The Economic Impact on Australian Patients with Neuroendocrine Tumours

BACKGROUND AND OBJECTIVE

Little is known about the economic burden to patients and families with neuroendocrine tumours (NETs) for medical out-of-pocket expenses and employment decisions. This study was performed to determine the extent and factors influencing the financial consequences of living with NETs and their effect on quality of life.

METHODS

We undertook an online cross-sectional survey using a targeted approach and collected Australian Medicare claims data. Validated surveys measured health-related quality of life (EuroQol 5-dimension 5-level [EuroQol-5D-5L]) and financial toxicity (COmprehenSive Financial Toxicity [COST]), supplemented with questions on employment and retirement, insurance and out-of-pocket medical expenses. Generalised linear models were performed to assess determinants of quality of life and out-of-pocket expenses recorded by Medicare.

RESULTS

The survey was answered by 204 patients with a mean age of 59 years who were diagnosed on average 5.2 years ago. Self-reported mean costs were 1698 Australian dollars ($A) (standard deviation [SD] $A2132) over 3 months (median $A877) and were highest for medical tests (mean $A376 [17% of total costs], SD $A722), travel-related expenses (mean $A289 [13%], SD $A559), and specialist visits (mean $A225 [10%], SD $A342) ($A1 = $US0.69). Imaging scans, surgery and travel expenses were the most common cost burdens reported by patients. Having private health insurance was the key determinant of higher out-of-pocket costs. Poorer quality of life was significantly associated with higher financial toxicity, not working due to cancer, nausea/diarrhoea, two or more co-morbidities and younger age.

CONCLUSIONS

Medical expenses are substantial for some patients with NETs. Quality of life is adversely affected for patients experiencing financial toxicity and avoiding early retirement is an important issue for supportive care services.

Patient reported experience of the burden of neuroendocrine tumors and impact of eSHINE Patient Support Program on patient quality of life

AIM

Neuroendocrine tumors (NETs) are an uncommon cancer and difficult to diagnose and treat. Treatment is complicated by debilitating side effects, impacting quality of life. This Australia-wide survey aimed to increase our understanding of the impact and burden of NETs on patient quality of life (QoL) and to assess the benefit of a patient support program (eSHINE).

METHOD

Consented patients from the eSHINE mailing list (n = 267) were invited to participate in an electronic self-reported survey comprising 29 questions on clinical characteristics, diagnosis, sociodemographics, impact of living with NETs and benefits of a patient support program. No formal sample size was calculated. All analyses were descriptive.

RESULTS

A total of 144 participants (54%) responded. A total of 129 (48%) completed all questions. Approximately half of respondents were female, from metropolitan and rural areas, aged over 65 years and had a primary diagnosis of gastrointestinal NETs. Fifty-eight percent had been diagnosed over 5 years ago. Twenty-seven percent reported seeing four or more healthcare professionals prior to being diagnosed. Living with NETs had a large impact on patients' QoL. 83.5% reported fatigue, 76% felt their emotional health was impacted by NETs and 75% reported reduced ability to participate in leisure activities. Access to a supportive network to manage and treat NETs was extremely important to participants. Eighty-five percent of respondents reported the eSHINE program had a positive impact on their QoL.

CONCLUSION

Patients value support from healthcare professionals and patient support programs such as eSHINE in managing NETs. The eSHINE Patient Support Program has a positive impact on patient QoL.

Consensus-Derived Quality Performance Indicators for Neuroendocrine Tumour Care

Quality performance indicators (QPIs) are used to monitor the delivery of cancer care. Neuroendocrine tumours (NETs) are a family of individually uncommon cancers that derive from neuroendocrine cells or their precursors, and can occur in most organs. There are currently no QPIs available for NETs and their heterogeneity makes QPI development difficult. CommNETs is a collaboration between NET clinicians, researchers and advocates in Canada, Australia and New Zealand. We created QPIs for NETs using a three-step consensus process. First, a multidisciplinary team used the nominal group technique to create candidates (n = 133) which were then curated into appropriateness statements (62 statements, 44 sub-statements). A two-stage modified RAND/UCLA Delphi consensus process was conducted: an online survey rated the statement appropriateness then the top-ranked statements (n = 20) were assessed in a face-to-face meeting. Finally, 10 QPIs met consensus criteria; documentation of primary site, proliferative index, differentiation, tumour board review, use of a structured pathology report, presence of distant metastasis, 5- and 10-year disease-free and overall survival. These NET QPIs will be trialed as a method to monitor and improve care for people with NETs and to facilitate international comparison.

Cushing's syndrome and hypothalamic-pituitary adrenal axis suppression induced by medroxyprogesterone acetate

The referral of a patient with features of Cushing's syndrome but with suppressed plasma cortisol and adrenocorticotrophic hormone concentrations prompted us to study the effect of medroxyprogesterone acetate (MPA) therapy on the adrenal axis. 11 women (aged 54-82 years) who were receiving 200-400 mg/day MPA were studied. Of these, four had subnormal plasma cortisol responses to a short synacthen test, and two more had borderline responses (30 min post-synacthen plasma cortisol results of 411 and 511 nmol/L). We conclude that suppression of the adrenal axis occurs relatively frequently in patients on MPA and that such patients should be checked for evidence of suppression before MPA therapy is withdrawn.

Salivary androgens in hirsutism: are they of use in routine evaluation?

In the biochemical evaluation of hirsutism, 50% or less of patients have an elevated total serum testosterone. Recent work has suggested that measuring salivary testosterone or a derived serum 'free testosterone index' may be of use in the evaluation of hyperandrogenism. We have measured serum total, derived serum free indices and salivary concentrations of testosterone and 5 alpha-dihydrotestosterone in an unselected group of hirsute patients in order to assess their value in the routine evaluation of hirsutism. The assays were performed using a novel oxidation procedure to overcome the need for chromatographic separation. The 'free testosterone index' gave the best discrimination. Salivary androgen concentrations were comparatively poor and cannot be recommended for routine use.

Testosterone assays: guidelines for the provision of a clinical biochemistry service

Approximately one year after the devolution of testosterone assays from the SAS, the Analytical Methods Working Party of the Association of Clinical Biochemists set up a working party to investigate the performance of the assays, to survey the available methodology and to give guidance on the factors that influence the assay. This document represents a summary of the deliberations of the group and forms one of a series of similar reports.

Specific thromboxane synthetase inhibition and retinopathy in insulin-dependent diabetics

We have previously reported that specific thromboxane synthetase inhibition may be associated with a reduction in albumin excretion rate in insulin-dependent diabetics (IDD). We now report studies of retinal morphology assessed by serial fluorescein angiography in 25 insulin-dependent diabetics during a 16-week double-blind, randomized, placebo-controlled study of the specific thromboxane synthetase inhibitor UK-38,485. Assessment of angiograms was by, computerized image analysis indicating the percentage area of vascularization and, panel scoring by 4 ophthalmologists who scored the posterior pole in each of the 4 angiograms "blind" according to a prearranged system. There was no significant change in percentage area of vascularization in either placebo or "active" group during the study. Panel scoring, however, suggested that some patients deteriorated whilst others remained unchanged or improved. There was, however, no significant difference in these parameters between those subjects on UK-38,485 and those on placebo. We conclude that specific thromboxane synthetase inhibition is not associated with any significant change in diabetic retinopathy over a 4-month period of study.

5 alpha-reductase deficiency: diagnosis via abnormal plasma levels of reduced testosterone derivatives

A case of 5 alpha-reductase deficiency is described who presented clinically as primary amenorrhoea. Plasma levels of the two isomers resulting from the 5 alpha-reduction of testosterone provide a simple method for diagnosing this condition. An intermediate abnormality was found in other family members consistent with the heterozygous state.

Specific thromboxane synthetase inhibition and albumin excretion rate in insulin-dependent diabetes

Albumin excretion rates (AER) were measured in 30 insulin-dependent diabetics during a 16-week double-blind, randomised, placebo-controlled study of the specific thromboxane synthetase inhibitor UK-38,485.6 of 15 subjects in the active group had microalbuminuria (defined as mean pretreatment AER 20-150 micrograms/min); in these patients AER fell from 32 +/- 3 micrograms/min to 11 +/- 1 micrograms/min at 8 weeks and 9 +/- 1 micrograms/min at 16 weeks. The AER rose again (to 29 +/- 8 micrograms/min) within 12 weeks of stopping the drug. There was no significant change in the 10 patients with microalbuminuria who received placebo. There was a strong correlation between change from baseline values and the baseline values themselves in the active, but not in the placebo group, and the change from baseline differed significantly between the two groups. There was no change in glycosylated haemoglobin or mean blood glucose levels during the study. In a separate study UK-38,485 caused significant suppression of thromboxane B2 synthesis in diabetic and non-diabetic subjects.

Bloodspot 17 alpha-hydroxyprogesterone radioimmunoassay for diagnosis of congenital adrenal hyperplasia and home monitoring of corticosteroid replacement therapy

A convenient and inexpensive radioimmunoassay for bloodspot 17 alpha-hydroxyprogesterone (17-OHP) has been evaluated in the screening of newborn infants for congenital adrenal hyperplasia (CAH) and for home monitoring of CAH patients on steroid replacement therapy. In the screening study, analysis of 491 bloodspots taken for routine screening programmes for phenylketonuria and hypothyroidism established the upper limit of normal for infants aged 5-10 days as 64 nmol 17-OHP/l blood (99.9 centile). Home monitoring of patients by examination of fingerprick bloodspot 17-OHP profiles taken by parents over Saturday and Sunday on consecutive weekends showed that changes in control occurred as a result of transition from inpatient to outpatient treatment or following adjustment of steroid replacement regimens. The method was found to be valuable in the diagnosis and management of children with CAH.

Measurement of capillary blood glucose in filter-paper spots: an aid to the assessment of diabetic control

A method of measuring glucose in capillary blood spotted on to filter paper was evaluated. Between-batch reproducibility was about 6%, and the glucose remained stable in the spots for up to four days. Adoption of the method should improve control of diabetes, particularly insulin-dependent forms.