The economic burden of cancer in the UK: a study of survivors treated with curative intent

Patient and Family Financial Burden in Cancer: A Focus on Differences across Four Provinces, and Reduced Spending Including Decisions to Forego Care in Canada

GOAL

This study aimed to examine provincial differences in patient spending for cancer care and reductions in household spending including decisions to forego care in Canada.

METHODS

Nine-hundred and one patients with cancer, from twenty cancer centers across Canada, completed a self-administered questionnaire (P-SAFE version 7.2.4) (344 breast, 183 colorectal, 158 lung, and 216 prostate) measuring direct and indirect costs and spending changes.

RESULTS

Provincial variations showed a high mean out-of-pocket cost (OOPC) of CAD 938 (Alberta) and a low of CAD 280 (Manitoba). Differences were influenced by age and income. Income loss was highest for Alberta (CAD 2399) and lowest for Manitoba (CAD 1126). Travel costs were highest for Alberta (CAD 294) and lowest for British Columbia (CAD 67). Parking costs were highest for Ontario (CAD 103) and lowest for Manitoba (CAD 53). A total of 41% of patients reported reducing spending, but this increased to 52% for families earning

CONCLUSIONS

Levels of financial burden for patients with cancer in Canada vary provincially, including for OOPC, travel and parking costs, and lost income. Decisions to forego cancer care are highest in relation to vitamins/supplements, CAM, and drugs. Provincial differences suggest that regional health policies and demographics may impact patients' overall financial burden.

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Key Words

• cancer
• financial burden
• financial toxicity
• foregone care
• out-of-pocket costs
• regional differences
• self-administered questionnaire

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MESH Headings

• Humans
• Neoplasms/economics
• Neoplasms/therapy
• Male
• Female
• Cost of Illness
• Middle Aged
• Aged
• Health Expenditures/statistics & numerical data
• Canada
• Surveys and Questionnaires
• Adult
• Manitoba

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Affiliation(s)

Christopher J. Longo DeGroote School of Business—Health Policy & Management, McMaster University, Hamilton, ON L8S 4L8, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada;
Tuhin Maity DeGroote School of Business—Health Policy & Management, McMaster University, Hamilton, ON L8S 4L8, Canada;
Margaret I. Fitch Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5S 1A1, Canada;
Jesse T. Young Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON M5T 1R8, Canada Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC 3052, Australia Centre for Adolescent Health, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia School of Population and Global Health, The University of Western Australia, Crawley, WA 6009, Australia Curtin School of Population Health, Curtin University, Bentley, WA 6102, Australia

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Out-of-pocket costs sustained in the last 12 months by cancer patients: an Italian survey-based study on individual expenses between 2017 and 2018

PURPOSE

Out of Pocket costs (OOP) sustained by cancer patients also in public NHS contribute to disease-related financial toxicity. Aim of the study was to investigate the amount and the types of OOP sustained by Italian cancer patients for care services.

METHODS

A sample survey was conducted by FAVO in December 2017-June 2018, in 39 adhering hospitals and 1289 patients diagnosed from 1985 to 2018, by standardized questionnaire inquiring on: yearly expenditure by cancer service, age, year of diagnosis, disease phase, cancer site, sex, marital status, education, residence. Univariate and multivariable regression analyses were performed between OOP and each variable. Multilevel mixed-effects negative binomial regression was used to assess the combined effects of patients characteristics on the differences in acquiring health services.

RESULTS

The yearly average OOP was 1841.81€, with the highest values for transports (359.34€) and for diagnostic examinations (259.82€). Significantly higher OOP were found in North and Centre than South and Islands (167.51 vs. 138.39). In the fully adjusted multivariable analysis, the variables significantly associated with higher than reference expenditure were: medium/high education (OR 1.22 [1.05-1.42], upper gastrointestinal tract cancer (OR 1.37 [1.06-1.77]), disease phase of treatments for cancer progression or pain therapy (OR 1.59 [1.30-1.93]).

CONCLUSION

Italian cancer patients in 2018 sustained OOP quite similar to those measured in 2012 to supplement NHS services. The main component of the OOP costs were diagnostic examination and transportation. The NHS should pay attention to potentiate its ability to answer unmet needs of patients with advanced cancer who are the most fragile ones.

IMPLICATIONS FOR CANCER SURVIVORS

Reinforcing the services where the main OOP expenses are located can help in promoting public health actions and reduce socio-economic needs that could compromise the receipt of optimal care along the whole disease course, from diagnosis to rehabilitation.

The Cancer Financial Experience (CAFÉ) study: randomized controlled trial of a financial navigation intervention to address cancer-related financial hardship

BACKGROUND

There is an urgent need for evidence on how interventions can prevent or mitigate cancer-related financial hardship. Our objectives are to compare self-reported financial hardship, quality of life, and health services use between patients receiving a financial navigation intervention versus a comparison group at 12 months follow-up, and to assess patient-level factors associated with dose received of a financial navigation intervention.

METHODS

The Cancer Financial Experience (CAFÉ) study is a multi-site randomized controlled trial (RCT) with individual-level randomization. Participants will be offered either brief (one financial navigation cycle, Arm 2) or extended (three financial navigation cycles, Arm 3) financial navigation. The intervention period for both Arms 2 and 3 is 6 months. The comparison group (Arm 1) will receive enhanced usual care. The setting for the CAFÉ study is the medical oncology and radiation oncology clinics at two integrated health systems in the Pacific Northwest. Inclusion criteria includes age 18 or older with a recent cancer diagnosis and visit to a study clinic as identified through administrative data. Outcomes will be assessed at 12-month follow-up. Primary outcomes are self-reported financial distress and health-related quality of life. Secondary outcomes are delayed or foregone care; receipt of medical financial assistance; and account delinquency. A mixed methods exploratory analysis will investigate factors associated with total intervention dose received.

DISCUSSION

The CAFÉ study will provide much-needed early trial evidence on the impact of financial navigation in reducing cancer-related financial hardship. It is theory-informed, clinic-based, aligned with patient preferences, and has been developed following preliminary qualitative studies and stakeholder input. By design, it will provide prospective evidence on the potential benefits of financial navigation on patient-relevant cancer outcomes. The CAFÉ trial's strengths include its broad inclusion criteria, its equity-focused sampling plan, its novel intervention developed in partnership with clinical and operations stakeholders, and mixed methods secondary analyses related to intervention dose offered and dose received. The resulting analytic dataset will allow for rich mixed methods analysis and provide critical information related to implementation of the intervention should it prove effective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05018000 . August 23, 2021.

Collection of cancer Patient Reported Outcome Measures (PROMS) to link with primary and secondary electronic care records to understand and improve long term cancer outcomes: A protocol paper

Introduction

More people are living with and beyond a cancer diagnosis. There is limited understanding of the long-term effects of cancer and cancer treatment on quality of life and personal and household finances when compared to people without cancer. In a separate protocol we have proposed to link de-identified data from electronic primary care and hospital records for a large population of cancer survivors and matched controls. In this current protocol, we propose the linkage of Patient Reported Outcomes Measures data to the above data for a subset of this population. The aim of this study is to investigate the full impact of living with and beyond a cancer diagnosis compared to age and gender matched controls. A secondary aim is to test the feasibility of the collection of Patient Reported Outcomes Measures (PROMS) data and the linkage procedures of the PROMs data to electronic health records data.

Materials and methods

This is a cross-sectional study, aiming to recruit participants treated at the Leeds Teaching Hospitals National Health Service Trust. Eligible patients will be cancer survivors at around 5 years post-diagnosis (breast, colorectal and ovarian cancer) and non-cancer patient matched controls attending dermatology out-patient clinics. They will be identified by running a query on the Leeds Teaching Hospitals Trust patient records system. Approximately 6000 patients (2000 cases and 4000 controls) will be invited to participate via post. Participants will be invited to complete PROMs assessing factors such as quality of life and finances, which can be completed on paper or online (surveys includes established instruments, and bespoke instruments (demographics, financial costs). This PROMs data will then be linked to routinely collected de-identified data from patient’s electronic primary care and hospital records.

Discussion

This innovative work aims to create a truly ‘comprehensive patient record’ to provide a broad picture of what happens to cancer patients across their cancer pathway, and the long-term impact of cancer treatment. Comparisons can be made between the cases and controls, to identify the aspects of life that has had the greatest impact following a cancer diagnosis. The feasibility of linking PROMs data to electronic health records can also be assessed. This work can inform future support offered to people living with and beyond a cancer diagnosis, clinical practice, and future research methodologies.

Sociodemographic and health factors associated with the risk of financial catastrophe when informal care for patients with haematological neoplasms is replaced by formal care

BACKGROUND

Cancer is one of the diseases with the highest incidence and mortality in the world, and one that requires greater care (formal and informal). At present, the traditional informal caregiver is disappearing. The objective is to analyse the sociodemographic and health factors associated with the possible catastrophic financial effect on households of replacing informal care by formal care for patients with blood cancer, during the different stages of treatment in Spain.

METHODS

A total of 139 patients with haematological neoplasm who underwent stem cell transplantation completed a longitudinal questionnaire during each of three treatment phases. Of this population, 88.49% received informal care. The households were classified into those where the replacement of informal care with formal care would impose a financial burden exceeding 40% of equivalent household income, versus those who would not suffer this consequence. Three logistic regression models (one for each treatment phase) were estimated and the corresponding marginal effects determined.

RESULTS

The factors associated with a higher probability of financial catastrophe were married marital status, low education level, fair to very poor self-perceived health status, the diagnosis of leukaemia in the pre-transplant and first-year post-transplant phases and of multiple myeloma disease in the final post-transplant phase.

CONCLUSIONS

These findings reveal the need to design social policies to meet the care needs of patients with blood cancer which at present are covered by informal care. Given the foreseeable elimination of this option, these families must be protected from the financial burden incurred from the use of privately-contracted assistance.

The economic impact of cancer diagnosis to individuals and their families: a systematic review

Background

The effect of a cancer diagnosis is wide-ranging with the potential to affect income, employment and risk of poverty. The aim of this systematic review is to identify the economic impact of a cancer diagnosis for patients and their families/caregivers.

Methods

The search covered peer-reviewed journals using MEDLINE, EMBASE, CINAHL, Cochrane Library, Epistemonikos and PsycINFO databases. Quality appraisal was undertaken using CASP tools. Monetary values were converted to US Dollars/2019 using a purchasing power parities (PPP) conversion factor. The review included articles up to and including January 2020, written in English language, for patients with cancer aged ≥ 18 years and focused on the costs up to 5 years following a cancer diagnosis.

Results

The search was run in January 2020 and updated in November 2021. Of the 7973 articles identified, 18 met the inclusion criteria. Studies were undertaken in the USA, Ireland, Canada, Australia, France, UK, Malaysia, Pakistan, China and Sri Lanka. The majority were cohort studies. Twelve reported out-of-pocket costs (range US$16–US$2523/month per patient/caregiver) consisting of medical expenses (e.g. surgery, radiotherapy and chemotherapy) and non-medical expenses (e.g. travel, food and childcare). Fourteen studies reported patient/caregiver loss of income and lost productivity (range 14–57.8%).

Conclusions

A high percentage of cancer patients and their families/caregivers experience out-of-pocket expenditure, loss of income and lost productivity. Future research is needed to observe the effects of continuing changes to healthcare policies and social protections on the economic burden among cancer patients and their families/caregivers.

The burden of colorectal cancer survivors in the Netherlands: costs, utilities, and associated patient characteristics

Purpose

The aim of this study is to assess the societal burden of colorectal cancer (CRC) survivorship 2–10 years post-diagnosis in terms of (1) societal costs, and (2) quality of life/utilities, and to analyze associated patient characteristics.

Methods

This is a cross-sectional, bottom-up prevalence-based burden of disease study, conducted from a societal perspective in the Netherlands. In total, 155 CRC survivors were included. Utilities were measured by the EQ-5D-5L, using the Dutch tariffs. A cost questionnaire was developed to obtain cost information. Subgroup analyses were performed, based on patient characteristics and sensitivity analyses.

Results

Of all CRC survivors, 81(54%) reported no problems for mobility, 133(88%) for self-care, 98(65%) for daily activities, 59(39%) for pain/discomfort, and 112(74%) for anxiety/depression on the EQ-5D-5L. The average EQ-5D-5L utility score was 0.82 (SD = 0.2) on a scale from 0 (death) to 1 (perfect health). Significant differences in utility score were found for gender, tumor stage, number of comorbidities, and lifestyle score. The average societal costs per CRC survivor per 6 months were estimated at €971 (min = €0, max = €32,425). Significant differences in costs were found for the number of comorbidities.

Conclusions

This study shows a considerable burden of CRC survivors 2–10 years after diagnosis, in comparison with survivors sooner after diagnosis and with healthy individuals in the Netherlands.

Implications for Cancer Survivors

Long-term care of CRC survivors should focus on improving the societal burden by identifying modifiable factors, as summarized in the WCRF/AICR lifestyle score, including body composition, physical activity, and diet.

Patient and family financial burden associated with cancer treatment in Canada: a national study

GOAL

To determine patient-reported financial and family burden associated with treatment of cancer in the previous 28 days across Canada.

METHODS

A self-administered questionnaire (P-SAFE v7.2.4) was completed by 901 patients with cancer from twenty cancer centres nationally (344 breast, 183 colorectal, 158 lung, 216 prostate) measuring direct and indirect costs related to cancer treatment and foregone care. Monthly self-reported out-of-pocket-costs (OOPCs) included drugs, homecare, homemaking, complementary/ alternative medicines, vitamins/supplements, family care, accommodations, devices, and "other" costs. Travel and parking costs were captured separately. Patients indicated if OOPC, travel, parking, and lost income were a financial burden.

RESULTS

Mean 28-day OOPCs were CA$518 (US Purchase Price Parity [PPP] $416), plus CA$179 (US PPP $144) for travel and CA$84 (US PPP $67) for parking. Patients self-reporting high financial burden had total OOPCs (33%), of CA$961 (US PPP $772), while low-burden participants (66%) had OOPCs of CA$300 (US PPP $241). "Worst burden" respondents spent a mean of 50.7% of their monthly income on OOPCs (median 20.8%). Among the 29.4% who took time off work, patients averaged 18.0 days off. Among the 26.0% of patients whose caregivers took time off work, caregivers averaged 11.5 days off. Lastly, 41% of all patients had to reduce spending. Fifty-two per cent of those who reduced spending were families earning < CA$50,000/year.

CONCLUSIONS

In our Canadian sample, high levels of financial burden exist for 33% of patients, and the severity of burden is higher for those with lower household incomes.

The Out-of-Pocket Cost Burden of Cancer Care-A Systematic Literature Review

BACKGROUND

Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care.

METHODS

A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs.

RESULTS

Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15-400 in Canada, USD 4-609 in Western Europe, and USD 58-438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40-71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively.

CONCLUSIONS

We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care.

Out-of-Pocket Costs and Perceived Financial Burden Associated with Prostate Cancer Treatment in a Quebec Remote Area: A Cross-Sectional Study

Background: In publicly funded healthcare systems, patients do not pay for medical visits but can experience costs stemming from travel or over-the-counter drugs. We lack information about the extent of this burden in Canadian remote regions. This study aimed to: (1) describe prostate cancer-related out-of-pocket costs and perceived financial burden, and (2) identify factors associated with such a perceived burden among prostate cancer patients living in a remote region of the province of Quebec (Canada). Methods: A cross-sectional study was conducted among 171 prostate cancer patients who consulted at the outpatient clinic of the Centre Hospitalier de Rouyn-Noranda. Results: The majority of patients (83%) had incurred out-of-pocket costs for their cancer care. The mean total cost incurred in the last three months was $517 and 22.3% reported a moderate, considerable or unsustainable burden. Multivariable analysis revealed that having incurred higher cancer-related out-of-pocket costs (OR: 1.001; 95%CI: 1.001-1.002) private drug insurance (vs. public, OR: 5.23; 95%CI: 1.13-24.17) was associated with a greater perceived financial burden. Having better physical health-related quality of life (OR: 0.95; 95%CI: 0.913-0.997), a university education (vs. elementary/high school level, OR: 0.03; 95%CI: 0.00-0.79), and an income between $40,000 and $79,999 (vs. ≤ $39,999, OR: 0.15; 95%CI: 0.03-0.69) were associated with a lower perceived burden. Conclusion: Prostate cancer patients incur out-of-pocket costs even if they were diagnosed many years ago and the perceived burden is significant. Greater attention should be paid to the development of services to help patients manage this burden.

Financial toxicity associated with a cancer diagnosis in publicly funded healthcare countries: a systematic review

PURPOSE

Financial toxicity related to cancer diagnosis and treatment is a common issue in developed countries. We seek to systematically summarize the extent of the issue in very high development index countries with publicly funded healthcare.

METHODS

We identified articles published Jan 1, 2005, to March 7, 2019, describing financial burden/toxicity experienced by cancer patients and/or informal caregivers using OVID Medline Embase and PsychInfo, CINAHL, Business Source Complete, and EconLit databases. Only English language peer-reviewed full papers describing studies conducted in very high development index countries with predominantly publicly funded healthcare were eligible (excluded the USA). All stages of the review were evaluated in teams of two researchers excepting the final data extraction (CJL only).

RESULTS

The searches identified 7117 unique articles, 32 of which were eligible. Studies were undertaken in Canada, Australia, Ireland, UK, Germany, Denmark, Malaysia, Finland, France, South Korea, and the Netherlands. Eighteen studies reported patient/caregiver out-of-pocket costs (range US$17-US$506/month), 18 studies reported patient/caregiver lost income (range 17.6-67.3%), 14 studies reported patient/caregiver travel and accommodation costs (range US$8-US$393/month), and 6 studies reported financial stress (range 41-48%), strain (range 7-39%), or financial burden/distress/toxicity among patients/caregivers (range 22-27%). The majority of studies focused on patients, with some including caregivers. Financial toxicity was greater in those with early disease and/or more severe cancers.

CONCLUSIONS

Despite government-funded universal public healthcare, financial toxicity is an issue for cancer patients and their families. Although levels of toxicity vary between countries, the findings suggest financial protection appears to be inadequate in many countries.

Regional multidisciplinary team intervention programme to improve colorectal cancer outcomes: study protocol for the Yorkshire Cancer Research Bowel Cancer Improvement Programme (YCR BCIP)

INTRODUCTION

Although colorectal cancer outcomes in England are improving, they remain poorer than many comparable countries. Yorkshire Cancer Research has, therefore, established a Bowel Cancer Improvement Programme (YCR BCIP) to improve colorectal cancer outcomes within Yorkshire and Humber, a region representative of the nation. It aims to do this by quantifying variation in practice, engaging with the colorectal multidisciplinary teams (MDTs) to understand this and developing educational interventions to minimise it and improve outcomes.

METHODS AND ANALYSIS

Initially, routine health datasets will be used to quantify variation in the demographics, management and outcomes of patients across the Yorkshire and Humber region and results presented to MDTs. The YCR BCIP is seeking to supplement these existing data with patient-reported health-related quality of life information (patient-reported outcome measures, PROMs) and tissue sample analysis. Specialty groups (surgery, radiology, pathology, clinical oncology, medical oncology, clinical nurse specialists and anaesthetics) have been established to provide oversight and direction for their clinical area within the programme, to review data and analysis and to develop appropriate educational initiatives.

ETHICS AND DISSEMINATION

The YCR BCIP is aiming to address the variation in practice to significantly improve colorectal cancer outcomes across the Yorkshire and Humber region. PROMs and tissue sample collection and analysis will help to capture the information required to fully assess care in the region. Engagement of the region's MDTs with their data will lead to a range of educational initiatives, studies and clinical audits that aim to optimise practice across the region.

Identifying the most prevalent unmet needs of cancer survivors in Australia: A systematic review

Understanding the unmet needs of cancer survivors is crucial to inform health service planning and optimize survivorship care. This systematic review sought to identify the most prevalent unmet needs of cancer survivors in Australia, and to determine personal, disease, and treatment-related variables correlated with unmet needs. Seventeen studies were included in the review. Substantial heterogeneity across the included studies precluded statistical pooling of the data; narrative synthesis and vote counting were used to synthesize results. Unmet needs were ranked by the number of endorsements (n) each item received. The most frequently reported unmet needs of Australian cancer survivors are for help with psychosocial issues, including fear of cancer recurrence (n = 14; 14-42%), uncertainty about the future (n = 9; 12-26%), worry about partners, friends, and families (n = 8; 12-26%), help to reduce stress (n = 8; 12-34%), and sexual changes (n = 7; 11-29%). Survivors also needed more help with physical issues, including fatigue (n = 7; 10-27%) and usual activities (n = 6; 13-27%), and expressed supportive care unmet needs, including for affordable hospital car parking (n = 7; 12-26%), information about available services (n = 7; 11-33%), and peer support (n = 6; 13-26%). Anxiety, depression, and lower overall and physical quality of life were significantly correlated with greater unmet needs, as were younger age and more advanced disease.

Workflow Requirements for Cost-of-Care Conversations in Outpatient Settings Providing Oncology or Primary Care: A Qualitative, Human-Centered Design Study

BACKGROUND

Patients prefer to discuss costs in the clinical setting, but physicians and teams may be unprepared to incorporate cost discussions into existing workflows.

OBJECTIVE

To understand and improve clinical workflows related to cost-of-care conversations.

DESIGN

Qualitative human-centered design study.

SETTING

2 integrated health systems in the U.S. Pacific Northwest: a system-wide oncology service line and a system-wide primary care service line.

PARTICIPANTS

Clinicians, clinical team members, operations staff, and patients.

MEASUREMENTS

Ethnographic observations were made at the integrated health systems, assessing barriers to and facilitators of discussing costs with patients. Three unique patient experiences of having financial concerns addressed in the clinic were designed. These experiences were refined after in-person interviews with patients (n = 20). Data were synthesized into a set of clinical workflow requirements.

RESULTS

Most patient cost concerns take 1 of 3 pathways: informing clinical care decision making, planning and budgeting concerns, and addressing immediate financial hardship. Workflow requirements include organizational recognition of the need for clinic-based cost-of-care conversations; access to cost and health plan benefit data to support each conversation pathway; clear team member roles and responsibilities for addressing cost-of-care concerns; a patient experience where cost questions are normal and each patient's preferences and privacy are respected; patients know who to go to with cost questions; patients' concerns are documented to minimize repetition to multiple team members; and patients learn their expected out-of-pocket costs before treatment begins.

LIMITATION

Results may have limited generalizability to other health care settings, and the study did not test the effectiveness of the workflows developed.

CONCLUSION

Clinic-based workflows for cost-of-care conversations that optimize patients' care experience require organizational commitment to addressing cost concerns, clear roles and responsibilities, appropriate and complete data access, and a team-based approach.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

An Educational Review About Using Cost Data for the Purpose of Cost-Effectiveness Analysis

This paper provides an educational review covering the consideration of costs for cost-effectiveness analysis (CEA), summarising relevant methods and research from the published literature. Cost data are typically generated by applying appropriate unit costs to healthcare resource-use data for patients. Trial-based evaluations and decision analytic modelling represent the two main vehicles for CEA. The costs to consider will depend on the perspective taken, with conflicting recommendations ranging from focusing solely on healthcare to the broader 'societal' perspective. Alternative sources of resource-use are available, including medical records and forms completed by researchers or patients. Different methods are available for the statistical analysis of cost data, although consideration needs to be given to the appropriate methods, given cost data are typically non-normal with a mass point at zero and a long right-hand tail. The choice of covariates for inclusion in econometric models also needs careful consideration, focusing on those that are influential and that will improve balance and precision. Where data are missing, it is important to consider the type of missingness and then apply appropriate analytical methods, such as imputation. Uncertainty around costs should also be reflected to allow for consideration on the impacts of the CEA results on decision uncertainty. Costs should be discounted to account for differential timing, and are typically inflated to a common cost year. The choice of methods and sources of information used when accounting for cost information within CEA will have an effect on the subsequent cost-effectiveness results and how information is presented to decision makers. It is important that the most appropriate methods are used as overlooking the complicated nature of cost data could lead to inaccurate information being given to decision makers.

Realist evaluation of cancer rehabilitation services in South Wales (REEACaRS): a mixed methods study protocol

INTRODUCTION

Long-term and late effects of cancer treatments can cause functional limitations and reduce quality of life. Cancer rehabilitation services, which can comprise physical exercise, psychological support and educational interventions depending on the individual's needs, have been found to have a positive effect on health-related quality of life worldwide. However, accessibility or the lack of awareness on available help can act as barriers and influence the uptake of services, resulting in people having unmet rehabilitation needs. In Wales, UK, 41% of people, who have had health and social care needs resulting from cancer and its treatments, reported that they did not receive care when needed. The reason for this lack of support has not yet been fully investigated. The aim of this study is to investigate the conditions in which cancer rehabilitation services work and their underpinning mechanisms in South Wales, UK, specifically addressing barriers, facilitators and costs.

METHODS AND ANALYSIS

Realist evaluation, which explains for whom a service works in what circumstances and how through context-mechanism-outcome pattern conjunctions, will be used in three phases to investigate the conditions in which cancer rehabilitation services work and their underpinning mechanisms. Phase 1 will be secondary analysis of a cancer rehabilitation database from a local Health Board to give context to who are accessing rehabilitation. Phase 2 will be thematic analysis of face-to-face, semistructured rehabilitation participant (n=20) and healthcare professional (n=20) interviews to explore the mechanisms of how cancer rehabilitation works. Phase 3 will be two case studies and cost-consequences analysis of cancer rehabilitation services.

ETHICS AND DISSEMINATION

This study received favourable ethical opinion from London South-East Research Ethics Committee (17/LO/2123) in December 2017. This project is part of the author's PhD thesis and it is expected that the findings will be disseminated in academic journals and at local and international conferences.

Literature review of the burden of prostate cancer in Germany, France, the United Kingdom and Canada

BACKGROUND

Prostate cancer is the most frequently reported cancer in males in Europe, and is associated with substantial morbidity and mortality. The aim of the current review was to characterize the clinical, economic and humanistic burden of disease associated with prostate cancer in France, Germany, the UK and Canada.

METHODS

Literature searches were conducted using the PubMed, EMBASE and Cochrane Library databases to identify studies reporting incidence and/or mortality rates, costs and health state utilities associated with prostate cancer in the settings of interest. For inclusion, studies were required to be published in English in full-text form from 2006 onwards.

RESULTS

Incidence studies showed that in all settings the incidence of prostate cancer has increased substantially over the past two decades, driven in part by increased uptake of prostate specific antigen (PSA) screening leading to earlier identification of tumors, but which has also led to over-treatment, compounding the economic burden of disease. Mortality rates have declined over the same time frame, driven by earlier detection and improvements in treatment. Both prostate cancer itself, as well as treatment and treatment-related complications, are associated with reduced quality of life.

CONCLUSIONS

Prostate cancer is associated with a significant clinical and economic burden, whilst earlier detection and aggressive treatment is associated with improved survival, over-treatment of men with indolent tumors compounds the already significant burden of disease and treatment can lead to long-term side effects including impotence and impaired urinary and/or bowel function. There is currently an unmet clinical need for diagnostic and/or prognostic tools that facilitate personalized prostate cancer treatment, and potentially reduce the clinical, economic and humanistic burden of invasive cancer treatment.

Self-reported and routinely collected electronic healthcare resource-use data for trial-based economic evaluations: the current state of play in England and considerations for the future

BACKGROUND

Randomised controlled trials (RCTs) are generally regarded as the "gold standard" for providing quantifiable evidence around the effectiveness and cost-effectiveness of new healthcare technologies. In order to perform the economic evaluations associated with RCTs, there is a need for accessible and good quality resource-use data; for the purpose of discussion here, data that best reflect the care received. Traditionally, researchers have developed questionnaires for resource-use data collection. However, the evolution of routinely collected electronic data within care services provides new opportunities for collecting data without burdening patients or caregivers (e.g. clinicians). This paper describes the potential strengths and limitations of each data collection method and then discusses aspects for consideration before choosing which method to use.

MAIN TEXT

We describe electronic data sources (large observational datasets, commissioning data, and raw data extraction) that may be suitable data sources for informing clinical trials and the current status of self-reported instruments for measuring resource-use. We assess the methodological risks and benefits, and compare the two methodologies. We focus on healthcare resource-use; however, many of the considerations have relevance to clinical questions. Patient self-report forms a pragmatic and cheap method that is largely under the control of the researcher. However, there are known issues with the validity of the data collected, loss to follow-up may be high, and questionnaires suffer from missing data. Routinely collected electronic data may be more accurate and more practical if large numbers of patients are involved. However, datasets often incur a cost and researchers are bound by the time for data approval and extraction by the data holders.

CONCLUSIONS

Owing to the issues associated with electronic datasets, self-reported methods may currently be the preferred option. However, electronic hospital data are relatively more accessible, informative, standardised, and reliable. Therefore in trials where secondary care constitutes a major driver of patient care, detailed electronic data may be considered superior to self-reported methods; with the caveat of requiring data sharing agreements with third party providers and potentially time-consuming extraction periods. Self-reported methods will still be required when a 'societal' perspective (e.g. quantifying informal care) is desirable for the intended analysis.

Core Items for a Standardized Resource Use Measure: Expert Delphi Consensus Survey

BACKGROUND

Resource use measurement by patient recall is characterized by inconsistent methods and a lack of validation. A validated standardized resource use measure could increase data quality, improve comparability between studies, and reduce research burden.

OBJECTIVES

To identify a minimum set of core resource use items that should be included in a standardized adult instrument for UK health economic evaluation from a provider perspective.

METHODS

Health economists with experience of UK-based economic evaluations were recruited to participate in an electronic Delphi survey. Respondents were asked to rate 60 resource use items (e.g., medication names) on a scale of 1 to 9 according to the importance of the item in a generic context. Items considered less important according to predefined consensus criteria were dropped and a second survey was developed. In the second round, respondents received the median score and their own score from round 1 for each item alongside summarized comments and were asked to rerate items. A final project team meeting was held to determine the recommended core set.

RESULTS

Forty-five participants completed round 1. Twenty-six items were considered less important and were dropped, 34 items were retained for the second round, and no new items were added. Forty-two respondents (93.3%) completed round 2, and greater consensus was observed. After the final meeting, 10 core items were selected, with further items identified as suitable for "bolt-on" questionnaire modules.

CONCLUSIONS

The consensus on 10 items considered important in a generic context suggests that a standardized instrument for core resource use items is feasible.

The Suspected CANcer (SCAN) pathway: protocol for evaluating a new standard of care for patients with non-specific symptoms of cancer

INTRODUCTION

Cancer survival in England lags behind most European countries, due partly to lower rates of early stage diagnosis. We report the protocol for the evaluation of a multidisciplinary diagnostic centre-based pathway for the investigation of 'low-risk but not no-risk' cancer symptoms called the Suspected CANcer (SCAN) pathway. SCAN is a new standard of care being implemented in Oxfordshire; one of a number of pathways implemented during the second wave of the Accelerate, Coordinate, Evaluate (ACE) programme, an initiative which aims to improve England's cancer survival rates through establishing effective routes to early diagnosis.

METHODS AND ANALYSIS

To evaluate SCAN, we are collating a prospective database of patients referred onto the pathway by their general practitioner (GP). Patients aged over 40 years, with non-specific symptoms such as weight loss or fatigue, who do not meet urgent cancer referral criteria or for whom symptom causation remains unclear after investigation via other existing pathways, can be referred to SCAN. SCAN provides rapid CT scanning, laboratory testing and clinic review within 2 weeks. We will follow all patients in the primary and secondary care record for at least 2 years. The data will be used to understand the diagnostic yield of the SCAN pathway in the short term (28 days) and the long term (2 years). Routinely collected primary and secondary care data from patients not referred to SCAN but with similar symptoms will also be used to evaluate SCAN. We will map the routes to diagnosis for patients referred to SCAN to assess cost-effectiveness. Acceptability will be evaluated using patient and GP surveys.

ETHICS AND DISSEMINATION

The Oxford Joint Research Office Study Classification Group has judged this to be a service evaluation and so outside of research governance. The results of this project will be disseminated by peer-reviewed publication and presentation at conferences.

Financial Impact of Colorectal Cancer and Its Consequences: Associations Between Cancer-Related Financial Stress and Strain and Health-Related Quality of Life

BACKGROUND

The financial impact and consequences of cancer on the lives of survivors remain poorly understood. This is especially true for colorectal cancer.

OBJECTIVE

We investigated objective cancer-related financial stress, subjective cancer-related financial strain, and their association with health-related quality of life in colorectal cancer survivors.

DESIGN

This was a cross-sectional postal survey.

SETTINGS

The study was conducted in Ireland, which has a mixed public-private healthcare system.

PATIENTS

Colorectal cancer survivors, diagnosed 6 to 37 months prior, were identified from the population-based National Cancer Registry.

MAIN OUTCOME MEASURES

Cancer-related financial stress was assessed as impact of cancer on household ability to make ends meet and cancer-related financial strain by feelings about household financial situation since cancer diagnosis. Health-related quality of life was based on European Organisation for Research and Treatment of Cancer QLQ-C30 global health status. Logistic regression was used to identify associations between financial stress and strain and low health-related quality of life (lowest quartile, score ≤50).

RESULTS

A total of 493 survivors participated. Overall, 41% reported cancer-related financial stress and 39% cancer-related financial strain; 32% reported both financial stress and financial strain. After adjustment for sociodemographic and clinical variables, the odds of low health-related quality of life were significantly higher in those who reported cancer-related financial stress postdiagnosis compared with those who reported no change in financial stress postcancer (OR = 2.54 (95% CI, 1.62-3.99)). The odds of low health-related quality of life were also significantly higher in those with worse financial strain postdiagnosis (OR =1.73 (95% CI, 1.09-2.72)). The OR for those with both cancer-related financial stress and financial strain was 2.59 (95% CI, 1.59-4.22).

LIMITATIONS

Survey responders were younger, on average, than nonresponders. Responders and nonresponders may have differed in cancer-related financial stress and strain or health-related quality of life.

CONCLUSIONS

Four in 10 colorectal cancer survivors reported an adverse financial impact of cancer. Cancer-related financial stress and strain were significantly associated with low health-related quality of life. To inform support strategies, additional research is needed to better understand how both objective and subjective financial distress influence survivors' health-related quality of life. See Video Abstract http://links.lww.com/DCR/A447.

Ultrasound imaging of splenomegaly as a proxy to monitor colon tumor development in Apc(min716/+) mice

Animal models of colon cancer are widely used to understand the molecular mechanisms and pathogenesis of the disease. These animal models require a substantial investment of time and traditionally necessitate the killing of the animal to measure the tumor progression. Several in vivo imaging techniques are being used in both human clinics and preclinical studies, albeit at high cost and requiring particular expertise. Here, we report that the progression of splenomegaly coincides with and positively correlates to colon tumor development in Apc^min716/+ mice expressing a mutant gene encoding an adenomatous polyposis coli protein truncated at amino acid 716. Ultrasound image‐based spleen size measurement precisely mirrors splenomegaly development in vivo in the tumor‐laden Apc^min716/+ mice. Moreover, the spleen dimensions extracted from the ultrasound sonograms are positively correlated with normalized spleen weight and the number and area of colon tumors. Hence, we propose measuring the spleen size in vivo by ultrasound imaging as a novel approach to estimate splenomegaly development and to indirectly monitor colon tumor development in Apc^min716/+ mice. The widespread use of ultrasound machines in the laboratory setting, coupled with the fact that it is a noninvasive method, make it a straightforward and useful tool for monitoring the experimental progress of colon cancer in mice and determining end points without killing animals strictly for diagnostics purposes.

Frequency of psycho-oncologic and social service counseling in cancer centers relative to center site and hospital characteristics: Findings from 879 center sites in Germany, Austria, Switzerland, and Italy

BACKGROUND

There is extensive evidence that patients with cancer and cancer survivors have a strong need for expert support in relation to the psychological and social consequences of the disease. The requirements set out in the German Cancer Society's cancer center certification system include the routine provision of psycho-oncologic care (POC) and social service counseling for every patient. The current study investigated which organizational and structural characteristics in hospitals account for variations in psychosocial care provision in these centers.

METHODS

Data routinely collected during the certification process regarding the percentages of psychosocial care provision and characteristics of center sites and hospitals were matched with data with regard to size of the municipality, teaching hospital status, and institutional ownership. Linear multilevel regression analyses were performed to identify the characteristics of hospitals and center sites that were related to psychosocial care provision.

RESULTS

Substantial differences were found for different types of cancer (eg, a greater provision of psychosocial care in centers specializing in breast rather than prostate cancer). There was more POC provision in longer-certified centers and less in rural areas and university hospitals. Much of the variation between hospitals remains unexplained.

CONCLUSIONS

Although the implementation of mandatory psychosocial services generally provides patients with access to POC and social service counseling, the wide differences in the provision of counseling indicate that additional measures are needed to avoid inequalities resulting from the center at which a patient receives cancer treatment. Cancer 2016;122:3538-3545. © 2016 American Cancer Society.