The impact of including future medical care costs when estimating the costs attributable to a disease: a colorectal cancer case study

Incorporating Future Medical Costs: Impact on Cost-Effectiveness Analysis in Cancer Patients

BACKGROUND

The inclusion of future medical costs in cost-effectiveness analyses remains a controversial issue. The impact of capturing future medical costs is likely to be particularly important in patients with cancer where costly lifelong medical care is necessary. The lack of clear, definitive pharmacoeconomic guidelines can limit comparability and has implications for decision making.

OBJECTIVE

The aim of this study was to demonstrate the impact of incorporating future medical costs through an applied example using original data from a clinical study evaluating the cost effectiveness of a sepsis intervention in cancer patients.

METHODS

A decision analytic model was used to capture quality-adjusted life-years (QALYs) and lifetime costs of cancer patients from an Australian healthcare system perspective over a lifetime horizon. The evaluation considered three scenarios: (1) intervention-related costs (no future medical cost), (2) lifetime cancer costs and (3) all future healthcare costs. Inputs to the model included patient-level data from the clinical study, relative risk of death due to sepsis, cancer mortality and future medical costs sourced from published literature. All costs are expressed in 2017 Australian dollars and discounted at 5%. To further assess the impact of future costs on cancer heterogeneity, variation in survival and lifetime costs between cancer types and the implications for cost-effectiveness analysis were explored.

RESULTS

The inclusion of future medical costs increased incremental cost-effectiveness ratios (ICERs) resulting in a shift from the intervention being a dominant strategy (cheaper and more effective) to an ICER of $7526/QALY. Across different cancer types, longer life expectancies did not necessarily result in greater lifetime healthcare costs. Incremental costs differed across cancers depending on the respective costs of managing cancer and survivorship, thus resulting in variations in ICERs.

CONCLUSIONS

There is scope for including costs beyond intervention costs in economic evaluations. The inclusion of future medical costs can result in markedly different cost-effectiveness results, leading to higher ICERs in a cancer population, with possible implications for funding decisions.

Estimating lifetime medical costs from censored claims data

Claims databases consisting of routinely collected longitudinal records of medical expenditures are increasingly utilized for estimating expected medical costs of patients with a specific condition. Survival data of the patients of interest are usually highly censored, and observed expenditures are incomplete. In this study, we propose a survival-adjusted estimator for estimating mean lifetime costs, which integrates the product of the survival function and the mean cost function over the lifetime horizon. The survival function is estimated by a new algorithm of rolling extrapolation, aided by external information of age- and sex-matched referents simulated from national vital statistics. The mean cost function is estimated by a weighted average of mean expenditures of patients in a number of months prior to their death, of which the number could be determined by observed costs in their final months, and the weights depend on extrapolated hazards. We evaluate the performance of the proposed approach in comparison with that of a popular method using simulated data under various scenarios and 2 cohorts of intracerebral hemorrhage and ischemic stroke patients with a maximum follow-up of 13 years and conclude that our new method estimates the mean lifetime costs more accurately.

A cardiovascular disease policy model: part 2-preparing for economic evaluation and to assess health inequalities

Objectives

This is the second of the two papers introducing a cardiovascular disease (CVD) policy model. The first paper described the structure and statistical underpinning of the state-transition model, demonstrating how life expectancy estimates are generated for individuals defined by ASSIGN risk factors. This second paper describes how the model is prepared to undertake economic evaluation.

Design

To generate quality-adjusted life expectancy (QALE), the Scottish Health Survey was used to estimate background morbidity (health utilities) and the impact of CVD events (utility decrements). The SF-6D algorithm generated utilities and decrements were modelled using ordinary least squares (OLS). To generate lifetime hospital costs, the Scottish Heart Health Extended Cohort (SHHEC) was linked to the Scottish morbidity and death records (SMR) to cost each continuous inpatient stay (CIS). OLS and restricted cubic splines estimated annual costs before and after each of the first four events. A Kaplan-Meier sample average (KMSA) estimator was then used to weight expected health-related quality of life and costs by the probability of survival.

Results

The policy model predicts the change in QALE and lifetime hospital costs as a result of an intervention(s) modifying risk factors. Cost-effectiveness analysis and a full uncertainty analysis can be undertaken, including probabilistic sensitivity analysis. Notably, the impacts according to socioeconomic deprivation status can be made.

Conclusions

The policy model can conduct cost-effectiveness analysis and decision analysis to inform approaches to primary prevention, including individually targeted and population interventions, and to assess impacts on health inequalities.

Long-term costs of colorectal cancer treatment in Spain

BACKGROUND

Assessing the long-term cost of colorectal cancer (CRC) increases our understanding of the disease burden. The aim of this paper is to estimate the long-term costs of CRC care by stage at diagnosis and phase of care in the Spanish National Health Service.

METHODS

Retrospective study on resource use and direct medical cost of a cohort of 699 patients diagnosed and treated for CRC in 2000-2006, with follow-up until 30 June 2011, at Hospital del Mar (Barcelona). The Kaplan-Meier sample average estimator was used to calculate observed 11-year costs, which were then extrapolated to 16 years. Bootstrap percentile confidence intervals were calculated for the mean long-term cost per patient by stage. Phase-specific, long-term costs for the entire CRC cohort were also estimated.

RESULTS

With regard to stage at diagnosis, the mean long-term cost per patient ranged from €20,708 (in situ) to €47,681 (stage III). The estimated costs increased at more advanced stages up to stage III and then substantially decreased in stage IV. In terms of treatment phase, the mean cost of the initial period represented 24.8 % of the total mean long-term cost, whereas the cost of continuing and advanced care phases represented 16.9 and 58.3 %, respectively.

CONCLUSIONS

This study is the first to provide long-term cost estimates for CRC treatment, by stage at diagnosis and phase of care, based on data from clinical practice in Spain, and it will contribute useful information for future studies on cost-effectiveness and budget impact of different therapeutic innovations in Spain.

Cost-Effectiveness of Chemotherapy for Breast Cancer and Age Effect in Older Women

BACKGROUND

Previous economic evaluations compared specific chemotherapy agents using input parameters from clinical trials and resource utilization costs. Cost-effectiveness of treatment groups (drug classes) using community-level effectiveness and cost data, however, has not been assessed for elderly patients with breast cancer.

OBJECTIVE

To assess the cost-effectiveness of chemotherapy regimens by age and disease stage under "real-world" conditions for patients with breast cancer.

METHODS

The Surveillance Epidemiology and End Results-Medicare data were used to identify patients with breast cancer with American Joint Committee on Cancer stage I/II/IIIa, hormone receptor-negative (estrogen receptor-negative and progesterone receptor-negative) patients from 1992 to 2009. Patients were categorized into three adjuvant treatment groups: 1) no chemotherapy, 2) anthracycline, and 3) non-anthracycline-based chemotherapy. Median life-years and quality-adjusted life-years (QALYs) were measured using Kaplan-Meier analysis and were evaluated against average total health care costs (2013 US dollars).

RESULTS

A total of 4575 patients (propensity score-matched) were included for the primary analysis. The anthracycline group experienced 12.05 QALYs and mean total health care costs of $119,055, resulting in an incremental cost-effectiveness ratio of $7,688 per QALY gained as compared with the no chemotherapy group (QALYs 7.81; average health care cost $86,383). The non-anthracycline-based group was dominated by the anthracycline group with lower QALYs (9.56) and higher health care costs ($122,791). Base-case results were found to be consistent with the best-case and worst-case scenarios for utility assignments. Incremental cost-effectiveness ratios varied by age group (range $3,790-$90,405 per QALY gained).

CONCLUSIONS

Anthracycline-based chemotherapy was found cost-effective for elderly patients with early stage (stage I, II, IIIa) breast cancer considering the US threshold of $100,000 per QALY. Further research may be needed to characterize differential effects across age groups.

Cost-utility analysis of chemotherapy regimens in elderly patients with stage III colon cancer

BACKGROUND

Chemotherapy prolongs survival for stage III colon cancer patients but community-level evidence on the effectiveness and cost effectiveness of treatment for elderly patients is limited. Comparisons were between patients receiving no chemotherapy, 5-fluorouracil (5-FU), and FOLFOX (5-FU + oxaliplatin).

METHODS

A retrospective cohort study was conducted using the Surveillance Epidemiology, and End Results (SEER)-Medicare linked database. Patients (≥65 years) with American Joint Committee on Cancer stage III colon cancer at diagnosis in 2004-2009 were identified. The 3-way propensity score matched sample included 3,534 patients. Effectiveness was measured in life-years and quality-adjusted life-years (QALYs). Medicare costs (2010 US dollars) were estimated from diagnosis until death or end of study.

RESULTS

FOLFOX patients experienced 6.06 median life-years and 4.73 QALYs. Patients on 5-FU had 5.75 median life-years and 4.50 median QALYs, compared to 3.42 and 2.51, respectively, for the no chemotherapy patients. Average total healthcare costs ranged from US$85,422 for no chemotherapy to US$168,628 for FOLFOX. Incremental cost-effectiveness ratios (ICER) for 5-FU versus no chemotherapy were US$17,131 per life-year gained and US$20,058 per QALY gained. ICERs for FOLFOX versus 5-FU were US$139,646 per life-year gained and US$188,218 per QALY gained. Results appear to be sensitive to age, suggesting that FOLFOX performs better for patients 65-69 and 80+ years old while 5-FU appears most effective and cost effective for the age groups 70-74 and 75-79 years.

CONCLUSION

FOLFOX appears more effective and cost effective than other strategies for colon cancer treatment of older patients. Results were sensitive to age, with ICERs exhibiting a U-shaped pattern.

Modeling and validating the cost and clinical pathway of colorectal cancer

BACKGROUND

Cancer is a major cause of morbidity and mortality, and colorectal cancer (CRC) is the third most common cancer in the world. The estimated costs of CRC treatment vary considerably, and if CRC costs in a model are based on empirically estimated total costs of stage I, II, III, or IV treatments, then they lack some flexibility to capture future changes in CRC treatment. The purpose was 1) to describe how to model CRC costs and survival and 2) to validate the model in a transparent and reproducible way.

METHODS

We applied a semi-Markov model with 70 health states and tracked age and time since specific health states (using tunnels and 3-dimensional data matrix). The model parameters are based on an observational study at Oslo University Hospital (2049 CRC patients), the National Patient Register, literature, and expert opinion. The target population was patients diagnosed with CRC. The model followed the patients diagnosed with CRC from the age of 70 until death or 100 years. The study focused on the perspective of health care payers.

RESULTS

The model was validated for face validity, internal and external validity, and cross-validity. The validation showed a satisfactory match with other models and empirical estimates for both cost and survival time, without any preceding calibration of the model.

CONCLUSIONS

The model can be used to 1) address a range of CRC-related themes (general model) like survival and evaluation of the cost of treatment and prevention measures; 2) make predictions from intermediate to final outcomes; 3) estimate changes in resource use and costs due to changing guidelines; and 4) adjust for future changes in treatment and trends over time. The model is adaptable to other populations.

The societal gain of medical development and innovation in gastroenterology

BACKGROUND

Gastroenterology has over the past 30 years evolved very rapidly. The societal benefits to which this has led are incompletely determined, yet form a mandate to determine the need for future innovations and further development of the field. A more thorough understanding of societal benefits may help to determine future goals and improve decision making.

AIMS

The objective of this article is to determine the societal gains of medical innovations in the field of gastroenterology in the past and future, using peptic ulcer disease as an example of past innovation and the implementation of colorectal cancer screening as an illustration of future gains.

METHODS

Literature searches were performed for data on peptic ulcer and colorectal cancer epidemiology, treatment outcomes, and costs. National and governmental databases in the Netherlands were searched to obtain the input for calculations of quality-adjusted life years (QALYs), health-adjusted life expectancy (HALE), and the corresponding societal benefit.

RESULTS

Since 1980 the improvements in peptic ulcer treatment have had a limited impact on life expectancy, rising from 83.6 years to 83.7 years, but have led to a yearly gain of 46,000 QALYs, caused by improved quality of life. These developments in the field of peptic ulcer translated into a yearly gain of 1.8 billion to 7.8 billion euros in 2008 compared with the 1980s. Mortality due to colorectal cancer is high, with 21.6 deaths per 100,000 per year in the Netherlands (European Standardized Rate (ESR)). The future implementation of a nationwide call-recall colorectal cancer screening by means of biennial fecal immunochemical testing (FIT) is expected to result in a 50%-80% mortality reduction and thus a gain of an estimated 35,000 life years per year, corresponding to 26,000 QALYs per year. The effects of the implementation of FIT screening can be translated to a future societal gain of 1.0 billion to 4.4 billion euro.

CONCLUSIONS

The innovations and developments in the field of gastroenterology have led to significant societal gains in the past three decades. This process will continue in the near future as a result of further developments. These calculations provide a template for calculations on the need for specialist training as well as research and implementation of new developments in our field.

Economic studies in colorectal cancer: challenges in measuring and comparing costs

Estimates of the costs associated with cancer care are essential both for assessing burden of disease at the population level and for conducting economic evaluations of interventions to prevent, detect, or treat cancer. Comparisons of cancer costs between health systems and across countries can improve understanding of the economic consequences of different health-care policies and programs. We conducted a structured review of the published literature on colorectal cancer (CRC) costs, including direct medical, direct nonmedical (ie, patient and caregiver time, travel), and productivity losses. We used MEDLINE to identify English language articles published between 2000 and 2010 and found 55 studies. The majority were conducted in the United States (52.7%), followed by France (12.7%), Canada (10.9%), the United Kingdom (9.1%), and other countries (9.1%). Almost 90% of studies estimated direct medical costs, but few studies estimated patient or caregiver time costs or productivity losses associated with CRC. Within a country, we found significant heterogeneity across the studies in populations examined, health-care delivery settings, methods for identifying incident and prevalent patients, types of medical services included, and analyses. Consequently, findings from studies with seemingly the same objective (eg, costs of chemotherapy in year following CRC diagnosis) are difficult to compare. Across countries, aggregate and patient-level estimates vary in so many respects that they are almost impossible to compare. Our findings suggest that valid cost comparisons should be based on studies with explicit standardization of populations, services, measures of costs, and methods with the goal of comparability within or between health systems or countries. Expected increases in CRC prevalence and costs in the future highlight the importance of such studies for informing health-care policy and program planning.

Cost of illness in patients with metastatic colorectal cancer

OBJECTIVES

To estimate total costs and metastatic colorectal cancer (mCRC)-related costs and assess primary cost drivers of treating newly diagnosed mCRC patients after the introduction of biologic therapies.

METHODS

Using a large national claims database, costs of mCRC patients were estimated in 2004-2009 by examining (1) the cost difference between mCRC patient and their matched non-cancer cohorts, and (2) mCRC-related costs. Costs were further assessed by phase of disease (diagnostic, treatment, and death). The survival analysis technique was used to estimate cost of handling variable length of follow-up and data censoring.

RESULTS

A total of 6,746 mCRC patients met all eligibility criteria, 6,675 of them were matched to patients without cancer. Among the three phases of disease, the treatment phase was the longest (16.4 months). Compared with matched patients with no cancer, total monthly costs were $14,585 higher for mCRC patients, which was driven by higher inpatient ($7,546) and outpatient ($6,749) care (p < 0.001 for all comparisons). During the study period, cost share of biologics increased from 4.8% among patients diagnosed in 2004 to 9.4% for those diagnosed in 2008.

CONCLUSIONS

The costs associated with treating mCRC are substantial. Inpatient and outpatient care remain key cost drivers in the medical management of mCRC. Cost chare of biologics was low, but increased between 2004 and 2009. The study sample only included patients with commercial and Medicare supplemental insurance in the US thus may not be generalizable to patients with other insurance or in other countries. Indirect costs associated with mCRC were not examined.

Estimating lifetime or episode-of-illness costs under censoring

Many analyses of healthcare costs involve use of data with varying periods of observation and right censoring of cases before death or at the end of the episode of illness. The prominence of observations with no expenditure for some short periods of observation and the extreme skewness typical of these data raise concerns about the robustness of estimators based on inverse probability weighting (IPW) with the survival from censoring probabilities. These estimators also cannot distinguish between the effects of covariates on survival and intensity of utilization, which jointly determine costs. In this paper, we propose a new estimator that extends the class of two-part models to deal with random right censoring and for continuous death and censoring times. Our model also addresses issues about the time to death in these analyses and separates the survival effects from the intensity effects. Using simulations, we compare our proposed estimator to the inverse probability estimator, which shows bias when censoring is large and covariates affect survival. We find our estimator to be unbiased and also more efficient for these designs. We apply our method and compare it with the IPW method using data from the Medicare-SEER files on prostate cancer.

When budgets are tight, there are better options than colonoscopies for colorectal cancer screening

A critical challenge facing cancer screening programs, particularly those aimed at uninsured people with low incomes, is choosing the screening test that makes the most efficient use of limited budgets. For colorectal cancer screening, there is growing momentum to use colonoscopy, which is an expensive test. In this study, we modeled scenarios to assess whether the use of fecal occult blood tests or colonoscopy provides the most benefit under conditions of budget constraints. We found that although colonoscopy is more accurate, under most scenarios, fecal occult blood tests would result in more individuals' getting screened, with more life-years gained.

The impact of detection and treatment on lifetime medical costs for patients with precancerous polyps and colorectal cancer

Understanding the costs associated with early detection of disease is important for determining the fiscal implications of government-funded screening programs. We estimate the lifetime medical costs for patients with screen-detected versus undetected polyps and early-stage colorectal cancer. Typically, cost-effectiveness studies of screening account only for the direct costs of screening and cancer care. Our estimates include costs for unrelated conditions. We applied the Kaplan-Meier Smoothing Estimator to estimate lifetime costs for beneficiaries with screen-detected polyps and cancer. Phase-specific costs and survival probabilities were calculated from the Surveillance, Epidemiology, and End Results-Medicare database for Medicare beneficiaries aged >or=65. We estimate costs from the point of detection onward; therefore, our results do not include the costs associated with screening. We used a modified version of the model to estimate what lifetime costs for these patients would have been if the polyps or cancer remained undetected, based on assumptions about the 'lead time' for polyps and early-stage cancer. For younger patients, polyp removal is cost saving. Treatment of early-stage cancer is cost increasing.

Lifetime and treatment-phase costs associated with colorectal cancer: evidence from SEER-Medicare data

BACKGROUND & AIMS

This study provides detailed estimates of lifetime and phase-specific colorectal cancer (CRC) treatment costs.

METHODS

This retrospective cohort study included patients aged 66 years and older, newly diagnosed with CRC in a Surveillance Epidemiology and End Results (SEER) registry (1996-2002), matched 1:1 (by age, sex, and geographic region) to patients without cancer from a 5% sample of Medicare beneficiaries. The Kaplan-Meier sample average estimator was used to estimate observed 10-year costs, which then were extrapolated to 25 years. A secondary analysis computed costs on a per-survival-year basis to adjust for differences in mortality by stage and age. Costs were expressed in 2006 US$, with future costs discounted 3% per year.

RESULTS

Our sample included 56,838 CRC patients (41,256 colon cancer [CC] patients and 15,582 rectal cancer [RC] patients; mean +/- SD age, 77.7 +/- 7.1 y; 55% women; and 86% white). Lifetime excess costs were $29,500 for CC and $26,500 for RC patients. Per survival year, stage IV CRC patients incurred $31,000 in excess costs compared with $3000 for stage 0 patients. CRC patients incurred excess costs of $33,500 in the initial phase, $4500/y in the continuing phase, and $14,500 in the terminal phase. RC patients had lower costs than CC patients in the initial phase, but higher costs in both the continuing and terminal phases.

CONCLUSIONS

Excess costs associated with CRC are striking and vary considerably by treatment phase, cancer subsite, and stage at diagnosis. Interventions aimed at earlier diagnosis and prevention have the potential to reduce cancer-related health care costs.

Costs of cancer care in the USA: a descriptive review

Although many studies assessing the cost of cancer care have been conducted in the US, to date, these studies and the underlying methods used to estimate costs have not been reviewed systematically. We conducted a descriptive review of the published literature on the cost of cancer care in the US, and identified 60 papers published between 1995 and 2006 pertinent to our study. We found heterogeneity across the studies in terms of the settings, populations studied, measurement of costs, and study methods. We also identified limitations in the generalizability of findings, the misclassification of patient groups and costs, and concerns with study methods. Among studies that reported costs of cancer care in multiple phases of care and for multiple tumor sites, costs were generally highest in the initial year following diagnosis and the last year of life, and lower in the continuing phase (i.e. the period between the initial and last year of life phases), following a 'u-shaped' curve. Within phase of care, costs for lung and colorectal cancer care were generally higher than those for breast and prostate cancer care, however, the long-term or lifetime costs for each type of cancer were more similar, reflecting the differences in survival and costs in each phase between the different disease types.

Cost considerations in the treatment of colorectal cancer

Colorectal cancer is among the most common malignancies in developed countries. Screening can reduce mortality significantly, although the most appropriate method is still under debate. Observational studies have revealed that lifestyle measures may also be beneficial for prevention of colorectal cancer. Surgery is still the most effective treatment modality for colorectal cancer. The survival benefits of chemotherapy are only modest. For nearly 5 decades, 5-fluorouracil (5-FU) has been the main cytotoxic agent for treatment of colorectal cancer. In the last decade, the new cytotoxic agents raltitrexed, irinotecan and oxaliplatin have been introduced, next to the oral 5-FU analogues capecitabine and tegafur in combination with uracil (UFT). Moreover, the immunotherapeutics bevacizumab and cetuximab have become approved for treatment of metastatic colorectal cancer. The economic implications of colorectal cancer treatment are substantial. The costs of treatment are mainly attributable to the early and terminal stage of the disease (i.e. surgery, hospitalisation, chemo- and immunotherapy and supportive care). The introduction of new chemo- and immunotherapeutics has caused a continuing increase of treatment expenditures. Therefore, comparative costs and cost effectiveness are important for assessing the value of new treatment regimens. The available study results suggest that addition of irinotecan or oxaliplatin to 5-FU/folinic acid dosage regimens is cost effective. Also, capecitabine is calculated to be cost effective when compared with 5-FU/folinic acid. For UFT, no comparative studies of cost effectiveness were found. Since raltitrexed and 5-FU/folinic acid have shown equal efficacy in terms of survival, cost-effectiveness analysis is considered not to be applicable and cost-minimisation analysis may be sufficient. At present, pharmacoeconomic analyses of combination treatment with the immunotherapeutics bevacizumab or cetuximab are not available, except for recent cost-effectiveness considerations by the UK National Institute for Health and Clinical Excellence with negative recommendations for both agents in the treatment of metastatic colorectal cancer. Given the high treatment costs, substantial toxicity and relatively limited efficacy of the fast changing chemo- and immunotherapeutic combinations for colorectal cancer, examination of cost-effectiveness studies should be conducted on a routine basis along with determination of clinical benefits.

Xeloda® in Adjuvant Colon Cancer Therapy (X-ACT) Trial: Overview of Efficacy, Safety, and Cost-Effectiveness

The X-ACT (Xeloda in Adjuvant Colon Cancer Therapy) trial compared the efficacy and safety of the oral fluoropyrimidine capecitabine with bolus 5-fluorouracil (5-FU)/leucovorin (LV; Mayo Clinic regimen) as adjuvant therapy for stage III colon cancer. A total of 1987 patients were enrolled at 164 centers worldwide. Disease-free survival (primary study endpoint) in the capecitabine arm was at least equivalent to that in the 5-FU/LV arm; the upper limit of the hazard ratio was significantly (P < 0.001) below the predefined margins for noninferiority. Capecitabine was also associated with significantly fewer fluoropyrimidine-related grade 3/4 adverse events (AEs; P < 0.001) and fewer AE-related hospital admissions/days than 5-FU/LV. Pharmacoeconomic analyses performed in several countries show that the savings in direct costs (drug administration and AE-related costs) associated with capecitabine versus 5-FU/LV offset the acquisition costs of the drug. Furthermore, capecitabine reduces patient travel time and costs, making it a "dominant" strategy (ie, less costly and more effective) in the adjuvant setting. In conclusion, efficacy, safety, convenience, and cost findings from the X-ACT trial show that capecitabine offers at least equivalent clinical benefit compared with bolus 5-FU/LV and can replace intravenous 5-FU/LV in the adjuvant treatment of stage III colon cancer. The X-ACT trial has not only helped to better define the role of capecitabine but has also broadened the options available to patients with early-stage disease to include a uniquely effective oral outpatient treatment.

Pharmacoeconomic analysis of adjuvant oral capecitabine vs intravenous 5-FU/LV in Dukes' C colon cancer: the X-ACT trial

Oral capecitabine (Xeloda®) is an effective drug with favourable safety in adjuvant and metastatic colorectal cancer. Oxaliplatin-based therapy is becoming standard for Dukes' C colon cancer in patients suitable for combination therapy, but is not yet approved by the UK National Institute for Health and Clinical Excellence (NICE) in the adjuvant setting. Adjuvant capecitabine is at least as effective as 5-fluorouracil/leucovorin (5-FU/LV), with significant superiority in relapse-free survival and a trend towards improved disease-free and overall survival. We assessed the cost-effectiveness of adjuvant capecitabine from payer (UK National Health Service (NHS)) and societal perspectives. We used clinical trial data and published sources to estimate incremental direct and societal costs and gains in quality-adjusted life months (QALMs). Acquisition costs were higher for capecitabine than 5-FU/LV, but higher 5-FU/LV administration costs resulted in 57% lower chemotherapy costs for capecitabine. Capecitabine vs 5-FU/LV-associated adverse events required fewer medications and hospitalisations (cost savings £3653). Societal costs, including patient travel/time costs, were reduced by >75% with capecitabine vs 5-FU/LV (cost savings £1318), with lifetime gain in QALMs of 9 months. Medical resource utilisation is significantly decreased with capecitabine vs 5-FU/LV, with cost savings to the NHS and society. Capecitabine is also projected to increase life expectancy vs 5-FU/LV. Cost savings and better outcomes make capecitabine a preferred adjuvant therapy for Dukes' C colon cancer. This pharmacoeconomic analysis strongly supports replacing 5-FU/LV with capecitabine in the adjuvant treatment of colon cancer in the UK.

Estimating Costs of Care for Patients with Newly Diagnosed Metastatic Colorectal Cancer

BACKGROUND

This study examines the resource use patterns and costs of care for patients with incident metastatic colorectal cancer (mCRC) based on analyses of retrospective claims data from selected health plans in the United States.

PATIENTS AND METHODS

A case-control analysis was performed using claims from years 1998-2004. Incident mCRC cases were identified based on evidence of a colorectal cancer diagnosis and a metastatic disease diagnosis. Incident mCRC cases could have no other evidence of cancer in the 1-year period before the date of their first mCRC diagnosis. Cases were matched to non-mCRC controls based on age, sex, geographic region, and duration of plan enrollment. Costs were evaluated by phase of disease: diagnosis, treatment, or death phases. Ordinary least squares regressions were performed to evaluate impact of covariates in each phase.

RESULTS

Total costs in the follow-up period averaged $97,031 more for mCRC cases than for controls. The main cost drivers for mCRC were hospitalizations ($37,369) and specialist visits ($34,582), which included chemotherapy administration. Approximately 40% of the 672 patients with mCRC who qualified for the phase analysis were identified with a fatal event during follow-up. Monthly costs were similar in the diagnostic phase ($12,205) and death phase ($12,328), but were significantly lower in the treatment phase ($4722). Both mean/median monthly costs increased over time during the study period, regardless of disease phase.

CONCLUSION

The economic burden of mCRC is substantial for patients with commercial health plans in the United States, and costs of care have increased substantially in recent years.

Life expectancy and the value of early detection

This paper presents a model of the benefits and costs of early detection of asymptomatic disease as they vary by age. The benefits of early detection tend toward zero as the risk of death from competing causes increases. Costs per detected case also decline with age, assuming that disease incidence rises with age, but are always strictly positive. On balance, there is always an age limit beyond which the costs associated with early detection outweigh the benefits. Application of the model to prostate cancer screening suggests that early detection above age 70 or so is not cost-effective.

Long term medical costs of motor vehicle casualties in Alberta (1999): a population-based, incidence approach

The purpose of this paper is to estimate the long term medical costs attributable to motor vehicle accidents (MVAs) for all persons in Alberta, Canada in 1999, primarily using observational data. Injury claims with personal identifiers for 1999 were reported by the automobile insurance companies. These records were linked to the provincial health registry which covers the entire population. The registry is linked to databases which identify all inpatient and outpatient (including emergency room) visits, physician services, and other health records. Utilization and costs were derived for all casualties who were admitted to hospital or seen in an emergency room, and for a large sample of other (low severity) cases; a sample of matched controls was derived and their costs were also estimated. Actual costs were obtained for 3 years, and longer term costs were projected for subsequent years. Total costs attributable to MVAs were estimated at over $117 million for 1999. Average net costs per casualty, reported by severity group, were: $22.9 thousand for hospital cases; $3.6 thousand for emergency room-only cases; and $157 for other cases. Long term costs were 65% of first year costs for hospitalized cases and 250% for emergency room cases. Overall, aggregate costs for all non-hospital cases exceeded those for hospitalized cases.

An economic viewpoint on alternative strategies for identifying persons with hereditary nonpolyposis colorectal cancer

PURPOSE

There is uncertainty regarding the optimal strategy for identifying mutation carriers among those with hereditary nonpolyposis colorectal cancer (HNPCC).

METHODS

We used decision analysis to compare the cost-effectiveness of 4 strategies among those with newly diagnosed colon cancer: (1) clinical and family history followed by microsatellite instability testing and germline testing (Bethesda guidelines); (2) universal microsatellite instability testing; (3) germline testing of those who meet clinical and family history criteria; and (4) universal germline testing.

RESULTS

The added cost per year of life saved (YLS) for each strategy was as follows: (1) 11,865 US dollars/YLS, (2) 35,617 US dollars/YLS, (3) 49,702 US dollars/YLS, and (4) 267,548 US dollars/YLS.

CONCLUSIONS

The Bethesda guidelines are the most cost-effectiveness approach to screen persons for HNPCC.

Screening, prevention and socioeconomic costs associated with the treatment of colorectal cancer

Colorectal cancer (CRC), the third most prevalent cancer worldwide, imposes a significant economic and humanistic burden on patients and society. One study conservatively estimated the annual expenditures for colorectal cancer to be approximately dollars US 5.3 billion in 2000, including both direct and indirect costs. However, other investigators estimated inpatient costs alone incurred in the US in 1994 to be around dollars US 5.14 billion. Therefore, the economic burden of colorectal cancer in the US could be projected to be somewhere in the range of dollars US 5.5-6.5 billion by considering that inpatient costs approximate 80% of total direct costs. No worldwide data have been published, but assuming that the US represents 25-40% of total expenditures in oncology, as seen for breast and lung cancers, a rough estimate for colorectal cancer would be in the range of dollars US 14-22 billion. Screening helps increase patient survival by diagnosing colorectal cancer early. The ideal method among the four tests most used (faecal occult blood test, flexible sigmoidoscopy, colonoscopy and double contrast barium enema) has not been identified. Economic studies of colorectal cancer screening are complex because of the many variables involved, as well as the fact that the outcomes must be followed for many years, and the lack of consensus on screening guidelines. Intuitively, modelling colorectal cancer is one way to overcome these hurdles; published modelling studies predict colorectal cancer screening programs to be within the threshold of dollars US 40000 per life-year saved. The faecal occult blood test appears to be the only clearly effective test, both from a clinical and an economic viewpoint. Important limitations are the invasiveness and inconvenience of the screening procedures, except faecal occult blood test. Patients' comfort and satisfaction are essential in improving compliance with screening recommendations, which appears to be low even in the US (35% of the general population aged over 40 years and 60% of the high-risk population), the country with the highest awareness and compliance in the world. Since colorectal cancer is generally a disease of the elderly, its economic burden is expected to grow in the near future, mainly due to population aging. Potential avenues to pursue in order to contain or reduce the economic burden of colorectal cancer would be the design and implementation of efficient screening programmes, the improvement of patient awareness and compliance with screening guidelines, the development of appropriate prevention programs (i.e. primary and secondary), and earlier diagnosis.

Estimating health care costs related to cancer treatment from SEER-Medicare data

BACKGROUND

Cancer-specific medical care costs are used by health service researchers, medical decision analysts, and health care policymakers. The SEER-Medicare database is a unique data resource that makes it possible to derive incidence- and prevalence-based estimates of cancer-related medical care costs by site and stage of disease, by treatment approach, and for age and gender strata for individuals older than 65 years.

OBJECTIVES

This paper describes the cost-related data available in the SEER-Medicare database, and discusses techniques and methods that have been used to derive various cost estimates from these data. The limitations of SEER-Medicare data as a source of cost estimates are also discussed.

RESULTS

Examples of cost estimates for colorectal and breast cancer derived from SEER-Medicare are presented, including estimates of incidence-based cost (average cost per patient) by the initial, terminal, and continuing care phases of cancer treatment. Estimates of cancer-related treatment costs, costs by type of treatment, and long-term costs are presented, as are prevalence-based costs (aggregate Medicare and national expenditures) by cancer type.

Colorectal cancer screening: an overview of current trends

Colorectal cancer can be cured and, in some cases, even prevented if detected early through screening. Studies have demonstrated that regular screening for colorectal cancer with fecal occult blood testing, sigmoidoscopy, or colonoscopy can reduce mortality from this disease. Unfortunately, rates of participation in these screening tests are unacceptably low among the U.S. population. Nurses have a significant role to play in assisting individuals to incorporate regular colorectal cancer screening into their health maintenance routines.

Lifetime cancer-attributable cost of care for long term survivors of colorectal cancer

OBJECTIVES

We aimed to determine cancer-related medical care costs for long term survivors of colorectal cancer.

METHODS

The SEER-Medicare database was used to measure lifetime cancer-attributable costs of care for those with colorectal cancer surviving at least 5 yr versus age- and gender-matched controls. Costs were directly estimated, stratified by age at diagnosis and stage at diagnosis, for years 6-11 after diagnosis and then modeled to estimate lifetime costs. Cost differences between cancer cases and controls were compared to expected costs based on published guidelines for postcancer surveillance.

RESULTS

Lifetime medical costs for long term survivors (future years not discounted) were up to $19,516 higher than control costs, and were highest for younger age groups and those with early-stage disease. Excess costs for cancer survivors exceeded expected surveillance costs by $2,223-8,822 for years 6-10 from the date of initial diagnosis.

CONCLUSIONS

Cancer-attributable medical costs can be substantial for long term survivors, and exceed expected costs of surveillance. Future research is need to determine the components of excess cost in this survivor group.