| |
Liver Cancer Triples, NO HCV Testing Funds: Aging with HCV
|
| |
| |
'Cirrhosis Projected To Double, Liver Cancer Rates Tripled (CDC), HCC in persons older than the age of 65 years with HCV infection has doubled during the last several years, consistent with our predictions; Screen for HCC Every 6 Months Recommended in Cirrhotics, 43% of HIV Coinfected Are Not Screened'.....
.....yet we have no systematic HCV testing programs funded by NYC, or in any other city/states/federal....will anyone step up to fund widespread testing? in NYC, the epicenter for HCV & injection drug use for 40 yrs there is no commitment to a systematic testing program for HCV
Aging of Hepatitis C Virus (HCV)-Infected Persons in the United ...
Gastroenterology Feb 2010.......
www.natap.org/2010/HCV/031110_02.htm
"Cirrhosis accounted for just 5% of all cases (diagnosed and undiagnosed) of CH-C (HCV) in 1989, 10% in 1998, and 20% in 2006, the proportion with cirrhosis is projected to reach 24.8% in 2010, 37.2% in 2020, and 44.9% in 2030).....HCC in persons older than the age of 65 years with HCV infection has doubled during the last several years....(The model suggests that decompensation became more common after 1995 and is currently estimated to be present in 11.7% of persons with cirrhosis (Figure 4). The proportion of cirrhotics with decompensation is expected to continue to rise at least through 2030)......critical to identify infected persons and treat their disease before advanced fibrosis or liver failure ensues......It is in the immediate best interest of patients, providers, insurers, and governments to promote guidelines and encourage better screening for infection and early antiviral treatment.68 Without such a proactive policy, it is likely that we will spend a considerable amount of resources during the next 2 or 3 decades dealing with liver failure in our elderly population."
---------------------------------
The burden of illness associated with hepatocellular carcinoma in the United States
Jnl of hepatology Jan 2009 Volume 50, Issue 1, Pages 89-99
in recent decades, HCC age-adjusted incidence rates have doubled3 and primary liver cancer mortality rates have increased faster than mortality rates for any other leading cause of cancer......Overall, the HCC rate increased from 2.7 per 100,000 persons in 2001 to 3.2 in 2006, with an APC of 3.5% (annual percent increase, translates to 10% increase over 3 yrs). The median age for diagnosis of HCC was 64 years overall, 62 years for males, and 69 years for femalesMost HCC is thought to be associated with either chronic hepatitis C virus (HCV) or hepatitis B virus (HBV) infection...... "in the United States HCC surveillance is not applied as widely as it is in many European and Far Eastern countries"....Liver cancer, primarily hepatocellular carcinoma (HCC), is the third leading cause of death from cancer worldwide and the ninth leading cause of cancer deaths in the United States (1,2)......The largest increases in HCC incidence rates were among whites (APC = 3.8[annual percent change]), blacks (APC = 4.8), and persons aged 50--59 years (APC = 9.1)
Hepatocellular Carcinoma --- United States, 2001-2006,
LINK to this URL:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5917a3.htm
---------------------------
Liver Cancer Rates Triple: Hepatocellular Carcinoma Incidence ...
"The principal findings in this report were that incidence rates of HCC tripled in the United States from 1975 through 2005, with marked recent increases among middle-aged black, Hispanic, and white males" "Overall age-adjusted incidence rates of HCC tripled between 1975 and 2005, rising from 1.6 per 100,000 to 4.9 per 100,000.....Between 1992 and 2005, overall incidence rates of HCC increased, with an annual percent change of 4.3% (P ≤ .05).....Coordination of existing HCC prevention efforts is needed. Gaps in HCC screening in the United States include limited HCV testing of current and former injection drug users......(from Jules: there is little or no HCV screening and screening for HCC. There is no Federal support for national screening and surveillance of HCV)
...www.natap.org/2009/HCV/060309_01.htm
--------------------------
Every 6-month HCC Screening Recommended.....Semiannual surveillance increases the detection rate of very early hepatocellular carcinomas
The cancer stage was more favorable in Group 1 (semiannual HCC screening), where single nodules <2cm were almost 5-fold more frequent than in Group 2 ...
www.natap.org/2010/HCV/050610_03.htm
----------------------
Screening for Hepatocellular Carcinoma (HCC) in HIV/HCV-Coinfected ...www.natap.org/2010/CROI/croi_117.htm
"A large proportion of HIV/HCV-infected patients with HCC (43%) were not screened......HCV/HIV coinfected patients get dismissed, they don't get screened for HCV, they don't get screened for HCC (liver cancer), they don't get treated for HCV, as a result they are more likely to get HCC, to die sooner than if they were screened for HCC or received HCV treatment, they are less likely to be eligible for transplant, less likely to get HCC treatment and they are more likely to have incurable HCC. That's why HCV is the leading cause of death & hospitalization in HIV except perhaps for AIDS."
"Incidence and mortality rates associated with HCC have doubled in the United States over the past 25 years, and given the current prevalence of HCV among persons aged 30-50 years, the US incidence and mortality rates of HCC are expected to double over the next 10-20 years [10]....... our results exhibit a considerable economic impact of HCC in the US and substantial national spending each year on this disease. We determined the annual cost of HCC in the United States to be $454.9 million, with per-patient costs of $32,907. Healthcare costs and lost productivity accounted for 89.2% and 10.8% of total cost, respectively. Costs associated with localized HCC accounted for the highest portion (44.5%) of the total cost of illness, at $202.5 million. Regional, distant, and unstaged HCC accounted for 31.0%, 13.9%, and 10.6%, respectively......Interventions to reduce the prevalence of HCC have the potential to yield sizable economic benefits. HCV increases the risk for HCC probably by promoting fibrosis and cirrhosis; virtually all HCV-related HCC cases occur among patients with cirrhosis....Once cirrhosis is established, the annual rate of HCC is relatively consistent in the published literature (Table 1), with most studies reporting rates between 1% and 4%....HCV infection increases the risk for HCC several-fold (up to 25 times) when noninfected people are used as an index populati0n......the time to cirrhosis ranged between 13 and 23 years, and to HCC between 17 and 31 years. Even within this select group of studies, there were large variations in the estimates of cirrhosis and HCC......Risk Factors for HCC in HCV: older age, older age at the time of acquisition of infection, male sex, heavy alcohol intake (more than 50 g/d), coinfection with HBV, or HIV"
Discussion
This study is the first to evaluate the annual economic burden of HCC in the United States, including healthcare costs and lost productivity. Our 1-year prevalence-based methodology, commonly used to study costs associated with other diseases as pioneered by Dorothy Rice in 1966 [44], included newly diagnosed HCC patients as well as patients diagnosed in previous years who were still alive and using resources at any point during the study year. Other prevalence-based studies have been conducted, often with less detailed data, to evaluate the annual burden of other cancers (generally ignoring lost productivity) [25], [26], [27]. Our methodology was advantageous in that we factored in all components of healthcare resource utilization as well as data on lost productivity.
We found the overall per-patient cost of HCC to be $32,907. With an average annual HCC prevalence of 13,824 cases in the United States, the total annual burden of HCC was thus estimated to be $454.9 million. This is at the low end of estimates of annual national spending on cancers, which range from $728 million for esophageal cancer to $8.3 billion for breast cancer (inflated to $2006) [30]. Adjusting for average follow-up, our findings indicate per-patient monthly costs of $7845. These results are in line with reported mean monthly cancer-related cost estimates ranging from $2358 for prostate cancer to $9,310 for pancreatic cancer (inflated to $2006) [27]. Finally, our results are consistent with other reported estimates of the cost of terminal cancer. Krahn reported an annual per-patient cost of terminal care of $65,405 (inflated to $2006) [45], while Taplin estimated a 6-month cost of terminal cancer of ~$23,412 (updated to $2006 and rounded) [46].
In actual clinical practice, HCC is found almost exclusively in cirrhotic HCV patients [11], [47]. Therefore, our study accounts for excess resource use and costs due to cirrhosis and its complications among HCC patients. By calculating additional cancer-related resource utilization as the difference between HCC patients and matched non-cancer controls (after subtracting out the resource use attributable to the major procedures noted above), we captured the excess use and costs attributable to cirrhosis as part of this remaining difference between cancer patients and controls. This methodology of identifying specific treatments as well as remaining differences between cancer patients and controls has allowed us to capture all possible resource use and costs attributable to HCC.
It should be noted that our study is subject to several limitations. First, we relied on administrative Medicare claims data for patients aged 65 years to assess treatment patterns and unit costs for HCC patients of all ages. To the extent that utilization and cost profiles differed between patients younger than 65 and those aged 65-69, our results may not be accurate. However, other studies have documented increased resource use among younger patients [26], [28], using methods similar to ours to adjust resource use among the elderly to be reflective of younger patients [28]. Recognizing that this assumption, although based on the literature, may not reflect actual clinical care because older patients may have more comorbidities, we conducted sensitivity analyses around this assumption. Since we selected patients aged 65-69 years to reflect the entire younger patient population, our base-case results can be viewed as conservative.
Second, the treatments used in this study may not be an accurate reflection of current treatment patterns for HCC, as some of the medications and procedures may have been prescribed for conditions other than HCC that patients were concomitantly experiencing. For example, it could not be determined whether patients were receiving radiation therapy for other types of cancer or as an experimental therapy for HCC. Similarly, those patients who were taking Megace (megestrol) and Zometa (zoledronic acid) may have had another cancer (e.g., breast) in addition to HCC. Furthermore, although the use of nutritional supplements is contraindicated in patients with late-stage HCC due to their effect on fluid and salt overload, we included estimates of nutritional supplement use based on literature indicating such use among cancer patients. Excluding this component would change our results by much less than 1%. It should also be noted that at the time this study was conducted, there was no standard therapy for advanced-stage HCC, and some treatment modalities that have since been determined to be ineffective for late-stage HCC were being administered to patients with advanced disease in the population being studied - such as radiofrequency ablation, arterial embolization, or surgical resection. The differences in past and current treatment patterns may also account for the high surgical costs observed in the study patients with regional and distant disease.
Third, due to the difficulty of assessing caregiver burden and because large studies of costs to caregivers for HCC patients have not been conducted, we did not account for this variable. Future work aimed at assessing caregiver burden would lend useful insights into this potentially important component of disease burden.
The SEER-Medicare data are subject to additional limitations, including potential inaccuracy of the diagnostic and procedural coding, demographic coding errors, potentially incomplete data on Medicare claims [48], as well as the fact that not all relevant healthcare services are covered by Medicare (e.g., prescription medications). We have attempted to supplement the data with findings from published literature on use of prescription medications in order to capture this component. And finally, healthcare claims were not available for all Medicare beneficiaries (e.g., those enrolled in HMOs).
Despite its limitations, the linked SEER-Medicare database has proven extremely useful for case selection and profiling cancer treatment patterns and survival for a multitude of cancers [49]. Combining the SEER and Medicare data provides information on both initial cancer diagnosis and later cancer treatment, as well as downstream medical care for cancer patients.
Our results are based on a sample of HCC patients alive and treated in 1999, the latest year for which data were available. Since that time, treatment has changed considerably, especially with regard to surgical treatment, liver transplantation, and radiological therapy. Our results are therefore reflective of treatment practices that were current at the time the study was conducted, and may significantly underreport the current therapies for HCC. Nevertheless, they can be used as a baseline against which to evaluate the impact of emerging pharmacologic treatments for advanced HCC. Future studies should incorporate the impact of such emerging treatments.
The general nature of our model makes it easily amenable to adaptation. Using local-area treatment pattern and unit cost data, the model can be applied to generate country-specific burden of illness estimates. Such adaptation to multiple countries would enable assessment of the global burden of HCC and comparison across countries.
In conclusion, our results exhibit a considerable economic impact of HCC in the US and substantial national spending each year on this disease. Interventions to reduce the prevalence of HCC have the potential to yield sizable economic benefits.
|
|
| |
| |
|
|
|
