Projected Impact on Labour Productivity Costs of Cancer-Related Premature Mortality in Europe 2018-2040.

AIM: To estimate the potential cost of lost labour productivity due to cancer-related premature mortality in Europe (EU-27 plus Norway, Switzerland, Iceland and United Kingdom) from 2018 to 2040. METHODS: Deaths and years of potential productive life lost due to 23 types of cancer were estimated for 2018-2040, for 31 European countries. The data were analysed by age groups, by sex and by year. Projected productivity costs were estimated by calculating gross earnings by country, gender and age group using the Human Capital Approach, adjusting for projected labour force participation and unemployment rates. Various data sources were used. Sensitivity analyses were conducted. RESULTS: Between 2018 and 2040, cancer is expected to cause around eight million premature deaths (58% male). The cumulative projected productivity costs in this respect are €1.3 trillion, representing an annual average of €58.7 billion, or 0.43% of the EU-27 gross domestic product. Labour productivity costs are projected to decrease by 6% from 2018 to 2040. The highest cost region is Western Europe, where Germany and France will experience the highest cumulative losses (€288 and €192 billion, respectively). The most costly cancers, in terms of total costs related to productivity losses, are of the lung and colorectum (€264.4 and €116.3 billion, respectively). In terms of average productivity cost per death, the most costly forms of cancer are Hodgkin lymphoma (€301,157) and melanoma (€260,522). CONCLUSION: The novel information presented could help national policymakers anticipate possible areas for cost savings. Action should be taken on disease prevention, on reducing mortality and on delaying the age of death due to Hodgkin lymphoma, brain cancer, leukaemia and melanoma. Furthermore, the study findings enhance our understanding of macroeconomic variables and could be useful in determining a re-allocation of health expenditures.

The economic impact of cancer mortality among working-age individuals in Brazil from 2001 to 2030.

BACKGROUND: About half of cancer deaths in Brazil occur among individuals of working-age (under 65 years for men, under 60 for women), resulting in a substantial economic impact for the country. We aimed to estimate the years of potential productive life lost (YPPLL) and value the productivity lost due to premature deaths from cancer between 2001 and 2015 and the projected to 2030. METHODS: We used the Human Capital Approach to estimate the productivity losses corresponding to YPPLL for cancer deaths in working age people (15-64 years). Mortality data were obtained from the Mortality Information System from 2001 to 2015 and projected between 2016 and 2030. Economic data were obtained from the Continuous National Household Sample Survey and forecasted to 2030. Productivity lost was calculated as the monetary value arising from YPPLL in Int$(2016). RESULTS: Between 2001 and 2030, a total of 2.3 million premature deaths from all cancers combined were observed and forecasted in Brazil (57% men, 43% women), corresponding to 32 million YPPLL and Int$141.3 billion in productivity losses (men: Int$102.5 billion, women: Int$38.8 billion). Between 2001 and 2030, among men, lung (Int$ 12.6 billion), stomach (Int$ 10.6 billion) and colorectal (Int$ 9.4 billion) cancers were expected to contribute to the greatest productivity losses; and among women, it will be for breast (Int$ 10.0 billion), cervical (Int$ 6.4 billion) and colorectal (Int$ 3.2 billion) cancers. CONCLUSIONS: Many preventable cancers result in high lost productivity, suggesting measure to reduce smoking prevalence, alcohol consumption, physical inactivity and inadequate diet, improving screening programs and increasing vaccination coverage for human papillomavirus and hepatitis B would have a positive impact on the economy, as well as reducing morbidity and mortality from cancer.

Estimating Global Friction Periods for Economic Evaluation: A Case Study of Selected OECD Member Countries.

BACKGROUND: The friction cost approach (FCA) offers an alternative to the dominant human capital approach to value productivity losses. Application of the FCA in practice is limited largely due to data availability. Recent attempts have tried to standardise the estimation of friction periods across Europe, but to date, this has not been attempted elsewhere. Our aim was to estimate friction periods for 17 Organisation for Economic Co-operation and Development (OECD) member countries between 2010 and 2021 based on routinely published data. METHODS: We derived friction period estimates for Australia, Austria, Canada, Czechia, Finland, Germany, Hungary, Japan, Korea, Luxembourg, Norway, Poland, Portugal, Sweden, Switzerland, the United Kingdom and the United States. Vacancy stock and flow data was sourced from the OECD's short-term labour situation database from 2010 to 2021, and included the impact of Covid-19 on the labour market. The estimated friction periods were applied to cost cancer-related premature mortality for the United States as an illustrative case. RESULTS: The average friction period in the five non-European countries (Australia, Canada, Korea, Japan and the United States) was 61.0 days (SD 9.4) (range between 44.8 days in Korea and 82.2 days in Canada) and the average friction period in the 12 European countries was 60.6 days (SD 14.8) (range between 34.1 days in Switzerland and 137.3 days in Czechia). In both cases, the outbreak of Covid-19 increased the length of the friction period. Our illustrative case revealed that productivity costs in the US were over a third lower using the study-specific friction period (56 days) compared with the conventionally assumed 90-day friction period applied in the literature as a default measure. CONCLUSIONS: Our results expand the potential application of the FCA outside of Europe and will support greater utilisation of the FCA and wider inclusion of productivity costs in societal-based economic evaluations based on the use of widely available and updated key labour market variables in our selected countries.

Cancer Premature Mortality Costs in Europe in 2020: A Comparison of the Human Capital Approach and the Friction Cost Approach.

The inclusion of productivity costs can affect the outcome of cost-effectiveness analyses. We estimated the value of cancer premature mortality productivity costs for Europe in 2020 using the Human Capital Approach (HCA) and compared these to the Friction Cost Approach (FCA). Cancer mortality data were obtained from GLOBOCAN 2020 by sex and five-year age groups. Twenty-three cancer sites for 31 European countries were included. The HCA and the FCA were valued using average annual gross wages by sex and age group and applied to Years of Potential Productive Life Lost. 2020 friction periods were calculated and all costs were in 2020 euros. Estimated cancer premature mortality costs for Europe in 2020 were EUR 54.0 billion (HCA) and EUR 1.57 billion (FCA). The HCA/FCA cost ratio for Europe was 34.4, but considerable variation arose across countries (highest in Ireland: 64.5 v lowest in Czech Republic: 11.1). Both the HCA and the FCA ranked lung, breast and colorectal as the top three most costly cancers in Europe, but cost per death altered rankings substantially. Significant cost differences were observed following sensitivity analysis. Our study provides a unique perspective of the difference between HCA and FCA estimates of productivity costs by cancer site and country in Europe.

Paid and unpaid productivity losses due to premature mortality from cancer in Europe in 2018.

When someone dies prematurely from cancer this represents a loss of productivity for society. This loss can be valued and provides a measure of the cancer burden. We estimated paid and unpaid productivity lost due to cancer-related premature mortality in 31 European countries in 2018. Lost productivity was estimated for all cancers combined and 23 cancer sites, overall, by region and country. Deaths aged 15 to 64 were abstracted from GLOBOCAN 2018. Unpaid time lost (housework, caring, volunteering) was derived from Eurostat. Paid and unpaid productivity losses were valued using the human capital approach. In total, 347,149 premature cancer deaths occurred (60% male). The total value of cancer-related lost productivity was €104.6 billion. Of this, €52.9 billion (50.6%) was due to lost paid work, and €51.7 billion (49.4%) to unpaid work. Females accounted for 36.7% of paid work costs but half (51.1%) of the unpaid work costs. Costs were highest in Western Europe (€52.0 billion). The most costly cancer was lung (€21.7 billion), followed by breast (€10.6 billion). The average loss per premature death was highest for Hodgkin's lymphoma (€506 345), melanoma (€450 694), brain cancer (€428 449) and leukaemia (€378 750). Cancer-related lost productivity costs are significant. Almost half are due to unpaid work losses, indicating the importance of considering both paid and unpaid labour in assessing the cancer economic burden. The high cost per premature death of some less common cancers illustrates the potential benefits that could accrue from investment in prevention and control of these cancers.

The cost of lost productivity due to premature mortality associated with COVID-19: a Pan-European study.

BACKGROUND: Economic cost estimates have the potential to provide a valuable alternative perspective on the COVID-19 burden. We estimate the premature mortality productivity costs associated with COVID-19 across Europe. METHODS: We calculated excess deaths between the date the cumulative total of COVID-19 deaths reached 10 in a country to 15th May 2020 for nine countries (Belgium, France, Germany, Italy, The Netherlands, Portugal, Spain, Sweden and Switzerland). Gender- and age-specific excess deaths and Years of Potential Productive Life Lost (YPPLL) between 30 and 74 years were calculated and converted into premature mortality productivity costs €2020 for paid and unpaid work using the Human Capital and the Proxy Good Approaches. Costs were discounted at 3.5%. RESULTS: Total estimated excess deaths across the nine countries were 18,614 (77% in men) and YPPLL were 134,190 (77% male). Total paid premature mortality costs were €1.07 billion (87% male) with Spain (€0.35 billion, 33.0% of total), Italy (€0.22 billion; 20.6%) and The Netherlands (€0.19 billion; 17.5%) ranking highest. Total paid and unpaid premature mortality costs were €2.89 billion (77% male). Premature mortality costs per death ranged between €40,382 (France) and €350,325 (Switzerland). Spain experienced the highest premature mortality cost as a proportion of Gross Domestic Product (0.11%). CONCLUSION: Even in the initial period of the pandemic in Europe, COVID-19-related premature mortality costs were significant across Europe. We provide policy makers and researchers with a valuable alternative perspective on the burden of the virus and highlight potential economic savings that may be accrued by applying timely public health measures.

Experiencing financial toxicity associated with cancer in publicly funded healthcare systems: a systematic review of qualitative studies.

PURPOSE: Understanding how patients and families experience, respond to, and cope with the financial burden associated with cancer could assist in identifying future research priorities and developing relevant interventions to assist patients and families facing financial hardship. This systematic review offers a synthesis of the qualitative evidence on cancer-related financial toxicity from the perspective of patients and/or informal caregivers in publicly funded healthcare systems where it might be expected that financial protection would be strongest. METHODS: Articles published between January 1, 2005, and March 7, 2019, describing financial burden experienced by cancer patients and/or informal caregivers were identified using OVID MEDLINE Embase and PsychInfo, CINAHL, Business Source Complete, and EconLit databases. English language, peer-reviewed qualitative papers describing studies conducted in countries with predominantly publicly funded healthcare systems were eligible. Quality appraisal was conducted using CASP Quality Appraisal Checklist. Narrative synthesis was completed with extracted data and themes identified inductively by all team members. RESULTS: Twelve articles were identified as eligible. Articles reported on 10 studies conducted in Australia (n = 2), Canada (n = 2), England (n = 3), and Ireland (n = 3). The papers illustrate the complexity and multifaceted nature of experiencing financial hardship following a cancer diagnosis. Each contributes to the whole picture, providing different viewpoints regarding various and diverse forms of financial hardship, the process of confronting financial challenges, working to overcome difficulties, and coping with the resulting impacts. Synthesis of the studies suggested five themes: household and medical costs are increased, financial resources are reduced, financial change and financial hardship vary, financial hardship has many consequences, various mitigation strategies are used. CONCLUSION: Cancer patients and their families can experience a broad range of impacts when they are facing and coping with financial toxicity. Consistent gaps in support highlight that strategies to mitigate financial effects related to travel, accommodation, medications, family support, and income replacement are needed for many patients and families even in the context of publicly funded healthcare systems. IMPLICATIONS FOR CANCER SURVIVORS: Survivors need to be informed early in their cancer experience about the potential financial burden associated with cancer treatment and its impact on survivors and their family members.

Can the sustainable development goals for cancer be met in Brazil? A population-based study.

Background: A one-third reduction in premature mortality (30-69 years) from chronic noncommunicable diseases is goal 3.4 of the United Nations Sustainable Development Goals (UN SDG). The burden of NCDs is expected to continue to increase in low- and middle-income countries, including Brazil. Objectives: The aim of this study was to assess geographical and temporal patterns in premature cancer mortality in Brazil between 2001 and 2015 and to predict this to 2030 in order to benchmark against the 3.4 SDG target. Methods: We used data on deaths from cancer in those aged 30-69, by age group, sex and cancer site, between 2001 and 2015 from the National Mortality Information System of Brazil (SIM). After correcting for ill-defined causes, crude and world age-standardised mortality rates per 100,000 inhabitants were calculated nationally and for the 5 regions. Predictions were calculated using NordPred, up to 2030. Results: The difference in observed (2011-2015) and predicted (2026-2030) mortality was compared against the SDG 3.4 target. Between 2011-2015 and 2026-2030 a 12.0% reduction in premature cancer age-standardised mortality rate among males and 4.6% reduction among females is predicted nationally. Across regions this varied from 2.8% among females in North region to 14.7% among males in South region. Lung cancer mortality rates are predicted to decrease among males but not among females nationally (men 28%, females 1.1% increase) and in all regions. Cervical cancer mortality rates are projected to remain very high in the North. Colorectal cancer mortality rates will increase for both sexes in all regions except the Southeast. Conclusions and recommendation: Cancer premature mortality is expected to decrease in Brazil, but the extent of the decrease will be far from the SDG 3.4 target. Nationally, only male lung cancer will be close to reaching the SDG 3.4 target, reflecting the government's long-term efforts to reduce tobacco consumption. Projected colorectal cancer mortality increases likely reflect the epidemiological transition. This and, cervical cancer control will continue to be major challenges. These results will help inform strategic planning for cancer primary prevention, early detection and treatment programs; such initiatives should take cognizance of the regional differences highlighted here.

Friction Costs and the Chain of Vacancies Problem: A Novel Vacancy Multiplier Solution.

OBJECTIVES: A key criticism of applying the friction cost approach (FCA) to productivity cost estimation is its focus on a single friction period. A more accurate estimate of the friction cost of worker absence requires consideration of the chain of secondary vacancies arising from the opening of a new primary vacancy. Currently, empirical evidence on this is almost absent. We suggest an original approach to empirically estimate productivity costs that include a chain of secondary vacancies. METHODS: The vacancy multiplier is based on labor market flows and transition probabilities between states of employment, unemployment, and economic inactivity. It is a summed infinite geometric series using a common ratio et - the probability of an employed person filling a new job vacancy in a given year. We report vacancy multipliers for 30 European countries for 2011-2019. RESULTS: The average multiplier across Europe is 2.21 (standard deviation [SD] = 0.40) in 2019, meaning that every new primary vacancy created a chain of secondary vacancies that increased the primary friction cost by a factor of 2.21. The equivalent multiplier is 1.99 (SD = 0.37) between 2011 and 2019. Romania had the lowest country-specific multiplier (1.11 in 2011), and Greece the highest (4.51 in 2011). CONCLUSIONS: Our results highlight the extent of underestimation of current FCA costs, comprise a resource for future researchers, and provide an implementable formula to compute the multiplier for other countries.

Employer survey to estimate the productivity friction period.

OBJECTIVES: The friction cost approach (FCA) is one way to estimate lost productivity, which considers the time taken to replace an employee, known as the friction period. The friction period may be influenced by local labour market conditions, limiting the relevance of international FCA estimates. The objective was to estimate the time and costs of replacing an employee in Australia. METHODS: Staff responsible for recruitment in businesses across Australia were surveyed about the last management and non-management employee hired, workforce composition, friction period time and costs, and team dynamic effects. Primary analyses were conducted on respondents that recruited in the past 12 months. The friction period was decomposed into three periods: recruitment decision, recruitment period, and training period. Descriptive statistics of the friction period time and costs, and team dynamic effects were calculated. RESULTS: The sample consisted of Australian businesses (N = 274), primarily micro-organisations (2-4 employees, 44%) in urban locations (75%). The time (12.3 weeks; SD 15.1) and costs ($6230; SD $17,502) to replace a manager were higher than those to replace non-managers (10.0 weeks, SD 13.01; $2666, sd $7849). The training period represented the longest time component in replacing an employee (38-40% of the total friction period). There was an increasing impact on other employees' productivity, particularly for absent managers as time off work increased. CONCLUSIONS: The friction period in Australia was similar to international estimates. Interestingly, the friction period mainly consisted of time outside the recruitment period; the decision to recruit and the training period.

Living well with chronic illness: How social support, loneliness and psychological appraisals relate to well-being in a population-based European sample.

Positive social and psychological appraisals may help maintain well-being in illness, but few studies have systematically investigated this in a European context. After controlling for sociodemographic, health and objective social factors, we employed multilevel regression modelling to establish if appraisals predict well-being in three illness groups (n = 10,577). In addition to health and financial status, positive appraisals were consistent predictors of well-being. Social appraisals had stronger associations with well-being than extent of social contact. Optimism and resilience appeared more important in those limited by health than those who were not. Findings may inform interventions aimed at supporting people coping with illness.

Advances in the methodological approach to friction period estimation: A European perspective.

The friction cost approach (FCA) estimates the productivity costs of disease from an employer's perspective but the lack of estimates of friction periods in different countries limits its use. Our aim was to use labour market aggregates to generate two alternative estimates of the friction period for European countries and to apply the FCA to illustrate the impact on cancer-related lost productivity costs. We included thirty countries (EU 27 + the United Kingdom, Switzerland and Norway). Base-case Method 1BC used annual Dutch vacancy stock and flow data (2001-2019) to estimate friction periods for this country. A regression model was employed using Dutch data and country-specific vacancy and unemployment rates to generate country-specific friction period estimates for the other 29 countries. Alternative Method 2ALT used country-specific newly occupied jobs as a proxy vacancy flow variable and vacancy stock data to generate friction period estimates. These were applied, within the FCA, to premature cancer mortality data (from GLOBOCAN2018) for all cancers combined for Western European countries. Costs are in €2018. Method 1BC estimated friction periods in 2018 ranged from 70.8 days for Greece to 145.9 days for the Czech Republic, with a mean duration of 95.3 days. Method 2ALT produced a mean friction period of 80.0 days. On average, across countries, Method 2ALT friction periods were 15.4 days (-18.5%) shorter than Method 1BC estimates. Friction period estimates over the last decade were shorter than those for 2018 reflecting lower vacancy rates. Total cancer premature mortality costs according to FCA Method 1BC amounted to €1.0 billion in 2018 for Western Europe compared to €0.99 billion for Method 2ALT. We developed two alternative - and viable - methods to estimate country-specific friction periods. These approaches will enable researchers to apply the FCA to estimate the productivity cost of diseases across Europe from an employer's perspective.

Financial toxicity associated with a cancer diagnosis in publicly funded healthcare countries: a systematic review.

PURPOSE: Financial toxicity related to cancer diagnosis and treatment is a common issue in developed countries. We seek to systematically summarize the extent of the issue in very high development index countries with publicly funded healthcare. METHODS: We identified articles published Jan 1, 2005, to March 7, 2019, describing financial burden/toxicity experienced by cancer patients and/or informal caregivers using OVID Medline Embase and PsychInfo, CINAHL, Business Source Complete, and EconLit databases. Only English language peer-reviewed full papers describing studies conducted in very high development index countries with predominantly publicly funded healthcare were eligible (excluded the USA). All stages of the review were evaluated in teams of two researchers excepting the final data extraction (CJL only). RESULTS: The searches identified 7117 unique articles, 32 of which were eligible. Studies were undertaken in Canada, Australia, Ireland, UK, Germany, Denmark, Malaysia, Finland, France, South Korea, and the Netherlands. Eighteen studies reported patient/caregiver out-of-pocket costs (range US$17-US$506/month), 18 studies reported patient/caregiver lost income (range 17.6-67.3%), 14 studies reported patient/caregiver travel and accommodation costs (range US$8-US$393/month), and 6 studies reported financial stress (range 41-48%), strain (range 7-39%), or financial burden/distress/toxicity among patients/caregivers (range 22-27%). The majority of studies focused on patients, with some including caregivers. Financial toxicity was greater in those with early disease and/or more severe cancers. CONCLUSIONS: Despite government-funded universal public healthcare, financial toxicity is an issue for cancer patients and their families. Although levels of toxicity vary between countries, the findings suggest financial protection appears to be inadequate in many countries.

HALO: Study protocol for a single-case experimental design study evaluating the moderating impact of a befriending intervention on the association between loneliness and health in older adults.

Background: Loneliness in later life is often addressed with befriending interventions, yet evidence for their effectiveness is limited. Meanwhile it is known that loneliness has a deleterious impact on health. The aim of the study is to evaluate whether a befriending service for older adults mitigates the impact of loneliness on health outcomes, and to identify mechanisms through which befriending interventions might impact upon health. Methods: A mixed methods design is used. The quantitative component utilises an AB single-case experimental design, to gather intensive longitudinal data. These data will be analysed using a generalised additive modelling approach. The qualitative component of the study uses semi-structured dyadic interviews, structured and analysed according to the principles of constructivist grounded theory. Findings will then be triangulated according to an existing mixed methods integration protocol. Discussion: This mixed methods design has the potential to inform national and international policy in relation to befriending interventions for older adults. In addition, there is the potential for study results to inform our theoretical understanding of the nature of the relationship between loneliness and health. Trial registration: ClinicalTrials.gov identifier NCT04301167 (10 th March 2020). Protocol version 1.1, 26 th June 2020.

Variation in the methodological approach to productivity cost valuation: the case of prostate cancer.

BACKGROUND: Standardised integration of productivity costs into health economic evaluations is hindered by equity and distributional concerns. Our aim was to explore the distributive impact of productivity cost methodological variation, describing the consequences for different groups. METHODS: 527 prostate cancer survivors (2-5 years post-diagnosis) completed questions on work patterns since diagnosis. Productivity loss, categorised into temporary/permanent absenteeism, reduced hours and presenteeism, were costed in €2012. Valuation approaches included the human capital approach (HCA) and the friction cost approach (FCA), with wage multipliers (WM) applied in additional analyses. Both national and self-reported wages were used. Costs were compared across socio-demographic and economic characteristics using non-parametric tests. RESULTS: The estimated base case (HCA, using national wages) total productivity cost was €44,201 per prostate cancer survivor. Permanent absenteeism accounted for the largest cost (€18,537), followed by reduced work hours (€11,130), presenteeism (€8148) and temporary absenteeism (€6386). Alternative valuation estimates ranged from - 90% (FCAnational wage: €4625) to + 82% (HCAWMself-reported wage: €80,485) compared to the base case and were consistently higher for self-reported wages compared to national wages. Statistically significant differences in productivity cost were found across four of the six survivor socio-demographic and economic characteristics by valuation approach, despite no significant difference in their physical unit equivalents. CONCLUSIONS: Our results indicate that the distributional impact of productivity costs varies by socio-economic and demographic characteristics. We advocate that: productivity loss should be reported in physical units where possible; cost estimation should be subject to sensitivity analysis, and only where this is not feasible, that the HCA and national wages be used to value productivity loss where equity concerns are paramount.

Beyond care burden: associations between positive psychological appraisals and well-being among informal caregivers in Europe.

PURPOSE: The burden of caring for a family member or friend can have a negative impact on caregiver health and well-being, yet caring can also have positive consequences. Understanding the factors that may enhance caregiver well-being is merited. METHODS: We used data gathered from the European Quality of Life Survey (EQLS). Using complete case analysis followed by multiple imputation analysis, a series of multilevel regression models were developed to systematically explore the role of three distinct blocks of factors in predicting caregiver well-being as measured by the WHO-5 well-being index: (1) sociodemographic and health factors, (2) care and burden-related factors, and (3) psychological and social appraisals. Differences between frequent caregivers and the general population were also compared on all measures. RESULTS: 36,908 respondents took part in EQLS, with 4171 (11%) identifying as frequent carers. While frequent caregivers reported lower well-being compared to the remaining population, most were happy with the amount of time spent caring. Our model explained approximately 32% of variance in well-being scores. After examining the role of known risk factors, all positive psychological appraisals were associated with higher well-being (p < .001). In order of magnitude these were optimism, perceived autonomy, sense of purpose, resilience, and perceived levels of social inclusion. Self-rated health was the strongest predictor of well-being while female carers and those with high levels of various burden measures reported lower well-being. CONCLUSIONS: Findings suggest that caregiver well-being is influenced by more than simply the burden of care. As well as attempting to reduce burden, interventions aimed at supporting caregivers could focus on fostering more positive appraisals to enhance well-being in this group.

Problems sleeping with prostate cancer: exploring possible risk factors for sleep disturbance in a population-based sample of survivors.

PURPOSE: This study aimed to investigate the prevalence of sleeping problems in prostate cancer survivors and to explore the role of predisposing, precipitating and perpetuating factors in this process. METHODS: Using a cross-sectional design, 3348 prostate cancer survivors between 2 and 18 years post diagnosis reported experiences of insomnia using the QLQC30, along with their sociodemographic characteristics, health status and treatment(s) received. The EQ5D-5L and QLQPR25 assessed survivors' overall and prostate cancer-specific health-related quality of life. A hierarchical multiple regression analysis was constructed with three blocks: (1) predisposing (e.g. demographics at diagnosis), (2) precipitating (e.g. disease extent, treatment) and (3) perpetuating factors (e.g. side effects). RESULTS: Nineteen percent of survivors reported significant problems sleeping. The final model accounted for 31% of the variance in insomnia scores (p < .001). In order of magnitude, associates of sleep disturbance were urinary symptoms (ß = 0.22; p < .001), experiencing symptoms of depression/anxiety (ß = 0.18; p < .001), hormone treatment-related symptoms (ß = 0.12; p = .001), pain (ß = 0.10; p < .001) and bowel symptoms (ß = 0.06; p = .005). Having a lower education and more comorbidities at diagnosis also predicted sleep problems. CONCLUSION: Results suggest that it is the ongoing adverse effects of prostate cancer and its treatment (e.g. urinary symptoms) that put survivors most at risk of sleep problems. Strong associations with symptoms of depression/anxiety were also observed. Findings highlight the need for health care practitioners to treat and manage adverse effects of prostate cancer treatment in order to mitigate sleep disturbance in survivors.

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.

Expecting the worst? The relationship between retrospective and prospective appraisals of illness on quality of life in prostate cancer survivors.

OBJECTIVE: Despite a generally good prognosis, many prostate cancer survivors have poor quality of life (QOL). A greater understanding of how psychological appraisals influence QOL is merited given their potentially modifiable nature. In this study, we considered how elements of survivors' retrospective and prospective appraisals relate to QOL. METHODS: A total of 1229 prostate cancer survivors between 2 and 5 years post-diagnosis, identified from a population-based National Cancer Registry, were asked questions on their socio-demographics, health, treatment received, and adverse-effects using a cross-sectional design. QOL was assessed using the EORTC QLQ-C30. Retrospective appraisals were assessed by asking survivors to reflect on their experience of treatment-related adverse-effects compared with their prior expectations. A fear of recurrence scale assessed prospective appraisals of future disease course. A multiple regression model explored the impact of psychological appraisals on QOL, after controlling for socio-demographic, treatment, and health-related factors. RESULTS: The model was significant explaining 37% of variance in QOL. The strongest associate with QOL was fear of recurrence (ß = -.29; P < .001). Survivors who experienced side effects that were worse than expected had significantly lower QOL (ß = -.10; P = .002). Other significant correlates of lower QOL were presence of comorbidities, having undergone a less invasive treatment, and having more advanced disease. Working at diagnosis and having a higher level of education were significantly associated with higher QOL. CONCLUSIONS: Results suggest both retrospective and prospective appraisals are independently related to QOL in prostate cancer. Providing survivors with more information about possible adverse effects of treatment, as well as providing appropriate information regarding future disease progression, may improve QOL.