma among patients who died within 1 year. The mean postdiagnosis cost for our cohort was $25 914 (95% CI $25 782–$26 046). Mean costs were lowest for melanoma ($8611 [95% CI $8221–$9001]) and highest for esophageal cancer ($50 620 [95% CI $47 677–$53 562] among patients who survived beyond 1 year after diagnosis, and ranged from $27 560 (95% CI $25 747–$29 373) for liver cancer to $81 655 (95% CI $58 361–$104 949) for testicular cancer among patients who died within 1 year.
Our research provides cancer-related cost estimates for the pre- and postdiagnosis phases and offers insight into the economic burden incurred by the Ontario health care system. These estimates can help inform policy-makers’ decisions regarding resource allocation for cancer prevention and control, and can serve as important input for economic evaluations.
PMCID: PMC3985946  PMID: 25077097
4.  End-of-Life Care for Lung Cancer Patients in the United States and Ontario 
Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems.
We identified care for non–small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999–2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)–Medicare data (N = 13 533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided.
Rates of chemotherapy use were statistically significantly higher for SEER–Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER–Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER–Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER–Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001).
NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.
PMCID: PMC3115676  PMID: 21593012
5.  Management of solitary 1 cm to 2 cm liver nodules in patients with compensated cirrhosis: A decision analysis 
Current guidelines, based on expert opinion, recommend that suspected 1 cm to 2 cm hepatocellular carcinoma (HCC) detected on screening be biopsied and, if positive, treated (eg, resection or transplantation). Alternative strategies are immediate treatment or observation until disease progression occurs.
A Markov decision model was developed that compared three management strategies – immediate resection, biopsy and resection if positive, and ultrasound surveillance every three months until disease progression – for a single 1 cm to 2 cm liver nodule suspicious for HCC following ultrasound screening and computed tomography confirmation. The cohort included 55-year-old patients with compensated cirrhosis and no significant comorbidities. The model used in the present study incorporated the probabilities of false-positive and false-negative results, needle-track seeding, HCC recurrence, cirrhosis progression and death. The quality-adjusted life expectancy (LE) and the unadjusted LE were evaluated and the model’s strength was assessed with sensitivity analyses.
In the base case analysis, biopsy, resection and surveillance yielded an unadjusted LE of 60.5, 59.7 and 56.6 months, respectively, and a quality-adjusted LE of 46.6, 45.6 and 43.8 months, respectively. In probabilistic sensitivity analyses, biopsy was the preferred strategy 69.5% of the time, resection 30.5% of the time and surveillance never. Resection was the optimal decision if the sensitivity of biopsy was very low (less than 0.45) or if the accuracy of the imaging tests resulted in a high percentage of HCC-positive patients (greater than 76%) in the screened cohort, as with expert interpretation of triphasic computed tomography.
The present model suggests that biopsy is the preferred management strategy for these patients. When postimaging probability of HCC is high or pathology expertise is lacking, resection is the best alternative. Surveillance is never the optimal strategy.
PMCID: PMC2657973  PMID: 17703248
Decision analysis; Hepatic resection; Hepatocellular carcinoma; Liver cirrhosis
6.  A Canadian national survey of attitudes and knowledge regarding preventive vaccines 
Vaccines have virtually eliminated many diseases, but public concerns about their safety could undermine future public health initiatives.
To determine Canadians' attitudes and knowledge about vaccines, particularly in view of increasing public concern about bioterrorism and the possible need for emergency immunizations after weaponized anthrax incidents and the events of September 11, 2001.
A 20-question survey based on well-researched dimensions of vaccine responsiveness was telephone-administered to a random sample of N = 1330 adult Canadians in January, 2002.
1057 (79.5%) completed the survey. Respondents perceived vaccines to be highly effective and demonstrated considerable support for further vaccine research. However, results also indicate a lack of knowledge about vaccines and uncertainty regarding the safety.
Support for vaccines is broad but shallow. While Canadians hold generally positive attitudes about vaccines, support could be undermined by widely publicized adverse events. Better public education is required to maintain support for future public health initiatives.
PMCID: PMC280696  PMID: 14613575
preventive vaccines; attitudes; knowledge; nationwide Canadian survey

Results 1-6 (6)