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- Ramandeep Singh Arora (India)
- Karina Braga Ribeiro (Brazil)
Introduction
- Karina Braga Ribeiro (Brazil)
- Ramandeep Singh Arora (India)
TRENDS AND VARIATIONS IN GLOBAL CHEMOTHERAPY PRICING: DATA FROM 95 COUNTRIES OVER EIGHT YEARS
- Catherine Habashy (United States of America)
Abstract
Background and Aims
Lack of transparency in chemotherapy pricing hinders efforts by governments and stakeholders to develop coordinated procurement policies, negotiate drug prices, and perform cost effectiveness analyses in pediatric cancer care. This study aimed to assess patterns and variations in global chemotherapy pricing with implications for the treatment of childhood cancer in low- and middle-income countries.
Methods
Data sources included Management Sciences for Health (MSH) data and IQVIA MIDAS data, which reflects estimates of marketplace activity obtained under license from IQVIA. MIDAS data on chemotherapy prices, manufacturers, and purchase volumes were retrieved on February 5, 2020 for the time period 2012-2019. Chemotherapy agents were selected based on their inclusion in frontline regimens for acute lymphoblastic leukemia, Burkitt lymphoma, Hodgkin lymphoma, low grade glioma, retinoblastoma, and Wilms tumor. Data were aggregated by region and income classification, and descriptive statistics were used to determine central tendency and variability of chemotherapy prices. Cummulative prices for treatment regimens were compared for each cancer subtype across income classification.
Results
A total of 212,429 data points were obtained from 95 countries: 41 high-income countries (HICs), 26 upper-middle income countries (UMICs), 19 lower-middle income countries (LMICs) and nine low-income countries (LICs). Forty-three percent of the data were from HICs, 27.4% from UMICs, 20% from LMICs, and 9.5% from LICs. While median drug prices for all chemotherapy agents were greater in HICs, prices varied substantially within income groups and did not correlate with gross domestic product (GDP). Prices of treatment regimens were higher for non-adapted protocols, hematologic malignancies, and higher risk stratification or stage. An inverse correlation was observed between volume of drug purchased and variance in drug prices.
Conclusions
As governments and stakeholders in LMICs scale healthcare systems for childhood cancer treatment, the findings of this study should inform efforts to develop evidence-based pricing policies, negotiate drug prices, and perform cost-effectiveness analyses in childhood cancer care.
A CLOUD-BASED DYNAMIC VISUALIZATION TOOL TO ESTIMATE GLOBAL COSTS ASSOCIATED WITH CHILDHOOD CANCER MEDICATIONS
- Nickhill Bhakta (United States of America)
Abstract
Background and Aims
Reliable access to quality chemotherapy is a barrier to effective global childhood cancer control efforts. To estimate global childhood cancer drug needs and costs, we developed a mathematical model to help policy makers and administrators plan procurement and formulate budget impact analyses. As data needs are context specific, this study aimed to develop a publicly-available dynamic visualization tool.
Methods
A mathematical model was used to estimate the global cost of cytotoxic medicines for children with cancer by location, drug type, and cancer type from 2015-2030. Relevant drugs from the World Health Organization (WHO) Essential Medicines List for Children were included. Total cost of chemotherapy was estimated by multiplication of disease burden, cumulative drug amount and drug costs under proper model assumptions. Burden was estimated using publicly available incidence and survival estimates, and stage/risk distribution from registry and literature estimates. Cumulative drug doses were calculated from standard regimens and age-based body surface area. Cost inputs were obtained from global data sources. R (http://www.R-project.org, version 4.0.4) and R Shiny package (https://CRAN.R-project.org/package=shiny, version 1.5.0) were used to develop the mathematical model and a graphical user interface (UI).
Results
The UI is available at https://chemoglobe.stjude.org. Results are based on 84,672,000 simulations. Interactive stacked bar plots present chemotherapy costs associated with 14 childhood cancer categories by WHO regions, World Bank income groups and United Nations subregions. Users may also select among six parameters and 32 options to dynamically appraise uncertainty in estimates. In performance testing, the tool takes eight seconds to update after parameter adjustments.
Conclusions
We successfully deployed version 1.0 of a cloud-based dynamic visualization tool to help stakeholders plan drug procurement and explore potential policy interventions relevant to their setting. Additional visualizations to allow point-and-click analyses of drug-specific costs, country estimates and temporal trends in case-finding are in development.
COMPARATIVE COSTS IN DIAGNOSTIC EVALUATION OF ACUTE LEUKEMIA IN THE UNITED STATES AND TWO LOWER-MIDDLE INCOME COUNTRIES
- Catherine Habashy (United States of America)
Abstract
Background and Aims
The current paradigm of diagnostic development in low- and middle-income countries (LMICs) is based on incremental implementation of expensive and complex high-income country testing approaches. Oxford Nanopore Technology (ONT) is a sequencing platform with very low capital costs and low material costs with emerging potential to replace traditional cancer diagnosis practices. This study aims to estimate the total and materials-only pathology costs for acute leukemia in the United States (US) and two LMICs compared with ONT.
Methods
Diagnostic costs (USD, 2021) for acute leukemia were calculated based on standard evaluations in hospitals in the US, Pakistan, and El Salvador. US costs were estimated using Centers for Medicare-Medicaid Services Current Procedural Terminology code charges for karyotyping, flow cytometry, fluorescent in situ hybridization (FISH), and limited molecular testing. Flow cytometry, karyotyping and FISH are used at Indus Hospital, Pakistan, while flow cytometry alone is used at Hospital Nacional de Ninos Benjamin Bloom, El Salvador. Costs at both institutions were identified using hospital administrative data. A secondary micro-costing analysis of ONT mRNA sequencing material costs across a range of sequencing depths (5x10^5 – 5x10^6 reads/sample) was completed for comparison.
Results
The estimated costs of routine diagnostic testing for acute leukemia in the US were $3,475 for acute lymphoblastic leukemia (ALL) and $5,493 for acute myeloid leukemia (AML). The per sample ALL/AML cost of diagnostic testing was $820 ($280 materials-only) in Pakistan (flow cytometry, karyotyping, FISH) and $612 ($261 materials-only) in El Salvador (flow cytometry only). The material cost for unbiased ONT mRNA sequencing ranged from $102/sample for shallow to $291/sample for deeper sequencing.
Conclusions
Access to acute leukemia diagnostic tests varies globally and is expensive. ONT sequencing is an emerging diagnostic technology that may be able to deliver cost savings while also allowing for comprehensive diagnosis of leukemia in LMICs using a singular testing platform and supply chain.
DEVELOPMENT AND VALIDATION OF A CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA POLICY MODEL CONSTRUCTED USING REAL WORLD POPULATION-BASED DATA
- Linda Luu (Canada)
Abstract
Background and Aims
While new effective but expensive immunotherapies are being approved for the treatment of childhood acute lymphoblastic leukemia (ALL), their cost-effectiveness remains unknown. We therefore aimed to use real-world population-based healthcare utilization and cost data to build and validate a microsimulation policy model for childhood ALL that allows flexible and rapid economic analyses of new agents
Methods
Children aged 0-17 diagnosed with primary ALL 2002-2012 in Ontario, Canada were identified through a provincial registry. Detailed disease, treatment, and outcome data were chart abstracted. Costs (2018 Canadian dollars) were obtained through linkage to population-based healthcare databases. Multistate survival analysis and linear regression modeled outcomes and costs associated with various disease states [e.g. relapse, bone marrow transplant (BMT)] respectively. A microsimulation model was developed using the fitted models and a simulated ALL population that was validated by comparing outcomes and costs across various patient subgroups.
Results
The overall simulated population had a 5-year survival of 94.0% (95th confidence interval 92.6- 95.4), and a cumulative incidence of relapse of 10.4% (9.0-12.3). Average 5-year cost was $252,700 (246,400-259,000). Comparing simulated subgroups yielded expected results. For example, superior outcomes and higher 5-year costs were seen among children with B-lineage vs. T-lineage disease [94.2% (92.4–95.7) vs. 88.5% (83.9-92.6); $253,900 (246,400 - 261,400) vs. $246,100 (221,100-271,034)]. Similar results were seen comparing end of induction minimal residual disease negative vs. positive patients [96.6% (95.5-97.6) vs. 87.8% (82.3- 91.3), $246,100 (238,100-254,100) vs. $286,200 (261,800-310,600)].
Conclusions
Projections from the microsimulation model are consistent with observed trends in Ontario and with published clinical data. Analyses are currently underway examining the cost-effectiveness of nelarabine in the treatment of upfront T-lineage ALL and of blinatumomab in the treatment of high-risk relapsed B-lineage ALL.
MAPPING OF RESOURCES AND PRIORITIES FOR PEDIATRIC HEMATOLOGY/ONCOLOGY IN 11 EURASIAN COUNTRIES: REPORT FROM EURASIAN ALLIANCE IN PEDIATRIC ONCOLOGY
- Kirill Kirgizov (Russian Federation)
Abstract
Background and Aims
Mapping of healthcare resources is important to optimize use of referral pathways, aid in prioritization of resource requests, and streamline communication with the ministry of health (MoH). This study describes resource mapping of pediatric hematology-oncology (PHO) services in 11 countries of the Eurasian Region, represented by countries in Eastern Europe and Central Asia.
Methods
Eleven countries part of the Eurasian Alliance in Pediatric Oncology (EurADO) provided data for mapping including: demographics and personnel, pediatric population, pediatric cancer cases, total workforce, palliative care and rehabilitation services availability, cancer registry presence, and three priority asks for the MoH to improve PHO care in the country. The generated country map includes: heat map (incidence/100,000 children), institutions providing PHO care (numbers and types of beds, equipment for diagnostics and treatment, workforce), blood bank supply, and educational resources. Additionally, a unified regional map of all 11 countries was created with proposed referral pathways.
Results
In total, 97 maps were prepared (85 regional maps of one of the countries, 11 individual country maps, and 1 regional map) representing 131 institutions. Analysis of PHO services identified limitations in the PHO workforce (3 countries reporting 0,3-0,5 pediatric oncologist per 100,000 children), diagnosis and treatment, with only 5 countries reporting access to all basic diagnostics (both laboratory and instrumental) and treatment (including surgery and HSCT). Palliative and rehabilitation care was available in only 7 and 5 countries, respectively. Population cancer registries are organized in 3 countries; hospital PHO registries in 8. Map review with local PHO leaders identified common asks for MoH and governmental authorities to improve PHO care, including improvement of diagnostics, cancer registration, and education (unification of PHO specialty).
Conclusions
Resource mapping allows for understanding of PHO services in Eurasia, informs development of referral pathways for diagnostics and treatment, and helps identify priority asks to improve PHO care.
DISPARITIES IN THE COST OF CARE: WORK FLEXIBILITY, SOCIAL SUPPORT, AND THE FINANCIAL IMPACT OF CANCER
- Erica M. Evans (United States of America)
Abstract
Background and Aims
Prior studies have documented disparities in financial burden after a cancer diagnosis. This study aims to characterize such disparities experienced by diverse families affected by pediatric cancer. We hypothesize that differing caregiver work flexibility and social support may account for disparities in financial burden.
Methods
Cross-sectional survey of 118 caregivers of children treated at University of California San Francisco Benioff Children’s Hospitals for any cancer requiring chemotherapy and/or radiation from March 2015 to March 2019. Financial burden was characterized by financial toxicity (COST score), income loss, and household material hardship (HMH; food, housing, or energy insecurity). The survey is composed of adaptations of 5 validated surveys assessing a family’s finances, workplace flexibility, financial stress, HMH, and social support. Caregivers completed the survey in-person or via phone, email or mail. Multivariable logistic regression models were used to estimate odds ratios and corresponding 95% confidence intervals.
Results
The population sampled was 66% White, 20% Hispanic, 59% high income (>400% federal poverty level), and 64% highly educated (minimum bachelor’s degree). Mean percent income loss was 9%. The prevalence of HMH increased from 23% of families at baseline to 39% at 12 months after diagnosis. Financial toxicity was significantly increased in low- and middle-income families compared to high-income (p< 0.01). Work flexibility was significantly higher in high-income families compared to low- (p = 0.02) and middle-income (p<0.01), but was not associated with HMH. Social support was strongly associated with reduced HMH (p=0.01).
Conclusions
HMH increases in the first year after pediatric cancer diagnosis. While higher income families reported greater work flexibility, this did not impact their likelihood of HMH. Social support, however, is associated with lower risk of HMH, suggesting that interventions to strengthen social support may mitigate some of the financial hardship of pediatric cancer.