Health expenditures and financial burden among patients with major gastrointestinal cancers relative to other common cancers in the United States

Diagnosis by Volatile Organic Compounds in Exhaled Breath in Exhaled Breath from Patients with Gastric and Colorectal Cancers

One in three cancer deaths worldwide are caused by gastric and colorectal cancer malignancies. Although the incidence and fatality rates differ significantly from country to country, the rates of these cancers in East Asian nations such as South Korea and Japan have been increasing each year. Above all, the biggest danger of this disease is how challenging it is to recognize in its early stages. Moreover, most patients with these cancers do not present with any disease symptoms before receiving a definitive diagnosis. Currently, volatile organic compounds (VOCs) are being used for the early prediction of several other diseases, and research has been carried out on these applications. Exhaled VOCs from patients possess remarkable potential as novel biomarkers, and their analysis could be transformative in the prevention and early diagnosis of colon and stomach cancers. VOCs have been spotlighted in recent studies due to their ease of use. Diagnosis on the basis of patient VOC analysis takes less time than methods using gas chromatography, and results in the literature demonstrate that it is possible to determine whether a patient has certain diseases by using organic compounds in their breath as indicators. This study describes how VOCs can be used to precisely detect cancers; as more data are accumulated, the accuracy of this method will increase, and it can be applied in more fields.

Financial Impact of Out-of-Pocket Costs Among Patients Undergoing Resection for Colorectal Carcinoma

Introduction

Little is known about the societal burden of cancer surgical care in terms of out-of-pocket (OOP) costs. The current study sought to define OOP costs incurred by patients undergoing colorectal cancer resection.

Methods

Privately insured patients undergoing colorectal cancer resection between 2013 and 2017 were identified from the IBM MarketScan database. Total and OOP costs were calculated within 1 year prior to and 1 year post surgery. A multivariable linear regression model was used to estimate total OOP costs relative to patient demographic and clinical characteristics.

Results

Among 10,935 patients, 7289 (66.7%) had primary colon cancer while 3643 (33.3%) had rectal cancer. Median total costs were US$93,967 (IQR US$51027–168,251). Median OOP costs were US$4417 (IQR US$2519–6943), or 4.5% (IQR 2.2–8.1%) of total costs. OOP costs varied over the course of patient care; specifically, median OOP costs in the preoperative period were US$432 (IQR US$130–1452) versus US$2146 (IQR US$851–3525) in the perioperative period and US$969 (IQR US$327–2239) in the postoperative period. On multivariable analysis, receipt of chemotherapy (+US$1368, 95%CI +US$1211 to +US$1525) or radiotherapy (+US$842, 95% CI +US$626 to +US$1059) was associated with higher total OOP costs. Patients with a health maintenance organization (HMO) (−US$2119, 95% CI −US$2550 to −US$1689) or a point-of-service plan (−US$938, 95% CI −US$1385 to −US$491) had lower total OOP costs than patients with comprehensive insurance. In contrast, patients with a consumer-driven or a high-deductible health plan had considerably higher total OOP costs than patients with comprehensive insurance (+US$1400, 95% CI +US$972 to +US$1827 and +US$3243, 95% CI +US$2767 to +US$3717, respectively).

Conclusions

Privately insured colorectal cancer patients undergoing surgical resection pay a median of US$4417 in OOP costs, or 4.5% of total costs. OOP costs varied with receipt of chemotherapy or radiotherapy, region of residence, and insurance plan type.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11755-2.

Prognostic Value of Combination of Inflammatory and Tumor Markers in Resectable Gastric Cancer

BACKGROUND

Inflammatory response and tumor marker levels have been shown to correlate with the prognosis in several human tumors. However, only a few studies on these markers have been performed in gastric cancer (GC) patients; the clinical significance of the combined markers is unclear. We aimed to evaluate the role of the combination of preoperative neutrophil-to-lymphocyte ratio (NLR) and carbohydrate antigen 19-9 (CA19-9) for predicting the prognosis of patients with GC.

METHODS

This retrospective study included 458 patients who underwent gastrectomy with curative intent between January 2013 and July 2014 in the second hospital of Lanzhou University. Receiver operating characteristic curve (ROC) was performed to determine the cut-off values for biomarkers, and their prognostic values were assessed using the Kaplan-Meier curve. The combined score indicators were established based on the optimal cut-off values, which range from 0 to 2. Prognostic significances for overall survival (OS) were assessed by univariate and multivariate Cox regression analysis. Nomogram was used as a visual supplement for the prognostic score system, and the predictive accuracy and discriminative ability were determined by the concordance index (C-index) and calibration curve.

RESULTS

The Kaplan-Meier survival analysis showed that the 1-, 3-, and 5-year OS were 66.2% (n = 303), 42.8% (n = 196), and 40.2% (n = 184) in all 458 patients, respectively. The high NLR (≥1.96), PLR (≥126), CA19-9 (≥27 U/mL), and CEA (≥ 5 ng/mL) were associated with poor prognosis of GC patients. The NLR + CA19-9 score indicator proved to be related to tumor size, lymph node metastasis, vascular invasion, perineural invasion, T stage, N stage, TNM stage, PLR, and CEA in patients with GC and an independent prognostic factor for prediction of 5-year OS (score 1: HR = 1.423, 95%CI: 1.049-1.929, P = 0.023; score 2: HR = 2.740, 95%CI: 1.882-3.990, P < 0.001). NLR + CA19-9 has a better predictive ability than other combined or single score indicators based on inflammation and tumor markers (AUC = 0.662, 95%CI: 0.616-0.705, P < 0.001). Moreover, a nomogram was established by the significant characteristics in the multivariate analysis for OS, which represented high accuracy (C-index = 0.692, 95%CI: 0.675-0.708).

CONCLUSION

NLR + CA19-9 can independently predict the overall survival of patients with gastric cancer after surgery. The prognostic nomogram based on NLR + CA19-9 is a convenient, economical, and effective prognostic system for clinical practice.

County-Level Variation in Utilization of Surgical Resection for Early-Stage Hepatopancreatic Cancer Among Medicare Beneficiaries in the USA

INTRODUCTION

Geographic variations in access to care exist in the USA. We sought to characterize county-level disparities relative to access to surgery among patients with early-stage hepatopancreatic (HP) cancer.

METHODS

Data were extracted from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Linked database from 2004 to 2015 to identify patients undergoing surgery for early-stage HP cancer . County-level information was acquired from the Area Health Resources Files (AHRF). Multivariable logistic regression analysis was performed to assess factors associated with utilization of HP surgery on the county level.

RESULTS

Among 13,639 patients who met inclusion criteria, 66.9% (n = 9125) were diagnosed with pancreatic cancer and 33.1% (n = 4514) of patients had liver cancer. Among patients diagnosed with early-stage liver and pancreas malignancy, two-thirds (n = 8878, 65%) underwent surgery. Marked county-level variation in the utilization of surgery was noted among patients with early-stage HP cancer ranging from 57.1% to more than 83.3% depending on which county a patient resided. After controlling for patient and tumor-related characteristics, counties with the highest quartile of patients living below the poverty level had 35% lower odds of receiving surgery for early stage HP cancer compared patients who lived in a county with the lowest proportion of patients below the poverty line (OR 0.65, 95% CI 0.55-0.77). In addition, patients residing in counties with the highest surgeon-to-population ratio (OR 2.01, 95% CI 1.52-2.65), as well as the highest hospital bed-to-population ratio (OR 1.29, 95% CI 1.07-1.54), were more likely to undergo surgical treatment for an early-stage HP malignancy.

CONCLUSION

Area-level variations among patients undergoing surgery for early-stage HP cancer were mainly due to differences in structural measures and county-level factors. Policies targeting high-poverty counties and improvement in structural measures may reduce variations in utilization of surgery among patients diagnosed with early-stage HP cancer.

The impact of social vulnerability subthemes on postoperative outcomes differs by racial/ethnic minority status

INTRODUCTION

Social vulnerability is an important driver of disparate surgical outcomes, however the extent to which certain types of vulnerability impact outcomes is poorly understood.

METHODS

Medicare beneficiaries 65 years or older who underwent one of four operations were identified. Multivariable mixed-effects logistic regression was used to measure the association of four social vulnerability subthemes from the social vulnerability index (SVI) were assessed relative to the likelihood to achieve a textbook outcome (TO).

RESULTS

Among 579,846 Medicare beneficiaries, median age was 74 years and most patients (536,455,92.5%) were White/non-Hispanic. On multivariable analysis, the overall impact of the composite SVI metric on the odds to achieve a postoperative TO was lower among White/non-Hispanic patients (Δ25%ile SVI:OR:0.98,95%CI:0.97-0.98) compared with ethnic/minority patients (Δ25%ile SVI:OR:0.93,95%CI:0.91-0.94). Increasing vulnerability in the subthemes of socioeconomic status (Δ25%ile SVI:ethnic/minority:OR:0.92, 95%CI:0.91-0.94) and household composition (Δ25%ile SVI:ethnic/minority:OR:0.92,95%CI:0.91-0.94) was associated with a greater likelihood not to achieve a TO among minority patients.

CONCLUSIONS

Worsening SES and household compositions & disability had a detrimental effect on odds of TO following surgery with the most pronounced effect on non-White minority patients.

End-of-Life Hospice Use and Medicare Expenditures Among Patients Dying of Hepatocellular Carcinoma

BACKGROUND

The increasing incidence of hepatocellular carcinoma (HCC) coupled with rising health care costs contributes to high end-of-life expenditures. The current study aimed to characterize health care expenditures and hospice use among patients with HCC using a large, national database.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was used to identify patients with HCC. Logistic regression was used to identify factors associated with overall hospice use and end-of-life expenditures among individuals who died of HCC.

RESULTS

Among 14,369 Medicare beneficiaries with HCC, 8069 (63.7 %) used hospice. Racial/ethnic minority patients were less likely to use hospice services during the last year of life than white patients (no hospice: n = 2034 [44.3 %] vs. hospice: n = 2513 [31.1 %]). Social vulnerability also had an impact on the likelihood of patients using hospice services; in particular, the probability of hospice use among patients declined as social vulnerability increased (P < 0.05). Hospice use was associated with an approximate $10,000 decrease in inpatient expenditures (hospice: US$7900 [IQR, US$0-26,600] vs. no hospice: US$18,000 [IQR $400-49,100]; P < 0.001) and $1300 decrease in outpatient expenditures (hospice: US$900 [IQR, US$0-4500] vs. non-hospice: US$2200 [IQR, US$200-7900; P < 0.001) compared with individuals who did not use hospice.

CONCLUSIONS

Minority patients and individuals residing in high-vulnerability areas were less likely to use hospice. Patients who used hospice at the end of life had a reduction in inpatient and outpatient Medicare claims. Patients with HCC in need of hospice services should be ensured timely referral regardless of race/ethnicity or social vulnerability.