The role of healthcare professionals in HPV communication with head and neck cancer patients: A narrative synthesis of qualitative studies.

INTRODUCTION: Prevalence rates of human papillomavirus positive (HPV+) head and neck cancers (HNC) have increased over the last decades. Communicating about HPV is an increasingly relevant part of HNC patient care. This systematic review was conducted to explore healthcare professionals' (HCP) views and experiences of discussing HPV with HNC patients. It also examined perceptions among different HCP groups of their professional roles in HPV discussions. METHODS: A narrative synthesis of qualitative research was conducted. Three databases-Embase, PsycINFO and CINAHL+-were searched from January 2007 to August 2018. Relevant data were extracted and synthesised thematically. RESULTS: Five studies were identified: four were qualitative and one used mixed methods. HCPs varied in their experience and views of discussing HPV. HCPs who engaged in these discussions believed they were beneficial for patients. All HCPs described the need to address their HPV knowledge deficits in order to provide clear HPV information. Changes in professional roles which were linked to HPV communication for HCPs involved in HNC patient care were also evident. CONCLUSIONS: Effective HPV discussions are an important part of patient-provider interactions. Evidence-based interventions and professional development activities which support HCPs in their HPV discussions with patients would be valuable.

Financial hardship associated with colorectal cancer survivorship: The role of asset depletion and debt accumulation.

OBJECTIVE: To estimate the prevalence of financial objective stress and subjective strain among colorectal cancer survivors and assess associated financial coping factors in Ireland, which has a mixed public-private health care system. METHODS: Colorectal cancer survivors were identified from the National Cancer Registry, and a sample of 496 respondents were included in the analysis. A postal survey collected information on survivor demographics, socio-economic background, medical characteristics, cancer-related financial hardship, debt accumulation, and asset depletion. Cancer-related financial objective stress and subjective strain were used as dependent variables in logistic regression analysis. RESULTS: Approximately 2 in 5 survivors experienced objective stress (40.9%) or subjective strain (39.4%). Depletion of savings (49.1%) was the most prevalent form of financial coping strategy. Factors significantly associated with increased objective stress were having a stoma (OR = 2.1; 95% CI, 1.1-3.9), using savings (OR = 9.4; 95% CI, 4.9-18.0), formally borrowing money (OR = 3.1; 95% CI, 1.0-9.6), and loans from family members/friends (OR = 3.8; 95% CI, 1.9-7.8). Not working (excluding retirees) (OR = 0.44; 95% CI, 0.20-0.96) was associated with decreased objective stress. Significant predictors of subjective strain included having dependents, a stoma, using savings (OR = 5.3; 95% CI, 2.9-9.5), and loans from family members/friends (OR = 2.0; 95% CI, 1.1-3.9) but excluded borrowing money. CONCLUSIONS: Cancer-related financial objective stress and subjective strain are common in colorectal cancer survivors, even where all citizens are entitled to publicly funded care, but the financial coping strategies significantly associated with these 2 measures differed. These findings will help inform targeted measures across disparate health care systems and survivor groups to alleviate financial hardship.

Direct costs of radiotherapy for rectal cancer: a microcosting study.

BACKGROUND: Radiotherapy provides significant benefits in terms of reducing risk of local recurrence and death from rectal cancer. Despite this, up-to-date cost estimates for radiotherapy are lacking, potentially inhibiting policy and decision-making. Our objective was to generate an up-to-date estimate of the cost of traditional radiotherapy for rectal cancer and model the impact of a range of potential efficiency improvements. METHODS: Microcosting methods were used to estimate total direct radiotherapy costs for long- (assumed at 45-50 Gy in 25 daily fractions over a 5 week period) and short-courses (assumed at 25 Gy in 5 daily fractions over a one week period). Following interviews and on-site visits to radiotherapy departments in two designated cancer centers, a radiotherapy care pathway for a typical rectal cancer patient was developed. Total direct costs were derived by applying fixed and variable unit costs to resource use within each care phase. Costs included labor, capital, consumables and overheads. Sensitivity analyses were performed. RESULTS: Radiotherapy treatment was estimated to cost between €2,080 (5-fraction course) and €3,609 (25-fraction course) for an average patient in 2012. Costs were highest in the treatment planning phase for the short-course (€1,217; 58% of total costs), but highest in the radiation treatment phase for the long-course (€1,974: 60% of total costs). By simultaneously varying treatment time, capacity utilization rates and linear accelerator staff numbers, the base cost fell by 20% for 5-fractions: (€1,660) and 35% for 25-fractions: (€2,354). CONCLUSIONS: Traditional radiotherapy for rectal cancer is relatively inexpensive. Moreover, significant savings may be achievable through service organization and provision changes. These results suggest that a strong economic argument can be made for expanding the use of radiotherapy in rectal cancer treatment.

How much does it cost to care for survivors of colorectal cancer? Caregiver's time, travel and out-of-pocket costs.

PURPOSE: Cancer treatment is increasingly delivered in an outpatient setting. This may entail a considerable economic burden for family members and friends who support patients/survivors. We estimated financial and time costs associated with informal care for colorectal cancer. METHODS: Two hundred twenty-eight carers of colorectal cancer survivors diagnosed on October 2007-September 2009 were sent a questionnaire. Informal care costs included hospital- and domestic-based foregone caregiver time, travel expenses and out-of-pocket (OOP) costs during two phases: diagnosis and treatment and ongoing care (previous 30 days). Multiple regression was used to determine cost predictors. RESULTS: One hundred fifty-four completed questionnaires were received (response rate = 68%). In the diagnosis and treatment phase, weekly informal care costs per person were: hospital-based costs, incurred by 99% of carers, mean = €393 (interquartile range (IQR), €131-€541); domestic-based time costs, incurred by 85%, mean = €609 (IQR, €170-€976); and domestic-based OOP costs, incurred by 68%, mean = €69 (IQR, €0-€110). Ongoing costs included domestic-based time costs incurred by 66% (mean = €66; IQR, €0-€594) and domestic-based OOP costs incurred by 52% (mean = €52; IQR, €0-€64). The approximate average first year informal care cost was €29,842, of which 85 % was time costs, 13% OOP costs and 2% travel costs. Significant cost predictors included carer age, disease stage, and survivor age. CONCLUSION: Informal caregiving associated with colorectal cancer entails considerable time and OOP costs. This burden is largely unrecognised by policymakers, service providers and society in general. These types of studies may facilitate health decision-makers in better assessing the consequences of changes in cancer care organisation and delivery.

Using resource modelling to inform decision making and service planning: the case of colorectal cancer screening in Ireland.

BACKGROUND: Organised colorectal cancer screening is likely to be cost-effective, but cost-effectiveness results alone may not help policy makers to make decisions about programme feasibility or service providers to plan programme delivery. For these purposes, estimates of the impact on the health services of actually introducing screening in the target population would be helpful. However, these types of analyses are rarely reported. As an illustration of such an approach, we estimated annual health service resource requirements and health outcomes over the first decade of a population-based colorectal cancer screening programme in Ireland. METHODS: A Markov state-transition model of colorectal neoplasia natural history was used. Three core screening scenarios were considered: (a) flexible sigmoidoscopy (FSIG) once at age 60, (b) biennial guaiac-based faecal occult blood tests (gFOBT) at 55-74 years, and (c) biennial faecal immunochemical tests (FIT) at 55-74 years. Three alternative FIT roll-out scenarios were also investigated relating to age-restricted screening (55-64 years) and staggered age-based roll-out across the 55-74 age group. Parameter estimates were derived from literature review, existing screening programmes, and expert opinion. Results were expressed in relation to the 2008 population (4.4 million people, of whom 700,800 were aged 55-74). RESULTS: FIT-based screening would deliver the greatest health benefits, averting 164 colorectal cancer cases and 272 deaths in year 10 of the programme. Capacity would be required for 11,095-14,820 diagnostic and surveillance colonoscopies annually, compared to 381-1,053 with FSIG-based, and 967-1,300 with gFOBT-based, screening. With FIT, in year 10, these colonoscopies would result in 62 hospital admissions for abdominal bleeding, 27 bowel perforations and one death. Resource requirements for pathology, diagnostic radiology, radiotherapy and colorectal resection were highest for FIT. Estimates depended on screening uptake. Alternative FIT roll-out scenarios had lower resource requirements. CONCLUSIONS: While FIT-based screening would quite quickly generate attractive health outcomes, it has heavy resource requirements. These could impact on the feasibility of a programme based on this screening modality. Staggered age-based roll-out would allow time to increase endoscopy capacity to meet programme requirements. Resource modelling of this type complements conventional cost-effectiveness analyses and can help inform policy making and service planning.

Inter-relationships between the economic and emotional consequences of colorectal cancer for patients and their families: a qualitative study.

BACKGROUND: While the evidence-base concerning the economic impact of cancer for patients and their families/carers has grown in recent years, there is little known about how emotional responses to cancer influence this economic impact. We investigated the economic costs of cancer in the context of patients' emotions and how these both shaped the patient and family burden. METHODS: Health professionals from six hospitals invited patients diagnosed with colorectal cancer (ICD10 C18-C20) within the previous year to take part in the study. Semi-structured face-to-face interviews were conducted with patients and, where available, a family member. Interviews covered medical and non-medical costs incurred as a result of cancer and the impact of these on the lives of the patient and their family. Interviews were audio-recorded. Recordings were transcribed verbatim and these data were analysed qualitatively using thematic content analysis. RESULTS: Twenty-two patients with colorectal cancer (17 colon and 5 rectal; 14 women and 8 men) were interviewed; 6 were accompanied by a family member. Important cancer-related financial outlays included: travel and parking associated with hospital appointments; costs of procedures; increased household bills; and new clothing. Cancer impacted on employed individuals' ability to work and depressed their income. The opportunity cost of informal care for carers/family members, especially immediately post-diagnosis, was a strong theme. All patients spoke of the emotional burden of colorectal cancer and described how this burden could lead to further costs for themselves and their families by limiting work and hindering their ability to efficiently manage their expenses. Some patients also spoke of how economic and emotional burdens could interact with each other. Support from employers, family/carers and the state/health services and patients' own attitudes influenced this inter-relationship. CONCLUSIONS: The economic impact of colorectal cancer on patients and their families is complex. This study suggests that the economic costs and the emotional impact of cancer are often related and can exacerbate each other, but that various factors can meditate this inter-relationship.

Time costs associated with informal care for colorectal cancer: an investigation of the impact of alternative valuation methods.

BACKGROUND: A societal perspective in economic evaluation necessitates that all resources associated with a disease or intervention should be valued; however, informal care time costs are rarely considered. OBJECTIVE: We estimated time allocated to care by informal carers of colorectal cancer survivors; and investigated the impact of applying alternative valuation methods to this time. METHODS: Colorectal cancer cases (ICD10 C18-C20) diagnosed 6-30 months previously and identified from the National Cancer Registry Ireland were invited to provide details of informal carers. Carers completed a postal questionnaire. Time estimates per week associated with hospital-related and domestic-related care activities were collected for two phases: diagnosis and initial treatment (initial 3 months) and ongoing care (previous 30 days). Seven valuation scenarios, based on variants of the opportunity cost approach (OCA), and the proxy good approach (PGA), were considered. The base-case was OCA with all carer time valued at the average national wage. RESULTS: We received 154 completed questionnaires (response rate = 68 %). Average weekly time allocated to caring was 42.5 h in the diagnosis and initial treatment phase and 16.9 h in the ongoing care phase. Under the base-case, average weekly time costs were 295 (95 % CI 255-344) for hospital-related activities and 630 (95 % CI 543-739) for domestic-related activities in the diagnosis and initial treatment phase and 359 (95 % CI 293-434) in the ongoing care phase. PGA estimates were 23 % below the base-case. Only one alternative scenario (occupation and gender-specific wages for carers in paid work and replacement wages for non-working carers) surpassed base-case costs, and the difference was modest. CONCLUSIONS: Overall, significant time is associated with informal caring in colorectal cancer. Different time valuation methods can produce quite different cost estimates. A standardised methodology for estimating informal care costs would facilitate better integration of these into economic evaluations.