Economic and Humanistic Burden of Cervical Cancer in the United States: Results from a Nationally Representative Survey

Understanding racial disparities in health care expenditures for cervical cancer

BACKGROUND

Cervical cancer demonstrates a notable efficacy in treatment, evidenced by a 92% 5-year survival rate among cases diagnosed at a localized stage. In 2020, the estimated annual national expenditure for cervical cancer care amounted to $2.3 billion in the United States. Limited real-world data are available for racial disparities in health care expenditures for cervical cancer.

OBJECTIVE

To evaluate racial disparities associated with annual health care expenditures among patients diagnosed with cervical cancer in the United States.

METHODS

A retrospective observational cohort study of annual health care expenditures in patients with cervical cancer diagnosed during 2014-2019 was performed using the Medical Expenditure Panel Survey data. In addition to the descriptive weighted analysis, an unadjusted analysis of the annual health care expenditure was conducted. An adjusted linear regression model with log transformation of the outcome variable was used to evaluate the total annual health care expenditure as well as expenditures by category across the racial groups.

RESULTS

Overall, 826 patients with cervical cancer were identified from the Medical Expenditure Panel Survey during 2014-2019. The majority were classified as White patients (81.2%) and in the age group of 45-64 years (44.65%). On average, the total annual health care expenditure was $11,537 (95% CI = $9,887-$13,186) among the White cohort, $10,659 (95% CI = $6,704-$14,614) among the African American cohort, and $8,726 (95% CI = $6,113-$11,340) among the Hispanic cohort. After adjusting for covariates, the average total annual health care expenditure for the Hispanic cohort was 35% of the total health care expenditure of the White cohort (P < 0.001) and 46% of the African American cohort's health care expenditure (P = 0.02). Specifically, adjusted costs of office-based and outpatient visits for the Hispanic cohort were 47% (P = 0.009) and 57% (P = 0.005) lower than for the White cohort, respectively. The total annual home health care expenditure for the African American cohort was 49% lower than White patients (P = 0.03), and the Hispanic cohort's total expenditure, excluding prescription medicines, was 57% lower than African American patients (P = 0.02).

CONCLUSIONS

This study provides valuable information regarding the health care disparities that need to be addressed among certain minority races. Reducing the disparities in health care spending across racial groups should be included as a crucial element in tackling well-established health care inequities.

Estimation of economic burden throughout course of cervical squamous intraepithelial lesion and cervical cancer in China: A nationwide multicenter cross-sectional study

Objective

Cervical squamous intraepithelial lesion (SIL) and cervical cancer are major threats to females' health and life in China, and we aimed to estimate the economic burden associated with their diagnosis and treatment.

Methods

A nationwide multicenter, cross-sectional, hospital-based survey was conducted in 26 qualified hospitals across seven administrative regions of China. We investigated females who had been pathologically diagnosed with SIL and cervical cancer, and included five disease courses ("diagnosis", "initial treatment", "chemoradiotherapy", "follow-up" and "recurrence/progression/metastasis") to estimate the total costs. The median and interquartile range (IQR) of total costs (including direct medical, direct non-medical, and indirect costs), reimbursement rate by medical insurance, and catastrophic health expenditures in every clinical stage were calculated.

Results

A total of 3,471 patients in different clinical stages were analyzed, including low-grade SIL (LSIL) (n=549), high-grade SIL (HSIL) (n=803), cervical cancer stage IA (n=226), IB (n=610), IIA (n=487), IIB (n=282), III (n=452) and IV (n=62). In urban areas, the estimated total costs of LSIL and HSIL were [Formula: see text]1,637.7 (IQR: [Formula: see text]956.4-[Formula: see text]2,669.2) and [Formula: see text]2,467.1 (IQR: [Formula: see text]1,579.1-[Formula: see text]3,762.3), while in rural areas the costs were [Formula: see text]459.0 (IQR: [Formula: see text]167.7-[Formula: see text]1,330.3) and [Formula: see text]1,230.5 (IQR: [Formula: see text]560.6-[Formula: see text]2,104.5), respectively. For patients with cervical cancer stage IA, IB, IIA, IIB, and III-IV, the total costs were [Formula: see text]15,034.9 (IQR: [Formula: see text]11,083.4-[Formula: see text]21,632.4), [Formula: see text]19,438.6 (IQR: [Formula: see text]14,060.0-[Formula: see text]26,505.9), [Formula: see text]22,968.8 (IQR: [Formula: see text]16,068.8-[Formula: see text]34,615.9), [Formula: see text]26,936.0 (IQR: [Formula: see text]18,176.6-[Formula: see text]41,386.0) and [Formula: see text]27,332.6 (IQR: [Formula: see text]17,538.7-[Formula: see text]44,897.0), respectively. Medical insurance covered 43%-55% of direct medical costs for cervical cancer patients, while the coverage for SIL patients was 19%-43%. For most cervical cancer patients, the expense was catastrophic, and the extent of catastrophic health expenditure was about twice large for rural patients than that for urban patients in each stage.

Conclusions

The economic burden of SIL and cervical cancer in China is substantial, with a significant proportion of the costs being avoidable for patients with LSIL. Even for those with medical insurance, catastrophic health expenditures are also a major concern for patients with cervical cancer, particularly for those living in rural areas.

Barriers and facilitators to effective cervical cancer screening in Belize: a qualitative analysis

PURPOSE

Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services.

METHODS

Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model.

RESULTS

We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening.

CONCLUSION

Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control.

Economic burden of cervical cancer and premalignant lesions associated with human papilloma virus: a societal perspective

BACKGROUND

Cervical cancer is one of the most common cancers in women, the cause of which is mostly human papilloma virus (HPV). The aim of this study was to determine the economic burden of cervical cancer and premalignant lesions associated with HPV infection from a societal perspective.

METHODS

The study is a partial economic evaluation (cost of illness), which was conducted cross-sectionally in the referral university clinic in Fars province in 2021. The prevalence-based and bottom-up approaches used to calculate the costs, the indirect costs were calculated by human capital approach.

RESULTS

The mean cost of premalignant lesions associated with HPV infection was USD 2,853 per patient, which 68.57% was direct medical costs. In addition, the mean cost of cervical cancer was USD 39,327 per patient, the largest share of which (57.9%) was related to indirect costs. The mean annual cost of cervical cancer patients in the country was estimated at USD 40,884,609 as well.

CONCLUSION

Cervical cancer and premalignant lesions associated with HPV infection imposed a significant economic burden on the health system and patients. The results of the present study can help health policymakers with efficient and equitable prioritization and allocation of resources.

Economic Burden of Cervical Cancer in Bulgaria

Bulgaria is among the European Union (EU) countries with the highest burden of cervical cancers and life expectancy below the EU average. The majority of cervical cancer cases (more than 95%) are caused by the human papillomavirus (HPV). The aim of this retrospective, cost of illness study is to identify direct healthcare costs of cervical cancer in Bulgaria from the payer perspective and to calculate indirect costs and the associated years of life lost. Costs data were sourced from the National Health Insurance Fund from January 2018 to December 2020. Years of life lost were calculated based on the country and gender-specific life expectancy. Indirect costs due to productivity loss were calculated using the human capital approach. The total treatment costs for 3540 patients with cervical cancer are EUR 5,743,657 (2018), EUR 6,377,508 (2019), and EUR 6,751,182 (2020). The costs associated with drug acquisition and administration accounted for the majority (63%) of total healthcare costs followed by hospital management costs (14%). An estimated total of 20,446 years of life were lost due to cervical cancer for the period 2018-2020. The costs of productivity losses are estimated at EUR 7,578,014. Our study showed that the economic burden of cervical cancer in Bulgaria is substantial. Focus on cervical cancer prevention via vaccination against the human papillomavirus, timely screening, early diagnosis, and higher vaccine coverage rates could reduce its economic burden in Bulgaria.

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.

Women with Cervical High-Risk Human Papillomavirus: Be Aware of Your Anus! The ANGY Cross-Sectional Clinical Study

Anogenital human papillomaviruses (HPV) are highly prevalent in sexually active populations, with HR-HPV being associated with dysplasia and cancers. The consequences of cervical HPV infection are well-known, whereas those of the anus are less clear. The correlation of cervical and anal HPVs with the increasing number of anal cancers in women has not been studied yet. The objective of our prospective study was to determine whether cervical and anal HPV correlated in a cohort of women recruited in a university hospital in Switzerland. Recruitment was conducted in the gynecology clinic, the colposcopy clinic, and the HIV clinic. Cervical and anal HPV genotyping and cytology were performed. Overall, 275 patients were included (360 were initially planned), and among them, 102 (37%) had cervical HR-HPV. Patients with cervical HR-HPV compared to patients without cervical HR-HPV were significantly younger (39 vs. 44 yrs, p < 0.001), had earlier sexual intercourse (17.2 vs. 18.3 yrs, p < 0.01), had more sexual partners (2.9 vs. 2.2, p < 0.0001), more dysplastic cervical cytology findings (42% vs. 19%, p < 0.0001) and higher prevalence of anal HR-HPV (59% vs. 24%, p < 0.0001). Furthermore, the HR-HPV group reported more anal intercourse (44% vs. 29%, p < 0.015). Multivariate analysis retained anal HR-HPV as independent risk factor for cervical HR-HPV (OR3.3, CI 1.2−9.0, p = 0.02). The results of this study emphasize that it is of upmost importance to screen women for anal HR-HPV when diagnosing cervical HR-HPV.

Human papillomavirus targets the YAP1-LATS2 feedback loop to drive cervical cancer development

Human papillomavirus (HPV) infection is very common in sexually active women, but cervical cancer only develops in a small fraction of HPV-infected women, suggesting that unknown intrinsic factors associated with the unique genetic/genomic background of the high-risk population play a critical role in cervical carcinogenesis. Although our previous studies have identified the hyperactivated YAP1 oncogene as a critical contributor to cervical cancer, the molecular mechanism by which YAP1 drives cervical cancer is unknown. In the present study, we found that although the hyperactivated YAP1 caused a malignant transformation of immortalized cervical epithelial cells, it induced cellular senescence in cultures of primary human cervical epithelial cells (HCvECs). However, the hyperactivated YAP1 induced malignant transformation of HCvECs in the presence of high-risk HPV E6/E7 proteins, suggesting that the hyperactivated YAP1 synergizes with HPV to initiate cervical cancer development. Our mechanistic studies demonstrate that YAP1, via up-regulating LATS2, formed a YAP1-LATS2 negative feedback loop in cervical epithelial cells to maintain homeostasis of cervical tissue. Intriguingly, we found that high-risk HPV targets LATS2 to disrupt the feedback loop leading to the malignant transformation of cervical epithelial cells. Finally, we report that mitomycin C, an FDA-approved drug that could upregulate LATS2 and drive cellular senescence in vitro and in vivo, induced a regression of cervical cancer in a pre-clinial animal model. Thus, high-risk HPV targeting the YAP1-LATS2 feedback loop represents a new mechanism of cervical cancer development.

Human Papillomavirus Vaccine Impact on Cervical Precancers in a Low-Vaccination Population

INTRODUCTION

Demonstrating human papillomavirus vaccine impact is critical for informing guidelines to increase vaccination and decrease human papillomavirus‒related outcomes, particularly in states with suboptimal vaccination coverage, such as Tennessee. This study examines the trends in high-grade cervical lesion incidence among Tennessee Medicaid-enrolled women aged 18-39 years and the subset of women who were screened for cervical cancer.

METHODS

Using a validated claims-based model to identify incident cervical intraepithelial neoplasia Grades 2 or 3 or adenocarcinoma in situ events, annual age group‒specific incidence rates from Tennessee Medicaid billing data, 2008-2018, were calculated. Significant trends were determined by Joinpoint. Analyses were conducted in 2020.

RESULTS

From 2008 to 2018, high-grade cervical lesion incidence significantly declined in women aged 18-20 years (average annual percentage change= -31.9, 95% CI= -38.6, -24.6), 21-24 years (average annual percentage change= -12.9, 95% CI= -22.3, -2.4), and 25-29 years (average annual percentage change= -6.4, 95% CI= -8.1, -4.6). Among screened women, rates significantly declined for ages 18-20 years (average annual percentage change= -20.3, 95% CI= -25.3, -15.0), 21-24 years (average annual percentage change= -10.2, 95% CI= -12.6, -7.8), and 25-29 years (average annual percentage change= -2.6, 95% CI= -3.9, -1.2). Trends from 2008 to 2018 were stable for older age groups (30-34 and 35-39 years).

CONCLUSIONS

Results show reductions in high-grade cervical lesion incidence among ages most likely to have benefited from the human papillomavirus vaccine. Declines among young, screened women suggest causes other than reduction in screening. Evidence of vaccine impact in populations with low-vaccination coverage, such as Tennessee, is promising.

Treatment patterns and economic burden among cervical and endometrial cancer patients newly initiating systemic therapy

Aim: To evaluate treatment patterns, healthcare resource use (HCRU) and all-cause healthcare costs among patients with cervical or endometrial cancer newly initiating systemic therapy. Methods: We identified patients with cervical or endometrial cancer newly initiating systemic therapy - a claims-based proxy for advanced disease - between 2014 and 2019, described them by line of therapy (LOT), and summarized the per patient per month (PPPM) HCRU and healthcare costs per LOT. Results: Among 1229 patients with cervical cancer and 2659 patients with endometrial cancer, LOT1 therapies included systemic only (cervical, 50.1%; endometrial, 83.2%) and systemic with radiation therapy (cervical, 49.9%; endometrial, 16.8%). Mean PPPM total costs were: LOT1 (cervical, $15,892; endometrial, $11,363), LOT2 ($20,193; $14,019) and LOT3+ ($16,576; $14,645). Conclusions: Overall, patients received guideline-concordant care and experienced significant economic burden, which increased with LOT.

Disparities in Cervical Cancer Screening with HPV Test among Females with Diabetes in the Deep South

Simple Summary

Diabetes is linked with poorer cervical cancer prognosis, and people residing in the Southern region of the U.S. are disproportionately diagnosed with diabetes and cancer. The HPV test was recently recognized as the preferred method of cervical cancer screening by the American Cancer Society. Through our observational study, we sought to investigate the HPV testing behaviors among females with and without diabetes across the U.S. Our nationally representative estimates reveal that less than half of females reported HPV testing, and females with diabetes in the Deep South have the lowest rates of HPV testing. Various risk factors were identified to significantly lower the odds of HPV testing, including a diabetes diagnosis, older age, living in the Southern region of the U.S., and absence of certain comorbidities. The lower rates of HPV testing among females with diabetes, especially those living in the Deep South, leave these populations vulnerable to cervical cancer.

Abstract

Background: Due to diabetes being linked with poorer cervical cancer prognosis, this study aimed to evaluate HPV testing behaviors among females with and without diabetes across the U.S. by geographic area in 2016, 2018, and 2020. Methods: This cross-sectional study used the Behavioral Risk Factor Surveillance System (BRFSS) from 2016, 2018, and 2020. The study population included females aged 25–69 years old, stratified by self-reported diabetes status. The primary outcome measure was cervical cancer screening behavior, which was evaluated by self-reported HPV test uptake/receipt (yes/no). Results: A total of 361,546 females from across the U.S. were sampled. Within the study population combined from all study years, the overall likelihood of receiving an HPV test was significantly lower among females with diabetes [37.95% (95% CI: 36.87–39.04)] compared to those without diabetes [46.21% (95% CI: 45.84–46.58)] (p < 0.001). Screening rates with HPV tests were lowest among females with diabetes in the South in 2016 (29.32% (95% CI: 26.82–31.83)), 2018 (39.63% (95% CI: 36.30–42.96)), and 2020 (41.02% (95% CI: 37.60–44.45)). Conclusions: Females with diabetes are screening with HPV tests less frequently than females without diabetes, and females living in the South, particularly states in the Deep South, report the lowest rates of HPV testing.

Hispanic Ethnicity and Cervical Cancer Precursors Among Low-Income Women in Arizona

Purpose

In the United States, Hispanics are more likely to be diagnosed with cervical cancer compared to Non-Hispanic Whites. Annually, 250,000 to 1 million women are diagnosed with a precursor to CC. The aim of this study was to assess whether Hispanics have a higher prevalence of cervical dysplasia compared to Non-Hispanics Whites among a population of low-income women.

Patients and Methods

We analyzed the results of 10,911 cervical cytology tests administered between 2003 and 2016 that were funded through the Center for Disease Control and Prevention’s (CDC) program for low-income, uninsured women entitled the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). In the state of Arizona, the program is called the Well Women HealthCheck Program (WWHP). Logistic regression was used to identify increased risk of dysplasia, including low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL/ICC), and multinomial logistic regression was used to assess increased likelihood for LSIL and HSIL/ICC as separate categories.

Results

In the crude analysis, Hispanic ethnicity was modestly associated with higher prevalence of LSIL (odds ratio (OR)=1.39, 95% CI=1.01–1.91), but this association was not statistically significant after adjusting for confounders. However, in the final models, lower income was independently associated with LSIL (adjusted odds ratio [aOR]=1.55, 95% CI=1.30–1.44), while smoking (aOR=2.88, 95% CI=1.21–6.84) and no history of Pap test within five years (aOR=3.54, 95% CI=1.61–6.99) were independently associated with HSIL.

Conclusion

After adjusting for confounding in a sample of low-income women with comparable Pap screening rates, ethnicity was not associated with greater prevalence of abnormal pap smears. However, other variables were independently associated with LSIL and HSIL. The higher proportion of LSIL cases among lower income individuals compared to those with higher incomes, and the higher proportion of HSIL cases observed among those screened least regularly stresses the importance of programs like WWHP: programs that target low-income, uninsured women. These programs help save lives.

Economic and humanistic burden associated with noncommunicable diseases among adults with depression and anxiety in the United States

Aims: This study estimated the economic and humanistic burden associated with chronic non-communicable diseases (NCCDs) among adults with comorbid major depressive and/or any anxiety disorders (MDD and/or AAD).Materials and methods: A retrospective analysis was conducted using the Medical Expenditure Panel Survey data (2010-2015). The analytic cohort included adults (≥18 years) with MDD only (C1), AAD only (C2), or both (C3). The presence of either of 6 NCCDs (cardiovascular diseases [CVD], pulmonary disorders [PD], pain, high cholesterol, diabetes, and obesity) were assessed. Study outcomes included healthcare costs, activity limitations, and quality of life. Multivariate regressions were conducted in each of the 3 cohorts to evaluate the association between the presence of NCCDs and outcomes.Results: The analytic sample included 9,160,465 patients: C1 (4,391,738), C2 (3,648,436), C3 (1,120,292). Pain (59%) was the most common condition, followed by CVD (55%), high cholesterol (50%), obesity (42%), PD (17%), and diabetes (14%). Mean annual healthcare costs were the greatest for C3 ($14,317), followed by C1 ($10,490) and C2 ($7,906). For C1, CVD was associated with the highest increment in annual costs ($3,966) followed by pain ($3,617). For C2, diabetes was associated with the highest incremental annual costs ($4,281) followed by PD ($2,997). For C3, cost trends were similar to those seen in C2. NCCDs resulted in a significant decrease in physical quality of life across all cohorts. Pain was associated with a significantly higher likelihood of self-reported physical, social, cognitive, and activity limitations compared to those without pain.Conclusions: 60% of patients with MDD and/or AAD had at least one additional NCCD, which significantly increased the economic and humanistic burden. These findings are important for payers and clinicians in making treatment decisions. These results underscore the need for development of multi-pronged interventions which aim to improve quality of life and reduce activity limitations among patients with mental health disorders and NCCDs.