Reassessing the value of high‐volume cancer care in the era of precision medicine

The ethical and economic discussions regarding the extreme costs of many new cancer therapies are familiar. The authors have long held that changes in cancer care delivery also are an important strategy, yielding large benefits at potentially far lower costs. To put this into context, the authors performed an analysis to compare the overall survival of patients receiving a complex oncologic surgery, radical cystectomy, at high‐volume and low‐volume centers. Propensity score weighting was performed to simulate random allocation into high‐volume versus low‐volume centers, as would be the case in a prospective trial. On average, patients undergoing surgery at high‐volume centers survived 15 months longer than those treated at low‐volume centers (57.0 months vs 41.8 months). Although there certainly are caveats in contrasting the survival benefit of different care settings with anticancer agents, this differential clearly rivals or exceeds the benefit of many expensive, recently approved agents. As the debate regarding the costs of cancer therapies continues, it is worth remembering that investments in simple systems‐based changes to improve cancer care delivery remain an important and likely cost‐effective strategy with which to improve the survival of patients with cancer. Cancer 2018;124:1319‐21 . © 2018 American Cancer Society.     

Patient navigation for breast and colorectal cancer in 3 community hospital settings: An economic evaluation

BACKGROUND:

The Ralph Lauren Cancer Center implemented patient navigation programs in sites across the United States building on the model pioneered by Harold P. Freeman, MD. Patient navigation targets medically underserved with the objective of reducing the time interval between an abnormal cancer finding, diagnostic resolution, and treatment initiation. In this study, the authors assessed the incremental cost effectiveness of adding patient navigation to standard cancer care in 3 community hospitals in the United States.

METHODS:

A decision‐analytic model was used to assess the cost effectiveness of a colorectal and breast cancer patient navigation program over the period of 1 year compared with standard care. Data sources included published estimates in the literature and primary costs, aggregate patient demographics, and outcome data from 3 patient navigation programs.

RESULTS:

After 1 year, compared with standard care alone, it was estimated that offering patient navigation with standard care would allow an additional 78 of 959 individuals with an abnormal breast cancer screening and an additional 21 of 411 individuals with abnormal colonoscopies to reach timely diagnostic resolution. Without including medical treatment costs saved, the cost‐effectiveness ratio ranged from $511 to $2080 per breast cancer diagnostic resolution achieved and from $1192 to $9708 per colorectal cancer diagnostic resolution achieved.

CONCLUSIONS:

The current results indicated that implementing breast or colorectal cancer patient navigation in community hospital settings in which low‐income populations are served may be a cost‐effective addition to standard cancer care in the United States. Cancer 2012. © 2012 American Cancer Society.     

Description and predictors of hospital costs of oesophageal cancer during the first year following diagnosis in Northern Ireland

The cost‐effectiveness of novel interventions in the treatment of cancer is well researched; however, relatively little attention is paid to the cost of many aspects of routine care. Oesophageal cancer is the ninth most common cancer in the UK and sixth most common cause of cancer death. It usually presents late and has a poor prognosis. The hospital costs incurred by oesophageal cancer patients diagnosed in Northern Ireland in 2005 (n = 198) were determined by review of medical records. The average cost of hospital care per patient in the 12 months from presentation was £7847. Variations in total hospital costs by age at diagnosis, gender, cancer stage, histological type, mortality at 1 year, co‐morbidity count and socio‐economic status were analysed using multiple regression analyses. Higher costs were associated with earlier stages of cancer and cancer stage remained a significant predictor of costs after controlling for cancer type, patient age and mortality at 1 year. Thus, although early detection of cancer usually improves survival, this would mean increased costs in the first year. Deprivation achieved borderline significance with those from more deprived areas having lower resource consumption relative to the more affluent.     

Alternative payment and care‐delivery models in oncology: A systematic review

Rising US health care costs have led to the creation of alternative payment and care‐delivery models designed to maximize outcomes and/or minimize costs through changes in reimbursement and care delivery. The impact of these interventions in cancer care is unclear. This review was undertaken to describe the landscape of new alternative payment and care‐delivery models in cancer care. In this systematic review, 22 alternative payment and/or care‐delivery models in cancer care were identified. These included 6 bundled payments, 4 accountable care organizations, 9 patient‐centered medical homes, and 3 other interventions. Only 12 interventions reported outcomes; the majority (n = 7; 58%) improved value, 4 had no impact, and 1 reduced value, but only initially. Heterogeneity of outcomes precluded a meta‐analysis. Despite the growth in alternative payment and delivery models in cancer, there is limited evidence to evaluate their efficacy. Cancer 2018. © 2018 American Cancer Society.     

Clinical practice patterns and cost effectiveness of human epidermal growth receptor 2 testing strategies in breast cancer patients

BACKGROUND:

Testing technologies are increasingly used to target cancer therapies. Human epidermal growth factor receptor 2 (HER2) testing to target trastuzumab for patients with breast cancer provides insights into the evidence needed for emerging testing technologies.

METHODS:

The authors reviewed literature on HER2 test utilization and cost effectiveness of HER2 testing for patients with breast cancer. They examined available evidence on: percentage of eligible patients tested for HER2; test methods used; concordance of test results between community and central/reference laboratories; use of trastuzumab by HER2 test result; and cost effectiveness of testing strategies.

RESULTS:

Little evidence was available to determine whether all eligible patients are tested, how many are retested to confirm results, and how many with negative HER2 test results still receive trastuzumab. Studies suggested that up to 66% of eligible patients had no documentation of testing in claims records, up to 20% of patients receiving trastuzumab were not tested or had no documentation of a positive test, and 20% of HER2 results may be incorrect. Few cost‐effectiveness analyses of trastuzumab explicitly considered the economic implications of various testing strategies.

CONCLUSIONS:

There was little information about the actual use of HER2 testing in clinical practice, but evidence suggested important variations in testing practices and key gaps in knowledge exist. Given the increasing use of targeted therapies, it is critical to build an evidence base that supports informed decision making on emerging testing technologies in cancer care. Cancer 2009. © 2009 American Cancer Society.     

Cancer pain management and the opioid crisis in America: How to preserve hard‐earned gains in improving the quality of cancer pain management

Cancer pain remains a feared consequence of the disease and its treatment. Although prevalent, cancer pain can usually be managed through the skillful application of pharmacologic and nonpharmacologic interventions. Unfortunately, access to these therapies has been hampered by interventions designed to contain another serious public health problem: the opioid misuse epidemic. This epidemic and the unintended consequences of efforts to control this outbreak are leading to significant barriers to the provision of cancer pain relief. Oncologists and other professionals treating those with cancer pain will require new knowledge and tools to provide safe and effective pain control while preventing additional cases of substance use disorders (SUDs), helping patients in recovery to maintain sobriety, and guiding those not yet in recovery to seek treatment. How do these 2 serious epidemics intersect and affect oncology practice? First, oncology professionals will need to adopt practices to prevent SUDs by assessing risk and providing safe pain care. Second, oncology practices are likely to see an increased number of patients with a current or past SUD, including opioid misuse. Few guidelines exist for the direct management of pain when opioids may be indicated in these individuals. Third, modified prescribing practices along with the education of patients and families are warranted to prevent the exposure of these medications to unintended persons. Finally, advocacy on behalf of those with cancer pain is imperative to avoid losing access to essential therapies, including opioids, for those who might benefit. Cancer 2018;124:2491‐7 . © 2018 American Cancer Society.     

PARP inhibitors in breast cancer: Bringing synthetic lethality to the bedside

Individuals with breast and ovarian cancer susceptibility gene 1 (BRCA1) or BRCA2 germline mutations have a significantly increased lifetime risk for breast and ovarian cancers. BRCA‐mutant cancer cells have abnormal homologous recombination (HR) repair of DNA. In these tumors, the base excision repair (BER) pathway is important for cell survival. The poly(adenosine diphosphate‐ribose) polymerase (PARP) enzymes play a key role in BER, and PARP inhibitors are effective in causing cell death in BRCA‐mutant cells while sparing normal cells—a concept called synthetic lethality. PARP inhibitors are the first cancer therapeutics designed to exploit synthetic lethality. Recent clinical trials in BRCA‐mutant, metastatic breast cancer demonstrated improved outcomes with single‐agent PARP inhibitors (olaparib and talazoparib) over chemotherapy. However, resistance to PARP inhibitors remains a challenge. Primarily due to myelosuppression, the combination of PARP inhibitors with chemotherapy has been difficult. Novel combinations with chemotherapy, immunotherapy, and other targeted therapies are being pursued. In this review, the authors discuss current knowledge of PARP inhibitors in BRCA‐mutant breast cancer and potential future directions for these agents. Cancer 2018;124:2498‐506 . © 2018 American Cancer Society.     

Costs and trends in pancreatic cancer treatment

BACKGROUND:

Pancreatic cancer poses a substantial morbidity and mortality burden in the United States, and predominantly affects older adults. The objective of this study was to estimate the direct medical costs of pancreatic cancer treatment in a population‐based cohort of Medicare beneficiaries, and the contribution of different treatment modalities and health care services to the total cost of care and trends in costs over time.

METHODS:

In the linked Surveillance, Epidemiology, and End Results (SEER)‐Medicare database, pancreatic cancer patients were identified who were aged 66 years or older and who were diagnosed from 2000 to 2007. Total direct medical costs were estimated from Medicare payments overall and within categories of care. Costs attributable to pancreatic cancer were estimated by subtracting the costs of medical care in a matched cohort of cancer‐free beneficiaries.

RESULTS:

A total of 15,037 patients were identified, of whom 97% were observed from diagnosis until death. Mean total direct medical costs were $65,500. Mean total costs were greater for patients with resectable locoregional disease ($134,700) than for those with unresectable locoregional or distant disease ($65,300 and $49,000, respectively). Hospitalizations and cancer‐directed procedures collectively accounted for the largest fraction of health care costs. The total cost of care appeared to increase slightly over the study period (P = .05). The mean costs attributable to pancreatic cancer were $61,700.

CONCLUSIONS:

Despite poor prognosis and short survival, the economic burden of pancreatic cancer in the elderly is substantial. Demographic trends, greater use of targeted therapies, and possible implementation of screening strategies are likely to impact treatment patterns and costs in the future. Cancer 2012. © 2012 American Cancer Society.     

Prehabilitation for medically frail patients undergoing surgery for epithelial ovarian cancer: a cost-effectiveness analysis

ObjectiveTo assess the potential cost-effectiveness of prehabilitation in medically frail patients undergoing surgery for epithelial ovarian cancer (EOC).MethodsWe created a cost-effectiveness model evaluating the impact of prehabilitation on a cohort of medically frail women undergoing primary surgical intervention for EOC. Cost was assessed from the healthcare system perspective via (1) inpatient charges from 2018–2019 institutional Diagnostic Related Grouping data for surgeries with and without major complications; (2) nursing facility costs from published market surveys. Major complication and non-home discharge rates were estimated from the literature. Based on published pilot studies, prehabilitation was determined to decrease these rates. Incremental cost-effectiveness ratio for cost per life year saved utilized a willingness-to-pay threshold of $100,000/life year. Modeling was performed with TreeAge software.ResultsIn a cohort of 4,415 women, prehabilitation would cost $371.1 Million (M) versus $404.9 M for usual care, a cost saving of $33.8 M/year. Cost of care per patient with prehabilitation was $84,053; usual care was $91,713. When analyzed for cost-effectiveness, usual care was dominated by prehabilitation, indicating prehabilitation was associated with both increased effectiveness and decreased cost compared with usual care. Sensitivity analysis showed prehabilitation was more cost effective up to a cost of intervention of $9,418/patient.ConclusionPrehabilitation appears to be a cost-saving method to decrease healthcare system costs via two improved outcomes: lower complication rates and decreased care facility requirements. It represents a novel strategy to optimize healthcare efficiency. Prospective studies should be performed to better characterize these interventions in medically frail patients with EOC.     

Health care costs of depression in patients diagnosed with cancer

Objective

Depression is common among patients diagnosed with cancer. Patients with cancer and depression use more health care services compared with nondepressed cancer patients. The current study seeks to estimate the added cost of depression in cancer patients in the first year after cancer diagnosis.

Methods

Health care charges were obtained for 2051 depressed and 11 182 nondepressed patients with an International Classification of Diseases, Ninth Revision, diagnosis of cancer in the 2014 calendar year from the University of California San Diego Healthcare System. The annual health care charges for cancer patients with and without depression were analyzed using generalized linear models with a log‐link function and gamma distribution, covarying for age, sex, race/ethnicity, comorbid diseases, and presence of metastatic disease. Total cost data were broken down into several categories including ambulatory care, emergency department visits, and hospital visits.

Results

Depressed cancer patients had total annual health care charges that were 113% higher than nondepressed cancer patients (B = 0.76; P < .001). The estimated mean charges for depressed patients were $235 337 compared with $110 650 for nondepressed patients. Depressed cancer patients incurred greater charges than nondepressed patients in ambulatory care (B = 0.70; P < .001), emergency department charges (B = 0.31; P < .001), and hospital charges (B = 0.39; P < .001).

Conclusions

Depressed cancer patients incur significantly higher health care charges across multiple cost categories including ambulatory care, emergency department visits, and hospital visits. Future research should investigate if interventions for detecting and treating depression are effective for reducing health care use and costs in cancer patients.

     

Prophylactic bilateral salpingo-oophorectomy (PBSO) with or without prophylactic bilateral mastectomy (PBM) or no intervention in BRCA1 mutation carriers: a cost-effectiveness analysis

Women with germline BRCA1 mutation have a significant risk of breast and/or ovarian cancer. Prophylactic bilateral mastectomy (PBM) and prophylactic bilateral salpingo-oophorectomy (PBSO) prevent cancer in mutation carriers.The cost-effectiveness of PBSO (age of 35 years) with or without PBM five years earlier was compared to a no intervention setting employing a marginal cost analysis. National data on cancer incidence, mortality rates and costs were implemented together with observed Norwegian BRCA1 data in a Markov model and PBSO was assumed to reduce the risk of ovarian cancer by 90%. A 3% discount rate was used.The additional health care cost per mutation carrier undergoing PBSO and PBM was €15,784, and 6.4 discounted life years gained (LYG) was indicated (PBSO alone with 100% acceptance 3.1 LYG). The additional cost per LYG was €1973 (PBSO alone €1749/LYG). Including all resource use, the figure was a cost of €496 and €1284 per LYG, respectively.PBSO with or without PBM in BRCA1 mutation carriers is cost-effective. A testing of all incident breast cancers to identify mutation carrying families should be explored.     

Limitations in health care access and utilization among long‐term survivors of adolescent and young adult cancer

BACKGROUND:

Health care outcomes for long‐term survivors of adolescent and young adult (AYA) cancer were compared with young adults without a cancer history, using the 2009 Behavioral Risk Factor Surveillance System data.

METHODS:

Eligible participants were 20 to 39 years of age. There were N = 979 who self‐reported a cancer diagnosis between the ages of 15 to 34 years and were at least 5 years from diagnosis (excluding nonmelanoma skin cancer). The remaining 67,216 participants with no cancer history were used as controls. Using multivariable regressions, relative risks and 95% confidence intervals were generated to examine the relationship of survivor status on indicators of poor health care (uninsured, no personal health care provider, no routine care, and avoiding seeing a doctor due to cost). Adjusted proportions were calculated by demographic groups. Results are weighted by Behavioral Risk Factor Surveillance System survey design.

RESULTS:

Although the proportion uninsured did not differ (21% of survivors vs 23% of controls), AYA survivors reported forgoing care due to cost at higher levels than controls (relative risk = 1.67, 95% CI = 1.44‐1.94). Cost barriers were particularly high for survivors aged 20 to 29 years (44% vs 16% of controls; P < .001) and female survivors (35% vs 18% of controls; P < .001). Survivors reporting poorer health had more cost barriers. Moreover, uninsured survivors tended to report lower use of health care than did controls.

CONCLUSIONS:

AYA cancer survivors may forgo health care due to cost barriers, potentially inhibiting the early detection of late effects. Expanding health insurance coverage for young cancer survivors may be insufficient without adequate strategies to reduce their medical cost burdens. Cancer 2012. © 2012 American Cancer Society.     

Surgery versus stereotactic body radiation therapy for stage I non–small cell lung cancer: A comprehensive review

Non–small cell lung cancer (NSCLC) is the leading cause of cancer‐related death in the United States. With the implementation of lung cancer screening, the number and proportion of patients diagnosed with early‐stage disease are anticipated to increase. Surgery is currently the standard of care for patients with operable stage I NSCLC. However, promising outcomes with stereotactic body radiation therapy (SBRT) in patients with inoperable disease has led to interest in directly comparing SBRT and surgery in operable patients. Unfortunately, early randomized trials comparing surgery and SBRT closed early because of poor accrual. In this article, the nuances of surgery and SBRT for early‐stage NSCLC are reviewed. Furthermore, retrospective and prospective analyses of SBRT in early‐stage NSCLC are discussed, and active randomized trials comparing these 2 approaches are described. Cancer 2018;124:667‐78. © 2017 American Cancer Society.     

Cost-effectiveness of chemoprevention of breast cancer using tamoxifen in a postmenopausal US population

BACKGROUND:

Previous cost‐effectiveness analyses of tamoxifen therapy account for breast cancer risk reduction during active treatment but not for its persistent protective effect after active treatment.

METHODS:

A detailed, continuous time, mathematical model of breast cancer and healthcare processes was used to simulate a postmenopausal population aged <55 years in a virtual trial comparing tamoxifen treatment with no treatment for lifetime follow‐up. Unlike previous work, the current model of tamoxifen therapy is based on a meta‐analysis of 4 randomized, placebo‐controlled chemoprevention trials with breast cancer risk reduction continuing for 10 years after treatment termination. Cancer incidence and survival data were derived from Surveillance, Epidemiology and End Results statistics. Noncancer disease incidences, quality‐adjusted life year (QALY) utility weights, and costs were derived from the literature.

RESULTS:

Tamoxifen treatment (vs no treatment) saved 29 QALYs in a population of 1000 postmenopausal women aged <55 years with an additional cost of $333,000 over the population's lifetime (average cost‐effectiveness ratio, $11,530 per QALY). Tamoxifen therapy, compared with no treatment, was cost saving when higher risk populations were targeted (5‐year risk ≥1.66%). The cost‐effectiveness results were sensitive to parameters that characterized menopausal symptoms and adverse side effects of tamoxifen.

CONCLUSIONS:

The current results indicated that tamoxifen chemoprophylaxis for postmenopausal women aged <55 years is a cost‐effective health policy that reduces breast cancer incidence and improves life expectancy. Focusing on a postmenopausal population aged <55 years minimized the threat of adverse events associated with tamoxifen. Cancer 2011. © 2011 American Cancer Society.     

Optimizing resource allocation for breast cancer prevention and care among Hong Kong Chinese women

BACKGROUND:

Recommendations about funding of interventions through the full spectrum of the disease often have been made in isolation. The authors of this report optimized budgetary allocations by comparing cost‐effectiveness data for different preventive and management strategies throughout the disease course for breast cancer in Hong Kong (HK) Chinese women.

METHODS:

Nesting a state‐transition Markov model within a generalized cost‐effectiveness analytic framework, costs and quality‐adjusted life‐years (QALYs) were compared to estimate average cost‐effectiveness ratios for the following interventions at the population level: biennial mass mammography (ages 40‐69 years or ages 40–79 years), reduced waiting time for postoperative radiotherapy (by 15% or by 25%), adjuvant endocrine therapy (either upfront aromatase inhibitor [AI] therapy or sequentially with tamoxifen followed by AI) in postmenopausal women with estrogen receptor‐positive disease, targeted immunotherapy in those with tumors that over express human epidermal growth factor receptor 2, and enhanced palliative services (either at home or as an inpatient). Usual care for eligible patients in the public sector was the comparator.

RESULTS:

In descending order, the optimal allocation of additional resources for breast cancer would be the following: a 25% reduction in waiting time for postoperative radiotherapy (in US dollars: $5000 per QALY); enhanced, home‐based palliative care ($7105 per QALY); adjuvant, sequential endocrine therapy ($17,963 per QALY); targeted immunotherapy ($62,092 per QALY); and mass mammography screening of women ages 40 to 69 years ($72,576 per QALY).

CONCLUSIONS:

Given the lower disease risk and different age profiles of patients in HK Chinese, among other newly emergent and emerging economies with similar transitioning epidemiologic profiles, the current findings provided direct evidence to support policy decisions that may be dissimilar to current Western practice. Cancer 2012. © 2012 American Cancer Society.     

A community-based approach to cancer counselling for patients and carers: a preliminary study

Objective: The delivery of psychological care services to people with cancer and their carers is a key clinical priority that has yet to be broadly implemented. The present study aimed to provide guidance for service provision by describing a community‐based intervention approach; outlining the characteristics, psychological concerns, and distress outcomes for people who utilise the service. Methods: Over a 3‐year period 681 patients and 520 significant others referred from a community‐based Cancer Helpline received tele‐based psychosocial interventions. Results: In this case series presenting problems varied between patients and significant others, with significant others reporting higher levels of distress (p<0.001). Both patients and significant others experienced decreases in distress over the period of the intervention (p<0.001). Conclusions: This study provides level IV evidence that the tele‐based intervention for cancer‐related distress is an effective approach to service delivery. A randomised control trial is currently underway to assess the effectiveness of this approach. Copyright © 2010 John Wiley & Sons, Ltd.     

National Cancer Institute Patient Navigation Research Program: methods, protocol, and measures

BACKGROUND.

Patient, provider, and systems barriers contribute to delays in cancer care, a lower quality of care, and poorer outcomes in vulnerable populations, including low‐income, underinsured, and racial/ethnic minority populations. Patient navigation is emerging as an intervention to address this problem, but navigation requires a clear definition and a rigorous testing of its effectiveness. Pilot programs have provided some evidence of benefit, but have been limited by evaluation of single‐site interventions and varying definitions of navigation. To overcome these limitations, a 9‐site National Cancer Institute Patient Navigation Research Program (PNRP) was initiated.

METHODS.

The PNRP is charged with designing, implementing, and evaluating a generalizable patient navigation program targeting vulnerable populations. Through a formal committee structure, the PNRP has developed a definition of patient navigation and metrics to assess the process and outcomes of patient navigation in diverse settings, compared with concurrent continuous control groups.

RESULTS.

The PNRP defines patient navigation as support and guidance offered to vulnerable persons with abnormal cancer screening or a cancer diagnosis, with the goal of overcoming barriers to timely, quality care. Primary outcomes of the PNRP are 1) time to diagnostic resolution; 2) time to initiation of cancer treatment; 3) patient satisfaction with care; and 4) cost effectiveness, for breast, cervical, colon/rectum, and/or prostate cancer.

CONCLUSIONS.

The metrics to assess the processes and outcomes of patient navigation have been developed for the NCI‐sponsored PNRP. If the metrics are found to be valid and reliable, they may prove useful to other investigators. Cancer 2008. © 2008 American Cancer Society.     

Dying with cancer, living well with advanced cancer

Introduction. There are 1.7 million deaths from cancer in Europe each year and by 2020 the World Health Organisation (WHO) estimates that, globally, more than 15 million people will experience cancer and 10 million will die from it each year. Furthermore, as new therapies are developed, people are living longer with cancer than in the past, and the population with cancer will be older.Materials and methods. We used epidemiologically based needs assessment approaches to estimate the number of people in Europe with symptoms and problems, published data and reviews to appraise treatment options, issues of communication, family care, bereavement and socio-demographic factors affecting care, and a European survey to consider the types of services. In addition, we used systematic literature review data to appraise the effectiveness of services and factors affecting place of death.Results. The quality of life of virtually all cancer patients with advanced disease is impaired by one or more symptoms, emotional, social, spiritual and communication concerns. Patients have a median of 11 symptoms. In Europe there are up to 1.6 million patients with pain each year, and in around one third of these it will be severe, requiring complex treatment. Almost an equal number are affected by fatigue, and more than 1 in 2 are affected by anxiety and/or depression, breathlessness, insomnia, nausea, constipation and/or anorexia. There is a complex interaction of factors affecting place of death – related to illness, the individual and environment – and although most people want to die at home, in most countries the majority of cancer patients die in hospital. In response to patient and family needs, systematic review shows the effectiveness of palliative care services. However, the distribution of services across Europe is inequitable.Conclusion. Palliative care is becoming increasingly recognised as a vital component of cancer care, but requires investment in research, education and services, incorporating appropriate needs assessment and outcome measurements.     

Efficient assessment of the most important symptoms in advanced prostate cancer: the NCCN/FACT‐P Symptom Index

Background: Owing to the spectrum of symptoms, side effects, and concerns in clinically advanced prostate cancer (PC), effective symptom assessment is imperative. In line with recent regulatory guidance on the development of patient‐reported outcomes, we undertook a multistep/multistudy approach to develop and test a new symptom index (NCCN FACT‐Prostate Symptom Index‐17 that can be used to examine the effectiveness of noncurative treatments in advanced PC. Methods: This included significant input from two waves of expert medical providers (n=66 and 11, respectively) and two waves of patient engagement and testing (n=50 and 24, respectively). The resulting 17‐item symptom index for advanced PC was then divided into sets or categories based on whether the symptoms are predominantly disease or treatment related. Results: Preliminary reliability estimates suggest good internal consistency (α=0.86) and relationships with expected outside validity criteria are moderate to strong. Conclusions: This new tool may help clinicians and researchers quickly target and measure important symptoms and concerns in advanced PC, leading to increased knowledge of treatment effectiveness of noncurative therapies and improvements in the quality of patient care. Copyright © 2010 John Wiley & Sons, Ltd.     

Improving bladder cancer patient care: a pharmacoeconomic perspective

Bladder cancer is the most expensive cancer per capita to treat in the US healthcare system. Substantial costs associated with the diagnosis, management and surveillance of bladder cancer account for the bulk of the expense; yet, for that cost, patients may not receive high-quality care. Herein the authors review the sources of expenditure associated with bladder cancer care, review population-level analyses of the quality of bladder cancer care in the USA, and discuss opportunities for quality improvement that may yield greater value for men and women newly diagnosed with bladder cancer.