ABSTRACT
This Viewpoint proposes 3 changes to the Enhancing Oncology Model of the US Centers for Medicare & Medicaid Services.
Subject(s)
Medical Oncology , Medicare , Humans , United States , MedicaidSubject(s)
Genital Neoplasms, Female/economics , Gynecology/economics , Medical Oncology/economics , Reimbursement Mechanisms , Drug Costs , Female , Genital Neoplasms, Female/therapy , Gynecology/methods , Health Care Costs , Humans , Medical Oncology/methods , Medicare/economics , Models, Economic , Reimbursement, Incentive , United StatesSubject(s)
Lung Neoplasms , Precision Medicine , Critical Pathways , Humans , Lung Neoplasms/therapyABSTRACT
Metastatic breast cancer (mBC) remains responsible for the majority of breast cancer deaths. Whereas clinical outcomes have improved with the development of novel therapies, resistance almost inevitably develops, indicating the need for novel therapeutic approaches for the treatment of mBC. Recent investigations into mBC genomic alterations have revealed novel and potential therapeutic targets. Most notably, therapies against PIK3CA mutation and germline BRCA1/2 mutations have solidified the role of targeted therapy in mBC, with treatments against these alterations now approved by the U.S. Food and Drug Administration (FDA) on the basis of clinical benefit for patients with mBC. Familiarity with relevant genomic alterations in mBC, technologies for mutation detection, methods of interpreting genomic alterations, and an understanding of their clinical impact will aid practicing clinicians in the treatment of mBC as the field of breast oncology moves toward the era of precision medicine.
Subject(s)
Breast Neoplasms/genetics , Genomics/methods , Female , Humans , Neoplasm MetastasisABSTRACT
PURPOSE: A shift in outpatient oncology care from the physician's office to hospital outpatient settings has generated interest in the effect of practice setting on outcomes. Our objective was to examine whether medical oncologists' prescribing of drugs and services for older adult patients with advanced cancer is used more in physicians' offices compared with hospital outpatient departments. METHODS: This was a retrospective comparative study. SEER-Medicare data (2004 to 2011) were used to identify Medicare beneficiaries diagnosed with advanced breast, colon, esophagus, non-small-cell lung, pancreatic, or stomach cancer. Between physicians' offices and hospital outpatient departments, we compared use of selected likely low-value supportive drugs, low-value therapeutic drugs, chemotherapy-related hospitalizations, and hospice. We used hierarchical modeling to assess differences between settings to account for correlation within physicians. RESULTS: Compared with patients treated in a hospital outpatient department, those treated in a physician's office setting were more likely to receive erythropoiesis-stimulating agents (odds ratio, 1.72; 95% CI, 1.53 to 1.94) and granulocyte colony-stimulating factors (odds ratio, 1.28; 95% CI, 1.18 to 1.38). For combination chemotherapy and nanoparticle albumin-bound-paclitaxel in patients with breast cancer, there was a trend toward higher use in physicians' offices, although this was not statistically significant. Chemotherapy-related hospitalizations and hospice did not vary by setting. CONCLUSION: We found somewhat higher use of several drugs for patients with advanced cancer in physicians' office settings compared with hospital outpatient departments. Findings support research to dissect the mechanisms through which setting might influence physicians' behavior.
Subject(s)
Neoplasms/therapy , Outpatient Clinics, Hospital , Physicians' Offices , Practice Patterns, Physicians' , Aged , Aged, 80 and over , Female , Humans , Male , Retrospective StudiesSubject(s)
Insurance, Health, Reimbursement/economics , Medical Oncology/economics , Medicare/economics , Value-Based Health Insurance/economics , Episode of Care , Humans , Insurance, Health, Reimbursement/legislation & jurisprudence , Medical Oncology/legislation & jurisprudence , Medicare/legislation & jurisprudence , Patient Care Bundles/economics , Quality Indicators, Health Care/economics , United StatesSubject(s)
Antineoplastic Agents/administration & dosage , Epidermolysis Bullosa Acquisita , Lymphoma, Mantle-Cell , Skin/pathology , Triamcinolone/administration & dosage , Biopsy/methods , Diagnosis, Differential , Epidermolysis Bullosa Acquisita/complications , Epidermolysis Bullosa Acquisita/diagnosis , Epidermolysis Bullosa Acquisita/pathology , Epidermolysis Bullosa Acquisita/therapy , Glucocorticoids , Humans , Injections, Intralesional , Lymphoma, Mantle-Cell/complications , Lymphoma, Mantle-Cell/drug therapy , Lymphoma, Mantle-Cell/pathology , Male , Middle Aged , Treatment OutcomeABSTRACT
Rising US health care costs have led to the creation of alternative payment and care-delivery models designed to maximize outcomes and/or minimize costs through changes in reimbursement and care delivery. The impact of these interventions in cancer care is unclear. This review was undertaken to describe the landscape of new alternative payment and care-delivery models in cancer care. In this systematic review, 22 alternative payment and/or care-delivery models in cancer care were identified. These included 6 bundled payments, 4 accountable care organizations, 9 patient-centered medical homes, and 3 other interventions. Only 12 interventions reported outcomes; the majority (n = 7; 58%) improved value, 4 had no impact, and 1 reduced value, but only initially. Heterogeneity of outcomes precluded a meta-analysis. Despite the growth in alternative payment and delivery models in cancer, there is limited evidence to evaluate their efficacy. Cancer 2018. © 2018 American Cancer Society.
Subject(s)
Health Care Costs , Medical Oncology/economics , Neoplasms/economics , Health Care Reform/economics , Health Expenditures , Humans , Medicare/economics , Neoplasms/epidemiology , Neoplasms/therapy , Patient Protection and Affordable Care Act/economics , Quality of Health Care , Reimbursement Mechanisms , United States/epidemiologyABSTRACT
The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse.
Subject(s)
Antineoplastic Agents/therapeutic use , Inappropriate Prescribing/statistics & numerical data , Medical Overuse/statistics & numerical data , Neoplasms/drug therapy , Antiemetics/economics , Antiemetics/therapeutic use , Antineoplastic Agents/economics , Hematopoietic Cell Growth Factors/economics , Hematopoietic Cell Growth Factors/therapeutic use , Humans , Inappropriate Prescribing/economics , Medical Overuse/economicsSubject(s)
Biosimilar Pharmaceuticals/administration & dosage , Breast Neoplasms/drug therapy , Receptor, ErbB-2/metabolism , Taxoids/administration & dosage , Trastuzumab/administration & dosage , Adult , Biosimilar Pharmaceuticals/adverse effects , Breast Neoplasms/metabolism , Disease Progression , Double-Blind Method , Female , Humans , Intention to Treat Analysis , Middle Aged , Survival Analysis , Taxoids/adverse effects , Trastuzumab/adverse effects , Treatment OutcomeABSTRACT
PURPOSE OF THE REVIEW: To understand the evidence for extending adjuvant aromatase inhibitor (AI) therapy from 5 to 10 years in post-menopausal women with hormone receptor positive (HR+) breast cancer. RECENT FINDINGS: Multiple large trials have investigated this question. The two trials most representative of the dilemma faced in clinical practice are the MA.17R and NSABP-B42 trials, which both investigated the benefit of continuing versus stopping AI therapy beyond 5 years. Both trials showed that extended AI therapy led to a reduction in new or recurrent breast cancers, but had no effect on survival outcomes when death from any cause was included. SUMMARY: The decision to extend AI therapy beyond 5 years remains a personalized one based on a discussion of the projected risk of recurrence, the expected benefits of prolonged AI treatment, and the patient's ability to tolerate side effects so that quality of life is preserved.
Subject(s)
Health Care Costs , Health Policy/economics , Medical Oncology/economics , Neoplasms/economics , Neoplasms/therapy , Patient Protection and Affordable Care Act/economics , Process Assessment, Health Care/economics , Quality Improvement/economics , Quality Indicators, Health Care/economics , Cost-Benefit Analysis , Delivery of Health Care, Integrated/economics , Delivery of Health Care, Integrated/legislation & jurisprudence , Early Detection of Cancer/economics , Health Care Costs/legislation & jurisprudence , Health Policy/legislation & jurisprudence , Health Services Accessibility/economics , Health Services Accessibility/legislation & jurisprudence , Humans , Insurance, Health, Reimbursement/economics , Insurance, Health, Reimbursement/legislation & jurisprudence , Medical Oncology/legislation & jurisprudence , Neoplasms/diagnosis , Patient Protection and Affordable Care Act/legislation & jurisprudence , Policy Making , Preventive Health Services/economics , Preventive Health Services/legislation & jurisprudence , Process Assessment, Health Care/legislation & jurisprudence , Quality Improvement/legislation & jurisprudence , Quality Indicators, Health Care/legislation & jurisprudence , Treatment Outcome , United StatesABSTRACT
Psoriasis is a chronic condition that affects more than 7 million Americans. This article explores the pathogenesis and physical signs of psoriasis. Over the past 2 decades enhanced understanding of the immunologic basis of psoriasis has led to the development of new systemic agents that have revolutionized the management of this disease, and these modalities, along with traditional therapies, are described.
Subject(s)
Psoriasis/etiology , Psoriasis/therapy , Chronic Disease , Humans , Psoriasis/diagnosisABSTRACT
BACKGROUND: Although breast cancer is the second leading cause of cancer-related mortality in women in the United States, few studies focus on the supportive care needs of patients living with metastatic breast cancer (MBC). OBJECTIVE: We studied quality of life (QOL), depression, anxiety, and prognostic understanding of patients with MBC. DESIGN: We conducted a cross-sectional study of 140 patients with MBC, stratified by receipt of endocrine therapy or chemotherapy. MEASUREMENTS: We evaluated anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). We assessed QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B), specifically measuring the FACT-B Trial Outcome Index (TOI), which includes physical and functional well-being and breast cancer-specific symptoms. Higher FACT-B TOI scores represent better QOL. We used a 12-item questionnaire to assess patients' perceptions of their prognosis and goals of therapy. RESULTS: Compared to those taking endocrine therapy (n = 40), patients receiving chemotherapy (n = 100) reported lower scores on the FACT-B TOI (66.1 versus 72.5, p < 0.01) and more depression symptoms (HADS-D >7; 22% versus 7.5%, p = 0.03). Higher scores on the FACT-B TOI were associated with lower depression (ß, -0.16; p < 0.01) and anxiety (ß, -0.11; p < 0.01), and patients who reported frequent prognostic conversations with their oncologists had less depression (ß, -1.28; p < 0.01). Thirty-nine percent (54/140) reported that their cancer was likely curable. CONCLUSION: Patients with MBC, particularly those treated with chemotherapy, may benefit from interventions to address their physical, functional, and breast cancer-related symptoms. Many do not report accurate prognostic understanding, and more frequent prognostic conversations might address this information gap.