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 UNIVERSAL PROBLEM Integration of New • Interest rates Technology in ‘Routine Care’ • Cost of maintenance without proper analysis of ‘Clinical Benefit’ complicates • Downtime of the machine Cost effectiveness analyses • Replacement cycle or life of machine

How New Technology is being Integrated in How New Technology is being Integrated in Radiation Oncology in ‘ of the world Radiation Oncology in ’ of the world ‘most parts most parts’ 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 Could be the BUT not the starting point Centre point & Precision Clinical Benefit Research (Clinical and Health Economic Evaluation) in Emerging Technology becomes a necessity in Emerging economies to provide a solid foundation

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 outcome 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

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 Use of fewer fractions, Higher initial cost of if safe would be to new technology may be great advantage for partly offset if it patients and provides clinical benefit ‘professionals’ alike to sufficient number of T T R R α / β ratio of Tumour D D Improve tumour control E E patients with suitable T T A A (1.5 - 2Gy) < late N N with similar or reduced O O I I T T tumours types responding normal C C A A R late & acute toxicity R F F O O tissue (2-4Gy); P P Y Y e.g. Prostate Cancer H H Better utilisation of health resources HYPOFRACTIONATED RT HYPOFRACTIONATED RT Tumour control &late toxicity comparable α / β ratio of Tumour (3 – 5Gy) similar or slightly higher than late HYPERRACTIONATED / ACCELERATED RT responding normal tissue (2-4Gy); HYPERRACTIONATED / ACCELERATED RT Improve tumour control without increasing late e.g. toxicity (possibly more acute toxicity) B r e (7-10Gy) much higher than late responding a s t α / β ratio of tumour C normal tissues (2-4Gy); e.g. Squamous Ca a n c e r H&N, Lung, Cervix Sarin R, Lancet R, Lancet Oncol Oncol. 2006 (7); 445 . 2006 (7); 445- -47 47 Sarin

Indian Indigenous Cancer Technology Development Programme 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 BHABHATRON - - TELECOBALT BHABHATRON TELECOBALT � Developed by BARC, Dept. of 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 11 th Five Year Plan in 2008

Indian Indigenous Cancer Technology Development Programme Bhabhatron II MISSION MODE Academia – Industry partnership can facilitate development of high quality and cost effective indigenous The Dept. of Atomic Energy & Tata Memorial Centre are continuing with coordinated efforts technology in developing to develop and validate Indigenous Equipment countries with some pre- for Cancer (LINAC, PACS, SIMULATOR etc.) existent technological base.

India is donating Bhabhatron Bhabhatron Telecobalt to Vietnam under the India is donating Telecobalt to Vietnam under the IAEA ‐ ‐ PACT (Programme Action for Cancer Therapy) IAEA 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 Indigenous Telecobalt Telecobalt Indigenous Two localities in Mumbai few miles apart Two bunkers in ACTREC sharing a wall Tomotherapy Tomotherapy