Susan T. Stewart

Forecasting the Effects of Obesity and Smoking on U.S. Life Expectancy

BACKGROUND Although increases in obesity over the past 30 years have adversely affected the health of the U.S. population, there have been concomitant improvements in health because of reductions in smoking. Having a better understanding of the joint effects of these trends on longevity and quality of life will facilitate more efficient targeting of health care resources. METHODS For each year from 2005 through 2020, we forecasted life expectancy and quality-adjusted life expectancy for a representative 18-year-old, assuming a continuation of past trends in smoking (based on data from the National Health Interview Survey for 1978 through 1979, 1990 through 1991, 1999 through 2001, and 2004 through 2006) and past trends in body-mass index (BMI) (based on data from the National Health and Nutrition Examination Survey for 1971 through 1975, 1988 through 1994, 1999 through 2002, and 2003 through 2006). The 2003 Medical Expenditure Panel Survey was used to examine the effects of smoking and BMI on health-related quality of life. RESULTS The negative effects of increasing BMI overwhelmed the positive effects of declines in smoking in multiple scenarios. In the base case, increases in the remaining life expectancy of a typical 18-year-old are held back by 0.71 years or 0.91 quality-adjusted years between 2005 and 2020. If all U.S. adults became nonsmokers of normal weight by 2020, we forecast that the life expectancy of an 18-year-old would increase by 3.76 life-years or 5.16 quality-adjusted years. CONCLUSIONS If past obesity trends continue unchecked, the negative effects on the health of the U.S. population will increasingly outweigh the positive effects gained from declining smoking rates. Failure to address continued increases in obesity could result in an erosion of the pattern of steady gains in health observed since early in the 20th century.

Active Surveillance Compared With Initial Treatment for Men With Low-Risk Prostate Cancer: A Decision Analysis

CONTEXT In the United States, 192,000 men were diagnosed as having prostate cancer in 2009, the majority with low-risk, clinically localized disease. Treatment of these cancers is associated with substantial morbidity. Active surveillance is an alternative to initial treatment, but long-term outcomes and effect on quality of life have not been well characterized. OBJECTIVE To examine the quality-of-life benefits and risks of active surveillance compared with initial treatment for men with low-risk, clinically localized prostate cancer. DESIGN AND SETTING Decision analysis using a simulation model was performed: men were treated at diagnosis with brachytherapy, intensity-modulated radiation therapy (IMRT), or radical prostatectomy or followed up by active surveillance (a strategy of close monitoring of newly diagnosed patients with serial prostate-specific antigen measurements, digital rectal examinations, and biopsies, with treatment at disease progression or patient choice). Probabilities and utilities were derived from previous studies and literature review. In the base case, the relative risk of prostate cancer-specific death for initial treatment vs active surveillance was assumed to be 0.83. Men incurred short- and long-term adverse effects of treatment. PATIENTS Hypothetical cohorts of 65-year-old men newly diagnosed as having clinically localized, low-risk prostate cancer (prostate-specific antigen level <10 ng/mL, stage ≤T2a disease, and Gleason score ≤6). MAIN OUTCOME MEASURE Quality-adjusted life expectancy (QALE). RESULTS Active surveillance was associated with the greatest QALE (11.07 quality-adjusted life-years [QALYs]), followed by brachytherapy (10.57 QALYs), IMRT (10.51 QALYs), and radical prostatectomy (10.23 QALYs). Active surveillance remained associated with the highest QALE even if the relative risk of prostate cancer-specific death for initial treatment vs active surveillance was as low as 0.6. However, the QALE gains and the optimal strategy were highly dependent on individual preferences for living under active surveillance and for having been treated. CONCLUSIONS Under a wide range of assumptions, for a 65-year-old man, active surveillance is a reasonable approach to low-risk prostate cancer based on QALE compared with initial treatment. However, individual preferences play a central role in the decision whether to treat or to pursue active surveillance.

Utilities for prostate cancer health states in men aged 60 and older

Purpose:We sought to measure utilities for prostate cancer health states in older men. Methods:A total of 162 men aged 60 years or older (52% of whom had been diagnosed with prostate cancer) provided standard gamble utilities for 19 health states associated with prostate cancer or its treatment using an interactive, computer-based utility assessment program. Demographics and experience with specific health states were examined as predictors of ratings using ordinary least squares regression analysis. Results:Mean utilities ranged from 0.67 to 0.84 for living with symptom-free cancer under conservative management (“watchful waiting”) and from 0.71 to 0.89 for symptoms occurring with treatment (prostatectomy, radiation, and hormone ablation). For long-term treatment complications, bowel problems (0.71) were rated as significantly worse than impotence (0.89), urinary difficulty (0.88), or urinary incontinence (0.83). Combinations of these conditions were rated as significantly worse than individual component states. Men who had experienced impotence or urinary incontinence rated these states as slightly better than men who had not experienced the specific problems. Conclusions:Both “watchful waiting” and treatment complications from prostate cancer treatments can have large impacts on quality of life. Mean ratings are important for use in policy-making and cost-effectiveness analyses. Variation in ratings across patients suggests that mean scores do not reflect individual preferences and that shared decision-making may be best for clinical decisions.

The Value of Medical Interventions for Lung Cancer in the Elderly Results from SEER-CMHSF

Lung cancer is the leading source of cancer mortality and spending. However, the value of spending on the treatment of lung cancer has not been conclusively demonstrated. The authors evaluated the value of medical care between 1983 and 1997 for nonsmall cell lung cancer in the elderly US population.

Estimating the risk of long-term erectile, urinary and bowel symptoms resulting from prostate cancer treatment

Reports on long-term complications resulting from treatment for localized prostate cancer are very inconsistent. In order to estimate the risks of long-term erectile dysfunction, urine symptoms and bowel symptoms following prostatectomy (RP), external conventional or conformal beam radiation (ERT or CRT) and brachytherapy (BRT), 98 papers from the PubMed and Cochrane Clinical Trial databases were selected, reviewed and critically evaluated. The majority of papers were institution-based retrospective and prospective follow-up studies; only two of these studies measured the risk of developing more than one treatment complication. Due to differences in study designs and populations, it is difficult to directly compare studies and not meaningful to calculate summary estimates. In addition to focusing on randomized clinical trials and well-designed population based studies, future research should adopt standardized methodologies and should measure the risk of developing more than one treatment complication.

The impact of symptoms and impairments on overall health in US national health data

Objective:To assess the effects on overall self-rated health of the broad range of symptoms and impairments that are routinely asked about in national surveys. Data:We use data from adults in the nationally representative Medical Expenditure Panel Survey (MEPS) 2002 with validation in an independent sample from MEPS 2000. Methods:Regression analysis is used to relate impairments and symptoms to a 100-point self-rating of general health status. The effect of each impairment and symptom on health-related quality of life (HRQOL) is estimated from regression coefficients, accounting for interactions between them. Results:Impairments and symptoms most strongly associated with overall health include pain, self-care limitations, and having little or no energy. The most prevalent are moderate pain, severe anxiety, moderate depressive symptoms, and low energy. Effects are stable across different waves of MEPS, and questions cover a broader range of impairments and symptoms than existing health measurement instruments. Conclusions:This method makes use of the rich detail on impairments and symptoms in existing national data, quantifying their independent effects on overall health. Given the ongoing availability of these data and the shortcomings of traditional utility methods, it would be valuable to compare existing HRQOL measures to other methods, such as the one presented herein, for use in tracking population health over time.

US Trends in Quality-Adjusted Life Expectancy From 1987 to 2008: Combining National Surveys to More Broadly Track the Health of the Nation

OBJECTIVES We used data from multiple national health surveys to systematically track the health of the US adult population. METHODS We estimated trends in quality-adjusted life expectancy (QALE) from 1987 to 2008 by using national mortality data combined with data on symptoms and impairments from the National Medical Expenditure Survey (1987), National Health Interview Survey (1987, 1994-1995, 1996), Medical Expenditure Panel Survey (1992, 1996, 2000-2008), National Nursing Home Survey (1985, 1995, and 1999), and Medicare Current Beneficiary Survey (1992, 1994-2008). We decomposed QALE into changes in life expectancy, impairments, symptoms, and smoking and body mass index. RESULTS Years of QALE increased overall and for all demographic groups-men, women, Whites, and Blacks-despite being slowed by increases in obesity and a rising prevalence of some symptoms and impairments. Overall QALE gains were large: 2.4 years at age 25 years and 1.7 years at age 65 years. CONCLUSIONS Understanding and consistently tracking the drivers of QALE change is central to informed policymaking. Harmonizing data from multiple national surveys is an important step in building this infrastructure.

Comparison of trends in US health-related quality of life over the 2000s using the SF-6D, HALex, EQ-5D, and EQ-5D visual analog scale versus a broader set of symptoms and impairments

Background:A number of instruments have been developed to measure health-related quality of life (HRQoL), differing in the health domains covered and their scoring. Although few such measures have been consistently included in US national health surveys over time, the surveys have included data on a broad range of symptoms and impairments, which enables the tracking of population health trends. Objectives:To compare trends in HRQoL as measured using existing instruments versus using a broader range of symptoms and impairments collected in multiple years of nationally representative data. Data and Measures:Data were from the 2000–2010 Medical Expenditure Panel Survey, which is nationally representative of the noninstitutionalized US population. Level of and trends in HRQoL derived from a broad range of survey symptoms and impairments (SSI) was compared with HRQoL from the SF-6D, the HALex, and, between 2000 and 2003, the EuroQol-5D (EQ-5D) and EQ-5D Visual Analog Scale. Results:Trends in HRQoL were similar using different measures. The SSI scores correlated 0.66–0.80 with scores from other measures and mean SSI scores were between those of other measures. Scores from all HRQoL measures declined similarly with increasing age and with the presence of comorbid conditions. Conclusions:Measuring HRQoL using a broader range of symptoms and impairments than those in a single instrument yields population health trends similar to those from other measures while making maximum use of existing data and providing rich detail on the factors underlying change.