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Background: Costs of cancer care can result in patient financial hardship; many professional organizations recommend provider discussions about treatment costs as part of high‐quality care. In this pilot study, the authors examined patient–provider cost discussions documented in the medical records of individuals who were diagnosed with advanced non–small cell lung cancer (NSCLC) and melanoma—cancers with recently approved, high‐cost treatment options. Methods: Individuals who were newly diagnosed in 2017–2018 with stage III/IV NSCLC (n = 1767) and in 2018 with stage III/IV melanoma (n = 689) from 12 Surveillance, Epidemiology, and End Results regions were randomly selected for the National Cancer Institute Patterns of Care Study. Documentation of cost discussions was abstracted from the medical record. The authors examined patient, treatment, and hospital factors associated with cost discussions in multivariable logistic regression analyses. Results: Cost discussions were documented in the medical records of 20.3% of patients with NSCLC and in 24.0% of those with melanoma. In adjusted analyses, privately insured (vs. publicly insured) patients were less likely to have documented cost discussions (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.37–0.80). Patients who did not receive systemic therapy or did not receive any cancer‐directed treatment were less likely to have documented cost discussions than those who did receive systemic therapy (OR, 0.39 [95% CI, 0.19–0.81] and 0.46 [95% CI, 0.30–0.70], respectively), as were patients who were treated at hospitals without residency programs (OR, 0.64; 95% CI, 0.42–0.98). Conclusions: Cost discussions were infrequently documented in the medical records of patients who were diagnosed with advanced NSCLC and melanoma, which may hinder identifying patient needs and tracking outcomes of associated referrals. Efforts to increase cost‐of‐care discussions and relevant referrals, as well as their documentation, are warranted. The authors examined patient–provider cost discussions documented in the medical records of individuals who were diagnosed with advanced non–small cell lung cancer and melanoma—cancers with high‐cost treatment options. Cost discussions were infrequently documented, which may hinder identifying patient cost barriers to care and tracking outcomes of associated referrals. [ABSTRACT FROM AUTHOR]

PURPOSE In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents weremapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areaswith differentHOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer--a leading cause of cancer deaths amenable to early detection and treatment. METHODS Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS). RESULTS There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guidelineconcordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively. CONCLUSION Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes. [ABSTRACT FROM AUTHOR]

PURPOSE: Use of genomic testing, especially multimarker panels, is increasing in the United States. Not all tests and related treatments are covered by health insurance, which can result in substantial patient out-of-pocket (OOP) costs. Little is known about oncologists' treatment decisions with respect to patient insurance coverage and OOP costs for genomic testing. METHODS: We identified 1,049 oncologists who used multimarker tumor panels from the 2017 National Survey of Precision Medicine in Cancer Treatment. Separate multivariable ordinal logistic regressions examined associations of oncologist-, practice-, and area-level characteristics and oncologists' ratings of importance (very, somewhat, or a little/not important) of insurance coverage and OOP costs for genomic testing in treatment decisions, adjusting for oncologist years of experience, sex, race and ethnicity, specialty, use of next-generation sequencing (NGS) tests, region, tumor boards, patient insurance mix, and area-level socioeconomic characteristics. RESULTS: Among oncologists, 47.3%, 32.7%, and 20.0% reported that patient insurance coverage for genomic testing was very, somewhat, or a little/not important, respectively, in treatment decisions. In addition, 56.9%, 28.0%, and 15.2% reported that OOP costs for testing were very, somewhat, or a little/not important, respectively. In adjusted analyses, oncologists who used NGS tests were more likely to report patient insurance and OOP costs as important (odds ratio [OR], 2.00 [95% CI, 1.16 to 3.45] and OR, 2.12 [95% CI, 1.22 to 3.68], respectively) in treatment decisions compared with oncologists who did not use these tests, as were oncologists who treated solid tumors, rather than only hematological cancers. More years of experience and higher percentages of Medicaid or self-paid/uninsured patients in the practice were associated with reporting insurance coverage (OR, 1.43 [95% CI, 1.09 to 1.89]) and OOP costs (OR, 1.51 [95% CI, 1.13 to 2.01]) as important. Oncologists in practices with molecular tumor boards for genomic tests were less likely to report coverage (OR, 0.63 [95% CI, 0.47 to 0.85]) and OOP costs (OR, 0.72 [95% CI, 0.53 to 0.97]) as important than their counterparts in practices without these tumor boards. CONCLUSION: Most oncologists rate patient health insurance and OOP costs for genomic tests as important considerations in subsequent treatment recommendations. Modifiable factors associated with these ratings can inform interventions to support patient-physician decision making about care. Most oncologists rate patient insurance & costs for genomic tests important in treatment recommendations. [ABSTRACT FROM AUTHOR]

PURPOSE Socioeconomic differences are partially responsible for racial inequities in cancer outcomes, yet the association of area-level socioeconomic disadvantage and race with end-of-life (EOL) cancer care quality is poorly understood. METHODS This retrospective study used electronic medical records from an academic health system to identify 33,635 adults with cancer who died between 2013 and 2019. Using multivariable logistic regression, we examined associations between decedent characteristics and EOL care, including emergency department (ED) visits, intensive care unit (ICU) stays, palliative care consultation (PCC), hospice order, and in-hospital deaths. Social deprivation index was used to measure socioeconomic disadvantages. RESULTS Racially minoritized decedents had higher odds of ICU stay than the least deprived White decedents (eg, other race Q3: aOR, 2.06 [99% CI, 1.26 to 0.3.39]). White and Black decedents from more deprived areas had lower odds of ED visit (White Q3: aOR, 0.382 [99% CI, 0.263 to 0.556]; Black Q3: aOR, 0.566 [99% CI, 0.373 to 0.858]) than least deprived White decedents. Compared with White decedents living in least deprived areas, racially minoritized decedents had higher odds of receiving PCC and hospice order, whereas White decedents in most deprived areas had lower odds of PCC (aOR, 0.727 [99% CI, 0.592 to 0.893]) and hospice order (aOR, 0.845 [99% CI, 0.724 to 0.986]). Greater deprivation was associated with greater odds of hospital death relative to least deprived White decedents, but only among minoritized decedents (eg, Black Q4: aOR, 2.16 [99% CI, 1.82 to 2.56]). CONCLUSION Area-level socioeconomic disadvantage is not uniformly associated with poorer EOL cancer care, with differences among decedents of different racial groups. [ABSTRACT FROM AUTHOR]

Despite advances toward universal health insurance coverage for children, coverage gaps remain. Using a nationwide sample of pediatric and adolescent cancer patients from the National Cancer Database, we examined effects of the Affordable Care Act (ACA) implementation in 2014 with multinomial logistic regressions to evaluate insurance changes between 2010-2013 (pre-ACA) and 2014-2017 (post-ACA) in patients aged younger than 18 years (n = 63 377). All statistical tests were 2-sided. Following the ACA, the overall percentage of Medicaid and Children's Health Insurance Program–covered patients increased (from 35.1% to 36.9%; adjusted absolute percentage change [APC] = 2.01 percentage points [ppt], 95% confidence interval [CI] = 1.31 to 2.71; P <.001), partly offset by declined percentage of privately insured (from 62.7% to 61.2%; adjusted APC = −1.67 ppt, 95% CI = −2.37 to −0.97; P <.001), leading to a reduction by 15% in uninsured status (from 2.2% to 1.9%; adjusted APC = −0.34 ppt, 95% CI = −0.56   to −0.12 ppt; P =.003). The largest declines in uninsured status were observed among Hispanic patients (by 23%; adjusted APC = −0.95 ppt, 95% CI = −1.67   to   −0.23 ppt; P =.009) and patients residing in low-income areas (by 35%; adjusted APC = −1.22 ppt, 95% CI = −2.22   to   −0.21 ppt; P =.02). We showed nationwide insurance gains among pediatric and adolescent cancer patients following ACA implementation, with greater gains in racial and ethnic minorities and those living in low-income areas. [ABSTRACT FROM AUTHOR]

Introduction: Health insurance is associated with better care in the U.S., but little is known about the associations of coverage disruptions (i.e., periods without insurance) with care access, receipt, and affordability.Methods: Adults aged 18-64 years with current private (n=124,746), public (n=30,932), or no (n=31,802) insurance coverage were identified from the 2011-2018 National Health Interview Survey. Data were analyzed in 2020. Separate multivariable logistic regressions evaluated the associations of having coverage disruptions or being uninsured with care access, receipt, and affordability.Results: Overall, 5.0% of currently insured adults with private and 10.7% with public insurance reported a coverage disruption in the previous year, representing nearly 9.1 million adults in 2018. Among currently uninsured, 24.9% reported coverage loss within the previous year, representing nearly 8.1 million adults in 2018. Among adults with current private or current public coverage, disruptions were associated with lower receipt of all preventive services (AOR=0.42, 95% CI=0.37, 0.46 and AOR=0.48, 95% CI=0.40, 0.58, respectively), with forgoing any needed care because of cost (AOR=4.79, 95% CI=4.44, 5.17 and AOR=4.28, 95% CI=3.86, 4.75), and with medication nonadherence because of cost (AOR=3.55, 95% CI=3.13, 4.03 and AOR=4.09, 95% CI=3.43, 4.88) compared with that among adults with continuous coverage (p<0.05). Longer disruptions among currently insured adults were significantly associated with worse care access, receipt, and affordability, with dose-response patterns. Currently uninsured adults, especially those with longer uninsured periods, reported significantly worse care access, receipt, and affordability than currently insured adults with coverage disruptions or continuous coverage.Conclusions: Findings highlight the importance of continuous insurance coverage; disruptions owing to the COVID-19 pandemic will likely have adverse consequences for care access and affordability. [ABSTRACT FROM AUTHOR]

Background: Use of genomic testing is increasing in the United States. Testing can be expensive, and not all tests and related treatments are covered by health insurance. Little is known about how often oncologists discuss costs of testing and treatment or about the factors associated with those discussions.Methods: We identified 1220 oncologists who reported discussing genomic testing with their cancer patients from the 2017 National Survey of Precision Medicine in Cancer Treatment. Multivariable polytomous logistic regression analyses were used to assess associations between oncologist and practice characteristics and the frequency of cost discussions. All statistical tests were two-sided.Results: Among oncologists who discussed genomic testing with patients, 50.0% reported often discussing the likely costs of testing and related treatments, 26.3% reported sometimes discussing costs, and 23.7% reported never or rarely discussing costs. In adjusted analyses, oncologists with training in genomic testing or working in practices with electronic medical record alerts for genomic tests were more likely to have cost discussions sometimes (odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.19 to 3.69) or often (OR = 2.22, 95% CI = 1.30 to 3.79), respectively, compared to rarely or never. Other factors statistically significantly associated with more frequent cost discussions included treating solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured.Conclusions: Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of electronic medical record alerts, may help improve cost discussions about genomic testing and related treatments. [ABSTRACT FROM AUTHOR]

Adolescent and young adult cancer survivors—those who were ages 15–39 at their first cancer diagnosis—have important health limitations. These survivors are at risk for higher health care expenditures and lost productivity, compared to adults without a history of cancer. Using Medical Expenditure Panel Survey data, we present nationally representative estimates of the economic burden among people who were diagnosed with cancer in adolescence or young adulthood. Our findings demonstrate that surviving cancer at this age is associated with a substantial economic burden. Compared to adults without a history of cancer, adolescent and young adult cancer survivors had excess annual medical expenditures of $3,170 per person and excess annual productivity losses of $2,250 per person. Multifaceted prevention strategies, including education and sustained intervention programs to ensure access to lifelong risk-based follow-up care, may be effective ways to improve the economic outcomes associated with cancer survivorship in this population. [ABSTRACT FROM AUTHOR]

BACKGROUND: Financial problems caused by cancer and its treatment can substantially affect survivors and their families and create barriers to seeking health care. METHODS: The authors Identified cancer survivors diagnosed as adults (n = 1556) from the nationally representative 2010 National Health Interview Survey. Using multivariable logistic regression analyses, the authors report sociodemo-graphic, clinical, and treatment-related factors associated with perceived cancer-related financial problems and the association between financial problems and forgoing or delaying health care because of cost. Adjusted percentages using the predictive margin-als method are presented. RESULTS: Cancer-related financial problems were reported by 31.8% (95% confidence interval, 29.3%-34.5%) of survivors. Factors found to be significantly associated with cancer-related financial problems in survivors included younger age at diagnosis, minority race/ethniclty, history of chemotherapy or radiation treatment, recurrence or multiple cancers, and shorter time from diagnosis. After adjustment for covariates, respondents who reported financial problems were more likely to report delay-ing (18.3% vs 7.4%) or forgoing overall medical care (13.8% vs 5.0%), prescription medications (14.2% vs 7.6%), dental care (19.8% vs 8.3%), eyeglasses (13.9% vs 5.8%), and mental health care (3.9% vs 1.6%) than their counterparts without financial problems (all PC.05). CONCLUSIONS: Cancer-related financial problems are not only disproportionately represented in survivors who are younger, members of a minority group, and have a higher treatment burden, but may also contribute to survivors forgoing or delaying medical care after cancer. [ABSTRACT FROM AUTHOR]

Purpose: Treatment options in patients with renal cell carcinoma have changed in recent years. However, few studies include detailed information on patient, clinical and health system characteristics in the evaluation of surgical management and the use of systemic therapies in community practice. Materials and Methods: We evaluated surgical management and the use of systemic treatments in a national population based sample of 1,263 patients with renal cell carcinoma newly diagnosed in 2004. Patients were identified from the Surveillance, Epidemiology and End Results Program as part of the Patterns of Care studies. We used descriptive statistics to assess treatment in the entire sample and logistic regression analysis to evaluate the associations between patient demographic, clinical and health system characteristics, and surgery in the subset of 1,032 patients who were potentially eligible for partial or radical nephrectomy and an open or laparoscopic procedure. Results: Surgical treatment in 64.7% of patients (95% CI 60.0%, 69.1%) was radical nephrectomy and most underwent an open rather than a laparoscopic procedure. Although the proportion of all patients receiving systemic treatments was small, 34.3% (95% CI 23.1, 47.5) of those with stage IV disease received systemic treatment. Few patients participated in clinical trials. On multivariate analysis patients who were female, nonwhite, with larger tumors, without comorbid conditions and treated at hospitals without a residency training program were more likely to undergo radical rather than partial nephrectomy (p <0.05). Patients with larger tumors treated at smaller hospitals were more likely to undergo an open rather than a laparoscopic procedure (p <0.05). Conclusions: In 2004 open radical nephrectomy was the most common surgical management for renal cell carcinoma. Few patients received systemic therapy. Patient demographic, clinical and health system characteristics were associated with surgery. Evaluation of the diffusion of surgical management and newer systemic agents, and trial participation in community practice will be important for future research. [Copyright &y& Elsevier]

Although the association between health insurance coverage and access to care is well documented, it is unclear whether the deleterious effects of being uninsured are strictly contemporaneous or whether previous disruptions in coverage have persistent effects. This study addresses this issue using nationally representative data covering 2011–2019 to estimate the extent to which disruptions in health insurance coverage continued to be associated with poor access even after coverage was regained. Analysis was conducted in 2022. Using a nationally representative cohort of insured adults aged 18–64 years (N=39,904) and multivariable logistic regression models, the authors estimated the association between past disruptions in coverage (occurring at least 1 year before) and the risks of lacking a usual source of care provider and having unmet medical need. Among insured nonelderly adults, the risk of being without a usual source of care provider was between 18% (risk ratio=1.18; 95% CI=1.00, 1.38) and 75% higher (risk ratio=1.75; 95% CI=1.56, 1.93) than for those with continuous coverage; the risk of having unmet medical needs was between 41% (risk ratio=1.41; 95% CI=1.00, 1.83) and 66% (risk ratio=1.66; 95% CI=1.26, 2.06) higher. Longer insurance disruptions were associated with a higher risk of lacking a usual source of care provider. Previous disruptions in health insurance coverage continued to be negatively associated with access to care for more than a year after coverage was regained. Improving access to care in the U.S. may require investing in policies and programs that help to strengthen coverage continuity among individuals with insurance coverage rather than focusing exclusively on helping uninsured individuals to gain coverage. [ABSTRACT FROM AUTHOR]

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

Purpose Although patient-provider communication is an essential component of health care delivery, little is known about the quality of these discussions among patients with cancer. Methods Data are from the 2011 Medical Expenditure Panel Survey Experiences with Cancer survey among 1,202 adult cancer survivors. We evaluated discussions with any provider after a cancer diagnosis about: (1) fol low-up care; (2) late or long-term treatment effects; (3) lifestyle recommendations, such as diet, exercise, and quitting smoking; and (4) emotional or social needs. Using a response scale ranging from "did not discuss" to "discussed in detail," a summary score was constructed to define communication quality as high, medium, or low. Patient factors associated with the quality of provider discussions were examined using multivariable polytomous logistic regression analyses. Results At the time of the survey, approximately one half of the patients (46%) were either within 1 year (24.1%) or between 1 and 5 years (22.0%) of treatment. More than one third of cancer survivors reported that they did not receive detailed communication about follow-up care, and more than one half reported that they did not receive detailed communication regarding late or long-term effects, lifestyle recommendations, or emotional and social needs. Only 24% reported high-quality communication for all four elements, indicating that the vast majority experienced suboptimal communication. In multivariable analysis, survivors reporting a high communication quality with providers included those who were within 1 year of treatment, between the ages of 18 and 64 years, non-Hispanic black or other ethnicity, and married. Conclusion Study findings demonstrate gaps in the communication quality experienced by cancer survivors in the United States and help identify survivors for targeted interventions. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Although adult survivors of childhood cancers have poorer health and greater health limitations than other adults, substantial gaps remain in understanding the economic consequences of surviving childhood cancer. Therefore, we estimated the economic burden of productivity losses among adult survivors of childhood cancers. METHODS: We examined health status, functional limitations, and productivity loss among adult survivors of childhood cancers (n = 239] diagnosed at ≤ 14 years of age compared with adults without a history of cancer (n = 304 265] by using the 2004-2014 National Health Interview Survey. We estimated economic burden using the productivity loss from health-related unemployment, missed work days, missed household productivity, and multivariable regression models controlling for age, sex, race/ethnicity, education, comorbidities, and survey year. RESULTS: Childhood cancer survivorship is associated with a substantial economic burden. Adult survivors of childhood cancers are more likely to be in poorer health, need assistance with personal care and routine needs, have work limitations, be unable to work because of health, miss more days of work, and have greater household productivity loss compared with adults without a history of cancer (all P < .05]. The annual productivity loss for adult survivors of childhood cancer is $8169 per person compared with $3083 per person for individuals without a history of cancer. CONCLUSIONS: These findings underscore the importance of efforts to reduce the health and economic burden among adult survivors of childhood cancer. In addition, this study highlights the potential productivity losses that could be avoided during adulthood from the prevention of childhood cancer in the United States. [ABSTRACT FROM AUTHOR]

Abstract: Context: Estimation of six-month prognosis is essential in hospice referral decisions, but accurate, evidence-based tools to assist in this task are lacking. Objectives: To develop a new prognostic model, the Patient-Reported Outcome Mortality Prediction Tool (PROMPT), for six-month mortality in community-dwelling elderly patients. Methods: We used data from the Medicare Health Outcomes Survey linked to vital status information. Respondents were 65 years old or older, with self-reported declining health over the past year (n =21,870), identified from four Medicare Health Outcomes Survey cohorts (1998–2000, 1999–2001, 2000–2002, and 2001–2003). A logistic regression model was derived to predict six-month mortality, using sociodemographic characteristics, comorbidities, and health-related quality of life (HRQOL), ascertained by measures of activities of daily living and the Medical Outcomes Study Short Form-36 Health Survey; k-fold cross-validation was used to evaluate model performance, which was compared with existing prognostic tools. Results: The PROMPT incorporated 11 variables, including four HRQOL domains: general health perceptions, activities of daily living, social functioning, and energy/fatigue. The model demonstrated good discrimination (c-statistic=0.75) and calibration. Overall diagnostic accuracy was superior to existing tools. At cut points of 10%–70%, estimated six-month mortality risk sensitivity and specificity ranged from 0.8% to 83.4% and 51.1% to 99.9%, respectively, and positive likelihood ratios at all mortality risk cut points ≥40% exceeded 5.0. Corresponding positive and negative predictive values were 23.1%–64.1% and 85.3%–94.5%. Over 50% of patients with estimated six-month mortality risk ≥30% died within 12 months. Conclusion: The PROMPT, a new prognostic model incorporating HRQOL, demonstrates promising performance and potential value for hospice referral decisions. More work is needed to evaluate the model. [Copyright &y& Elsevier]