Cost of cancer care: issues and implications

Spectroscopy and absolute quantum efficiency of near-infrared electrochemiluminescence for a macrocyclic palladium complex

Electrochemiluminescence (ECL) is widely applied as a reliable tool in clinical diagnosis, including immunoassays, cancer biomarker detection, etc. Metal complexes with emission in the near-infrared (NIR) range possess distinct features such as high transmission and minimal tissue auto-absorption, making them versatile for applications in biosensing and other fields. Through ECL spectral studies of an O-linked nonaromatic benzitripyrrin (C^N^N^N) macrocyclic palladium complex (Pd1) with multiple pyrrole structures, we observed emission peaks from the Qx(0,0) and its vibronic Qx(0,1) bands during both photoluminescence (PL) and ECL. Notably, the emission from the Qx(0,1) band was significantly enhanced in the ECL spectrum, demonstrating higher selectivity for near-infrared light at 743 nm. In the ECL annihilation pathway, the appearance of ECL signals showed a strong correlation with the redox processes of the tri-pyrrin structure, revealing a cyclic tri-pyrrin ligand-centered nature with contributions from the metal center. Upon the introduction of tripropylamine (TPrA) and benzoyl peroxide (BPO) coreactants, the ECL signals exhibited enhancements ranging from several hundred to tens of times. Various reaction routes within different coreactant systems are extensively discussed. Additionally, the absolute quantum efficiencies of the Pd1/TPrA coreactant system were determined, showing efficiencies of 0.0032% ± 0.0005% and 0.000074% ± 0.000016% during pulsing and CV scan processes, respectively. This work addresses gaps in the study of palladacycle complexes in ECL and provides insights into the design of NIR luminescent structures that contribute to the fast screening and deep tissue penetration bioimaging techniques.

Evaluating drug stability and sterility in single-dose vials when accessed with a closed system transfer device

Background

Impact of drug wastage is a legitimate and persistent concern. Financial impact of drug waste is borne by the hospital network, patients, and healthcare systems. Measures to reduce drug wastage may have a positive impact throughout healthcare systems.

Objective

This study investigated the stability and sterility of single-dose vials when repeatedly accessed with a closed system transfer device. By evaluating the sterility and stability, these results may be used to validate the extension of vial usage and lead to potential drug wastage reduction.

Methods

Sterility testing was performed in accordance with US Pharmacopeia 71. A closed system transfer device was incorporated into simulated compounding tasks, utilizing growth media. Simulated compounding tasks were performed in the clinical environment, followed by incubation to stimulate growth. Stability testing was performed in accordance with US Pharmacopeia monographs at multiple timepoints post access. Test samples were comparatively tested via high-performance liquid chromatography to freshly opened vials at each timepoint.

Results

No growth was observed in test samples. Control vials displayed growth, where appropriate. The drugs retained stability, when compared to freshly opened vials at 0, 24, 48, and 72 h, post access.

Conclusions

This study confirms that closed system transfer devices do not contribute to microbial contamination of drug vials, following the repeated access, for up to 7 days and the tested drugs retained equivalent chemical stability for up to 72 h post access. This study may offer a manner by which a facility may assess single-dose vials' sterility and stability, following repeated access by a closed system transfer device.

How should the healthcare system support cancer survivors? Survivors' and health professionals' expectations and perception on comprehensive cancer survivorship care in Korea: a qualitative study

BACKGROUND

Qualitative research on cancer survivors' need for comprehensive cancer survivorship care within the health care system is limited. Our study aimed to understand cancer survivors' and health professionals' expectations and perceptions for developing a comprehensive cancer survivorship care system in South Korea.

METHODS

An exploratory qualitative study was conducted. A total of 16 subjects (11 cancer survivors and 5 health professionals) were purposively sampled from Regional Cancer Survivorship Centers or Cancer Survivor Clinics in Korea. In-depth semi-structured online or face-to-face interviews were conducted. Six steps of thematic analysis were used to analyze data.

RESULTS

The following four primary themes emerged from the interviews: 1) introducing a customized follow-up care system to improve continuity of survivorship care, 2) implementing educational strategies for both survivors and health professionals to manage changed health, and 3) accepting cancer survivors as companions. These three themes included a total of nine subthemes. As a result, the comprehensive survivorship model identified needs in terms of 1) changes in the medical healthcare system and core services that can accommodate the cancer survivors' condition and 2) necessary care services and social support for cancer survivors.

CONCLUSIONS

This study identified the existing gaps in Korea's current healthcare system regarding comprehensive cancer survivorship care for cancer survivors. Further research on eHealth-based counseling and educational support, the payment models of cancer survivorship care within universal health coverage, and changing social perceptions to strengthen the biopsychosocial needs of cancer survivors is needed.

Evaluating Work Impairment as a Source of Financial Toxicity in Cancer Healthcare and Negative Impacts on Health Status

How the socioeconomic factors intersect for a particular patient can determine their susceptibility to financial toxicity, what costs they will encounter during treatment, the type and quality of their care, and the potential work impairments they face. The primary goal of this study was to evaluate financial factors leading to worsening health outcomes by the cancer subtype. A logistic model predicting worsening health outcomes while assessing the most influential economic factors was constructed by the University of Michigan Health and Retirement Study. A forward stepwise regression procedure was implemented to identify the social risk factors that impact health status. Stepwise regression was done on data subsets based on the cancer types of lung, breast, prostate, and colon cancer to determine whether significant predictors of worsening health status were different or the same across cancer types. Independent covariate analysis was also conducted to cross-validate our model. On the basis of the model fit statistics, the two-factor model has the best fit, that is, the lowest AIC among potential models of 3270.56, percent concordance of 64.7, and a C-statistics of 0.65. The two-factor model used work impairment and out-of-pocket costs, significantly contributing to worsening health outcomes. Covariate analysis demonstrated that younger patients with cancer experienced more financial burdens leading to worsening health outcomes than elderly patients aged 65 years and above. Work impairment and high out-of-pocket costs were significantly associated with worsening health outcomes among cancer patients. Matching the participants who need the most financial help with appropriate resources is essential to mitigate the financial burden.

Significance

Among patients with cancer, work impairment and out-of-pocket are the two primary factors contributing to adverse health outcomes. Women, African American or other races, the Hispanic population, and younger individuals have encountered higher work impairment and out-of-pocket costs due to cancer than their counterparts.

Economic Burden of Cancer for the First Five Years after Cancer Diagnosis in Patients with Human Immunodeficiency Virus in Korea

This study aimed to estimate the medical cost of cancer in the first five years of diagnosis and in the final six months before death in people who developed cancer after human immunodeficiency virus (HIV) infection in Korea. The study utilized the Korea National Health Insurance Service-National Health Information Database (NHIS-NHID). Among 16,671 patients diagnosed with HIV infection from 2004 to 2020 in Korea, we identified 757 patients newly diagnosed with cancer after HIV diagnosis. The medical costs for 60 months after diagnosis and the last six months before death were calculated from 2006 to 2020. The mean annual medical cost due to cancer in HIV-infected people with cancer was higher for acquired immunodeficiency syndrome (AIDS)-defining cancers (48,242 USD) than for non-AIDS-defining cancers (24,338 USD), particularly non-Hodgkin's lymphoma (53,007 USD), for the first year of cancer diagnosis. Approximately 25% of the cost for the first year was disbursed during the first month of cancer diagnosis. From the second year, the mean annual medical cost due to cancer was significantly reduced. The total medical cost was higher for non-AIDS-defining cancers, reflecting their higher incidence rates despite lower mean medical costs. The mean monthly total medical cost per HIV-infected person who died after cancer diagnosis increased closer to the time of death. The estimated burden of medical costs in patients with HIV in the present study may be an important index for defining healthcare policies in HIV patients in whom the cancer-related burden is expected to increase.

Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers

BACKGROUND

Medication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited.

OBJECTIVE

To describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering.

DESIGN

and Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after "go-live" of the RTPB system(s) between 2019 and 2020.

MAIN MEASURES

Implementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates.

KEY RESULTS

Differences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after "go-live," RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered.

CONCLUSIONS

In this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.

Prostate cancer aggressiveness and financial toxicity among prostate cancer patients

INTRODUCTION

Financial toxicity (FT) is a growing concern among cancer survivors that adversely affects the quality of life and survival. Individuals diagnosed with aggressive cancers are often at a greater risk of experiencing FT. The objectives of this study were to estimate FT among prostate cancer (PCa) survivors after 10-15 years of diagnosis, assess the relationship between PCa aggressiveness at diagnosis and FT, and examine whether current cancer treatment status mediates the relationship between PCa aggressiveness and FT.

METHODS

PCa patients enrolled in the North Carolina-Louisiana Prostate Cancer Project (PCaP) were recontacted for long-term follow-up. The prevalence of FT in the PCaP cohort was estimated. FT was estimated using the COmprehensive Score for Financial Toxicity, a validated measure of FT. The direct effect of PCa aggressiveness and an indirect effect through current cancer treatment on FT was examined using causal mediation analysis.

RESULTS

More than one-third of PCa patients reported experiencing FT. PCa aggressiveness was significantly independently associated with high FT; high aggressive PCa at diagnosis had more than twice the risk of experiencing FT than those with low or intermediate aggressive PCa (adjusted odds ratio [aOR] = 2.13, 95% CI = 1.14-3.96). The proportion of the effect of PCa aggressiveness on FT, mediated by treatment status, was 10%, however, the adjusted odds ratio did not indicate significant evidence of mediation by treatment status (aOR = 1.05, 95% CI = 0.95-1.20).

CONCLUSIONS

Aggressive PCa was associated with high FT. Future studies should collect more information about the characteristics of men with high FT and identify additional risk factors of FT.

Is Hospital Hospice Service Associated with Efficient Healthcare Utilization in Deceased Lung Cancer Patients? Hospital Charges at Their End of Life

In July 2015, South Korea began applying National Health Insurance reimbursement to inpatient hospice service. It is now appropriate and relevant to evaluate how hospice care is associated with healthcare utilization in terminal lung cancer patients. We used nationwide NHI claims data of lung cancer patients from 2008-2018 and identified a sample of patients deceased after July 2016. We transposed the dataset into a retrospective cohort design where a unit of analysis was each lung cancer patients' healthcare utilization. The differences in hospital charges per day were investigated depending on the patient's use of hospice service before death with the Generalized Linear Model (GLM) analysis. Additionally, subgroup analysis and the propensity score matching method were used to validate the model using the claims information of 25,099 patients. About 17.0% of patients used hospice services (N = 4260). With other variables adjusted, hospice service utilization by deceased lung cancer patients was associated with statistically significant lower hospital charges per day at the end of life (1 month, 3 months, and 6 months before death) compared to non-users. A similar trend was found in the propensity score matching model analysis. We found lower end-of-life hospital charges per day among lung cancer patients who received hospice services near death. The ever-expanding aging population requires health policymakers and the National Health Insurance program to expand hospice services for terminal cancer patients in underserved regions and hospitals that do not provide hospice.

Extragastric recurrence in patients who underwent surgical resection of stage I gastric cancer: Incidence, risk factors, and value of abdominal computed tomography as a postoperative surveillance method

Extragastric recurrence after radical resection of stage I gastric cancer is very rare. We investigated the incidence of extragastric recurrence and risk factors in patients who underwent surgical resection of stage I gastric cancer and evaluated the value of abdominal CT as a surveillance tool. This retrospective study enrolled 914 patients with stage I gastric cancer who underwent surgical resection at a single tertiary hospital. We investigated extragastric recurrence during the follow-up period, and disease-free survival (DFS) was assessed. Over a median follow-up period of 39 months, the overall incidence of extragastric recurrence was 2.2% (20/914). Risk factors for extragastric recurrence included deep submucosal invasion (SM2-3), muscularis propria invasion, and lymph node metastasis (hazard ratio [HR]=10.37, 28.101, and 6.843; P = .028, .002, and .001, respectively). Based on the number of risk factors, patients were stratified into 3 subgroups: low-risk (pT1aN0, pT1b(SM1)N0, 496/914), moderate-risk (pT1aN1, pT1b(SM1)N1, pT1b(SM2-3)N0, pT2N0, 369/914), and high-risk (pT1b(SM2-3)N1, 49/914). DFS was significantly longer in the low-risk group, followed by the moderate-risk and high-risk groups. We propose that postoperative CT surveillance should be omitted for stage 1A cases involving the mucosa and SM1 because of the extreme rarity of extragastric recurrence.

Home is best. Self-administration of subcutaneous Bortezomib at home in patients with multiple myeloma - A mixed method study

OBJECTIVES

To examine the perspectives of patients and healthcare professionals of self-administration of subcutaneous (SC) injection of Bortezomib in the homes of patients with Multiple Myeloma (MM), and to assess organizational aspects.

METHODS

A prospective, clinical, parallel mixed-method design with a qualitative core and a quantitative supplementary component was conducted at a single hematological centre in Denmark. Qualitative data were obtained from individual, semi-structured interviews with patients (n = 10) and a focus group interview with healthcare professionals (n = 5); data were analyzed using a hermeneutic approach. Quantitative data were acquired from time registrations performed by patients and nurses and descriptively analyzed applying a micro-costing approach, using cost data per individual.

RESULTS

In general, patients and healthcare professionals were pleased with self-administration as patient empowerment increased. Qualitative findings yielded three themes: "Home is best", "Everyone is different", and "Safety first". Quantitative data were confirmative and revealed self-administration to be time saving for patients and nurses. In a Danish context, delivery of the medicine to the patient's home was slightly more expensive than administration at the hospital.

CONCLUSIONS

Self-administration of SC Bortezomib in the homes of patients with MM is advantageous for patients and healthcare professionals. It is feasible, safe, and timesaving. These advantages come with a negligible increase in expenses.

L-cysteine embedded core-shell ZnO microspheres composed of nanoclusters enhances anticancer activity against liver and breast cancer cells

Nano-based products have become an apparent and effective option to treat liver cancer, which is a deadly disease, and minimize or eradicate these problems. The Core-shell ZnO microspheres composed of nanoclusters (ZnOMS-NCs) have shown that it is very worthwhile to administer the proliferation rate in HepG2 and MCF-7 cancer cells even at a very low concentration (5 μg/mL). ZnOMS-NCs were prepared through hydrothermal solution process and well characterized. The MTT assay revealed that the cytotoxic effects were dose-dependent (2.5 μg/mL-100 μg/mL) on ZnOMS-NCs. The diminished activity in cell viability induces the cytotoxicity response to the ZnOMS-NCs treatment of human cultured cells. The qPCR data showed that the cells (HepG2 and MCF-7) were exposed to ZnOMS-NCs and exhibited up-and downregulated mRNA expression of apoptotic and anti-apoptotic genes, respectively. In conclusion, flow cytometric data exhibited significant apoptosis induction in both cancer cell lines at low concentrations. The possible mechanism also describes the role of ZnOMS-NCs against cancer cells and their responses.

Public procurement of antineoplastic agents used for treating breast cancer in Brazil between 2013 and 2019

Background

Breast cancer is the most common cancer among women in Brazil and the country’s public health care system is the main care provider. Timely treatment can increase the chance of cure, prevent metastasis and improve quality of life. Effective public procurement of antineoplastic agents can therefore improve access to drug therapy. This study investigates patterns in the procurement of selected antineoplastic agents used for treating breast cancer by public bodies and avoidable expenditure on these drugs between January 2013 and December 2019.

Methods

We selected antineoplastic agents used for adjuvant or preoperative chemotherapy listed in the 2018 Breast Cancer Diagnosis and Treatment Guidelines and included in category L of the WHO Anatomical Therapeutic Chemical classification system. We analyzed regular purchases of antineoplastic agents registered in the Integrated General Services Administration System (SIASG), considering purchased quantity, unit price, date of purchase and procuring entity. Prices were inflation-adjusted to July 2019 based on the National Consumer Price Index.

Results

A total of 10 antineoplastic agents were selected. Trastuzumab and tamoxifen accounted for the largest share of total spending and largest volume of purchases, respectively. The Ministry of Education was the largest purchaser in volume terms of all the drugs studied, except trastuzumab 440 mg, where the category “Other Institutions” accounted for most purchases, and vinorelbine 20 mg, where the Ministry of Health made most purchases. The category “Other Institutions” accounted for the largest share of total spending. Total avoidable expenditure was R$99,130,645. Prices paid for medicines and avoidable expenditure were highest in the Ministry of Defense.

Conclusions

The differences observed in the performance of different categories of buyers as to amounts purchased and prices practiced for antineoplastic agents could be reduced by employing strategies to expand the centralization of purchases, resulting in expanded access to breast cancer medicines in the public sector.

Spending outcomes among patients with cancer in accountable care organizations 4 years after implementation

BACKGROUND

The long-term impact of affordable care organizations (ACOs) on cancer spending remains unknown. The authors examined whether practices that became ACOs altered their spending for patients with cancer in the first 4 years after ACO implementation.

METHODS

By using national Medicare data from 2011 to 2017, a random sample of 20% of fee-for-service Medicare beneficiaries aged 65 years and older with cancer was obtained (n = 866,532), and each patient was assigned to a practice. Practices that became ACOs in the Medicare Shared Savings Program were matched to non-ACO practices. Total, cancer-specific, and service category-specific yearly spending per patient was calculated. A difference-in-differences model was used to determine spending changes associated with ACO status for patients with cancer in the 4 years after ACO implementation.

RESULTS

The introduction of ACOs did not have a significant impact on overall spending for patients with cancer in the 2 years after ACO implementation (difference, -$38; 95% CI, -$268, $191; P = .74). Changes in spending also did not differ between ACO and non-ACO patients within service categories or among the 11 cancer types examined. The lack of difference in spending for patients with cancer in ACO and non-ACO practices persisted in the third and fourth years after ACO implementation (difference, -$120; 95% CI, -$284, $525; P = .56).

CONCLUSIONS

ACOs did not significantly change spending for patients with cancer in the first 4 years after their implementation compared with non-ACOs. This prompts a reevaluation of the current efficacy of ACOs in reducing spending for cancer care and may encourage policymakers to reconsider the incentive structures of ACOs.

LAY SUMMARY

Accountable care organizations (ACOs) were developed to curtail health care spending and improve quality, but their effects on cancer spending in their first 2 years have been minimal. The long-term impact of ACOs on cancer spending remains unknown. By using data from 866,532 Medicare beneficiaries with cancer, the authors observed that the association of a practice with an ACO did not significantly change total yearly spending per patient in the first 4 years after ACO implementation. This finding prompts a reevaluation of the current efficacy of ACOs in reducing spending for cancer care.

Tissue miR-200c-3p and circulating miR-1290 as potential prognostic biomarkers for colorectal cancer

Epithelial–mesenchymal transition (EMT)-related cancers generally elicit low immune responses. EMT is regulated by several microRNAs (miRNAs) in cancers. Thus, this study aimed to evaluate the prognostic potential of EMT-related miRNAs as biomarkers in colorectal cancer (CRC). Formalin-fixed paraffin-embedded tumor and normal tissue and plasma samples were obtained from 65 patients with pathologically confirmed CRC. In addition, plasma samples were obtained from 30 healthy volunteers. Immunohistochemical staining for E-cadherin, ZEB1, PD-1, PD-L1, CD3, CD4, CD8, Foxp3, and CD68 was conducted on tissue samples. Droplet digital polymerase chain reaction (ddPCR) analysis was performed to evaluate miR-21-5p, 34a-5p, 138-5p, 200a-3p, 200b-5p, 200c-3p, 630, 1246, and 1290 expression in tissue samples and miR-630, 1246, and 1290 expression in plasma samples. miR-21-5p, 34a-5p, 630, 1246, and 1290 expression was higher in tumor tissues than in normal tissues (P < 0.05). EMT was significantly associated with reduced tumor-infiltrating T cells. Moreover, miR-21-5p, miR-34a-5p, miR-200a-3p, and miR-200c-3p expression was negatively correlated with T cell density (P < 0.05). High tissue levels of miR-200c-3p were associated with poor overall survival (OS) (P < 0.001). CRC patients with the EMT phenotype had poor OS; however, PD-L1 positivity and abundant PD-1 positive immune cells were correlated with better OS (P < 0.05). miR-1246 and miR-1290 levels were significantly higher in the plasma of patients with CRC than in the plasma of healthy controls (P < 0.05). High plasma levels of miR-1290 were correlated with advanced stage and poor OS (P < 0.05). The tissue expression of miR-200c-3p and plasma levels of miR-1290 measured by ddPCR indicate their potential as prognostic biomarkers for CRC.

Outpatient Dental Treatment Expenditure for Patients with Oromaxillofacial Cancer: A Cohort Study in Taiwan

The information on the outpatient expenditure of patients with oromaxillofacial cancer is minimal. This study aimed to compare the average annual expenditure on dental treatment for these patients 5 years before and 5 years after oromaxillofacial cancer diagnosis. In this study, 7731 patients who received oromaxillofacial cancer diagnosis in 2005 were selected from the Registry of Catastrophic Illness Database as the case-cohort. In the control cohort, 38,655 people without cancer were selected from the National Health Insurance Research Database, with the case–control ratio being 1:5. All participants were observed for 5 years before diagnosis and 5 years after diagnosis. The conditional logistic regression model was used to determine the odds ratios of annual expenditures incurred by participants in the case-cohort. The measurement results indicated that in the oromaxillofacial cancer cohort, the average annual dental expenditure levels at 1, 2, 3, 4, and 5 years after diagnosis were US $97.34, US $77.23, US $109.65, US $128.43, and US $128.03 and those at these years before diagnosis were US $37.52, US $32.10, US $31.86, US $29.14, and US $29.35, respectively. In conclusion, the average annual expenditure on the dental treatment of oromaxillofacial cancer patients after five years of diagnosis was increased compared to five years before diagnosis.

Size-Dependent Cytotoxic and Molecular Study of the Use of Gold Nanoparticles against Liver Cancer Cells

The size of nanomaterials influences physicochemical parameters, and variations in the size of nanomaterials can have a significant effect on their biological activities in cells. Due to the potential applicability of nanoparticles (NPs), the current work was designed to carry out a size-dependent study of gold nanoparticles (GNPs) in different dimensions, synthesized via a colloidal solution process. Three dissimilar-sized GNPs, GNPs-1 (10–15 nm), GNPs-2 (20–30 nm), and GNPs-3 (45 nm), were prepared and characterized via transmission electron microscopy (TEM), high-resolution TEM (HR-TEM), hydrodynamic size, zeta potential, and UV-visible spectroscopy, and applied against liver cancer (HepG2) cells. Various concentrations of GNPs (1, 2, 5, 10, 50, and 100 µg/mL) were applied against the HepG2 cancer cells to assess the percentage of cell viability via MTT and NRU assays; reactive oxygen species (ROS) generation was also used. ROS generation was increased by 194%, 164%, and 153% for GNPs-1, GNPs-2, and GNPs-3, respectively, in the HepG2 cells. The quantitative polymerase chain reaction (qPCR) data for the HepG2 cells showed up-regulation in gene expression of apoptotic genes (Bax, p53, and caspase-3) when exposed to the different-sized GNPs, and defined their respective roles. Based on the results, it was concluded that GNPs of different sizes have the potential to induce cancer cell death.

Comparison of Prices and Affordability of Cancer Medicines in 16 Countries in Europe and Latin America

BACKGROUND

There are concerns that high prices of cancer medicines may limit patient access. Since information on prices for cancer medicines and their impact on affordability is lacking for several countries, particularly for lower income countries, this study surveys prices of originator cancer medicines in Europe and Latin America and assesses their affordability.

METHODS

For 19 cancer medicines, public procurement and ex-factory prices, as of 2017, were surveyed in five Latin American (LATAM) countries (Brazil, Chile, Colombia, Mexico, and Peru) and 11 European countries (Austria, France, Germany, Greece, Hungary, the Netherlands, Poland, Romania, Spain, Sweden, and the UK). Price data (public procurement prices in LATAM and ex-factory prices in Europe) in US dollar purchasing power parities (PPP) were analyzed per defined daily dose. Affordability was measured by setting medicines prices in relation to national minimum wages.

RESULTS

The prices of cancer medicines varied considerably between countries. In European countries with higher levels of income, PPP-adjusted prices tended to be lower than in European countries of lower income and LATAM countries. Except for one medicine, all surveyed medicines were considered unaffordable in most countries. In European countries of lower income and LATAM countries, more than 15 days' worth of minimum wages would be required by a worker to purchase one defined daily dose of several of the studied medicines.

CONCLUSIONS

The high prices and large unaffordability of cancer medicines call for strengthening pricing policies with the aim of ensuring affordable treatment in cancer care.

Development of a predictive model for extragastric recurrence after curative resection for early gastric cancer

BACKGROUND

Stratification of patients who undergo curative resection for early gastric cancer (EGC) is warranted due to the heterogeneity in the risk of developing extragastric recurrence (EGR). Therefore, we aimed to stratify the need for postoperative surveillance for EGR detection in patients with EGC by developing a model for predicting EGR-free survival.

METHODS

This retrospective cohort study included patients who underwent postoperative surveillance after curative resection of EGC (n = 4149). Cox proportional hazard models were used to identify predictors to build a model for predicting EGR-free survival. Bootstrap-corrected c-index and calibration plots were used for internal and external (n = 2148) validations.

RESULTS

A risk-scoring system was constructed using variables significantly associated with EGR-free survival: pathologic T stage (pT1b[sm1], hazard ratio [HR] 4.928; pT1b[sm2], HR 5.235; pT1b[sm3], HR 7.748) and N stage (pN1, HR 4.056; pN2, HR 9.075; pN3, HR 30.659). Patients were dichotomized into a very-low-risk group or a low-or-greater-risk group. The 5-year EGR-free survival rates differed between the two groups (99.9 vs. 97.3%). The discriminative performance of the model was 0.851 (Uno's c-index) and 0.751 in the internal and external cohorts, respectively. The calibration slope was 0.916 and 1.131 in the internal and external cohorts, respectively.

CONCLUSIONS

Our model for predicting EGR-free survival based on the pathologic T and N stages may be useful for stratifying patients who have undergone curative surgery for EGC. The results suggest that patients in the very-low-risk group may be spared from postoperative surveillance considering their extremely high EGR-free survival rate.

The scope of childhood cancer in South Africa: A response to 'Childhood cancers in a section of the South African private health sector - Analysis of medicines claims data'

Childhood cancer is an under resourced medical field that is emerging as a great healthcare concern in low- and middle-income countries such as South Africa. Therefore, reporting data in this field that may inform policymakers should be representative of the subject matter. This article aims to discuss why medicines claims as an indicator for incidence, as per an article published in 2020, is not representative of childhood malignancies in the South African setting. Literature to support the commentary were sourced using Pubmed, Google scholar, and data presented by members of the South African Children’s Cancer Study Group (SACCSG). Private medical aid coverage in South Africa between 2002 and 2018 varied between 15.5% and 18.2%. Of these, 9.5% were children under 18 years and 3.5% were under the age of six. Only 13.5% of children were treated in private paediatric oncology units during 2015. The limitations in the study were the variable medical aid coverage, the disproportionate age representation, and lack of reliable indicators for measurement and calculation of incidence. Utilising one medicines claims data base to evaluate the incidence of childhood cancer in South Africa is not representative and cannot inform policy.

Medical Service Use and Charges for Cancer Care in 2018 for Privately Insured Patients Younger Than 65 Years in the US

IMPORTANCE

Currently, there are limited published data regarding resource use and spending on cancer care in the US.

OBJECTIVE

To characterize the most frequent medical services provided and the associated spending for privately insured patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the MarketScan database for the calendar year 2018 from a sample of 27.1 million privately insured individuals, including patients with a diagnosis of the 15 most prevalent cancers, predominantly from large insurers and self-insured employers. Overall societal health care spending was estimated for each cancer type by multiplying the mean total spending per patient (estimated from MarketScan) by the number of privately insured patients living with that cancer in 2018, as reported by the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Analyses were performed from February 1, 2018, to July 8, 2021.

EXPOSURES

Evaluation and management as prescribed by treating care team.

MAIN OUTCOMES AND MEASURES

Current Procedural Terminology and Healthcare Common Procedure Coding System codes based on cancer diagnosis code.

RESULTS

The estimated cost of cancer care in 2018 for 402 115 patients with the 15 most prevalent cancer types was approximately $156.2 billion for privately insured adults younger than 65 years in the US. There were a total of 38.4 million documented procedure codes for 15 cancers in the MarketScan database, totaling $10.8 billion. Patients with breast cancer contributed the greatest total number of services (10.9 million [28.4%]), followed by those with colorectal cancer (3.9 million [10.2%]) and prostate cancer (3.6 million [9.4%]). Pathology and laboratory tests contributed the highest number of services performed (11.7 million [30.5%]), followed by medical services (6.3 million [16.4%]) and medical supplies and nonphysician services (6.1 million [15.9%]). The costliest cancers were those of the breast ($3.4 billion [31.5%]), followed by lung ($1.1 billion [10.2%]) and colorectum ($1.1 billion [10.2%]). Medical supplies and nonphysician services contributed the highest total spent ($4.0 billion [37.0%]), followed by radiology ($2.1 billion [19.4%]) and surgery ($1.8 billion [16.7%]).

CONCLUSIONS AND RELEVANCE

This analysis suggests that patients with breast, colorectal, and prostate cancers had the greatest number of services performed, particularly for pathology and laboratory tests, whereas patients with breast, lung, lymphoma, and colorectal cancer incurred the greatest costs, particularly for medical supplies and nonphysician services. The cost of cancer care in 2018 for the 15 most prevalent cancer types was estimated to be approximately $156.2 billion for privately insured adults younger than 65 years in the US.

Financial Toxicity in People Living with Advanced Cancer: A New, Deadly, and Poorly Addressed Effect of Cancer and Necessary Treatment

OBJECTIVES

Advances in cancer treatments have allowed improved outcomes, even with advanced disease. However, this progress has resulted in a new toxic effect termed 'financial toxicity.' Financial toxicity severely impacts quality of life, even among those insured. The purpose of this article is to gain better understanding of this relatively new concept to better care for our patients, presented primarily from a US perspective.

DATA SOURCES

These include medical databases (PubMed, Scopus) and researcher experience.

CONCLUSION

Financial toxicity is highly prevalent in patients with advanced cancer, and it is associated with multiple worsened outcomes. Those with advancing cancer are at accumulating risk of financial toxicity, exacerbated by other known risk factors. The effects of financial toxicity are debilitating, resulting in deleterious physical, psychological, spiritual, and social effects drastically affecting quality of life. Coping strategies such as taking less than prescribed therapy, delays seeking care, and poorly managed comorbid conditions potentially cause increased symptoms and worse outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Careful assessments by multidisciplinary health care teams could allow early intervention, timely referral to health professionals including social work or financial navigators, and provision of emotional support. Further studies are needed to explore solutions on an institutional and national level that can guide health policy and the creation of practice models that can reduce the harm of financial toxicity.

Income loss after a cancer diagnosis in Germany: An analysis based on the socio-economic panel survey

BACKGROUND AND AIMS

Cancer treatments often require intensive use of healthcare services and limit patients' ability to work, potentially causing them to become financially vulnerable. The present study is the first attempt to measure, on the German national level, the magnitude of absolute income loss after a cancer diagnosis.

METHODS

This study analyzes data from the Socio-Economic Panel (SOEP) survey, one of the largest and most comprehensive household surveys in Germany, consisting of approximately 20,000 individuals, who are traced annually. The empirical strategy consists of ordinary least squares (OLS) and multinomial logistic estimators to measure changes in job income, work status, working hours, and pension as a result of reporting a cancer diagnosis for the period between 2009 and 2015. Sample consistency checks were conducted to limit measurement error biases.

RESULTS

Our results show that job incomes dropped between 26% and 28% within the year a cancer diagnosis was reported. The effect persisted for two years after the diagnosis and was no longer observable after four years. The finding was linked to an increased likelihood of unemployment and a reduction of working hours by 24%. Pension levels, on the other hand, were not affected by a cancer diagnosis.

CONCLUSIONS

These findings suggest that many cancer patients are exposed to financial hardship in Germany, particularly when the cancer diagnosis occurs during their working age and before requirements to obtain a pension are met. Further research seems warranted to identify particularly vulnerable patient groups.

The relationship between financial hardship and incident diabetic kidney disease in older US adults - a longitudinal study

Background

Financial hardship is associated with poor health, however the association of financial hardship and incident diabetic kidney disease (DKD) is unknown. This study aimed to examine the longitudinal relationship between financial hardship and incident DKD among older adults with diabetes.

Methods

Analyses were conducted in 2735 adults age 50 or older with diabetes and no DKD using four waves of data (2006–2012) from the Health and Retirement Study, a national longitudinal cohort. The primary outcome was incident DKD. Financial hardship was based on three measures: 1) difficulty paying bills; 2) food insecurity; and 3) cost-related medication non-adherence using validated surveys. A dichotomous financial hardship variable (0 vs 1 or more) was constructed based on all three measures. Cox regression models were used to estimate the association between financial hardship, change in financial hardship experience and incident DKD adjusting for demographics, socioeconomic status, and comorbidities.

Results

During the median follow-up period of 4.1 years, incident DKD rate was higher in individuals with versus without financial hardship (41.2 versus 27/1000 person years). After adjustment, individuals with financial hardship (HR 1.32, 95% CI 1.04–1.68) had significantly increased likelihood of developing DKD compared to individuals without financial hardship. Persistent financial hardship (adjusted HR 1.52 95% CI 1.06–2.18) and negative financial hardship (adjusted HR 1.54 95% CI 1.02–2.33) were associated with incident DKD compared with no financial hardship experience. However, positive financial hardship was not statistically significant in unadjusted and adjusted (adjusted HR 0.89 95% CI 0.55–1.46) models. Cost-related medication non-adherence (adjusted HR 1.43 95% CI 1.07–1.93) was associated with incident DKD independent of other financial hardship measures.

Conclusions

Financial hardship experience is associated with a higher likelihood of incident DKD in older adults with diabetes. Future studies investigating factors that explain the relationship between financial hardship and incident DKD are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02373-3.

Psychiatric problems of anxiety and depression disorder are associated with medical service utilization and survival among patients with cervical cancer

OBJECTIVE

There are few nationwide studies regarding the long-term analysis of cervical cancer patients in Taiwan. Thus, this study aimed to evaluate medical service utilization, and survival among cervical cancer patients initially diagnosed with or without anxiety and/or depressive disorders.

MATERIALS AND METHODS

This was a retrospective longitudinal study using data from the National Health Insurance Research Database from 1996 to 2010. The study subjects were cervical cancer patients identified by ICD-9-CM codes 180.X, while subjects with anxiety and/or depressive disorders were identified using the following codes: 300.0X-300.9X (minus 300.4X) for anxiety disorder, and 296.2X, 296.3X, 300.4, and 311.X for depressive disorder. The cervical patients with anxiety or/and depression disorder were classified as anxiety/depression (AD) group or the non-disorder (ND) group. Propensity score matching (PSM) was used to adjust for differences between the AD and ND groups. T-tests were used to evaluate differences in medical utilization and the Kaplan-Meier method was used to evaluate survival conditions between the two groups. Statistical analyses were performed using SPSS Statistics 20.0.

RESULTS

A total of 3664 patients were identified, with 862 (23.5%) having anxiety, 149 (4.1%) with depression, and 349 (9.5%) having both anxiety and depression. In total, 1360 cervical cancer patients had anxiety/depression disorders. After PSM, the AD group had significantly more outpatient department (OPD) visits than the ND group (p < 0.001) but the survival status was better in the AD group than the ND group (p < 0.001).

CONCLUSIONS

Cervical cancer patients with anxiety/depression disorders visited the OPD more frequently than those without anxiety/depression disorders but had better survival status. Gynecologists should also consider cancer patients' mental status during follow-up, referring patients to psychiatric professionals for appropriate psychiatric care if appropriate.

Comparing Manufacturer Submitted and Pan-Canadian Oncology Drug Review Reanalysed Incremental Cost-Effectiveness Ratios for Novel Oncology Drugs

BACKGROUND

To determine the magnitude of difference between manufacturer-submitted and pan-Canadian Oncology Drug Review (pCODR) calculated incremental cost-effectiveness ratios (ICERs), incremental cost (ΔC), and incremental effectiveness (ΔE); to examine whether there is a significant difference in the proportion of ICERs deemed cost-effective; to evaluate trends in the ICERs over time; and to identify methodological issues in manufacturer-submitted economic models.

METHODS

Economic guidance reports for all drug indications submitted from July 2011-November 2018 were extracted from the pCODR database. Cumulative distribution plots were constructed to compare the manufacturer-submitted economic values with both the pCODR lower- and upper-reanalyzed estimates. The proportion of drug reviews considered cost-effective at varying willingness-to-pay (WTP) thresholds by the manufacturer and pCODR were calculated. Manufacturer changes in ICERs over time from 2012 to 2018 were determined. Recurring methodological issues with manufacturer submissions were tallied.

RESULTS

There were 73 unique indications that were included. Manufacturer-submitted ICERs were consistently lower than pCODR estimates for most indications. Manufacturer-submitted ICERs were generally more cost-effective over a range of WTP thresholds. From 2012 to 2018, manufacturer and economic guidance panel (EGP) lower limit reanalyzed ICERs did not change significantly over time. However, EGP upper limit re-analyses did show decreasing cost-effectiveness (increasing ICERs). The two most common issues identified in the manufacturer-submitted models were related to survival time horizon and utility estimates.

CONCLUSIONS

Manufacturers tend to overestimate the cost-effectiveness of their therapies when submitting economic models to pCODR. Although certain methodological issues are still common in manufacturer-submitted models, revision rates are high for most issues raised by pCODR.

Assessing the financial toxicity in Tunisian cancer patients using the Comprehensive Score for Financial Toxicity (COST)

BACKGROUND

Cancer care-related out-of-pocket expenses and financial toxicity (FT) are a rising burden for patients. We aimed to evaluate patient-reported FT and to identify relevant correlates within a Tunisian population.

METHODS

We conducted a survey using the 11-item Comprehensive Score for Financial Toxicity (COST) that could range from 0 = high to 44 = low. FT was grade 0 if ≥ 26, grade 1 = (14-25), grade 2 = (1-13), and grade 3 = 0. Scores were collected along with data regarding patient medical/social features and out-of-pocket expenses. Univariate and multivariate analyses were performed to identify factors associated with higher financial burden.

RESULTS

Among the 179 participants, median COST score was 20.8 (Q1 17-Q3 24), with 80.4% of patients experiencing financial toxicity: grade 0 = 20%, grade 1 = 68.4%, grade 2 = 11.7%, grade 3 = 0%. Most patients (66.5%) used to work before cancer and 44.7% reported ceasing work because of cancer. The time to go to the hospital was > 30 min in 66.5% of cases. Unemployment, time to hospital > 30 min, ceasing work because of cancer, and expenses on non-chemotherapy drugs exceeding 70 dinars (25 US dollars) were mostly associated with higher FT on univariate analysis. Distance to hospital and ceasing work because of cancer were the single most significant factors in multivariate analysis.

CONCLUSIONS

Losing work due to cancer and unequal distribution of health care particularly in cities with long travel times to the nearest hospital are the main sources of financial distress.

Out-of-pocket spending of deceased cancer patients in five European countries and Israel

OBJECTIVE

Cancer imposes a substantial economic burden on society, health and social care systems, patients and their families. This study aims to examine the out-of-pocket spending of cancer patients in their last year of life, in six countries with health insurance system hat have a defined benefits package.

METHODS

Data from SHARE and SHARE End-of-Life surveys among people aged +50 were analysed. Family members of deceased persons were interviewed in order to learn about the circumstances of their relative's death.

RESULTS

The average out-of-pocket spending for health and social services during the last year of life was 4.5% of the total household income, 2.2% in the Netherlands, 4.3% in Israel, 5% in Germany, 5.1% in Austria, 5.1% in Belgium and 8.2% in Switzerland. Whereas the out-of-pocket spending on nursing home care was 7.8% of the total household income in Switzerland, in the Netherlands and in Israel it was negligible. In contrast, the out-of-pocket spending for home care due to disability surged to 5.6% in Israel and 3.7% in Austria, whereas in other countries it was very low.

CONCLUSION

This information is important to health and social policymakers, in order to better adapt the benefits package to the patients' needs.

Financial Toxicity

Objective:

to identify evidence in the literature about financial toxicity in cancer patients during chemotherapy treatment.

Methods:

this is a mini review with search in the following databases: Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, National Library of Medicine and Scopus. Articles were surveyed from July 2018 to February 2019 using the following descriptors and Boolean operators: “financial toxicity” OR “financial difficulties” AND “cancer” AND “chemotherapy”.

Results:

the search totaled 64 articles. After exclusion of duplicates that did not meet the inclusion criteria, the final sample was composed of five articles published in 2013, 2015, 2017 and 2018. Financial difficulty caused by cancer treatment and its impact on quality of life was a frequent expression used in the studies.

Conclusion:

studies show that financial toxicity damages the quality of life of patients. A scarcity of studies on the subject was also observed, possibly because this is a new concept.

Serum exosomal miR-122 as a potential diagnostic and prognostic biomarker of colorectal cancer with liver metastasis

Background: Liver is the most common site for metastatic spread of CRC at the time of diagnosis which leads to high mortality. This study aimed to identify novel circulating exosomal miRNAs as biomarkers of colorectal cancer (CRC) with liver metastasis (LM).

Materials and methods: Candidate miRNAs were selected through integrated analysis of Gene Expression Omnibus (GEO) database as well as clinical samples. Exosomes isolated from serum and cultured media were identified by using transmission electron microscopy (TEM) and western blot. The expression levels and diagnostic value of candidate miRNAs were further tested and validated through qRT-PCR and receiver operating characteristic curve (ROC) analysis. The association of candidate miRNA expressions with patients' prognosis was analyzed with logistic regression and Cox proportional hazards regression models.

Results: After integrated analysis of three GEO datasets and clinical samples, miR-122 was discovered to be remarkably overexpressed in tissues of CRC patients. Then we revealed that elevated serum miR-122 was tumor-derived by being packaged into exosomes. The expressions of serum exosomal miR-122 were significantly upregulated in CRC patients, especially in those with LM. Serum exosomal miR-122 expressions could differentiate CRC patients with LM from healthy controls and patients without LM with area under the ROC curve (AUC) of 0.89 and 0.81. Uni- and multivariate logistic regression showed that serum exosomal miR-122 was an independent prognostic indicator of CRC patients.

Conclusions: Serum exosomal miR-122 was a novel potential diagnostic and prognostic biomarker in CRC patients with LM.

A multidisciplinary review of the policy, intellectual property rights, and international trade environment for access and affordability to essential cancer medications

In 2015, the World Health Organization (WHO) Expert Committee approved the addition of 16 cancer medicines to the WHO Model List of Essential Medicines (EML), bringing the total number of cancer medicines on the list to 46. This change represented the first major revision to the EML oncology section in recent history and reinforces international recognition of the need to ensure access and affordability for cancer treatments. Importantly, many low and middle-income countries rely on the EML, as well as the children’s EML, as a guide to establish national formularies, and moreover use these lists as tools to negotiate medicine pricing. However, EML inclusion is only one component that impacts cancer treatment access. More specifically, factors such as intellectual property rights and international trade agreements can interact with EML inclusion, drug pricing, and accessibility. To better understand this dynamic, we conducted an interdisciplinary review of the patent status of EML cancer medicines compared to other EML noncommunicable disease medicines using the 17th, 18th, 19th, 20th, and 21st editions of the list. We also explored the interaction of intellectual property rights with the international trade regime and how trade agreements can and do impact cancer treatment access and affordability. Based on this analysis, we conclude that patent status is simply one factor in the complex international environment of health systems, IPR policies, and trade regimes and that aligning these oftentimes disparate interests will require shared global governance across the cancer care continuum.

The evolving role of antiangiogenic therapies in glioblastoma multiforme: current clinical significance and future potential

Introduction: Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor in adults, but its prognosis remains poor despite significant advances in our understanding of its molecular biology and investigation of numerous treatment modalities. Despite conventional treatment consisting of surgical resection, radiotherapy, and temozolomide marginally prolonging survival, most GBM patients die within 2 years of initial diagnosis. Bevacizumab (Bev) is the best-studied antiangiogenic agent for GBM and currently the only FDA-approved second-line treatment. Areas covered: Areas covered in this review include the molecular pathways of angiogenesis in glioblastoma, specifically the overexpression of vascular endothelial growth factor (VEGF) and robust formation of tumor neovasculature. In addition, this review covers pharmacological targeting of this process as a longstanding attractive clinical strategy, specifically by Bev. Expert opinion: This review attempts to discuss the history of early studies of antiangiogenic treatment for GBM that eventually failed in subsequent studies and the evolving modern role of Bev in the course of treatment for a variety of indications, including symptom control, reduced glucocorticoid use, and improved quality of life.

The Economic Burden of Breast Cancer Survivors in Korea: A Descriptive Study Using a 26-Month Micro-Costing Cohort Approach

Background:

This study analyzed the burden of cancer treatment costs on patients by calculating the monthly amount of medical expenses paid by breast cancer patients for two years after mastectomy.

Methods:

Among those who were diagnosed with breast cancer and had received treatment at one of two academic medical centers in Seoul between 2003 and 2011, 1,087 patients who underwent mastectomy and received follow-up for at least two years were recruited. A micro-costing approach from the provider’s perspective, based on a retrospective review of patient medical claim records, was used to analyze cancer treatment cost of care. The cohort’s number of hospitalizations, total hospitalization duration, and number of outpatient visits were noted, and the total amount of medical expenses, out-of-pocket (OOP) expenditures, uninsured costs, and OOP ratio were calculated.

Results:

The total amount of medical expenses tended to increase by year, whereas the OOP expenditure ratio decreased. The OOP expenditure ratio was highest in the first month post-operation. Around one quarter of the total OOP payments incurred over the course of three months: one month before the operation, the month of the operation, and one month post-operation.

Conclusion:

OOP payment burden on patients was concentrated in the initial phase of treatment, and items not covered by the National Health Insurance caused an additional increase in patients’ burden in the initial phase. The economic burden of cancer treatment varies considerably. In order to alleviate patients’ medical expenses burden, the timing of expenditures and the possible financial burden on cancer survivors, they should be understood more fully and possibly addressed in interventions aimed at reducing the cancer burden.

Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications

Patients experiencing financial distress as a side-effect of cancer are not only reported in the United States, but also in third-party payer healthcare systems in Europe. Since validated survey instruments are a prerequisite for robust and comparable results, we aimed to compile and classify available instruments to enable both a better understanding of the underlying construct of financial toxicity and to facilitate further studies that are adjustable to various healthcare systems. We did a systematic literature search on studies that provide data on perceived cancer-related financial distress experienced by adult patients using PubMed, CINAHL and Web of Science databases up to 2018. We analyzed all detected instruments, items domains and questions with regard to their wording, scales and the domains of financial distress covered. Among 3298 records screened, 41 publications based on 40 studies matched our inclusion criteria. Based on the analysis of 352 different questions we identified 6 relevant subdomains that represent perceptions of and reactions to experienced financial distress: (i) active financial spending, (ii) use of passive financial resources, (iii) psychosocial responses, (iv) support seeking, (v) coping with care or (vi) coping with ones' lifestyle. We found an inconsistent coverage and use of these domains that makes it difficult to compare and quantify the prevalence of financial distress. Moreover, some existing instruments do not reflect relevant domains for patients in third-party payer systems. There is neither a consistent understanding of the construct of financial burden nor do available instruments cover all relevant aspects of a patients' distress perception. We encourage using the identified six domains to further develop survey instruments and adjust them to different health systems.

Concise Review: The High Cost of High Tech Medicine: Planning Ahead for Market Access

Cellular therapies and other regenerative medicines are emerging as potentially transformative additions to modern medicine, but likely at a staggering financial cost. Public health care systems’ budgets are already strained by growing and aging populations, and many private insurer's budgets are equally stretched. The current systems that most payers employ to manage their cash flow are not structured to absorb a sudden onslaught of very expensive prescriptions for a large portion of their covered population. Despite this, developers of new regenerative medicines tend to focus on the demands of regulators, not payers, in order to be compliant throughout the clinical trials phases, and to develop a product that ultimately will be approvable. It is not advisable to assume that an approved product will automatically become a reimbursed product, as examples from current practice in hematopoietic stem cell transplantation in the U.S. demonstrate; similarly, in Europe numerous Advanced‐therapy Medicinal Products achieved market authorization but failed to secure reimbursement (e.g., Glybera, Provenge, ChondroCelect, MACI). There are however strategies and approaches that developers can employ throughout clinical development, in order to generate clinical and health economic data which will be necessary to demonstrate the value proposition of the new product and help ensure market access for patients; furthermore, performance based managed entry agreements coupled with post‐launch evidence generation can help overcome challenges around product uncertainty at launch and reduce market access delays. Stem Cells Translational Medicine2017;6:1723–1729

Prevalence, Predictors, and Implications for Appropriate Use of Active Surveillance Management Among Black Men Diagnosed With Low-risk Prostate Cancer

BACKGROUND

Consensus guidelines recommend that active surveillance (AS) be considered in the management of men with low-risk prostate cancer (LRPC). The objective was to evaluate the prevalence and predictors of an AS approach in black men (BM) diagnosed with LRPC after inclusion of AS in LRPC consensus guidelines.

MATERIALS AND METHODS

BM and white men (WM) diagnosed with LRPC (prostate-specific antigen ≤10 ng/mL, Gleason score [GS] ≤6, clinical stage T1-T2a) between 2010 and 2013 were identified from the National Cancer Database. Logistic regression models were used to assess the likelihood of AS over time and to examine associations between sociodemographic characteristics (SDCs) and the receipt of AS. A subanalysis was performed to assess the likelihood of GS upgrading on prostatectomy specimens for cases that received definitive treatment with radical prostatectomy.

RESULTS

Overall, 9% of BM (N=15,242) with LRPC were managed with AS. The likelihood of BM undergoing AS increased from 2010 and for all subsequent years of the study period (P<0.001). Uninsured BM were twice as likely as those with private insurance to undergo AS (odds ratio [OR]=1.97; 95% confidence interval [CI], 1.51-2.58; P<0.001). BM were less likely than WM (N=86,655) to receive AS (OR=0.82; 95% CI, 0.77-0.87; P<0.001). However, on multivariate analysis adjusted for SDCs, there was no significant difference in AS utilization between the 2 race groups. Nearly half of BM (47.5%) treated with radical prostatectomy had a postprostatectomy GS≥7, and BM were 17% more likely to experience postprostatectomy upgrading to GS≥7 when compared with WM (OR=1.17; 95% CI, 1.08-1.26; P<0.001).

CONCLUSIONS

The utilization of AS for BM with LRPC seems to be increasing, is influenced by SDCs, and may not differ from AS utilization among WM. Careful consideration of prostate biopsy technique and sampling as well as SDCs at time of treatment planning may be necessary to ensure adequate evaluation of prostatic disease and appropriate disease management for BM with LRPC.

ZC3H12A Expression in Different Stages of Colorectal Cancer

Identification of CRC patients with early-stage disease provides the opportunity for curative local resection. However, robust markers for stage I tumor prediction are yet to be developed. We analyzed RNA-sequencing data of 221 CRC samples using the TCGA dataset to identify novel biomarkers for stage I CRC. We next validated the TCGA finding in an independent GEO cohort of 290 CRC patients and in a third cohort of 110 CRC tumors and matched normal samples. We further performed correlative analysis of ZC3H12A gene expression with clinicopathologic features and disease-free survival. Expression correlation of ZC3H12A with the chemokine ligands was evaluated via Student’s t-test. In the TCGA cohort, stage I CRC patients had significantly higher ZC3H12A mRNA expression as compared with the other three stages combined and with the other individual stages in a pairwise manner (P<0.001 for all comparisons). The significant association of ZC3H12A gene expression with stages was further validated in the GEO cohort and in the additional third cohort. In support of these findings, we further found that patients with lower ZC3H12A expression had more aggressive tumor features and shorter disease-free survival. Biologically, ZC3H12A expression was significantly correlated with expression of three chemokine ligands (CXCL1, CXCL2 and CXCL3), suggesting that immune response dysregulation likely contributes to CRC development. Our results demonstrate ZC3H12A’s potential role in identification of CRC patients with early-stage disease.

All that glitters is not gold: Panning cytotoxic natural products and derivatives with a fused tricyclic backbone by the estimation of their leadlikeness for cancer treatment

Tricyclic compounds call the attention because of their pharmacological properties, and are considered a preferred platform for the development of drugs. Especially, in cancer treatment, these planar compounds are known for their ability to stack with DNA base pairs, acting as intercalators. In this sense, natural products (NPs) are a prodigal source of polycyclic compounds, comprising classes, such as carbolines, anthraquinones and xanthones. However, most of these compounds lack suitable physico-chemical properties, compatible to oral bioaviability. In this perspective, this paper aims to overview the role of tricyclic cores in the development of cytotoxic compounds, focusing on the leadlikeness estimation of the most prominent NP classes and their synthetic derivatives.

Impact of Cost on the Safety of Cancer Pharmaceuticals

Cancer care drug costs are rising due to a variety of factors, and safety concerns account for some of the cost. At the same time, clinical and economic concerns drive drug safety improvements. This chapter examines pressures on drug costs due to the complexity of care and drug therapies, marked structure in which care is provided, and regulatory requirements driving safety.

Cancer survivors' needs during various treatment phases after multimodal treatment for colon cancer - is there a role for eHealth?

BACKGROUND

More colon cancer patients are expected to fully recover after treatment due to earlier detection of cancer and improvements in general health- and cancer care. The objective of this study was to gather participants' experiences with full recovery in the different treatment phases of multimodal treatment and to identify their needs during these phases. The second aim was to propose and evaluate possible solutions for unmet needs by the introduction of eHealth.

METHODS

A qualitative study based on two focus group discussions with 22 participants was performed. The validated Supportive Care Needs Survey and the Cancer Treatment Survey were used to form the topic list. The verbatim transcripts were analyzed with Atlas.ti. 7th version comprising open, axial and selective coding. The guidelines of the consolidated criteria for reporting qualitative research (COREQ) were used.

RESULTS

Experiences with the treatment for colon cancer were in general positive. Most important unmet needs were 'receiving information about the total duration of side effects', 'receiving information about the minimum amount of chemo needed to overall survival' and 'receiving a longer aftercare period (with additional attention for psychological guidance)'. More provision of information online, a chat function with the oncological nurse specialist via a website, and access to scientific articles regarding the optimal dose of chemotherapy were often mentioned as worthwhile additions to the current health care for colon cancer.

CONCLUSIONS

Many of the unmet needs of colon cancer survivors occur during the adjuvant treatment phase and thereafter. To further optimize recovery and cancer care, it is necessary to have more focus on these unmet needs. More attention for identifying patients' problems and side-effects during chemotherapy; and identifying patients' supportive care needs after finishing chemotherapy are necessary. For some of these needs, eHealth in the form of blended care will be a possible solution.

Access to innovative cancer medicines in a middle-income country - the case of Mexico

BACKGROUND

Cancer has become the third cause of death in Mexico. Treatment for cancer is often complex and lengthy. New and better medicines enter the market at high prices, which may limit access. Like most Latin American countries, Mexico has an essential cancer medicines list that includes innovative medicines. Their accessibility and use in the public sector remains unknown. Therefore, we describe the use, as a proxy of access, of innovative and essential cancer medicines in the public sector in Mexico, by insurance institution, and by five regions between 2010 to 2016.

METHODS

We used drug utilization research methods to assess the use of eight patented cancer medicines. Through the national transparency platform, we obtained data on the quantities of these medicines used in all public health facilities and social health insurance institutions and recalculated those figures into defined daily dose (DDD) per 1000 population per year.

RESULTS

Overall, the use of all medicines increased over the years, especially for trastuzumab, rituximab and imatinib. The use of innovative medicines was higher per population covered in social health insurance institutions than in governmental facilities. Throughout the study period, the Central region (including Mexico City) has used more medicines per population than the other regions.

CONCLUSIONS

The use and access of some essential innovative cancer medicines has increased over the years, but remains unequal across insurance schemes and regions. Particularly, the Ministry of Health Insurance scheme and Northern and Western regions in the country would benefit from additional efforts to increase access to essential cancer medicines.

Trends in Antineoplastic Receipt after Medicare Payment Reform: Implications for Future Oncology Payment Design

Background

The Medicare Modernization Act (MMA) reduced reimbursement for many antineoplastics delivered in outpatient settings, altering practice patterns for some cancers. To further evaluate the MMA's effect, we focus on colon cancer, where longstanding fluorouracil-based regimens were augmented in 2004 with 3 newly-approved drugs (oxaliplatin, bevacizumab, and/or cetuximab). Staggered implementation of MMA reimbursement changes (physician offices implemented reimbursement changes in 2005 vs hospital outpatient departments(OPD) in 2006) provide a natural experiment to examine policy effects.

Methods

Using the 2000-2009 SEER-Medicare data, we examined antineoplastic use among 59,642 stage II-IV colon cancer patients. Using multivariate logistic regression models, we conducted difference-in-differences analyses to examine an interaction between time (pre-post MMA) and setting (physician offices versus OPDs) on antineoplastic receipt, adjusting for patient and cancer characteristics. A significant interaction indicates different practice patterns in physician offices versus OPD during the staggered implementation.

Results

After the reimbursement change in 2007-09 relative to 2000-03, use of fluorouracil-based therapy decreased slightly (Marginal Probability(MP): -0.07 stage II; -0.05 stage III; -0.05 stage IV; p< 0.01), while use of new drugs increased substantially (MP: 0.48 stage II; 0.69 stage III, 0.79 stage IV; p< 0.01). The interaction between MMA implementation and physician office setting was significant when examining use of new agents for Stage IV disease only.

Conclusions

Our results indicate that providers responded to reimbursement changes after the MMA by increasing use of newly approved agents, but the magnitude of the response was small and limited to individuals diagnosed with Stage IV disease.

Spending Among Patients With Cancer in the First 2 Years of Accountable Care Organization Participation

Purpose

Spending on patients with cancer can be substantial and has continued to increase in recent years. Accountable Care Organizations (ACOs) are arguably the most important national experiment to control health care spending, yet how ACOs are managing patients with cancer diagnoses is largely unknown. We aimed to determine whether practices that became ACOs had changes in overall or cancer-specific spending among patients with cancer.

Methods

Using 2011 to 2015 national Medicare claims, practices that became part of ACOs were identified and matched to non-ACO practices within the same geographic region. We calculated total and category-specific annual spending per beneficiary as well as spending for and utilization of emergency departments, inpatient admissions, hospice, chemotherapy, and radiation therapy. A difference-in-differences model was used to examine changes in spending and utilization associated with ACO contracts in the Medicare Shared Savings Program for beneficiaries with cancer.

Results

We found that the introduction of ACOs had no meaningful impact on overall spending in patients with cancer (−$308 per beneficiary in ACOs v −$319 in non-ACOs; difference, $11; 95% CI, −$275 to $297; P = .94). We found no changes in total spending in patients within any of the 11 different cancer types examined. Finally, changes in spending and utilization did not meaningfully differ between ACO and non-ACO patients within various categories, including cancer-specific categories.

Conclusion

Compared with patients with cancer treated at non-ACO practices, being a patient with a cancer diagnosis in a Medicare ACO is not associated with significantly reduced spending or heath care utilization. The introduction of ACOs does not seem to have had any meaningful effect on spending or utilization for patients with a cancer diagnosis.

Expanding the Scope of Evidence-Based Cancer Care

This article explores how oncology research can be expanded to ensure that research spending results in maximum benefit. The focus has shifted to the value and quality of care, which view cancer care with the perspective of the patient at the center and cover the spectrum of care. Because there is no agreed-upon definition for value in cancer care, we overview various contributions to defining value and quality in oncology. We outline how cancer care costs are measured in the United States and explore outcome measures that have been proposed and implemented to enable us to assess value in oncology.

Impact of psychiatric comorbidities on health care utilization and cost of care in multiple myeloma

Approximately one third of cancer patients suffer from comorbid mood disorders that are associated with increased cost and poorer outcomes. The majority of patients with multiple myeloma (MM) are treated with corticosteroids; as many as three fourths of those taking corticosteroids develop neuropsychiatric complications, likely increasing morbidity and cost of care. MM patients diagnosed between 1991 and 2010 and reported in the Surveillance Epidemiology, and End Results-Medicare database were characterized as MM-Only, MM+Psychiatric (any psychiatric condition, preexisting or post-MM), or MM+Depression (depression as the only psychiatric diagnosis, preexisting or post-MM). Differences in demographic characteristics, occurrence of clinical myeloma-defining events (MDEs), health care utilization (inpatient, outpatient, ambulatory claims), and cost of care during the first 6 months of MM diagnosis were analyzed. Psychiatric comorbidities were reported more frequently in females, and racial minorities had lower rates of psychiatric comorbidities. All clinical MDEs were more common in the MM+Psychiatric and MM+Depression groups; within them, the majority were more common in patients diagnosed with the psychiatric condition or depression after MM compared with it being a preexisting condition. Health care utilization in all treatment settings was higher in those with psychiatric comorbidities. Cost of care within the first 6 months after MM diagnosis was significantly higher in the MM+Psychiatric and MM+Depression groups. This increase in cost was more pronounced for patients from racial minorities diagnosed with a psychiatric condition, including depression. Psychiatric comorbidities significantly impact the clinical presentations, health care utilization, and cost among patients with MM. These findings need to be addressed for improved survivorship of MM patients.

Short-term survival after colorectal cancer in a screened versus unscreened population

Aims: United States' (US) colorectal cancer (CRC) screening and treatment practices seek to reduce mortality. We examined the survival of US patients compared with patients in the virtually unscreened Norwegian population. Methods: We compared short-term survival after CRC between the US and Norway using relative survival (RS) and excess mortality (EMR) analyses. The CRC patients were aged 50 and older diagnosed in the US (Surveillance, Epidemiology and End Results registry, 2004, N=9511) and in Norway (Cancer Registry of Norway, 2003-2005, N=8256). Results: Death occurred within three years for 39% of the CRC patients. Stage distributions were more favorable for US patients. Stage-specific survival was similar for localized and regional cancers, but more favorable for US distant cancers. In multivariate models of patient, tumor and treatment characteristics, patients (especially below age 80) in the US experienced longer survival (EMR 0.9, CI 0.8-0.9). Stage-specific analyses showed, however, that survival for localized cancers was relatively shorter in the US than in Norway (EMR 1.4, CI 1.1-1.8), but longer for distant cancers (EMR 0.8, CI 0.7-0.8). Conclusions: The enhanced survival for US CRC patients likely reflects a screening-related earlier diagnostic stage distribution, as well as prioritized life extension for patients with metastatic cancers, reflecting vastly different health care systems in the two countries. CRC screening is currently under consideration in Norway. For survival outcomes, the current findings do not discourage such an implementation. Other screening-related aspects such as feasibility and cost-benefit are, however, also relevant and warrant further research within a socialized health system.