Quality of Life and Cost-Effectiveness in Lung Cancer Care

  • 楊 思雋

Student thesis: Doctoral Thesis


Late diagnosis is a fundamental obstacle to improving the outcomes of lung cancer screening with low-dose computed tomography (CT) can reduce lung-cancer mortality However there is still a lack of consensus on the cost-effectiveness of CT-screening to detect operable lung cancer Because different palliative treatments for inoperable lung cancer might not show difference in overall survival choosing a treatment with better quality of life (QoL) becomes important To optimize lung cancer care this dissertation aims to: 1 Develop a method adjusting for lead-time bias to estimate the cost-effectiveness of implementing CT screening for lung cancer in Taiwan; 2 Compare dynamic changes in QoL after three first-line therapies for EGFR mutation-positive advanced non-small cell lung cancer To evaluate the cost-effectiveness of CT screening we estimated quality-adjusted life expectancy (QALE) loss-of-QALE and lifetime healthcare expenditures per case of lung cancer stratified by pathology and stage from a nation-wide 13-year follow-up cohort Cumulative stage distributions for CT-screening and no-screening were assumed equal to those for CT-screening and radiography-screening in the National Lung Screening Trial to estimate the savings of loss-of-QALE and additional costs of lifetime healthcare expenditures after CT screening Costs attributable to screen-negative subjects false-positive cases and radiation-induced lung cancer were included to obtain the incremental cost-effectiveness ratio from the public payer’s perspective To compare QoL after different tyrosine kinase inhibitors (TKIs) we assessed the utility values and QoL scores of patients from 2011 to 2016 using the EuroQol five-dimension and World Health Organization Quality-of-Life—Brief questionnaires QoL functions after initiation of treatment were estimated using a kernel smoothing method Dynamic changes in major determinants were repeatedly assessed for constructing mixed models After dividing the incremental costs (US$22 769) by savings of loss-of-QALE (1 16 quality-adjusted life year (QALY)) the incremental cost-effectiveness ratio for CT screening was US$19 695 per QALY This ratio would fall to US$10 953 per QALY if the stage distribution for CT-screening was the same as that of screen-detected cancers in the NELSON trial A total of 344 patients with 934 repeated assessments were enrolled in the QoL study There were significantly lower QoL scores for afatinib versus gefitinib in physical psychological social domains and 10 facets After controlling for performance status disease progression and other confounders in the mixed models these effects still existed The differences seemed to appear 10 months after initiation of treatment We also found that patients with exon 19 deletions showed consistently higher utility value and QoL scores in most domains and facets after initiation of treatment In conclusion low-dose CT screening for lung cancer among high-risk smokers would be cost-effective in Taiwan As only about 5% of our women are smokers future research is necessary to identify the high-risk groups among non-smokers and increase the coverage Patients with exon 19 deletions receiving first-line TKIs for advanced non-small cell lung cancer had better QoL The initial detection of lower scores of QoL for afatinib in comparison with gefitinib warrants more studies for corroboration
Date of Award2018 Feb 5
Original languageEnglish
SupervisorJung-Der Wang (Supervisor)

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