Annual patient time costs associated with medical care among cancer survivors in the United States

Home Time Among Older Adults With Acute Myeloid Leukemia Following Chemotherapy

Importance

Patients with acute myeloid leukemia (AML) recognize days spent at home (home time) vs in a hospital or nursing facility as an important factor in treatment decision making. No study has adequately described home time among older adults with AML.

Objective

To describe home time among older adults with AML (aged ≥66 years) and compare home time between 2 common treatments: anthracycline-based chemotherapy and hypomethylating agents (HMAs).

Design, Setting, and Participants

A cohort of adults aged 66 years or older with a new diagnosis of AML from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in 2004 to 2016 was identified. Individuals were stratified into anthracycline-based therapy, HMAs, or chemotherapy, not otherwise specified (NOS) using claims.

Main Outcomes and Measures

The primary outcome was home time, quantified by subtracting the total number of person-days spent in hospitals and nursing facilities from the number of person-days survived and dividing by total person-days. A weighted multinomial regression model with stabilized inverse probability of treatment weighting to estimate adjusted home time was used.

Results

The cohort included 7946 patients with AML: 2824 (35.5%) received anthracyclines, 2542 (32.0%) HMAs, and 2580 (32.5%) were classified as chemotherapy, NOS. Median (IQR) survival was 11.0 (5.0-27.0) months for those receiving anthracyclines and 8.0 (3.0-17.0) months for those receiving HMAs. Adjusted home time for all patients in the first year was 52.4%. Home time was highest among patients receiving HMAs (60.8%) followed by those receiving anthracyclines (51.9%). Despite having a shorter median survival, patients receiving HMAs had more total days at home and 33 more days at home in the first year on average than patients receiving anthracyclines (222 vs 189).

Conclusions and Relevance

This retrospective study of older adults with AML using SEER-Medicare data and propensity score weighting suggests that the additional survival afforded by receiving anthracycline-based therapy was entirely offset by admission to the hospital or to nursing facilities.

Health Care Contact Days Among Older Cancer Survivors

PURPOSE

Health care contact days-days spent receiving health care outside the home-represent an intuitive, practical, and person-centered measure of time consumed by health care.

METHODS

We linked 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days (ie, spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice or receiving ambulatory care including an office visit, procedure, treatment, imaging, or test) and described patterns of total and ambulatory contact days. Using weighted Poisson regression models, we identified factors associated with contact days.

RESULTS

We included 1,168 older adults representing 4.51 million cancer survivors (median age, 76.4 years, 52.8% women). The median (IQR) time from cancer diagnosis was 65 (27-126) months. In 2019, these adults had mean (standard deviation) total contact days of 28.4 (27.6) and ambulatory contact days of 24.2 (23.6). These included days for tests (8.0 [8.8]), imaging (3.6 [4.1]), visits with any clinicians (12.4 [11.5]), and visits with primary care clinicians (4.4 [4.7]), and nononcology specialists (7.1 [9.4]) specifically. Sixty-four percent of days with a nonvisit ambulatory service (eg, a test) were not on the same day as a clinician visit. Factors associated with more total contact days included younger age, lower income, more chronic conditions, poor self-rated health, and tendency to "go to doctor as soon as feel bad."

CONCLUSION

Older adult cancer survivors spent nearly 1 month of the year receiving health care outside the home. This care was largely ambulatory, often delivered by nononcologists, and varied by factors beyond clinical characteristics. These results highlight the need to recognize patient burdens and improve survivorship care delivery, including through care coordination.

Cancer diagnosis and treatment in working-age adults: Implications for employment, health insurance coverage, and financial hardship in the United States

The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019-2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.

Characterization of time toxicity in older patients with metastatic breast cancer

PURPOSE

Recognizing that receiving healthcare can be time intensive and burdensome, time toxicity has been conceptualized as the time spent by patients seeking healthcare. This study investigates the association between age at diagnosis and time toxicity for patients with Metastatic Breast Cancer (MBC) and identifies major components of care that confer the greatest time toxicity.

METHODS

We conducted a retrospective cohort study among patients with MBC aged 67 or older using the SEER-Medicare database. We assessed time toxicity using the number of encounter days patients interacted with the healthcare system per 100 days, within the first year of starting cancer treatment. We used a Poisson model to analyze the association between age and encounter days, adjusting for clinical and sociodemographic factors. We stratified the mean encounter days for each age cohort by treatment types.

FINDINGS

The final sample included 2949 patients; 51.4% were between 70 and 79 years old, and 81.3% were white. Although unadjusted analysis showed an association between older age and more encounter days (Rate Ratio (RR) 1.12; 95% CI 1.02, 1.22), there was no significant association after adjusting for comorbidities and treatment type. Patients with more than three comorbidities had significantly higher encounter days compared to those without comorbidities [RR 1.36 (95% CI 1.26, 1.46)]. Receipt of radiotherapy [RR: 1.45 95% CI (1.37, 1.54)] was associated with more encounter days compared to not receiving radiotherapy, while receipt of bone-modifying agents was associated with fewer encounter days compared to not using Bone modifying agents [RR 0.75 (95% CI 0.70, 0.79)].

CONCLUSION

Our study identified comorbidities and cancer treatment modality, including radiotherapy, as the factors affecting time toxicity in older patients with MBC. Assessment of an individual's comorbid medical conditions and types of treatment planned are crucial to understanding age-related impacts on encounter days and to support shared decision making in older patients.

Logistic burdens of cancer care: A qualitative study

Cancer treatment often creates logistic conflicts with everyday life priorities; however, these challenges and how they are subjectively experienced have been largely unaddressed in cancer care. Our goal was to describe time and logistic requirements of cancer care and whether and how they interfered with daily life and well-being. We conducted interviews with 20 adults receiving cancer-directed treatment at a single academic cancer center. We focused on participants' perception of the time, effort, and energy-intensiveness of cancer care activities, organization of care requirements, and preferences in how to manage the logistic burdens of their cancer care. Participant interview transcripts were analyzed using an inductive thematic analysis approach. Burdens related to travel, appointment schedules, healthcare system navigation, and consequences for relationships had roots both at the system-level (e.g. labs that were chronically delayed, protocol-centered rather than patient-centered bureaucratic requirements) and in individual circumstances (e.g. greater stressors among those working and/or have young children versus those who are retired) that determined subjective burdensomeness, which was highest among patients who experienced multiple sources of burdens simultaneously. Our study illustrates how objective burdens of cancer care translate into subjective burden depending on patient circumstances, emphasizing that to study burdens of care, an exclusive focus on objective measures does not capture the complexity of these issues. The complex interplay between healthcare system factors and individual circumstances points to clinical opportunities, for example helping patients to find ways to meet work and childcare requirements while receiving care.

Accounting for Nonhealth and Future Costs in Cost-Effectiveness Analysis: Distributional Impacts of a US Cancer Prevention Strategy

OBJECTIVE

To provide up-to-date and comprehensive US data tables to estimate future net resource use, including nonlabor market production, and examine distributional impacts of including nonhealth and future costs in cost-effectiveness results.

METHODS

Using a published US cancer prevention simulation model, the paper evaluated the lifetime cost effectiveness of implementing a 10% excise tax on processed meats across age- and sex-specific population subgroups. The model examined multiple scenarios accounting for cancer-related healthcare expenditure (HCE) only, cancer-related and unrelated background HCE, adding productivity benefits (i.e., patient time, cancer-related productivity loss, and background labor and nonlabor market production), and with nonhealth consumption costs, adjusted for household economies of scale. Additional analyses include using population-average versus age-sex-specific estimates for quantifying production and consumption value, as well as comparing direct model estimation versus postcorrections with Meltzer's approximation for incorporating future resource use.

RESULTS

Accounting for nonhealth and future costs impacted cost-effectiveness results across population subgroups, often leading to changes in "cost-saving" determination. Including nonlabor market production had a noticeable impact on estimating future resource use and reduced the bias toward undervaluing productivity among females and older populations. The use of age-sex-specific estimates resulted in less favorable cost-effectiveness results compared with population-average estimates. Meltzer's approximation provided reasonable corrections among the middle-aged population for re-engineering cost-effectiveness ratios from a healthcare sector to a societal perspective.

CONCLUSION

With updated US data tables, this paper can help researchers conduct a comprehensive value assessment to reflect net resource use (health and nonhealth resource use minus production value) from a societal perspective.

What is the cost-effectiveness of menu calorie labelling on reducing obesity-associated cancer burdens? An economic evaluation of a federal policy intervention among 235 million adults in the USA

OBJECTIVE

To assess the impact of menu calorie labelling on reducing obesity-associated cancer burdens in the USA.

DESIGN

Cost-effectiveness analysis using a Markov cohort state-transition model.

SETTING

Policy intervention.

PARTICIPANTS

A modelled population of 235 million adults aged ≥20 years in 2015-2016.

INTERVENTIONS

The impact of menu calorie labelling on reducing 13 obesity-associated cancers among US adults over a lifetime was evaluated for: (1) effects on consumer behaviours; and (2) additional effects on industry reformulation. The model integrated nationally representative demographics, calorie intake from restaurants, cancer statistics and estimates on associations of policy with calorie intake, dietary change with body mass index (BMI) change, BMI with cancer rates, and policy and healthcare costs from published literature.

MAIN OUTCOME MEASURES

Averted new cancer cases and cancer deaths and net costs (in 2015 US$) among the total population and demographic subgroups were determined. Incremental cost-effectiveness ratios from societal and healthcare perspectives were assessed and compared with the threshold of US$150 000 per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analyses incorporated uncertainty in input parameters and generated 95% uncertainty intervals (UIs).

RESULTS

Considering consumer behaviour alone, this policy was associated with 28 000 (95% UI 16 300 to 39 100) new cancer cases and 16 700 (9610 to 23 600) cancer deaths averted, 111 000 (64 800 to 158 000) QALYs gained, and US$1480 (884 to 2080) million saved in cancer-related medical costs among US adults. The policy was associated with net cost savings of US$1460 (864 to 2060) million and US$1350 (486 to 2260) million from healthcare and societal perspectives, respectively. Additional industry reformulation would substantially increase policy impact. Greater health gains and cost savings were predicted among young adults, Hispanic and non-Hispanic Black individuals.

CONCLUSIONS

Study findings suggest that menu calorie labelling is associated with lower obesity-related cancer burdens and reduced healthcare costs. Policymakers may prioritise nutrition policies for cancer prevention in the USA.

Achieving greater value for veterans through full cost transparency in primary care

The COVID-19 pandemic has led to increased use of telephone and video encounters in the Veterans Health Administration and many other healthcare systems. One important difference between these virtual modalities and traditional face-to-face encounters is the different cost-sharing, travel costs, and time costs that patients face. Making the full costs of different visit modalities transparent to patients and their clinicians can help patients obtain greater value from their primary care encounters. From April 6, 2020 to September 30, 2021 the VA waived all copayments for Veterans receiving care from the VA, but since this policy was temporary it is important that Veterans receive personalized information about their expected costs so they can obtain the most value from their primary care encounters. To test the feasibility, acceptability, and preliminary effectiveness of this approach, our team conducted a 12 week pilot project at the VA Ann Arbor Healthcare System from June-August 2021 in which we made personalized estimates of out-of-pocket, travel, and time costs available and transparent to patients and clinicians in advance of scheduled encounters and at the point of care. We found that it was feasible to generate and deliver personalized cost estimates in advance of visits, that this information was acceptable to patients, and that patients who used cost estimates during a visit with a clinician found this information helpful and would want to receive it again in the future. To achieve greater value in healthcare, systems must continue to pursue new ways to provide transparent information and needed support to patients and clinicians. This means ensuring clinical visits provide the highest levels of access, convenience, and return on patients' healthcare-associated spending while minimizing financial toxicity.

Estimated Indirect Cost Savings of Using Telehealth Among Nonelderly Patients With Cancer

IMPORTANCE

Patients with cancer typically have greater financial hardships and time costs than individuals without cancer. The COVID-19 pandemic has exacerbated this, while posing substantial challenges to delivering cancer care and resulting in important changes in care-delivery models, including the rapid adoption of telehealth.

OBJECTIVE

To estimate patient travel, time, and cost savings associated with telehealth for cancer care delivery.

DESIGN, SETTING, AND PARTICIPANTS

An economic evaluation of cost savings from completed telehealth visits from April 1, 2020, to June 30, 2021, in a single-institution National Cancer Institute-Designated Comprehensive Cancer Center. All patients aged 18 to 65 years who completed telehealth visits within the designated time frame and had a Florida mailing address documented in their electronic medical record were included in the study cohort. Data were analyzed from April 2020 to June 2021.

MAIN OUTCOMES AND MEASURES

The main outcome was estimated patient cost savings from telehealth, which included 2 components: costs of travel (defined as roundtrip distance saved from car travel) and potential loss of productivity due to the medical visit (defined as loss of income from roundtrip travel plus loss of income from in-person clinic visits). Two different models with a combination of 2 different mileage rates ($0.56 and $0.82 per mile) and census tract-level median hourly wages were used.

RESULTS

The study included 25 496 telehealth visits with 11 688 patients. There were 4525 (3795 patients) new or established visits and 20 971 (10 049 patients) follow-up visits. Median (IQR) age was 55.0 (46.0-61.0) years among the telehealth visits, with 15 663 visits (61.4%) by women and 18 360 visits (72.0%) by Hispanic non-White patients. According to cost models, the estimated mean (SD) total cost savings ranged from $147.4 ($120.1) at $0.56/mile to $186.1 ($156.9) at $0.82/mile. For new or established visits, the mean (SD) total cost savings per visit ranged from $176.6 ($136.3) at $0.56/mile to $222.8 ($177.4) at $0.82/mile, and for follow-up visits, the mean (SD) total cost savings per visit was $141.1 ($115.3) at $0.56/mile to $178.1 ($150.9) at $0.82/mile.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, telehealth was associated with savings in patients time and travel costs, which may reduce the financial toxicity of cancer care. Expansion of telehealth oncology services may be an effective strategy to reduce the financial burden among patients with cancer.

Opportunity Costs of Surgical Resection and Perioperative Chemotherapy for Locoregional Pancreatic Adenocarcinoma

PURPOSE

Given the perioperative morbidity and intensity of multimodality treatment, patients with resected pancreatic ductal adenocarcinoma (PDAC) spend a substantial amount of time in clinical care. The primary aim was to determine total time spent in multimodality care for patients with locoregional PDAC.

METHODS

A cohort study of all patients who underwent curative-intent resection for PDAC at a single-institution, tertiary care center was performed (2015-2019). Exact times for all relevant visits were abstracted from the primary medical record, and travel time was calculated. Care time was divided into preoperative, surgical, radiation, and systemic therapy phases of care. Primary outcome measures were the percentage of total survival time (TST) and percentage of overall survival (OS) days spent in receipt of care.

RESULTS

One hundred seven patients were included. Patients spent a median of 5.0% (interquartile range [IQR] 2.4%-10.1%) of TST and 11.0% (IQR, 5.7%-20.4%) of OS days in receipt of clinical care. Preoperative, surgical, radiation, and systemic therapy phases of care comprised a median of 0.9% (IQR, 0.4%-2.2%), 3.0% (IQR, 1.9%-6.8%), 4.4% (IQR, 3.6%-6.3%), and 10.0% (IQR, 6.2%-14.1%) of OS days. The median per-visit travel time was 60 minutes (IQR, 32-120), and the median cumulative travel time was 22.0 hours (IQR, 12.0-51.5). 12.1% (n = 13) and 7.8% (n = 4) of patients spent > 10% of TST in receipt of surgical and systemic therapy care, respectively.

CONCLUSION

Patients with locoregional pancreatic cancer spend a considerable percentage of their survival time in receipt of oncologic care. Further research to determine predictors of increased time burden is warranted to better inform shared decision making.

Financial toxicity in cancer care: origins, impact, and solutions

Financial toxicity describes the financial burden and distress that can arise for patients, and their family members, as a result of cancer treatment. It includes direct out-of-pocket costs for treatment and indirect costs such as travel, time, and changes to employment that can increase the burden of cancer. While high costs of cancer care have threatened the sustainability of access to care for decades, it is only in the past 10 years that the term "financial toxicity" has been popularized to recognize that the financial burdens of care can be just as important as the physical toxicities traditionally associated with cancer therapy. The past decade has seen a rapid growth in research identifying the prevalence and impact of financial toxicity. Research is now beginning to focus on innovations in screening and care delivery that can mitigate this risk. There is a need to determine the optimal strategy for clinicians and cancer centers to address costs of care in order to minimize financial toxicity, promote access to high value care, and reduce health disparities. We review the evolution of concerns over costs of cancer care, the impact of financial burdens on patients, methods to screen for financial toxicity, proposed solutions, and priorities for future research to identify and address costs that threaten the health and quality of life for many patients with cancer.

Disparities in Health and Economic Burdens of Cancer Attributable to Suboptimal Diet in the United States, 2015‒2018

Objectives. To quantify disparities in health and economic burdens of cancer attributable to suboptimal diet among US adults. Methods. Using a probabilistic cohort state-transition model, we estimated the number of new cancer cases and cancer deaths, and economic costs of 15 diet-related cancers attributable to suboptimal intake of 7 dietary factors (a low intake of fruits, vegetables, dairy, and whole grains and a high intake of red and processed meats and sugar-sweetened beverages) among a closed cohort of US adults starting in 2017. Results. Suboptimal diet was estimated to contribute to 3.04 (95% uncertainty interval [UI] = 2.88, 3.20) million new cancer cases, 1.74 (95% UI = 1.65, 1.84) million cancer deaths, and $254 (95% UI = $242, $267) billion economic costs among US adults aged 20 years or older over a lifetime. Diet-attributable cancer burdens were higher among younger adults, men, non-Hispanic Blacks, and individuals with lower education and income attainments than other population subgroups. The largest disparities were for cancers attributable to high consumption of sugar-sweetened beverages and low consumption of whole grains. Conclusions. Suboptimal diet contributes to substantial disparities in health and economic burdens of cancer among young adults, men, racial/ethnic minorities, and socioeconomically disadvantaged groups. (Am J Public Health. 2021;111(11):2008-2018. https://doi.org/10.2105/AJPH.2021.306475).

Annual Report to the Nation on the Status of Cancer, Part 2: Patient Economic Burden Associated With Cancer Care

BACKGROUND

The American Cancer Society, National Cancer Institute, Centers for Disease Control and Prevention, and North American Association of Central Cancer Registries provide annual information about cancer occurrence and trends in the United States. Part 1 of this annual report focuses on national cancer statistics. This study is part 2, which quantifies patient economic burden associated with cancer care.

METHODS

We used complementary data sources, linked Surveillance, Epidemiology, and End Results-Medicare, and the Medical Expenditure Panel Survey to develop comprehensive estimates of patient economic burden, including out-of-pocket and patient time costs, associated with cancer care. The 2000-2013 Surveillance, Epidemiology, and End Results-Medicare data were used to estimate net patient out-of-pocket costs among adults aged 65 years and older for the initial, continuing, and end-of-life phases of care for all cancer sites combined and separately for the 21 most common cancer sites. The 2008-2017 Medical Expenditure Panel Survey data were used to calculate out-of-pocket costs and time costs associated with cancer among adults aged 18-64 years and 65 years and older.

RESULTS

Across all cancer sites, annualized net out-of-pocket costs for medical services and prescriptions drugs covered through a pharmacy benefit among adults aged 65 years and older were highest in the initial ($2200 and $243, respectively) and end-of-life phases ($3823 and $448, respectively) and lowest in the continuing phase ($466 and $127, respectively), with substantial variation by cancer site. Out-of-pocket costs were generally higher for patients diagnosed with later-stage disease. Net annual time costs associated with cancer were $304.3 (95% confidence interval = $257.9 to $350.9) and $279.1 (95% confidence interval = $215.1 to $343.3) for adults aged 18-64 years and ≥65 years, respectively, with higher time costs among more recently diagnosed survivors. National patient economic burden, including out-of-pocket and time costs, associated with cancer care was projected to be $21.1 billion in 2019.

CONCLUSIONS

This comprehensive study found that the patient economic burden associated with cancer care is substantial in the United States at the national and patient levels.

Out-of-pocket costs in gastrointestinal cancer patients: Lack of a perfectly framed problem contributing to financial toxicity

Fighting cancer is an economically expensive challenge for both health care payers, and the patients and their families and the median costs for cancer care are rapidly increasing in the last decade. Although both direct and indirect costs of medical assistance have been a frequent source of distress and contention, however analysis of the non-medical expenses incurred directly by cancer patients has not received adequate attention. Developing a deeper understanding of so-called "out-of-pocket" costs may be necessary. Out-of-pocket costs for medical care range from 7 % to 11 % of medical costs for all payers. However, the range of out-of-pocket costs shows considerable variability in different studies. In this review, we reviewed available data concerning direct and indirect medical costs, including psychosocial ones.

Healthcare utilization and spending among older patients diagnosed with Non-Hodgkin lymphoma

BACKGROUND

Developing appropriate care models for patients diagnosed with non-Hodgkin lymphoma (NHL) >65y require examination of current healthcare utilization patterns and cost, but non-malignant condition-specific utilization and Medicare spending among older patients has not been characterized.

METHODS

Using SEER-Medicare, 14,533 patients diagnosed with NHL at age > 65 between 2008 and 2015 and a comparable non-cancer cohort (n = 14,533) were identified. Hospitalizations and outpatient visits for 109 non-malignant conditions were grouped into ten categories, allowing condition-specific utilization and spending calculation from diagnosis to 5y, censoring at blood or marrow transplantation, 6mo prior to death or end (12/31/2016). Using the 90th percentile as a cut-off, factors associated with high-hospitalization rates and high-spending were evaluated.

RESULTS

Patients with NHL were 1.5-fold more likely to be hospitalized and 1.8-fold more likely to experience outpatient visits when compared with the non-cancer cohort. Patients with NHL had greater aging-related, cardiovascular, and gastrointestinal hospitalizations than controls (p < 0.001). Average Medicare spending/visit was higher for patients with NHL (hospitalization: $16,950 vs. $13,474, p < 0.001; outpatient: $1176 vs. $392, p < 0.001). Factors associated with high-utilization and high-spending included diffuse large B cell lymphoma subtype, non-white race, and residence in low-education area.

CONCLUSIONS

Older patients with NHL experienced higher utilization and higher spending per-utilization compared to a non-cancer cohort over five years from cancer diagnosis. Clinical and demographic sub-groups demonstrated increased risk for the highest spending and utilization. The substantial utilization and spending for non-malignant conditions among older patients with NHL provides quantifiable evidence for survivor-adapted healthcare management policies.

Cost-effectiveness Analysis of Nutrition Facts Added-Sugar Labeling and Obesity-Associated Cancer Rates in the US

Importance

Obesity-associated cancer burdens are increasing in the US. Nutrition policies, such as the Nutrition Facts added-sugar labeling, may reduce obesity-associated cancer rates.

Objective

To evaluate the cost-effectiveness of Nutrition Facts added-sugar labeling and obesity-associated cancer rates in the US.

Design, Setting, and Participants

A probabilistic cohort state-transition model was used to conduct an economic evaluation of added-sugar labeling and 13 obesity-associated cancers among 235 million adults aged 20 years or older by age, sex, and race/ethnicity over a median follow-up of 34.4 years. Policy associations were considered in 2 scenarios: with consumer behaviors and with additional industry reformulation. The model integrated nationally representative population demographics, diet, and cancer statistics; associations of policy intervention with diet, diet change and body mass index, and body mass index with cancer risk; and policy and health-related costs from established sources. Data were analyzed from January 8, 2019, to May 6, 2020.

Main Outcomes and Measures

Net costs and incremental cost-effectiveness ratio were estimated from societal and health care perspectives. Probabilistic sensitivity analyses incorporated uncertainty in input parameters and generated 95% uncertainty intervals (UIs).

Results

Based on consumer behaviors, the policy was associated with a reduction of 30 000 (95% UI, 21 600-39 300) new cancer cases and 17 100 (95% UI, 12 400-22 700) cancer deaths, a gain of 116 000 (95% UI, 83 800-153 000) quality-adjusted life-years, and a saving of $1600 million (95% UI, $1190 million-$2030 million) in medical costs associated with cancer care among US adults over a lifetime. The policy was associated with a savings of $704 million (95% UI, $44.5 million-$1450 million) from the societal perspective and $1590 million (95% UI, $1180 million-$2020 million) from the health care perspective. Additional industry reformulation to reduce added-sugar amounts in packaged foods and beverages would double the impact. Greater health gains and cost savings were expected among young adults, women, and non-Hispanic Black individuals than other population subgroups.

Conclusions and Relevance

These findings suggest that the added-sugar labeling is associated with reduced costs and lower rates of obesity-associated cancers. Policymakers may consider and prioritize nutrition policies for cancer prevention in the US.

Cost-Effectiveness of a National Sugar-Sweetened Beverage Tax to Reduce Cancer Burdens and Disparities in the United States

BACKGROUND

Sugar-sweetened beverage (SSB) consumption contributes to obesity, a risk factor for 13 cancers. Although SSB taxes can reduce intake, the health and economic impact on reducing cancer burdens in the United States are unknown, especially among low-income Americans with higher SSB intake and obesity-related cancer burdens.

METHODS

We used the Diet and Cancer Outcome Model, a probabilistic cohort state-transition model, to project health gains and economic benefits of a penny-per-ounce national SSB tax on reducing obesity-associated cancers among US adults aged 20 years and older by income.

RESULTS

A national SSB tax was estimated to prevent 22 075 (95% uncertainty interval [UI] = 16 040-28 577) new cancer cases and 13 524 (95% UI = 9841-17 681) cancer deaths among US adults over a lifetime. The policy was estimated to cost $1.70 (95% UI = $1.50-$1.95) billion for government implementation and $1.70 (95% UI = $1.48-$1.96) billion for industry compliance, while saving $2.28 (95% UI = $1.67-$2.98) billion cancer-related healthcare costs. The SSB tax was highly cost-effective from both a government affordability perspective (incremental cost-effectiveness ratio [ICER] = $1486, 95% UI = -$3516-$9265 per quality-adjusted life year [QALY]) and a societal perspective (ICER = $13 220, 95% UI = $3453-$28 120 per QALY). Approximately 4800 more cancer cases and 3100 more cancer deaths would be prevented, and $0.34 billion more healthcare cost savings would be generated among low-income (federal poverty-to-income ratio [FPIR] ≤ 1.85) than higher-income individuals (FPIR > 1.85).

CONCLUSIONS

A penny-per-ounce national SSB tax is cost-effective for cancer prevention in the United States, with the largest health gains and economic benefits among low-income Americans.

Health care-related time costs in patients with metastatic breast cancer

BACKGROUND

Burdens related to time spent receiving cancer care may be substantial for patients with incurable, life-limiting cancers such as metastatic breast cancer (MBC). Estimates of time spent on health care are needed to inform treatment-related decision-making.

METHODS

Estimates of time spent receiving cancer-related health care in the initial 3 months of treatment for patients with MBC were calculated using the following data sources: (a) direct observations from a time-in-motion quality improvement evaluation (process mapping); (b) cross-sectional patient surveys; and (c) administrative claims. Average ambulatory, inpatient, and total health care time were calculated for specific treatments which differed by antineoplastic type and administration method, including fulvestrant (injection, hormonal), letrozole (oral, hormonal), capecitabine (oral, chemotherapy), and paclitaxel (infusion, chemotherapy).

RESULTS

Average total time spent on health care ranged from 7% to 10% of all days included within the initial 3 months of treatment, depending on treatment. The greatest time contributions were time spent traveling for care and on inpatient services. Time with providers contributed modestly to total care time. Patients receiving infusion/injection treatments, compared with those receiving oral therapy, spent more time in ambulatory care. Health care time was higher for patients receiving chemotherapeutic agents compared to those receiving hormonal agents.

CONCLUSION

Time spent traveling and receiving inpatient care represented a substantial burden to patients with MBC, with variation in time by treatment type and administration method.

Perceptions of time spent pursuing cancer care among patients, caregivers, and oncology professionals

PURPOSE

Patients with cancer spend significant time receiving treatment and recovering from side effects. Little is known about how patients and their caregivers perceive time spent receiving cancer treatment and how this impacts health-related quality of life (HRQoL). Our study aims to characterize perceptions of time invested in receiving cancer therapy as experienced by patients, caregivers, and oncology professionals.

METHODS

We conducted semi-structured interviews with patients undergoing treatment for advanced lung cancer and melanoma, their informal caregivers, and oncology professionals (physicians, nurses, social workers, and chaplains). Participants received and provided care at a tertiary cancer center. Interviews were audiorecorded and transcribed verbatim. Transcripts were analyzed qualitatively using predominantly inductive coding to identify themes relating to time perception and cancer care.

RESULTS

We interviewed 29 participants (11 patients, 7 informal caregivers, and 11 oncology professionals) and found they consistently differentiated between time remaining in life ("existential time") and time required to manage cancer treatment and symptoms ("chronological time"). Patients and caregivers reported distress around the mechanics of oncologic care that interrupted their daily lives (hobbies, activities). Participants described the impact of time invested in cancer care on dimensions of quality of life, ranging from minimal to substantial negative impact.

CONCLUSIONS

We found that the time spent undergoing cancer treatment affects well-being and often prevents patients and caregivers from participating in meaningful activities. The investment of personal time undergoing cancer therapy for patients with advanced solid tumors merits further study and can enhance communication between patients, caregivers, and their oncologists.

The psychosocial cost burden of cancer: A systematic literature review

Background and Objective

Psychosocial costs, or quality of life costs, account for psychological distress, pain, suffering and other negative experiences associated with cancer. They contribute to the overall economic burden of cancer that patients experience. But this category of costs remains poorly understood. This hinders opportunities to make the best cancer control policy decisions. This study explored the psychosocial cost burden associated with cancer, how studies measure psychosocial costs and the impact of this burden.

Methods

A systematic literature review of academic and grey literature published from 2008 to 2018 was conducted by searching electronic databases, guided by the Institute of Medicine’s conceptualization of psychosocial burden. Results were analyzed using a narrative synthesis and a weighted proportion of populations affected was calculated. Study quality was assessed using the Ottawa‐Newcastle instrument.

Results

A total of 25 studies were included. There was variation in how psychosocial costs were conceptualized and an inconsistent approach to measurement. Most studies measured social dimensions and focused on the financial consequences of paying for care. Fewer studies assessed costs associated with the other domains of this burden, including psychological, physical, and spiritual dimensions. Fourty‐four percent of cancer populations studied were impacted by psychosocial costs and this varied by disease site (38%‐71%). Two studies monetized the psychosocial cost burden, estimating a lifetime cost per case ranging from CAD$427753 to CAD$528769. Studies were of varying quality; 60% of cross‐sectional studies had a high risk of bias.

Conclusions

Consistency in approach to measurement would help to elevate this issue for researchers and decision makers. At two‐thirds of the total economic burden of cancer, economic evaluations should account for psychosocial costs to better inform decision‐making. More support is needed to address the psychosocial cost burden faced by patients and their families.

Patient-Provider Discussions About Out-of-Pocket Costs of Cancer Care in the U.S

INTRODUCTION

Despite the importance of cost-related discussions in cancer care, little is known about the prevalence or drivers of these discussions in clinical practice. This study estimates the prevalence and examines the correlates of cancer survivors' discussions about out-of-pocket costs of cancer care with providers.

METHODS

The 2016 and 2017 Medical Expenditure Panel Survey Experiences with Cancer Surveys were used to identify 1,550 survivors who responded to the question on discussion about out-of-pocket costs of cancer care. Multivariable multinomial logistic regression examined the correlates of discussions about out-of-pocket costs. Analyses were performed in 2019.

RESULTS

Approximately one quarter of cancer survivors reported having discussed the out-of-pocket costs of cancer care. In multivariable analyses, respondents in the following categories were less likely to report no cost discussion than any cost discussion: black non-Hispanic/other race (RRR=0.67, 95% CI=0.45, 0.98; white non-Hispanic race as reference), no health insurance at diagnosis (RRR=0.51, 95% CI=0.27, 0.95; private health insurance as reference), and any experience of financial hardship (RRR=0.48, 95% CI=0.35, 0.66; no financial hardship as reference).

CONCLUSIONS

Patient-reported discussions about out-of-pocket costs for cancer care are infrequent in the U.S. The findings highlight the needs to improve the understanding of the barriers and facilitators for effective discussions about out-of-pocket costs of cancer care.

Cost Effectiveness of Nutrition Policies on Processed Meat: Implications for Cancer Burden in the U.S

INTRODUCTION

Processed meats are associated with increased risk of colorectal and stomach cancers, but health and economic impacts of policies to discourage processed meats are not well established. This paper aims to evaluate the cost effectiveness of implementing tax and warning labels on processed meats.

METHODS

A probabilistic cohort-state transition model was developed in 2018, including lifetime and short-term horizons, healthcare, and societal perspectives, and 3% discount rates for costs and health outcomes. The model simulated 32 subgroups by age, gender, and race/ethnicity from the U.S. adult population and integrated nationally representative 2011-2014 data on processed meat consumption, with etiologic effects of processed meat consumption on cancer incidence, medical and indirect societal costs, and policy costs.

RESULTS

Over a lifetime, the 10% excise tax would prevent 77,000 cases of colorectal cancer (95% uncertainty interval=56,800, 107,000) and 12,500 cases of stomach cancer (95% uncertainty interval=6,880, 23,900), add 593,000 quality-adjusted life years (95% uncertainty interval=419,000, 827,000), and generate net savings of $2.7 billion from a societal perspective, including $1.1 billion healthcare costs saved. The warning label policy would avert 85,400 cases of colorectal cancer (95% uncertainty interval=56,600, 141,000) and 15,000 cases of stomach cancer (95% uncertainty interval=6,860, 34,500), and add 660,000 quality-adjusted life years (95% uncertainty interval=418,000, 1,070,000), with net savings of $4.5 billion from a societal perspective, including $1.3 billion healthcare costs saved. In subgroup analyses, greater health and economic benefits accrued to (1) younger subpopulations, (2) subpopulations with greater cancer risk, and (3) those with higher baseline processed meat consumption.

CONCLUSIONS

The model shows that implementing tax or warning labels on processed meats would be a cost-saving strategy with substantial health and economic benefits. The findings should encourage policy makers to consider nutrition-related policies to reduce cancer burden.

National and State Estimates of Lost Earnings From Cancer Deaths in the United States

Importance

Information on the economic burden of cancer mortality can serve as a tool in setting policies and prioritizing resources for cancer prevention and control. However, contemporary data are lacking for the United States nationally and by state.

Objective

To estimate lost earnings due to death from cancer overall and for the major cancers in the United States nationally and by state.

Design, Setting, and Participants

Person-years of life lost (PYLL) were calculated using numbers of cancer deaths and life expectancy data in individuals aged 16 to 84 years who died from cancer in the United States in 2015. The annual median earnings in the United States were used to assign a monetary value for each PYLL by age and sex. Cancer mortality and life expectancy data were obtained from the National Center for Health Statistics and annual median earnings from the US Census Bureau's 2016 Current Population Survey's March Annual Social and Economic Supplement. Data analysis was performed from October 22, 2018, to February 25, 2019.

Main Outcomes and Measures

Lost earnings due to cancer death, represented as estimated future wages in the absence of premature death.

Results

A total of 8 739 939 person-years of life were lost to cancer death in persons aged 16 to 84 years in the United States in 2015, translating to lost earnings of $94.4 billion (95% CI, $91.7 billion-$97.3 billion). For individual cancer sites, lost earnings were highest for lung cancer ($21.3 billion), followed by colorectal ($9.4 billion), female breast ($6.2 billion), and pancreatic ($6.1 billion) cancer. Age-standardized lost earning rates per 100 000 were lowest in the West and highest in the South, ranging from $19.6 million (95% CI, $19.1 million-$20.2 million) in Utah to $35.3 million ($34.4 million-$36.3 million) in Kentucky. Approximately 2.4 million PYLL and $27.7 billion (95% CI, $26.9 billion-$28.5 billion) in lost earnings (29.3% of total that occurred in 2015) would have been avoided in 2015 if all states had the same age-specific PYLL or lost earning rates as Utah.

Conclusions and Relevance

Our findings indicate large state variation in the economic burden of cancer and suggest the potential for substantial financial benefit through delivery of effective cancer prevention, screening, and treatment to minimize premature cancer mortality in all states.

Communicating the Financial Burden of Treatment With Patients

In recent years, high health care costs and the financial burden of cancer care have received increased attention. In response to the financial burden of cancer care, patients may jeopardize their health outcomes by not properly adhering to prescribed therapies or even forgoing and delaying care in an effort to defray costs. In addition, the financial burden experienced by patients with cancer may negatively impact clinical outcomes, such as quality of life, physical and psychological symptoms, and potentially, even survival. Notably, in the current era of targeted treatment and immunotherapies for patients with cancer, the rising costs of cancer continue to remain at the forefront of patient concerns. Therefore, a critical need exists to determine how best to assist patients with the cost burden of cancer diagnosis and treatment.

Costs of cancer along the care continuum: What we can expect based on recent literature

BACKGROUND

Cancer costs should be discussed by patients and providers, but information is not readily available. Results from recently published studies (in the last 5 years) on direct and indirect cancer costs may help guide these discussions.

METHODS

The authors reviewed studies published between 2013 and 2017 that reported direct health care costs and indirect (productivity losses) costs. The annual mean total and net costs of cancer were summarized for all payers and for survivors only by age (ages 18-64 and ≥65 years), by phase of care (initial [ie, 12 months from diagnosis], continuing, and end-of-life [ie, 12 months before death]), or for recently diagnosed (within 1-2 years of diagnosis) and longer term survivors.

RESULTS

For all payers combined, costs for cancers like breast, prostate, colorectal, and lung cancers were $20,000 to $100,000 in the initial phase, $1000 to $30,000 annually in the continuing phase, and ≥$60,000 in the end-of-life phase. Annual out-of-pocket costs to recently diagnosed survivors were >$1000 for medical care and time costs, approximately $2000 for productivity losses, and from $2500 to >$4000 for employment disability, depending on age. For longer term survivors, the cost of medical care was approximately $1500 for older survivors and $747 for younger survivors, time costs were $831 to $955 for older survivors and $459 to $630 for younger survivors, and productivity losses were approximately $800. Disability among long-term survivors was similar to that among short-term survivors. Limitations of the reviewed studies included older data and under-representation of higher cost cancers.

CONCLUSIONS

Frequently updated cost information for all cancer types is needed to guide discussions of anticipated short-term and long-term cancer-related costs with survivors. Cancer 2018;000:000-000. © 2018 American Cancer Society.

Costs of Cancer Care for Elderly Patients with Neuroendocrine Tumors

BACKGROUND

The incidence and prevalence of neuroendocrine tumors (NETs) have been steadily rising. NETs can arise in various parts of the body and have distinct pathogenesis, clinical manifestations, treatment, and survival compared to other neoplasms. The magnitude of the economic burden of NETs is largely unknown. This study aimed to estimate the cost of illness for NETs among elderly patients based on a large amount of observational data.

METHODS

We estimated the direct medical costs by phase of care using the Surveillance, Epidemiology, and End Results-Medicare data, including claims from January 1, 2002 through to December 31, 2012. Patients' care was categorized into three phases: initial phase (first year after diagnosis), terminal phase (last year of life), and continuing phase (the period between). We estimated the cost of illness by calculating the difference in medical costs between NET patients and a matched sample from a non-cancer control group.

RESULTS

Our study sample included 8409 elderly NET patients in the initial phase, 9218 patients in the continuing phase, and 7897 in the terminal phase. The mean cost of care for the initial phase was $46,462 in 2016 US dollars; mean cost of care for the terminal phase with a cancer-related death was $122,702; while the mean cost of care for the continuing phase was $10,457. The mean 5-year cost was $87,079.

CONCLUSIONS

This population-based study showed that NET patients had substantial continuing phase costs and 5-year costs. Among elderly NET patients, those with pancreas as the primary cancer site had the highest costs.

Is Cancer History Associated With Assets, Debt, and Net Worth in the United States?

Background

Financial hardships experienced by cancer survivors have become a prominent public health issue in the United States. Few studies of financial hardship have assessed financial holdings, including assets, debts, and their values, associated with a cancer history.

Methods

Using the 2008-2011 Medical Expenditure Panel Survey, we identified 1603 cancer survivors and 34 915 individuals age 18-64 years without a cancer history to assess associations between self-reported cancer history and assets, debts, and net worth. Distributions of self-reported asset and debt ownership, their values, and net worth were compared for adults with and without a cancer history with chi-square statistics. Multivariable ordered probit regression analysis was conducted to assess the association between cancer history and net worth using a two-sided Wald test. All analyses were stratified by age group (18-34, 35-44, 45-54, and 55-64 years). Statistical tests were two-sided.

Results

Among those age 45-54 years, cancer survivors had a lower proportion of home ownership than individuals without a cancer history (59.0% vs 67.1%, P = .0014) and were statistically significantly more likely to have negative net worth (≤-$3000) and less likely to have positive net worth (≥$3000). Cancer survivors were more likely to have debt than individuals without a cancer history, especially among those age 18-34 years (41.3% vs 27.1%, P < .001).

Conclusions

Cancer history is associated with lower asset ownership, more debt, and lower net worth, especially in survivors age 45-54 years. Longitudinal studies of financial holdings will be important to inform development of interventions to reduce financial hardship.

Rectal Cancer Survivors' Participation in Productive Activities

CONTEXT

Rectal cancer and its treatment impair survivors' productivity.

OBJECTIVE

To assess determinants of market and nonmarket employment, job search, volunteering, and homemaking among survivors five years or longer after diagnosis.

DESIGN

We mailed questionnaires to 1063 survivors who were members of Kaiser Permanente (Northern California, Northwest) during 2010 and 2011.

MAIN OUTCOME MEASURES

Productive activities, functional health status, and bowel management at the time of the survey.

RESULTS

Response rate was 60.5% (577/953). Higher comorbidity burdens were associated with lower productivity for men and women rectal cancer survivors. Productive survivors were younger and had lower disease stage and age at diagnosis, higher household income and educational attainment, and fewer comorbidity burdens and workplace adjustments than did nonproductive survivors (p < 0.05 each; 2-sided). Productive rectal cancer survivors were evenly split by sex.

CONCLUSION

Staying productive is associated with better mental health for rectal cancer survivors. Rectal cancer survivors with multiple chronic conditions, higher disease stage, lower productive activities, and older age need better access to medical care and closer monitoring of the quality of their care, including self-care. To capture the full extent of the involvement of survivors in all types of productive activities, research should routinely include measures of employment, searching for employment, homemaking, and volunteering. Counting market and nonmarket productive activities is innovative and recognizes the continuum of contributions survivors make to families and society. Health care systems should routinely monitor rectal cancer survivors' medical care access, comorbidities, health-related quality of life, and productive activities.

The burden of selected cancers in the US: health behaviors and health care resource utilization

Objective

To characterize the disease burden among survivors of those cancers having the highest incidence in the US.

Methods

Adult (≥18 years) survivors of the 11 most frequently diagnosed cancers were identified from publically available data sources, including the Surveillance Epidemiology and End Results 9 1973-2012, National Health Interview Survey 2013, and the Medical Expenditure Panel Survey 2011. Chi-square tests and one-way analyses of variance were utilized to assess differences between cancer survivors and non-cancer controls in behavioral characteristics, symptoms and functions, preventative screenings, and health care costs.

Results

Hematologic malignancies, melanoma, and breast, prostate, lung, colon/rectal, bladder, kidney/renal, uterine, thyroid, and pancreatic cancers had the highest incidence rates. Breast cancer had the highest incidence among women (156.4 per 100,000) and prostate cancer among men (167.2 per 100,000). The presence of pain (P=0.0003), fatigue (P=0.0005), and sadness (P=0.0012) was consistently higher in cancer survivors 40-64 years old vs. non-cancer controls. Cancer survivors ≥65 years old had higher rates of any functional limitations (P=0.0039) and reported a lack of exercise (P<0.0001) compared with the non-cancer controls. However, obesity rates were similar between cancer survivors and non-cancer controls. Among cancer survivors, an estimated 13.5 million spent $169.4 billion a year on treatment, with the highest direct expenditures for breast cancer ($39 billion), prostate cancer ($37 billion), and hematologic malignancies ($25 billion). Prescription medications and office-based visits contributed equally as the cost drivers of direct medical spending for breast cancer, while inpatient hospitalization was the driver for prostate (52.8%) and lung (38.6%) cancers.

Conclusion

Understanding the resource utilization implications, health, and well-being of cancer survivors can inform approaches to interventions for improving long-term care.

Economic Burden of Chronic Conditions Among Survivors of Cancer in the United States

Purpose The prevalence of cancer survivorship and chronic health conditions is increasing. Limited information exists on the economic burden of chronic conditions among survivors of cancer. This study examines the prevalence and economic effect of chronic conditions among survivors of cancer. Methods Using the 2008 to 2013 Medical Expenditure Panel Survey, we present nationally representative estimates of the prevalence of chronic conditions (heart disease, high blood pressure, stroke, emphysema, high cholesterol, diabetes, arthritis, and asthma) and multiple chronic conditions (MCCs) and the incremental annual health care use, medical expenditures, and lost productivity for survivors of cancer attributed to individual chronic conditions and MCCs. Incremental use, expenditures, and lost productivity were evaluated with multivariable regression. Results Survivors of cancer were more likely to have chronic conditions and MCCs compared with adults without a history of cancer. The presence of chronic conditions among survivors of cancer was associated with substantially higher annual medical expenditures, especially for heart disease ($4,595; 95% CI, $3,262 to $5,927) and stroke ($3,843; 95% CI, $1,983 to $5,704). The presence of four or more chronic conditions was associated with increased annual expenditures of $10,280 (95% CI, $7,435 to $13,125) per survivor of cancer. Annual lost productivity was higher among survivors of cancer with other chronic conditions, especially stroke ($4,325; 95% CI, $2,687 to $5,964), and arthritis ($3,534; 95% CI, $2,475 to $4,593). Having four or more chronic conditions was associated with increased annual lost productivity of $9,099 (95% CI, $7,224 to $10,973) per survivor of cancer. The economic impact of chronic conditions was similar among survivors of cancer and individuals without a history of cancer. Conclusion These results highlight the importance of ensuring access to lifelong personalized screening, surveillance, and chronic disease management to help manage chronic conditions, reduce disruptions in employment, and reduce medical expenditures among survivors of cancer.

Communication between oncologists and lymphoma survivors during follow-up consultations: A qualitative analysis

Cancer survivors often experience both short- and long-term challenges as a result of their cancer treatment. Many patients report feeling "lost in transition" following cancer treatment. The oncologist plays a key role in helping the patient to transition to survivorship. The purpose of this paper is to provide a descriptive understanding of the clinical care delivered during follow-up visits for lymphoma patients transitioning from active therapy into survivorship. We used thematic text analysis to identify themes in transcripts of audio recordings of 21 physicians and their patients in follow-up visits within 3 years of completing lymphoma treatment. Conversations between oncologists and patients during follow-up visits addressed a variety of themes, including specific health concerns, follow-up care, health promotion, prior treatment and test results, overall health status, emotional communication and affective tone, post-treatment rehabilitation, discussions occurring in the patient's physical examination, and social issues. However, the frequency with which these themes were discussed varied. In addition, there did not appear to be a consistent framework for these visits. The varied nature of the follow-up visits analyzed in this study suggests the need for increased structure in survivorship-care consultations.

Quality of Patient-Provider Communication Among Cancer Survivors: Findings From a Nationally Representative Sample

PURPOSE

Although patient-provider communication is an essential component of health care delivery, little is known about the quality of these discussions among patients with cancer.

METHODS

Data are from the 2011 Medical Expenditure Panel Survey Experiences with Cancer survey among 1,202 adult cancer survivors. We evaluated discussions with any provider after a cancer diagnosis about: (1) follow-up care; (2) late or long-term treatment effects; (3) lifestyle recommendations, such as diet, exercise, and quitting smoking; and (4) emotional or social needs. Using a response scale ranging from "did not discuss" to "discussed in detail," a summary score was constructed to define communication quality as high, medium, or low. Patient factors associated with the quality of provider discussions were examined using multivariable polytomous logistic regression analyses.

RESULTS

At the time of the survey, approximately one half of the patients (46%) were either within 1 year (24.1%) or between 1 and 5 years (22.0%) of treatment. More than one third of cancer survivors reported that they did not receive detailed communication about follow-up care, and more than one half reported that they did not receive detailed communication regarding late or long-term effects, lifestyle recommendations, or emotional and social needs. Only 24% reported high-quality communication for all four elements, indicating that the vast majority experienced suboptimal communication. In multivariable analysis, survivors reporting a high communication quality with providers included those who were within 1 year of treatment, between the ages of 18 and 64 years, non-Hispanic black or other ethnicity, and married.

CONCLUSION

Study findings demonstrate gaps in the communication quality experienced by cancer survivors in the United States and help identify survivors for targeted interventions.

The impact of chronic conditions on the economic burden of cancer survivorship: a systematic review

INTRODUCTION

This systematic review examines the excess cost of chronic conditions on the economic burden of cancer survivorship among adults in the US. Areas covered: Twelve published studies were identified. Although studies varied substantially in populations, comorbidities examined, methods, and types of cost reported, costs for cancer survivors with comorbidities generally increased with greater numbers of comorbidities or an increase in comorbidity index score. Survivors with comorbidities incurred significantly more in total medical costs, out-of-pocket costs, and costs by service type compared to cancer survivors without additional comorbidities. Expert commentary: Cancer survivors with comorbidities bear significant excess out-of-pocket costs and their care is also more expensive to the healthcare system. On-going evaluation of different payment models, care coordination, and disease management programs for cancer survivors with comorbidities will be important in monitoring impact on healthcare costs.

Procedural Impact of a Dedicated Interventional Oncology Service Line in a National Cancer Institute Comprehensive Cancer Center

PURPOSE

We tested the hypothesis that establishing a dedicated interventional oncology (IO) clinical service line would increase clinic visits and procedural volumes at a single quaternary care academic medical center.

METHODS

Two time periods were defined: July 2012 to June 2013 (pre-IO clinic) and July 2013 to June 2014 (first year of dedicated IO service). Staff was recruited, and clinic space was provided in the institution's comprehensive cancer center. Clinic visits and procedure numbers were documented using the institution's electronic medical record and billing forms. IO procedures included were transarterial chemoembolization, Y-90 radioembolization, perfusion mapping for Y-90, portal vein embolization, and bland embolization. We compared changes in clinic visit and procedure numbers using paired t tests. Changes after IO initiation were compared to 1-year changes in the Medicare 5% Limited Data Set by cross-referencing Current Procedure Terminology and International Classification of Diseases codes in 2012 and 2013.

RESULTS

Clinic visits increased from 9 to 204 (P = .003, t = 8.89, df = 3). Procedures increased from 60 to 239 (P = .018, t = 3.85, df = 4). Procedural volumes increased at least 150% for each subtype. The volumes in the 5% Limited Data Set did not change significantly over the 2-year period (443 to 385, P > .05).

CONCLUSIONS

The establishment of a dedicated IO service significantly increased clinic visits and procedural volumes. National trends were unchanged, suggesting that the impact of our program was not part of a sudden increase of IO procedures.

Financial Hardship Associated With Cancer in the United States: Findings From a Population-Based Sample of Adult Cancer Survivors

PURPOSE

To estimate the prevalence of financial hardship associated with cancer in the United States and identify characteristics of cancer survivors associated with financial hardship.

METHODS

We identified 1,202 adult cancer survivors diagnosed or treated at ≥ 18 years of age from the 2011 Medical Expenditure Panel Survey Experiences With Cancer questionnaire. Material financial hardship was measured by ever (1) borrowing money or going into debt, (2) filing for bankruptcy, (3) being unable to cover one's share of medical care costs, or (4) making other financial sacrifices because of cancer, its treatment, and lasting effects of treatment. Psychological financial hardship was measured as ever worrying about paying large medical bills. We examined factors associated with any material or psychological financial hardship using separate multivariable logistic regression models stratified by age group (18 to 64 and ≥ 65 years).

RESULTS

Material financial hardship was more common in cancer survivors age 18 to 64 years than in those ≥ 65 years of age (28.4% v 13.8%; P < .001), as was psychological financial hardship (31.9% v 14.7%, P < .001). In adjusted analyses, cancer survivors age 18 to 64 years who were younger, female, nonwhite, and treated more recently and who had changed employment because of cancer were significantly more likely to report any material financial hardship. Cancer survivors who were uninsured, had lower family income, and were treated more recently were more likely to report psychological financial hardship. Among cancer survivors ≥ 65 years of age, those who were younger were more likely to report any financial hardship.

CONCLUSION

Cancer survivors, especially the working-age population, commonly experience material and psychological financial hardship.

How do patients receiving radiotherapy in a Dutch hospital value their time? A contingent valuation study

Aim

Cancer patients spend a lot of time receiving medical care. Our study investigates patients’ preferences regarding reducing the time involved in non-palliative radiotherapy care.

Methods

A total of 142 Dutch patients were included in our study. Using a contingent valuation survey, we measured the proportion of patients who preferred to reduce their patients’ time, splitting it into five different categories, and, for those who did, whether and how much they were willing to pay for this to happen.

Results

About 50% of the patients preferred to reduce their time waiting for admission by 1 week and their travel time by half; 20 and 62% wanted to reduce their waiting time by half and their treatment time from 20 to 5 minutes, respectively; 36% preferred to be treated 7 instead of 5 days a week; and 20% of those wishing to reduce their patients’ time were willing to pay, and their mean willingness to pay (WTP) ranged from £0·32 to £18·1 per hour’s reduction of their time.

Conclusion

Half of the patients seem to assess their patients’ time as reasonable. The other half preferred to reduce it, but only about 20% of them were willing to pay for it to happen and their mean WTP was low.