The need for a comprehensive and integrated approach to lung cancer policy in Europe

Lung cancer is the leading cause of cancer-related deaths in Europe. Europe's Beating Cancer Plan calls for a comprehensive approach to the disease in general but not specifically to lung cancer. Such a comprehensive approach, integrating efforts to strengthen anti-tobacco policies, early detection and underlying models of care, is sorely needed for lung cancer - particularly considering disruptions to care during the COVID-19 pandemic. In a recently published think piece, a multidisciplinary group of experts proposed four key policy priority areas. First, to reduce stigma and improve awareness of potential symptoms, there is a need to foster a better understanding of lung cancer - among the public and healthcare professionals. Second, opportunities for early detection should be enhanced, and the implementation of targeted screening through low-dose computed tomography should be encouraged as a complement to smoking cessation services. This complementarity should be recognised and built into joint policy proposals, with development and better integration of screening and smoking cessation programmes on the ground. Third, the socioeconomic inequalities underpinning disparities in outcomes in people with lung cancer must be addressed, with targeted approaches to overcome barriers to access Finally, the overall quality of lung cancer care must be improved, making multidisciplinary care available to all and ensuring survivorship is given due attention.

Creating a better journey of care for patients with heart valve disease

Heart valve disease has been described as ‘the next cardiac epidemic’, with prevalence expected to double by 2040 and triple by 2060 due to the ageing of the population. Yet until now, it has been characterized by scarce data, limited research, and low general awareness compared with other cardiovascular diseases. Effective treatment options exist for heart valve disease, and early detection and treatment can dramatically change disease progression, improve quality of life, and reduce mortality. Unfortunately, in too many patients, heart valve disease is undetected, undiagnosed, untreated, or treated too late, leading to avoidable deaths and costs, and significant compromises to people’s quality of life. These gaps in the patient pathway can be remedied through appropriate policy action, with a focus on: early detection and diagnosis; timely intervention; patient-centred follow-up care; patient engagement and empowerment; psychological support; and better data to guide practice. Ensuring all patients have access to appropriate diagnosis and care without delays is imperative as we look towards rebuilding stronger and more resilient health systems, and ‘build back better’ after the coronavirus disease-19 pandemic.

The life-course approach to vaccination: Harnessing the benefits of vaccination throughout life

Vaccination beyond childhood brings significant benefits at the individual, community and socio-economic levels. Despite this, immunisation programmes often fail to deliver the vaccines which could protect those at risk of vaccine-preventable diseases. In this commentary, we argue that the benefits of vaccination beyond childhood must be more widely understood and furthermore, that action must be taken by policymakers, healthcare professionals and patient and civil society organisations to ensure that the benefits of vaccination are fully realised. We outline five areas where change is needed to ensure vaccination across the life-course becomes truly embedded in national immunisation programmes. This includes investing in robust data collection and analysis; ensuring coordinated, multidisciplinary leadership from the top; engaging healthcare professionals; changing public perceptions of vaccination; and integrating vaccination into schools and workplaces.

Barriers and Opportunities in Genetic Testing for BRCA Gene Mutations in Europe: A Strategic Policy Response to Support Women and Families At Risk for Breast Cancer

Background and context: An estimated 12.5% of women are at risk for breast cancer. 5%-10% of these cases are hereditary, and of these, 20%-25% are due to BRCA gene mutations. Women with BRCA mutations are at higher risk of early onset, recurrence and of triple-negative breast cancer, with fewer treatment options. These women need to be supported to seek genetic testing as early as possible. They also need support and guidance to inform family members, consider preventive interventions and obtain appropriate care and counseling. Aim: To provide an overview of the BRCA genetic testing policy landscape in Europe and highlight barriers to women and their families to access testing, information and support. Strategy: A pragmatic review of international published and gray literature. With a focus on Europe and Israel, we looked for epidemiologic data in six countries and assessed the systems, policies and services in place for genetic testing, counseling and care. This was complemented by semistructured telephone interviews with healthcare professionals, researchers and patient representatives. Policy process: We must develop comprehensive cancer control plans that provide for high-quality prevention, treatment and care for all women with BRCA mutations, whether they develop breast cancer. The unmet needs of later-stage and more difficult-to-treat breast cancers, such as BRCA-mutated or triple-negative must not be neglected. Outcomes: Current BRCA genetic testing guidelines are insufficient. Testing eligibility is restricted to high-risk patients, despite evidence that over half of women diagnosed with BRCA-related breast cancer could be missed with this approach. Access barriers to information and services include: too few genetic counselors to provide information and support to women and their families; limited primary care genetics knowledge which may lead to low referral rates and unequal testing access based on region, age and race. Individuals may also forego testing for fear of discrimination by employers or insurance companies or the effect a positive test might have on families and relationships. What was learned: Opportunities to address the unmet needs of women considering BRCA genetic testing include: greater public awareness and understanding of testing; building professional capacity to better support those getting tested and policies to protect women against discrimination from employers or insurers. The emotional impact on women who undergo testing must also be considered, as well as the provision of appropriate information, support and care through every stage of a woman's experience. This research offers a starting point for discussion with policymakers and patient organizations to ensure pathways and policies are place which integrate the patient experience into comprehensive care pathways and national cancer control plans.

Identifying critical steps towards improved access to innovation in cancer care: a European CanCer Organisation position paper

In recent decades cancer care has seen improvements in the speed and accuracy of diagnostic procedures; the effectiveness of surgery, radiation therapy and medical treatments; the power of information technology; and the development of multidisciplinary, specialist-led approaches to care. Such innovations are essential if we are to continue improving the lives of cancer patients across Europe despite financial pressures on our healthcare systems. Investment in innovation must be balanced with the need to ensure the sustainability of healthcare budgets, and all health professionals have a responsibility to help achieve this balance. It requires scrutiny of the way care is delivered; we must be ready to discontinue practices or interventions that are inefficient, and prioritise innovations that may deliver the best outcomes possible for patients within the limits of available resources. Decisions on innovations should take into account their long-term impact on patient outcomes and costs, not just their immediate costs. Adopting a culture of innovation requires a multidisciplinary team approach, with the patient at the centre and an integral part of the team. It must take a whole-system and whole-patient perspective on cancer care and be guided by high-quality real-world data, including outcomes relevant to the patient and actual costs of care; this accurately reflects the impact of any innovation in clinical practice. The European CanCer Organisation is committed to working with its member societies, patient organisations and the cancer community at large to find sustainable ways to identify and integrate the most meaningful innovations into all aspects of cancer care.

Burden of Illness in Hereditary Angioedema: A Conceptual Model

The objective of the Hereditary Angioedema Burden of Illness Study in Europe was to assess the real-world experience of hereditary angioedema (HAE) from the patient perspective. Based on open-ended qualitative interviews with 30 patients from Spain, Germany and Denmark, 5 key themes emerged characterizing the impact of HAE on health-related quality of life (HRQoL): (i) unnecessary treatments and procedures, (ii) symptom triggers, (iii) attack impacts, (iv) caregiver impacts, and (v) long-term impacts. Patients for example experience unnecessary medical procedures due to diagnostic delays; anxiety and fear about attacks, and passing HAE to children; reduced work/school productivity; and limited career/educational achievement. Patient caregivers also experience worry and work/activity interruption during the attacks. In conclusion, a conceptual model was developed illustrating the hypothesized relationships among the wide-ranging short- and long-term HRQoL impacts of HAE. These findings can be used to highlight important issues in clinical management, raise awareness of the patients' experience among policymakers and help guide measurement of HRQoL outcomes in future studies in HAE.

Socioeconomic burden of hereditary angioedema: results from the hereditary angioedema burden of illness study in Europe

Background

Hereditary angioedema (HAE) due to C1 inhibitor deficiency is a rare but serious and potentially life-threatening disease marked by spontaneous, recurrent attacks of swelling. The study objective was to characterize direct and indirect resource utilization associated with HAE from the patient perspective in Europe.

Methods

The study was conducted in Spain, Germany, and Denmark to assess the real-world experience of HAE via a cross-sectional survey of HAE patients, including direct and indirect resource utilization during and between attacks for patients and their caregivers over the past 6 months. A regression model examined predictors of medical resource utilization.

Results

Overall, 164 patients had an attack in the past 6 months and were included in the analysis. The most significant predictor of medical resource utilization was the severity of the last attack (OR 2.6; p < 0.001). Among patients who sought medical care during the last attack (23%), more than half utilized the emergency department. The last attack prevented patients from their normal activities an average of 4–12 hours. Patient and caregiver absenteeism increased with attack severity and frequency. Among patients who were working or in school (n = 120), 72 provided work/school absenteeism data, resulting in an estimated 20 days missing from work/school on average per year; 51% (n = 84) indicated that HAE has hindered their career/educational advancement.

Conclusion

HAE poses a considerable burden on patients and their families in terms of direct medical costs and indirect costs related to lost productivity. This burden is substantial at the time of attacks and in between attacks.

The administration of rescue medication to children with prolonged acute convulsive seizures in a non-hospital setting: an exploratory survey of healthcare professionals' perspectives

Timely administration of rescue medication for prolonged convulsive seizures lasting more than 5 min is necessary to prevent progression to status epilepticus in children. The Practices in Emergency and Rescue Medication for Epilepsy Managed with Community Administered Therapy (PERFECT™) initiative was set up to gain a better understanding of how prolonged convulsive seizures in children are managed when they occur outside of the hospital. We present the findings from an exploratory telephone survey of 128 healthcare professionals (HCPs) (85 pediatric neurologists and neurologists, 28 community pediatricians, and 15 epilepsy nurses) from six EU countries, conducted as part of the PERFECT™ initiative. Among HCPs, there was greater awareness of local protocols and lesser awareness of national or international guidelines. HCPs were not very aware of how prolonged convulsive seizures were managed outside of the hospital and had few professional links to schools or other settings where these seizures were most likely to occur. Approximately one third believed that lack of confidence and fear of liability were barriers to caregivers administering treatment in schools, as was insufficient training of caregivers in the wider community on the management of prolonged convulsive seizures.

CONCLUSION

Results of this HCP survey have identified several clear gaps that need to be addressed: clearer guidance that spans all settings of care, greater dissemination of such guidelines across the chain of care, more open communication and better links between HCPs and schools, and systematic training of all relevant caregivers on the appropriate management of prolonged convulsive seizures.

The humanistic burden of hereditary angioedema: results from the Burden of Illness Study in Europe

Hereditary angioedema (HAE) is a rare but potentially life-threatening disease marked by spontaneous, recurrent attacks of swelling. The broad range of consequences of HAE on patients' lives is not well understood. The study objective was to comprehensively characterize the burden of illness and impact of HAE types I and II from the patient perspective. The HAE Burden of Illness Study in Europe was conducted in Spain, Germany, and Denmark to assess the real-world experience of HAE from the patient perspective via a one-time survey, which included items on clinical characteristics and physical and emotional impacts. One hundred eighty-six patients participated; 59% reported having an attack at least once a month, 67% reported moderate-to-severe pain during their last attack, and 74% reported moderate-to-severe swelling. The most common sites of the last attack were the abdomen and extremities; 24% experienced an attack in more than one site. The impact of HAE on daily activities was high during attacks and did not vary significantly by body site affected; patients also reported that HAE impacted their daily activities between attacks. Patients reported substantial anxiety about future attacks, traveling, and passing HAE to their children. Based on Hospital Anxiety and Depression Scale scores, 38 and 14% had clinically meaningful anxiety and depression, respectively. Despite standard of care, HAE patients still have frequent and painful attacks. Patients experience substantial impairment physically and emotionally both during and between attacks. A better understanding of these effects may help in the clinical management of HAE patients.

Report from a Viral Hepatitis Policy Forum on implementing the WHO Framework for Global Action on viral hepatitis in North Asia

BACKGROUND & AIMS

The World Health Organisation (WHO) Prevention & Control of Viral Hepatitis Infection: Framework for Global Action offers a global vision for the prevention and control of viral hepatitis. In October 2012, the Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP) organised the North Asia Workshop on Viral Hepatitis in Taipei to discuss how to implement the WHO Framework in the North Asia region. This paper presents outcomes from this workshop.

METHODS

Twenty-eight representatives from local liver associations, patient organisations, and centres of excellence in Hong Kong, Japan, Korea, and Taiwan participated in the workshop.

FINDINGS

Priority areas for action were described along the four axes of the WHO Framework: (1) awareness, advocacy and resources; (2) evidence and data; (3) prevention of transmission; and (4) screening and treatment. Priorities included: axis 1: greater public and professional awareness, particularly among primary care physicians and local advocacy networks. Axis 2: better economic data and identifying barriers to screening and treatment uptake. Axis 3: monitoring of vaccination outcomes and targeted harm reduction strategies. Axis 4: strengthening links between hospitals and primary care providers, and secure funding of screening and treatment, including for hepatocellular carcinoma.

CONCLUSIONS

The WHO Framework provides an opportunity to develop comprehensive and cohesive policies in North Asia and the broader region. A partnership between clinical specialists, primary care physicians, policy makers, and people with or at risk of viral hepatitis is essential in shaping future policies.

Are we failing to provide adequate rescue medication to children at risk of prolonged convulsive seizures in schools?

OBJECTIVE

This paper explores the issues that arise from the discussion of administering rescue medication to children who experience prolonged convulsive seizures in mainstream schools in the UK.

SITUATION ANALYSIS

Current guidelines recommend immediate treatment of children with such seizures (defined as seizures lasting more than 5 min) to prevent progression to status epilepticus and neurological morbidity. As children are unconscious during prolonged convulsive seizures, whether or not they receive their treatment in time depends on the presence of a teacher or other member of staff trained and able to administer rescue medication. However, it is thought that the situation varies between schools and depends mainly on the goodwill and resources available locally.

RECOMMENDATIONS

A more systematic response is needed to ensure that children receive rescue medication regardless of where their seizure occurs. Possible ways forward include: greater use of training resources for schools available from epilepsy voluntary sector organisations; consistent, practical information to schools; transparent guidance outlining a clear care pathway from the hospital to the school; and implementation and adherence to each child's individual healthcare plan.

IMPLICATIONS

Children requiring emergency treatment for prolonged convulsive seizures during school hours test the goals of integrated, person-centred care as well as joined-up working to which the National Health Service (NHS) aspires. As changes to the NHS come into play and local services become reconfigured, every effort should be made to take account of the particular needs of this vulnerable group of children within broader efforts to improve the quality of paediatric epilepsy services overall.

The importance of measuring the velocity of diameter expansion on MRI in upfront management of suspected WHO grade II glioma - case report

A right insular lesion was incidentally discovered in a 48-year-old male. Morphological and metabolic radiological characteristics on magnetic resonance imaging (MRI) were in favor of a World Health Organization (WHO) grade II glioma. Despite being advised that surgery was appropriate, the patient elected for conservative management. A second MRI was performed 5 months after, and interpreted as unchanged. A third MRI 4 months later demonstrated a significant increase in tumor size and enhancement in a new distant tumor focus. The patient was referred to our center and underwent surgical resection. Histopathology revealed a grade III astrocytoma. A retrospective quantitative measurement of the radiological growth between the two first MRIs yielded a growth rate of 12 mm/year. This value, highly suggestive of a malignant glioma, should have triggered surgery at the time of the second MRI. We conclude that, whenever surgical treatment of a suspected WHO grade II gliomas is postponed, assessing tumor kinetics quantitatively is important to identify patients whose tumor is indeed a WHO grade III glioma. The tumor should be indeed followed by serial MRIs with quantitative measurement of tumor growth, not just "eyeball" qualitative examination. Immediate treatment is indicated in patients with radiological tumor expansion of greater than 8mm/year.

The hereditary angioedema burden of illness study in Europe (HAE-BOIS-Europe): background and methodology

Background

Hereditary angioedema (HAE) is a rare but serious disease marked by swelling attacks in the extremities, face, trunk, airway, or abdominal areas that can be spontaneous or the result of trauma and other triggers. It can be life-threatening due to the risk of asphyxiation. While there have been major advancements in our understanding of the immunogenetics of HAE, there are significant gaps in the literature regarding understanding of the humanistic and economic impact of the disease, particularly in Europe. The purpose of the HAE Burden of Illness Study-Europe (HAE-BOIS-Europe), the development and methodology of which is described here, is to better understand the management and impact of HAE from the patient perspective in Europe.

Methods/Design

This is a cross-sectional study in which retrospective data were also collected being conducted in Denmark, Germany and Spain. The study is open to patients ages 12 and older with a diagnosis of HAE-I or HAE-II. Data collection includes: (i) a survey on individuals’ health care resource use, direct and indirect medical costs, impact on work and school, treatment satisfaction, and emotional functioning (via the Hospital Anxiety and Depression Scale); and (ii) one-on-one interviews to collect detailed descriptive data and patient testimonials on the impact of HAE on patients’ health-related quality of life.

Discussion

The present manuscript describes the development and plans for implementing a multi-country European study with the aim of characterizing the humanistic and economic burden of HAE from the patient perspective. This study will help raise awareness of HAE as a rare but debilitating condition with wide-ranging impacts.

The state of hepatitis B and C in Europe: report from the hepatitis B and C summit conference*

Worldwide, the hepatitis B virus (HBV) and the hepatitis C virus (HCV) cause, respectively, 600,000 and 350,000 deaths each year. Viral hepatitis is the leading cause of cirrhosis and liver cancer, which in turn ranks as the third cause of cancer death worldwide. Within the WHO European region, approximately 14 million people are chronically infected with HBV, and nine million people are chronically infected with HCV. Lack of reliable epidemiological data on HBV and HCV is one of the biggest hurdles to advancing policy. Risk groups such as migrants and injecting drug users (IDU) tend to be under-represented in existing prevalence studies; thus, targeted surveillance is urgently needed to correctly estimate the burden of HBV and HCV. The most effective means of prevention against HBV is vaccination, and most European Union (EU) countries have universal vaccination programmes. For both HBV and HCV, screening of individuals who present a high risk of contracting the virus is critical given the asymptomatic, and thereby silent, nature of disease. Screening of migrants and IDUs has been shown to be effective and potentially cost-effective. There have been significant advances in the treatment of HCV and HBV in recent years, but health care professionals remain poorly aware of treatment options. Greater professional training is needed on the management of hepatitis including the treatment of liver cancer to encourage adherence to guidelines and offer patients the best possible outcomes. Viral hepatitis knows no borders. EU Member States, guided by the EU, need to work in a concerted manner to implement lasting, effective policies and programmes and make tackling viral hepatitis a public health priority.

The state of hepatitis B and C in Europe: report from the hepatitis B and C summit conference*

Worldwide, the hepatitis B virus (HBV) and the hepatitis C virus (HCV) cause, respectively, 600,000 and 350,000 deaths each year. Viral hepatitis is the leading cause of cirrhosis and liver cancer, which in turn ranks as the third cause of cancer death worldwide. Within the WHO European region, approximately 14 million people are chronically infected with HBV, and nine million people are chronically infected with HCV. Lack of reliable epidemiological data on HBV and HCV is one of the biggest hurdles to advancing policy. Risk groups such as migrants and injecting drug users (IDU) tend to be under-represented in existing prevalence studies; thus, targeted surveillance is urgently needed to correctly estimate the burden of HBV and HCV. The most effective means of prevention against HBV is vaccination, and most European Union (EU) countries have universal vaccination programmes. For both HBV and HCV, screening of individuals who present a high risk of contracting the virus is critical given the asymptomatic, and thereby silent, nature of disease. Screening of migrants and IDUs has been shown to be effective and potentially cost-effective. There have been significant advances in the treatment of HCV and HBV in recent years, but health care professionals remain poorly aware of treatment options. Greater professional training is needed on the management of hepatitis including the treatment of liver cancer to encourage adherence to guidelines and offer patients the best possible outcomes. Viral hepatitis knows no borders. EU Member States, guided by the EU, need to work in a concerted manner to implement lasting, effective policies and programmes and make tackling viral hepatitis a public health priority.

Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK

BACKGROUND & AIMS

To examine the effect of malnutrition on clinical outcomes and healthcare resource use from initial diagnosis by a general practitioner (GP) in the UK.

METHODS

1000 records of malnourished patients were randomly selected from The Health Improvement Network database and matched with a sample of 996 patients' records with no previous history of malnutrition. Patients' outcomes and resource use were quantified for six months following diagnosis.

RESULTS

Malnourished patients utilised significantly more healthcare resources (e.g. 18.90 versus 9.12 GP consultations; p < 0.001, and 13% versus 5% were hospitalised; p < 0.05). The six-monthly cost of managing the malnourished and non-malnourished group was £1753 and £750 per patient respectively, generating an incremental cost of care following a diagnosis of malnutrition of £1003 per patient. Thirteen percent and 2% of patients died in the malnourished and non-malnourished group respectively (p < 0.001). Independent predictors of mortality were: malnutrition (OR: 7.70); age (per 10 years) (OR: 10.46); and the Charlson Comorbidity Index Score (per unit score) (OR: 1.24).

CONCLUSION

The healthcare cost of managing malnourished patients was more than twice that of managing non-malnourished patients, due to increased use of healthcare resources. After adjusting for age and comorbidity, malnutrition remained an independent predictor of mortality.

Assessing the economic merits of managing cytomegalovirus infection in organ and stem cell transplantation

Two preventative approaches exist to manage cytomegalovirus (CMV), a common infection in recipients of organ and stem cell transplants: prophylaxis--the prevention of viraemia--and pre-emptive therapy--the prevention of manifestation of disease in patients who have viraemia. Economic evaluation may provide a helpful framework to inform the choice between these two approaches. However, several issues arise. Direct comparisons of prophylaxis and pre-emptive therapy are rare and there are few epidemiological data that depict the full natural history of CMV infection and disease. There is a need for large, prospective randomised trials that directly compare these two strategies and are of sufficient duration to assess their overall impact on direct and indirect effects of CMV as well as patient quality of life. These methodological issues are relevant to the economic evaluation of preventative measures in other clinical settings and highlight the need for a rigorous evaluative framework to best inform decision making about the optimal strategy for patients.

[Economic evaluation of the new national breast cancer screening programme in France: application to the Bouche-du-Rhone district]

The purpose is to measure the costs of the new national breast cancer screening programme in France and to compare these with those of the previous programme in the Bouches-du-Rhône district. Direct screening costs and costs related to diagnosis and assessment were collected. Costs are presented by screening period, by organisms involved in the screening program and by corresponding phase within the screening process. The total cost of the screening program total cost has increased from 5587487 euros to 9345469 euros between the two campaigns. The main reasons are the investment costs in the new screening program, the increase in the target population and the increased fee for programs. This study presents a first estimate of the costs related to the new national breast cancer screening program. Results of this study may help to guide future decisions on the further development of breast cancer screening in France.

Building a model to determine the cost-effectiveness of breast cancer screening in France

This paper describes the methods and initial validation of a cost-effectiveness model developed to simulate the breast cancer screening situation in France. The first screening pilot programmes were set up in France in 1989 to test the feasibility of a decentralized screening model based in a large number of existing non-dedicated radiology centres. The present cost-effectiveness model was built as a tool to help guide current policy discussions on the future of screening in France. This Markov model compares the costs and effects expected when a screening programme is offered to a given cohort of women to those expected in the absence of screening. The model was initially validated using current results from the Bas-Rhin screening programme and local cancer registry epidemiological data. Over a 20-year period, 315 274 women would attend for screening, of whom 12 491 would be recalled for further assessment. 4423 cancers would be detected, resulting in 637 deaths. Screening allows the detection of 106 additional cancer cases, thereby preventing 92 deaths, and saves 1522 life-years compared with a situation without screening. Breast cancer mortality is reduced by 12.6%, yielding a cost-effectiveness ratio of 137 000 FF per life-year saved. The results of initial analyses suggest that the model is capable of suitably assessing the impact of breast cancer screening in terms of costs and effects. Further scenario analyses are needed to understand the impact of screening policy changes on the costs and effectiveness of future screening programmes.

Impact of thalassemia major on patients and their families

OBJECTIVE

To describe the burden of thalassemia major and its treatment, in terms of prevalence of iron-overload-related complications, direct and indirect costs, and the patient's physical and social well-being.

METHODS

From October 1999 to May 2000 a survey of patients with thalassemia major was conducted in ten countries: Cyprus, Egypt, Greece, Hong Kong, India, Iran, Italy, Jordan, Taiwan, and the United States.

RESULTS

1,888 questionnaires (65%) were returned. The responses suggest that nowadays patients begin blood transfusions, and most use desferrioxamine (84.8%), but iron-related complications, including life-threatening ones such as heart disease, are still common.

CONCLUSIONS

There remains a need to improve the management of thalassemia, as many patients with iron-related complications experience physical and social limitations.

An international survey of patients with thalassemia major and their views about sustaining life-long desferrioxamine use

BACKGROUND

Management of thalassemia major requires patients to have life-long access to a treatment regimen of regular blood transfusions coupled with iron chelation therapy. The objective of this study was to investigate patients' reasons for missing iron chelation therapy with desferrioxamine, and the support to sustain life-long adherence to treatment.

METHODS

From October 1999 to May 2000 a survey of patients with thalassemia major was conducted in ten countries: Cyprus, Egypt, Greece, Hong Kong, India, Iran, Italy, Jordan, Taiwan, and the United States.

RESULTS

1,888 questionnaires (65%) were returned. Most patients (1,573) used desferrioxamine, and 79% administered a dose at least 4 days a week. Inaccessibility of the drug was a common reason for missing a dose in India (51%), and in Iran (25%), whereas, in any other country, it was a reason for less than 17% of patients. Overall, 58% reported reasons for missing a dose related to their beliefs or feelings about the medication, and 42% drug-related side effects.

CONCLUSION

Many patients miss doses of desferrioxamine and an opportunity remains to develop interventions that provide more support to sustain use of desferrioxamine.

Practice and policy of measuring quality of life and health economics in cancer clinical trials: a survey among co-operative trial groups

BACKGROUND

Co-operative groups have played an important role in the advance of health-related quality of life (HRQL) research. However, definitions of the concept, criteria for selection of existing instruments and methods for data collection and interpretation remain poorly defined in the literature. A survey was conducted amongst the major cancer co-operative groups in order to gain a better understanding of their current policy and processes to ensure optimal HRQL data collection within cancer clinical trials. The topic of health economics was similarly addressed.

METHODS

A written questionnaire was addressed to 16 major European and North American cancer co-operative groups. Eleven groups responded (response rate: 69%). however, one group could not provide information for the survey, thus ten questionnaires were available for analysis.

RESULTS

The results from this survey among co-operative groups show that HRQL (more than health economics) is recognized as an important, although usually secondary, outcome measure in oncology trials. On the whole, co-operative groups have a rather flexible policy towards the inclusion of HRQL (and HE) into their clinical trials, and practice is very much on a case-by-case basis, but use standard practice guidelines and internal procedures is to ensure well-defined study protocols and enhance good quality studies.

Economics and health-related quality of life in antiemetic therapy: recommendations for trial design

Emesis (nausea and vomiting) is one of the most important toxicities associated with chemotherapy. Although it is not life threatening, it has a major impact on a patient's health-related quality of life (HRQL) and overall response to chemotherapy. New antiemetics are expensive and well-conducted comparative health economic studies are rare. The aim of the study was to review the literature in the area of chemotherapy-induced emesis in cancer patients and to offer recommendations for the inclusion of these outcomes in the design of clinical trials for new antiemetic therapies. The economic literature was reviewed based on methodological standards for economic evaluation. Many studies did not comply with standards, specifically with regard to the choice of alternatives, chosen perspective, setting, type of emesis, measurement of costs and defining outcomes (including health-related quality of life). These issues are described for each study and recommendations for trial design are presented. The role of economic data is to support decision making in choosing between competing antiemetic therapies. It is the combination of clinical outcomes, costs and health-related quality of life, which will allow treating physicians to comprehensively assess the relative value of antiemetic therapies and to provide the most cost-effective therapy for their patients.

[The cost of breast cancer screening in France]

PURPOSE

This paper presents the cost of two decentralised breast cancer screening programmes in France, in the Bas-Rhin and the Bouches du Rhône districts. Materials and methods. The costs directly related to running the two screening programmes were collected for the time period 1990-1997. Only direct costs of each programme, excluding assessment and treatment costs, are included in the cost analysis. Costs are presented per screening period, per programme attender and per cancer detected by screening.

RESULTS

The screening programme costs an average of 397 francs per woman screened and 90,828 francs per cancer detected in the Bas-Rhin, and 379 francs and 76,159 francs, respectively, in the Bouches du Rhône.

CONCLUSIONS

These costs are high compared to those of existing centralised programmes. Further research is needed to investigate means of ensuring the optimal efficiency of these programmes. The results of this study may help guide future decisions on the further development of breast cancer screening in France.

Cost effectiveness of letrozole in the treatment of advanced breast cancer in postmenopausal women in the UK

OBJECTIVE

To simulate the treatment of postmenopausal women with advanced breast cancer from second-line hormone therapy to death, and to generate estimates of the cost and effectiveness of letrozole and megestrol in order to determine the incremental cost effectiveness of letrozole, expressed as cost per life-years gained.

DESIGN

A decision-analytic model, using Markov process techniques, was designed to evaluate the lifetime clinical and economic consequences of treatment with letrozole compared with standard care with megestrol. The model was based on clinical trial results showing a clear advantage of letrozole in terms of time to progression and duration of response.

SETTING

The setting of the study was that of the UK healthcare system in 1996.

PATIENTS AND PARTICIPANTS

A hypothetical cohort of patients, identical to the patients recruited for the AR/BC2 clinical trial, who were postmenopausal women with advanced breast cancer who had previously failed to respond to first-line or adjuvant anti-estrogen therapy.

INTERVENTIONS

The dosages of medications were 2.5 and 160 mg/day for letrozole and megestrol, respectively. The analysis covered the period from treatment initiation until death (lifetime model). Effectiveness was expressed as survival and time without progression, and the model also included all relevant economic measures.

MAIN OUTCOME MEASURES AND RESULTS

Based on the model, the average survival time of the letrozole group was 2.1 years (25.3 months) versus 1.9 years (21.5 months) for the megestrol group, a gain in survival of 2.4 months (10.5%). The average time without progression, cumulatively calculated over the different treatment options, amounted to 20.2 months for letrozole and 17.8 months for megestrol, an increase of 13.7% for the former patients. The total average cost per patient for the treatment of advanced breast cancer starting from second-line hormone therapy until death was higher in the letrozole group at 7547 Pounds versus 6820 Pounds for the megestrol group (discounted at an annual rate of 5%), leading to an incremental cost-effectiveness ratio of 3588 Pounds per life-year gained (1996 values).

CONCLUSIONS

Based on the assumptions used in this model, letrozole offers a suitable alternative to megestrol in the treatment of second-line hormone therapy.

Cost of illness and disease severity in a cohort of French patients with Parkinson's disease

OBJECTIVE

To assess the relationship between severity and progression of illness in Parkinson's disease and the use of healthcare resources.

DESIGN AND SETTING

This was a prospective cost-of-illness study conducted in France based on clinical observation over a 6-month period of patients with Parkinson's disease treated in the hospital or community setting. Regression analyses were performed to construct the model that offered the best explanation for health expenditures using clinical and sociodemographic indicators.

PATIENTS AND PARTICIPANTS

All patients included in the study had well-defined idiopathic Parkinson's disease, were aged > 35 years, were receiving treatment with levodopa or other antiparkinsonian agents, and were capable of completing questionnaires, alone or with the help of a household member. The final study population consisted of 294 patients, of whom 54 were enrolled by general practitioners and 240 by neurologists.

INTERVENTIONS

Investigators completed a clinical questionnaire at the beginning and end of the 6-month observation period. Patients completed a questionnaire on their daily living conditions at the beginning and end of the study, and also completed monthly reports of healthcare use and loss of productivity. Patients with motor fluctuations also filled in fluctuation diaries on 4 consecutive days at the beginning and end of the 6-month period. Resource data collected included hospital stays, ancillary care, drug therapy, medical visits and transportation. Social costs were evaluated in nonmonetary terms, with the exception of costs of adapting the home environment. Transfer payments were analysed using reports from patients.

MAIN OUTCOME MEASURES AND RESULTS

Hospital stays were the most expensive component of care (39% of costs), followed by ancillary care (30%) and drug therapy (22%). The mean medical cost was 308 euros (EUR) [$US357] for patients followed by a general practitioner and EUR2580 ($US2993) for patients followed by a neurologist. Costs also varied with age and motor fluctuations. Medical costs were strongly correlated with most clinical indicators and the cost generally progressed in line with the severity of the disease. The strongest correlation was between clinical indicators and ancillary care costs.

CONCLUSIONS

These results confirm the importance of the social burden of Parkinson's disease. The regression results could be used to evaluate the benefit of novel treatments that reduce the intensity of motor fluctuations.

[Opportunistic screening of breast cancer in France]

In France, one fears that opportunistic screening levels have risen in parallel with the development of district screening programmes. However the absence of a specific nomenclature for mammography renders its evaluation difficult. This study aims to quantify the importance of opportunistic screening in 2 districts with existing screening programmes. Mammograms done outside of the screening programmes were identified using Sickness Fund data. Reasons for prescription were identified through a survey of radiologists. These data were compared to programme attendance rates. In 1995, 9% of women aged 40 years or more had a mammogram outside of the screening programme. This rate is higher among women under the age of 55 when compared to older women. Opportunistic screening accounted for 27% of mammograms outside the screening programme, yet this rate reached 58% if one includes mammograms in asymptomatic women with personal or family risk factors. The data presented in this study confirm the importance of opportunistic screening in France, namely in peri-menopausal women. Screening programmes allow for the continuous evaluation of the quality and effectiveness of screening. The coexistance of opportunistic and organized screening should not be permitted to continue. The results of ongoing cost-effectiveness studies will allow to determine the relative cost-effectiveness of organized screening in France.

A comparison of the performance and impact of breast cancer screening programmes in East Anglia, U.K. and Bouches du Rhône, France

The purpose of this study was to compare results from the first screening round of two breast cancer screening programmes of similar design implemented in different health care settings. The East Anglian programme is part of the U.K. National Health Service Breast Screening Programme, which is a centralised programme with a limited number of dedicated screening units. The Bouches du Rhône programme is one of 13 French programmes based on a decentralised model using existing radiology clinics. Compliance and cancer detection rates were lower in the Bouches du Rhône programme. Detection rates for small invasive cancers (< or = 10 mm) were similar in the two programmes, although larger cancers (> or = 20 mm) were detected in the Bouches du Rhône programme. Significantly, the shift towards more favourable distribution of prognostic characteristics associated with screen-detected breast cancers compared with those arising outside the programme is less marked in the Bouches du Rhône programme. This is probably due to the more favourable underlying disease status in the district resulting from a long history of breast awareness and spontaneous mammography.

[Modalities of reading of detection mammographies of the programme in the Bouches-du-Rhône. Results and costs 1990-1995]

In the Bouches du Rhône breast cancer screening programme, mammograms are read by two separate radiologists of different levels of training. All women with at least one positive reading are recalled for further assessment. During the first round, 3,477 of the 95,967 screenees were recalled by the first reader and 2,321 by the expert reader. The expert increased cancer detection by 15% and 45% of cancers detected by the expert were smaller than 11 mm. The marginal cost of double reading was 21,838 Francs per additional cancer detected. Double reading thus allowed for the detection of cancers of good prognosis which would have gone undetected by a single reader. Its cost seems justified by its impact on the effectiveness of the screening programme.