Costs of cancer along the care continuum: What we can expect based on recent literature

Beyond the PSA: The hidden costs of screening in prostate cancer

The diagnostic workup following a positive prostate‐specific antigen test may lead to significant out‐of‐pocket costs for patients. Providers should incorporate costs into shared decision‐making with patients; in parallel, policymakers and payers must identify solutions to mitigate financial burdens that risk widening existing disparities in prostate cancer care.

Financial hardship screening among Native American patients with cancer: a qualitative analysis

BACKGROUND

Cancer-related financial hardship is an increasingly recognized concern for patients, families, and caregivers. Many Native American (NA) patients are at increased risk for cancer-related financial hardship due to high prevalence of low income, medical comorbidity, and lack of private health insurance. However, financial hardship screening (FHS) implementation for NA patients with cancer has not been reported. The objective of this study is to explore facilitators and barriers to FHS implementation for NA patients.

METHODS

We conducted key informant interviews with NA patients with cancer and with clinical staff at an academic cancer center. Included patients had a confirmed diagnosis of cancer and were referred to the cancer center through the Indian Health Service, Tribal health program, or Urban Indian health program. Interviews included questions regarding current financial hardship, experiences in discussing financial hardship with the cancer care and primary care teams, and acceptability of completing a financial hardship screening tool at the cancer center. Clinical staff included physicians, advanced practice providers, and social workers. Interviews focused on confidence, comfort, and experience in discussing financial hardship with patients. Recorded interviews were transcribed and thematically analyzed using MAXQDA® software.

RESULTS

We interviewed seven patients and four clinical staff. Themes from the interviews included: 1) existing resources and support services; 2) challenges, gaps in services, and barriers to care; 3) nuances of NA cancer care; and 4) opportunities for improved care and resources. Patients identified financial challenges to receiving cancer care including transportation, lodging, food insecurity, and utility expenses. Patients were willing to complete a FHS tool, but indicated this tool should be short and not intrusive of the patient's financial information. Clinical staff described discomfort in discussing financial hardship with patients, primarily due to a lack of training and knowledge about resources to support patients. Having designated staff familiar with I/T/U systems was helpful, but perspectives differed regarding who should administer FHS.

CONCLUSIONS

We identified facilitators and barriers to implementing FHS for NA patients with cancer at both the patient and clinician levels. Findings suggest clear organizational structures and processes are needed for financial hardship to be addressed effectively.

Onco@home: comparing the costs and reimbursement of cancer treatment at home with the standard of care

BACKGROUND

Oncological home hospitalization (HH) was implemented in a Belgian context to evaluate the feasibility of oncological HH. In a first HH model (HH1), implemented by three Belgian hospitals, two home nursing organizations and a grouping of independent nurses, the blood draw and monitoring prior to intravenous therapy was performed by a trained home nurse at the patient's home the day before the visit to the day hospital. In a second HH model (HH2), implemented in one hospital, the administration of two subcutaneous treatments (Azacitidine and Bortezomib) for myelodysplastic syndrome and multiple myeloma were provided at home instead of in the hospital. A previous study on this pilot showed that oncological HH is feasible and safe and improves the Quality of Life. The aim of this study is to investigate the cost and reimbursement of cancer treatment in these two HH models compared to the Standard of Care (SOC).

METHODS

A bottom-up micro-costing study was conducted to compare the costs and revenues for the providers (hospitals and home care organizations) of the SOC and the HH models.

RESULTS

Costs associated to HH were higher than the SOC in the hospital. Comparing revenues with costs, the research revealed that the reimbursement from the National Health Insurance of HH for oncological patients is insufficient. In HH1, costs were higher than in the SOC (+ €50.4). There was a reduction in costs in the hospital by moving the blood draw to the home setting (-€23.9), but the costs in home care were higher (+ €74.3). The extra revenues in home care (+ €33.6) were insufficient to cover the costs. The cost difference between the SOC and HH2 (+ €9.5 for Azacetidine) was smaller than in HH1. But, there was almost no funding for subcutaneous administration in home care. If the product is administered in a day hospital, the hospital receives a revenue of €124 per administration, while in home care the funding is €5 per visit.

CONCLUSION

Costs of HH are higher and the reimbursement from Belgian NHI is insufficient to organize HH. As a result, HH for oncology patient is still limited in Belgium.

Healthcare costs of cancer among children, adolescents, and young adults: A scoping review

OBJECTIVE

To collate and critically review international evidence on the direct health system costs of children and adolescents and young adults (AYA) with cancer.

METHODS

We conducted searches in PubMed, MEDLINE, CINAHL, and Scopus. Articles were limited to studies involving people aged 0-39 years at cancer diagnosis and published from 2012 to 2022. Two reviewers screened the articles and evaluated the studies using the Consolidated Health Economic Evaluation Reporting Standards checklist. The reviewers synthesized the findings using a narrative approach and presented the costs in 2022 US dollars for comparability.

RESULTS

Overall, the mean healthcare costs for all cancers in the 5 years post diagnosis ranged from US$36,670 among children in Korea to US$127,946 among AYA in the USA. During the first year, the mean costs among children 0-14 years ranged from US$34,953 in Chile to over US$130,000 in Canada. These were higher than the costs for AYA, estimated at US$61,855 in Canada. At the end of life, the mean costs were estimated at over US$300,000 among children and US$235,265 among adolescents in Canada. Leukemia was the most expensive cancer type, estimated at US$50,133 in Chile, to US$152,533 among children in Canada. Overall, more than a third of the total cost is related to hospitalizations. All the included studies were of good quality.

CONCLUSIONS

Healthcare costs associated with cancer are substantial among children, and AYA. More research is needed on the cost of cancer in low- and middle-income countries and harmonization of costs across countries.

Developing a national implementation strategy to accelerate uptake of evidence-based family caregiver support in U.S. cancer centers

OBJECTIVE

Characterize key factors and training needs of U.S. cancer centers in implementing family caregiver support services.

METHODS

Sequential explanatory mixed methods design consisting of: (1) a national survey of clinicians and administrators from Commission-on-Cancer-accredited cancer centers (N = 238) on factors and training needed for establishing new caregiver programs and (2) qualitative interviews with a subsample of survey respondents (N = 30) to elicit feedback on survey findings and the outline of an implementation strategy to facilitate implementation of evidence-based family caregiver support (the Caregiver Support Accelerator). Survey data was tabulated using descriptive statistics and transcribed interviews were analyzed using thematic analysis.

RESULTS

Top factors for developing new caregiver programs were that the program be: consistent with the cancer center's mission and strategic plan (87%), supported by clinic leadership (86.5%) and providers and staff (85.7%), and low cost or cost effective (84.9%). Top training needs were how to: train staff to implement programs (72.3%), obtain program materials (63.0%), and evaluate program outcomes (62.6%). Only 3.8% reported that no training was needed. Qualitative interviews yielded four main themes: (1) gaining leadership, clinician, and staff buy-in and support is essential; (2) cost and clinician burden are major factors to program implementation; (3) training should help with adapting and marketing programs to local context and culture; and (4) the Accelerator strategy is comprehensive and would benefit from key organizational partnerships and policy standards.

CONCLUSION

Findings will be used to inform and refine the Accelerator implementation strategy to facilitate the adoption and growth of evidence-based cancer caregiver support in U.S. cancer centers.

Cost items in melanoma patients by clinical characteristics and time from diagnosis

Background

Costs related to the care of melanoma patients have been rising over the past few years due to increased disease incidence as well as the introduction of innovative treatments. The aim of this study is to analyse CMM cost items based on stage at diagnosis, together with other diagnostic and prognostic characteristics of the melanoma.

Methods

Analyses were performed on 2,647 incident cases of invasive CMM that were registered in 2015 and 2017 in the Veneto Cancer Registry (RTV). Direct melanoma-related costs per patient were calculated for each year ranging from 2 years before diagnosis to 4 years after, and were stratified by cost items such as outpatient services, inpatient drug prescriptions, hospital admissions, hospice admissions, and emergency room treatment. Average yearly costs per patient were compared according to available clinical-pathological characteristics. Lastly, log-linear multivariable analysis was performed to investigate potential cost drivers among these clinical-pathological characteristics.

Findings

Overall, the average direct costs related to melanoma are highest in the first year after diagnosis (€2,903) and then decrease over time. Hospitalization costs are 8 to 16 times higher in the first year than in subsequent years, while the costs of outpatient services and inpatient drugs decrease gradually over time. When stratified by stage it is observed that the higher expenditure associated with more advanced stages of CMM is mainly due to inpatient drug use.

Conclusion

The results of the present study show that grouping patients according to tumour characteristics can improve our understanding of the different cost items associated with cutaneous malignant melanoma. CMM patients experience higher costs in the first year after diagnosis due to higher hospitalization and outpatient services. Policy makers should consider overall and stage-specific annual costs when allocating resources for the management of CMM patients.

Heterogeneity of financial toxicity and associated risk factors for older cancer survivors in China

In China, older cancer survivors may show heterogeneity in financial toxicity (FT). We aimed to identify FT profiles among older Chinese cancer survivors and examine the association between FT profiles and individual characteristics. We used a latent profile analysis to categorize participants and a multinomial logistic regression to examine the associations. We identified three distinct FT profiles: high, moderate, and low. Participants aged 65-69 years, with a monthly household income ≥ 5,000 CNY and a high school education or above were more likely to be classified into the moderate than high FT profile, a monthly household income ≥ 5,000 CNY increased the likelihood of being in the low FT profile and living alone negatively affected the odds of being in the low FT profile. The findings identified heterogeneity in FT among this population, may help identify high-risk groups, and may enable early intervention.

Financial navigation: Staff perspectives on patients' financial burden of cancer care

PURPOSE

To describe perceptions of financial navigation staff concerning patients' cancer-related financial burden.

METHODS

This qualitative descriptive study used a semi-structured interview guide to examine perceptions of financial navigation staff concerning patients' cancer-related financial burden. Staff who provided financial navigation support services to cancer patients were interviewed from different types of cancer programs across seven states representing rural, micropolitan, and urban settings. Interviews lasted approximately one hour, were audio recorded, and transcribed. Transcripts were double coded for thematic analysis.

RESULTS

Thirty-five staff from 29 cancer centers were interviewed. The first theme involved communication issues related to patient and financial navigation staff expectations, timing and the sensitive nature of financial discussions. The second theme involved the multi-faceted impact of financial burden on patients, including stress, difficulty adhering to treatments, and challenges meeting basic, non-medical needs. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Cancer-related financial burden has a profound impact on cancer survivors' health and non-health outcomes. Discussions regarding cancer-related costs between cancer survivors and healthcare team members could help to normalize conversations and mitigate the multi-faceted determinants and effects of cancer-related financial burden. As treatment may span months and years and unexpected costs arise, having this discussion regularly and systematically is needed.

Fabrication of a Dual-Targeted Liposome-Coated Mesoporous Silica Core-Shell Nanoassembly for Targeted Cancer Therapy

Nanoparticles have been suggested as drug-delivery systems for chemotherapeutic drugs to allow for controlled drug release profiles and selectivity to target cancer cells. In addition, nanoparticles can be used for the in situ generation and amplification of reactive oxygen species (ROS), which have been shown to be a promising strategy for cancer treatment. Thus, a targeted nanoscale drug-delivery platform could be used to synergistically improve cancer treatment by the action of chemotherapeutic drugs and ROS generation. Herein, we propose a promising chemotherapy strategy where the drug-loaded nanoparticles generate high doses of ROS together with the loaded ROS-generating chemotherapeutic drugs, which can damage the mitochondria and activate cell death, potentiating the therapeutic outcome in cancer therapy. In the present study, we have developed a dual-targeted drug-delivery nanoassembly consisting of a mesoporous silica core loaded with the chemotherapeutic, ROS-generating drug, paclitaxel (Px), and coated with a liposome layer for controlled drug release. Two different lung cancer-targeting ligands, folic acid and peptide GE11, were used to target the overexpressed nonsmall lung cancer receptors to create the final nanoassembly (MSN@Px) L-GF. Upon endocytosis by the cancer cells, the liposome layer was degraded by the intracellular lipases, and the drug was rapidly released at a rate of 65% within the first 20 h. In vitro studies confirmed that this nanoassembly was 8-fold more effective in cancer therapy compared to the free drug Px.

Developing a Conceptual Framework for Socioeconomic Impact Research in European Cancer Patients: A 'Best-Fit' Framework Synthesis

BACKGROUND

Multiple studies have indicated a socioeconomic impact of cancer and cancer care on patients and their families. Existing instruments designed to measure this impact lack consensus in their conceptualization of the issue. Further, various terminologies have been used in the literature (e.g., financial burden, financial hardship, financial stress) without clear definitions and consistent conceptual background. Based on a targeted review of existing models addressing the socioeconomic impact of cancer, our goal was to develop a comprehensive framework from a European perspective.

METHOD

A 'best-fit' framework synthesis was applied. First, we systematically identified existing models to generate a priori concepts. Second, we systematically identified relevant European qualitative studies and coded their results against these a priori concepts. Inclusion and exclusion criteria were predefined and applied thoroughly in these processes. Thematic analysis and team discussions were applied to finalize the (sub)themes in our proposed conceptual framework. Third, we examined model structures and quotes from qualitative studies to explore relationships among (sub)themes. This process was repeated until no further change in (sub)themes and their relationships emerged.

RESULT

Eighteen studies containing conceptual models and seven qualitative studies were identified. Eight concepts and 20 sub-concepts were derived from the included models. After coding the included qualitative studies against the a priori concepts and following discussions among team members, seven themes and 15 sub-themes were included in our proposed conceptual framework. Based on the identified relationships, we categorized themes into four groups: causes, intermediate consequences, outcomes and risk factors.

CONCLUSION

We propose a Socioeconomic Impact Framework based on a targeted review and synthesis of existing models in the field and adapted to the European perspective. Our work contributes as an input to a European consensus project on socioeconomic impact research by an Organization European Cancer Institute (OECI) Task Force.

Financial toxicity in cancer patients and subsequent risk of repeat acute care utilization

Background

Acute care (AC) visits by cancer patients are costly sources of healthcare resources and can exert a financial burden of oncology care both for individuals with cancer and healthcare systems. We sought to identify whether cancer patients who reported more severe initial financial toxicity (FT) burdens shouldered excess risks for acute care utilization.

Methods

In 225 adult patients who participated in the Economic Strain and Resilience in Cancer (ENRICh) survey study of individuals receiving ambulatory cancer care between March and September 2019, we measured the baseline FT (a multidimensional score of 0-10 indicating the least to most severe global, material, and coping FT burdens). All AC visits, including emergency department (ED) and unplanned hospital admissions, within 1-year follow-up were identified. The association between the severity of FT and the total number of AC visits was tested using Poisson regression models.

Results

A total of 18.6% (n = 42) of patients had any AC visit, comprising 64.3% hospital admissions and 35.7% ED visits. Global FT burden was associated with the risk of repeat AC visits within 1-year follow-up (RR = 1.17, 95% CI 1.07-1.29, P < 0.001 for every unit increase), even after adjusting for sociodemographic and disease covariates. When examining subdimensions of FT, the burden of depleted FT coping resources (coping FT) was strongly associated with the risk of repeat AC visits (RR = 1.27, 95% CI 1.15-1.40, P < 0.001) while material FT burden showed a trend toward association (RR = 1.07, 95% CI 0.99-1.15, P = 0.07).

Conclusion

In this prospective study of acute oncology care utilization outcomes among adult cancer patients, FT was a predictor of a higher burden of acute care visits. Patients with severely depleted material and also practical and social coping resources were at particular risk for repeated visits. Future studies are needed to identify whether early FT screening and intervention efforts may help to mitigate urgent acute care utilization burdens.

The many "costs" of transportation: Examining what cancer caregivers experience as transportation obstacles

BACKGROUND

Transportation has been identified as a specific source of burden for cancer caregivers. This study examined cancer caregivers' subjective experiences and objectives costs associated with transportation over a 6-month period of providing end-of-life care to a family member or friend.

METHODS

This was a multi-site longitudinal, prospective cohort study that followed 223 caregiver-patient dyads. Data were collected using biweekly, semi-structured interviews for up to 6 months and collection of all caregiving related receipts. Interviews were coded and analyzed using a comparative, iterative analysis and actual out of pockets costs were described using descriptive statistics.

RESULTS

Over the 6-month study period most caregivers (n = 143; 74%) discussed transportation at one or more timepoints. Average biweekly transportations costs to caregivers were $43.6. Caregivers described (n = 56; 39%) multiple direct and indirect costs of transportation, and 58% (n = 84) discussed the need for transportations services or assistance at the institutional level.

CONCLUSIONS

Caregivers described the multifaceted costs of transportation they experienced which are in line with previous work. Alongside descriptions of direct costs, caregivers described key opportunity costs, such as personal and work time forgone to transporting patients. Caregivers also made suggestions for institutional and/or civic based solutions to facilitate reliable modes of transportation, rather than individual-level intervention.

Expanding research on the impact of financial hardship on emotional well-being: guidance of diverse stakeholders to the Emotional Well-Being and Economic Burden of Disease (EMOT-ECON) Research Network

The Emotional Well-Being and Economic Burden (EMOT-ECON) Research Network is one of six research networks funded by the National Institutes of Health (NIH) to advance research about emotional well-being (EWB), and the only one that focuses on addressing how economic burden due to disease or illness affects EWB. The network convened researchers, patients, patient advocates, health care providers and other stakeholders from across the US to discuss the significance of addressing the impact of the economic burden of disease on EWB, the complexity of this prevalent problem for patients and families, and the research gaps that still need to be studied to ultimately develop strategies to reduce the impact of economic burden of disease on EWB and health. Participants identified some important future areas of research as those investigating: (i) prevalent and relevant emotions for patients experiencing economic burden of disease and financial hardship, and how their broader outlook on life is impacted; (ii) constructs and contexts that influence whether the economic burden is stressful; (iii) strategies to deal and cope and their positive or negative effects on EWB and health; and (iv) multi-level and multi-stakeholder interventions to address economic factors (e.g., costs, ability to pay), administrative burdens, education and training, and especially patients' emotional as well as financial status.

"Both a life saver and totally shameful": young adult cancer survivors' perceptions of medical crowdfunding

PURPOSE

Young adults (YAs) diagnosed with cancer face high financial burden at a time in their lives when they are financially vulnerable. Some turn to medical crowdfunding, that is, using social media and other means to raise funds or resources to offset medical and usual life expenses. Major research gaps exist regarding the experiences of those who pursued crowdfunding. Thus, the study purpose was to describe the perceptions of, and experiences with, medical crowdfunding among a sample of YA cancer survivors.

METHODS

In February 2021, we distributed an online survey to YAs with a history of a cancer diagnosis, who had received grants from an organization that offers financial assistance. We calculated descriptive statistics on the crowdfunding sample and employed thematic analysis to analyze the open-ended questions.

RESULTS

In this sample (N = 113), 46 YA cancer survivors had engaged in medical crowdfunding and shared their perceptions and experiences. Our central theme, "The Crowdfunding Compromise" captures the trade-offs participants faced, which included subthemes of "crowdfunding as useful/helpful," "factors associated with crowdfunding success," and "questioning the why?".

CONCLUSIONS

Among YA cancer survivors, medical crowdfunding brings shame and stigma in addition to financial support. YA cancer survivors demonstrate resilience in their attempts to find individual solutions to financial problems created by unchecked health care costs, the US health insurance infrastructure, and lack of legislation.

IMPLICATIONS FOR CANCER SURVIVORS

This study fills an important gap in understanding individual-level crowdfunding experiences. Implications include system-level approaches to addressing cancer-related financial burden and potential worsening of existing disparities through medical crowdfunding.

Factors Associated with the Decision to Decline Chemotherapy in Metastatic Non-Small Cell Lung Cancer

(1) Background: Disparities in cancer treatment and outcomes have long been well-documented in the medical literature. With the eruption of advances in new treatment modalities, the long-existing disparities are now being further uncovered and brought to the attention of the medical community. While social health determinants have previously been linked to treatment disparities in lung cancer, we analyzed data from the National Cancer Database to explore sociodemographic and geographic factors related to accepting or declining physician-recommended chemotherapy. Patients diagnosed with metastatic lung cancer between 2004 and 2016 who declined chemotherapy recommended by their physicians were included in this study. Multivariate logistic regression analysis was performed. Cox Regression and Kaplan-Meier analyses were performed to look for survival characteristics. (2) Results: 316,826 patients with Stage IV lung cancer were identified. Factors related to a higher rate of refusal by patients included older age > 70, female sex, low income, lack of insurance coverage, residency in the New England region, and higher comorbidity. Patients living in areas with lower education were less likely to decline chemotherapy. (3) Conclusion: Further understanding of the factors impacting treatment decisions would be essential to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.

Prevalence of Food Insecurity Among Cancer Survivors in the United States: A Scoping Review

BACKGROUND

Medical financial hardship is an increasingly common consequence of cancer treatment and can lead to food insecurity. However, food security status is not routinely assessed in the health care setting, and the prevalence of food insecurity among cancer survivors is unknown.

OBJECTIVE

This scoping review aimed to identify the prevalence of food insecurity among cancer survivors in the United States before the COVID-19 pandemic.

METHODS

Five databases (PubMed, Scopus, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Web of Science, and ProQuest Dissertations and Theses) were systematically searched for articles that reported on food security status among US patients receiving active cancer treatment or longer-term cancer survivors and were published between January 2015 and December 2020.

RESULTS

Among the 15 articles meeting the inclusion criteria, overall food insecurity prevalence ranged from 4.0% among women presenting to a gynecologic oncology clinic to 83.6% among patients at Federally Qualified Health Centers. Excluding studies focused specifically on Federally Qualified Health Center patients, prevalence of food insecurity ranged from 4.0% to 26.2%, which overlaps the food insecurity prevalence in the general US population during the same time period (range, 10.5% to 14.9%). Women were more likely than men to report being food insecure, and the prevalence of food insecurity was higher among Hispanic and Black patients compared with non-Hispanic White patients.

CONCLUSIONS

Given significant heterogeneity in study populations and sample sizes, it was not possible to estimate an overall food insecurity prevalence among cancer survivors in the United States. Routine surveillance of food security status and other social determinants of health is needed to better detect and address these issues.

Mechanisms of radioresistance and the underlying signaling pathways in colorectal cancer cells

Radiotherapy is one of the most common modalities for the treatment of a wide range of tumors, including colorectal cancer (CRC); however, radioresistance of cancer cells remains a major limitation for this treatment. Following radiotherapy, the activities of various cellular mechanisms and cell signaling pathways are altered, resulting in the development of radioresistance, which leads to therapeutic failure and poor prognosis in patients with cancer. Furthermore, even though several inhibitors have been developed to target tumor resistance, these molecules can induce side effects in nontumor cells due to low specificity and efficiency. However, the role of these mechanisms in CRC has not been extensively studied. This review discusses recent studies regarding the relationship between radioresistance and the alterations in a series of cellular mechanisms and cell signaling pathways that lead to therapeutic failure and tumor recurrence. Our review also presents recent advances in the in vitro/in vivo study models aimed at investigating the radioresistance mechanism in CRC. Furthermore, it provides a relevant biochemical basis in theory, which can be useful to improve radiotherapy sensitivity and prolong patient survival.

Housing Insecurity Among Patients With Cancer

Social determinants of health are the economic and environmental conditions under which people are born, live, work, and age that affect health. These structural factors underlie many of the long-standing inequities in cancer care and outcomes that vary by geography, socioeconomic status, and race and ethnicity in the United States. Housing insecurity, including lack of safe, affordable, and stable housing, is a key social determinant of health that can influence-and be influenced by-cancer care across the continuum, from prevention to screening, diagnosis, treatment, and survivorship. During 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing social determinants of health, including food, housing, and transportation insecurity, and their associations with cancer care and patient outcomes. This dissemination commentary summarizes the formal presentations and panel discussions from the webinar devoted to housing insecurity. It provides an overview of housing insecurity and health care across the cancer control continuum, describes health system interventions to minimize the impact of housing insecurity on patients with cancer, and identifies challenges and opportunities for addressing housing insecurity and improving health equity. Systematically identifying and addressing housing insecurity to ensure equitable access to cancer care and reduce health disparities will require ongoing investment at the practice, systems, and broader policy levels.

Financial hardship and mental health among cancer survivors during the COVID-19 pandemic: An analysis of the US COVID-19 Household Impact Survey

Purpose

Our objective was to (1) identify associated characteristics of financial hardship (FH), and (2) evaluate associations of FH with mental health symptoms among cancer survivors during the COVID-19 pandemic.

Methods

Using data from the nationally representative COVID-19 Impact Survey, we defined cancer survivors as those with a self-reported diagnosis of cancer (n = 854,7.6%). We defined FH using the following question: "Based on your current financial situation, how would you pay for an unexpected $400 expense?" Multivariable Poisson regression was used to estimate adjusted prevalence ratios (aPR) with 95% confidence intervals (95%CI) to identify associated characteristics of FH and associations of FH with mental health symptoms among cancer survivors overall and by age (18-59 years/60+ years).

Results

Forty-one percent of cancer survivors reported FH, with 58% in 18-59 and 33% in 60+ year old respondents. Compared to cancer survivors aged 60+ years, those aged 30-44 (aPR:1.74,95% CI:1.35-2.24), and 45-59 years (aPR:1.60,95% CI:1.27-1.99) were more likely to report FH. Compared to non-Hispanic(NH)-White cancer survivors, NH-Black cancer survivors had a 56% higher prevalence of FH (aPR:1.56; 95% CI: 1.23-1.97). Among 60+ years aged cancer survivors, NH-Black (aPR:1.80; 95% CI: 1.32-2.45) and NH-Asian cancer survivors (aPR:10.70,95% CI:5.6-20.7) were more likely to experience FH compared to their NH-White counterparts. FH was associated with feeling anxious (aPR:1.51,95% CI:1.11-2.05), depressed (aPR:1.66,95% CI:1.25-2.22), and hopeless (aPR:1.84,95% CI:1.38-2.44).

Conclusion

Minoritized communities, younger adults, and cancer survivors with low socioeconomic status had a higher burden of FH, which was associated with feelings of anxiety, depression, and hopelessness.

Assessing Patient-Reported Financial Hardship in Patients With Cancer in Routine Clinical Care

PURPOSE

Financial hardship (FH) in cancer care is a growing challenge for patients, their caregivers, and health care providers with impact on morbidity and mortality. In this study, we report on a standardized approach to describe the prevalence and predictors for FH as part of routine clinical workflow. We also report on the association of FH with survival in our cancer patient population.

METHODS

This study includes patients who completed a FH screen at least once between 2018 and 2020. Demographics, disease state, and mortality data were extracted from the medical records. Multivariable logistic regression models were used to examine association of sociodemographic and disease variables with FH. By using propensity score weighting to account for differences in demographic and clinical factors between patients with and without FH, we then fit Cox proportional hazards models to examine the relationship between FH and survival.

RESULTS

The study cohort included 31,154 patients. FH was reported by 14% (n = 4,250) of the patients. A significantly higher likelihood of having FH (P < .001 for all) was reported by racial/ethnic minority patients; those who were unemployed/disabled, single, or divorced; patients from disadvantaged neighborhoods; and those who were self-pay or had government insurance. Older age, being retired, and living farther from the cancer center were associated with significantly less likelihood of endorsing FH. Patients who endorsed FH had a lower survival (hazard ratio for mortality 1.46).

CONCLUSION

Our study identified key groups more likely to report FH in a relatively affluent population at a large cancer center and showed an adverse association between FH and survival. Further research is needed to develop clinical care pathways for patients at high risk for worse financial and clinical outcomes.

Cancer cost profiles: The Epicost estimation approach

Sustainability of cancer burden is becoming increasingly central in the policy makers' debate, and poses a challenge for the welfare systems, due to trends towards greater intensity of healthcare service use, which imply increasing costs of cancer care. Measuring and projecting the economic burden associated with cancer and identifying effective policies for minimising its impact are important issues for healthcare systems. Scope of this paper is to illustrate a novel comprehensive approach (called Epicost) to the estimation of the economic burden of cancer, based on micro-data collected from multiple data sources. It consists of a model of cost analysis to estimate the amount of reimbursement payed by the National Health Service to health service providers (hospitals, ambulatories, pharmacies) for the expenses incurred in the diagnoses and treatments of a cohort of cancer patients; these cancer costs are estimated in various phases of the disease reflecting patients' patterns of care: initial, monitoring and final phase. The main methodological features are illustrated using a cohort of colon cancer cases from a Cancer Registry in Italy. This approach has been successfully implemented in Italy and it has been adapted to other European countries, such as Belgium, Norway and Poland in the framework of the Innovative Partnership for Action Against Cancer (iPAAC) Joint Action, sponsored by the European Commission. It is replicable in countries/regions where population-based cancer registry data is available and linkable at individual level with administrative data on costs of care.

Navigating financial toxicity in patients with cancer: A multidisciplinary management approach

Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.

Cost-Related Medication Nonadherence and Patient Cost Responsibility for Rural and Urban Cancer Survivors

PURPOSE

The relationship between out-of-pocket spending and cost-related medication nonadherence among older rural- and urban-dwelling cancer survivors is not well understood.

METHODS

This retrospective cohort study used the Surveillance, Epidemiology, and End Results Program, Medicare claims, and the Consumer Assessment of Healthcare Providers and Systems survey linked data resource linked data (2007-2015) to investigate the relationship between cancer survivors' cost responsibility in the year before and after report of delaying or not filling a prescription medication because of cost in the past 6 months (cost-related medication nonadherence). Secondary exposures and outcomes included Medicare spending and utilization. Generalized linear models assessed bidirectional relationships between cost-related medication nonadherence, spending, and utilization. Effects of residence were assessed via interaction terms.

RESULTS

Of 6,591 older cancer survivors, 13% reported cost-related medication nonadherence. Survivors were a median 8 years (interquartile range, 4.5-12.5 years) from their cancer diagnosis, 15% were dually Medicare/Medicaid-eligible, and prostate (40%) and breast (32%) cancer survivors were most prevalent. With every $500 USD increase in patient cost responsibility, risk of cost-related medication nonadherence increased by 3% (risk ratio, 1.03; 95% CI, 1.02 to 1.04). After report of cost-related medication nonadherence, patient cost responsibility was 22% higher (95% CI, 1.11 to 1.32) compared with those not reporting nonadherence, amounting to $523 USD (95% CI, $430 USD to $630 USD). Medicare spending and utilization were also higher before and after report of cost-related nonadherence versus none. For survivors residing in rural (18%) and urban (82%) areas, residence did not modify adherence or cost outcomes.

CONCLUSION

A bidirectional relationship exists between patient cost responsibility and cost-related medication nonadherence. Interventions reducing urban- and rural-dwelling survivor health care costs and cost-related adherence barriers are needed.

Implementing patient navigation programs: Considerations and lessons learned from the Alliance to Advance Patient-Centered Cancer Care

BACKGROUND

Six multidisciplinary cancer centers were selected and funded by the Merck Foundation (2017-2021) to collaborate in the Alliance to Advance Patient-Centered Cancer Care ("Alliance"), an initiative to improve patient access, minimize health disparities, and enhance the quality of patient-centered cancer care. These sites share their insights on implementation and expansion of their patient navigation efforts.

METHODS

Patient navigation represents an evidence-based health care intervention designed to enhance patient-centered care and care coordination. Investigators at 6 National Cancer Institute-designated cancer centers outline their approaches to reducing health care disparities and synthesize their efforts to ensure sustainability and successful transferability in the management of patients with cancer and their families in real-world health care settings.

RESULTS

Insights are outlined within the context of patient navigation program effectiveness and supported by examples from Alliance cancer center sites: 1) understand the patient populations, particularly underserved and high-risk patients; 2) capitalize on the existing infrastructure and institutional commitment to support and sustain patient navigation; and 3) build capacity by mobilizing community support outside of the cancer center.

CONCLUSIONS

This process-level article reflects the importance of collaboration and the usefulness of partnering with other cancer centers to share interdisciplinary insights while undergoing intervention development, implementation, and expansion. These collective insights may be useful to staff at other cancer centers that look to implement, enhance, or evaluate the effectiveness of their patient navigation interventions.

Cancer Survivorship and Supportive Care Economics Research: Current Challenges and Next Steps

BACKGROUND

Rapid growth in the number of cancer survivors raises numerous questions about health and economic outcomes among survivors along with their families, caregivers, and employers. Health economics theory and methods can contribute to many open questions to improve survivorship.

METHODS

In this paper, we review key areas where more research is needed and describe strategies for improving data infrastructure, research funding, and capacity building to strengthen survivorship health economics research.

CONCLUSIONS

Health economics has broadened an understanding of key supply- and demand-side factors that promote cancer survivorship. To ensure necessary research in survivorship health economics moving forward, we recommend dedicated funding, inclusion of health economics outcomes in primary data collection, and investments in secondary data sets.

Geographical Disparities and Factors Associated With the Decision to Decline Chemotherapy in Breast Cancer

PURPOSE

Social determinants of health have been linked to treatment-related disparities in breast cancer. We analyzed data from a large national registry to explore factors related to accepting or declining recommended chemotherapy and whether patients' decisions vary geographically across the United States.

METHODS

We used the National Cancer Database to study treatment decision making in patients with advanced breast cancer (American Joint Committee on Cancer clinical stage III-IV) between 2004 and 2017. We focused the analysis on patients who were recommended chemotherapy by their physicians but who declined this treatment. Multivariate logistic regression analysis was performed.

RESULTS

A total of N = 215,284 patients with stage III and IV breast cancers were included. Patients in the New England region were more likely to refuse chemotherapy compared with the rest, with patients in the East South Central regions (AL, KY, MS, and TN) and West South Central (AR, LA, OK, and TX) noted to be least likely to refuse chemotherapy. Factors related to a higher rate of refusal by patients included older age > 70 years; hormone receptor-positive tumors; and having higher comorbidity. Patients identified as Hispanic, those who are privately insured, and patients at academic institutions were less likely to decline chemotherapy.

CONCLUSION

This analysis identified a significant difference in rates of refusal of recommended chemotherapy by geographical location, insurance status, and treatment facility after adjusting for known social determinants of health. Further understanding of the factors affecting treatment decisions would be important to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.

Prescription drug coverage satisfaction and medication nonadherence among Medicare beneficiaries with cancer

BACKGROUND

Medication nonadherence among older patients with cancer can have profound health consequences. This study examines the association between prescription drug coverage satisfaction and medication nonadherence among Medicare beneficiaries with cancer.

METHODS

We analyzed the 2017 Medicare Current Beneficiary Survey Public Use File of beneficiaries aged ≥65 years with reported non-skin cancer (n = 806). Beneficiaries were considered to have medication nonadherence if they reported: skipping doses, taking smaller doses than prescribed, or delaying or not filling a prescription because of cost. A survey-weighted logistic model, adjusted for covariates, was conducted to examine the association between prescription drug coverage satisfaction and medication nonadherence.

RESULTS

Of study beneficiaries with cancer, 14.7% reported medication nonadherence. Higher proportions of beneficiaries with medication nonadherence were dissatisfied with the amount paid for medications (33.2% vs. 11.0%, p < 0.001) and the medications included on formulary (29.5% vs 5.2%, p < 0.001). In the adjusted analysis, the risk for medication nonadherence was higher among those who were dissatisfied with the amount paid for medications (OR = 2.22; p = 0.050) and the medications included on formulary (OR = 5.03; p = 0.005).

CONCLUSIONS

Strategic mitigation of these barriers is essential to improving health outcomes in this at-risk population.

Divergent Patterns in Care Utilization and Financial Distress between Patients with Blood Cancers and Solid Tumors: A National Health Interview Survey Study, 2014-2020

Introduction: Important differences exist between the presentation, treatment, and survivorship of patients and survivors with blood cancers. Furthermore, existing research in financial toxicity has not fully addressed the relationship between medical care utilization and patient-reported outcomes of financial barriers and distress. We answered these questions by using a nationally representative survey. Methods: Respondents with blood cancers and solid tumors from the National Health Interview Survey were identified (2014−2020). We identified 23 survey questions as study outcomes and grouped them into three domains of medical care utilization, financial barriers to care, and financial distress. Associations between the three domains and associations of study outcomes between cancer types were examined using weighted univariate analyses and multivariable linear and logistic regressions. Results: The final study group consisted of 6248 respondents with solid tumors and 398 with blood cancers (diagnosed ≤ 5 years). Across all respondents with cancer, higher medical care utilization is generally associated with increased financial barriers to care. Compared to respondents with solid tumors, respondents with blood cancers had a higher level of medical care utilization (β = 0.36, p = 0.02), a lower level of financial barriers to care (β = −0.19, p < 0.0001), and a higher level of financial distress in affording care (β = 0.64, p = 0.03). Conclusions: Patients and survivors with blood cancers and solid tumors demonstrate divergent patterns in care utilization, financial barriers, and financial distress. Future research and interventions on financial toxicity should be tailored for individual cancer groups, recognizing the differences in medical care utilization, which affect the experienced financial barriers.

Long-Term Healthcare Utilization and the Cost of Bipolar Disorder Among Participants in a Large Employer's Health Benefit Plan

OBJECTIVE

Bipolar disorder (BD) is a chronic illness with recurrent exacerbations. The objective was to evaluate longitudinal costs related to BD in an employer-sponsored medical plan.

METHODS

This analysis utilized 5 years of administrative claims data. Claimants with a diagnosis of BD were matched to plan members (1:5) based on age, sex, and years of follow-up.

RESULTS

Medical costs for hospitalized BD members were 3.5 times more expensive than the general population (BDhosp = $92.2K vs General population = $26.8K). Average 5-year paid costs among hospitalized members with BD was $107K, $105.4K with cancer, and $103.3K with myocardial infarction (MI).

CONCLUSIONS

Hospitalized BD plan members consumed more than 3.5 times the medical resources and were similar in longitudinal costs when compared with members with other costly conditions. These findings highlight the need for novel employer-sponsored programs to help manage BD.

Cost-Effectiveness of Nutrient Supplementation in Cancer Survivors

Cancer patients are at risk for malnutrition; the aim of this study was to provide a cost-effectiveness analysis of dietary supplementation in cancer survivors. We estimated prevalence of supplementation, hospitalization rates, quality of life (QOL), cost of care and mortality among cancer survivors. We built a decision analytic model to simulate life-long costs of health care and supplementation and QOL among cancer survivors with and without supplementation. Cost of supplements was derived from national pharmacy databases including single- and multivitamin formularies. One-way and probabilistic sensitivity analysis were performed to evaluate the robustness of the incremental cost-effectiveness ratio (ICER) to changes in supplementation costs and duration. The study cohort represented the national cancer survivor population (average age 61 years, 85% white, 52% male, and 94% insured). Hospitalization rates for supplement users and non-users were 12% and 21%, respectively. The cost of hospitalization was $4030. Supplementation was associated with an additional 0.48 QALYs (10.26 vs. 9.78) at the incremental cost of $2094 ($236,933 vs. $234,839) over the remaining lifetime of survivors (on average 13 years). Adequate nutrition provides a cost-effective strategy to achieving potentially optimum health. Further studies are needed to determine the effects of specific nutrient doses and supplementation on long-term outcomes per cancer type.

Strategies to Mitigate Chemotherapy and Radiation Toxicities That Affect Eating

Background: Cancer and its therapy is commonly associated with a variety of side effects that impact eating behaviors that reduce nutritional intake. This review will outline potential causes of chemotherapy and radiation damage as well as approaches for the amelioration of the side effects of cancer during therapy. Methods: Information for clinicians, patients, and their caregivers about toxicity mitigation including nausea reduction, damage to epithelial structures such as skin and mucosa, organ toxicity, and education is reviewed. Results: How to anticipate, reduce, and prevent some toxicities encountered during chemotherapy and radiation is detailed with the goal to improve eating behaviors. Strategies for health care professionals, caregivers, and patients to consider include (a) the reduction in nausea and vomiting, (b) decreasing damage to the mucosa, (c) avoiding a catabolic state and muscle wasting (sarcopenia), and (d) developing therapeutic alliances with patients, caregivers, and oncologists. Conclusions: Although the reduction of side effects involves anticipatory guidance and proactive team effort (e.g., forward observation, electronic interactions, patient reported outcomes), toxicity reduction can be satisfying for not only the patient, but everyone involved in cancer care.

Cost-effectiveness of physical activity interventions in cancer survivors of developed countries: a systematic review

PURPOSE

Physical activity has been shown to improve survival and quality of life of cancer patients. Due to differences in patient populations, healthcare settings, and types of intervention, cost-effectiveness analyses of physical activity interventions in cancer survivors are difficult to compare. Available evidence from breast cancer survivor research has shown inconsistent results, and transfer of results to other types of cancer is not straightforward. This paper systematically reviewed current evidence on the cost-effectiveness of physical activity interventions in cancer survivors independent of cancer type compared to usual care or another experimental intervention.

METHODS

The literature search was conducted in seven databases and enhanced by a search for gray literature. Eligible studies were restricted to developed countries and assessed using the CHEERS, CHEC, and PHILIPS checklists. The study protocol was pre-published in PROSPERO.

RESULTS

Seven studies, five cost-utility, and two combined cost-utility/cost-effectiveness analyses fully met the inclusion criteria. They covered eight different types of cancer and various interventions. The cost-effectiveness analyses were of moderate to high methodological quality. A high probability of cost-effectiveness was reported in two analyses. One intervention appeared to be not cost-effective, and one to be cost-effective only from an organizational perspective. Three other analyses reported a cost-effectiveness better than US$ 101,195 (€ 80,000) per QALY gained.

CONCLUSIONS

Physical activity interventions in cancer survivors of developed countries were cost-effective in some but not all clinical trials reviewed.

IMPLICATIONS FOR CANCER SURVIVORS

Cost-effectiveness of physical activity interventions appear to depend upon the intensity of the activity.

Pluralistic task shifting for a more timely cancer diagnosis. A grounded theory study from a primary care perspective

OBJECTIVE

To explore how cancer could be diagnosed in a more timely way.

DESIGN

Grounded theory analysis of primary care physicians' free text survey responses to: 'How do you think the speed of diagnosis of cancer in primary care could be improved?'. Secondary analysis of primary care physician interviews, survey responses, literature.

SETTING

Primary care in 20 European Örenäs Research Group countries.

SUBJECTS

Primary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015-2019).

MAIN OUTCOME MEASURES

Conceptual explanation of how to improve timeliness of cancer diagnosis.

RESULTS

Pluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing - among nurses, physicians, nurse assistants, secretaries, and patients - and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers, and clinicians. Financial task shifting that involves cost tracking followed by reallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early-stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late.

CONCLUSIONS

We present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis.Key pointsCancer diagnosis is under-researched in primary care, especially theoretically. Thus, inspired by classic grounded theory, we analysed and conceptualised the field:Pluralistic task shifting is a conceptual explanation of how the timeliness of cancer diagnosis could be improved, with data derived mostly from primary care physicians.This includes task sharing and changing tasks including screening and cancer fast-tracks to accelerate cancer case finding, and requires cognitive task shifting emphasising learning, and digital task shifting involving the use of eHealth and telemedicine.Financial task shifting with cost tracking and reallocation of funds is eventually necessary for successful pluralistic task shifting to happen.

Reduction in Standard Cancer Screening in 2020 throughout the U.S

Cancer screening is an important way to reduce the burden of cancer. The COVID-19 pandemic created delays in screening with the potential to increase cancer disparities in the United States (U.S.). Data from the 2014-2020 Behavioral Risk Factor Surveillance System (BRFSS) survey were analyzed to estimate the percentages of adults who reported cancer screening in the last 12 months consistent with the U.S. Preventive Services Task Force (USPSTF) recommendation for cervical (ages 21-65), breast (ages 50-74), and colorectal cancer (ages 50-75) prior to the pandemic. Cancer screening percentages for 2020 (April-December excluding January-March) were compared to screening percentages for 2014-2019 to begin to look at the impact of the COVID-19 pandemic. Screening percentages for 2020 were decreased from those for 2014-2019 including several underserved racial groups. Decreases in mammography and colonoscopy or sigmoidoscopy were higher among American Indian/Alaskan Natives, Hispanics, and multiracial participants, but decreases in pap test were also highest among Hispanics, Whites, Asians, and African-Americans/Blacks. Decreases in mammograms among women ages 40-49 were also seen. As the 2020 comparison is conservative, the 2021 decreases in cancer screening are expected to be much greater and are likely to increase cancer disparities substantially.

Health impacts of bike-sharing systems in the U.S

BACKGROUND

Bike-sharing systems (BSS) are short-term bike rentals that can be borrowed from one location and retired to another at the conclusion of the trip. In 2019, 109,589 BSS trips were made each day in the U.S, and half of those in New York City (NYC).

AIM

This study aims to quantify the health risks and benefits of BSS in the U.S. and NYC.

METHODS

This study followed a quantitative health impact assessment approach to estimate the risks and benefits of BSS. Specifically, we quantified the health impacts of physical activity, air pollution, and traffic incidents. We analyzed all the trips made by BSS in the U.S. and NYC. Input data on transport, traffic safety, air quality, and physical activity were collated from public records and scientific publications. We modeled the health impacts on adult users related to mortality, disease incidence, disability-adjusted life years (DALYs), and health economic impacts (related to morbidity and mortality).

RESULTS

We estimated that in the U.S. BSS trips resulted in an annual reduction of 4.7 premature deaths, 737 DALYs, and 36 million $USD in health economic impacts, mainly derived from the increment in physical activity. In NYC, we estimated an annual reduction of 2 premature deaths, 355 DALYs, and 15 million $USD in health economic impacts.

CONCLUSION

BSS in the U.S. and NYC provide a health benefit for bicyclists. Improvements in air quality and traffic safety across U.S. cities will maximize the health benefits of BSS.

Out-of-pocket costs in gastrointestinal cancer patients: Lack of a perfectly framed problem contributing to financial toxicity

Fighting cancer is an economically expensive challenge for both health care payers, and the patients and their families and the median costs for cancer care are rapidly increasing in the last decade. Although both direct and indirect costs of medical assistance have been a frequent source of distress and contention, however analysis of the non-medical expenses incurred directly by cancer patients has not received adequate attention. Developing a deeper understanding of so-called "out-of-pocket" costs may be necessary. Out-of-pocket costs for medical care range from 7 % to 11 % of medical costs for all payers. However, the range of out-of-pocket costs shows considerable variability in different studies. In this review, we reviewed available data concerning direct and indirect medical costs, including psychosocial ones.

Cancer prevalence by phase of care: an indicator for assessing health service needs

INTRODUCTION

Cancer prevalence (people alive on a certain date in a population who previously had a cancer diagnosis) is expected to increase in the United States and Europe due to improvements in survival and population aging. Examination of prevalence by phase of care allows us to identify subgroups of patients according to their care trajectories, thus allowing us to improve health care planning, resource allocation, and calculation of costs.

METHODS

A new method to estimate prevalence by phase of care using grouped data is illustrated. Prevalence is divided into 3 mutually exclusive phases: initial, continuing, and end-of-life. An application to US and Italian data is applied to prevalent cases diagnosed with colon-rectum, stomach, lung, or breast cancer.

RESULTS

The distribution of phase of care prevalence estimated by cancer type and sex and results from the two datasets are very similar. Most survivors are in the continuing phase; the end-of-life phase is larger for cancers with worse prognosis. All phases prevalence is generally higher in the Italian than in the US dataset, except for lung cancer in women, where prevalence proportion in the Italian dataset is 30% lower than in the United States.

DISCUSSION

Incidence, survival, and population age structure are the main determinants of prevalence and they can affect differences in all phases of prevalence, as well as in discrete phases. Incidence is the most influential determinant. Ours is the first study that compares prevalence by phase of care between two populations in Italy and the United States. Despite great differences in health care management in the two countries, we found extremely similar distribution of survivors by phase of care for most cancer sites under study.

[Current challenges in cancer care in Brussels-capital region: A qualitative study]

Cancer is a disease with multidimensional consequences accompanied by new challenges in order to guarantee optimal care involving physical, psychological and social consequences of the disease and his treatments. The objective of this study is to identify the main challenges encountered by different stakeholders around cancer, including patients, in Brussels. This qualitative study was carried out with various stakeholders in the field of oncology. The semi-structured interviews and focus groups were transcribed directly and the data collected was analysed manually. Healthcare professionals and patients face many challenges in the current context of oncology care. Communication difficulties can affect the therapeutic relationship and the sharing of complex information. The increasing complexity of therapeutic strategies complicates interprofessional collaborations and care coordination. In a context of early return home and home hospitalization in particular, continuity in care and collaboration between the different lines of care are crucial. Patients face a variety of challenges, such as managing long-term side effects and post-cancer difficulties, including redefining their social and professional identities. Finally, cancer involves financial toxicity and social inequalities in health are particularly marked. Cancer is a complex disease which management involves a growing number of caretakers. It is also frequently synonymous with disruption in the personal, social and professional life of patients. The emerging themes of this study are closely interconnected and communication seems to occupy a central place. A holistic approach to the individual and inter-professional interactions could guide future prospects for the overall management of this constantly changing field.

Associations of Household Income with Health-Related Quality of Life Following a Colorectal Cancer Diagnosis Varies With Neighborhood Socioeconomic Status

BACKGROUND

Existing evidence indicates household income as a predictor of health-related quality of life (HRQoL) following a colorectal cancer diagnosis. This association likely varies with neighborhood socioeconomic status (nSES), but evidence is limited.

METHODS

We included data from 1,355 colorectal cancer survivors participating in the population-based Puget Sound Colorectal Cancer Cohort (PSCCC). Survivors reported current annual household income; we measured HRQoL via the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) tool. Using neighborhood data summarized within a 1-km radial buffer of Census block group centroids, we constructed a multidimensional nSES index measure. We employed survivors' geocoded residential addresses to append nSES score for Census block group of residence. With linear generalized estimating equations clustered on survivor location, we evaluated associations of household income with differences in FACT-C mean score, overall and stratified by nSES. We used separate models to explore relationships for wellbeing subscales.

RESULTS

We found lower household income to be associated with clinically meaningful differences in overall FACT-C scores [<$30K: -13.6; 95% confidence interval (CI): -16.8 to -10.4] and subscale wellbeing after a recent colorectal cancer diagnosis. Relationships were slightly greater in magnitude for survivors living in lower SES neighborhoods.

CONCLUSIONS

Our findings suggest that recently diagnosed lower income colorectal cancer survivors are likely to report lower HRQoL, and modestly more so in lower SES neighborhoods.

IMPACT

The findings from this work will aid future investigators' ability to further consider the contexts in which the income of survivors can be leveraged as a means of improving HRQoL.

End-of-life cost trajectories and the trade-off between treatment costs and life-extension: Findings from the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cohort study

BACKGROUND

Few studies have assessed how patient preferences influence end-of-life costs.

AIM

To estimate mean monthly healthcare costs in 2019 Singapore Dollars (SGD) at five time points within the last year of life and identify how patients' preferences for the trade-off between treatment cost containment and life-extension and other factors affect these costs.

DESIGN

Mean monthly costs were quantified in the last 1, 3, 6, 9, and 12-months before death. Univariate and multivariate analyses were conducted.

SETTING/PARTICIPANTS

Billing records for 286 deceased participants in the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cancer cohort study in Singapore.

RESULTS

Mean monthly costs were $5140 (95% CI: $4750; $5520) in the 12-months before death and rose to $8350 (95% CI: $7110; $9590) 1-month before death. Participants preferring higher cost containment/less life-extension defied the trend of increasing costs closer to death (mean monthly costs of $4630 (95% CI: $3690; $ 5580) and $4850 (95% CI: $2850; $6850) (12-months and 1-month before death respectively). Participants preferring lower cost containment/more life-extension had costs that were $1050 (95% CI: $49; $2051) and $5220 (95% CI: $2320; $8130) higher than those preferring lower costs/less life-extension 12-months and 1-month before death respectively.

CONCLUSIONS

On average, cancer patients in Singapore can expect to spend $61,680 in the last year of life. Of broader relevance is that patient preferences and other observable factors clearly influence these costs, suggesting that policymakers and patients can better predict and budget for end-of-life costs by considering these factors.

Economic Burden of Cancer on Cancer Patients Treated at Hawassa University Comprehensive Specialized Hospital

Cancer causes the highest economic loss of all of the leading 15 causes of death worldwide. The economic loss includes the loss of income and the expenses associated with health care costs. The Low awareness of the community toward cancer, the inadequacy of professionals and service providers, and the high budget consuming nature of the treatments are creating a great burden on the cancer patients. The objective of this study was to calculate patient side cancer treatment cost and to assess the contributing factors, among the cancer patients who were treated at Hawassa University Comprehensive Specialized Hospital. The health facility based cross-sectional study design was employed using a consecutive sampling technique. Questionnaires was used to collect primary data; while chart was used to collect the secondary data. Indirect costs incurred on these patients due to off job days were checked. Descriptive and inferential statistics were applied to illustrate the data. On average, $209.99 was spent on treatment by each cancer patients. Of these, medication cost is the highest ($20.77, IQR = 0.53-112.56) from the direct medical costs, and transportation cost is the highest ($58.33, IQR = 22.0-131.67) from the indirect medical costs. Inpatients paid $245.16 (IQR = 147.64-439.20); while outpatients paid $147.37 (IQR = 81.42-240.50). The patients lose about 55.99% of their average annual income. Outpatients pay $0, 92 less than in patients (P = 0.00, CI -0.72-0.34), and the cost increases by $0.2 for the patients who came from Oromia. The cost of transportation and medication were the one which were significantly affecting the burden; but the total cost of treatment was lesser when compared to similar studies done in different areas. The cost balances toward the patients who came from the Oromiya region. Treatment service has to be extended to West Arsi Zone to minimize the cost of transportation and awareness about cancer is needed in the first place and due attention has to be given to thyroid cancer. Furthermore, facility side study should be done to see the complete picture of the burden.

The economic burden of cervical cancer in Eswatini: Societal perspective

Background

Cervical cancer imposes considerable economic burden on societies and individuals. There is lack of evidence regarding this from the developing world and particularly from sub-Saharan Africa. Therefore, the study aimed to estimate the societal costs of cervical cancer in Eswatini.

Materials and methods

The cost of illness study (CoI) was applied using national specific clinical and registry data from hospitals, registries and reports to determine the prevalence of cervical intraepithelial neoplasia (CIN) and cervical cancer in Eswatini in 2018. Cost data included direct medical costs (health care utilization in inpatient and outpatient care), direct non-medical costs (patient costs for traveling) and indirect costs based on productivity loss due to morbidity (patient time during diagnosis and treatment) and premature mortality.

Results

The estimated total annual cost for cervical cancer was $19 million (ranging between $14 million and $24 million estimated with lower and upper bounds). Direct cost represented the majority of the costs at 72% ($13.7 million) out of which total pre-cancerous treatment costs accounted for 0.7% ($94,161). The management of invasive cervical cancer was the main cost driver with costs attributable to treatment for FIGO III and FIGO IV representing $1.7 million and $8.7 million respectively. Indirect costs contributed 27% ($5.3 million) out of which productivity loss due to premature mortality represented the majority at 67% ($3.5 million).

Conclusion

The economic burden of cervical cancer in Eswatini is substantial. National public health prevention strategies with prophylactic HPV vaccine and screening for cervical lesions should therefore be prioritized to limit the extensive costs associated with cervical cancer.

Breast Cancer-Related Employment Disruption and Financial Hardship in the Sister Study

Background

More than one-half of breast cancer cases are diagnosed among women aged younger than 62 years, which may result in employment challenges. This study examined whether cancer-related employment disruption was associated with increased financial hardship in a national US study of women with breast cancer.

Methods

Women with breast cancer who were enrolled in the Sister or Two Sister Studies completed a survivorship survey in 2012. Employment disruption was defined as stopping work completely or working fewer hours after diagnosis. Financial hardship was defined as: 1) experiencing financial problems paying for cancer care, 2) borrowing money or incurring debt, or 3) filing for bankruptcy because of cancer. Prevalence ratios and 95% confidence intervals for the association between employment disruption and financial hardship were estimated using multivariable Poisson regression with robust variance.

Results

We analyzed data from women employed at diagnosis (n = 1628). Women were a median age of 48 years at diagnosis and 5.6 years from diagnosis at survey completion. Overall, 27.3% of women reported employment disruption (15.4% stopped working; 11.9% reduced hours), and 21.0% experienced financial hardship (16.0% had difficulty paying for care; 12.6% borrowed money or incurred debt; 1.8% filed for bankruptcy). In adjusted analysis, employment disruption was associated with nearly twice the prevalence of financial hardship (prevalence ratio = 1.93, 95% confidence interval = 1.58 to 2.35).

Conclusions

Women experiencing employment disruptions after breast cancer may be more vulnerable to financial hardship. Findings highlight the need to target risk factors for employment disruption, facilitate return to work or ongoing employment, and mitigate financial consequences after cancer.

Health care costs of breast, prostate, colorectal and lung cancer care by clinical stage and cost component

OBJECTIVE

To measure 3-year care costs of breast, prostate, colorectal and lung cancers disaggregated by site and clinical stage.

METHOD

A retrospective observational design was employed to investigate care costs of cases recorded in the Registry of the Basque Country between 2010 and 2015. Data gathered included TNM stage and demographic, clinical and resource use variables. Total costs per patient with stage IV disease were calculated by combining generalized linear models with parametric survival analysis. Unit costs were obtained from the analytical accounting system of the Basque Health Service.

RESULTS

The sample comprised 23,782 cancer cases (7801 colorectal, 5530 breast, 4802 prostate and 5649 lung cancer). The mean 3-year costs per patient with stage I to III disease were €11,323, €13,727, €8,651 and €12,023 for colorectal, breast, prostate and lung cancer, respectively. The most important cost components were surgery and chemotherapy. Total survival-adjusted costs until death for patients with stage IV disease (€27,568, €26,296, €16,151 and €15,931 for breast, colorectal, lung and prostate cancer, respectively) were higher than the 3-year costs for those with earlier-stage disease.

CONCLUSIONS

This study quantitatively shows the pattern of changes in the economic burden of cancer throughout its natural history and the great magnitude of this burden for the health system. The use of indicators based on real-world data from each regional health service would allow cancer care in each region to be tailored to local population needs.

Developing a Value Framework: Utilizing Administrative Data to Assess an Enhanced Care Initiative

BACKGROUND

There remains no tool to quantify the total value of comparative processes in health care. Hospital administrative data sets are emerging as valuable sources to evaluate performance. Thus, we use a framework to simultaneously assess multiple domains of value associated with an enhanced recovery initiative using national administrative data.

MATERIALS AND METHODS

Risk-stratified clinical pathways for patients undergoing pancreatic surgery were implemented in 2016 at our institution. We used a national administrative database to characterize changes in value associated with this initiative. Value metrics assessed included in-hospital mortality, complication rates, length of stay (LOS), 30-day readmission rates, and institutional costs. We compared our performance with other hospitals both before and after implementation of the pathways. Metrics were graphed on radar charts to assess overall value.

RESULTS

22,660 cases were assessed. Comparing 75 cases at our institution and 5520 cases at all other hospitals before pathway implementation, mean in-hospital LOS was 9.6 versus 10.8 d, in-hospital mortality was 0.0% versus 1.9%, mean costs were $23,585 versus $21,387, 30-day readmission rates were 1.3% versus 7.4%, and complication rates were 8.0% versus 11.2%, respectively. Comparing 334 cases at our institution and 16,731 cases at all other hospitals after pathway implementation, mean in-hospital LOS was 7.7 versus 10.3 d, in-hospital mortality was 0.3% versus 1.6%, mean costs were $19,428 versus $22,032, 30-day readmission rates were 6.6% versus 7.5%, and complication rates were 6.3% versus 10.3%, respectively. Notably, LOS and institutional costs were reduced at our institution after implementation of the enhanced clinical care pathways. Our costs were higher than comparators before implementation, but lower than comparators after implementation.

CONCLUSIONS

Herein, we used an analytic framework and used national administrative data to assess the value of an enhanced care initiative as benchmarked with data from other hospitals. We thus illustrate how to identify and measure opportunities for targeted improvements in health care delivery. We also recognize the limitations of the use of administrative data in a comprehensive assessment of value in health care.

COVID-19 and financial toxicity in patients with renal cell carcinoma

Purpose

To ascertain renal cell carcinoma (RCC) financial toxicity on COVID-19 during the COVID-19 crisis as patients are struggling with therapeutic and financial implications.

Methods

An online survey was conducted from March 22 to March 25, 2020. It included baseline demographic, clinicopathologic, treatment-related information, anxiety levels related to COVID-19, questions related to financial concerns about COVID-19 as well as the validated 11-item COST measure.

Results

Five-hundred-and-thirty-nine patients (39%:58% male:female) from 14 countries responded. 23% of the patients did not feel in control of their financial situation but 8% reported being very satisfied with their finances. The median COST score was 21.5 (range 1–44). Metastatic patients who have not started systemic therapy had a COST score (19.8 range 2–41) versus patients on oral systemic therapy had a COST score (23.9 range 4–44). Patients in follow-up after surgery had a median COST score at 20.8 (range 1–40). A low COST scores correlated (p < 0.001) were female gender (r = 0.108), younger age (r = 0.210), urban living situation (r = 0.68), a lower educational level (r = 0.155), lower income (r = 0.165), higher anxiety about acquiring COVID-19 (r = 0.198), having metastatic disease (r = 0.073) and a higher distress score about cancer progression (r = 0.224).

Conclusion

Our data highlight severe financial impact of COVID-19. Acknowledging financial hardship and thorough counseling of cancer patients should be part of the conversation during the pandemic. Treatment and surveillance of RCC patients might have to be adjusted to contemplate financial and medical needs.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03476-6) contains supplementary material, which is available to authorized users.

Telemedicine in Oncology and Reimbursement Policy During COVID-19 and Beyond

The first confirmed case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 20, 2020. As of September 17, 2020, there were more than 6.6 million confirmed cases and 196,277 deaths. Limited data are available on outcomes of immunocompromised patients, but early published reports from China indicate that those with cancer have a 3.5 times higher risk of ICU admission, mechanical ventilation, or death than those without cancer. Because of the uncertain behavior of COVID-19, it has become imperative for practices to limit exposure to vulnerable patients. Telemedicine has been one of the cornerstones of caring for patients with cancer during the COVID-19 pandemic. This review provides an overview of reimbursement policy by public and private payers before and during the COVID-19 pandemic, describes implications in cancer care, and offers considerations for future reimbursement policy.