[Show abstract][Hide abstract] ABSTRACT: Background
Over the last decade, multiple chemotherapies/targeted biologics have been approved for metastatic colorectal cancer (mCRC). However, evidence is limited with regards to the array of treatments received by mCRC patients.
This study examines treatment sequences (first- to third-line chemotherapy/targeted biologics) and the factors associated with first-line targeted biologics and common treatment sequences for elderly mCRC patients treated in a community setting.
A retrospective cohort study was conducted in mCRC patients diagnosed from January 2004 through December 2009 using the Surveillance, Epidemiology and End Results Medicare-linked database. The treatment sequences administered to elderly mCRC patients were empirically identified.
Of 4418 mCRC patients who received treatment, 1370 (31 %) received first, second, and third line; 1164 (26 %) received first and second line; and 1884 (43 %) received only first line. The most common first line of treatment for mCRC patients was 5-fluorouracil/leucovorin + oxaliplatin (FOLFOX) + bevacizumab (23 %) and FOLFOX (23 %). 5-fluorouracil/leucovorin + irinotecan (FOLFIRI)-based regimens were commonly (22 %) administered in second line. The most common treatment sequence was first-line oxaliplatin or irinotecan followed by second-line oxaliplatin or irinotecan + bevacizumab followed by a third-line targeted biologic. Of patients who received first-line therapy, 47 % also received a targeted biologic, and the factors associated were age, comorbidity score, cancer site, geographic location, and year of diagnosis.
Elderly mCRC patients receive a multitude of treatments in various sequences. Further exploration of the comparative effectiveness of treatment sequences may yield important information for improving mCRC survival.
Full-text · Article · Jan 2016 · Drugs - Real World Outcomes
[Show abstract][Hide abstract] ABSTRACT: To examine the impact of health insurance status on tumor stage at diagnosis, treatment rendered, and overall survival, we identified 52,566 breast cancer patients and 34,316 colorectal cancer patients aged 20 or older in 2007-2010 from Texas Cancer Registry. Those aged younger than 65 years without health insurance coverage had significantly higher risks of mortality than those with private health insurance regardless of tumor stage, chemotherapy, or surgery for colorectal cancer. However, in patients younger than 65 years with breast cancer, the risk of mortality was not significantly higher for those who received chemotherapy or cancer-directed surgery in patients without insurance coverage compared with those with private health insurance. In Medicare beneficiaries aged 65 years or older, risk of mortality was not significantly different between those with Medicare only and those with additional private health insurance, except an increased mortality in patients without chemotherapy for breast and colorectal cancer and in those without receiving surgery for colorectal cancer.
No preview · Article · Nov 2015 · Journal of Health Care for the Poor and Underserved
[Show abstract][Hide abstract] ABSTRACT: Objective:
To determine the effectiveness of erythropoietin-stimulating agent (ESA) and granulocyte colony-stimulating factor (CSF) in reducing blood transfusion needs and neutropenia incidence in community-dwelling elderly ovarian cancer patients.
The SEER (Surveillance Epidemiology and End Results)-Medicare database was used to identify 5572 women with stage III/IV ovarian cancer who received chemotherapy. To assess clinical effectiveness, we categorized patients based on the number of administrations of ESA (ie, epoetin-alfa and darbepoetin-alfa) and CSF (ie, filgrastim and pegfilgrastim). To evaluate effect on survival, patients were categorized as receiving ESA only, CSF only, ESA + CSF, and no ESA/CSF.
Two thirds of patients received growth factor support (24% ESA only, 13% CSF only, 30% ESA + CSF). Depending on the number of epoetin-alfa administrations, ESA was associated with 48% to 56% lower need for blood transfusion compared with no ESA (hazard ratio for 1-3 claims, 0.47; 4-6 claims, 0.52; 7-10 claims, 0.48; ≥11 claims, 0.44). Patients who received at least 3 prophylactic filgrastim administrations had 71% to 98% lower risk of developing neutropenia (hazard ratio for 3-4 claims, 0.29; ≥5 claims, 0.02) compared with those without CSF. Effectiveness was comparable for darbepoetin-alfa and pegfilgrastim use. Overall survival was longer in those who received CSF only; however, the risk of mortality after 24 months was higher in those who received ESA (P = 0.0005). All models were adjusted for relevant covariates.
Erythropoietin-stimulating agents were effective in reducing blood transfusion need. Granulocyte colony-stimulating factors were effective in lowering neutropenia incidence and also were associated with improved survival in elderly ovarian cancer patients. Findings are consistent with clinical trials and clinical guidelines.
No preview · Article · Oct 2015 · International Journal of Gynecological Cancer
[Show abstract][Hide abstract] ABSTRACT: Objectives:
To examine racial/ethnic and geographical disparities in cancer care and costs during the last 6 months of life for lung cancer decedents after the Food and Drug Administration's approval of expensive bevacizumab in October 2006.
We identified 37,393 cases from the Surveillance, Epidemiology and End Results (SEER) cancer registries and Medicare linked databases who were diagnosed with non-small cell lung cancer of all stages in 1991-2009 and died between July 2007 and December 2010.
Overall, the proportion of patients receiving chemotherapy/targeted therapy (31.0%), bevacizumab (4.6%), growth factors (16.0%), surgery (2.8%), and hospice care (60.9) in the last 6 months of life was higher in whites than in other ethnic populations. Hospitalization rate was higher in blacks (83.2%) than in whites (76.0%) and others (78.0%). Those from metro areas had slightly higher percentages of receiving chemotherapy/targeted therapy, bevacizumab, growth factors, and hospice care, but had a higher hospitalization rate and lower emergency care visit. Mean total health care cost was $42,749 for the last 6 months of life in patients with lung cancer. Adjusted mean health care cost in the last 6 months of life was significantly higher in blacks or other ethnic population as compared to whites.
There were substantial racial/ethnic and geographic disparities in the types of cancer care and costs in the last 6 months of life among lung cancer decedents, regardless of the length of survival times and hospice care status. A clinical guideline may help the appropriate use of costly treatment modalities and minimize racial/geographic disparities.
No preview · Article · Oct 2015 · Lung cancer (Amsterdam, Netherlands)
[Show abstract][Hide abstract] ABSTRACT: Background Previous economic evaluations compared specific chemotherapy agents using input parameters from clinical trials and resource utilization costs. Cost-effectiveness of treatment groups (drug classes) using community-level effectiveness and cost data, however, has not been assessed for elderly patients with breast cancer. Objective To assess the cost-effectiveness of chemotherapy regimens by age and disease stage under "real-world" conditions for patients with breast cancer. Methods The Surveillance Epidemiology and End Results-Medicare data were used to identify patients with breast cancer with American Joint Committee on Cancer stage I/II/IIIa, hormone receptor-negative (estrogen receptor-negative and progesterone receptor-negative) patients from 1992 to 2009. Patients were categorized into three adjuvant treatment groups: 1) no chemotherapy, 2) anthracycline, and 3) non-anthracycline-based chemotherapy. Median life-years and quality-adjusted life-years (QALYs) were measured using Kaplan-Meier analysis and were evaluated against average total health care costs (2013 US dollars). Results A total of 4575 patients (propensity score-matched) were included for the primary analysis. The anthracycline group experienced 12.05 QALYs and mean total health care costs of $119,055, resulting in an incremental cost-effectiveness ratio of $7,688 per QALY gained as compared with the no chemotherapy group (QALYs 7.81; average health care cost $86,383). The non-anthracycline-based group was dominated by the anthracycline group with lower QALYs (9.56) and higher health care costs ($122,791). Base-case results were found to be consistent with the best-case and worst-case scenarios for utility assignments. Incremental cost-effectiveness ratios varied by age group (range $3,790-$90,405 per QALY gained). Conclusions Anthracycline-based chemotherapy was found cost-effective for elderly patients with early stage (stage I, II, IIIa) breast cancer considering the US threshold of $100,000 per QALY. Further research may be needed to characterize differential effects across age groups.
[Show abstract][Hide abstract] ABSTRACT: Adjuvant chemotherapy is a key component of advanced ovarian cancer treatment, when surgery alone is not sufficient. Recurrence is common in ovarian cancer patients and most women require prolonged second-line and higher-line chemotherapy. With newer targeted therapies, modest improvements in survival and quality of life may be attained at substantial cost, but the relative economic efficiency of these newer agents remains unknown.
We undertook this systematic review to comprehensively evaluate the cost-effectiveness of various chemotherapeutic and targeted therapy alternatives for ovarian cancer.
We searched Medline, PubMed, and Embase databases to identify economic evaluations published over the last 18 years (1996-2014). From the 2513 unique papers retrieved, 74 full texts were selected for full-text review based on a priori eligibility criteria. Two authors independently reviewed these articles to determine eligibility for final review. The quality of the included studies was assessed using the Quality of Health Economic Studies (QHES).
A total of 28 studies were included for reporting. Administration of intravenous cisplatin-paclitaxel combination chemotherapy for first-line treatment was the most cost-effective alternative (2014 US dollars [USD] equivalent incremental cost-effectiveness ratio [ICER] ~US$17,000-US$27,000 per life year gained [LYG]), while the use of bevacizumab did not demonstrate similar value for money (2014 USD equivalent ICER was greater than US$200,000 per quality-adjusted life-year [QALY]). For second-line treatment, the use of platinum-paclitaxel combination or platinum monotherapy was cost-effective compared with platinum monotherapy or best supportive care, respectively, in women with recurrent platinum-sensitive disease. For patients with partial platinum sensitivity, pegylated liposomal doxorubicin (PLD) plus trabectedin may be cost-effective (2014 USD equivalent ICER was ~US$57,000-US$62,000 per QALY) compared with PLD alone. For recurrent platinum-resistant cases, there was limited evidence to conclude the most valuable treatment; though one study showed that best supportive care was most cost-effective, while second-line monotherapy with doxorubicin (2014 USD equivalent ICER was ~US$90,000 per LYG) may also be cost-effective compared with best supportive care.
Despite varying methodological approaches and multiple sources for cost and effectiveness inputs, this systematic review demonstrated that standard platinum-taxane combination chemotherapy for first-line treatment was most cost-effective. There was unanimous agreement that bevacizumab was not a cost-effective front-line therapy compared with platinum-taxane combination for the overall ovarian cancer population, though its use in the high-use population may yield better value. For second-line treatment, platinum-based chemotherapy remained cost-effective among patients with recurrent platinum-sensitive disease, while there was limited evidence to conclude the most valuable treatment alternative among patients with recurrent platinum-resistant disease. Future research incorporating real-world data is essential to corroborate findings from trial-based economic evaluations. In addition, for improving consistency in reporting and quality of studies, incorporating QALYs in this population is important, especially since chemotherapy is administered for lengthy periods of time.
No preview · Article · Jun 2015 · PharmacoEconomics
[Show abstract][Hide abstract] ABSTRACT: No study has previously reported the utilization and adherence to hormone therapy for Medicare Part-D beneficiaries with breast cancer. This study was conducted using the Surveillance, Epidemiology, and End Results-Medicare-linked data to assess socio-demographic, geographic, and other variations in the receipt of hormone therapy among patients with hormone receptor-positive breast cancer and to assess adherence to hormone therapy within 1-year follow-up. The percentage of patients who received hormone therapy was calculated and stratified by chemotherapy status (yes or no). Logistic regression models were performed to assess the variations associated with the use of selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), and hormone therapy (SERMs or AIs). Of 25,128 women with hormone receptor-positive breast cancer in 2006-2009 who were enrolled in Medicare Part-D program, 70.8 % received hormone therapy, 22.2 % received SERM, and 56.9 % received AIs. Among those receiving chemotherapy, significant predictors of receiving hormone therapy included age, tumor stage, surgery type, radiation therapy; significant predictors of receiving SERM included race, year of diagnosis, and tumor stage; and significant predictors of receiving AI included age, race, socioeconomic status, geographic location, tumor stage, and radiation therapy. For those without receiving chemotherapy, most of the above factors were significant, but differed across each drug class. In conclusion, over two-thirds of hormone receptor-positive breast cancer patients received hormone therapy, and still 29.2 % of patients did not receive it. Tumor and clinical factors are the most significant predictors for the receipt of hormone therapy.
No preview · Article · May 2015 · Medical Oncology
[Show abstract][Hide abstract] ABSTRACT: To determine whether the effect of androgen deprivation therapy (ADT) on the risk of biochemical failure varies at different doses of radiation in patients treated with definitive external beam radiation for intermediate risk prostate cancer (IRPC).
This study included 1218 IRPC patients treated with definitive external beam radiation therapy to the prostate and seminal vesicles from June 1987 to January 2009 at our institution. Patient, treatment, and tumor information was collected, including age, race, Gleason score, radiation dose, PSA, T-stage, and months on ADT.
The median follow-up was 6 years. A total of 421(34.6%) patients received ADT, 211 (17.3%) patients experienced a biochemical failure, and 38 (3.1%) developed distant metastasis. On univariable analyses, higher PSA, earlier year of diagnosis, higher T-stage, lower doses of radiation, and the lack of ADT were associated with an increased risk of biochemical failure. No difference in biochemical failure was seen among different racial groups or with the use of greater than 6 months of ADT compared with less than 6 months. On multivariate analysis, the use of ADT was associated with a lower risk of biochemical failure than no ADT (HR, 0.599; 95% CI, 0.367-0.978; P < 0.04) and lower risk of distant metastasis (HR, 0.114; 95% CI, 0.014-0.905; P = 0.04).
ADT reduced the risk of biochemical failure and distant metastasis in both low- and high dose radiation groups among men with intermediate-risk PCa. Increasing the duration of ADT beyond 6 months did not reduce the risk of biochemical failures. Better understanding the benefit of ADT in the era of dose escalation will require a randomized clinical trial.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to use the most recent national data for a large cohort of patients diagnosed with breast cancer to evaluate temporal trend of receiving hematopoietic growth factors from 2000 to 2009 and to examine significant factors associated with increasing trends and geographic variations. We identified 26,130 women aged 65-89 years who were diagnosed with breast cancer and received chemotherapy in 2000-2009 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Colony-stimulating factors (CSFs) were identified if there was a claim from the following procedure codes: filgrastim, pegfilgrastim, or sargramostim. Erythropoiesis-stimulating agents (ESAs) were identified if there was a claim from the following procedure codes: epoetin or darbepoetin. Overall, 51.7% of patients with breast cancer received CSFs, which increased from 21.7% in 2000 to 63.2% in 2009. The percentage of patients receiving pegfilgrastim increased from 2.7% in 2000 to 19.5% in 2003 and then continuously to 49.7% in 2009. The overall percentage of patients receiving ESAs was 39.3%, which increased from 26.4% in 2000 to 60.8% in 2006, and then decreased significantly from 40.7% in 2007 to 12.9% in 2009. The receipt of both CSFs and ESAs differed significantly across different geographic areas. The receipt of CSFs continued to increase from 2000 to 2009, and pegfilgrastim started to replace filgrastim since 2003. The receipt of ESAs increased until 2006 and then declined substantially due to the black box warning. There were substantial geographic variations in the use of these hematopoietic growth factors. Copyright
No preview · Article · Mar 2015 · American Journal of Therapeutics
[Show abstract][Hide abstract] ABSTRACT: Few studies have examined the cancer incidence trends in the state of Texas, and no study has ever been conducted to compare the temporal trends of breast and colorectal cancer incidence in Texas with those of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) in the United States. This study aimed to conduct a parallel comparison between the Texas Cancer Registry and the National Cancer Institute's SEER on cancer incidence from 1995 to 2011. A total of 951,899 breast and colorectal cancer patients were included. Age-adjusted breast cancer incidence was 134.74 per 100,000 in Texas and 131.78 per 100,000 in SEER in 1995-2011, whereas age-adjusted colorectal cancer incidence was 50.52 per 100,000 in Texas and 49.44 per 100,000 in SEER. Breast cancer incidence increased from 1995 to 2001, decreased from 2002 to 2006, and then remained relatively stable from 2007 to 2011. For colorectal cancer, the incidence increased in 1995‑1997, and then decreased continuously from 1998 to 2011 in Texas and SEER areas. Incidence rates and relative risks by age, gender and ethnicity were identical between Texas and SEER.
Full-text · Article · Feb 2015 · International Journal of Oncology
[Show abstract][Hide abstract] ABSTRACT: Purposes:
To estimate what proportion of improvement in relative survival was attributable to smaller stage/size due to early detection and what proportion was attributable to cancer chemotherapy in patients with colorectal cancer (CRC).
We studied 69,718 patients with CRC aged ≥ 66 years in 1992-2009 from Surveillance, Epidemiology, and End Results registries. Study periods were categorized into three periods according to the major changes or advances in screening and chemotherapy regimens: (1) Period-1 (1992-1995), during which there was no evidence-based recommendation for routine CRC screening and 5-fluorouracil was the mainstay for chemotherapy; (2) Period-2 (1996-2000), during which evidences and guidelines supported the use of fecal occult blood test (FOBT) and sigmoidoscopy for routine CRC screening; and (3) Period-3 (2001-2009), during which Medicare Program added the full coverage for colonoscopy screening to average-risk individuals, and several newly developed chemotherapy regimens were approved. Outcome variables included the likelihood of being diagnosed at an early stage or with a small tumor size, and improvement in relative survival.
Compared to period-1, likelihood of being diagnosed with early stage CRC increased by 20% in period-2 (odds ratio = 1.2, 95%CI: 1.1-1.2) and 30% in period-3 (1.3, 1.2-1.4); and likelihood of being diagnosed with small-size CRC increased by 60% in period-2 and 110% in period-3. Similarly, 5-year overall relative survival increased from 51% in period-1 to 56% in period-2 and 60% in period-3. Increase in survival attributable to migration in stage/size was 9% in period-2 and 20% in period-3, while the remaining survival improvement during period-2 and period-3 were largely attributable to more effective chemotherapy regimens (≥ 71.6%) and other treatment factors (≤ 25%).
Improvements in CRC screening resulted in a migration of CRC toward earlier tumor stage and smaller size, which contributed to ≤ 20% of survival increase. Survival improvement over the past 2 decades was largely explained by more effective chemotherapy regimens (≥ 71.6%).
No preview · Article · Nov 2014 · Cancer Epidemiology
[Show abstract][Hide abstract] ABSTRACT: Background
Previous studies found that the risk of breast cancer–related death is greater in estrogen receptor (ER)-negative disease than in ER-positive disease within 5 years of diagnosis, but greater for ER-positive disease than for ER-negative disease more than 5 years after diagnosis. This phenomenon is referred to as ER-positive and -negative crossover. Our aim was to evaluate this crossover by determining the timing of the hazard of breast cancer death by patient, clinical, and tumor factors.
Patients with breast cancer diagnosed between 1990 and 2005 were identified from the Surveillance, Epidemiology, and End Results database. The cohort was evaluated by age at diagnosis, race, tumor ER status, tumor and nodal stage, and tumor grade. Disease-specific (DS) hazard rates were calculated.
Of the 439,444 patients identified, 77.5% had ER-positive disease. Overall, ER-negative to ER-positive DS hazard rates crossed between the years 7 and 8 after diagnosis. Earlier crossover was linked to black or Hispanic race, young age (<40 years), or tumors that were larger, higher grade, or affected the nodes. Young black (<40 years) patients who had a T3/T4 tumor with positive nodes, grade III or undifferentiated, had the earliest crossover, in year 4.
The timing of crossover of death hazard for ER-positive and ER-negative disease varies by clinical and tumor factors. These findings may help guide recommendations regarding the duration of endocrine therapy for patients with ER-positive cancer.
[Show abstract][Hide abstract] ABSTRACT: Background: Childhood cancer relies heavily on inpatient hospital services to deliver tumor-directed therapy and manage toxicities. Hospitalizations have increased over the past decade, though not uniformly across childhood cancer diagnoses. Analysis of the reasons for admission of children with cancer could enhance comparison of resource use between cancers, and allow clinical practice data to be interpreted more readily. Such comparisons using nationwide data sources are difficult because of numerous subdivisions in the International Classification of Diseases Clinical Modification (ICD-9) system and inherent complexities of treatments. This study aimed to develop a systematic approach to classifying cancer-related admissions in administrative data into categories that reflected clinical practice and predicted resource use.
Full-text · Article · Oct 2014 · BMC Medical Informatics and Decision Making
[Show abstract][Hide abstract] ABSTRACT: None of previous studies has provided the detailed pattern, variation, and temporal trend in the use of growth factors for patients with colorectal cancer. The aim of the study was to examine the temporal trend and predictors of receiving hematopoietic growth factors in a large nationwide and population-based cohort of patients with colorectal cancer in the USA from 1992 to 2009. We studied 50,768 patients diagnosed with colorectal cancer at age 65-89 years in 1992-2009 in the Surveillance, Epidemiology and End Results areas who received chemotherapy as part of initial therapy within 12 months of diagnosis according to Medicare data. Growth factors were identified for colony-stimulating factors (CSFs) and for erythropoiesis-stimulating agents (ESAs). Overall, 16.3 % received CSFs and 26.5 % received ESAs with an increase from 0.8 and 1.5 % in 1992 to 29.4 and 14.1 % in 2009, respectively. Compared with patients diagnosed in 1992-1994, those diagnosed in 1995-1997 were >2 times more likely to receive CSFs and ESAs, whereas patients diagnosed recently in 2007-2009 were >22 times and 4 times to receive CSFs and ESAs, respectively. Gender, marital status, comorbidity scores, geographic area, year of diagnosis, tumor stage, number of lymph nodes, and risk profile for febrile neutropenia were statistically significant predictors of using CSFs and ESAs. There were substantial temporal and geographic variations in the use of hematopoietic growth factors in patients with colorectal cancer following chemotherapy. More studies would be needed to explore the effectiveness of hematopoietic growth factors in preventing and treating neutropenia, anemia, and infection.
No preview · Article · Oct 2014 · Medical Oncology
[Show abstract][Hide abstract] ABSTRACT: Previous results from research on menopausal hormone therapy (MHT) and lung cancer survival have been mixed and most have not studied women who used estrogen therapy (ET) exclusively. We examined the associations between MHT use reported at baseline and lung cancer-specific mortality in the prospective California Teachers Study cohort. Among 727 postmenopausal women diagnosed with lung cancer from 1995 through 2007, 441 women died before January 1, 2008. Hazard Ratios (HR) and 95% Confidence Intervals (CI) for lung-cancer-specific mortality were obtained by fitting multivariable Cox proportional hazards regression models using age in days as the timescale. Among women who used ET exclusively, decreases in lung cancer mortality were observed (HR, 0.69; 95% CI, 0.52-0.93). No association was observed for estrogen plus progestin therapy use. Among former users, shorter duration (<5 years) of exclusive ET use was associated with a decreased risk of lung cancer mortality (HR, 0.56; 95% CI, 0.35-0.89), whereas among recent users, longer duration (>15 years) was associated with a decreased risk (HR, 0.60; 95% CI, 0.38-0.95). Smoking status modified the associations with deceases in lung cancer mortality observed only among current smokers. Exclusive ET use was associated with decreased lung cancer mortality.