Quality of life, treatments, and patients' willingness to pay for a complete remission of cervical cancer in Taiwan

Willingness to pay for an mRNA-based anti-cancer treatment: results from a contingent valuation study in Israel

BACKGROUND

mRNA technology is currently being investigated for a range of oncology indications. We assessed the willingness to pay (WTP) of the general population in Israel for a hypothetical novel mRNA-based treatment for oncology indications.

METHODS

We used a contingent valuation methodology to elicit WTP using a web-based questionnaire. A sample of adult participants were presented with a hypothetical scenario in which an mRNA-based intervention increased the likelihood of a cure for various cancer types from 20% to 40% (half of the sample), or 60% (the other half of the sample).

RESULTS

531 respondents completed the questionnaire. The mean, median and mode WTP for the proposed hypothetical treatment in both scenarios were ILS65,000 (± ILS114,000), ILS20,000 and ILS50,000, respectively (1USD = 3.4ILS). The WTP was skewed towards zero, and 9.6% of the respondents were not willing to pay any amount. WTP higher amounts was significantly associated with higher income (p < 0.01), self-reported good health (p < 0.05), supplementary health insurance (p < 0.05), Jews compared to other populations (p < 0.01), interest in technology (p < 0.001) and a tendency to adopt medical innovations (p < 0.001). No statistical difference between the 40% vs. the 60% potential cure scenarios was found. Logistic and OLS regressions indicated that age, religion, income, and interest in adopting medical innovations were the best predictors of respondents' WTP.

CONCLUSION

Despite the scientific breakthroughs in oncology treatment over the last few decades, many types of cancer are still incurable. Given the expected development of innovative mRNA-based treatments for cancer, these results should inform policymakers, the pharmaceutical industry and other stakeholders on the future coverage and reimbursement of these technologies incorporating patients' and societal views. To date, WTP considerations have not been given much weight in prioritization of drug reimbursement processes, neither in Israel nor in other countries. As a pioneer in adoption of the mRNA technology, Israel can also lead the incorporation of WTP considerations in this field.

Quality-adjusted survival in women with gynecologic malignancies receiving IMRT after surgery: A Ppatient Rreported Ooutcome study of NRG oncology's RTOG 1203

INTRODUCTION

NRG/RTOG 1203 compared 3-D conformal radiotherapy (3D CRT) to intensity-modulated radiotherapy (IMRT) in patients with endometrial or cervical cancer requiring post-operative radiotherapy after hysterectomy. The purpose of this study was to report the first quality-adjusted survival analysis comparing the two treatments.

METHODS

NRG/RTOG 1203 randomized patients having undergone hysterectomy to either 3DCRT or IMRT. Stratification factors included RT dose, chemotherapy, and disease site. The EQ-5D, both index and visual analog scale (VAS), were obtained at baseline, 5 weeks after the start of RT, 4-6 weeks post RT and 1 and 3-years post RT. EQ-5D index and VAS scores along with quality-adjusted survival (QAS) were compared between treatment arms using the t-test at a two-sided significance level of 0.05.

RESULTS

NRG/RTOG 1203 enrolled 289 patients of which 236 consented to participate in the patient reported outcome (PRO) assessments. QAS was higher in women treated with IMRT, 1374 vs 1333 days (p = 0.5) compared to patients treated with 3DCRT, but this difference was not statistically different. Patients treated with IMRT had less of a decline in VAS score 5 weeks post RT, -5.04, compared to patients treated with 3DCRT, -7.48, although not statistically significant (p = 0.38).

CONCLUSION

This is the first report of the use of the EQ-5D comparing two radiotherapy techniques in the treatment of gynecologic malignancies after surgery. While there were no significant differences in QAS and VAS scores between patients who received IMRT vs. 3DCRT, RTOG 1203 was not powered to show statistical differences in these secondary endpoints.

Willingness to pay for cancer prevention, screening, diagnosis, and treatment: a systematic review

INTRODUCTION

Willingness to pay (WTP) studies examine the maximum amount of money an individual is willing to pay for a specified health intervention, and can be used to inform coverage and reimbursement decisions. Our objectives were to assess how people value cancer-related interventions, identify differences in the methodologies used, and review the trends in studies' publication.

AREAS COVERED

We extracted PubMed and EconLit articles published in 1997-2020 that reported WTP for cancer-related interventions, characterized the methodological differences and summarized each intervention's mean and median WTP values. We reviewed 1,331 abstracts and identified 103 relevant WTP studies, of which 37 (36%) focused on treatment followed by screening (26), prevention (21), diagnosis (7) and other interventions (12). The methods used to determine WTP values were primarily discrete-choice questions (n = 54, 52%), bidding games (15), payment cards (12) and open-ended questions (12). We found a wide variation in WTP reported values ranged from below $100 to over $20,000.

EXPERT OPINION

The WTP literature on oncology interventions has grown rapidly. There is considerable heterogeneity with respect to the type of interventions and diseases assessed, the respondents' characteristics, and the study methodologies. This points to the need to establish international guidelines for best practices in this field.

Determination of a cost-effectiveness threshold for cancer interventions in Iran

Background and objectives

The estimation of a cost- Effectiveness (CE) threshold from the perspective of those who have experienced a life-threatening disease can provide empirical evidence for health policy makers to make the best allocation decisions on limited resources. The aim of the current study was to empirically determine the CE threshold for cancer interventions from the perspective of cancer patients in Iran.

Methods

A composite time trade-off (cTTO) task for deriving quality adjusted life-year (QALY) and a double-bounded dichotomous choice (DBDC) approach followed by open-ended question for examining patients' willingness-to-pay were performed. A nationally representative sample of 580 cancer patients was recruited from the largest governmental cancer centers in Iran between June 2021 and January 2022, and data were gathered using face-to-face interviews. The CE threshold was calculated using the nonparametric Turnbull model and parametric interval-censored Weibull regression model. Furthermore, the factors that affect the CE threshold were determined using the parametric model.

Results

The estimated CE threshold using the nonparametric Turnbull model and parametric interval-censored Weibull regression model was IRR 440,410,000 (USD 10,485.95) and IRR 595,280,000 (USD 14,173.33) per QALY, respectively. Gender, age, education, income, type of cancer, and current treatment status were significantly associated with the estimated CE threshold.

Conclusions

The value of parametric model-based threshold in this study was 1.98 times the Iranian GDP per capita, which was lower than the CE threshold value recommended by the WHO (i.e., 3 times the GDP per capita) for low-and middle-income countries.

Willingness-to-pay for cancer treatment and outcome: a systematic review

BACKGROUND

Understanding patient preferences in cancer management is essential for shared decision-making. Patient or societal willingness-to-pay (WTP) for desired outcomes in cancer management represents their preferences and values of these outcomes.

OBJECTIVE

The aim of this systematic review is to critically evaluate how current literature has addressed WTP in relation to cancer treatment and achievement of outcomes.

METHODS

Seven databases were searched from inception until 2 March 2021 to include studies with primary data of WTP values for cancer treatments or achievement of outcomes that were elicited using stated preference methods.

RESULTS

Fifty-four studies were included in this review. All studies were published after year 2000 and more than 90% of the studies were conducted in high-income countries. Sample size of the studies ranged from 35 to 2040, with patient being the most studied population. There was a near even distribution between studies using contingent valuation and discrete choice experiment. Based on the included studies, the highest WTP values were for a quality-adjusted life year (QALY) ($11,498-$589,822), followed by 1-year survival ($3-$198,576), quality of life (QoL) improvement ($5531-$139,499), and pain reduction ($79-$94,662). Current empirical evidence suggested that improvement in QoL and pain reduction had comparable weights to survival in cancer management.

CONCLUSION

This systematic review provides a summary on stated preference studies that elicited patient preferences via WTP and summarised their respective values. Respondents in this review had comparable WTP for 1-year survival and QoL, suggesting that improvement in QoL should be emphasised together with survival in cancer management.

Innovation in health care through information technology (IT): The role of incentives

For several years now, information technology (IT) has been hailed as an innovation that will revolutionize medicine and health care more generally. Yet adoption of new IT in the healthcare sector has been slow, possibly reflecting a lack of interest. In economic terms, the incentives of the major players in health care may work against new IT, which fosters process and organizational innovation much more than product innovation. While product innovation causes an increase in consumers' willingness to pay and is therefore welcomed by those working in the healthcare sector, process innovation is resisted because it often means performing the same service but at a lower cost. This is also true of organizational innovation, which frequently entails vertical integration and hence a loss of autonomy (as evidenced by the difficulties of creating Managed Care Organizations). The objective of this paper therefore is to predict the circumstances in which (both current and potential) patients, physicians, hospitals, health insurers, and governments are likely to support innovation in health care through IT.

A Study of Patients' Willingness to Pay for a Basic Outpatient Copayment and Medical Service Quality in Taiwan

Patients might be willing to pay more to obtain better quality medical services when they recognize that high-level hospitals have better quality. However, published papers have not found solid empirical evidence to support this possibility. Therefore, the purpose of this study is to empirically investigate patients’ willingness to pay (WTP) for an outpatient copayment. The study aims to analyze the difference between the two WTP values: to implement a hierarchy of medical care and to improve the quality of medical services. This study administered a questionnaire using the contingent valuation method with a quasi-bidding game for patients’ WTP and the SERVQUAL scale for medical service quality. The Wilcoxon signed-rank test was employed to test the difference between the two WTP values, notably to implement a hierarchy of medical care and to improve the quality of medical services. Both of the WTP values are higher than the academic medical centre’s current copayment NT$420 (approximately US$14); the percentage of respondents willing to pay a higher copayment declined when the outpatient copayment was increased, and the patients’ WTP to have better medical service quality was significantly higher than that to implement a hierarchy of medical care. Patients’ desire to receive better medical services from higher-level hospitals might be stronger than their desire to implement hierarchical medical care. This study reported the relationship between the respondents’ perceived medical service quality and WTP for having better service quality by using regression models. The respondents’ perceptions of medical service quality, especially for “reliability” and “assurance,” would positively affect their WTP. Policy makers should focus on improving the quality of medical services.

Risk Factors and Behaviours of Schoolchildren with Myopia in Taiwan

Importance: Because of the high prevalence of myopia in Taiwan, understanding the risk factors for its development and progression is important to public health. Background: This study investigated the risk factors for myopia and their influence on the progression of myopia in schoolchildren in Taiwan. Design: Patients’ clinical records were obtained retrospectively from ophthalmologists. Questionnaires were given to collect demographic information, family background, hours spent on daily activities, myopia progression, and treatment methods. Participants: From a regional medical hospital in northern Taiwan, 522 schoolchildren with myopia participated in the study. Written informed consent was obtained from participants of legal age or the parents or legal guardians of younger children. Methods: Multivariable regression analyses were performed. Myopia measured in cycloplegic spherical equivalent (SE) was analysed, controlling for patients’ family and demographic information as well as their daily activity behaviours. Main Outcome Results: Children with high myopic parents were more myopic. Earlier onset age of myopia was associated with a higher level of myopia and greater annual myopic progression. Children reporting longer time usage of electronic devices had greater progression of myopia. Boys tended to be more myopic than girls. Lower levels of myopia were associated with more outdoor activities, and better vision care knowledge in children and parents. Conclusions and Relevance: In addition to genetics, education and environment can influence the development of myopia. Health policies for schoolchildren should promote protective activities and vision care knowledge at a young age, to protect the eyesight of schoolchildren.

Cost-benefit analysis of vaccination: a comparative analysis of eight approaches for valuing changes to mortality and morbidity risks

BACKGROUND

There is increasing interest in estimating the broader benefits of public health interventions beyond those captured in traditional cost-utility analyses. Cost-benefit analysis (CBA) in principle offers a way to capture such benefits, but a wide variety of methods have been used to monetise benefits in CBAs.

METHODS

To understand the implications of different CBA approaches for capturing and monetising benefits and their potential impact on public health decision-making, we conducted a CBA of human papillomavirus (HPV) vaccination in the United Kingdom using eight methods for monetising health and economic benefits, valuing productivity loss using either (1) the human capital or (2) the friction cost method, including the value of unpaid work in (3) human capital or (4) friction cost approaches, (5) adjusting for hard-to-fill vacancies in the labour market, (6) using the value of a statistical life, (7) monetising quality-adjusted life years and (8) including both productivity losses and monetised quality-adjusted life years. A previously described transmission dynamic model was used to project the impact of vaccination on cervical cancer outcomes. Probabilistic sensitivity analysis was conducted to capture uncertainty in epidemiologic and economic parameters.

RESULTS

Total benefits of vaccination varied by more than 20-fold (£0.6-12.4 billion) across the approaches. The threshold vaccine cost (maximum vaccine cost at which HPV vaccination has a benefit-to-cost ratio above one) ranged from £69 (95% CI £56-£84) to £1417 (£1291-£1541).

CONCLUSIONS

Applying different approaches to monetise benefits in CBA can lead to widely varying outcomes on public health interventions such as vaccination. Use of CBA to inform priority setting in public health will require greater convergence around appropriate methodology to achieve consistency and comparability across different studies.

Health-related quality of life as measured by the EQ-5D in the prevention, screening and management of cervical disease: A systematic review

PURPOSE

Cost-effectiveness analyses (CEAs) of screening can be highly sensitive to the health-related quality of life (HRQoL) effects of screen tests and subsequent treatment. Accordingly, accurate assessment of HRQoL is essential. We reviewed the literature regarding HRQoL in cervical prevention and management in order to appraise the current evidence regarding this important input to CEA.

METHODS

We searched the MEDLINE, Scopus and EconLit databases for studies that estimated HRQoL in cervical cancer prevention and management published January 1995-December 2015. The primary inclusion criterion was for studies that assess HRQoL using the EQ-5D. Data were abstracted from eligible studies on setting, elicitation group, sample size, elicitation instruments, health state valuations, study design and follow-up. We assessed the quality and comparability of the studies with a particular focus on the HRQoL reported across states and groups.

RESULTS

Fifteen papers met the inclusion criteria. Most used patient elicitation groups (n = 11), 2 used the general public and 2 used a mix of both. Eight studies were cross-sectional and seven were longitudinal. Six studies used both the EQ-5D-3L and the EQ-VAS together with other measures of overall HRQoL or condition-specific instruments. Extensive heterogeneity was observed across study characteristics.

CONCLUSIONS

Our results reveal the challenges of sourcing reliable estimates of HRQoL for use in CEAs of cervical cancer prevention and treatment. The EQ-5D appears insufficiently sensitive for some health states. A more general problem is the paucity of HRQoL estimates for many health states and their change over time.

Quality of life among survivors of early-stage cervical cancer in Taiwan: an exploration of treatment modality differences

PURPOSE

Women with early-stage cervical cancer may experience changes in their quality of life (QoL) due to treatment or to the effects of the cancer. In this study, we examined differences in QoL by treatment modality between women who underwent surgery only and those treated with concurrent chemoradiation (CCRT).

METHODS

The sample of 290 women had been diagnosed with stage I-II cervical cancer. Data were collected on these women's demographic and disease characteristics, general QoL, and cancer-specific QoL using an author-designed demographic-disease survey, the European Organization for Research and Treatment of Cancer QoL questionnaire, and the Taiwanese-version Cervical Cancer Module 24 questionnaire, respectively. Data were analyzed by descriptive statistics and analysis of covariance.

RESULTS

Women with cervical cancer who underwent surgery only had significantly worse constipation and body image than those treated with CCRT. Women who underwent CCRT had worse physical and role functioning than those who underwent surgery only. Women who had CCRT also reported worse symptoms, such as fatigue, appetite loss, diarrhea, financial difficulties, sexual enjoyment, and sexual/vaginal functioning, than those who had only surgery.

CONCLUSIONS

Our results add knowledge about QoL in women with early-stage cervical cancer who receive different treatment modalities. When suggesting treatment modalities for women with cervical cancer, health professionals should also consider changes in women's QoL after cancer treatment. To improve women's QoL after treatment, professionals should also offer timely and individualized interventions based on women's cervical cancer treatment.

Adolescent and Young Adult Cancer Survivors' Valuation of Post-Treatment Recommended Care

PURPOSE

Examine whether survivors of adolescent and young adult (AYA) cancer value recommended post-treatment care using focus groups and a willingness to pay (WTP) survey. WTP, a measure of value, indicates the dollar amount individuals are willing to pay to use a service.

METHODS

Participants were recruited through the Utah Cancer Registry. N = 28 survivors diagnosed with cancer at ages 15-39 and currently aged ≥18 participated in focus groups, and N = 4 in phone interviews (participation rate = 50%). All participants responded to a demographic survey and WTP questions based on one-time and monthly payments for annual visits. Focus group participants responded to an open-ended question on the value of follow-up care. Interval regressions identified factors associated with WTP. Qualitative analysis summarized themes for the open-ended question.

RESULTS

Focus group participants reported valuing follow-up care as it brings peace of mind and helps them manage their health. Yet, 38% reported not having a cancer-related visit in the previous year. Only 27% and 43% of survivors agreed to pay any one-time and monthly payments, respectively. The monthly payment mean WTP was $41 (95% confidence interval [CI]: 31-84), equating to $494 annually, which is greater than the mean WTP for one-time payment ($362, 95% CI: 293-432, p < 0.001), suggesting that survivors may prefer monthly payments. Several factors, including being female and in better health, predicted higher WTP.

CONCLUSION

Many AYA cancer survivors report not visiting their doctors annually for post-treatment care despite verbally valuing care. Models that demonstrate high quality and distribute costs over time should be evaluated to encourage survivors to receive recommended care.

Study of Patients' Willingness to Pay for a Cure of Chronic Obstructive Pulmonary Disease in Taiwan

Objectives: Chronic Obstructive Pulmonary Disease (COPD) is one of the fastest growing causes of death worldwide. However, few studies, if any, have been conducted that have investigated patient profiles in Asia. This paper analyzes patient willingness to pay (WTP) as a function of patient disease severity, health-related quality of life (HRQL), and smoking behavior in Taiwan. Study Design: A cross-sectional survey was conducted using in-person interviews with COPD patients. A hypothetical scenario was designed and presented to ascertain each subject’s willingness to pay (WTP) for a cure for COPD. Methods: A survey of subjects with COPD was performed in Taiwan. The contingent valuation method (CVM) was employed to measure patient financial burden, which was analyzed along with covariates that included various types of health-related quality of life (HRQL), severity level, and demographic background. Multivariate regression and simulation methods were employed for analysis. Results: A total of 142 subjects were interviewed, with an average annual WTP of approximately $1422 USD (or 42,662.37 NTD, New Taiwan Dollars). The annual WTP for patients 55 years of age or younger, $5709.06, was the highest and equivalent to approximately one-third of Taiwan average annual personal income or quadruple the spending amount of the Taiwan National Bureau of Health Insurance (NBHI) for each COPD patient. Current cigarette smokers were willing to pay a substantially higher amount than former smokers and nonsmokers, which reflects a psychological desire for redemption in COPD patients. Conclusions: The results of this study provide directions for the relevant authorities regarding the alleviation of suffering as a result of COPD. Appropriate health promotion measures, such as measures to reduce tobacco usage, early diagnosis, and active treatment, may be necessary to contain the escalating costs related to COPD and to prevent this epidemic from worsening.

Evaluation of health-related quality of life for hypothesized medical states associated with cervical cancer

BACKGROUND

When evaluating health-economics for cervical cancer prevention policies in Japan, it is important to use Japanese value settings. This study aimed to obtain preference-based measures (preference measures) for hypothesized health states among healthy Japanese women, and to examine differences between the EuroQol-5D (EQ-5D) and standard gamble (SG) instruments.

MATERIALS AND METHODS

The investigation was performed among female students at a nursing university. We used written hypothetical scenarios describing three grades of cervical intraepithelial neoplasia (CIN) and eight stages of cervical cancer, both at diagnosis and after medical intervention. Preference measures were evaluated using both EQ-5D and SG.

RESULTS

We received responses from 136 women. The mean number of respondents per stage was 24.6 (SD: 2.7). At diagnosis, average EQ-5D scores for CIN1, CIN2, CIN3, IA1, IA2, IB1, IB2, IIA, IIB, III, and IV stages were 0.84 (0.14), 0.78 (0.12), 0.73 (0.10), 0.78 (0.12), 0.72 (0.12), 0.63 (0.13), 0.64 (0.12), 0.68 (0.08), 0.62 (0.13), 0.55 (0.21), and 0.18 (0.24), respectively. Using one-way analysis of variance with the Tukey-Kramer method for multiple comparisons (each stage vs. CIN1), we found significant differences for IB1 and more advanced stages (p<0.05). After medical intervention, corresponding EQ-5D scores were 0.84 (0.12), 0.81 (0.12), 0.84 (0.12), 0.80 (0.15), 0.78 (0.11), 0.64 (0.15), 0.63 (0.15), 0.71 (0.15), 0.50 (0.17), 0.52 (0.17), 0.21 (0.28). The multiple comparisons identified significant differences for IB1 and more advanced stages, excepting IIA (p<0.05). SG evaluations were more variable and relatively higher than EQ-5D evaluations.

CONCLUSIONS

We obtained preference measures for three grades of CIN1-3 and eight stages of cervical cancer. In combination with appropriate sensitivity analyses, these preference measures will provide a basis for an economic evaluation of cervical cancer prevention in Japan. We suggest that EQ-5D is appropriate for cost-utility analysis of this topic.

Assessing whether there is a cancer premium for the value of a statistical life

This article estimates whether there is a cancer risk premium for the value of a statistical life using stated preference valuations of cancer risks for a large, nationally representative US sample. The present value of an expected cancer case that occurs after a one decade latency period is $10.85m, consistent with a cancer premium that is 21% greater than the median value of a statistical life estimates for acute fatalities. This cancer premium is smaller than the premium proposed for policy analyses in the UK and the USA. There is also a greater premium for policies that reduce cancer risks to zero and for risk reductions affecting those who perceive themselves to have a greater than average probability of having cancer.

Evaluating PET-CT in routine surveillance and follow-up after treatment for cervical cancer: a cost-effectiveness analysis

OBJECTIVE

To undertake a cost-effectiveness analysis that compares positron emission tomography - computed tomography (PET-CT) imaging plus standard practice with standard practice alone in the diagnosis of recurrent or persistent cervical cancer during routine surveillance and follow-up of women who have previously been diagnosed and treated.

DESIGN

Model-based economic evaluation using data from a systematic review, supplemented with data from other sources, and taking a UK National Health Service (NHS) perspective.

SETTING

Secondary Care in England.

POPULATION

Women at least 3 months after the completion of treatment, with either recurrent or persistent cervical cancer.

METHODS

A state transition (Markov) model was developed using TreeAge Pro 2011. The structure of the model was informed by the reviews of the trials and clinical input. In the model, two diagnostic strategies were examined. A one-way sensitivity analysis, probabilistic sensitivity analysis, and a value of information analysis were also carried out.

MAIN OUTCOME MEASURES

Cost-effectiveness based on incremental cost per quality-adjusted life year (QALY).

RESULTS

Adding PET-CT to the current treatment strategy of clinical examination and scanning [magnetic resonance imaging (MRI) and/or CT scan] during the routine surveillance and follow-up of women with recurrent or persistent cervical cancer is significantly more costly, with only a minimal increase in effectiveness. The incremental cost-effectiveness ratio (ICER) for the strategy of PET-CT as an adjunct to the standard treatment strategy that included clinical examination, MRI, and/or CT scan, compared with the usual treatment alone, was over £1 million per QALY.

CONCLUSION

The results of the current analysis suggest that use of PET-CT in the diagnosis of recurrent or persistent cervical cancer is not cost-effective. Current guidelines recommending imaging using PET-CT as a diagnostic or surveillance tool need to be reconsidered in light of these results. This study did not specifically investigate the use of PET-CT in women with symptoms and radiological suspicion of recurrence where exenteration was considered. More research in that specific area is required.