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Advancing Health Economics, Services, Policy and Ethics
Collecting Real World Evidence: HTA’s perspective
Dr. Kelvin Chan, MD FRCPC MSc (Clin Epi) MSc (Biostats)
Clinical Lead, Provincial Drug Reimbursement Programs, CCO
Co-Director, Canadian Centre for Applied Research in Cancer
Control
Medical Oncologist, Sunnybrook Odette Cancer Centre
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• What types of uncertainty do HTA committees encounter in their
deliberations?
• How often does pCODR Expert Review Committee (pERC) request
collecting evidence to reduce uncertainty?
• What types of information can be potentially obtained by
collecting real world evidence (RWE)?
Contents
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Disclaimer
• Member of HTAs
• pCODR Expert Review Committee
• Committee to Evaluate Drugs
• Ontario Steering Committee of Cancer Drugs
• Personal opinion
• Does not represent the views of U of Toronto, pCODR, CED,
OSCCD, CCO, Ministry etc.
• Information from publicly available source
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Ontario Cancer Plan IV (2015-2019)
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Health Technology Assessment (HTA) Committee’s
Recommendations
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Recent Example
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In general, HTA committees (pCODR, CED, OSCCD) consider the
following inputs:
•Clinical benefit (from clinical trial data) – Efficacy
(survival) data – Safety data – Quality of Life (QOL) data
•Patient values
•Cost-effectiveness and budget impact
•Adoption feasibility
Things that HTA committees consider before making a
recommendation to fund (or not to fund)
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• Uncertainty in clinical data – Survival data
• Missing or limited • Surrogate of overall survival •
Non-comparative • Short term data
– Safety data • Missing data/Late data
– Quality of life data • Missing data (numerous examples)
Uncertainty in clinical data
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Non-Comparative Data Romidepsin in Peripheral T-Cell
Lymphoma
“It was noted that due to the limitations of relying on
non-comparative, non-randomized evidence and the heavy reliance on
extrapolation of overall survival data, there was substantial
uncertainty in the
magnitude of the net clinical benefit associated with
romidepsin.”
- pCODR Expert Review Committee Final Recommendation
Adapted from Piekarz et al. BLOOD 2011 Adapted from Coiffier et
al. JCO 2012
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Missing Quality of Life Data Vismodegib in Basal Cell
Carcinoma
“… quality of life and functional outcomes are very important in
this population. Patients with BCC who are inappropriate for
surgery may experience severe disfigurement, leading to extreme
social
isolation and decreased quality of life.”
- pCODR Expert Review Committee Final Recommendation
• Survival is main a concern for patients with locally advanced
or metastatic disease
• Disease progression may lead to facial disfigurement, and thus
a decreased QoL
• This study presents no QoL data, however researchers connected
a response and decreased tumour size to an improvement in overall
QoL
Adapted from Sekulic et al. NEJM 2012
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• Cost-effectiveness analysis and budget impact analysis
• Model structure and methods – Comparator and long term
clinical efficacy
• Uncertainty in the inputs of the model – Number of patients –
Duration of drug treatments – Resource utilization
• Underestimation of ICER (sometimes 1-2 fold difference)
• Underestimation of BIA
Economic evidence: Estimation or “guess-timation”
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Short Term Survival Data Pembrolizumab in Unresectable
Metastatic Melanoma
“In the absence of longer term data, pERC was unable to accept
this assumption of prolonged benefit and agreed with the EGP’s use
of alternative data sources to extrapolate survival in both
settings.”
- pCODR Expert Review Committee Final Recommendation
Adapted from Robert et al. NEJM 2015
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• Trial patients are different from real world patients – e.g.
age, co-morbidities, performance status, diffusion – Intensive
monitoring on trial
• Different practice patterns in the real world – Duration of
treatment (treatment until progression vs.
discontinuation before progression) – Dose intensity of
treatment in the trials vs. in the real world – Management of
side-effects (e.g. febrile neutropenia are
managed mostly as in-patient in Ontario)
• Sequencing of subsequent lines of available therapy –
Different from what was available on the trial
• Changes in drug price over time (e.g. generics) – Drop in
price in the older drugs will make the new drug less cost-
effective
Loss in “Translation”: Uncertainty about
Translating clinical trial evidence to the real world
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EXPERIENCE OF pCODR EXPERT REVIEW COMMITTEE (pERC)
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Requesting Real World Evidence
• pCODR 60 reviews (Up to Feb 2016) • Total of 21 pCODR reviews
requested Real World
Evidence • 13 pCODR reviews explicitly requested Real World
Evidence • 10 pCODR reviews potentially requested Real World
Evidence Potential RWE Request: Unclear if pERC requested RWE,
but it could be beneficial
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Next Steps for Real World Evidence Collection
7
1 1
2 2
10
Inform magnitude of clinical benefit and cost-effectiveness or
the true cost-effectiveness
Define the potential clinical benefit or magnitude of clinical
benefit
Define the population or disease
Inform duration of treatment
Inform duration of treatment and cost-effectiveness
Inform sequencing of available therapies
23 requests for RWE for 21 studies
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Breakdown of pCODR Reviews
60 Final Recommendations
11
39
10
Positive Recommendation Conditional Recommendation Negative
Recommendation
(4 requested RWE)
(17 requested RWE)
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Temporal Trends in RWE Requests 60 pERC Final
Recommendations
0
6
12
18
24
2012 2013 2014 2015 2016
Nu
mb
er o
f R
eco
mm
end
atio
ns
Final Recommendation Issue Year
Negative Recommendations
Without RWE Request
With RWE Request
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Breakdown by Tumour Site
60 pERC Final Recommendations
0
6
12
18
24
Heme Melanoma GI GU Lung Breast Other Gyne
Nu
mb
er
of
Rec
om
me
nd
atio
ns
Tumour Site
Negative Recommendations
Without RWE Request
With RWE Request
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Breakdown by Study Characteristics: 21 Studies
0
2
4
6
8
10
Nu
mb
er o
f St
ud
ies
Primary Endpoint of Final Recommendations Requesting RWE
DSV (Decrease in Spleen Volume), MCyR (Major Cytogenetic
Response), MaHR (Major Haematological Response)
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WHAT REAL WORLD EVIDENCE CAN WE
COLLECT?
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Potential Deliverables (effectiveness, safety, quality of life,
cost-effectiveness)
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Potential Deliverables (verify economic models)
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Discussions
• HTA committees commonly make best possible recommendations
based on substantial uncertainties
• pCODR ERC commonly requests for the collection for further
evidence to reduce uncertainties
– How can further evidence be collected? • Routinely collected
data (population-based admin data) • Evidence building program
(prospective collection of data) • Real world experiments (real
world pragmatic randomized trials)
– Who will use this evidence once collected? • Practitioners and
patients – informed treatment decisions • Policy decision-makers
and payers • Re-HTA (recommendation-makers)