Trends in end-of-life care and health care spending in women with uterine cancer.

BACKGROUND: High-intensity care including hospitalizations, chemotherapy, and other interventions at the end of life is costly and often of little value for cancer patients. Little is known about patterns of end-of-life care and resource utilization for women with uterine cancer. OBJECTIVE: We examined the costs and predictors of aggressive end-of-life care for women with uterine cancer. STUDY DESIGN: In this observational cohort study the Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify women age ≥65 years who died from uterine cancer from 2000 through 2011. Resource utilization in the last month of life including ≥2 hospital admissions, >1 emergency department visit, ≥1 intensive care unit admission, or use of chemotherapy in the last 14 days of life was examined. High-intensity care was defined as the occurrence of any of the above outcomes. Logistic regression models were developed to identify factors associated with high-intensity care. Total Medicare expenditures in the last month of life are reported. RESULTS: Of the 5873 patients identified, the majority had stage IV cancer (30.2%), were white (79.9%), and had endometrioid tumors (47.6%). High-intensity care was rendered to 42.5% of women. During the last month of life, 15.0% had ≥2 hospital admissions, 9.0% had a hospitalization >14 days, 15.3% had >1 emergency department visits, 18.3% had an intensive care unit admission, and 6.6% received chemotherapy in the last 14 days of life. The percentage of women who received high-intensity care was stable over the study period. Characteristics of younger age, black race, higher number of comorbidities, stage IV disease, residence in the eastern United States, and more recent diagnosis were associated with high-intensity care. The median Medicare payment during the last month of life was $7645. Total per beneficiary Medicare payments remained stable from $9656 (interquartile range $3190-15,890) in 2000 to $9208 (interquartile range $3309-18,554) by 2011. The median health care expenditure was 4 times as high for those who received high-intensity care compared to those who did not (median $16,173 vs $4099). CONCLUSION: Among women with uterine cancer, high-intensity care is common in the last month of life, associated with substantial monetary expenditures, and does not appear to be decreasing.

Surgical wait time: A new health indicator in women with endometrial cancer.

OBJECTIVE: To evaluate factors associated with delayed surgical treatment among women with endometrial cancer. METHODS: Using the National Cancer Database (NCDB), we analyzed time to first surgery for epithelial endometrial cancer patients who underwent surgical treatment from 2003 to 2011. Poisson regression was used to examine delays >6weeks between diagnosis and surgery, controlled for patients' sociodemographic and clinical characteristics. Survival for women diagnosed between 2003 and 2006 with timely versus delayed surgery was compared using Cox proportional hazards regression. RESULTS: The study included 112,041 women diagnosed at 1108 continuously reporting NCDB hospitals. Survival through 2011 was available for 40,184 women. All patients underwent hysterectomy. Twenty-eight percent of patients underwent surgery >6weeks after diagnosis. Poisson regression estimates indicated that being younger than 40years old, being black or Hispanic, having Medicaid or being uninsured, or being from the lowest education quartile were associated with a significantly higher likelihood of surgical wait time>6weeks. Patients diagnosed in 2010-2011 were more likely (IRR 1.32, 95% CI 1.24-1.40) to undergo surgery >6weeks after diagnosis compared to patients treated in 2003. Survival for women with surgical wait times >6weeks was worse than those treated within 6weeks of diagnosis (HR 1.14, 95% CI 1.09-1.20). CONCLUSIONS: Being a minority patient and having lower socioeconomic status or poor insurance coverage were associated with an increased likelihood of delayed surgical treatment. Wait times >6weeks from diagnosis of endometrial cancer to definitive surgery may have a negative impact on survival.

Impact of wait times on survival for women with uterine cancer.

PURPOSE: To determine whether wait time from histologic diagnosis of uterine cancer to time of definitive surgery by hysterectomy had an impact on all-cause survival. PATIENTS AND METHODS: Women in Ontario with a confirmed histopathologic diagnosis of uterine cancer between April 1, 2000, and March 31, 2009, followed by surgery were identified in the Ontario Cancer Registry. Survival was calculated by using the Kaplan-Meier method. Factors were evaluated for their prognostic effect on survival by using Cox proportional hazards regression. Wait time was evaluated in a multivariable model after adjusting for other significant factors. RESULTS: The final study population included 9,417 women; 51.9% had surgery by a gynecologist, and 69.9% had endometrioid adenocarcinoma. Five-year survival for women with wait times of 0.1 to 2, 2.1 to 6, 6.1 to 12, or more than 12 weeks was 71.1%, 81.8%, 79.5%, and 71.9%, respectively. Wait times of ≤ 2 weeks were adversely prognostic for survival after adjusting for other significant factors in the multivariable model, and patients with wait times of more than 12 weeks had worse survival than those who had wait times between 2.1 and 12.0 weeks. CONCLUSION: To the best of our knowledge, this is the first report in a large population-based cohort demonstrating that longer wait times from diagnosis of uterine cancer to definitive surgery have a negative impact on overall survival.

The impact of income on clinical outcomes in FIGO stages I to II endometrioid adenocarcinoma of the uterus.

OBJECTIVE(S): To determine the influence of income on clinical outcomes in patients with surgical stages I to II endometrioid adenocarcinoma of the uterus. METHODS: We retrospectively analyzed the records of 660 women initially treated from 1985 to 2009. On the basis of income data obtained from the 2000 US census, patients were separated into various income groups (halves, tertiles, and quartiles) based on median household income, with most focus on the half income groups. RESULTS: Income groups were similar regarding treatments received and characteristics, with the exception of more African American (AA), unmarried patients, and a predilection for higher grade in the lower half income group (LHIG). Compared with the upper half income group (UHIG), the LHIG had lower disease-specific survival (DSS) (5 y: 93.9% vs. 97.0% and 10 y: 90.1% vs. 95.9%; P=0.023) and a trend toward lower overall survival (OS) (5 y: 83.4% vs. 86.5% and 10 y: 62.6% vs. 68.5%; P=0.067). In patients with higher-risk features, differences in outcomes between LHIG and UHIG were more pronounced; 10-year OS of 43.4% versus 60.2% (P=0.004) and 10-year DSS of 75.0% versus 93.0% (P=0.007), respectively. Regarding race, AA patients in the LHIG had lower OS than AA in the UHIG. On univariate analysis, income group and race were significant predictors for DSS, but on multivariate analysis, they were not statistically significant. CONCLUSIONS: Despite similar treatments and characteristics, a small decrease in DSS and a trend toward reduced OS was observed in LHIG patients, but income group was not statistically significant on multivariate analysis of outcome. These differences were more significant in patients with high-risk features.

Cost-benefit analysis of laparoscopic surgery versus laparotomy for patients with endometrioid endometrial cancer: experience from an institute in China.

AIM: To compare the clinical outcomes and associated costs between laparoscopic and abdominal surgery for patients with endometrioid endometrial cancer. METHODS: From 2003 to 2008, 115 patients who underwent laparoscopically-assisted surgery for endometrioid endometrial cancers were enrolled in this retrospective study. Another 123 patients who had abdominal surgery for the same histological type of endometrial cancer were included as the control group. The clinico-pathological variables, surgical outcome, costs, death and case recurrence of the two groups were compared. RESULTS: There was no difference in the patients' age, body mass index, FIGO stage, histological grade or surgical types between the two groups. The patients in the laparoscopy group had less blood loss (P = 0.010), a shorter hospital stay (P < 0.001), less postoperative pain (P < 0.001) and lower complication rates (P < 0.001) than those treated by laparotomy. The total costs in the laparoscopy group were higher than that in the laparotomy group ($2073 vs $1638, P < 0.001). Patients in the laparoscopy group returned to usual activity more quickly (P = 0.001) and went back to work earlier (P = 0.013) than those in laparotomy group. With a median follow-up of 42 months for the laparoscopy group and 40 months for the laparotomy group, there was no significant difference in the number of cases with respect to death (P = 1.000) or recurrence (P = 1.000). CONCLUSIONS: Laparoscopically-assisted surgery is as effective as the laparotomy approach for the treatment of early-stage and advanced-stage endometrial cancer. The relatively higher cost of the laparoscopic surgery may be compensated by its benefits. In developing countries such as China, laparoscopically-assisted surgery is also an attractive alternative for selected patients with endometrial cancer.

Cost effectiveness of laparoscopy versus laparotomy in early stage endometrial cancer: a randomised trial.

OBJECTIVE: To determine the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) in early stage endometrial cancer alongside a multicenter randomised controlled trial (RCT). METHODS: An economic analysis was conducted in 279 patients (TLH n=185; TAH n=94) with early stage endometrial cancer from a societal perspective, including all relevant costs over a three month time horizon. Health outcomes were expressed in terms of major complication-free rate and in terms of utility based on women's response to the EQ-5D. Comparisons of costs per major complication-free patient gained and costs with utility gain and costs were made, using incremental cost effectiveness ratios. RESULTS: The mean major complication-free rate and median utility scores were comparable between TLH and TAH at three months. TLH is more costly intraoperatively (Δ$1.129) and less costly postoperatively in-hospital (Δ$-1.350) compared to TAH. Incremental costs per major complication-free patient were $-52. Higher cost ($249) were generated while no gains in utility (-0.02) were observed for TLH compared to TAH. Analysing utility at six weeks, incremental costs per additional point on the EQ-5D scale were $1.617. CONCLUSION: TLH is cost effective compared to TAH, based on major complication-free rate as measure of effect. Along with future cost saving strategies in laparoscopy, TLH is assumed to be cost effective for both effect measures. Therefore and due to comparable safety, TLH should be recommended as a standard-of-care surgical procedure in early endometrial cancer.