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Ehsan AN, Wu CA, Minasian A, Singh T, Bass M, Pace L, Ibbotson GC, Bempong-Ahun N, Pusic A, Scott JW, Mekary RA, Ranganathan K. Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2255388. [PMID: 36753274 PMCID: PMC9909501 DOI: 10.1001/jamanetworkopen.2022.55388] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/20/2022] [Indexed: 02/09/2023] Open
Abstract
Importance Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments. Objective To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally. Data Sources A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022. Study Selection A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review. Data Extraction and Synthesis A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model. Main Outcomes and Measures FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis. Results Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries. Conclusions and Relevance Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.
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Affiliation(s)
- Anam N. Ehsan
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Catherine A. Wu
- Harvard Medical School, Boston, Massachusetts
- Department of Plastic Surgery, University of California, Orange
| | - Alexandra Minasian
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tavneet Singh
- School of Pharmacy, MCPHS University, Boston, Massachusetts
| | - Michelle Bass
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lydia Pace
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Geoffrey C. Ibbotson
- United Nations Institute for Training and Research, Palais des Nations, Geneva, Switzerland
- The Global Surgery Foundation, Geneva, Switzerland
| | - Nefti Bempong-Ahun
- United Nations Institute for Training and Research, Palais des Nations, Geneva, Switzerland
- The Global Surgery Foundation, Geneva, Switzerland
| | - Andrea Pusic
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - John W. Scott
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Rania A. Mekary
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- School of Pharmacy, MCPHS University, Boston, Massachusetts
| | - Kavitha Ranganathan
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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2
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Spees LP, Wheeler SB, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Leapman M, Gross CP, Dinan MA. Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma. Cancer Med 2021; 10:6653-6665. [PMID: 34480518 PMCID: PMC8495289 DOI: 10.1002/cam4.4201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 01/25/2023] Open
Abstract
Background Improving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC). Methods We used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence. Results Among the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87). Conclusions Our results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Bradford E Jackson
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA.,Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, North Carolina, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Deborah R Kaye
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Tian Zhang
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Daniel George
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Michael Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michaela A Dinan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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3
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Eldaly AS. Cancer screening: the collateral damage of the pandemic in Egypt. J Egypt Public Health Assoc 2021; 96:14. [PMID: 34076748 PMCID: PMC8170625 DOI: 10.1186/s42506-021-00073-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/06/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Abdullah S Eldaly
- Department of Plastic and Reconstructive Surgery, Tanta University Hospitals, Tanta, Egypt.
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Winn AN, Fergestrom NM, Pezzin LE, Laud PW, Neuner JM. The impact of generic aromatase inhibitors on initiation, adherence, and persistence among women with breast cancer: Applying multi-state models to understand the dynamics of adherence. Pharmacoepidemiol Drug Saf 2020; 29:550-557. [PMID: 32196839 DOI: 10.1002/pds.4995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/13/2020] [Accepted: 02/26/2020] [Indexed: 01/30/2023]
Abstract
PURPOSE Clinical trials have clearly documented the survival benefit of aromatase inhibitors (AIs); however, many women fail to initiate (primary nonadherence) or remain adherent to AIs (secondary nonadherence). Prior studies have found that costs impact secondary nonadherence to medications but have failed to examine primary nonadherence. The purpose of this study is to examine primary and secondary adherence following the reduction in copays due to the introduction of generic AIs. METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, we identified 50 054 women diagnosed with incident breast cancer between 2008 and 2013. We compare women whose copays would change and those whose would not, due to the receipt of cost-sharing subsidies before and after generics were introduced using a difference-in-difference (DinD) analysis. To examine primary and secondary nonadherence, we rely on a multistate model with four states (Not yet initiated, User, Not Using, and Death). We adjusted for baseline factors using inverse probability treatment weights and then simulated adherence for 36 months following diagnosis. RESULTS The generic introduction of AIs resulted in patients initiating AIs faster (DinD = -4.7%, 95%CI = -7.0, -2.3; patients not yet initiating treatment at 6-months), being more adherent (DinD ranging in absolute increase of 8.1%-10.4%) and being less likely to not be using the therapy (DinD range in absolute decrease of 1.2% at 6 months to 8.8% at 24 months) for women that do not receive a subsidy after generics were available. CONCLUSIONS Introduction of generic alternatives to AIs significantly reduced primary and secondary nonadherence.
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Affiliation(s)
- Aaron N Winn
- Department of Clinical Sciences, School of Pharmacy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole M Fergestrom
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liliana E Pezzin
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Purushottam W Laud
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joan M Neuner
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Center for the Advancing Population Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Section of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Smith GL, Lopez-Olivo MA, Advani PG, Ning MS, Geng Y, Giordano SH, Volk RJ. Financial Burdens of Cancer Treatment: A Systematic Review of Risk Factors and Outcomes. J Natl Compr Canc Netw 2019; 17:1184-1192. [PMID: 31590147 PMCID: PMC7370695 DOI: 10.6004/jnccn.2019.7305] [Citation(s) in RCA: 197] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/29/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with cancer experience financial toxicity from the costs of treatment, as well as material and psychologic stress related to this burden. A synthesized understanding of predictors and outcomes of the financial burdens associated with cancer care is needed to underpin strategic responses in oncology care. This study systematically reviewed risk factors and outcomes associated with financial burdens related to cancer treatment. METHODS MEDLINE, Embase, PubMed, PsychINFO, and the Cochrane Library were searched from study inception through June 2018, and reference lists were scanned from studies of patient-level predictors and outcomes of financial burdens in US patients with cancer (aged ≥18 years). Two reviewers conducted screening, abstraction, and quality assessment. Variables associated with financial burdens were synthesized. When possible, pooled estimates of associations were calculated using random-effects models. RESULTS A total of 74 observational studies of financial burdens in 598,751 patients with cancer were identified, among which 49% of patients reported material or psychologic financial burdens (95% CI, 41%-56%). Socioeconomic predictors of worse financial burdens with treatment were lack of health insurance, lower income, unemployment, and younger age at cancer diagnosis. Compared with patients with health insurance, those who were uninsured demonstrated twice the odds of financial burdens (pooled odds ratio [OR], 2.09; 95% CI, 1.33-3.30). Financial burdens were most severe early in cancer treatment, did not differ by disease site, and were associated with worse health-related quality of life (HRQoL) and nearly twice the odds of cancer medication nonadherence (pooled OR, 1.70; 95% CI, 1.13-2.56). Only a single study demonstrated an association with increased mortality. Studies assessing the comparative effectiveness of interventions to mitigate financial burdens in patients with cancer were lacking. CONCLUSIONS Evidence showed that financial burdens are common, disproportionately impacting younger and socioeconomically disadvantaged patients with cancer, across disease sites, and are associated with worse treatment adherence and HRQoL. Available evidence helped identify vulnerable patients needing oncology provider engagement and response, but evidence is critically needed on the effectiveness of interventions designed to mitigate financial burden and impact.
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Affiliation(s)
- Grace L. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Maria A. Lopez-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pragati G. Advani
- Division of Cancer Epidemiology and Genetics, National Institutes of Health, National Cancer Institute, Bethesda, Maryland
| | - Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H. Giordano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert J. Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Witte J, Mehlis K, Surmann B, Lingnau R, Damm O, Greiner W, Winkler EC. Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications. Ann Oncol 2019; 30:1061-1070. [PMID: 31046080 PMCID: PMC6637374 DOI: 10.1093/annonc/mdz140] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patients experiencing financial distress as a side-effect of cancer are not only reported in the United States, but also in third-party payer healthcare systems in Europe. Since validated survey instruments are a prerequisite for robust and comparable results, we aimed to compile and classify available instruments to enable both a better understanding of the underlying construct of financial toxicity and to facilitate further studies that are adjustable to various healthcare systems. We did a systematic literature search on studies that provide data on perceived cancer-related financial distress experienced by adult patients using PubMed, CINAHL and Web of Science databases up to 2018. We analyzed all detected instruments, items domains and questions with regard to their wording, scales and the domains of financial distress covered. Among 3298 records screened, 41 publications based on 40 studies matched our inclusion criteria. Based on the analysis of 352 different questions we identified 6 relevant subdomains that represent perceptions of and reactions to experienced financial distress: (i) active financial spending, (ii) use of passive financial resources, (iii) psychosocial responses, (iv) support seeking, (v) coping with care or (vi) coping with ones' lifestyle. We found an inconsistent coverage and use of these domains that makes it difficult to compare and quantify the prevalence of financial distress. Moreover, some existing instruments do not reflect relevant domains for patients in third-party payer systems. There is neither a consistent understanding of the construct of financial burden nor do available instruments cover all relevant aspects of a patients' distress perception. We encourage using the identified six domains to further develop survey instruments and adjust them to different health systems.
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Affiliation(s)
- J Witte
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - K Mehlis
- Department of Medical Oncology, Programme for Ethics and Patient Oriented Care, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
| | - B Surmann
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - R Lingnau
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - O Damm
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - W Greiner
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld
| | - E C Winkler
- Department of Medical Oncology, Programme for Ethics and Patient Oriented Care, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany.
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Lee MJ, Khan MM, Salloum RG. Recent Trends in Cost-Related Medication Nonadherence Among Cancer Survivors in the United States. J Manag Care Spec Pharm 2018; 24:56-64. [PMID: 29290172 PMCID: PMC10398090 DOI: 10.18553/jmcp.2018.24.1.56] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cancer survivors avoid necessary medications due to costs. OBJECTIVE To estimate the prevalence of cost-related medication non-adherence (CRN) by age and insurance status over a number of years in a national sample of U.S. cancer survivors. METHODS Using the 1999-2012 National Health Interview Survey, we examined the prevalence and correlates of self-reported CRN, that is, patient-reported inability to afford prescribed medications within the past 12 months, resulting in nonadherence among cancer survivors. Descriptive statistics and multivariate logistic regression models were used to identify time trends in CRN among cancer survivors. RESULTS In a nationally representative sample of 20,517 cancer survivors from 1999 to 2012, 1,788 (8.7%) survivors reported CRN, representing approximately 436,498 individuals nationally. CRN increased significantly from 11.8% (1999-2005) to 16.9% (2006-2012) among younger cancer survivors (P < 0.001). Among young cancer survivors (aged 45-64 years), the uninsurance rate was higher for those reporting CRN in the years 2006-2012 (48.5%) than in the earlier period (42.5%; P = 0.043). Among older cancer survivors, insurance coverage through Medicare only was lower for individuals reporting CRN in the years 2006-2012 (5.8%) than in the earlier period (7.8%; P = 0.0210). In adjusted models, younger cancer survivors without health insurance were more likely to report CRN than those with supplemental private insurance with Medicare, and older cancer survivors with Medicare only were more likely to report CRN than those with supplemental private insurance with Medicare. CONCLUSIONS Increasing trends in CRN were evident among younger cancer survivors. DISCLOSURES No external funding was received for this work. The authors have no conflicts of interest to report. Study concept and design were contributed by Lee, along with Khan and Salloum. Lee collected the data, and data interpretation was performed by Lee, Khan, and Salloum. The manuscript was written primarily by Lee, with assistance from Khan and Salloum, and revised by Lee, Khan, and Salloum.
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Affiliation(s)
- Min Jee Lee
- 1 Arnold School of Public Health, University of South Carolina, Columbia
| | - M Mahmud Khan
- 1 Arnold School of Public Health, University of South Carolina, Columbia
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Ferreira AR, Palha A, Correia L, Filipe P, Rodrigues V, Miranda A, André R, Fernandes J, Gouveia J, Passos-Coelho JL, Moreira A, Brito M, Ribeiro J, Metzger-Filho O, Lin NU, Costa L, Vaz-Luis I. Treatment adoption and relative effectiveness of aromatase inhibitors compared to tamoxifen in early breast cancer: A multi-institutional observational study. Breast 2017; 37:107-113. [PMID: 29131988 DOI: 10.1016/j.breast.2017.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/18/2017] [Accepted: 11/03/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Since 2005, aromatase inhibitors (AIs) have been the adjuvant treatment of choice for postmenopausal women with early breast cancer (BC). In this study we characterize the adoption of AIs in Portugal, variables associated with treatment administration, and compare its effectiveness (either in monotherapy or sequential therapy) to tamoxifen monotherapy (TAM). PATIENTS AND METHODS This was a retrospective cohort study that included postmenopausal women with stage I-III hormone receptor (HR) positive BC diagnosed from 2006 to 2008 and treated with adjuvant endocrine therapy in four participating institutions. RESULTS Of the 1283 eligible patients, 527 (41%) received an AI (16% as monotherapy, 25% as sequential therapy) and 756 (59%) TAM. Patients treated with AI had less differentiated tumors, with higher TNM stage, and were more frequently HER2-positive. Use of AI also differed by center (use range from 33% to 75%, p < 0.001). With a median follow-up of 6.3 years and controlling for clinicopathological and treatment characteristics, treatment with AI had a better overall survival (OS) when compared with TAM (adjusted-HR 0.55, 95% CI 0.37-0.81). CONCLUSION AIs were successfully introduced as adjuvant treatment for HR-positive BC in Portuguese hospitals. Its use was influenced by tumor and patient characteristics, but also center of care. In this large cohort, AI use was associated with an OS benefit.
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Affiliation(s)
- Arlindo R Ferreira
- Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal
| | - Ana Palha
- Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal
| | - Lurdes Correia
- Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal
| | - Pedro Filipe
- Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal
| | - Vasco Rodrigues
- Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal
| | - Ana Miranda
- Registo Oncológico Regional do Sul, Instituto Português de Oncologia F. G. de Lisboa, R. Prof. Lima Basto, 1099-023 Lisbon, Portugal
| | - Rosário André
- Registo Oncológico Regional do Sul, Instituto Português de Oncologia F. G. de Lisboa, R. Prof. Lima Basto, 1099-023 Lisbon, Portugal
| | - João Fernandes
- Hospitais CUF Lisboa, R. Mário Botas, 1998-018 Lisbon, Portugal
| | - Joaquim Gouveia
- Hospitais CUF Lisboa, R. Mário Botas, 1998-018 Lisbon, Portugal
| | | | - António Moreira
- Instituto Português de Oncologia F. G. de Lisboa, R. Prof. Lima Basto, 1099-023 Lisbon, Portugal
| | - Margarida Brito
- Instituto Português de Oncologia F. G. de Lisboa, R. Prof. Lima Basto, 1099-023 Lisbon, Portugal
| | - Joana Ribeiro
- Fundação Champalimaud, Av. Brasília, 1400-038 Lisbon, Portugal
| | | | - Nancy U Lin
- Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA
| | - Luís Costa
- Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal
| | - Inês Vaz-Luis
- Institut Gustave Roussy, Unit INSERM 981, 114 Rue Edouard Vaillant, 94800 Villejuif, France; Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA.
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Socioeconomic Disparities in Mortality Among Women With Incident Breast Cancer Before and After Implementation of Medicare Part D. Med Care 2017; 55:463-469. [PMID: 28030476 PMCID: PMC5391268 DOI: 10.1097/mlr.0000000000000685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Breast cancer patients exhibit survival disparities based on socioeconomic status (SES). Disparities may be attributable to access to expensive oral endocrine agents. Objectives: Define recent socioeconomic disparities in breast cancer survival and determine whether these improved after implementation of the Medicare Part D program. Design: Difference-in-difference natural experiment of women diagnosed and treated before or after implementation of Medicare Part D. Subjects: Female Medicare beneficiaries with early-stage breast cancer: 54,772 diagnosed in 2001 and 46,371 in 2007. Measures: SES was based on Medicaid enrollment and zip code per capita income, all-cause mortality from Medicare, and cause of death from National Death Index. Results: Among women diagnosed pre-Part D, 40.5% of poor beneficiaries had died within 5 years compared with 20.3% of high-income women (P<0.0001). Post-Part D, 33.6% of poor women and 18.4% of high-income women died by 5 years. After adjustment for potential confounders, improvement in all-cause mortality post-Part D was greater for poorer women compared with more affluent women (P=0.002). However, absolute improvement in breast cancer-specific mortality was 1.8%, 1.2%, and 0.8% (P=0.88 for difference in improvement by SES), respectively for poor, near-poor, and high-income women, whereas analogous improvement in mortality from other causes was 5.1%, 3.8%, and 0.9% (P=0.067 for difference in improvement by SES). Conclusions: Large survival disparities by SES exist among breast cancer patients. The Part D program successfully ameliorated SES disparities in all-cause mortality. However, improvement was concentrated in causes of death other than breast cancer, suggesting remaining gaps in care.
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Biggers A, Shi Y, Charlson J, Smith EC, Smallwood AJ, Nattinger AB, Laud PW, Neuner JM. Medicare D Subsidies and Racial Disparities in Persistence and Adherence With Hormonal Therapy. J Clin Oncol 2016; 34:4398-4404. [PMID: 27998232 DOI: 10.1200/jco.2016.67.3350] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose To investigate the role of out-of-pocket cost supports through the Medicare Part D Low-Income Subsidy on disparities in breast cancer hormonal therapy persistence and adherence by race or ethnicity. Methods A nationwide cohort of women age ≥ 65 years with a breast cancer operation between 2006 and 2007 and at least one prescription filled for oral breast cancer hormonal therapy was identified from all Medicare D enrollees. The association of race or ethnicity with nonpersistence (90 consecutive days with no claims for a hormonal therapy prescription) and nonadherence (medication possession rate < 80%) was examined. Survival analyses were used to account for potential differences in age, comorbidity, or intensity of other treatments. Results Among the 25,111 women in the study sample, 77% of the Hispanic and 70% of the black women received a subsidy compared with 21% of the white women. By 2 years, 69% of black and 70% of Hispanic patients were persistent compared with 61% of white patients. In adjusted analyses, patients in all three unsubsidized race or ethnicity groups had greater discontinuation than subsidized groups (white patients: hazard ratio [HR], 1.83; 95% CI, 1.70 to 1.95; black patients: HR, 2.09; 95% CI, 1.73 to 2.51; Hispanic patients: HR, 3.00; 95% CI, 2.37 to 3.89). Racial or ethnic persistence disparities that were present for unsubsidized patients were not present or reversed among subsidized patients. All three subsidized race or ethnicity groups also had higher adherence than all three unsubsidized groups, although with the smallest difference occurring in black women. Conclusion Receipt of a prescription subsidy was associated with substantially improved persistence to breast cancer hormonal therapy among white, black, and Hispanic women and lack of racial or ethnic disparities in persistence. Given high subsidy enrollment among black and Hispanic women, policies targeted at low-income patients have the potential to also substantially reduce racial and ethnic disparities.
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Affiliation(s)
- Alana Biggers
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
| | - Yushu Shi
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
| | - John Charlson
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
| | - Elizabeth C Smith
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
| | - Alicia J Smallwood
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
| | - Ann B Nattinger
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
| | - Purushottam W Laud
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
| | - Joan M Neuner
- Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI
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Azzani M, Roslani AC, Su TT. Financial burden of colorectal cancer treatment among patients and their families in a middle-income country. Support Care Cancer 2016; 24:4423-32. [PMID: 27225528 DOI: 10.1007/s00520-016-3283-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 05/16/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND In Malaysia, the healthcare system consists of a government-run universal healthcare system and a co-existing private healthcare system. However, with high and ever rising healthcare spending on cancer management, cancer patients and their families are likely to become vulnerable to a healthcare-related financial burden. Moreover, they may have to reduce their working hours and lose income. To better understand this issue, this study aims to assess the financial burden of colorectal cancer patients and their families in the first year following diagnosis. METHODS Data on patient costs were collected prospectively in the first year following diagnosis by using a self-administered questionnaire and telephone interviews at three time points for all four stages of colorectal cancer. The patient cost data consisted of direct out-of-pocket payments for medical-related expenses such as hospital stays, tests and treatment and for non-medical items such as travel and food associated with hospital visits. In addition, indirect cost data related to the loss of productivity of the patient and caregiver(s) was assessed. The patient's perceived level of financial difficulty and types of coping strategy were also explored. RESULT The total 1-year patient cost (both direct and indirect) increased with the stage of colorectal cancer: RM 6544.5 (USD 2045.1) for stage I, RM 7790.1 (USD 2434.4) for stage II, RM 8799.1 (USD 2749.7) for stage III and RM 8638.2 (USD 2699.4) for stage IV. The majority of patients perceived paying for their healthcare as somewhat difficult. The most frequently used financial coping strategy was a combination of current income and savings. CONCLUSION Despite the high subsidisation in public hospitals, the management of colorectal cancer imposes a substantial financial burden on patients and their families. Moreover, the majority of patients and their families perceive healthcare payments as difficult. Therefore, it is recommended that policy- and decision-makers should further consider some financial protection strategies and support for cancer treatment because cancer is a very costly and chronic disease.
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Affiliation(s)
- Meram Azzani
- Centre for Population Health (CePH), Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - April Camilla Roslani
- University of Malaya Cancer Research Institute (UMCRI), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Tin Tin Su
- Centre for Population Health (CePH), Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
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Kale HP, Carroll NV. Self-reported financial burden of cancer care and its effect on physical and mental health-related quality of life among US cancer survivors. Cancer 2016; 122:283-9. [PMID: 26991528 DOI: 10.1002/cncr.29808] [Citation(s) in RCA: 246] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/06/2015] [Accepted: 11/02/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cancer-related financial burden has been linked to cancer survivors (CS) forgoing/delaying medical care, skipping follow-up visits, and discontinuing medications. To the authors' knowledge, little is known regarding the effect of financial burden on the health-related quality of life of CS. METHODS The authors analyzed 2011 Medical Expenditure Panel Survey data. Financial burden was present if one of the following problems was reported: borrowed money/declared bankruptcy, worried about paying large medical bills, unable to cover the cost of medical care visits, or other financial sacrifices. The following outcomes were evaluated: Physical Component Score (PCS) and Mental Component Score (MCS) of the 12-Item Short-Form Health Survey (SF-12), depressed mood, psychological distress, and worry related to cancer recurrence. The authors also assessed the effect of the number of financial problems on these outcomes. RESULTS Of the 19.6 million CS analyzed, 28.7% reported financial burden. Among them, the average PCS (42.3 vs 44.9) and MCS (48.1 vs 52.1) were lower for those with financial burden versus those without. In adjusted analyses, CS with financial burden had significantly lower PCS (β = -2.45), and MCS (β = -3.05), had increased odds of depressed mood (odds ratio, 1.95), and were more likely to worry about cancer recurrence (odds ratio, 3.54). Survivors reporting ≥ 3 financial problems reported statistically significant and clinically meaningful differences (≥3 points) in the mean PCS and MCS compared with survivors without financial problems. CONCLUSIONS Cancer-related financial burden was associated with lower health-related quality of life, increased risk of depressed mood, and a higher frequency of worrying about cancer recurrence among CS.
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Affiliation(s)
- Hrishikesh P Kale
- Division of Pharmacoeconomics and Health Outcomes, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Norman V Carroll
- Division of Pharmacoeconomics and Health Outcomes, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
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13
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Lee M, Salloum RG. Racial and ethnic disparities in cost-related medication non-adherence among cancer survivors. J Cancer Surviv 2015; 10:534-44. [PMID: 26620816 DOI: 10.1007/s11764-015-0499-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 11/17/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Cancer survivors are delaying or avoiding necessary care due to costs, and medication non-adherence is an important aspect of deferred treatment. This study estimates the prevalence of cost-related medication non-adherence (CRN) by race and ethnicity and examines factors associated with CRN among cancer survivors. METHODS Using the 2006-2013 National Health Interview Survey, we examine self-reported CRN among cancer survivors compared with cancer-free controls. Descriptive statistics and multiple logistic regression models were used to identify factors associated with CRN among cancer survivors. RESULTS In a nationally representative sample of 472,542 adults, 10,998 participants reported a history of cancer and 461,544 did not. Among 10,998 cancer survivors, 1397 (12.70 %) reported CRN. Among older cancer survivors, African-Americans were 2.64 times more likely (95 % confidence interval (CI), 1.73 to 4.01) and Hispanics 2.07 times more likely (95 % CI, 1.32 to 3.24) than whites to report CRN. Among younger cancer survivors, Hispanics were 1.61 times more likely (95 % CI, 1.23 to 2.10) than whites to report CRN. CONCLUSIONS Significant racial and ethnic disparities in CRN were evident among cancer survivors. Older African-American and Hispanic overall survivors were more likely to report CRN in the past year compared with non-Hispanic whites. IMPLICATIONS FOR CANCER SURVIVORS Given increasing prescription drug expenditure, it is important to closely monitor CRN in high-risk subgroups. Racial and ethnic minority groups at high risk for CRN should be counseled on the importance of medication adherence and offered support services to promote medication adherence. Further studies are warranted to establish effective policies and interventions in vulnerable populations.
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Affiliation(s)
- Minjee Lee
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
| | - Ramzi G Salloum
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL, USA
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Lee M, Khan MM. Gender differences in cost-related medication non-adherence among cancer survivors. J Cancer Surviv 2015; 10:384-93. [PMID: 26350680 DOI: 10.1007/s11764-015-0484-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/27/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE It has been reported that cancer survivors are delaying or avoiding necessary care due to costs. Medication non-adherence is one of the important aspects of deferred treatment. This study estimates the prevalence of cost-related medication non-adherence (CRN) by gender and factors associated with CRN among cancer survivors. METHODS Using 2006-2013 National Health Interview Survey (NHIS), we examined self-reported CRN among cancer survivors by gender. Descriptive statistics and multiple logistic regression models were used to examine gender differences in CRN. RESULTS In a nationally representative sample of 15,159 cancer survivors, 7.4% of male and 12.5% of female reported CRN. Overall, the prevalence of CRN was found to be the highest for uninsured group and the lowest for Medicare, but gender differences persist for all insurance types, including Medicare. After controlling for relevant covariates, female cancer survivors were 27% more likely (odds ratio (OR) = 1.27, confidence intervals (CI), 1.06-1.53) than male to report CRN. With higher number of comorbidities and activity limitations, CRN rates tend to increase for both male and female cancer survivors. CONCLUSIONS Significant gender differences in CRN were found among cancer survivors after controlling for differences in sociodemographic, health status, and insurance coverage. IMPLICATIONS FOR CANCER SURVIVORS Given the rapid increase in prescription drug costs, it is important to monitor closely the CRN in high-risk subgroups.
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Affiliation(s)
- Minjee Lee
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene St, Suite 357, Columbia, SC, 29208, USA
| | - M Mahmud Khan
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, 915 Greene St, Suite 357, Columbia, SC, 29208, USA.
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Nattinger AB, Pezzin LE, McGinley EL, Charlson JA, Yen TWF, Neuner JM. Patient costs of breast cancer endocrine therapy agents under Medicare Part D vs with generic formulations. SPRINGERPLUS 2015; 4:54. [PMID: 25674506 PMCID: PMC4320689 DOI: 10.1186/s40064-015-0827-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 11/15/2022]
Abstract
Purpose The high expense of newer, more effective adjuvant endocrine therapy agents (aromatase inhibitors [AIs]) for postmenopausal breast cancer contributes to socioeconomic disparities in breast cancer outcomes. This study compares endocrine therapy costs for breast cancer patients during the first five years of Medicare Part D implementation, and when generic alternatives became available. Methods The out of pocket patient costs for AIs and tamoxifen under Medicare Part D drug plans were determined for 2006–2011 from the CMS Website for the 50 US states and District of Columbia. Results Between 2006 and 2010, the mean annual patient drug cost under Medicare Part D in the median state rose 19% for tamoxifen, 113% for anastrozole, 89% for exemestane, and 129% for letrozole, resulting in median annual out of pocket costs in 2010 of $701, $3050, $2804, and $3664 respectively. However, the 2011 availability of generic AI preparations led to median annual costs in 2011 of $804, $872, $1837, and $2217 respectively. Not included in the reported patient costs, the mean monthly drug premiums in the median state increased 58% in 2011 compared to 2007. Conclusions The more effective AI agents became considerably more expensive during the first several years of the Medicare Part D program. Cost decreased with the introduction of generic agents, an intervention that was independent of the Part D program. It is unlikely that the Part D program ameliorated existing socioeconomic disparities in survival among breast cancer patients, but the availability of generic agents may do so.
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Affiliation(s)
- Ann Butler Nattinger
- Division of General Internal Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI USA ; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 USA
| | - Liliana E Pezzin
- Division of General Internal Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI USA ; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 USA
| | - Emily L McGinley
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 USA
| | - John A Charlson
- Division of Hematology-Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI USA ; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 USA
| | - Tina W F Yen
- Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI USA ; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 USA
| | - Joan M Neuner
- Division of General Internal Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI USA ; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 USA
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The perceived cancer-related financial hardship among patients and their families: a systematic review. Support Care Cancer 2014; 23:889-98. [PMID: 25337681 DOI: 10.1007/s00520-014-2474-y] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The escalating health-care spending for cancer management has caused cancer patients to struggle further as a result of financial burden. This systematic review was carried out to investigate the prevalence of perceived financial hardship and associated factors among cancer patients and their families. METHODS A systematic search for studies concerning the perception of financial burden among cancer patients and their families was conducted. Several electronic resources such as Medline, Elsevier (Science Direct), Web of Science, Embase, PubMed, CINAHL and Scopus (SciVerse) were searched. Additionally, manual search through indices citation was also thoroughly utilized. The main outcome of interest was the prevalence of perceived financial hardship among cancer patients and their families. Studies reported only the cost of cancer treatment and qualitative studies were excluded. Our search was limited to articles that were published from 2003 to 2013. RESULT Ten studies were included in this review and with a majority originating from high-income countries. The prevalence of the financial burden perception was reported between 14.8 and 78.8 %. The most frequent and significant risk factor reported associated with the perception of financial difficulty was the households with low income. Discontinuation of treatment and poverty were conversely the important consequences of financial burden in cancer patients and their families. CONCLUSION Evidently, cancer is a long-term illness that requires a high financial cost, and a significant number of cancer patients and families struggle with financial difficulty. Identifying such groups with a high risk of facing financial difficulty is a crucial measure to ensure safety nets are readily available for these targeted population.
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Kent EE, Forsythe LP, Yabroff KR, Weaver KE, de Moor JS, Rodriguez JL, Rowland JH. Are survivors who report cancer-related financial problems more likely to forgo or delay medical care? Cancer 2013; 119:3710-7. [PMID: 23907958 DOI: 10.1002/cncr.28262] [Citation(s) in RCA: 291] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 04/10/2013] [Accepted: 05/10/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Financial problems caused by cancer and its treatment can substantially affect survivors and their families and create barriers to seeking health care. METHODS The authors identified cancer survivors diagnosed as adults (n=1556) from the nationally representative 2010 National Health Interview Survey. Using multivariable logistic regression analyses, the authors report sociodemographic, clinical, and treatment-related factors associated with perceived cancer-related financial problems and the association between financial problems and forgoing or delaying health care because of cost. Adjusted percentages using the predictive marginals method are presented. RESULTS Cancer-related financial problems were reported by 31.8% (95% confidence interval, 29.3%-34.5%) of survivors. Factors found to be significantly associated with cancer-related financial problems in survivors included younger age at diagnosis, minority race/ethnicity, history of chemotherapy or radiation treatment, recurrence or multiple cancers, and shorter time from diagnosis. After adjustment for covariates, respondents who reported financial problems were more likely to report delaying (18.3% vs 7.4%) or forgoing overall medical care (13.8% vs 5.0%), prescription medications (14.2% vs 7.6%), dental care (19.8% vs 8.3%), eyeglasses (13.9% vs 5.8%), and mental health care (3.9% vs 1.6%) than their counterparts without financial problems (all P<.05). CONCLUSIONS Cancer-related financial problems are not only disproportionately represented in survivors who are younger, members of a minority group, and have a higher treatment burden, but may also contribute to survivors forgoing or delaying medical care after cancer.
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Affiliation(s)
- Erin E Kent
- Outcomes Research Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
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Ito K, Elkin E, Blinder V, Keating N, Choudhry N. Cost-effectiveness of full coverage of aromatase inhibitors for Medicare beneficiaries with early breast cancer. Cancer 2013; 119:2494-502. [DOI: 10.1002/cncr.28084] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 02/07/2013] [Accepted: 02/15/2013] [Indexed: 12/15/2022]
Affiliation(s)
- Kouta Ito
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts
| | - Elena Elkin
- Center for Health Policy and Outcomes, Department of Epidemiology and Biostatistics; Memorial Sloan-Kettering Cancer Center; New York New York
| | - Victoria Blinder
- Health Outcomes Research Group, Department of Epidemiology and Biostatistics; Memorial Sloan-Kettering Cancer Center; New York New York
- Breast Cancer Medicine Service, Department of Medicine; Memorial Sloan-Kettering Cancer Center; New York New York
| | - Nancy Keating
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts
- Department of Health Care Policy; Harvard Medical School; Boston Massachusetts
| | - Niteesh Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts
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Neuner JM, Yen TW, Sparapani RA, Laud PW, Nattinger AB. Fracture risk and adjuvant hormonal therapy among a population-based cohort of older female breast cancer patients. Osteoporos Int 2011; 22:2847-55. [PMID: 21170643 PMCID: PMC3166362 DOI: 10.1007/s00198-010-1493-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 11/01/2010] [Indexed: 02/05/2023]
Abstract
UNLABELLED The risk of hip and other fractures was examined among a population-based group of older women with breast cancer. Women using aromatase inhibitors (AIs) were found to be over three times more likely to have a hip fracture over approximately 3 years' follow-up. Other fracture risk factors were also identified. INTRODUCTION Aromatase inhibitors have been shown in randomized trials to increase total fracture risk compared with tamoxifen, but the fracture risks in the trials were relatively low, and no difference in hip fracture has been demonstrated. METHODS A population-based cohort of 2003 breast cancer survivors ≥65 were followed prospectively for a median of 36 months. Patient survey information regarding adjuvant breast cancer therapies, prescription osteoporosis treatments, and other factors potentially associated with fracture was supplemented with cancer registry information. Hip and total nonvertebral fractures were determined using a validated Medicare algorithm, and the association of these fractures with adjuvant hormonal therapies was examined using Cox models. RESULTS The cohort of 2,748 women with a mean age of 72.8 (SD 5.4) included 28.2% who took an aromatase inhibitor and 27.8% tamoxifen. There were 41 hip fractures (1.5%) and 218 nonvertebral fractures (7.9%) among the cohort. Subjects using AIs (adjusted hazard ratio 3.24 (1.05, 9.98)) and subjects not using hormone therapy (3.32 (1.14, 9.65)) were more likely than users of tamoxifen to have a hip fracture. Bisphosphonate use was more common among AI users but did not explain these results. Users of AIs were more likely to have nonvertebral fractures, but this result did not reach statistical significance (adjusted hazard 1.34 (0.92, 1.94)). CONCLUSIONS Hip and other fractures were common in an older population-based cohort of breast cancer survivors, and aromatase inhibitor use was associated with an increase in the short-term risk of hip fractures not detected in randomized controlled trials.
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Affiliation(s)
- J M Neuner
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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Five-year patterns of adjuvant hormonal therapy use, persistence, and adherence among insured women with early-stage breast cancer. Breast Cancer Res Treat 2011; 130:681-9. [PMID: 21842245 DOI: 10.1007/s10549-011-1703-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 07/27/2011] [Indexed: 10/17/2022]
Abstract
Adjuvant hormonal therapy (HT) for breast cancer improves survival, yet studies have shown that early discontinuation and suboptimal adherence are common. We aimed to expand existing literature by describing patterns of HT use, specifically focusing on the prevalence and predictors of treatment interruptions of varying durations. We identified 2,207 women who were diagnosed with early-stage breast cancer and who initiated adjuvant HT between July 1, 2000 and 2005, and were followed through August 1, 2006, at a New England health plan. Of 58% of women who initiated HT within 12 months after diagnosis, 769 (54.6%) used tamoxifen, 354 (25.1%) used an aromatase inhibitor, and 285 (20.3%) switched between the two agents during the follow-up period. By the end of the first year of treatment, 79% of women remained on therapy without gaps exceeding 60 days and 85% without gaps exceeding 180 days. By year 5, only 27 and 29% remained without 60- and 180-day gaps, respectively. Results from extended Cox proportional hazards regression models indicated that only age ≥ 70 years (vs. less than 50 years) was consistently associated with an increased likelihood of treatment gaps, with hazard ratio (HR) of 2.00 [95% CI 1.36-2.94] for gaps of ≥ 60 days, HR 2.09 [1.38-3.16] for gaps of ≥ 90 days, and HR 2.14 [1.36-3.37] for gaps of ≥ 180 days in the first follow-up year, with similar results in subsequent years. Longer gaps were associated with a lower likelihood of resuming therapy. In summary, interruptions in HT therapy began in the first year after initiating treatment and continued through subsequent years and were common among insured women, particularly the elderly. Clinicians caring for breast cancer survivors should explicitly ask women about their medication use, explore barriers to adherence, and encourage them to continue long-term therapy as advised by treatment guidelines.
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Nekhlyudov L, Madden J, Graves AJ, Zhang F, Soumerai SB, Ross-Degnan D. Cost-related medication nonadherence and cost-saving strategies used by elderly Medicare cancer survivors. J Cancer Surviv 2011; 5:395-404. [PMID: 21800053 DOI: 10.1007/s11764-011-0188-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 06/02/2011] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study was conducted to compare cost-related medication nonadherence among elderly Medicare enrollees with and without cancer and to describe the strategies cancer survivors used to offset the costs of medications. METHODS Using the 2005 Medicare Current Beneficiary Survey and Medicare claims, we compared self-reported cost-related medication nonadherence (CRN), spending less on basic needs to afford medicines, and cost reduction strategies among elderly beneficiaries with and without cancer. Descriptive statistics and logistic regression models were used to characterize and compare these populations. RESULTS In a nationally representative sample of 9,818 non-institutionalized elderly Medicare enrollees, 1,392 (14%) were classified as cancer survivors based on Medicare claims. Cancer survivors were older, more highly educated, more likely to be male and non-Hispanic, and more likely to have multiple comorbidities, poorer health status, and employer-paid medication coverage. While 10% of cancer survivors and 11% without cancer reported CRN, about 6% and 9% (p = 0.004) of those with and without cancer, respectively, reported spending less on basic needs to offset the costs of medications. Cancer survivors who reported CRN (n = 143) had lower income (62.2% versus 48.6%, p = 0.11) and were more likely to be African-American (13.0% versus 6.4%, p = 0.033) and have non-employer-based medication insurance (p = 0.002) compared to those who did not report CRN. In adjusted analyses, CRN among the two groups was similar, but with some subgroup differences noted by gender and cancer type. Use of cost reduction strategies was mostly similar among cancer survivors and those without cancer. CONCLUSION Cost-related medication nonadherence medication is common among elderly Medicare beneficiaries, but appears to be similar among those with and without cancer.
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Affiliation(s)
- Larissa Nekhlyudov
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA.
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Yen TWF, Czypinski LK, Sparapani RA, Guo C, Laud PW, Pezzin LE, Nattinger AB. Socioeconomic factors associated with adjuvant hormone therapy use in older breast cancer survivors. Cancer 2010; 117:398-405. [PMID: 20824718 DOI: 10.1002/cncr.25412] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 03/25/2010] [Accepted: 04/05/2010] [Indexed: 11/09/2022]
Abstract
BACKGROUND The authors sought to identify socioeconomic (SES) factors associated with adjuvant hormone therapy (HT) use among a contemporary population of older breast cancer survivors. METHODS Telephone surveys were conducted among women (ages 65-89 years) residing in 4 states (California, Florida, Illinois, and New York) who underwent initial breast cancer surgery in 2003. Demographic, SES, and treatment information was collected. RESULTS Of 2191 women, 67% received adjuvant HT with either tamoxifen or an aromatase inhibitor (AI); 71% of those women were on an AI. When adjusting for multiple demographic and SES factors, predictors of HT use were better education (high school degree or higher), better informational/emotional support, and younger age (ages 65-79 years). Race/ethnicity, income, and insurance coverage for medication costs were not associated with receiving HT. For those on HT, when adjusting for all other factors, women were more likely to receive an AI if they had insurance coverage for some or all medication costs, if they were wealthier, if they had better informational/emotional support, and if they were younger (ages 65-69 years). CONCLUSIONS The majority of older women in this population-based cohort received adjuvant HT, and the adoption of AIs was early. The results indicted that providers should be aware that a woman's education level and support system influence her decision to take HT. Given the high cost of AIs, their benefits in postmenopausal women with hormone receptor-positive breast cancer, and the current finding that women with no insurance coverage for medication costs were significantly less likely to receive an AI, we recommend that policymakers address this issue.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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