Abstract PD6-07: Trends in the cost of care for breast cancer among women with commercial insurance

Background: Breast cancer care imposes a significant financial burden to U.S. healthcare systems and has become a key focus in the health care debate. Therapies for breast cancer are expensive, and the economic burden of these therapies may be rising due to the rapid introduction of pricey new drugs and techniques. There are limited data on the health care costs of individuals with breast cancer after initial diagnosis and how these costs have changed over time.

Methods: We conducted a retrospective analysis of commercially insured adult women with newly diagnosed non-metastatic breast cancer (identified via previously published claims-based algorithms) using 2007-2016 data from a large US health plan available in OptumLabs® Data Warehouse. We included patients with continuous health plan coverage for at least 2 years after initial diagnosis 2007-2014 and assessed how total health care spending and out-of-pocket costs (paid amounts) changed over this time. Costs were adjusted to 2016 US dollars using the general Consumer Price Index. Inpatient, outpatient, and outpatient pharmacy costs were evaluated. A multivariable logistic regression model was used to examine predictors of above average cost (cost > mean for that year of diagnosis).

Results: A total of 12,446 newly diagnosed breast cancer patients were identified (mean age, 51.6 years). Forty percent had undergone mastectomy, 38% chemotherapy, and 63% radiation. After adjustment for inflation, total healthcare costs increased 29.7% from 2007 to 2014 (Table 1), with increases primarily observed during the first year after diagnosis. Out-of-pocket costs remained relatively stable, and accounted for 5.3% of the total spending. Approximately 80% of the total costs were related to care received in the outpatient setting. Factors independently associated with above average spending included treatment with mastectomy [OR 1.78 (95% CI 1.5-2.1)], reconstruction [OR 3.0 (95% CI 2.6-3.5)], radiation [OR 4.0 (95% CI 3.4-4.7)] and chemotherapy [OR 18.4 (95% CI 16.6-20.3].

Table 1.Average healthcare spending over time Mean cost during first year after diagnosisMean cost during second year after diagnosisYear of diagnosistotalout-of-pockettotalout-of-pocket2007$80,296.17$4,271.25$16,559.21$1,907.012008$84,126.70$4,445.78$16,785.43$2,205.982009$88,331.45$4,728.42$17,005.68$2,214.932010$91,502.58$5,067.78$17,243.91$2,126.192011$93,826.40$5,089.45$16,862.45$2,027.962012$96,690.06$5,449.91$17,814.09$2,179.262013$104,064.93$5,678.19$17,087.47$2,115.972014$104,169.74$5,620.51$16,714.12$1,590.67

Conclusions: Breast cancer care is increasingly expensive during the first year after diagnosis, and costs are greatest for the recipients of more aggressive treatments. Costs during the second year after diagnosis have remained relatively stable.

Citation Format: Ruddy KJ, Sangaralingham LR, Freedman RA, Jemal A, Mougalian SS, Keegan T, Loprinzi CL, Gross CP, Henk HJ, Shah N. Trends in the cost of care for breast cancer among women with commercial insurance [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-07.

Cancer deaths and cases attributable to lifestyle factors and infections in China, 2013

Background

The burden of cancer in China is high, and it is expected to further increase. Information on cancers attributable to potentially modifiable risk factors is essential in planning preventive measures against cancer. We estimated the number and proportion of cancer deaths and cases attributable to ever-smoking, second-hand smoking, alcohol drinking, low fruit/vegetable intake, excess body weight, physical inactivity, and infections in China, using contemporary data from nationally representative surveys and cancer registries.

Methods

The number of cancer deaths and cases in 2013 were obtained from the National Central Cancer Registry of China and data on most exposures were obtained from the China National Nutrition and Health Survey 2002 or 2006 and Global Adult Tobacco Smoking 2010. We used a bootstrap simulation method to calculate the number and proportion of cancer deaths and cases attributable to risk factors and their corresponding 95% confidence intervals (CIs), allowing for uncertainty in data.

Results

Approximately 718 000 (95% CI 702 100-732 200) cancer deaths in men and 283 100 (278 800-288 800) cancer deaths in women were attributable to the studied risk factors, accounting for 52% of all cancer deaths in men and 35% in women. The numbers for incident cancer cases were 952 500 (95% CI 934 200-971 400) in men and 442 700 (437 200-447 900) in women, accounting for 47% of all incident cases in men and 28% in women. The greatest proportions of cancer deaths attributable to risk factors were for smoking (26%), HBV infection (12%), and low fruit/vegetable intake (7%) in men and HBV infection (7%), low fruit/vegetable intake (6%), and second-hand smoking (5%) in women.

Conclusions

Effective public health interventions to eliminate or reduce exposure from these risk factors, notably tobacco control and vaccinations against carcinogenic infections, can have considerable impact on reducing the cancer burden in China.

Abstract P2-01-06: Patterns of axillary evaluation in older patients (pts) with breast cancer and impact on adjuvant therapy

Background:

Axillary lymph node status has traditionally been a key factor in informing adjuvant therapy recommendations for pts with breast cancer. With increased emphasis on tumor biology, this information may be less relevant, particularly in older populations where competing comorbidity frequently influences treatment decisions. We examined patterns of axillary surgery in older breast cancer pts and the impact axillary surgery has on treatment receipt.

Methods:

We identified women aged ≥65 with Stage I-III invasive breast cancer diagnosed during 2012-2013 from the National Cancer Data Base who did not have clinically positive nodes and underwent cancer-directed surgery. Nodal surgery type and receipt of adjuvant therapies were examined. Multivariable logistic regression was used to examine the associations of axillary surgery receipt with pt, clinical and facility factors.

Results:

Among 69,414 eligible women, 40% were aged 65-70, 42% aged 71-80 and 18% aged >80. 91% had axillary surgery (67% sentinel lymph node biopsy, 11% axillary lymph node dissection, 13% unspecified axillary surgery), and 24% of pts had pathologically positive nodes. 10% of pts (stage IIB-III) received adjuvant chemotherapy, 81% (hormone receptor positive) received adjuvant hormonal therapy, 67% (breast conservation or stage III postmastectomy) received radiation. In adjusted analyses, increasing age and neoadjuvant hormonal therapy were strongly associated with lower odds of axillary surgery. Region and mastectomy were strongly associated with higher odds of axillary surgery. The table shows variables associated with axillary surgery.

VariableAdjusted OR (95% CI) for having any axillary surgery*Age (vs. 65-70) 71-75.64 (.58-.71)76-80.34 (.31-.37)>80.08 (.07-.09)Diagnosed in 2013 (vs. 2012)1.08 (1.02-1.15)Stage (vs. II) I1.25 (1.13-1.38)III.73 (.60-.89)Grade (vs. 1) 21.22 (1.14-1.31)31.24 (1.13-1.37)HER2 status (vs. positive) Negative.83 (.73-.93)Tumor size (vs. ≤2 cm) >2-5cm1 (.91-1.11)>5cm.56 (.47-.67)Comorbidity score (vs. 0) 1.85 (.79-.92)>/=2.62 (.56-.68)Region (vs. New England)Range 1.66-2.67 (1.42-3.12)Case volume (vs. high) Low.82 (.73-.93)Medium.98 (.91-1.06)Insurance (vs. private) Uninsured.69 (.44-1.09)Medicaid.67 (.52-.86)Medicare.84 (.77-.93)Median household income ($) (vs. >46K) <30,0001.06 (.95-1.18)30,000-34,9991.11 (1.01-1.21)35,000-45,9991.08 (1.01-1.16)Neoadjuvant hormonal therapy (vs. not).49 (.42-.59)Surgery (vs. BCS) Mastectomy, no recon3.37 (3.09-3.68)Mastectomy, +recon2.76 (2.16-3.51)  *Adjusted for table variables plus race, hormone receptor status, and facility type (none significantly associated with axillary surgery)

Axillary surgery and younger age were significantly associated with receipt of adjuvant chemotherapy, radiation, and hormonal therapy.

Conclusion:

Within the NCDB, 91% of pts age ≥65 with clinically node-negative breast cancer undergo surgical staging of the axilla, and axillary surgery was associated with adjuvant therapy receipt. The impact of routine node assessment on treatment and outcome has been questioned, and further study in this population of pts is warranted.

Citation Format: Dominici LS, Sineshaw H, Jemal A, Lin A, King TA, Freedman RA. Patterns of axillary evaluation in older patients (pts) with breast cancer and impact on adjuvant therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-06.

Breastfeeding and breast cancer risk by receptor status--a systematic review and meta-analysis

BACKGROUND

Breastfeeding is inversely associated with overall risk of breast cancer. This association may differ in breast cancer subtypes defined by receptor status, as they may reflect different mechanisms of carcinogenesis. We conducted a systematic review and meta-analysis of case-control and prospective cohort studies to investigate the association between breastfeeding and breast cancer by estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status.

DESIGN

We searched the PubMed and Scopus databases and bibliographies of pertinent articles to identify relevant articles and used random-effects models to calculate summary odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

This meta-analysis represents 27 distinct studies (8 cohort and 19 case-control), with a total of 36 881 breast cancer cases. Among parous women, the risk estimates for the association between ever (versus never) breastfeeding and the breast cancers negative for both ER and PR were similar in three cohort and three case-control studies when results were adjusted for several factors, including the number of full-term pregnancies (combined OR 0.90; 95% CI 0.82-0.99), with little heterogeneity and no indication of publication bias. In a subset of three adjusted studies that included ER, PR, and HER2 status, ever breastfeeding showed a stronger inverse association with triple-negative breast cancer (OR 0.78; 95% CI 0.66-0.91) among parous women. Overall, cohort studies showed no significant association between breastfeeding and ER+/PR+ or ER+ and/or PR+ breast cancers, although one and two studies (out of four and seven studies, respectively) showed an inverse association.

CONCLUSIONS

This meta-analysis showed a protective effect of ever breastfeeding against hormone receptor-negative breast cancers, which are more common in younger women and generally have a poorer prognosis than other subtypes of breast cancer. The association between breastfeeding and receptor-positive breast cancers needs more investigation.

Breast cancer survival in Ethiopia: a cohort study of 1,070 women

There is little information on breast cancer (BC) survival in Ethiopia and other parts of sub-Saharan Africa. Our study estimated cumulative probabilities of distant metastasis-free survival (MFS) in patients at Addis Ababa (AA) University Radiotherapy Center, the only public oncologic institution in Ethiopia. We analyzed 1,070 females with BC stage 1-3 seen in 2005-2010. Patients underwent regular follow-up; estrogen receptor-positive and -unknown patients received free endocrine treatment (an independent project funded by AstraZeneca Ltd. and facilitated by the Axios Foundation). The primary endpoint was distant metastasis. Sensitivity analysis (worst-case scenario) assumed that patients with incomplete follow-up had events 3 months after the last appointment. The median age was 43.0 (20-88) years. The median tumor size was 4.96 cm [standard deviation (SD) 2.81 cm; n = 709 information available]. Stages 1, 2 and 3 represented 4, 25 and 71%, respectively (n = 644). Ductal carcinoma predominated (79.2%, n = 1,070) as well as grade 2 tumors (57%, n = 509). Median follow-up was 23.1 (0-65.6) months, during which 285 women developed metastases. MFS after 2 years was 74% (69-79%), declining to 59% (53-64%) in the worst-case scenario. Patients with early stage (1-2) showed better MFS than patients with stage 3 (85 and 66%, respectively). The 5-year MFS was 72% for stages 1 and 2 and 33% for stage 3. We present a first overview on MFS in a large cohort of female BC patients (1,070 patients) from sub-Saharan Africa. Young age and advanced stage were associated with poor outcome.

Race, neighbourhood characteristics and disparities in chemotherapy for colorectal cancer

BACKGROUND

Studies have found significant race/ethnic and age differences in receipt of adjuvant chemotherapy for stages III colon and II/III rectal cancers. Little is known about the role of neighbourhood factors in these disparities.

METHODS

The 4748 Black and White patients from the Georgia Comprehensive Cancer Registry were diagnosed with stages III colon and II/III rectal cancers between 2000 and 2004. Neighbourhood poverty, segregation (% Black residents) and rurality were linked to each patient using census tract identifiers. Multilevel analyses explored the role of neighbourhood characteristics and the nested association of patient race within categories of neighbourhoods in receipt of chemotherapy.

RESULTS

Odds of receiving chemotherapy for urban and suburban patients were 38% (95% CI 1.09 to 1.74) and 53% (95% CI 1.20 to 1.94) higher than for rural patients. However, odds of receiving chemotherapy for urban Black patients were 24% (95% CI 0.62 to 0.94) lower than for their White counterparts. Receipt of chemotherapy did not significantly differ between Blacks and Whites residing in suburban or rural areas.

CONCLUSION

Black-White disparities in receipt of chemotherapy among Georgia colorectal cancer patients were confined to urban patients. Disparities in receipt of this treatment for rural patients were found irrespective of patient race. Our findings highlight geographic areas where targeted interventions might be needed.

Creation of an epidemic: The tobacco industry (TI) and smoking-related adenocarcinoma (AD) of the lung

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Background: When epidemiologic research first demonstrated an association between cigarette smoking (CS) and lung cancer (LC) in the 1950s, AD comprised about 5% of LCs and was only weakly related to CS. In the 1960s and 1970s, AD increased sharply, and became strongly related to CS. Methods: We conducted an epidemiological and ecological analysis correlating time trends in LC histology with changes in cigarette design and TI actions over the past 30 yrs. We utilized SEER data on 307,797 LCs diagnosed from 1975 to 2003 to analyze time trends of age-standardized incidence rates of each LC subtype: AD, squamous (SQ), small cell, and large cell. Comparisons were drawn based on sex, race, and age. Because SEER contains no data on CS, other sources were utilized to correlate changing histology to time trends in smoking prevalence, the changing cigarette, and TI actions. Results: Among all pts, AD surpassed SQ by 1980–84 to become the most common histology. AD increased 62% from 1975–79 to 1995–99, but fell 8% in 2000–03. SQ peaked in 1980–84 and dropped 35% by 2000–03. AD surpassed SQ in 1985–89 in men, while AD was already most common in women by 1975–79. AD rose 38% in men from 1975–79 to 1995–99, while it doubled in women during this interval. Among whites, AD surpassed SQ by 1980–84, although this did not occur among blacks for another decade. Nonetheless, AD incidence has consistently been higher in black men than in other subgroups. AD was already most common in pts <50 yrs by 1975–79, while AD rapidly increased and surpassed SQ in all other age groups by 1990–94. By 2000–03, AD comprised 47% of all LCs (42% in men; 52% in women; 59% in pts <50 yrs). Currently, AD is the most common histology in both sexes, races, and in all age groups. Trends in AD correlate with the wide-scale adoption by smokers of filtered and low tar cigarettes, and with increasing nitrosamine levels in cigarettes. Conclusions: The rise of AD, particularly in women and younger persons, is consistent with the hypothesis that changes in cigarette design and composition was responsible for this rise. These changes were introduced by the TI in response to mounting evidence that CS caused other forms of LC. While low tar cigarettes do not reduce LC risk, their adoption appears to be responsible for creating an epidemic of smoking-related lung AD.

No significant financial relationships to disclose.

Recent trends in cutaneous melanoma incidence among whites in the United States

BACKGROUND

It is not yet clear whether increasing melanoma incidence is real or whether recent incidence trends mainly reflect improved diagnosis. To address this question, we examined the most recent melanoma incidence patterns among the white population stratified by sex, age, tumor stage, and tumor thickness by use of data from the Surveillance, Epidemiology, and End Results Program.

METHODS

We examined log-transformed age-specific rates for melanoma by 5-year age groups and time periods by year of diagnosis and birth cohort. Melanoma trends were further examined among broader age groups (<40 years, 40-59 years, and > or =60 years) by tumor stage and tumor thickness. Rates were age-adjusted to the 1970 U.S. standard population, and trends were tested by use of a two-sided Student's t test.

RESULTS

Melanoma incidence increased in females born since the 1960s. From 1974-1975 through 1988-1989, upward trends for the incidence of localized tumors and downward trends for the incidence of distant-stage tumors occurred in the age group under 40 years. In the more recent time period, 1990-1991 through 1996-1997, age specific rates among females compared with males generally remained stable or declined more for distant-stage tumors and increased less for local-stage tumors. Thin tumors (<1 mm) increased statistically significantly in all age groups (P<.05 for all), except in men under age 40 years. In contrast, rates for thick tumors (> or =4 mm) increased statistically significantly (P =.0003) only in males aged 60 years and older.

CONCLUSION

Melanoma incidence may well continue to rise in the United States, at least until the majority of the current population in the middle-age groups becomes the oldest population. The recent trends may reflect increased sunlight exposure.

Recent trends in lung cancer mortality in the United States

BACKGROUND

Previous age-period-cohort analyses of lung cancer incidence and mortality rates in the United States have demonstrated a decrease in risk by birth cohort through 1950, consistent with declining trends in smoking prevalence. This study was conducted to examine recent lung cancer trends, including trends among the cohorts born after 1950.

METHODS

Lung cancer mortality rates from 1970 through 1997 for whites aged 24--83 years and for blacks aged 30--83 years were investigated. Using age--period--cohort analyses with 2-year age and 2-year calendar-period intervals, we examined changes in the slope of the trends in birth-cohort and calendar-period effects. All statistical tests are two-sided.

RESULTS

There was an unexpected, statistically significant moderation in the rate of decrease of the birth-cohort trend in lung cancer mortality for whites born after 1950, with a corresponding smaller and statistically nonsignificant moderation for blacks. These data are consistent with smoking initiation rates: Rates of both cigarette and marijuana smoking initiation increased for children aged 12--17 years from 1965 through 1977. There was a statistically significant decrease in the slope of the calendar-period trend for lung cancer mortality in 1990 for both whites and blacks that was observed primarily in people 55 years of age and older.

CONCLUSIONS AND IMPLICATIONS

The birth-cohort pattern of lung cancer mortality after 1950 appears to reflect the early impact of teenage cigarette smoking on lung cancer risk in people under the age of 45 years, although a contribution from marijuana smoking cannot be ruled out. This result provides additional support for increasing smoking cessation and prevention programs for teenagers. The calendar-period decrease in lung cancer mortality after 1990 may reflect the long-term benefits of reductions in tobacco carcinogens in cigarettes and increases in smoking cessation beginning around 1960.

Retinoblastoma incidence and sunlight exposure

To evaluate positive findings from an earlier report, we studied the relation between retinoblastoma incidence and ultraviolet (UV-B) radiation levels in the Surveillance, Epidemiology, and End Results (SEER) programme areas of the USA using weighted regression, as well as in international data after adjusting for race, economic development, and climate. The association was not statistically significant within the USA (P > 0.20). At an international level, the relation was significant overall and after adjusting for economic development, but it was not significant after adjusting for race and tropical climate, suggesting that environmental factors other than UV-B may be responsible for the geographic patterns of retinoblastoma.

Cancer surveillance series: changing patterns of cutaneous malignant melanoma mortality rates among whites in the United States

BACKGROUND

Mortality from melanoma among whites is still increasing in the United States. In this study, we describe the changing patterns of melanoma mortality rates among whites by demographic factors and geography and further assess the relationship between the geographic patterns and the UV radiation (UV-B) level.

METHODS

Age-adjusted incidence and mortality rates were computed by use of the 1970 U.S. population standard. Annual percent changes of mortality were estimated by fitting regression lines to the logarithm of rates. The relationships between melanoma mortality rates and UV-B level over time were assessed by weighted regressions. All statistical tests were two-sided.

RESULTS

From 1950-1954 through 1990-1994, melanoma mortality rates increased by 191% and 84% among males and females, respectively. Mortality rates peaked in the 1930 through 1950 birth cohorts for females and in the 1935 through 1950 birth cohorts for males. In the 1950 through 1969 study period, melanoma mortality rates showed a strong North-South gradient, but the gradient weakened in recent periods. The absolute change in mortality for a 10% increase in UV-B among females decreased from 0.08 additional deaths per 100 000 person-years in 1950-1959 to 0.01 additional deaths in 1990-1995. In contrast, the absolute change in mortality among males showed little change over time; additional deaths increased from 0.11 to 0.12 per 100 000 person-years.

CONCLUSIONS

Melanoma mortality in the United States reflects the complex interplay of UV radiation levels in each geographic region, the sun-protection behaviors of each generation of males and females in childhood and adulthood, the geographic mobility of the population, and the risk awareness and early detection.

Recent geographic patterns of lung cancer and mesothelioma mortality rates in 49 shipyard counties in the United States, 1970-94

BACKGROUND

Lung cancer mortality rates among white males in the United States were observed to be elevated during 1950-69 in counties with shipbuilding industries during World War II; risk was found to be associated with asbestos exposure. We evaluated the geographic patterns in more recent years, 1970-94, for whites and compared them with the 1950-69 patterns.

METHODS

We calculated age-adjusted rates and estimated rate ratios between comparison groups.

RESULTS

Rates generally were higher in shipyard counties than in all nonshipyard counties and in coastal nonshipyard counties for both sexes and time periods. Rates increased markedly from 1950-69 to 1970-94 in all groups, with the changes more pronounced in females than males. Pleural mesothelioma mortality rates were also significantly higher in shipyard counties than coastal nonshipyard counties in all regions among males but not among females.

CONCLUSIONS

The more pronounced changes in lung cancer mortality rates among females in shipyard counties may be attributed to the combined effects of low asbestos exposures and changes in smoking behavior. Am. J. Ind. Med. 37:512-521, 2000. Published 2000 Wiley-Liss, Inc.

Analysis of DNA adduct, S-[2-(N7-guanyl)ethyl]glutathione, by liquid chromatography/mass spectrometry and liquid chromatography/tandem mass spectrometry

Sensitive and specific isotope dilution liquid chromatography/mass spectrometry (LC/MS) and liquid chromatography/tandem mass spectrometry (LC/MS/MS) methods were developed for the detection and quantitative analysis of S-[2-(N7-guanyl)ethyl]glutathione as a DNA adduct formed upon exposure of animals to carcinogenic 1,2-dihaloethanes. Separation and analysis were performed using microbore HPLC coupled in-line to an electrospray ionization triple quadrupole mass spectrometer. S-[2-(N7-guanyl)[2H4]-ethyl] glutathione was synthesized and used as internal standard. These methods provide structural confirmation of the adduct as well as quantitative analysis with the accuracy and precision necessary to measure biologically relevant levels in small tissue sample sizes (< 1 g). The sample detection limits in in vivo tissue extracts were 100 pg and 5 pg on-column for LC/MS and LC/MS/MS methods, respectively. Selected-ion monitoring mode was used to monitor the product ions of the doubly charged molecular ion. The application of these methods was demonstrated by measuring the DNA adduct levels in rat and fish samples after exposure to 1,2-dihaloethanes. The method has application in studies of DNA adduct formation as a biological marker of exposure to carcinogens and for environmental monitoring of 1,2-dihaloethanes.

The estimated long-term impact of tsetse control on the size of the population of cattle in the Didessa Valley, western Ethiopia

The long-term impact of tsetse control on cattle population size in the Didessa Valley, western Ethiopia, was analysed using an age-structured population model. A prior analytical assessment revealed that the risk of cattle dying in the tsetse-unprotected villages ranged from 4 to 9 times higher than in the tsetse-protected village. Model results show that during a period of 10 years the cattle population in the tsetse-protected village of Meti is likely to increase from 167 to 583 animals, while that in the adjacent tsetse-unprotected village of Gale remains almost constant. Model simulations also predict that improving the survival rate of calves in the tsetse-unprotected villages of Taikiltu and Temoloko (which presently have calf mortality rates of up to 35% would bring a substantial increase in their cattle population.