bluuebunny/crossref_metadata_2025_split huggingface dataset:
Potentially avoidable hospitalizations in patients with advanced cancer.
Authors: Johnson Connor , Xiao Yian , El-Jawahri Areej , Wong Risa , D'Arpino Sara , Moran Samantha M.C. , Lage Daniel E , Temel Brandon , Ruddy Margaret , Pirl William F. , Traeger Lara , Lennes Inga Tolin , Cashavelly Barbara J. , Martinson Holly S , Jackson Vicki , Greer Joseph A. , Ryan David P. , Hochberg Ephraim P. , Temel Jennifer S. , Nipp Ryan David 
Published: September 2018

e18275 Background: Cancer patients and their clinicians often wish to avoid preventable hospital admissions, but efforts to understand the predictors of avoidable hospitalizations are lacking. We sought to examine reasons for hospital admissions in patients with advanced cancer, identify potentially avoidable hospitalizations (PAH), and explore predictors of PAH. Methods: We prospectively enrolled hospitalized patients with advanced cancer from 9/2014 - 11/2014 as part of a longitudinal data repository to define symptom burden in this population. Upon admission, we assessed patients’ symptom burden (Edmonton Symptom Assessment System [ESAS]; scored 0-10). We created a summated ESAS physical symptom variable. We used consensus-driven medical record review to identify the primary reason for each hospital admission and categorize it as PAH or not based on of an adaptation of Graham’s criteria for PAH. We used mixed multivariable logistic regression analyses to identify predictors of PAH. Results: We assessed 477 hospital admissions in 200 consecutively admitted patients (mean age = 64.6; 47% female; 67% married). Over half of admissions came through the emergency department (56%). The most common reasons for admissions were fever/infection (30%), symptoms (26%), and planned admission for chemotherapy or procedure (10%). We identified 149 (31%) as PAH. Among these PAH, 45 (30%) were readmissions due to failure of timely outpatient follow-up (within 7 days of discharge) and 44 (30%) were due to premature discharge from prior hospitalization. In a mixed logistic regression model, being married (odds ratio [OR] 0.48 [0.28-0.81]; p < 0.01) was associated with lower likelihood of PAH, while higher physical symptom burden (OR 1.02 [1.00-1.04]; p = 0.04) was associated with greater likelihood of PAH. Conclusions: We identified that a substantial proportion of hospitalizations in patients with advanced cancer are potentially avoidable, often related to failure of timely outpatient follow-up and premature hospital discharge. Our results demonstrate that patients’ symptom burden predicts PAH, thus underscoring the need to address patients’ symptoms in order to reduce preventable hospital admissions.
Risk of gastrointestinal and hepatic toxicities in patients with hormone receptor-positive HER2-negative breast cancer treated with CDK 4/6 inhibitors: A systematic review and meta-analysis of randomized controlled trials.
Authors: Tun Aung , Thein Kyaw Zin , Thar Yu Yu , Nayak Asha , Guevara Elizabeth 
Published: September 2018

e18284 Background: CDK4/6 inhibitors are proven to be beneficial in patients with hormone receptor-positive HER2-negative breast cancer. Studies have suggested an increased risk of gastrointestinal (GI) events. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the risk of GI and hepatic toxicities. Methods: We systematically conducted a comprehensive literature search using MEDLINE and EMBASE databases through January 1, 2017. RCTs that mention GI symptoms and/or elevation of liver enzymes as adverse effects were incorporated in the analysis. Mantel-Haenszel method was used to calculate the estimated pooled risk ratio with 95% confidence interval (CI). Results: Five RCTs with a total of 2021 patients were eligible for analysis. The study arm used palbociclib-letrozole, palbociclib-fulvestrant, and ribociclib-letrozole while the control arm used placebo with letrozole or fulvestrant. The relative risks of all-grade elevated AST was 2.6 (95% CI: 1.15–5.86; p = 0.02); all-grade elevated ALT: 2.82 (95% CI: 1.25–6.36; p = 0.01); all-grade stomatitis: 3.32 (95% CI: 2.09-5.28; p < 0000.1); all-grade nausea: 1.79 (95%CI: 1.25-2.58; p = 0.002); all-grade vomiting:1.55 (95% CI: 0.92-2.63; p = 0.10); and all-grade diarrhea: 1.59 (95% CI 1.28-1.98; p < 0.0001). The relative risks of high-grade elevated AST was 3.08 (95% CI: 1.42–6.67; p = 0.004); high-grade elevated ALT: 7.2 (95% CI: 2.81–18.43; p < 0.0001); high-grade stomatitis: 2.01 (95% CI: 0.22-18.02; p = 0.53); high-grade nausea: 0.76 (95%CI: 0.12-4.78; p = 0.77); high-grade vomiting: 0.88 (95% CI: 0.19-4.13; p = 0.87); and high-grade diarrhea: 1.23 (95% CI 0.52-2.92; p = 0.64). Conclusions: Our meta-analysis demonstrated that CDK 4/6 inhibitor-based regimens are associated with a higher risk of all-grade and high-grade elevated AST and ALT. Moreover, the regimen is associated with increased risk of all-grade stomatitis, nausea and diarrhea. Recognizing these adverse effects may help clinicians in delivering proper supportive care and thereby enhancing patients’ quality of life.
Comparison of incidence and average cost per toxicity in patients treated with nivolumab and pembrolizumab.
Authors: Mason Neil Thomas , Antonia Scott Joseph , Khushalani Nikhil I. , McLeod Howard L. 
Published: September 2018

e18292 Background: PD-1 inhibitors such as nivolumab and pembrolizumab have demonstrated efficacy in numerous metastatic cancers. However, these drugs are also some of the most expensive and can have severe adverse side effects. However, most available data comes from clinical trials rather than patients treated in clinical practice as standard-of-care. This study reports the incidence of severe toxicities in a number of cancer types and estimates the per patient cost of managing these toxicities. Methods: All patients treated with nivolumab or pembrolizumab between January 1, 2014 through April 30, 2016 were identified at Moffitt Cancer Center (nivolumab N=74, pembrolizumab N=134). Toxicities occurring during or within 2 months of stopping treatment were identified and graded using the CTCAE 4.0 criteria. A cost of care analysis was performed comparing patients with Grade 3-5 toxicities to patients with Grade 0-2 toxicities. Results: The most common severe toxicities were anemia, dyspnea, dermatitis, hepatitis, and renal failure (Table 1). The average cost of care for patients experiencing Grade 3-5 toxicities was $640 and $4,784 higher than those without toxicity in nivolumab and pembrolizumab, respectively. Conclusions: Primary cost drivers differed between the two drugs with outpatient visits and additional pharmacy costs driving nivolumab cost while inpatient stays and radiation therapy drove costs with pembrolizumab. The large difference between the toxicity cost of each group could be due to the heterogeneity of cancer types treated with nivolumab versus primarily melanoma in the case of pembrolizumab or the smaller sample size of nivolumab patients. [Table: see text]
Value of life and time: A survivorship perspective.
Authors: Hinkel Jennifer M. , Sexton Daniel B. , Egan-Kunicki Justine 
Published: September 2018

e18298 Background: Common tools to quantify value of life years after a cancer diagnosis include the Quality Adjusted Life Year (QALY). This measure is partly based on health utility states derived from Quality of Life (QoL) survey instruments such as the EQ-5D. Research has identified shortcomings in applying the QALY, including the potential for underestimating value. QoL surveys may fail to capture the full range of potential health states, or the values derived may fail to reflect patient perspectives of value. Methods: An online survey was piloted with a convenience sample of cancer survivors via two US survivor Facebook groups over two weeks in Jan. 2017 to explore these themes. Results: 116 complete responses were analyzed (of 123 respondents). Original diagnoses included solid tumors and hematologic malignancies, and respondents were between one and 32 years post-diagnosis (PoD). Most (101, 87%) had completed active treatment. A majority (85, 73%) rated PoD years as having more value than years pre-diagnosis (PreD). 83% (98) indicated that they felt their time is more valuable since their diagnosis. While the majority of respondents (57%) assigned a lower value to the 12 months immediately following diagnosis compared to the value of a PreD year, a majority (55%) also valued the most recent twelve months to have equal or greater value than a PreD year. Many assigned higher valuations to PoD years even when simultaneously reporting limitations in Activities of Daily Living (ADLs). Conclusions: Comparing survivor valuations of PoD life years to valuations derived by utility state instruments has not been heavily researched. This survey generates additional hypotheses. First, assuming PoD years hold lower value than PreD years may underestimate value compared to a survivor’s view. Second, QoL instruments may not be capturing positive changes in PoD years, some of which have been documented in psychology research, such as Post-Traumatic Growth or increased feeling of meaningfulness. Further investigation is imperative to ensure that value determinations have a solid evidentiary basis and reflect patient-centered viewpoints, particularly as the “value debate” influences patient access to care.
The impact of pricing strategy on the cost of oral anti-cancer drugs during dose reductions.
Authors: Truong Judy , Chan Kelvin K. , Mai Helen , Chambers Alexandra , Sabharwal Mona , Trudeau Maureen E. , Cheung Matthew C. 
Published: September 2018

e18312 Background: The pricing strategy of oral medications can affect their costs. The strategy of flat pricing per tablet may increase drug costs in the event of dose reductions requiring more tablets, as there is a single price for different tablet strengths, but the impact is largely unknown. With the strategy of linear pricing, the tablet price increases with its strength. We sought to determine the impact of pricing strategy on the cost of oral anti-cancer drugs during dose reductions. Methods: Oral anti-cancer drugs reviewed by the pan-Canadian Oncology Drug Review were identified between July 2011 to January 2015. The pricing strategy of these drugs was reviewed. We examined the percentage change in cost per mg and cost per 28 days as a result of dose reduction from dose level 0 to -1 and -2 for each drug. Results: Seventeen drugs for use in 20 indications were included in the analysis. There were 3 drugs for hematological malignancies and 14 drugs for solid cancers. Fifty-nine percent (10/17) of these drugs were available in multiple strengths; five of them utilized fixed pricing per tablet strategy and the other 5 utilized linear pricing. The remaining drugs (7/17) were available in a single strength tablet. Dose reductions generally increased the cost per mg for drugs using flat pricing per tablet, with a mean increase of 82% (range: 25%-200%) at dose level -1 and 100% (range: 0%-200%) at dose level -2. Dose reduction had no effect on the cost per mg of drug for drugs using linear pricing apart from lenalidomide, which had increased costs due to minimal price variation between the highest and lowest tablet strengths. In general, dose reduction did not decrease the cost per 28 days of drug for drugs using flat pricing per tablet, but was proportionally reduced in drugs using linear pricing. Conclusions: While there is a general expectation that the cost of drugs should decrease with dose reduction, oral anti-cancer drugs using flat pricing per tablet have increased cost per mg and no decrease in cost per 28 days despite dose reduction. Future economic evaluations should account for the impact of dose reductions for oral drugs using the flat pricing per tablet strategy on cost-effectiveness and budget.
Cost-effectiveness of genotype-guided aspirin use for colorectal cancer prevention.
Authors: Biltaji Eman , Au Trang H. , Walker Brandon , Ose Jennifer , Ulrich Cornelia M , Stenehjem David D. , Brixner Diana I. 
Published: September 2018

e18318 Background: Colonoscopy is the “gold standard” for colorectal cancer (CRC) screening. However, adherence rates are low and detection is not optimal. Concomitant aspirin chemoprevention is recommended by US Preventive Task Force, but bleeding complications can be limiting. Variant genotypes in aspirin metabolism can modify CRC and adenoma risk. Genotype guided aspirin (ggASA) use will identify a targeted average-risk population for maximal aspirin benefit while minimizing adverse events rates compared to the general population. We conducted a cost-effectiveness analysis (CEA) of primary chemoprevention in CRC using ggASA compared to no intervention, and colonoscopy ±general aspirin in healthy average-risk individuals. Methods: Our Markov decision analytical model consisted of 5 possible health states: no CRC/polyps, adenoma, pre-clinical CRC, CRC, and death. Model probabilities for CRC and its prevalence were estimated using SEER database and published literature. A microsimulation of 10,000 individuals aged 50-64 years was used to estimate cost-effectiveness from US payer perspective over lifetime. One way and probabilistic sensitivity analyses and model validation results will be reported in the final poster. Results: Our results suggest that compared to colonoscopy and no intervention, ggASA was associated with fewer CRC cases, and CRC-related deaths and MI cases. Compared to colonoscopy + general aspirin, ggASA was associated with fewer bleeding events, similar rates of CRC and CRC-related deaths, and fewer MI cases prevented. From a cost-effectiveness standpoint, ggASA use over a lifetime had the lowest costs and highest quality adjusted life years gained compared to other strategies, if testing costs were ignored. Once genetic testing costs exceeds $63, colonoscopy + general aspirin becomes the most cost effective strategy. Between genetic testing cost of $63-283, the costs of using ggASA per quality adjusted life year gained is below $100,000. Conclusions: Genotype-guided aspirin use precisely identifies an average-risk population, and lowers adverse events rates compared to general aspirin. The economic value of genotype-guided aspirin is dependent on the genetic testing costs.
Financial toxicity of cancer treatment at a large academic cancer center.
Authors: Ahuja Parikh Divya , Amin Krunal , Hall Evan Thomas , Patel Manali I. 
Published: September 2018

e18323 Background: Many studies have shown that patients with cancer are at higher risk of financial difficulty than those without cancer. Given the rising cost of cancer therapy it is important to study the financial distress associated with cancer care. Therefore, we assessed patient reported financial toxicity at a large tertiary academic cancer institute. Methods: From July 2014 to August 2014, we asked 300 patients at the Stanford Cancer Center to participate in an 11-item questionnaire about costs incurred with cancer care. We calculated patient-reported financial toxicity using the COST score, validated at the University of Chicago (scores range from 0-44 with higher values indicating higher financial burden). We obtained demographic information including sex (male or female), education level (high school or less, associates/bachelors degree, or masters/professional degree), race (white or non-white) and annual household income ( < $49,999, $50,000-$99,999, or > $100,000) and used multivariable logistic regression to analyze the association between demographic factors and COST score. Results: Out of the 300 patients approached 254 patients (84.7%) participated in the survey. Nearly half (46%) responded that they “worry about the financial problems in the future as a result of illness or treatment“ quite a bit (4) or very much (5). More than half (52%) reported “I feel I have no choice about the amount of money I spend on care” quite a bit (4) or very much (5). Of patients without missing data (n = 184, 61.3%), the mean COST score was 21 (range 2-41). There were no significant differences in COST score by sex, education level, or race. However, there was a significant difference in COST score by annual household income with a higher degree of financial burden in the lowest income group (OR = 1.04, CI = 0.69-1.38, p < 0.001). Conclusions: Financial toxicity is an unmet concern among patients in our single institution study, with increased burden expressed by those in lower income groups. Our results demonstrate that financial toxicity is a critical concern despite our limited sample. Multicenter studies should be conducted to better characterize the risk factors and serve as a basis for interventions for patients at risk for financial toxicity.
Cost effectiveness in a supportive care unit.
Authors: Morin Sophie , Leroy Pauline , Aubaret Christophe , Legeay Karine , Saadi Alexandre , Brami Cloé , Gervais Claire , Herve Christian , Mamzer Marie-France , Sauvajot Clarisse , Guillou Anne , Garnier Barbara , Lecuru Fabrice , Waechter Lorraine , Scotte Florian 
Published: September 2018

e18326 Background: Supportive care in cancer (SCC) may create a financial burden, compared to a standard cancer department. In 2011, a specific SCC inpatient unit was developed in an academic hospital, based on a multidisciplinary approach in order to anticipate patient’s disability and limit emergency hospitalization. Assess the cost effectiveness of the SCC unit expenses and benefits compared to Medical (MO) and Gastro-Intestinal (GI) oncology departments. Methods: Data were analyzed over a six year period (2011-2016). Cost of hospital stays and cost per year were calculated based on the hospital’s standard cost accounting method. Hospital benefits were calculated as the difference between total incomes and total expenses (cost and Diagnosis Related Group tariffs for the stay) and results were compared (period available for comparison 2011 to 2014). Results: Total costs for the hospital, primarily due to staff expenses, were lower for the SCC unit compared to MO and GI in 2011 and 2014, as well as the daily cost per stay (DCS). Benefit per year was also higher for the SCC unit permitting it, to benefit financially compared to the two other oncology units (Table). Incomes reimbursed by the National Health system for SCC unit were 1,632,601 euros in 2015 and 2,096,285 euros in 2016 with a total of 357 and 408 patients admitted in the 8 bed SCC unit in 2015 and 2016 respectively. Conclusions: The SCC unit was less expensive to operate compared to our other oncology units. Our results suggest that its development permitted the oncology department to enhance its quality of care without any additional expenses. [Table: see text]
Cancer antigen 125 (CA125) and the law of unintended consequences.
Authors: Alken Scheryll Paula , Coate Linda E. , Woulfe Bernie , O'Leary NIamh , Capin Ivana M , Blake Ophelia , Gupta Rajnish K. 
Published: September 2018

e18327 Background: CA125 is a serum tumour marker used to monitor patients with ovarian cancer (OvCa). Its usefulness as a screening tool remains unproven. There is no restriction in its use at our institution, a university teaching hospital. We sought to establish patterns of testing during one calendar year (2013), focussing on the economic costs of such unrestricted testing. Methods: A lookback of the CA125 reports issued by the Biochemistry Laboratory was undertaken. The CA125 requests were from physicians within the hospital & from the community. Individual requests for CA125 & those part of tumour marker panel were included & correlated with radiology & histopathology records to identify subsequent investigations (invxs) & diagnoses (dxs). Economic costings were provided by hospital finance department. For the purpose of this study we only included the costs of invxs triggered by out of range CA 125 test results. Results: In 2013, 7,132 CA125 measurements were performed. 871 repeat tests, 40 tests performed on men & 16 tests with inadequate patient identifiers were excluded. Of the remaining 6,205 patient tests; median age was 53yrs (range 13 – 96yrs); median CA125 was 5.5 IU/L (range 0.1 – 22452 IU/L). Out of range tests (>35 IU/L) led to 619 ultrasound scans, 339 CT scans. In total, 20 new cases of OvCa were dx. The crude cost per new dx was €11,459.80. Median time to diagnosis was 4 days (range -2 – 251), median CA125 at dx was 271 (range 8.1 - 9444). Median age at dx was 62 (range 40 – 87). 65% of dx were made during inpatient stays;10% by family physicians;25% by gynaecologists. There was a statistically significant difference in median CA125 in patients diagnosed with OvCa, compared to those who were not dx with a malignant condition (p<0.0001); this was not true of age at dx (p=0.27). Conclusions: This study underlines the lack of efficacy in unrestricted serum CA125 testing & that such testing creates a significant economic burden on hospitals, far in excess of the cost of the CA125 test alone. We plan to implement guidelines in our institution & will reassess this issue following an education programme with local clinicians. [Table: see text]
Burden of acute myeloid leukemia (AML) in a U.S. commercially insured population.
Authors: Hagiwara May , Sharma Arati , Chung Karen C , Delea Thomas E. 
Published: September 2018

e18330 Background: AML accounts for 25% of acute leukemias in adults worldwide, with an estimated 5-year survival of 26% in the US. Up-to-date information on the clinical and economic burden of AML among US commercially insured patients (pts) is needed to inform reimbursement decisions. Methods: This retrospective study of the burden of AML in a US commercially insured population used the IMS PharMetrics Plus health insurance claims database. Adults with ≥1 claim with a diagnosis (Dx) of AML (ICD-9-CM 205.00, 205.01, or 205.02 or ICD-10-CM C92.00, C92.40, C92.50, C92.01, C92.41, C92.51, C92.02, C92.42, C92.52) during the study period (Jan 2008 through Dec 2015) were identified. To avoid rule-out diagnoses, pts with only 1 outpatient claim (or >1 claim on a single day) with a Dx of AML not in relapse or remission were excluded. Annual incidence and total and AML-related inpatient and outpatient healthcare costs per person year (PY) were calculated by age and gender. For cost analyses, pts with newly diagnosed AML were assessed. To ensure adequate claims history to identify all prevalent cases, prevalence was calculated for the last year of the study period. Results: 26,344 adults with AML were identified during the study period, which covered 228.3 million PY of enrollment. The incidence rate was 4.9 per 100,000 PY. Incidence was greatest in men and pts aged 60+ years. Prevalence was 12.2 per 100,000 persons. Among 11,170 newly diagnosed AML pts, total average costs were $352,138 per PY. 63% of costs were for AML-related care. 70% of AML-related costs were for inpatient care. Costs were greatest for men, pts aged 45-59 years, and during the first 6 months post-diagnosis. Conclusions: Although AML is relatively rare, its economic burden to US commercial insurers is substantial. [Table: see text]