Publications by authors named "Shuangshuang Fu"

39 Publications

Sensitivity of Psychosocial Distress Screening to Identify Cancer Patients at Risk for Financial Hardship During Care Delivery.

JCO Oncol Pract 2021 May 27:OP2001009. Epub 2021 May 27.

Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: Patients with cancer frequently encounter financial hardship, yet systematic strategies to identify at-risk patients are not established in care delivery. We assessed sensitivity of distress-based screening to identify patients with cancer-related financial hardship and associated care delivery outcomes.

Methods: A survey of 225 patients at a large cancer center assessed cancer-related financial hardship (0-10 Likert scale; highest quintile scores ≥ 5 defined severe hardship). Responses were linked to electronic medical records identifying patients' distress screening scores 6 months presurvey (0-10 scale) and outcomes of missed cancer care visits and bad debt charges (unrecovered patient charges) within 6 months postsurvey. A positive screen for distress was defined as score ≥ 4. We analyzed screening test characteristics for identifying severe financial hardship within 6 months and associations between financial hardship and outcomes using logistic models.

Results: Although patients with positive distress screens were more likely to report financial hardship (odds ratio [OR], 1.21; 1.08-1.37; < .001), a positive distress screen was only 48% sensitive and 70% specific for identifying severe financial hardship. Patients with worse financial hardship scores were more likely to miss oncology care visits within 6 months (for every additional point in financial hardship score from 0 to 10, OR, 1.28; 1.12-1.47; < .001). Of patients with severe hardship, 72% missed oncology visits versus 35% without severe hardship ( = .006). Patients with worse hardship were more likely to incur any bad debt charges within 6 months (OR, 1.32; 1.13-1.54; < .001).

Conclusion: Systematic financial hardship screening is needed to help mitigate adverse care delivery outcomes. Existing distress-based screening lacks sensitivity.
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http://dx.doi.org/10.1200/OP.20.01009DOI Listing
May 2021

Outcomes of the First Pregnancy After Fertility-Sparing Surgery for Early-Stage Ovarian Cancer.

Obstet Gynecol 2021 06;137(6):1109-1118

Department of Gynecologic Oncology and Reproductive Medicine, the Department of Health Services Research, Division of Cancer Prevention and Population Sciences, and the Department of Breast Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, Texas; the Department of Obstetrics and Gynecology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; the Department of Obstetrics and Gynecology, the University of Texas Medical Branch at Galveston, Galveston, Texas; and the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, and the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York.

Objective: To evaluate the outcomes of the first pregnancy after fertility-sparing surgery in patients treated for early-stage ovarian cancer.

Methods: We performed a retrospective study of women aged 18-45 years with a history of stage IA or IC ovarian cancer reported to the California Cancer Registry for the years 2000-2012. These data were linked to the 2000-2012 California Office of Statewide Health Planning and Development birth and discharge data sets to ascertain oncologic characteristics and obstetric outcomes. We included in the case group ovarian cancer patients who conceived at least 3 months after fertility-sparing surgery. The primary outcome was preterm birth, and only the first pregnancy after cancer diagnosis was considered. Secondary outcomes included small-for-gestational-age (SGA) neonates, neonatal morbidity (respiratory support within 72 hours after birth, hypoxic-ischemic encephalopathy, seizures, infection, meconium aspiration syndrome, birth trauma, and intracranial or subgaleal hemorrhage), and severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Propensity scores were used to match women in a 1:2 ratio for the case group and the control group. Wald statistics and logistic regressions were used to evaluate outcomes.

Results: A total of 153 patients who conceived after fertility-sparing surgery were matched to 306 women in a control group. Histologic types included epithelial (55%), germ-cell (37%), and sex-cord stromal (7%). Treatment for ovarian cancer was not associated with preterm birth before 37 weeks of gestation (13.7% vs 11.4%; odds ratio [OR] 1.23, 95% CI 0.69-2.20), SGA neonates (birth weight less than the 10th percentile: 11.8% vs 12.7%; OR 0.91, 95% CI 0.50-1.66), severe maternal morbidity (2.6% vs 1.3%; OR 2.03, 95% CI 0.50-8.25), or neonatal morbidity (both 5.9% OR 1.00, 95% CI 0.44-2.28).

Conclusion: Patients who conceived at least 3 months after surgery for early-stage ovarian cancer did not have an increased risk of adverse obstetric outcomes.
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http://dx.doi.org/10.1097/AOG.0000000000004394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141030PMC
June 2021

Vitamin D protects glomerular mesangial cells from high glucose-induced injury by repressing JAK/STAT signaling.

Int Urol Nephrol 2021 Jun 3;53(6):1247-1254. Epub 2021 May 3.

Department of Nephrology and Laboratory of Kidney Disease, Changsha Clinical Research Center for Kidney DiseaseHunan Clinical Research Center for Chronic Kidney Disease, Hunan Provincial People's Hospital, Hunan Normal University, 61#, Jiefang West Road, Changsha, 410005, Hunan Province, People's Republic of China.

Aim: High glucose (HG) induces the production of transforming growth factor (TGF)-β and reactive oxygen species, which further activates JAK/STAT signaling and promotes the synthesis of matrix proteins, contributes to the pathophysiological processes of diabetic nephropathy. This study aims to investigate the protection role of vitamin D (VD) in the kidney in high glucose condition.

Methods: Rat glomerular mesangial cells were cultured in high glucose medium, with or without VD or VD receptor (VDR) siRNAs treatment. The levels of TGF-β and fibronectin were detected by qRT-PCR, immunoblotting and enzyme-linked immunosorbent assay (ELISA). The levels of phosphorylated JAK2, STAT1 and STAT3, and JAK/STAT signaling downstream genes were examined by immunoblotting and qRT-PCR.

Results: In rat glomerular mesangial cells, VD treatment can repress the tyrosine phosphorylation of JAK2, STAT1 and STAT3. VD inhibited TGF-β and fibronectin expression which was rescued by vitamin d receptor (VDR) siRNA and STATs inhibitor perficitinib. The JAK/STAT signaling downstream protein coding genes including SOCS1, SOCS3 and type IV collagen were repressed by VD. Meanwhile, the expression of non-coding RNAs such as miR-181a, miR-181b, was repressed by VD, and the expression of miR-34a and Let-7b was upregulated by VD.

Conclusion: Vitamin D (VD) treatment inhibits the function of HG on fibronectin production through regulating JAK/STAT pathway. These results provide direct evidences that VD protects glomerular mesangial cells from high glucose-induced injury through repressing JAK/STAT signaling, which has the potential for clinical DN treatment.
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http://dx.doi.org/10.1007/s11255-020-02728-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144147PMC
June 2021

Patient cost sharing during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment in ovarian cancer.

Am J Obstet Gynecol 2021 Feb 4. Epub 2021 Feb 4.

Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cancer Prevention and Population Sciences Division, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address:

Background: More patients with ovarian cancer are being treated with poly(adenosine diphosphate-ribose) polymerase inhibitors because regulatory agencies have granted these drugs new approvals for a variety of treatment indications. However, poly(adenosine diphosphate-ribose) polymerase inhibitors are expensive. When administered as a maintenance therapy, these drugs may be administered for months or years. How much of this cost patients experience as out-of-pocket spending is unknown.

Objective: This study aimed to estimate the out-of-pocket spending that patients experience during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment and to characterize which healthcare services account for that spending.

Study Design: A retrospective cohort study was performed with a sample of patients with ovarian cancer treated between 2014 and 2017 with olaparib, niraparib, or rucaparib. Patients were identified using MarketScan, a health insurance claims database. All insurance claims during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment were collected. The primary outcome variable was the patients' out-of-pocket spending (copayment, coinsurance, and deductibles) during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment for the medication itself. Other outcomes of interest included out-of-pocket spending for other healthcare services, the types and frequency of other healthcare services used, health plan spending, the estimated proportion of patients' household income used each month for healthcare, and patients' out-of-pocket spending immediately before poly(adenosine diphosphate-ribose) polymerase inhibitor treatment.

Results: We identified 503 patients with ovarian cancer with a median age of 55 years (interquartile range, 50-62 years); 83% of those had out-of-pocket spendings during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment. The median treatment duration was 124 days (interquartile range, 66-240 days). The mean out-of-pocket spending for poly(adenosine diphosphate-ribose) polymerase inhibitors was $305 (standard deviation, $2275) per month. On average, this accounted for 44.8% (standard deviation, 34.8%) of the patients' overall monthly out-of-pocket spending. The mean out-of-pocket spending for other healthcare services was $165 (standard deviation, $769) per month. Health plans spent, on average, $12,661 (standard deviation, $15,668) per month for poly(adenosine diphosphate-ribose) polymerase inhibitors and $7108 (standard deviation, $15,254) per month for all other healthcare services. The cost sharing for office visits, laboratory tests, and imaging studies represented the majority of non-poly(adenosine diphosphate-ribose) polymerase inhibitor treatment out-of-pocket spending. The average amount patients paid for all healthcare services per month during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment was $470 (standard deviation, $2407), which was estimated to be 8.7% of the patients' monthly household income. The mean out-of-pocket spending in the 12 months before poly(adenosine diphosphate-ribose) polymerase inhibitor treatment was $3110 (standard deviation, $6987).

Conclusion: Patients can face high out-of-pocket costs for poly(adenosine diphosphate-ribose) polymerase inhibitors, although the sum of cost sharing for other healthcare services used during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment is often higher. The spending on healthcare costs consumes a large proportion of these patients' household income. Patients with ovarian cancer experience high out-of-pocket costs for healthcare, both before and during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment.
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http://dx.doi.org/10.1016/j.ajog.2021.01.029DOI Listing
February 2021

Oncological outcomes of laparoscopic radical hysterectomy versus radical abdominal hysterectomy in patients with early-stage cervical cancer: a multicenter analysis.

Int J Gynecol Cancer 2021 Apr 27;31(4):504-511. Epub 2021 Jan 27.

Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia

Introduction: Recent evidence has shown adverse oncological outcomes when minimally invasive surgery is used in early-stage cervical cancer. The objective of this study was to compare disease-free survival in patients that had undergone radical hysterectomy and pelvic lymphadenectomy, either by laparoscopy or laparotomy.

Methods: We performed a multicenter, retrospective cohort study of patients with cervical cancer stage IA1 with lymph-vascular invasion, IA2, and IB1 (FIGO 2009 classification), between January 1, 2006 to December 31, 2017, at seven cancer centers from six countries. We included squamous, adenocarcinoma, and adenosquamous histologies. We used an inverse probability of treatment weighting based on propensity score to construct a weighted cohort of women, including predictor variables selected a priori with the possibility of confounding the relationship between the surgical approach and survival. We estimated the HR for all-cause mortality after radical hysterectomy with weighted Cox proportional hazard models.

Results: A total of 1379 patients were included in the final analysis, with 681 (49.4%) operated by laparoscopy and 698 (50.6%) by laparotomy. There were no differences regarding the surgical approach in the rates of positive vaginal margins, deep stromal invasion, and lymphovascular space invasion. Median follow-up was 52.1 months (range, 0.8-201.2) in the laparoscopic group and 52.6 months (range, 0.4-166.6) in the laparotomy group. Women who underwent laparoscopic radical hysterectomy had a lower rate of disease-free survival compared with the laparotomy group (4-year rate, 88.7% vs 93.0%; HR for recurrence or death from cervical cancer 1.64; 95% CI 1.09-2.46; P=0.02). In sensitivity analyzes, after adjustment for adjuvant treatment, radical hysterectomy by laparoscopy compared with laparotomy was associated with increased hazards of recurrence or death from cervical cancer (HR 1.7; 95% CI 1.13 to 2.57; P=0.01) and death for any cause (HR 2.14; 95% CI 1.05-4.37; P=0.03).

Conclusion: In this retrospective multicenter study, laparoscopy was associated with worse disease-free survival, compared to laparotomy.
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http://dx.doi.org/10.1136/ijgc-2020-002086DOI Listing
April 2021

Impact of provider type and number of providers on surveillance testing among survivors of head and neck cancers.

Cancer 2021 May 20;127(10):1699-1711. Epub 2021 Jan 20.

Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Guidelines for follow-up after head and neck cancer (HNC) treatment recommend frequent clinical examinations and surveillance testing. Here, the authors describe real-world follow-up care for HNC survivors and variations in surveillance testing.

Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study examined a population-based cohort of HNC survivors between 2001 and 2011 Usage of cross-sectional head and neck imaging (CHNI), chest imaging (CI), positron emission tomography (PET), fiberoptic nasopharyngolaryngoscopy (FNPL), and, in irradiated patients, thyroid function testing (TFT) was captured over 2 consecutive surveillance years. Multivariate modeling with logistic regression analyses was used to assess variations by clinical factors, nonclinical factors, number and types of providers seen and their evolution over time.

Results: Among 13,836 HNC survivors, the majority saw a medical, radiation, or surgical oncologist and a primary care provider (PCP; 81.7%) in their first year of surveillance. However, only 58.1% underwent either PET or CHNI, 47.8% underwent CHNI, 64.1% underwent CI, 32.5% underwent PET scans, 55.0% underwent FNPL, and 55.9% underwent TFT. In multivariate analyses, patients who followed up with more providers and those who followed up with both a PCP and an oncologist were more likely to undergo surveillance testing (P < .007). However, adjusting for providers seen did not explain the variations in surveillance testing rates based on age, race, education, income level, and place of residence. Over time, there was a gradual increase in the use of PET scans and TFT during surveillance years.

Conclusions: In this large SEER-Medicare data study, only half of HNC survivors received the recommended testing, and greater compliance was seen in those who followed up with both an oncologist and a PCP. More attention is needed to minimize variations in surveillance testing across sociodemographic groups.
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http://dx.doi.org/10.1002/cncr.33402DOI Listing
May 2021

An economic and disease transmission model of human papillomavirus and oropharyngeal cancer in Texas.

Sci Rep 2021 Jan 19;11(1):1802. Epub 2021 Jan 19.

Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX, 77030, USA.

In 2017, 46,157 and 3,127 new oropharyngeal cancer (OPC) cases were reported in the U.S. and Texas, respectively. About 70% of OPC were attributed to human papillomavirus (HPV). However, only 51% of U.S. and 43.5% of Texas adolescents have completed the HPV vaccine series. Therefore, modeling the demographic dynamics and transmission of HPV and OPC progression is needed for accurate estimation of the economic and epidemiological impacts of HPV vaccine in a geographic area. An age-structured population dynamic model was developed for the U.S. state of Texas. With Texas-specific model parameters calibrated, this model described the dynamics of HPV-associated OPC in Texas. Parameters for the Year 2010 were used as the initial values, and the prediction for Year 2012 was compared with the real age-specific incidence rates in 23 age groups for model validation. The validated model was applied to predict 100-year age-adjusted incidence rates. The public health benefits of HPV vaccine uptake were evaluated by computer simulation. Compared with current vaccination program, increasing vaccine uptake rates by 50% would decrease the cumulative cases by 4403, within 100 years. The incremental cost-effectiveness ratio of this strategy was $94,518 per quality-adjusted life year (QALY) gained. Increasing the vaccine uptake rate by 50% can: (i) reduce the incidence rates of OPC among both males and females; (ii) improve the quality-adjusted life years for both males and females; (iii) be cost-effective and has the potential to provide tremendous public health benefits in Texas.
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http://dx.doi.org/10.1038/s41598-021-81375-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815750PMC
January 2021

Employment disruption following the diagnosis of endometrial cancer.

Gynecol Oncol 2021 01 9;160(1):199-205. Epub 2020 Nov 9.

Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America. Electronic address:

Background: Oncologic treatment has been associated with unemployment. As endometrial cancer is highly curable, it is important to assess whether patients experience employment disruption after treatment. We evaluated the frequency of employment change following endometrial cancer diagnosis and assessed factors associated with it.

Methods: A cohort of patients 18-63 years-old who were diagnosed with endometrial cancer (January 2009-December 2017) were identified in the Truven MarketScan database, an insurance claims database of commercially insured patients in the United States. All patients who were working full- or part-time at diagnosis were included and all employment changes during the year following diagnosis were identified. Clinical information, including use of chemotherapy and radiation, were identified using Common Procedural Terminology codes, and International Statistical Classification of Diseases codes. Cox proportional hazards models incorporating measured covariates were used to evaluate the impact of treatment and demographic variables on change in employment status.

Results: A total of 4381 women diagnosed with endometrial cancer who held a full-time or part-time job 12 months prior to diagnosis were identified. Median age at diagnosis was 55 and a minority of patients received adjuvant therapy; 7.9% received chemotherapy, 4.9% received external-beam radiation therapy, and 4.1% received chemoradiation. While most women continued to work following diagnosis, 21.7% (950) experienced a change in employment status. The majority (97.7%) of patients had a full-time job prior to diagnosis. In a multivariable analysis controlling for age, region of residence, comorbidities, insurance plan type and presence of adverse events, chemoradiation recipients were 34% more likely to experience an employment change (HR 1.34, 95% CI 1.01-1.78), compared to those who only underwent surgery.

Conclusion: Approximately 22% of women with employer-subsidized health insurance experienced a change in employment status following the diagnosis of endometrial cancer, an often-curable disease. Chemoradiation was an independent predictor of change in employment.
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http://dx.doi.org/10.1016/j.ygyno.2020.10.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7779695PMC
January 2021

Retrospective Analysis of Clinical Outcomes in Patients with Immunoglobulin A Nephropathy and Persistent Hematuria Following Renin-Angiotensin System Blockade.

Med Sci Monit 2020 Aug 21;26:e922839. Epub 2020 Aug 21.

Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland).

BACKGROUND Recent guidelines recommend that patients with immunoglobulin A nephropathy (IgAN) and proteinuria 0.5-1 g/d and >1 g/d be treated with long-term renin-angiotensin system blockade (RASB). This study investigated whether patients with IgAN and persistent hematuria, but without proteinuria, can benefit from RASB. MATERIAL AND METHODS IgAN patients with persistent hematuria at four centers were recruited from January 2013 to December 2018. Patients were divided into those who did and did not receive long-term RASB. The primary outcome was the appearance of proteinuria, and the secondary outcomes were the decreased percentage of hematuria, rate of decline in estimated glomerular filtration rate (eGFR) and final blood pressure. The effects of RASB on these outcomes were assessed by multivariate Cox regression models and propensity score matching. RESULTS Of the 110 eligible patients, 44 (40.0%) received RASB and 66 (60.0%) did not. Treated patients had higher diastolic pressure. The unadjusted primary outcome, the appearance of proteinuria, was significantly less frequent in individuals who were than who were not treated with RASB. Multivariate Cox regression showed that RASB reduced the risk of the primary outcome and the levels of hematuria. The rate of eGFR decline and final blood pressure did not differ in the two groups. CONCLUSIONS RASB reduced the risk of proteinuria development and increased the remission of hematuria in patients with IgAN who presented with persistent hematuria alone. RASB, however, did not affect blood pressure in patients without hypertension and did not affect the rate of eGFR decline.
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http://dx.doi.org/10.12659/MSM.922839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456162PMC
August 2020

National trends in bowel and upper abdominal procedures in ovarian cancer surgery.

Int J Gynecol Cancer 2020 08 2;30(8):1195-1202. Epub 2020 Jul 2.

Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA

Objectives: In the United States, trends in the initial treatment approach for ovarian cancer reflect a shift in paradigm toward the increased use of neoadjuvant chemotherapy and interval cytoreductive surgery. The aim of this study was to evaluate the trends in surgical cytoreductive procedures in ovarian cancer patients who underwent either primary or interval cytoreductive surgery.

Methods: This retrospective, population-based study examined patients with stage III/IV ovarian cancer diagnosed between January 2000 and December 2013 identified using SEER-Medicare. Small or large bowel resection, ostomy creation, and upper abdominal procedures were identified using relevant billing codes and compared over time. A 1:1 primary and interval cytoreductive propensity matched cohort was created using demographic and clinical variables. 30-day complications and the use of acute care services were compared.

Results: A total of 5417 women were identified. 34% underwent bowel resections, 16% ostomy creation, and 8% upper abdominal procedures. There was an increase in bowel resections and upper abdominal procedures from 2000 to 2013 in patients who underwent primary cytoreductive surgery. Compared with patients who received primary cytoreduction, patients who underwent interval cytoreductive surgery were less likely to undergo bowel resection (OR=0.50; 95% CI [0.41, 0.61]) or ostomy creation (OR=0.48; 95% CI [0.42, 0.56]). Upper abdominal procedures did not differ between groups. For patients who underwent primary cytoreductive surgery, these procedures were associated with intensive care unit stay (4.6% vs <2%, P<0.01). In both primary and interval cytoreductive surgery patients, the receipt of bowel and upper abdominal procedures was associated with multiple 30-day postoperative complications and higher rates of readmission and emergency room visits.

Conclusions: The performance of upper abdominal procedures in ovarian cancer patients increased from 2000 to 2013. Interval cytoreductive surgery was associated with decreased likelihood of bowel surgery. In matched primary and interval cytoreductive surgery cohorts, the receipt of these procedures were associated with the increased likelihood of postoperative complications and use of acute care services.
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http://dx.doi.org/10.1136/ijgc-2020-001243DOI Listing
August 2020

Lifetime health care costs of oropharyngeal cancer for commercially insured patients in the United States.

Head Neck 2020 09 2;42(9):2321-2329. Epub 2020 May 2.

Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Background: Incidence of oropharyngeal cancer (OPC) is expected to increase but its health care cost is unknown. The purpose for this study was to estimate the phase-specific lifetime health care costs of OPC for commercially insured individuals in the United States.

Methods: We used the Truven MarketScan Commercial Claims and Encounter Database to identify our patient population. Cox survival analysis was used to estimate patients' monthly survival probabilities. We determined the ratios of the cumulative costs up to a particular survival probability and the costs from that time point to death for all subjects who died before end of the 5-year follow-up period. This relationship was then used to predict phase-specific lifetime health care costs.

Results: Our study included 2445 patients with OPC. The predicted phase-specific lifetime health care costs attributable to OPC were $88 872, $24 038, and $1537 in the initial, continuous, and terminal phases, respectively, among commercially insured patients.
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http://dx.doi.org/10.1002/hed.26201DOI Listing
September 2020

Body mass index and attitudes towards health behaviors among women with endometrial cancer before and after treatment.

Int J Gynecol Cancer 2020 02 15;30(2):187-192. Epub 2019 Dec 15.

Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA

Introduction: Some experts have argued that obesity-related malignancies such as endometrial cancer are a "teachable moment" that lead to meaningful changes in health behaviors. It is unclear if endometrial cancer survivors lose weight following treatment. Our goal with this investigation was to evaluate post-treatment changes in body mass index (BMI) and attitudes towards health behaviors in endometrial cancer survivors.

Methods: Incident endometrial cancer cases undergoing surgery between 2009-2015 were identified in the Marketscan Commercial database and linked with BMI data and health behavior questionnaires from the Marketscan Health Risk Assessment database. Patients were excluded for insufficient BMI data. Standard statistical methods, including the two-sample Wilcoxon rank sum test, χ test, and McNemar's test, were used.

Results: 655 patients with a median age of 54 (IQR 49-58) were identified and analyzed. Median duration of follow-up was 595 days (IQR 360-1091). Mean pre- and post-treatment BMI was 35.5 kg/m (median 35.0; IQR 27.0-42.3) and 35.6 kg/m (median 34.3; IQR 28.0-42.0), respectively. Median BMI change in the entire cohort was 0 kg/m (IQR -1.0 to 2.0). Weight gain (n=302; 46.1%) or no change in weight (n=106; 16.2%) was seen in most patients. Among the 302 patients who gained weight, the mean pre-treatment BMI was 34.0 kg/m and mean increase was 2.8 kg/m (median 2.0; IQR 1.0-3.4). Among the 247 cases who lost weight, the mean pre-treatment BMI was 38.6 kg/m and mean decrease was 3.2 kg/m (median 2.0; IQR 1.0-4.0). No pre- to post-treatment differences were observed in health behavior questionnaires regarding intention to better manage their diet, exercise more, or lose weight.

Discussion: Most endometrial cancer survivors gain weight or maintain the same weight following treatment. No post-treatment changes in attitudes regarding weight-related behaviors were observed. The systematic delivery of evidence-based weight loss interventions should be a priority for survivors of endometrial cancer.
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http://dx.doi.org/10.1136/ijgc-2019-000999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307445PMC
February 2020

Comparative Effectiveness of Chemotherapy, Rituximab, and Bendamustine in Medicare Beneficiaries With Mantle-Cell Lymphoma.

Clin Lymphoma Myeloma Leuk 2019 11 30;19(11):e616-e623. Epub 2019 Aug 30.

Department of Epidemiology, Human Genetics, and Environmental Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX.

Background: Over the past 2 decades, rituximab, bortezomib, and bendamustine have been approved to treat mantle-cell lymphoma (MCL). To date, few studies have evaluated the comparative effectiveness of these novel agents. Therefore, this study evaluated the comparative effectiveness of those novel agents in elderly patients newly diagnosed with MCL.

Patients And Methods: All newly diagnosed MCL patients aged 66 or older were identified from Surveillance, Epidemiology, and End Results Program (SEER)-Medicare databases from 1999 to 2013. Patients were categorized into 4 groups on the basis of their first-line treatment regimens: chemotherapy alone, rituximab ± chemotherapy, bortezomib ± chemotherapy, and bendamustine ± chemotherapy. Multivariable proportional hazard regressions with 1-year follow-up from treatment were performed to compare the all-cause, MCL-specific, and noncancer mortality rates. Sensitivity analyses using propensity score-adjusted and instrumental variable-adjusted regressions were also conducted.

Results: A total of 1215 MCL patients were included. The bortezomib group was not included in the primary analyses because of the small sample size (n = 24). On multivariable analyses, the rituximab group showed significant decrease in both 1-year all-cause mortality (hazard ratio [HR] = 0.38, 95% confidence interval [CI], 0.25-0.59) and MCL-specific mortality (HR = 0.38; 95% CI, 0.24-0.60) compared to the chemotherapy-alone group. The bendamustine group showed significant decrease in 1-year MCL-specific mortality (HR = 0.49; 95% CI, 0.24-0.99) compared to the chemotherapy-alone group. The results from sensitivity analyses were similar to those from primary analyses.

Conclusion: For elderly patients with newly diagnosed MCL, rituximab-based regimen and bendamustine-based regimen as first-line treatment significantly decreased 1-year mortality rates compared to chemotherapy alone.
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http://dx.doi.org/10.1016/j.clml.2019.08.014DOI Listing
November 2019

Direct medical cost of oropharyngeal cancer among patients insured by Medicaid in Texas.

Oral Oncol 2019 09 4;96:21-26. Epub 2019 Jul 4.

Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States. Electronic address:

Objectives: The aim of this study was to estimate the direct 2-year mean incremental medical care costs for incident oropharyngeal cancer (OPC) from the perspective of the Texas Medicaid program.

Methods: OPC patients treated from 2008 to 2012 were selected in the Texas Medicaid database. Using a two-step 1:1 propensity score matching method, we selected controls to determine the differential cost associated with OPC. Monthly and yearly direct costs were estimated for 2 years after the cancer diagnosis. For patients without 2-year complete follow-up, a generalized linear model with gamma distribution and log link function was applied to predict costs for the censored months.

Results: A total of 352 patients with OPC and the same number of controls were included in the study. Among OPC patients, 204 (58%) were covered by Medicaid and Medicare, and 148 patients (42%) were insured under Medicaid only. The adjusted first- and second-year mean differential costs were $45,102 and $11,684 for Medicaid-only enrollees and $5734 and $2162 for Medicaid-Medicare dual-eligible enrollees, respectively. Being male, Hispanic, Medicaid-only eligible, living in the Harlingen region, and having more comorbidities were positively associated with monthly cost. Lubbock residents experienced lower costs.

Conclusions: The direct incremental medical costs associated with OPCs among patients insured by Texas Medicaid were substantial in the first 2 years after cancer diagnosis and should be considered in assessing the economic consequences of increasing the investment in HPV vaccination in Texas.
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http://dx.doi.org/10.1016/j.oraloncology.2019.06.033DOI Listing
September 2019

Cost Effectiveness of Transplant, Conventional Chemotherapy, and Novel Agents in Multiple Myeloma: A Systematic Review.

Pharmacoeconomics 2019 12;37(12):1421-1449

Division of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX, 77030, USA.

Background: Treatments for multiple myeloma (MM) have been rapidly evolving. Newly developed treatment regimens are likely to be more effective but also cost more than conventional therapies.

Objective: We conducted a systematic review to compare the cost effectiveness of different classes of MM treatment.

Methods: We searched the PubMed, MEDLINE, Web of Science, and EMBASE databases for studies published during 1990-2018 comparing the cost effectiveness of transplant, chemotherapeutic and novel MM treatments. Titles and abstracts were independently reviewed for eligibility by two investigators. The quality of the included studies was evaluated using the 16-item, validated Quality of Health Economics Studies instrument.

Results: Twenty-four publications were included in the systematic review and summarized according to treatment regimen and line. For first-line treatment, transplant was the most cost-effective option for transplant-eligible MM patients [the incremental cost-effectiveness ratio (ICER) was $4053-€45,460 per quality-adjusted life-year (QALY) gained, and $3848-$72,852 per life-year gained (LYG)], and the ICER for novel agents compared with conventional chemotherapy was $59,076 per QALY and $220,681 per LYG. For second-line treatment, in comparisons of novel agent-based regimens, ICERs were inconsistent. However, bortezomib-based regimens, lenalidomide plus dexamethasone, and pomalidomide plus dexamethasone were each cost effective compared with dexamethasone alone (ICERs showed cost saving, £30,153 per QALY gained, and €39,911 per LYG, respectively).

Conclusions: For transplant-eligible MM patients, transplant is a cost-effective first-line treatment. More cost-effectiveness analyses comparing novel agents in the first-line treatment regimen are warranted to determine which agent or regimen is the most cost effective. In the second-line setting, it is unclear which novel agent-based regimen is most cost effective, but bortezomib-based regimens, lenalidomide plus dexamethasone, and pomalidomide plus dexamethasone were each cost effective compared with dexamethasone alone.
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http://dx.doi.org/10.1007/s40273-019-00828-yDOI Listing
December 2019

Utilization of rehabilitation services in patients with head and neck cancer in the United States: A SEER-Medicare analysis.

Head Neck 2019 09 25;41(9):3299-3308. Epub 2019 Jun 25.

Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Head and neck cancer (HNC) and its treatment lead to functional impairments. Rehabilitation by speech-language pathology (SLP) and occupational/physical therapy (OT/PT) can decrease morbidity.

Methods: The Surveillance, Epidemiology and End Results-Medicare data for patients with HNC diagnosed between 2002 and 2011 was utilized to evaluate posttreatment rehabilitation.

Results: In 16 194 patients, the overall utilization rate was 20.7% for SLP and 26.2% for OT/PT services. Treatment modality was significantly associated rehabilitation utilization. Compared to patients treated with primary surgery, those treated with primary radiotherapy had significantly lower odds of OT/PT utilization. Patients treated with surgery plus adjuvant treatment and primary concurrent chemoradiation had higher odds of SLP utilization compared to patients treated with surgery alone.

Conclusions: Rehabilitation services appeared to be underutilized by patients with HNC in the United States and vary with treatment modality. There is a need to improve integration of rehabilitation services into the HNC care continuum.

Summary: Rehabilitation services are underutilized by patients with HNC during posttreatment surveillance in the United States. Treatment modality significantly impacts rehabilitation utilization patterns.
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http://dx.doi.org/10.1002/hed.25844DOI Listing
September 2019

Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and gynecologic oncology surgical outcomes.

Gynecol Oncol 2019 08 14;154(2):405-410. Epub 2019 Jun 14.

Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. Electronic address:

Objective: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national survey of inpatient experience. This study evaluated the association between HCAHPS survey results and outcomes in gynecologic cancer surgery.

Methods: This observational study used HCAHPS survey data from 2009 to 2011 to assign hospitals into score terciles. The Nationwide Inpatient Sample (NIS) database was used to identify admissions during the same time period for gynecologic cancer-specific surgeries. Data sources were linked at the hospital level. Postoperative complications, mortality, and prolonged length of stay were compared between higher and lower scoring hospitals. Complications were grouped as 'surgical', 'medical', or 'care team'. Mixed effects models were used to evaluate the associations between hospitals' HCAHPS scores and outcomes after adjustment for patient and hospital-level variables.

Results: 17,509 linked encounters in 651 hospitals across the U.S. were identified, with 51% uterine, 40% ovarian, and 9% cervical cancer surgical admissions. In-hospital mortality was lower in hospitals in the top HCAHPS score terciles compared to bottom HCAHPS score tercile (odds ratio (OR) 0.54, 95% CI: 0.31-0.94). Surgery in higher scoring HCAHPS hospitals was associated with less 'surgical' complications (OR 0.82, 95% CI 0.69-0.98). No association was found between 'medical', 'care team', overall complications, or prolonged hospitalization (p > 0.05) and HCAHPS scores.

Conclusions: Gynecologic oncology surgeries performed in top HCAHPS tercile hospitals were associated with lower in-hospital mortality and surgical complications compared to surgeries performed in bottom tercile hospitals. Associations between HCAHPS scores and other adverse events were not seen.
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http://dx.doi.org/10.1016/j.ygyno.2019.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6810571PMC
August 2019

National patterns of care and fertility outcomes for reproductive-aged women with endometrial cancer or atypical hyperplasia.

Am J Obstet Gynecol 2019 11 22;221(5):474.e1-474.e11. Epub 2019 May 22.

Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address:

Background: Although it is uncommon, the incidence of endometrial cancer and atypical hyperplasia among reproductive-aged women is increasing. The fertility outcomes in this population are not well described.

Objective: We aim to describe the patterns of care and fertility outcomes of reproductive-aged women with endometrial cancer or atypical hyperplasia.

Materials And Methods: A cohort of women aged ≤45 years with endometrial cancer or atypical hyperplasia diagnosed in 2000 to 2014 were identified in Truven Marketscan, an insurance claims database of commercially insured patients in the United States. Treatment information, including use of progestin therapy, hysterectomy, and assisted fertility services, was identified and collected using a combination of Common Procedural Terminology codes, International Statistical Classification of Diseases and Related Health Problems codes, and National Drug Codes. Pregnancy events were identified from claims data using a similar technique. Patients were categorized as receiving progestin therapy alone, progestin therapy followed by hysterectomy, or standard surgical management with hysterectomy alone. Multivariable logistic regression was performed to assess factors associated with receiving fertility-sparing treatment.

Results: A total of 4007 reproductive-aged patients diagnosed with endometrial cancer or atypical hyperplasia were identified. The majority of these patients (n = 3189; 79.6%) received standard surgical management. Of the 818 patients treated initially with progestins, 397 (48.5%) subsequently underwent hysterectomy, whereas 421 (51.5%) did not. Patients treated with progestin therapy had a lower median age than those who received standard surgical management (median age, 36 vs 41 years; P < .001). The proportion of patients receiving progestin therapy increased significantly over the observation period, with 24.9% treated at least initially with progestin therapy in 2014 (P < .001). Multivariable analysis shows that younger age, a diagnosis of atypical hyperplasia diagnosis rather than endometrial cancer, and diagnosis later in the study period were all associated with a greater likelihood of receiving progestin therapy (P < .0001). Among the 421 patients who received progestin therapy alone, 92 patients (21.8%; 92/421) had 131 pregnancies, including 49 live births for a live birth rate of 11.6%. Among the 397 patients treated with progestin therapy followed by hysterectomy, 25 patients (6.3%; 25/397) had 34 pregnancies with 13 live births. The median age of patients who experienced a live birth following diagnosis during the study period was 36 years (interquartile range, 33-38). The use of some form of assisted fertility services was observed in 15.5% patients who were treated with progestin therapy. Among patients who experienced any pregnancy event following diagnosis, 54% of patients used some form of fertility treatment. For patients who experienced a live birth following diagnosis, 50% of patients received fertility treatment. Median time to live birth following diagnosis was 756 days (interquartile range, 525-1077). Patients treated with progestin therapy were more likely to experience a live birth if they had used assisted fertility services (odds ratio, 5.9; 95% confidence interval, 3.4-10.1; P < .0001).

Conclusion: The number of patients who received fertility-sparing treatment for endometrial cancer or atypical hyperplasia increased over time. However, the proportion of women who experience a live birth following these diagnoses is relatively small.
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http://dx.doi.org/10.1016/j.ajog.2019.05.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7069241PMC
November 2019

Cervical, Vaginal, and Vulvar Cancer Costs Incurred by the Medicaid Program in Publicly Insured Patients in Texas.

J Low Genit Tract Dis 2019 Apr;23(2):102-109

Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX.

Objectives: To determine from the perspective of the State of Texas, the direct medical care costs associated with cervical, vaginal, and vulvar cancers in Texas Medicaid enrollees.

Materials And Methods: We conducted a case-control study and searched Texas Medicaid databases between 2008 and 2012 for eligible cancer patients. A comparison group was selected for each cancer site using a 2-step 1:1 propensity score matching method. Patients were followed for 2 years after cancer diagnosis to estimate monthly and yearly direct medical costs. For each cancer site, the differential cost between patients and the matched comparison individuals was the estimated cost associated with cancer.

Results: The study included 583 cervical, 62 vaginal, and 137 vulvar cancer patients and equal numbers of cancer-free comparison individuals. Among the cases, 322 cervical cancer patients, 46 vaginal cancer patients, and 102 vulvar cancer patients were Medicaid-Medicare dual eligible enrollees. For Medicaid-only enrollees, the adjusted first- and second-year mean total differential costs were US $19,859 and $3,110 for cervical cancer, US $19,627 and $4,582 for vaginal cancer, and US $7,631 and $777 for vulvar cancer patients, respectively. For Medicaid-Medicare dual eligible enrollees, adjusted first- and second-year mean total differential costs incurred by Medicaid were US $2,565 and $792 for cervical cancer, US $1,293 and $181 for vaginal cancer, and US $1,774 and $1,049 for vulvar cancer patients, respectively.

Conclusions: The direct medical costs associated with cervical, vaginal, and vulvar cancers in Texas Medicaid were substantial in the first 2 years after cancer diagnosis, but dual eligibility for Medicare coverage attenuated Medicaid costs.
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http://dx.doi.org/10.1097/LGT.0000000000000472DOI Listing
April 2019

Impact of Serious Mental Illness on Medicaid and Other Public Healthcare Costs in Texas.

Adm Policy Ment Health 2019 07;46(4):498-506

Division of Management, Policy, and Community Health, The University of Texas-Houston School of Public Health, Houston, USA.

Medicaid-enrolled adults with serious mental illness may be dually-enrolled in Medicare, and may receive health care services from other state and local programs. To understand cross-program costs of care, we linked 2012 payment data across Medicaid, Medicare, state, and local programs. Average costs were calculated according to presence/absence of SMI, Medicare coverage, SSI coverage, medical comorbidities, and other characteristics. Costs for Medicaid adults with SMI were 57.4% greater than adults without SMI, but only 23.6% of costs were SMI-related. Greater costs were associated with Medicaid-Medicare dual-eligibility, multiple SMI diagnoses, and medical comorbidities. The results support cross-program efforts such as joint Medicaid-Medicare managed care and integrated care.
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http://dx.doi.org/10.1007/s10488-019-00929-yDOI Listing
July 2019

Mean treatment cost of incident cases of penile cancer for privately insured patients in the United States.

Urol Oncol 2019 04 17;37(4):294.e17-294.e25. Epub 2019 Jan 17.

Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: The aims of this study were to estimate the short-term cost of treating newly diagnosed penile cancer and determine the correlates of penile cancer treatment cost in the United States.

Methods: The Truven MarketScan database was used to identify commercially insured patients with penile cancer newly diagnosed during 2011 to 2014. A control group without HPV-related cancer diagnosis was selected by matching to the case group by the propensity score method. Total healthcare costs in the 2 years after the cancer diagnosis index date were measured for each patient. The mean difference between case and control groups was considered the cancer-related cost. For patients without complete 2-year data, a generalized linear regression was performed to predict cost for censored months and identify predictors associated with monthly cost.

Results: A total of 250 patients with newly diagnosed penile cancer and 250 matched controls were included in the study. The adjusted mean differential healthcare cost for penile cancer was $76,404 in the first 2 years. For the penile cancer group, cost peaked in month 1 at $10,202 and dropped substantially each month thereafter until month 7, when the cost was $4,295. After month 7, the monthly cost remained steady at $2,700 to $4,200.

Conclusions: The estimated average cost of penile cancer for insured patients in the United States was about $76,000 in the first 2 years after diagnosis. Monthly cost was directly related to age, length of follow-up, comorbidity score, and prediagnosis cost.
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http://dx.doi.org/10.1016/j.urolonc.2019.01.004DOI Listing
April 2019

Increase in survival for patients with mantle cell lymphoma in the era of novel agents in 1995-2013: Findings from Texas and national SEER areas.

Cancer Epidemiol 2019 02 6;58:89-97. Epub 2018 Dec 6.

Department of Epidemiology, Human Genetics, and Environmental Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA. Electronic address:

Background: Over the past 20 years, many novel agents and treatment regimens have been developed to treat mantle cell lymphoma (MCL). This study aimed to determine the impact of these new regimens on the survival of MCL patients from 1995 to 2013.

Methods: All newly diagnosed adult MCL patients in the Surveillance, Epidemiology, and End Results (SEER) and Texas Cancer Registry (TCR) databases were included. Patients were grouped into 4 calendar periods based on the time when new novel agents became available: chemotherapy-only (1995-1998, P1), rituximab + chemotherapy (1999-2004, P2), bortezomib and HyperCVAD (2005-2008, P3), bendamustine and Nordic regimen (2009-2013, P4). Associations between these time periods and survival outcomes were analyzed using the Kaplan-Meier method and Cox proportional hazard regressions.

Results: A total of 7,555 SEER patients and 2,055 TCR patients were identified. All-cause mortality rates decreased significantly from 1995 to 2013 (SEER, P < 0.001; TCR, P = 0.03). Multivariable analysis of SEER data showed that the risk of MCL-specific death decreased significantly over the study period with hazard ratios of 0.82 (P2 vs. P1), 0.66 (P3 vs. P1), and 0.58 (P4 vs. P1) (P < 0.0001). Similar results were observed for TCR data (P < 0.0001). In an analysis stratified by tumor stage, only patients with advanced- stage tumors showed a significantly decreased risk of death in both SEER (P < 0.0001) and TCR (P = 0.002) datasets.

Conclusion: Survival outcome for MCL patients improved from 1995 to 2013, especially for patients with advanced-stage tumors, potentially reflecting the impact of the introduction of novel agents and new therapeutic regimens.
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http://dx.doi.org/10.1016/j.canep.2018.12.002DOI Listing
February 2019

Health Care Costs of Anal Cancer in a Commercially Insured Population in the United States.

J Manag Care Spec Pharm 2018 Nov;24(11):1156-1164

1 Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston.

Background: The incidence and death rate of anal cancer in the United States has been increasing on average 2%-3% per year over the past 10 years. Human papillomavirus (HPV) vaccination is a potentially viable prevention strategy, since about 80% of anal cancers are attributable to HPV. To understand the effect of HPV vaccination, it is important to estimate the treatment costs for the HPV-related disease.

Objective: To estimate the 2-year per patient mean direct health care costs associated with anal cancer in a commercially insured population in the United States.

Methods: All newly diagnosed anal cancer patients were identified from a 2011-2014 Truven MarketScan database. Matched population controls were selected from the database with a 2-step matching method using demographic, comorbidity, and health care cost variables. Costs for the first 2 years were measured for cancer patients and controls. The difference in costs between the groups was calculated to estimate the costs associated with anal cancer treatment. A generalized linear model with gamma distribution and log link function was applied to estimate the costs for censored months for the patients who did not have at least 2 years of follow-up.

Results: 1,976 patients with anal cancer and 1,976 controls were included in the study. The first 2-year per patient adjusted mean cost associated with anal cancer treatment was $127,531 (SD = $189,064). Male sex, cancer diagnosis, higher Charlson Comorbidity Index score, and higher prediagnosis costs were significantly associated with higher monthly costs. Higher psychiatric diagnostic group scores were associated with lower monthly costs. Anal cancer treatment costs were highest in the first 6 months after diagnosis (per patient per month [PPPM] mean = $12,846), leveling off at a much lower monthly cost during the subsequent 18 months of the 2-year period (PPPM mean = $3,717).

Conclusions: The first 2-year costs associated with anal cancer treatment were substantial. Given that approximately 80% of anal cancers are attributable to HPV infection, this study provides important parameters for estimating the potential economic benefit of HPV vaccination.

Disclosures: This research was accomplished within the Oropharynx Program at The University of Texas MD Anderson Cancer Center and was funded in part through the Stiefel Oropharyngeal Research Fund. The authors report funding contributions from the Christopher and Susan Damico Chair in Viral Associated Malignancies (The University of Texas MD Anderson). This work was supported by generous philanthropic contributions, including a contribution from the Lyda Hill Foundation, to The University of Texas MD Anderson HPV-Related Cancers Moon Shot Program. The authors have nothing to disclose.
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http://dx.doi.org/10.18553/jmcp.2018.24.11.1156DOI Listing
November 2018

Reply to "Letter to the Editor in response to the article, 'The epidemiology of oral human papillomavirus infection in healthy populations: A systematic review and meta-analysis'".

Oral Oncol 2018 11 9;86:307. Epub 2018 Oct 9.

Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. Electronic address:

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http://dx.doi.org/10.1016/j.oraloncology.2018.10.002DOI Listing
November 2018

Age-Structured Population Modeling of HPV-related Cervical Cancer in Texas and US.

Sci Rep 2018 09 25;8(1):14346. Epub 2018 Sep 25.

Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200, Pressler Street, Houston, TX, USA.

Human papillomavirus (HPV)-related cervical cancer is a major public health threat to women, with >10,000 new cases diagnosed annually in the United States between 2008 and 2012. Since HPV vaccines can protect against ~80% of HPV-associated cervical cancers, the economic and epidemiological impacts of HPV vaccination have been extensively investigated, particularly at the national level. However, vaccination policies are state-specific, and state-level models are required for state-specific policy decisions. This study adapted an age-structured population model to describe the dynamics of HPV-related cervical cancer in Texas, with model parameters calibrated for Texas. The Year 2000 parameter set was the start point, and the model's predictions from 2001-2010 were well matched with the real incidence numbers in 23 age groups, suggesting the validity of the model. Application of the model to the Year 2010 parameter set predicted that, over the next 10 decades, incidence would decrease rapidly within the first decade and more slowly thereafter. Sensitivity analysis determined the impact of selected parameters (e.g., vaccine coverage rate) on future disease incidence. When compared with the US parameter sets, the Texas population was more sensitive to changes in HPV transmission and vaccination (e.g., ~8% difference in the predicted disease decline).
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http://dx.doi.org/10.1038/s41598-018-32566-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6156590PMC
September 2018

Medical Care Costs Associated with Genital Warts for Commercially Insured US Patients.

Pharmacoeconomics 2018 11;36(11):1355-1365

Department of Management, Policy, and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St., Houston, TX, 77030, USA.

Introduction: Genital warts are caused by infection with human papillomavirus (HPV) and are associated with significant morbidity. Primary prevention of genital warts is possible through HPV vaccination, but vaccination rates remain low in the USA. When deciding to implement HPV vaccination programs, public health officials and policy makers rely on cost-effectiveness studies that accurately reflect costs associated with morbidity and mortality. However, previous information on the cost of treating genital warts was outdated.

Objectives: We estimated the mean direct medical care costs associated with genital warts in the USA.

Methods: This was a retrospective case-control study of patients diagnosed with genital warts and matched controls. We used commercial healthcare claims data from 2011 through 2014 to estimate total 1- and 2-year costs from date of diagnosis. We used a generalized linear model to identify factors associated with monthly costs.

Results: We identified 34,686 eligible cases of genital warts during the period 2011-2014. The first 2-year mean direct medical cost differences between cases and controls were US$6737 for the USA. Costs were significantly higher in the first 3 months following diagnosis and were higher among older individuals, women, those with co-morbidities or psychiatric illnesses, and those located in the south and southwest USA.

Conclusions: The mean direct cost of treating genital warts is approximately US$6700 in the first 2 years after diagnosis in the USA. These data can assist policy makers in decisions with respect to allocation of resources to implement HPV vaccine programs.
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http://dx.doi.org/10.1007/s40273-018-0691-9DOI Listing
November 2018

The epidemiology of oral human papillomavirus infection in healthy populations: A systematic review and meta-analysis.

Oral Oncol 2018 07 21;82:91-99. Epub 2018 May 21.

Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1445, Houston, TX 77030, USA. Electronic address:

Human papillomavirus (HPV) is a potentially oncogenic sexually transmitted infection. As the incidence of oropharyngeal cancer (OPC) caused by oral HPV infections is rising, further investigation into the natural history of such infections is needed. This systematic review and meta-analysis aimed to synthesize data on the prevalence, incidence, clearance, and persistence of oral HPV infections in healthy individuals. A systematic review of literature published between January 1995 and August 2017 was conducted using Ovid MEDLINE, PubMed, Embase, and the Cochrane Library. Meta-analysis of prevalence and incidence data was conducted. Clearance and persistence data were extracted. Sixty-six studies met the inclusion criteria. Meta-analysis demonstrated an overall prevalence of 7.7% for all types of HPV and 1.4% for high-risk HPV16. The overall incidence was 4.38 cases per 1000 person-months for all HPV types and 0.92 cases per 1000 person-months for HPV16. This systematic review and meta-analysis demonstrated that oral HPV infection has a lower prevalence and incidence than cervicogenital HPV infection in healthy individuals. Nonetheless, oral HPV is still an important concern, given its oncogenicity and the rising incidence of oropharyngeal cancer. Consistency of methodology will allow for better future comparisons, particularly of infection clearance and persistence.
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http://dx.doi.org/10.1016/j.oraloncology.2018.04.005DOI Listing
July 2018

Costs of Cancer Care for Elderly Patients with Neuroendocrine Tumors.

Pharmacoeconomics 2018 08;36(8):1005-1013

Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1444, Houston, TX, 77030, USA.

Background: The incidence and prevalence of neuroendocrine tumors (NETs) have been steadily rising. NETs can arise in various parts of the body and have distinct pathogenesis, clinical manifestations, treatment, and survival compared to other neoplasms. The magnitude of the economic burden of NETs is largely unknown. This study aimed to estimate the cost of illness for NETs among elderly patients based on a large amount of observational data.

Methods: We estimated the direct medical costs by phase of care using the Surveillance, Epidemiology, and End Results-Medicare data, including claims from January 1, 2002 through to December 31, 2012. Patients' care was categorized into three phases: initial phase (first year after diagnosis), terminal phase (last year of life), and continuing phase (the period between). We estimated the cost of illness by calculating the difference in medical costs between NET patients and a matched sample from a non-cancer control group.

Results: Our study sample included 8409 elderly NET patients in the initial phase, 9218 patients in the continuing phase, and 7897 in the terminal phase. The mean cost of care for the initial phase was $46,462 in 2016 US dollars; mean cost of care for the terminal phase with a cancer-related death was $122,702; while the mean cost of care for the continuing phase was $10,457. The mean 5-year cost was $87,079.

Conclusions: This population-based study showed that NET patients had substantial continuing phase costs and 5-year costs. Among elderly NET patients, those with pancreas as the primary cancer site had the highest costs.
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http://dx.doi.org/10.1007/s40273-018-0656-zDOI Listing
August 2018

Pioglitazone and bladder cancer risk: a systematic review and meta-analysis.

Cancer Med 2018 04 24;7(4):1070-1080. Epub 2018 Feb 24.

Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana.

Current evidence about the association between pioglitazone and bladder cancer risk remains conflict. We aimed to assess the risk of bladder cancer associated with the use of pioglitazone and identify modifiers that affect the results. We systematically searched PubMed, Embase, and Cochrane Central Register of Controlled Trials from inception to 25 August 2016 for randomized controlled trials (RCTs) and observational studies that evaluated the association between pioglitazone and bladder cancer risk. Conventional and cumulative meta-analyses were used to calculate the odds ratio (OR) with 95% confidence interval (CI). A restricted spline regression analysis was used to examine the dose-response relationship with a generalized least-squares trend test. We included two RCTs involving 9114 patients and 20 observational studies (n = 4,846,088 individuals). An increased risk of bladder cancer in patients treated with pioglitazone versus placebo was noted from RCTs (OR, 1.84; 95%CI, 0.99 to 3.42). In observational studies, the increased risk of bladder cancer was slight but significant among ever-users of pioglitazone versus never-users (OR, 1.13; 95%CI, 1.03 to 1.25), which appeared to be both time- (P = 0.003) and dose-dependent (P = 0.05). In addition, we observed the association differed by region of studies (Europe, United States, or Asia) or source of funding (sponsored by industry or not). Current evidence suggests that pioglitazone may increase the risk of bladder cancer, possibly in a dose- and time-dependent manner. Patients with long-term and high-dose exposure to pioglitazone should be monitored regularly for signs of bladder cancer.
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http://dx.doi.org/10.1002/cam4.1354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5911601PMC
April 2018

Trends and variations in mantle cell lymphoma incidence from 1995 to 2013: A comparative study between Texas and National SEER areas.

Oncotarget 2017 Dec 3;8(68):112516-112529. Epub 2017 Nov 3.

Department of Epidemiology, Human Genetics, and Environmental Science, School of Public Health, The University of Texas Health Science Center in Houston, Houston, Texas 77030, USA.

Background: Few studies have assessed mantle cell lymphoma (MCL) incidence trends in the U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) areas. Previous studies were 5 to 9 years old and MCL incidence in Texas remains unknown. This study updated the temporal trends and variations of MCL incidence in the SEER areas and compared them with counterpart data in Texas.

Results: From 1995 to 2013, there were 2, 435 and 5, 193 newly diagnosed MCL patients in Texas and SEER areas. Age-adjusted MCL incidence was 0.91 per 100,000 persons per year in Texas and 1.01 in SEER areas. MCL incidence increased steadily with an annual percent change (APC) of 2.56% in SEER areas and an APC of 2.16% in Texas. In SEER areas, APCs for MCL incidence were significantly different from zero in patients with advanced stage tumor (3.33%), male (2.71%), elderly patients ≥ 80 years old (4.21%) and non-Hispanic white patients (2.83%) (all < 0.05). Similar patterns were found in Texas for both incidence rates and APCs.

Materials And Methods: We identified all adult patients with newly diagnosed MCL in Texas Cancer Registry and SEER databases from 1995 to 2013. Age-adjusted incidence rates were calculated and negative binomial regression model was used to assess the factors associated with MCL incidence.

Conclusions: MCL incidence rates increased over time in both Texas and SEER areas, with increases being greater in male, non-Hispanic white, and elderly patient ≥70 years with advanced stage tumors. Texas has similar MCL incidence trends and disparities as the national SEER areas.
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http://dx.doi.org/10.18632/oncotarget.22367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5762529PMC
December 2017