The national economic burden of cancer: an update

Free Tissue Transfer versus Pedicled Flap Cost in Head and Neck Cancer

OBJECTIVE: We sought to compare the overall 1-year management costs for patients receiving a free tissue transfer with those of patients receiving a pedicled flap reconstruction as a component of their primary head and neck cancer treatment.

STUDY DESIGN AND SETTING: Case-control, cost identification analysis of 21 matched pairs of patients and multivariate analysis of variables associated with treatment costs was conducted in a tertiary referral academic institution.

RESULTS: No significant difference in total 1-year charges between the pedicled and free tissue transfer groups was found. A structured measure of patient comorbidity was the only variable significantly associated with total 1-year charges.

CONCLUSIONS: Total 1-year treatment costs of primary upper aerodigestive tract cancers are similar for patients reconstructed with free tissue transfer or a pedicled flap.

SIGNIFICANCE: Within the context of overall 1-year management costs, the primary determinants of health care expense for these patients are comorbidity and extent of disease, not reconstructive technique.

Stress among Care Givers: The Impact of Nursing a Relative with Cancer

AIMS

The aim of the present study is to assess the level and areas of stress among care givers nursing their loved ones suffering from cancer.

SETTING AND DESIGN

An assessment of care givers' stress providing care to cancer patients at Cipla Palliative Care Center was conducted. The study involves data collection using a questionnaire and subsequent analysis.

MATERIALS AND METHODS

A close-ended questionnaire that had seven sections on different aspects of caregivers' stress was developed and administered to 137 participants and purpose of conducting the survey was explained to their understanding. Caregivers who were willing to participate were asked to read and/or explained the questions and requested to reply as per the scales given. Data was collected in the questionnaires and was quantitatively analyzed.

RESULTS

The study results showed that overall stress level among caregivers is 5.18 ± 0.26 (on a scale of 0-10); of the total, nearly 62% of caregivers were ready to ask for professional help from nurses, medical social workers and counselors to cope up with their stress.

CONCLUSION

Stress among caregivers ultimately affects quality of care that is being provided to the patient. This is also because they are unprepared to provide care, have inadequate knowledge about care giving along with financial burden, physical and emotional stress. Thus interventions are needed to help caregivers to strengthen their confidence in giving care and come out with better quality of care.

Additional financial costs borne by cancer patients: a narrative review

PURPOSE

To review out-of-pocket costs related to cancer that are borne by patients and their families.

METHODS

A literature search using key terms relating to out-of-pocket costs incurred by cancer patients and their families was undertaken to generate a comprehensive narrative synthesis of the information available.

RESULTS

Four themes were identified: measuring costs; sources of costs; the impact of costs and reducing costs. The wide variety of measures for ascertaining hidden costs makes comparison of findings difficult; some articles cover a very narrow range of costs. Qualitative research is useful for elucidating a wide range of costs. Costs pertaining to hospital visits, nutrition and clothing are widely mentioned. Low additional expenditure may indicate that needs/wants are going unmet. Financial capacity to cope and subjective perception of impact are important. Low income, younger age, chemotherapy and living rurally are associated with greater impact. Extra expense can exert long-term effects on family finances. Primary care follow-up, telemedicine and treatments that entail fewer visits may serve to reduce patient costs.

CONCLUSIONS

The key question is how to organise/deliver cancer care in order to reduce additional expenses to patients and families. Future research could identify critical time-points and demographic groups susceptible to significant additional costs, in order to target support at those most in need.

The economic burden of cancer in Korea in 2002

Cancer is the leading cause of death and one of the most significant healthcare expenses in Korea. The purpose of this study was to estimate the economic burden of cancer on Korean society. We studied the medical, non-medical, morbidity and mortality costs related to cancer treatment, lost productivity and premature death. Healthcare claims for 2002 obtained from the Health Insurance Review Agency were used to estimate medical expenditures; these were linked with the Korean Central Cancer Registry database to identify cancer patients. The number of deaths used to estimate mortality costs was obtained from the Annual Report of Mortality from the National Statistics Office of Korea. Moreover, data from the Korean National Statistics Office and Ministry of Labor were used to calculate life expectancy at the age of death, labour force participation, and average age- and gender-specific earnings. In 2002, the estimated total economic cost of cancer amounted to $9.4 billion (1.72% of GDP) at a 3% discount rate. Medical care costs amounted to 13.7% of total costs, non-medical costs 6.5%, morbidity costs 14.5%, and mortality costs accounted for 65.3%. Increased prevention, earlier diagnosis, new therapies and effective cancer control policies are needed to reduce the economic burden of cancer in Korea.

Economic burden of metastatic bone disease in the U.S

BACKGROUND

Previous research has documented the prevalence of primary bone cancer; however, there are few data available regarding the impact of metastatic bone disease (MBD) on national expenditure. In this study, the authors quantified the prevalence and direct medical care costs of patients with MBD and the resulting cost impact on U.S. oncology expenditure.

METHODS

Anonymous, patient-level data on health care utilization and cost were obtained from the Thomson Medstat MarketScan research databases. In total, 396,200 patients who were diagnosed with cancer between 2000 and 2004 were selected for the study. Patients with MBD were matched subsequently to non-MBD controls. A 2-part linear regression model was used to compare cases with controls to quantify the incremental cost associated with the disease.

RESULTS

Cancer prevalence in the U.S. during the study period was estimated at 4,861,987 cases annually, and 5.3% (n=256,137) of those patients had MBD. Rates of MBD were highest in patients with multiple myeloma (28.8%) and lung cancer (15.6%). The mean direct medical cost for all cancers combined was $75,329 for patients with MBD and $31,382 for controls. Regression-adjusted, incremental costs were $44,442 (P<.001) across all cancer types. The incremental cost was highest for patients with multiple myeloma ($63,455) and lowest for patients with lung cancer ($24,946).

CONCLUSIONS

The national cost burden for patients with MBD was estimated at $12.6 billion, which is 17% of the $74 billion in total direct medical cost estimated by the National Institutes of Health, suggesting that MBD is a significant driver of overall oncology cost.

The direct medical cost of diabetes in Israel

Diabetes mellitus is an important chronic disease with a growing prevalence that absorbs an ever increasing investment of resources. This population-based study evaluated the direct medical costs of diabetes mellitus in an HMO setting. We evaluated both the total cost of diabetic patients and their added cost in comparison to other HMO members (diabetes-related costs). Data were obtained for the years 1999-2001 in a cohort of 24,632 diabetic patients followed up for 3 years drawn from the computerized medical administrative database of a large HMO in Israel, insuring around 25% of the population. The mean direct cost of the medical treatment of a diabetic patient rose 29% from US $2,017 in 1999 to $2,601 in 2001 (in 2001 terms) in comparison to a 19.7% rise (from $1,246 to $1,492). Hospitalizations, medication, and physician visits account for 39%, 29%, and 21% of the total diabetic patient costs, respectively. Dialysis, insulin intake, impaired creatinine, and elevated HbA1c were associated with increased expenditures. According to our results, the total national medical cost of diabetes alone in 2001 was $317 million and that of diabetic patients was $564 million, 6.9% and 12.4% of the total Israeli HMO budget, respectively. The study presents the use of a population-based computerized database to comprehensively assess the economic burden of disease and the potential savings from prevention. The study data suggest a rise in the cost of diabetes which has implications for prevention and treatment policies.

Estimating the cost of cancer: results on the basis of claims data analyses for cancer patients diagnosed with seven types of cancer during 1999 to 2000

PURPOSE

Cancer accounts for 60.9 billion dollars in direct medical costs and 15.5 billion dollars for indirect morbidity costs. These estimates are derived primarily from national surveys or Federal databases. We derive estimates of the costs of cancer using administrative databases, which include claims and employment-related information on individuals insured by private or Medicare supplemental health plans.

METHODS

A retrospective matched-cohort control analysis was performed using 1998 to 2000 databases with information on insurance claims, benefits, and health productivity for 3 million privately insured employees, their dependents, and early retirees. Study patients had new diagnoses of one of seven types of cancer (n = 12,709). Controls without cancer were matched at a 3:1 ratio by demographics. A variable follow-up length was used (maximum of 2 years). Direct costs included health care costs for patients and deductibles and copayments for caregivers. Indirect costs of work absence and short-term disability (STD) were calculated for a subgroup of cancer patients and caregivers.

RESULTS

Mean monthly health care costs ranged from 2,187 dollars for prostate cancer to 7,616 dollars for pancreatic cancer, most often driven by hospitalization. Costs for controls were 329 dollars per month. Indirect morbidity costs to employees with cancer averaged 945 dollars, a result of a mean monthly loss of 2.0 workdays and 5.0 STD days.

CONCLUSION

The economic burden of cancer is substantial. It is feasible to derive tumor-specific estimates of direct and indirect costs for large numbers of cancer patients using administrative databases. Policy makers charged with providing annual cost-of-cancer estimates should incorporate data obtained from a broad range of sources.

The economics of the colony-stimulating factors in the prevention and treatment of febrile neutropenia

Healthcare costs continue to rise with hospitalization representing the single largest component of direct medical costs associated with cancer care. Neutropenia and its complications including febrile neutropenia remain the major dose-limiting toxicity associated with systemic cancer chemotherapy. Febrile neutropenia often occurs early in the course of chemotherapy and is associated with substantial morbidity, mortality and cost. The colony-stimulating factors (CSFs) have been used effectively in a variety of clinical settings to prevent or treat febrile neutropenia and to assist patients receiving dose-intensive chemotherapy. A meta-analysis of the available randomized controlled trials (RCTs) has confirmed the efficacy of prophylactic CSFs. Economic models based on measures of resource utilization derived from RCTs have provided estimates of expected treatment costs along with febrile neutropenia risk threshold estimates for the cost saving use of the CSFs. Recent studies have demonstrated the potential value of targeting the CSFs toward patients at greatest risk based on accurate and valid predictive models.

Using Patients As Their Own Controls for Cost Evaluation of Phase I Clinical Trials

Purpose

Little is known about the cost of phase I trials in cancer patients compared with that of standard treatments, yet the former is often assumed to be greater than the latter. Our objective was to utilize a new approach, using patients as their own controls, to compare in a pilot study the costs of care for patients on phase I trials with those incurred for standard treatment.

Patients and Methods

We retrospectively assessed the direct medical costs (DMCs) of 59 patients participating in one of two phase I trials (TRIAL) in solid tumors conducted at Memorial Hospital (MH): (1) perillyl alcohol, and (2) flavopiridol with paclitaxel. Paired-control DMCs were those accrued by the same patient while receiving standard chemotherapy regimens just before (PRE; n = 41) or after (POST; n = 29) the trial at MH, averaged per day.

Results

For the 41 PRE patients, the median and mean DMCs per day for the clinical trial versus standard treatment were (US $) $123 v $133 and $219 v $267, respectively. For the 29 POST patients, the median and mean DMCs for the clinical trial versus standard treatment were $157 v $152 and $226 v $226, respectively. Using a linear mixed model, there was no significant difference between TRIAL and standard treatment DMCs (P = .54).

Conclusion

Using patients as their own controls represents a new, efficient method for evaluating the cost of phase I trials, and it warrants further study. The results of our pilot study do not suggest that phase I trials always cost payers more than standard treatment.

Out-of-pocket health-care expenditures among older Americans with cancer

OBJECTIVE

There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).

METHODS

We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.

RESULTS

Of the 6370 respondents, 5382 (84%) reported No CA, 812 (13%) reported CA/No Tx, and 176 (3%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27% of their yearly income on OOPE compared to only 5% of yearly income for high-income individuals with no cancer history (P < .01).

CONCLUSIONS

Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.

Description and predictors of direct and indirect costs of pain reported by cancer patients

The purpose of this study was to describe direct and indirect costs associated with pain in cancer patients and to examine potential predictors of these costs. The study surveyed cancer outpatients about direct costs resulting from pain-related hospitalizations, emergency department visits, physician office visits, and use of analgesic medications and indirect costs related to money spent on pain-related transportation, complementary methods to improve pain management, educational materials, over-the counter medication, domestic support, and childcare. Furthermore, the study examined age, marital status, race, income level, pain severity, pain interference, and presence of breakthrough pain as predictors of direct and indirect costs. Three hundred and seventy-three cancer outpatients were sampled. One hundred and forty-four cancer patients (39%) reported experiencing cancer-related pain and completed the study questionnaires. Seventy-six percent (76%) of the patients had experienced at least one pain-related cost, resulting in an average monthly direct cost of US$ 891/month per patient. Sixty-nine percent (69%) of patients had experienced some type of direct medical cost due to pain, resulting in an average total direct pain-related cost of US$ 825/month per patient. Fifty-seven percent (57%) of patients reported incurring at least one indirect pain-related expense for an average indirect cost of US$ 61/month per patient. Higher pain intensity, greater pain interference, and presence of breakthrough pain predicted higher direct and indirect medical expenses. Younger age and lower income level also predicted higher direct medical expenses.

Validity of cancer registry data for measuring the quality of breast cancer care

BACKGROUND

Various groups have called for a national system to monitor the quality of cancer care. The validity of cancer registry data for quality of cancer care has not been well studied. We investigated the validity of such information in the California Cancer Registry.

METHODS

We compared registry data associated with care with data abstracted from the medical records of patients diagnosed with breast cancer. We also calculated a quality score for each subject by determining the proportion of four evidence-based quality indicators that were met and then compared overall quality scores obtained from registry and medical record data. All statistical tests were two-sided.

RESULTS

Records of 304 patients were studied. Compared with the medical record data gold standard, the accuracy of registry data was higher for hospital-based services (sensitivity = 95.0% for mastectomy, 94.9% for lumpectomy, and 95.9% for lymph node dissection) than for ambulatory services (sensitivity = 9.8% for biopsy, 72.2% for radiation therapy, 55.6% for chemotherapy, and 36.2% for hormone therapy). On average, quality scores calculated from registry data were 11 percentage points (95% confidence interval [CI] = 9 to 13 percentage points, P<.001) lower than those calculated from medical record data. Quality scores calculated from registry data were 5 percentage points (95% CI = 3 to 7 percentage points) lower for patients with stage I breast cancer, 16 percentage points (95% CI = 12 to 20 percentage points) lower for patients with stage II breast cancer, and 20 percentage points (95% CI = 8 to 32 percentage points) lower for patients with stage III breast cancer than were corresponding scores calculated from medical record data (all P<.001). The greater difference in quality scores for stage II and III patients revealed that disease severity and setting of care affected the validity of registry data.

CONCLUSIONS

Cancer registry data for quality measurement may not be valid for all care settings, but registries could provide the infrastructure for collecting data on the quality of cancer care. We urge that funding be increased to augment data collection by cancer registries.

Economic evaluation of filgrastim, sargramostim, and sequential sargramostim and filgrastim after myelosuppressive chemotherapy

Filgrastim alone and sequential sargramostim and filgrastim have been shown to be more effective than sargramostim alone in the mobilization of CD34(+) cells after myelosuppressive chemotherapy (MC). We sought to compare costs and resource use associated with these regimens. Data were collected prospectively alongside a multicenter, randomized trial of filgrastim, sargramostim, and sequential sargramostim and filgrastim. Direct medical costs were calculated for inpatient and outpatient visits and procedures, including administration of growth factors and MC. We followed 156 patients for 30 days or until initiation of high-dose chemotherapy. The main outcome measures were resource use and costs of inpatient and outpatient visits, platelet and red blood cell transfusions, antibiotic use, and apheresis procedures. Hospital admissions, red blood cell transfusions, and use of i.v. antibiotics were significantly more common in the sargramostim group than in the other treatment arms. In univariate and multivariable analyses, total costs were higher for patients receiving sargramostim alone than for patients in the other groups. Mean costs in multivariable analysis for the filgrastim and sequential sargramostim and filgrastim arms were not significantly different. Filgrastim alone and sequential sargramostim and filgrastim are less costly than sargramostim alone after MC, as well as therapeutically more beneficial.

Economic analysis of randomized, controlled trials

To facilitate the comparison of different treatment strategies, measures have been developed that bring together clinical, quality-of-life, and economic outcomes into summary measures such as the quality-adjusted life year, cost-effectiveness, and cost-utility ratios. A number of different types of economic evaluations have been developed, including cost-minimization, cost-effectiveness, and cost-utility analyses. Performance of economic analyses in association with randomized, controlled trials (RCT) has gained increasing enthusiasm in recent years. However, economic measures in RCTs are often outcomes of secondary interest and associated with frequent missing data and inadequate sample size. Variability in the cost measures used and the lack of agreement on clinically meaningful cost differences further limit the conclusions derived from such studies. Economic analyses should be limited to large trials with important trade-offs between efficacy and cost. The strengths and limitations of such analyses are discussed, and guidelines are offered for proper economic analyses in randomized, controlled trials.

Breast cancer patients' out-of-pocket expenses

Patients with cancer soon discover that there is much more to the cost of treatment than hospital and physician bills. Out-of-packet expenses for transportation, food supplements, over-the-counter medications, distractions, telephone bills, insurance premiums--at a time when employment may be out of the question--can be a significant drain on family finances. Women with regional breast cancer reported their estimates of out-of-pocket expenses incurred during 1 month of outpatient chemotherapy. All women in the study were covered by some form of insurance. Mean monthly out-of-pocket costs were $360 (SD = $346), and ranged from $36 to $1224. Additional costs for wigs, special events, gifts, and alternative treatment incurred since diagnosis, ranged from $20 to $3700. These costs excluded expenses for health providers. Very low and very high expenditures may indicate risks concealed from providers that may have subsequent impact on long-term capacity to sustain treatment. Nurses can help families anticipate expenses and prioritize referrals to community agencies.

Clinical economics of head and neck malignancies

With the continued increase in medical expenditures and the growing awareness that resources are not limitless, there is increasing pressure to curb health care costs and to establish priorities. As potential solutions are proposed and implemented, there is understandable concern that policy choices may adversely affect both the access to and the quality of care. Economic analyses are one tool used to optimize resource allocation decisions. The primary goal of these analyses is to maximize value and efficiency, not necessarily to decrease spending. The current focus on cost cutting is often associated with a more truncated, nonsocietal perspective (e.g., that of the payer or provider). To be most useful, these analyses must be methodologically rigorous. Standard guidelines, such as those established by Eisenberg, are helpful. As shown in the reports applicable to head and neck malignancies that have been discussed here, many articles published in the clinical literature must be interpreted cautiously, because fundamental methodological concerns (e.g., using costs rather than charges, discounting to a common base year) were frequently not addressed. Economic investigations are one aspect of the broader fields of outcomes and health services research. It is easy to underestimate how greatly economic studies depend on the availability of high quality noneconomic data. In that context, current initiatives in evidence-based medicine (EBM), using the best available evidence (considering for example, the type of trial, the quality of the research, and the credentials of the researcher) to help clinicians practice in situations where doubt may exist in the diagnosis, treatment, or prognosis of patients, will likely grow in importance. Evidence-based clinical practice guidelines and systematic literature reviews are manifestations of this trend. Historically, disease control measures and survival have been the primary and points in clinical cancer studies. Economic analyses and studies evaluating other end points (e.g., function, quality of life) will likely play a larger role in the future in evaluating the diagnosis, treatment, and follow-up of head, neck and other malignancies.

Determining costs of health care services for cost-effectiveness analyses: the case of cervical cancer prevention and treatment

OBJECTIVES

To estimate costs for the prevention and treatment of cervical cancer based on resource utilization and to compare those costs to published estimates and to local charges and reimbursements.

DESIGN

Cost estimates for cervical cancer prevention services were based on clinic staff time, use of specialized equipment and supplies, laboratory costs, and clinic overhead. Cost estimates for cervical cancer treatment were based on HMO expenditures for cervical cancer patients and control patients. These costs were adjusted for stage distribution and survival rates. Published cost estimates were obtained from a systematic review of the medical literature between 1990 and 1996.

SETTING

Three family planning clinics (for prevention costs) and a staff-model HMO (for treatment costs).

PATIENTS

For treatment costs: 98 cervical cancer patients and 133,058 female control patients, matched by age and chronic disease score.

MAIN OUTCOME MEASURES

Estimated costs for prevention and treatment of cervical cancer. Cost-to-charge and cost-to-reimbursement ratios.

RESULTS

Costs of cervical cancer prevention and treatment services have been determined using a variety of methods. We found substantial variation in these estimates, even for studies with similar methodologies. Detailed resource-based estimation suggests that prevention costs are generally lower than those previously published in the literature, whereas the costs of cervical cancer treatment are generally higher.

CONCLUSIONS

It is practical and desirable to employ resource use-based estimates of medical costs in cost-effectiveness analyses. Failure to do so for cervical cancer may affect policy recommendations by understating the relative benefits of prevention programs.

The economics of febrile neutropenia: implications for the use of colony-stimulating factors

The occurrence of fever and neutropenia following cancer chemotherapy generally prompts hospitalisation for evaluation and treatment. Colony-stimulating factors (CSFs) have been shown to reduce the risk of febrile neutropenia (FN) and the need for hospitalisation in such patients. This study was undertaken to obtain estimates of the actual institutional costs associated with FN and the impact of these costs on threshold estimates for the appropriate use of CSFs. Total hospital expenditures for patients admitted with FN over a 2 year period were studied. A cost allocation function was utilised to allocate all direct costs for non-revenue-generating support centres to revenue-generating service centres as indirect costs. A cost accounting function was then utilised to allocate direct and indirect costs for each service centre to the charge code level. Two groups of patients were defined based on diagnostic codes to represent the spectrum of patients with FN. Total hospital costs were estimated and incorporated into a cost model for the use of CSFs. Variation in the total cost of hospitalisation for FN relates primarily to differences in the average length of stay. The daily cost of hospitalisation was comparable in the groups studied, averaging between US$1675 and US$1892. Incorporation of these cost estimates into the cost model yielded FN risk threshold projections for CSF use in the range of 20-25%. Preliminary studies suggest that incorporation of non-medical, indirect and intangible costs into the CSF decision models will further decrease FN risk threshold projections. Total hospitalisation cost estimates for managing patients with FN are greater than those previously reported, reducing projected FN risk thresholds for CSF use.

Pharmacoeconomics of Cancer Therapy

BACKGROUND: In 1990, annual costs of the diagnosis and treatment of cancer reached nearly $100 billion and currently constitutes approximately 10% of health care expenditures in the United States. As new and often more expensive therapies for cancer treatment become available, the health care decision-maker must consider the cost effectiveness of the therapy. METHODS: Key principles of economic analyses and the inherent differences among these analyses are reviewed. Results: While pharmacoeconomic analyses are increasingly being used in treatment decision-making, several issues relating to study design, data collection, and research methods are controversial. CONCLUSIONS: Pharmacoeconomics analyses are necessary in the current health care environment, but the assumptions used within the analyses warrant careful evaluation.

Health service studies in the terminally ill cancer patient

The number of high quality health service research studies in care of the terminally ill patient is very limited. For some areas of care, such as coordination of care for the dying, the clinical benefit is not clear, but the cost-effectiveness evidence seems compelling enough to provide services. For others, such as the use of advanced directives or hospice care, the ethical and medical rationale is compelling, but the evidence of clinical benefit or better cost-effectiveness is limited.

[Could the evaluation of the cost of complications be a worthwhile means to improve radiotherapy?]

At the present time, the current improvement of technical and dosimetric aspects of radiation oncology has to be evaluated in terms of potential benefit for the patient and the society. For this last point of view, specially designed economic analyses must be performed in order to justify the number of resources involved by these technical improvements. If the question is how the current technical procedures could reduce the risk of undesirable side-effects, the response cannot be immediately drawn from the literature. This paper emphasizes the possibility to evaluate the role of side-effects as endpoints of economic analyses when using special models in medical decision making such as Markov's. Only few oncologic situations are reliable to properly analyze the relationship between sophisticated radiation techniques and the incidence of post-radiation complications. These situations should be selected when prospective economic analyses are planned in the field of radiation therapy.

Current estimates of the economic cost of obesity in the United States

This study was undertaken to update and revise the estimate of the economic impact of obesity in the United States. A prevalence-based approach to the cost of illness was used to estimate the economic costs in 1995 dollars attributable to obesity for type 2 diabetes mellitus, coronary heart disease (CHD), hypertension, gallbladder disease, breast, endometrial and colon cancer, and osteoarthritis. Additionally and independently, excess physician visits, work-lost days, restricted activity, and bed-days attributable to obesity were analyzed cross-sectionally using the 1988 and 1994 National Health Interview Survey (NHIS). Direct (personal health care, hospital care, physician services, allied health services, and medications) and indirect costs (lost output as a result of a reduction or cessation of productivity due to morbidity or mortality) are from published reports and inflated to 1995 dollars using the medical component of the consumer price index (CPI) for direct cost and the all-items CPI for indirect cost. Population-attributable risk percents (PAR%) are estimated from large prospective studies. Excess work-lost days, restricted activity, bed-days, and physician visits are estimated from 88,262 U.S. citizens who participated in the 1988 NHIS and 80,261 who participated in the 1994 NHIS. Sample weights have been incorporated into the NHIS analyses, making these data generalizable to the U.S. population. The total cost attributable to obesity amounted to $99.2 billion dollars in 1995. Approximately $51.64 billion of those dollars were direct medical costs. Using the 1994 NHIS data, cost of lost productivity attributed to obesity (BMI> or =30) was $3.9 billion and reflected 39.2 million days of lost work. In addition, 239 million restricted-activity days, 89.5 million bed-days, and 62.6 million physician visits were attributable to obesity in 1994. Compared with 1988 NHIS data, in 1994 the number of restricted-activity days (36%), bed-days (28%), and work-lost days (50%) increased substantially. The number of physician visits attributed to obesity increased 88% from 1988 to 1994. The economic and personal health costs of overweight and obesity are enormous and compromise the health of the United States. The direct costs associated with obesity represent 5.7% of our National Health Expenditure in the United States.

Economic analyses in health care: an introduction to the methodology with an emphasis on radiation therapy

Payers are increasingly interested in knowing whether they are receiving value for the dollars they spend on health care. Because economic analysis will be used as a means of evaluating radiation therapy, it is important that radiation oncologists understand the basic methodology employed in such analyses. This review article describes the four basic types of economic analyses: cost minimization, cost effectiveness, cost utility, and cost benefit. Specification of alternative therapies, choice of perspective of the analysis, measurements of costs and benefits, and the role of discounting and sensitivity analyses are discussed. Published economic analyses that pertain directly to treatment with radiation therapy are reviewed. Finally, we close with a brief discussion of the potential areas for future economic outcomes research in radiation oncology.

An analysis of the cost of clinical surveillance after primary therapy for women with early stage invasive breast cancer

Routine surveillance for distant metastases in women with early stage breast cancer has limited clinical utility and can result in large medical care costs. In order to estimate breast cancer surveillance costs, we used the results of a survey administered to a random sample of physician members of the American Society of Clinical Oncology. The survey measured the frequency in which radiographic and laboratory tests are ordered for postmenopausal women with stage I or II breast cancer after the completion of surgery and radiation or adjuvant chemotherapy if indicated. There were 209 completed surveys representing a response rate of 48%. The volume of tests ordered was expressed in terms of Medicare's relative value units (RVUs) and 1993 cost equivalents. The mean total RVUs over 5 years post-diagnosis was 43.8 (interquartile range 30.1-54.2) which represents a cost of $1369 using the 1993 Medicare conversion factor of $31.249. A cumulative logistic regression model categorized RVUs according to intensity of care (minimal, average, and intensive). While medical oncologists compared to surgeons and radiation oncologists, and physicians practicing in the Northeast and Midwest, compared to those practicing in the South and West, were more likely to adopt an intensive practice style, these differences were not statistically significant (p = 0.1). None of the other provider characteristics evaluated, including gender, prior experience, and practice type, had a significant effect on physician practice in a multivariate model. The data showed a wide variation among providers in surveillance practice patterns that was largely unexplained by physician demographics. These results are consistent with the physician practice style hypothesis which suggests that wide variations in treatment patterns result from uncertainty regarding effectiveness of care.

Role of chemopreventers in human diet

Recent research has confirmed that many common foods contain nonnutritive components that may provide protection against chronic disease including some forms of cancer. These naturally occurring compounds, which possess anticarcinogenic and other beneficial properties, are referred to as chemopreventers. The predominant mechanism of their protective action is due to their antioxidant activity and the capacity to scavenge free radicals. Among the most investigated chemopreventers are some vitamins, plant polyphenols, flavonoids, catechins, and some components in spices. The majority of chemopreventers are available in and consumed from vegetables, fruits, grains, and tea. Various naturally occurring chemicals in garlic, soybeans, tea, and red wine appear to be responsible for the beneficial effect of these commodities on several chronic diseases. This article will review some recent studies in the search for the beneficial effects of dietary chemopreventers on human health.

An evaluation of clinical follow-up in women with early stage breast cancer among physician members of the American Society of Clinical Oncology

Routine clinical follow-up for distant metastatic disease among women with early stage breast cancer is of uncertain clinical benefit. In order to evaluate current practice patterns, we administered a mailed survey to a stratified random sample of physician members of the American Society of Clinical Oncology (ASCO) (N = 435). The survey assessed the frequency and motivation for ordering follow-up medical tests in asymptomatic postmenopausal women with stage I or II breast cancer. The response rate was 55%, distributed as 39% radiation oncologists, 32% medical oncologists, and 29% surgeons. In the first year after treatment, physicians performed, on average, one physical examination every 3 months, one blood panel (CBC, alkaline phosphatase and liver function tests) every 4 months, and one chest radiograph every 9 months. In addition, 38% of the respondents ordered CEA and 21% ordered CA 15-3 levels, 28% ordered bone scans, and less than 4% ordered CT scans, bone surveys, or bone marrow biopsies in the first year after treatment. A logistic regression analysis controlling for physician age, gender, sub-specialty, practice type, years of experience, number of breast cancer patients treated annually, geographic region, and community size, showed that surgeons were less likely to order blood tests (p < 0.001) and tumor markers (p < 0.0029) than medical oncologists in years 3 and 5 of follow-up. Compared to physicians practicing in the northeast, those from the midwest were less likely to order chest radiographs in year 3 of follow-up (p = 0.0028). Other provider characteristics had no significant effect on test ordering behavior. The results of this survey suggest that relatively uniform practice patterns in regard to the follow-up of postmenopausal women with early stage breast cancer exist among ASCO physicians.

Public health initiatives in cancer prevention and control

Cancer-related health-care costs in dollars and in human lives are staggering. Reduction of cancer mortality depends largely on the access of the public to cancer prevention and control programs. Efforts by the federal government such as passage of the National Cancer Act and congressional appropriations have been important contributions. The national commitment to cancer prevention and control is evident through goals and programs of the National Cancer Institute, the Department of Health and Human Services, the American Cancer Society, and the Centers for Disease Control and Prevention. Prevention is also a focus of nursing organizations and industry.

The impact of therapy with filgrastim (recombinant granulocyte colony-stimulating factor) on the health care costs associated with cancer chemotherapy

The objective of the study was to estimate the net impact on health resource utilisation of using recombinant granulocyte colony-stimulating factor (filgrastim) following myelosuppressive chemotherapy. Cost minimisation of the study medication in a randomised, double-blind, placebo-controlled clinical trial was conducted in teaching institutions and affiliated community hospitals participating in a clinical trial. 68 patients with small cell lung cancer undergoing cyclophosphamide, doxorubicin and etoposide chemotherapy were randomised to blinded placebo or filgrastim study medication at three or 14 clinical trials sites. The patients received daily subcutaneous injections of filgrastim or placebo, initiated 24 h after chemotherapy and continued until the neutrophil count exceeded 10,000 x 10(6)/l after the time of the expected nadir. Differences in total charges, costs and Medicare payments between treatment groups were the main outcomes measured. Compared to placebo patients, filgrastim-treated patients had significantly fewer and less resource-intensive hospitalisations. After accounting for filgrastim purchase and administration, the charge model predicts overall savings from filgrastim use in a clinical setting in which the risk of febrile neutropenia is high for patients not receiving filgrastim. The Medicare and cost models predict only a partial recapture of the cost of filgrastim therapy. The health care resources impact of filgrastim was sensitive to the risk of hospitalisation with febrile neutropenia, and to the perspective chosen for measuring resource utilisation (charges, costs or Medicare payments). The adjunctive use of filgrastim following myelosuppressive chemotherapy leads to partial or complete recapture of the cost of purchasing and administering the product.

Are prescription drug prices high?

The U.S. pharmaceutical industry has been criticized because its products are perceived to be too expensive, yet prescription medicines remain the least expensive form of therapy. At this time, we are experiencing a dramatic increase in the risks and costs of pharmaceutical research and development (R&D). An example may be seen in the R&D history of lovastatin. The U.S. pharmaceutical industry continues to lead the world in the discovery and development of important new medicines because it assumes greater financial risk and invests more of its sales dollar in R&D than virtually any other industry. Where such a risk is posed, there must continue to be the potential for profits. Pharmaceutical companies must set responsible prices, must keep price increases down, and must help improve access to important medicines.