Expected years of life lost for six potentially preventable cancers in the United States

Strategic use of resources to enhance colorectal cancer screening for patients with diabetes (SURE: CRC4D) in federally qualified health centers: a protocol for hybrid type ii effectiveness-implementation trial

BACKGROUND

Persons with diabetes have 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from priority health disparities populations. Federally qualified health centers (FQHCs) struggle to implement CRC screening programs for average risk patients. Strategies to effectively prioritize and optimize CRC screening for patients with diabetes in the primary care safety-net are needed.

METHODS

Guided by the Exploration, Preparation, Implementation and Sustainment Framework, we conducted a stakeholder-engaged process to identify multi-level change objectives for implementing optimized CRC screening for patients with diabetes in FQHCs. To identify change objectives, an implementation planning group of stakeholders from FQHCs, safety-net screening programs, and policy implementers were assembled and met over a 7-month period. Depth interviews (n = 18-20) with key implementation actors were conducted to identify and refine the materials, methods and strategies needed to support an implementation plan across different FQHC contexts. The planning group endorsed the following multi-component implementation strategies: identifying clinic champions, development/distribution of patient educational materials, developing and implementing quality monitoring systems, and convening clinical meetings. To support clinic champions during the initial implementation phase, two learning collaboratives and bi-weekly virtual facilitation will be provided. In single group, hybrid type 2 effectiveness-implementation trial, we will implement and evaluate these strategies in a in six safety net clinics (n = 30 patients with diabetes per site). The primary clinical outcomes are: (1) clinic-level colonoscopy uptake and (2) overall CRC screening rates for patients with diabetes assessed at baseline and 12-months post-implementation. Implementation outcomes include provider and staff fidelity to the implementation plan, patient acceptability, and feasibility will be assessed at baseline and 12-months post-implementation.

DISCUSSION

Study findings are poised to inform development of evidence-based implementation strategies to be tested for scalability and sustainability in a future hybrid 2 effectiveness-implementation clinical trial. The research protocol can be adapted as a model to investigate the development of targeted cancer prevention strategies in additional chronically ill priority populations.

TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov (NCT05785780) on March 27, 2023 (last updated October 21, 2023).

Lifetime risk, life expectancy, loss-of-life expectancy and lifetime healthcare expenditure for Stevens-Johnson syndrome/toxic epidermal necrolysis in Taiwan: follow-up of a nationwide cohort from 2008 to 2019

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) not only cause acute, devastating mucocutaneous reactions but also have long-lasting implications on survivors' lives.

OBJECTIVES

To quantify the lifetime burden of SJS/TEN.

METHODS

The cumulative incidence rate (CIR), life expectancy (LE), loss-of-life expectancy (LoLE) and lifetime healthcare expenditure (HE) for SJS/TEN were estimated over the period from 2008 to 2019 using data from the National Health Insurance Research Database of Taiwan and life tables of vital statistics.

RESULTS

In this nationwide cohort of 6552 incident SJS/TEN cases, a trend towards a decrease in the CIR was observed between 2008 and 2019. Compared with the general population, patients with SJS/TEN experience a tremendous loss of 9.43 (1.06) [mean (SEM)] years of LE after diagnosis of SJS/TEN. Male patients with SJS/TEN had higher LoLE [10.74 (1.22) vs. 7.69 (1.43) years] and annual HE than females. Younger age at diagnosis of SJS/TEN was associated with longer LE but greater LoLE and higher lifetime HE. Patients with intensive care unit admission on diagnosis, malignancy, diabetes mellitus, end-stage renal disease and SJS/TEN-associated sequelae experienced substantially greater LoLE and HE per life year.

CONCLUSIONS

Patients with SJS/TEN suffer substantial loss-of-LE and HE, particularly young patients, compared with the general population. These data provide a reference estimate of the lifetime burden of SJS/TEN to help health authorities evaluate the cost-effectiveness of future preventive and treatment strategies to minimize the burden of SJS/TEN.

Estimation of disability free life expectancy in non small cell lung cancer based on real world data

To quantify the societal impact of disability in patients with non-small cell lung cancer (NSCLC), this study estimated the disability-free life expectancy (DFLE), loss-of-DFLE and explored their associations with quality-adjusted life expectancy (QALE) and loss-of-QALE. We interlinked national databases and applied a rolling-over algorithm to estimate the lifetime survival function for patients with NSCLC. Using the EuroQOL-5 Dimension (EQ-5D) and Barthel index (BI), we repeatedly measured the quality-of-life and disability functions of NSCLC patients who visited our hospital from 2011 to 2020. Age-, sex-matched referents were simulated from lifetables of the same calendar year of diagnosis. We categorized BI scores ≤ 70 as in need of long-term care and constructed linear mixed models to estimate the utility values and disability scores. We collected 960 cases and 3088 measurements. The proportions of measurements without disability at age 50-64 and in stage I-IIIa, 50-64 and stage IIIb-IV, 65-89 and stage I-IIIa and 65-89 and stage IIIb-IV were 97.3%, 89.3%, 94.8%,78.3%, corresponding to DFLEs of 15.3, 2.4, 6.8, 1.2 years and losses-of-DFLE of 8.1, 20.7, 4.0, 8.6 years, respectively, indicating that advanced stage had a stronger effect than old age. Survivors in advanced stages showed increased demands for assistance in almost all subitems. The DFLEs seemed to be approximate to the QALEs and the latter were shorter than the former due to discomfort and depression. From a societal perspective, future health technology assessment should consider the impact of lifetime duration of functional disability. Early diagnosis of NSCLC may decrease the burden of long-term care.

Impact of racial disparities on potential years of life lost due to gynecologic cancer in the United States: Trends from 1975 to 2017 based on SEER database

INTRODUCTION

We assessed potential years of life lost (PYLL) in women secondary to gynecologic cancers (cervical, uterine, ovarian, vaginal, vulvar, and other) in the United States from 1975 to 2017 using SEER database. We also highlight racial disparities and economic costs of mortality from gynecologic malignancies.

METHODS

PYLL up to and including age 75 years were calculated [75 - (age at diagnosis + overall survival)] after stratifying for tumor site. Subgroup comparison was done using nonparametric method Kruskal-Wallis H with post-hoc analysis. Linear regression model was used to calculate every five-year incremental trends. Productivity losses were calculated using mortality data multiplied by age-adjusted estimated total lifetime productivity.

RESULTS

Total 304,995 patients were included with 1,472,152.67 PYLL from 1975 to 2017. Median PYLL for cervical cancer (12.58 years) was higher than other gynecologic malignancies (0.83, 6.00, 0.67 and - 0.25 years respectively for uterine, ovarian, vaginal and vulvar cancers). The median PYLL for Non-Hispanic White (NHW) population was lower than women from other racial groups for uterine, ovarian and vulvar cancers. From 1975 to 2017, median PYLL trend in the entire cohort showed a steady increment (p < 0.001, B1 = 1.65 years). Most rapid rise was noted in cervical cancer (p < 0.001, B1 = 2.68 years) and Hispanic population (p < 0.001, B1 = 1.92). Total productivity loss was $79 billion during 1975-2017 with maximum loss seen in uterine cancer and NHW population.

CONCLUSION

Ours is the first study to analyze PYLL in gynecologic malignancies and estimate productivity losses due to premature deaths. Data shows a clear trend pointing towards racial and ethnic disparities.

Epidemiological/Disease and Economic Burdens of Cervical Cancer in 2010-2014: Are Younger Women at Risk?

OBJECTIVE

Cervical cancer is an important factor threatening women's health in China. This study examined the epidemiological and economic burden of cervical cancer among the medically insured population, which could provide data support for government departments to formulate policies.

METHODS

All new cases of cervical cancer under the Urban Employee Basic Medical Insurance (UEBMI) plan in a provincial capital city in eastern China from 2010 to 2014 were collected. The Cox proportional hazard model was used to analyze the factors affecting the survival rates for cervical cancer. Outpatient and hospitalization expenses were used to assess the direct economic burden, and the Potential Years of Life Loss (PYLL) and potential economic loss were calculated by the direct method to assess indirect burden.

RESULTS

During the observation period, there were 1115 new cases and 137 deaths. The incidence rate was 14.85/100,000 person years, the mortality was 1.82/100,000 person years, and the five-year survival rate was 75.3%. The age of onset was mainly concentrated in the 30-59 age group (82.9%) and the tendency was towards younger populations. The age of onset (HR = 1.037, 95% CI = 1.024-1.051), the frequency of hospitalization services (HR = 1.085, 95% CI = 1.061-1.109), and the average length of stay (ALOS) (HR = 1.020, 95% CI = 1.005-1.051) were the related factors affecting overall survival. Among the direct economic burden, the average outpatient cost was $4314, and the average hospitalization cost was $12,007. The average outpatient and hospitalization costs within 12 months after onset were $2871 and $8963, respectively. As for indirect burden, the average Potential Years of Life Loss (PYLL) was 27.95 years, and the average potential economic loss was $95,200.

CONCLUSIONS

The epidemiological and economic burden reported in the study was at a high level, and the onset age of cervical patients gradually became younger. The age of onset, the frequency of hospitalization services and the ALOS of cervical cancer patients should be given greater attention. Policymakers and researchers should focus on the trend of younger onset age of cervical cancer and the survival situation within 12 months after onset. Early intervention for cervical cancer patients, particularly younger women, may help reduce the burden of cervical cancer.

Lifetime Risks, Life Expectancy, and Health Care Expenditures for Rheumatoid Arthritis: A Nationwide Cohort Followed Up From 2003 to 2016

Objective

This study was undertaken to estimate the cumulative incidence rate of rheumatoid arthritis (RA) in the Taiwanese population ages 16–84 years, and life expectancy, loss of life expectancy, and lifetime health care expenditures for incident RA in Taiwan after 2003, when biologics began to be prescribed.

Methods

We obtained all claims data for the period 1999 to 2016 from the National Health Insurance program of Taiwan, and validated the data against the Catastrophic Illness Registry to establish the study cohort. We estimated the survival function for RA and extrapolated to lifetime using a rolling‐over algorithm. For every RA case, we simulated sex‐, age‐, and calendar year–matched referents from vital statistics and estimated their life expectancy. The difference between the life expectancy of the referent and the life expectancy of the RA patient was the loss of life expectancy for the RA patient. Average monthly health care expenditures were multiplied by the corresponding survival rates and summed up throughout the lifetime to calculate the lifetime health care expenditures.

Results

A total of 29,352 new RA cases were identified during 2003–2016. There was a decreasing trend in cumulative incidence rate in those ages 16–84 for both sexes. Mean life expectancy after diagnosis of RA was 26.3 years, and mean lifetime cost was $72,953. RA patients had a mean loss of life expectancy of 4.97 years. Women with RA survived 1–2 years longer than men with RA of the same age, which resulted in higher lifetime expenditures for the former. Since the life expectancy for women in Taiwan was 6–7 years higher than that for men, the loss of life expectancy for women with RA was higher than that for men with RA. Annual health care expenditures were similar for both sexes.

Conclusion

Our findings indicate that since biologics became available, RA patients have lived longer and had higher lifetime expenditures, which should be monitored and evaluated for cost‐effectiveness.

Estimating the impact of increasing cervical cancer screening in the National Breast and Cervical Cancer Early Detection Program among low-income women in the USA

PURPOSE

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cervical cancer screening to low-income women. This study estimated the health benefits gained in terms of life years (LYs) saved and quality-adjusted life years (QALYs) gained if cervical cancer screening by the NBCCEDP increased to reach more eligible women.

METHODS

Data from Surveillance, Epidemiology, and End Results, NBCCEDP, and Medical Expenditure Panel Surveys were used. LYs saved and QALYs gained/100,000 women were estimated using modeling methods. They were used to predict additional health benefits gained if screening by the NBCCEDP increased from 6.5% up to 10-25% of the eligible women.

RESULTS

Overall, per 100,000 women screened by the NBCCEDP, 1,731 LYs were saved and 1,608 QALYs were gained. For white women, 1,926 LYs were saved and 1,780 QALYs were gained/100,000 women screened by the NBCCEDP. For black women, 1,506 LYs were saved and 1,300 QALYs were gained/100,000 women screened. If the proportion of eligible women screened by the NBCCEDP increased to 10-25%, the estimated health benefits would range from 6,626-34,896 LYs saved and 6,153-32,407 QALYs gained.

CONCLUSIONS

The reported estimates emphasize the value of cervical cancer screening program by extending LE in low-income women. Further, it demonstrates that screening a higher percentage of eligible women in the NBCCEDP may yield more health benefits.

Age-standardized expected years of life lost: quantification of cancer severity

Background

The critical implications of the expected years of life lost (EYLL) index of cancer for health policy assessments have been largely overlooked. We advocate to standardize life lost indices.

Methods

Using the Taiwan Cancer Registry database as an example, we calculated the EYLL and the age-standardized EYLL to facilitate comparisons among cancer types (a total of 903,935 patients from the database). The International Cancer Survival Standard was used for calculating age-standardized EYLL.

Results

Pancreatic cancer is the most severe cancer in Taiwan, with the greatest age-standardized EYLL for the men (15.6 years) and women (18.0 years) as well as for the men and women combined (16.6 years). Negative correlations were observed between unstandardized EYLL of cancer and mean age at diagnosis.

Conclusions

The unstandardized EYLL represents an overall assessment of disease burden, whereas the age-standardized EYLL is a suitable measure of disease severity. We suggest that both measures be incorporated into routine annual reports of cancer statistics alongside the usual incidence and mortality rates and their age-standardized counterparts.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6843-9) contains supplementary material, which is available to authorized users.

Impact of bilateral biopsy-detected prostate cancer on an active surveillance population

BACKGROUND

To assess factors that can predict active surveillance (AS) failure on serial transrectal ultrasound guided biopsies in patients with low-risk prostate cancer.

METHODS

We evaluated the records of 144 consecutive patients enrolled in AS between 2007 and 2014 at a single academic institution. Low risk inclusion criteria included PSA < 10 ng/ml, cT1c or cT2a, Grade Group (GG) 1, < 3 positive cores, and < 50% tumor in a single core with the majority having a PSA density of < 0.15. AS reclassification was defined as progression to GG ≥2, 3 or more cores, or core tumor volume ≥ 50%. Univariate and multivariate Cox proportional hazards regression analysis was used to determine predictors of reclassification and a match-pair analysis performed on a control group of patients choosing surgery.

RESULTS

Inclusion criteria were met by 130 men with a median follow-up of 52 months. The reclassification or AS failure rate was 38.5%, with the majority 41/50 (82%) finding GG ≥ 2 cancer. Most patients had unilateral disease on diagnostic biopsy (94.6%), but 40.7% had bilateral cancer detected during follow-up. Men with bilateral detected tumor were more likely to ultimately fail AS than patients with unilateral tumors (HR 4.089; P < 0.0001) and failed earlier with a reclassification-free survival of 32 vs 119 months respectively. In a matched-pair analysis using a population of 211 concurrent patients that chose radical prostatectomy rather than AS, 76% of patients with unilateral cancer on biopsy had bilateral cancer on final pathology.

CONCLUSIONS

The finding of bilateral prostate cancer on biopsy is associated with earlier AS reclassification. Finding bilateral disease may not represent disease progression, but rather enhanced detection of more extensive disease highlighting the importance of confirmatory biopsy.

Breast Cancer Incidence by Stage Before and After Change in Screening Guidelines

INTRODUCTION

The U.S. Preventive Services Task Force changed breast cancer screening guidelines in November 2009 for mammograms in women aged 40-49 and 50-74 years. The aim of this study was to assess the impact of the 2009 guideline changes on breast cancer incidence by stage among women aged 40-49 and 50-74 years in the U.S.

METHODS

This was a cross-sectional trend analysis of the impact of 2009 guideline change on breast cancer incidence by stage, using data from the National Program for Cancer Registries and Surveillance, Epidemiology, and End Results Incidence-U.S. Cancer Statistics 2001-2014 database among women aged 40-74 years. Incidence was age adjusted to the U.S. standard population. Data were collected in 2001-2014, released in 2017, and analyzed in 2018.

RESULTS

Among women aged 40-49 years, the 4-year average annual incidence of breast cancer increased slightly in 2011-2014 for in situ, localized, and distant cancer, but decreased for regional cancer compared with the incidence in 2006-2009. Among women aged 50-74 years, the 4-year average annual incidence of breast cancer increased in 2011-2014 for localized and distant cancer, but decreased for in situ and regional cancer. Joinpoint analyses revealed that annual percentage changes decreased after 2009 for distant cancer among both women aged 40-49 and 50-74 years. The composition of breast cancer by stage was similar between 2006-2009 and 2011-2014 among both women aged 40-49 and 50-74 years.

CONCLUSIONS

Changes in breast cancer screening by the 2009 U.S. Preventive Services Task Force guidelines had little immediate adverse effects on the stage distribution of breast cancer diagnoses in the U.S. Monitoring the incidence by cancer stages over time is needed.

Trends in breast cancer mortality by stage at diagnosis among young women in the United States

BACKGROUND

Assessing trends in breast cancer survival among young women who are largely unaffected by breast cancer screening will provide important information regarding improvements in the effectiveness of cancer care for breast cancer in the last few decades.

METHODS

The cohort for this study consisted of women who were diagnosed with breast cancer between ages 20 and 39 years from the Surveillance, Epidemiology, and End Results program's 9-registry areas from 1975 to 2015. Trends in the breast cancer incidence rate and survival were assessed among young women.

RESULTS

Among women aged 20 to 39 years, breast cancer incidence increased from 24.6 per 100,000 in 1975 to 31.7 per 100,000 in 2015 (annual percent change, 0.5; 95% confidence interval [CI], 0.4-0.6). Among women with breast cancer, 5-year breast-cancer-specific survival increased significantly from 74.0% during 1975 to 1979 to 88.5% during 2010 to 2015 (hazard ratio for dying from breast cancer for 2010-2015 vs 1975-1979, 0.37; 95% CI, 0.32-0.41). The increase in cancer-specific survival reached a plateau in 2005; however, among young women with metastatic breast cancer, it continued to increase after 2005, from 45.6% during 2005 to 2009 to 56.5% during 2010 to 2015 (hazard ratio for dying from breast cancer for 2010-2015 vs 2005-2009, 0.74; 95% CI, 0.60-0.92). Similar patterns also were observed for 5-year overall survival and among women aged 20 to 29 years and those aged 30 to 39 years.

CONCLUSIONS

There were substantial improvements in the effectiveness of breast cancer treatment on overall and cancer-specific survival from 1975 to 2015. However, improvements appeared to have reached a plateau after 2005, except among young women with metastatic breast cancer, in whom survival continued to improve throughout the period.

Estimate dynamic changes of dysfunction and lifelong spent for psychiatric care needs in patients with schizophrenia

BACKGROUND

Disturbance of functionality is one of the core features of schizophrenia, and has deleterious effects on a patient's employment, increased healthcare costs, and a large societal burden. Thus, if a patient's disability status could be predicted, and interventions needed identified in advance, poor outcomes could be prevented. To achieve this aim, we developed a method by which to assess dynamic changes of dysfunction and estimate the lifetime duration of disability in patients with schizophrenia, as a proxy for assessing their specialized healthcare needs.

METHODS

The proposed method was developed based on a nationwide database and a cross-sectional survey. The primary analysis investigated the dynamic change in the proportion of patients with manifested disability over time, while the secondary analysis estimated the lifetime duration of disability, obtained as the proportion of patients with manifested disability multiplied by the survival probability throughout the life of patients.

RESULTS

The average lifetime duration of manifested disability of global functioning was estimated to be 20.9 years, which represents approximately 73% of the whole lifetime of patients. The duration of disability in socially-useful activities was estimated to be 15.6 years, while that in personal and social relationships was 17.5 years. The female patients had a longer duration of manifested disability (22.9 years) than the male patients (19.5 years).

CONCLUSIONS

The developed method of analysis indicated that the longest lifetime durations of manifest disability were observed in the areas of socially-useful activities and personal and social relationships, and the proportions of patients with these disabilities rapidly increased at 200 months after diagnosis.

Years of life lost due to malignant neoplasms of the digestive system in Poland in the years 2000-2014

Background

Every fourth death that occurs in Poland is caused by a malignant neoplasm. A particularly negative epidemiological situation relates to colorectal cancers; in 2015 they constituted the fifth most important cause of years of life lost (YLL) in Poland.

Objective

We aimed to analyse YLL due to malignant neoplasms of the digestive system in Poland in between 2000 and 2014.

Methods

The study material included a database containing information gathered from 5,601,568 death certificates of Poles who died in 2000-2014. YLLs were calculated with the use of the standard expected years of life lost index (SEYLL).

Results

In the 15-year study period, malignant neoplasms of the digestive system contributed to 213,041 deaths in males and 177,644 deaths in females, which corresponded to a loss of 158.6 years per 10,000 men and 105.3 years per 10,000 women. Neoplasms of the large intestine (23.6%), stomach (22.0%) and pancreas (17.4%) contributed the most. A time trend analysis revealed (p < 0.05) a growing tendency of YLLs due to neoplasms of the large intestine and pancreas, and a decreasing trend due to neoplasms of the stomach.

Conclusion

Malignant neoplasms of the digestive system, especially of the large intestine, are becoming a more common cause of premature mortality in Poland.

Lifetime risks, loss of life expectancy, and health care expenditures for 19 types of cancer in Taiwan

Background

The mortality rates for different cancers are no longer an efficient tool for making national policy. The purpose of this study were to quantify the lifetime risks, life expectancies (LEs) after diagnosis, expected years of life lost (EYLL), and lifetime health care expenditures for 19 major cancers in Taiwan.

Methods

A total of 831,314 patients with 19 pathologically proven cancers were abstracted from the Taiwan Cancer Registry from 1998 to 2012. They were linked to the National Mortality Registry (1998–2014) and National Health Insurance reimbursement database (1998–2013) for survival and health care costs. We estimated the cumulative incidence rate for ages 0–79 years and the lifetime survival function for patients with different cancer sites. The EYLL was calculated by subtracting the LE of each cancer cohort from that of the age- and sex-matched referents simulated from national life tables. The estimated lifetime cost was calculated by adding up the product of survival probability and mean cost at the corresponding duration-to-date after adjustment for the inflation to the year of 2013.

Results

There were 5 cancers with a lifetime risk exceeding 4%: colorectal, liver, lung, and prostate in males, and breast and colorectal in females. Cancers with EYLL of >10 years were: esophageal, intrahepatic bile ducts, liver, pancreas, oral, nasopharyngeal, leukemia, lung, and gallbladder, extrahepatic bile ducts and biliary tract in males, and intrahepatic bile ducts, pancreas, nasopharyngeal, lung, esophageal, leukemia, liver, gallbladder, extrahepatic bile ducts and biliary tract, ovary, and stomach in females. Cancers with lifetime health care expenditures exceeding US$50,000 to the National Health Insurance were as follows: leukemia, kidney, testis, renal pelvis and ureter in males, and renal pelvis and ureter, leukemia, breast, urinary bladder, kidney, ovary, and nasopharyngeal in females. All these impacts should be considered in health policy decisions.

Conclusion

The impacts of cancer in Taiwan are very large. Future studies must consider both quality of life and the entire impact from societal perspectives.

Estimating health benefits and cost-savings for achieving the Healthy People 2020 objective of reducing invasive colorectal cancer

This study aims to quantify the aggregate potential life-years (LYs) saved and healthcare cost-savings if the Healthy People 2020 objective were met to reduce invasive colorectal cancer (CRC) incidence by 15%. We identified patients (n=886,380) diagnosed with invasive CRC between 2001 and 2011 from a nationally representative cancer dataset. We stratified these patients by sex, race/ethnicity, and age. Using these data and data from the 2001-2011 U.S. life tables, we estimated a survival function for each CRC group and the corresponding reference group and computed per-person LYs saved. We estimated per-person annual healthcare cost-savings using the 2008-2012 Medical Expenditure Panel Survey. We calculated aggregate LYs saved and cost-savings by multiplying the reduced number of CRC patients by the per-person LYs saved and lifetime healthcare cost-savings, respectively. We estimated an aggregate of 84,569 and 64,924 LYs saved for men and women, respectively, accounting for healthcare cost-savings of $329.3 and $294.2 million (in 2013$), respectively. Per person, we estimated 6.3 potential LYs saved related to those who developed CRC for both men and women, and healthcare cost-savings of $24,000 for men and $28,000 for women. Non-Hispanic whites and those aged 60-64 had the highest aggregate potential LYs saved and cost-savings. Achieving the HP2020 objective of reducing invasive CRC incidence by 15% by year 2020 would potentially save nearly 150,000 life-years and $624 million on healthcare costs.

Causes of death and expected years of life lost among treated opioid-dependent individuals in the United States and Taiwan

AIMS

This study compared the cause-specific standardized mortality ratios (SMRs) and expected years of life lost (EYLL) among opioid-dependent individuals in the United States and Taiwan.

METHODS

Survival data came from two cohorts followed until 2014: The U.S. data were based on a randomized trial of 1267 opioid-dependent participants enrolled between 2006 and 2009; the Taiwan data were from a study of 983 individuals that began in 2006, when opioid agonist treatment (OAT) was implemented in Taiwan. SMRs were calculated for each national cohort and compared. Kaplan-Meier estimation was performed on the survival data, then lifespans were extrapolated to 70 years (840 months) to estimate life expectancy using a semi-parametric method. EYLLs for both cohorts were estimated by subtracting their life expectancies from the age- and gender-matched referents within the general population of their respective country.

RESULTS

Compared with age- and gender-matched referents, the SMRs were 3.2 for the U.S. sample and 7.8 for the Taiwan sample; the EYLLs were 7.7 and 16.4 years, respectively. Half of decedents died of unnatural causes in both cohorts; overdose deaths predominated in the U.S. and suicide in Taiwan.

CONCLUSIONS

Our study identified differences by country in EYLL and causes of deaths. These findings suggest that intervention strategies to reduce mortality risk by overdose (particularly in the U.S.) and suicide (particularly in Taiwan) are urgently needed in these countries.

Content, Usability, and Utilization of Plain Language in Breast Cancer Mobile Phone Apps: A Systematic Analysis

BACKGROUND

Breast cancer is one of the leading contributors to preventable illness and death among women. Although mobile phone apps provide unprecedented opportunity to engage women along the cancer continuum, little is known about the availability, content, and usability of breast cancer mobile phone apps.

OBJECTIVE

This study analyzed the content and adherence to literate design standards of all breast cancer-related apps available on the App Store and Google Play, as well as the relationship between their content, user ratings, and price.

METHODS

Following identification and downloading of all available breast cancer mobile phone apps in October 2015, 101 apps were confirmed as focusing on breast cancer. Based on prior research, we adapted and applied a content analysis scheme that was specific to breast cancer apps, including their main purpose, relevance to the cancer care continuum, and adherence to usability standards outlined by the Institute of Medicine (IOM).

RESULTS

The most common aim of apps was educational (73/101, 72.3%), followed by behavior change (24/101, 23.9%), fundraising (20/101, 19.8%), and advocacy (14/101, 13.9%). On the cancer continuum, primary prevention (strategies to prevent cancer cells from occurring) was mentioned in almost one-third of the apps (30/101, 29.7%). Less than half of the apps (46/101, 45.5%) presented information about mammography and/or breast clinical exam, and 53 apps (52.5%) discussed breast self-exam (which is no longer recommended). Symptoms of cancer prediagnosis, such as a lump, were discussed in almost half of the apps (48/101, 47.5%) and a similar number of apps included information about genetic risk for breast cancer (47/101, 46.5%). Information about breast cancer diagnosis was included in 42 apps (41.58%) and 43 (42.6%) apps discussed treatment options. Survivorship issues were addressed in 17 (16.8%) apps. Only one (1.0%) app discussed hospice. Adherence to usability recommendations was low. The median composite score was 3 (mean 2.60, SD 1.20) of the six recommended usability items. With eight plain language items, the median of the composite health literacy score was 5 (mean 5.06, SD 2.00). Most apps did not use easy-to-understand words (44/101, 43.6%) and few (24/101, 23.8%) defined key terms.

CONCLUSIONS

Current breast cancer apps provide important information about breast cancer, but the most common topic covered is breast self-examination, a non-evidence-based screening strategy. Apps that focus on evidence-based strategies on the cancer continuum are needed, with a notable pressing need for apps that would address survivorship and end of life. Finally, developers of breast cancer apps should adhere to IOM standards to meet the needs of diverse populations and reduce current disparities.

Racial/ethnicity disparities in invasive breast cancer among younger and older women: An analysis using multiple measures of population health

INTRODUCTION

Few studies have examined age and racial/ethnic disparities in invasive breast cancer among younger (age 15-44 years) vs. older (age 45-64 years) women. This study estimates disparities in breast cancer among younger compared with older women by race/ethnicity using five measures of population health: life expectancy (LE), expected years of life lost (EYLL), cumulative incidence rate (CIR), and incidence and mortality rate ratios (IRR and MRR).

METHODS

Using Surveillance, Epidemiology, and End Results data, LE and EYLL were estimated from a cohort of 15-44 and 45-64 years, non-Hispanic black (NHB), non-Hispanic white (NHW), and Hispanic women diagnosed with breast cancer, 2000-2013. Survival function was obtained from the study years and then extrapolated to lifetime using the Monte Carlo method. The CIR, IRR and MRR were calculated using 2009-2013 breast cancer incidence and mortality rates from the Centers for Disease Control and Prevention's National Program of Cancer Registries.

RESULTS

The estimated LE ranged from 32.12 to 7.42 years for localized to distant stages among younger NHB women compared to 33.05 to 9.95 years for younger NHW women. The estimated EYLL was 12.78 years for younger women, and 4.99 for older women. By race/ethnicity, it was 15.53 years for NHB, 14.23 years for Hispanic and 11.87 years for NHW (P<0.00025). The CIR for age-group 15-44 years (CIR15-44) indicated a 1 in 86 probability for NHB compared to a 1 in 87 probability for NHW being diagnosed with breast cancer by age 45. The estimated age-adjusted incidence rate for NHB-to-NHW women was IRR=1.10 (95%, CI=1.08-1.11) and the corresponding mortality rate was MRR=2.02 (95%, CI=1.94-2.11).

CONCLUSIONS

The breast cancer disparities between younger NHB compared to NHW women highlight the need for expanded efforts to address these disparities through primary prevention and to improve access to quality healthcare to minority women with breast cancer.

Life Expectancy and Lifetime Health Care Expenditures for Type 1 Diabetes: A Nationwide Longitudinal Cohort of Incident Cases Followed for 14 Years

OBJECTIVES

To assess additional life expectancy (LE), expected years of life lost , and lifetime health care expenditures after type 1 diabetes diagnosis, stratified by sex and age of first diagnosis (early: 0-12 years; late: 13-40 years).

METHODS

A longitudinal cohort of patients with diabetes was constructed from Taiwan's National Health Insurance Research Database of 1999 to 2012. The survival functions for diabetic patients and age- and sex-matched general population were estimated by using a semiparametric extrapolation method with annual life tables. The average monthly health care expenditures were multiplied by the corresponding monthly survival rates and summed to calculate the lifetime health care expenditures. Cox proportional hazard models were constructed to corroborate the effects of sex and age, after being adjusted for comorbidities, complications, and calendar years.

RESULTS

A total of 2386 cases (45% early diagnosis, 49% males) were identified. An additional LE after diabetes diagnosis was 45.12 years, with an estimated 17.63 years of life lost. The predicted total and diabetes-related lifetime costs were $56,939 and $102,140, respectively. Early diagnosed patients had a longer LE and lower health care spending compared with those of late-diagnosed patients. Male patients had a shorter LE and a higher expected years of life lost than the female patients, which corresponded to lower lifetime costs for the former. The Cox model results for overall mortality corroborated these trends.

CONCLUSIONS

Early detection of type 1 diabetes and sex-specific strategies would probably improve long-term health outcomes and save on the cost of diabetes care.

Years of life that could be saved from prevention of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) causes premature death and loss of life expectancy worldwide. Its primary and secondary prevention can result in a significant number of years of life saved.

AIM

To assess how many years of life are lost after HCC diagnosis.

METHODS

Data from 5346 patients with first HCC diagnosis were used to estimate lifespan and number of years of life lost after tumour onset, using a semi-parametric extrapolation having as reference an age-, sex- and year-of-onset-matched population derived from national life tables.

RESULTS

Between 1986 and 2014, HCC lead to an average of 11.5 years-of-life lost for each patient. The youngest age-quartile group (18-61 years) had the highest number of years-of-life lost, representing approximately 41% of the overall benefit obtainable from prevention. Advancements in HCC management have progressively reduced the number of years-of-life lost from 12.6 years in 1986-1999, to 10.7 in 2000-2006 and 7.4 years in 2007-2014. Currently, an HCC diagnosis when a single tumour <2 cm results in 3.7 years-of-life lost while the diagnosis when a single tumour ≥ 2 cm or 2/3 nodules still within the Milan criteria, results in 5.0 years-of-life lost, representing the loss of only approximately 5.5% and 7.2%, respectively, of the entire lifespan from birth.

CONCLUSIONS

Hepatocellular carcinoma occurrence results in the loss of a considerable number of years-of-life, especially for younger patients. In recent years, the increased possibility of effectively treating this tumour has improved life expectancy, thus reducing years-of-life lost.

Estimation of life expectancy, loss-of-life expectancy, and lifetime healthcare expenditures for schizophrenia in Taiwan

By employing a novel semi-parametric extrapolation method, the life expectancies after the first hospitalization for schizophrenia and the associated lifetime healthcare expenditures were both estimated. Based on the linkage between the National Health Insurance Research Database and the National Mortality Registry of Taiwan, we have established a schizophrenic cohort for 2000-2010 and followed up to 2011. Survival function was estimated through Kaplan-Meier's method and extrapolated throughout life. We applied a simple linear regression to the logit-transformed survival ratio between the schizophrenic cohort and the sex-, age-matched referents via Monte Carlo simulation from the national life table. The monthly survival probability was multiplied by the average healthcare expenditures and summed throughout life to estimate the lifelong cost reimbursed by the National Health Insurance. The results showed that patients diagnosed at age 20-29 had the highest expected years of life lost (EYLL), 15 and 9years, in men and women, respectively, with corresponding lifetime healthcare expenditures of USD 48,000 and 53,000. Males generally had higher health cost per life-year than their female counterparts across their lifespan. We applied the same method to the first 6years of the cohort and extrapolated to 12years, which showed that the relative biases for different age strata were less than 5%. We thus concluded that the semi-parametric extrapolation method might provide a timely estimation of lifetime outcomes for health care planning of schizophrenia.

A comprehensive analysis on expected years of life lost due to pancreatic cancer

BACKGROUND

Pancreatic cancer represents a fatal malignancy leading to premature death and loss of life expectancy. The aim of the present study was to assess how many years of life are lost due to this cancer, in relationship with surgery and ageing.

METHODS

Data from 716 consecutive patients discharged from a tertiary referral hospital (2002-2012) with a diagnosis of pancreatic cancer and with complete clinical and follow-up data were used to estimate the number of years of life-lost (YLL) through a semi-parametric extrapolation having an age-, sex- and year-of-onset- matched population derived from national life tables as reference.

RESULTS

The mean entire lifespan estimated for the 716 patients was 1.4 years (95% C.I.:0.8-1.9) resulting in a number of YLL after diagnosis of 12 years (95% C.I.:11.5-12.6) per person. Surgical patients (147 cases; 20.5%) were younger and experienced higher post-diagnostic lifespan (3.5 years) than non-surgical older individuals (0.8 years; p < 0.001). These figures were reflected on the number of expected YLL (EYLL) that remained substantially unaffected by surgery (p = 0.821). Patients aged ≤68 years experienced the highest number of EYLL (20.8 years); whereas elderly patients had a loss of life that corresponded to only 6% of the entire life they had already lived.

CONCLUSIONS

In a typical pancreatic cancer cohort, surgery was not able to modify population-based statistics because of a different age at tumor onset which nullifies any benefit from a "lifespan from birth" perspective. Pancreatic cancer in younger individuals must be ranked within the very first causes of EYLL due to malignancy.

Effect of age on survival in patients undergoing resection of hepatocellular carcinoma

Background

The benefit of surgical intervention for cancer should be estimated in relation to the life expectancy of the general population. The aim of this study was to provide a measure of relative survival after hepatectomy for hepatocellular carcinoma (HCC).

Methods

Consecutive patients with liver cirrhosis and HCC who underwent hepatectomy were divided into age quartiles for analysis. Short- and mid-term survival rates were used to estimate survival until death for all patients, in relation to age and other co-variables. Years of life lost (YLL) were estimated using a reference cohort, derived from the general population matched for sex, age and year of diagnosis.

Results

Some 919 patients were included in the study. The following age quartiles were identified: less than 60 years (229 patients), 60–66 years (230), 67–70 years (231) and over 70 years (229). Postoperative mortality rates were similar between age quartiles, as were survival rates up to 3 years (P = 0·404). A statistically significant reduction in 5–10-year survival rates was observed with ageing (P = 0·001). Relative survival calculation showed that the youngest age quartile (less than 60 years) experienced the longest entire postoperative lifespan (15·6 years) but also the greatest number of YLL (11·0 years). Patients aged over 70 years had the shortest entire postoperative lifespan (6·4 years) but also the smallest number of YLL (3·7 years).

Conclusion

Although survival after liver resection for HCC is shortest in elderly patients, relative survival estimates suggest that hepatectomy can be of benefit in these patients, with a small loss of the entire individual lifespan.

Aromatase inhibitors for prevention of breast cancer in postmenopausal women: a narrative review

OBJECTIVE

The increasing incidence of breast cancer (BC) worldwide has resulted in widespread interest in primary prevention therapies. A number of large randomized trials have shown that selective estrogen receptor modulators can reduce the relative risk for BC by 30% to 40% in high-risk women. In early-stage BC, aromatase inhibitors (AIs) showed a 35% relative reduction in the risk of contralateral BCs compared with tamoxifen. In this narrative review, we discuss the role of AIs in the primary prevention of BC and novel research on combination hormone therapy-medical therapy for the primary prevention of BC.

METHODS

Using PubMed/Medline, we comprehensively searched for studies of BC primary prevention using AIs, including studies of novel methods of prevention using combination hormone therapy-BC prevention.

RESULTS

Two large multicenter, prospective, randomized, placebo-controlled trials have evaluated AIs--anastrozole (International Breast Cancer Intervention Study II) and exemestane (Mammary Prevention 3)--for BC risk reduction in women at increased risk for BC, which we summarize. We identified five studies (three completed and two ongoing) of combination AI-hormone therapy that are undergoing investigation for BC risk reduction.

CONCLUSIONS

AIs are effective at BC risk reduction, although long-term follow-up data are required to assess whether this risk reduction will result in reduced mortality. Combination hormone therapy-AI for BC risk reduction is experimental and warrants further investigation.

Years of potential life lost for brain and CNS tumors relative to other cancers in adults in the United States, 2010

BACKGROUND

Years of potential life lost (YPLL) complement incidence and survival rates by measuring how much a patient's life is likely to be shortened by his or her cancer. In this study, we examine the impact of death due to brain and other central nervous system (CNS) tumors compared to other common cancers in adults by investigating the YPLL of adults in the United States.

METHODS

Mortality and life table data were obtained from the Centers for Disease Control and Prevention's National Center for Health Statistics Vital Statistics Data for 2010. The study population included individuals aged 20 years or older at death who died from one of the selected cancers. YPLL was calculated by taking an individual's age at death and finding the corresponding expected remaining years of life using life table data.

RESULTS

The cancers with the greatest mean YPLL were other malignant CNS tumors (20.65), malignant brain tumors (19.93), and pancreatic cancer (15.13) for males and malignant brain tumors (20.31), breast cancer (18.78), and other malignant CNS tumors (18.36) for females. For both sexes, non-Hispanic whites had the lowest YPLL, followed by non-Hispanic blacks, and Hispanics.

CONCLUSION

Malignant brain and other CNS tumors have the greatest mean YPLL, thereby reflecting their short survival time post diagnosis. These findings will hopefully motivate more research into mitigating the impact of these debilitating tumors.

Years of potential life lost due to breast and cervical cancer: a challenge for Brazilian public policy

BACKGROUND

The purpose of the article was to analyze the years of potential life lost (YPLL) of women who died from breast and cervical cancer in the State of Parana, Southern Brazil. This was a temporal trend study (2000 to 2010) about the coefficients of mortality and the years of potential life lost in women aged 20 to 70 years.

MATERIALS AND METHODS

Data were obtained through the database of the Department of the Unified Health System (DATASUS) and the National Mortality Information System.

RESULTS

There was a loss of 125.075 YPLL due to breast cancer, with an average of 11.370 YPLL. Regarding cervical cancer, the figure obtained was 91.625 YPLL from 2000 to 2010, with an average of 8.329 YPLL. Increased risk of death from breast cancer was observed for women aged 50 to 59 years, with a significant increase among those in the age group from 40 to 49 years. There was an increased rate of cervical cancer among women 40 to 69 years.

CONCLUSIONS

The risk of death grows with increasing age, being higher from 40 years. Prevention is paramount for both cancers. Thus, preventive measures are required and a reassessment of political strategies should be adopted.

Estimation of life expectancy and the expected years of life lost among heroin users in the era of opioid substitution treatment (OST) in Taiwan

BACKGROUND

Opioid substitution treatment (OST) has been implemented in Taiwan since 2006. We estimated the life expectancy (LE) and expected years of life lost (EYLL) in a cohort of heroin users stratified by OST for comparison.

METHODS

A total of 1283 heroin users recruited from 2006 to 2008 were linked to the National Mortality Registry until the end of 2011. Among them, 983 received OST, while 300 did not. Kaplan-Meier estimation for survival was performed, and it was extrapolated to 50 years to obtain the LE using a semi-parametric method. We further estimated the EYLL for both cohorts by subtracting their life expectancies from the age- and sex-matched referents of the general population. Cause-specific standardized mortality ratios (SMRs) were calculated and compared with the national cohort to validate the representativeness of this sample.

RESULTS

After extrapolation to 50 years of survival, the estimated average LE and EYLL were 27.4 and 10.6 for OST subjects, respectively, while those of the non-OST were 20.2 and 18.4 years. The all-cause mortality rates (per 1000 person-years) in the observational period for the OST and non-OST group were 15.5 and 23.9, respectively, representing a 7.5- and 10.2-fold SMR compared to the general population, indicating a high representativeness for our sample. But SMR of suicide mortality elevated 16.2 and 3.1 folds in OST and non-OST group, respectively.

CONCLUSIONS

OST saves 7.8 EYLL more than non-OST after accounting for lead time bias. Effective suicide prevention programs could enhance its life-saving effect, especially among those co-morbid with depressive disorders.

Hyaluronan expression in primary and secondary brain tumors

BACKGROUND

Collectively, primary and secondary brain tumors represent a major public health challenge. Glioblastoma (GBM) is the most common primary brain tumor in adults and is associated with a dismal 5-year survival of only 10%. Breast cancer causes secondary tumors; it occurs in 200,000 patients yearly and 30% of these individuals develop brain metastases which also lead to a very poor prognosis. GBM and primary breast tumors are known to express hyaluronan (HA) which may serve as a therapeutic target.

METHODS

For the present study we had two aims: (I) to identify suitable preclinical models for HA in GBM by examining HA expression in human GBM cell lines implanted orthotopically in mice; and (II) to determine whether breast cancer brain metastases in human patients express HA similar to the primary tumor. Forty human surgical samples of primary breast tumors and breast cancer brain metastases were processed and stained for HA. Athymic nu/nu mice were orthotopically implanted with one of 15 GBM lines and after tumors were established, quantitative immunohistochemistry determined whether.

RESULTS

HA was expressed. All GBM cell lines and patient-derived orthotopic tumors did express HA, with 3 primary human lines expressing the highest staining intensity, above that of normal brain. All 40 human primary breast tumors and brain metastases examined also contained HA, though staining intensity was highly variable.

CONCLUSIONS

Our data support the use of specific patient-derived GBM cell lines in nu/nu mice for preclinical studies on HA-targeting therapies. Additionally, our research provides a basis for the assessment of HA expression and HA-targeting therapeutic agents for the treatment of breast cancer brain metastases.

Life expectancy and expected years of life lost to oral cancer in Taiwan: a nation-wide analysis of 22,024 cases followed for 10 years

OBJECTIVES

This analysis examined the life expectancies (LE) and expected years of life lost (EYLL) in relation to oral cancer in Taiwan.

MATERIALS AND METHODS

A semi-parametric extrapolation method was applied to estimate gender, age, histology, subsite, and stage stratified LE, EYLL of 22,024 pathologically verified oral cancer patients retrospectively recruited from the National Cancer Registry of Taiwan during 2002-2009, who were followed up to 2011.

RESULTS

The patients were predominantly male 20,101, (91.3%), and over 80% were less than 65years old. The mean age at diagnosis of males was younger than that of females (52.73years vs. 60.76years). The LE after diagnosis was longer among females than males (15.26years vs. 12.73years), with a smaller loss of the corresponding EYLL (8.88years vs. 14.05years), which prevails after stratification by age and stage. More than half of the oral cancer cases were diagnosed at a later stage, with 2921 cases (13.3%) of stage III and 8488 (38.5%) of stage IV. The five-year overall survival rate of oral cancer for stages I, II, III, and IV were 78.98%, 69.38%, 54.62%, and 36.17%, respectively. The earlier the diagnosis, the longer the life expectancy and the smaller the EYLL.

CONCLUSIONS

We concluded that early detection and early intervention of oral cancer can prolong life expectancy and reduce the years of life lost, indicating the importance of proactive screening and oral hygiene.

Comparison of expected health impacts for major cancers: integration of incidence rate and loss of quality-adjusted life expectancy

PURPOSE

The study aims to quantify the expected impacts of different cancers through multiplying the incidence rate by loss-of-QALE (quality-adjusted life expectancy), with QALY (quality-adjusted life year) as the common unit, to aid prevention policy decisions.

METHODS

464,722 patients with pathologically verified cancer registered in the Taiwan Cancer Registry during 1998-2009 were used to estimate lifetime survival through Kaplan-Meier estimation combined with a semi-parametric method. A convenience sample for measuring the utility value with EQ-5D was conducted with 11,453 cancer patients, with the results then multiplied by the survival functions to estimate QALE. The loss-of-QALE was calculated by subtracting the QALE of each cancer cohort from the life expectancy of the corresponding age- and gender-matched reference population. The cumulative incidence rates from age 20 to 79 (CIR₂₀₋₇₉) were calculated to estimate the lifetime risk of cancer for each organ-system.

RESULTS

Liver and lung cancer were found the highest expected lifetime health impacts in males and females, or expected lifetime losses of 0.97 and 0.41 QALYs that could be averted, respectively. While the priority changes for prevention based on expected health impacts were slightly different for females based on standardized mortality rates, those of males involve a broader spectrum, including oral, colorectal, esophageal and stomach cancer.

CONCLUSION

The integration of incidence rate with loss-of-QALE could be used to represent the expected losses that could be averted by prevention, which may be useful in prioritizing strategies for cancer control.

Estimation of savings of life-years and cost from early detection of cervical cancer: a follow-up study using nationwide databases for the period 2002-2009

BACKGROUND

Few studies consider both the survival and financial benefits of detection of invasive cervical cancer (ICC) at earlier stages. This study estimated the savings in life-years and costs from early diagnosis of cervical cancer using an ex post approach.

METHODS

A total of 28,797 patients diagnosed with cervical cancer in the period 2002-2009 were identified from the National Cancer Registry of Taiwan, and linked to the National Mortality Registry until the end of 2011. Life expectancies (LE) for cancer at different stages were estimated using a semi-parametric extrapolation method. The expected years of life lost (EYLL) for cancer were calculated by subtracting the LE of the cancer cohort from that of the age-and sex-matched general population. The mean lifetime costs after diagnosis paid by the single-payer National Health Insurance during (NHI) 2002-2010 were estimated by multiplying average monthly expenditures by the survival probabilities and summing up over lifetime.

RESULTS

ICC at stages 1 to 4 had an average EYLL of 6.33 years, 11.64 years, 12.65 years, and 18.61 years, respectively, while the related lifetime costs paid by the NHI were $7,020, $10,133, $11,120, and $10,015 US dollars, respectively; the younger the diagnosis age, the higher the savings with regard to EYLL. The mean lifetime costs of managing cervical cancer were generally lower for the earlier stages compared with stages 3 and 4.

CONCLUSIONS

Early detection of ICC saves lives and reduces healthcare costs. These health benefits and monetary savings can be used for cost-effectiveness assessments and the promotion of regular proactive screening, especially among older women.

Years of life lost as a measure of cancer burden on a national level

Background:

The severity of cancers is often measured in number of deaths. However, number of years of life lost (YLL) may be a more appropriate indicator of impact on society. Here we have calculated the YLL of adult cancers in Norway for the year 2012, as well as for the previous 15-year period.

Methods:

Data on age composition, expected remaining years of life, total numbers of deaths and deaths due to cancer were retrieved from the National Census Agency Statistics Norway. YLL were calculated for both sexes aged 25–99 years based on each individual's age at death, and the expected remaining years of life at that age.

Results:

Cancer deaths represented 25.8% of all adult deaths in 2012, with a lower fraction of females (28.7% in men and 23.1% in women), whereas cancer represented 35.2% of all YLL, with a higher fraction of females (32.8% in men and 37.8% in women). Females loose on average more life years to cancer than men (14.9 vs 12.7 years). Average YLL varied from 23.7 (cervical cancer) to 7.9 (prostate cancer). Lung cancer caused almost as many YLL alone (22.1% of cancer-caused YLL) as colon, prostate and breast cancer combined (23.1%). From 1997 to 2012, cancer-caused YLL as a fraction of all YLL increased from 32.5% to 35.2%, but with major differences among diagnoses.

Conclusions:

Cancer is a major and increasing cause of premature deaths, and YLL may be a more accurate measure than number of deaths. Public health efforts and research funding should be explicitly directed at preventing premature deaths.

Estimation of potential gain in quality of life from early detection of cervical cancer

OBJECTIVE

To estimate the lifetime gain in the health-related quality of life (HRQOL) from early detection of cervical cancer.

METHODS

A consecutive, cross-sectional sample of 421 patients with cervical cancer was administered the World Health Organization Quality of Life-brief version questionnaires. A nationwide sample of 22,543 patients with invasive cervical cancer (ICC) was collected from the national cancer registry for estimation of lifetime survival function from 1998 to 2007, which was further multiplied by the ratio of HRQOL score functions for patients with ICC and patients with carcinoma in situ (CIS), and summed up over lifetime to obtain expected relative-quality-adjusted survival. The difference between lifetime survival and the expected relative-quality-adjusted survival gives the expected total dissatisfied time during the life course.

RESULTS

In comparison with patients with CIS postconization, patients with ICC showed consistently lower scores in the physical and psychological domains and that of sexual life after adjustment for other risk factors. The expected years of life lost for an invasive cancer was 6.48 years using the general population as the reference cohort, while the durations of equivalent to living with a very dissatisfied HRQOL were 1.71 and 0.25 for the physical and psychological domains, respectively, and 1.47 years for sexual life. Validation of the extrapolation method based on a subcohort followed from the 6th to the 13th year shows a relative bias of 0.4%. Sensitivity analysis with 37,000 CIS cases as the reference cohort yields a similar result.

CONCLUSIONS

Early detection of cervical cancer not only avoids premature mortality but also prevents long-term living under lower HRQOL scores, including sexual life.

Inaccuracies in oral cavity-pharynx cancer coded as the underlying cause of death on U.S. death certificates, and trends in mortality rates (1999-2010)

OBJECTIVE

To enhance surveillance of mortality from oral cavity-pharynx cancer (OCPC) by considering inaccuracies in the cancer site coded as the underlying cause of death on death certificates vs. cancer site in a population-based cancer registry (as the gold standard).

METHODS

A database was used for 9 population-based cancer registries of the Surveillance, Epidemiology and End Results (SEER) Program, including deaths in 1999-2010 for patients diagnosed in 1973-2010. Numbers of deaths and death rates for OCPC in the SEER population were modified for apparent inaccuracies in the cancer site coded as the underlying cause of death.

RESULTS

For age groups <65 years, deaths from OCPC were underestimated by 22-35% by using unmodified (vs. modified) numbers, but temporal declines in death rates were still evident in the SEER population and were similar to declines using routine mortality data for the entire U.S. population. Deaths were underestimated by about 70-80% using underlying cause for tonsillar cancers, strongly associated with human papillomavirus (HPV) infection, but a lack of decline in death rates was still evident.

CONCLUSION

Routine mortality statistics based on underlying cause of death underestimate OCPC deaths but demonstrate trends in OCPC death rates that require continued surveillance in view of increasing incidence rates for HPV-related OCPC.

Lung cancer screening with low-dose computed tomography for primary care providers

This review provides an update on lung cancer screening with low-dose computed tomography (LDCT) and its implications for primary care providers. One of the unique features of lung cancer screening is the potential complexity in patient management if an LDCT scan reveals a small pulmonary nodule. Additional tests, consultation with multiple specialists, and follow-up evaluations may be needed to evaluate whether lung cancer is present. Primary care providers should know the resources available in their communities for lung cancer screening with LDCT and smoking cessation, and the key points to be addressed in informed and shared decision-making discussions with patients.

Prostate specific membrane antigen (PSMA) expression in primary gliomas and breast cancer brain metastases

Background

Primary and secondary brain cancers are highly treatment resistant, and their marked angiogenesis attracts interest as a potential therapeutic target. Recent observations reveal that the microvascular endothelium of primary high-grade gliomas expresses prostate specific membrane antigen (PSMA). Breast cancers express PSMA and they frequently form secondary brain tumors. Hence we report here our pilot study addressing the feasibility of PSMA targeting in brain and metastatic breast tumors, by examining PSMA levels in all glioma grades (19 patients) and in breast cancer brain metastases (5 patients).

Methods

Tumor specimens were acquired from archival material and normal brain tissues from autopsies. Tissue were stained and probed for PSMA, and the expression levels imaged and quantified using automated hardware and software. PSMA staining intensities of glioma subtypes, breast tumors, and breast tumor brain metastases were compared statistically versus normals.

Results

Normal brain microvessels (4 autopsies) did not stain for PSMA, while a small proportion (<5%) of healthy neurons stained, and were surrounded by an intact blood brain barrier. Tumor microvessels of the highly angiogenic grade IV gliomas showed intense PSMA staining which varied between patients and was significantly higher (p < 0.05) than normal brain. Grade I gliomas showed moderate vessel staining, while grade II and III gliomas had no vessel staining, but a few (<2%) of the tumor cells stained. Both primary breast cancer tissues and the associated brain metastases exhibited vascular PSMA staining, although the intensity of staining was generally less for the metastatic lesions.

Conclusions

Our results align with and extend previous data showing PSMA expression in blood vessels of gliomas and breast cancer brain metastases. These results provide a rationale for more comprehensive studies to explore PSMA targeted agents for treating secondary brain tumors with PSMA expressing vasculature. Moreover, given that PSMA participates in angiogenesis, cell signaling, tumor survival, and invasion, characterizing its expression may help guide later investigations of the poorly understood process of low grade glioma progression to glioblastoma.

Future initiatives to reduce lung cancer incidence in the United Kingdom: smoking cessation, radon remediation and the impact of social change

Aims:

Smoking and radon cause lung cancer, with smoking being the more significant risk factor. Although programmes to identify UK houses with raised radon levels and to encourage remedial action started in 1990, uptake has been limited and those most at risk, smokers and young families, are not being reached. The risks from smoking and radon are multiplicative. Public health campaigns have reduced smoking prevalence significantly. Since most radon-induced lung cancers occur in smokers, reducing the number of smokers will reduce the number of radon-induced lung cancers. This article considers the impact of reducing smoking prevalence on the effectiveness of radon remediation programmes, combining this with demographic trends and regional variations to assess implications for future public health.

Methods:

Results on cost-effectiveness of smoking cessation and radon remediation programmes were combined with government figures for smoking prevalence to estimate the number of cancers averted and the cost-effectiveness of such programmes, taking into account demographic changes, including increasing life expectancy. Regional variations in smoking prevalence and smoking cessation programmes were reviewed, comparing these to the geographic variation of radon.

Results:

The continuing impact of smoking cessation programmes in reducing smoking prevalence will reduce the number of radon-induced lung cancers, but with a lag. Smoking cessation programmes are more cost-effective than radon remediation programmes, presenting an additional opportunity to reduce radon risk to smokers. Regional data show no correlation between smoking prevalence and radon levels.

Conclusions:

Reduced smoking prevalence reduces the effectiveness of radon remediation programmes. This, coupled with limited uptake of radon remediation, suggests that radon remediation programmes should be targeted, and that an integrated public health policy for smoking and radon is appropriate. Lack of correlation between smoking prevalence and radon suggests that local assessment of relative priorities for public health strategies, such as the ‘Total Place’ initiative, is appropriate.

Assessing progress in reducing the burden of cancer mortality, 1985-2005

PURPOSE

Measuring the effect of cancer interventions must take into account rising cancer incidence now that people live longer because of declines in mortality from cardiovascular disease (CVD). Cancer mortality rates in the population do not accomplish this objective. We sought a measure that would reveal the effects of changing mortality rates from other diseases.

METHODS

We obtained annual breast, colorectal, lung, and prostate cancer mortality rates from the Surveillance, Epidemiology, and End Results registries; we obtained noncancer mortality rates from national death certificates, 1975 to 2005. We used life-table methods to calculate the burden of cancer mortality as the average person-years of life lost (PYLL) as a result of cancer (cancer-specific PYLL) and quantify individual-and perhaps offsetting-contributions of the two factors that affect cancer-specific PYLL: mortality rates as a result of cancer and other-cause mortality.

RESULTS

Falling cancer mortality rates reduced the burden of mortality from leading cancers, but increasing cancer incidence as a result of decreasing other-cause mortality rates partially offset this progress. Between 1985 and 1989 and between 2000 and 2004, the burden of lung cancer in males declined by 0.1 year of life lost. This decline reflects the sum of two effects: decreasing lung cancer mortality rates that reduced the average burden of lung cancer mortality by 0.33 years of life lost and declining other-cause mortality rates that raised it by 0.23 years. Other common cancers showed similar patterns.

CONCLUSION

By using a measure that accounts for increased cancer incidence as a result of improvements in CVD mortality, we find that prior assessments have underestimated the impact of cancer interventions.

Estimation of physical functional disabilities and long-term care needs for patients under maintenance hemodialysis

Supplemental Digital Content is available in the text.

Background and Objectives:

Physical functional disabilities in hemodialysis (HD) patients may increase their mortality and long-term care needs. The aim of this study was to estimate the changes of proportion for different physical functional disabilities along time after beginning HD and the lifelong care needs.

Methods:

We used a population-based cohort consisting of 84,657 incident HD patients in Taiwan between 1998 and 2009 to estimate the survival function and extrapolate to lifetime through a semiparametric method. The Barthel Index (BI) was used to measure the functional disability levels cross-sectionally in 1334 HD patients recruited from 9 HD centers. A BI score <50 was considered as severe disability. Lifetime care needs were obtained by extrapolating the age-stratified survival functions to lifetime and then multiplying them with proportions of different kinds of functional disabilities over time.

Results:

On average, HD patients had at least 6.4, 2.0, and 1.3 years without disability, with moderate disability, and severe disability, respectively. The most common care needs were stair-climbing and bathing, which were 3.0 and 1.7 years, respectively. HD patients were expected to have about 3 years living with disabilities for those beginning HD at an age above 35 years; however, the older the patient, the higher the proportion of functional disabilities and care needs.

Conclusions:

HD patients are in need of long-term care and require early intervention and resource planning. The method developed in this study can also be applied to other chronic illnesses with various functional disabilities.

Estimating the lifelong health impact and financial burdens of different types of lung cancer

BACKGROUND

Owing to the high mortality and rapidly growing costs related to lung cancer, it is worth examining the health benefits of prevention for major types of lung cancer. This study attempts to quantify the quality-adjusted life expectancy (QALE), loss-of-QALE, and lifetime healthcare expenditures of patients with different pathological types of lung cancer.

METHODS

A national cohort consisting of 66,535 patients with pathologically verified lung cancer was followed for 13 years (1998-2010) to obtain the survival function, which was further extrapolated to lifetime. Between 2011 and 2012, EuroQol 5-dimension questionnaires were used to measure the quality of life (QoL) for 1,314 consecutive, cross-sectional samples. After multiplying the lifetime survival function by the utility values of QoL, we estimated the QALE and loss-of-QALE. We also collected the monthly healthcare expenditures, which included National Health Insurance-reimbursed and out-of-pocket direct medical costs, for 2,456 patients from 2005 to 2012. These values were multiplied by the corresponding survival probabilities to calculate lifetime healthcare expenditures after adjustments with medical care inflation rates and annual discount rates.

RESULTS

The QALE for patients with small cell lung cancer, squamous cell carcinoma, and adenocarcinoma were 1.21, 2.37, and 3.03 quality-adjusted life year (QALY), with the corresponding loss-of-QALE of 13.69, 12.22, and 15.03 QALY, respectively. The lifetime healthcare expenditures were US$ 18,455 ± 1,137, 20,599 ± 1,787, and 36,771 ± 1,998, respectively.

CONCLUSIONS

The lifelong health impact and financial burdens in Taiwan are heavier for adenocarcinoma than for squamous cell carcinoma. The cost-effectiveness of prevention programs could be directly compared with that of treatment strategies to improve patient value. And the methodology could be applied to other chronic diseases for resources planning of healthcare services.

Suitable trial designs and cohorts for preventive breast cancer agents

Effective chemoprevention of oestrogen receptor (ER)-positive breast cancer has been shown convincingly using several selective ER modulators and the aromatase inhibitor exemestane. Although these agents are well tolerated and the numbers needed-to-treat in the prevention setting are similar to other established preventive interventions, uptake has been poor in clinical practice because of difficulties in visualizing risk, predicting individual outcomes and measuring treatment benefit. In addition, new agents targeting ER-negative breast cancer are urgently needed. The development of new agents is hampered by the lack of suitable biomarkers and targets, as well as regulatory and financial considerations. Establishing breast cancer chemoprevention in standard clinical practice will require advances in many different fields, including biomarker research, the development of more powerful tools to predict and communicate the risks and benefits of treatments and establishing innovative trial designs. Furthermore, changes in regulatory procedures could reduce the size and cost of trials needed in the prevention setting. Identification of biomarkers for risk and efficacy that are easily accessible, such as blood-based biomarkers, will be key to future chemoprevention strategies.

Estimation of the long-term care needs of stroke patients by integrating functional disability and survival

Objectives

This study aimed to estimate the dynamic changes of different physical functional disabilities and life-time care needs for patients with stroke.

Data Sources and Study Design

We examined a hospital-based cohort including 16,043 patients who had their first stroke during 1995–2010. The Barthel Index (BI) was used to measure disability levels in 1,162 consecutive patients, with a total of 1,294 measurements at the stroke clinics and the rehabilitation wards, and a cross-sectional design.

Extraction Methods

The survival function was extrapolated to lifetime by a semi-parametric method and multiplied with proportions of different disabilities over time to obtain the long-term care needs for different stroke subtypes.

Principal Findings

On average, stroke patients would suffer at least 0.86 years with mild disability, 1.24 years with moderate disability and 1.39 years with severe disability, as measured by the BI. Among these, patients with a cardio-embolic infarct or intracerebral hemorrhage (ICH) suffered more than 2 years of severe disability. Assistance in bathing was the most common need for care in stroke patients.

Conclusions

Among different subtypes of stroke, cardio-embolic infarct and ICH lead to the longest durations of severe physical functional disability. The method presented in this work may also be applied to other chronic diseases and different functional disabilities.