Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care

PURPOSE

This study was conducted to evaluate the effect of stage at diagnosis, age, and level of comorbidity (presence of other illness) on the costs of treating three types of cancer among members of a health maintenance organization.

METHODS

Among 388,000 members enrolled anytime during 1990 and 1991 in Group Health Cooperative (GHC) of Puget Sound (Washington State), we estimated the total and net direct costs of medical care for colon, prostate, and breast cancers, including both incident (290, 554, and 645 patients, respectively) and prevalent (1046, 1295, and 2299 patients, respectively) cases. We summarized costs for initial, continuing, and terminal phases of care. Net costs were the difference between the costs of the care of each case subject and the average costs of the care for all enrollees without the cancer of interest who were of the same sex and in the same 5-year age group. Differences in estimated total and net costs by stage at diagnosis, age, and comorbidity were separately evaluated using multivariate regression modeling. All P values were two-sided. Comorbidity was based on a score calculated from 1988 pharmacy data.

RESULTS

Total costs of initial care increased with stage at diagnosis for colon (P = .0013) and breast (P < .0001) cancer cases, but not for prostate cancer cases. Total initial costs decreased with age for prostate (P = .0225) and breast (P = .0002) cancers but did not change with degree of comorbidity for any of the three cancers. Total continuing medical care costs increased with stage at diagnosis for colon (P < .0001) and breast (P < .0001) cancer cases but not for prostate cancer cases. Total terminal care costs were similar by stage for all three cancers. Net initial costs differed with stage for all three cancers (P < .05). Net continuing care costs increased with stage (P < .0001) and decreased with age (P < .001) for colon and breast cancers but not for prostate cancer. Net continuing care costs decreased with comorbidity for all three cancers (P = .004, P = .011, and P < .0001 for colon, prostate, and breast cancers, respectively). Among regional stage cancers, continuing care costs decreased with age for colon (P < .0017) and breast (P = .033) cancers but not for prostate cancers.

CONCLUSIONS

The results show that total costs vary by stage at diagnosis and age, but the patterns of variation differ for each cancer. Costs of cancer are not simply additive to costs of other conditions.

IMPLICATIONS

More needs to be done to explore the reasons and implications of age-related cost differences. Cost-effectiveness analyses of cancer control interventions that shift cancer stage distributions may need to consider both the age and comorbidity of the target populations.

Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening

BACKGROUND AND AIMS

Recent legislation passed in July 2001 provides coverage for all Medicare beneficiaries for average-risk screening colonoscopy.

METHODS

We analyzed the Clinical Outcomes Research Initiative national endoscopic database to characterize colonoscopy practice patterns before and after the introduction of this coverage.

RESULTS

Between January 1998 and May 2002, 205,638 patients underwent colonoscopy, of whom 8.3% underwent average-risk colon cancer screening. The proportion of procedures performed for average-risk screening has increased dramatically from 4.6% (before July 2001) to 14.2% (after July 2001). With the increased volume of average-risk screening examinations, colonic lesion detection (masses and polyps greater than 9 mm) has declined (4.9% before July 2001 to 3.8% after July 2001).

CONCLUSIONS

There has been a dramatic increase in the rates of screening colonoscopy during the past 4 years. If rates continue to increase, optimal resource utilization will assume increasing importance.

Types of alternative medicine used by patients with breast, colon, or prostate cancer: predictors, motives, and costs

OBJECTIVE

Assess predictors and costs of various types of alternative medicine used by adult patients with cancer. DESIGN, LOCATION, SUBJECTS: Telephone survey of 356 patients with colon, breast, or prostate cancer identified from the population-based Cancer Surveillance System of western Washington.

RESULTS

Overall, 70.2% of patients used at least one type of alternative medicine, with 16.6% seeing alternative providers, 19.1% using mental/other therapy, and 64.6% taking dietary supplements. Compared to males, females were five times more likely to see an alternative provider and about twice as likely to use mental therapies or supplements (p < 0.05 for all). Older patients were less likely to use mental/other therapy. Higher education (but not income) was associated with use of all types of alternative medicine. Patients with multiple medical treatments were two times more likely to take dietary supplements compared to patients having only surgery (p < 0.01). Varying by the type of alternative therapy, 83%-97% of patients reported that they used alternative medicine for general health and well-being while 8% to 56% reported use for treatment of cancer. Almost all patients reported that the alternative therapy improved their well-being. Expenditures for alternative medicine averaged $68 per user per year, but ranged from $4 to $14,659.

CONCLUSIONS

Given the high prevalence of use and that patients believed that alternative medicine improved their well-being, clinicians should show an open mind toward these treatment choices and encourage frank discussion. Familiarity and some knowledge regarding use of alternative medicine is important in cases where interactions between conventional and alternative medicine may occur. It is also important to identify potential patient needs for mental health support beyond conventional care and support patients who want to make healthful lifestyle changes. Longitudinal investigations are urgently needed to investigate associations of alternative medicine use with survival and quality of life in patients with cancer.

Which colon cancer screening test? A comparison of costs, effectiveness, and compliance

PURPOSE

Recent media reports have advocated the use of colonoscopy for colorectal cancer screening. However, colonoscopy is expensive compared with other screening modalities, such as fecal occult blood testing and flexible sigmoidoscopy. We sought to determine the cost effectiveness of different screening strategies for colorectal cancer at levels of compliance likely to be achieved in clinical practice.

METHODS

A Markov decision model was used to examine screening strategies, including fecal occult blood testing alone, fecal occult blood testing combined with flexible sigmoidoscopy, flexible sigmoidoscopy alone, and colonoscopy. The timing and frequency of screening was varied to assess optimal screening intervals. Sensitivity analyses were conducted to assess the factors that have the greatest effect on the cost effectiveness of screening.

RESULTS

All strategies are cost effective versus no screening, at less than $20,000 per life-year saved. Direct comparison suggests that the most effective strategies are twice-lifetime colonoscopy and flexible sigmoidoscopy combined with fecal occult blood testing. Assuming perfect compliance, flexible sigmoidoscopy combined with fecal occult blood testing is slightly more effective than twice-lifetime colonoscopy (at ages 50 and 60 years) but is substantially more expensive, with an incremental cost effectiveness of $390,000 per additional life-year saved. However, compliance with primary screening tests and colonoscopic follow-up for polyps affect screening decisions. Colonoscopy at ages 50 and 60 years is the preferred test regardless of compliance with the primary screening test. However, if follow-up colonoscopy for polyps is less than 75%, then even once-lifetime colonoscopy is preferred over most combinations of flexible sigmoidoscopy and fecal occult blood testing. Costs of colonoscopy and proportion of cancer arising from polyps also affect cost effectiveness.

CONCLUSIONS

Colonoscopic screening for colorectal cancer appears preferable to current screening recommendations. Screening recommendations should be tailored to the compliance levels achievable in different practice settings.

Racial disparities and socioeconomic status in association with survival in a large population-based cohort of elderly patients with colon cancer

BACKGROUND

To the authors' knowledge, few studies have addressed racial disparities in the survival of patients with colon cancer by adequately incorporating treatment and socioeconomic factors in addition to patient and tumor characteristics.

METHODS

The authors studied a nationwide and population-based, retrospective cohort of 18,492 men and women who were diagnosed with stage II or III colon cancer at age >or=65 years between 1992 and 1999. This cohort was identified from the Surveillance, Epidemiology, and End Results (SEER) cancer registries-Medicare linked databases and included up to 11 years of follow-up.

RESULTS

A larger proportion (70%) of African-American patients with colon cancer fell into the poorest quartiles of socioeconomic status compared with Caucasians (21%). Patients who lived in communities with the lowest socioeconomic level had 19% higher all-cause mortality compared with patients who lived in communities with the highest socioeconomic status (hazards ratio [HR], 1.19; 95% confidence interval [95% CI], 1.13-1.26; P < .001 for trend). The risk of dying was reduced only slightly after controlling for race/ethnicity (HR, 1.17; 95% CI, 1.10-1.24). Compared with Caucasian patients with colon cancer, African-American patients were 21% more likely to die after controlling for age, sex, comorbidity scores, tumor stage, and grade (HR, 1.21; 95% CI, 1.12-1.30). After also adjusting for definitive therapy and socioeconomic status, the HR of mortality was only marginally significantly higher in African Americans compared with Caucasians for all-cause mortality (HR, 1.10; 95% CI, 1.02-1.19) and colon cancer-specific mortality (HR, 1.16; 95% CI, 1.01-1.33).

CONCLUSIONS

Lower socioeconomic status and lack of definitive treatment were associated strongly with decreased survival in both men and women with colon cancer. Racial disparities in survival were explained substantially by differences in socioeconomic status.

Randomized clinical trial of the costs of open and laparoscopic surgery for colonic cancer

BACKGROUND

There has been no randomized clinical trial of the costs of laparoscopic colonic resection (LCR) compared with those of open colonic resection (OCR) in the treatment of colonic cancer.

METHODS

A subset of Swedish patients included in the Colon Cancer Open Or Laparoscopic Resection (COLOR) trial was included in a prospective cost analysis; costs were calculated up to 12 weeks after surgery. All relevant costs to society were included. No effects of the procedures, such as quality of life or survival, were taken into account.

RESULTS

Two hundred and ten patients were included in the primary analysis, 98 of whom had LCR and 112 OCR. Total costs to society did not differ significantly between groups (difference in means for LCR versus OCR euro1846; P = 0.104). The cost of operation was significantly higher for LCR than for OCR (difference in means euro1171; P < 0.001), as was the cost of the first admission (difference in means euro1556; P = 0.015) and the total cost to the healthcare system (difference in means euro2244; P = 0.018).

CONCLUSION

Within 12 weeks of surgery for colonic cancer, there was no difference in total costs to society incurred by LCR and OCR. The LCR procedure, however, was more costly to the healthcare system.

Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

BACKGROUND

Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction.

METHODS

Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures.

RESULTS

Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941).

CONCLUSIONS

Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

Postsurgical surveillance of colon cancer: preliminary cost analysis of physician examination, carcinoembryonic antigen testing, chest x-ray, and colonoscopy

OBJECTIVE

This study is the first to examine the relative and absolute costs of physician examination, carcinoembryonic antigen (CEA) assessment, chest x-ray, and colonoscopy in detecting recurrent disease in patients who have undergone surgical resection for primary colon carcinoma.

METHODS

Of the 1356 Eastern Cooperative Oncology Group patients in Intergroup Protocol 0089 who underwent surgical resection for Dukes' B2 and C colon carcinoma, 421 patients who developed recurrent disease were reviewed. Follow-up testing was performed according to protocol guidelines, with the cost of each test equal to 1995 Medicare reimbursement. Follow-up was defined as the time to recurrence for the 421 patients in whom disease recurred (mean 18.6 months) or up to 5 years for the additional 930 patients in whom disease did not recur (mean 38.6 months). Patients were divided into three categories: nonrecurrent, recurrent but not resectable, and recurrent but resectable with curative intent. The estimated mean cost of each test in detecting group 3 (recurrent but resectable) patients was calculated.

RESULTS

Of the 421 patients who developed recurrent disease, 96 underwent surgical resection of their disease with curative intent (group 3). For group 3 patients, the first indication of recurrent disease was CEA testing (30), chest x-ray (12), colonoscopy (14), and other (40). Of the 40 "other" patients, 24 presented with symptoms. Routine physician examination, however, failed to identify a single resectable recurrence, and the total cost for physician examination was $418,615. The detection rate for CEA testing was 2.2%, the total cost was $170,880, and the cost per recurrence was $5,696. The detection rate for chest x-ray was 0.9%, the total cost was $120,934, and the cost per recurrence was $10,078. The detection rate of colonoscopy was 1%, the total cost was $641,344, and the cost per recurrence was $45,810.

CONCLUSIONS

CEA measurement was the most cost-effective test in detecting potentially curable recurrent disease. Physician visits were useful only in the evaluation of symptoms; a routine physician examination had no added benefit.

Randomized clinical trial of laparoscopic versus open left colonic resection

BACKGROUND

The main aim of this study was to compare short-term results and long-term outcomes of patients undergoing laparoscopic versus open left colonic resection.

METHODS

Between February 2000 and December 2004, all adult patients undergoing elective left colonic resection were assessed for eligibility to the study. The protocol for postoperative care was the same in both groups. Cost-benefit analysis was based on hospital costs. Quality of life, long-term morbidity and 5-year survival were also evaluated.

RESULTS

Some 268 patients undergoing left colonic resection were assigned randomly to the laparoscopic (n = 134) or open (n = 134) approach. The short-term morbidity rate was 20.1 per cent in the open group and 11.9 per cent in the laparoscopic group (P = 0.094). Hospital stay was longer in the open group (8.7 versus 7.0 days for the laparoscopic approach; P = 0.002). Cost-benefit analysis showed an additional cost of euro66 per patient randomly allocated to the laparoscopic group. Quality of life was significantly improved in the laparoscopic group 6 months after surgery, but no difference was found subsequently. The long-term morbidity rate was 11.9 per cent in the open group and 7.5 per cent in the laparoscopic group (P = 0.413). The 5-year survival rate of patients with cancer was 66 and 72 per cent for open and laparoscopic groups respectively (P = 0.321).

CONCLUSION

Laparoscopic left colonic resection resulted in an earlier recovery after surgery. As cost-benefit analysis and long-term follow-up showed similar results, the laparoscopic approach should be preferred to open surgery.

Laparoscopic vs open colectomy for colon cancer: results from a large nationwide population-based analysis

PURPOSE

Laparoscopic colectomy has only recently become an accepted technique for the treatment of colon cancer. We sought to analyze factors that affect the type of resection performed and associated outcomes from a large nationwide database.

METHODS

All admissions with a primary diagnosis of colon cancer undergoing elective resection were selected from the 2003 and 2004 Nationwide Inpatient Samples. Multiple linear and logistic regression analyses were used to compare outcome measures and identify independent predictors of a laparoscopic approach.

RESULTS

We identified 98,923 admissions (mean age 69.2 years). They were predominately Caucasian (81%), had localized disease (63%), had private insurance (56%), and had surgery performed in urban hospitals (87%). Laparoscopic resection was performed in 3,296 cases (3.3%) and was associated with a lower complication rate (18% vs 22%), shorter length of stay (6 vs 7.6 days), decreased need for skilled aftercare (5% vs 11%), and lower mortality (0.6% vs 1.4%, all P<0.01). There was no significant difference in the total hospital charges between the groups ($34,685 vs $34,178, P=0.19). Independent predictors of undergoing laparoscopic resection were age<70 (odds ratio [OR]=1.2, P<0.01), national region (Midwest OR=1.9, West OR=2.0, P<0.01), and lower disease stage (OR=2.5, P<0.01). Ethnic category and insurance status showed no significant association with operative method (P>0.05).

CONCLUSIONS

Laparoscopy for colon cancer is associated with improved outcomes in unadjusted analysis and similar charges compared to open resection. We found no influence of race or payer status on the utilization of a laparoscopic approach.

Immunotherapy with autologous tumor cell-BCG vaccine in patients with colon cancer: a prospective study of medical and economic benefits

We have completed a multicenter, randomized controlled phase III clinical trial in Stages II and III colon cancer patients with active specific immunotherapy (ASI) using autologous tumor cells with an immunomodulating adjuvant bacillus Callmette-Guerin (BCG) vaccine (OncoVAX) in an adjuvant setting. In this study, patients were randomized to receive either OncoVAX therapy or no therapy after surgical resection of the primary tumor and stratified by stage of disease. Since the biologic essence of the effective tumor immunotherapy is the presence in the vaccine of a minimum number of viable, metabolically active, autologous tumor cells, the processing of the vaccine product, occurred within 48 h after surgery. Analysis of prognostic benefit in the pivotal phase III trial, with a 5.8 year median follow-up, showed that a beneficial effect of OncoVAX is statistically significant for all endpoints including recurrence-free interval, overall survival, and recurrence-free survival in Stage II colon cancer patients. Surgery alone cures approximately 65% of Stage II (Dukes B2, B3) colon cancer patients. In the remaining patients, OncoVAX in an adjuvant setting, significantly prolongs recurrence-free interval (57.1% relative risk reduction) and significantly improves 5-year overall survival and recurrence-free survival. No statistically significant prognostic benefits were achieved in Stage III (Duke's C1-C3) patients. A health economics assessment was performed on these results in Stage II colon cancer patients using disease-free survival and overall survival (for the entire intent-to-treat population). Cost-effectiveness, cost-utility and sensitivity analysis were applied with, cost of life years, recurrence-free life years and quality adjusted life years (QALYs) as the primary endpoints to this analysis. The perspective of the economic analysis was the current direct medical cost established by the health care providers. The introduction of new technologies often leads to additional costs. This report verified that the use of OncoVAX for patients with Stage II colon cancer not only has significant prognostic benefit and positive clinical outcomes, but also showed that OncoVAX therapy yields impressive health economics benefits.

Incremental Cost of Emergency Versus Elective Surgery

OBJECTIVE

To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery.

BACKGROUND

Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist.

METHODS

Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses.

RESULTS

A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures.

CONCLUSIONS

Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.

Emergency surgery for colonic cancer in a defined population

Background

The aim of this study was to identify risk factors in emergency surgery for colonic cancer in a large population and to investigate the economic impact of such surgery.

Methods

Data from the colonic cancer registry (1997–2001) of the Uppsala/Örebro Regional Oncological Centre were analysed and classified by hospital category. Some 3259 patients were included; 806 had an emergency and 2453 an elective procedure. Data for calculating effects on health economy were derived from a national case-costing register.

Results

Patients who had emergency surgery had more advanced tumours and a lower survival rate than those who had an elective procedure (5-year survival rate 29·8 versus 52·4 per cent; P &lt; 0·001). There was a stage-specific difference in survival, with poorer survival both for patients with stage I and II tumours and for those with stage III tumours after emergency compared with elective surgery (P &lt; 0·001). Emergency surgery was associated with a longer hospital stay (mean 18·0 versus 10·0 days; P &lt; 0·001) and higher costs (relative cost 1·5 (95 per cent confidence interval 1·4 to 1·6)) compared with elective surgery. The duration of hospital stay was the strongest determinant of cost (r2 = 0·52, P &lt; 0·001).

Conclusion

Emergency surgery for colonic cancer is associated with a stage-specific increase in mortality rate.

Health care costs of obesity in New Zealand

OBJECTIVE

To estimate the costs of health care that are attributable to obesity in New Zealand.

METHODS

The 1991 health care costs of non-insulin dependent diabetes, coronary heart disease, hypertension, gallstone disease, post-menopausal breast cancer and colon cancer were estimated and multiplied by the population attributable factor for obesity for each condition. The relative risk estimates were taken from the literature, the obesity prevalence from a 1990 New Zealand survey, and the costs and volumes of services were taken from a variety of sources and covered hospital (inpatient and outpatient) services, general practitioner consultations, pharmaceuticals, laboratory tests and ambulance services. Calculations were conservative and net of goods and services tax.

RESULTS

A conservative estimate of the health care costs attributable to obesity for the six conditions was NZ$135 million. This represents about 2.5% of total health care costs which is similar to analyses from other countries.

CONCLUSIONS

The health care costs of obesity as estimated are considerable. However, the total cost of overfatness to the New Zealand population is far greater than this because lesser degrees of overfatness, the health care costs of other obesity-related conditions such as arthritis, the costs to individuals of weight-loss programs and the indirect and intangible costs were not included in the analysis. A substantial and wide-ranging public health effort is needed to turn around the increasing prevalence and costs of obesity.

Surgeon volume and elective resection for colon cancer: an analysis of outcomes and use of laparoscopy

BACKGROUND

Surgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer.

STUDY DESIGN

We performed a retrospective study of patients who underwent resection for colon cancer, using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes.

RESULTS

A total of 17,749 patients were included in this study. The average age of the cohort was 65 years and 51% of patients were female. After adjustment for potential confounders, compared with LVS, HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS, OR 1.16 95% CI 1.65, 1.26). Postoperative complications were significantly lower in patients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were $927 (95% CI -$1,567 to -$287) lower in the HVS group compared with the LVS group.

CONCLUSIONS

Higher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association.

Race and Insurance Differences in the Receipt of Adjuvant Chemotherapy Among Patients With Stage III Colon Cancer

PURPOSE

Although the incidence and mortality of colon cancer in the United States has declined over the past two decades, blacks have worse outcomes than whites. Variations in treatment may contribute to mortality differentials.

METHODS

Patients diagnosed with stage III colon cancer were randomly sampled from the SEER program from the years 1990, 1991, 1995, 2000, 2005, and 2010. Patients were categorized as non-Hispanic white (n = 835) or black (n = 384). Treatment data were obtained from a review of the medical records, and these data were verified through contact with the original treating physicians. Log-binomial regression models were used to estimate the association between race and receipt of adjuvant chemotherapy. Effect modification by insurance was assessed with use of single referent models.

RESULTS

Receipt of adjuvant chemotherapy among both white and black patients increased from the period encompassing the years 1990 and 1991 (white, 58%; black, 45%) to the year 2005 (white, 72%; black, 71%) and then decreased in the year 2010 (white, 66%; black, 57%). There were marked racial disparities in the time period of 1990 to 1991 and again in 2010, with black patients less likely to receive adjuvant chemotherapy as compared with white patients (risk ratio [RR], .82; 95% CI, .72 to .93). For black patients, receipt of adjuvant chemotherapy did not differ across insurance categories (RR for private insurance, .80; 95% CI, .69 to .93; RR for Medicare, .84; 95% CI, .69 to 1.02; and RR for Medicaid, .84; 95% CI, .69 to 1.02), although a larger proportion had Medicaid in all years of the study as compared with white patients.

CONCLUSION

The chemotherapy differential narrowed after the time period of 1990 to 1991, but our findings suggest that the disparity reemerged in 2010. Recent decreases in chemotherapy use may be due, in part, to the economic downturn and an increase in Medicaid coverage.

Long-term cost-effectiveness of weight management in primary care

BACKGROUND

As obesity prevalence and health-care costs increase, Health Care providers must prevent and manage obesity cost-effectively.

METHODS

Using the 2006 NICE obesity health economic model, a primary care weight management programme (Counterweight) was analysed, evaluating costs and outcomes associated with weight gain for three obesity-related conditions (type 2 diabetes, coronary heart disease, colon cancer). Sensitivity analyses examined different scenarios of weight loss and background (untreated) weight gain.

RESULTS

Mean weight changes in Counterweight attenders was -3 kg and -2.3 kg at 12 and 24 months, both 4 kg below the expected 1 kg/year background weight gain. Counterweight delivery cost was pound59.83 per patient entered. Even assuming drop-outs/non-attenders at 12 months (55%) lost no weight and gained at the background rate, Counterweight was 'dominant' (cost-saving) under 'base-case scenario', where 12-month achieved weight loss was entirely regained over the next 2 years, returning to the expected background weight gain of 1 kg/year. Quality-adjusted Life-Year cost was pound2017 where background weight gain was limited to 0.5 kg/year, and pound2651 at 0.3 kg/year. Under a 'best-case scenario', where weights of 12-month-attenders were assumed thereafter to rise at the background rate, 4 kg below non-intervention trajectory (very close to the observed weight change), Counterweight remained 'dominant' with background weight gains 1 kg, 0.5 kg or 0.3 kg/year.

CONCLUSION

Weight management for obesity in primary care is highly cost-effective even considering only three clinical consequences. Reduced healthcare resources use could offset the total cost of providing the Counterweight Programme, as well as bringing multiple health and Quality of Life benefits.

Construct validity of medicare chemotherapy claims: the case of 5FU

BACKGROUND

The elderly are under represented in clinical trials of cancer therapy and the elderly who are enrolled may be unrepresentative.

OBJECTIVE

To assess whether Medicare claims data might be used to understand the benefits and tolerance of chemotherapy in the general elderly population, the construct validity of Medicare 5FU claims for elderly colon cancer patients within the SEER-Medicare data set was determined.

METHODS

In this validation study of Medicare chemotherapy claims from the linked the SEER-Medicare data set, the patterns of 5FU chemotherapy claims were evaluated for an incident cohort of elderly colon cancer patients (n = 15,039) during the 13 months following their diagnosis. Patterns of Medicare National Claims History (NCH) 5FU claims were evaluated with respect to prespecified patient-level disease and demographic factors from the data set.

RESULTS

Twenty-two percent of patients had at least one detectable 5FU claim during the observation period. Among those patients, the median dose of 5FU was 1000 mg, the median interval between 5FU claims was 7 days, and the median number of claims during this period was 24. Multivariate regression revealed expected associations between demographic and disease factors and the likelihood of having a Medicare NCH 5FU claim. With increasing cancer stage, patients' likelihood of having a 5FU claim increased. Younger patients, married patients, white patients, patients with low comorbidity, and patients living in urban and less impoverished regions were each more likely to have 5FU claims.

CONCLUSION

Because their pattern is consistent with the standard of medical care and with previously described associations with disease and demographic factors, it was concluded that Medicare NCH claims for 5FU administration in the SEER-Medicare data set exhibit construct validity. Criterion validation studies with an external gold standard should be pursued to determine the sensitivity and specificity of chemotherapy codes in the Medicare NCH files.

Cost-effectiveness analysis of oxaliplatin compared with 5-fluorouracil/leucovorin in adjuvant treatment of stage III colon cancer in the US

BACKGROUND

The MOSAIC trial demonstrated that oxaliplatin/5-fluorouracil/leucovorin (FU/LV) (FOLFOX4) as adjuvant treatment of TNM stage II and III colon cancer significantly improves disease-free survival compared with 5-FU/LV alone. For stage III patients the 4-year disease-free survival (DFS) was 69% in the FOLFOX4 arm vs 61% in the LV5FU2 arm, P = .002). The cost-effectiveness of FOLFOX4 in stage III patients was evaluated from a US Medicare perspective.

METHODS

By using individual patient-level data from the MOSAIC trial (median follow-up: 44.2 months), DFS and overall survival (OS) were estimated up to 4 years from randomization. DFS was extrapolated from 4 to 5 years by fitting a Weibull model and subsequent survival was estimated from life tables. OS beyond 4 years was predicted from the extrapolated DFS estimates and observed survival after recurrence. Costs were calculated from trial data and external estimates of resources to manage recurrence.

RESULTS

Patients on FOLFOX4 were predicted to gain 2.00 (95% confidence interval [CI]: 0.63, 3.37) years of DFS over those on 5-FU/LV. The predicted life expectancy of stage III patients on FOLFOX4 and 5-FU/LV was 17.61 and 16.26 years, respectively. Mean total lifetime disease-related costs were $56,300 with oxaliplatin and $39,300 with 5-FU/LV. Compared with 5-FU/LV, FOLFOX4 was estimated to cost $20,600 per life-year gained and $22,800 per quality-adjusted life-year (QALY) gained, discounting costs and outcomes at 3% per annum.

CONCLUSIONS

FOLFOX4 is likely to be cost-effective compared with 5-FU/LV in the adjuvant treatment of stage III colon cancer. The incremental cost-effectiveness ratio compares favorably with other funded interventions in oncology.

Surveillance after curative colon cancer resection: practice patterns of surgical subspecialists

BACKGROUND

In the literature, suggested strategies for the follow-up of colon cancer patients after potentially curative resections vary widely. The optimal regimen to monitor for recurrences and new primary tumors remains unknown. The nationwide cost impact of wide practice variation is also unknown.

METHODS

The 1,070 members of The Society of Surgical Oncology (SSO) were surveyed using a detailed questionnaire to measure the practice patterns of surgical experts nationwide. Respondents were asked how often they use nine separate methodologies in follow-up during years 1-5 postsurgery for TNM stage I, II, and III patients. Costs were estimated for representative less and more intensive strategies.

RESULTS

Evaluable responses were received from 349 members (33%). Office visit and carcinoembryonic antigen analysis were performed most frequently. SSO members generally see patients every 3 months in years 1-2, every 6 months in years 3-4, and annually thereafter. There was wide variability in test ordering patterns and moderate variation between SSO and previously surveyed American Society of Colon and Rectal Surgeons members. The charge differential between representative less and more intensive follow-up strategies for each annual U.S. patient cohort is approximately $800 million.

CONCLUSIONS

Actual practice patterns vary widely, indicating lack of consensus regarding optimal follow-up. The enormous cost differential associated with such variation is difficult to justify because there is no proven benefit of more intensive follow-up.

Follow-up in colorectal cancer patients: a cost-benefit analysis

BACKGROUND

No conclusive evidence exists concerning the effectiveness of follow-up programs after curative surgery for colorectal cancer, and presently cost-benefit analyses have not indicated that follow-up strategies increase survival or quality of life.

METHODS

Five hundred five patients who survived curative surgery for stage I-III colorectal adenocarcinoma were closely followed for at least 4 years.

RESULTS

One hundred forty-one (28%) patients had recurrence. Of these, 32 underwent one or more surgical procedures for cure, whereas 109 could only benefit from palliation. Eighteen were cured. The mean survival of all recurrent cases was 44.4 months. Of those operated on with curative intent, the mean survival was 69.3 months compared with 37.1 months in those operated on with palliative intent. Of those 18 patients who were cured by reoperative surgery, the average survival was 81.4 months. The overall follow-up cost was $1,914,900 (U.S.) for the 505 patients; $13,580 (U.S.) for each recurrence, $59,841 (U.S.) for each case treated for cure, and $136,779 (U.S.) for those effectively cured.

CONCLUSIONS

Careful postoperative monitoring is expensive yet effective when one considers that one-quarter of the detected recurrences were suitable for potentially curative second surgery; however, only 3.6% of the original group were effectively cured. Follow-up programs should be tailored according to the stage and site of the primary to reduce costs.

Colon cancer prevention in Italy: cost-effectiveness analysis with CT colonography and endoscopy

BACKGROUND

Colorectal cancer (CRC) is a major cause of mortality in Italy. Although prevention of CRC is possible, its cost-effectiveness when applied to the Italian population is unknown. Recently, computerized tomographic colonography (CTC) has been proposed for CRC screening.

AIM

To compare the efficacy and cost-effectiveness of CTC screening in a simulated Italian population with those of colonoscopy and flexible sigmoidoscopy (FS).

METHODS

The cost-effectiveness of different screening strategies was compared using a Markov process computer model, in which in a hypothetical population of 100,000 50 year-olds were investigated by CTC, colonoscopy or FS every decade. Outcomes were projected to the Italian national level.

RESULTS

CRC incidence reduction was calculated at 40.9%, 38.2%, and 31.8% with colonoscopy, CTC and FS, respectively. As compared to no screening, all screening programs were shown to be cost-saving, allowing a saving of 11 Euro, 17 Euro, and 48 Euro per person with colonoscopy, FS and CTC, respectively. FS appeared to be less cost-effective than CTC, whilst colonoscopy appeared to be an expensive option as compared to CTC. Undiscounted national expenditure was calculated to be 1,042,489,512 Euro, 1,093,268,285 Euro, and 1,198,783,428 Euro for FS, CTC and colonoscopy, respectively, as compared to 695,818,078 Euro without screening.

CONCLUSION

CRC screening is cost-saving in Italy, irrespective of the technique applied. CTC appeared to be more cost-effective than FS, and it may also become a valid alternative to colonoscopy.

A cost-effectiveness analysis of folic acid fortification policy in the United States

OBJECTIVE

To quantify the health and economic outcomes associated with changes in folic acid consumption following the fortification of enriched grain products in the USA.

DESIGN

Cost-effectiveness analysis.

SETTING

Annual burden of disease, quality-adjusted life years (QALY) and costs were projected for four steady-state strategies: no fortification, or fortifying with 140, 350 or 700 microg folic acid per 100 g enriched grain. The analysis considered four health outcomes: neural tube defects (NTD), myocardial infarctions (MI), colon cancers and B12 deficiency maskings.

SUBJECTS

The US adult population subgroups defined by age, gender and race/ethnicity, with folate intake distributions from the National Health and Nutrition Examination Surveys (1988-1992 and 1999-2000), and reference sources for disease incidence, utility and economic estimates.

RESULTS

The greatest benefits from fortification were predicted in MI prevention, with 16 862 and 88 172 cases averted per year in steady state for the 140 and 700 microg fortification levels, respectively. These projections were between 6261 and 38 805 for colon cancer and 182 and 1423 for NTD, while 15-820 additional B12 cases were predicted. Compared with no fortification, all post-fortification strategies provided QALY gains and cost savings for all subgroups, with predicted population benefits of 266 649 QALY gained and $3.6 billion saved in the long run by changing the fortification level from 140 microg/100 g enriched grain to 700 microg/100 g.

CONCLUSIONS

The present study indicates that the health and economic gains of folic acid fortification far outweigh the losses for the US population, and that increasing the level of fortification deserves further consideration to maximise net gains.

Adjuvant therapy for stage III colon cancer: economics returns to research and cost-effectiveness of treatment

BACKGROUND

In 1989, the National Cancer Institute issued a clinical announcement advising physicians of the benefits of combined levamisole and fluorouracil as an adjuvant treatment for patients with stage III colon cancer.

PURPOSE

We have estimated the cost-effectiveness of the combined treatment and estimated the social return on the National Institutes of Health (NIH) research investment that led to this innovative cancer treatment.

METHODS

A computer simulation model, CAN*TROL, was used to estimate costs and benefits for a population cross-section receiving the adjuvant treatment. A method similar to "Q-TWiST" was used to assess the impact of quality-of-life adjustments.

RESULTS

For a typical base-line case, the calculated cost-effectiveness is a very favorable $2094 per year of life saved. Using a variety of less favorable assumptions, cost-effectiveness is still less than $5000 per year of life saved, again a favorable value. Quality-of-life adjustments have a negligible effect on the cost-effectiveness outcome. The net present value of the return to the NIH research investment is estimated to be $1.66 billion.

CONCLUSIONS

Under a wide range of reasonable assumptions, adjuvant therapy for stage III colon cancer appears to be a very cost-effective procedure. The investment in the research that resulted in this therapy promises to yield a high return.