RESUMEN
Background: Health insurance has been shown to be a key determinant in cancer care, but it is unknown as to what extent insurance status affects treatments provided to papillary thyroid cancer (PTC) patients. We hypothesized that insured patients with PTC would have lower-risk tumors at diagnosis and be more likely to receive adjuvant therapies at follow-up. Methods: The American College of Surgeons' National Cancer Database was queried to identify all patients diagnosed with PTCs >2 mm in size from 2004 to 2015. Patients were grouped according to insurance status, and frequency of high-risk features and microcarcinoma at diagnosis were assessed. Multivariable analyses were used to identify independent predictors of more extensive treatment: total thyroidectomy (vs. lobectomy), lymphadenectomy, and radioactive iodine (RAI). Results: There were 190,298 patients who met inclusion criteria; the majority of patients had private insurance (139,675 [73.4%]) and were female (144,824 [76.1%]). Uninsured patients, as compared with privately insured patients, had higher rates of extrathyroidal extension of their cancers (25.2% vs. 18.9%, p < 0.001), lymphovascular invasion (16.2% vs. 12.0%, p < 0.001), and positive margins on final pathology (16.0% vs. 12.2%, p < 0.001). Conversely, patients with private insurance were 51% more likely to have microcarcinomas at diagnosis (odds ratio [OR] = 1.51 [confidence interval {CI} 1.35-1.68], p < 0.001) than uninsured patients, controlling for demographic, socioeconomic, and hospital factors. Private insurance was an independent predictor for treatment with total thyroidectomy (OR = 1.18 [CI 1.01-1.37], p < 0.05), formal lymphadenectomy (OR = 1.22 [CI 1.09-1.36], p < 0.001), and adjuvant RAI therapy (OR = 1.35 [CI 1.18-1.54], p < 0.001) as compared with no insurance, adjusted for socioeconomic, demographic, hospital, and oncologic differences. Patients with Medicare or Medicaid were no more likely to receive these treatments than uninsured patients. Conclusions: Privately insured patients have less aggressive PTCs at diagnosis, and they are more likely to be treated with total thyroidectomy, lymphadenectomy, and RAI compared with uninsured patients. Clinicians should take caution to ensure proper referral and follow-up for under- and uninsured patients to reduce disparities in treatment.
Asunto(s)
Cobertura del Seguro/estadística & datos numéricos , Cáncer Papilar Tiroideo/economía , Cáncer Papilar Tiroideo/terapia , Adulto , Anciano , Femenino , Humanos , Seguro de Salud , Radioisótopos de Yodo/uso terapéutico , Escisión del Ganglio Linfático/economía , Masculino , Medicaid , Medicare , Persona de Mediana Edad , Radiofármacos/uso terapéutico , Programa de VERF , Factores Socioeconómicos , Tiroidectomía/economía , Estados UnidosRESUMEN
BACKGROUND: Several studies and a meta-analysis showed that fibrin sealant patches reduced lymphatic drainage after various lymphadenectomy procedures. Our goal was to investigate the impact of these patches on drainage after axillary dissection for breast cancer. METHODS: In a phase III superiority trial, we randomized patients undergoing breast-conserving surgery at 14 Swiss sites to receive versus not receive three large TachoSil® patches in the dissected axilla. Axillary drains were inserted in all patients. Patients and investigators assessing outcomes were blinded to group assignment. The primary endpoint was total volume of drainage. RESULTS: Between March 2015 and December 2016, 142 patients were randomized (72 with TachoSil® and 70 without). Mean total volume of drainage in the control group was 703 ml [95% confidence interval (CI) 512-895 ml]. Application of TachoSil® did not significantly reduce the total volume of axillary drainage [mean difference (MD) -110 ml, 95% CI -316 to 94, p = 0.30]. A total of eight secondary endpoints related to drainage, morbidity, and quality of life were not improved by use of TachoSil®. The mean total cost per patient did not differ significantly between the groups [34,253 Swiss Francs (95% CI 32,625-35,880) with TachoSil® and 33,365 Swiss Francs (95% CI 31,771-34,961) without, p = 0.584]. In the TachoSil® group, length of stay was longer (MD 1 day, 95% CI 0.3-1.7, p = 0.009), and improvement of pain was faster, although the latter difference was not significant [2 days (95% CI 1-4) vs. 5.5 days (95% CI 2-11); p = 0.2]. CONCLUSIONS: TachoSil® reduced drainage after axillary dissection for breast cancer neither significantly nor relevantly.
Asunto(s)
Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Drenaje , Fibrinógeno/uso terapéutico , Escisión del Ganglio Linfático , Trombina/uso terapéutico , Técnicas de Cierre de Heridas/instrumentación , Anciano , Axila , Combinación de Medicamentos , Femenino , Fibrinógeno/economía , Costos de la Atención en Salud , Humanos , Tiempo de Internación , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/economía , Mastectomía Segmentaria , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Trombina/economía , Técnicas de Cierre de Heridas/economíaRESUMEN
PURPOSE: Malignant melanoma has become a major growing interdisciplinary problem in public health worldwide. Sentinel lymph node excision (SLNE) in conjunction with preoperative SPECT/CT is considered the most sensitive and specific staging test for the detection of micrometastatic melanoma in regional lymph nodes. Among patients with clinically lymph node-negative melanoma, the use of SPECT/CT-aided SLNE compared with SLNE alone has been found to be associated with a higher frequency of metastatic involvement and a higher rate of disease-free survival. The aim of this study was to analyse the cost-effectiveness of SLNE with preoperative SPECT/CT for detecting sentinel lymph nodes versus that of standard SLNE with preoperative lymphoscintigraphy from a single-institution database. METHODS: Cost-effectiveness analysis of two surgical approaches for SLNE for malignant melanoma at the University Hospital Essen, Skin Cancer Center in Essen, Germany. Between March 2003 and April 2011 464 patients eligible for SLNE were identified . Of these patients, 403 with clinically negative lymph nodes who underwent SLNE with or without preoperative SPECT/CT qualified for subsequent analysis. RESULTS: Between March 2003 and October 2008, 254 patients were operated upon with the standard technique. From November 2008, 149 patients underwent the SPECT/CT technique. Cost analysis showed a mean cost saving of
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Escisión del Ganglio Linfático/economía , Linfocintigrafia , Melanoma/diagnóstico , Melanoma/cirugía , Imagen Multimodal , Periodo Preoperatorio , Tomografía Computarizada de Emisión de Fotón Único , Anciano , Anestesia General , Anestesia Local , Análisis Costo-Beneficio , Femenino , Humanos , Tiempo de Internación , Escisión del Ganglio Linfático/efectos adversos , Masculino , Melanoma/diagnóstico por imagen , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Neoplasias Cutáneas , Tomografía Computarizada por Rayos X , Melanoma Cutáneo MalignoAsunto(s)
Biopsia con Aguja Fina/economía , Neoplasias de la Mama/cirugía , Mama/patología , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/cirugía , Secciones por Congelación/economía , Escisión del Ganglio Linfático/economía , Ganglios Linfáticos/patología , Biopsia del Ganglio Linfático Centinela/economía , Axila , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Carcinoma Intraductal no Infiltrante/economía , Carcinoma Intraductal no Infiltrante/patología , Ahorro de Costo , Femenino , Humanos , Italia , Mastectomía Segmentaria/economía , Programas Nacionales de Salud/economía , Estadificación de Neoplasias , Reoperación/economía , Sensibilidad y Especificidad , Ultrasonografía Intervencional/economíaRESUMEN
We evaluated the effectiveness and the cost of axillary staging in breast cancer patients by ultrasound-guided fine-needle aspiration cytology (US-FNAC), sentinel node biopsy (SNB), and frozen sections of the sentinel node to achieve the target of the highest number of immediate axillary dissections. From January 2003 through October 2005, a total of 404 consecutive eligible breast cancer patients underwent US-FNAC of suspicious axillary lymph nodes. If tumor cells were found, immediate axillary dissection was proposed (33% of node-positive cases). If US or cytology was negative, SNB was performed. Frozen sections of the sentinel node allowed immediate axillary dissection in 31% of node-positive cases. The remaining 36% underwent delayed axillary dissection. We compared our policy with clinical evaluation of the axilla, showing better specificity of US-FNAC, the cost balanced by a 12% reduction of SNBs, and a marked reduction of unnecessary axillary dissections resulting from false-positive clinical staging. Moreover, the comparison between our policy and permanent histology of the sentinel node showed an 8% cost saving, mainly associated with the immediate axillary dissections. US-FNAC of axillary lymph nodes in breast cancer patients reliably predicts the presence of metastases and therefore refers a significant number of patients to the appropriate surgical treatment, avoiding an SNB. As cost saving to the health care system in our study is mainly related to one-step axillary surgery, US-FNAC of axillary lymph nodes and frozen section of the sentinel node generate significant cost saving for patients who have metastatic nodes.
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Biopsia con Aguja Fina/economía , Neoplasias de la Mama/cirugía , Mama/patología , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/cirugía , Secciones por Congelación/economía , Escisión del Ganglio Linfático/economía , Ganglios Linfáticos/patología , Biopsia del Ganglio Linfático Centinela/economía , Axila , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Carcinoma Intraductal no Infiltrante/economía , Carcinoma Intraductal no Infiltrante/patología , Ahorro de Costo , Femenino , Humanos , Italia , Mastectomía Segmentaria/economía , Programas Nacionales de Salud/economía , Estadificación de Neoplasias , Reoperación/economía , Sensibilidad y Especificidad , Ultrasonografía Intervencional/economíaRESUMEN
OBJECTIVES: The feasibility and accuracy of sentinel lymph node biopsy (SLNB) in the treatment of breast cancer is widely acknowledged today. The aim of our study was to compare the hospital-related costs of this strategy with those of conventional axillary lymph node dissection (ALND). METHODS: A retrospective study was carried out to determine the total direct medical costs for each of the two medical strategies. Two patient samples (n = 43 for ALND; n = 48 for SLNB) were selected at random among breast cancer patients at the Centre Leon Bérard, a comprehensive cancer treatment center in Lyon, France. Costs related to ALND carried out after SLNB (either immediately or at a later date) were included in SLNB costs (n = 18 of 48 patients). RESULTS: Total direct medical costs were significantly different in the two groups (median 1965.86 Euro versus 1429.93 Euro, p = 0.0076, Mann-Whitney U-test). The total cost for SLNB decreased even further for patients who underwent SLNB alone (median, 1,301Euro). Despite the high cost of anatomic pathology examinations and nuclear medicine (both favorable to ALND), the difference in direct medical costs for the two strategies was primarily due to the length of hospitalization, which differs significantly depending on the technique used (9-day median for ALND versus 3 days for SLNB, p < 0.0001). CONCLUSIONS: A lower morbidity rate is favorable to the generalization of SLNB, when the patient's clinical state allows for it. From an economic point of view, SLNB also seems to be preferred, particularly because our results confirm those found in two published studies concerning the cost of SLNB.
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Neoplasias de la Mama/economía , Neoplasias de la Mama/cirugía , Escisión del Ganglio Linfático/economía , Biopsia del Ganglio Linfático Centinela/economía , Axila , Costos y Análisis de Costo , Femenino , Humanos , Estudios RetrospectivosRESUMEN
OBJECTIVE: To perform a cost analysis of the emerging technology of lymphatic mapping for patients with malignant melanoma. DESIGN: A retrospective, computer-aided chart and financial cost and charge review of consecutive patients with the diagnosis of melanoma registered at a cancer center from December, 1995 to March, 1996. PARTICIPANTS: 73 consecutive patients with the diagnosis of Stage 1 and 2 melanoma (cutaneous disease only) had nodal staging of their disease with either a sentinel node (SLN) biopsy or an elective complete node dissection (ELND). This was determined largely by patient choice and the protocol in operation at the time of the presentation of the patient to the clinic. OUTCOMES MEASURED: There were no deaths in the series. Patient morbidity endpoints included rates of infection, incidence of extremity lymphedema, development of a seroma in the regional nodal basin wound and wound healing. Clinical outcome was measured by the ability to obtain complete nodal staging information with the new lymphatic mapping technology, and recurrence rates in the nodal basin after a negative SLN biopsy. Total charges, direct costs and total costs were calculated from all hospital, OR, pathology and lab charges. Professional fees were included in the analysis. RESULTS: Group 1 patients (50) had melanomas greater than 0.76 mm in thickness treated with a wide local excision (WLE), lymphatic mapping and SLN biopsy under general anesthesia. Five patients (Group 2) had their procedure performed under a straight local anesthesia. Group 3 patients (18) had nodal staging performed with an elective node dissection. In Groups 1 and 2, if the SLN was positive for micrometastases, the patients were taken back to the OR for a complete node dissection. The total charges per patient were $13,835, $6,853 and $19,285, respectively. Significant dollar savings were achieved if the nodal staging could be accomplished with the lymphatic mapping technology (p = 0.001). Morbidity was significantly less in Groups 1 and 2 compared to Group 3. After a mean follow-up of three years, only one patient has recurred in a SLN negative basin. CONCLUSIONS: With 38,300 new cases of melanoma diagnosed each year in the United States, a projected savings of $172 million per year (general anesthesia) and $350 million per year (local anesthesia) could be realized if this new mapping technology could be incorporated into the care of the melanoma patient. Patient morbidity is minimized, nodal staging is complete and patients return to work sooner. Recently approved adjuvant therapy can be applied in a selective fashion, treating only those patients in which a documented benefit has been obtained, saving the health care system more dollars. Initial investment in defining the technology was minimal.