INTRODUCTION: Therapeutic options for men with metastatic prostate cancer have increased in the past decade. We studied recent treatment patterns for men with metastatic prostate cancer and how treatment patterns have changed over time. METHODS: Using the Surveillance, Epidemiology, and End Results‒Medicare database, we identified fee-for-service Medicare beneficiaries who either were diagnosed with metastatic prostate cancer or developed metastases following diagnosis, as indicated by the presence of claims with diagnoses codes for metastatic disease, between 2007 and 2017. We evaluated treatment patterns using claims. RESULTS: We identified 29,800 men with metastatic disease, of whom 4721 (18.8%) had metastatic disease at their initial diagnosis. The mean age was 77 years, and 77.9% of patients were non-Hispanic White. The proportion receiving antineoplastic agents within 3 years of the index date increased over time (from 9.7% in 2007 to 25.9% in 2017; P < .001). Opioid use within 3 years of prostate cancer diagnosis was stable during 2007 to 2013 (around 73%) but decreased through 2017 to 65.5% (P < .001). Patients diagnosed during 2015 to 2017 had longer median survival (32.6 months) compared to those diagnosed during 2007 to 2010 (26.6 months; P < .001). CONCLUSIONS: Most metastatic prostate cancer patients do not receive life-prolonging antineoplastic therapies. Improved adoption of effective cancer therapies when appropriate may increase length and quality of survival among metastatic prostate cancer patients.

BACKGROUND: Few studies have comprehensively compared health-related quality of life (HRQoL) between metastatic prostate cancer survivors, survivors with non-metastatic disease, and men without a cancer history. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) data linkage to identify men aged ≥ 65 years enrolled in Medicare Advantage (MA) plans. Prostate cancer survivors were diagnosed between 1988 and 2017 and completed MHOS surveys between 1998 and 2019. We analyzed data from 752 metastatic prostate cancer survivors (1040 survey records), 19,583 localized or regional prostate cancer survivors (non-metastatic; 30,121 survey records), and 784,305 men aged ≥ 65 years without a cancer history in the same SEER regions (1.15 million survey records). We used clustered linear regressions to compare HRQoL measures at the person-level using the Veterans RAND 12 Item Health Survey (VR-12) T-scores for general health and physical and mental component summaries. RESULTS: Compared to men without a cancer history, prostate cancer survivors were older, more likely to be married, and had higher socioeconomic status. Compared to men without a cancer history, metastatic prostate cancer survivors reported lower general health (T-score differences [95% confidence interval]: - 6.26, [- 7.14, - 5.38], p < .001), physical health (- 4.33, [- 5.18, - 3.48], p < .001), and mental health (- 2.64, [- 3.40, - 1.88], p < .001) component summaries. Results were similar for other VR-12 T-scores. In contrast, non-metastatic prostate cancer survivors reported similar VR-12 T-scores as men without a cancer history. Further analyses comparing metastatic and non-metastatic prostate cancer survivors support these findings. CONCLUSION: Interventions to improve health-related quality of life for men diagnosed with metastatic prostate cancer merit additional investigation. IMPLICATIONS FOR CANCER SURVIVORS: Interventions to improve health-related quality of life for metastatic prostate cancer survivors merit additional investigation.

BACKGROUND: Cancer diagnosis and treatment can substantially affect health and financial outcomes for patients and families. Research in health care delivery across the cancer control continuum includes diverse activities led by multiple government and private sector organizations. Assessing the economic drivers and influencing factors associated with costs across this continuum is challenging as organizations leading research efforts often do not have forums to share data, develop linkages, and explore collaborative opportunities. OBJECTIVE: To describe the objectives, activities, and goals of the Interagency Consortium to Promote Health Economics Research on Cancer (HEROiC) to strengthen data resources and capacity for collaborative patient-focused cancer health economics research. MAIN ARGUMENT: HEROiC's goals include assessing the economic burden of cancer; examining the effects of policies, health care setting/system factors, and health service delivery approaches across the cancer control continuum; and enhancing collaborations among researchers and organizations. CONCLUSIONS: Data resources to study economic outcomes associated with cancer control are highly fragmented; HEROIC provides a forum to collaboratively develop, enhance, and utilize data resources and infrastructure for patient-centered cancer health economics research. This includes sharing data resources, developing linkages, identifying new data collection venues, and creating and supporting the dissemination of evidence-based information to diverse stakeholders. These efforts provide critical information to address the economic burden of cancer. RELEVANCE TO THE SPECIAL ISSUE: Cancer diagnosis and treatment affect patient health and financial outcomes. This commentary describes how HEROiC will enhance research data infrastructure and collaborations to support patient-centered research with the goal of reducing the economic burden of cancer.

PURPOSE: To facilitate use of timely, granular, and publicly available data on COVID-19 mortality, we provide a method for imputing suppressed COVID-19 death counts in the National Center for Health Statistic's 2020 provisional mortality data by quarter, county, and age. METHODS: We used a Bayesian approach to impute suppressed COVID-19 death counts by quarter, county, and age in provisional data for 3,138 US counties. Our model accounts for multilevel data structures; numerous zero death counts among persons aged <50 years, rural counties, early quarters in 2020; highly right-skewed distributions; and different levels of data granularity (county, state or locality, and national levels). We compared three models with different prior assumptions of suppressed COVID-19 deaths, including noninformative priors (M1), the same weakly informative priors for all age groups (M2), and weakly informative priors that differ by age (M3) to impute the suppressed death counts. After the imputed suppressed counts were available, we assessed three prior assumptions at the national, state/locality, and county level, respectively. Finally, we compared US counties by two types of COVID-19 death rates, crude (CDR) and age-standardized death rates (ASDR), which can be estimated only through imputing suppressed death counts. RESULTS: Without imputation, the total COVID-19 death counts estimated from the raw data underestimated the reported national COVID-19 deaths by 18.60%. Using imputed data, we overestimated the national COVID-19 deaths by 3.57% (95% CI: 3.37%-3.80%) in model M1, 2.23% (95% CI: 2.04%-2.43%) in model M2, and 2.96% (95% CI: 2.76%-3.16%) in model M3 compared with the national report. The top 20 counties that were most affected by COVID-19 mortality were different between CDR and ASDR. CONCLUSIONS: Bayesian imputation of suppressed county-level, age-specific COVID-19 deaths in US provisional data can improve county ASDR estimates and aid public health officials in identifying disparities in deaths from COVID-19.

BACKGROUND: Recent advancements in the clinical management of metastatic prostate cancer include several costly therapies and diagnostic tests. The objective of this study was to provide updated information on the cost to payers attributable to metastatic prostate cancer among men aged 18 to 64 years with employer-sponsored health plans and men aged 18 years or older covered by employer-sponsored Medicare supplement insurance. METHODS: By using Merative MarketScan commercial and Medicare supplemental data for 2009-2019, the authors calculated differences in spending between men with metastatic prostate cancer and their matched, prostate cancer-free controls, adjusting for age, enrollment length, comorbidities, and inflation to 2019 US dollars. RESULTS: The authors compared 9011 patients who had metastatic prostate cancer and were covered by commercial insurance plans with a group of 44,934 matched controls and also compared 17,899 patients who had metastatic prostate cancer and were covered by employer-sponsored Medicare supplement plans with a group of 87,884 matched controls. The mean age of patients with metastatic prostate cancer was 58.5 years in the commercial samples and 77.8 years in the Medicare supplement samples. Annual spending attributable to metastatic prostate cancer was $55,949 per person-year (95% confidence interval [CI], $54,074-$57,825 per person-year) in the commercial population and $43,682 per person-year (95% CI, $42,022-$45,342 per person-year) in the population covered by Medicare supplement plans, both in 2019 US dollars. CONCLUSIONS: The cost burden attributable to metastatic prostate cancer exceeds $55,000 per person-year among men with employer-sponsored health insurance and $43,000 among those covered by employer-sponsored Medicare supplement plans. These estimates can improve the precision of value assessments of clinical and policy approaches to the prevention, screening, and treatment of prostate cancer in the United States.

INTRODUCTION: We sought to estimate per patient and annual aggregate health care costs related to metastatic prostate cancer. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified fee-for-service Medicare beneficiaries ages 66 and older diagnosed with metastatic prostate cancer or claims with diagnosis codes for metastatic disease (indicating tumor progression following diagnosis) between 2007 and 2017. We measured annual health care costs and compared costs between cases and a sample of beneficiaries without prostate cancer. RESULTS: We estimate that per-patient annual costs attributable to metastatic prostate cancer are $31,427 (95% CI: $31,219-$31,635; 2019 dollars). Annual attributable costs rose over time, from $28,311 (95% CI: $28,047-$28,575) in 2007-2013 to $37,055 (95% CI: $36,716-$37,394) in 2014-2017. In aggregate, health costs attributable to metastatic prostate cancer are $5.2 to $8.2 billion per year. CONCLUSIONS: The per patient annual health care costs attributable to metastatic prostate cancer are substantial and have increased over time, corresponding to the approval of new oral therapies used in treating metastatic prostate cancer.

The annual direct medical cost attributable to human papillomavirus (HPV) in the United States over the period 2004-2007 was estimated at $9.36 billion in 2012 (updated to 2020 dollars). The purpose of this report was to update that estimate to account for the impact of HPV vaccination on HPV-attributable disease, reductions in the frequency of cervical cancer screening, and new data on the cost per case of treating HPV-attributable cancers. Based primarily on data from the literature, we estimated the annual direct medical cost burden as the sum of the costs of cervical cancer screening and follow-up and the cost of treating HPV-attributable cancers, anogenital warts, and recurrent respiratory papillomatosis (RRP). We estimated the total direct medical cost of HPV to be $9.01 billion annually over the period 2014-2018 (2020 U.S. dollars). Of this total cost, 55.0% was for routine cervical cancer screening and follow-up, 43.8% was for treatment of HPV-attributable cancer, and less than 2% was for treating anogenital warts and RRP. Although our updated estimate of the direct medical cost of HPV is slightly lower than the previous estimate, it would have been substantially lower had we not incorporated more recent, higher cancer treatment costs.

PURPOSE: We report the prevalence and economic cost of skin cancer treatment compared to other cancers overall in the USA from 2012 to 2018. METHODS: Using the Medical Expenditure Panel Survey full-year consolidated data files and associated medical conditions and medical events files, we estimate the prevalence, total costs, and per-person costs of treatment for melanoma and non-melanoma skin cancer among adults aged ≥ 18 years in the USA. To understand the changes in treatment prevalence and treatment costs of skin cancer in the context of overall cancer treatment, we also estimate the prevalence, total costs, and per-person costs of treatment for non-skin cancer among US adults. RESULTS: During 2012-15 and 2016-18, the average annual number of adults treated for any skin cancer was 5.8 (95% CI: 5.2, 6.4) and 6.1 (95% CI: 5.6, 6.6) million, respectively, while the average annual number of adults treated for non-skin cancers rose from 10.8 (95% CI: 10.0, 11.5) to 11.9 (95% CI: 11.2, 12.6) million, respectively. The overall estimated annual costs rose from $8.0 (in 2012-2015) to $8.9 billion (in 2016-18) for skin cancer treatment and $70.2 to $79.4 billion respectively for non-skin cancer treatment. CONCLUSION: The prevalence and economic cost of skin cancer treatment modestly increased in recent years. Given the substantial cost of skin cancer treatment, continued public health attention to implementing evidence-based sun-safety interventions to reduce skin cancer risk may help prevent skin cancer and the associated treatment costs.

OBJECTIVE: State-issued behavioral policy interventions (BPIs) can limit community spread of COVID-19, but their effects on COVID-19 transmission may vary by level of social vulnerability in the community. We examined the association between the duration of BPIs and the incidence of COVID-19 across levels of social vulnerability in US counties. METHODS: We used COVID-19 case counts from USAFacts and policy data on BPIs (face mask mandates, stay-at-home orders, gathering bans) in place from April through December 2020 and the 2018 Social Vulnerability Index (SVI) from the Centers for Disease Control and Prevention. We conducted multilevel linear regression to estimate the associations between duration of each BPI and monthly incidence of COVID-19 (cases per 100000 population) by SVI quartiles (grouped as low, moderate low, moderate high, and high social vulnerability) for 3141 US counties. RESULTS: Having a BPI in place for longer durations (ie, 2 months) was associated with lower incidence of COVID-19 compared with having a BPI in place for <1 month. Compared with having no BPI in place or a BPI in place for <1 month, differences in marginal mean monthly incidence of COVID-19 per 100000 population for a BPI in place for 2 months ranged from -4 cases in counties with low SVI to -401 cases in counties with high SVI for face mask mandates, from -31 cases in counties with low SVI to -208 cases in counties with high SVI for stay-at-home orders, and from -227 cases in counties with low SVI to -628 cases in counties with high SVI for gathering bans. CONCLUSIONS: Establishing COVID-19 prevention measures for longer durations may help reduce COVID-19 transmission, especially in communities with high levels of social vulnerability.

CONTEXT: Mask mandates are one form of nonpharmaceutical intervention that has been utilized to combat the spread of SARS-CoV2, the virus that causes COVID-19. OBJECTIVE: This study examines the association between state-issued mask mandates and changes in county-level and hospital referral region (HRR)-level COVID-19 hospitalizations across the United States. DESIGN: Difference-in-difference and event study models were estimated to examine the association between state-issued mask mandates and COVID-19 hospitalization outcomes. PARTICIPANTS: All analyses were conducted with US county-level data. INTERVENTIONS: State-issued mask mandates. County-level data on the mandates were collected from executive orders identified on state government Web sites from April 1, 2020, to December 31, 2020. MAIN OUTCOME MEASURES: Daily county-level (and HRR-level) estimates of inpatient beds occupied by patients with confirmed or suspected COVID-19 were collected by the US Department of Health and Human Services. RESULTS: The state issuing of mask mandates was associated with an average of 3.6 fewer daily COVID-19 hospitalizations per 100 000 people (P < .05) and a 1.2-percentage-point decrease in the percentage of county beds occupied with COVID-19 patients (P < .05) within 70 days of taking effect. Event study results suggest that this association increased the longer mask mandates were in effect. In addition, the results were robust to analyses conducted at the HRR level. CONCLUSIONS: This study demonstrated that state-issued mask mandates were associated with reduction in COVID-19 hospitalizations across the United States during the earlier portion of the pandemic. As new variants of the virus cause spikes in COVID-19 cases, reimposing mask mandates in indoor and congested public areas, as part of a layered approach to community mitigation, may reduce the spread of COVID-19 and lessen the burden on our health care system.

Objectives: This study assessed the associations between parent intent to have their child receive the COVID-19 vaccination, and demographic factors and various child activities, including attendance at in-person education or childcare. Methods: Persons undergoing COVID-19 testing residing in Minnesota and Los Angeles County, California with children aged &lt;12 years completed anonymous internet-based surveys between 10 May and 6 September 2021 to assess factors associated with intention to vaccinate their child. Factors influencing the parents' decision to have their child attend in-person school or childcare were examined. Estimated adjusted odds rations (AORs, 95% CI) were computed between parents' intentions regarding children's COVID-19 vaccination and participation in school and extra-curricular activities using multinomial logistic regression. Results: Compared to parents intending to vaccinate their children (n = 4686 [77.2%]), those undecided (n = 874 [14.4%]) or without intention to vaccinate (n = 508 [8.4%]) tended to be younger, non-White, less educated, and themselves not vaccinated against COVID-19. Their children more commonly participated in sports (aOR:1.51 1.17-1.95) and in-person faith or community activities (aOR:4.71 3.62-6.11). A greater proportion of parents without intention to vaccinate (52.5%) indicated that they required no more information to make their decision in comparison to undecided parents (13.2%). They further indicated that additional information regarding vaccine safety and effectiveness would influence their decision. COVID-19 mitigation measures were the most common factors influencing parents' decision to have their child attend in-person class or childcare. Conclusions: Several demographic and socioeconomic factors are associated with parents' decision whether to vaccinate their &lt;12-year-old children for COVID-19. Child participation in in-person activities was associated with parents' intentions not to vaccinate. Tailored communications may be useful to inform parents' decisions regarding the safety and effectiveness of vaccination.

PURPOSE: Treatments for endocrine-refractory or triple-negative metastatic breast cancer (mBC) are modestly effective at prolonging life and improving quality of life but can be extremely expensive. Given these tradeoffs in quality of life and cost, the optimal choice of treatment sequencing is unclear. Cost-effectiveness analysis can explicitly quantify such tradeoffs, enabling more informed decision making. Our objective was to estimate the societal cost-effectiveness of different therapeutic alternatives in the first- to third-line sequences of single-agent chemotherapy regimens among patients with endocrine-refractory or triple-negative mBC. METHODS: Using three dynamic microsimulation models of 10,000 patients each, three cohorts were simulated, based upon prior chemotherapy exposure: (1) unexposed to either taxane or anthracycline, (2) taxane- and anthracycline-exposed, and (3) taxane-exposed/anthracycline-naive. We focused on the following single-agent chemotherapy regimens as reasonable and commonly used options in the first three lines of therapy for each cohort, based upon feedback from oncologists treating endocrine-refractory or triple-negative mBC: (1) for taxane- and anthracycline-unexposed patients, paclitaxel, capecitabine (CAPE), or pegylated liposomal doxorubicin; (2) for taxane- and anthracycline-exposed patients, Eribulin, CAPE, or carboplatin; and (3) for taxane-exposed/anthracycline-naive patients, pegylated liposomal doxorubicin, CAPE, or Eribulin. RESULTS: In each cohort, accumulated quality-adjusted life-years were similar between regimens, but total societal costs varied considerably. Sequences beginning first-line treatment with paclitaxel, carboplatin, and CAPE, respectively, for cohorts 1, 2, and 3, had lower costs and similar or slightly better outcomes compared with alternative options. CONCLUSION: In this setting where multiple single-agent chemotherapy options are recommended by clinical guidelines and share similar survival and adverse event trajectories, treatment sequencing approaches that minimize costs early may improve the value of care.

In the past 2 decades, the demand for information on health economics research to guide health care decision making has substantially increased. Studies have provided evidence that eliminating or reducing tobacco use; eating a healthy diet, including fruit and vegetables; being physically active; reducing alcohol consumption; avoiding ultraviolet radiation; and minimizing exposure to environmental and occupational carcinogenic agents should substantially reduce cancer incidence in the population. The benefits of these primary prevention measures in reducing cancer incidence are not instantaneous. Therefore, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention. This article provides an overview of health economics research related to primary prevention of cancer. We addressed the following questions: 1) What are the gaps and unmet needs for performing health economics research focused on primary prevention of cancer? 2) What are the challenges and opportunities to conducting health economics research to evaluate primary prevention of cancer? and 3) What are the future directions for enhancing health economics research on primary prevention of cancer? Modeling primary prevention of cancer is often difficult given data limitations, long delays before the policy or intervention is effective, possible unintended effects of the policy or intervention, and the necessity of outside expertise to understand key inputs or outputs to the modeling. Despite these challenges, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention of cancer.

PURPOSE: Suboptimal diet is a preventable cause of cancer. We aimed to estimate the economic burden of diet-associated cancer among US adults. METHODS: We used a Comparative Risk Assessment model to quantify the number of new cancer cases attributable to seven dietary factors among US adults ages 20 + years. A Markov cohort model estimated the 5-year medical costs for 15 diet-associated cancers diagnosed in 2015. We obtained dietary intake from 2013 to 2016 National Health and Nutrition Examination Survey, cancer incidence, and survival from 2008 to 2014 Surveillance, Epidemiology, and End Results (SEER) program, and medical costs from 2007 to 2013 linked SEER-Medicare data. RESULTS: The estimated 5-year medical costs of new diet-associated cancer cases diagnosed in 2015 were $7.44 (2018 US$). Colorectal cancer had the largest diet-related 5-year medical costs of $5.32B. Suboptimal consumption of whole grains ($2.76B), dairy ($1.82B), and high consumption of processed meats ($1.5B) accounted for the highest medical costs. Per-person medical costs attributable to suboptimal diet vary by gender, race, and age group. CONCLUSIONS: Suboptimal diet contributes substantially to the economic burden of diet-associated cancers among US adults. This study highlights the need to implement population-based strategies to improve diet and reduce cancer burden in the US.

BACKGROUND: This study projected the number of metastatic breast cancer (mBC) cases and costs (medical and productivity) attributable to mBC through 2030 among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older women (aged 65 years and older). METHODS: We developed a stock/flow model in which women enter the mBC population at initial diagnosis (de novo stage IV) or through progression of an earlier-stage cancer. Women exit the mBC population through death. Input parameters by age and phase of treatment came from the US Census, Surveillance, Epidemiology, and End Results and peer-reviewed literature. RESULTS: In 2030, we estimated there would be 246 194 prevalent cases of mBC, an increase of 54.8% from the 2015 estimate of 158 997. We estimated total costs (medical and productivity) of mBC across all age groups and phases of care were $63.4 billion (95% sensitivity range = $59.4-$67.4 billion) in 2015 and would increase to $152.4 billion (95% sensitivity range = $111.6-$220.4 billion) in 2030, an increase of 140%. Trends in estimated costs were higher for younger and midlife women than for older women. CONCLUSIONS: The cost of mBC could increase substantially in the coming decade, especially among younger and midlife women. Although accounting for trends in incidence, progression, and survival, our model did not attempt to forecast structural changes such as technological innovations in breast cancer treatment and health-care delivery reforms. These findings can motivate early detection activities, direct value-driven mBC treatment, and provide a useful baseline against which to measure the effect of prevention and treatment efforts.

INTRODUCTION: We estimated the lifetime medical costs of diagnosed cases of diseases attributable to human papillomavirus (HPV) infections acquired in 2018. METHODS: We adapted an existing mathematical model of HPV transmission and associated diseases to estimate the lifetime number of diagnosed cases of disease (genital warts; cervical intraepithelial neoplasia; and cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers) attributable to HPV infections that were acquired in 2018. For each of these outcomes, we multiplied the estimated number of cases by the estimated lifetime medical cost per case obtained from previous studies. We estimated the costs of recurrent respiratory papillomatosis in a separate calculation. Future costs were discounted at 3% annually. RESULTS: The estimated discounted lifetime medical cost of diseases attributable to HPV infections acquired in 2018 among people aged 15-59 years was $774 million (in 2019 U.S. dollars), of which about half was accounted for by infections in those aged 15-24 years. HPV infections in women accounted for about 90% of the lifetime number of diagnosed cases of disease and 70% of the lifetime cost attributable to HPV infections acquired in 2018 among ages 15-59 years. CONCLUSIONS: We estimated the lifetime medical costs of diseases attributable to HPV infections acquired in 2018 to be $774 million. This estimate is lower than previous estimates and likely represents the impact of HPV vaccination. The lifetime cost of disease attributable to incident HPV infections is expected to decrease further over time as HPV vaccination coverage increases.

CONTEXT: The Community Preventive Services Task Force recommends engaging community health workers to increase breast, cervical, and colorectal cancer screenings on the basis of strong evidence of effectiveness. This systematic review examines the economic evidence of these interventions. EVIDENCE ACQUISITION: A systematic literature search was performed with a search period through April 2019 to identify relevant economic evaluation studies. All monetary values were adjusted to 2018 U.S. dollars, and the analysis was completed in 2019. EVIDENCE SYNTHESIS: A total of 19 studies were included in the final analysis with 3 on breast cancer, 5 on cervical cancer, 9 on colorectal cancer, and 2 that combined costs for breast and cervical cancers and for breast, cervical, and colorectal cancers. For cervical cancer screening, 2 U.S. studies reported incremental cost per quality-adjusted life year saved of $762 and $34,405. For colorectal cancer screening, 2 U.S. studies reported both a negative incremental cost and an increase in quality-adjusted life years saved with colonoscopy screening. CONCLUSIONS: Engaging community health workers to increase cervical and colorectal cancer screenings is cost effective on the basis of estimated incremental cost-effectiveness ratios that were less than the conservative $50,000 per quality-adjusted life year threshold. In addition, quality-adjusted life years saved from colorectal screening with colonoscopy were associated with net healthcare cost savings.

Cancer has substantial economic impacts for patients, their families and/or caregivers, employers, and the health care system. However, there is only limited understanding of how economic issues can affect access to cancer care services and the receipt of high-quality cancer care. Health economics research in cancer is particularly timely due to the large and increasing number of patients with cancer and cancer survivors, but there are many factors that may create barriers to performing cancer health economics research. This commentary has identified important topics and questions in cancer health economics research and will assist in the development of this critical field.

INTRODUCTION: The objective of this study was to assess incremental costs and benefits of a human papillomavirus (HPV) vaccination program expanded to include "mid-adults" (adults aged 27 through 45 years) in the United States. METHODS: We adapted a previously published, dynamic mathematical model of HPV transmission and HPV-associated disease to estimate the incremental costs and benefits of a 9-valent HPV vaccine (9vHPV) program for people aged 12 through 45 years compared to a 9vHPV program for females aged 12 through 26 years and males aged 12 through 21 years. RESULTS: A 9vHPV program for females aged 12 through 26 years and males aged 12 through 21 years was estimated to cost < $10,000 quality-adjusted life year (QALY) gained, compared to no vaccination. Expanding the 9vHPV program to include mid-adults was estimated to cost $587,600 per additional QALY gained when including adults through age 30 years, and $653,300 per additional QALY gained when including adults through age 45 years. Results were most sensitive to assumptions about HPV incidence among mid-adults, current and historical vaccination coverage, vaccine price, and the impact of HPV diseases on quality of life. CONCLUSIONS: Mid-adult vaccination is much less cost-effective than the comparison strategy of routine vaccination for all adolescents at ages 11 to 12 years and catch-up vaccination for women through age 26 years and men through age 21 years.

OBJECTIVES: Studies of local stage prostate cancer survivors suggest that treatments carry risk of persistent impotence, incontinence, and bowel dysfunction. To examine impacts of cancer type and side effects on health-related quality of life (HRQoL) in long-term cancer survivorship, we evaluated 5-year follow-up of patients with prostate cancer and compared results with a matched group of male long-term survivors of other local-stage cancers. MATERIALS AND METHODS: We examined genitourinary, bowel and sexual symptoms, and general quality of life. Matched survivors of colorectal, lung, and bladder cancers were recruited via registries in 3 different regions in the United States. Patients were surveyed 3-5 years after diagnosis with the SF-12 and EPIC to evaluate general mental and physical health-related quality of life (HRQoL) and patient function and bother. RESULTS: We analyzed responses from long-term prostate (n = 77) and bladder, colorectal, and lung cancer (n = 124) patients. In multivariate analysis, long-term local stage prostate cancer survivors had significantly higher SF-12 physical component scores but did not differ from long-term survivors of other cancers in terms of their SF-12 mental summary scores. Prostate survivors had similar mental, urinary, bowel, and sexual HRQoL compared to long-term survivors of other local stage cancers. CONCLUSION: Long-term general and prostate-specific HRQoL was similar between local stage prostate and bladder, colorectal, and lung patients with cancer. Future research focusing on factors other than initial treatment and the cancer type per se may provide more meaningful information regarding factors that predict disparities on HRQoL among longer-term survivors of early stage male cancers.

BACKGROUND: The objective of the current study was to estimate productivity costs due to metastatic breast cancer (mBC) via productive time lost among survivors and potential life-years lost from premature mortality among 3 age groups: younger (aged 18-44 years), midlife (aged 45-64 years), and older (aged >/=65 years) women. METHODS: The authors estimated the number of work and home productivity days missed due to mBC by age group using data from the 2000 to 2016 National Health Interview Survey. Years of potential life lost (YPLL) due to mBC were calculated for each age group using 2015 National Vital Statistics System data. The authors valued both sources of lost productivity time using the Current Population Survey and prior studies. RESULTS: The per-woman value of lost productive days (work and home) due to mBC ranged from $680 for older women to $5169 for younger women. In 2015, the value of lost work and home productivity days associated with mBC nationally was $67 million for younger women, $246 million for midlife women, and $66 million for older women. YPLL were highest among midlife women (403,786 life-years), followed by older women (248,522 life-years) and younger women (95,943 life-years). Midlife women were found to have the highest market value of YPLL ($4.1 billion), followed by younger women ($1.6 billion) and older women ($527 million). CONCLUSIONS: The results of the current study demonstrated that mBC generates a high economic burden through lost productivity, especially among midlife women.

PURPOSE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cervical cancer screening to low-income women. This study estimated the health benefits gained in terms of life years (LYs) saved and quality-adjusted life years (QALYs) gained if cervical cancer screening by the NBCCEDP increased to reach more eligible women. METHODS: Data from Surveillance, Epidemiology, and End Results, NBCCEDP, and Medical Expenditure Panel Surveys were used. LYs saved and QALYs gained/100,000 women were estimated using modeling methods. They were used to predict additional health benefits gained if screening by the NBCCEDP increased from 6.5% up to 10-25% of the eligible women. RESULTS: Overall, per 100,000 women screened by the NBCCEDP, 1,731 LYs were saved and 1,608 QALYs were gained. For white women, 1,926 LYs were saved and 1,780 QALYs were gained/100,000 women screened by the NBCCEDP. For black women, 1,506 LYs were saved and 1,300 QALYs were gained/100,000 women screened. If the proportion of eligible women screened by the NBCCEDP increased to 10-25%, the estimated health benefits would range from 6,626-34,896 LYs saved and 6,153-32,407 QALYs gained. CONCLUSIONS: The reported estimates emphasize the value of cervical cancer screening program by extending LE in low-income women. Further, it demonstrates that screening a higher percentage of eligible women in the NBCCEDP may yield more health benefits.

INTRODUCTION: Despite the importance of cost-related discussions in cancer care, little is known about the prevalence or drivers of these discussions in clinical practice. This study estimates the prevalence and examines the correlates of cancer survivors' discussions about out-of-pocket costs of cancer care with providers. METHODS: The 2016 and 2017 Medical Expenditure Panel Survey Experiences with Cancer Surveys were used to identify 1,550 survivors who responded to the question on discussion about out-of-pocket costs of cancer care. Multivariable multinomial logistic regression examined the correlates of discussions about out-of-pocket costs. Analyses were performed in 2019. RESULTS: Approximately one quarter of cancer survivors reported having discussed the out-of-pocket costs of cancer care. In multivariable analyses, respondents in the following categories were less likely to report no cost discussion than any cost discussion: black non-Hispanic/other race (RRR=0.67, 95% CI=0.45, 0.98; white non-Hispanic race as reference), no health insurance at diagnosis (RRR=0.51, 95% CI=0.27, 0.95; private health insurance as reference), and any experience of financial hardship (RRR=0.48, 95% CI=0.35, 0.66; no financial hardship as reference). CONCLUSIONS: Patient-reported discussions about out-of-pocket costs for cancer care are infrequent in the U.S. The findings highlight the needs to improve the understanding of the barriers and facilitators for effective discussions about out-of-pocket costs of cancer care.

PURPOSE: We estimated average medical costs due to metastatic breast cancer (mBC) among younger (aged 18-44), midlife (aged 45-64), and older women (aged 65 and older) by phase of care: initial, continuing, and terminal. METHODS: We used 2003-2014 North Carolina cancer registry data linked with administrative claims from public and private payers. We developed a claims-based algorithm to identify breast cancer patients who progressed to metastatic disease. We matched breast cancer patients (mBC and earlier stage) to non-cancer patients on age group, county of residence, and insurance plan. Outcomes were average monthly medical expenditures and expected medical expenditures by phase. We used regression to estimate excess costs attributed to mBC as the difference in mean payments between patients with mBC (N = 4806) and patients with each earlier-stage breast cancer (stage 1, stage 2, stage 3, and unknown stage; N = 21,772) and non-cancer controls (N = 109,631) by treatment phase and age group. RESULTS: Adjusted monthly costs for women with mBC were significantly higher than for women with earlier-stage breast cancer and non-cancer controls for all age groups and treatment phases except the initial treatment among women with stage 3 breast cancer at diagnosis. The largest expected total costs were for women aged 18-44 with mBC during the continuing phase ($209,961 95% Confidence Interval $165,736-254,186). CONCLUSIONS: We found substantial excess costs for mBC among younger women and during the continuing and terminal phases of survivorship. It is important to assess whether this care is high value for these women.

This study examines the prevalence at which cancer survivors and their spouses/partners in the US stay at their jobs to maintain employer-based health insurance.

Little is known about the association between health insurance literacy and financial hardship among cancer survivors. Using the 2016 Medical Expenditure Panel Survey Experiences with Cancer self-administered questionnaire, we evaluated the associations between health insurance literacy and medical financial hardship and nonmedical financial sacrifices among adult cancer survivors in the United States. Of the survivors, 18.9% aged 18-64 years and 14.6% aged 65 years and older reported health insurance literacy problems. In both age groups (18-64 and >65 years), from multivariable logistic regressions, survivors with health insurance literacy problems were more likely to report any material (adjusted odds ratio [AOR] = 3.02, 95% confidence interval [CI] = 1.53 to 5.96; AOR = 3.33, 95% CI = 1.69 to 6.57, respectively) or psychological (AOR = 5.53, 95% CI = 2.35 to 13.01; AOR = 8.79, 95% CI = 4.55 to 16.97, respectively) hardship, as well as all types of nonmedical financial sacrifices than those without these problems. Future longitudinal studies are warranted to test causality and assess whether improving health insurance literacy can mitigate financial hardship.

Awareness of the link between breast cancer and risk factors such as family history of breast cancer and alcohol consumption may help modify health behaviors. To reduce risk factors for breast cancer among young women, it is important to understand overall levels of risk awareness and socioeconomic differences in awareness. Data from the National Survey of Family Growth 2011-2015 were used to examine awareness of two risk factors for breast cancer, positive family history and alcohol consumption, among women aged 15-44 years (n = 10,940) in the United States by presence of risk factors and by socioeconomic characteristics. Prevalence of positive family history, non-binge, and binge drinking was 30%, 29%, and 31%, respectively among women aged 15-44. Awareness of positive family history of breast cancer as a risk factor for breast cancer was 88%, whereas for alcohol consumption it was 25%. Awareness of family history as a risk factor was higher among women with positive family history of breast cancer compared to those without. Current drinkers were more likely to believe that alcohol was not a risk factor for breast cancer compared to those who did not drink. Racial/ethnic minority women and those with lower education and income had lower awareness of family history as a risk factor. Awareness of alcohol consumption as a risk factor for breast cancer was low across all socioeconomic groups. Evidence-based interventions to increase risk awareness and decrease excessive alcohol use among young women are needed to reduce the risk of developing breast cancer.

Background: In recent years, most insurance plans eliminated cost-sharing for breast cancer screening and recommended screening intervals changed, and newer modalities-digital mammography and breast tomosynthesis-became more widely available. The objectives of this study are to examine how these changes affected utilization, frequency, and costs of breast cancer screening among commercially insured women, and to understand factors associated with utilization and frequency of screening. Materials and Methods: This study used commercial insurance claims data for women 50 to 64 years of age, continuously enrolled in commercial insurance plans during 2012-2016. Results: Of the 685,737 eligible women, 20% were not screened, 40% received annual screening, 24% received biennial screening, and 16% were screened less frequently than recommended during the time period examined. Sociodemographic factors such as age <60 years, rurality, and fee-for-service insurance were associated with low screening utilization. Patients who received annual screening incurred approximately 1.78 times higher costs compared to those who received biennial screening during the study period. Digital mammography was the most costly and commonly used modality along with computer-aided detection. Conclusions: Evidence-based interventions to promote screening among women who are screened less frequently are needed along with interventions to move toward biennial screening rather than annual screening. Increasing provider awareness regarding breast cancer screening rates and frequency among various sociodemographic groups is essential to guide provider recommendations and shared decision making. The results of this study can guide targeted public health interventions to reduce barriers to screening, and can also serve as inputs for economic analyses of screening interventions and programs.

PURPOSE: The purpose of this paper is to provide a brief overview of economic analysis methods used in estimating the costs and benefits of public health programs and systematically review the application of these methods to the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Published literature on economic analyses of the NBCCEDP was systematically reviewed. The Consensus on Health Economic Criteria checklist was used to assess methodological quality of the included studies. RESULTS: Methods available for economic analysis of public health programs include program cost, cost-effectiveness, cost-utility, cost-benefit analysis, and budget impact analysis. Of these, program cost analysis, cost-effectiveness analysis, and cost-utility analysis have been applied to the NBCCEDP in previously published literature. CONCLUSION: While there have been multiple program cost analyses, there are relatively fewer cost-effectiveness and cost-utility studies and no cost-benefit and budget impact analysis studies to evaluate the NBCCEDP. Addressing these gaps will inform implementation of effective public health programs with equitable resource allocation to all population subgroups.

CONTEXT: The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions. EVIDENCE ACQUISITION: A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018. EVIDENCE SYNTHESIS: Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817. CONCLUSIONS: Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.