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The American Journal of Managed Care April 2018
Delivering on the Value Proposition of Precision Medicine: The View From Healthcare Payers
Jane Null Kogan, PhD; Philip Empey, PharmD, PhD; Justin Kanter, MA; Donna J. Keyser, PhD, MBA; and William H. Shrank, MD, MSHS
Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare
Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
Cost Sharing and Branded Antidepressant Initiation Among Patients Treated With Generics
Jason D. Buxbaum, MHSA; Michael E. Chernew, PhD; Machaon Bonafede, PhD; Anna Vlahiotis, MA; Deborah Walter, MPA; Lisa Mucha, PhD; and A. Mark Fendrick, MD
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The Well-Being of Long-Term Cancer Survivors
Jeffrey Sullivan, MS; Julia Thornton Snider, PhD; Emma van Eijndhoven, MS, MA; Tony Okoro, PharmD, MPH; Katharine Batt, MD, MSc; and Thomas DeLeire, PhD
Financial Burden of Healthcare Utilization in Consumer-Directed Health Plans
Xinke Zhang, PhD; Erin Trish, PhD; and Neeraj Sood, PhD
Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Physician and Patient Tools to Improve Chronic Kidney Disease Care
Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Limited Distribution Networks Stifle Competition in the Generic and Biosimilar Drug Industries
Laura Karas, MD, MPH; Kenneth M. Shermock, PharmD, PhD; Celia Proctor, PharmD, MBA; Mariana Socal, MD, PhD; and Gerard F. Anderson, PhD
Provider and Patient Burdens of Obtaining Oral Anticancer Medications
Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE

The Well-Being of Long-Term Cancer Survivors

Jeffrey Sullivan, MS; Julia Thornton Snider, PhD; Emma van Eijndhoven, MS, MA; Tony Okoro, PharmD, MPH; Katharine Batt, MD, MSc; and Thomas DeLeire, PhD
This study compares the well-being of long-term cancer survivors with that of US residents of similar age and demographic characteristics, patients recently diagnosed with cancer, and individuals with chronic illness.
ABSTRACT

Objectives: To compare the well-being of long-term cancer survivors with that of US residents of similar age and demographic characteristics, patients recently diagnosed with cancer, and individuals with chronic illness.

Study Design: Retrospective observational study.

Methods: Using the Health and Retirement Study, a survey of US residents older than 50 years, we defined 4 cohorts: long-term cancer survivors (>4 years post diagnosis), individuals recently diagnosed with cancer (≤4 years post diagnosis), individuals with chronic illness, and US residents older than 50 years (“nationally representative cohort”). Well-being measures included self-reported health, utility, happiness, medical utilization and spending, employment, and earnings, and these measures were compared across cohorts, adjusting for survey year, demographic characteristics, smoking, and number of comorbidities. We imputed medical spending using the Medical Expenditure Panel Survey and the Medicare Current Beneficiary Survey. 

Results: Long-term cancer survivors fared significantly better than those recently diagnosed with cancer, those with chronic illness, and individuals in the nationally representative cohort in the majority of well-being measures (<.05), including fewer doctor visits, hospitalizations, and hospital nights; better utility and self-reported health; and greater likelihood of employment. Long-term cancer survivors had lower healthcare spending than those recently diagnosed with cancer (<.01) and significantly greater happiness than the nationally representative cohort and those with chronic illness (<.05). 

Conclusions: Although patients with cancer experience diminished well-being in the short term across a variety of measures, in the long term, cancer survivors do as well as or better than US residents of similar age and demographic characteristics. This finding is striking given that one might expect long-term cancer survivors to do worse than similar individuals without a history of cancer.

Am J Manag Care. 2018;24(4):188-195
Takeaway Points
  • Although patients with cancer experience diminished well-being in the short term across a variety of measures, in the long term, cancer survivors do as well as or better than US residents of similar age and demographic characteristics.
  • We found that long-term cancer survival has an effect on well-being comparable with that of many chronic conditions. This is notable given that 70% of US residents older than 50 years have at least 1 comorbidity.
  • Advances in cancer care that offer a chance of long-term survival may enable patients to experience a high quality of life.
Cancer care is changing rapidly. Over the past 60 years in the United States, population aging and declining mortality from heart disease have led to an increase in the total number of deaths from cancer.1 However, this increase in the total number of deaths masks substantial improvement in the cancer mortality risk faced by individuals. Adjusting for population aging, cancer mortality rates in the United States have declined by 23% from 1990 to 2012, from 214.95 to 166.40 per 100,000 individuals.2 Reasons for this decline include advances in early detection and treatment and decreased smoking.3 Although the debate continues about the efficacy of the “war on cancer” and further progress is needed,4-7 the trend of improving mortality is clear. Studies examining many tumor types have found that advances in care have led to significant mortality declines in recent decades.8-10 These reductions in mortality have increased the number of cancer survivors.

However, surviving cancer does not guarantee a high quality of life. Adverse effects of cancer treatment are well documented. Cardiac toxicities are a known complication of specific chemotherapeutics used in breast and other solid tumors, leaving many cancer survivors with degrees of heart failure.11Radiotherapy in patients with breast cancer has been linked to an increased risk of coronary events.12 Impairment of renal function is a complication of certain cancer treatment regimens, often resulting in acute damage and chronic kidney disease.13-16

Patients with cancer also face an increased risk of second primary malignancies.17-22 For example, a meta-analysis found that patients treated for Hodgkin lymphoma are at increased risk of developing second primary lung cancer.17 A study of testicular cancer survivors found that, compared with surgery only, radiotherapy below the diaphragm significantly increased the risk of second primary cancers or cardiovascular diseases.18

Because long-term cancer survivors face the risk of second primary malignancies and may live with complications from treatment toxicities, one might expect that they would experience a low quality of life. However, research to date has tended to focus on clinical and short-term outcomes, while comparatively little is known about the well-being of long-term cancer survivors. As improvements in treatment have made long-term survival a possibility for some patients with advanced cancers, understanding the well-being of long-term survivors is of increasing importance. 

In this study, we measured the well-being of long-term cancer survivors and compared their well-being with that of individuals recently diagnosed with cancer, individuals with chronic illness, and US residents of similar age and demographic characteristics. According to the CDC, “There is no consensus around a single definition of well-being.”23 Therefore, we studied a variety of well-being measures encompassing patients’ health, life satisfaction, and productivity.

METHODS

This study compared well-being outcomes across 4 cohorts: 1) long-term cancer survivors, 2) patients recently diagnosed with cancer, 3) individuals with at least 1 nonterminal chronic illness, and 4) a nationally representative sample of US residents older than 50 years. Regression analysis was used to compare outcomes across the cohorts, adjusting for survey year, demographic characteristics, smoking, and number of comorbidities. A study schematic is presented in Figure 1.

Cohort Selection and Data Sources

We used the Health and Retirement Study (HRS), a nationally representative biannual survey of US residents older than 50 years, to construct the 4 cohorts and follow their well-being outcomes over time. The HRS was designed to illuminate various aspects of US residents’ lives, including health, finances, and employment, as they approach and move into retirement.24

The common definition of long-term survival in individuals who have had a cancer diagnosis is 5 years post diagnosis.25-31 Because the HRS data are only collected every 2 years, we chose 4 years as the threshold for separating short- from long-term cancer survivors (ie, long-term survivors were diagnosed at least 4 years ago, whereas short-term survivors were diagnosed less than 4 years ago). This definition enabled us to focus on long-term survivors beyond the acute treatment phase. Taking a long-term perspective was important because research suggests that the transition from patient to long-term survivor can be challenging,32 and we sought to understand survivors’ well-being after that transition has been undertaken.

The chronic illness cohort included individuals with a diagnosis of diabetes, hypertension, heart disease, lung disease, or prior stroke, but with no prior cancer diagnosis. The nationally representative cohort consisted of all individuals older than 50 years in the 2010 HRS data, as this was the most recent nationally representative wave in the HRS. The cohorts were analyzed over 2004 through 2012 at the person-year level, although we used HRS data from as far back as 1992 to identify whether patients were short-term or long-term cancer survivors. A patient could appear in multiple cohorts. 

Because most outcomes in the HRS data are self-reported, these data are not ideally suited for tracking medical expenditures. Therefore, we developed an algorithm to impute total medical expenditures, including medical and pharmacy costs, in the HRS based on 2 data sets: the Medicare Current Beneficiary Survey (MCBS) for those older than 65 years and the Medical Expenditure Panel Survey (MEPS) for those between ages 50 and 64 years.

Specifically, we used the MCBS Cost and Use files, which combine results of a nationally representative survey of Medicare beneficiaries with administrative data to obtain accurate estimates of Medicare program spending.33 Health conditions were identified using the Health Status and Functioning (Community) data file from the Cost and Use files. We used the MCBS and the HRS from 1992 to 2010 to develop this imputation and applied it to our 2004-2012 HRS sample.

To estimate the medical expenditures of individuals aged between 50 and 64 years, we used the MEPS years 2000 through 2010. Although MEPS is based on survey data, it is designed to measure healthcare cost and utilization.34 In addition, the MEPS data were used to estimate utility for everyone older than 50 years based on the EQ-5D-3L measure, a utility measure introduced by the EuroQol Group in 1990. All health conditions were identified via self-reports from the MEPS condition files and household consolidated files.


 
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