The Health Economics of Cancer Care
A renal cell carcinoma case study
Health Economics focuses on the efficiency, effectiveness and value in healthcare. It compares the costs and consequences of alternative courses of action. Specifically, it involves the effective development and application of resources to improve the populations health and is employed to ensure maximum health gain from the available and finite resources. As such, health economic analysis and evaluation forms an integral component in the development of public health guidance.
We speak to Dr Alex Thompson, a Senior Research Fellow based at the Manchester Centre for Health Economics (MCHE) about the importance of health economics within the cancer care continuum, with specific reference to his recent article focusing on the cost-effectiveness model of renal cell carcinoma (RCC) surveillance in hereditary leiomyomatosis and renal cell carcinoma (HLRCC).
Please could you detail your role in the Manchester Centre for Health Economics?
As a Senior Research Fellow in Health Economics, my work involves conducting health economics analysis in a wide variety of areas including diagnostic tests, medical devices and digital health interventions.
As well as evaluating interventions and services in clinical trials, I support the early development of new innovative technologies. I support researchers at The University of Manchester who might be considering commercialising their ideas to identify the key value propositions for their technology.
I also work with many external small and medium-sized enterprises who have health technologies and are seeking to identify their value and how they can be best focused and developed to be implemented into the health care system.
What is the importance of Health Economics?
Health economics is extremely important. An easy way to view it is as a total overview of the benefits, harms and costs associated with certain policies and drugs. For example, in England and Wales, The National Institute for Health and Care Excellence (NICE) sits alongside the NHS and act as an advisory service for governmental agencies for the implementation of policies and the approval of drugs for use in the NHS.
The NHS has finite resources which need to be divided between multiple diseases. Finances are one such resource that need to be appropriately allocated across the entire health ecosystem. Thus, for a drug or a policy to be implemented in the NHS it needs to be shown to generate incremental health gains versus what we’re used to with current standards of care. For example, you can classify your remaining health as the length of your life but also the quality of said life. These are combined to form quality adjusted life years (QALYs) which are used as a measure for the quantity of benefit from a drug or policy along with the costs. The NHS is usually willing to pay around £20,000 – £30,000 for one QALY.
In essence, health economics informs where money should be spent and how we choose the right amount of money to be spent in all different disease areas. For example, we could increase the number of women being screened for breast cancer, but perhaps we’d be better off spending that resource screening for prostate cancer or lung cancer. Health economics provides the tools to compare the benefits, harms and costs of these different kind of decisions.
Will health economics and cost effectiveness analysis be something we will see more of in the coming years?
Health economics is already very common in the UK due to the unique way the health care system is funded and provided here. Virtually all new technologies usually involve some formal assessment on the health economics to establish whether value for money can be established. However, the problems faced by the NHS are shared with many countries across the world. Ageing populations are leading to an increasing demand for services, there are increased expectations for better care for the same need and a constant supply of new and potentially expensive technologies coming through research pipelines.
I would therefore expect that the demand for health economic analysis is likely to continue to grow to identify the high value technologies which can benefit patients and protect the health care system from spiralling costs.
Please could you provide an overview of your work on the early detection of renal cell carcinoma (RCC)?
For this research, I was funded by the Biomedical Research Council, which is part of The University of Manchester and one of the key themes, is the early detection of cancer. Within this theme, Dr Emma Woodward, a clinical geneticist and ACED Co-Director of Research, had a research program which was looking at rare hereditary cancers in the population. Specifically, she was looking at hereditary leiomyomatosis and renal cell cancer (HLRCC) which is a tumour predisposition syndrome that leads to the development of cutaneous and uterine leiomyomata, and renal cell carcinoma (RCC).
For those with HLRCC, Emma and her team found that the overall lifetime risk of developing RCC was around 20%. Additionally, HLRCC-associated RCC is very aggressive, with over 60% of symptomatic presentations being at stage three of four, where mean survival averages 15.8 months. However, it was shown in this study that RCCs detected through MRI surveillance (renal imaging surveillance) were all picked up at stage one, and thus were treatable through surgical intervention.
So, then the question arose: Is it cost effective to conduct annual surveillance on members of the population with HLRCC?
What did the economic analysis show?
Unfortunately, renal imaging for members of the population with HLRCC had not previously been evaluated for cost-effectiveness. MRI surveillance for HLRCC is not always used, and as such, there is no current surveillance strategy for HLRCC-associated RCC within the NHS.
So, with the knowledge that annual renal MRI surveillance is clinically effective, I joined with Dr Emma Woodward, to evaluate the cost effectiveness of annual renal MRI surveillance in individuals with HLRCC who had not yet developed RCC. The benefits were measured in life-years gained (LYG), quality-adjusted life years (QALYs) and cost in GBP.
The outcomes provided by the model showed that RCC screening in patients with HLRCC was cost effective at all age groups modelled. It showed that this method was slightly more expensive than the current care to screen people, but the health gains were worth the additional costs. As such, this real-world economic analysis highlighted that lifelong screening of HLRCC patients is beneficial in terms of cost to the NHS, life-years gained and quality of life for patients for all age groups modelled.
Finally, what advice would you give to someone who wants to engage with a health economist on a piece of work?
I would advise for them to come to the meeting and work program with an open mind as to how health economics might be able to shape, develop and evaluate your research idea. We have lots of different and clever methodological tools in our ‘toolbox’. We also are quite likely to have a unique and hopefully insightful way of looking at problems.