Michael T. Halpern

Unequal cancer survivorship care: addressing cultural and sociodemographic disparities in the clinic.

The number of individuals diagnosed with cancer is growing worldwide. Cancer patients from underserved populations have widely documented disparities through the continuum of cancer care. As the number of cancer survivors (i.e., individuals who have completed cancer treatment) from underserved populations also continue to grow, these individuals may continue to experience barriers to survivorship care, resulting in persistent long-term negative impacts on health and quality of life. In addition, there is limited participation of survivors from underserved populations in clinical trials and other research studies. To address disparities and change practices in survivorship care, a better understanding of the roles of both socioeconomic status (SES) and of culture in cancer care disparities and the relevance of these to providing high-quality care is needed. SES and culture often overlap but are not identical; understanding the impact of each is especially relevant to survivorship care. To enhance health equity among cancer survivors, clinicians need to practice culturally competent care, address cultural beliefs and practices that may influence survivors’ beliefs and activities, gain awareness of historical patterns of medical care in the survivor’s community, and consider how barriers to cross-cultural communications may hinder communication in clinical settings. While the design and implementation of survivorship care programs emphasizing effectiveness and equity is complex and potentially time consuming, it is critical for providing optimal care for all survivors, including those from the most vulnerable populations.

Regulations and policies regarding e-cigarettes

Electronic cigarettes (e‐cigarettes) are a growing public health concern because of a dramatic increase in use by adolescents and the uncertainty of potential health impacts. These health concerns and lack of an established federal regulatory scheme have led many local and state governments to address the regulatory void for e‐cigarettes by incorporating them into the statutory definition of tobacco or by passing laws specific to the use of e‐cigarettes. In August 2016, the US Food and Drug Administration issued a final rule deeming e‐cigarettes within their authority; providing uniform requirements like premarket approval applications, Harmful and Potentially Harmful Constituents reporting, and warning labels; and establishing 18 years as a minimum age of purchase. Although the impact on the publics health remains uncertain, regulations and laws governing e‐cigarettes continue to develop. This review highlights the available data regarding safety and public health impacts of e‐cigarettes and details the status of US regulations and policies affecting their sale and use. Cancer 2017;123:3007–14.

Disparities in care by insurance status for individuals with rheumatoid arthritis: analysis of the medical expenditure panel survey, 2006-2009.

Abstract Objective: Treatment guidelines for rheumatoid arthritis (RA) recommend early, aggressive treatment with nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs) to minimize long-term disability. We aimed to assess differences in medical resource utilization, drug therapy, and health outcomes among RA patients by insurance type in the United States. Methods: Individuals with a self-reported diagnosis of RA were identified in the Medical Expenditure Panel Survey (MEPS) database, 2006–2009. Data regarding sociodemographic characteristics, insurance type and status, and outcomes (including health care resource utilization, prescription medication use, health status, and patient-reported barriers to health care) were extracted. Multivariable regression analyses were used to examine the impact of insurance type (private, Medicare, Medicaid, or uninsured) on outcome measures while controlling for age group, sex, and race/ethnicity. Results: A total of 693 individuals with a self-reported diagnosis of RA during the study period were identified; 423 were aged 18–64 years and 270 were aged ≥65 years. Among patients aged 18–64, those with Medicaid or who were uninsured were less likely than those with private insurance to visit a rheumatologist (adjusted odds ratio [aOR] 0.13 and 0.17, respectively; p < .001) and to receive biologic DMARDS (aOR 0.09 [p < .001] and 0.16 [p < .01], respectively); those with Medicaid were also less likely to receive nonbiologic DMARDS (aOR 0.26 [p < .01]). Those with Medicaid were more likely than those with private insurance to be unable/delayed in getting prescription drugs (aOR 2.9 [p < .05]), to experience cognitive, social, and physical limitations (aOR 8.7 [p < .001], 4.7 [p < .001], and 2.5 [p < .05], respectively); they also reported significantly lower general health and health-related quality of life. Patients aged ≥65 experienced greater equity in care and outcomes. Conclusions: Younger RA patients with Medicaid (including those who receive coverage under the Medicaid expansion component of the Affordable Care Act) may be at risk for inadequate treatment.

Insurance status, health equity, and the cancer care continuum

Although significant resources are spent on research in an effort to find better ways to prevent, detect, and treat many diseases, numerous pattern-of-care studies have found that a substantial number of Americans do not enjoy the benefits of these new diagnostics and therapies. As a result, clinical outcomes are not solely a function of the patient’s clinical status. Indeed, this is the cause of many of the disparities in health outcomes and translates into a considerable number of individuals who experience potentially preventable increased morbidity and mortality. This is especially true in cancer. Patient sociodemographic and cultural characteristics are often associated with barriers to the receipt of high-quality and timely cancer care. These barriers, in turn, may significantly affect an individual patient’s long-term functional status, quality of life, and survival. Understanding the factors that create cancer health care disparities can help researchers, clinicians, and policymakers develop strategies and interventions to reduce them. Overcoming disparities and promoting health equity may be the most expedient way to improve outcomes for individuals diagnosed with cancer. Disparities is a term often applied to racial inequity in health care, but disparities in the availability and receipt of quality care (preventive, diagnostic, treatment, and palliative care services) translate into significant population effects by socioeconomic status or region of residence. For example, the United States as a whole has had a greater than 40% decline in age-adjusted colorectal cancer death rates since 1991. Although a number of states have had dramatic declines in colorectal death rates, 10 states have had less than a 10% decrease. Similar disparities by state have been observed in changes in breast cancer death rates. Many studies have reported on barriers to optimal cancer care associated with health insurance status. In particular, studies have shown that uninsured patients are more likely to present with advanced disease, are less likely to receive definitive treatment, and are more likely to die of their disease. This issue of Cancer includes 2 articles that add to the literature showing that factors related to socioeconomic status can increase the risk for poor outcomes after a cancer diagnosis. Using population-based data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute, these studies explore the impact of insurance status on the stage at presentation, receipt of care, and outcomes among individuals with 2 very different cancers: glioblastoma multiforme (GBM) and testicular germ cell neoplasm. In both studies, a lack of insurance correlates with an increased likelihood of a delayed presentation for care, less than optimal treatment, and poorer outcomes. Markt et al examined insurance-based disparities among men with germ cell neoplasms. This is particularly relevant because this type of cancer is most common among younger men (20-44 years old), who are also the most likely to be uninsured. In their analysis, a small number of patients who were 65 years old or older (n 5 206) were excluded “because of a lack of reliable Medicare data in SEER and because we were interested in testicular GCTs [germ cell tumors], which are more commonly diagnosed in men younger than 65 years.” Although testicular cancers are uncommon among males who are 65 years old or older, the authors are incorrect in stating that SEER does not contain reliable information on Medicare status. In multivariate analyses, Markt et al found that uninsured and Medicaid-covered patients had a significantly increased risk of presenting with larger testicular cancer tumors or metastatic disease (defined as stage II or III), whereas among all patients with metastatic disease, those who were uninsured or had Medicaid coverage were more likely to

Impact of caregiver activities and social supports on multidimensional caregiver burden: analyses from nationally-representative surveys of cancer patients and their caregivers

PurposeInformal caregivers of individuals with cancer may experience substantial burdens. To develop interventions to support these caregivers, it is crucial to quantify and understand the domains of burdens potentially experienced by caregivers and factors contributing to each domain.MethodsUsing data from two national surveys, the National Survey of Caregiving (NSOC) linked to the National Health and Aging Trends Survey (NHATS), we identified all participants in the NHATS diagnosed with cancer who had a caregiver participating in the NSOC. Guided by a theoretical model, twenty-two items in the NSOC related to caregiver health, mood and outlook were included in factor analysis to develop scales capturing domains of burden. Multivariable regression analyses examined whether activities performed by caregivers and supports for caregivers were associated with these burden scales.ResultsAnalysis of responses from 373 caregivers of cancer patients identified three scales: emotional burden; psychological burden; and relationship with the patient. Providing assistance managing medical care was associated with increased emotional and psychological burden, while assistance with non-medical issues increased psychological burden and worsened relationships with patients. Caregiver provision of direct patient care activities was also associated with increased burden but improved relationships with patients. Use of caregiver supports showed mixed associations with burden.ConclusionsUsing a nationally-representative sample of cancer patients and their caregivers and brief publicly-available survey questions, we present three scales addressing different aspects of caregiver burden that are responsive to caregiver activities and social supports. This may assist in developing and evaluating intervention to decrease caregiver burden.

Evaluation of effectiveness of survivorship programmes: how to measure success?

Although the number of cancer survivors has increased substantially in the past two decades, the evidence base regarding the effectiveness of cancer survivorship programmes is inadequate. Survivorship programmes tend to evaluate their effectiveness by assessing changes in patient-reported outcomes, symptoms and health status, knowledge, and receipt of cancer surveillance in programme participants. However, more comprehensive and high-quality evaluations of survivorship programmes are needed, including assessments using a broader set of measures. These expanded evaluations can include assessments of programme structure; long-term outcomes, such as survival, quality-adjusted life-years, and functional status; receipt of social support, nutritional, rehabilitative, and fertility preservation services; programme value, including costs and avoidance of inappropriate resource utilisation; and ability of programmes to increase access to needed survivorship care services and health equity. In this Series paper, we provide examples of assessment measures for currently used survivorship programmes, discuss the rationale for and potential benefits of expanded types of evaluation measures, and identify how these measures correspond to several evaluation frameworks. We conclude that use of a common, expanded set of measures to facilitate broad comparisons across survivorship programmes and thorough and systematic evaluations will help to identify the optimal programmes for individual survivors, improve outcomes, and prove the value of survivorship care.

Costs of Providing Infusion Therapy for Rheumatoid Arthritis in a Hospital-based Infusion Center Setting

PURPOSE Many hospital-based infusion centers treat patients with rheumatoid arthritis (RA) with intravenous biologic agents, yet may have a limited understanding of the overall costs of infusion in this setting. The purposes of this study were to conduct a microcosting analysis from a hospital perspective and to develop a model using an activity-based costing approach for estimating costs associated with the provision of hospital-based infusion services (preparation, administration, and follow-up) in the United States for maintenance treatment of moderate to severe RA. METHODS A spreadsheet-based model was developed. Inputs included hourly wages, time spent providing care, supply/overhead costs, laboratory testing, infusion center size, and practice pattern information. Base-case values were derived from data from surveys, published studies, standard cost sources, and expert opinion. Costs are presented in year-2017 US dollars. The base case modeled a hospital infusion center serving patients with RA treated with abatacept, tocilizumab, infliximab, or rituximab. FINDINGS Estimated overall costs of infusions per patient per year were

The health care experience of patients with cancer during the last year of life: Analysis of the SEER-CAHPS data set

36,663 (rituximab),

Reasons for Underutilization of Bariatric Surgery: The Role of Insurance Benefit Design

36,821 (tocilizumab),

Projecting the adequacy of the multiple sclerosis neurologist workforce

44,973 (infliximab), and