Determinants of Medicare Costs for Elderly Patients With Oral Cavity and Pharyngeal Cancers.

IMPORTANCE: In the United States, nearly 8400 patients die each year from oral cavity and pharynx cancers, most of whom are 65 years and older; however, the costs attributable to these cancers are not well described. OBJECTIVE: To identify the primary determinants of cost in patients with oral and pharyngeal cancer. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort analysis of data from Medicare and Surveillance, Epidemiology, and End Results hospitals (January 1, 1995, through December 31, 2005), we studied patients 66 years and older with newly diagnosed oral cavity (n = 6724) and pharyngeal (n = 3987) cancers. MAIN OUTCOMES AND MEASURES: Five-year cumulative costs, defined as Medicare Parts A and B payments, were estimated using inverse probability weighting. Linear regression analysis with inverse probability weighting was used in multivariate analyses of costs to estimate the effects of covariates on cumulative costs. RESULTS: In multivariate analyses, costs were significantly increased by demographics, comorbidities, and treatment selection. Compared with white patients, African Americans accumulated $11,450 (95% CI, $1320-$22,299) and $25,093 (95% CI, $14,917-$34,985) more in costs for oral cavity and pharyngeal cancers, respectively. The presence of 1 or 2 comorbidities increased the mean 5-year cumulative costs by $13,342 (95% CI, $6248-$19,186) and $14,139 (95% CI, $6009-$22,217) for patients with oral cavity and pharyngeal cancers, respectively. For 3 or more comorbidities, the mean 5-year cumulative costs increased by $22,196 (95% CI, $15,319-$28,614) and $27,799 (95% CI, $19,139-$36,702) for patients with oral cavity and pharyngeal cancers, respectively. Patients who received chemotherapy accumulated a mean of $26,919 (95% CI, $18,309-$35,056) and $37,407 (95% CI, $29,971-$44,644) more in costs by 5 years for oral cavity and pharyngeal cancers, respectively. CONCLUSIONS AND RELEVANCE: Oral and pharyngeal cancer is burdensome to elderly patients from a Medicare cost perspective. Several factors were associated with 5-year costs, including some modifiable factors that may be potential targets for interventions to reduce overall costs.

Adjusting for unrecorded consumption in survey and per capita sales data: quantification of impact on gender- and age-specific alcohol-attributable fractions for oral and pharyngeal cancers in Great Britain.

AIMS: Large discrepancies are typically found between per capita alcohol consumption estimated via survey data compared with sales, excise or production figures. This may lead to significant inaccuracies when calculating levels of alcohol-attributable harms. Using British data, we demonstrate an approach to adjusting survey data to give more accurate estimates of per capita alcohol consumption. METHODS: First, sales and survey data are adjusted to account for potential biases (e.g. self-pouring, under-sampled populations) using evidence from external data sources. Secondly, survey and sales data are aligned using different implementations of Rehm et al.'s method [in (2010) Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example. Pop Health Metrics 8, 1-12]. Thirdly, the impact of our approaches is tested by using our revised survey dataset to calculate alcohol-attributable fractions (AAFs) for oral and pharyngeal cancers. RESULTS: British sales data under-estimate per capita consumption by 8%, primarily due to illicit alcohol. Adjustments to survey data increase per capita consumption estimates by 35%, primarily due to under-sampling of dependent drinkers and under-estimation of home-poured spirits volumes. Before aligning sales and survey data, the revised survey estimate remains 22% lower than the revised sales estimate. Revised AAFs for oral and pharyngeal cancers are substantially larger with our preferred method for aligning data sources, yielding increases in an AAF from the original survey dataset of 0.47-0.60 (males) and 0.28-0.35 (females). CONCLUSION: It is possible to use external data sources to adjust survey data to reduce the under-estimation of alcohol consumption and then account for residual under-estimation using a statistical calibration technique. These revisions lead to markedly higher estimated levels of alcohol-attributable harm.

Comparison of efficacy, safety, and cost-effectiveness of in-office cup forcep biopsies versus operating room biopsies for laryngopharyngeal tumors.

OBJECTIVE: To compare the diagnostic yield, safety, and cost of biopsies of laryngopharyngeal tumor performed in an office setting with those performed in the operating room (OR) under general anesthesia. STUDY DESIGN: This was a retrospective review of patients' records at Boston Medical Center from 2006 to 2008. METHODS: In-office biopsies were performed using flexible digital videolaryngoscopy with cup forcep biopsies taken via the working channel in patients in whom cancer was strongly suspected. Patients whose in-office biopsies were nondiagnostic or suspected to be falsely negative were taken to the OR for biopsy under general anesthesia and served as the control group. RESULTS: Twelve patients fit the selection criteria and had in-office biopsies attempted. One patient could not tolerate the in-office biopsy. Seven of the 11 in-office biopsies performed were diagnostic for squamous cell carcinoma. The average cost (facility and professional otolaryngology charges) for an in-office biopsy was $2053.91. Five of these patients required further biopsy in the OR at an average cost (charges for surgeon, OR, anesthesia, and recovery room) of $9024.47. There were no significant complications reported for any of the procedures. CONCLUSIONS: In patients with strongly suspected laryngopharyngeal cancer, in-office cup forcep biopsies were 64% diagnostic. When compared with the OR, in-office cup biopsies of laryngopharyngeal tumor are safe and considerably more cost-effective. Although 36% of patients required operative biopsies, the cost would have been considerably higher in this cohort if all patients had gone to the OR for biopsies.

The cost burden of oral, oral pharyngeal, and salivary gland cancers in three groups: commercial insurance, Medicare, and Medicaid.

BACKGROUND: Head and neck cancers are of particular interest to health care providers, their patients, and those paying for health care services, because they have a high morbidity, they are extremely expensive to treat, and of the survivors only 48% return to work. Consequently the economic burden of oral cavity, oral pharyngeal, and salivary gland cancer (OC/OP/SG) must be understood. The cost of these cancers in the U.S. has not been investigated. METHODS: A retrospective analysis of administrative claims data for 6,812 OC/OP/SG cancer patients was undertaken. Total annual health care spending for OC/OP/SG cancer patients was compared to similar patients without OC/OP/SG cancer using propensity score matching for enrollees in commercial insurance, Medicare, and Medicaid. Indirect costs, as measured by short term disability days were compared for employed patients. RESULTS: Total annual health care spending for OC/OP/SG patients during the year after the index diagnosis was $79,151 for the Commercial population. Health care costs were higher for OC/OP/SG cancer patients with Commercial Insurance ($71,732, n = 3,918), Medicare ($35,890, n = 2,303) and Medicaid ($44,541, n = 585) than the comparison group (all p < 0.01). Commercially-insured employees with cancer (n = 281) had 44.9 more short-term disability days than comparison employees (p < 0.01). Multimodality treatment was twice the cost of single modality therapy. Those patients receiving all three treatments (surgery, radiation, and chemotherapy) had the highest costs of cost of care, from $96,520 in the Medicare population to $153,892 in the Commercial population. CONCLUSIONS: In the U.S., the cost of OC/OP/SG cancer is significant and may be the most costly cancer to treat in the U.S. The results of this analysis provide useful information to health care providers and decision makers in understanding the economic burden of head and neck cancer. Additionally, this cost information will greatly assist in determining the cost-effectiveness of new technologies and early detection systems. Earlier identification of cancers by patients and providers may potentially decrease health care costs, morbidity and mortality.

Incidence and costs of treatment-related complications among patients with advanced squamous cell carcinoma of the head and neck.

OBJECTIVE: To evaluate the incidence and costs of complications due to radiotherapy alone vs platinum-based chemoradiotherapy among patients diagnosed as having advanced squamous cell carcinoma of the head and neck (ASCCHN) from a payer perspective. DESIGN: Retrospective cohort study. SETTING: Data from the PharMetrics Patient-Centric Database from June 2000 through June 2006. PATIENTS: The study included patients with ASCCHN and an indication of a secondary malignant neoplasm (both identified based on International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes), 124 of whom were treated with radiotherapy alone and 77 of whom were treated with chemoradiotherapy (including 53 with cisplatin plus radiotherapy, 26 with carboplatin plus radiotherapy, and 2 with cisplatin and carboplatin plus radiotherapy). The patients were assigned to 1 of 2 cohorts based on treatment type-radiotherapy only and platinum-based chemoradiotherapy-and were followed up for 6 months. MAIN OUTCOME MEASURES: Incidence and costs of treatment-related complications associated with chemotherapy in ASCCHN. RESULTS: We found significantly (P < .001) higher rates of treatment-related complications among patients receiving chemoradiotherapy (86%) than among patients receiving only radiotherapy (51%). The mean per-patient costs associated with treatment-related complications were approximately $10 000 higher among patients who received chemoradiotherapy than among those treated with radiotherapy alone (P < .001). These costs represented 17% of the total costs during follow-up for patients who received chemoradiotherapy and 11% of costs for those who received radiotherapy. The most expensive complications were dehydration and/or electrolyte imbalance and oral complications. CONCLUSIONS: Our study results suggest that the attributable incidence and costs of treatment-related complications associated with chemotherapy in ASCCHN are substantial. The emergence of safer treatments may have the advantage of alleviating this cost burden.

Health and economic implications of HPV vaccination in the United States.

BACKGROUND: The cost-effectiveness of prophylactic vaccination against human papillomavirus types 16 (HPV-16) and 18 (HPV-18) is an important consideration for guidelines for immunization in the United States. METHODS: We synthesized epidemiologic and demographic data using models of HPV-16 and HPV-18 transmission and cervical carcinogenesis to compare the health and economic outcomes of vaccinating preadolescent girls (at 12 years of age) and vaccinating older girls and women in catch-up programs (to 18, 21, or 26 years of age). We examined the health benefits of averting other HPV-16-related and HPV-18-related cancers, the prevention of HPV-6-related and HPV-11-related genital warts and juvenile-onset recurrent respiratory papillomatosis by means of the quadrivalent vaccine, the duration of immunity, and future screening practices. RESULTS: On the assumption that the vaccine provided lifelong immunity, the cost-effectiveness ratio of vaccination of 12-year-old girls was $43,600 per quality-adjusted life-year (QALY) gained, as compared with the current screening practice. Under baseline assumptions, the cost-effectiveness ratio for extending a temporary catch-up program for girls to 18 years of age was $97,300 per QALY; the cost of extending vaccination of girls and women to the age of 21 years was $120,400 per QALY, and the cost for extension to the age of 26 years was $152,700 per QALY. The results were sensitive to the duration of vaccine-induced immunity; if immunity waned after 10 years, the cost of vaccination of preadolescent girls exceeded $140,000 per QALY, and catch-up strategies were less cost-effective than screening alone. The cost-effectiveness ratios for vaccination strategies were more favorable if the benefits of averting other health conditions were included or if screening was delayed and performed at less frequent intervals and with more sensitive tests; they were less favorable if vaccinated girls were preferentially screened more frequently in adulthood. CONCLUSIONS: The cost-effectiveness of HPV vaccination will depend on the duration of vaccine immunity and will be optimized by achieving high coverage in preadolescent girls, targeting initial catch-up efforts to women up to 18 or 21 years of age, and revising screening policies.

The economic burden of noncervical human papillomavirus disease in the United States.

OBJECTIVE: The purpose of this study was (1) to estimate the direct medical costs of 7 major noncervical human papillomavirus (HPV)-related conditions that include genital cancers, mouth and oropharyngeal cancers, anogenital warts, and juvenile-onset recurrent respiratory papillomatosis, and (2) to approximate the economic burden of noncervical HPV disease. STUDY DESIGN: For each condition, we synthesized the best available secondary data to produce lifetime cost per case estimates, which were expressed in present value. Using an incidence-based approach, we then applied these costs to develop an aggregate measure of economic burden. RESULTS: The economic burden that was associated with noncervical HPV-6-, -11-, -16-, and -18-related conditions in the US population in the year 2003 approximates $418 million (range, $160 million to $1.6 billion). CONCLUSION: The economic burden of noncervical HPV disease is substantial. Analyses that assess the value of investments in HPV prevention and control programs should take into account the costs and morbidity and mortality rates that are associated with these conditions.

Cost of care for early- and late-stage oral and pharyngeal cancer in the California Medicaid population.

BACKGROUND: This study documents the direct medical costs associated with treating oral and pharyngeal squamous cell carcinoma (OSCC) as early- or late-stage disease according to the current standard of care. METHODS: This retrospective analysis of California Medicaid claims data calculated direct payments for patients diagnosed with OSCC. Patients were defined as being treated for early- or late-stage disease based on treatment modality. Regression determined significant predictors of year-1 cost of care following diagnosis. RESULTS: Median year-1 cost of care following initial diagnosis was $25,319 for the 229 patients identified. Regression results determined that treatment modality and medical comorbidities were significant in predicting costs (p < .05). Costs for patients treated as having early-stage OSCC were approximately 36% less than for those treated as having late-stage disease (p = .002). CONCLUSION: Treatment for OSCC is a significant cost from Medicaid's perspective, and these data suggest early detection may ease its economic burden.

Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap.

BACKGROUND: Pharyngoesophageal defects are commonly reconstructed with free jejunal or fasciocutaneous flaps, with various outcomes, and a direct comparison is lacking. METHODS: Fifty-seven circumferential pharyngoesophageal reconstructions with an anterolateral thigh flap (n = 26 patients) performed by a single surgeon or jejunal flap (n = 31 patients) performed by six experienced surgeons between 1998 and 2004 were reviewed and outcomes were compared. RESULTS: Total flap loss occurred in one (4 percent) and two (6 percent) patients, fistula rates were 8 percent and 3 percent, and stricture rates were 15 percent and 19 percent in the anterolateral thigh and jejunal flap groups, respectively (p > 0.5). A completely oral diet was achieved in 95 percent and 65 percent, and fluent tracheoesophageal speech was achieved in 89 percent and 22 percent of patients with the anterolateral thigh and jejunal flaps, respectively (p < 0.01). The mean lengths of postoperative ventilator support, intensive care unit stay, and hospital stay were 1.0 +/- 0.2, 1.7 +/- 1.0, and 8.0 +/- 3.7 days for the anterolateral thigh flap group and 2.2 +/- 3.0, 3.0 +/- 3.2, and 12.6 +/- 7.9 days for the jejunal flap group (p < 0.001 for all), respectively. Mean hospital charges per patient were $8694 and $12,651 for the anterolateral thigh and jejunal flap groups, respectively (p = 0.02). CONCLUSIONS: With the limitations of comparing a single surgeon's results with those of multiple surgeons, the anterolateral thigh flap appears to offer better speech and swallowing functions and quicker recovery and to be more cost-effective than the jejunal flap for pharyngoesophageal reconstruction. The complication rates were similar.

Costs and effectiveness in the care of patients with oral and pharyngeal cancer: analysis of a paradox.

Oropharyngeal cancer is estimated to be the ninth most common cancer worldwide. Its prognosis is largely dependent upon tumour-stage at the time of diagnosis. Stage I and II oropharyngeal cancers are characterized by a 5-year survival rate ranging from 70% to 90%, and the management of these early carcinomas is usually of short duration, easy and very cost-effective. On the other hand, the diagnostic evaluation, treatment and management of complications and recurrences of advanced stage oral tumours (stage III and IV) are often very long, complex and costly. They also have very poor prognosis with survival figures dropping to about 20%. Nowadays, most oropharyngeal cancers are detected at a late stage with an overall 5-year survival rate of around 45-50%, and with a conspicuous increase in treatment costs and a worsening of prognosis. Even if formal and comprehensive cost-effectiveness and cost-benefit analyses are not currently available in the oropharyngeal cancer literature, it seems clear that, in the care of these patients, the enormous consumption of resources is not associated with acceptable outcomes. New initiatives should be evaluated, planned and developed for the care of patients with oral and pharyngeal cancer. These strategies should be directed at prevention and early diagnosis in order to increase patient survival and quality of life and decrease the consumption of health care resources.

[Radiotherapy of epipharyngeal carcinoma: successes and limits as examples of new treatment strategies]. / Strahlentherapie des Epipharynxkarzinoms: Erfolge und Grenzen als Beispiel neuer Behandlungsstrategien.

In treating cancer patients, disease free survival and survival have been improved during the last decade by technical progress and new systemic therapies. In radiation therapy as well as in any other cancer treatment potential long-term side effects and complications need special attention. The success of doubling tumour control by radiation therapy in patients with head and neck tumours illustrates the needs of long-term follow-ups. Cost-effectiveness has to be considered, when treatment results of RT equal surgical results, as it is often the case in head and neck tumours as well as in other malignant diseases.

Treatment costs for patients with head and neck cancer.

A national health program is inevitable if medical care costs continue to soar as they have in recent years. Those of us treating patients with cancer of the head and neck are aware that the costs are high, but many are not aware of the actual figures involved. In this study, five typical head and neck cancer patients were selected, and the costs incurred by these patients were calcualted. Both direct and indirect medical expenses were considered and are presented. In addition, we report the representative costs of various treatment modalities. An awareness of medical care costs plus appropriate consideration of them in the planning and administration of treatment may help to reduce health care expenses. If we do not control these costs, the government undoubtedly will.