Barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia: a qualitative multicentre study.

OBJECTIVE: To explore and compare barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia. DESIGN: A qualitative interview study with thematic analysis of transcripts. PARTICIPANTS: 67 patients with self-discovered breast symptoms were included in the analysis. Of these, 36% were of Malay ethnicity, 39% were Chinese and 25% Indian, with an average age of 58 years (range 24-82 years). The number of women diagnosed at early stages of cancer almost equalled those at advanced stages. Approximately three-quarters presented with a painless lump, one-quarter experienced a painful lump and 10% had atypical symptoms. SETTING: University hospital setting in Singapore and Malaysia. RESULTS: Patients revealed barriers to early presentation not previously reported: the poor quality of online website information about breast symptoms, financial issues and the negative influence of relatives in both countries, while perceived poor quality of care and services in state-run hospitals and misdiagnosis by healthcare professionals were reported in Malaysia. The pattern of presentation by ethnicity remained unchanged where more Malay delayed help-seeking and had more advanced cancer compared to Chinese and Indian patients. CONCLUSIONS: There are few differences in the pattern of presentation and in the reported barriers to seek medical care after symptom discovery between Singapore and Malaysia despite their differing economic status. Strategies to reduce delayed presentation are: a need to improve knowledge of disease, symptoms and causes, quality of care and services, and quality of online information; and addressing fear of diagnosis, treatment and hospitalisation, with more effort focused on the Malay ethnic group. Training is needed to avoid missed diagnoses and other factors contributing to delay among health professionals.

Pre-vaccination type-specific HPV prevalence in confirmed cervical high grade lesions in the Maori and non-Maori populations in New Zealand.

BACKGROUND: New Zealand initiated HPV vaccination in 2008, and has attained 3-dose coverage of ~50 % in 12-13 year old girls. Due to the success of program initiatives in Maori girls, higher coverage rates of ~60 % have been achieved in this group. We have previously reported a benchmark overall pre-vaccination prevalence of oncogenic HPV infection in high grade cervical lesions in New Zealand. The current extended analysis provides separate pre-vaccination benchmark prevalence for Maori and non-Maori women. METHODS: The National Cervical Screening Programme Register (NCSP-R) was used to identify any woman aged 20-69 years of age with an index high grade cytology report from 2009-2011. Extended recruitment was performed until 2012 in clinics with a high proportion of Maori women. Ethnicity status was based on self-reported information by participating women through phone contact supplemented by recordings on the study questionnaire (the NCSP-R was not used to extract ethnicity status). A total of 730 women consented to participate and had a valid HPV test result; 418 of these had histologically-confirmed cervical intraepithelial neoplasia (CIN) 2/3 lesions (149 Maori, 269 non-Maori). The prevalence of any cervical oncogenic HPV infection, HPV16, and HPV18 was calculated in women with CIN2/3. RESULTS: In confirmed CIN2/3, the prevalence of any oncogenic HPV, HPV16 and HPV18 was 96 % (95 % CI:91-99 %), 54 % (95 % CI:46-63 %), 11 % (95 % CI:7-18 %) in Maori and 96 % (95 % CI:93-98 %), 54 % (95 % CI:48-60 %), 11 % (95 % CI:7-15 %) in non-Maori women, respectively. Age-specific patterns of infection for HPV16/18 in confirmed CIN2/3 differed between the two groups (Pinteraction = 0.02), with a lower prevalence in younger vs. older Maori women (57 % in 20-29 years vs 75 % in 40-69 years) but a higher prevalence in younger vs. older non-Maori women (70 % in 20-29 years vs 49 % in 40-69 years); the difference in the age-specific patterns of infection for HPV16/18 was not significant either when considering confirmed CIN2 alone (p = 0.09) or CIN3 alone (p = 0.22). CONCLUSIONS: The overall prevalence of vaccine-included types in CIN2/3 was similar in Maori and non-Maori women, implying that the long-term effects of vaccination will be similar in the two groups.

Development of a quality framework for models of cervical screening and its application to evaluations of the cost-effectiveness of HPV vaccination in developed countries.

BACKGROUND: HPV vaccination has now been introduced in most developed countries, but this has occurred in the context of established cervical cancer screening mechanisms which provide population-level protection against the most common HPV-related cancer. Therefore, estimating the cost-effectiveness of HPV vaccination to further reduce HPV-related disease depends in large part on the estimation of the effectiveness of the cervical screening 'background'. The aim of this study was to systematically review and assess methods for simulating cervical screening in decision analytic models used for evaluation of HPV vaccination. METHODS: Existing quality frameworks for economic models were extended to develop a specific quality framework for models of cervical screening. This involved domains for model structure, parameterisation (data sources) and validation (consistency). A systematic review of economic evaluations of HPV vaccination was then conducted, and assessment of cervical screening model components was then performed via application of the new quality framework. RESULTS: Generally, models took into account population-level cervical screening participation, but were inconsistent in their approach to modelling abnormal smear management, diagnostic evaluation and treatment of precancerous disease. There was also considerable variability in the accuracy of modelling clinical pathways and the scope of validation performed for screening-related outcomes, with focus directed towards cervical cancer targets. Only a few models comprehensively validated against observed pre-cancerous abnormalities. CONCLUSION: Models of HPV vaccination in developed countries can be improved by further attention to the 'background' modelling of secondary protection via cervical screening. The quality framework developed for this review can be used to inform future HPV vaccination evaluations, including evaluations of the cost-effectiveness of male vaccination and next generation HPV vaccines, and to assess models used to evaluate new cervical screening technologies and recommendations.

A survey of population-based utility scores for cervical cancer prevention.

BACKGROUND: With human papillomavirus (HPV) vaccination introduced in a number of countries, there is considerable interest in evaluating the cost-effectiveness of HPV testing as the primary cervical screening test in these settings. However, the availability of utility scores for these newer interventions is limited. Our aim in this paper is to present utility scores for HPV vaccination, HPV testing and cytology based screening states among women targeted for cervical screening. METHODS: We invited a random sample of women targeted for cervical screening (aged 20-69 years) living in Sydney, Australia, to participate in a face-to-face interview. Participants were asked to indicate preferences (rank and utility scores) for 10 hypothetical health states relating to HPV vaccination, cytology and primary HPV screening, cervical precursor disease and early stage cervical cancer. Preferences for hypothetical health states were measured through ranking then a two-stage standard gamble. Each participant's own health state was measured as a utility score using the EQ5D. Potential differences by age were assessed using the Wilcox Rank Sum test. RESULTS: A maximum of 276 women were contacted, of which 43 (mean age 49 years) agreed to be interviewed (15.6%). The overall health state of women as measured by the EQ5D was 0.86 (95% CI: 0.83-0.89). Of the 10 health states, the highest ranked were 'normal cytology' and 'HPV vaccination' (equal 1st). States involving an HPV positive result with a subsequent normal cytology or colposcopy were ranked below those for low grade cytological abnormalities with or without a subsequent colposcopic normal result (ranks 3-4 vs. 4-5). However, mean utility scores were broadly similar for all health states, except cervical cancer. No significant differences in scores were identified between age groups. CONCLUSION: Our survey suggests health states relating to HPV testing are ranked below 'low grade cytology' disease abnormalities. However, this difference was minimal on the utility scale, as most values for health states were largely clustered. These results provide a preliminary set of non-clinic population-based utilities that may be used with other values to explore the economic implications of introducing HPV testing as a primary screening tool in the context of HPV vaccination.

Pregnancy during breast cancer: does a mother's parity status modify an offspring's mortality risk?

To assess whether children born to primiparous women around the time of a breast cancer diagnosis have an increased mortality risk. From the merged Swedish Multi-Generation and Cancer Registers, we identified 49,750 eligible children whose mother was diagnosed with breast cancer between 1958 and 2010. Mortality rates in offspring were compared to the background population using standardized mortality ratios (SMR), adjusted for calendar year of birth, attained age, and sex, and calculated for each category of timing of delivery (before, around, or after mother's diagnosis) and mother's parity status. Hazard ratios were assessed using a Cox proportional hazards model and adjusted for socioeconomic status, year of birth and mother's age at birth. Children born to a primiparous woman around a breast cancer diagnosis had a mortality rate five times greater than the background population (SMR 5.26, 95 % CI 1.93-11.5), whereas children born to a multiparous woman had a twofold increase (SMR 2.40, 95 % CI 1.10-4.55). Children of primiparous women born around diagnosis had an adjusted hazard ratio fourfold to that of children of primiparous women born before their mother's diagnosis (HR 4.29, 95 % CI 1.68-8.91), whereas hazard ratios for children of primiparous or multiparous women born at other times were not statistically significant. Children born to primiparous women around a breast cancer diagnosis have an increased relative mortality risk. Although relative risk is increased, in absolute terms children born from a cancer complicated pregnancy do relatively well. Additional investigations are needed to elucidate the reason(s) underlying this observation before the information can be used to inform patient counseling and clinical care.

The impact of a two- versus three-yearly cervical screening interval recommendation on cervical cancer incidence and mortality: an analysis of trends in Australia, New Zealand, and England.

OBJECTIVES: To assess the impact of cervical screening interval recommendations on cervical cancer incidence and mortality during periods of organized and opportunistic screening in Australia (2-yearly screening interval for organized screening), New Zealand (3 yearly interval for organized screening), and England (3/5 yearly interval for organized screening). METHODS: Changes in cervical cancer rates over two 10-year periods were assessed in each country among women aged 20-69 years using a standardized rate ratio (SRR). The SRR for opportunistic screening was calculated from 1973-1977 to 1983-1987 (mortality only), and for organized screening from 1993-1997 to 2003-2007 (mortality and incidence). RESULTS: During the period of opportunistic cervical screening, mortality reduced by 24% in Australia and 10% in England and Wales [Australia: SRR 0.76 (95% CI 0.71-0.83); England and Wales: SRR 0.90 (95% CI 0.87-0.93)]; no statistically significant reduction was observed in New Zealand [SRR 0.95 (95% CI 0.82-1.11)]. After the introduction of organized screening, mortality reduced 39-45% in each country [Australia: SRR 0.56 (95% CI 0.51-0.62); New Zealand: SRR 0.53 (95% CI 0.44-0.63); England and Wales: SRR 0.61 (95% CI 0.58-0.64)], while incidence reduced 19-38% [New Zealand: SRR 0.62 (95% CI 0.56-0.69); Australia: SRR 0.64 (95% CI 0.61-0.72); England: SRR 0.81 (95% CI 0.78-0.83)]. CONCLUSION: In the era of opportunistic screening, some reductions were observed in cervical cancer mortality rates, but these were relatively modest and seen inconsistently between countries. After the introduction of organized cervical screening, cervical cancer mortality rates fell by a similar amount (~40% or more) in all countries, and incidence fell by more than a third in Australia and New Zealand and by approximately one-fifth in England. Although several factors are likely to have influenced these observed reductions in cervical cancer rates, these findings do not support the more frequent 2-yearly cervical screening interval recommendation in Australia.

Type-specific oncogenic human papillomavirus infection in high grade cervical disease in New Zealand.

BACKGROUND: The national Human Papillomavirus (HPV) Immunisation Programme in New Zealand was introduced in 2008, and involves routine vaccination of girls 12-13 years with a catch-up for females aged up to 19 years. The aims of this study were to measure the pre-vaccination prevalence of oncogenic HPV infection in women aged 20-69 years who were participating in the New Zealand National Cervical Screening Programme (NZ-NCSP) and who were: (1) referred with high grade cytology with a subsequent histologically-confirmed high grade cervical intraepithelial neoplasia (CIN2/3) or adenocarcinoma in situ (AIS); or (2) were in the wider group of women who had a cytological prediction of high grade squamous disease or glandular abnormality (ASC-H/ HSIL+/AGC/AIS). METHODS: Women aged 20-69 years appearing on the NZ-NCSP register between August 2009-February 2011 with a cytology record of ASC-H/HSIL+/AGC/AIS were invited to participate in the study. Liquid-based cytology specimens were tested for 37 HPV types using Linear Array genotyping. The prevalence of type-specific HPV infection was reported within women with histologically-confirmed CIN 2/3 and within the wider group with ASC-H/HSIL+/AGC/AIS cytology. Age-specific trends for the relative proportion of HPV 16/18 vs. other oncogenic types in CIN2/3 were assessed. RESULTS: A total of 594 women with ASC-H/HSIL+/AGC/AIS cytology and a valid HPV test were recruited; of these 356 (60%) had confirmed CIN2/3 and 6 (1%) had confirmed AIS or glandular dysplasia. Positivity rates for any oncogenic HPV infection and for HPV16 and/or 18 within confirmed CIN2/3-AIS were 95% (95%CI: 92-97%) and 60% (54-65%) respectively; in all women with ASC-H/HSIL+/AGC/AIS cytology it was 87% (84-89%) and 53% (49-57%), respectively. The most common reported HPV types in women with CIN 2/3 were 16 (51%), 52 (19%), 31 (17%), 33 (13%) and 18 (12%). A trend for higher rates of HPV 16/18 infection compared to other oncogenic types was observed in younger women (p=0.0006). CONCLUSIONS: The prevalence of HPV 16/18 in confirmed high grade disease in New Zealand is comparable to that observed in Australia and European countries. Test positivity rates for type 52 appear higher than in comparable studies in other developed countries. A greater proportion of high grade lesions in younger women appear to be associated with HPV 16/18 infection.

Using administrative health data to describe colorectal and lung cancer care in New South Wales, Australia: a validation study.

BACKGROUND: Monitoring treatment patterns is crucial to improving cancer patient care. Our aim was to determine the accuracy of linked routinely collected administrative health data for monitoring colorectal and lung cancer care in New South Wales (NSW), Australia. METHODS: Colorectal and lung cancer cases diagnosed in NSW between 2000 and 2002 were identified from the NSW Central Cancer Registry (CCR) and linked to their hospital discharge records in the NSW Admitted Patient Data Collection (APDC). These records were then linked to data from two relevant population-based patterns of care surveys. The main outcome measures were the sensitivity and specificity of data from the CCR and APDC for disease staging, investigative procedures, curative surgery, chemotherapy, radiotherapy, and selected comorbidities. RESULTS: Data for 2917 colorectal and 1580 lung cancer cases were analysed. Unknown disease stage was more common for lung cancer in the administrative data (18%) than in the survey (2%). Colonoscopies were captured reasonably accurately in the administrative data compared with the surveys (82% and 79% respectively; 91% sensitivity, 53% specificity) but all other colorectal or lung cancer diagnostic procedures were under-enumerated. Ninety-one percent of colorectal cancer cases had potentially curative surgery recorded in the administrative data compared to 95% in the survey (96% sensitivity, 92% specificity), with similar accuracy for lung cancer (16% and 17%; 92% sensitivity, 99% specificity). Chemotherapy (~40% sensitivity) and radiotherapy (sensitivity≤30%) were vastly under-enumerated in the administrative data. The only comorbidity that was recorded reasonably accurately in the administrative data was diabetes. CONCLUSIONS: Linked routinely collected administrative health data provided reasonably accurate information on potentially curative surgical treatment, colonoscopies and comorbidities such as diabetes. Other diagnostic procedures, comorbidities, chemotherapy and radiotherapy were not well enumerated in the administrative data. Other sources of data will be required to comprehensively monitor the primary management of cancer patients.

Postsurgical pathology reporting of thyroid cancer in New South Wales, Australia.

BACKGROUND: Clear, accurate, and complete reporting of postsurgical pathology is crucial for the correct evaluation and management of thyroid cancer patients. This study aimed to describe the completeness, as defined by international guidelines, of pathology reporting in a cohort of newly diagnosed thyroid cancer patients in New South Wales (NSW) and to identify factors associated with the completeness of reports. METHODS: Postsurgical pathology reports, held by the NSW Central Cancer Registry, for 448 thyroid cancer patients were reviewed. Presence or absence of recommended key features (tumor histology type, maximum dimension, focality, completeness of excision, extrathyroidal extension, lymphovascular invasion, and lymph node involvement) was recorded. Associations between the number of key items reported and several patient characteristics were investigated. RESULTS: For 285 (63.6%) patients one or more key pathological features were missing, with 177 (39.5%) missing one only, 88 (19.6%) missing two, and 20 (4.5%) missing three or more. Extrathyroidal extension was the most poorly reported key feature, being present in only 228 (50.9%) reports [95% confidence interval 46.2, 55.6]. Pathology reports were less complete for patients with small tumor size (p<0.001) or localized spread (p<0.001). Synoptic reports were significantly more complete than narrative-style reports (98.3% vs. 27.1%, p<0.001). CONCLUSIONS: Postsurgical pathology reporting of differentiated thyroid cancer in NSW was found to be far from complete, with 64% of reports missing information on at least one feature that is considered internationally to be a critical factor in the prognosis and treatment of thyroid cancer patients. Synoptic reporting reduces the number of key features missing from pathology reports.

Pathways to the diagnosis of thyroid cancer in New South Wales: a population-based cross-sectional study.

BACKGROUND: Over the past few decades, an increase in the incidence of thyroid cancer has been recorded in many countries around the world including Australia. Heightened medical surveillance and increased technological sensitivity could be contributing to greater detection of asymptomatic disease. OBJECTIVES: To describe the pathways to diagnosis of thyroid cancer for a cohort of newly diagnosed patients in New South Wales (NSW), Australia, and compare these pathways by age, sex, place of residence, ethnic background, medical insurance status, and disease characteristics. METHODS: A total of 452 newly diagnosed cases of thyroid cancer were recruited through the population-based NSW Central Cancer Registry. Participants completed a questionnaire and diary of doctor visits and investigations that led to their diagnosis. Tumor characteristics were obtained from pathology reports. RESULTS: Forty percent of patients initially presented to their doctor with a lump or symptom specific to thyroid cancer and 60% had their cancer detected incidentally during a medical encounter. Men were more likely than women to be diagnosed after imaging for another health concern versus reporting a thyroid lump or symptom (p = 0.001). Thyroid cancer diagnosis after imaging for another health concern increased with age (p = 0.023), and larger tumors were less likely to be diagnosed after treatment for a benign thyroid disease (p = 0.040). CONCLUSION: As the majority of participants had incidental diagnoses, the reported incidence of thyroid cancer is likely to be influenced by diagnostic technology and medical surveillance practices. This, however, probably only partly explains the observed rise in the incidence of thyroid cancer in NSW.

Evaluation of primary HPV-DNA testing in relation to visual inspection methods for cervical cancer screening in rural China: an epidemiologic and cost-effectiveness modelling study.

BACKGROUND: A new lower-cost rapid-throughput human papillomavirus (HPV) test (careHPV, Qiagen, Gaithersburg, USA) has been shown to have high sensitivity for the detection of high grade cervical intraepithelial neoplasia. METHODS: We assessed the outcomes and cost-effectiveness of careHPV screening in rural China, compared to visual inspection with acetic acid, when used alone (VIA) or in combination with Lugol's iodine (VIA/VILI). Using data on sexual behaviour, test accuracy, diagnostic practices and costs from studies performed in rural China, we estimated the cost-effectiveness ratio (CER) and associated lifetime outcomes for once-lifetime and twice-lifetime screening strategies, and for routine screening at 5-yearly, 10-yearly and IARC-recommended intervals. The optimal age range for once-lifetime screening was also assessed. RESULTS: For all strategies, the relative ordering of test technologies in reducing cervical cancer incidence and mortality was VIA (least effective); VIA/VILI; careHPV@1.0 pg/ml and careHPV@0.5 pg/ml (most effective). For once-lifetime strategies, maximum effectiveness was achieved if screening occurred between 35-50 years. Assuming a participation rate of ~70%, once-lifetime screening at age 35 years would reduce cancer mortality by 8% (for VIA) to 12% (for careHPV@0.5) over the long term, with a CER of US$557 (for VIA) to $959 (for careHPV@1.0) per life year saved (LYS) compared to no intervention; referenced to a 2008 GDP per capita in Shanxi Province of $2,975. Correspondingly, regular screening with an age-standardised participation rate of 62% (which has been shown to be achievable in this setting) would reduce cervical cancer mortality by 19-28% (for 10-yearly screening) to 43-54% (using IARC-recommended intervals), with corresponding CERs ranging from $665 (for 10-yearly VIA) to $2,269 (for IARC-recommended intervals using careHPV@1.0) per LYS. CONCLUSIONS: This modelled analysis suggests that primary careHPV screening compares favourably to visual inspection screening methodologies in rural China, particularly if used as part of a regular screening program.

Prevention of cervical cancer in rural China: evaluation of HPV vaccination and primary HPV screening strategies.

Comprehensive evaluation of the cost-effectiveness of HPV vaccination in China has not previously been performed. The objective of this study was to evaluate vaccination as an alternative or addition to primary HPV screening with careHPV (Qiagen, Gaithersburg, USA), and to assess the threshold total cost per vaccinated girl (CVG) at which strategies involving vaccination would become viable compared to screening-only strategies in rural China. We used data from field studies in Shanxi Province to support modelling of HPV vaccination and screening, including local information on sexual behaviour, HPV prevalence, test accuracy, treatment protocols and costs. We evaluated several strategies involving screening once or twice per lifetime or at regular 5-yearly intervals, with or without vaccination of young females at age 15 years, assuming 70% coverage for both screening and vaccination. We also predicted cross-sectional cancer incidence each year to the year 2050 for a range of strategies. We found that strategies involving vaccination would be cost-effective at CVGs of US$50-54 or less, but at CVGs >$54, screening-only strategies would be more cost-effective. If vaccination of young cohorts is combined with two rounds of careHPV screening for women aged 30-59 years in 2012 and 2027, a predicted indicative 33% reduction in cervical cancer incidence by 2030 would be sustained until 2050, with incidence rates decreasing thereafter. In conclusion, taking into account estimated vaccine delivery costs (for 3 doses), a per-dose HPV vaccine cost of approximately <$9-14 would be required for strategies involving vaccination to be cost-effective. Overall, combined screening and vaccination approaches are required to maximise outcomes in rural China.

Underutilization of radiotherapy for lung cancer in New South Wales, Australia.

BACKGROUND: Lung cancer is the leading cause of cancer death in most developed countries. Radiotherapy is important in its treatment, with an estimated optimal utilization rate between 45% and 68% at initial diagnosis. The objective of this study was to describe radiotherapy practice for lung cancer in New South Wales (NSW), Australia. METHODS: Patients with lung cancer were identified prospectively from the NSW Central Cancer Registry (CCR) from November 1, 2001 to December 31, 2002. Questionnaires were mailed to diagnosing and treating clinicians to obtain detailed information on diagnosis, staging, referrals, and treatment. The authors describe referral for and receipt of radiotherapy treatment. RESULTS: Of 1812 patients with lung cancer patients who were identified, 943 patients (52%) were referred for radiotherapy, 846 patients (47%) received a radiotherapy questionnaire, and 727 patients (40%) received radiotherapy. Compared with optimal radiotherapy, there was less curative radiotherapy to the primary site (20% actual vs 50% optimal), and there was more palliative radiotherapy to metastatic sites (36% actual vs 11% optimal). The greatest shortfall in radiotherapy use was observed in patients who had limited stage small cell lung cancer (46% actual vs 94% optimal). The use of combined-modality treatment for stage III nonsmall cell lung cancer and for limited stage small cell lung cancer was uncommon. CONCLUSIONS: There is underutilization of radiotherapy for lung cancer in NSW, especially in small cell lung cancer. The use of combined-modality treatment for potentially curable lung cancers is suboptimal. These issues have to be addressed to improve survival and quality of life for patients with lung cancer.

Gaps in optimal care for lung cancer.

PURPOSE: Lung cancer is the leading cause of cancer death in Australia, but little is known about how Australian patients with this disease are managed. METHODS: Lung cancer patients diagnosed from November 1, 2001 to December 31, 2002 were identified through the population-based New South Wales Central Cancer Registry. Information was collected on diagnosis, staging, referrals, and treatment. Cross-tabulations and logistic regression examined factors related to not receiving cancer-specific therapy. RESULTS: There were 2931 potentially eligible patients registered by the Central Cancer Registry and completed questionnaires were obtained for 1812 patients (62%); median age 71 years and 66% men. The pathology was non-small cell in 71%, small cell in 15% and not confirmed in 13% of patients. Eleven percent of patients did not see a lung cancer specialist and 33% received no cancer-specific therapy after initial diagnosis. Treatment utilization rates were 17% for surgery, 39% for radiotherapy, and 30% for chemotherapy. Factors significantly associated with having no cancer-specific therapy included female gender, older age, weight loss, poorer performance status, advanced or unknown disease stage, and consultation with a low patient volume lung cancer specialist or a non-lung cancer specialist. The median survival was 172 days and 2-year crude survival was 17%. CONCLUSIONS: Treatment patterns were in broad concordance with present national guidelines. Nevertheless, a significant proportion of lung cancer patients did not receive cancer-specific therapy. Treatment decisions should be multidisciplinary and decision-makers should include experienced lung cancer specialists.

Evidence-based medicine is affordable: the cost-effectiveness of current compared with optimal treatment in rheumatoid and osteoarthritis.

OBJECTIVE: To determine the cost-effectiveness of averting the burden of disease. We used secondary population data and metaanalyses of various government-funded services and interventions to investigate the costs and benefits of various levels of treatment for rheumatoid arthritis (RA) and osteoarthritis (OA) in adults using a burden of disease framework. METHOD: Population burden was calculated for both diseases in the absence of any treatment as years lived with disability (YLD), ignoring the years of life lost. We then estimated the proportion of burden averted with current interventions, the proportion that could be averted with optimally implemented current evidence-based guidelines, and the direct treatment cost-effectiveness ratio in dollars per YLD averted for both treatment levels. RESULTS: The majority of people with arthritis sought medical treatment. Current treatment for RA averted 26% of the burden, with a cost-effectiveness ratio of dollar 19,000 per YLD averted. Optimal, evidence-based treatment would avert 48% of the burden, with a cost-effectiveness ratio of dollar 12,000 per YLD averted. Current treatment of OA in Australia averted 27% of the burden, with a cost-effectiveness ratio of dollar 25,000 per YLD averted. Optimal, evidence-based treatment would avert 39% of the burden, with an unchanged cost-effectiveness ratio of dollar 25,000 per YLD averted. CONCLUSION: While the precise dollar costs in each country will differ, the relativities at this level of coverage should remain the same. There is no evidence that closing the gap between evidence and practice would result in a drop in efficiency.