Economic burden and treatment patterns of gynecologic cancers in the United States: evidence from the Medical Expenditure Panel Survey 2007-2014.

OBJECTIVE: This study estimated nationally representative medical expenditures of gynecologic cancers, described treatment patterns and assessed key risk factors associated with the economic burden in the United States. METHODS: A retrospective repeated measures design was used to estimate the effect of gynecologic cancers on medical expenditures and utilization among women. Data were extracted from the Medical Expenditure Panel Survey (weighted sample of 609,787 US adults) from 2007 to 2014. Using the behavioral model of health services utilization, characteristics of cancer patients were examined and compared among uterine, cervical, and ovarian cancer patients. Multivariable linear regression models were conducted on medical expenditure with a prior logarithmic transformation. RESULTS: The estimated annual medical expenditure attributed to gynecologic cancers was $3.8 billion, with an average cost of $6,293 per patient. The highest annual cost per person was ovarian cancer ($13,566), followed by uterine cancer ($6,852), and cervical cancer ($2,312). The major components of medical costs were hospital inpatient stays (53%, $2.03 billion), followed by office-based visits (15%, $559 million), and outpatient visits (13%, $487 million). Two key prescription expenditures were antineoplastic hormones (10.3%) and analgesics (9.2%). High expenditures were significantly associated with being a married woman (p<0.001), having private health insurance (p<0.001), being from a low- and middle-income family (p<0.001), or living in the Midwest or the South (p<0.001). CONCLUSION: The key risk factors and components were well described for the economic burden of gynecologic cancers. With a growing population of cancer patients, efforts to reduce the burden of gynecologic cancers are warranted.

Comparing venous thromboembolism prophylactic strategies for ambulatory multiple myeloma patients on immunomodulatory drug therapy.

PURPOSE: Patients with multiple myeloma have an increased incidence of venous thromboembolism. The risk for venous thromboembolism further increases when these patients are placed on immunomodulatory drug therapy. This study aims to determine the incidence of venous thromboembolism in patients with multiple myeloma receiving immunomodulatory drug therapy in the ambulatory setting at UC Health and to investigate adherence with guidelines developed by The National Comprehensive Cancer Network for venous thromboembolism prevention in this patient population. METHODS: A retrospective chart review of patients with multiple myeloma initiated on immunomodulatory drug therapy between January 2000 and January 2014 was conducted. RESULTS: Sixty-two cases met inclusion criteria and were included for analysis. The National Comprehensive Cancer Network guidelines were followed in 33.9% of cases. The rate of venous thromboembolism was 4.8% in guideline adherent cases and 12.2% in guideline nonadherent cases (p = 0.65). The overall incidence of venous thromboembolism was 9.7%. No patients on a low-molecular-weight-heparin agent or warfarin developed a venous thromboembolism, 7.9% patients on aspirin therapy developed a venous thromboembolism, and 23.1% patients on no pharmacologic thromboprophylaxis developed a venous thromboembolism (p = 0.26). CONCLUSION: Ambulatory patients with multiple myeloma who are considered for immunomodulatory drug therapy should be placed on pharmacologic thromboprophylaxis based on individual venous thromboembolism and bleeding risk factors. This study identified the need for increased adherence to national guidelines for venous thromboembolism prevention in patients with multiple myeloma receiving immunomodulatory drug therapy so as to increase the quality of care provided at UC Health.

The effects of a palliative care program on antidepressant use and continuing maintenance medications in near end-of-life oncology patients (the HEALED study).

RATIONAL: The use of antidepressants and maintenance medications for cancer patients in a palliative care setting is controversial. The effectiveness of antidepressants and consequences of discontinuing maintenance medications are unknown in this population. OBJECTIVE: Compare the quality of life of patients taking and not taking antidepressants at entry to a palliative care clinic, and to observe maintenance medication use in this population, along with consequences of stopping them. METHODS: Prospective, monthly review of medications, quality of life, and hospitalizations were recorded from oncology patients that attended a palliative care clinic. In addition, a retrospective chart review of medications and hospitalizations of oncology patients that did and did not attend a palliative care clinic was performed. RESULTS: Forty-three prospective patients were enrolled. Patients had similar quality of life whether or not they were taking antidepressants (p = 0.52). Number of maintenance medications at entry and at final evaluation did not change (p = 0.45). No hospitalizations were caused by discontinuation of maintenance medications. QOL of patients did not decline after coming to the clinic based on the baseline and second FACT-G questionnaires (p = 0.84). Fifty-six patients were included in the retrospective portion of this study. The non-palliative care patients had higher proportions of maintenance medications and rates of hospitalizations when compared to the palliative care patients. CONCLUSION: Quality of life is essentially the same between palliative care patients, whether they are receiving antidepressants or not.

Development of an outpatient oncology symptom management clinic.

The Symptom Management Clinic (SMC) at University Hospital in Cincinnati, OH, was established to meet identified needs of patients with cancer seen in an outpatient setting. The initial step in the formation of the SMC consisted of the development of a business plan and the presentation of that business plan to the hospital administration. The development of clinic procedures using the creation of a guideline for pain management as an example is presented, as are medication reconciliation and patient teaching. Implications for clinical practice include the essential nature of collaborative relationships among medical oncologists, nursing, pharmacy, and administrative staff members. Interdisciplinary collaboration among the staff of the SMC facilitated referral to appropriate services within the institution and community.

Thromboembolic events in patients with colorectal cancer receiving the combination of bevacizumab-based chemotherapy and erythropoietin stimulating agents.

OBJECTIVE: To investigate whether the incidence of thromboembolic events (venous and arterial) increases when bevacizumab-based chemotherapy and erythropoietin stimulating agents (ESAs) are used in combination versus alone. METHODS: A retrospective, pilot study of 79 colorectal cancer patients treated with chemotherapy were divided into 3 groups: bevacizumab (n = 28), ESA (n = 21), and bevacizumab plus ESA (n = 28). The primary end point was the incidence of thromboembolic events. Secondary endpoints included median time-to-event; effect of anticoagulation; and association with concurrent chemotherapy, baseline risk factors, hemoglobin, and performance status. RESULTS: The incidence of thromboembolic events was 11% in the bevacizumab group, 23.8% in the ESA group, and 30% in the combination group (P = 0.194). The median time-to-event was 7.5, 3.5, and 2.5 months, respectively (P = 0.060). The 5 month difference in time-to-event between the bevacizumab group and combination group was significant (P = 0.045). When combining all patients, ESA treatment, prior venous thromboembolic event (VTE), obesity, cardiac disease, and use of exogenous hormones were strong predictors for thromboembolic events. Prior VTE was a strong predictor in those patients in the combination group. CONCLUSION: The incidence of thromboembolic events was increased with the combination of bevacizumab plus ESA compared with either agent alone with chemotherapy. Median time-to-event in the combination group was significantly shorter compared with the bevacizumab group. Prior VTE, cardiac disease, obesity, and exogenous hormone use should be taken in consideration when using the combination of bevacizumab and ESAs.

Epidemiology, pathophysiology, and initial management of chronic immune thrombocytopenic purpura.

PURPOSE: The incidence and epidemiology, the pathogenesis, the clinical symptoms and diagnosis and the first-line therapies for the management of chronic immune thrombocytopenic purpura (ITP) are discussed. In addition, the recommendations of two expert panels for the management of ITP are summarized. SUMMARY: The diagnosis and management of chronic ITP are a challenge to the clinician caring for patients with this disease. Because the pathophysiology of ITP is not completely understood, a variety of medical interventions have been utilized in the management of ITP. National guidelines have established that oral corticosteroids are considered to be first-line therapy for chronic ITP. In addition, the use of intravenous immune globulin has demonstrated efficacy in the treatment of the disease. Intravenous methylprednisolone, anti-D immunoglobulin, and splenectomy have been utilized in recurrent or refractory cases. The use of other immunosuppressant medications and newer thrombopoietin stimulating agents may offer additional treatment options, as presented in the subsequent article. CONCLUSION: The initial management of chronic ITP should consist of the use of oral corticosteroids according to national guidelines. In the absence of a response to this first-line therapy, intravenous gamma globulin, intravenous methylprednisolone, anti-D immunoglobulin, or splenectomy may be considered. These treatments may also be utilized to manage recurrent cases of ITP, prior to consideration of second-line therapies.

Symptom management needs of oncology outpatients.

QUESTION: What were the needs of outpatients for symptom management? METHOD: A multidisciplinary team assembled to determine the need for a symptom management clinic. Two surveys were developed for potential users: one for the outpatients and the other for the attending oncologists. INTERVENTION: During a 3-week period, outpatients were approached after registering for the oncology clinic and while waiting for their appointment. Ninety-five percent of the outpatients approached completed the survey. FINDINGS: A total of 112 surveys revealed that outpatients would attend a symptom management clinic for relief of pain (50%), fatigue (40%), nausea/vomiting (30%), and/or sleeping difficulty (30%). A total of 16 surveys completed by oncologists revealed that outpatients could use more assistance with pain (81%), diet (75%), depression (69%), and/or fatigue (56%). Outpatients felt they would benefit from meeting with a nurse (35%), social worker (21%), dietician (18%), and/or pharmacist (18%). While oncologists thought that the following would complement care: dietician (69%), psychologist (69%), nurse (56%), and/or social worker (56%). Fifty-one percent of the outpatients indicated that they would attend a symptom management clinic and all but one oncologist would refer to this clinic. DISCUSSION: While there exists some disconnect between perceived need for symptom management between outpatient and oncologist, it is evident that pain is the symptom of primary concern. An interdisciplinary team of oncologist, nurse, social worker, dietician, pharmacist, and psychologist could collaboratively address the presenting symptoms. Users, both outpatients and oncologists perceive benefit from a collaborative and interdisciplinary symptom management clinic.

Treatment of cancer-associated thrombosis: distinguishing among antithrombotic agents.

The risk of cancer-associated thrombosis can be substantial, depending on tumor type, extent of cancer, and type of treatment. Unfractionated heparin and warfarin have been used in the prevention of cancer-associated thrombosis, but low-molecular-weight heparin (LMWH) is widely used for the prevention of venous thromboembolism in high-risk patients. Long-term management with warfarin is associated with close monitoring, an increased risk of drug interactions, and bleeding. LMWHs may offer an alternative outpatient treatment strategy for prophylactic treatment because of their simpler dosing, more predictable anticoagulant activity, and improved safety profile. Clinical trials examining the treatment of venous thromboembolism with LMWH in patients with cancer suggest a survival advantage for the treated groups. Subtle differences in the pharmacokinetics of available LMWHs exist, and each LMWH should be regarded as a distinct drug. Pharmacists should be aware of the US Food and Drug Administration-approved uses for each LMWH, dosing options, and the advantages and disadvantages of available delivery systems for various patient populations. Pharmacists can play a major role in educating patients and other health care professionals on risk factor recognition, patient risk stratification, and proper agent selection for prevention and treatment of cancer-associated thrombosis.

Prevalence, causes, and impact of cancer-associated thrombosis.

PURPOSE: Despite advances in the treatment of venous thromboembolism (VTE) in the cancer population, cancer-associated thrombosis remains a serious and potentially life-threatening disease. This article will review the scope and impact of cancer-associated thrombosis, some of the possible risk factors, and current practice patterns. SUMMARY: Epidemiology data identify thrombosis as the second leading cause of mortality in cancer patients following the disease itself. The risk of recurrent VTE and all-cause death is 3-fold higher in patients with concurrent VTE and malignancy compared to non-cancer patients with VTE. It has been estimated that one in seven hospitalized cancer patients who die do so from a pulmonary embolism. Risk factors for cancer-associated thrombosis include tumor type, anti-tumor therapy, surgery, and immobility. Furthermore, an idiopathic VTE can be a predictor of occult malignancy, with one study suggesting that individuals who present with an unprovoked episode of VTE have a 10% frequency of subsequent cancer. The Fundamental Research in Oncology and Thrombosis (FRONTLINE) study collected data on the perceived risks and practice patterns with regard to VTE in cancer patients undergoing surgical and medical management of their malignancy. Additionally, the study provided information on international and regional practice patterns for the management of VTE in cancer patients. Respondents indicated that brain and pancreatic tumors were associated with an increased risk of VTE. Eight percent of respondents considered the use of central venous access lines to be associated with a high risk of VTE. The FRONTLINE study also indicated that surgeons are more likely to use thromboprophylaxis than medical oncologists and that low molecular weight heparins (LMWHs) are the most commonly used method for prevention of VTE. CONCLUSION: Cancer patients are at greater risk of VTE and death compared to non-cancer patients; therefore, optimizing methods for the treatment and prevention of thrombosis is of particular importance in this population.