1
|
Lee DJ, El-Khoury H, Tramontano AC, Alberge JB, Perry J, Davis MI, Horowitz E, Redd R, Sakrikar D, Barnidge D, Perkins MC, Harding S, Mucci L, Rebbeck TR, Ghobrial IM, Marinac CR. Mass spectrometry-detected MGUS is associated with obesity and other novel modifiable risk factors in a high-risk population. Blood Adv 2024; 8:1737-1746. [PMID: 38212245 PMCID: PMC10997907 DOI: 10.1182/bloodadvances.2023010843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/31/2023] [Accepted: 11/11/2023] [Indexed: 01/13/2024] Open
Abstract
ABSTRACT Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant condition of multiple myeloma with few known risk factors. The emergence of mass spectrometry (MS) for the detection of MGUS has provided new opportunities to evaluate its risk factors. In total, 2628 individuals at elevated risk for multiple myeloma were enrolled in a screening study and completed an exposure survey (PROMISE trial). Participant samples were screened by MS, and monoclonal proteins (M-proteins) with concentrations of ≥0.2 g/L were categorized as MS-MGUS. Multivariable logistic models evaluated associations between exposures and MS outcomes. Compared with normal weight (body mass index [BMI] of 18.5 to <25 kg/m2), obesity (BMI of ≥30 kg/m2) was associated with MS-MGUS, adjusting for age, sex, Black race, education, and income (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.21-2.47; P = .003). High physical activity (≥73.5 metabolic equivalent of task (MET)-hours per week vs <10.5 MET-hours per week) had a decreased likelihood of MS-MGUS (OR, 0.45, 95% CI, 0.24-0.80; P = .009), whereas heavy smoking and short sleep had increased likelihood of MS-MGUS (>30 pack-years vs never smoker: OR, 2.19; 95% CI, 1.24-3.74; P = .005, and sleep <6 vs ≥6 hours per day: OR, 2.11; 95% CI, 1.26-3.42; P = .003). In the analysis of all MS-detected monoclonal gammopathies, which are inclusive of M-proteins with concentrations of <0.2 g/L, elevated BMI and smoking were associated with all MS-positive cases. Findings suggest MS-detected monoclonal gammopathies are associated with a broader range of modifiable risk factors than what has been previously identified. This trial was registered at www.clinicaltrials.gov as #NCT03689595.
Collapse
Affiliation(s)
- David J. Lee
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Habib El-Khoury
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Jean-Baptiste Alberge
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jacqueline Perry
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Maya I. Davis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Erica Horowitz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Redd
- Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | - Lorelei Mucci
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Timothy R. Rebbeck
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Irene M. Ghobrial
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Center for Early Detection and Interception of Blood Cancers, Dana-Farber Cancer Institute, Boston, MA
| | - Catherine R. Marinac
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Center for Early Detection and Interception of Blood Cancers, Dana-Farber Cancer Institute, Boston, MA
| |
Collapse
|
2
|
Paudel R, Tramontano AC, Cronin C, Wong SL, Dizon DS, Jenkins HH, Bian J, Osarogiagbon RU, Schrag D, Hassett MJ. Assessing Patient Readiness for an Electronic Patient-Reported Outcome-Based Symptom Management Intervention in a Multisite Study. JCO Oncol Pract 2024; 20:77-84. [PMID: 38011613 PMCID: PMC10827290 DOI: 10.1200/op.23.00339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/08/2023] [Accepted: 10/16/2023] [Indexed: 11/29/2023] Open
Abstract
PURPOSE While the use of electronic patient-reported outcomes (ePROs) in routine clinical practice is increasing, barriers to patient engagement limit adoption. Studies have focused on technology access as a key barrier, yet other characteristics may also confound readiness to use ePROs including patients' confidence in using technology and confidence in asking clinicians questions. METHODS To assess readiness to use ePROs, adult patients from six US-based health systems who started a new oncology treatment or underwent a cancer-directed surgery were invited to complete a survey that assessed access to and confidence in the use of technology, ease of asking clinicians questions about health, and symptom management self-efficacy. Multivariable ordinal logistic regression models were fit to assess the association between technology confidence, ease of asking questions, and symptom management self-efficacy. RESULTS We contacted 3,212 individuals, and 1,043 (33%) responded. The median age was 63 years, 68% were female, and 75% reported having access to patient portals. Over 80% had two or more electronic devices. Most patients reported high technology confidence, higher ease of asking clinicians questions, and high symptom management self-efficacy (n = 692; 66%). Patients with high technology confidence also reported higher ease of asking nurses about their health (adjusted odds ratio [AOR], 4.58 [95% CI, 2.36 to 8.87]; P ≤ .001). Those who reported higher ease of asking nurses questions were more likely to report higher confidence in managing symptoms (AOR, 30.54 [95% CI, 12.91 to 72.30]; P ≤ .001). CONCLUSION Patient readiness to use ePROs likely depends on multiple factors, including technology and communication confidence, and symptom management self-efficacy. Future studies should assess interventions to address these factors.
Collapse
Affiliation(s)
| | | | | | | | - Don S. Dizon
- Lifespan Cancer Institute and Brown University, Providence, RI
| | | | | | | | | | | |
Collapse
|
3
|
Kuczmarski TM, Tramontano AC, Mozessohn L, LaCasce AS, Roemer L, Abel GA, Odejide OO. Mental health disorders and survival among older patients with diffuse large B-cell lymphoma in the USA: a population-based study. Lancet Haematol 2023; 10:e530-e538. [PMID: 37271158 PMCID: PMC10654921 DOI: 10.1016/s2352-3026(23)00094-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Mental health disorders can potentially decrease quality of life and survival in patients with cancer. Little is known about the survival implications of mental health disorders in patients with diffuse large B-cell lymphoma (DLBCL). We aimed to evaluate the effect of pre-existing depression, anxiety, or both on survival in a US cohort of older patients with DLBCL. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we identified patients aged 67 years or older, diagnosed with DLBCL in the USA between Jan 1, 2001, and Dec 31, 2013. We used billing claims to identify patients with pre-existing depression, anxiety, or both before their DLBCL diagnosis. We compared 5-year overall survival and lymphoma-specific survival between these patients and those without pre-existing depression, anxiety, or both using Cox proportional analyses, adjusting for sociodemographic and clinical characteristics, including DLBCL stage, extranodal disease, and B symptoms. FINDINGS Among 13 244 patients with DLBCL, 2094 (15·8%) had depression, anxiety, or both disorders; 6988 (52·8%) were female, and 12 468 (94·1%) were White. The median follow-up for the cohort was 2·0 years (IQR 0·4-6·9 years). 5-year overall survival was 27·0% (95% CI 25·1-28·9) for patients with these mental health disorders versus 37·4% (36·5-38·3) for those with no mental health disorder (hazard ratio [HR] 1·37, 95% CI 1·29-1·44). Although survival differences between mental health disorders were modest, those with depression alone had the worst survival compared with no mental health disorder (HR 1·37, 95% CI 1·28-1·47), followed by those with depression and anxiety (1·23, 1·08-1·41), and then anxiety alone (1·17, 1·06-1·29). Individuals with these pre-existing mental health disorders also had lower 5-year lymphoma-specific survival, with depression conferring the greatest effect (1·37, 1·26-1·49) followed by those with depression and anxiety (1·25, 1·07-1·47) and then anxiety alone (1·16, 1·03-1·31). INTERPRETATION Pre-existing depression, anxiety, or both disorders present within 24 months before DLBCL diagnosis, worsens prognosis for patients with DLBCL. Our data underscore the need for universal and systematic mental health screening for this population, as mental health disorders are manageable, and improvements in this prevalent comorbidity might affect lymphoma-specific survival and overall survival. FUNDING American Society of Hematology, National Cancer Institute, Alan J Hirschfield Award.
Collapse
Affiliation(s)
| | - Angela C Tramontano
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lee Mozessohn
- Department of Hematology and Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ann S LaCasce
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lizabeth Roemer
- Department of Psychology, University of Massachusetts, Boston, MA, USA
| | - Gregory A Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Oreofe O Odejide
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA; Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA.
| |
Collapse
|
4
|
Stavrou E, Qiu J, Zafar A, Tramontano AC, Isakoff S, Winer E, Schrag D, Manz C. Breast Medical Oncologists' Perspectives of Telemedicine for Breast Cancer Care: A Survey Study. JCO Oncol Pract 2022; 18:e1447-e1453. [PMID: 35671420 PMCID: PMC9509057 DOI: 10.1200/op.22.00072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/21/2022] [Accepted: 05/09/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The COVID-19 pandemic forced rapid adoption of telemedicine (TM) for breast oncology visits in the United States, but the appropriate role of postpandemic TM is uncertain. We sought to understand physician and advance practice practitioner perspectives on the use of TM for outpatient breast cancer care through an electronically administered survey. METHODS Breast medical oncology clinicians at two academic cancer centers and five satellite locations affiliated with the Dana Farber Cancer Institute and the Massachusetts General Cancer Center were invited to respond to a 21-question survey administered in September 2021 about clinicians' perceptions and attitudes toward TM during the previous 12 months. RESULTS Of the 71 survey invitations, 51 clinicians (36 physicians and 15 advance practice practitioners) provided survey responses (response rate = 72%). Ninety-two percent of respondents (n = 47) agreed that TM visits enhance patient care. Ninety-two percent of respondents (n = 46) also agreed that TM is valuable for early-stage breast cancer follow-up visits. Most respondents felt that there was no difference between TM and face-to-face (F2F) visits when it came to patient adherence, ease of ordering tests, ease of accessing patient records, and workflow outside of the visit (82%, 82%, 78%, and 53%, respectively). Fifty-one percent of respondents (n = 26) said that TM was better for timely access to follow-up appointments. Most respondents said that F2F visits were better for seeing physical problems, personal connection with patients, overall quality of visits, and patient-physician communication (100%, 75%, 65%, and 63%, respectively). CONCLUSION Breast clinicians believe that TM is a valuable tool to enhance outpatient breast cancer care. TM was felt to be appropriate for routine follow-up visits and second opinion consultations and is as good as or better than F2F visits for several routine aspects of breast cancer care.
Collapse
Affiliation(s)
| | | | - Affan Zafar
- Dana Farber Cancer Institute
- Harvard Medical School
- Brigham and Women's Hospital
| | | | - Steven Isakoff
- Harvard Medical School
- Massachusetts General Cancer Center
| | - Eric Winer
- Dana Farber Cancer Institute
- Harvard Medical School
| | | | - Christopher Manz
- Dana Farber Cancer Institute
- Harvard Medical School
- Brigham and Women's Hospital
| |
Collapse
|
5
|
Manz CR, Tramontano AC, Uno H, Parikh RB, Bekelman JE, Schrag D. Association of Oncologist Participation in Medicare's Oncology Care Model With Patient Receipt of Novel Cancer Therapies. JAMA Netw Open 2022; 5:e2234161. [PMID: 36173630 PMCID: PMC9523492 DOI: 10.1001/jamanetworkopen.2022.34161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Medicare's Oncology Care Model (OCM) was an alternative payment model that tied performance-based payments to cost and quality goals for participating oncology practices. A major concern about the OCM regarded inclusion of high-cost cancer therapies, which could potentially disincentivize oncologists from prescribing novel therapies. OBJECTIVE To examine whether oncologist participation in the OCM changed the likelihood that patients received novel therapies vs alternative treatments. DESIGN, SETTING, AND PARTICIPANTS This cohort study of Surveillance, Epidemiology, and End Results (SEER) Program data and Medicare claims compared patient receipt of novel therapies for patients treated by oncologists participating vs not participating in the OCM in the period before (January 2015-June 2016) and after (July 2016-December 2018) OCM initiation. Participants included Medicare fee-for-service beneficiaries in SEER registries who were eligible to receive 1 of 10 novel cancer therapies that received US Food and Drug Administration approval in the 18 months before implementation of the OCM. The study excluded the Hawaii registry because complete data were not available at the time of the data request. Patients in the OCM vs non-OCM groups were matched on novel therapy cohort, outcome time period, and oncologist specialist status. Analysis was conducted between July 2021 and April 2022. EXPOSURES Oncologist participation in the OCM. MAIN OUTCOMES AND MEASURES Preplanned analyses evaluated patient receipt of 1 of 10 novel therapies vs alternative therapies specific to the patient's cancer for the overall study sample and for racial subgroups. RESULTS The study included 2839 matched patients (760 in the OCM group and 2079 in the non-OCM group; median [IQR] age, 72.7 [68.3-77.6] years; 1591 women [56.0%]). Among patients in the non-OCM group, 33.2% received novel therapies before and 40.1% received novel therapies after the start of the OCM vs 39.9% and 50.3% of patients in the OCM group (adjusted difference-in-differences, 3.5 percentage points; 95% CI, -3.7 to 10.7 percentage points; P = .34). In subgroup analyses, second-line immunotherapy use in lung cancer was greater among patients in the OCM group vs non-OCM group (adjusted difference-in-differences, 17.4 percentage points; 95% CI, 4.8-30.0 percentage points; P = .007), but no differences were seen in other subgroups. Over the entire study period, patients with oncologists participating in the OCM were more likely to receive novel therapies than those with oncologists who were not participating (odds ratio, 1.47; 95% CI, 1.09-1.97; P = .01). CONCLUSIONS AND RELEVANCE This study found that participation in the OCM was not associated with oncologists' prescribing novel therapies to Medicare beneficiaries with cancer. These findings suggest that OCM financial incentives did not decrease patient access to novel therapies.
Collapse
Affiliation(s)
- Christopher R. Manz
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medical Oncology, Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ravi B. Parikh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Justin E. Bekelman
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Deborah Schrag
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
6
|
Lui G, Hassett MJ, Tramontano AC, Uno H, Punglia RS. Regional Disparities in the Use and Delivery of Adjuvant Radiation Therapy after Lumpectomy for Breast Cancer in the Medicare Population. Adv Radiat Oncol 2022; 7:101017. [DOI: 10.1016/j.adro.2022.101017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/24/2022] [Indexed: 11/27/2022] Open
|
7
|
Abstract
IMPORTANCE Patient factors help explain disparities in breast cancer treatments and outcomes. OBJECTIVE To determine the extent to which geospatial variation in initial breast cancer care can be attributed to region vs patient factors with the aim of guiding quality improvement efforts. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective population-based cohort study from January 1, 2007, through December 31, 2016, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database that included 31 571 patients diagnosed with stage I to III breast cancer from 2007 through 2013. Five metrics of care delivery were defined: stage I at diagnosis, chemotherapy receipt, radiation therapy receipt, endocrine therapy (ET) initiation (year 1), and ET continuation (years 3-5). Data analysis was performed from January to June 2021. EXPOSURES Stage I diagnosis and treatment with chemotherapy, radiation therapy, or ET. MAIN OUTCOMES AND MEASURES For each metric, total variance was attributed proportionally to 4 domains-random, patient factors (eg, age, race and ethnicity, socioeconomic status), region (health service area [HSA]), and unexplained-using hierarchical multivariable modeling. RESULTS Of 31 571 total patients (median [IQR] age, 71 [68-75] years), 19 391 (61.4%) had stage I disease at diagnosis. Among eligible patients, 17 297 of 21 190 (81.6%) received radiation therapy, 7204 of 9903 (72.8%) received chemotherapy, 13 115 of 26 855 (48.8%) initiated ET, and 13 944 of 26 855 (52.1%) continued ET. Geospatial density (ie, heat) maps highlight regional performance patterns. For all 5 metrics, region/HSA explained more observed variation (24%-48%) than patient factors (1%-4%); the largest share of variation was unexplained (35%-54%). The metrics with the largest proportion of total variance attributed to region/HSA were ET initiation and continuation (28% and 39%, respectively). CONCLUSIONS AND RELEVANCE In this cohort study, there was substantial unexplained geospatial variation in initial breast cancer care. The variance attributed to region/HSA was multifold larger than that explained by patient factors. The importance of patient factors such as race and ethnicity notwithstanding, future quality improvement efforts should focus on reducing unwarranted geospatial variation, especially including optimizing the delivery of ET in low-performing regions.
Collapse
Affiliation(s)
- Michael J. Hassett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Harvard Medical School, Boston, Massachusetts,Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Rinaa S. Punglia
- Harvard Medical School, Boston, Massachusetts,Department of Radiation Oncology, Brigham & Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
8
|
Seaman SJ, Jorgensen EM, Tramontano AC, Jones DB, Mendiola ML, Ricciotti HA, Hur HC. Use of Fundamentals of Laparoscopic Surgery Testing to Assess Gynecologic Surgeons: A Retrospective Cohort Study of 10-Years Experience. J Minim Invasive Gynecol 2020; 28:794-800. [PMID: 32681993 DOI: 10.1016/j.jmig.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To compare the Fundamentals of Laparoscopic Surgery (FLS) exam scores between obstetrics and gynecology (OBGYN) and general surgery (GS) providers. DESIGN This is a retrospective cohort study at a single institution from July 2007 to May 2018. Categorical and continuous variables were analyzed with χ2 test, t test, and Wilcoxon rank sum test. SETTING Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, a tertiary care academic medical center. PATIENTS All providers who took the FLS exam at the Carl J. Shapiro Simulation and Skills Center at BIDMC. INTERVENTIONS FLS certification. MEASUREMENTS AND MAIN RESULTS A total of 205 BIDMC trainees and faculty took the FLS exam between July 2007 and May 2018, of which 176 were identified to be OBGYN or GS providers. The FLS certification pass rate was high for both specialties (97.0% OBGYN vs 96.1% sGS, p = .76). When comparing all providers, no significant difference was found in the mean manual skill test scores between surgical specialties (594.9 OBGYN vs 601.0 GS, p = .59); whereas, a significant difference was noted in the mean cognitive scores, with GS providers scoring higher than OBGYN providers (533.8 OBGYN vs 583.4 GS, p <.001). However, when adjusting for several variables in a multivariate linear regression model, surgical specialty was not a predictor for cognitive scores. In the multivariate analysis, age, sex, and test year were predictors for cognitive scores, with higher scores associated with younger age, male sex, and advancing calendar year. None of the variables were significant predictors of manual scores. CONCLUSION Both OBGYN and GS providers had extremely high FLS pass rates. In the multivariate analysis, surgical specialty was not a predictor for higher FLS test scores for either manual or cognitive test scores. Although OBGYN residency programs offer fewer years of training, OBGYN trainees demonstrate the capacity to perform well on the FLS exam.
Collapse
Affiliation(s)
- Sierra J Seaman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York (Dr. Seaman); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Drs. Jorgensen, Mendiola, Ricciotti, and Hur); Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr. Jones); Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts (Ms. Tramontano)
| | - Elisa M Jorgensen
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York (Dr. Seaman); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Drs. Jorgensen, Mendiola, Ricciotti, and Hur); Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr. Jones); Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts (Ms. Tramontano)
| | - Angela C Tramontano
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York (Dr. Seaman); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Drs. Jorgensen, Mendiola, Ricciotti, and Hur); Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr. Jones); Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts (Ms. Tramontano)
| | - Daniel B Jones
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York (Dr. Seaman); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Drs. Jorgensen, Mendiola, Ricciotti, and Hur); Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr. Jones); Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts (Ms. Tramontano)
| | - Monica L Mendiola
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York (Dr. Seaman); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Drs. Jorgensen, Mendiola, Ricciotti, and Hur); Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr. Jones); Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts (Ms. Tramontano)
| | - Hope A Ricciotti
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York (Dr. Seaman); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Drs. Jorgensen, Mendiola, Ricciotti, and Hur); Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr. Jones); Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts (Ms. Tramontano)
| | - Hye-Chun Hur
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York (Dr. Seaman); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Drs. Jorgensen, Mendiola, Ricciotti, and Hur); Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Dr. Jones); Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts (Ms. Tramontano).
| |
Collapse
|
9
|
Laszkowska M, Tramontano AC, Kim J, Camargo MC, Neugut AI, Abrams JA, Hur C. Racial and ethnic disparities in mortality from gastric and esophageal adenocarcinoma. Cancer Med 2020; 9:5678-5686. [PMID: 32573964 PMCID: PMC7402817 DOI: 10.1002/cam4.3063] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/20/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background Racial/ethnic differences in mortality have not been well studied for either non‐cardia gastric cancer (NCGC) or cardia gastric cancer (CGC). The aim of this study was to examine the US mortality rates for these cancer subtypes, as well as esophageal adenocarcinoma (EAC) as a comparator. Methods We identified 14 164 individuals who died from NCGC, 5235 from CGC, and 13 982 from EAC in the Surveillance, Epidemiology, and End Results database between 2004 and 2016. Age‐adjusted incidence‐based mortality rates and corresponding annual percent changes (APCs) were calculated. Analyses were stratified by race/ethnicity, age, and stage of disease at diagnosis. Results The mortality rate in NCGC was two‐ to threefold higher in blacks, Hispanics, and Asians/Pacific Islanders (PI) than non‐Hispanic whites, and was significant across all age groups and stages of disease (P < .01). Mortality in CGC was higher in non‐Hispanic whites than blacks and Asians/PI, particularly in individuals in the 50‐64 year age group and those with stage IV disease. Mortality in EAC was two‐ to sixfold higher in non‐Hispanic whites than all other groups across all age groups and stages of disease. From 2004 to 2016, mortality rates were stable across all racial/ethnic groups in NCGC and CGC, and in minority groups with EAC, but have been rising in non‐Hispanic whites with EAC (APC 3.03, 95% CI 0.17‐5.96). Conclusions This is the largest study of incidence‐based mortality in CGC and NCGC and demonstrates racial/ethnic differences in mortality between these subtypes. Mortality rates for NCGC are highest in minority groups, and have been stable in recent years despite declining incidence. Mortality rates for CGC are marginally higher in middle‐aged non‐Hispanic whites with advanced disease, though have remained stable. In contrast, mortality in EAC has been rising for non‐Hispanic whites, in parallel to incidence. Further studies are needed to refine prevention strategies for high‐risk individuals dying from these specific cancer subtypes.
Collapse
Affiliation(s)
- Monika Laszkowska
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Judith Kim
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - M Constanza Camargo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Alfred I Neugut
- Department of Medicine, Division of Hematology/Oncology, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| |
Collapse
|
10
|
Tramontano AC, Chen Y, Watson TR, Eckel A, Hur C, Kong CY. Racial/ethnic disparities in colorectal cancer treatment utilization and phase-specific costs, 2000-2014. PLoS One 2020; 15:e0231599. [PMID: 32287320 PMCID: PMC7156060 DOI: 10.1371/journal.pone.0231599] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/26/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Our study analyzed disparities in utilization and phase-specific costs of care among older colorectal cancer patients in the United States. We also estimated the phase-specific costs by cancer type, stage at diagnosis, and treatment modality. METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients aged 66 or older diagnosed with colon or rectal cancer between 2000-2013, with follow-up to death or December 31, 2014. We divided the patient's experience into separate phases of care: staging or surgery, initial, continuing, and terminal. We calculated total, cancer-attributable, and patient-liability costs. We fit logistic regression models to determine predictors of treatment receipt and fit linear regression models to determine relative costs. All costs are reported in 2019 US dollars. RESULTS Our cohort included 90,023 colon cancer patients and 25,581 rectal cancer patients. After controlling for patient and clinical characteristics, Non-Hispanic Blacks were less likely to receive treatment but were more likely to have higher cancer-attributable costs within different phases of care. Overall, in both the colon and rectal cancer cohorts, mean monthly cost estimates were highest in the terminal phase, next highest in the staging phase, decreased in the initial phase, and were lowest in the continuing phase. CONCLUSIONS Racial/ethnic disparities in treatment utilization and costs persist among colorectal cancer patients. Additionally, colorectal cancer costs are substantial and vary widely among stages and treatment modalities. This study provides information regarding cost and treatment disparities that can be used to guide clinical interventions and future resource allocation to reduce colorectal cancer burden.
Collapse
Affiliation(s)
- Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Yufan Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Tina R. Watson
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Chin Hur
- Columbia University Medical Center, New York City, New York, United States of America
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| |
Collapse
|
11
|
Jang SR, Truong H, Oh A, Choi J, Tramontano AC, Laszkowska M, Hur C. Cost-effectiveness Evaluation of Targeted Surgical and Endoscopic Therapies for Early Colorectal Adenocarcinoma Based on Biomarker Profiles. JAMA Netw Open 2020; 3:e1919963. [PMID: 32150269 PMCID: PMC7063501 DOI: 10.1001/jamanetworkopen.2019.19963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States. The prognosis for patients with CRC varies widely, but new prognostic biomarkers provide the opportunity to implement a more individualized approach to treatment selection. OBJECTIVE To assess the cost-effectiveness of 3 therapeutic strategies, namely, endoscopic therapy (ET), laparoscopic colectomy (LC), and open colectomy (OC), for patients with T1 CRC with biomarker profiles that prognosticate varying levels of tumor progression in the US payer perspective. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation study, a Markov model was developed for the cost-effectiveness analysis. Risks of all-cause mortality and recurrent cancer after ET, LC, or OC were estimated with a 35-year time horizon. Quality of life was based on EuroQoL 5 Dimensions scores reported in the published literature. Hospital and treatment costs reflected Medicare reimbursement rates. Deterministic and probabilistic sensitivity analyses were performed. Data from patients with T1 CRC and 6 biomarker profiles that included adenomatous polyposis coli (APC), TP53 and/or KRAS, or BRAFV600E were used as inputs for the model. Data analyses were conducted from February 27, 2019, to May 13, 2019. EXPOSURES Endoscopic therapy, LC, and OC. MAIN OUTCOMES AND MEASURES The primary outcomes were unadjusted life-years, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) between competing treatment strategies. RESULTS Endoscopic therapy had the highest QALYs and the lowest cost and was the dominant treatment strategy for T1 CRC with the following biomarker profiles: BRAFV600E, APC(1)/KRAS/TP53, APC(2) or APC(2)/KRAS or APC(2)/TP53, or APC(1) or APC(1)/KRAS or APC(1)/TP53. The QALYs gained ranged from 16.97 to 17.22, with costs between $68 902.75 and $77 784.53 in these subgroups. For the 2 more aggressive biomarker profiles with worse prognoses (APC(2)/KRAS/TP53 and APCwt [wild type]), LC was the most effective strategy (with 16.45 and 16.61 QALYs gained, respectively) but was not cost-effective. Laparoscopic colectomy cost $65 234.87 for APC(2)/KRAS/TP53 and $71 250.56 for APCwt, resulting in ICERs of $113 290 per QALY and $178 765 per QALY, respectively. CONCLUSIONS AND RELEVANCE This modeling analysis found that ET was the most effective strategy for patients with T1 CRC with less aggressive biomarker profiles. For patients with more aggressive profiles, LC was more effective but was costly, rendering ET the cost-effective option. This study highlights the potential utility of prognostic biomarkers in T1 CRC treatment selection.
Collapse
Affiliation(s)
- Se Ryeong Jang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- now with College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Han Truong
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Aaron Oh
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jin Choi
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Monika Laszkowska
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
| | - Chin Hur
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
| |
Collapse
|
12
|
Chen Y, Criss SD, Watson TR, Eckel A, Palazzo L, Tramontano AC, Wang Y, Mercaldo ND, Kong CY. Cost and Utilization of Lung Cancer End-of-Life Care Among Racial-Ethnic Minority Groups in the United States. Oncologist 2020; 25:e120-e129. [PMID: 31501272 PMCID: PMC6964141 DOI: 10.1634/theoncologist.2019-0303] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/06/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The end-of-life period is a crucial time in lung cancer care. To have a better understanding of the racial-ethnic disparities in health care expenditures, access, and quality, we evaluated these disparities specifically in the end-of-life period for patients with lung cancer in the U.S. MATERIALS AND METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to analyze characteristics of lung cancer care among those diagnosed between the years 2000 and 2011. Linear and logistic regression models were constructed to measure racial-ethnic disparities in end-of-life care cost and utilization among non-Hispanic (NH) Asian, NH black, Hispanic, and NH white patients while controlling for other risk factors such as age, sex, and SEER geographic region. RESULTS Total costs and hospital utilization were, on average, greater among racial-ethnic minorities compared with NH white patients in the last month of life. Among patients with NSCLC, the relative total costs were 1.27 (95% confidence interval [CI], 1.21-1.33) for NH black patients, 1.36 (95% CI, 1.25-1.49) for NH Asian patients, and 1.21 (95% CI, 1.07-1.38) for Hispanic patients. Additionally, the odds of being admitted to a hospital for NH black, NH Asian, and Hispanic patients were 1.22 (95% CI, 1.15-1.30), 1.47 (95% CI, 1.32-1.63), and 1.18 (95% CI, 1.01-1.38) times that of NH white patients, respectively. Similar results were found for patients with SCLC. CONCLUSION Minority patients with lung cancer have significantly higher end-of-life medical expenditures than NH white patients, which may be explained by a greater intensity of care in the end-of-life period. IMPLICATIONS FOR PRACTICE This study investigated racial-ethnic disparities in the cost and utilization of medical care among lung cancer patients during the end-of-life period. Compared with non-Hispanic white patients, racial-ethnic minority patients were more likely to receive intensive care in their final month of life and had statistically significantly higher end-of-life care costs. The findings of this study may lead to a better understanding of the racial-ethnic disparities in end-of-life care, which can better inform future end-of-life interventions and help health care providers develop less intensive and more equitable care, such as culturally competent advanced care planning programs, for all patients.
Collapse
Affiliation(s)
- Yufan Chen
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Steven D. Criss
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Tina R. Watson
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Lauren Palazzo
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Ying Wang
- BC Cancer VancouverVancouverBritish ColumbiaCanada
| | - Nathaniel D. Mercaldo
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
13
|
Tramontano AC, Chen Y, Watson TR, Eckel A, Sheehan DF, Peters MLB, Pandharipande PV, Hur C, Kong CY. Pancreatic cancer treatment costs, including patient liability, by phase of care and treatment modality, 2000-2013. Medicine (Baltimore) 2019; 98:e18082. [PMID: 31804317 PMCID: PMC6919520 DOI: 10.1097/md.0000000000018082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Our study provides phase-specific cost estimates for pancreatic cancer based on stage and treatment. We compare treatment costs between the different phases and within the stage and treatment modality subgroups. METHODS Our cohort included 20,917 pancreatic cancer patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed between 2000 and 2011. We allocated costs into four phases of care-staging (or surgery), initial, continuing, and terminal- and calculated the total, cancer-attributable, and patient-liability costs in 2018 US dollars. We fit linear regression models using log transformation to determine whether costs were predicted by age and calendar year. RESULTS Monthly cost estimates were high during the staging and surgery phases, decreased over the initial and continuing phases, and increased during the three-month terminal phase. Overall, the linear regression models showed that cancer-attributable costs either remained stable or increased by year, and either were unaffected by age or decreased with older age; continuing phase costs for stage II patients increased with age. CONCLUSIONS Our estimates demonstrate that pancreatic cancer costs can vary widely by stage and treatment received. These cost estimates can serve as an important baseline foundation to guide resource allocation for cancer care and research in the future.
Collapse
Affiliation(s)
| | - Yufan Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Tina R. Watson
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Deirdre F. Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Mary Linton B. Peters
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, MA
- Harvard Medical School, Boston, MA
| | - Pari V. Pandharipande
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Chin Hur
- Columbia University Medical Center, New York City, NY
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| |
Collapse
|
14
|
Tramontano AC, Chen Y, Watson TR, Eckel A, Hur C, Kong CY. Esophageal cancer treatment costs by phase of care and treatment modality, 2000-2013. Cancer Med 2019; 8:5158-5172. [PMID: 31347306 PMCID: PMC6718574 DOI: 10.1002/cam4.2451] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Detailed cost estimates are not widely available for esophageal cancer. Our study estimates phase-specific costs for esophageal cancer by age, year, histology, stage, and treatment for older patients in the United States and compares these costs within stage and treatment modalities. METHODS We identified 8061 esophageal cancer patients in the Surveillance, Epidemiology, and End Results-Medicare database for years 1998-2013. Total, cancer-attributable, and patient-liability costs were calculated based on separate phases of care-staging (or surgery), initial, continuing, and terminal. We estimated costs by treatment modality within stage and phase for esophageal adenocarcinoma and squamous cell carcinoma separately. We fit linear regression models using log transformation to determine cost by age and calendar year. All costs are reported in 2018 US dollars. RESULTS Overall, mean (95% CI) monthly total cost estimates were high during the staging ($8953 [$8385-$9485]) and initial phases ($7731 [$7492-$7970]), decreased over the continuing phase ($2984 [$2814-$3154]), and increased substantially during the 6-month terminal phase ($18 150 [$17 211-$19 089]). This pattern of high staging and initial phase costs, decreasing continuing phase costs, and increasing terminal phase costs was seen in all stages. The highest staging costs were in stages III ($9249, $8025-$10 474) and II ($9171, $7642-$10 699). The highest initial phase cost was in stage IV, $9263 ($8758-49 768), the lowest continuing phase cost was in stage I, $2338 ($2160-$2517), and the highest terminal phase costs were in stages II ($20 533, $17 772-$23 293) and III ($20 599, $18 268-$22 929). The linear regression models showed that cancer-attributable costs remained stable over the study period and were unaffected by age for most histology, stage, and treatment modality subgroups. CONCLUSIONS Our estimates demonstrate that esophageal cancer costs can vary widely by histology, stage, and treatment. These cost estimates can be used to guide future resource allocation for esophageal cancer care and research.
Collapse
Affiliation(s)
- Angela C. Tramontano
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Yufan Chen
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Tina R. Watson
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Andrew Eckel
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Chin Hur
- Columbia University Medical CenterNew York CityNew York
| | - Chung Yin Kong
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts,Harvard Medical SchoolBostonMassachusetts
| |
Collapse
|
15
|
Yamamoto KN, Nakamura A, Liu LL, Stein S, Tramontano AC, Kartoun U, Shimizu T, Inoue Y, Asakuma M, Haeno H, Kong CY, Uchiyama K, Gonen M, Hur C, Michor F. Computational modeling of pancreatic cancer patients receiving FOLFIRINOX and gemcitabine-based therapies identifies optimum intervention strategies. PLoS One 2019; 14:e0215409. [PMID: 31026288 PMCID: PMC6485645 DOI: 10.1371/journal.pone.0215409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/01/2019] [Indexed: 01/03/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) exhibits a variety of phenotypes with regard to disease progression and treatment response. This variability complicates clinical decision-making despite the improvement of survival due to the recent introduction of FOLFIRINOX (FFX) and nab-paclitaxel. Questions remain as to the timing and sequence of therapies and the role of radiotherapy for unresectable PDAC. Here we developed a computational analysis platform to investigate the dynamics of growth, metastasis and treatment response to FFX, gemcitabine (GEM), and GEM+nab-paclitaxel. Our approach was informed using data of 1,089 patients treated at the Massachusetts General Hospital and validated using an independent cohort from Osaka Medical College. Our framework establishes a logistic growth pattern of PDAC and defines the Local Advancement Index (LAI), which determines the eventual primary tumor size and predicts the number of metastases. We found that a smaller LAI leads to a larger metastatic burden. Furthermore, our analyses ascertain that i) radiotherapy after induction chemotherapy improves survival in cases receiving induction FFX or with larger LAI, ii) neoadjuvant chemotherapy improves survival in cases with resectable PDAC, and iii) temporary cessations of chemotherapies do not impact overall survival, which supports the feasibility of treatment holidays for patients with FFX-associated adverse effects. Our findings inform clinical decision-making for PDAC patients and allow for the rational design of clinical strategies using FFX, GEM, GEM+nab-paclitaxel, neoadjuvant chemotherapy, and radiation.
Collapse
Affiliation(s)
- Kimiyo N. Yamamoto
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, United States of America
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Akira Nakamura
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Lin L. Liu
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Shayna Stein
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America
| | - Uri Kartoun
- Center for Systems Biology, Center for Assessment Technology & Continuous Health (CATCH), Massachusetts General Hospital, Boston, MA, United States of America
| | - Tetsunosuke Shimizu
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Yoshihiro Inoue
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Mitsuhiro Asakuma
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Hiroshi Haeno
- Mathematical Biology Laboratory, Department of Biology, Faculty of Sciences, Kyushu University, Fukuoka, Japan
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kazuhisa Uchiyama
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America
| | - Franziska Michor
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, United States of America
- Center for Cancer Evolution, Dana-Farber Cancer Institute, Boston, MA, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, MA, United States of America
| |
Collapse
|
16
|
Thay S, Peprah SA, Hur C, Tramontano AC, Maling E, Goldstein AT, Hong C. Prevalence of Cervical Dysplasia in HIV-Positive and HIV-Negative Women at the Sihanouk Hospital Center of
HOPE, Phnom Penh , Cambodia. Asian Pac J Cancer Prev 2019; 20:653-659. [PMID: 30816687 PMCID: PMC6897022 DOI: 10.31557/apjcp.2019.20.2.653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: There is a high burden of cervical cancer in Cambodia, yet published data on the prevalence of cervical dysplasia and the risk factors contributing to the development of pre-cancerous lesions in Cambodian women is very limited. In addition, as it is well known that HIV positivity increases cervical cancer risk, it is important to quantify the prevalence of cervical dysplasia and carcinoma among Cambodian women living with HIV disease. Methods: A cross-sectional study was conducted with a sample of 499 HIV+ and 501 HIV- Cambodian women at the Sihanouk Hospital Center of HOPE. Visual inspection with 5% acetic acid was the method of screening. Colposcopy was performed on all VIA+ patients, and subsequent treatment followed WHO guidelines. Logistic regression models, stratified by both HIV+ and HIV- groups, were used to assess significant factors associated with having dysplasia. Results: VIA+ results were prevalent in both the HIV+ and HIV- arms of the study. The HIV+ patients were more likely to have a lower age at coitarche, lower weight, 2 or more lifetime sexual partners, two or greater pregnancies, or be unmarried. The estimated prevalence of VIA detected cervical dysplasia was 11% for the entire study sample, 13.4% in the HIV positive (HIV+) group and 8.6% in the HIV negative (HIV-) group (OR: 1.65; 95% CI: 1.10, 2.48; p=0.01). For the HIV+ group, having a history of 4 or more full-term pregnancies (OR: 3.42; 95% CI: 1.01-11.64; p=0.049) was found to be significantly associated with having an increased risk of developing cervical dysplasia in the multivariate model. Conclusion: Cervical dysplasia is prevalent in both HIV positive and negative Cambodian women and a VIA based national screening programs need to be developed and expanded to provide access to affordable and effective treatment for cervical dysplasia and cancers.
Collapse
|
17
|
Palazzo LL, Sheehan DF, Tramontano AC, Kong CY. Disparities and Trends in Genetic Testing and Erlotinib Treatment among Metastatic Non-Small Cell Lung Cancer Patients. Cancer Epidemiol Biomarkers Prev 2019; 28:926-934. [PMID: 30787053 DOI: 10.1158/1055-9965.epi-18-0917] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/13/2018] [Accepted: 02/14/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite reports of socioeconomic disparities in rates of genetic testing and targeted therapy treatment for metastatic non-small cell lung cancer (NSCLC), little is known about whether such disparities are changing over time. METHODS We performed a retrospective analysis to identify disparities and trends in genetic testing and treatment with erlotinib. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified 9,900 patients with stage IV NSCLC diagnosed in 2007 to 2011 at age 65 or older. We performed logistic regression analyses to identify patient factors associated with odds of receiving a genetic test and erlotinib treatment, and to assess trends in these differences with respect to diagnosis year. RESULTS Patients were more likely to receive genetic testing if they were under age 75 at diagnosis [odds ratio (OR), 1.55] independent of comorbidity level, and this age-based gap showed a decrease over time (OR, 0.93). For untested patients, erlotinib treatment was associated with race (OR, 0.58, black vs. white; OR, 2.45, Asian vs. white), and was more likely among female patients (OR, 1.45); for tested patients, erlotinib treatment was less likely among low-income patients (OR, 0.32). Most of these associations persisted or increased in magnitude. CONCLUSIONS Race and sex are associated with rates of erlotinib treatment for patients who did not receive genetic testing, and low-income status is associated with treatment rates for those who did receive testing. The racial disparity remained stable over time, while the income-based disparity grew larger. IMPACT Attention to reducing disparities is needed as precision cancer treatments continue to be developed.
Collapse
Affiliation(s)
- Lauren L Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
18
|
Sheehan DF, Criss SD, Chen Y, Eckel A, Palazzo L, Tramontano AC, Hur C, Cipriano LE, Kong CY. Lung cancer costs by treatment strategy and phase of care among patients enrolled in Medicare. Cancer Med 2018; 8:94-103. [PMID: 30575329 PMCID: PMC6346221 DOI: 10.1002/cam4.1896] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/01/2018] [Accepted: 11/06/2018] [Indexed: 12/16/2022] Open
Abstract
Background We studied trends in lung cancer treatment cost over time by phase of care, treatment strategy, age, stage at diagnosis, and histology. Methods Using the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database for years 1998‐2013, we allocated total and patient‐liability costs into the following phases of care for 145 988 lung cancer patients: prediagnosis, staging, surgery, initial, continuing, and terminal. Patients served as self‐controls to determine cancer‐attributable costs based on individual precancer diagnosis healthcare costs. We fit linear regression models to determine cost by age and calendar year for each stage at diagnosis, histology, and treatment strategy and presented all costs in 2017 US dollars. Results Monthly healthcare costs prior to lung cancer diagnosis were $861 for a 70 years old in 2017 and rose by an average of $17 per year (P < 0.001). Surgery in 2017 cost $30 096, decreasing by $257 per year (P = 0.007). Chemotherapy and radiation costs remained stable or increased for most stage and histology groups, ranging from $4242 to $8287 per month during the initial six months of care. Costs during the final six months of life decreased for those who died of lung cancer or other causes. Conclusions Cost‐effectiveness analyses of lung cancer control interventions in the United States have been using outdated and incomplete treatment cost estimates. Our cost estimates enable updated cost‐effectiveness analyses to determine the benefit of lung cancer control from a health economics point of view.
Collapse
Affiliation(s)
- Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven D Criss
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Yufan Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Lauren Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts.,Department of Radiology, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
19
|
Peters MLB, Eckel A, Mueller PP, Tramontano AC, Weaver DT, Lietz A, Hur C, Kong CY, Pandharipande PV. Progression to pancreatic ductal adenocarcinoma from pancreatic intraepithelial neoplasia: Results of a simulation model. Pancreatology 2018; 18:928-934. [PMID: 30143405 PMCID: PMC9201992 DOI: 10.1016/j.pan.2018.07.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/26/2018] [Accepted: 07/28/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To gain insight into the natural history and carcinogenesis pathway of Pancreatic Intraepithelial Neoplasia (PanIN) lesions by building a calibrated simulation model of PanIN progression to pancreatic ductal adenocarcinoma (PDAC) METHODS: We revised a previously validated simulation model of solid PDAC, calibrating the model to fit data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program and published literature on PanIN prevalence by age. We estimated the likelihood of progression from PanIN states (1, 2, and 3) to PDAC and the time between PanIN onset and PDAC (dwell time). We evaluated a hypothetical intervention to test for and treat PanIN 3 lesions to estimate the potential benefits from PanIN detection. RESULTS We estimated the lifetime probability of progressing from PanIN 1 to PDAC to be 1.5% (men), 1.3% (women). Progression from PanIN 1 to PDAC took 33.6 years and 35.3 years, respectively, and from PanIN 3 to PDAC took 11.3 years and 12.3 years. A hypothetical test for PanIN 3 detection and treatment could provide a maximum, average life expectancy gain of 40 days. CONCLUSIONS Our modeling analysis estimates PanINs have a relatively indolent course to PDAC, supporting the feasibility of potential future early detection strategies.
Collapse
Affiliation(s)
- Mary Linton B Peters
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, USA,Institute for Technology Assessment, Massachusetts General Hospital, USA,Corresponding author. Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Shapiro 9, Boston, MA, 02215, USA. (M.L.B. Peters)
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, USA
| | - Peter P. Mueller
- Institute for Technology Assessment, Massachusetts General Hospital, USA
| | | | - Davis T. Weaver
- Institute for Technology Assessment, Massachusetts General Hospital, USA
| | - Anna Lietz
- Institute for Technology Assessment, Massachusetts General Hospital, USA
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, USA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, USA
| | | |
Collapse
|
20
|
Nipp RD, Tramontano AC, Kong CY, Hur C. Patterns and predictors of end-of-life care in older patients with pancreatic cancer. Cancer Med 2018; 7:6401-6410. [PMID: 30426697 PMCID: PMC6308041 DOI: 10.1002/cam4.1861] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Little is known about end-of-life care among patients with pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results-Medicare linked database to analyze patterns of hospice use and end-of-life treatment in patients with PDAC. METHODS We included patients diagnosed with PDAC between 2000-2011 and who had died by December 31, 2012. We assessed patterns of hospice use, chemotherapy receipt, and intensive care unit (ICU) admissions at end-of-life. We used multivariable logistic regression to investigate predictors of end-of-life care. RESULTS In our cohort of 16 309 patients, 70.5% enrolled in hospice, of which 29.1% enrolled in the last 7 days of life. Use of hospice increased over time, from 61.6% in 2000 to 77.5% in 2012 (P-value for trend <0.0001). Among the entire cohort, 6.4% received chemotherapy within the last 14 days of life and 13.1% were admitted to the ICU within the last 30 days of life. Late ICU admissions increased over time, while chemotherapy receipt at the end-of-life decreased. Patients who were older, female, with higher SES, or from the South or Midwest were more likely to enroll in hospice. Those who were younger or male were more likely to receive chemotherapy or have an ICU admission at the end-of-life. CONCLUSION Although hospice enrollment has increased among patients with PDAC, late enrollment still occurs in a substantial proportion of patients. While chemotherapy at the end-of-life has decreased slightly, ICU admissions at the end-of-life have continued to increase. Further research is needed to determine effective ways of enhancing end-of-life care for patients with PDAC.
Collapse
Affiliation(s)
- Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chung Yin Kong
- Harvard Medical School, Boston, Massachusetts.,Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chin Hur
- Harvard Medical School, Boston, Massachusetts.,Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
21
|
Tramontano AC, Nipp R, Mercaldo ND, Kong CY, Schrag D, Hur C. Survival Disparities by Race and Ethnicity in Early Esophageal Cancer. Dig Dis Sci 2018; 63:2880-2888. [PMID: 30109578 PMCID: PMC6738563 DOI: 10.1007/s10620-018-5238-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/01/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND Survival outcome disparities among esophageal cancer patients exist, but are not fully understood. AIMS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to determine whether survival differences among racial/ethnic patient populations persist after adjusting for demographic and clinical characteristics. METHODS Our study included T1-3N0M0 adenocarcinoma and squamous cell cancer patients diagnosed between 2003 and 2011. We compared survival among two racial/ethnic patient subgroups using Cox proportional hazards methods, adjusting for age, sex, histology, marital status, socioeconomics, SEER region, comorbidities, T stage, tumor location, diagnosis year, and treatment received. RESULTS Among 2025 patients, 87.9% were White and 12.1% were Nonwhite. Median survival was 18.7 months for Whites vs 13.8 months for Nonwhites (p = 0.01). In the unadjusted model, Nonwhite patients had higher risk of mortality (HR = 1.29, 95% CI 1.11-1.49, p < 0.0001) when compared to White patients; however, in the Cox regression adjusted model there was no significant difference (HR = 0.94, 95% CI 0.80-1.10, p = 0.44). Surgery, chemotherapy, younger age, lower T stage, and lower Charlson comorbidity score were significant predictors in the full adjusted model. CONCLUSIONS Differences in mortality risk by race/ethnicity appear to be largely explained by additional factors. In particular, associations were seen in surgery and T stage. Further research is needed to understand potential mechanisms underlying the differences and to better target patients who can benefit from treatment options.
Collapse
Affiliation(s)
- Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center, Boston, USA
| | - Nathaniel D. Mercaldo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, USA,Department of Radiology, Massachusetts General Hospital Cancer Center, Boston, USA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, USA
| | - Deborah Schrag
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, USA,Gastrointestinal Division, Harvard Medical School, Boston, USA
| |
Collapse
|
22
|
Tramontano AC, Nipp R, Kong CY, Yerramilli D, Gainor JF, Hur C. Hospice use and end-of-life care among older patients with esophageal cancer. Health Sci Rep 2018; 1:e76. [PMID: 30623099 PMCID: PMC6266462 DOI: 10.1002/hsr2.76] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/07/2018] [Accepted: 06/18/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Hospice and end-of-life health care utilization among patients with esophageal cancer are understudied. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to analyze hospice use and end-of-life treatment patterns. METHODS We included patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2000 and 2011 and who had died by December 31, 2013. We evaluated patterns of hospice enrollment, chemotherapy receipt, radiation receipt, acute care hospitalizations, and intensive care unit (ICU) admissions at end of life. We used multivariate logistic regression to evaluate possible associations with hospice use, late ICU admission, and late chemotherapy receipt. RESULTS Our study included 6449 patients; 3597 (55.8%) enrolled in hospice. Among hospice enrolled patients, 31.4% enrolled in the last 7 days of life. Hospice enrollment increased over time, from 43.2% in 2000 to 59.6% in 2013. Patients who were older, female, with stage IV disease, or those with higher socioeconomic status were more likely to enroll in hospice. Among all patients, 19.1% had an ICU admission within the last 30 days and 4.6% received chemotherapy within the last 14 days of life. Those who were Black or Asian (compared to White), married, or had a comorbidity score >1 were more likely to have a late ICU admission. Males and younger patients were more likely to receive chemotherapy at end of life. CONCLUSION Hospice enrollment rates among patients with esophageal cancer have increased over time; however, a significant percentage of patients enrolls near the end of life. Further research is needed to improve understanding of how end-of-life care decisions for these patients are made.
Collapse
Affiliation(s)
| | - Ryan Nipp
- Department of Medicine, Division of Hematology and OncologyMassachusetts General Hospital Cancer Center & Harvard Medical SchoolBostonMAUSA
| | - Chung Yin Kong
- Institute for Technology AssessmentMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Divya Yerramilli
- Department of Radiation OncologyMassachusetts General HospitalBostonMAUSA
| | - Justin F. Gainor
- Department of Medicine, Division of Hematology and OncologyMassachusetts General Hospital Cancer Center & Harvard Medical SchoolBostonMAUSA
| | - Chin Hur
- Institute for Technology AssessmentMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| |
Collapse
|
23
|
Nipp R, Tramontano AC, Kong CY, Pandharipande P, Dowling EC, Schrag D, Hur C. Disparities in cancer outcomes across age, sex, and race/ethnicity among patients with pancreatic cancer. Cancer Med 2018; 7:525-535. [PMID: 29322643 PMCID: PMC5806100 DOI: 10.1002/cam4.1277] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/05/2017] [Accepted: 11/08/2017] [Indexed: 01/14/2023] Open
Abstract
Age, sex, and racial/ethnic disparities exist, but are understudied in pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to determine whether survival and treatment disparities persist after adjusting for demographic and clinical characteristics. Our study included PDAC patients diagnosed between 1992 and 2011. We used Cox regression to compare survival across age, sex, and race/ethnicity within early-stage and late-stage cancer subgroups, adjusting for marital status, urban location, socioeconomics, SEER region, comorbidities, stage, lymph node status, tumor location, tumor grade, diagnosis year, and treatment received. We used logistic regression to compare differences in treatment received across age, sex, and race/ethnicity. Among 20,896 patients, 84% were White, 9% Black, 5% Asian, and 2% Hispanic. Median age was 75; 56% were female and 53% had late-stage cancer. Among early-stage patients in the adjusted Cox model, older patient subgroups had worse survival compared with ages 66-69 (HR > 1.1, P < 0.01 for groups >69); no survival differences existed between sexes. Black (HR = 1.1, P = 0.01) and Hispanic (HR = 1.2, P < 0.01) patients had worse survival compared with White. Among late-stage cancer patients, patients over age 84 had worse survival than those aged 66-69 (HR = 1.1, P < 0.01), and males (HR = 1.08, P < 0.01) had worse survival than females; there were no racial/ethnic differences. Older age and minority race/ethnicity were associated with lower likelihood of receiving chemotherapy, radiation, and/or surgery. Age and racial/ethnic disparities in survival outcomes and treatment received exist for PDAC patients; these disparities persist after adjusting for differences in demographic and clinical characteristics.
Collapse
Affiliation(s)
- Ryan Nipp
- Department of MedicineDivision of Hematology and OncologyMassachusetts General Hospital Cancer CenterBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
| | - Angela C. Tramontano
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Chung Yin Kong
- Harvard Medical SchoolBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Pari Pandharipande
- Harvard Medical SchoolBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Emily C. Dowling
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Deborah Schrag
- Dana‐Farber Cancer InstituteHarvard Medical SchoolBostonMassachusetts
| | - Chin Hur
- Harvard Medical SchoolBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
- Gastrointestinal DivisionHarvard Medical SchoolBostonMassachusetts
| |
Collapse
|
24
|
Yeh JM, Tramontano AC, Hur C, Schrag D. Comparative effectiveness of adjuvant chemoradiotherapy after gastrectomy among older patients with gastric adenocarcinoma: a SEER-Medicare study. Gastric Cancer 2017; 20:811-824. [PMID: 28205057 PMCID: PMC5557693 DOI: 10.1007/s10120-017-0693-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 01/14/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since the INT-0116 trial reported a survival advantage, postoperative chemoradiotherapy (CRT) has been a care standard for US patients in whom gastric adenocarcinoma has been diagnosed. We sought to estimate the association between treatment and survival among the older US Medicare population. METHODS This is a retrospective cohort study of Medicare beneficiaries aged 65-79 years with stage IB-III gastric adenocarcinoma diagnosed between 2002 and 2009 in a Surveillance, Epidemiology, and End Results region. Patients were categorized on the basis of treatment: (1) gastrectomy only and (2) gastrectomy plus adjuvant CRT. We examined factors associated with receipt of adjuvant CRT, including stage at diagnosis, comorbidity, and tumor subtype. Overall survival was measured from 90 days after gastrectomy until death or the censoring date of December 31, 2010. RESULTS Of the 1519 patients who underwent gastrectomy, 41.7% received adjuvant CRT. Factors associated with adjuvant CRT included age younger than 75 years at cancer diagnosis and stage II or stage III cancer. The median overall survival from the time of gastrectomy was 25.1 months (interquartile range 43.7 months) for gastrectomy only and 26.9 months (interquartile range 40.9 months) for adjuvant CRT. Multivariable and propensity-score-stratified models demonstrated a survival benefit associated with adjuvant CRT [hazard ratio (HR) 0.58; 95% confidence interval (CI) 0.50-0.67], although the magnitude was greater for stage II tumors (HR 0.50; 95% CI 0.39-0.61) and stage III tumors (HR 0.58; 95% CI 0.45-0.73) than for stage IB tumors (HR 1.02; 95% CI 0.71-1.45). CONCLUSIONS Adjuvant CRT, in conjunction with gastrectomy, was associated with a survival benefit among older patients with stage II or stage III tumors.
Collapse
Affiliation(s)
- Jennifer M. Yeh
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Deborah Schrag
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
25
|
Heberle CR, Omidvari AH, Ali A, Kroep S, Kong CY, Inadomi JM, Rubenstein JH, Tramontano AC, Dowling EC, Hazelton WD, Luebeck EG, Lansdorp-Vogelaar I, Hur C. Cost Effectiveness of Screening Patients With Gastroesophageal Reflux Disease for Barrett's Esophagus With a Minimally Invasive Cell Sampling Device. Clin Gastroenterol Hepatol 2017; 15:1397-1404.e7. [PMID: 28238953 PMCID: PMC5827938 DOI: 10.1016/j.cgh.2017.02.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/03/2017] [Accepted: 02/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is important to identify patients with Barrett's esophagus (BE), the precursor to esophageal adenocarcinoma (EAC). Patients with BE usually are identified by endoscopy, which is expensive. The Cytosponge, which collects tissue from the esophagus noninvasively, could be a cost-effective tool for screening individuals with gastroesophageal reflux disease (GERD) who are at increased risk for BE. We developed a model to analyze the cost effectiveness of using the Cytosponge in first-line screening of patients with GERD for BE with endoscopic confirmation, compared with endoscopy screening only. METHODS We incorporated data from a large clinical trial of Cytosponge performance into 2 validated microsimulation models of EAC progression (the esophageal adenocarcinoma model from Massachusetts General Hospital and the microsimulation screening analysis model from Erasmus University Medical Center). The models were calibrated for US Surveillance, Epidemiology and End Results data on EAC incidence and mortality. In each model, we simulated the effect of a 1-time screen for BE in male patients with GERD, 60 years of age, using endoscopy alone or Cytosponge collection of tissue, and analysis for the level of trefoil factor 3 with endoscopic confirmation of positive results. For each strategy we recorded the number of cases of EAC that developed, the number of EAC cases detected with screening by Cytosponge only or by subsequent targeted surveillance, and the number of endoscopies needed. In addition, we recorded the cumulative costs (including indirect costs) incurred and quality-adjusted years of life lived within each strategy, discounted at a rate of 3% per year, and computed incremental cost-effectiveness ratios (ICERs) among the 3 strategies. RESULTS According to the models, screening patients with GERD by Cytosponge with follow-up confirmation of positive results by endoscopy would reduce the cost of screening by 27% to 29% compared with screening by endoscopy, but led to 1.8 to 5.5 (per 1000 patients) fewer quality-adjusted life years. The ICERs for Cytosponge screening compared with no screening ranged from $26,358 to $33,307. For screening patients by endoscopy compared with Cytosponge the ICERs ranged from $107,583 to $330,361. These results were sensitive to Cytosponge cost within a plausible range of values. CONCLUSIONS In a comparative modeling analysis of screening strategies for BE in patients with GERD, we found Cytosponge screening with endoscopic confirmation to be a cost-effective strategy. The greatest benefit was achieved by endoscopic screening, but with an unfavorable cost margin.
Collapse
Affiliation(s)
- Curtis R. Heberle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA,Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ayman Ali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA,Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Sonja Kroep
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - John M. Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Joel H. Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, and Division of Gastroenterology University of Michigan Medical School Ann Arbor, MI, USA
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Emily C. Dowling
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - William D. Hazelton
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - E. Georg Luebeck
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
26
|
Kroep S, Heberle CR, Curtius K, Kong CY, Lansdorp-Vogelaar I, Ali A, Wolf WA, Shaheen NJ, Spechler SJ, Rubenstein JH, Nishioka NS, Meltzer SJ, Hazelton WD, van Ballegooijen M, Tramontano AC, Gazelle GS, Luebeck EG, Inadomi JM, Hur C. Radiofrequency Ablation of Barrett's Esophagus Reduces Esophageal Adenocarcinoma Incidence and Mortality in a Comparative Modeling Analysis. Clin Gastroenterol Hepatol 2017; 15:1471-1474. [PMID: 28089850 PMCID: PMC5507756 DOI: 10.1016/j.cgh.2016.12.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/28/2016] [Accepted: 12/28/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Sonja Kroep
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Curtis R Heberle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Kit Curtius
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Centre for Tumour Biology, Barts Cancer Institute, London, United Kingdom
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Ayman Ali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - W Asher Wolf
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Stuart J Spechler
- Esophageal Diseases Center, Department of Medicine, Veterans Affairs (VA) North Texas Health Care System, and the University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, and Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Norman S Nishioka
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - William D Hazelton
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - E Georg Luebeck
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John M Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
27
|
Pandharipande PV, Alabre CI, Coy DL, Zaheer A, Miller CM, Herring MS, Tramontano AC, Dowling EC, Eisenberg JD, Ashar BH, Halpern EF, Donelan K, Gazelle GS. Changes in Physician Decision Making after CT: A Prospective Multicenter Study in Primary Care Settings. Radiology 2016; 281:835-846. [DOI: 10.1148/radiol.2016152887] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
28
|
Greer JA, Tramontano AC, McMahon PM, Pirl WF, Jackson VA, El-Jawahri A, Parikh RB, Muzikansky A, Gallagher ER, Temel JS. Cost Analysis of a Randomized Trial of Early Palliative Care in Patients with Metastatic Nonsmall-Cell Lung Cancer. J Palliat Med 2016; 19:842-8. [DOI: 10.1089/jpm.2015.0476] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Joseph A. Greer
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Pamela M. McMahon
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - William F. Pirl
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vicki A. Jackson
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi B. Parikh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alona Muzikansky
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily R. Gallagher
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer S. Temel
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
29
|
Hur C, Tramontano AC, Dowling EC, Brooks GA, Jeon A, Brugge WR, Gazelle GS, Kong CY, Pandharipande PV. Early Pancreatic Ductal Adenocarcinoma Survival Is Dependent on Size: Positive Implications for Future Targeted Screening. Pancreas 2016; 45:1062-6. [PMID: 26692444 PMCID: PMC4912943 DOI: 10.1097/mpa.0000000000000587] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreatic ductal adenocarcinoma (PDAC) has not experienced a meaningful mortality improvement for the past few decades. Successful screening is difficult to accomplish because most PDACs present late in their natural history, and current interventions have not provided significant benefit. Our goal was to identify determinants of survival for early PDAC to help inform future screening strategies. METHODS Early PDACs from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program database (2000-2010) were analyzed. We stratified by size and included carcinomas in situ (Tis). Overall cancer-specific survival was calculated. A Cox proportional hazards model was developed and the significance of key covariates for survival prediction was evaluated. RESULTS A Kaplan-Meier plot demonstrated significant differences in survival by size at diagnosis; these survival benefits persisted after adjustment for key covariates in the Cox proportional hazards analysis. In addition, relatively weaker predictors of worse survival included older age, male sex, black race, nodal involvement, tumor location within the head of the pancreas, and no surgery or radiotherapy. CONCLUSIONS For early PDAC, we found tumor size to be the strongest predictor of survival, even after adjustment for other patient characteristics. Our findings suggest that early PDAC detection can have clinical benefit, which has positive implications for future screening strategies.
Collapse
Affiliation(s)
- Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Gastroenterology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily C. Dowling
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gabriel A. Brooks
- Dana Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Alvin Jeon
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Gastroenterology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - William R. Brugge
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Gastroenterology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - G. Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Pari V. Pandharipande
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
30
|
Corey KE, Klebanoff MJ, Tramontano AC, Chung RT, Hur C. Screening for Nonalcoholic Steatohepatitis in Individuals with Type 2 Diabetes: A Cost-Effectiveness Analysis. Dig Dis Sci 2016; 61:2108-17. [PMID: 26825843 PMCID: PMC4920690 DOI: 10.1007/s10620-016-4044-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 01/16/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Individuals with type 2 diabetes are at heightened risk for nonalcoholic fatty liver disease, which gives rise to nonalcoholic steatohepatitis (NASH) and cirrhosis. Yet, current guidelines do not recommend screening for NASH among these high-risk patients. Using a simulation model, we assessed the effectiveness and cost-effectiveness of screening diabetic patients for NASH. METHODS A Markov model was constructed to compare two management strategies for 50-year-olds with diabetes. In the No Screening strategy, patients do not undergo screening, although NASH may be diagnosed incidentally over their lifetime. In the NASH Screening strategy, all patients receive a one-time screening ultrasound. Individuals with fatty infiltration on ultrasound then have a liver biopsy, and those found to have NASH receive medical therapy, which decreases progression to cirrhosis. Endpoints evaluated included quality-adjusted life years (QALYs) gained, costs, and incremental cost-effectiveness ratios (ICERs). RESULTS Screening for NASH decreased the number of individuals who developed cirrhosis by 12.9 % and resulted in an 11.9 % decrease in liver-related deaths. However, screening resulted in 0.02 fewer QALYs, due to the disutility associated with treatment, and was therefore dominated by the No Screening strategy. When the model excluded this quality-of-life decrement, screening became cost-effective, at an ICER of $42,134 per QALY. CONCLUSIONS Screening for NASH may improve liver-related outcomes, but is not cost-effective at present, due to side effects of therapy. As better tolerated treatments for NASH become available, even with modest efficacy, screening for NASH will become cost-effective.
Collapse
Affiliation(s)
- Kathleen E. Corey
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Matthew J. Klebanoff
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA,Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Chin Hur
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
31
|
Pandharipande PV, Reisner AT, Binder WD, Zaheer A, Gunn ML, Linnau KF, Miller CM, Avery LL, Herring MS, Tramontano AC, Dowling EC, Abujudeh HH, Eisenberg JD, Halpern EF, Donelan K, Gazelle GS. CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making. Radiology 2016; 278:812-21. [DOI: 10.1148/radiol.2015150473] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
32
|
Tramontano AC, Sheehan DF, McMahon PM, Dowling EC, Holford TR, Ryczak K, Lesko SM, Levy DT, Kong CY. Evaluating the impacts of screening and smoking cessation programmes on lung cancer in a high-burden region of the USA: a simulation modelling study. BMJ Open 2016; 6:e010227. [PMID: 26928026 PMCID: PMC4780060 DOI: 10.1136/bmjopen-2015-010227] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 02/02/2016] [Accepted: 02/09/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE While the US Preventive Services Task Force has issued recommendations for lung cancer screening, its effectiveness at reducing lung cancer burden may vary at local levels due to regional variations in smoking behaviour. Our objective was to use an existing model to determine the impacts of lung cancer screening alone or in addition to increased smoking cessation in a US region with a relatively high smoking prevalence and lung cancer incidence. SETTING Computer-based simulation model. PARTICIPANTS Simulated population of individuals 55 and older based on smoking prevalence and census data from Northeast Pennsylvania. INTERVENTIONS Hypothetical lung cancer control from 2014 to 2050 through (1) screening with CT, (2) intensified smoking cessation or (3) a combination strategy. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were lung cancer mortality rates. Secondary outcomes included number of people eligible for screening and number of radiation-induced lung cancers. RESULTS Combining lung cancer screening with increased smoking cessation would yield an estimated 8.1% reduction in cumulative lung cancer mortality by 2050. Our model estimated that the number of screening-eligible individuals would progressively decrease over time, indicating declining benefit of a screening-only programme. Lung cancer screening achieved a greater mortality reduction in earlier years, but was later surpassed by smoking cessation. CONCLUSIONS Combining smoking cessation programmes with lung cancer screening would provide the most benefit to a population, especially considering the growing proportion of patients ineligible for screening based on current recommendations.
Collapse
Affiliation(s)
- Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela M McMahon
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Emily C Dowling
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Theodore R Holford
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Karen Ryczak
- Northeast Regional Cancer Institute, Scranton, Pennsylvania, USA
| | - Samuel M Lesko
- Northeast Regional Cancer Institute, Scranton, Pennsylvania, USA
| | - David T Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
33
|
Lowry KP, Gazelle GS, Gilmore ME, Johanson C, Munshi V, Choi SE, Tramontano AC, Kong CY, McMahon PM. Personalizing annual lung cancer screening for patients with chronic obstructive pulmonary disease: A decision analysis. Cancer 2015; 121:1556-62. [PMID: 25652107 PMCID: PMC4492436 DOI: 10.1002/cncr.29225] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Revised: 11/15/2014] [Accepted: 11/19/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Lung cancer screening with annual chest computed tomography (CT) is recommended for current and former smokers with a ≥30-pack-year smoking history. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of developing lung cancer and may benefit from screening at lower pack-year thresholds. METHODS We used a previously validated simulation model to compare the health benefits of lung cancer screening in current and former smokers ages 55-80 with ≥30 pack-years with hypothetical programs using lower pack-year thresholds for individuals with COPD (≥20, ≥10, and ≥1 pack-years). Calibration targets for COPD prevalence and associated lung cancer risk were derived using the Framingham Offspring Study limited data set. We performed sensitivity analyses to evaluate the stability of results across different rates of adherence to screening, increased competing mortality risk from COPD, and increased surgical ineligibility in individuals with COPD. The primary outcome was projected life expectancy. RESULTS Programs using lower pack-year thresholds for individuals with COPD yielded the highest life expectancy gains for a given number of screens. Highest life expectancy was achieved when lowering the pack-year threshold to ≥1 pack-year for individuals with COPD, which dominated all other screening strategies. These results were stable across different adherence rates to screening and increases in competing mortality risk for COPD and surgical ineligibility. CONCLUSIONS Current and former smokers with COPD may disproportionately benefit from lung cancer screening. A lower pack-year threshold for screening eligibility may benefit this high-risk patient population.
Collapse
Affiliation(s)
- Kathryn P Lowry
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Massachusetts General Hospital, Institute for Technology Assessment, Boston, Massachusetts
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Hur C, Choi SE, Kong CY, Wang GQ, Xu H, Polydorides AD, Xue LY, Perzan KE, Tramontano AC, Richards-Kortum RR, Anandasabapathy S. High-resolution microendoscopy for esophageal cancer screening in China: A cost-effectiveness analysis. World J Gastroenterol 2015; 21:5513-23. [PMID: 25987774 PMCID: PMC4427673 DOI: 10.3748/wjg.v21.i18.5513] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 09/03/2014] [Accepted: 11/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To study the cost-effectiveness of high-resolution microendoscopy (HRME) in an esophageal squamous cell carcinoma (ESCC) screening program in China. METHODS A decision analytic Markov model of ESCC was developed. Separate model analyses were conducted for cohorts consisting of an average-risk population or a high-risk population in China. Hypothetical 50-year-old individuals were followed until age 80 or death. We compared three different strategies for both cohorts: (1) no screening; (2) standard endoscopic screening with Lugol's iodine staining; and (3) endoscopic screening with Lugol's iodine staining and an HRME. Model parameters were estimated from the literature as well as from GLOBOCAN, the Cancer Incidence and Mortality Worldwide cancer database. Health states in the model included non-neoplasia, mild dysplasia, moderate dysplasia, high-grade dysplasia, intramucosal carcinoma, operable cancer, inoperable cancer, and death. Separate ESCC incidence transition rates were generated for the average-risk and high-risk populations. Costs in Chinese currency were converted to international dollars (I$) and were adjusted to 2012 dollars using the Consumer Price Index. RESULTS The main outcome measurements for this study were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). For the average-risk population, the HRME screening strategy produced 0.043 more QALYs than the no screening strategy at an additional cost of I$646, resulting in an ICER of I$11808 per QALY gained. Standard endoscopic screening was weakly dominated. Among the high-risk population, when the HRME screening strategy was compared with the standard screening strategy, the ICER was I$8173 per QALY. For both the high-risk and average-risk screening populations, the HRME screening strategy appeared to be the most cost-effective strategy, producing ICERs below the willingness-to-pay threshold, I$23500 per QALY. One-way sensitivity analysis showed that, for the average-risk population, higher specificity of Lugol's iodine (> 40%) and lower specificity of HRME (< 70%) could make Lugol's iodine screening cost-effective. For the high-risk population, the results of the model were not substantially affected by varying the follow-up rate after Lugol's iodine screening, Lugol's iodine test characteristics (sensitivity and specificity), or HRME specificity. CONCLUSION The incorporation of HRME into an ESCC screening program could be cost-effective in China. Larger studies of HRME performance are needed to confirm these findings.
Collapse
|
35
|
Tramontano AC, Schrag DL, Malin JK, Miller MC, Weeks JC, Swan JS, McMahon PM. Catalog and comparison of societal preferences (utilities) for lung cancer health states: results from the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Med Decis Making 2015; 35:371-87. [PMID: 25670839 DOI: 10.1177/0272989x15570364] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The EQ-5D and SF-6D are 2 health-related quality-of-life indexes that provide preference-weighted measures for use in cost-effectiveness analyses. METHODS The National Cancer Institute's Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium included the EQ-5D and SF-12v2 in their survey of newly diagnosed lung cancer patients. Utilities were calculated from patient-provided scores for each domain of the EQ-5D or the SF-6D. Utilities were calculated for categories of cancer type, stage, and treatment. RESULTS There were 5015 enrolled lung cancer patients with a baseline survey in CanCORS; 2396 (47.8%) completed the EQ-5D, and 2344 (46.7%) also completed the SF-12v2. The mean (standard deviation) utility from the EQ-5D was 0.78 (0.18), and from the SF-6D (derived from SF-12v2) was 0.68 (0.14). The EQ-5D demonstrated a ceiling effect, with 20% of patients reporting perfect scores, translating to a utility of 1.0. No substantial SF-6D floor effects were noted. Utilities increased with age and decreased with stage and comorbidities. Patient-reported (EQ-5D) visual analog scale scores for health status had a moderate (r = 0.48, p < 0.0001) positive correlation with utilities. A subset (n = 1474) completed follow-up EQ-5D questionnaires 11-13 months after diagnosis. Among these patients, there was a nonsignificant decrease in mean utility for stage IV and an increase in mean utility for stages I, II, and III. CONCLUSION This study generated a catalog of community-weighted utilities applicable to societal-perspective cost-effectiveness analyses of lung cancer interventions and compared utilities based on the EQ-5D and SF-6D. Potential users of these scores should be aware of the limitations and think carefully about their use in specific studies.
Collapse
Affiliation(s)
- Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (ACT, MCM, JSS, PMM)
| | - Deborah L Schrag
- Dna-Farber Cancer Institute, Boston, MA (DLS, JCW),Department of Radiology, Harvard Medical School, Boston, MA (DLS, JSS, PMM)
| | | | - Melecia C Miller
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (ACT, MCM, JSS, PMM)
| | - Jane C Weeks
- Dna-Farber Cancer Institute, Boston, MA (DLS, JCW)
| | - J Shannon Swan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (ACT, MCM, JSS, PMM),Department of Radiology, Harvard Medical School, Boston, MA (DLS, JSS, PMM)
| | - Pamela M McMahon
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA (ACT, MCM, JSS, PMM),Department of Radiology, Harvard Medical School, Boston, MA (DLS, JSS, PMM)
| |
Collapse
|
36
|
Choi SE, Perzan KE, Tramontano AC, Kong CY, Hur C. Statins and aspirin for chemoprevention in Barrett's esophagus: results of a cost-effectiveness analysis. Cancer Prev Res (Phila) 2013; 7:341-50. [PMID: 24380852 DOI: 10.1158/1940-6207.capr-13-0191-t] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Data suggest that aspirin, statins, or a combination of the two drugs may lower the progression of Barrett's esophagus to esophageal adenocarcinoma. However, aspirin is associated with potential complications such as gastrointestinal bleeding and hemorrhagic stroke, and statins are associated with myopathy. We developed a simulation disease model to study the effectiveness and cost effectiveness of aspirin and statin chemoprevention against esophageal adenocarcinoma. A decision analytic Markov model was constructed to compare four strategies for Barrett's esophagus management; all regimens included standard endoscopic surveillance regimens: (i) endoscopic surveillance alone, (ii) aspirin therapy, (iii) statin therapy, and (iv) combination therapy of aspirin and statin. Endpoints evaluated were life expectancy, quality-adjusted life years (QALY), costs, and incremental cost-effectiveness ratios (ICER). Sensitivity analysis was performed to determine the impact of model input uncertainty on results. Assuming an annual progression rate of 0.33% per year from Barrett's esophagus to esophageal adenocarcinoma, aspirin therapy was more effective and cost less than (dominated) endoscopic surveillance alone. When combination therapy was compared with aspirin therapy, the ICER was $158,000/QALY, which was above our willingness-to-pay threshold of $100,000/QALY. Statin therapy was dominated by combination therapy. When higher annual cancer progression rates were assumed in the model (0.5% per year), combination therapy was cost-effective compared with aspirin therapy, producing an ICER of $96,000/QALY. In conclusion, aspirin chemoprevention was both more effective and cost less than endoscopic surveillance alone. Combination therapy using both aspirin and statin is expensive but could be cost-effective in patients at higher risk of progression to esophageal adenocarcinoma.
Collapse
Affiliation(s)
- Sung Eun Choi
- Massachusetts General Hospital, 101 Merrimac Street, 10th Floor, Boston, MA 02114.
| | | | | | | | | |
Collapse
|
37
|
McMahon PM, Kong CY, Johnson BE, Weinstein MC, Weeks JC, Tramontano AC, Cipriano LE, Bouzan C, Gazelle GS. Chapter 9: The MGH-HMS lung cancer policy model: tobacco control versus screening. Risk Anal 2012; 32 Suppl 1:S117-24. [PMID: 22882882 PMCID: PMC3478757 DOI: 10.1111/j.1539-6924.2011.01652.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The natural history model underlying the MGH Lung Cancer Policy Model (LCPM) does not include the two-stage clonal expansion model employed in other CISNET lung models. We used the LCPM to predict numbers of U.S. lung cancer deaths for ages 30-84 between 1975 and 2000 under four scenarios as part of the comparative modeling analysis described in this issue. The LCPM is a comprehensive microsimulation model of lung cancer development, progression, detection, treatment, and survival. Individual-level patient histories are aggregated to estimate cohort or population-level outcomes. Lung cancer states are defined according to underlying disease variables, test results, and clinical events. By simulating detailed clinical procedures, the LCPM can predict benefits and harms attributable to a variety of patient management practices, including annual screening programs. Under the scenario of observed smoking patterns, predicted numbers of deaths from the calibrated LCPM were within 2% of observed over all years (1975-2000). The LCPM estimated that historical tobacco control policies achieved 28.6% (25.2% in men, 30.5% in women) of the potential reduction in U.S. lung cancer deaths had smoking had been eliminated entirely. The hypothetical adoption in 1975 of annual helical CT screening of all persons aged 55-74 with at least 30 pack-years of cigarette exposure to historical tobacco control would have yielded a proportion realized of 39.0% (42.0% in men, 33.3% in women). The adoption of annual screening would have prevented less than half as many lung cancer deaths as the elimination of cigarette smoking.
Collapse
Affiliation(s)
- Pamela M McMahon
- Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
McMahon PM, Kong CY, Bouzan C, Weinstein MC, Cipriano LE, Tramontano AC, Johnson BE, Weeks JC, Gazelle GS. Cost-effectiveness of computed tomography screening for lung cancer in the United States. J Thorac Oncol 2011; 6:1841-8. [PMID: 21892105 PMCID: PMC3202298 DOI: 10.1097/jto.0b013e31822e59b3] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION A randomized trial has demonstrated that lung cancer screening reduces mortality. Identifying participant and program characteristics that influence the cost-effectiveness of screening will help translate trial results into benefits at the population level. METHODS Six U.S. cohorts (men and women aged 50, 60, or 70 years) were simulated in an existing patient-level lung cancer model. Smoking histories reflected observed U.S. patterns. We simulated lifetime histories of 500,000 identical individuals per cohort in each scenario. Costs per quality-adjusted life-year gained ($/QALY) were estimated for each program: computed tomography screening; stand-alone smoking cessation therapies (4-30% 1-year abstinence); and combined programs. RESULTS Annual screening of current and former smokers aged 50 to 74 years costs between $126,000 and $169,000/QALY (minimum 20 pack-years of smoking) or $110,000 and $166,000/QALY (40 pack-year minimum), when compared with no screening and assuming background quit rates. Screening was beneficial but had a higher cost per QALY when the model included radiation-induced lung cancers. If screen participation doubled background quit rates, the cost of annual screening (at age 50 years, 20 pack-year minimum) was below $75,000/QALY. If screen participation halved background quit rates, benefits from screening were nearly erased. If screening had no effect on quit rates, annual screening costs more but provided fewer QALYs than annual cessation therapies. Annual combined screening/cessation therapy programs at age 50 years costs $130,500 to $159,700/QALY, when compared with annual stand-alone cessation. CONCLUSIONS The cost-effectiveness of computed tomography screening will likely be strongly linked to achievable smoking cessation rates. Trials and further modeling should explore the consequences of relationships between smoking behaviors and screen participation.
Collapse
Affiliation(s)
- Pamela M McMahon
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
McMahon PM, Kong CY, Weinstein MC, Tramontano AC, Cipriano LE, Johnson BE, Weeks JC, Gazelle GS. Adopting helical CT screening for lung cancer: potential health consequences during a 15-year period. Cancer 2008; 113:3440-9. [PMID: 18988293 PMCID: PMC2782879 DOI: 10.1002/cncr.23962] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Simulation modeling can synthesize data from single-arm studies of lung cancer screening and tumor registries to investigate computed tomography (CT) screening. This study estimated changes in lung cancer outcomes through 2005, had chest CT screening been introduced in 1990. METHODS Hypothetical individuals with smoking histories representative of 6 US cohorts (white males and females aged 50, 60, and 70 years in 1990) were simulated in the Lung Cancer Policy Model, a comprehensive patient-level simulation model of lung cancer development, screening, and treatment. A no screening scenario corresponded to observed outcomes. We simulated 3 screening scenarios in current or former smokers with > or =20 pack-years as follows: 1-time screen in 1990; and annual, and twice-annually screenings beginning in 1990 and ending in 2005. Main outcomes were days of life between 1990 and 2005 and life expectancy in 1990 (estimated by simulating life histories past 2005). RESULTS All screening scenarios yielded reductions (compared with no screening) in lung cancer-specific mortality by 2005, with larger reductions predicted for more frequent screening. Compared with no screening, annual screening of ever-smokers with at least 20 pack-years of cigarette exposure provided ever-smokers with an additional 11 to 33 days of life by 2005, or an additional 3-10 weeks of (undiscounted) life expectancy. In sensitivity analyses, the largest effects on gains from annual screening were due to reductions in screening adherence and increased smoking cessation. CONCLUSIONS The adoption of CT screening, had it been available in 1990, might have resulted in a modest gain in life expectancy.
Collapse
Affiliation(s)
- Pamela M McMahon
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Stahl JE, Tramontano AC, Swan JS, Cohen BJ. Balancing urgency, age and quality of life in organ allocation decisions--what would you do? A survey. J Med Ethics 2008; 34:109-115. [PMID: 18234950 DOI: 10.1136/jme.2006.018291] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE Explore public attitudes towards the trade-offs between justice and medical outcome inherent in organ allocation decisions. BACKGROUND The US Task Force on Organ Transplantation recommended that considerations of justice, autonomy and medical outcome be part of all organ allocation decisions. Justice in this context may be modeled as a function of three types of need, related to age, clinical urgency, and quality of life. METHODS A web-based survey was conducted in which respondents were asked to choose between two hypothetical patients who differed in clinical urgency (time to death <1 year), age, pretransplant and post-transplant quality of life, and life expectancy. RESULTS A pool of 1600 people were notified via email about the survey; 623 (39%) responded. Respondents preferred giving organs to younger people up to an age difference of <15.4 years (SD 18) and more clinically urgent people up to a difference in urgency of <2.54 months (SD 3). Priority varied with the quality of life of the worst-off patient and the relative status of the patients. If both had worse than average quality of life, respondents preferred the better-off patient. When both had better than average quality of life, they preferred the worse-off patient. In analysis according to age versus clinical urgency, the older the patient, the more urgency needed to receive priority. In quality of life versus clinical urgency, the better the control's quality of life, the more urgency the competing patient required. The worse the patient's post-transplant outcome, the more urgency needed to receive priority. CONCLUSIONS It appears that clinical urgency is only one of many factors influencing attitudes about allocation decisions and that respondents may invoke different principles of fairness depending the relative clinical status of patients.
Collapse
Affiliation(s)
- J E Stahl
- Massachusetts General Hospital, Institute for Technology Assessment, 101 Mermac St, 10th floor, Boston, MA 02114, USA.
| | | | | | | |
Collapse
|
41
|
Gazelle GS, Halpern EF, Ryan HS, Tramontano AC. Utilization of diagnostic medical imaging: comparison of radiologist referral versus same-specialty referral. Radiology 2007; 245:517-22. [PMID: 17940306 DOI: 10.1148/radiol.2452070193] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively compare the frequency with which patients underwent diagnostic medical imaging procedures during episodes of outpatient medical care according to whether their physicians referred patients for imaging to themselves and/or physicians in their same specialty or to radiologists. MATERIALS AND METHODS Institutional review board approval was not necessary for this HIPAA-compliant study. An insurance claims database from a large national employer-based health plan was obtained. Claims data from 1999-2003 were grouped into episodes of care for six conditions: cardiopulmonary disease, coronary and/or cardiac disease, extremity fracture, knee pain, intraabdominal malignancy, and stroke. For each condition, each referring physician's behavior was categorized as either "same-specialty referral" or "radiologist referral" on the basis of that physician's entire history of imaging referrals for the condition. The frequency with which patients underwent diagnostic medical imaging procedures during episodes of care was compared according to whether their physicians referred patients for imaging to themselves and/or same-specialty physicians or to radiologists. Rates were compared by using chi(2) tests, and logistic regression was used to compare utilization rates, with patient age and number of comorbidities as covariates. RESULTS For the conditions evaluated, physicians who referred patients to themselves or to other same-specialty physicians for diagnostic imaging used imaging between 1.12 and 2.29 times as often, per episode of care, as physicians who referred patients to radiologists (P < .005 for all comparisons). Adjusting for patient age and comorbidity, the likelihood of imaging was 1.196-3.228 times greater for patients cared forby same-specialty-referring physicians. CONCLUSION Same-specialty-referring physicians tend to utilize imaging more frequently than do physicians who refer their patients to radiologists. These results cannot be explained by differences in case mix (because analyses were performed within six specific conditions of interest), patient age, or comorbidity.
Collapse
Affiliation(s)
- G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA 02114-4724, USA
| | | | | | | |
Collapse
|
42
|
Hur C, Chan AT, Tramontano AC, Gazelle GS. Coxibs versus combination NSAID and PPI therapy for chronic pain: an exploration of the risks, benefits, and costs. Ann Pharmacother 2006; 40:1052-63. [PMID: 16720709 DOI: 10.1345/aph.1g493] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To systematically review studies qualitatively to compare the risks (gastrointestinal [GI] and cardiovascular) and benefits (pain control) of cyclooxygenase-2 inhibitors (coxibs) relative to an alternative therapy of a nonselective nonsteroidal antiinflammatory drug (NSAID) combined with a proton-pump inhibitor (PPI) and explore circumstances when coxibs may be appropriate. METHODS Relevant studies were identified through a search of MEDLINE (Ovid Technologies, 1985-November 2005; English language, clinical trial), PubMed (1985-November 2005; English language, clinical trial, humans), and the Cochrane Collaboration using the terms selective COX-2 inhibitors and coxibs, as well as the various chemical names for specific coxib agents. Studies that compared a coxib with a nonselective NSAID and provided data concerning our outcomes of interest were included and categorized by the outcome variable, as well as by the specific coxib studied. RESULTS The majority of the numerous studies that evaluated pain as an endpoint showed no difference between coxib and nonselective NSAID therapy. However, while limited, preliminary safety data regarding the effects of both classes on the upper and lower GI tract suggest coxib superiority. Although coxibs are associated with an increased risk of cardiovascular adverse events (CVEs) compared with placebo, this effect has not been conclusively shown compared with nonselective NSAIDs. Currently, coxib therapy is more expensive than combination therapy using a nonselective NSAID plus a PPI. CONCLUSIONS Compared with combination therapy including a nonselective NSAID and PPI, coxibs provide equivalent pain control and may have a lower GI tract complication profile, but at an unknown increased risk of CVEs and a greater financial cost. Coxib therapy may be an appropriate treatment for chronic pain in select patients with higher risks of GI complications, lower risk of CVEs, and in whom greater cost is not a restraint.
Collapse
Affiliation(s)
- Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital Gastrointestinal Unit, Harvard Medical School, Boston, 02114, USA.
| | | | | | | |
Collapse
|