Increasing complexity of cancer care : how displaced treatments impact efficiency, cost-effectiveness and equity

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[Background] Medical technology is increasing the number of available treatments for cancer. For advanced cancer an increasing number of treatments can result in an increasing treatment sequence. Treatments are given one after another in a cycle of treatment, failure and then another treatment. Newly added treatments may not replace existing treatments. The movement of existing treatments into later lines of therapy is displacement. Displacement poses challenges for economic evaluation. This thesis addresses three questions. 1. Does the displacement of a treatment alter its cost-effectiveness? 2. If the cost-effectiveness becomes less favourable can any resulting societal welfare loss be corrected by changing the price? 3. Can the required price change be calculated in Australia? [Methods] A theoretical framework is developed for displacement in cancer treatment. The implications of decision-making criteria and information gaps are assessed. Real-world data is used to estimate the number of treatments and lines of therapy received by patients, and costs of care. A systematic review and meta-analysis of randomised controlled trials which reported treatment outcomes of multiple lines of therapy is undertaken. The cost-effectiveness of displacing treatments for breast cancer, colorectal cancer and non-small cell lung cancer are modelled. [Results] The displacement of a treatment may result in dynamic and allocative inefficiencies. Real-world data showed 13-18% of participants received four or more lines of therapy. The mean health services cost of cancer care was approximately $4 000 per month. Displacement resulted in decreased effectiveness, an increased toxicity per unit time and reduced treatment length. In the modelling, there was an increase in the incremental cost-effectiveness ratio with displacement. After displacement, reducing the price of cancer treatments by 32% was required to restore cost-effectiveness. [Conclusions] There is the potential for displacement in Australia. Displacement results in an increasing incremental cost-effectiveness ratio of a treatment. This can be corrected with price changes in most circumstances. The Australian real-world data did not record all the treatments that were received by patients. Therefore, it is not able to be used to calculate the price changes that are required with displacement. The addition of new treatments in Australia should consider the impact of displacement on currently subsidised treatments. A failure to do this results in biased assessments of the benefits and costs of new treatments. It will likely underestimate the cost and overestimate the benefit. Therefore, the potential for displacement should be considered in cancer treatment funding to ensure equity and cost-effectiveness.
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