Association of race/ethnicity and patient care experiences with healthcare utilization and healthcare costs among prostate cancer survivors: A SEER-CAHPS study.

INTRODUCTION: This study aimed to evaluate the association of race/ethnicity and patient care experiences (PCEs) with healthcare utilization and costs among US older adults with prostate cancer (PCa). MATERIALS AND METHODS: The study used data from 2007 to 2015 Surveillance, Epidemiology, and End Results dataset linked to Medicare Consumer Assessment of Healthcare Providers and Systems survey and Medicare claims (SEER-CAHPS). We identified males aged ≥65 years who completed a CAHPS survey within 6-60 months post-PCa diagnosis. Covariate-adjusted associations of six CAHPS PCE composite measures with any emergency department visit and any inpatient stay (using logistic regressions), and with total part A and part B Medicare costs (using generalized linear models) were examined by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, and other). RESULTS: Among 1834 PCa survivors, a 1-point higher score for getting care quickly was associated with higher odds (odds ratio 1.08; 95% confidence interval [CI]: 1.02-1.15; p = 0.009) of any inpatient stay in Hispanic patients. Higher total costs were associated with a 1-point higher score for getting needed care among Hispanic patients ($590.84; 95% CI: $262.15, $919.53; p < 0.001); a 1-point higher score for getting care quickly among Hispanic patients ($405.26; 95% CI: $215.83, $594.69; p < 0.001); and a 1-point higher score for customer service among patients belonging to other races ($361.69; 95% CI: $15.68, $707.69; p = 0.04). DISCUSSION: We observed differential associations by race/ethnicity between PCEs and healthcare utilization and costs. Further research is needed to explore the causes of these associations.

Role of Patient Characteristics and Insurance Type in Newly Diagnosed Multiple Myeloma Care Disparities.

PURPOSE: Little is known about the role of social determinants of health (SDOH) in the utilization of novel treatments among patients with newly diagnosed multiple myeloma (NDMM). METHODS: This retrospective cohort study used Taussig Cancer Center's Myeloma Patient Registry to identify adults with NDMM between January 1, 2017, and December 31, 2021. Electronic health records data captured treatment with (1) triplet or quadruplet regimen and (2) lenalidomide during the first year after NDMM, and (3) stem-cell transplant (SCT) through December 31, 2022. Multivariable logistic regression models examined associations of demographic/clinical characteristics and SDOH with care patterns. RESULTS: We identified 569 patients with median age at diagnosis of 66 years (IQR, 59-73); 55% were male, 76% White, 23% Black, 1.1% other races, insured by Medicare (51%), private payer (38%), Medicaid (8.3%), and self-pay/other (1.8%). In the multivariable models, self-pay/other payers (adjusted odds ratio [AOR], 0.15 [95% CI, 0.03 to 0.54]) was associated with lower odds of triplet or quadruplet regimen, compared with Medicare. Private insurance (AOR, 0.48 [95% CI, 0.27 to 0.86]) and self-pay/other payers (AOR, 0.16 [95% CI, 0.04 to 0.74]) had lower odds of lenalidomide. Black patients (v White; AOR, 0.47 [95% CI, 0.26 to 0.85]) and patients treated at regional hospitals (v Taussig Cancer Center; AOR, 0.27 [95% CI, 0.12 to 0.57]) had lower odds of SCT. The odds of receiving triplet or quadruplet regimen, lenalidomide, and SCT also varied by the year of NDMM. CONCLUSION: Care for NDMM varied based on race, insurance type, year of diagnosis, and treatment facility. It may be useful to examine the impact of insurance-related characteristics and recent policy initiatives on care disparities.

Palliative Intent Treatment and Palliative Care Delivery for Individuals With Advanced Nonsmall Cell Lung Cancer and Melanoma: A Patterns of Care Study.

Introduction: This study aimed to describe the patterns of palliative intent treatment and/or palliative care (PC) delivery among a population-based sample of individuals diagnosed with advanced nonsmall cell lung cancer (NSCLC) or advanced melanoma. Methods: Data from 655 advanced-stage melanoma patients and 2688 advanced-stage NSCLC patients included in the National Cancer Institute's 2017/2018 Patterns of Care study were analyzed. Bivariate and multivariate logistic regression analyses examined factors associated with (1) receipt of PC (including palliative surgery, radiation, and/or systemic therapy after cancer diagnosis, and PC consultations); and (2) timing from diagnosis to receipt of PC. Proportional hazards models also examined factors associated with timing of receipt of PC after diagnosis. Results: A total of 23.5% of those with melanoma and 52.6% of those with NSCLC received some type of PC. For melanoma, stage 4 (vs. stage 3) was associated with higher receipt of PC and receipt within three months of diagnosis. For NSCLC, stage 4 (vs. stage 3) and a diagnosis of depression or psychosocial distress within three months of diagnosis were significantly associated with receipt of PC and receipt within three months of diagnosis. Conclusion: Study findings indicate that those with advanced-stage cancer or who report distress are more likely to receive palliative intent treatment and/or PC. Given that individuals with advanced cancers are living longer and often experience long-lasting symptoms, it is critical to identify and overcome barriers for broadly delivering comprehensive palliative and supportive care.

Lung cancer diagnosis and mortality beyond 15 years since quit in individuals with a 20+ pack-year history: A systematic review.

Current US lung cancer screening recommendations limit eligibility to adults with a pack-year (PY) history of ≥20 years and the first 15 years since quit (YSQ). The authors conducted a systematic review to better understand lung cancer incidence, risk and mortality among otherwise eligible individuals in this population beyond 15 YSQ. The PubMed and Scopus databases were searched through February 14, 2023, and relevant articles were searched by hand. Included studies examined the relationship between adults with both a ≥20-PY history and ≥15 YSQ and lung cancer diagnosis, mortality, and screening ineligibility. One investigator abstracted data and a second confirmed. Two investigators independently assessed study quality and certainty of evidence (COE) and resolved discordance through consensus. From 2636 titles, 22 studies in 26 articles were included. Three studies provided low COE of elevated lung cancer incidence beyond 15 YSQ, as compared with people who never smoked, and six studies provided moderate COE that the risk of a lung cancer diagnosis after 15 YSQ declines gradually, but with no clinically significant difference just before and after 15 YSQ. Studies examining lung cancer-related disparities suggest that outcomes after 15 YSQ were similar between African American/Black and White participants; increasing YSQ would expand eligibility for African American/Black individuals, but for a significantly larger proportion of White individuals. The authors observed that the risk of lung cancer not only persists beyond 15 YSQ but that, compared with individuals who never smoked, the risk may remain significantly elevated for 2 or 3 decades. Future research of nationally representative samples with consistent reporting across studies is needed, as are better data from which to examine the effects on health disparities across different populations.

Association of race/ethnicity and patient care experiences with receipt of definitive treatment among prostate cancer survivors: a SEER-CAHPS study.

PURPOSE: This study aimed to evaluate the association of race/ethnicity, patient care experiences (PCEs), and receipt of definitive treatment and treatment modality among older adults in the United States (US) with localized prostate cancer (PCa). METHODS: Using Surveillance, Epidemiology and End Results dataset linked to Medicare Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) for 2007-2015, we identified men aged ≥ 65 years who completed a CAHPS survey within one year before and one year after PCa diagnosis. Associations of race/ethnicity (non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, non-Hispanic Asian (NHA), and other) and of interactions between race/ethnicity and PCEs (getting needed care, getting care quickly, doctor communication, and care coordination) with the receipt of definitive PCa treatment and treatment modality within 3 and 6 months of diagnosis were examined using logistic regressions. RESULTS: Among 1,438 PCa survivors, no racial/ethnic disparities in the receipt of definitive treatment were identified. However, NHB patients were less likely to receive surgery (vs. radiation) within 3 and 6 months of PCa diagnosis than NHW patients (OR 0.397, p = 0.006 and OR 0.419, p = 0.005), respectively. Among NHA patients, a 1-point higher score for getting care quickly was associated with lower odds (OR 0.981, p = 0.043) of receiving definitive treatment within 3 months of PCa diagnosis, whereas among NHB patients, a 1-point higher score for doctor communication was associated with higher odds (OR 1.023, p = 0.039) of receiving definitive treatment within 6 months of PCa diagnosis. DISCUSSION: We observed differential associations between PCEs and receipt of definitive treatment based on patient race/ethnicity. Further research is needed to explore these associations.

Use of pembrolizumab among older adults with cancer in the United States, before and after FDA approval of its tumor-agnostic indication.

INTRODUCTION: Pembrolizumab, an anticancer immunotherapy agent, has received multiple approvals since its first approval by the U.S. Food and Drug Administration (FDA) in 2014. Limited data exist on its real-world use and shifts post tumor-agnostic approval in 2017 for the treatment of patients with any microsatellite instability-high/mismatch repair deficient (MSI-H/dMMR) solid tumors. This study analyzes pembrolizumab's pre and post-tumor-agnostic approval use among older U.S. adults, revealing its evolving role in oncology practice. METHODS: Using the Surveillance, Epidemiology and End Results (SEER)-Medicare data (2014-2019), we examined the cancer sites of pembrolizumab recipients before and after tumor-agnostic approval. Cancer sites were classified based on the timing of site-specific approvals (before/after tumor-agnostic approval) or no site-specific approval, and inclusion in MSI-H/dMMR clinical trials. RESULTS: The total number of pembrolizumab recipients increased from 4221 in the pre-agnostic period to 20 479 in the post-agnostic period. Pembrolizumab was used for a broad range of cancer types, including cancers that had no FDA-approved site-specific indications at the time of use (25.8% in pre- and 24.6% in post-agnostic periods). The proportion of pembrolizumab recipients receiving pembrolizumab for cancers with site-specific approvals before tumor-agnostic approval decreased from 77.3% to 70.8%. The proportion of pembrolizumab recipients receiving pembrolizumab for cancers that gained site-specific approvals following tumor-agnostic approval almost doubled (6.8% to 13.0%). The proportion of pembrolizumab recipients with cancers included in MSI-H/dMMR trials also doubled (12.3% to 25.5%) following tumor-agnostic approval. CONCLUSIONS: Pembrolizumab use has expanded over time among older adults with cancer, extending beyond those with FDA-approved site-specific indications.

Enhancing Cancer Economic Data Resources: The Interagency Consortium to Promote Health Economics Research on Cancer (HEROiC).

BACKGROUND: Cancer diagnosis and treatment can substantially affect health and financial outcomes for patients and families. Research in health care delivery across the cancer control continuum includes diverse activities led by multiple government and private sector organizations. Assessing the economic drivers and influencing factors associated with costs across this continuum is challenging as organizations leading research efforts often do not have forums to share data, develop linkages, and explore collaborative opportunities. OBJECTIVE: To describe the objectives, activities, and goals of the Interagency Consortium to Promote Health Economics Research on Cancer (HEROiC) to strengthen data resources and capacity for collaborative patient-focused cancer health economics research. MAIN ARGUMENT: HEROiC's goals include assessing the economic burden of cancer; examining the effects of policies, health care setting/system factors, and health service delivery approaches across the cancer control continuum; and enhancing collaborations among researchers and organizations. CONCLUSIONS: Data resources to study economic outcomes associated with cancer control are highly fragmented; HEROIC provides a forum to collaboratively develop, enhance, and utilize data resources and infrastructure for patient-centered cancer health economics research. This includes sharing data resources, developing linkages, identifying new data collection venues, and creating and supporting the dissemination of evidence-based information to diverse stakeholders. These efforts provide critical information to address the economic burden of cancer. RELEVANCE TO THE SPECIAL ISSUE: Cancer diagnosis and treatment affect patient health and financial outcomes. This commentary describes how HEROiC will enhance research data infrastructure and collaborations to support patient-centered research with the goal of reducing the economic burden of cancer.

Hub-and-Spoke centralized intervention to optimize colorectal cancer screening and follow-up: A pragmatic, cluster-randomized controlled trial protocol.

BACKGROUND: Guidelines recommend screening for colorectal cancer (CRC), but participation and abnormal test follow up rates are suboptimal, with disparities by demography. Evidence-based interventions exist to promote screening, but community adoption and implementation are limited. METHODS: The San Diego Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) program is an academic-community partnership testing regional implementation of a Hub-and-Spoke model for increasing CRC screening and follow-up. The "hub" is a non-academic, non-profit organization that includes 17 community health center (CHC) systems, serving over 190 rural and urban clinic sites. The "spokes" are 3 CHC systems that oversee 11-28 clinics each, totaling over 60 clinics. Using a cluster-randomized trial design, 9 clinics were randomized to intervention and 16 to usual care. Within intervention clinics, approximately 5000 eligible patients not up-to-date with CRC screening per year were identified for intervention. Interventions include an invitation primer, a mailed fecal immunochemical test with completion instructions, and phone and text-based reminders (hub) and patient navigation protocol to promote colonoscopy completion after abnormal FIT (spoke). Outcomes include: 1) proportion of patients up-to-date with screening after three years in intervention versus non-intervention clinics; 2) proportion of patients with abnormal FIT completing colonoscopy within six months of the abnormal result. Implementation science measures are collected to assess acceptability, intervention and usual care adaptations, and sustainability of the intervention strategies. CONCLUSION: This large-scale, regional cluster randomized trial among CHCs serving diverse populations is anticipated to accelerate progress in CRC prevention in underserved populations. TRIAL REGISTRATION: NCT04941300.

Association of Employment Disruptions and Financial Hardship Among Individuals Diagnosed with Cancer in the United States: Findings from a Nationally Representative Study.

Financial hardship (FH), defined as adverse patient effects due to cancer costs, is experienced by approximately half of individuals diagnosed with cancer. Many individuals diagnosed with cancer also experience disruptions with their employment. This study examines associations of employment disruptions and FH among a nationally representative sample of individuals diagnosed with cancer in the United States. We utilized 2016/2017 Medical Expenditure Panel Survey Experiences with Cancer data from individuals who worked for pay following cancer diagnosis. Employment disruption included taking extended paid time off work; switching to part-time/less demanding jobs; and/or retiring early due to cancer diagnosis/treatment. FH domains included: material (e.g., borrowing money/financial sacrifices); psychologic (e.g., worrying about medical bills/income); and behavioral (delaying/forgoing healthcare services because of cost). Multivariable logistic regression analyses determined associations of employment disruption and FH. Among 732 individuals with a cancer history, 47.4% experienced employment disruptions; 55.9% experienced any FH. Any FH was significantly more common among individuals with versus without employment disruptions across multiple measures and domains (68.7% vs. 44.5%; P value of difference <0.0001). Individuals with employment disruptions were more likely to have any FH [OR, 2.38; 95% confidence interval (CI), 1.62-3.52] and more FHs (OR, 2.76; 95% CI, 1.96-3.89]. This study highlights that employment disruptions are common and significantly associated with multiple domains of FH among individuals with a cancer history. Employer workplace accommodation, physician discussions regarding potential impacts of cancer care on employment, and other policies to minimize employment disruptions among individuals diagnosed with cancer may reduce FH in this vulnerable population. Significance: Individuals diagnosed with cancer may have employment disruptions; they may also develop FHs. People with cancer who have employment changes are more likely to also have FHs. Physicians and employers can help individuals with cancer through advancing planning, workplace assistance, and improved medical leave and insurance policies.

Applying computer text mining algorithms for oversampling tumor mutation status in medical records for the NCI Patterns of Care studies.

BACKGROUNDS: The National Cancer Institute (NCI) conducts Patterns of Care (POC) studies for selected cancer sites under a Congressional Mandate. These studies aim to collect treatment information beyond what is typically collected by the NCI's Surveillance, Epidemiology, and End Results (SEER) Program. The 2019 POC study focused on non-small cell lung cancer (NSCLC) and melanoma cancer sites. For the NSCLC cases, one of the primary sampling objectives was to oversample patients who tested positive for EGFR/ALK mutations, but initial information on mutation test results was unavailable prior to selecting the study sample. METHODS: To address this, text mining algorithms were developed to screen all eligible NSCLC cases from the SEER database. These algorithms were designed to identify the mutation test status, allowing for stratified sampling based on SEER registry, sex, race/ethnicity, and tumor mutation test results. RESULTS: The final NSCLC sample included 2,434 patients aged 20+ with advanced stage (IIIB-IVB) NSCLC diagnosed in 2017 and 2018. Among this sample, 692 cases (13.2%) tested positive for EGFR/ALK mutations. An evaluation of the text mining algorithms performance, based on cases where both algorithm results and known EGFR/ALK status from medical chart abstraction were available, showed good results: sensitivity of 77.6%, specificity of 90.8%, and an overall accuracy 84.8%. CONCLUSIONS: The adaption of text mining algorithm proved effective in oversample patients with uncommon conditions in studies where electronic medical records are accessible. The 2019 POC study provides valuable data for researchers to evaluate cancer therapy details and patient characteristics, particularly among those with EGFR/ALK test positive cases.

Differences in racial/ethnic disparities in patient care experiences between prostate cancer survivors and males without cancer: A SEER-CAHPS study.

INTRODUCTION: Our purpose was to evaluate whether racial/ethnic disparities in patient care experiences (PCEs) differ between males with prostate cancer ("PCa group") and males without cancer ("non-cancer group"). MATERIALS AND METHODS: This retrospective study used 2007-2015 National Cancer Institute's Surveillance, Epidemiology and End Results registry data linked to Consumer Assessment of Healthcare Providers and Systems surveys. PCa and non-cancer groups were propensity score matched 1:5 on demographic and clinical characteristics. Differences in racial/ethnic disparities (DRD) (non-Hispanic Black [NHB], Hispanic, non-Hispanic Asian [NHA], and Other Races compared to non-Hispanic White [NHW]) in PCEs (getting needed care, getting care quickly, doctor communication, customer service, and getting needed prescription drugs) were compared between matched PCa and non-cancer groups. Per prior literature, DRD in PCE scores were categorized as small (<3), medium (≥3 but <5) or large (≥5). RESULTS: There were 7312 males in the PCa group and 36,559 matched males in the non-cancer group. Within each group, all racial/ethnic minority categories reported worse scores compared to NHW individuals (p < 0.05) for ≥3 PCE composite measures. Compared to PCa group, a larger NHA-NHW difference was observed in non-cancer group for getting needed care (-4.65 in PCa vs. -7.77 in non-cancer; DRD = 3.11, p = 0.029) and doctor communication (-2.46 in PCa vs. -4.85 in non-cancer; DRD = 2.38, p = 0.023). DISCUSSION: In both PCa and non-cancer groups, racial/ethnic minorities reported worse experiences compared to NHW individuals for several PCE measures. However, the difference in getting needed care and doctor communication between NHA and NHW individuals were more pronounced in non-cancer group than PCa group.

Association of Patient Experience of Care and Radiation Therapy Initiation Among Women With Early-Stage Breast Cancer.

PURPOSE: For women diagnosed with early-stage breast cancer, lumpectomy followed by radiation therapy (RT) has been a guideline-recommended treatment. However, lumpectomy followed by hormonal therapy is also an approved treatment for certain women. It is unclear what patient-driven factors are related to decisions to receive RT. This study examined relationships between patient-reported experience of care, an important dimension of health care quality, and receipt of RT after lumpectomy. METHODS AND MATERIALS: We used National Cancer Institute Surveillance, Epidemiology, and End Results data linked to the CMS Medicare Consumer Assessment of Healthcare Providers and Systems patient surveys (SEER-CAHPS) to examine experiences of care among women diagnosed with local/regional stage breast cancer 2000 to 2017 who received lumpectomy, were enrolled in fee-for-service Medicare, completed a CAHPS survey ≤18 months after diagnosis, and survived for this study period. Experience of care was assessed by patient-provided scores for physicians, doctor communication, care coordination, and other aspects of care. Multivariable logistic regression models assessed associations of receipt of external beam RT with care experience and patient sociodemographic and clinical characteristics. RESULTS: The study population included 824 women; 655 (79%) received RT. Women with higher experience of care scores for their personal doctor were significantly more likely to have received any RT (odds ratio [OR], 1.18; P = .033). Nonsignificant trends were observed for associations of increased RT with higher CAHPS measures of doctor communications (OR, 1.15; P = .055) and care coordination (OR, 1.24; P = .051). In contrast, women reporting higher scores for Part D prescription drug plans were significantly less likely to have received RT (OR, 0.78; P = .030). CONCLUSIONS: Patient experience of care was significantly associated with receipt of RT after lumpectomy among women with breast cancer. Health care organization leaders may want to consider incorporating experience of care into quality improvement initiatives and other activities that aim to improve patient decision-making, care, and outcomes.

Rural-Urban Disparities in Patient Care Experiences among Prostate Cancer Survivors: A SEER-CAHPS Study.

BACKGROUND: We sought to evaluate rural-urban disparities in patient care experiences (PCEs) among localized prostate cancer (PCa) survivors at intermediate-to-high risk of disease progression. METHODS: Using 2007-2015 Surveillance Epidemiology and End Results (SEER) data linked to Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, we analyzed survivors' first survey ≥6 months post-diagnosis. Covariate adjusted linear regressions were used to estimate associations of treatment status (definitive treatment vs. none) and residence (large metro vs. metro vs. rural) with PCE composite and rating measures. RESULTS: Among 3779 PCa survivors, 1798 (53.2%) and 370 (10.9%) resided in large metro and rural areas, respectively; more rural (vs. large metro) residents were untreated (21.9% vs. 16.7%; p = 0.017). Untreated (vs. treated) PCa survivors reported lower scores for doctor communication (ß = -2.0; p = 0.022), specialist rating (ß = -2.5; p = 0.008), and overall care rating (ß = -2.4; p = 0.006). While treated rural survivors gave higher (ß = 3.6; p = 0.022) scores for obtaining needed care, untreated rural survivors gave lower scores for obtaining needed care (ß = -7.0; p = 0.017) and a lower health plan rating (ß = -7.9; p = 0.003) compared to their respective counterparts in large metro areas. CONCLUSIONS: Rural PCa survivors are less likely to receive treatment. Rural-urban differences in PCEs varied by treatment status.

Racial/Ethnic Disparities in Patient Care Experiences among Prostate Cancer Survivors: A SEER-CAHPS Study.

PURPOSE: To evaluate racial/ethnic disparities in patient care experiences (PCEs) among prostate cancer (PCa) survivors. METHODS: This retrospective study used 2007-2015 National Cancer Institute Surveillance, Epidemiology and End Results registry data linked to Consumer Assessment of Healthcare Providers and Systems surveys. First survey ≥ 6 months post-PCa diagnosis was analyzed. We performed multivariable linear regression, adjusting for demographic and clinical covariates, to evaluate the association of race/ethnicity (non-Hispanic Whites (NHWs), non-Hispanic Black (NHBs), Hispanic, non-Hispanic Asian (NHAs), and other races) with PCE composite measures: getting needed care, doctor communication, getting care quickly, getting needed prescription drugs (Rx), and customer service. RESULTS: Among 7319 PCa survivors, compared to NHWs, Hispanics, NHBs and NHAs reported lower scores for getting care quickly (ß = -3.69; p = 0.002, ß = -2.44; p = 0.021, and ß = -6.44; p < 0.001, respectively); Hispanics scored worse on getting needed care (ß = -2.16; p = 0.042) and getting needed Rx (ß = -2.93; p = 0.009), and NHAs scored worse on customer service (ß = -7.60; p = 0.003), and getting needed Rx (ß = -3.08; p = 0.020). However, NHBs scored better than NHWs on doctor communication (ß = 1.95, p = 0.006). No statistically significant differences were found between other races and NHWs. CONCLUSIONS: Comparing to NHWs, Hispanics and NHAs reported worse experiences on several PCE composite measures, while NHBs reported worse scores on one but better scores on another PCE composite measure. Further research is needed to understand the reasons behind these disparities and their influence on healthcare utilization and health outcomes among PCa survivors.

Cost-Related Medication Nonadherence and Patient Cost Responsibility for Rural and Urban Cancer Survivors.

PURPOSE: The relationship between out-of-pocket spending and cost-related medication nonadherence among older rural- and urban-dwelling cancer survivors is not well understood. METHODS: This retrospective cohort study used the Surveillance, Epidemiology, and End Results Program, Medicare claims, and the Consumer Assessment of Healthcare Providers and Systems survey linked data resource linked data (2007-2015) to investigate the relationship between cancer survivors' cost responsibility in the year before and after report of delaying or not filling a prescription medication because of cost in the past 6 months (cost-related medication nonadherence). Secondary exposures and outcomes included Medicare spending and utilization. Generalized linear models assessed bidirectional relationships between cost-related medication nonadherence, spending, and utilization. Effects of residence were assessed via interaction terms. RESULTS: Of 6,591 older cancer survivors, 13% reported cost-related medication nonadherence. Survivors were a median 8 years (interquartile range, 4.5-12.5 years) from their cancer diagnosis, 15% were dually Medicare/Medicaid-eligible, and prostate (40%) and breast (32%) cancer survivors were most prevalent. With every $500 USD increase in patient cost responsibility, risk of cost-related medication nonadherence increased by 3% (risk ratio, 1.03; 95% CI, 1.02 to 1.04). After report of cost-related medication nonadherence, patient cost responsibility was 22% higher (95% CI, 1.11 to 1.32) compared with those not reporting nonadherence, amounting to $523 USD (95% CI, $430 USD to $630 USD). Medicare spending and utilization were also higher before and after report of cost-related nonadherence versus none. For survivors residing in rural (18%) and urban (82%) areas, residence did not modify adherence or cost outcomes. CONCLUSION: A bidirectional relationship exists between patient cost responsibility and cost-related medication nonadherence. Interventions reducing urban- and rural-dwelling survivor health care costs and cost-related adherence barriers are needed.

Health insurance and financial hardship in cancer survivors during the COVID-19 pandemic.

Uninsured or underinsured individuals with cancer are likely to experience financial hardship, including forgoing healthcare or non-healthcare needs such as food, housing, or utilities. This study evaluates the association between health insurance coverage and financial hardship among cancer survivors during the COVID-19 pandemic. This cross-sectional analysis used Patient Advocate Foundation (PAF) survey data from May to July 2020. Cancer survivors who previously received case management or financial aid from PAF self-reported challenges paying for healthcare and non-healthcare needs during the COVID-19 pandemic. Associations between insurance coverage and payment challenges were estimated using Poisson regression with robust standard errors, which allowed for estimation of adjusted relative risks (aRR). Of 1,437 respondents, 74% had annual household incomes <$48,000. Most respondents were enrolled in Medicare (48%), 22% in employer-sponsored insurance, 13% in Medicaid, 6% in an Affordable Care Act (ACA) plan, and 3% were uninsured. Approximately 31% of respondents reported trouble paying for healthcare during the COVID-19 pandemic. Respondents who were uninsured (aRR 2.58, 95% confidence interval [CI] 1.83-3.64), enrolled in an ACA plan (aRR 1.86, 95% CI 1.28-2.72), employer-sponsored insurance (aRR 1.70, 95% CI 1.23-2.34), or Medicare (aRR 1.49, 95% CI 1.09-2.03) had higher risk of trouble paying for healthcare compared to Medicaid enrollees. Challenges paying for non-healthcare needs were reported by 57% of respondents, with 40% reporting trouble paying for food, 31% housing, 28% transportation, and 20% internet. In adjusted models, Medicare and employer-sponsored insurance enrollees were less likely to have difficulties paying for non-healthcare needs compared to Medicaid beneficiaries. Despite 97% of our cancer survivor sample being insured, 31% and 57% reported trouble paying for healthcare and non-healthcare needs during the COVID-19 pandemic, respectively. Greater attention to both medical and non-medical financial burden is needed given the economic pressures of the COVID-19 pandemic.

Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions.

Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.

Introduction to the Supplement: Is Now the Time for the Future of Cancer Economics Research?

The National Cancer Institute's Division of Cancer Control and Population Sciences hosted a virtual conference, The Future of Cancer Health Economics Research, in December 2020. This conference brought together a multidisciplinary group of researchers and other stakeholders interested in supporting and developing the field of cancer health economics research to help improve both patient outcomes and health-care systems. The introduction to the supplement describes the origins and planning for the conference and the conference sessions and presentations. The papers included in this supplement, arising from the conference sessions, help strengthened our understanding of what is cancer health economics research and how this field can provide even greater contributions in the future.

Research on the Economics of Cancer-Related Health Care: An Overview of the Review Literature.

We reviewed current literature reviews regarding economics of cancer-related health care to identify focus areas and gaps. We searched PubMed for systematic and other reviews with the Medical Subject Headings "neoplasms" and "economics" published between January 1, 2010, and April 1, 2020, identifying 164 reviews. Review characteristics were abstracted and described. The majority (70.7%) of reviews focused on cost-effectiveness or cost-utility analyses. Few reviews addressed other types of cancer health economic studies. More than two-thirds of the reviews examined cancer treatments, followed by screening (15.9%) and survivorship or end-of-life (13.4%). The plurality of reviews (28.7%) cut across cancer site, followed by breast (20.7%), colorectal (11.6%), and gynecologic (8.5%) cancers. Specific topics addressed cancer screening modalities, novel therapies, pain management, or exercise interventions during survivorship. The results indicate that reviews do not regularly cover other phases of care or topics including financial hardship, policy, and measurement and methods.

Health Economics Research in Primary Prevention of Cancer: Assessment, Current Challenges, and Future Directions.

In the past 2 decades, the demand for information on health economics research to guide health care decision making has substantially increased. Studies have provided evidence that eliminating or reducing tobacco use; eating a healthy diet, including fruit and vegetables; being physically active; reducing alcohol consumption; avoiding ultraviolet radiation; and minimizing exposure to environmental and occupational carcinogenic agents should substantially reduce cancer incidence in the population. The benefits of these primary prevention measures in reducing cancer incidence are not instantaneous. Therefore, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention. This article provides an overview of health economics research related to primary prevention of cancer. We addressed the following questions: 1) What are the gaps and unmet needs for performing health economics research focused on primary prevention of cancer? 2) What are the challenges and opportunities to conducting health economics research to evaluate primary prevention of cancer? and 3) What are the future directions for enhancing health economics research on primary prevention of cancer? Modeling primary prevention of cancer is often difficult given data limitations, long delays before the policy or intervention is effective, possible unintended effects of the policy or intervention, and the necessity of outside expertise to understand key inputs or outputs to the modeling. Despite these challenges, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention of cancer.