Projections of the costs associated with colorectal cancer care in the United States, 2000-2020

Promoting physical activity through supervised vs motivational behavior change interventions in breast cancer survivors on aromatase inhibitors (PAC-WOMAN): protocol for a 3-arm pragmatic randomized controlled trial

BACKGROUND

Aromatase inhibitors (AI) are frequently used to treat hormone-receptor-positive breast cancer, but they have multiple adverse effects (e.g., osteoporosis, arthralgia), resulting in premature therapy discontinuation/switch. Physical activity (PA) can attenuate these negative effects and improve quality of life (QoL). However, most cancer survivors fail to perform/sustain adequate PA levels, especially in the long-term. Theory-based interventions, using evidence-based behavior change techniques, aimed at promoting long-term behavior change in breast cancer survivors are effective, but remain scarce and fail to promote self-regulatory skills and better-quality motivations associated with sustained PA adoption. This paper describes the design of the PAC-WOMAN trial, which will test the long-term effectiveness and cost-effectiveness of two state of the art, group-based interventions encouraging sustained changes in PA, sedentary behavior, and QoL. Additional aims include examining the impact of both interventions on secondary outcomes (e.g., body composition, physical function), and key moderators/mediators of short and long-term changes in primary outcomes.

METHODS

A 3-arm pragmatic randomized controlled trial, involving a 4-month intervention and a 12-month follow-up, will be implemented, in a real exercise setting, to compare: 1) brief PA counseling/motivational intervention; 2) structured exercise program vs. waiting-list control group. Study recruitment goal is 122 hormone-receptor-positive breast cancer survivors (stage I-III), on AI therapy (post-primary treatment completion) ≥ 1 month, ECOG 0-1. Outcome measures will be obtained at baseline, 4 months (i.e., post-intervention), 10 and 16 months. Process evaluation, analyzing implementation determinants, will also be conducted.

DISCUSSION

PAC-WOMAN is expected to have a relevant impact on participants PA and QoL and provide insights for the improvement of interventions designed to promote sustained adherence to active lifestyle behaviors, facilitating its translation to community settings.

TRIAL REGISTRATION

April 20, 2023 - NCT05860621. April 21, 2023 - https://doi.org/10.17605/OSF.IO/ZAQ9N April 27, 2023 - UMIN000050945.

Trends in cost of treatment of lung cancer patients in 2014-2019 in Finland - a descriptive register study

AIM

The aim of this descriptive study is to analyze the cost for the treatment of NSCLC and SCLC patients (2014-2019) in Finland. The primary objective is to understand recent (2014-2019) cost developments.

METHODS

The study is retrospective and based on hospital register data. The study population consists of NSCLC and SCLC patients diagnosed in four out of the five Finnish university hospitals. The final sample included 4047 NSCLC patients and 766 SCLC patients.

RESULTS

Cost of the treatment in lung cancer is increasing. Both the average cost of the first 12 months as well as the first 24 months after diagnosis increases over time. For patients diagnosed in 2014, the average cost of the first 24 months was 19,000 €and for those diagnosed in 2015 22,000 €. The annual increase in the nominal 24-month costs was 10.4% for NSCLC and 7.3% for SCLC patients.

CONCLUSION

The average cost per patient has increased annually for both NSCLC and SCLC. Possible explanations to the cost increase are increased medicine costs (especially in NSCLC), and the increased percentage of patients being actively treated.

An economic evaluation of reducing colorectal cancer surveillance intensity

Aim: Analyze the impact of national implementation of 'low intensity' post-treatment colorectal cancer surveillance compared with current practices. Materials & methods: Create a population-level Markov model to estimate impacts of expansion of low versus high intensity surveillance post-treatment on healthcare utilization, costs and caregiver time loss. Results: Shifting to low intensity colorectal cancer surveillance would reduce patient burden by 301,830 h per patient annually over 5 years. Cost reductions over 5 years were US$43.5 million for Medicare and US$4.2 million for Medicaid. Total societal cost savings equaled US$104.2 million. Conclusion: National implementation of low intensity post-treatment colorectal cancer surveillance has the potential to significantly reduce burden and costs on patients and their caregivers with no added risks to health.

Medical Service Use and Charges for Cancer Care in 2018 for Privately Insured Patients Younger Than 65 Years in the US

IMPORTANCE

Currently, there are limited published data regarding resource use and spending on cancer care in the US.

OBJECTIVE

To characterize the most frequent medical services provided and the associated spending for privately insured patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the MarketScan database for the calendar year 2018 from a sample of 27.1 million privately insured individuals, including patients with a diagnosis of the 15 most prevalent cancers, predominantly from large insurers and self-insured employers. Overall societal health care spending was estimated for each cancer type by multiplying the mean total spending per patient (estimated from MarketScan) by the number of privately insured patients living with that cancer in 2018, as reported by the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Analyses were performed from February 1, 2018, to July 8, 2021.

EXPOSURES

Evaluation and management as prescribed by treating care team.

MAIN OUTCOMES AND MEASURES

Current Procedural Terminology and Healthcare Common Procedure Coding System codes based on cancer diagnosis code.

RESULTS

The estimated cost of cancer care in 2018 for 402 115 patients with the 15 most prevalent cancer types was approximately $156.2 billion for privately insured adults younger than 65 years in the US. There were a total of 38.4 million documented procedure codes for 15 cancers in the MarketScan database, totaling $10.8 billion. Patients with breast cancer contributed the greatest total number of services (10.9 million [28.4%]), followed by those with colorectal cancer (3.9 million [10.2%]) and prostate cancer (3.6 million [9.4%]). Pathology and laboratory tests contributed the highest number of services performed (11.7 million [30.5%]), followed by medical services (6.3 million [16.4%]) and medical supplies and nonphysician services (6.1 million [15.9%]). The costliest cancers were those of the breast ($3.4 billion [31.5%]), followed by lung ($1.1 billion [10.2%]) and colorectum ($1.1 billion [10.2%]). Medical supplies and nonphysician services contributed the highest total spent ($4.0 billion [37.0%]), followed by radiology ($2.1 billion [19.4%]) and surgery ($1.8 billion [16.7%]).

CONCLUSIONS AND RELEVANCE

This analysis suggests that patients with breast, colorectal, and prostate cancers had the greatest number of services performed, particularly for pathology and laboratory tests, whereas patients with breast, lung, lymphoma, and colorectal cancer incurred the greatest costs, particularly for medical supplies and nonphysician services. The cost of cancer care in 2018 for the 15 most prevalent cancer types was estimated to be approximately $156.2 billion for privately insured adults younger than 65 years in the US.

Cancer-Attributable Medical Costs for Colorectal Cancer Patients by Phases of Care: What Is the Effect of a Prior Cancer History?

Medical care costing studies have excluded patients with a prior cancer history. This study aims to update methods for estimating medical care costs attributable to cancer and to evaluate the effect of a prior history of cancer on costs for colorectal cancer (CRC) patients. We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data and matched cancer patients to controls without cancer to estimate cancer-attributable costs by phases of care using Medicare 2007-2013 claims. CRC annualized average cancer-attributable costs were $56.0 K, $5.3 K, $92.5 K, and $24.3 K in the initial, continuing, and end-of-life cancer and noncancer death phases, respectively, in 2014 dollars. Costs were higher for patients diagnosed with more advanced stage, younger ages, and nonwhite races. Costs for patients with prior cancers were consistently higher than patients without prior cancers, especially in the continuing (4.9 K vs 7.2 K) and end-of-life noncancer death (22.7 K vs 30.0 K). Our CRC costs improve previous estimates by using more recent data and updated methods.

Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System

INTRODUCTION

Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs.

MATERIALS AND METHODS

Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics.

RESULTS

The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment.

CONCLUSIONS

In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

Return on Investment of Free Colorectal Cancer Screening Tests in a Primarily Rural Uninsured or Underinsured Population in Northeast Texas

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in the USA. Its economic impact is extensive, and preventive screening services are warranted to help prevent it.

OBJECTIVE

We sought to examine the return on investment, in terms of reduced costs attributed to cancer prevention, of a CRC screening outreach program providing education and screening in a primarily rural region targeting the uninsured and underinsured.

METHODS

The expenditures of the Northeast Texas CRC screening program were calculated for the years of 2016 and 2017. Prices ($US) were adjusted for inflation and converted to year 2017 values. The costs saved were calculated using the estimated costs of CRC care present in the literature.

RESULTS

For fiscal years 2016 and 2017, the program provided an average return of $US1.46-2.06 for every tax dollar spent. Estimated cost avoidance was $US165,080 per avoided case and estimated cost avoidance of $US245,601 among early-stage cancer cases detected, resulting in potential savings ranging from $US3,893,676 to $US4,837,923.

CONCLUSION

A CRC outreach program providing education and screening operating in less densely populated regions yields a positive return on investment.

Pancreatic cancer treatment costs, including patient liability, by phase of care and treatment modality, 2000-2013

OBJECTIVES

Our study provides phase-specific cost estimates for pancreatic cancer based on stage and treatment. We compare treatment costs between the different phases and within the stage and treatment modality subgroups.

METHODS

Our cohort included 20,917 pancreatic cancer patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed between 2000 and 2011. We allocated costs into four phases of care-staging (or surgery), initial, continuing, and terminal- and calculated the total, cancer-attributable, and patient-liability costs in 2018 US dollars. We fit linear regression models using log transformation to determine whether costs were predicted by age and calendar year.

RESULTS

Monthly cost estimates were high during the staging and surgery phases, decreased over the initial and continuing phases, and increased during the three-month terminal phase. Overall, the linear regression models showed that cancer-attributable costs either remained stable or increased by year, and either were unaffected by age or decreased with older age; continuing phase costs for stage II patients increased with age.

CONCLUSIONS

Our estimates demonstrate that pancreatic cancer costs can vary widely by stage and treatment received. These cost estimates can serve as an important baseline foundation to guide resource allocation for cancer care and research in the future.

Assessing adherence and cost-benefit of colorectal cancer screening for accountable providers

The objective of this study was to assess adherence and costs-benefits of colorectal cancer (CRC) screenings from an accountable care organization/population health perspective. We performed a retrospective review of 94 patients (50-75 years of age) in an integrated safety net system for whom fecal CRC screening was abnormal for the period of June 1, 2014, to June 1, 2016. A cost-benefit model was constructed using Medicare payment rates and a sensitivity analysis. Most patients included in the study (64/94, 68%) received or were offered a colonoscopy. Of those receiving a colonoscopy, 24 of 45 (53%) had an abnormal finding. Total direct medical costs avoided by screening the patient panel was $32,926 but could have exceeded $63,237 had more patients received follow-up colonoscopies. A sensitivity analysis with 1000 patients demonstrated total monetary benefits between $2.2 million and $8.16 million when follow-up and colonoscopy rates were allowed to vary. Although the resulting rates of follow-up were within the range reported in the literature, there is room for improvement, especially considering the monetary benefit that could be used on other diseases. Health systems and payers should work cooperatively to structure payment models to better incentivize CRC screenings.

Cost-Effectiveness of Colorectal Cancer Screening Strategies-A Systematic Review

BACKGROUND & AIMS

Widespread screening for colorectal cancer (CRC) has reduced its incidence and mortality. Previous studies investigated the economic effects of CRC screening. We performed a systematic review to provide up-to-date evidence of the cost effectiveness of CRC screening strategies by answering 3 research questions.

METHODS

We searched PubMed, National Institute for Health Research Economic Evaluation Database, Social Sciences Citation Index (via the Web of Science), EconLit (American Economic Association) and 3 supplemental databases for original articles published in English from January 2010 through December 2017. All monetary values were converted to US dollars (year 2016). For all research questions, we extracted, or calculated (if necessary), per-person costs and life years (LYs) and/or quality-adjusted LYs, as well as the incremental costs per LY gained or quality-adjusted LY gained compared with the baseline strategy. A cost-saving strategy was defined as one that was less costly and equally or more effective than the baseline strategy. The net monetary benefit approach was used to answer research question 2.

RESULTS

Our review comprised 33 studies (17 from Europe, 11 from North America, 4 from Asia, and 1 from Australia). Annual and biennial guaiac-based fecal occult blood tests, annual and biennial fecal immunochemical tests, colonoscopy every 10 years, and flexible sigmoidoscopy every 5 years were cost effective (even cost saving in most US models) compared to no screening. In addition, colonoscopy every 10 years was less costly and/or more effective than other common strategies in the United States. Newer strategies such as computed tomographic colonography, every 5 or 10 years, was cost effective compared with no screening.

CONCLUSIONS

In an updated review, we found that common CRC screening strategies and computed tomographic colonography continued to be cost effective compared to no screening. There were discrepancies among studies from different regions, which could be associated with the model types or model assumptions.

The Economic Burden of Breast Cancer Survivors in Korea: A Descriptive Study Using a 26-Month Micro-Costing Cohort Approach

Background:

This study analyzed the burden of cancer treatment costs on patients by calculating the monthly amount of medical expenses paid by breast cancer patients for two years after mastectomy.

Methods:

Among those who were diagnosed with breast cancer and had received treatment at one of two academic medical centers in Seoul between 2003 and 2011, 1,087 patients who underwent mastectomy and received follow-up for at least two years were recruited. A micro-costing approach from the provider’s perspective, based on a retrospective review of patient medical claim records, was used to analyze cancer treatment cost of care. The cohort’s number of hospitalizations, total hospitalization duration, and number of outpatient visits were noted, and the total amount of medical expenses, out-of-pocket (OOP) expenditures, uninsured costs, and OOP ratio were calculated.

Results:

The total amount of medical expenses tended to increase by year, whereas the OOP expenditure ratio decreased. The OOP expenditure ratio was highest in the first month post-operation. Around one quarter of the total OOP payments incurred over the course of three months: one month before the operation, the month of the operation, and one month post-operation.

Conclusion:

OOP payment burden on patients was concentrated in the initial phase of treatment, and items not covered by the National Health Insurance caused an additional increase in patients’ burden in the initial phase. The economic burden of cancer treatment varies considerably. In order to alleviate patients’ medical expenses burden, the timing of expenditures and the possible financial burden on cancer survivors, they should be understood more fully and possibly addressed in interventions aimed at reducing the cancer burden.

Cost of benign versus oncologic colon resection among fee-for-service Medicare enrollees

BACKGROUND AND OBJECTIVES

Reimbursement for colonic pathology by the Centers for Medicare and Medicaid Services (CMS) are grouped in the Medicare Severity-Diagnosis Related Groups (MS-DRG). With limited available data, we sought to compare the relative impact of malignant vs benign colonic pathology on reimbursement under the MS-DRG system.

METHODS

We used 5% national Medicare data from 2011 to 2014. Patients were classified as having benign disease or malignancy. Descriptive statistics and multivariate regression analysis were used to evaluate the surgical approach and health resource utilization.

RESULTS

Of 10 928 patients, most were Non-Hispanic White women. The majority underwent open colectomy in both cohorts (P < .001). Colectomy for benign disease was associated with higher total charges (P < .001) and a longer length of stay (P = .0002). Despite higher charges, payments were not significantly different between the cohorts (P = .434). Both inpatient mortality and discharge to a rehab facility were higher in the oncologic group (P < .001).

CONCLUSION

Payment methodology for colectomy under the CMS MS-DRG system does not appear to accurately reflect the episode cost of care. The data suggest that inpatient costs are not fully compensated. A transition to value-based payments with expanded episode duration will require a better understanding of unique costs before adoption.

The New Frontier: the Intestinal Microbiome and Surgery

The microbiome exerts a remarkable effect on human physiology. The study of the human-microbiome relationship is a burgeoning field with great potential to improve our understanding of health and disease. In this review, we address common surgical problems influenced by the human microbiome and explore what is thus far known about this relationship. These include inflammatory bowel disease, colorectal neoplasms, and diverticular disease. We will also discuss the effect of the microbiome on surgical complications, specifically anastomotic leak. We hope that further research in this field will enlighten our management of these and other surgical problems.

Semiparametric Estimation of Longitudinal Medical Cost Trajectory

Estimating the average monthly medical costs from disease diagnosis to a terminal event such as death for an incident cohort of patients is a topic of immense interest to researchers in health policy and health economics because patterns of average monthly costs over time reveal how medical costs vary across phases of care. The statistical challenges to estimating monthly medical costs longitudinally are multifold; the longitudinal cost trajectory (formed by plotting the average monthly costs from diagnosis to the terminal event) is likely to be nonlinear, with its shape depending on the time of the terminal event, which can be subject to right censoring. The goal of this paper is to tackle this statistically challenging topic by estimating the conditional mean cost at any month t given the time of the terminal event s. The longitudinal cost trajectories with different terminal event times form a bivariate surface of t and s, under the constraint t ≤ s. We propose to estimate this surface using bivariate penalized splines in an Expectation-Maximization algorithm that treats the censored terminal event times as missing data. We evaluate the proposed model and estimation method in simulations and apply the method to the medical cost data of an incident cohort of stage IV breast cancer patients from the Surveillance, Epidemiology and End Results-Medicare Linked Database.

Cost-effectiveness of low-dose CT screening for lung cancer in a European country with high prevalence of smoking-A modelling study

OBJECTIVES

In Europe, there is uncertainty about the potential effects and cost-effectiveness of low dose computed tomography screening for lung cancer and about the applicability of results of North American studies. We aimed to estimate the effects and cost-effectiveness of lung cancer screening in a population-based setting in Switzerland where the smoking prevalence is high.

MATERIALS AND METHODS

The MIcrosimulation Screening ANalysis-Lung (MISCAN) model was adapted using country specific input parameters regarding lung cancer epidemiology, smoking behaviours, and treatment costs. The effects and costs of 648 screening scenarios with different screening start and stop ages, smoking eligibility criteria, and screening intervals were examined from a public healthcare system perspective across a lifetime horizon in a cohort born between 1935 and 1965.

RESULTS

All screening scenarios showed an increase in the total number of detected lung cancer cases and a decrease in lung cancer mortality. On the efficiency frontier, 15 of 27 scenarios showed incremental cost-effectiveness ratios below € 50,000 per life year gained. These scenarios reduced lung cancer mortality by 6-15% while increasing incidence of lung cancer diagnoses by 2-6%.

CONCLUSION

These results suggest that lung cancer screening may be cost-effective in Switzerland, a high-income, European country with high smoking prevalence.

Comparison of claims data on hospitalization rates and repeat procedures in patients receiving a bowel preparation prior to colonoscopy

OBJECTIVES

To evaluate outcomes of colorectal screening using sodium picosulfate and magnesium citrate compared with other prescription bowel-preparation agents. Primary endpoints were rates of procedure-associated hospitalizations, diagnosis at hospitalization, and rates of early repeat screenings.

METHODS

This retrospective cohort study identified patients using the Truven Health Analytics MarketScan databases, which contain fully adjudicated, de-identified, medical- and prescription-drug claims, as well as demographic and enrollment information for individuals with commercial, Medicaid, and Medicare supplemental insurance coverage. Patients who had a colonoscopy or sigmoidoscopy over a 3-year period were identified using International Classification of Diseases Clinical Modification procedure codes, recorded on claims from physicians and facilities. First, screening colonoscopy was identified for each patient, and the study was limited to those patients who could be observed for ≥6 months before and 3 months after the screening procedure. Total number of hospitalizations and rates of early repeat screenings were evaluated for all patients who received sodium picosulfate and magnesium citrate and compared with those who received other bowel-preparation agents. Individual prescription medications that could affect the outcome of the cleansing agent were identified; further evaluations were made to establish whether patients had comorbid conditions, such as chronic kidney disease, cardiovascular disease, or psychiatric illness. Statistical methods included descriptive statistics, two-tailed t-tests, and multivariate logistic regression.

RESULTS

A total of 566,628 procedures were identified in the MarketScan databases and included in the study. Sodium picosulfate and magnesium citrate performed well in terms of safety outcomes, with no hospitalizations due to diagnosis of hyponatremia, dehydration, or other fluid disorders in the 10 days after procedure. Early repeat rates among sodium picosulfate and magnesium citrate patients were comparable with rates observed for all other cleansing agents.

CONCLUSION

Outcomes of colorectal screening using sodium picosulfate and magnesium citrate were not significantly different compared with other prescription bowel-preparation agents.

Defining payments associated with the treatment of colorectal cancer

BACKGROUND

While bundled payments aim to reduce variations in health care spending across the continuum of care, data reporting on variations in payments for privately insured patients undergoing treatment for colon cancer (CC) are lacking. The current study sought to characterize variations in payments received for the treatment of CC using a cohort of commercially insured patients.

METHODS

Patients who underwent a colectomy for CC were identified using the MarketScan Database for 2010-2014. Multivariable regression analysis was used to calculate and compare risk-adjusted payments between patients.

RESULTS

A total of 18,337 patients were identified who met inclusion criteria. The median risk-adjusted payment for surgery was $26,408 (IQR: $19,193-$38,037) ranging from $19,762 (IQR: $15,595-$25,636) among patients in the lowest quartile of payments to $33,809 (IQR: $24,783-$48,254) for patients in the highest (+△71.1%). The median risk-adjusted payment for chemotherapy was $70,090 (IQR: $57,813-$83,216); compared with patients in the lowest quartile of payments, payments associated with chemotherapy were 40.4% higher among patients in the highest quartile of payments (Q1 versus Q4: $56,827 [IQR: 49,173-65,353] versus $79,801 [IQR: 67,270-90,999]). When stratified by treatment type, patients in the highest two quartiles of risk-adjusted payments accounted for a total of 58.5% of all payments, whereas patients in the lower two quartiles of risk-adjusted payments accounted for only 41.5% of all payments. A younger patient age, increasing patient comorbidity and undergoing an open operation were associated with higher overall payments.

CONCLUSIONS

Wide variations in payments exist for the treatment for colon cancer. Episode-based bundle payments for surgery and chemotherapy may differentially impact reimbursement for CC.

Years of Life and Productivity Loss from Potentially Avoidable Colorectal Cancer Deaths in U.S. Counties with Lower Educational Attainment (2008-2012)

Background: Educational attainment (EA) is inversely associated with colorectal cancer risk. Colorectal cancer screening can save lives if precancerous polyps or early cancers are found and successfully treated. This study aims to estimate the potential productivity loss (PPL) and associated avoidable colorectal cancer-related deaths among screen-eligible adults residing in lower EA counties in the United States.Methods: Mortality and population data were used to examine colorectal cancer deaths (2008-2012) among adults aged 50 to 74 years in lower EA counties, and to estimate the expected number of deaths using the mortality experience from high EA counties. Excess deaths (observed-expected) were used to estimate potential years life lost, and the human capital method was used to estimate PPL in 2012 U.S. dollars.Results: County-level colorectal cancer death rates were inversely associated with county-level EA. Of the 100,857 colorectal cancer deaths in lower EA counties, we estimated that more than 21,000 (1 in 5) was potentially avoidable and resulted in nearly $2 billion annual productivity loss.Conclusions: County-level EA disparities contribute to a large number of potentially avoidable colorectal cancer-related deaths. Increased prevention and improved screening potentially could decrease deaths and help reduce the associated economic burden in lower EA communities. Increased screening could further reduce deaths in all EA groups.Impact: These results estimate the large economic impact of potentially avoidable colorectal cancer-related deaths in economically disadvantaged communities, as measured by lower EA. Cancer Epidemiol Biomarkers Prev; 26(5); 736-42. ©2016 AACR.

Performance and Cost-Effectiveness of Computed Tomography Lung Cancer Screening Scenarios in a Population-Based Setting: A Microsimulation Modeling Analysis in Ontario, Canada

BACKGROUND

The National Lung Screening Trial (NLST) results indicate that computed tomography (CT) lung cancer screening for current and former smokers with three annual screens can be cost-effective in a trial setting. However, the cost-effectiveness in a population-based setting with >3 screening rounds is uncertain. Therefore, the objective of this study was to estimate the cost-effectiveness of lung cancer screening in a population-based setting in Ontario, Canada, and evaluate the effects of screening eligibility criteria.

METHODS AND FINDINGS

This study used microsimulation modeling informed by various data sources, including the Ontario Health Insurance Plan (OHIP), Ontario Cancer Registry, smoking behavior surveys, and the NLST. Persons, born between 1940 and 1969, were examined from a third-party health care payer perspective across a lifetime horizon. Starting in 2015, 576 CT screening scenarios were examined, varying by age to start and end screening, smoking eligibility criteria, and screening interval. Among the examined outcome measures were lung cancer deaths averted, life-years gained, percentage ever screened, costs (in 2015 Canadian dollars), and overdiagnosis. The results of the base-case analysis indicated that annual screening was more cost-effective than biennial screening. Scenarios with eligibility criteria that required as few as 20 pack-years were dominated by scenarios that required higher numbers of accumulated pack-years. In general, scenarios that applied stringent smoking eligibility criteria (i.e., requiring higher levels of accumulated smoking exposure) were more cost-effective than scenarios with less stringent smoking eligibility criteria, with modest differences in life-years gained. Annual screening between ages 55-75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago yielded an incremental cost-effectiveness ratio of $41,136 Canadian dollars ($33,825 in May 1, 2015, United States dollars) per life-year gained (compared to annual screening between ages 60-75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago), which was considered optimal at a cost-effectiveness threshold of $50,000 Canadian dollars ($41,114 May 1, 2015, US dollars). If 50% lower or higher attributable costs were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $38,240 ($31,444 May 1, 2015, US dollars) or $48,525 ($39,901 May 1, 2015, US dollars), respectively. If 50% lower or higher costs for CT examinations were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $28,630 ($23,542 May 1, 2015, US dollars) or $73,507 ($60,443 May 1, 2015, US dollars), respectively. This scenario would screen 9.56% (499,261 individuals) of the total population (ever- and never-smokers) at least once, which would require 4,788,523 CT examinations, and reduce lung cancer mortality in the total population by 9.05% (preventing 13,108 lung cancer deaths), while 12.53% of screen-detected cancers would be overdiagnosed (4,282 overdiagnosed cases). Sensitivity analyses indicated that the overall results were most sensitive to variations in CT examination costs. Quality of life was not incorporated in the analyses, and assumptions for follow-up procedures were based on data from the NLST, which may not be generalizable to a population-based setting.

CONCLUSIONS

Lung cancer screening with stringent smoking eligibility criteria can be cost-effective in a population-based setting.

Human Blood Autoantibodies in the Detection of Colorectal Cancer

Colorectal cancer (CRC) is the second most common malignancy in the western world. Early detection and diagnosis of all cancer types is vital to improved prognosis by enabling early treatment when tumours should be both resectable and curable. Sera from 3 different cohorts; 42 sera (21 CRC and 21 matched controls) from New York, USA, 200 sera from Pittsburgh, USA (100 CRC and 100 controls) and 20 sera from Dundee, UK (10 CRC and 10 controls) were tested against a panel of multiple tumour-associated antigens (TAAs) using an optimised multiplex microarray system. TAA specific IgG responses were interpolated against the internal IgG standard curve for each sample. Individual TAA specific responses were examined in each cohort to determine cutoffs for a robust initial scoring method to establish sensitivity and specificity. Sensitivity and specificity of combinations of TAAs provided good discrimination between cancer-positive and normal serum. The overall sensitivity and specificity of the sample sets tested against a panel of 32 TAAs were 61.1% and 80.9% respectively for 6 antigens; p53, AFP, K RAS, Annexin, RAF1 and NY-CO16. Furthermore, the observed sensitivity in Pittsburgh sample set in different clinical stages of CRC; stage I (n = 19), stage II (n = 40), stage III (n = 34) and stage IV (n = 6) was similar (73.6%, 75.0%, 73.5% and 83.3%, respectively), with similar levels of sensitivity for right and left sided CRC. We identified an antigen panel of sufficient sensitivity and specificity for early detection of CRC, based upon serum profiling of autoantibody response using a robust multiplex antigen microarray technology. This opens the possibility of a blood test for screening and detection of early colorectal cancer. However this panel will require further validation studies before they can be proposed for clinical practice.

Cost Analysis of Free Colonoscopies in an Uninsured Population at Increased Risk for Colorectal Cancer

BACKGROUND

Uninsured patients have poor access to screening colonoscopy and subsequently present with advanced stages of colorectal cancer (CRC) that beget worse outcomes and higher total costs. Providing pro bono colonoscopies to uninsured patients at high risk for CRC can detect early stage disease and be cost-effective.

STUDY DESIGN

Patients considered at increased risk for CRC were offered free screening colonoscopies. Patient data from these colonoscopies were collected during a 12-month period, and the incidence of CRC was compared with a control group of uninsured patients from the Surveillance, Epidemiology, and End Results (SEER) registry. Published estimates derived from SEER Medicare data of health expenditures by CRC stage were used to develop a cost model. To compare overall costs between our cohort and the SEER control, the mean initial cost of care (up to 1 year) was weighted by the stage-specific CRC incidence in each group.

RESULTS

There were 682 uninsured patients screened, with 9 cancers identified (stage 0, n = 1; stage I, n = 3; stage II, n = 2; and stage III, n = 3) for an incidence of 1.3%. A total cost of $388,137 was estimated to be incurred during the initial phase of care. Compared with the SEER control, our cohort included more early stage cancers and subsequently had a marginally lower per-patient initial cost ($43,126 vs $43,736).

CONCLUSIONS

Our screening criteria successfully identified a high-risk population with an overall 1.3% incidence of CRC. For these patients, the provision of free screening colonoscopies identified earlier-stage tumors and appears to be cost-neutral.

The short-run causal effect of tumor detection and treatment on psychosocial well-being, work, and income

This paper estimates the short-run causal effect of tumor detection and treatment on psychosocial well-being, work and income. Tumor detection can be considered as a random event, so that we can compare individuals' average outcomes in the year of diagnosis with the year before. We argue for using panel data estimation techniques that enable us to control for observed and unobserved information intrinsic to the individual and time constants. We use data of a national representative panel in the Netherlands that includes health survey information and data on work, education, and income between 2007 and 2012. Our findings show differences in the psychosocial dysfunction of men and women in response to tumor detection and treatment. Women, not men, are decreasingly likely to participate in the labor force as a result of malignant tumor detection, while no significant effects are found on her personal or household income. We also demonstrate that fixed effects panel data models are superior to matching techniques.

Variation in Medicare Payments for Colorectal Cancer Surgery

PURPOSE

Colorectal cancer (CRC) is the second most expensive cancer in the United States. Episode-based bundled payments may be a strategy to decrease costs. However, it is unknown how payments are distributed across hospitals and different perioperative services.

METHODS

We extracted actual Medicare payments for patients in the fee-for-service Medicare population who underwent CRC surgery between January 2004 and December 2006 (N = 105,016 patients). Payments included all service types from the date of hospitalization up to 1 year later. Hospitals were ranked from least to most expensive and grouped into quintiles. Results were case-mix adjusted and price standardized using empirical Bayes methods. We assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variation in payment.

RESULTS

There is wide variation in total payments for CRC care within the first year after CRC surgery. Actual Medicare payments were $51,345 per patient in the highest quintile and $26,441 per patient in the lowest quintile, representing a difference of Δ = $24,902. Differences were persistent after price standardization (Δ = $17,184 per patient) and case-mix adjustment (Δ = $4,790 per patient). Payments for the index surgical hospitalization accounted for the largest share (65%) of payments but only minimally varied (11.6%) across quintiles. However, readmissions and postacute care services accounted for substantial variations in total payments.

CONCLUSION

Medicare spending in the first year after CRC surgery varies across hospitals even after case-mix adjustment and price standardization. Variation is largely driven by postacute care and not the index surgical hospitalization. This has significant implications for policy decisions on how to bundle payments and define episodes of surgical CRC care.

Colorectal Cancer Initial Diagnosis: Screening Colonoscopy, Diagnostic Colonoscopy, or Emergent Surgery, and Tumor Stage and Size at Initial Presentation

INTRODUCTION/BACKGROUND

Rates of colorectal cancer screening are improving but remain suboptimal. Limited information is available regarding how patients are diagnosed with colorectal cancer (for example, asymptomatic screened patients or diagnostic workup because of the presence of symptoms). The purpose of this investigation was to determine how patients were diagnosed with colorectal cancer (screening colonoscopy, diagnostic colonoscopy, or emergent surgery) and tumor stage and size at diagnosis.

PATIENTS AND METHODS

Adults evaluated between 2011 and 2014 with a diagnosis of colorectal cancer were identified. Clinical notes, endoscopy reports, surgical reports, radiology reports, and pathology reports were reviewed. Sex, race, ethnicity, age at the time of initial diagnosis, method of diagnosis, presenting symptom(s), and primary tumor size and stage at diagnosis were recorded. Colorectal cancer screening history was also recorded.

RESULTS

The study population was 54% male (265 of 492) with a mean age of 58.9 years (range, 25-93 years). Initial tissue diagnosis was established at the time of screening colonoscopy in 10.7%, diagnostic colonoscopy in 79.2%, and during emergent surgery in 7.1%. Cancers diagnosed at the time of screening colonoscopy were more likely to be stage 1 than cancers diagnosed at the time of diagnostic colonoscopy or emergent surgery (38.5%, 7.2%, and 0%, respectively). Median tumor size was 3.0 cm for the screening colonoscopy group, 4.6 cm for the diagnostic colonoscopy group, and 5.0 cm for the emergent surgery group. At least 31% of patients diagnosed at the time of screening colonoscopy, 19% of patients diagnosed at the time of diagnostic colonoscopy, and 26% of patients diagnosed at the time of emergent surgery had never undergone a screening colonoscopy.

CONCLUSION

Nearly 90% of colorectal cancer patients were diagnosed after development of symptoms and had more advanced disease than asymptomatic screening patients. Colorectal cancer outcomes will be improved by improving rates of colorectal cancer screening.

The cost of absenteeism and short-term disability associated with colorectal cancer: a case-control study

OBJECTIVE

Examine the incremental impact of absenteeism and short-term disability associated with colorectal cancer (CRC).

METHODS

Absenteeism and short-term disability data were used for a case-control analysis of a healthy cohort (controls) compared with CRC patients (cases). Cases were matched to controls on the basis of age, sex, and region of residence. Multivariate regression models examined the costs of absenteeism and short-term disability, controlling for patient characteristics, prior medical costs, and patient general health.

RESULTS

Compared with controls, CRC patients experience significantly higher short-term disability costs (mean, $45,716 vs $7367 [P < 0.0001]; median, $35,827 vs $7365 [P < 0.0001]), as well as significantly higher absenteeism costs (mean, $8841 vs $4596 [P < 0.0001]; median, $9971 vs $4795 [P < 0.0001]) in the 1 year after diagnosis of CRC.

CONCLUSIONS

Colorectal cancer is associated with significant work-related productivity loss costs in the first year after diagnosis.

Medical Costs and Healthcare Utilization among Cancer Decedents in the Last Year of Life in 2009

Purpose

The purpose of this study was to evaluate the cancer care cost during the last year of life of patients in Korea.

Materials and Methods

We studied the breakdown of spending on the components of cancer care. Cancer decedents in 2009 were identified from the Korean Central Cancer Registry and linked with the Korean National Health Insurance Claims Database. The final number of patients included in the study was 70,558.

Results

In 2009, the average cancer care cost during the last year of life was US $15,720. Patients under age 20 spent US $53,890 while those 70 or over spent US $11,801. Those with leukemia incurred the highest costs (US $43,219) while bladder cancer patients spent the least (US $13,155). General costs, drugs other than analgesics, and test fees were relatively high (29.7%, 23.8%, and 20.7% of total medical costs, respectively). Analgesic drugs, rehabilitation, and psychotherapy were still relatively low (4.3%, 0.7%, and 0.1%, respectively). Among the results of multiple regression analysis, few were notable. Age was found to be negatively related to cancer care costs while income level was positively associated. Those classified under distant Surveillance, Epidemiology, and End Results stages of cancer and higher comorbidity level also incurred higher cancer care costs.

Conclusion

Average cancer care costs varied significantly by patient characteristics. However, the study results suggest an underutilization of support services likely due to lack of alternative accommodations for terminal cancer patients. Further examination of utilization patterns of healthcare resources will help provide tailored evidence for policymakers in efforts to reduce the burdens of cancer care.

Colonoscopy: the current king of the hill in the USA

Colonoscopy is the dominant colorectal cancer screening strategy in the USA. There are no randomized controlled trials completed of screening colonoscopy, but multiple lines of evidence establish that colonoscopy reduces colorectal cancer incidence in both the proximal and distal colon. Colonoscopy is highly operator dependent, but systematic efforts to measure and improve quality are impacting performance. Colonoscopy holds a substantial advantage over other strategies for detection of serrated lesions, and a recent case-control study suggests that once-only colonoscopy or colonoscopy at 20-year intervals, by a high-level detector, could ensure lifetime protection from colorectal cancer for many patients.

KRAS mutational concordance between primary and metastatic colorectal adenocarcinoma

KRAS mutation analysis is commonly performed on tissue samples obtained from primary colorectal cancers (CRCs). The metastatic lesions of CRC are usually considered as qualitatively similar or even identical to the primary tumors. The aim of this study was to evaluate the spectrum and distribution of KRAS mutations in a large collection of CRCs, while also evaluating the concordance of primary and metastatic lesions among available paired specimens from the same patients. A total of 729 patients with histologically confirmed advanced CRC at the University Hospital and Local Health Unit (Sassari, Italy) were included. Clinical and pathological features were obtained from medical records and/or pathology reports. Formalin-fixed, paraffin-embedded tissue samples were used for mutation analysis. Genomic DNA was isolated using a standard protocol; the coding sequence and splice junctions of exons 2 and 3 in the KRAS gene were screened by direct automated sequencing. Overall, 219 (30%) KRAS mutations were found; 208 (30.1%) were identified in the 690 primary tumors and 11 (28.2%) in the 39 metastatic tissue samples. Among the 31 (4.3%) patients who had paired samples of primary CRC and synchronous or asynchronous metastases, 28 (90.3%) showed consistent mutation patterns between the primary tumors and metastatic lesions. In one case, an additive mutation (Q61L) was found in the metastatic tissue, while two other discrepant cases exhibited a different mutation distribution; Q61H in the primitive lesion and G13V in the metastatic lesion in one case, and a mutated primary tumor (Q61L) and wild-type metastasis in another case. The results of this study confirm that a high concordance exists between the results of KRAS mutation analysis performed in primitive and metastatic CRCs; independent subclones may be generated in a limited amount of patients.

The cost of lost productivity due to premature cancer-related mortality: an economic measure of the cancer burden

BACKGROUND

Most measures of the cancer burden take a public health perspective. Cancer also has a significant economic impact on society. To assess this economic burden, we estimated years of potential productive life lost (YPPLL) and costs of lost productivity due to premature cancer-related mortality in Ireland.

METHODS

All cancers combined and the 10 sites accounting for most deaths in men and in women were considered. To compute YPPLL, deaths in 5-year age-bands between 15 and 64 years were multiplied by average working-life expectancy. Valuation of costs, using the human capital approach, involved multiplying YPPLL by age-and-gender specific gross wages, and adjusting for unemployment and workforce participation. Sensitivity analyses were conducted around retirement age and wage growth, labour force participation, employment and discount rates, and to explore the impact of including household production and caring costs. Costs were expressed in €2009.

RESULTS

Total YPPLL was lower in men than women (men = 10,873; women = 12,119). Premature cancer-related mortality costs were higher in men (men: total cost = €332 million, cost/death = €290,172, cost/YPPLL = €30,558; women: total cost = €177 million, cost/death = €159,959, cost/YPPLL = €14,628). Lung cancer had the highest premature mortality cost (€84.0 million; 16.5% of total costs), followed by cancers of the colorectum (€49.6 million; 9.7%), breast (€49.4 million; 9.7%) and brain & CNS (€42.4 million: 8.3%). The total economic cost of premature cancer-related mortality in Ireland amounted to €509.5 million or 0.3% of gross domestic product. An increase of one year in the retirement age increased the total all-cancer premature mortality cost by 9.9% for men and 5.9% for women. The inclusion of household production and caring costs increased the total cost to €945.7 million.

CONCLUSION

Lost productivity costs due to cancer-related premature mortality are significant. The higher premature mortality cost in males than females reflects higher wages and rates of workforce participation. Productivity costs provide an alternative perspective on the cancer burden on society and may inform cancer control policy decisions.

Annual financial impact of well-differentiated thyroid cancer care in the United States

BACKGROUND

Well-differentiated thyroid cancer (WDTC) is a prevalent disease, which is increasing in incidence faster than any other cancer. Substantial direct medical care costs are related to the diagnosis and treatment of newly diagnosed patients as well as the ongoing surveillance of patients who have a long life expectancy. Prior analyses of the aggregate health care costs attributable to WDTC in the United States have not been reported.

METHODS

A stacked cohort cost analysis was performed on the US population from 1985 to 2013 to estimate the number of WDTC survivors in 2013. Incidence rates, and cancer-specific and overall survival were based on Surveillance, Epidemiology, and End Results (SEER) data. Current and projected direct medical care costs attributable to the care of patients with WDTC were then estimated. Health care-related costs and event probabilities were based on Medicare reimbursement schedules and the literature.

RESULTS

Estimated overall societal cost of WDTC care in 2013 for all US patients diagnosed after 1985 is $1.6 billion. Diagnosis, surgery, and adjuvant therapy for newly diagnosed patients (41%) constitutes the greatest proportion of costs, followed by surveillance of survivors (37%), and nonoperative death costs attributable to thyroid cancer care (22%). Projected 2030 costs (in 2013 US dollars) based on current incidence trends exceed $3.5 billion.

CONCLUSIONS

Health care costs of WDTC are substantial. Unlike other cancers, the majority of the cost is incurred in the initial and continuing phases of care. With the projected increasing incidence, population, and survival trends, costs will continue to escalate.

Making the case for cost-effectiveness research

Cost-effectiveness research is a component of clinical outcomes that addresses both cost and outcomes simultaneously, providing an understanding of what incremental costs, if any, are required for better clinical outcomes. In the current health care climate, these analyses are increasingly performed, and critical, as practitioners must optimize patient care at lower costs. This review discusses cost effectiveness research, its utilization in surgical oncology, and future opportunities provided by its methodologies.

Social Determinants Associated with Colorectal Cancer Screening in an Urban Community Sample of African-American Men

Background

African-American men are disproportionately burdened with colorectal cancer (CRC). Research is scarce on the social determinants that may influence CRC screening as the primary strategy for early detection among African-American males.

Methods

African-American men over the age of 18 years (n = 558) were recruited from a community health fair and anonymously surveyed about their health and cancer screening behaviors. A social ecological theoretical framework was utilized to identify intrapersonal, interpersonal, organizational, and community predictors of CRC screening, which may be associated with social determinants of health and health behaviors. Analysis included correlations and logistic regression.

Results

The mean age of participants was 54.3 years with 85.8% of men being over 40 years of age. Regarding CRC screening: 50.5% (n = 282) of African-American male participants had received any type of CRC screening at any time. Positive predictors of CRC screening included: health insurance status, older age, having spoken with a health provider about family cancer risk, and having a regular doctor. However, employment status and poor self-rated health were negative predictors of the outcome.

Conclusions

Social determinants of health, such as healthcare access and interactions with health systems, along with employment play a critical role in facilitating CRC screening completion in high-risk underserved populations such as African-American men.

Cancer prevalence in United States, Nordic Countries, Italy, Australia, and France: an analysis of geographic variability

BACKGROUND

The objectives of this study were to quantitatively assess the geographic heterogeneity of cancer prevalence in selected Western Countries and to explore the associations between its determinants.

METHODS

For 20 cancer sites, 5-year cancer prevalence, incidence, and survival were observed and age standardised for the mid 2000s in the United States, Nordic European Countries, Italy, Australia, and France.

RESULTS

In Italy, 5-year crude prevalence for all cancers was 1.9% in men and 1.7% in women, while it was ∼1.5% in all other countries and sexes. After adjustment for the different age distribution of the populations, cancer prevalence in the United States was higher (20% in men and 10% in women) than elsewhere. For all cancers combined, the geographic heterogeneities were limited, though relevant for specific cancers (e.g., prostate, showing >30% higher prevalence in the United States, or lung, showing >50% higher prevalence in USA women than in other countries). For all countries, the correlations between differences of prevalence and differences of incidence were >0.9, while prevalence and survival were less consistently correlated.

CONCLUSION

Geographic differences and magnitude of crude cancer prevalence were more strongly associated with incidence rates, influenced by population ageing, than with survival rates. These estimates will be helpful in allocating appropriate resources.

Cost profiles of colorectal cancer patients in Italy based on individual patterns of care

Background

Due to changes in cancer-related risk factors, improvements in diagnostic procedures and treatments, and the aging of the population, in most developed countries cancer accounts for an increasing proportion of health care expenditures. The analysis of cancer-related costs is a topic of several economic and epidemiological studies and represents a research area of great interest to public health planners and policy makers. In Italy studies are limited either to some specific types of expenditures or to specific groups of cancer patients. Aim of the paper is to estimate the distribution of cancer survivors and associated health care expenditures according to a disease pathway which identifies three clinically relevant phases: initial (one year following diagnosis), continuing (between initial and final) and final (one year before death).

Methods

The methodology proposed is based on the reconstruction of patterns of care at individual level by combining different data sources, surveillance data and administrative data, in areas covered by cancer registration.

Results

A total colorectal cancer-related expenditure of 77.8 million Euros for 18012 patients (corresponding to about 4300 Euros per capita) is estimated in 2006 in two Italian areas located in Tuscany and Veneto regions, respectively. Cost of care varies according to the care pathway: 11% of patients were in the initial phase, and consumed 34% of total expenditure; patients in the final (6%) and in the continuing (83%) phase consumed 23% and 43% of the budget, respectively. There is an association between patterns of care/costs and patients characteristics such as stage and age at diagnosis.

Conclusions

This paper represents the first attempt to attribute health care expenditures in Italy to specific phases of disease, according to varying treatment approaches, surveillance strategies and management of relapses, palliative care. The association between stage at diagnosis, profile of therapies and costs supports the idea that primary prevention and early detection play an important role in a public health perspective. Results from this pilot study encourage the use of such analyses in a public health perspective, to increase understanding of patient outcomes and economic consequences of differences in policies related to cancer screening, treatment, and programs of care.

Colorectal cancer screening with blood-based biomarkers: cost-effectiveness of methylated septin 9 DNA versus current strategies

BACKGROUND

Screening reduces colorectal cancer mortality, but many persons remain unscreened. Screening with a blood test could improve screening rates. We estimated the comparative effectiveness and cost-effectiveness of colorectal cancer screening with emerging biomarkers, illustrated by a methylated Septin 9 DNA plasma assay ((m)SEPT9), versus established strategies.

METHODS

We conducted a cost-utility analysis using a validated decision analytic model comparing (m)SEPT9, fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), sigmoidoscopy, and colonoscopy, projecting lifetime benefits and costs.

RESULTS

In the base case, (m)SEPT9 decreased colorectal cancer incidence by 35% to 41% and colorectal cancer mortality by 53% to 61% at costs of $8,400 to $11,500/quality-adjusted life year gained versus no screening. All established screening strategies were more effective than (m)SEPT9. FIT was cost saving, dominated (m)SEPT9, and was preferred among all the alternatives. Screening uptake and longitudinal adherence rates over time strongly influenced the comparisons between strategies. At the population level, (m)SEPT9 yielded incremental benefit at acceptable costs when it increased the fraction of the population screened more than it was substituted for other strategies.

CONCLUSIONS

(m)SEPT9 seems to be effective and cost-effective compared with no screening. To be cost-effective compared with established strategies, (m)SEPT9 or blood-based biomarkers with similar test performance characteristics would need to achieve substantially higher uptake and adherence rates than the alternatives. It remains to be proven whether colorectal cancer screening with a blood test can improve screening uptake or long-term adherence compared with established strategies.

IMPACT

Our study offers insights into the potential role of colorectal cancer screening with blood-based biomarkers.

Costs during the first five years following cancer diagnosis in Korea

OBJECTIVES

We estimated the total medical costs incurred during the 5 years following a cancer diagnosis and annual medical use status for the six most prevalent cancers in Korea.

METHODS

From January 1 to December 31, 2006, new patients registered with the six most prevalent cancers (stomach, liver, lung, breast, colon, and thyroid) were randomly selected from the Korea Central Cancer Registry, with 30% of patients being drawn from each cancer group. For the selected patients, cost data were generated using National Health Insurance claims data from the time of cancer diagnosis in 2006 to December 31, 2010. The total number of patients selected was 28,509. Five-year total medical costs by tumor site and Surveillance, Epidemiology, and End Results (SEER) stage at the time of diagnosis, and annual total medical costs from diagnosis, were estimated. All costs were calculated as per-patient net costs.

RESULTS

Mean 5-year net costs per patient varied widely, from $5,647 for thyroid cancer to $20,217 for lung cancer. Advanced stage at diagnosis was associated with a 1.8-2.5-fold higher total cost, and the total medical cost was highest during the first year following diagnosis and decreased by the third or fourth year.

CONCLUSIONS

The costs of cancer care were substantial and varied by tumor site, annual phase, and stage at diagnosis. This indicates the need for increased prevention, earlier diagnosis, and new therapies that may assist in reducing medical costs.

Association between health-related quality of life and colorectal cancer screening

Conflicting information currently exists about the role played by health-related quality of life (HRQOL) in influencing colorectal cancer screening. The current study aimed to determine the relationship between HRQOL and colorectal cancer screening, using nationally representative public data from the Behavioral Risk Factor Surveillance System (BRFSS). The 2010 BRFSS data were used for this study. Individuals younger than age 50 years were excluded from the study. Missing data were imputed using the multiple imputation technique. Multiple multivariate logistic regression models were fitted to the data to determine the association between different components of HRQOL (physical HRQOL, mental HRQOL, activity limitation caused by poor mental or physical HRQOL, and general health status) and receipt of colorectal cancer screening tests (fecal occult blood testing [FOBT] in the past year, sigmoidoscopy in the past 5 years, and colonoscopy in the past 10 years). The study sample comprised 301,488 individuals. Approximately 12% of the respondents had received FOBT in the past year, 62.6% had received sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years, and 65.4% had received either of the screening tests within appropriate time frames. After controlling for demographic and health-related covariates, an inverse relationship was observed between HRQOL and colorectal cancer screening with the exception of mental HRQOL and FOBT. The relationship between mental HRQOL and FOBT was found to be nonsignificant. Policy makers should consider including HRQOL as an important parameter when designing interventions aimed at improving colorectal cancer screening rates.

Comparative effectiveness and cost-effectiveness of screening colonoscopy vs. sigmoidoscopy and alternative strategies

OBJECTIVES

Fecal occult blood testing (FOBT) and sigmoidoscopy are proven to decrease colorectal cancer (CRC) incidence and mortality. Sigmoidoscopy's benefit is limited to the distal colon. Observational data are conflicting regarding the degree to which colonoscopy affords protection against proximal CRC. Our aim was to explore the comparative effectiveness and cost-effectiveness of colonoscopy vs. sigmoidoscopy and alternative CRC screening strategies in light of the latest published data.

METHODS

We performed a contemporary cost-utility analysis using a Markov model validated against data from randomized controlled trials of FOBT and sigmoidoscopy. Persons at average CRC risk within the general US population were modeled. Screening strategies included those recommended by the United States (US) Preventive Services Task Force, including colonoscopy every 10 years (COLO), flexible sigmoidoscopy every 5 years (FS), annual fecal occult blood testing, annual fecal immunochemical testing (FIT), and the combination FS/FIT. The main outcome measures were quality-adjusted life-years (QALYs) and costs.

RESULTS

In the base case, FIT dominated other strategies. The advantage of FIT over FS and COLO was contingent on rates of uptake and adherence that are well above current US rates. Compared with FIT, FS and COLO both cost <$50,000/QALY gained when FIT per-cycle adherence was <50%. COLO cost $56,800/QALY gained vs. FS in the base case. COLO cost <$100,000/QALY gained vs. FS when COLO yielded a relative risk of proximal CRC of <0.5 vs. no screening. In probabilistic analyses, COLO was cost-effective vs. FS at a willingness-to-pay threshold of $100,000/QALY gained in 84% of iterations.

CONCLUSIONS

Screening colonoscopy may be cost-effective compared with FIT and sigmoidoscopy, depending on the relative rates of screening uptake and adherence and the protective benefit of colonoscopy in the proximal colon. Colonoscopy's cost-effectiveness compared with sigmoidoscopy is contingent on the ability to deliver ~50% protection against CRC in the proximal colon.

Direct medical costs of care for Chinese patients with colorectal neoplasia: a health care service provider perspective

OBJECTIVES

To estimate the direct medical cost of colorectal neoplasia (CRN) from newly diagnosed to the completion of the tumour-specific treatment in the initial year of disease across stages and tumour primary sites.

METHODS

Only direct medical costs from the perspective of the health care service provider were incorporated in the cost analysis (in 2009 USD) using a bottom-up approach. Tumour-specific treatments of surgery, chemotherapy and radiotherapy data in the initial year of disease were identified from the 401 CRN adult patients by a review of their medical records. Service utilization for diagnosis, staging, pre-operative assessment and post-operative follow-up consultations was estimated from the recommendations of established surveillance and clinical practice guidelines.

RESULTS

Direct medical cost for the care of a newly diagnosed CRN was ranging from $1941 for low-risk polyp to $45 115 for stage IV colorectal cancer in the initial year of care. Costs of care showed a gradient increase from $1748 for low-risk colonic polyps to $42 899 for stage IV colon cancer, and from $2232 for low-risk rectal polyps to $48 453 for stage IV rectal cancers. Diagnostic/pre-operative assessment and treatment accounted for most of total costs of colorectal polyp (58.9-76.7%) and cancer (60.8-85.2%) care.

CONCLUSION

The results provided stage and site-specific estimations of the direct medical costs of CRN in a Chinese population that can assist policy decision making and facilitate health care service planning and cost-effectiveness evaluations.

Biomarkers, bundled payments, and colorectal cancer care

Changes in the management of cancers such as colorectal cancer (CRC) are urgently needed, as such cancers continue to be one of the most commonly diagnosed cancers; CRC accounts for 21% of all cancers and is responsible for mortalities second only to lung cancer in the United States. A comprehensive science-driven approach towards markedly improved early detection/screening to efficacious targeted therapeutics with clear diagnostic and prognostic markers is essential. In addition, further changes addressing rising costs, stemming from recent health care reform measures, will be brought about in part by changes in how care is reimbursed. For oncology, the advances in genomics and biomarkers have the potential to define subsets of patients who have a prognosis or response to a particular type of therapy that differs from the mean. Better definition of a cancer's behavior will facilitate developing care plans tailored to the patient. One method under study is episode-based payment or bundling, where one payment is made to a provider organization to cover all expenses associated with a discrete illness episode. Payments will be based on the average cost of care, with providers taking on a risk for overutilization and outliers. For providers to thrive in this environment, they will need to know what care a patient will require and the costs of that care. A science-driven "personalized approach" to cancer care has the potential to produce better outcomes with reductions in the use of ineffectual therapies and costs. This promising scenario is still in the future, but progress is being made, and the shape of things to come for cancer care in the age of genomics is becoming clearer.