Lung cancer management in limited resource settings: guidelines for appropriate good care.

Lung cancer is a major cause of cancer death worldwide and is becoming an increasing problem in developing countries. It is important that, in countries where health care resources are limited, these resources are used most effectively and cost-effectively. The authors, with the support of the International Atomic Energy Agency, drew on existing evidence-based clinical guidelines, published systematic reviews and meta-analyses, as well as recent research publications, to summarise the current evidence and to make broad recommendations on the non-surgical treatment of patients with lung cancer. Tables were constructed which summarise the different treatment options for specific groups of patients, the increase in resource use for and the likely additional clinical benefit from each option. These tables can be used to assess the cost-effectiveness and appropriateness of different interventions in a particular health care system and to develop local clinical guidelines.

The cost of lung cancer in Turkey.

The aim of this study was to evaluate the individual and societal burden of lung cancer in Turkey. A total of 103 cases with lung cancer attended our department between January 2002 and February 2003 were included in our study prospectively. The primary outcome measure was the cost of disease until death of the patients or the end of study. All the costs were expressed as United States dollars (USD) and were estimated regarding the effective exchange rate at the time of recording. Descriptive statistics, chi-square, Fisher's exact test, Kaplan-Meier analysis and non-parametric "Bootsraping" tests were performed to evaluate the data. The average survival was 6.8 months. The estimated total direct cost for the entire group was 564.490 USD, and the direct cost per patient was 5.480 +/- 4.088 USD. The total cost of lung cancer in the study group was 1.473.530 USD, with a per-patient cost of 14.306 +/- 17.705 USD. The average direct cost per life year was 18.058 +/- 25.775 USD. Age, gender and histopathology did not affect the cost, whereas direct medical costs were increased with increasing stage. With the low life expectancy and cure rates, lung cancer has been alerting for the cost minimization and disease control measures.

Cost of lung cancer: a methodological review.

Cost of illness (COI) studies estimate the overall economic burden of a specific disease, rather than simply treatment-related costs. While having been criticised for not allowing resource prioritisation, COI studies can provide useful guidance, so long as they adhere to accepted methodology. The aim of this review is to analyse the methods used to evaluate the cost of lung cancer. Because of the increasing incidence and high direct and indirect costs of lung cancer, it is an important disease in terms of economic implications, and therefore provides a relevant example with which to review COI study methodologies. First, the key points of the methodology relating to COI studies were identified. COI studies relating to lung cancer were then reviewed, focussing on an analysis of the different methods used and an identification of the strengths and weaknesses of each approach. The COI studies that were analysed confirmed that lung cancer is a costly illness, and that hospitalisation and treatments account for a large part of direct costs, while indirect costs represent a large part of the total costs. The review also showed that COI studies adopted significantly different approaches to estimate the costs of lung cancer, reflecting a lack of consensus on the methodology of COI studies in this area. Hence, to increase the credibility of COI studies, closer agreement among researchers on methodological principles would be desirable.

Cost effectiveness of increasing the dose intensity of chemotherapy with granulocyte colony-stimulating factor in small-cell lung cancer: based on data from the Medical Research Council LU19 trial.

BACKGROUND: The use of granulocyte colony-stimulating factor (G-CSF) can enable dose intensification of chemotherapy in small-cell lung cancer (SCLC). However, given its acquisition cost, it is important to assess its cost effectiveness within a resource-constrained health service. OBJECTIVE: To assess the cost effectiveness, from the UK NHS perspective, of G-CSF given in addition to doxorubicin, cyclophosphamide and etoposide (ACE) versus ACE alone in the management of SCLC. METHODS: Using data from a UK Medical Research Council trial (LU19) to assess chemotherapy dose intensification in patients with previously untreated SCLC of any disease extent, a retrospective cost-effectiveness analysis was undertaken. Resource use data, including hospitalisations and non-protocol cancer treatments, were collected during the first 6-month treatment phase of the trial. Mean costs ( pound, 2003 values) of managing patients in the two arms of the trial were calculated. Mean survival duration was calculated for the two groups using patient-specific follow-up data collected in the trial. Incremental cost-effectiveness analysis was undertaken, and uncertainty in cost effectiveness was expressed using cost-effectiveness acceptability curves. RESULTS: The use of G-CSF in addition to ACE chemotherapy is more costly ( 4647 pounds) but results in longer mean survival duration (0.20 years; 0.18 years when discounted). This generates an incremental cost per additional life-year of 25,816 pounds for ACE + G-CSF therapy. The probability of the addition of G-CSF being cost effective, if decision makers are willing to pay 30,000 pounds for an additional life-year, is 0.57. Secondary analysis suggests that cost effectiveness is likely to be sensitive to assumptions about the health-related quality of life (HR-QOL) experienced by patients. CONCLUSION: Based on data collected in the LU19 trial, chemotherapy dose intensification using G-CSF in SCLC adds to health service costs but increases survival duration. Its overall cost effectiveness is likely to be finely balanced.

[Evaluation of clinical practice in pulmonary oncology: a review of the literature]. / Evaluation des pratiques en cancérologie pulmonaire: analyse de la littérature.

INTRODUCTION: Evaluation of clinical practice in pulmonary oncology aims to improve both the quality of care and the control of costs. REVIEW OF THE LITERATURE: A Medline search of the literature allowed analysis of the published studies of the evaluation of clinical practice. They showed that though 82-95% of patients with small cell bronchial carcinoma were treated with a combination of etoposide and cisplatin, less than half of the patients with non-small cell cancer received treatment. VIEWPOINT: Various factors such as age, comorbidity, race, socio-economic status and gender affect the treatment decisions. There is also a discrepancy between the trial data and clinical practice that could be explained by two factors. On one hand advances are not always adopted by doctors and on the other hand the patient populations treated may sometimes be different from those in the trials. CONCLUSION: Though the number of published studies is still low an increase is to be expected on account of the publication of new regulations concerning the evaluation of clinical practice and the appropriate use of drugs.

Routine use of granulocyte colony-stimulating factor is not cost-effective and does not increase patient comfort in the treatment of small-cell lung cancer: an analysis using a Markov model.

PURPOSE: The clinical indications and economic consequences of human granulocyte colony-stimulating factor (G-CSF) prescription during small-cell lung cancer (SCLC) chemotherapy remain controversial. The aim of this study, based on a Markov model, was to assess the impact of routine G-CSF use in the treatment of SCLC on costs and patient comfort. Markov models allow the modeling SCLC chemotherapy, in which the risk of febrile neutropenia (FN) is continuous over time and may occur more than once. PATIENTS AND METHODS: We used a Markov model to compare three strategies: a chemotherapy dose reduction after FN and nonuse of G-CSF ("never" strategy), secondary use of G-CSF ("CSF if FN" strategy) and primary use of G-CSF ("systematic CSF" strategy). Model baseline probabilities were based on a review of medical records for all patients (n = 39) treated for SCLC in our unit during 1993 (when G-CSF was not used) and on published reductions in the incidence of FN obtained by using G-CSF. Two different types of rewards were used: a cost-utility scale that took into account the costs of FN (CFN) episodes and G-CSF (CCSF) courses; and a comfort-utility scale that took into account the discomfort of FN and G-CSF therapy. Costs were analyzed from the health care payer's perspective and utilities were assessed prospectively in standardized interviews with treated SCLC patients. RESULTS: The never strategy was the least costly ($4,875 [United States] versus $5,816 and $7,690 for CSF if FN and systematic CSF) and gave the highest comfort value (378 U v 365 and 327 for CSF if FN and systematic CSF). Sensitivity analyses showed that the never strategy remains the less costly when the probability of a first FN episode was less than 49%, the probability of FN recurrence was less than 60%, or the CFN was less than $6,077, or the CCSF was greater than $863. In terms of patient comfort, the never strategy was the best choice, except for patients who considered that a course of G-CSF caused little or no discomfort, whether or not it prevented FN. CONCLUSION: Routine use of G-CSF during SCLC chemotherapy is not justified by clinical benefits, improved patient comfort, or economic considerations.

Cost-effectiveness of cancer chemotherapy: an economic evaluation of a randomized trial in small-cell lung cancer.

An economic evaluation of a randomized trial of cyclophosphamide, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and vincristine alone or alternating with etoposide (VP-16) and cisplatin in extensive small-cell lung cancer (SCLC) was undertaken. A survival benefit of 1.6 months in favor of alternating chemotherapy was associated with an additional cost of $450 (1984 Canadian dollars) per patient. This translated to a cost of $3,370 per year of life gained. Sensitivity analyses demonstrated that the cost-effectiveness (CEA) of alternating chemotherapy was greatest when treatment was given on an outpatient basis. The results of the evaluation were sensitive to hospitalization rates, but even the most unfavorable analyses revealed the CEA of alternating chemotherapy to be comparable to that of treatments of common nonmalignant diseases. It is concluded that the CEA of alternating chemotherapy for SCLC was favorable when compared with accepted treatments for nonmalignant diseases. The survival benefit seen with alternating chemotherapy was felt to be clinically significant and alternating chemotherapy is recommended as routine therapy for extensive SCLC.

Application of an algorithm for staging small-cell lung cancer can save one third of the initial evaluation costs.

OBJECTIVE: Design of a cost-effective algorithm for staging disease in patients with small-cell lung cancer. DESIGN: An algorithm was constructed by analyzing all permutations of a sequence of procedures required to stage disease in patients with small-cell lung cancer. Procedural costs were determined, and the model was applied to the small-cell lung cancer patient population treated at the National Cancer Institute, Bethesda, Md, from 1973 to 1989. The final algorithm was derived from the permutation with the lowest cost per accurately staged patient. SETTING: A single government institute, the National Cancer Institute. PATIENTS: Four hundred fifty-one patients with previously untreated, consecutive histologically documented small-cell lung cancer entered into therapeutic protocols at the National Cancer Institute from April 1973 through July 1989. Data were obtained from small-cell lung cancer protocol databases and patients' medical records. MAIN OUTCOME MEASURE: The cost per patient of each sequence of staging procedures when applied to the patient population. RESULTS: The least expensive sequence of procedures saved $1418 per patient when compared with application of a standard set of staging procedures to all patients. The major factor in reducing costs was the concept of stopping the staging procedures after a site of distant metastatic disease had been identified. CONCLUSIONS: An algorithm consisting of a set of sequential staging procedures can accurately stage disease in patients with small-cell lung cancer and save more than one third of the costs of an inclusive standard set of staging procedures.

The impact of therapy with filgrastim (recombinant granulocyte colony-stimulating factor) on the health care costs associated with cancer chemotherapy.

The objective of the study was to estimate the net impact on health resource utilisation of using recombinant granulocyte colony-stimulating factor (filgrastim) following myelosuppressive chemotherapy. Cost minimisation of the study medication in a randomised, double-blind, placebo-controlled clinical trial was conducted in teaching institutions and affiliated community hospitals participating in a clinical trial. 68 patients with small cell lung cancer undergoing cyclophosphamide, doxorubicin and etoposide chemotherapy were randomised to blinded placebo or filgrastim study medication at three or 14 clinical trials sites. The patients received daily subcutaneous injections of filgrastim or placebo, initiated 24 h after chemotherapy and continued until the neutrophil count exceeded 10,000 x 10(6)/l after the time of the expected nadir. Differences in total charges, costs and Medicare payments between treatment groups were the main outcomes measured. Compared to placebo patients, filgrastim-treated patients had significantly fewer and less resource-intensive hospitalisations. After accounting for filgrastim purchase and administration, the charge model predicts overall savings from filgrastim use in a clinical setting in which the risk of febrile neutropenia is high for patients not receiving filgrastim. The Medicare and cost models predict only a partial recapture of the cost of filgrastim therapy. The health care resources impact of filgrastim was sensitive to the risk of hospitalisation with febrile neutropenia, and to the perspective chosen for measuring resource utilisation (charges, costs or Medicare payments). The adjunctive use of filgrastim following myelosuppressive chemotherapy leads to partial or complete recapture of the cost of purchasing and administering the product.

A pharmacoeconomic evaluation of cisplatin in combination with either etoposide or etoposide phosphate in small cell lung cancer.

To compare etoposide and etoposide phosphate (Etopophos; Bristol-Myers Squibb Company, Princeton, NJ) in maximizing the cost efficiency of care for patients with small cell lung cancer (SCLC), we obtained pharmacoeconomic data from a phase II randomized study of these agents. This clinical investigation assessed the efficacy and toxicity of etoposide phosphate combined with cisplatin in treating SCLC. In the economic analysis, we identified resources expended during chemotherapy and related concomitant procedures and matched them with the current procedure terminology level of costs for the provider and the payor. The valuation process was conducted in the specific point-of-care (outpatient v inpatient) setting. The appropriate pharmacoeconomic analytic tool used when comparators are considered to achieve equivalent clinical outcomes is cost-minimization analysis. We provide the cost-minimization analysis from two oncology care perspectives: the provider and the payor. In addition, a payor/ provider cost reduction model was constructed to illustrate the potential economic effects achieved through more efficient use of the outpatient chemotherapy facility due to the ease of administration of etoposide phosphate. The provider's average cost per patient for treating an SCLC patient for six cycles in US dollars is $26,764.48 for etoposide versus $26,026.70 for etoposide phosphate. The payor's average treatment cost per patient for treating an SCLC patient for six cycles for the respective regimens was $34,270.65 and $34,320.70. When the time savings associated with the etoposide phosphate regimen are applied to the outpatient chemotherapy facility, the adjusted average treatment costs per patient for the payor are $2,797.29 less than the costs for using the standard etoposide intravenous formulation. Delivering an etoposide phosphate regimen accrued adjusted savings of $2,897.03 per patient. Based on these results, etoposide phosphate is a superior pharmacoeconomic alternative compared with standard etoposide chemotherapy in managing SCLC. The potential increase in patient volume conferred by the relative simplicity of etoposide phosphate administration would have a significant impact on operations in terms of scheduling patients and staff and increasing operational efficiencies, thereby facilitating cost reductions in excess of $2,700 per patient when an etoposide phosphate regimen is chosen over an etoposide regimen.

Cost-effectiveness analysis of somatostatin receptor scintigraphy.

UNLABELLED: We analyzed the results of conventional imaging and somatostatin receptor scintigraphy in 150 patients with neuroendocrine tumors. METHODS: The outcomes of combinations of imaging modalities were compared in terms of tumor localization, effect on patient management and financial costs. RESULTS: In patients with carcinoids, a combination of somatostatin receptor scintigraphy, chest radiograph and ultrasound of the upper abdomen had a high sensitivity for tumor localization, and detected lesions in patients in whom no tumor was found with conventional imaging, justifying the greater cost. In patients with medullary thyroid carcinoma, somatostatin receptor scintigraphy adds little to the information obtained with conventional imaging and therefore should not be used as a screening method. In patients with paraganglioma, CT scanning of the region where a paraganglioma is suspected, followed by somatostatin receptor scintigraphy to detect multicentricity has the best cost effectiveness ratio. In patients with gastrinomas, the combination of somatostatin receptor scintigraphy and CT scanning of the upper abdomen had the highest sensitivity. The relatively high cost of this process is outweighed by its demonstrating a resectable tumor. In patients with insulinomas, the highest yield against the lowest cost is obtained if somatostatin receptor scintigraphy is only performed if CT scanning fails to demonstrate the tumor. CONCLUSIONS: Somatostatin receptor scintigraphy should be performed in patients with small-cell lung carcinoma because it can lead to a change of stage and may demonstrate otherwise undetected brain metastases. The cost increase is outweighed by the omission of unnecessary treatment for some of the patients and by the possibility of irradiating brain metastases at an early stage, which may lead to a better quality of life.

The restaging of responding patients with limited small cell lung cancer. Is it really useful?

A retrospective review of data on patients entered on two limited small cell lung cancer studies of the National Cancer Institute of Canada (BR.3 and BR.6) was undertaken to determine the value of restaging and rebronchoscopy in responding patients. An economic evaluation was also done. Repeat scans (brain, liver) and bronchoscopy were carried out in 190 patients and 5 (2.6 percent) were positive, despite other evidence suggesting response. One hundred thirty-nine of 324 patients who achieved complete response on the two trials underwent rebronchoscopy. Among these, 122 (87.7 percent) were negative and eight (5.8 percent) were inconclusive. Nine (6.5 percent) were positive despite other evidence suggesting the patient had achieved a complete response. A small group of nine patients with positive rebronchoscopy survived for a shorter time than the group with negative or inconclusive rebronchoscopies. The survival difference was only statistically significant when analyzed using the log rank test, but it was not significant when analyzed by the Wilcoxon test. The economic analysis showed that it costs $11,333 per patient reclassified when scans were redone in these patients. The cost could even have been higher had we used present-day scanning techniques (computed tomography and magnetic resonance imaging), although they might be slightly more sensitive. The cost of rebronchoscopy per patient reclassified was $14,960. Therefore, we recommend that restaging (scans or rebronchoscopy) not be done in responding patients with limited small cell lung cancer, thus potentially saving health care dollars as well as reducing patient inconvenience with no detrimental effect on survival.

An estimate of the cost of conducting phase II trials in lung cancer.

OBJECTIVE: Although it is commonly assumed that clinical trials are more costly than standard therapy, there have been no previous studies of the cost of conducting phase II trials in lung cancer. We retrospectively analyzed two National Cancer Institute of Canada phase II trials in previously untreated small cell lung cancer (SCLC) to determine the costs of conducting the trials in a cancer treatment centre. Both studies were clinical trials undertaken as part of the NCIC's Investigational New Drug program: IND 69 and IND 50 evaluated docetaxel (taxotere) and gemcitabine, respectively. METHODS: data management costs in a Canadian cancer treatment centre were determined from the time estimates provided by data managers to complete various protocol related tasks. Nursing and pharmacy personnel measured the time and supplies necessary to prepare and administer the chemotherapy. Physician fees were determined from the type and number of care visits required by the clinical protocols. Laboratory tests and imaging studies were costed according to the Ontario Health Insurance Plan (OHIP) Schedule of Fees and Benefits. To estimate whether phase II trials are more costly than standard treatment, we determined the cost of four cycles of VP-16-cisplatin, a standard treatment for SCLC. RESULTS: The total cost of performing the docetaxel study was $18443 for an average cost per case of $1317 and an average cost per treatment cycle of $683. The gemcitabine study cost more, due to the fact that the drug proved to be active against SCLC and more cycles of therapy were administered to a larger number of patients. Laboratory and administration costs were also higher, because of the drug administration schedule. The total cost of this study was estimated to be $64670 and the average cost per patient entered was $2230 with an average cost per treatment cycle of $898. In comparison, the estimated cost of four cycles of VP-16-cisplatin chemotherapy was $3948 or $987 per treatment cycle. The major cost drivers in the clinical trials were laboratory and imaging tests which made up 17 and 39%, respectively, of the costs of the taxotere study, and 29 and 27%, respectively, for the gemcitabine study. Data management costs contributed 21 and 13% of the total costs, respectively. CONCLUSION: As the main cost drivers in these phase II clinical trials are laboratory and imaging tests, the cost of clinical trials could potentially be reduced by ensuring that only essential tests are required by protocol. Not surprisingly, the cost of conducting a trial of an active agent is greater than for an inactive agent, because more patients are treated and each patient receives more treatment. The implications for the per-case funding of phase II clinical trials are discussed.

Economic evaluation of lenograstim for prophylaxis of chemotherapy-induced neutropenia in patients with small cell lung cancer.

The impact of lenograstim, recombinant human granulocyte colony-stimulating factor, on healthcare costs was evaluated on the basis of the results of a clinical trial of the drug in patients receiving VICE (vincristine, ifosfamide, carboplatin and etoposide) chemotherapy for small cell lung cancer (SCLC). The use of lenograstim resulted in a significant (p < 0.03) increase in the cumulative chemotherapy dose intensity (125% with lenograstim vs 118% without). Lenograstim was found to have no significant impact on the use of healthcare resources for administration of chemotherapy, chemotherapy-induced neutropenia, and associated infections. The cost of healthcare for the lenograstim group (excluding lenograstim acquisition costs) was 700 pounds higher per patient than that for the group not treated with lenograstim (95% CI -930 pounds to 2300 pounds). The use of lenograstim to intensify the chemotherapy dose is likely to increase the costs of treatment for SCLC. However, any increased costs need to be balanced against the potential cost savings associated with the possible long term benefits resulting from chemotherapy dose intensification.

G-CSF as prophylaxis of febrile neutropenia in SCLC.

OBJECTIVES: In 1991, small cell lung cancer (SCLC) was reported as the first tumour type where colony stimulating factor (CSF) support was clinically effective. We reviewed 13 health services research studies that addressed CSF use as supportive care for SCLC. METHODS: Findings from American Society of Clinical Oncology (ASCO) membership surveys, patterns of care studies, ASCO evidence-based guidelines and cost-effectiveness studies for CSF use were reviewed. RESULTS: For primary prophylaxis for SCLC, ASCO CSF clinical guidelines clearly do not support granulocyte (G)-CSF use. Cost-effectiveness models indicate that CSF use in this setting is associated with as much as US$1900 incremental patient care costs per cycle given an 18% febrile neutropenia rate. ASCO membership surveys found that < 10% of respondents supported CSF as primary prophylaxis while a patterns-of-care study found 55% use. In the secondary prophylaxis setting, ASCO CSF guidelines in 1994, 1996 and 1997 were equally supportive of CSF use versus dose reduction but dose-reduction was considered the preferred option in 2000. Over half of the ASCO member respondents in 1994 and in 1997 supported G-CSF use; cost-effectiveness models indicated that CSF use incurred an additional US$144 and 277 per cycle and the patterns of care study found 27% use of CSF in the community practice setting. CONCLUSIONS: In 2002, the findings of a decade of health services studies have shifted towards not being supportive of CSF use for primary or secondary prophylaxis for SCLC patients.

Economic analyses and lung cancer.

The economic assessment of treatments or medical strategies has been the subject of an increasing number of publications. The elevated costs and relative lack of efficacy of many treatments of chronic diseases such as lung cancer are an added impetus to such analyses. In the first part of this review, we summarise the theoretical basis of economic assessment, the tools available and the limitations of these methods. In the second part, we examine their application to the treatment of lung cancer. We discuss the evaluation of the cost of these cancers to society, economic assessment of new chemotherapeutic drugs, and the place of cost-effectiveness analysis in randomized trials. In the last part, we outline the interest and future of such considerations for clinicians. These methods, which provide complementary data for clinicians when making decisions on therapeutic options, will be adopted more widely in coming years.

[Clinical and economic evaluation of the initial assessment of small cell cancer of the lung. Alternatives to classic evaluation. LGTO. The Lyon Group of Thoracic Oncology]. / Evaluation clinique et économique du bilan initial des cancers du poumon à petites cellules. Alternatives à un bilan classique. GLOT. Groupe Lyonnais d'Oncologie Thoracique.

Alternatively to the usual evaluation summary, a characteristic of small cell lung cancer, is the probability of significant diffuse metastases; the prognosis is directly linked to the extent of these metastases. Moreover, the assessment of the initial extension becomes heavier and more costly as investigations continue and each new technology appears. In order to evaluate the contribution of each examination, a classification has been established as a function of the time-scale to obtain the results, of the technology involved, or whether the investigation is painful or not and any likelihood of iatrogenic side-effects. An assessment in three stages is proposed to achieve the most effective and cheapest diagnosis possible. In relation to the usual technique of assessment this sequential approach allows for a 27% reduction in the time-scale for the diagnosis of diffuse disease, 51.3% in terms of technical involvement, 46.3% in terms of pain and discomfort and 53.9% in terms of iatrogenic potential. At the same time a reduction in cost of 47.5% is observed.

Survival of older patients with cancer in the Veterans Health Administration versus fee-for-service Medicare.

PURPOSE: The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. PATIENTS AND METHODS: We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. RESULTS: VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non-small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large-B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. CONCLUSION: The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.