Healthcare costs in patients with metastatic lung cancer receiving chemotherapy

Real-World Data on Metastatic Lung Cancer: Cost Analyses in Brazil From a Private Insurance Company's Perspective

PURPOSE

Non-small cell lung cancer (NSCLC) is often diagnosed at late stages, leading to escalated treatment expenses. This study aimed to elucidate the costs of lung cancer treatment in a private health care setting in Brazil.

MATERIALS AND METHODS

We conducted a retrospective cohort study, regarding costs, survival, and quality of care of stage IV NSCLC in a private health company in Brazil.

RESULTS

A total of 819 individuals were included, with median age 64.9 years. With a 1-year follow-up, patients had a median of four hospital admissions, with a median length of stay in of 6.2 days. Survival rates were higher for patients treated with targeted therapy (hazard ratio [HR], 0.38 [95% CI, 0.25 to 0.56]), immunotherapy (HR, 0.52 [95% CI, 0.40 to 0.68]), or both treatments sequentially (0.41 [95% CI, 0.25 to 0.68]). Patients submitted to sequentially targeted therapy and immunotherapy had the higher total costs (mean, $172,828 USD) compared with patients treated with immunotherapy (mean, $138,125 USD), targeted therapy (mean, $117,068 USD), and only chemotherapy (mean, $47,625 USD). As expected, longer survival was translated into more third-line therapy (P < .001), and higher mean costs with cancer-related hospital admissions ($24,554 USD chemo, $31,835 USD immuno, $28,228 USD targeted, and $35,494 USD for both therapies). However, costs did not increase in proportion to the survival benefit. Despite longer survival, patients undergoing targeted therapy or immunotherapy had median number of hospital admissions and length of stay similar to those who underwent chemotherapy alone.

CONCLUSION

Higher survival rates and costs were found for patients exposed to modern treatments for advanced NSCLC. Cost-effectiveness thresholds definitions are warranted for managing costs, particularly in developing countries.

Evolution of Diagnoses, Survival, and Costs of Oncological Medical Treatment for Non-Small-Cell Lung Cancer over 20 Years in Osona, Catalonia

Non-small-cell lung cancer (NSCLC) has experienced several diagnostic and therapeutic changes over the past two decades. However, there are few studies conducted with real-world data regarding the evolution of the cost of these new drugs and the corresponding changes in the survival of these patients. We collected data on patients diagnosed with NSCLC from the tumor registry of the University Hospital of Vic from 2002 to 2021. We analyzed the epidemiological and pathological characteristics of these patients, the diverse oncological treatments administered, and the survival outcomes extending at least 18 months post-diagnosis. We also collected data on pharmacological costs, aligning them with the treatments received by each patient to determine the cost associated with individualized treatments. Our study included 905 patients diagnosed with NSCLC. We observed a dynamic shift in histopathological subtypes from squamous carcinoma in the initial years to adenocarcinoma. Regarding the treatment approach, the use of chemotherapy declined over time, replaced by immunotherapy, while molecular therapy showed relative stability. An increase in survival at 18 months after diagnosis was observed in patients with advanced stages over the most recent years of this study, along with the advent of immunotherapy. Mean treatment costs per patient ranged from EUR 1413.16 to EUR 22,029.87 and reached a peak of EUR 48,283.80 in 2017 after the advent of immunotherapy. This retrospective study, based on real-world data, documents the evolution of pathological characteristics, survival rates, and medical treatment costs for NSCLC over the last two decades. After the introduction of immunotherapy, patients in advanced stages showed an improvement in survival at 18 months, coupled with an increase in treatment costs.

Healthcare Costs and Resource Utilisation of Italian Metastatic Non-Small Cell Lung Cancer Patients

This study evaluated the economic burden of metastatic non-small cell lung cancer patients before and after the availability of an immuno-oncology (IO) regimen as a first-line (1L) treatment. Patients from 2014 to 2020 were categorized according to mutational status into mutation-positive and negative/unknown groups, which were further divided into pre-1L IO and post-1L IO sub-groups depending on the availability of pembrolizumab monotherapy in 1L. Healthcare costs and HCRU for a 1L treatment and overall follow-up were reported as the mean total and per-month cost per patient by groups. Of 644 patients, 125were mutation-positive and 519 negative/unknown (229 and 290 in pre- and post-1L IO, respectively). The mean total per-patient cost in 1L was lower in pre- (EUR 7804) and post-1L IO (EUR 19,301) than the mutation-positive group (EUR 45,247), persisting throughout overall disease follow-up. However, this difference was less when analyzing monthly costs. Therapy costs were the primary driver in 1L, while hospitalization costs rose during follow-up. In both mutation-positive and post-IO 1L groups, the 1L costs represented a significant portion (70.1% and 66.3%, respectively) of the total costs in the overall follow-up. Pembrolizumab introduction increased expenses but improved survival. Higher hospitalisation and emergency room occupation rates during follow-up reflected worsening clinical conditions of the negative/unknown group than the mutation-positive population.

Technology-based supportive care for metastatic breast cancer patients

PURPOSE

Metastatic breast cancer (MBC) patients are living longer. However, symptom burden remains a significant issue. Technology-based interventions may assist. The purpose of this study was to test a virtual assistant for addressing symptoms in MBC using the Amazon Echo Show with Alexa.

METHODS

In this partial crossover randomized trial, the immediate treatment group was exposed to the intervention, called Nurse AMIE (Addressing Metastatic Individuals Everyday) for 6 months. The comparison group was unexposed for the first 3 months and then exposed for 3 months. The randomized controlled trial (RCT) during the first 3 months allowed for the evaluation of intervention effects on symptoms and function. The partial crossover maximized exposure to the intervention for evaluation of feasibility, usability, and satisfaction. RCT outcome data were collected at baseline and 3 months. Feasibility, usability, and satisfaction data were collected throughout the first 3 months of intervention exposure.

RESULTS

Forty-two MBC patients were randomized (1:1). Participants were 53 ± 11 years old and 4 ± 7 years from diagnosis with metastatic disease. No significant effects on psychosocial distress, pain, sleep disturbance, fatigue (vitality), quality of life, or chair stands were noted, despite high levels of acceptability (51%), feasibility (65%), and satisfaction (70%).

CONCLUSION

A high level of participant acceptability, feasibility, usability, and satisfaction all suggest further research on this platform is warranted. The lack of statistically significant effects on symptoms, quality of life, and function may be the result of small sample size.

CLINICALTRIALS

GOV REGISTRATION NUMBER

NCT04673019 (registration date: December 17, 2020).

Effect of Clinical Trial Participation on Costs to Payers in Metastatic Non-Small-Cell Lung Cancer

PURPOSE

The costs associated with clinical trial enrollment remain uncertain. We hypothesized that trial participation is associated with decreased total direct medical costs to health care payers in metastatic non-small-cell lung cancer.

METHODS

In this retrospective cohort study, we linked clinical data from electronic medical records to sociodemographic data from a cancer registry and claims data from Medicare and two private insurance plans. We used a difference-in-difference analysis to estimate mean per patient per month total direct medical costs for patients enrolled on a second-line (2L) trial versus patients receiving standard-of-care 2L systemic therapy.

RESULTS

Among 70 eligible patients, the difference-in-difference of mean per patient per month total direct medical costs between 2L trial participants and nonparticipants was -$6,663 (P = .01), for a mean savings of $45,308 per patient for the duration of 2L trial therapy. In a secondary analysis by primary insurance payer, this difference-in-difference was -$5,526 (P = .26) for patients with commercial insurance and -$7,432 (P = .01) for patients with Medicare.

CONCLUSION

Participation in a 2L trial was associated with a $6,663 per month cost savings to health care payers for the duration of trial participation. Further studies are necessary to elucidate differences in cost savings from trial participation for Medicare and commercial payers. If confirmed, these results support health care payer investment in programs to improve clinical trial access and enrollment.

Lifetime survival and medical costs of lung cancer: a semi-parametric estimation from South Korea

Background

It is essential to have information on the disease burden of lung cancer at an individual level throughout the life; however, few such results have been reported. Thus, this study aimed to assess the lifetime disease burden in patients with lung cancer by assessing various factors, such as survival, years of life lost (YLL) and medical expenditure in South Korea based on real-world data and extrapolation.

Methods

Newly diagnosed lung cancer patients (n = 2919) in 2004–2010 were selected and observed until the end of 2015 using nationwide reimbursement claim database. The patients were categorised into the Surgery group, Chemo and/or Radiotherapy group (CTx/RTx), and Surgery+CTx/RTx according to their treatment modality. Age- and sex-matched control subjects were selected from among general population using the life table. The survival and cost data after diagnosis were analysed by a semi-parametric method, the Kaplan–Meier analysis for the first 100 months and rolling extrapolation algorithm for 101–300 months. YLL were derived from the difference in survival between patients and controls.

Results

Lifetime estimates (standard error) were 4.5 (0.2) years for patients and 14.5 (0.1) years for controls and the derived YLL duration was 10.0 (0.2) years. Lifetime survival years showed the following trend: Surgery (14.2 years) > Surgery+CTx/RTx (8.5 years) > CTx/RTx group (3.0 years), and YLL were increased as lifetime survival years decreased (2.3, 8.7, 12.2 years, respectively). The mean lifetime medical cost was estimated at 30,857 USD/patient. Patients in the Surgery group paid higher treatment cost in first year after diagnosis, but the overall mean cost per year was lower at 4359 USD compared with 7075USD of Surgery+CTx/RTx or 7626USD of CTx/RTx group.

Conclusions

Lung cancer has resulted in about 10 years of life lost in overall patients. The losses were associated with treatment modality, and the results indicated that diagnosing lung cancer in patients with low stage disease eligible for surgery is beneficial for reducing disease burden in terms of survival and treatment cost per year throughout the life.

State-Level Disparity in Lung Cancer Survival in the United States

Rationale: The cancer mortality-to-incidence ratio (MIR) can serve as a population-based indicator for cancer care outcomes. In the US, evaluation of lung cancer survival by individual states has not been evaluated. Objective: To assess the association between lung cancer survival by using MIRs and state-level health disparities in the United States. Methods: We calculated 5-year lung cancer MIR averages from 2011 to 2015 using the United States Cancer Statistics (USCS) data. America's Health Rankings (AHR) is a platform using weighted measures in five different categories to calculate annual state health rankings. Five-year averages from 2011 to 2015 of the health uninsured rate and 4-year averages from 2011 to 2014 of health spending per capita were obtained from the U.S. Census Bureau and Centers for Medicare & Medicaid Services. Linear regression analyses were performed to determine the associations between cancer survival value (CSV) = (1 - MIR) × 100% and state health variables. Results: During the study period, the 5-year averages of age-adjusted incidence, mortality rates, and CSVs were 60.3 ± 2.1 per 100,000 population, 43.4 ± 2.1 per 100,000, and 27.9 ± 3.9%, respectively. Among the 50 states, Connecticut had the highest CSV (38.6 ± 1.7%) whereas Nevada had the lowest CSV (18.7 ± 6.5%). Hawaii had the highest health ranking and Mississippi had the lowest ranking in 2016. States with better health rankings, lower health uninsured rates, and higher health spending were significantly associated with higher CSVs (R ² = 0.418, P < 0.001; R ² = 0.352, P < 0.001; R ² = 0.142, P = 0.007, respectively). Conclusions: There are significant differences in lung cancer survival within the United States. Lung cancer survival by using CSV was strongly associated with state health disparities, and it can be an applicable measure to evaluate the state-level health disparities in the United States.

Cost of Disease Progression in Patients with Metastatic Breast, Lung, and Colorectal Cancer

INTRODUCTION

To reduce health care costs and improve care, payers and physician groups are piloting value-based and episodic or bundled-care payment models in oncology. Disease progression and associated costs may affect these models, particularly if such programs do not account for disease severity and progression risk across patient populations. This study estimated the incremental cost of disease progression in patients diagnosed with metastatic breast cancer (mBC), colorectal cancer (mCRC) and lung cancer (mLC) and compared costs among patients with and without progression.

METHODS

This was a retrospective study using U.S. administrative claims data from commercial and Medicare Advantage health care enrollees with evidence of mBC, mCRC, and mLC and systemic antineoplastic agent use from July 1, 2006, to August 31, 2014. Outcome measures included disease progression, 12-month health care costs, and 3-year cumulative predictive health care costs.

RESULTS

Of 5,709 patients with mBC, 3,707 patients with mCRC, and 5,201 patients with mLC, 56.8% of patients with mBC, 58.1% of those with mCRC, and 80.3% of those with mLC patients had evidence of disease progression over 12 months. Among patients with mBC and mCRC, adjusted and unadjusted health care costs were significantly higher among progressors versus nonprogressors. Per-patient-per-month costs, which accounted for variable follow-up time, were almost twice as high among progressors versus nonprogressors in patients with mBC, mCRC, and mLC. In each of the three cancer types, delays in progression were associated with lower health care costs.

CONCLUSION

Progression of mLC, mBC, and mCRC was associated with higher health care costs over a 12-month period. Delayed cancer progression was associated with substantial cost reductions in patients with each of the three cancer types.

IMPLICATIONS FOR PRACTICE

Data on the rates and incremental health care costs of disease progression in patients with solid tumor cancers are lacking. This study estimated the incremental costs of disease progression in patients diagnosed with lung cancer, breast cancer, and colorectal cancer and compared health care costs in patients with and without evidence of disease progression in a real-world population. The data obtained in our study quantify the economic value of delaying or preventing disease progression and may inform payers and physician groups about value-based payment programs.

Accuracy of administrative databases in detecting primary breast cancer diagnoses: a systematic review

OBJECTIVE

To define the accuracy of administrative datasets to identify primary diagnoses of breast cancer based on the International Classification of Diseases (ICD) 9th or 10th revision codes.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, Web of Science and the Cochrane Library (April 2017).

ELIGIBILITY CRITERIA

The inclusion criteria were: (a) the presence of a reference standard; (b) the presence of at least one accuracy test measure (eg, sensitivity) and (c) the use of an administrative database.

DATA EXTRACTION

Eligible studies were selected and data extracted independently by two reviewers; quality was assessed using the Standards for Reporting of Diagnostic accuracy criteria.

DATA ANALYSIS

Extracted data were synthesised using a narrative approach.

RESULTS

From 2929 records screened 21 studies were included (data collection period between 1977 and 2011). Eighteen studies evaluated ICD-9 codes (11 of which assessed both invasive breast cancer (code 174.x) and carcinoma in situ (ICD-9 233.0)); three studies evaluated invasive breast cancer-related ICD-10 codes. All studies except one considered incident cases.The initial algorithm results were: sensitivity ≥80% in 11 of 17 studies (range 57%-99%); positive predictive value was ≥83% in 14 of 19 studies (range 15%-98%) and specificity ≥98% in 8 studies. The combination of the breast cancer diagnosis with surgical procedures, chemoradiation or radiation therapy, outpatient data or physician claim may enhance the accuracy of the algorithms in some but not all circumstances. Accuracy for breast cancer based on outpatient or physician's data only or breast cancer diagnosis in secondary position diagnosis resulted low.

CONCLUSION

Based on the retrieved evidence, administrative databases can be employed to identify primary breast cancer. The best algorithm suggested is ICD-9 or ICD-10 codes located in primary position.

TRIAL REGISTRATION NUMBER

CRD42015026881.

Review of economic analyses of treatment for non-small-cell lung cancer (NSCLC)

INTRODUCTION

During the past few years, medical-economic evaluation of lung cancers (LCs) has become unavoidable. Total management costs have been rising constantly, with values almost doubling every 10 years. The financial impact will be even greater with the new molecules now marketed. The methodology for these studies conforms with international recommendations but must be adapted to the new stakes of LC management.

AREAS COVERED

This review provides an overview of the available literature concerning the economics of treating non-small-cell lung cancer (NSCLC). We first address the global costs of LCs. Detailed analyses were then computed for the different LC stages: localized, locally advanced and metastatic. For metastatic NSCLC, subsections are devoted to targeted therapies and immunotherapies.

EXPERT COMMENTARY

Drug costs are one of the major challenges of LC management. The multiplication of medical-economic analyses will assure better access to the marketing of these new and expensive therapeutic agents, but also to the selection of the best management strategy for these cancers.

Real-World Treatment Patterns, Overall Survival, and Occurrence and Costs of Adverse Events Associated With First-line Therapies for Medicare Patients 65 Years and Older With Advanced Non-small-cell Lung Cancer: A Retrospective Study

PURPOSE

This study sought to better understand real-world treatment patterns, overall and non-small-cell lung cancer (NSCLC)-specific survival, adverse event (AE) occurrence, and economic impact of first-line cancer therapies in Medicare patients.

PATIENTS AND METHODS

This retrospective cohort study identified patients ≥ 65 years in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database who received a first-time advanced (stage IV) NSCLC diagnosis from 2007 to 2011, and who received first-line platinum-based chemotherapy from 2007 through mid-2013. First-line regimens, healthcare resource use, occurrence of AEs, and associated costs (2013 US dollars) were analyzed. Median survival was determined using the Kaplan-Meier method.

RESULTS

Surprisingly, only 46% of patients (n = 13,472) with stage IIIB/IV NSCLC received systemic therapy, and 5931 received platinum-based therapy. The mean age was 73 years, with 3354 (57%) males; 1489 (25%) had squamous and 4442 (75%) nonsquamous histology. The most common regimens were carboplatin doublets (70%), including carboplatin/paclitaxel (38%), carboplatin/pemetrexed (12%), carboplatin/gemcitabine (11%), and carboplatin/docetaxel (7%). The median overall survival from first-line therapy initiation was 7.2 months (95% confidence interval, 7.0-7.5 months). Dyspnea and anemia were the most common AEs of interest, whereas atypical pneumonia was associated with the greatest AE-related costs (mean, $5044). The mean total per-patient-per-month cost was $11,909, with AE-related costs comprising 9% of total costs. The highest costs and survival were observed for patients treated with carboplatin/pemetrexed and bevacizumab/carboplatin/paclitaxel.

CONCLUSIONS

These real-world data illustrate the most common first-line regimens by histology, overall survival, AEs, and some of the high AE-related costs of therapy for advanced NSCLC, and provides extremely useful information for clinicians.

Health care resource use among patients with advanced non-small cell lung cancer: the PIvOTAL retrospective observational study

Background

Data are scarce regarding real-world health care resource use (HCRU) for non-small cell lung cancer (NSCLC). An understanding of current clinical practices and HCRU is needed to provide a benchmark for rapidly evolving NSCLC management recommendations and therapeutic options. The objective of this study was to describe real-world HCRU for patients with advanced NSCLC.

Methods

This multinational, retrospective chart review study was conducted at academic and community oncology sites in Italy, Spain, Germany, Australia, Japan, South Korea, Taiwan, and Brazil. Deidentified data were drawn from medical records of 1440 adults (≥18 years old) who initiated systemic therapy (2011 to mid-2013) for a new, confirmed diagnosis of advanced or metastatic (stage IIIB or IV) NSCLC. We summarized HCRU associated with first and subsequent lines of systemic therapy for advanced/metastatic NSCLC.

Results

The proportion of patients who were hospitalized at least once varied by country from 24% in Italy to 81% in Japan during first-line therapy and from 22% in Italy to 84% in Japan during second-line therapy; overall hospitalization frequency was 2.5–11.1 per 100 patient-weeks, depending on country. Emergency visit frequency also varied among countries (overall from 0.3–5.9 per 100 patient-weeks), increasing consistently from first- through third-line therapy in each country. The outpatient setting was the most common setting of resource use. Most patients in the study had multiple outpatient visits in association with each line of therapy (overall from 21.1 to 59.0 outpatient visits per 100 patient-weeks, depending on country). The use of health care resources showed no regular pattern associated with results of tests for activating mutations of the epidermal growth factor receptor (EGFR) gene or anaplastic lymphoma kinase (ALK) gene rearrangements.

Conclusions

HCRU varied across countries. These findings suggest differing approaches to the clinical management of advanced NSCLC among the eight countries. Comparative findings and an understanding of country-specific clinical practices can help to identify areas of need and guide future resource allocation for patients with advanced NSCLC. Further studies evaluating the costs associated with resource use are warranted.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2946-8) contains supplementary material, which is available to authorized users.

"Factors associated with non-small cell lung cancer treatment costs in a Brazilian public hospital"

BACKGROUND

The present study estimated the cost of advanced non-small cell lung cancer care for a cohort of 251 patients enrolled in a Brazilian public hospital and identified factors associated with the cost of treating the disease, considering sociodemographic, clinical and behavioral characteristics of patients, service utilization patterns and survival time.

METHODS

Estimates were obtained from the survey of direct medical cost per patient from the hospital's perspective. Data was collected from medical records and available hospital information systems. The ordinary least squares (OLS) method with logarithmic transformation of the dependent variable for the analysis of cost predictors was used to take into account the positive skewness of the costs distribution.

RESULTS

The average cost of NSCLC was US$ 5647 for patients, with 71% of costs being associated to outpatient care. The main components of cost were daily hospital bed stay (22.6%), radiotherapy (15.5%) and chemotherapy (38.5%). The OLS model reported that, with 5% significance level, patients with higher levels of education, with better physical performance and less advanced disease have higher treatment costs. After controlling for the patient's survival time, only education and service utilization patterns were statistically significant. Individuals who were hospitalized or made use of radiotherapy or chemotherapy had higher costs. The use of these outpatient and hospital services explained most of the treatment cost variation, with a significant increase of the adjusted R2 of 0.111 to 0.449 after incorporation of these variables in the model. The explanatory power of the complete model reached 62%.

CONCLUSIONS

Inequities in disease treatment costs were observed, pointing to the need for strategies that reduce lower socioeconomic status and population's hurdles to accessing cancer care services.

Brain metastases in non-small cell lung cancer patients on epidermal growth factor receptor tyrosine kinase inhibitors: symptom and economic burden

OBJECTIVE

This study describes the symptom and economic burden associated with brain metastases (BM) in patients with non-small cell lung cancer (NSCLC) receiving epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (EGFR-TKIs).

METHODS

This retrospective study included adults with ≥2 medical claims, within 90 days, for lung cancer and ≥1 administration of EGFR-TKIs. Based on ICD-9 codes, patients were stratified into cohorts by type of metastases (BM, other metastases [OM], or no metastases [NM]), and by when the metastasis diagnosis occurred (synchronous or asynchronous).

RESULTS

The population (synchronous BM [SBM] = 24, synchronous OM [SOM] = 23, asynchronous BM [ASBM] = 15, asynchronous OM [ASOM] = 49, NM = 85) was mostly female (57%), average age 69 years (SD = 11). SBM patients experienced more fatigue and nausea/vomiting compared with SOM and NM patients and more headaches and loss of appetite than NM patients. ASBM was associated with more fatigue, nausea/vomiting, headaches, pain/numbness, altered mental status, and seizures than NM, and more headaches and pain/numbness than ASOM. SBM patients experienced a greater increase in per-member-per-month all-cause total healthcare costs after diagnosis ($20,301) vs SOM ($9,131, p = .001) and NM ($2,493, p = .001). ASBM's cost increase between baseline and follow-up ($7,867) did not differ from ASOM's ($4,947, p = .195); both were larger than NM ($2,493, p = .001 and p = .009, respectively).

LIMITATIONS

EGFR mutation status was inferred based on EGFR-TKI treatment, not by molecular testing. Patients were from US commercial insurance plans; results may not be generalizable to other populations.

CONCLUSIONS

Among patients with EGFR-TKI-treated NSCLC, patients with BM experienced more symptoms and, when diagnosed synchronously, had significant increases in total medical costs vs patients with OM and NM. Therapeutic options with central nervous system activity may offer advantages in symptomatology and costs in EGFR-mutated patients with BM.

Relationship between lenalidomide dose modification, duration of therapy, and long-term outcomes in patients with myelodysplastic syndromes

Dose reductions or interruptions may be required to manage treatment-associated adverse events among patients with myelodysplastic syndromes (MDS) treated with lenalidomide; such modifications are recommended to sustain therapy and maximize treatment duration. The aim of this retrospective case-control study was to determine the relationship between lenalidomide dose modification (DM), duration of lenalidomide therapy (DOT), and patient outcomes in patients with MDS. Those patients with database follow-up >20months (n=305) were more likely to have received erythropoiesis-stimulating agents (ESAs) (P=0.004), had longer median DOT (P<0.001), and higher rate of DM (P<0.001) versus those with shorter follow-up (n=306). Multivariate analysis indicated that lenalidomide DM (odds ratio [OR] 1.08) and prior ESA treatment (OR 2.40) were significantly associated with longer follow-up; transfusion dependence before lenalidomide initiation was associated with a significantly shorter follow-up (OR 0.60). These data suggest that effective management of lenalidomide treatment using dose reduction and/or delay is associated with longer DOT, which can improve patient outcomes.

Estimated costs of advanced lung cancer care in a public reference hospital

OBJECTIVE

To estimate the direct medical costs of advanced non-small cell lung cancer care.

METHODS

We assessed a cohort of 277 patients treated in the Brazilian National Cancer Institute in 2011. The costs were estimated from the perspective of the hospital as a service provider of reference for the Brazilian Unified Health System. The materials and procedures used were identified and quantified, per patient, and we assigned to them monetary values, consolidated in phases of the assistance defined. The analyses had a descriptive character with costs in Real (R$).

RESULTS

Overall, the cohort represented a cost of R$2,473,559.91, being 71.5% related to outpatient care and 28.5% to hospitalizations. In the outpatient care, costs with radiotherapy (34%) and chemotherapy (22%) predominated. The results pointed to lower costs in the initial phase of treatment (7.2%) and very high costs in the maintenance phase (61.6%). Finally, we identified statistically significant differences of average cost by age groups, education levels, physical performance, and histological type.

CONCLUSIONS

This study provides a current, useful, and relevant picture of the costs of patients with non-small cell lung cancer treated in a public hospital of reference and it provides information on the magnitude of the problem of cancer in the context of public health. The results confirm the importance of radiation treatment and hospitalizations as the main components of the cost of treatment. Despite some losses of follow-up, we assess that, for approximately 80% of the patients included in the study, the estimates presented herein are satisfactory for the care of the disease, from the perspective of a service provider of reference of the Brazilian Unified Health System, as it provides elements for the management of the service, as well as for studies that result in more rational forms of resource allocation.

Cost Effectiveness of Pembrolizumab vs. Standard-of-Care Chemotherapy as First-Line Treatment for Metastatic NSCLC that Expresses High Levels of PD-L1 in the United States

OBJECTIVES

Our objectives were to evaluate the cost effectiveness of pembrolizumab compared with standard-of-care (SoC) platinum-based chemotherapy as first-line treatment in patients with metastatic non-small-cell lung cancer (NSCLC) that expresses high levels of programmed death ligand-1 (PD-L1) [tumour proportion score (TPS) ≥50%], from a US third-party public healthcare payer perspective.

METHODS

We conducted a partitioned-survival model with a cycle length of 1 week and a base-case time horizon of 20 years. Parametric models were fitted to Kaplan-Meier estimates of time on treatment, progression-free survival and overall survival from the KEYNOTE-024 randomized clinical trial (patients aged ≥18 years with stage IV NSCLC, TPS ≥50%, without epidermal growth factor receptor (EGFR)-activating mutations or anaplastic lymphoma kinase (ALK) translocations who received no prior systemic chemotherapy) and validated with long-term registry data. Quality-adjusted life-years (QALYs) were calculated based on EuroQoL-5 Dimensions (EQ-5D) utility data collected in the trial. Costs ($US, year 2016 values) for drug acquisition/administration, adverse events and clinical management were included. Costs and outcomes were discounted at 3% per year. A series of deterministic and probabilistic sensitivity analyses were performed to test the robustness of the results.

RESULTS

In the base-case scenario, pembrolizumab resulted in an expected gain of 1.31 life-years (LYs) and 1.05 QALYs and an incremental cost of $US102,439 compared with SoC. The incremental cost per QALY gain was $US97,621/QALY and the incremental cost per LY gain was $US78,344/LY.

CONCLUSIONS

Pembrolizumab is projected to be a cost-effective option compared with SoC platinum-based chemotherapy as first-line treatment in adults with metastatic NSCLC expressing high levels of PD-L1.

Costs, Trends, and Related Factors in Treating Lung Cancer Patients in 67 Hospitals in Guangxi, China

Lung cancer is a common disease with high mortality in China. Recent economic advances have led to improved medical capabilities, while costs associated with treating this disease have increased. Such change contributes to a commonly held belief that healthcare costs are out of control. However, few studies have examined this issue. Here, we use 34,678 hospitalization summary reports from 67 Guangxi hospitals (period 2013-2016) to document costs, temporal trends, and associated factors. Findings from this study are surprising in that they debunk the myth of uncontrolled healthcare costs. In addition, results and experiences from Guangxi are informative for other comparable regions.

Physician Agency and Patient Survival

We investigate the role of physician agency in determining health care supply and patient outcomes. We show that an increase in health care supply due to a change in private physician incentives has a theoretically ambiguous impact on patient welfare. The increase can reflect either induced demand for ineffective care or a reduction in prior rationing of effective care. Furthermore, physician market structure matters in determining the welfare effects of changes in private physician incentives. We then analyze a change to Medicare fees that caused physicians to increase their provision of chemotherapy. We find that this increase in treatment improved patient survival, extending median life expectancy for lung cancer patients by about 18%. Consistent with the model, we find that while the treatment response was larger in less concentrated markets, survival improvements were larger in more concentrated markets.

Genomic Sequencing Procedure Microcosting Analysis and Health Economic Cost-Impact Analysis: A Report of the Association for Molecular Pathology

The increasing use of advanced nucleic acid sequencing technologies for clinical diagnostics and therapeutics has made vital understanding the costs of performing these procedures and their value to patients, providers, and payers. The Association for Molecular Pathology invested in a cost and value analysis of specific genomic sequencing procedures (GSPs) newly coded by the American Medical Association Current Procedural Terminology Editorial Panel. Cost data and work effort, including the development and use of data analysis pipelines, were gathered from representative laboratories currently performing these GSPs. Results were aggregated to generate representative cost ranges given the complexity and variability of performing the tests. Cost-impact models for three clinical scenarios were generated with assistance from key opinion leaders: impact of using a targeted gene panel in optimizing care for patients with advanced non-small-cell lung cancer, use of a targeted gene panel in the diagnosis and management of patients with sensorineural hearing loss, and exome sequencing in the diagnosis and management of children with neurodevelopmental disorders of unknown genetic etiology. Each model demonstrated value by either reducing health care costs or identifying appropriate care pathways. The templates generated will aid laboratories in assessing their individual costs, considering the value structure in their own patient populations, and contributing their data to the ongoing dialogue regarding the impact of GSPs on improving patient care.

Effect of a Nurse-Led Psychoeducational Intervention on Healthcare Service Utilization Among Adults With Advanced Cancer

PURPOSE/OBJECTIVES

To examine differences in healthcare service utilization among patients with advanced cancer participating in a nurse-led psychoeducational intervention.

DESIGN

Secondary analysis of trial data.

SETTING

Four Michigan cancer centers.

SAMPLE

484 patients with advanced cancer.

METHODS

Patients were randomized to three groups.

MAIN RESEARCH VARIABLES

Study arm (brief, extensive, or control), ED visitation (one or more times versus none), inpatient hospitalizations (one or more times versus none), and covariates.

FINDINGS

No significant differences in ED visits or inpatient hospitalizations were observed among study arms. ED visits were more frequent for patients with lung or colorectal cancer, more comorbidities, and lower baseline QOL. Baseline QOL was associated with inpatient hospitalizations in the adjusted analysis.

CONCLUSIONS

The psychoeducational intervention, either in brief or extensive format, is unlikely to increase healthcare service utilization.

IMPLICATIONS FOR NURSING

Efficacious nurse-led psychoeducational interventions to improve QOL do not place undue burdens on the healthcare system and may improve care.

Validity of breast, lung and colorectal cancer diagnoses in administrative databases: a systematic review protocol

INTRODUCTION

Breast, lung and colorectal cancers constitute the most common cancers worldwide and their epidemiology, related health outcomes and quality indicators can be studied using administrative healthcare databases. To constitute a reliable source for research, administrative healthcare databases need to be validated. The aim of this protocol is to perform the first systematic review of studies reporting the validation of International Classification of Diseases 9th and 10th revision codes to identify breast, lung and colorectal cancer diagnoses in administrative healthcare databases.

METHODS AND ANALYSIS

This review protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) 2015 statement. We will search the following databases: MEDLINE, EMBASE, Web of Science and the Cochrane Library, using appropriate search strategies. We will include validation studies that used administrative data to identify breast, lung and colorectal cancer diagnoses or studies that evaluated the validity of breast, lung and colorectal cancer codes in administrative data. The following inclusion criteria will be used: (1) the presence of a reference standard case definition for the disease of interest; (2) the presence of at least one test measure (eg, sensitivity, positive predictive values, etc) and (3) the use of data source from an administrative database. Pairs of reviewers will independently abstract data using standardised forms and will assess quality using a checklist based on the Standards for Reporting of Diagnostic accuracy (STARD) criteria.

ETHICS AND DISSEMINATION

Ethics approval is not required. We will submit results of this study to a peer-reviewed journal for publication. The results will serve as a guide to identify appropriate case definitions and algorithms of breast, lung and colorectal cancers for researchers involved in validating administrative healthcare databases as well as for outcome research on these conditions that used administrative healthcare databases.

TRIAL REGISTRATION NUMBER

CRD42015026881.

Cost-Effectiveness of Surgery, Stereotactic Body Radiation Therapy, and Systemic Therapy for Pulmonary Oligometastases

INTRODUCTION

Pulmonary oligometastases have conventionally been managed with surgery and/or systemic therapy. However, given concerns about the high cost of systemic therapy and improvements in local treatment of metastatic cancer, the optimal cost-effective management of these patients is unclear. Therefore, we sought to assess the cost-effectiveness of initial management strategies for pulmonary oligometastases.

METHODS AND MATERIALS

A cost-effectiveness analysis using a Markov modeling approach was used to compare average cumulative costs, quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) among 3 initial disease management strategies: video-assisted thoracic surgery (VATS) wedge resection, stereotactic body radiation therapy (SBRT), and systemic therapy among 5 different cohorts of patient disease: (1) melanoma; (2) non-small cell lung cancer adenocarcinoma without an EGFR mutation (NSCLC AC); (3) NSCLC with an EGFR mutation (NSCLC EGFRm AC); (4) NSCLC squamous cell carcinoma (NSCLC SCC); and (5) colon cancer. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to analyze uncertainty with regard to model parameters.

RESULTS

In the base case, SBRT was cost effective for melanoma, with costs/net QALYs of $467,787/0.85. In patients with NSCLC, the most cost-effective strategies were SBRT for AC ($156,725/0.80), paclitaxel/carboplatin for SCC ($123,799/0.48), and erlotinib for EGFRm AC ($147,091/1.90). Stereotactic body radiation therapy was marginally cost-effective for EGFRm AC compared to erlotinib with an incremental cost-effectiveness ratio of $126,303/QALY. For colon cancer, VATS wedge resection ($147,730/2.14) was the most cost-effective strategy. Variables with the greatest influence in the model were erlotinib-associated progression-free survival (EGFRm AC), toxicity (EGFRm AC), cost of SBRT (NSCLC SCC), and patient utilities (all histologies).

CONCLUSIONS

Video-assisted thoracic surgery wedge resection or SBRT can be cost-effective in select patients with pulmonary oligometastases, depending on histology, efficacy, and tolerability of treatment and patient preferences.

Cost-components of lung cancer care within the first three years after initial diagnosis in context of different treatment regimens

OBJECTIVES

Although lung cancer is of high epidemiological relevance in Germany, evidence on its economic implications is scarce. Sound understanding of current care structures and associated expenditures is required to comprehensively judge the additional benefit of novel interventions in lung cancer care. Adopting a payer perspective, our study aims to analyze expenditures for individuals with incident lung cancer.

MATERIAL AND METHODS

Patients with an initial diagnosis of lung cancer (ICD-10 code C34) in 2009 were searched in a large, nationwide base of health insurance claims data and grouped according to initial treatment (Surgery, Chemotherapy/Radiotherapy, No specific treatment). All-cause SHI and lung cancer-related spending was assessed for a patient-individual three-year time frame after initial diagnosis. Expenditures per case and expenditures per year survived were calculated via Generalized Linear Gamma Models adjusted for age, gender, living region, baseline metastases, multiple tumors and initial treatment regimen using time under observation as a weighting factor.

RESULTS

17,478 individuals were identified. Lung cancer-related expenditures peaked within the first six months after initial diagnosis. Following, they declined subsequently and so did their share in all-cause SHI spending. Lung cancer-related expenditures per case were estimated at €20,400 (53% of all-cause expenditures) with a huge variance according to initial treatment regimen [

SURGERY

€20,400, Chemotherapy/Radiotherapy: €26,300, No specific treatment: €4200]. Cost per year survived amounted to €15,500 (55% of all cause expenditures) [

SURGERY

€11,600, Chemotherapy/Radiotherapy: €20,200, No specific treatment: €7600].

CONCLUSION

Analyses of lung cancer-related expenditures need to take into account treatment strategies and survival. Our study is representative for a large share of the population and provides detailed, patient-level information on costs of care and their compilation. Results render estimates available for the cost of lung cancer e.g. for budget impact analyses, cost-effectiveness analyses of screening and prevention schemes, or prognostic models of life-time expenditures per lung cancer case.

Use of Bevacizumab in Community Settings: Toxicity Profile and Risk of Hospitalization in Patients With Advanced Non-Small-Cell Lung Cancer

PURPOSE

Little is known regarding toxicities and hospitalizations in community-based settings for patients with advanced non-small-cell lung cancer (NSCLC) who received commonly prescribed carboplatin-paclitaxel (CP) or carboplatin-paclitaxel-bevacizumab (CPB) chemotherapy.

METHODS

Patients with stages IIIB-IV NSCLC age ≥ 21 years diagnosed between 2005 and 2010 who received first-line CP or CPB were identified at four health maintenance organizations (N = 1,109). Using patient and tumor characteristics and hospital and ambulatory encounters from automated data in the 180 days after chemotherapy initiation, the association between CP and CPB and toxicities and hospitalizations were evaluated with χ(2) tests and propensity score-adjusted regression models.

RESULTS

Patients who received CPB were significantly younger and had significantly more bleeding, proteinuria, and GI perforation events (all P < .05). For these patients, the unadjusted odds ratio associated with the likelihood of having a hospitalization was 0.46 (95% CI, 0.32 to 0.67). As shown by multivariable and propensity score-adjusted models, patients who received CPB were less likely to have been hospitalized (odds ratio, 0.48; 95% CI, 0.32 to 0.71) and had fewer total hospitalizations (rate ratio, 0.62; 95% CI, 0.47 to 0.82) and hospital days (rate ratio, 0.53; 95% CI, 0.47 to 0.60) than patients who received CP.

CONCLUSION

Consistent with earlier randomized clinical trials, significantly more toxicity events were identified in patients treated with CPB. However, both unadjusted and adjusted models showed that patients who received CPB were less likely than patients who received CP to experience a hospital-related event after the initiation of chemotherapy. Findings here confirm the need for adherence to clinical recommendations for judicious use of CPB, but provide reassurance regarding the relative risk for hospitalizations.

[Chemotherapy at the end of life for patients with lung cancer. A practice analysis]

RATIONALE

Few studies have analyzed the aggressiveness of the care (continuation of active treatments) at the end of life in patients with lung cancer. The objective of this study was to assess practices in this setting in a university department of respiratory medicine.

PATIENTS AND METHODS

This retrospective study has consecutively included all patients who were managed for lung cancer and died over a period of 18 months. The analysis focused on the characteristics of the patients, the modalities of cancer treatment and the delays between the last active treatment and death.

RESULTS

The overall median survival of the 94 patients included was 9.6 months; 92% of patients having received at least one active treatment. During the 4 and 2 weeks periods preceding death, respectively 55% and 22% of the patients received active treatments. The median time between the last day of active treatment and death was 27 days.

CONCLUSION

These results, in concordance with the published data, showed that end of life active treatment in patients with lung cancer is a complex problem. We need prospective multicentric studies, with testing tools allowing better sharing of the decisions on active treatment between the medical team, the patient and his family.

Estimation of lung cancer diagnosis and treatment costs based on a patient-level analysis in Catalonia (Spain)

BACKGROUND

Assessing of the costs of treating disease is necessary to demonstrate cost-effectiveness and to estimate the budget impact of new interventions and therapeutic innovations. However, there are few comprehensive studies on resource use and costs associated with lung cancer patients in clinical practice in Spain or internationally. The aim of this paper was to assess the hospital cost associated with lung cancer diagnosis and treatment by histology, type of cost and stage at diagnosis in the Spanish National Health Service.

METHODS

A retrospective, descriptive analysis on resource use and a direct medical cost analysis were performed. Resource utilisation data were collected by means of patient files from nine teaching hospitals. From a hospital budget impact perspective, the aggregate and mean costs per patient were calculated over the first three years following diagnosis or up to death. Both aggregate and mean costs per patient were analysed by histology, stage at diagnosis and cost type.

RESULTS

A total of 232 cases of lung cancer were analysed, of which 74.1% corresponded to non-small cell lung cancer (NSCLC) and 11.2% to small cell lung cancer (SCLC); 14.7% had no cytohistologic confirmation. The mean cost per patient in NSCLC ranged from 13,218 Euros in Stage III to 16,120 Euros in Stage II. The main cost components were chemotherapy (29.5%) and surgery (22.8%). Advanced disease stages were associated with a decrease in the relative weight of surgical and inpatient care costs but an increase in chemotherapy costs. In SCLC patients, the mean cost per patient was 15,418 Euros for limited disease and 12,482 Euros for extensive disease. The main cost components were chemotherapy (36.1%) and other inpatient costs (28.7%). In both groups, the Kruskall-Wallis test did not show statistically significant differences in mean cost per patient between stages.

CONCLUSIONS

This study provides the costs of lung cancer treatment based on patient file reviews, with chemotherapy and surgery accounting for the major components of costs. This cost analysis is a baseline study that will provide a useful source of information for future studies on cost-effectiveness and on the budget impact of different therapeutic innovations in Spain.

Utilization of intravenous bisphosphonates in patients with bone metastases secondary to breast, lung, or prostate cancer

Purpose

Cancer patients with bone metastases (BMets) are predisposed to skeletal complications. Bone-targeted therapies such as denosumab or intravenous bisphosphonates (IVBs) reduce the risk of these complications. This study characterized patterns of IVB use in these patients in the USA.

Methods

This was a retrospective, observational study using the Truven Health MarketScan® Commercial and Medicare databases (2002–2011). Subjects with ≥1 claims of diagnosis of breast, lung, or prostate cancer (BC, LC, or PC) and ≥1 claims of BMets diagnosis were included. The date of first BMet diagnosis claim was the “index date.” Key exclusion criteria were diagnosis of other primary cancer, receipt of IVB, or <6 months continuous enrollment pre-index. Cumulative incidence of treatment initiation, interruption, and discontinuation were estimated. Proportions of IVB claims with chemotherapy administered on the same day and with renal monitoring within 2 weeks prior were summarized. Multivariate regressions assessing factors associated with IVB initiation were conducted.

Results

Cumulative incidence of IVB initiation at 12 months post-index was greatest for BC followed by PC and LC, and it declined with age in all tumor types, e.g., in BC from 62 % at age <50 years to 47 % at age ≥75 years. At 12 months, IVB treatment interruption ranged from 16 % (LC) to 31 % (PC), with discontinuation ranging from 46 % (BC) to 83 % (LC).

Conclusions

IVBs are used more frequently in patients with BMets secondary to BC than PC or LC. Many patients interrupt or discontinue IVB therapy within 12 months of initiation potentially impacting effectiveness.

Early integration of palliative care services with standard oncology care for patients with advanced cancer

Scientific advances in novel cancer therapeutics have led to remarkable changes in oncology practice and longer lives for patients diagnosed with incurable malignancies. However, the myriad options for treatment have established a culture of cancer care that has not been matched with a similar availability of efficacious supportive care interventions aimed at relieving debilitating symptoms due to progressive disease and treatment side effects. Accumulating data show that the introduction of palliative care services at the time of diagnosis of advanced cancer leads to meaningful improvement in the experiences of patients and family caregivers by emphasizing symptom management, quality of life, and treatment planning. In this review article, the rationale and evidence base for this model of early palliative care services integrated into standard oncology care are presented. In addition, the implications and limitations of the existing data to 1) elucidate the mechanisms by which early palliative care benefits patients and families; 2) guide the dissemination and application of this model in outpatient settings; and 3) inform health care policy regarding the delivery of high-quality, cost-effective, and comprehensive cancer care are discussed.

Treatment patterns and healthcare costs among patients with advanced non-small-cell lung cancer

SUMMARY Aim: To identify contemporary first- and second-line treatment patterns for advanced non-small-cell lung cancer (aNSCLC) and associated costs. Methods: This study identified aNSCLC patients through an oncology registry linked to a large US commercial claims database. Patients with aNSCLC (stage IIIb or IV) and continuous enrollment in the health plan from diagnosis until death were included. First and second lines of therapy and their associated costs were determined. Results: The most common first-line regimens (n = 335) were platinum–taxane doublets alone (29%) or in combination with bevacizumab (14%) or pemetrexed (6%). Most second-line regimens (n = 74) contained pemetrexed, bevacizumab and/or erlotinib. Mean total healthcare costs ranged from US$19,182 to US$167,847 (first-line) and from US$35,737 to US$135,364 (second-line). Systemic therapy represented 20–55% of first-line and 22–68% of second-line total costs. Conclusion: Pemetrexed and targeted therapies are prevalent in both first- and second-line regimens. Total and systemic therapy-related costs exhibited considerable variability by regimen.

Factors predicting resource utilization and survival after major amputation

OBJECTIVE

Major amputation is associated with increased short-term healthcare resource utilization (RU), early mortality, and socioeconomic status (SES) disparities. Our objective is to study patient-specific and SES-related predictors of long-term RU and survival after amputation.

METHODS

This retrospective analysis identified 364 adult patients who underwent index major amputation for critical limb ischemia from January 1995 through December 2000 at two tertiary centers with outcomes through December 2010. Age, gender, SES (race, income, insurance, and marital status), comorbidities (congestive heart failure [CHF], diabetes, diabetes with complications, and renal failure [RF]), subsequent procedures, cumulative length of stay (cLOS), and mortality were analyzed. Bivariate and multivariate Poisson regression for subsequent procedures and cLOS and Cox proportional hazard modeling for all-cause mortality were undertaken.

RESULTS

During a mean follow-up of 3.25 years, amputation patients had mean cLOS of 71.2 days per person-year (median, 17.6), 19.5 readmissions per person-year (median, 2.1), 0.57 amputation-related procedures (median, 0), and 0.31 cardiovascular procedures (median, 0). Below-knee amputation as the index procedure was performed in 70% of patients, and 25% had additional amputation procedures. Of readmissions at ≤ 30 days, 52% were amputation-related. Overall mortality during follow-up was 86.9%; 37 patients (10.2%) died within 30 days. Among patients surviving >30 days, multivariate Poisson regression demonstrated that younger age (incidence rate ratio [IRR], 0.98), public insurance (IRR, 1.63), CHF (IRR, 1.60), and RF (IRR, 2.12) were associated with increased cLOS. Diabetes with complications (IRR, 1.90) and RF (IRR, 2.47) affected subsequent amputation procedures. CHF (IRR, 1.83) and RF (IRR, 3.67) were associated with a greater number of cardiovascular procedures. Cox proportional hazard modeling indicated older age (hazard ratio [HR], 1.04), CHF (HR, 2.26), and RF (HR, 2.60) were risk factors for decreased survival. Factors associated with SES were not significantly related to the outcomes.

CONCLUSIONS

This study found that RU is high for amputees, and increased RU persists beyond the perioperative period. Results were similar across SES indices, suggesting higher SES may not be protective against poor outcomes when limb salvage is no longer attainable. These findings support the hypothesis that SES disparities may be more modifiable during earlier stages of care for critical limb ischemia.