Results from the Ontario breast screening program, 1990–1995

Objective The Ontario breast screening program (OBSP) is a provincial breast screening programme offering two view mammography, clinical breast examination, instruction in breast self examination, and systematic two year recall to Ontario women 50 years and older. This paper presents the results of the programme's intermediate outcomes from 1990 to 1995 and compares them with recommended standards and other published programmes. Methods Programme data from a provincial screening programme in a large Canadian province were collated from 18 sites in operation between July 1990 and December 1995. Results In its first five years of operation, 215 738 screens were performed on 142 173 women. The referral rates for initial and rescreens are 13.8% and 8.6% respectively. A total of 1718 women were diagnosed with cancer, 1325 at initial screens and 393 at rescreens, resulting in cancer detection rates of 9.3 and 5.3/1000. The cancer detection rates for invasive cancers were 8.3/1000 at initial screens and 4.5/1000 at rescreens. The benign to malignant biopsy ratio was 1.5:1 at initial screens and 1.3:1 at rescreens. Of the 1358 cancers diagnosed at initial screens, 11.6% were in situ and 50.3% of invasive cancers of known size were &lt;15 mm. For women with invasive cancer where nodal status was known, 71.3% were node negative. The proportions at rescreens were 15.7%, 60.0%, and 76.0% respectively. Conclusions While the OBSP has achieved the standards suggested by other studies and programmes during its first five years of operation, there is work to be done to increase participation and obtain more complete data on tumour size and nodal status. </jats:p

False-Positive Result and Reattendance in the Ontario Breast Screening Program

Objective: To determine the association between initial screen result and returning for a second screen in an organised breast screening programme for women with a biennial screening recommendation. Setting: Women who attended the Ontario Breast Screening Program (OBSP). Methods: A retrospective cohort study was conducted of 140,723 Ontario women aged 50 years ond older who had an initial screen at the OBSP between 1 July 1990 and 31 December 1995 and were followed until 30 June 1998. Rescreening rates at 36 months and risk ratio estimates were calculated using survival methods. Age of women, year of screen, region (within Ontario) and initial screen result were compared. For initial screen results, returning for a second screen was examined by integration of screening centre with an assessment programme and by modality of referral. Results: Women with a false-positive result were less likely to return for a second screen as were women aged 70 and older and those living in regions of Ontario with fewer OBSP screening centres. However, there were minimal differences in reattendance behaviour by initial screen result for women screened at the OBSP centre with an assessment programme. Conclusions: Integration of breast screening and assessment services improved reattendance of women with false-positive screen results within an organised screening programme. </jats:sec

Verification of imatiNib cost-effectiveness in advanced gastrointestinal stromal tumor in British Columbia (VINCE)

10049 Background: To evaluate the cost-effectiveness of imatinib in British Columbia Cancer Agency (BCCA) patients with advanced gastrointestinal stromal tumors (GIST) in terms of median overall survival (OS) and median progression-free survival (PFS). Results were also compared to imatinib literature reports. Methods: A pragmatic, retrospective medical record review identified BCCA patients with advanced GIST who received imatinib or historical treatment during successive, pre-specified time periods. Data was collected on survival, duration of therapy, progression free status, and cost of drug, labour and supplies. Primary outcome was the cost-effectiveness of imatinib based on median-OS (Kaplan Meier method). Secondary outcomes were cost-effectiveness based on median overall-PFS, cost of therapy per patient, 1-year OS, and 1-year PFS. This study was conducted from the perspective of the BCCA. Sensitivity analyses varying effectiveness over the 95% CI, cost over the range of treatment duration, discounting level at 0, 3 and 5%, and comparing effectiveness to literature controls were performed. Life expectancy (mean survival), was also calculated and used in the CE sensitivity analysis. Results: Forty-six and 47 patients in the imatinib and historical groups respectively were analyzed. Median-OS in the imatinib group was 66.7 months (95% CI 61.7, infinity) compared to 7.7 months (95% CI 6.0, 12.6) in the historical group. Median-PFS was 45.3 months (95% CI 24.4, infinity) and 5.6 months (95% CI 3.5, 8.5) respectively. The 1-year OS and 1-year PFS for the imatinib group was 95.4% (95% CI 82.9, 99.2) and 81.4% (95% CI 66.1, 91.1) compared to 32.6% (95% CI 20.0, 48.1) and 17.4% (95% CI 8.3 - 32.0) in the historical group. No difference was seen between the imatinib study results and literature reports. The annual incremental cost-effectiveness ratio was $15,882 per median life year gained and$23,603 per median year of PFS for imatinib. Conclusions: Imatinib for advanced GIST is a cost- effective treatment in BC. Results were robust across the range of sensitivity analyses performed. No significant financial relationships to disclose. </jats:p

Room for improvement? A quality-of-life assessment in patients with malignant bowel obstruction

This prospective study followed 35 patients admitted to hospital with malignant bowel obstruction (MBO) to evaluate quality of life (QOL). Subjects completed the Edmonton Symptom Assessment Scale (ESAS) and Rotterdam Symptom Checklist (RSCL) at recruitment, and at one week, one month and three months. The highest ranked ESAS scores at recruitment (which was generally 18-36 hours post admission to hospital) included loss of appetite (median=7.5), fatigue (6.5) and overall well-being (6.0). The total ESAS score improved by 7.5, 11.5 and 11.0 points respectively at one week, one month and three months (p&lt;0.05, p&lt;0.01, NS). RSCL median scores for physical and psychological subscales were high at baseline (36.2, 42.9) and improved significantly at one week and one month (p&lt;0.05). Psychological functioning appeared to be worsening by three months and at no time did activity level improve significantly. The overall QOL score was extremely poor at baseline (6.0 median) improving to 3.3 at one month (median fall=1.0, p&lt;0.05) and 3.4 at three months. Further work should address the lack of improvement in activity and apparent deterioration in psychological functioning after one month. </jats:p

Cost-effectiveness (CE) analysis of CHOP and rituximab for diffuse large B-cell lymphoma (DLBCL) in British Columbia (BC)

6623 Background: The BC Cancer Agency (BCCA) provides province-wide, population-based care. Outcomes are monitored to verify therapeutic effectiveness and justify funding for systemic treatment policies. The CE of rituximab with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) (CHOP-R) for DLBCL was compared to its predecessor, CHOP alone. Methods: This was a pragmatic population-based CE analysis based on the original cohort of advanced DLBCL patients described by Sehn et al (JCO 2005) who received either CHOP or CHOP-R between Sept 1999 and Aug 2002 (18-months pre and post availability of rituximab in BC) according to standard BCCA treatment policy at the time. The primary endpoint was CE in terms of life-expectancy (LE) at a median follow-up of 4 years (cost-per-life-year-gained). Costs were incorporated into a decision analysis including primary systemic therapy and downstream chemotherapy, radiotherapy, and stem-cell transplant (SCT). Actual incidence of each downstream therapy was converted to a probability for each group. Downstream therapy costs were then multiplied by these probabilities and added to the respective primary treatment costs. The CE analysis took the BCCA perspective which includes all direct costs for active cancer treatment, and hospitalization for SCT, but not ambulatory supportive care. Sensitivity analyses varying LE to the extremes of its 95% CI, modeling out to 15 years and discounting at 0, 3, and 5% were performed. Results: 292 patients were included and categorized to treatment received: 148 CHOP and 144 CHOP-R (median follow- up 5.4 and 4 years respectively). LE to 4 years was 30.18 months for CHOP and 39.44 for CHOP-R. OS at 4 years was 48.8% and 70.1% for CHOP and CHOP-R respectively (p&lt;0.0001) Respective costs of primary and downstream therapy were $4,682 and$7,198 for CHOP versus $26,366 and$6,228 for CHOP-R. The incremental CE ratio at 4 years median follow-up was $26,844 CDN per life year gained. Results were robust across univariate sensitivity analyses conducted. Conclusions: At 4 years median follow-up, CHOP-R improves LE and appears to be economically attractive at conventional thresholds. CE is an increasingly useful tool for the BCCA in making decisions about new cancer therapies. No significant financial relationships to disclose. </jats:p