Kevin Houck

Does comparative effectiveness research promote rationing of cancer care

Comparative effectiveness research aims to inform health-care decisions by patients, clinicians, and policy makers. However, questions related to what information is relevant, and how to view the relative attributes of alternative interventions have political, social, and medical considerations. In particular, questions about whether cost is a relevant factor, and whether cost-effectiveness is a desirable or necessary component of such research, have become increasingly controversial as the area has gained prominence. Debate has emerged about whether comparative effectiveness research promotes rationing of cancer care. At the heart of this debate are questions related to the role and limits of patient autonomy, physician discretion in health-care decision making, and the nature of scientific knowledge as an objective good. In this article, we examine the role of comparative effectiveness research in the USA, UK, Canada, and other health-care systems, and the relation between research and policy. As we show, all health systems struggle to balance access to cancer care and control of costs; comparative effectiveness data can clarify choices, but does not itself determine policy or promote rationing of care.

ReCAP: Physician Experience and Attitudes Toward Addressing the Cost of Cancer Care

PURPOSE We surveyed US cancer doctors to examine current attitudes toward cost discussions and how they influence decision making and practice management. METHODS We conducted a self-administered, anonymous, electronic survey of randomly selected physician ASCO members to evaluate the frequency and nature of cost discussions reported by physicians, attitudes toward discussions of cost in clinics, and potential barriers. RESULTS A total of 333 of 2,290 physicians responded (response rate [RR], 15%; adjusted RR after omitting nonpracticing physician ASCO members, 25%), Respondent practice settings were 45% academic and 55% community/private practice. Overall, 60% reported addressing costs frequently/always in clinic, whereas 40% addressed costs rarely/never. The largest reported barrier was lack of resources to guide discussions. Those who reported frequent discussions were significantly more likely to prioritize treatments in terms of cost and believed doctors should explain patient and societal costs. A total of 36%did not believe that doctors should discuss costs with patients. Academic practitioners were significantly less likely to discuss costs (odds ratio [OR], 0.41; P = .001) and felt less prepared for such discussions (OR, 0.492; P = .005) but were more likely to consider costs to the patient (OR, 2.68; P = .02) and society (OR, 1.822; P = .02). CONCLUSION Although the majority of respondents believe it is important to consider out-of-pocket costs to patients, a substantial proportion do not discuss or consider costs of cancer care. Lack of consensus on the importance of such discussions and uncertainty regarding the optimal timing and content appear to be barriers to addressing costs of care with patients.

The Effect of Hospital Volume on Breast Cancer Mortality.

Objective: The aim of this study was to determine whether hospital volume was associated with mortality in breast cancer, and what thresholds of case volume impacted survival. Background: Prior literature has demonstrated improved survival with treatment at high volume centers among less common cancers requiring technically complex surgery. Methods: All adults (18 to 90 years) with stages 0-III unilateral breast cancer diagnosed from 2004 to 2012 were identified from the American College of Surgeons National Cancer Data Base (NCDB). A multivariable Cox proportional hazards model with restricted cubic splines was used to examine the association of annual hospital volume and overall survival, after adjusting for measured covariates. Intergroup comparisons of patient and treatment characteristics were conducted with X2 and analysis of variance (ANOVA). The log-rank test was used to test survival differences between groups. A multivariable Cox proportional hazards model was used to estimate hazard ratios (HRs) associated with each volume group. Results: One million sixty-four thousand two hundred and fifty-one patients met inclusion criteria. The median age of the sample was 60 (interquartile range 50 to 70). Hospitals were categorized into 3 groups using restricted cubic spline analysis: low-volume (<148 cases/year), moderate-volume (148 to 298 cases/year), and high-volume (>298 cases/year). Treatment at high volume centers was associated with an 11% reduction in overall mortality for all patients (HR 0.89); those with stage 0-I, ER+/PR+ or ER+/PR- breast cancers derived the greatest benefit. Conclusions: Treatment at high volume centers is associated with improved survival for breast cancer patients regardless of stage. High case volume could serve as a proxy for the institutional infrastructure required to deliver complex multidisciplinary breast cancer treatment.

Cost Implications of an Evidence-Based Approach to Radiation Treatment After Lumpectomy for Early-Stage Breast Cancer

INTRODUCTION Breast cancer treatment costs are rising, and identification of high-value oncology treatment strategies is increasingly needed. We sought to determine the potential cost savings associated with an evidence-based radiation treatment (RT) approach among women with early-stage breast cancer treated in the United States. PATIENTS AND METHODS Using the National Cancer Database, we identified women with T1-T2 N0 invasive breast cancers treated with lumpectomy during 2011. Adjuvant RT regimens were categorized as conventionally fractionated whole-breast irradiation, hypofractionated whole-breast irradiation, and omission of RT. National RT patterns were determined, and RT costs were estimated using the Medicare Physician Fee Schedule. RESULTS Within the 43,247 patient cohort, 64% (n = 27,697) received conventional RT, 13.3% (n = 5,724) received hypofractionated RT, 1.1% (n = 477) received accelerated partial-breast irradiation, and 21.6% (n = 9,349) received no RT. Among patients who were eligible for shorter RT or omission of RT, 57% underwent treatment with longer, more costly regimens. Estimated RT expenditures of the national cohort approximated

Impact of the elimination of cost sharing for mammographic breast cancer screening among rural US women: A natural experiment

420.2 million during 2011, compared with

Fatigue in long-term non-Hodgkin lymphoma survivors.

256.2 million had women been treated with the least expensive regimens for which they were safely eligible. This demonstrated a potential annual savings of

Abstract P3-07-22: Predictors of neoadjuvant chemotherapy use in women with breast cancer: A review of 169,329 patients from the American College of Surgeons' National Cancer Database

164.0 million, a 39% reduction in associated treatment costs. CONCLUSION Among women with early-stage breast cancer after lumpectomy, use of an evidence-based approach illustrates an example of high-value care within oncology. Identification of high-value cancer treatment strategies is critically important to maintaining excellence in cancer care while reducing health care expenditures.

Abstract P1-15-10: Low utilization of hypofractionated radiotherapy for the treatment of early-stage breast cancer in the US

Rural US women experience disparities in breast cancer screening and outcomes. In 2006, a national rural health insurance provider, the National Rural Electric Cooperative Association (NRECA), eliminated out‐of‐pocket costs for screening mammography.

Abstract P1-10-02: Adjuvant radiation after lumpectomy: A cost comparison of treatment patterns in 43,247 women from the National Cancer Data Base

239 Background: Fatigue is a common and distressing effect of cancer and its treatment, potentially affecting quality of life (QOL) for years after treatment. However, the prevalence and persistence of fatigue among long-term survivors of non-Hodgkin lymphoma (NHL) remains unknown. We aimed to identify demographic, clinical, and psychosocial risk factors for persistent fatigue in this population. METHODS In 2010, surveys were mailed to 682 NHL survivors who participated in a study 5 years earlier; respondents were, on average, 10.4 years post diagnosis. Standardized measures of QOL, symptoms, medical history, and demographic variables were reported at both time points. We defined significant fatigue conservatively as 0.5 standard deviations below the SF-36 scales cutoff for fatigue, and we defined persistent fatigue as significant fatigue at both time points. Chi-square, t-tests, and logistic regression were used to determine risk factors and predictors for persistent fatigue. RESULTS 30.8% (n = 172) and 33.0% (n = 186) of patients reported significant fatigue at time point 1 and 2, respectively; 20% of patients had persistent fatigue. Patients with persistent fatigue were more likely to report: female gender, income <

National survey of breast cancer screening in rural America.

30,000, less than college education, less exercise, active disease, chemotherapy, at least one recurrence of their disease, less social support, an average of 3.8 more comorbidities, and significantly more posttraumatic stress than those without persistent fatigue (all p < .05). Logistic regression showed that education less than college, more comorbidities, less exercise, and more posttraumatic stress were independent predictors of persistent fatigue (all p < .05). CONCLUSIONS Fatigue plagues one-third of NHL survivors and persists in one-fifth of this population even years after diagnosis. These findings could inform clinical practice in NHL survivorship and highlight targets for intervention.