Health care-related time costs in patients with metastatic breast cancer

Home time among older adults with acute myeloid leukemia by therapy intensity

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Health Care Contact Days Among Older Cancer Survivors

PURPOSE

Health care contact days-days spent receiving health care outside the home-represent an intuitive, practical, and person-centered measure of time consumed by health care.

METHODS

We linked 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days (ie, spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice or receiving ambulatory care including an office visit, procedure, treatment, imaging, or test) and described patterns of total and ambulatory contact days. Using weighted Poisson regression models, we identified factors associated with contact days.

RESULTS

We included 1,168 older adults representing 4.51 million cancer survivors (median age, 76.4 years, 52.8% women). The median (IQR) time from cancer diagnosis was 65 (27-126) months. In 2019, these adults had mean (standard deviation) total contact days of 28.4 (27.6) and ambulatory contact days of 24.2 (23.6). These included days for tests (8.0 [8.8]), imaging (3.6 [4.1]), visits with any clinicians (12.4 [11.5]), and visits with primary care clinicians (4.4 [4.7]), and nononcology specialists (7.1 [9.4]) specifically. Sixty-four percent of days with a nonvisit ambulatory service (eg, a test) were not on the same day as a clinician visit. Factors associated with more total contact days included younger age, lower income, more chronic conditions, poor self-rated health, and tendency to "go to doctor as soon as feel bad."

CONCLUSION

Older adult cancer survivors spent nearly 1 month of the year receiving health care outside the home. This care was largely ambulatory, often delivered by nononcologists, and varied by factors beyond clinical characteristics. These results highlight the need to recognize patient burdens and improve survivorship care delivery, including through care coordination.

Administrative burden for patients in U.S. health care settings Post-Affordable Care Act: A scoping review

Administrative burdens are the costs associated with receiving a service or accessing a program. Based on the Herd & Moynihan framework, they occur in three subcategories: learning costs, compliance costs, and psychological costs. Administrative burdens manifest inequitably, more significantly impacting vulnerable populations. Administrative burdens may impact the health of those trying to access services, and in some cases block access to health-promoting services entirely. This scoping review examined studies focused on the impact on patients of administrative burden administrative burden in health care settings in the U.S. following the passage of the Affordable Care Act. We queried databases for empirical literature capturing patient administrative burden, retrieving 1578 records, with 31 articles ultimately eligible for inclusion. Of the 31 included studies, 18 used quantitative methods, nine used qualitative methods, three used mixed methods, and one was a case study. In terms of administrative burden subcategories, most patient outcomes reported were learning (22 studies) and compliance costs (26 studies). Psychological costs were the most rarely reported; all four studies describing psychological costs were qualitative in nature. Only twelve studies connected patient demographic data with administrative burden data, despite previous research suggesting an inequitable burden impact. Additionally, twenty-eight studies assessed administrative burden and only three attempted to reduce it via an intervention, resulting in a lack of data on intervention design and efficacy.

Geriatric assessment-derived deficit accumulation and patient-reported treatment burden in older adults with bladder cancer

BACKGROUND

When a person's workload of healthcare exceeds their resources, they experience treatment burden. At the intersection of cancer and aging, little is known about treatment burden. We evaluated the association between a geriatric assessment-derived Deficit Accumulation Index (DAI) and patient-reported treatment burden in older adults with early-stage, non-muscle-invasive bladder cancer (NMIBC).

METHODS

We conducted a cross-sectional survey of older adults with NMIBC (≥65 years). We calculated DAI using the Cancer and Aging Research Group's geriatric assessment and measured urinary symptoms using the Urogenital Distress Inventory-6 (UDI-6). The primary outcome was Treatment Burden Questionnaire (TBQ) score. A negative binomial regression with LASSO penalty was used to model TBQ. We further conducted qualitative thematic content analysis of responses to an open-ended survey question ("What has been your Greatest Challenge in managing medical care for your bladder cancer") and created a joint display with illustrative quotes by DAI category.

RESULTS

Among 119 patients, mean age was 78.9 years (SD 7) of whom 56.3% were robust, 30.3% pre-frail, and 13.4% frail. In the multivariable model, DAI and UDI-6 were significantly associated with TBQ. Individuals with DAI above the median (>0.18) had TBQ scores 1.94 times greater than those below (adjusted IRR 1.94, 95% CI 1.33-2.82). Individuals with UDI-6 greater than the median (25) had TBQ scores 1.7 times greater than those below (adjusted IRR 1.70, 95% CI 1.16-2.49). The top 5 themes in the Greatest Challenge question responses were cancer treatments (22.2%), cancer worry (19.2%), urination bother (18.2%), self-management (18.2%), and appointment time (11.1%).

CONCLUSIONS

DAI and worsening urinary symptoms were associated with higher treatment burden in older adults with NMIBC. These data highlight the need for a holistic approach that reconciles the burden from aging-related conditions with that resulting from cancer treatment.

Lifespan and medical expenditure prognosis for cancer metastasis - a simulation modeling using semi-Markov process

BACKGROUND AND OBJECTIVE

A key reason of high mortality of cancers is attributed to the metastasized cancer, whereas, the medical expense for the treatment of cancer metastases generates heavily financial burden. The population size of metastases cases is small and comprehensive inferencing and prognosis is hard to conduct.

METHODS

Because metastases and finance state can develop dynamic transitions over time, this study proposes a semi-Markov model to perform risk and economic evaluation associated to major cancer metastasis (i.e., lung, brain, liver and lymphoma cancer) against rare cases. A nationwide medical database in Taiwan was employed to derive a baseline study population and costs data. The time until development of metastasis and survivability from metastasis, as well as the medical costs were estimated through a semi-Markov based Monte Carlo simulation.

RESULTS

In terms of the survivability and risk associated to metastatic cancer patients, 80% lung and liver cancer cases are tended to metastasize to other part of the body. The highest cost is generated by brain cancer-liver metastasis patients. The survivors group generated approximately 5 times more costs, in average, than the non-survivors group.

CONCLUSIONS

The proposed model provides a healthcare decision-support tool to evaluate the survivability and expenditure of major cancer metastases.

Evaluating the Time Toxicity of Cancer Treatment in the CCTG CO.17 Trial

PURPOSE

The time spent in pursuing treatments for advanced cancer can be substantial. We have previously proposed a pragmatic and patient-centered metric of these time costs-which we term time toxicity-as any day with physical health care system contact. This includes outpatient visits (eg, bloodwork, scans, etc), emergency department visits, and overnight stays in a health care facility. Herein, we sought to assess time toxicity in a completed randomized controlled trial (RCT).

METHODS

We conducted a secondary analysis of the Canadian Cancer Trials Group CO.17 RCT that evaluated weekly cetuximab infusions versus supportive care alone in 572 patients with advanced colorectal cancer. Initial results reported a 6-week improvement in median overall survival (OS) with cetuximab (6.1 v 4.6 months). Subsequent analyses reported that benefit was restricted to patients with K-ras wild-type tumors. We calculated patient-level time toxicity by analyzing trial forms. We considered days without health care contact as home days. We compared medians of time measures across arms and stratified results by K-ras status.

RESULTS

In the overall population, median time toxic days were higher in the cetuximab arm (28 v 10, P < .001) although median home days were not statistically different between arms (140 v 121, P = .09). In patients with K-ras-mutated tumors, cetuximab was associated with almost numerically equal home days (114 days v 112 days, P = .571) and higher time toxicity (23 days v 11 days, P < .001). In patients with K-ras wild-type tumors, cetuximab was associated with more home days (186 v 132, P < .001).

CONCLUSION

This proof-of-concept feasibility study demonstrates that measures of time toxicity can be extracted through secondary analyses of RCTs. In CO.17, despite an overall OS benefit with cetuximab, home days were statistically similar across arms. Such data can supplement traditional survival end points in RCTs. Further work should refine and validate the measure prospectively.

Cost-Effectiveness of Pharmacologic Treatment Options for Women With Endocrine-Refractory or Triple-Negative Metastatic Breast Cancer

PURPOSE

Treatments for endocrine-refractory or triple-negative metastatic breast cancer (mBC) are modestly effective at prolonging life and improving quality of life but can be extremely expensive. Given these tradeoffs in quality of life and cost, the optimal choice of treatment sequencing is unclear. Cost-effectiveness analysis can explicitly quantify such tradeoffs, enabling more informed decision making. Our objective was to estimate the societal cost-effectiveness of different therapeutic alternatives in the first- to third-line sequences of single-agent chemotherapy regimens among patients with endocrine-refractory or triple-negative mBC.

METHODS

Using three dynamic microsimulation models of 10,000 patients each, three cohorts were simulated, based upon prior chemotherapy exposure: (1) unexposed to either taxane or anthracycline, (2) taxane- and anthracycline-exposed, and (3) taxane-exposed/anthracycline-naive. We focused on the following single-agent chemotherapy regimens as reasonable and commonly used options in the first three lines of therapy for each cohort, based upon feedback from oncologists treating endocrine-refractory or triple-negative mBC: (1) for taxane- and anthracycline-unexposed patients, paclitaxel, capecitabine (CAPE), or pegylated liposomal doxorubicin; (2) for taxane- and anthracycline-exposed patients, Eribulin, CAPE, or carboplatin; and (3) for taxane-exposed/anthracycline-naive patients, pegylated liposomal doxorubicin, CAPE, or Eribulin.

RESULTS

In each cohort, accumulated quality-adjusted life-years were similar between regimens, but total societal costs varied considerably. Sequences beginning first-line treatment with paclitaxel, carboplatin, and CAPE, respectively, for cohorts 1, 2, and 3, had lower costs and similar or slightly better outcomes compared with alternative options.

CONCLUSION

In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.

Work productivity among patients with metastatic breast cancer in the United States

OBJECTIVE

To characterize workplace productivity measures in patients with metastatic breast cancer (mBC) using line of therapy (LOT) and first line (1 L) regimen.

METHODS

A retrospective cohort study was conducted using IBM's MarketScan Commercial Claims and Encounters (CCAE) and Health and Productivity Management (HPM) databases. The cohort included patients diagnosed with mBC who initiated 1 L treatment between 2/3/2015 and 6/30/2018. Productivity was measured using days absent from work and short- and long-term disability (STD, LTD) claims by LOT and 1 L regimen (any cyclin-dependent kinase 4/6 inhibitor [CDK4/6i], endocrine monotherapy, chemotherapy only, or other anti-cancer therapy [OACT]). LOT was defined using regimen-based progression.

RESULTS

Overall, 548 patients were included; 148, 129, 145, and 126 received endocrine monotherapy, CDK4/6i, chemotherapy only, and OACT, respectively. The rate of LTD increased significantly by 3.1 and 2.6 times from 1 L to second line (2 L) and from 2 L to subsequent lines, respectively. Patients receiving 1 L chemotherapy had 2.4- and 2.7-times odds of using STD and LTD compared to patients receiving 1 L CDK4/6i.

CONCLUSIONS

Regimen-based disease progression is associated with increased use of STD and LTD. Patients with a 1 L regimen of chemotherapy have significantly higher odds of using STD or LTD than patients using 1 L CDK4/6i.

Estimation of time cost of anti-cancer drugs approved based on comparisons to best supportive care: A cross sectional analysis

BACKGROUND

Financial costs from cancer treatment are increasingly recognized, but what has historically been underrecognized is the time cost of therapy. We sought to estimate the time burden of anti-cancer drugs approved based on comparisons to best supportive care (BSC), with the assumption that without this drug, a patient could have been treated with observation, home palliative care or hospice services, with minimal time seeking medical care.

METHODS

We searched all FDA approvals (2009 - March 2022) for randomized trials that used BSC as a treatment option for an anti-tumor drug in the metastatic setting and abstracted data on treatment related activities. We then estimated time spent on these activities using previously calculated times.

RESULTS

Of the 13 drugs tested against BSC, nine studies demonstrated an improvement in median OS (median 2.1 months). The median monthly time spent for patients in the intervention arm of BSC trials was 15.8 h.

CONCLUSION

Time is a valuable resource for people who have cancer, but especially for patients who may have few to no remaining treatment options, and yet, we found that patients can spend up to 16 h in anti-cancer drug related activities per month.

POLICY SUMMARY

Because survival outcomes are variable for patients being treated in later lines of therapy, time resources are a valuable consideration in the treatment plan.

Auricular Acupuncture During Chemotherapy Infusion in Breast Cancer Patients: A Feasibility Study

Introduction: Breast cancer patients undergoing chemotherapy experience multiple distressing symptoms. The authors investigated the feasibility and potential benefits of auricular acupuncture during chemotherapy infusion in this population. Materials and Methods: Women with stage I-III breast cancer undergoing chemotherapy were enrolled and followed for three chemotherapy cycles. During the first cycle of chemotherapy that participants received after study enrollment, they were provided with educational materials. During the second and third cycles of chemotherapy after enrollment, they received auricular acupuncture. The primary outcome was feasibility, assessed by recruitment, retention, and completion of assessments. Secondary outcomes included symptom burden (Edmonton Symptom Assessment System-Revised Version) and anxiety (State-Trait Anxiety Inventory-State), assessed at four timepoints for each cycle: day 1, pre-education/acupuncture (T1); day 1, post-education/acupuncture (T2); day 2 (T3); and day 5 (T4). Nausea and vomiting (Multinational Association of Supportive Care in Cancer [MASCC] Antiemesis Tool) were assessed on days 2 and 5. Paired t test was used to compare patient-reported outcomes during cycle 1 (education) versus an average of outcomes during cycles 2 and 3 (acupuncture). Results: Twenty-six patients were enrolled, of which 24 completed all acupuncture sessions and 22 completed all outcome assessments. In cycles 2 and 3 versus cycle 1, participants experienced significant reductions in symptom burden (change from T1 to T4: -7.9 ± 13.6, p = 0.02), anxiety (change from T1 to T2: -3.3 ± 6.5, p = 0.02), and nausea severity on day 2 (-1.3 ± 2.6, p = 0.04). Conclusions: The delivery of auricular acupuncture during chemotherapy infusion was feasible and associated with reduction of symptom burden, anxiety, and nausea in breast cancer patients. Larger-scale clinical studies are needed to confirm these findings. Clinical Trial Registration number: NCT03170648.

Opportunity Costs of Surgical Resection and Perioperative Chemotherapy for Locoregional Pancreatic Adenocarcinoma

PURPOSE

Given the perioperative morbidity and intensity of multimodality treatment, patients with resected pancreatic ductal adenocarcinoma (PDAC) spend a substantial amount of time in clinical care. The primary aim was to determine total time spent in multimodality care for patients with locoregional PDAC.

METHODS

A cohort study of all patients who underwent curative-intent resection for PDAC at a single-institution, tertiary care center was performed (2015-2019). Exact times for all relevant visits were abstracted from the primary medical record, and travel time was calculated. Care time was divided into preoperative, surgical, radiation, and systemic therapy phases of care. Primary outcome measures were the percentage of total survival time (TST) and percentage of overall survival (OS) days spent in receipt of care.

RESULTS

One hundred seven patients were included. Patients spent a median of 5.0% (interquartile range [IQR] 2.4%-10.1%) of TST and 11.0% (IQR, 5.7%-20.4%) of OS days in receipt of clinical care. Preoperative, surgical, radiation, and systemic therapy phases of care comprised a median of 0.9% (IQR, 0.4%-2.2%), 3.0% (IQR, 1.9%-6.8%), 4.4% (IQR, 3.6%-6.3%), and 10.0% (IQR, 6.2%-14.1%) of OS days. The median per-visit travel time was 60 minutes (IQR, 32-120), and the median cumulative travel time was 22.0 hours (IQR, 12.0-51.5). 12.1% (n = 13) and 7.8% (n = 4) of patients spent > 10% of TST in receipt of surgical and systemic therapy care, respectively.

CONCLUSION

Patients with locoregional pancreatic cancer spend a considerable percentage of their survival time in receipt of oncologic care. Further research to determine predictors of increased time burden is warranted to better inform shared decision making.

Characterizing head and neck cancer survivors' discontinuation of survivorship care

BACKGROUND

Little is known about cancer survivors who discontinue survivorship care. The objective of this study was to characterize patients with head and neck cancer who discontinue survivorship care with their treating institution and identify factors associated with discontinuation.

METHODS

This was a retrospective cohort study of patients diagnosed with head and neck cancer between January 1, 2014, and December 31, 2016, who received cancer-directed therapy at the University of Iowa Hospitals and Clinics (UIHC). Eligible patients achieved a cancer-free status after curative-intent treatment and made at least 1 visit 90+ days after treatment completion. The primary outcome was discontinuation of survivorship care, which was defined as a still living survivor who had not returned to a UIHC cancer clinic for twice the expected interval. Demographic and oncologic factors were examined to identify associations with discontinuation.

RESULTS

Ninety-seven of the 426 eligible patients (22.8%) discontinued survivorship care at UIHC during the study period. The mean time in follow-up for those who discontinued treatment was 15.4 months. Factors associated with discontinuation of care included an unmarried status (P = .036), a longer driving distance to the facility (P = .0031), and a single-modality cancer treatment (P < .0001). Rurality was not associated with discontinuation (24.3% vs 21.6% for urban residence; P = .52), nor was age, gender, or payor status.

CONCLUSIONS

The study results indicate that a sizeable percentage of head and neck cancer survivors discontinue care with their treating institution. Both demographic and oncologic factors were associated with discontinuation at the treating institution, and this points to potential clinical and care delivery interventions.

Health care-related time costs in patients with metastatic breast cancer

BACKGROUND

Burdens related to time spent receiving cancer care may be substantial for patients with incurable, life-limiting cancers such as metastatic breast cancer (MBC). Estimates of time spent on health care are needed to inform treatment-related decision-making.

METHODS

Estimates of time spent receiving cancer-related health care in the initial 3 months of treatment for patients with MBC were calculated using the following data sources: (a) direct observations from a time-in-motion quality improvement evaluation (process mapping); (b) cross-sectional patient surveys; and (c) administrative claims. Average ambulatory, inpatient, and total health care time were calculated for specific treatments which differed by antineoplastic type and administration method, including fulvestrant (injection, hormonal), letrozole (oral, hormonal), capecitabine (oral, chemotherapy), and paclitaxel (infusion, chemotherapy).

RESULTS

Average total time spent on health care ranged from 7% to 10% of all days included within the initial 3 months of treatment, depending on treatment. The greatest time contributions were time spent traveling for care and on inpatient services. Time with providers contributed modestly to total care time. Patients receiving infusion/injection treatments, compared with those receiving oral therapy, spent more time in ambulatory care. Health care time was higher for patients receiving chemotherapeutic agents compared to those receiving hormonal agents.

CONCLUSION

Time spent traveling and receiving inpatient care represented a substantial burden to patients with MBC, with variation in time by treatment type and administration method.