Impact of metastatic colorectal cancer stage and number of treatment courses on patient health care costs and utilization

Cost of treating metastatic colorectal cancer: a systematic review

OBJECTIVE

The cost of treating metastatic colorectal cancer places a significant economic burden on individuals, populations, and health care. However, there is a paucity of information on the costs of the contemporary management of metastatic colorectal cancer. This systematic review aims to review the literature to estimate the direct cost of treating metastatic colorectal cancer.

STUDY DESIGN

Systematic review.

METHODS

MEDLINE, Embase, Web of Science, Evidence-Based Medicine Reviews: National Health Service Economic Evaluation Database Guide, EconLit, and grey literature from the 1st of January 2000 to the 1st of February 2020 were all searched for studies reporting the direct costs of treating metastatic colorectal cancer. The methodological quality of the included studies was assessed using the Evers' Consensus on Health Economic Criteria checklist.

RESULTS

In total, 39,489 records were retrieved, and 29 studies were included. Costs of treating metastatic colorectal cancer varied because of the heterogeneity of treatment. Studies reported average costs ranged from $12,346 to $293,461. Studies that included the cost of systemic therapy reported an estimated cost of almost $300,000.

CONCLUSION

The existing evidence indicates that the cost of treating metastatic colorectal cancer places a significant economic burden on healthcare systems despite differences in methodology and treatment heterogeneity. Future research needs to define the cost components of treating metastatic colorectal cancer to improve comparability and examine the relationship between spending, overall survival, and quality of life. Identifying these costs and their impact on health care budgets can help policymakers plan health system expenditure.

The impact of COVID-19 pandemic in the colorectal cancer prevention

BACKGROUND

The coronavirus disease 2019 (COVID-19) has led to a policy of severe restrictions in almost all countries strongly involved by the pandemic. National Health System is among activities suffering from the COVID-19 and the lockdown.

AIM

To evaluate the impact of COVID-19 in colorectal cancer (CRC) prevention.

METHODS

We report the change in the hospital organization to meet the growing healthcare needs determined by COVID-19. The limitations of CRC prevention secondary to COVID-19 and their effects on the healthcare are analyzed considering the features of the CRC screening programs in the average-risk population and endoscopic surveillance in patients with inflammatory bowel diseases (IBD).

RESULTS

The interruption of CRC prevention may lead to a delayed diagnosis of CRC, possibly in a more advanced stage. The economic burden and the impact on workload for gastroenterologists, surgeons, and oncologists will be greater as long as the CRC prevention remains suspended. To respond to the increased demand for colonoscopy once COVID-19 will be under control, we should optimize the resources. It will be necessary to stratify the CRC risk and reach an order of priority. It should be implemented the number of health workers, equipment, and spaces dedicated to performing colonoscopy for screening purpose and in subjects with alarm symptoms in the shortest time. To this aim, the funds earmarked for healthcare should be increased.

CONCLUSION

The economic impact will be dramatic, but COVID-19 is the demonstration that healthcare has to be the primary goal of humans.

Management and intensity of medical end-of-life care in people with colorectal cancer during the year before their death in 2015: A French national observational study

The care pathway of patients with colorectal cancer (CRC) 1 year prior to death, their causes of death and the healthcare use, and associated expenditure remain poorly described together. People managed for CRC (2014‐2015), covered by the national health insurance general scheme and who died in 2015 were selected from the national health data system. A total of 15 361 individuals (mean age: 75 years, SD: 12.5 years) were included, almost 66% of whom died in short‐stay hospital (SSH), 9% in hospital at home (HaH), 4% in rehabilitation units (Rehab), 6% in skilled nursing homes (SNH), and 15% at home. At least one other cancer was identified for one‐third of these people. Almost one‐half of people presented cardiovascular comorbidity, 21% had chronic respiratory disease, and 13% had a neurological or degenerative disease. During the last month of life, 83% were admitted at least once to SSH, 39% had at least one emergency department admission, 17% were admitted to an intensive care unit, 15% received at least one chemotherapy session (<60 years: 27%), and 5% received oral chemotherapy. Eighty‐eight percent of the 60% of individuals who received hospital palliative care (HPC) vs 75% of those without HPC were admitted to SSH at least once during the last month. Cancer was the main cause of death for 84% (SSH: 85%, home: 77%) and corresponded to CRC for 64% of them. The mean annual expenditure per person during the last year of life was €43 398 (SSH: €48 804). This study suggests a relatively high level of HPC use during the year before death for people with CRC in France. High rates of emergency department, intensive care, and chemotherapy use were observed during the last month of life. However, management is very largely SSH‐based with a small proportion of deaths at home.

Financial Toxicity in Advanced and Metastatic Cancer: Overburdened and Underprepared

Patients with metastatic or advanced cancer are likely to be particularly susceptible to financial hardship for reasons related both to the characteristics of metastatic disease and to the characteristics of the population living with metastatic disease. First, metastatic cancer is a resource-intensive condition with expensive treatment and consistent, high-intensity monitoring. Second, patients diagnosed with metastatic disease are disproportionately uninsured and low income and from racial or ethnic minority groups. These vulnerable subpopulations have higher cancer related financial burden even in earlier stages of illness, potentially resulting from fewer asset reserves, nonexisting or less generous health insurance benefits, and employment in jobs with less flexibility and fewer employment protections. This combination of high financial need and high financial vulnerability makes those with advanced cancer an important population for additional study. In this article, we summarize why financial toxicity is burdensome for patients with advanced disease; review prior work in the metastatic or advanced settings specifically; and close with implications and recommendations for research, practice, and policy.

SIR-Spheres® Y-90 resin microspheres in chemotherapy refractory or intolerant patients with metastatic colorectal cancer

Selective internal radiation therapy is a form of intra-arterial brachytherapy used to treat primary liver cancer and liver metastases. This article aims to provide an overview of the clinical, economic, organizational legal, social and ethical impact of selective internal radiation therapy using SIR-Spheres Y-90 resin microspheres in the treatment of patients with unresectable, liver-dominant metastatic colorectal cancer who are refractory to or intolerant of chemotherapy. A systematic literature review was performed by querying PubMed, Scopus, EBSCO, CRD and GIN. Two reviewers blindly screened the records retrieved against predefined inclusion/exclusion criteria. The selected studies where summarized following a simplified version of the EuNetHTA Core Model® 2.1. The studies included evaluated selective internal radiation therapy in first-line or further-line treatment and showed a good safety and tolerability profile and significant improvement in efficacy expressed as time to liver progression, progression-free survival and overall survival. Selective internal radiation therapy should be provided in specialized centres and administered by a multidisciplinary team. A hub-and-spoke network could be a viable option to guarantee access to this technology across jurisdictions. The lack of a specific diagnosis-related group tariff accounting for the cost of the device could be seen as the major obstacle to a fair diffusion of this technology. The economic evaluations currently available show the cost-effectiveness of this technology in the population under study. Selective internal radiation therapy using SIR-Spheres Y-90 resin microspheres appears to be a clinically effective and cost-effective option in the treatment of metastatic colorectal cancer patients who are chemotherapy refractory or chemotherapy intolerant.

Direct medical cost associated with colorectal cancer in north of Jordan

Colorectal cancer (CRC) is mainly characterized as the malignant and impaired growth of rectal cells in the intestinal region. Direct medical cost is related to resources, which are directly used in treating the patient, that mainly includes the cost of drugs, diagnostic, treatment, follow-up, rehabilitation, and hospital admission. The objective of this study is to estimate and analyze direct medical costs attributable to CRC in Jordan. A retrospective analysis of a cohort patients treated for CRC data has been performed to determine direct medical costs attributable to CRC in Jordan. The prevalence-based approach has been used in addition to the "bottom up" approach to accumulate 1-year time costs of CRC. Demographic, clinical, and economic data have been collected and analyzed using SPSS for windows. Costs were estimated by a bottom-up approach, in which each service component was identified and valued at the most detailed level, to provide greater transparency and reliability in economic evaluation of health care services. This study quantified the economic burden associated with CRC by Jordanian patients in King Abdullah University Hospital from the perspective of health care providers (public sector). Total CRC cost in the year 2014 was estimated to JD 695,608, and the most expensive stage for all sites was stage 4 reaching a cost of JD 5147. Advanced disease stages were associated with an increase in total cost and chemotherapy costs. In conclusion, results of this study propose that direct medical costs associated with CRC are considerable. Most of the cost was devoted for medications, primarily chemotherapy. Advanced stages were associated with higher cost and largest number of patients.

Characteristics and treatment patterns among US patients with hairy cell leukemia: a retrospective claims analysis

AIM

Describe hairy cell leukemia (HCL) treatment patterns using a large, nationally representative US database.

PATIENTS & METHODS

Adults newly diagnosed with HCL (1 January 2006 to 30 June 2014) with continuous health plan enrollment ≥180 days pre- and 90 days post-diagnosis were identified from the QuintilesIMS PharMetrics Plus Health Plan Claims Database. Treatment patterns by line of therapy were assessed over the variable follow-up.

RESULTS

Among 749 HCL patients (77.4% male; mean age 55.6; mean 32.3 months follow-up), only 37.7% initiated first-line therapy during the available follow-up in a mean of 4.4 months following diagnosis; the majority (75.5%) received cladribine (mean duration 7.3 days). Thirty-eight patients (5.1%) received second-line treatment.

CONCLUSION

Over 2.7 years follow-up, more than a third of patients initiated first-line therapy which appeared to provide a long-lasting response.

Cost-Effectiveness of Treatment Sequences of Chemotherapies and Targeted Biologics for Elderly Metastatic Colorectal Cancer Patients

BACKGROUND

Treatment patterns for metastatic colorectal cancer (mCRC) patients have changed considerably over the last decade with the introduction of new chemotherapies and targeted biologics. These treatments are often administered in various sequences with limited evidence regarding their cost-effectiveness.

OBJECTIVE

To conduct a pharmacoeconomic evaluation of commonly administered treatment sequences among elderly mCRC patients.

METHODS

A probabilistic discrete event simulation model assuming Weibull distribution was developed to evaluate the cost-effectiveness of the following common treatment sequences: (a) first-line oxaliplatin/irinotecan followed by second-line oxaliplatin/irinotecan + bevacizumab (OI-OIB); (b) first-line oxaliplatin/irinotecan + bevacizumab followed by second-line oxaliplatin/irinotecan + bevacizumab (OIB-OIB); (c) OI-OIB followed by a third-line targeted biologic (OI-OIB-TB); and (d) OIB-OIB followed by a third-line targeted biologic (OIB-OIB-TB). Input parameters for the model were primarily obtained from the Surveillance, Epidemiology, and End Results-Medicare linked dataset for incident mCRC patients aged 65 years and older diagnosed from January 2004 through December 2009. A probabilistic sensitivity analysis was performed to account for parameter uncertainty. Costs (2014 U.S. dollars) and effectiveness were discounted at an annual rate of 3%.

RESULTS

In the base case analyses, at the willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life-year (QALY) gained, the treatment sequence OIB-OIB (vs. OI-OIB) was not cost-effective with an incremental cost-effectiveness ratio (ICER) per patient of $119,007/QALY; OI-OIB-TB (vs. OIB-OIB) was dominated; and OIB-OIB-TB (vs. OIB-OIB) was not cost-effective with an ICER of $405,857/QALY. Results similar to the base case analysis were obtained assuming log-normal distribution. Cost-effectiveness acceptability curves derived from a probabilistic sensitivity analysis showed that at a WTP of $100,000/QALY gained, sequence OI-OIB was 34% cost-effective, followed by OIB-OIB (31%), OI-OIB-TB (20%), and OIB-OIB-TB (15%).

CONCLUSIONS

Overall, survival increases marginally with the addition of targeted biologics, such as bevacizumab, at first line and third line at substantial costs. Treatment sequences with bevacizumab at first line and targeted biologics at third line may not be cost-effective at the commonly used threshold of $100,000/QALY gained, but a marginal decrease in the cost of bevacizumab may make treatment sequences with first-line bevacizumab cost-effective. Future economic evaluations should validate the study results using parameters from ongoing clinical trials.

DISCLOSURES

This study was supported in part by a grant from the Agency for Healthcare Research and Quality (R01-HS018956) and in part by a grant from the Cancer Prevention and Research Institute of Texas (RP130051), which were obtained by Du. The authors report no conflicts of interest. Study concept and design were primarily contributed by Parikh, along with the other authors. All authors participated in data collection, and Parikh took the lead in data interpretation and analysis, along with Lairson and Morgan, with assistance from Du. The manuscript was written primarily by Parikh, along with Lairson, Morgan, and Du, and revised by Parikh.

Clinical and economic outcomes by first-line treatment among women with HR+/HER2- metastatic breast cancer in a large US health plan database

BACKGROUND

Guidelines recommend that women with hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) metastatic breast cancer (mBC) initiate hormonal therapy before chemotherapy. This study compared outcomes of women with mBC who received chemotherapy first vs hormonal therapy.

METHODS

A retrospective cohort study of women with mBC was conducted using a large US commercial health plan database between January 1, 2008-April 30, 2013. Subjects had evidence of a HR+/HER2- tumor sub-type in a cancer registry and use of chemotherapy or hormonal therapy in claims. Subjects were continuously enrolled for ≥6 months after metastasis and assigned to cohorts for receiving chemotherapy only or hormonal therapy only during first-line (CT-1L vs HT-1L). Adjusted incidence rates of clinically significant events were compared using a negative binomial model, and adjusted healthcare costs were compared using a generalized linear model.

RESULTS

Three hundred and twenty-four women with HR+/HER2- mBC met the selection criteria; 179 (55%) received CT-1L and 145 (45%) received HT-1L. Mortality rates did not differ between cohorts (unadjusted incidence rate ratio (IRR) = 1.67, 95% CI = 0.82-3.46; adjusted IRR = 0.64, 95% CI = 0.32-1.27). Adjusted average total all-cause healthcare costs were $11 090 for women with CT-1L and $6743 for women with HT-1L (cost ratio =1.64, 95% CI =1.36-1.99).

CONCLUSIONS

Observed use of first-line chemotherapy (>50%) was higher than expected given the HR + molecular profile of the tumors. Chemotherapy use during first-line did not appear to be associated with a survival benefit, but was associated with significantly higher costs compared with the use of hormonal therapy during first-line; however, this comparison is limited by demographic and baseline characteristic differences between the two cohorts. This study contributes to understanding real-world treatment patterns and the associated clinical and economic outcomes of using chemotherapy vs hormonal therapy as a first-line treatment option for the HR+/HER2- mBC population.

Inhibition of Wnt Signaling by Silymarin in Human Colorectal Cancer Cells

Silymarin from milk thistle (Silybum marianum) has been reported to show an anti-cancer activity. In previous study, we reported that silymarin induces cyclin D1 proteasomal degradation through NF-κB-mediated threonine-286 phosphorylation. However, mechanism for the inhibition of Wnt signaling by silymarin still remains unanswered. Thus, we investigated whether silymarin affects Wnt signaling in human colorectal cancer cells to elucidate the additional anti-cancer mechanism of silymarin. Transient transfection with a TOP and FOP FLASH luciferase construct indicated that silymarin suppressed the transcriptional activity of β-catenin/TCF. Silymarin treatment resulted in a decrease of intracellular β-catenin protein but not mRNA. The inhibition of proteasome by MG132 and GSK3β inhibition by SB216763 blocked silymarin-mediated downregulation of β-catenin. In addition, silymarin increased phosphorylation of β-catenin and a point mutation of S33Y attenuated silymarin-mediated β-catenin downregulation. In addition, silymarin decreased TCF4 and increased Axin expression in both protein and mRNA level. From these results, we suggest that silymarin-mediated downregulation of β-catenin and TCF4 may result in the inhibition of Wnt signaling in human colorectal cancer cells.

Patterns of Treatment Sequences in Chemotherapy and Targeted Biologics for Metastatic Colorectal Cancer: Findings from a Large Community-Based Cohort of Elderly Patients

Background

Over the last decade, multiple chemotherapies/targeted biologics have been approved for metastatic colorectal cancer (mCRC). However, evidence is limited with regards to the array of treatments received by mCRC patients.

Objective

This study examines treatment sequences (first- to third-line chemotherapy/targeted biologics) and the factors associated with first-line targeted biologics and common treatment sequences for elderly mCRC patients treated in a community setting.

Methods

A retrospective cohort study was conducted in mCRC patients diagnosed from January 2004 through December 2009 using the Surveillance, Epidemiology and End Results Medicare-linked database. The treatment sequences administered to elderly mCRC patients were empirically identified.

Results

Of 4418 mCRC patients who received treatment, 1370 (31 %) received first, second, and third line; 1164 (26 %) received first and second line; and 1884 (43 %) received only first line. The most common first line of treatment for mCRC patients was 5-fluorouracil/leucovorin + oxaliplatin (FOLFOX) + bevacizumab (23 %) and FOLFOX (23 %). 5-fluorouracil/leucovorin + irinotecan (FOLFIRI)-based regimens were commonly (22 %) administered in second line. The most common treatment sequence was first-line oxaliplatin or irinotecan followed by second-line oxaliplatin or irinotecan + bevacizumab followed by a third-line targeted biologic. Of patients who received first-line therapy, 47 % also received a targeted biologic, and the factors associated were age, comorbidity score, cancer site, geographic location, and year of diagnosis.

Conclusion

Elderly mCRC patients receive a multitude of treatments in various sequences. Further exploration of the comparative effectiveness of treatment sequences may yield important information for improving mCRC survival.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0059-9) contains supplementary material, which is available to authorized users.

Luffa echinata Roxb. Induced Apoptosis in Human Colon Cancer Cell (SW-480) in the Caspase-dependent Manner and Through a Mitochondrial Apoptosis Pathway

BACKGROUND

Luffa echinata Roxb. (LER) (Cucurbitaceae) showed tremendous medicinal importance and are being used for the treatment of different ailments.

OBJECTIVE

In this study, the antiproliferative properties and cell death mechanism induced by the extract of the fruits of LER were investigated.

MATERIALS AND METHODS

MTT and LDH assay were used to test the antiproliferative and cytotoxicity of LER extract, respectively. The intracellular ROS were measured by a fluorometric assay. The expression of several apoptotic-related proteins in SW-480 cells treated by LER was evaluated by Western blot analysis.

RESULTS

The methanolic extract of LER fruits inhibited the proliferation of human colon cancer cells (SW-480) in both dose- and time-dependent manners. The LER-treated cells showed obvious characteristics of cell apoptosis, including cell shrinkage, destruction of the monolayer, and condensed chromatin. In addition, treatments of various concentrations of LER extracts caused the release of lactate dehydrogenase as a dose-dependent manner via stimulation of the intracellular metabolic system. LER induced apoptosis, DNA fragmentation, and cellular ROS accumulation in SW-480 cells. Treatment of LER on SW-480 cells promoted the expression of caspases, Bax, Bad, and p53 proteins and decreased the levels of Bcl-2 and Bcl-XL.

CONCLUSIONS

These results indicated that treatment with LER-induced cell death in mitochondrial apoptosis pathway by regulating pro-apoptotic proteins via the up regulation of the p53 protein. These findings highlight the potentials of LER in the treatment of human colon cancer.

SUMMARY

LER induced apoptosis, DNA fragmentation, and cellular ROS accumulation in SW-480 cells. Treatment of LER on SW-480 cells promoted the expression of caspases, Bax, Bad, and p53 proteins and decreased the levels of Bcl-2 and Bcl-XL.

Systemic therapy for colorectal cancer: patterns of chemotherapy and biologic therapy use in nationally representative US claims database

BACKGROUND

Treatment strategies for colorectal cancer (CRC) are highly variable. The aim of this study is to examine the patterns of chemotherapy and biologic therapy use for CRC patients in a national medical claims database.

METHODS

A retrospective and observational analysis was performed using the i3 Innovus claims database to identify healthcare services consumed by patients aged 18 years and older, diagnosed with CRC between 1 January 2005 and 30 June 2009 in commercial health plans.

RESULTS

Of 9,876 subjects diagnosed with CRC, fluorouracil (23.5 %) and capecitabine (10.0 %) were the dominant first-line monotherapies, followed by bevacizumab (3.2 %) and oxaliplatin (2.9 %). The most common combination regimen at first line and first and second line was FOLFOX (fluorouracil, leucovorin, and oxaliplatin; more than 25 %). The combinations FOLFIRI (fluorouracil, leucovorin, and irinotecan) plus bevacizumab (14.2 %) and FOLFOX plus bevacizumab (13.9 %) were significantly more frequent in third and successive lines of CRC therapy than other regimens (χ(2) = 191.2; P < 0.01). Additionally, the average annualized cost of CRC treatment for all patients was $US66,452, and the adjusted analysis demonstrated that patients receiving FOLFOX-A (FOLFOX + avastin) or FOLFIRI-A (FOLFIRI + avastin) had higher costs for CRC treatment.

CONCLUSIONS

With the exception of a sizeable portion of patients on monotherapy, the treatment patterns for CRC were largely consistent with National Comprehensive Cancer Network (NCCN) guidelines.

Emodin suppresses Wnt signaling in human colorectal cancer cells SW480 and SW620

Wnt signaling is involved in the regulation of cell proliferation, differentiation and apoptosis. Its aberrant activation is a key event in the pathogenesis and progression of human colorectal cancers. Dietary phytochemicals are gaining importance as chemotherapeutic agents owing to their potential to prevent, delay or reverse oncogenesis. Here we demonstrate that emodin (1,3,8-trihydroxy-6-methylanthraquinone), an anthraquinone present in the roots and bark of several medicinal plants, down regulates Wnt signaling pathway in human colorectal cancer cells (SW480 and SW620) by down regulating TCF/LEF transcriptional activity. Emodin significantly down regulated the expression of key players of Wnt signaling (β-catenin and TCF7L2) and also that of its various downstream targets (cyclin D1, c-Myc, snail, vimentin, MMP-2 and MMP-9). Two novel targets of emodin׳s action were discovered namely Wnt co-activator p300 (down regulated) and repressor HBP1 (up regulated). Morphological changes induced by emodin suggest mesenchymal to epithelial transition accompanied by the increase in E-cadherin expression in human colorectal cancer cells but a differentiation marker (alkaline phosphatase) was activated only in SW620 cells (metastatic origin) and not in SW480 cells (primary tumor-derived). Moreover, our data indicate that reactive oxygen species plays a key role in emodin-mediated down regulation of Wnt signaling as emodin-mediated inhibition of migration and induction of growth arrest were partially rescued by the reactive oxygen species scavenger ascorbic acid. Effects of emodin shown in this study may provide important insights for the use of this anthraquinone as a potential complementary and integrated medicine for the treatment of human colorectal cancer.