Jens Olsen

Gallstones, cholecystectomy and risk of cancers of the liver, biliary tract and pancreas

SummaryTo examine the association between gallstones and cholecystectomy, we conducted a nationwide population-based cohort study in Denmark. Patients with a discharge diagnosis of gallstones from 1977 to 1989 were identified from the Danish National Registry of Patients and followed up for cancer occurrence until death or the end of 1993 by record linkage to the Danish Cancer Registry. Included in the cohort were 60 176 patients, with 471 450 person–years of follow-up. Cancer risks were estimated by standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) stratified by years of follow-up and by cholecystectomy status. Among patients without cholecystectomy, the risks at 5 or more years of follow-up were significantly elevated for cancers of liver (SIR = 2.0, CI = 1.2–3.1) and gallbladder (SIR = 2.7, CI = 1.5–4.4) and near unity for cancers of extrahepatic bile duct (SIR = 1.1), ampulla of Vater (SIR = 1.0) and pancreas (SIR = 1.1). The excess risk of liver cancer was seen only among patients with a history of hepatic disease. Among cholecystectomy patients, the risks at 5 or more years of follow-up declined for cancers of liver (SIR = 1.1) and extrahepatic bile duct (SIR = 0.7), but were elevated for cancers of ampulla of Vater (SIR = 2.0, CI = 1.0–3.7) and pancreas (SIR = 1.3, CI = 1.1–1.6). These findings confirm that gallstone disease increases the risk of gallbladder cancer, whereas cholecystectomy appears to increase the risk of cancers of ampulla of Vater and pancreas. Further research is needed to clarify the carcinogenic risks associated with gallstones and cholecystectomy and to define the mechanisms involved.

Increased intake of fruit and vegetables: estimation of impact in terms of life expectancy and healthcare costs.

OBJECTIVES There is strong evidence that a high consumption of fruit and vegetables reduces the risk of developing many cancers. This study examined the economic consequences for the healthcare sector if people followed the recommendations and increased their intake of fruit and vegetables. DESIGN A life table was used to describe a base case population with respect to life expectancy, cancer incidence and healthcare costs. Relative risks of cancer for a high versus a low intake of fruit and vegetables were obtained from the literature and were used to simulate populations with a higher intake of fruit and vegetables. The empirical data consist of a 20% sample of the Danish population that was followed from 1993 to 1997. Civil registration numbers were used to link various computerised registers, in order to describe each individual in the sample in terms of morbidity, mortality and healthcare costs. RESULTS The average daily intake of fruit and vegetables was assumed to be approximately 250 g for the general Danish population. Simulated intakes of 400 g and 500 g increased the life expectancy by 0.8 and 1.3 years, respectively. In addition, it was estimated that 19% and 32% of the cancer incidence could be prevented. The aggregate healthcare costs remained stable, as the resources saved due to a lower cancer incidence were offset by healthcare costs imposed by the fact that healthy people live longer and require more healthcare. However, the variations across age groups and health sectors were substantial. DISCUSSION The study adopted a healthcare sector perspective. Only costs from hospitalisation and primary care were included in the calculations. The costs of changing peoples dietary habits, i.e. education, information and promotion as well as other costs that would be relevant from a societal perspective, have not been taken into account. Furthermore, the transition from one level of intake to another is not the focus of the analysis, although it might take decades to observe the full effect of the dietary changes. CONCLUSION Empirical evidence suggests that a considerable fraction of all cancer incidences can be prevented by a higher intake of fruit and vegetables. That may result in improved public health (gain in life years) at no additional cost to the healthcare sector.

Human papillomavirus transmission and cost-effectiveness of introducing quadrivalent HPV vaccination in Denmark

OBJECTIVES The objective of this study was to simulate human papillomavirus (HPV) infection in a heterosexual population and subsequently analyze the incremental costs and effects of introducing a vaccination program against HPV types 6, 11, 16, and 18 in Denmark compared with screening alone. METHODS The analysis was performed in two phases. First, an agent-based transmission model was developed that described the HPV transmission without and with HPV vaccination. Second, an analysis of the incremental costs and effects was performed. The results of prevalence estimates of HPV, genital warts, cervical intraepithelial neoplasia (CIN1-3), and cervical cancer in the model simulations before and after introduction of HPV vaccination were extrapolated to the Danish population figures. Incremental costs and effects were then estimated. Future costs and effects were discounted. RESULTS Cost-effectiveness ratios for annual vaccination of 12-year-old girls, with a vaccination rate of 70 percent without a catch-up program, were estimated at approximately 1,917 euro per quality-adjusted life-year (QALY, 3 percent discount rate) and 10,846 euro/QALY (5 percent discount rate), given a 62-year time horizon. CONCLUSIONS A vaccination program would incur extra vaccination costs but would save treatment costs and improve both quality of life and survival.

Risk of colorectal cancer and other cancers in patients with gall stones

BACKGROUND: The occurrence of gall stones has repeatedly been associated with an increased risk for cancer of the colon, but risk associated with cholecystectomy remains unclear. AIMS: To evaluate the hypothesis in a nationwide cohort of more than 40,000 gall stone patients with complete follow up including information of cholecystectomy and obesity. PATIENTS: In the population based study described here, 42,098 patients with gall stones in 1977-1989 were identified in the Danish Hospital Discharge Register. METHODS: These patients were linked to the Danish Cancer Registry to assess their risks for colorectal and other cancers during follow up to the end of 1992. RESULTS: The analysis showed a modest increase in the number of cancers at all sites combined (n = 3940; RR, 1.07; 95% confidence intervals (CI), 1.0 to 1.1). A weak association was found for cancer of the colon (n = 360; RR, 1.09; 95% CI 1.0 to 1.2), which remained unchanged when analysed by sex, anatomical subsite, and duration of follow up. Multivariate analysis with adjustment for cholecystectomy and clinically defined obesity did not change these estimates to any significant extent. Excess risks were found for cancers of the pancreas and the small intestine. A non-significant increased risk for breast cancer was seen in women five years after initial discharge for gall stones. CONCLUSION: A borderline significant association was seen between gall stones and cancer of the colon, and for cancer of pancreas and small intestine as well as for breast cancer in women.

Cost-effectiveness of human papillomavirus vaccine in reducing the risk of cervical cancer in Ireland due to HPV types 16 and 18 using a transmission dynamic model

We evaluated the cost-effectiveness of combining a cervical cancer screening programme with a national HPV vaccination programme compared to a screening programme alone to prevent cervical dysplasia and cervical cancer related to HPV types 16 and 18 in the Irish healthcare setting. The incremental cost effectiveness of vaccination strategies for 12-year-old females (base-case) and 12-26-year-old catch-up vaccination strategies were examined. The base-case incremental cost-effectiveness ratio was euro17,383/LYG. Using a probabilistic sensitivity analysis about the base-case, the 95% CI for cost per LYG was (euro3400 to euro38,400). This suggests that vaccination against HPV types 16 and 18 would be cost-effective from the perspective of the Irish healthcare payer.

Neoplasm to neoplasm metastasis: a renal oncocytoma with metastatic bronchogenic carcinoma

An unusual case of metastasis of neoplasm to a benign neoplasm is reported. The initial malignancy, a small-cell bronchogenic carcinoma, was found to have metastasis to a renal oncocytoma. A review of the literature indicates, according to our knowledge, no similar case.

Prediction of costs, effectiveness, and disease control of a population-based program using home sampling for diagnosis of urogenital Chlamydia trachomatis Infections.

Objective: To estimate the incremental effects and costs of a home sampling screening approach for Chlamydia trachomatis over the current in-office screening practice in Denmark. Goals: To assess the effect of a new screening strategy. Study Design: A dynamic Monte Carlo model estimated prevalence and incidence over 10 years for a home sampling screening program and the current in-office screening. Subsequently, the incremental number of major outcomes averted (MOA) and the related direct and indirect costs were estimated. Results: Infection prevalence after 10 years was 1.0% with a home sampling program and 4.2% with the current in-office screening practice. The total costs per MOA reached

Nutritional care of medical inpatients: a health technology assessment

3186 during the first year of the home sampling strategy, but in year 4, the accumulated indirect costs offset the direct costs, and the program henceforth saved society costs. Conclusions: Home sampling should be considered a relevant alternative to the current practice of in-office screening.

Revisiting the cost-effectiveness of universal HPV-vaccination in Denmark accounting for all potentially vaccine preventable HPV-related diseases in males and females

BackgroundThe inspiration for the present assessment of the nutritional care of medical patients is puzzlement about the divide that exists between the theoretical knowledge about the importance of the diet for ill persons, and the common failure to incorporate nutritional aspects in the treatment and care of the patients. The purpose is to clarify existing problems in the nutritional care of Danish medical inpatients, to elucidate how the nutritional care for these inpatients can be improved, and to analyse the costs of this improvement.MethodsQualitative and quantitative methods are deployed to outline how nutritional care of medical inpatients is performed at three Danish hospitals. The practices observed are compared with official recommendations for nutritional care of inpatients. Factors extraneous and counterproductive to optimal nutritional care are identified from the perspectives of patients and professional staff. A review of the literature illustrates the potential for optimal nutritional care. A health economic analysis is performed to elucidate the savings potential of improved nutritional care.ResultsThe prospects for improvements in nutritional care are ameliorated if hospital management clearly identifies nutritional care as a priority area, and enjoys access to management tools for quality assurance. The prospects are also improved if a committed professional at the ward has the necessary time resources to perform nutritional care in practice, and if the care staff can requisition patient meals rich in nutrients 24 hours a day. At the kitchen production level prospects benefit from a facilitator contact between care and kitchen staff, and if the kitchen staff controls the whole food path from the kitchen to the patient. At the patient level, prospects are improved if patients receive information about the choice of food and drink, and have a better nutrition dialogue with the care staff. Better nutritional care of medical patients in Denmark is estimated to hold a cost savings potential reaching approximately USD 22 million.ConclusionEvery hospital and every bed ward has its strengths and weaknesses, but none of the participating bed wards fully satisfy nutritional care success criteria. All organisational levels have a significant potential for improvements of nutritional care of medical inpatients.

Cost-effectiveness of nutritional counseling for obese patients and patients at risk of ischemic heart disease

ObjectiveThe purpose of this study was to assess the consequences of a national immunization program with HPV vaccine for both boys and girls in Denmark, including the prophylactic effects on all potentially vaccine preventable HPV-associated diseases in male and female.MethodsThe study focussed on the quadrivalent vaccine which protects against HPV type 6, 11, 16 and 18, and the vaccine’s protection against genital warts, cervical intraepithelial neoplasia, cervical cancer, anogenital cancer (anal, penile, vaginal and vulvar cancer) and head and neck cancer (oral cavity, oropharyngeal, hypopharyngeal and laryngeal cancer) were included in the analyses. In general, the analysis was performed in two phases. First, an agent-based transmission model that described the HPV transmission without and with HPV vaccination was applied. Second, an analysis of the incremental costs and effects was performed. The model did not include naturally-acquired immunity to HPV in the simulations.ResultsIn the base case result (i.e. vaccination of girls only, 85% vaccination rate, private market price at € 123 per dose ex. VAT) an ICER of 3583 €/QALY (3-dose regime) is estimated when all HPV-related diseases are taken into account. Vaccination of girls & boys vs. vaccination of girls only an ICER of 28,031 €/QALY (2-dose regime) and 41,636 €/QALY (3-dose regime) is estimated.ConclusionsExtension of the current HPV programme in Denmark to include boys and girls is a cost effective preventive intervention that would lead to a faster prevention of cancers, cancer precursors and genital warts in men and women.