Lung cancer treatment costs, including patient responsibility, by disease stage and treatment modality, 1992 to 2003

Cost-effectiveness of large-panel next-generation sequencing in guiding first-line treatment decisions for patients with nonsquamous advanced non-small cell lung cancer

BACKGROUND

Clinical practice guidelines recommend broad-panel genomic profiling to identify actionable genomic alterations for patients with advanced non-small cell lung cancer (aNSCLC).

OBJECTIVE

To assess the cost-effectiveness of large-panel next-generation sequencing (LP-NGS) compared with current empirical single-gene test (SGT) patterns to inform first-line treatment decisions for patients with aNSCLC from a US commercial payer perspective, accounting for the effect of testing turnaround time and time to treatment initiation.

METHODS

We developed a discrete-event simulation model to estimate the impact of LP-NGS vs SGT for patients with nonsquamous aNSCLC. Discrete events and timing included testing patterns, receipt of the initial test result, treatment initiation (targeted vs nontargeted therapies), switching, retesting, rebiopsies, clinical trial participation, progression on therapy, and death. LP-NGS and SGT cohorts each comprised 100,000 adults with aNSCLC simulated over a 5-year postdiagnosis period, assumed to have the same distribution of genomic alterations. The model predicted the proportion of patients receiving appropriate first-line therapy according to clinical practice guidelines. Economic outcomes included expected life-years gained, quality-adjusted life-years, and the total costs of care over 5 years. Sensitivity and scenario analyses explored the robustness of the base-case model results.

RESULTS

In the base-case model, LP-NGS was likely to identify more alterations than SGT. Total 5-year costs per patient were $539,658 for LP-NGS and $544,550 for SGT (net difference, $4,892 lower costs per patient for LP-NGS), which is likely to be cost-effective 95.1% of the time. The most influential model parameters on the 5-year total costs of care were preprogression nondrug medical costs on nontargeted therapy, NGS turnaround time, and clinical trial participation.

CONCLUSIONS

This study suggests that LP-NGS to guide first-line treatment decisions is clinically more appropriate (more likely to identify alterations and subsequently allocate patients to clinically appropriate therapy) and provides a dominant cost-effectiveness treatment strategy over 5 years for patients with newly diagnosed aNSCLC in the United States.

Surgical-decision making in the setting of unsuspected N2 disease: a cost-effectiveness analysis

Background

Identification of unsuspected nodal metastasis may occur at the time of operation for a stage I non-small cell lung cancer. Guidelines for this scenario are unclear. Our goal was to assess the cost-effectiveness of aborting the operation in an attempt to first provide neoadjuvant systemic therapy compared with upfront resection.

Methods

A computer simulation Markov model with a lifetime horizon was constructed to compare the costs and clinical outcomes, as measured by quality-adjusted life-years (QALYs), of upfront resection at the time of identification of unsuspected N2 mediastinal disease vs. aborting initial resection and continuing with neoadjuvant therapy prior to resection. Input parameters for the model were derived from published literature with costs measured from the healthcare perspective. The incremental cost-effectiveness ratio (ICER) was evaluated with a willingness-to-pay (WTP) threshold of $150,000/QALY. Both deterministic (one-, two-, and three-way) and probabilistic sensitivity analysis (PSA) were performed to assess the impact of variation in input parameter values on model results.

Results

Aborting initial resection in favor of neoadjuvant therapy resulted in both higher costs ($40,415 vs. $29,873) and more QALYs (3.95 vs. 2.84) relative to upfront resection, yielding an ICER of $9,526/QALY. While variation in overall survival had a significant impact on the ICER, perioperative variables did not. As the annual mortality of best-case therapy in the abort group increased from a base-case estimate of 11% to 15%, the ICER exceeded the WTP threshold of $150,000/QALY. Subsequent one- and two-way sensitivity analyses did not find substantially alter the overall results. PSA resulted in aborting resection to be cost-effective in 99.7% of samples, with 13% of samples dominating upfront resection.

Conclusions

Treatment of stage IIIa lung cancer requires the input of a multidisciplinary team who must consider cost, quality of life, and overall survival. As new treatments are developed, further analyses should be performed to determine optimal therapy.

A multi-dimensional assessment of financial hardship of cancer patients using existing health system data

BACKGROUND

Existing financial hardship screening does not capture the multifaceted and dynamic nature of the problem. The use of existing health system data is a promising way to enable scalable and sustainable financial hardship screening.

METHODS

We used existing data from 303 adult patients with cancer at the University of Virginia Comprehensive Cancer Center (2016-2018). All received distress screening and had a valid financial assistance screening based solely on household size-adjusted income. We constructed a composite index that integrates multiple existing health system data (Epic, distress screening, and cancer registry) to assess comprehensive financial hardship (e.g., material conditions, psychological responses, and coping behaviors). We examined differences of at-risk patients identified by our composite index and by existing single-dimension criterion. Dynamics of financial hardship over time, by age, and cancer type, were examined by fractional probit models.

RESULTS

At-risk patients identified by the composite index were generally younger, better educated, and had a higher annual household income, though they had lower health insurance coverage. Identified periods to intervene for most patients are before formal diagnosis, 2 years, and 6 years after diagnosis. Within 2 years of diagnosis and more than 4 years after diagnosis appear critical for subgroups of patients who may suffer from financial hardship disparities.

CONCLUSION

Existing health system data provides opportunities to systematically measure and track financial hardship in a systematic, scalable and sustainable way. We find that the dimensions of financial hardship can exhibit different patterns over time and across patient subgroups, which can guide targeted interventions. The scalability of the algorithm is limited by existing data availability.

Overall survival with adjuvant atezolizumab after chemotherapy in resected stage II-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase III trial

BACKGROUND

IMpower010 (NCT02486718) demonstrated significantly improved disease-free survival (DFS) with adjuvant atezolizumab versus best supportive care (BSC) following platinum-based chemotherapy in the programmed death-ligand 1 (PD-L1)-positive and all stage II-IIIA non-small-cell lung cancer (NSCLC) populations, at the DFS interim analysis. Results of the first interim analysis of overall survival (OS) are reported here.

PATIENT AND METHODS

The design, participants, and primary-endpoint DFS outcomes have been reported for this phase III, open-label, 1 : 1 randomised study of atezolizumab (1200 mg q3w; 16 cycles) versus BSC after adjuvant platinum-based chemotherapy (1-4 cycles) in adults with completely resected stage IB (≥4 cm)-IIIA NSCLC (per the Union Internationale Contre le Cancer and American Joint Committee on Cancer staging system, 7th edition). Key secondary endpoints included OS in the stage IB-IIIA intent-to-treat (ITT) population and safety in randomised treated patients. The first pre-specified interim analysis of OS was conducted after 251 deaths in the ITT population. Exploratory analyses included OS by baseline PD-L1 expression level (SP263 assay).

RESULTS

At a median of 45.3 months' follow-up on 18 April 2022, 127 of 507 patients (25%) in the atezolizumab arm and 124 of 498 (24.9%) in the BSC arm had died. The median OS in the ITT population was not estimable; the stratified hazard ratio (HR) was 0.995 [95% confidence interval (CI) 0.78-1.28]. The stratified OS HRs (95% CI) were 0.95 (0.74-1.24) in the stage II-IIIA (n = 882), 0.71 (0.49-1.03) in the stage II-IIIA PD-L1 tumour cell (TC) ≥1% (n = 476), and 0.43 (95% CI 0.24-0.78) in the stage II-IIIA PD-L1 TC ≥50% (n = 229) populations. Atezolizumab-related adverse event incidences remained unchanged since the previous analysis [grade 3/4 in 53 (10.7%) and grade 5 in 4 (0.8%) of 495 patients, respectively].

CONCLUSIONS

Although OS remains immature for the ITT population, these data indicate a positive trend favouring atezolizumab in PD-L1 subgroup analyses, primarily driven by the PD-L1 TC ≥50% stage II-IIIA subgroup. No new safety signals were observed after 13 months' additional follow-up. Together, these findings support the positive benefit-risk profile of adjuvant atezolizumab in this setting.

A better cost:benefit analysis yields better and fairer results: EPA's lead and copper rule revision

When conducted on a societal level, cost-benefit analysis (CBA) can indicate policies that best allocate scarce public resources. Done incompletely, CBA can produce spurious, biased results. To estimate the potential health benefits of EPA's recent Lead and Copper Drinking Water Rule Revision (LCRR), we used EPA's exposure, compliance, and effect coefficient estimates to monetize 16 of the health endpoints EPA has determined are causally related to lead exposure. In addition, we monetized one health endpoint that EPA has used elsewhere: preterm birth. We estimated that the total annual health benefits of the LCRR greatly exceed EPA's estimated annual costs: $9 billion vs $335 million (2016$). Our benefit estimates greatly exceed EPA's benefit estimates. There are also nonhealth benefits because lead generally contaminates drinking water through the corrosion of plumbing components that contain lead. The LCRR therefore has 2 components: reducing how corrosive the water is and limited replacement of lead pipes. Reducing corrosion damage to drinking water and wastewater infrastructure and residential appliances that use water yields significant annualized material benefits also: $2-8 billion (2016$). Effectively, the health benefits are free. Finally, while actual exposure data are limited, the available data on lead-contaminated drinking water exhibits known risk patterns, disproportionately burdening low-income and minority populations and women. This economic analysis demonstrates that to maximize national benefits and improve equity, the LCRR should be as rigorous as possible.

Human Urinary Volatilome Analysis in Renal Cancer by Electronic Nose

Currently, in clinical practice there are still no useful markers available that are able to diagnose renal cancer in the early stages in the context of population screening. This translates into very high costs for healthcare systems around the world. Analysing urine using an electronic nose (EN) provides volatile organic compounds that can be easily used in the diagnosis of urological diseases. Although no convincing results have been published, some previous studies suggest that dogs trained to sniff urine can recognize different types of tumours (bladder, lung, breast cancer) with different success rates. We therefore hypothesized that urinary volatilome profiling may be able to distinguish patients with renal cancer from healthy controls. A total of 252 individuals, 110 renal patients and 142 healthy controls, were enrolled in this pilot monocentric study. For each participant, we collected, stabilized (at 37 °C) and analysed urine samples using a commercially available electronic nose (Cyranose 320^®). Principal component (PCA) analyses, discriminant analysis (CDA) and ROC curves were performed to provide a complete statistical analysis of the sensor responses. The best discriminating principal component groups were identified with univariable ANOVA analysis. The study correctly identified 79/110 patients and 127/142 healthy controls, respectively (specificity 89.4%, sensitivity 71.8%, positive predictive value 84.04%, negative predictive value 80.37%). In order to test the study efficacy, the Cross Validated Accuracy was calculated (CVA 81.7%, p < 0.001). At ROC analysis, the area under the curve was 0.85. The results suggest that urine volatilome profiling by e-Nose seems a promising, accurate and non-invasive diagnostic tool in discriminating patients from controls. The low costs and ease of execution make this test useful in clinical practice.

Cost of Lung Cancer: A Systematic Review

OBJECTIVES

We performed a systematic review of studies estimating the cost of illness of lung cancer to compare costs between studies and examine cost drivers, emphasizing generalizability and methodological choices.

METHODS

A systematic search on studies published in English on cost of illness of lung cancer was performed in MEDLINE (PubMed), Embase, Web of Science, and Scopus. Databases were searched in January 2017, and records were screened based on eligibility criteria. The systematic search was updated on May 7, 2020. The quality of included studies was appraised using a modified Drummond checklist.

RESULTS

Of the 4891 records screened, 19 records were included. Most of the studies were cross-sectional and retrospective and used a prevalence-based approach and a bottom-up approach. Direct medical costs ranged from 4484.13 US dollars purchasing power parity to 45 364.48 US dollars purchasing power parity. Total medical costs as a percentage of total gross domestic product (GDP) ranged from 0.00248 to 0.1326 (median 0.0217), and total medical costs as a percentage of total health expenditure ranged from 0.038 to 0.836 (median 0.209).

CONCLUSIONS

There was considerable methodological heterogeneity that made it difficult to compare results between studies. The costs of lung cancer are substantial and impose a substantial economic burden on patients, healthcare systems, and societies. By comparing cancer costs with total health expenditures and GDP per capita, it can be concluded that lung cancer imposes a considerable economic burden on patients and healthcare systems in countries with lower GDP per capita and higher incidence rate.

Clinical Prognosis of Lung Cancer in Patients with Moderate Chronic Kidney Disease

The clinical outcomes of patients with lung cancer coexisting with chronic kidney disease (CKD) are reported to have been conflicting. There is insufficient evidence for treatment and prognosis of lung cancer according to renal function in patients with CKD. We evaluate clinical course and prognostic factors of lung cancer according to the renal function of moderate CKD patients. A retrospective, multicenter study of lung cancer patients with moderate CKD was performed. Moderate CKD was defined as having an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. CKD was classified as stage 3, stage 4, and stage 5 according to eGFR. The cumulative mortality of lung cancer was calculated by competing risks survival analysis, and the risk factors were evaluated by the Cox-proportional hazards model. Among the lung cancer patients with moderate CKD (n = 181), median overall survival (OS) was 11.1 (4.2−31.3) months for stage 3 CKD patients, 6.0 (1.8−16.3) months for stage 4 CKD patients, and 4.7 (2.1−40.1) months for stage 5 CKD patients (p = 0.060), respectively. In a subgroup analysis, CKD stage was associated with an increased mortality in early-stage non-small cell lung cancer (NSCLC). Cox regression analysis revealed that age ≥ 75 years (adjusted hazard ratio (aHR), 1.581; 95% confidence interval (CI), 1.082−2.310), Charlson comorbidity index (aHR, 1.669; 95% CI, 10.69−2.605), and stage IV NSCLC (aHR, 2.395; 95% CI, 1.512−3.796) were associated with increased mortality risk, whereas adenocarcinoma (aHR, 0.580; 95% CI, 0.352−0.956) and stage 3 CKD (aHR, 0.598; 95% CI, 0.399−0.895) were associated with decreased mortality risk. In conclusion, the mortality risk of patients with lung cancer was lower in stage 3 CKD compared with stage 4 or 5 CKD. In addition, in the early stages of NSCLC, the CKD stage affected the prognosis, but not in the advanced stage NSCLC.

Alcohol Abuse, Morbid Obesity, Depression, Congestive Heart Failure, and Chronic Pulmonary Disease are Risk Factors for 90-Day Readmission After Arthroscopic Rotator Cuff Repair

Purpose

The purpose of this study was to report the rate and causes of 90-day readmissions after arthroscopic rotator cuff repair.

Methods

A retrospective query from January 2005 to March 2014 was performed using a nationwide administrative claims registry. Patients and complications were identified using International Classification of Disease, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Patients who underwent arthroscopic rotator cuff repair (RCR) and were readmitted within 90 days after their index procedure were identified. Patients not readmitted represented controls. Patients readmitted were stratified into separate cohorts depending on the primary cause of readmission, which included cardiac, endocrine, hematological, infectious, gastrointestinal, musculoskeletal (MSK), neoplastic, neurological or psychiatric, pulmonary, and renal. Risk factors assessed were comorbidities comprising the Elixhauser-Comorbidity Index (ECI). Primary outcomes analyzed and compared included cause for readmission, patient demographics, risk factors, in-hospital length of stay (LOS), and costs. Pearson’s chi-square was used to compare patient demographics, and multivariate binomial logistic regression was used to calculate odds ratios (OR) on patient-related risk factors for 90-day readmissions.

Results

10,425 readmitted patients and 301,625 control patients were identified, representing a 90-day readmission rate of 3.5%. The causes of readmissions were primarily related to infectious diseases (15%), MSK (15%), and cardiac (14%) complications. The most common MSK readmissions were osteoarthrosis of the leg or shoulder (24.8%) and spinal spondylosis (8.4%). Multivariate binomial logistic regression analyses demonstrated patients with alcohol abuse (OR, 1.42; P < .0001), morbid obesity (OR, 1.38; P < .0001), depression (OR, 1.35; P < .0001), congestive heart failure (OR, 1.34; P < 0.0001), and chronic pulmonary disease (OR, 1.28; P < .0001) were at the greatest risk of readmissions after RCR.

Conclusions

Significant differences exist among patients readmitted, and those patients who do not require hospital readmission within 90 days following arthroscopic rotator cuff repairs. Readmissions are associated with significant patient comorbidities and were primarily related to medically based complications.

Level of Evidence

Level III, prognostic, retrospective cohort study.

Social support can alleviate the fear of cancer recurrence in postoperative patients with lung carcinoma

OBJECTIVE

To explore the status and influencing factors of the fear of cancer recurrence (FCR) in postoperative patients with lung carcinoma (LC).

METHODS

The survey results of 219 LC patients who underwent surgical treatment in a tertiary grade A cancer hospital in Beijing from January 2020 to September 2021 were retrospectively analyzed by using the general information questionnaire, Social Support Rating Scale (SSRS), and the Fear of Progression Questionnaire-Short Form (FoP-Q-SF).

RESULTS

The score of the FoP-Q-SF was (25.68±3.15 points) in postoperative LC patients, and education level and per capita monthly household income were identified as the independent risk factors affecting FCR. There was an inverse correlation between FCR and social support in postoperative LC patients (P<0.05).

CONCLUSIONS

Postoperative LC patients experience a moderate-level of FCR, especially females and those with a low family income. Social support plays an essential role in alleviating FCR. Nursing suggestions should be given according to individual differences of patients, and social health service resources should be effectively utilized to reduce FCR.

Volatilome Analysis in Prostate Cancer by Electronic Nose: A Pilot Monocentric Study

Urine analysis via an electronic nose provides volatile organic compounds easily usable in the diagnosis of urological diseases. Although challenging and highly expensive for health systems worldwide, no useful markers are available in clinical practice that aim to anticipate prostate cancer (PCa) diagnosis in the early stages in the context of wide population screening. Some previous works suggested that dogs trained to smell urine could recognize several types of cancers with various success rates. We hypothesized that urinary volatilome profiling may distinguish PCa patients from healthy controls. In this study, 272 individuals, 133 patients, and 139 healthy controls participated. Urine samples were collected, stabilized at 37 °C, and analyzed using a commercially available electronic nose (Cyranose C320). Statistical analysis of the sensor responses was performed off-line using principal component (PCA) analyses, discriminant analysis (CDA), and ROC curves. Principal components best discriminating groups were identified with univariable ANOVA analysis. groups were identified with univariable ANOVA analysis. Here, 110/133 and 123/139 cases were correctly identified in the PCa and healthy control cohorts, respectively (sensitivity 82.7%, specificity 88.5%; positive predictive value 87.3%, negative predictive value 84.2%). The Cross Validated Accuracy (CVA 85.3%, p < 0.001) was calculated. Using ROC analysis, the area under the curve was 0.9. Urine volatilome profiling via an electronic nose seems a promising non-invasive diagnostic tool.

Microwave Ablation versus Stereotactic Body Radiotherapy for Stage I Non-Small Cell Lung Cancer: A Cost-Effectiveness Analysis

PURPOSE

To assess the cost-effectiveness of microwave ablation (MWA) and SBRT for patients with inoperable stage I non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

A literature search was performed in MEDLINE with broad search clusters. A decision-analysis model was constructed over a 5-year period. The model incorporated treatment-related complications and long-term recurrence. All clinical parameters were derived from the literature with preference to long-term prospective trials. A healthcare payers' perspective was adopted. Outcomes were measured in quality-adjusted life years (QALY) extracted from prior studies and United States dollars from Medicare reimbursements and prior studies. Base case calculations, probabilistic sensitivity analysis with 10,000 Monte Carlo simulations, and multiple one- and two-way sensitivity analyses were performed.

RESULTS

MWA yielded a health benefit of 2.31 QALY at a cost of $195,331, whereas SBRT yielded a health benefit of 2.33 QALY at a cost of $225,271. The incremental cost-effectiveness ratio was $1,480,597/QALY, indicating that MWA is the more cost-effective strategy. The conclusion remains unchanged in probabilistic sensitivity analysis with MWA being the optimal cost strategy in 99.84% simulations. One-way sensitivity analyses revealed that MWA remains cost-effective when its annual recurrence risk is below 18.4% averaged over 5 years, when the SBRT annual recurrence risk is above 1.44% averaged over 5 years, or when MWA is at least $7,500 cheaper than SBRT.

CONCLUSION

Microwave ablation appears to be a more cost-effective than stereotactic body radiotherapy for patients with inoperable stage I non-small cell lung cancer.

Cancer in Patients Referred Abroad For Health Care and Related Foreign Currency Expenses

Background:

There is limited access to health services in Burundi, as most of the services such as cancer care are unavailable. Burundian citizen who can afford the costs involved in seeking treatment elsewhere are referred abroad. The purpose of this study was to assess the proportion of patients suffering from cancer among patients referred abroad for healthcare and to evaluate the costs incurred by those patients in relation to what the country would save by establishing cancer healthcare facilities.

Methodology:

The study was performed retrospectively from January 2016 to December 2018. With approval of Ministry of Public Health and AIDS control, the data was collected from medical reports at the general management of health facilities and AIDS control office. All patients with medical reports containing the reason for referral were included in the study. Medical reports assessing occupational disability were excluded. Data analysis was performed using Statistical Package for the Social Sciences (SPSS).

Results:

Male, female and unclear was 45.3%, 39.9% and 14.8% respectively. Average age was 31,82. The main reason for referral was MRI (21.7%). Cancer patients represented 18% of all patients referred abroad for healthcare and the most common type of cancer found was breast (26.5%), genitourinary (15.7%) and digestive (14,2%). If all patients from 2016-2018 were referred to Kenya, Uganda, Rwanda, India or Europe for 30 years, the country would spend in foreign currency US$3,858,229; US$638,342.80; US$21,288,592; US$10,410,192.90; US$54,718,329.70 respectively. Also, if all patients estimated by Globocan in 2018 were to be referred to these countries, the cost of foreign currencies would be US$52,455,122.60; US$38,264,740.88; US$129,272,590.40; US$81,330,325.94; US$276,601,008.02 respectively.

Conclusion:

There is a good number of cancer patients among patients referred abroad for health care. The estimated costs incurred by patients referred abroad for cancer care are far greater than funds needed to setup modern cancer care centres in Burundi.

SPECT/CT versus planar imaging to determine treatment strategy for non-small-cell lung cancer: a cost-effectiveness analysis

Aim: SPECT/CT has been found to improve predicted postoperative forced expiratory volume in one second (ppoFEV₁) assessments in patients with non-small-cell lung cancer (NSCLC). Methods: An economic simulation was developed comparing the cost-effectiveness of SPECT/CT versus planar scintigraphy for a US payer. Clinical outcomes and cost data were obtained through review of the published literature. Results: SPECT/CT increased the accuracy ppoFEV₁ assessment, changing the therapeutic decision for 1.3% of nonsurgical patients to a surgical option, while 3.3% of surgical patients shifted to more aggressive procedures. SPECT/CT led to an expected cost of $4694 per life year gained, well below typical thresholds. Conclusion: SPECT/CT resulted in substantially improved health outcomes and was found to be highly cost-effective.

Treatment Patterns, Outcomes, and Costs Associated With Localized Upper Tract Urothelial Carcinoma

Background

Upper tract urothelial carcinoma (UTUC) is a heterogeneous disease that presents a clinical management challenge for the urologic surgeon. We assessed treatment patterns, costs, and survival outcomes among patients with nonmetastatic UTUC.

Methods

We identified 4114 patients diagnosed with nonmetastatic UTUC from 2004 to 2013 in the Survival Epidemiology, and End Results-Medicare population-based database. Patients were stratified into low- or high-risk disease groups. Median total costs from 30 days prior to diagnosis through 365 days after diagnosis were compared between groups. Overall and cancer-specific survival were evaluated using Cox proportional hazards regression. All statistical tests were 2-sided.

Results

After risk stratification, 1027 (24.9%) and 3087 (75.0%) patients were classified into low- vs high-risk UTUC groups. Most patients underwent at least 1 surgical intervention (95.1%); 68.4% underwent at least 1 endoscopic intervention. Patients diagnosed with high- vs low-risk UTUC were more likely to undergo nephroureterectomy (83.6% vs 72.0%; P < .001); few patients with low-risk disease were exclusively managed endoscopically (16.9%). At 365 days after diagnosis, costs of care for high- vs low-risk UTUC were statistically significantly higher ($108 520 vs $91 233; median difference $16 704, 95% confidence interval [CI] = $11 619 to $21 778; P < .001). Those with high-risk UTUC had worse cancer-specific and overall survival compared with patients with low-risk UTUC (cancer-specific survival hazard ratio [HR] = 4.14, 95% CI = 3.19 to 5.37; overall survival HR = 1.78, 95% CI = 1.62 to 1.96).

Conclusions

UTUC continues to be managed primarily with nephroureterectomy, regardless of risk stratification, and patients with high-risk UTUC have worse overall and cancer-specific survival. Substantial costs are associated with management of low- and high-risk UTUC, with the latter being more costly up to 1 year from diagnosis.

A Cost-Effectiveness Analysis of Lung Cancer Screening With Low-Dose Computed Tomography and a Diagnostic Biomarker

Background

The Lung Computed Tomography Screening Reporting and Data System (Lung-RADS) reduces the false-positive rate of lung cancer screening but introduces prolonged periods of uncertainty for indeterminate findings. We assess the cost-effectiveness of a screening program that assesses indeterminate findings earlier via a hypothetical diagnostic biomarker introduced in place of Lung-RADS 3 and 4A guidelines.

Methods

We evaluated the performance of the US Preventive Services Task Force (USPSTF) recommendations on lung cancer screening with and without a hypothetical noninvasive diagnostic biomarker using a validated microsimulation model. The diagnostic biomarker assesses the malignancy of indeterminate nodules, replacing Lung-RADS 3 and 4A guidelines, and is characterized by a varying sensitivity profile that depends on nodules' size, specificity, and cost. We tested the robustness of our findings through univariate sensitivity analyses.

Results

A lung cancer screening program per the USPSTF guidelines that incorporates a diagnostic biomarker with at least medium sensitivity profile and 90% specificity, that costs $250 or less, is cost-effective with an incremental cost-effectiveness ratio lower than $100 000 per quality-adjusted life year, and improves lung cancer-specific mortality reduction while requiring fewer screening exams than the USPSTF guidelines with Lung-RADS. A screening program with a biomarker costing $750 or more is not cost-effective. The health benefits accrued and costs associated with the screening program are sensitive to the disutility of indeterminate findings and specificity of the biomarker, respectively.

Conclusions

Lung cancer screening that incorporates a diagnostic biomarker, in place of Lung-RADS 3 and 4A guidelines, could improve the cost-effectiveness of the screening program and warrants further investigation.

Radiologists' Increasing Role in Population Health Management: AJR Expert Panel Narrative Review

Population health management (PHM) is the holistic process of improving health outcomes of groups of individuals through the support of appropriate financial and care models. Radiologists' presence at the intersection of many aspects of healthcare, including screening, diagnostic imaging, and image-guided therapies, provides significant opportunity for increased radiologist engagement in PHM. Further, innovations in artificial intelligence and imaging informatics will serve as critical tools to improve value in healthcare through evidence-based and equitable approaches. Given radiologists' limited engagement in PHM to date, it is imperative to define the specialty's PHM priorities so that the radiologists' full value in improving population health is realized. In this expert review, we explore programs and future directions for radiology in PHM.

Economic burden of lung cancer in Turkey: a cost of illness study from payer perspective

BACKGROUND

This study was designed to estimate economic burden of lung cancer in Turkey from payer perspective based on expert panel opinion on practice patterns in clinical practice.

METHODS

In this cost of illness study, direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations/interventions, drug treatment, adverse events and metastasis. Indirect cost was calculated based on lost productivity due to early retirement, morbidity and premature death resulting from the illness, the value of lost productivity due to time spent by family caregivers and cost of formal caregivers.

RESULTS

Cost analysis revealed the total per patient annual direct medical cost for small cell lung cancer to be €8772), for non-small-cell lung cancer to be €10,167. Total annual direct medical cost was €497.9 million, total annual indirect medical cost was €1.1 billion and total economic burden of lung cancer was €1.6 billion. Hospitalization/interventions (41%) and indirect costs (68.6%) were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively.

CONCLUSIONS

Our findings indicate per patient direct medical costs of small cell lung cancer and non-small-cell lung cancer to be substantial and comparable, indicating the substantial economic burden of lung cancer in terms of both direct and indirect costs. Our findings indicate that hospitalization/interventions cost item and indirect costs were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively. Our findings emphasize the potential role of improved cancer prevention and early diagnosis strategies, by enabling cost savings related to drug treatment and metastasis management cost items, in sustainability of cancer treatments.

Economic costs of terminal care for selected non-communicable diseases from a healthcare perspective: a review of mortality records from a tertiary hospital in Nigeria

INTRODUCTION

WHO revealed that morbidity and mortality from non-communicable diseases (NCDs) are on the increase and NCDs accounted for approximately 29% of all deaths in Nigeria in 2016. This study was conducted to estimate the economic cost of selected NCDs-lung cancer, liver cancer and liver cirrhosis. These diseases are known to be associated with key modifiable health risk behaviours (smoking and alcohol use), which are prevalent in Nigeria and often commence during the adolescent years.

METHODS

Data were obtained between 2016 and 2017, from mortality records of patients managed for the selected diseases in the University College Hospital, a major referral centre in Nigeria. Information on costs of treatment, clinic visits, admission and transportation was obtained. Average costs of terminal in-patient care and transportation costs (in 2020 prices) were computed per patient. Costs were converted to the US dollar equivalent using the current official rate of US$1: ₦360.50.

RESULTS

Twenty-two (out of 90 cases recorded) could be retrieved and all the patients had been diagnosed in the terminal stages of the disease. The average direct costs were ₦510 152.62 (US$1415.13) for an average of 49.2 days of terminal care for lung cancer; ₦308 950.27 (US$857.00) and ₦238 121.83 (US$660.53) for an average of 16.6 and 21.7 days of terminal care for patients managed for liver cancer and liver cirrhosis, respectively.

CONCLUSION

The economic costs of each of the diseases were very high. Findings emphasise the need for aggressive efforts to promote primary prevention, improve early diagnosis and provide affordable treatment in view of the fact that the monthly minimum wage is less than US$85.00 and treatment costs are borne out-of-pocket by the generality of the population in Nigeria.

Burden of Tracheal, Bronchus, and Lung Cancer and Its Attributable Risk Factors in 204 Countries and Territories, 1990 to 2019

INTRODUCTION

Understanding trends in the annual incidence, mortality, and disability-adjusted life-years (DALYs) for tracheal, bronchus, and lung (TBL) cancer globally is important to enable appropriate targeting of resources for prevention, clinical practice improvement, and research. The aim of this study was to determine the global, regional, and national burdens of TBL cancer in 204 countries and territories from 1990 to 2019 by age, sex, and sociodemographic index.

METHODS

Estimates were produced through various data inputs including the following: cancer registries (n_site-years = 5318), vital registration (n_site-years = 22,553), vital registration-sample (n_site-years = 825), and verbal autopsies (n_site-years = 516). Annual incidence, mortality, and DALYs were estimated and presented as counts and age-standardized rates per 100,000 population.

RESULTS

There were 2.3 million (95% uncertainty interval [UI]: 2.1-2.5) incident cases of TBL cancer, with an age-standardized annual incidence rate of 27.7 (95% UI: 25.3-30), which decreased by 2.6% (95% UI: -12.4 to 6.5) between 1990 and 2019. TBL cancer was responsible for 2 million (95% UI: 1.9-2.2) deaths globally with an age-standardized death rate of 25.2 (95% UI: 23.2-27), a decrease of 7.8% (95% UI: -15.9 to 0.2) between 1990 and 2019. Moreover, TBL accounted for 45.9 million (95% UI: 42.3-49.3) DALYs at the global level, with an age-standardized rate of 551.6 (95% UI: 509-593.1) DALYs per 100,000 population. The standardized DALY rate declined by 16.2% (95% UI: -24 to -8.2) from 1990 to 2019. Greenland (77.7 [95% UI: 64.4-90.6]), Monaco (75.6 [95% UI: 61.4-90.8]), and Montenegro (56.7 [95% UI: 46.5-68.9]) had the three highest age-standardized annual incidence rates. The aforementioned three countries also had the three highest age-standardized death and DALY rates of TBL cancer. Honduras (68% [95% UI: 14.5-137.7]), Cabo Verde (62.2% [95% UI: 24.1-101.3]), and Monaco (58.2% [95% UI: 19.2-109.7]) had the largest increase in age-standardized annual incidence rates for TBL cancer during 1990 to 2019. The largest increases were found in age-standardized death rates of TBL cancer in Honduras (67.1% [95% UI: 14.7-133.1]), Cabo Verde (64.4% [95% UI: 25-103.4]), and Mozambique (49.9% [95% UI: 7.9 -101.3]). Age-standardized annual incidence and death rates were higher in male than female individuals and increased with population aging. There were nonlinear but generally positive associations between age-standardized DALY rates with corresponding sociodemographic index of countries. Globally, smoking (62.4%), ambient particulate matter (15.3%), and high fasting plasma glucose (9.9%) had the top three highest percent of attributable DALYs owing to TBL cancer in 2019 for both sexes.

CONCLUSIONS

This study found a decline in burden globally but with some countries having an increase. These results are crucial to set priorities for prevention and treatment of TBL cancer and would be beneficial for policymakers, government officials, clinicians, and researchers.

Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules

IMPORTANCE

Whether guideline-concordant lung nodule evaluations lead to better outcomes remains unknown.

OBJECTIVE

To examine the association between the intensity of lung nodule diagnostic evaluations and outcomes, safety, and health expenditures.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study analyzed health plan enrollees at Kaiser Permanente Washington in Seattle, Washington, and Marshfield Clinic in Marshfield, Wisconsin, with an incidental lung nodule detected between January 1, 2005, and December 31, 2015. Included patients were 35 years or older, had no high suspicion of infection, had no history of malignant neoplasm, and had no evidence of advanced lung cancer on nodule detection. Data analysis was conducted from January 7 to August 19, 2020.

EXPOSURES

With the 2005 Fleischner Society guidelines (selected for their applicability to the time frame under investigation) as the comparator, 2 other intensities of lung nodule evaluation were defined. Guideline-concordant evaluation followed the guidelines. Less intensive evaluation was the absence of recommended testing, longer-than-recommended surveillance intervals, or less invasive testing than recommended. More intensive evaluation consisted of testing when the guidelines recommended no further testing, shorter-than-recommended surveillance intervals, or more invasive testing than recommended.

MAIN OUTCOMES AND MEASURES

The main outcome was the proportion of patients with lung cancer who had stage III or IV disease, radiation exposure, procedure-related adverse events, and health expenditures 2 years after nodule detection.

RESULTS

Among the 5057 individuals included in this comparative effectiveness research study, 1925 (38%) received guideline-concordant, 1863 (37%) less intensive, and 1269 (25%) more intensive diagnostic evaluations. The entire cohort comprised 2786 female patients (55%), and the mean (SD) age was 67 (13) years. Adjusted analyses showed that compared with guideline-concordant evaluations, less intensive evaluations were associated with fewer procedure-related adverse events (risk difference [RD], -5.9%; 95% CI, -7.2% to -4.6%), lower mean radiation exposure (-9.5 milliSieverts [mSv]; 95% CI, -10.3 mSv to -8.7 mSv), and lower mean health expenditures (-$10 916; 95% CI, -$16 112 to -$5719); no difference in stage III or IV disease was found among patients diagnosed with lung cancer (RD, 4.6%; 95% CI, -22% to +31%). More intensive evaluations were associated with more procedure-related adverse events (RD, +8.1%; 95% CI, +5.6% to +11%), higher mean radiation exposure (+6.8 mSv; 95% CI, +5.8 mSv to +7.8 mSv), and higher mean health expenditures ($20 132; 95% CI, +$14 398 to +$25 868); no difference in stage III or IV disease was observed (RD, -0.5%; 95% CI, -28% to +27%).

CONCLUSIONS AND RELEVANCE

This study found inconclusive evidence of an association between less intensive diagnostic evaluations and more advanced stage at lung cancer diagnosis compared with guideline-concordant care; higher intensities of diagnostic evaluations were associated with greater procedural complications, radiation exposure, and expenditures. These findings underscore the need for more evidence on better ways to evaluate lung nodules and to avoid unnecessarily intensive diagnostic evaluations of lung nodules.

Estimated Costs and Long-term Outcomes of Patients With High-Risk Non-Muscle-Invasive Bladder Cancer Treated With Bacillus Calmette-Guérin in the Veterans Affairs Health System

IMPORTANCE

Management of high-risk non-muscle-invasive bladder cancer (NMIBC) represents a clinical challenge due to high failure rates despite prior bacillus Calmette-Guérin (BCG) therapy.

OBJECTIVE

To describe real-world patient characteristics, long-term outcomes, and the economic burden in a population with high-risk NMIBC treated with BCG therapy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study identified 412 patients with high-risk NMIBC from 63 139 patients diagnosed with bladder cancer who received at least 1 dose of BCG within Department of Veterans Affairs (VA) centers across the US from January 1, 2000, to December 31, 2015. Adequate induction BCG therapy was defined as at least 5 installations, and adequate maintenance BCG therapy was defined as at least 7 installations. Data were analyzed from January 2, 2020, to January 20, 2021.

EXPOSURES

Intravesical BCG therapy, including adequate induction BCG therapy, was defined as at least 5 intravesical instillations of BCG within 70 days from BCG therapy start date. Adequate maintenance BCG therapy was defined as at least 7 installations of BCG within 274 days of the start (the first instillation) of adequate induction BCG therapy (ie, adequate induction BCG plus some form of additional BCG).

MAIN OUTCOMES AND MEASURES

The Kaplan-Meier method was used to estimate outcomes, including event-free survival. All-cause expenditures were summarized as medians with corresponding interquartile ranges (IQRs) and adjusted to 2019 USD.

RESULTS

Of the 412 patients who met inclusion criteria, 335 (81%) were male and 77 (19%) were female, with a median age of 67 (IQR, 61-74) years. Follow-up was 2694 person-years. A total of 392 patients (95%) received adequate induction BCG therapy, and 152 (37%) received adequate BCG therapy. For all patients with high-risk NMIBC, the 10-year progression-free survival rate and disease-specific death rate were 78% and 92%, respectively. Patients with carcinoma in situ (Cis) had worse disease-free survival than those without Cis (hazard ratio [HR], 1.85; 95% CI, 1.34-2.56). Total median costs at 1 year were $29 459 (IQR, $14 991-$52 060); at 2 years, $55 267 (IQR, $28 667-$99 846); and at 5 years, $117 361 (IQR, $59 680-$211 298). Patients with progressive disease had significantly higher median 5-year costs ($232 729 [IQR, $151 321-$341 195] vs $94 879 [IQR, $52 498-$172 631]; P < .001), with outpatient care, pharmacy, and surgery-related costs contributing.

CONCLUSIONS AND RELEVANCE

Despite adequate induction BCG therapy, only 37% of patients received adequate BCG therapy. Patients with Cis had increased risk of progression, and progression regardless of Cis was associated with significantly increased costs relative to patients without progression. Extrapolating cost figures, regardless of progression, resulted in nationwide costs at 1 year of $373 million for patients diagnosed with high-risk NMIBC in 2019.

Health care costs of breast, prostate, colorectal and lung cancer care by clinical stage and cost component

OBJECTIVE

To measure 3-year care costs of breast, prostate, colorectal and lung cancers disaggregated by site and clinical stage.

METHOD

A retrospective observational design was employed to investigate care costs of cases recorded in the Registry of the Basque Country between 2010 and 2015. Data gathered included TNM stage and demographic, clinical and resource use variables. Total costs per patient with stage IV disease were calculated by combining generalized linear models with parametric survival analysis. Unit costs were obtained from the analytical accounting system of the Basque Health Service.

RESULTS

The sample comprised 23,782 cancer cases (7801 colorectal, 5530 breast, 4802 prostate and 5649 lung cancer). The mean 3-year costs per patient with stage I to III disease were €11,323, €13,727, €8,651 and €12,023 for colorectal, breast, prostate and lung cancer, respectively. The most important cost components were surgery and chemotherapy. Total survival-adjusted costs until death for patients with stage IV disease (€27,568, €26,296, €16,151 and €15,931 for breast, colorectal, lung and prostate cancer, respectively) were higher than the 3-year costs for those with earlier-stage disease.

CONCLUSIONS

This study quantitatively shows the pattern of changes in the economic burden of cancer throughout its natural history and the great magnitude of this burden for the health system. The use of indicators based on real-world data from each regional health service would allow cancer care in each region to be tailored to local population needs.

Longitudinal Trends of Financial Toxicity in Patients With Lung Cancer: A Prospective Cohort Study

BACKGROUND

Cancer therapy is associated with severe financial burden. However, the magnitude and longitudinal patient relationship with financial toxicity (FT) in the initial course of therapy is unclear.

METHODS

Patients with stage II-IV lung cancer were recruited in a prospective longitudinal study between July 2018 and March 2020. FT was measured via the validated COmprehensive Score for financial Toxicity (COST) at the time of cancer diagnosis and at 6-month follow-up (6MFU). 6MFU data were compared with corresponding baseline data. A lower COST score indicates increased financial hardship.

RESULTS

At the time of analysis, 215 agreed to participate. Subsequently, 112 patients completed 6MFU. On average, slightly more FT was observed at diagnosis compared with 6MFU (median COST_base 25 v COST_6M 27; P < .001); however, individual patients experienced large changes in FT. At 6MFU, 27.7% of patients had made financial sacrifices to pay for treatment but only 4.5% refused medical care based on cost. Median reported out-of-pocket (OOP) costs for the initial 6 months of cancer treatment was $2,496 (range, $0-25,900). Risk factors for FT at diagnosis were unique from risk factors at 6MFU. Actual OOP expenses were not correlated with FT; however, inability to predict upcoming treatment expenses resulted in higher FT at 6MFU.

DISCUSSION

FT is a pervasive challenge during the initiation of lung cancer treatment. Few patients are willing to sacrifice medical care regardless of the cost. Risk factors for FT evolve, resulting in unique interventional targets throughout therapy.

Estimating the disease burden of lung cancer attributable to residential radon exposure in Korea during 2006-2015: A socio-economic approach

Estimating the lung cancer disease burden can provide evidence for public health practitioners, researchers, and policymakers. This study uses claim data from lung cancer patients for 2006-2015 from the Korean National Health Insurance Service to estimate the lung cancer burdens attributable to residential radon in Korea using disability-adjusted life years (DALY) and patients' annual economic burden with societal perspectives using the cost-of-illness (COI) method. The number of patients increased during our study period (from 35,866 to 59,168). The disease burden and that attributable to residential radon, respectively, increased from 517.57 to 695.74 and 64.62 (95%; CIs 61.33-67.69) to 86.99 (95%; CIs 82.7-91.1) DALYs per 100,000 patients. The percentage of years lost due to disability among the DALY doubled from 8% to 17%. The cost for all the patients was US$2.33 billion, with US$292 (95%; CIs 278-306) million attributable to residential radon. During the last decade, the lung cancer disease burden increased by 1.34 times, with a doubled percentage of non-fatal burden and average annual growth rate of 9.5% of the total cost. Hence, the burden and cost of lung cancer in Korean provinces have been steadily increasing. The findings could be used as input data for future cost-effectiveness analysis of policies regarding radon reduction.

The knockdown of LncRNA AFAP1-AS1 suppressed cell proliferation, migration, and invasion, and promoted apoptosis by regulating miR-545-3p/hepatoma-derived growth factor axis in lung cancer

Lung cancer is one of the most common human cancers. Long noncoding RNA AFAP1-AS1 (LncRNA AFAP1-AS1) and microRNA-545-3p (miR-545-3p) were reported to play important roles in lung cancer development. This study aimed to elucidate the functional mechanisms of AFAP1-AS1 and miR-545-3p in lung cancer. Quantitative real time polymerase chain reaction was carried out to determine the levels of AFAP1-AS1, miR-545-3p and hepatoma-derived growth factor (HDGF). Cell proliferation, apoptosis, migration and invasion were detected by 3-(4, 5-dimethyl-2-thiazolyl)-2, 5-diphenyl-2-H-tetrazolium bromide assay, flow cytometry, and transwell migration and invasion assays, respectively. Furthermore, the interaction between miR-545-3p and AFAP1-AS1 or HDGF was predicted by bioinformatics analysis software starbase and confirmed by the dual luciferase reporter assay. Western blot assay was used to detect the protein level of HDGF. Besides, murine xenograft model was conducted through injecting A549 cells transfected with sh-AFAP1-AS1. The expression levels of AFAP1-AS1 and HDGF were increased, while miR-545-3p was decreased in lung cancer tissues and cells. AFAP1-AS1 knockdown suppressed lung cancer cell proliferation, migration, and invasion and induced apoptosis. Furthermore, AFAP1-AS1 mediated cell progression through regulating miR-545-3p expression. In addition, miR-545-3p negatively regulated the expression level of HDGF via binding 3'-untranslated region of HDGF. As expected, AFAP1-AS1 knockdown inhibited lung cancer progression via affecting miR-545-3p/HDGF axis. Besides, AFAP1-AS1 knockdown suppressed lung cancer tumor growth in vivo. Collectively, our results suggested that AFAP1-AS1 promoted the development of lung cancer via regulating miR-545-3p/HDGF axis, providing a potential target for the treatment of lung cancer.

Estimated direct costs of non-small cell lung cancer by stage at diagnosis and disease management phase: A whole-disease model

Background

Non‐small cell lung cancer (NSCLC) is the first cause of cancer‐related death among men and the second among women worldwide. It also poses an economic threat to the sustainability of healthcare services. This study estimated the direct costs of care for patients with NSCLC by stage at diagnosis, and management phase of pathway recommended in local and international guidelines.

Methods

Based on the most up‐to‐date guidelines, we developed a very detailed “whole‐disease” model listing the probabilities of all potentially necessary diagnostic and therapeutic actions involved in the management of each stage of NSCLC. We assigned a cost to each procedure, and obtained an estimate of the total and average per‐patient costs of each stage of the disease and phase of its management.

Results

The mean expected cost of a patient with NSCLC is 21,328 € (95% C.I. −20 897−22 322). This cost is 16 291 € in stage I, 19530 € in stage II, 21938 € in stage III, 22175 € in stage IV, and 28 711 € for a Pancoast tumor. In the early stages of the disease, the main cost is incurred by surgery, whereas in the more advanced stages radiotherapy, medical therapy, treatment for progressions, and supportive care become variously more important.

Conclusions

An estimation of the direct costs of care for NSCLC is fundamental in order to predict the burden of new oncological therapies and treatments on healthcare services, and thus orient the decisions of policy‐makers regarding the allocation of resources.

Key points

Significant findings of the study

The high costs of surgery make the early stages of the disease no less expensive than the advanced stages.

What this study adds

An estimation of the direct costs of care is fundamental in order to orient the decisions of policy‐makers regarding the allocation of resources.

Comparing Costs of Radical Versus Partial Cystectomy for Patients Diagnosed With Localized Muscle-Invasive Bladder Cancer: Understanding the Value of Surgical Care

OBJECTIVE

To compare costs associated with radical versus partial cystectomy. Prior studies noted substantial costs associated with radical cystectomy, however, they lack surgical comparison to partial cystectomy.

METHODS

A total of 2305 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 to December 31, 2011 were included. Total Medicare costs within 1 year of diagnosis following radical versus partial cystectomy were compared using inverse probability of treatment-weighted propensity score models. Cox regression and competing risks analysis were used to determine overall and cancer-specific survival, respectively.

RESULTS

Median total costs were not significantly different for radical than partial cystectomy in 90 days ($73,907 vs $65,721; median difference $16,796, 95% CI $10,038-$23,558), 180 days ($113,288 vs $82,840; median difference $36,369, 95% CI $25,744-$47,392), and 365 days ($143,831 vs $107,359; median difference $34,628, 95% CI $17,819-$53,558), respectively. Hospitalization, surgery, pathology/laboratory, pharmacy, and skilled nursing facility costs contributed largely to costs associated with either treatment. Patients who underwent partial cystectomy had similar overall survival but had worse cancer-specific survival (Hazard Ratio 1.45, 95% Confidence Interval, 1.34-1.58, P < .001) than patients who underwent radical cystectomy.

CONCLUSION

While treatments for bladder cancer are associated with substantial costs, we showed radical cystectomy had comparable total costs when compared to partial cystectomy among patients with muscle-invasive bladder cancer. However, partial cystectomy resulted in worse cancer-specific survival further supporting radical cystectomy as a high-value surgical procedure for muscle-invasive bladder cancer.

Racial/ethnic disparities in colorectal cancer treatment utilization and phase-specific costs, 2000-2014

BACKGROUND

Our study analyzed disparities in utilization and phase-specific costs of care among older colorectal cancer patients in the United States. We also estimated the phase-specific costs by cancer type, stage at diagnosis, and treatment modality.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients aged 66 or older diagnosed with colon or rectal cancer between 2000-2013, with follow-up to death or December 31, 2014. We divided the patient's experience into separate phases of care: staging or surgery, initial, continuing, and terminal. We calculated total, cancer-attributable, and patient-liability costs. We fit logistic regression models to determine predictors of treatment receipt and fit linear regression models to determine relative costs. All costs are reported in 2019 US dollars.

RESULTS

Our cohort included 90,023 colon cancer patients and 25,581 rectal cancer patients. After controlling for patient and clinical characteristics, Non-Hispanic Blacks were less likely to receive treatment but were more likely to have higher cancer-attributable costs within different phases of care. Overall, in both the colon and rectal cancer cohorts, mean monthly cost estimates were highest in the terminal phase, next highest in the staging phase, decreased in the initial phase, and were lowest in the continuing phase.

CONCLUSIONS

Racial/ethnic disparities in treatment utilization and costs persist among colorectal cancer patients. Additionally, colorectal cancer costs are substantial and vary widely among stages and treatment modalities. This study provides information regarding cost and treatment disparities that can be used to guide clinical interventions and future resource allocation to reduce colorectal cancer burden.

Comorbidity in lung cancer patients and its association with medical service cost and treatment choice in China

Background

It is evident that comorbidity exacerbate the complexity of the management of lung cancer, however, limited research has been conducted to investigate the impact of comorbidity on health service utilization and cost, as well as the treatment choice among lung cancer patients. We examined the association of comorbidity with medical service utilization, cost and treatment choice among lung cancer patients in China.

Methods

We used claims data from China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) between 2013 to 2016 and data from Hospital Information System (HIS) Database in Beijing Cancer Hospital (BCH). Elixhauser Comorbidity Index was used to assess comorbidity. Negative binomial regression, generalized linear model (GLM) with a gamma distribution and a log link, and logistic regression was applied to assess the associations between comorbidity and medical service utilization, cost and treatment choice, respectively.

Results

Among 8655 patients with lung cancer, 31.3% of had at least one comorbid conditions. Having comorbidity was associated with increased number of annual outpatient visits (1.6, 95%CI: 1.3, 1.9) and inpatients admissions (0.8, 95%CI, 0.70, 0.90), increased outpatient (USD635.5, 95%CI: 490.3, 780.8) and inpatient expenditure (USD2 470.3, 95CI%: 1998.6, 2941.9), as well as increased possibility of choosing radio therapy (OR: 1.208, 95%CI:1.012–1.441) and chemotherapy (1.363, 1.196–1.554), and decreased possibility of choosing surgery (0.850, 0.730–0.989). The medical utilization and expenditure, the possibility of choosing radiotherapy increases, and the possibility of choosing surgery decreases with the increasing number of chronic conditions. There are variations in the association with medical service utilization and expenditure, and treatment choice among individuals with different types of comorbid conditions.

Conclusion

Comorbidity among lung cancer patients restricts the potential treatment choices and poses an extra substantial health care burden. Our findings provide implications for both the clinical management and health service planning and financing for lung cancer patients.

Cost-effectiveness of Canakinumab for Prevention of Recurrent Cardiovascular Events

Importance

In the Canakinumab Anti-inflammatory Thrombosis Outcome Study (CANTOS) trial, the anti-inflammatory monoclonal antibody canakinumab significantly reduced the risk of recurrent cardiovascular events in patients with previous myocardial infarction (MI) and high-sensitivity C-reactive protein (hs-CRP) levels of 2 mg/L or greater.

Objective

To estimate the cost-effectiveness of adding canakinumab to standard of care for the secondary prevention of major cardiovascular events over a range of potential prices.

Design, Setting, and Participants

A state-transition Markov model was constructed to estimate costs and outcomes over a lifetime horizon by projecting rates of recurrent MI, coronary revascularization, infection, and lung cancer with and without canakinumab treatment. We used a US health care sector perspective, and the base case used the current US market price of canakinumab of $73 000 per year. A hypothetical cohort of patients after MI aged 61 years with an hs-CRP level of 2 mg/L or greater was constructed.

Interventions

Canakinumab, 150 mg, administered every 3 months plus standard of care compared with standard of care alone.

Main Outcomes and Measures

Lifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.

Results

Adding canakinumab to standard of care increased life expectancy from 11.31 to 11.36 years, QALYs from 9.37 to 9.50, and costs from $242 000 to $1 074 000, yielding an incremental cost-effectiveness ratio of $6.4 million per QALY gained. The price would have to be reduced by more than 98% (to $1150 per year or less) to meet the $100 000 per QALY willingness-to-pay threshold. These results were generally robust across alternative assumptions, eg, substantially lower health-related quality of life after recurrent cardiovascular events, lower infection rates while receiving canakinumab, and reduced all-cause mortality while receiving canakinumab. Including a potential beneficial effect of canakinumab on lung cancer incidence improved the incremental cost-effectiveness ratio to $3.5 million per QALY gained. A strategy of continuing canakinumab selectively in patients with reduction in hs-CRP levels to less than 2 mg/L would have a cost-effectiveness ratio of $819 000 per QALY gained.

Conclusions and Relevance

Canakinumab is not cost-effective at current US prices for prevention of recurrent cardiovascular events in patients with a prior MI. Substantial price reductions would be needed for canakinumab to be considered cost-effective.

Survival, Chemotherapy Treatments, and Health Care Utilization Among Patients with Advanced Small Cell Lung Cancer: An Observational Study

INTRODUCTION

Most cases of small cell lung cancer (SCLC) are diagnosed at an advanced stage. The objective of this study was to investigate patient characteristics, survival, chemotherapy treatments, and health care use after a diagnosis of advanced SCLC in subjects enrolled in a health system network.

METHODS

This was a retrospective cohort study of patients aged ≥ 18 years who either were diagnosed with stage III/IV SCLC or who progressed to advanced SCLC during the study period (2005-2015). Patients identified from the Indiana State Cancer Registry and the Indiana Network for Patient Care were followed from their advanced diagnosis index date until the earliest date of the last visit, death, or the end of the study period. Patient characteristics, survival, chemotherapy regimens, associated health care visits, and durations of treatment were reported. Time-to-event analyses were performed using the Kaplan-Meier method.

RESULTS

A total of 498 patients with advanced SCLC were identified, of whom 429 were newly diagnosed with advanced disease and 69 progressed to advanced disease during the study period. Median survival from the index diagnosis date was 13.2 months. First-line (1L) chemotherapy was received by 464 (93.2%) patients, most commonly carboplatin/etoposide, received by 213 (45.9%) patients, followed by cisplatin/etoposide (20.7%). Ninety-five (20.5%) patients progressed to second-line (2L) chemotherapy, where topotecan monotherapy (20.0%) was the most common regimen, followed by carboplatin/etoposide (14.7%). Median survival was 10.1 months from 1L initiation and 7.7 months from 2L initiation.

CONCLUSION

Patients in a regional health system network diagnosed with advanced SCLC were treated with chemotherapy regimens similar to those in earlier reports based on SEER-Medicare data. Survival of patients with advanced SCLC was poor, illustrating the lack of progress over several decades in the treatment of this lethal disease and highlighting the need for improved treatments.

Integrated, Multidisciplinary Management of Pulmonary Nodules Can Streamline Care and Improve Adherence to Recommendations

Every year millions of pulmonary nodules are discovered incidentally and through lung cancer screening programs. Management of these nodules is often suboptimal, with low follow-up rates and poor provider understanding of management approaches. There is an emerging body of literature about how to optimize management of pulmonary nodules. The Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) at Massachusetts General Hospital was founded in 2012 to manage pulmonary nodules via a multidisciplinary approach with optimized support staff. Recommendations from clinic providers and treatment details were recorded for all patients seen at the PNLCSC. Adherence to recommendations and outcomes were also tracked and reviewed. From October 2012 to September 2019, 1,136 patients were seen at the PNLCSC, each for a mean of 1.8 appointments (range, 1-10). A total of 356 procedures were recommended by the clinic and 271 patients were referred for surgery and/or radiation. The majority of interventions (74%) were recommended at the initial PNLCSC appointment. In total, 211 patients (19%) evaluated at the PNLCSC had pathologically confirmed pulmonary malignancies or were treated empirically with radiation. Among patients followed by the clinic, the adherence rate to clinic recommendations was 95%. This study shows how a multidisciplinary approach to pulmonary nodule management can streamline care and optimize follow-up. The PNLCSC provides a template that can be replicated in other health systems. It also provides an example of how multidisciplinary approaches can be applied to other complex conditions. IMPLICATIONS FOR PRACTICE: This work demonstrates how an integrated, multidisciplinary approach to management of pulmonary nodules can streamline patient care and improve adherence to provider recommendations. This approach has the potential to improve patient outcomes and reduce health care costs.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chemotherapy treatments, costs of care, and survival for patients diagnosed with small cell lung cancer: A SEER-Medicare study

OBJECTIVES

The effectiveness and costs of new treatments should be assessed in relation to existing practice. We describe treatments, survival and costs for advanced or metastatic small cell lung cancer (SCLC) patients receiving systemic therapy in the period preceding the introduction of immunotherapies.

MATERIALS AND METHODS

This was a retrospective cohort study of patients aged ≥65 years, identified using linked Surveillance, Epidemiology, and End Results and Medicare databases. Individuals with a new primary diagnosis of SCLC between January 2007 and December 2013 were followed until December 2014. Chemotherapy treatments, health care visits and costs (in 2016 USD), and survival were determined by line of therapy.

RESULTS

A total of 11 812 patients were identified with SCLC. First-line (1L) chemotherapy was received by 6509 (55.1%) patients, most (93.2%) with carboplatin- (71.0%) or cisplatin- (22.2%) based therapies, typically combined with etoposide (79.2%). Second- (2L) and third- (3L) line chemotherapies were received by 2238 (18.9%) and 679 (5.7%) patients, of which 48.4% and 30.9%, respectively, were platinum-based. The median durations of 1L, 2L, and 3L carboplatin-based therapies were 5.9, 4.8, and 5.4 months, respectively, and the corresponding durations of cisplatin-based therapies were 5.3, 4.2, and 5.3 months. During 1L, 2L, and 3L chemotherapies, patients averaged 8.2, 7.4, and 7.3 health care visits per month, respectively, and incurred total mean health care costs of $60 223, $42 636, and $35 903 per patient, respectively. Median survival from the start of 1L, 2L, and 3L chemotherapy was 9.2, 6.0, and 5.7 months, respectively.

CONCLUSION

First-line chemotherapy was primarily platinum-based, and a plethora of different regimens was used for 2L and 3L chemotherapies. Median survival from the start of 1L chemotherapy was 9 months, with an associated health care cost of $60 000. These data highlight an unmet medical need among SCLC patients receiving systemic therapy.

Comparing Survival Outcomes and Costs Associated With Radical Cystectomy and Trimodal Therapy for Older Adults With Muscle-Invasive Bladder Cancer

Importance

Radical cystectomy is the guidelines-recommended treatment of muscle-invasive bladder cancer, but a resurgence of trimodal therapy has occurred. Limited comparative data are available on outcomes and costs attributable to these 2 treatments.

Objective

To compare the survival outcomes and costs between trimodal therapy and radical cystectomy in older adults with muscle-invasive bladder cancer.

Design, Setting, and Participants

This population-based cohort study used data from the Surveillance, Epidemiology, and End Results-Medicare linked database. A total of 3200 older adults (aged ≥66 years) with clinical stage T2 to T4a bladder cancer diagnosed from January 1, 2002, to December 31, 2011, and with claims data available through December 31, 2013, were included in the analysis. Patients who received radical cystectomy underwent either only surgery or surgery in combination with radiotherapy or chemotherapy. Patients who received trimodal therapy underwent transurethral resection of the bladder followed by radiotherapy and chemotherapy. Propensity score matching by sociodemographic and clinical characteristics was used. Data analysis was performed from August 1, 2017, to March 11, 2018.

Main Outcomes and Measures

Overall survival and cancer-specific survival were evaluated using the Cox proportional hazards regression model and the Fine and Gray competing risk model. All Medicare health care costs for inpatient, outpatient, and physician services within 30, 90, and 180 days of treatment were compared. The total amount spent nationwide was estimated, using 180-day medical costs between treatments, by the total number of new cases of muscle-invasive bladder cancer in the United States in 2011.

Results

Of the 3200 patients who met the inclusion criteria, 2048 (64.0%) were men and 1152 (36.0%) were women, with a mean (SD) age of 75.8 (6.0) years. After propensity score matching, 687 patients (21.5%) underwent trimodal therapy and 687 patients (21.5%) underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased overall survival (hazard ratio [HR], 1.49; 95% CI, 1.31-1.69) and cancer-specific survival (HR, 1.55; 95% CI, 1.32-1.83). No differences in costs at 30 days were observed between trimodal therapy ($15 233 in 2002 vs $18 743 in 2011) and radical cystectomy ($17 990 in 2002 vs $21 738 in 2011). However, median total costs were significantly higher with trimodal therapy than with radical cystectomy at 90 days ($80 174 vs $69 181; median difference, $8964; Hodges-Lehmann 95% CI, $3848-$14 079) and at 180 days ($179 891 vs $107 017; median difference, $63 771; Hodges-Lehmann 95% CI, $55 512-$72 029). Extrapolating these figures to the total US population revealed $335 million in excess spending for trimodal therapy compared with the less costly radical cystectomy ($492 million) for patients who received a muscle-invasive bladder cancer diagnosis in 2011.

Conclusions and Relevance

Trimodal therapy was associated with significantly decreased overall survival and cancer-specific survival as well as $335 million in excess spending in 2011. These findings have important health policy implications regarding the appropriate use of high value-based care among older adults with invasive bladder cancer who are candidates for either radical cystectomy or trimodal therapy.

Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer

Importance

Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days.

Objective

To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs.

Design, Setting, and Participants

This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018.

Main Outcomes and Measures

Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias.

Results

Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis.

Conclusions and Relevance

Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

Next-generation sequencing in liquid biopsy: cancer screening and early detection

In recent years, the rapid development of next-generation sequencing (NGS) technologies has led to a significant reduction in sequencing cost with improved accuracy. In the area of liquid biopsy, NGS has been applied to sequence circulating tumor DNA (ctDNA). Since ctDNA is the DNA fragments released by tumor cells, it can provide a molecular profile of cancer. Liquid biopsy can be applied to all stages of cancer diagnosis and treatment, allowing non-invasive and real-time monitoring of disease development. The most promising aspects of liquid biopsy in cancer applications are cancer screening and early diagnosis because they can lead to better survival results and less disease burden. Although many ctDNA sequencing methods have enough sensitivity to detect extremely low levels of mutation frequency at the early stage of cancer, how to effectively implement them in population screening settings remains challenging. This paper focuses on the application of liquid biopsy in the early screening and diagnosis of cancer, introduces NGS-related methods, reviews recent progress, summarizes challenges, and discusses future research directions.

Esophageal cancer treatment costs by phase of care and treatment modality, 2000-2013

BACKGROUND

Detailed cost estimates are not widely available for esophageal cancer. Our study estimates phase-specific costs for esophageal cancer by age, year, histology, stage, and treatment for older patients in the United States and compares these costs within stage and treatment modalities.

METHODS

We identified 8061 esophageal cancer patients in the Surveillance, Epidemiology, and End Results-Medicare database for years 1998-2013. Total, cancer-attributable, and patient-liability costs were calculated based on separate phases of care-staging (or surgery), initial, continuing, and terminal. We estimated costs by treatment modality within stage and phase for esophageal adenocarcinoma and squamous cell carcinoma separately. We fit linear regression models using log transformation to determine cost by age and calendar year. All costs are reported in 2018 US dollars.

RESULTS

Overall, mean (95% CI) monthly total cost estimates were high during the staging ($8953 [$8385-$9485]) and initial phases ($7731 [$7492-$7970]), decreased over the continuing phase ($2984 [$2814-$3154]), and increased substantially during the 6-month terminal phase ($18 150 [$17 211-$19 089]). This pattern of high staging and initial phase costs, decreasing continuing phase costs, and increasing terminal phase costs was seen in all stages. The highest staging costs were in stages III ($9249, $8025-$10 474) and II ($9171, $7642-$10 699). The highest initial phase cost was in stage IV, $9263 ($8758-49 768), the lowest continuing phase cost was in stage I, $2338 ($2160-$2517), and the highest terminal phase costs were in stages II ($20 533, $17 772-$23 293) and III ($20 599, $18 268-$22 929). The linear regression models showed that cancer-attributable costs remained stable over the study period and were unaffected by age for most histology, stage, and treatment modality subgroups.

CONCLUSIONS

Our estimates demonstrate that esophageal cancer costs can vary widely by histology, stage, and treatment. These cost estimates can be used to guide future resource allocation for esophageal cancer care and research.

Cost of screening for lung cancer in Australia

BACKGROUND

Lung cancer screening can reduce lung cancer mortality. Australian cost estimates are important to inform policy but remain uncertain.

AIM

To describe the first direct medical costs associated with lung cancer screening in Australia.

METHODS

Single-centre prospective screening cohort. Healthy volunteers (age 60-74 years, current or former smokers quit <15 years prior to enrolment, ≥30 pack-years exposure) underwent baseline and two annual incidence computed tomography (CT) screening scans. Health status and healthcare usage data were collated for 5 years. The main outcome measures were: rates of lung cancer; individual healthcare resource use derived from multiple data sources adjusted to 2018 Australian Medicare Benefits Schedule values.

RESULTS

A total of 256, 239, 233 participants was screened at each round respectively; 12 participants were diagnosed with lung cancer during screening and 2 during follow-up: 9 underwent surgery, 4 received concurrent chemoradiation, 1 received palliative chemotherapy. One surgical case died from lymphoma 1407 days after diagnosis, all other surgical cases survived >5 years. Non-surgical median survival post-diagnosis was 654 days. Gross trial cost was Australian dollar (AU$) 965 665 (AU$397 396 CT scans; AU$29 303 false-positive scan work-up; AU$96 340 true-positive scan workup; AU$336 914 lung cancer treatment; AU$104 712 lung cancer follow-up post-treatment). Average total direct medical cost per participant was AU$3 768. Average direct cost of surgery was AU$22 659; average non-surgical cost was AU$47 395 (radiotherapy, chemotherapy, palliative care).

CONCLUSIONS

Advanced cancer cost more to treat and had worse survival than early cancer. Screening costs are similar to international studies and suggest that lung cancer early detection could limit treatment costs and improve outcomes.

Collaborative response to arsenic-contaminated soil in an Appalachian Kentucky neighborhood

The aim of this study was to identify factors associated with an increased exposure to arsenic-contaminated soil in a Kentucky neighborhood as part of collaborative public health response. An exposure assessment survey was administered to residents and toenail clippings and soil samples analyzed for arsenic concentration. The associations between exposure variables and arsenic concentrations were evaluated using a multivariate-generalized estimating equation. An ecological assessment of cancer incidence in the community was also conducted using standardized incidence ratio maps. Median toenail arsenic was 0.48 micrograms/gram (µg/g), twice the expected regional level of 0.2 µg/g. Mean residence surface soil arsenic level was 64.8 ppm. An increase of 1 ppm of residence concentration was significantly associated with a 0.003 µg/g rise in toenail levels. Concentrations for respondents who engaged in digging were 0.68 µg/g significantly higher compared to individuals who did not. No significantly elevated rates of lung or bladder cancer were observed in the affected ZIP codes. Living in areas with high soil arsenic contamination might lead to (1) increased exposure; (2) elevated residence soil arsenic concentrations and (3) the action of digging in the soil was associated with elevated toenail arsenic levels. Based upon elevated soil levels identified, residents were recommended to move from the contaminated environment until remediation was complete. Additional recommendations included regular health-care follow-up.

Cost of treating recurrent respiratory papillomavirus in commercially insured and medicaid patients

OBJECTIVES

The study objective was to estimate the first 2 years' direct costs of treating new cases of juvenile-onset and adult-onset recurrent respiratory papillomatosis (RRP) and determine the predictors of treatment costs.

METHODS

Cases were patients diagnosed with RRP in commercial insurance claims in 2011-2014 and Texas Medicaid in 2008-2012 for treatment of RRP. Controls were patients without a diagnosis of HPV-related cancer or RRP, matched with cases by age, sex, geographic area, date of diagnosis of RRP, and propensity score. Total health care costs in the first 2 years after diagnosis were obtained from cases and matched controls. A generalized linear model was created to identify predictors of monthly costs.

RESULTS

In commercially insured patients, a total of 122 cases of juvenile-onset (<18 years old) and 1824 cases of adult-onset (≥18 years old) RRP were identified. The mean first 2 years' cost difference between cases and controls was $58,733 for juvenile-onset disease and $11,185 for adult-onset disease after model adjustments. In the Texas Medicaid population, 73 cases of juvenile-onset and 96 cases of adult-onset RRP were identified. The mean first 2 years' cost difference between cases and controls was $76,115 for juvenile-onset disease and $4,633 for adult-onset disease after model adjustments.

CONCLUSION

The first 2 years' medical costs difference of juvenile-onset and adult-onset RRP among commercially insured and Medicaid population were approximately $60,000 to $70,000 and $5,000 to $11,000, respectively, and should be considered in HPV vaccination promotion investment decisions.

LEVEL OF EVIDENCE

N/A Laryngoscope, 130:1186-1194, 2020.

Cost-Effectiveness Analysis of Lung Cancer Screening Accounting for the Effect of Indeterminate Findings

Background

Numerous health policy organizations recommend lung cancer screening, but no consensus exists on the optimal policy. Moreover, the impact of the Lung CT screening reporting and data system guidelines to manage small pulmonary nodules of unknown significance (a.k.a. indeterminate nodules) on the cost-effectiveness of lung cancer screening is not well established.

Methods

We assess the cost-effectiveness of 199 screening strategies that vary in terms of age and smoking eligibility criteria, using a microsimulation model. We simulate lung cancer-related events throughout the lifetime of US-representative current and former smokers. We conduct sensitivity analyses to test key model inputs and assumptions.

Results

The cost-effectiveness efficiency frontier consists of both annual and biennial screening strategies. Current guidelines are not on the frontier. Assuming 4% disutility associated with indeterminate findings, biennial screening for smokers aged 50–70 years with at least 40 pack-years and less than 10 years since smoking cessation is the cost-effective strategy using $100 000 willingness-to-pay threshold yielding the highest health benefit. Among all health utilities, the cost-effectiveness of screening is most sensitive to changes in the disutility of indeterminate findings. As the disutility of indeterminate findings decreases, screening eligibility criteria become less stringent and eventually annual screening for smokers aged 50–70 years with at least 30 pack-years and less than 10 years since smoking cessation is the cost-effective strategy yielding the highest health benefit.

Conclusions

The disutility associated with indeterminate findings impacts the cost-effectiveness of lung cancer screening. Efforts to quantify and better understand the impact of indeterminate findings on the effectiveness and cost-effectiveness of lung cancer screening are warranted.

Health Technology Assessment Challenges in Oncology: 20 Years of Value in Health

BACKGROUND

Oncology treatments have changed from chemotherapies to targeted therapies and more recently immuno-oncology. This has posed special challenges in the field of health technology assessment (HTA): capturing quality of life (QOL) associated with toxicity due to chemotherapy, crossover upon progression in targeted therapy trials, and survival extrapolation for immuno-oncology drugs.

OBJECTIVES

To showcase 20 years of Value in Health (ViH) publications in oncology.

METHODS

A review was undertaken of oncology articles published in ViH from May 1998 to August 2018. Full-length articles published in ViH with the keywords "oncology," "cancer," "h(a)ematology," and "malignancy" were included for review. Conference abstracts were excluded.

RESULTS

Four major themes were identified: (1) QOL and the development of multiple functional assessment of cancer therapy tools and mapping instruments; (2) analysis of clinical evidence using indirect comparisons, network analyses, and adjustment for crossovers; (3) modeling, Markov models, partitioned survival models, and extrapolation methods; and (4) financial implications and how to deal with uncertainty, introduction of conditional reimbursement, managed entry, and risk share agreements.

DISCUSSION

This review article highlights the important role ViH has played in disseminating HTA research in oncology. A few key issues loom on the horizon: precision medicine, further development and practical application of new QOL measures, methods for translating clinical evidence, and exploration of modeling techniques. For a better understanding of the complex interplay between access and financial risk management, ViH will no doubt continue to promote pioneering research in HTA and oncology.

Economic burden of lung cancer: A retrospective cohort study in South Korea, 2002-2015

We evaluated the survival rates and medical expenditure in patients with lung cancer using a nationwide claims database in South Korea. A retrospective observational cohort study design was used, and 2,919 lung cancer patients and their matched controls were included. Medical expenditures were analyzed with the Kaplan-Meier sample average method, and patients were categorized into 4 groups by operation and primary treatment method (i.e. Patients with operation: OP = surgery, OP+CTx/RTx = surgery with anti-cancer drugs or radiotherapy; Patients without operation: CTx/RTx = anti-cancer drugs or radiotherapy, Supportive treatment). The 5-year medical expenditure per case was highest in the OP+CTx/RTx group ($36,013), followed by the CTx/RTx ($23,134), OP ($22,686), and supportive treatment group ($3,700). Lung cancer-related anti-cancer drug therapy was the major cost driver, with an average 53% share across all patients. Generalized linear regression revealed that monthly medical expenditure in lung cancer patients, after adjustment for follow-up month, was approximately 3.1–4.3 times higher than that in the control group (cost ratio for OP = 3.116, OP+CTx/RTx = 3.566, CTx/RTx = 4.340, supportive treatment = 4.157). The monthly medical expenditure at end of life was estimated at $2,139 for all decedents, and approximately a quarter of patients had received chemotherapy in the last 3 months. In conclusion, this study presented the quantified treatment costs of lung cancer on various aspects compared with matched controls according to the treatment of choice. In this study, patients with operation incurred lower lifetime treatment costs than patients with CTx/RTx or supportive treatment, indicating that the economic burden of lung cancer was affected by treatment method. Further studies including both cancer stage and treatment modality are needed to confirm these results and to provide more information on the economic burden according to disease severity.

Lung cancer costs by treatment strategy and phase of care among patients enrolled in Medicare

Background

We studied trends in lung cancer treatment cost over time by phase of care, treatment strategy, age, stage at diagnosis, and histology.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database for years 1998‐2013, we allocated total and patient‐liability costs into the following phases of care for 145 988 lung cancer patients: prediagnosis, staging, surgery, initial, continuing, and terminal. Patients served as self‐controls to determine cancer‐attributable costs based on individual precancer diagnosis healthcare costs. We fit linear regression models to determine cost by age and calendar year for each stage at diagnosis, histology, and treatment strategy and presented all costs in 2017 US dollars.

Results

Monthly healthcare costs prior to lung cancer diagnosis were $861 for a 70 years old in 2017 and rose by an average of $17 per year (P < 0.001). Surgery in 2017 cost $30 096, decreasing by $257 per year (P = 0.007). Chemotherapy and radiation costs remained stable or increased for most stage and histology groups, ranging from $4242 to $8287 per month during the initial six months of care. Costs during the final six months of life decreased for those who died of lung cancer or other causes.

Conclusions

Cost‐effectiveness analyses of lung cancer control interventions in the United States have been using outdated and incomplete treatment cost estimates. Our cost estimates enable updated cost‐effectiveness analyses to determine the benefit of lung cancer control from a health economics point of view.

CT-pathologic correlation in lung adenocarcinoma and squamous cell carcinoma

Distinguishing lung adenocarcinoma from squamous cell carcinoma (SCC) is clinically important. Computed tomography (CT) scan is an economical, effective, noninvasive, commonly available, and quick diagnostic way for lung cancer. In this study, we aim to compare the CT characteristics in adenocarcinoma and SCC.Data from 275 cases (259 adenocarcinoma and 16 SCC) were retrospectively compared. CT characteristics, including lesion size and shape, single/multifocal lesions, location of the tumor, the margin of lobes, whether the lesion had deep lobulated margin, bronchial cut-off sign, signs of dilated bronchial arteries, signs of vascular bundle thickening, signs of short burrs, spinous processes, and pleural indentation, were compared in 148 cases (137 adenocarcinoma and 11 SCC).Patients with adenocarcinoma were more likely to be female (44.2% vs 25.0%, P = .017). Compared with SCC, adenocarcinomas were more likely to have deep lobulated margin (81.0% vs 54.5%, P = .038), less likely to have smooth lobes margin (2.7% vs 83.3%, P < .001), more likely to have vascular bundle thickening (37.2% vs 0, P = .016) and pleural indentation (59.9% vs 18.2%, P = .01), and marginally less likely to have dilated bronchial arteries (17.5% vs 45.5%, P = .064). No significant difference was observed regarding to characteristics, including tumor size, location of the tumor, signs of bronchial cut-off, dilated bronchial arteries, short burrs, or spinous processes.CT scan has the potential to help to distinguish lung adenocarcinoma and SCC in a fast and commonly available way. CT could be a rough but fast way to diagnosis, and may thus shorten the waiting time to treatment and allow more time for clinicians, patients, and their families to prepare for future treatment.

Optimal Information Collection Policies in a Markov Decision Process Framework

BACKGROUND

The cost-effectiveness and value of additional information about a health technology or program may change over time because of trends affecting patient cohorts and/or the intervention. Delaying information collection even for parameters that do not change over time may be optimal.

METHODS

We present a stochastic dynamic programming approach to simultaneously identify the optimal intervention and information collection policies. We use our framework to evaluate birth cohort hepatitis C virus (HCV) screening. We focus on how the presence of a time-varying parameter (HCV prevalence) affects the optimal information collection policy for a parameter assumed constant across birth cohorts: liver fibrosis stage distribution for screen-detected diagnosis at age 50.

RESULTS

We prove that it may be optimal to delay information collection until a time when the information more immediately affects decision making. For the example of HCV screening, given initial beliefs, the optimal policy (at 2010) was to continue screening and collect information about the distribution of liver fibrosis at screen-detected diagnosis in 12 years, increasing the expected incremental net monetary benefit (INMB) by $169.5 million compared to current guidelines.

CONCLUSIONS

The option to delay information collection until the information is sufficiently likely to influence decisions can increase efficiency. A dynamic programming framework enables an assessment of the marginal value of information and determines the optimal policy, including when and how much information to collect.