Do patients with haematological malignancies suffer financial burden? A cross-sectional study of patients seeking care through a publicly funded healthcare system.

BACKGROUND: It is increasingly appreciated that some patients with cancer will experience financial burden due to their disease but little is known specifically about patients with haematological malignancies. Therefore, this study aimed to measure financial toxicity experienced by patients with haematological malignancies in the context of a publicly funded health care system. METHOD: All current patients diagnosed with leukaemia, lymphoma or multiple myeloma, from two major metropolitan health services in Melbourne, Australia were invited to complete a survey capturing; patient demographics, employment status, income sources, financial coping and insurances, OOP expenses and self-reported financial toxicity using a validated measure. RESULTS: Of the 240 people approached, 113 (47 %) participated and most had leukaemia (62 %). Forty-seven (42 %) participants experienced some degree of financial toxicity using the Comprehensive Score for financial toxicity (COST) instrument. On multivariate linear regression, older age (>65 years, p = 0.007), higher monthly income (>$8000, p = 0.008), not having and being forced into unemployment or early retirement (p < 0.001) remained significantly associated with less financial toxicity. CONCLUSION: Financial toxicity is present in Australian haematology patients and those at higher risk may be patients of working age, those without private health insurance and patients that have been forced to retire early or have become unemployed due to their diagnosis.

Non-transplantable cord blood units as a source for adoptive immunotherapy of leukaemia and a paradigm of circular economy in medicine.

Advances in immunotherapy with T cells armed with chimeric antigen receptors (CAR-Ts), opened up new horizons for the treatment of B-cell lymphoid malignancies. However, the lack of appropriate targetable antigens on the malignant myeloid cell deprives patients with refractory acute myeloid leukaemia of effective CAR-T therapies. Although non-engineered T cells targeting multiple leukaemia-associated antigens [i.e. leukaemia-specific T cells (Leuk-STs)] represent an alternative approach, the prerequisite challenge to obtain high numbers of dendritic cells (DCs) for large-scale Leuk-ST generation, limits their clinical implementation. We explored the feasibility of generating bivalent-Leuk-STs directed against Wilms tumour 1 (WT1) and preferentially expressed antigen in melanoma (PRAME) from umbilical cord blood units (UCBUs) disqualified for allogeneic haematopoietic stem cell transplantation. By repurposing non-transplantable UCBUs and optimising culture conditions, we consistently produced at clinical scale, both cluster of differentiation (CD)34+ cell-derived myeloid DCs and subsequently polyclonal bivalent-Leuk-STs. Those bivalent-Leuk-STs contained CD8+ and CD4+ T cell subsets predominantly of effector memory phenotype and presented high specificity and cytotoxicity against both WT1 and PRAME. In the present study, we provide a paradigm of circular economy by repurposing unusable UCBUs and a platform for future banking of Leuk-STs, as a 'third-party', 'off-the-shelf' T-cell product for the treatment of acute leukaemias.

Catastrophic health expenditures of households living with pediatric leukemia in China.

BACKGROUND: Leukemia can create a significant economic burden on the patients and their families. The objective of this study is to assess the medical expenditure and compensation of pediatric leukemia, and to explore the incidence and determinants of catastrophic health expenditure (CHE) among households with pediatric leukemia patients in China. METHODS: A cross-sectional interview was conducted among households living with pediatric leukemia using a questionnaire in two tertiary hospitals. CHE was defined as out-of-pocket (OOP) payments that were greater than or equal to 40% of a household's capacity to pay (CTP). Chi-square tests and logistic regression analysis were performed to identify the determinants of CHE. RESULTS: Among 242 households living with pediatric leukemia, the mean OOP payment for pediatric leukemia healthcare was $9860, which accounted for approximately 35.7% of the mean household's CTP. The overall incidence of CHE was 43.4% and showed a downward trend with the lowest income group at 69.0% to the highest income group at 16.1%. The logistic regression model found that medical insurance, frequency of hospital admissions, charity assistance, and income level were significant predictors of CHE. CONCLUSION: The results revealed that pediatric leukemia had a significant catastrophic effect on families, especially those with lower economic status. The occurrence of CHE in households living with pediatric leukemia could be reduced by addressing income disparity. In addition, extending coverage and improving compensation from medical insurance could also alleviate CHE. Some other measures that can be implemented are to address the barriers of charity assistance for vulnerable groups.

Cost of illness of leukemia in Japan - Trend analysis and future projections.

BACKGROUND: Leukemia is a deadly hematological malignancy that usually affects all age groups and imposes significant burden on public funds and society. The objective of this study was to analyze the cost of illness (COI) of leukemia, and to mark out the underlying driving factors, in Japan. METHODS: COI method was applied to the data from government statistics. We first summed up the direct and indirect costs from 1996 to 2014; then future COI for the year 2017-2029 was projected. RESULTS: Calculated COI showed an upward trend with a 13% increase from 1996 to 2014 (270-305 billion yen). Increased COI was attributed to an increase in direct costs. Although mortality cost accounted for the largest proportion of COI, but followed a downward trend. Decreased mortality costs reflected the effects of aging. Mortality cost per person also decreased, however, the percentage of mortality cost for individuals ≥65 years of age increased consistently from 1996 to 2014. If a similar trend in health-related indicators continue, COI would remain stable from 2017 to 2029 regardless of models. CONCLUSION: COI of leukemia increased from 1996 to 2014, but was projected to decrease in foreseeable future. With advancement of new therapies, leukemia has become potentially curable and require long-term care; so direct cost and morbidity cost will remain unchanged. This reveal the further continuing burden on public funds. Thus, the information obtained from this study can be regarded as beneficial to future policy making with respect to government policies in Japan.

[A pragmatic approach to managing expensive therapies]. / Une approche pragmatique pour gérer les traitements onéreux - Chroniques génomiques.

Inflated drug prices necessarily raise the issue of rational allocation of health care resources. The system operated by the NICE agency in the UK attempts to do this by calculating the cost per quality-adjusted life year gained (QALY) and recommending funding only for drugs whose cost per QALY falls under a certain threshold. The whole process is documented in detail and easily accessible, and often results in significant discounts on drug prices. Given that some kind of rationing of health care is inevitable, the rational and transparent process followed by NICE has a number of positive features.

Trends and territorial inequalities of incidence and survival of childhood leukaemia and their relations to socioeconomic status in Hungary, 1971-2015.

The Hungarian Childhood Cancer Registry, a population-based national registry of the Hungarian Paediatric Haemato-Oncology Network founded in 1971, monitors the incidence and mortality of childhood cancer. Our aims were to carry out a longitudinal study to investigate the trends and spatial inequalities of incidence and survival of leukaemia, and the association between survival and deprivation in Hungary. All cases of childhood leukaemia and myelodysplasia were analysed (3157 cases, 1971-2015, age: 0-14 years). Time trends and the annual percentage change in direct standardized incidence and mortality were assessed. Survival and association with deprivation were assessed using the Kaplan-Meier method and Cox regression. Incidence rates of leukaemia (23.5-56.0/million) increased with an average annual percent change (AAPC) of 1%, determined by an increase in the incidence of acute lymphoblastic leukaemia (14.6-39.2/million, AAPC: 1.25%). Kaplan-Meier analysis showed a significant improvement in overall survival over the study period. Starting from 25% of cases surviving 5 years in the 70s; the overall 5-year survival reached 80% by 2010. Survival differences were observed with sex, leukaemia type and age at diagnosis. A reverse association was found in the survival probability of leukaemia by degree of deprivation. The Cox proportional hazards model verified a significant reverse association with deprivation [hazard ratio=1.08 (1.04-1.12)]. This is the first nationwide study to confirm the prognostic role of deprivation on the basis of a large cohort of patients with childhood leukaemia during a 45-year period. To maintain further improvement in treatment results, it is important to detect inequalities. Our results showed that deprivation may also be important in the survival of leukaemia.

Costs for Childhood and Adolescent Cancer, 90 Days Prediagnosis and 1 Year Postdiagnosis: A Population-Based Study in Ontario, Canada.

BACKGROUND: Childhood and adolescent cancers are uncommon, but they have important economic and health impacts on patients, families, and health care systems. Few studies have measured the economic burden of care for childhood and adolescent cancers. OBJECTIVES: To estimate costs of cancer care in population-based cohorts of children and adolescents from the public payer perspective. METHODS: We identified patients with cancer, aged 91 days to 19 years, diagnosed from 1995 to 2009 using cancer registry data, and matched each to three noncancer controls. Using linked administrative health care records, we estimated total and net resource-specific costs (in 2012 Canadian dollars) during 90 days prediagnosis and 1 year postdiagnosis. RESULTS: Children (≤14 years old) numbered 4,396: 36% had leukemia, 21% central nervous system tumors, 10% lymphoma, and 33% other cancers. Adolescents (15-19 years old) numbered 2,329: 28.9% had lymphoma. Bone and soft tissue sarcoma, germ cell tumor, and thyroid carcinoma each comprised 12% to 13%. Mean net prediagnosis costs were $5,810 and $1,127 and mean net postdiagnosis costs were $136,413 and $62,326 for children and adolescents, respectively; the highest were for leukemia ($157,764 for children and $172,034 for adolescents). In both cohorts, costs were much higher for patients who died within 1 year of diagnosis. Inpatient hospitalization represented 69% to 74% of postdiagnosis costs. CONCLUSIONS: Treating children with cancer is costly, more costly than treating adolescents or adults. Substantial survival gains in children mean that treatment may still be very cost-effective. Comprehensive age-specific population-based cost estimates are essential to reliably assess the cost-effectiveness of cancer care for children and adolescents, and measure health system performance.

Financial Assistance for Patients Who Relocate for Specialist Care in Hematology: Practical Findings to Inform Nursing Supportive Care.

AIMS: This article examines findings on the need for, awareness of, and critical time for referral to financial assistance for patients who have to relocate for specialist care for hematological malignancies. DESIGN: The study involved descriptive qualitative research based on in-depth interviews that were audio-recorded, transcribed verbatim, coded, and thematically analyzed. PARTICIPANTS: Forty-five hematology patients purposively selected from the client database of the Leukaemia Foundation of Queensland were interviewed for the study. RESULTS AND CONCLUSION: The findings indicate that there is a critical period at the initial point of diagnosis and start of treatment when patients are experiencing shock, confusion, and a sense of being overwhelmed by stress, fear, and uncertainty about the future. The stress can be exacerbated by the loss of work and a period of waiting to access income (e.g., from superannuation or approval to receive a pension). For some patients, this is a critical period when individuals need support and advice to avoid long-term financial problems. However, at this point in time, many individuals do not know how to access financial advice or assistance from leading cancer supportive care organizations. The findings have practical implications to inform the work by many nurses who provide psychosocial care to hematology patients.

Factors and Costs Associated With Delay in Treatment Initiation and Prolonged Length of Stay With Inpatient EPOCH Chemotherapy in Patients With Hematologic Malignancies.

Reducing delays related to inpatient chemotherapy may reduce healthcare costs. Using a national database, we identified patients with lymphoma/leukemia with ≥1 etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone (EPOCH) chemotherapy claim and evaluated chemotherapy initiation delay (ID), >1 day from admission. Standard tests/procedures prior to initiation were evaluated. Among 4453 inpatient cycles, 19.7% had ID, odds ratio 2.28 (95% confidence interval: 1.83-2.85) with cycle 1 compared to cycle 2, and mean costs were higher in patients with ID than without ID (p < .0001). Prior to cycle 1, patients were more likely to undergo routine diagnostic procedures compared to subsequent cycles. Efforts to perform routine procedures prior to admission may reduce hospital length of stay and costs.

Nosocomial infections among acute leukemia patients in China: An economic burden analysis.

BACKGROUND: The economic burden associated nosocomial infections (NIs) in patients with acute leukemia (AL) in China was unclear. A prospective study was conducted to quantify the medical cost burden of NIs among AL patients. METHODS: Nine hundred ninety-four patients diagnosed with AL between January 2011 and December 2013 were included. Relevant necessary information was extracted from the hospital information system and hospital infection surveillance system. The primary outcome was incidence of NIs and the secondary was economic burden results, including extra medical costs and prolonged length of stay (LOS). We estimated the total incremental cost of NIs by comparing all-cause health care costs in patients with versus without infections. Prolonged duration of stay was compared in patients with different infections. RESULTS: Of 994 patients with AL, 277 (27.9%) experienced NIs. NI was associated with a total incremental cost of $3,092 per patient ($5,227 vs $2,135; P < .01) and infected patients experienced a longer LOS (21 vs 10 days; P < .01). Patients with multisite infection had the highest total medical cost ($8,474.90 vs $2,209.90; P < .01) and the longest LOS (25 vs 15 days; P < .01). Western medicine was the main contributor to the rise of total cost in all kinds of infections. CONCLUSIONS: NI was associated with higher medical costs, which imposed an economic burden on patients with AL. The study highlights the influence of NIs on LOS and health care costs and appeal to the establishment of prophylactic measures for NIs to reduce the unnecessary waste of medical resources in the long run.

Scientific Achievements May Not Reach Everyone: Understanding Disparities in Acute Leukemia.

Over the past decade, scientific advancements have resulted in improved survival from acute leukemia. Continued advancements are expected given the attention to precision medicine and the resulting growth in development and adoption of risk-stratified, personalized therapies. While precision medicine has great potential to improve acute leukemia outcomes, there remain significant barriers to ensuring equitable access to these technologies and receipt of these prescribed targeted, personalized therapies. Over the past 3 years, studies report persistent outcome disparities among patients from specific racial and ethnic backgrounds, insurance and socioeconomic status, and other socio-demographic factors after a diagnosis of acute leukemia. A few recent studies examine etiologies for acute leukemia disparities and highlight the importance of ensuring access and equitable delivery of scientific advancements. In the context of continued scientific progress, future strategies require thoughtfully considered improvements in the delivery of care that can overcome the current challenges our patients face.

Proposed minimal panel of antibodies for cost-effectiveness and accuracy in acute leukemias immunophenotyping: Prospective study at a tertiary care center.

INTRODUCTION: Flowcytometry has an essential role in the diagnosis and classification of acute leukemias. However, there exists a great degree of inter-laboratory variability on issues like panel selection, antibody combinations, gating strategies, fluorochromes, and clonal selection. AIM: The primary aim of this study was to derive a minimal panel of antibodies and evaluate its diagnostic usefulness in acute leukemias by flowcytometry by using the detailed immune-phenotype of different lineage-specific or non-specific markers. MATERIALS AND METHODS: This prospective observational study involved 400 newly diagnosed cases of acute leukemias. Bone marrow aspirate samples were subjected to morphological evaluation, cytogenetics and flow cytometric immunophenotyping. RESULTS: A minimal panel of eight antibodies comprising of CD45/CD34/CD19/MPO/cytoCD3/CD64/CD117/CD79a was derived by applying different permutations and combinations with a diagnostic yield of 97.5%. The minimal panel was further validated by testing in an independent cohort of patients with similar demographic characteristics, where it showed a high diagnostic yield of 98% in comparison with the screening panels proposed by other recently published studies. CONCLUSION: It may be concluded that the diagnostic performance of the eight antibody panel is better than most other panels used across the different laboratories in terms of yield, number of antibodies used and the scientific approach used to derive and validate the results and so henceforth may be applied in any setting with limited resources for better diagnostic accuracy.

Medical Costs and Healthcare Utilization among Cancer Decedents in the Last Year of Life in 2009.

PURPOSE: The purpose of this study was to evaluate the cancer care cost during the last year of life of patients in Korea. MATERIALS AND METHODS: We studied the breakdown of spending on the components of cancer care. Cancer decedents in 2009 were identified from the Korean Central Cancer Registry and linked with the Korean National Health Insurance Claims Database. The final number of patients included in the study was 70,558. RESULTS: In 2009, the average cancer care cost during the last year of life was US $15,720. Patients under age 20 spent US $53,890 while those 70 or over spent US $11,801. Those with leukemia incurred the highest costs (US $43,219) while bladder cancer patients spent the least (US $13,155). General costs, drugs other than analgesics, and test fees were relatively high (29.7%, 23.8%, and 20.7% of total medical costs, respectively). Analgesic drugs, rehabilitation, and psychotherapy were still relatively low (4.3%, 0.7%, and 0.1%, respectively). Among the results of multiple regression analysis, few were notable. Age was found to be negatively related to cancer care costs while income level was positively associated. Those classified under distant Surveillance, Epidemiology, and End Results stages of cancer and higher comorbidity level also incurred higher cancer care costs. CONCLUSION: Average cancer care costs varied significantly by patient characteristics. However, the study results suggest an underutilization of support services likely due to lack of alternative accommodations for terminal cancer patients. Further examination of utilization patterns of healthcare resources will help provide tailored evidence for policymakers in efforts to reduce the burdens of cancer care.

Statewide Longitudinal Hospital Use and Charges for Pediatric and Adolescent Patients With Cancer.

PURPOSE: We investigated longitudinal hospitalization outcomes (total charges, hospital days and admissions) among pediatric and adolescent patients with cancer compared with individuals from the general population without cancer using a novel and efficient three-step regression procedure. METHODS: The statewide Utah Population Database, with linkages to the Utah Cancer Registry, was used to identify 1,651 patients who were diagnosed with cancer from 1996 to 2009 at ages 0 to 21 years. A comparison group of 4,953 same-sex and -age individuals was generated from birth certificates. Claims-based hospitalization data from 1996 to 2012 were retrieved from the Utah Department of Health. Using the regression method, we estimated survival (differences due to survival) and intensity (differences due to resource accumulation) effects of the cancer diagnosis on hospitalization outcomes within 10 years after diagnosis. RESULTS: At 10 years after diagnosis, on average, patients with cancer incurred $51,723 (95% CI, $48,100 to $58,284) more in charges, spent 30 additional days (95% CI, 27.7 to 36.1 days) in the hospital, and had 5.7 (95% CI, 5.4 to 6.4) more admissions than the comparison group. Our analyses showed that the highest hospitalization burden occurred during the first 4 years of diagnosis. Patients with leukemia incurred the greatest hospitalization burden throughout the 10 years from diagnosis. Intensity effects explained the majority of differences in hospital outcomes. CONCLUSION: Our results suggest that children and adolescents who were diagnosed with cancer in 2014 in the United States will incur over $800 million more in hospital charges than individuals without cancer by 2024. Interventions to reduce this burden should be explored in conjunction with improving health and survival outcomes.

Productivity loss due to premature mortality caused by blood cancer: a study based on patients undergoing stem cell transplantation.

INTRODUCTION: Stem cell transplantation has been used for many years to treat haematological malignancies that could not be cured by other treatments. Despite this medical breakthrough, mortality rates remain high. Our purpose was to evaluate labour productivity losses associated with premature mortality due to blood cancer in recipients of stem cell transplantations. METHODS: We collected primary data from the clinical histories of blood cancer patients who had undergone stem cell transplantation between 2006 and 2011 in two Spanish hospitals. We carried out a descriptive analysis and calculated the years of potential life lost and years of potential productive life lost. Labour productivity losses due to premature mortality were estimated using the Human Capital method. An alternative approach, the Friction Cost method, was used as part of the sensitivity analysis. RESULTS: Our findings suggest that, in a population of 179 transplanted and deceased patients, males and people who die between the ages of 30 and 49 years generate higher labour productivity losses. The estimated loss amounts to over €31.4 million using the Human Capital method (€480,152 using the Friction Cost method), which means an average of €185,855 per death. The highest labour productivity losses are produced by leukaemia. However, lymphoma generates the highest loss per death. CONCLUSIONS: Further efforts are needed to reduce premature mortality in blood cancer patients undergoing transplantations and reduce economic losses.

Outcomes of Clostridium difficile infection in hospitalized leukemia patients: a nationwide analysis.

BACKGROUND The incidence of Clostridium difficile infection (CDI) has increased among hospitalized patients and is a common complication of leukemia. We investigated the risks for and outcomes of CDI in hospitalized leukemia patients. METHODS Adults with a primary diagnosis of leukemia were extracted from the United States Nationwide Inpatient Sample database, 2005-2011. The primary outcomes of interest were CDI incidence, CDI-associated mortality, length of stay (LOS), and charges. In a secondary analysis, we sought to identify independent risk factors for CDI in leukemia patients. Logistic regression was used to derive odds ratios (ORs) adjusted for potential confounders. RESULTS A total of 1,243,107 leukemia hospitalizations were identified. Overall CDI incidence was 3.4% and increased from 3.0% to 3.5% during the 7-year study period. Leukemia patients had 2.6-fold higher risk for CDI than non-leukemia patients, adjusted for LOS. CDI was associated with a 20% increase in mortality of leukemia patients, as well as 2.6 times prolonged LOS and higher hospital charges. Multivariate analysis revealed that age >65 years (OR, 1.13), male gender (OR, 1.14), prolonged LOS, admission to teaching hospital (OR, 1.16), complications of sepsis (OR, 1.83), neutropenia (OR, 1.35), renal failure (OR, 1.18), and bone marrow or stem cell transplantation (OR, 1.27) were significantly associated with CDI occurrence. CONCLUSIONS Hospitalized leukemia patients have greater than twice the risk of CDI than non-leukemia patients. The incidence of CDI in this population increased 16.7% from 2005 to 2011. Development of CDI in leukemia patients was associated with increased mortality, longer LOS, and higher hospital charges.

Total costs and clinical outcome of hematopoietic stem cell transplantation in adults with leukemia: comparison between reduced-intensity and myeloablative conditioning.

The total cost of hematopoietic stem cell transplantation (HSCT) as well as the financial impact of HSCT on the house holds of patients have been elusive. Between 2005 and 2012, we analyzed 191 HSCT in adult patients with leukemia with reduced-intensity conditioning (RIC) regimen (n = 79) and with myeloablative conditioning (MAC) regimen (n = 112). The direct medical costs were calculated from healthcare claims obtained from the Seoul National University Hospital, and the direct non-medical and the indirect costs were calculated from national statistics. The mean direct medical cost was $55,039, direct non-medical cost was $6394, and indirect cost was $7503 from transplantation to one yr after transplantation in the RIC group and $72,916, $6993, and $9057 in the MAC group, respectively, based on the exchange rate of Korean won 1060 = US$1. The total costs for one yr were $68,938 and $88,967, constituting for 273% and 357% of the per capita income, respectively. The total costs, direct medical costs, and indirect costs showed statistically significant differences (p = 0.006, p = 0.007, and p = 0.017). No significant differences were found for leukemia-free survival and overall survival. RIC-HSCT provides lower costs within the first year of transplantation with comparable long-term clinical outcomes.

Socioeconomic disparities in survival from childhood leukemia in the United States and globally: a meta-analysis.

BACKGROUND: Despite advancements in the treatment of childhood leukemia, socioeconomic status (SES) may potentially affect disease prognosis. This study aims to evaluate whether SES is associated with survival from childhood leukemia. METHODS: The US National Cancer Institute Surveillance, Epidemiology and End Results Program (SEER) 1973-2010 data were analyzed; thereafter, results were meta-analyzed along with those from survival (cohort) studies examining the association between SES indices and survival from childhood leukemia (end-of-search date: 31 March 2014). Random-effects models were used to calculate pooled effect estimates (relative risks, RRs); meta-regression was also used. RESULTS: We included 29 studies yielding 28 804 acute lymphoblastic leukemia (ALL), 3208 acute myeloblastic leukemia (AML) and 27 650 'any' leukemia (denoting joint reporting of all subtypes) cases. According to individual-level composite SES indices, children from low SES suffered from nearly twofold higher death rates from ALL (pooled RR: 1.83, 95% confidence interval 1.00-3.34, based on four study arms); likewise, death RRs derived from an array of lower area-level SES indices ranged between 1.17 and 1.33 (based on 11 study arms). Importantly, the survival gap between higher and lower SES seemed wider in the United States, with considerably (by 20%-82%) increased RRs for death from ALL in lower SES. Regarding AML, poorer survival was evident only when area-level SES indices were used. Lastly, remoteness indices were not associated with survival from childhood leukemia. CONCLUSION: Children with lower SES suffering childhood leukemia do not seem to equally enjoy the impressive recent survival gains. Special health policy strategies and increased awareness of health providers might minimize the effects of socioeconomic disparities.