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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
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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.
DISCUSSION

Our study results show a marked improvement in cancer survivors’ well-being in the long term compared with the first 4 years after diagnosis. Moreover, long-term cancer survivors fared at least as well as average US residents across a variety of well-being measures, controlling for demographics and the number of comorbidities. When comorbidities were not controlled for, long-term cancer survivors had modestly higher healthcare utilization and spending and modestly lower self-reported health and employment compared with average US residents. Taken together, these results suggest that when long-term cancer survivors fare worse than individuals without cancer, it is due to their comorbidity burden. These differences tended to be modest in size (eg, 1 extra doctor visit over 2 years). Moreover, even without controlling for comorbidity burden, there were no differences in happiness, utility, or earnings between long-term cancer survivors and average US residents.

Our analysis indicated that 70% of US residents older than 50 years have at least 1 comorbidity. Therefore, the fact that long-term cancer survivors fare comparably with others their age, many of whom are also dealing with health conditions, suggests that in the long term, cancer has an effect on well-being comparable with that of many chronic conditions.

Previous literature has compared the well-being of cancer survivors with that of individuals with chronic illness.39,40 Steel et al studied the difference in health-related quality of life (HRQoL) of individuals with hepatocellular carcinoma (HCC), individuals with chronic liver disease (CLD), and the general population.39 Those with HCC had statistically significantly poorer HRQoL than those with CLD and the general population. Those with HCC and CLD had better social and family well-being than the general population. 

In a similar study, Elliot et al compared the well-being of cancer survivors without other chronic conditions, cancer survivors with chronic conditions, and individuals with chronic conditions other than cancer with that of healthy individuals.40 They found that, generally, the well-being outcomes of cancer survivors without chronic conditions did not statistically differ from those of individuals with 1 chronic condition. 

Other studies have compared the well-being of cancer survivors with that of the general population. Using data from the American Cancer Society’s Study of Cancer Survivors, Zhou et al showed that ovarian cancer survivors had an HRQoL similar to that of the general population 1 year post diagnosis.41 Kunitake et al found that long-term colorectal cancer survivors had better overall physical and mental health compared with the general population.30 Similarly, Greenwald et al found that cervical cancer does not reduce the quality of life of long-term survivors,42 and Schmidt et al found that breast cancer survivors may experience long-term quality of life comparable with that of the general population.43 Finally, Thong et al found that although disease progression reduces cancer survivors’ quality of life, the effect diminishes over time.31

Our study echoes the existing literature in finding that long-term cancer survivors fared as well as or sometimes better than the general population. The main contribution of our study is that it investigates short- and long-term cancer survivors’ well-being across a variety of measures in a large, nationally representative sample.

Our findings are important given that recent breakthroughs in cancer treatment have raised the prospect of long-term survival for increased numbers of cancer patients. For example, new immuno-oncology agents, including ipilimumab, pembrolizumab, and nivolumab, have offered significant survival gains to patients,44-48 and preliminary data suggest the prospect of long-term survival for some metastatic cancer patients.49

Limitations

Our study does have limitations. First, the HRS data do not distinguish between cancer types and, therefore, we were unable to perform separate analyses by tumor type. As such, our results represent the experience of the “average” cancer survivor and will overrepresent those with particularly common or less deadly cancers. 

Second, the most recent nationally representative cohort in the HRS was in 2010, which was a recession year. Because the nationally representative cohort was constructed from the 2010 survey year and all other cohorts were constructed from the 2004-2012 survey years, secular trends could affect the well-being outcomes. However, we controlled for this by including survey year indicators in our analysis.

Third, in studying the well-being of cancer survivors, we necessarily limited the analysis to those who survived. Thus, we cannot definitively determine whether the observed changes in cancer survivors’ well-being between the short- and long-term time horizons are due to cancer survivorship itself or to characteristics potentially common to individuals more likely to survive cancer. 

Finally, we focused mainly on objective measures of well-being rather than subjective measures. However, focusing on objective measures does come with the advantage that, in doing so, we avoided any biases that can result from the way that subjective well-being outcomes are measured, as these outcomes can be subject to self-reporting or measurement bias.50

CONCLUSIONS

Our study results are striking, given concerns that patients with cancer may experience a low quality of life.51 Although we do find that quality of life is reduced in the short term, we find that it solidly rebounds in the years after diagnosis, becoming comparable with or even better than that of others of similar age and demographic characteristics. The high quality of life experienced by long-term cancer survivors is relevant in the midst of debate about the cost and value of cancer care. Although cost and other up-front considerations are important, it is also important to keep the patient’s perspective in mind. Prior research has shown that patients value therapies that give them a chance of long-term survival.52 Our study shows that the well-being of long-term cancer survivors eventually recovers, becoming similar to or even better than that of the general population. To the extent that long-term survivors enjoy a high quality of life, it makes interventions offering patients with cancer a chance of long-term survival more valuable.

Author Affiliations: Precision Health Economics (JS, JTS, EvE), Los Angeles, CA; Bristol-Myers Squibb (TO), Plainsboro, NJ; Wake Forest Baptist Medical Center (KB), Winston-Salem, NC; Georgetown University (TD), Washington, DC.

Source of Funding: Financial support for this research was provided by Bristol-Myers Squibb (BMS).

Author Disclosures: Mr Sullivan, Dr Thornton Snider, and Ms van Eijndhoven are employed at Precision Health Economics, which receives consulting fees from life sciences companies, including BMS. Dr Okoro was formerly employed as senior manager of health economics and outcomes research at BMS, has attended conferences on behalf of BMS, and formerly owned stock in BMS. Drs Batt and DeLeire have worked as consultants for Precision Health Economics. 

Authorship Information: Concept and design (JS, JTS, EvE, TO, KB, TD); acquisition of data (JS); analysis and interpretation of data (JS, JTS, EvE, TO, KB, TD); drafting of the manuscript (JTS, EvE, KB); critical revision of the manuscript for important intellectual content (JS, JTS, EvE, TO, KB, TD); statistical analysis (JS, JTS, EvE); provision of patients or study materials (EvE, JS); obtaining funding (TO); administrative, technical, or logistic support (JS, JTS, EvE); and supervision (JS, KB). 

Address Correspondence to: Julia Thornton Snider, PhD, Precision Health Economics, 11100 Santa Monica Blvd, Ste 500, Los Angeles, CA 90025. Email: julia@precisionhealtheconomics.com.
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