Willingness to Pay for a Quality-Adjusted Life Year among Gastrointestinal Cancer Patients at a Tertiary Hospital of Vietnam, 2022.

BACKGROUND: Gastrointestinal (GI) cancer burden in Asia is increasing, and Vietnam is no exception. Assessing the affordability of achieving a quality-adjusted life year (QALY) in gastrointestinal cancer patients Vietnam, as well as identifying predictors of willingness to pay (WTP) per QALY, is crucial to decision-making around medical intervention prioritization and performing medical technology assessments for these cancers. OBJECTIVES: Our study aimed to estimate WTP/QALY gained and associated factors among patients diagnosed with GI cancer at a tertiary hospital in Hue, Vietnam. METHODS: A cross-sectional descriptive study, using contingent valuation methodology was conducted among 231 patients at tertiary hospital in 2022. A double limited dichotomous choice and the EQ-5D-5L were utilised to estimate WTP and QALY, respectively. Quantile regression was applied to determine predictors of WTP/QALY. RESULTS: The mean and median maximum WTP/QALY gained among GI patients was $15,165.6 (42,239.6) and $4,365.6 (IQR: 1,586.5-14,552.0), respectively, which was equal to 3.68 times the 2022 gross domestic product (GDP) per capita in Vietnam.  Additionally, cancer severity was found to have a significant impact  on WTP per QALY gained, with a higher amount identified among patients with earlier stages of GI cancer. Furthermore, living in an urban dwelling and patients' treatment modalities were significantly associated with WTP/QALY. CONCLUSION: Evidence from our study can be used to inform how decision-makers in Vietnam to determine the cost-effectiveness of GI cancer interventions.

Patient and provider factors predict non-surgical management for complex upper gastrointestinal cancers.

BACKGROUND: Surgery is the only potentially curative treatment for non-metastatic upper gastrointestinal cancers. We analyzed patient and provider characteristics associated with non-surgical management. METHODS: We queried the National Cancer Database for patients with upper gastrointestinal cancers from 2004 to 2018 who underwent surgery, refused surgery, or for whom surgery was contraindicated. Multivariate logistic regression identified factors associated with surgery being refused or contraindicated, and Kaplan-Meier curves assessed survival. RESULTS: We identified 249,813 patients based on our selection criteria-86.3% had surgery, 2.4% refused, and for 11.3%, surgery was contraindicated. Median overall survival was 48.2 months for patients who underwent surgery versus 16.3 and 9.4 months for the refusal and contraindicated groups. Medical and non-medical factors predicted both surgery refusals and contraindications, such as increasing age (odds ratio = 1.07 and 1.03, respectively, P < .001), Black race (odds ratio = 1.72 and 1.45, P < .001), comorbidities (Charlson-Deyo score 2+, odds ratio = 1.18 and 1.66, P < .001), low socioeconomic status (odds ratio = 1.70 and 1.40, P < .001), no health insurance (odds ratio = 3.26 and 2.34, P < .001), community cancer programs (odds ratio = 1.43 and 1.40, P < .001), low volume facilities (odds ratio = 1.82 and 1.52, P < .001), and stage 3 disease (odds ratio = 1.51 and 6.50, P < .001). On subset analysis (excluding patients age >70, Charlson-Deyo score 2+, and stage 3 cancer), non-medical predictors of both outcomes were similar. CONCLUSION: Refusal of and medical contraindications for surgery profoundly impact overall survival. The same factors (ie, race, socioeconomic status, hospital volume, and hospital type) predict these outcomes. These findings suggest variation and potential bias that may exist between physicians and patients discussing cancer surgery.

The clinical and financial cost of mental disorders among elderly patients with gastrointestinal malignancies.

The clinical and financial effects of mental disorders are largely unknown among gastrointestinal (GI) cancer patients. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we identified patients whose first cancer was a primary colorectal, pancreatic, gastric, hepatic/biliary, esophageal, or anal cancer as well as those with coexisting depression, anxiety, psychotic, or bipolar disorder. Survival, chemotherapy use, total healthcare expenditures, and patient out-of-pocket expenditures were estimated and compared based on the presence of a mental disorder. We identified 112,283 patients, 23,726 (21%) of whom had a coexisting mental disorder. Median survival for patients without a mental disorder was 52 months (95% CI 50-53 months) and for patients with a mental disorder was 43 months (95% CI 42-44 months) (p < 0.001). Subgroup analysis identified patients with colorectal, gastric, or anal cancer to have a significant association between survival and presence of a mental disorder. Chemotherapy use was lower among patients with a mental disorder within regional colorectal cancer (43% vs. 41%, p = 0.01) or distant colorectal cancer subgroups (71% vs. 63%, p < 0.0001). The mean total healthcare expenditures were higher for patients with a mental disorder in first year following the cancer diagnosis (increase of $16,823, 95% CI $15,777-$18,173), and mean patient out-of-pocket expenses were also higher (increase of $1,926, 95% CI $1753-$2091). There are a substantial number of GI cancer patients who have a coexisting mental disorder, which is associated with inferior survival, higher healthcare expenditures, and greater personal financial burden.

Economic Impact of the Introduction of Outpatient Medical Specialist Care (ASV) of Gastrointestinal Cancer Patients from a German Hospital Management Perspective.

INTRODUCTION: The treatment of cancer patients in Germany is characterized by sectoral separation of the in- and outpatient care accompanied by 2 separate reimbursement systems. By introducing the Guideline of Outpatient Medical Specialist Care in accordance with §116b SGB V (ASV) in 2014, the German legislation empowers office-based physicians and hospitals to jointly provide medical care in the ambulatory setting. METHODS: A 1-year period each before and after the introduction of ASV was compared by means of data from the Center for Integrated Oncology Cologne at the University Hospital of Cologne. Only adults with a reliable diagnosis of gastrointestinal tumor (GIT) were considered. RESULTS: Overall, 1,872 cases were considered in the analysis showing significant (p < 0.001) higher median values of revenues across ICD-subgroups for ASV (EUR 427.46) compared to Ambulatory Treatments in Hospitals (EUR 234.21). The exemplary analysis of revenues in neoplasms of the pancreas shows EUR 173.69 on average which are only invoiceable through ASV: flat rate incl. surcharges (EUR 117.79; 68%), structure lump sum (EUR 29.49; 17%), positron-emission tomography (PET)/CT (EUR 13.53; 18%), and ASV consultation hour (EUR 12.89; 7%). DISCUSSION/CONCLUSION: ASV leads to significant higher revenues across different ICD-subgroups for patients suffering from severe GIT. The collaboration of hospital and office-based physicians ensures patient-centered care with accumulated expertise and avoidance of double examinations. Thus, the inclusion of additional services in the Uniform Value Scale (invoiceable for ASV) is legitimated and enables cost-covering care for the involved parties.

Health expenditures and financial burden among patients with major gastrointestinal cancers relative to other common cancers in the United States.

BACKGROUND: Gastrointestinal cancers contribute substantially to the cost of health care. We sought to quantify and compare the financial burden associated with treatment of gastrointestinal cancers versus other common nongastrointestinal cancers. METHODS: The Medical Expenditure Panel Survey from 2006 to 2015 was used to identify individuals with gastrointestinal cancer, other nongastrointestinal cancer (breast/prostate or lung), or no history of malignancy. Total and out-of-pocket medical expenditures were compared. Among each cohort, risk of high and catastrophic financial burden was determined. RESULTS: A total of 90,344 individuals were identified, which was extrapolated to a national representative sample of 95,449,062 individuals. Overall, an estimated 365,367 (0.4%) individuals had a gastrointestinal cancer while 2,015,724 (2.1%) had lung, breast, or prostate cancer. Mean adjusted total health expenditures was greater among patients with gastrointestinal cancer ($13,716; 95% confidence interval, $9,805-$17,628) versus patients with nongastrointestinal cancer ($8,665; 95% confidence interval, $8,222-$9,108) or individuals without cancer ($5,807; 95% confidence interval $5,740-$5,874). An estimated 15.8% (n = 57,898) and 7.1% (n = 25,956) of patients with gastrointestinal cancer experienced a high and catastrophic financial burden, respectively. Patients with gastrointestinal cancer had a 64% increased odds of experiencing catastrophic financial burden compared with patients without a history of cancer (odds ratio 1.64, 95% confidence interval, 1.17-2.31). Furthermore, patients with a gastrointestinal cancer had nearly 40% increased odds of high financial burden associated with their care compared with patients without cancer (odds ratio 1.37; 95% confidence interval, 1.00-1.88). CONCLUSION: The risk of experiencing catastrophic financial burden among patients with gastrointestinal cancer was considerable, as roughly 1 in 7 patients experienced high financial burden, and 1 in 13 had a catastrophic financial burden.

Economic value of nutritional support methods in gastrointestinal cancer: A quantitative meta-analysis.

BACKGROUND AND OBJECTIVES: Multiple studies of the relative economic value of different nutritional support methods for patients with gastrointestinal cancer have provided inconsistent results. METHODS AND STUDY DESIGN: The PUBMED and EMBASE databases were systematically searched through September 30, 2018to identify latent studies of the benefits of parenteral nutrition (PN), enteral nutrition (EN) or conventional intervention (CI) in gastrointestinal cancer patients. A fixed-effects model or random-effects model was applied depending on the heterogeneity of the studies. Statistical analysis was conducted using R software. A total of 728 studies were reviewed, and 21 studies published from 1998 to 2018 were included in the final analysis. RESULTS: The results showed that the hospitalization expenditure of the EN group was 3938 RMB less than that of the PN group. Similarly, the EN group had a shorter length of hospitalization than the PN and CI groups. The infection rate was lower in the EN group (12%) than in the PN group (16%) and CI group (20%). Subgroup analysis showed that gastrointestinal cancer patients who received oral nutritional supplements had the lowest infection rate (11%) after surgery. CONCLUSIONS: EN, especially oral nutritional supplements, has a positive economic impact on patients with gastrointestinal cancer, based on reductions in the post-operative infection rate, length of hospitalization, and hospitalization expenditure.

The impact of financial toxicity in gastrointestinal cancer patients.

BACKGROUND: Biopsychosocial distress screening is a critical component of comprehensive cancer care. Financial issues are a common source of distress in this patient population. This study uses a biopsychosocial distress screening tool to determine the factors associated with financial toxicity and the impact of these stressors on gastrointestinal cancer patients. METHODS: A 48-question, proprietary distress screening tool was administered to patients with gastrointestinal malignancies from 2009 to 2015. This validated, electronically-administered tool is given to all new patients. Responses were recorded on a 5-point Likert scale from 1 (not a problem) to 5 (very severe problem), with responses rated at ≥3 indicative of distress. Univariate and multivariate logistic regressions were used to analyze the data. RESULTS: Most of the 1,027 patients had colorectal (50%) or hepatobiliary (31%) malignancies. Additionally, 34% of all patients expressed a high level of financial toxicity. Age greater than 65 (odds ratio: 0.63, 95% confidence interval: 0.47-0.86, P < .01), college education (odds ratio: 0.53, 95% confidence interval: 0.38-0.73, P < .0001), being partnered (odds ratio: 0.61, 95% confidence interval: 0.44-0.84, P < .01), and annual income greater than $40,000 (odds ratio: 0.27, 95% confidence interval: 0.19-0.38, P < .0001) were all protective against financial toxicity on univariate analysis. Also, heavy tobacco use was associated significantly with increased distress on univariate analysis (odds ratio: 2.79, 95% confidence interval: 1.38-5.78, P < .01). With the exception of partnered status (odds ratio: 1.18, 95% confidence interval: 0.76-1.85, P = .46), all these variables retained their significant association with financial toxicity in the multivariate model. CONCLUSION: Financial toxicity impacts a large number of cancer patients. Further study of at-risk populations may identify patients who would benefit from pre-emptive education and counseling interventions as part of their routine cancer care.

[Reimbursement differences in the ambulatory specialized care (ASV) compared to the previous care system. An exemplary analysis in medical oncology treating gastrointestinal malignancies]. / Vergütungsunterschiede bei der ambulanten spezialfachärztlichen Versorgung (ASV) im Vergleich zur bisherigen Behandlungsform.Eine explorative Analyse an drei Einrichtungen der Fachgruppe internistische Onkologie im Indikationsbereich gastrointestinale Tumoren.

INTRODUCTION AND AIM: The ambulatory specialized care (ASV) act (Sect. 116b of the Social Code Fifth Book [SGB V]) is intended to enable patients with a rare disease or a special course of disease or patients needing a highly specialized treatment to get access to outpatient care by office-based as well as hospital doctors. Data concerning care, service performance and fees - in comparison to the usual contract with the statutory insurance or the former Sect. 116b SGB V - are lacking. We explored the question whether differences in reimbursement between ASV and the previous system exist and which factors are influencing them. METHODS: We analyzed ICD-10 diagnoses, performance parameters as well as budgets and service fees in the former care system of medical oncologists in the institutions of three ASV participants of two federal countries treating gastrointestinal malignancies. We compared the results (fees, remuneration) to those from the statutory contract system and the former ambulatory care of hospitals and calculated the differences. Data were analyzed descriptively and analytically using SPSS. RESULTS: The analyses showed significant differences in the reimbursement rates between both office-based teams due to different budgets in the statutory contract system of the different federal countries. This led to additional remuneration of 12.5 to 49 % in ASV. The increase in fees of the hospital-guided team was exclusively due to the ASV-only fees of chapter 51 of EBM since there were no limitations of budgets even in the former system. DISCUSSION AND CONCLUSION: Exemplified with the ASV subgroup GIT, our study shows for the analyzed medical specialty that the difference in reimbursement in ASV is mostly due to the federal country-specific budgets and that the increase in honoraria can be substantial. Due to differences in budgets and quota systems, there may be different results in other ASV indications and specialist groups as well as in other federal states. Irrespective of these arguments, further aspects need to be taken into account when participation in ASV is considered.

Financial toxicity risk among adult patients undergoing cancer surgery in the United States: An analysis of the National Inpatient Sample.

BACKGROUND AND OBJECTIVE: Financial hardship occurring as a result of cancer treatment has been termed financial toxicity and is an established side effect of the cancer treatment. We investigated the risk of financial toxicity among patients undergoing surgery for gastrointestinal cancers. METHODS: All uninsured and privately insured patients who underwent surgery for a gastrointestinal cancer were identified from the National Inpatient Sample. Publicly available government data were used estimate income, food expenditure, and average maximum out-of-pocket expenditure. Risk of financial toxicity was defined as health expenditure ≥ 40% of postsubsistence income. RESULTS: Among the 78 545 patients in the analytic cohort, 73 305 individuals had private insurance while 5240 patients were uninsured. Overall median hospital charges were $58 651 (IQR: $37 912-$95 379). Approximately 90% of uninsured and 10% of privately insured patients were at risk of financial toxicity. At the subpopulation level, patients in the lowest income quartile, undergoing emergency surgery, black or hispanic individuals, and those undergoing surgery for esophageal or colon cancer were more likely to experience catastrophic costs following surgery (P < .001). CONCLUSION: Approximately 9 in 10 uninsured and 1 in 10 privately insured patients with cancer were at risk of financial toxicity after the surgery. Targeted interventions are needed to provide financial protection to patients undergoing the cancer treatment.

Cost-effectiveness of edoxaban versus dalteparin for the treatment of cancer-associated thrombosis.

Malignancy is a well-established risk factor for venous thromboembolism and while low-molecular-weight heparin therapy has been standard of care for cancer-associated thrombosis for many years, many patients find injection therapy burdensome. The direct oral anticoagulant edoxaban has been shown to be noninferior to dalteparin for the treatment of cancer-associated thrombosis. In a Markov simulation model, edoxaban with 6-month time horizon and a United States societal perspective with 2017 US dollars, edoxaban was the preferred strategy in the general cancer population (6-month cost $6061 with 0.34 quality adjusted life years) and in a subgroup of patients with gastrointestinal malignancy (6-month cost $7227 with 0.34 quality adjusted life years). The incremental cost effectiveness ratio of dalteparin compared to edoxaban was $1,873,535 in the general oncology population and $694,058 in the gastrointestinal malignancy population.

Optimizing the dose in patients treated with imatinib as first line treatment for gastrointestinal stromal tumours: A cost-effectiveness study.

AIMS: Patients with metastatic gastrointestinal stromal tumours (GIST) are treated in first line with the oral tyrosine kinase inhibitor, imatinib, until progressive disease. With this fixed dosing regimen, only approximately 40% of patients reach adequate plasma levels within the therapeutic index. Therapeutic drug monitoring (TDM) is a solution to reach plasma levels within the therapeutic index. However, introducing TDM will also increase costs, due to prolonged imatinib use and laboratory costs. The aim of this study was to evaluate the cost-effectiveness of TDM in patients with metastatic/unresectable GIST treated with imatinib as a first line treatment, compared with fixed dosing. METHODS: A survival model was created to simulate progression, mortality and treatment costs over a 5-year time horizon, comparing fixed dosing vs TDM-guided dosing. The outcomes measured were treatments costs, life-years and quality-adjusted life-years. RESULTS: Total costs over the 5-year time horizon were estimated to be €106 994.85 and €150 477.08 for fixed dosing vs TDM-guided dosing, respectively. A quality-adjusted life year gain of 0.74 (95% confidence interval 0.66-0.90) was estimated with TDM-guided dosing compared to fixed dosing. An average incremental cost-effectiveness ratio of €58 785.70 per quality-adjusted life year gained was found, mainly caused by longer use and higher dosages of imatinib. CONCLUSION: Based on the currently available data, this analysis suggests that TDM-guided dosing may be a cost-effective intervention for patients with metastatic/unresectable GIST treated with imatinib which will be improved when imatinib losses its patency.

First-line systemic treatment adherence, healthcare resource utilization, and costs in patients with gastrointestinal neuroendocrine tumors (GI NETs) in the USA.

AIMS: To assess treatment adherence, healthcare resource utilization, and costs in gastrointestinal neuroendocrine tumor (GI NET) patients initiating pharmacologic treatments in the US. METHODS: In two US commercial claims databases, patients ≥18 years with ≥1 inpatient or ≥2 outpatient GI NET claims within 12 months were identified. The first claim for pharmacologic treatments (e.g. somatostatin analogs [SSAs], cytotoxic chemotherapy [CC], targeted therapy [TT]) following diagnosis, between July 1, 2009 - December 31, 2014, was defined as the index date. A 6-month pre-index NET treatment-free period, and ≥1-year post-index enrollment were required. Proportion of days covered (PDC) was calculated during the follow-up period. Outcomes were reported separately for patients with 1- and 2-years post-index enrollment. Descriptive statistics, including means, standard deviations, and frequencies and percentages for continuous and categorical data, respectively, were reported. RESULTS: Of 1,322 patients with 1-year follow-up, 847 initiated SSA, 397 CC, 35 TT, two interferon, and 41 various combinations. Mean (SD) PDC was 0.669 (0.331) for SSA, 0.466 (0.236) for CC, and 0.505 (0.328) for TT. Mean (SD) office visits and hospitalizations, respectively, were 20.5 (13.5) and 0.59 (1.03) for SSA, 30.5 (19.8) and 0.89 (1.45) for CC, and 17.7 (12.5) and 1.23 (1.93) for TT. Total annual cost for patients during year 1 was $99,691 (82,423) for SSA, $134,912 (116,078) for CC, and $158,397 (82,878) for TT. Among 685 patients with 2-years follow-up, annual mean costs in year 2 were $8,071, $58,944, and $36,248 lower than year 1 for SSA, CC, and TT, respectively. LIMITATIONS: Findings may not be generalizable to the US population. Claims are designed for reimbursement, not research. The study may under-estimate costs not covered by insurance. CONCLUSION: This study reports utilization and costs associated with different treatment therapies. Costs were higher in year 1 than year 2. This two-database study offers new information on the magnitude and trends in the cost of pharmacologically-treated GI NETs.

Compensation Claims for Sub-substandard Care of Patients with Gastroentero-pancreatic Neuroendocrine Tumors: A Nationwide Descriptive Study of Cases Between 2005-2016 in Norway.

BACKGROUND: Management of patients with neuroendocrine tumors of the gastrointestinal tract or pancreas (GEP-NENs) poses diagnostic and therapeutic challenges. This study described the medico-legal claims reported to a national governmental system that oversees compensation to patients with GEP-NENs Materials and Methods: An electronic search of the Norwegian System of Compensation to Patients database was performed to identify claims evaluated between 2005-2016. The clinical information and the medico-legal evaluation were reviewed. RESULTS: We identified seven patients, five women and two men, with a median age of 57 (range=47-73) years. Delayed diagnosis (median diagnostic delay of 18 (range=6-48) months) was the main cause for claims in six out of the seven patients). Four patients received financial compensation based on the claim judgement. CONCLUSION: This review of claims that were evaluated by the Norwegian System of Compensation to Patients showed that a timely diagnosis of GEP-NENs remains a clinical challenge.

EPIDEMIOLOGY OF GASTROINTESTINAL NEUROENDOCRINE TUMORS IN A U.S. COMMERCIALLY INSURED POPULATION.

OBJECTIVE: To estimate incidence and prevalence of gastrointestinal neuroendocrine tumors (GI NETs) in U.S. commercially insured patients. METHODS: This was a retrospective, cross-sectional study using 2009 to 2014 data from MarketScan and PharMetrics commercial claims databases. Patients were 18 to 64 years old, and had 1 inpatient or 2 outpatient claims with GI NET, identified by International Classification of Diseases, 9th Revision, Clinical Modification codes. Incidence was calculated as number of patients with NET who were disease-free for 2 years prior, divided by number of enrollees and reported as per million person-years (PMPY). Prevalence was calculated as the number of GI NET patients divided by the number of enrollees per year. RESULTS: The annual number of patients with GI NET ranged from 2,014 to 3,413 in MarketScan and 1,436 to 2,336 in PharMetrics. Incidence increased from 2011 to 2014: 67.0 to 79.1 PMPY in MarketScan and 47.4 to 58.2 PMPY in PharMetrics. Incidence increased by 24.3% in females and 10.7% in males in MarketScan, and by 17.6% in females and 29.3% in males in PharMetrics. Incidence increased with age and was highest in the 45 to 54 and 55 to 64 age groups. Prevalence increased from 77.9 to 131.2 per million per year (MarketScan) and 50.8 to 108.9 (PharMetrics) from 2009 to 2014. Prevalence was generally higher in females than males and highest in 55 to 64 year olds. These increases may be due to better diagnostics, increased awareness of NET among clinicians and pathologists, and/or actual increase in disease. CONCLUSION: Clinicians may see GI NET with increasing frequency and should become more familiar with its presentation and treatment. ABBREVIATIONS: GI = gastrointestinal; ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; NET = neuroendocrine tumor; PMPY = per million person-years; SEER = Surveillance, Epidemiology, and End Results.

Utility of a multidisciplinary tumor board in the management of pancreatic and upper gastrointestinal diseases: an observational study.

BACKGROUND & OBJECTIVES: Multidisciplinary tumor boards (MDTBs) are frequently employed in cancer centers but their value has been debated. We reviewed the decision-making process and resource utilization of our MDTB to assess its utility in the management of pancreatic and upper gastrointestinal tract conditions. METHODS: A prospectively-collected database was reviewed over a 12-month period. The primary outcome was change in management plan as a result of case discussion. Secondary outcomes included resources required to hold MDTB, survival, and adherence to treatment guidelines. RESULTS: Four hundred seventy cases were reviewed. MDTB resulted in a change in the proposed plan of management in 101 of 402 evaluable cases (25.1%). New plans favored obtaining additional diagnostic workup. No recorded variables were associated with a change in plan. For newly-diagnosed cases of pancreatic ductal adenocarcinoma (n = 33), survival time was not impacted by MDTB (p = .154) and adherence to National Comprehensive Cancer Network guidelines was 100%. The estimated cost of physician time per case reviewed was $190. CONCLUSIONS: Our MDTB influences treatment decisions in a sizeable number of cases with excellent adherence to national guidelines. However, this requires significant time expenditure and may not impact outcomes. Regular assessments of the effectiveness of MDTBs should be undertaken.

Cost effectiveness of surveillance for GI cancers.

Gastrointestinal (GI) diseases are among the leading causes of death in the world. To reduce the burden of GI diseases, surveillance is recommended for some diseases, including for patients with inflammatory bowel diseases, Barrett's oesophagus, precancerous gastric lesions, colorectal adenoma, and pancreatic neoplasms. This review aims to provide an overview of the evidence on cost-effectiveness of surveillance of individuals with GI conditions predisposing them to cancer, specifically focussing on the aforementioned conditions. We searched the literature and reviewed 21 studies. Despite heterogeneity of studies in terms of settings, study populations, surveillance strategies and outcomes, most reviewed studies suggested at least some surveillance of patients with these GI conditions to be cost-effective. For some high-risk conditions frequent surveillance with 3-month intervals was warranted, while for other conditions, surveillance may only be cost-effective every 10 years. Further studies based on more robust effectiveness evidence are needed to inform and optimise surveillance programmes for GI cancers.

Overcoming Cost Implications of Mutational Analysis in Patients with Gastrointestinal Stromal Tumors: A Pragmatic Approach.

BACKGROUND: Genetic analysis of tissue derived from patients with advanced gastrointestinal stromal tumors (GISTs) is not uniformly applied on a national and international level, even though mutational data can provide clinically relevant prognostic and predictive information, especially in patients qualifying for treatment with expensive targeted agents. METHODS: The current article describes the rationale for genetic testing of GIST tissue, looks at financial implications associated with such analysis and speculates on potential cost savings introduced by routine mutational testing and tailored use of tyrosine kinase inhibitors based on genotyping. This work is based on a hypothetical analysis of epidemiological data, drug costs, reimbursement criteria and market research figures. RESULTS: The cost burden for routine genotyping of important genes in GISTs, especially in patients at high risk for relapse after primary surgery and in advanced, inoperable metastatic disease, is relatively low. The early identification of GISTs with primary resistance mutations should be the basis for personalized GIST treatment and reimbursement of drugs. As illustrated by Belgian figures, the exclusive use of a drug such as imatinib in patients who are likely to benefit from the agent based on genetic information can lead to significant cost savings, which outweigh the costs for testing. CONCLUSIONS: Mutational analysis of GIST should be considered early in all patients at risk for relapse after curative surgery and in the case of advanced, inoperable, metastatic disease. The costs for the actual genotyping should not be used as an argument against profiling of the tumor. The adjuvant and palliative systemic treatment of GISTs should be personalized based on the genotype and other known prognostic and predictive factors. Reimbursement criteria for essential agents such as imatinib should be adapted accordingly.

COST-EFFECTIVENESS OF PERIOPERATIVE IMMUNONUTRITION IN GASTROINTESTINAL ONCOLOGIC SURGERY: A SYSTEMATIC REVIEW.

INTRODUCTION: Costs, length of hospital staying and morbidity are frequently and significantly increased as a result of infections and other complications following surgical procedure for gastrointestinal tract cancer. Recently, improving host defence mechanisms have become a target of interest. Immunonutrition aims at improving immunity, most likely providing key nutrients to maintain T-lymphocyte and other host defence. AIM: To evaluate the immunonutrition in cancer patients who are operated by digestive diseases and assess the cost-effectiveness of this supplementation. METHODS: This study consisted of a systematic review of the literature based on reference analyses retrieved from current databases such as PubMed, Lilacs and SciELO. The search strategy was defined by terms related to immunonutrition [immunonutrition, arginine, omega-3 and nucleotides] in combination with [costs, cost-effective and cost-effectiveness] as well as [gastrointestinal cancer surgery, oesophageal, gastric or pancreatic surgery] in English, Portuguese or Spanish language. For cost analyses, currencies used in the manuscripts were all converted to American dollars (US$) in order to uniform and facilitate comparison. Six prospective randomized studies were included in this review. CONCLUSION: The cost-effectiveness was positive in most of studies, demonstrating that this diet can significantly reduce hospital costs in the North hemisphere. However, similar studies needed to be carried to determine such results among us.

INTRODUÇÃO: Custos, tempo de hospitalização e morbidade estão frequentemente aumentados na presença de infecções e outras complicações decorrentes de procedimentos cirúrgicos para o câncer gastrointestinal. Recentemente, a melhora de mecanismos de defesa do hospedeiro tem se tornado um alvo de interesse. Nutrição adequada está fortemente relacionada com competência imune e redução de infeções. Imunonutrição objetiva a melhora da imunidade, principalmente para manutenção de linfócitos-T e outras defesas. OBJETIVO: Avaliar a imunonutrição em pacientes oncológicos que são operados por doenças do aparelho digestivo e avaliar a relação custo-eficácia desta suplementação. MÉTODO: Revisão sistemática da literatura baseada nas bases de dados PubMed, Lilacs e SciELO. A busca foi realizada com combinação de descritores em inglês e português relacionados ao tema da revisão: [immunonutrition, arginine, omega-3, nucleotides] combinado com [costs, cost-effective, cost-effectiveness] e [gastrointestinal cancer surgery, oesophageal, gastric or pancreatic surgery]. Para análise de custos, moedas usadas nos artigos foram todas convertidas para dólar americano. Seis estudos randomizados prospectivos foram incluídos nesta revisão. CONCLUSÃO: O custo-benefício foi positivo na maioria dos estudos, sugerindo que este tipo de dieta reduz significativamente os custos hospitalares nos países do hemisfério norte. Contudo, estudos similares de custo-benefício devem ser realizados para definir o real custo-benefício em nosso meio.