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CONTEXT Provider-based human papillomavirus (HPV) vaccine promotion interventions have been widely implemented; however, the effectiveness of these approaches is unclear. OBJECTIVES This systematic review assessed the effects and costs of provider-based interventions designed to increase HPV vaccination coverage. A meta-analysis was conducted to estimate pooled effect sizes of the interventions. DATA SOURCES We searched PubMed, Medline, Embase, and the Cochrane Library. STUDY SELECTION We identified articles on provider-based HPV vaccine promotion interventions published in English between 2007 and 2021. DATA EXTRACTION Information about the interventions’ effects and costs was extracted from the studies. A meta-analysis was performed to estimate the pooled intervention effects, including changes in the HPV vaccine initiation rate, HPV vaccine completion rate, and the percentage of patients receiving the next needed dose. RESULTS We identified 32 studies of provider-based interventions to improve the HPV vaccination rate. The reported intervention strategies included provider training, provider reminders, and provider assessment and feedback. In the meta-analysis, we found significant improvements in the HPV vaccine initiation rate (3.7%) and the percentage of patients receiving the next needed dose (9.4%). LIMITATIONS Because of the limited number of studies, we were unable to compare the same outcomes between different provider-based approaches. We found the high heterogeneity across studies. The random effects method was applied to adjust for study heterogeneity, the heterogeneity remined high for certain outcomes. CONCLUSIONS Provider-based interventions were effective in improving HPV vaccination rates. Sustainability and continuous implementation are the central factors that contributed to intervention success.

Supplemental Figure S1 presents the study flow chart.

Screening for colorectal cancer is cost-effective, but many U.S. women are nonadherent, and the cost-effectiveness of web-based tailored screening interventions is unknown. A randomized controlled trial, COBRA (Increasing Colorectal and Breast Cancer Screening), was the source of information for the economic evaluation. COBRA compared screening among a Usual Care group to: (i) tailored Phone Counseling intervention; (ii) tailored Web intervention; and (iii) tailored Web + Phone intervention groups. A sample of 1,196 women aged 50 to 75 who were nonadherent to colorectal cancer screening were recruited from Indiana primary care clinics during 2013 to 2015. Screening status was obtained through medical records at recruitment with verbal confirmation at consent, and at 6-month follow-up via medical record audit and participant self-report. A "best sample" analysis and microcosting from the patient and provider perspectives were applied to estimate the costs and effects of the interventions. Statistical uncertainty was analyzed with nonparametric bootstrapping and net benefit regression analysis. The per participant cost of implementing the Phone Counseling, Web-based, and Web + Phone Counseling interventions was $277, $314, and $336, respectively. The incremental cost per person screened for the Phone Counseling compared with no intervention was $995, while the additional cost of Web and the Web + Phone compared with Phone Counseling did not yield additonal persons screened. Tailored Phone Counseling significantly increased colorectal cancer screening rates compared with Usual Care. Tailored Web interventions did not improve the screening rate compared with the lower cost Phone Counseling intervention.

Supplementary figure S1 shows cost and effect differences between Usual Care and Phone groups.

Supplemental Table S2 presents the results of sensitivity analyses for the number of screening tests completed based on ITT model adjusted base case estimates.

Supplemental text S1 and S2 provides explanatory texts to help non-cost-effectiveness expert to fully understand the scatterplots derived from non-parametric bootstrapping and Cost-Effectiveness Acceptability Curves.

Screening for colorectal and breast cancer is considered cost effective, but limited evidence exists on cost-effectiveness of screening promotion interventions that simultaneously target both cancers. Increasing Colorectal and Breast Cancer Screening (Project COBRA), a randomized controlled trial conducted in the community, examined the cost-effectiveness of an innovative tailored web-based intervention compared with tailored telephone counseling and usual care. Screening status at 6 months was obtained by participant surveys plus medical record reviews. Cost was prospectively measured from the patient and provider perspectives using time logs and project invoices. Relative efficiency of the interventions was quantified by the incremental cost-effectiveness ratios. Nonparametric bootstrapping and net benefit regression analysis were used to assess statistical uncertainty of the results. The average cost per participant to implement the Phone counseling, Web-based, and Web + Phone counseling interventions were $277, $314, and $337, respectively. Comparing Phone counseling with usual care resulted in an additional cost of $300 (95% confidence interval [CI]: $283–$320) per cancer screening test and $421 (95% CI: $400–$441) per additional person screened in the target population. Phone counseling alone was more cost-effective than the Web + Phone intervention. Web-based intervention alone was more costly but less effective than the Phone counseling. When simultaneously promoting screening for both colorectal and breast cancer the Web-based intervention was less cost-effective compared with Phone and Web + Phone strategies. The results suggest that targeting multiple cancer screening may improve the cost-effectiveness of cancer screening interventions.Prevention Relevance:This study informs researchers, decision makers, healthcare providers, and payers about the improved cost-effectiveness of targeting multiple cancer screenings for cancer early detection programs.

Supplementary table S1 shows the total and per person costs by activity.

Supplemental Figure S3 and S4 present the statistical uncertainty of the results comparing Web + Phone to Phone intervention. Supplemental Figure S3 presents 1000 simulated replicates of the cost and effect differences between Web + Phone and Phone intervention from primary ITT analysis using model adjusted estimates. Supplemental Figure S4 presents the probability of Web + Phone intervention being cost-effective compared to Phone intervention varied by willingness-to-pay threshold.

Patient selection flowchart

Propensity score distribution between case and control group

Background: The incidence of oropharyngeal cancer is rising rapidly, with the majority of cases being attributable to human papillomavirus (HPV). Despite the availability of a vaccine, rates of HPV vaccination among Texas youth are low. The healthcare cost of oropharyngeal cancer in Texas is unknown. The aims of this study were to estimate the first 2-year cost of treating new cases of oropharyngeal cancer and determine the predictors of oropharyngeal cancer treatment cost in Texas.Methods: This study included a retrospective cohort of 467 Texas patients with commercial insurance claims data with oropharyngeal cancer diagnosed from 2011 to 2014 and a control group of 467 noncancer patients obtained with propensity score matching. Total healthcare cost during the first 2 years after the index date was measured. A generalized linear model was used to identify predictors of monthly cost during the 2 years after the index date.Results: The mean differential adjusted healthcare cost for oropharyngeal cancer cases was $139,749 in the first 2 years. The mean adjusted monthly cost in the first 2 years was $6,693 for cases and $870 for controls. Age, comorbidity, mental health, prediagnostic healthcare cost, and time index were significant predictors of monthly cost.Conclusions: Medical care cost was about $140,000 in the first 2 years after diagnosis of oropharyngeal cancer among commercially insured patients in Texas.Impact: The cost estimates provide important parameters for development of decision-analytic models to inform decision makers about the potential value of initiatives for increasing the HPV immunization rate in the state. Cancer Epidemiol Biomarkers Prev; 26(9); 1443–9. ©2017 AACR.

Supplemental Figure Legends; Supplemental Table 1. Three-digit zip codes for Texas regions; Supplemental Table 2. Procedure codes for identifying OPC treatment modalities; Supplemental Table 3. Summary of the time (days) to initiation of the first modality of therapy during the 2-year follow-up; Supplemental Table 4. Generalized linear model with log link function for the mean monthly cost for the first 2 years after the index date between cases and controls; Supplemental Table 5. Unadjusted and adjusted cost during the first 1 year after the index date for OPC patients and matched controls

The adjusted 2-year cost distributions between case and controls

The unadjusted cost of pre- and post-period between cases and controls

Background: Home-based self-sampling for human papillomavirus (HPV) testing may be an alternative for women not attending clinic-based cervical cancer screening. Methods: We assessed barriers to care and motivators to use at-home HPV self-sampling kits during the COVID-19 pandemic as part of a randomized controlled trial evaluating kit effectiveness. Participants were women aged 30-65 and under-screened for cervical cancer in a safety-net healthcare system. We conducted telephone surveys in English/Spanish among a subgroup of trial participants, assessed differences between groups, and determined statistical significance at pResults: Over half of 233 survey participants reported that clinic-based screening (Pap) is uncomfortable (67.8%), embarrassing (52.4%), and discomfort seeing male providers (63.1%). The last two factors were significantly more prevalent among Spanish versus English speakers (66.4% vs. 30% (p=0.000) and 69.9 vs. 52.2% (p=0.006), respectively). Most women who completed the kit found Pap more embarrassing (69.3%), stressful (55.6%), and less convenient (55.6%) than the kit. The first factor was more prevalent among Spanish versus English speakers (79.6% vs. 53.38%, p=0.001) and among patients with elementary education or below. Conclusions: The COVID-19 pandemic influenced most (59.5%) to participate in the trial due to fear of COVID, difficulty making appointments, and ease of using kits. HPV self-sampling kits may reduce barriers among under-screened women in a safety-net system. Funding: This study is supported by a grant from the National Institute for Minority Health and Health Disparities (NIMHD, R01MD013715, PI: JR Montealegre). Clinical trial number: NCT03898167.

ObjectivesTo compare cancer centre (CC) executives’ attitudes towards palliative care between National Cancer Institute-designated CCs (NCI-CCs) and non-NCI-designated CCs (non-NCI-CCs) in 2018 and to examine the changes in attitudes and beliefs between 2009 and 2018.MethodsCC chief executives at all NCI-CCs and a random sample of non-NCI-CCs were surveyed from April to August 2018. Twelve questions examined the executives’ attitudes towards palliative care integration, perceived barriers and self-assessments. The primary outcome was agreement on the statement ‘a stronger integration of palliative care services into oncology practice will benefit patients at my institution.’ Survey findings from 2018 were compared with data from 2009 to examine changes in attitudes.Results52 of 77 (68%) NCI-CCs and 88 of 126 (70%) non-NCI-CCs responded to the survey. A vast majority of executives at NCI-CCs and non-NCI-CCs endorsed palliative care integration (89.7% vs 90.0%; p>0.999). NCI-CCs were more likely to endorse increasing funding for palliative care (52.5% vs 23.1%; p=0.01) and hiring physician specialists (70.0% vs 37.5%; p=0.004) than non-NCI-CCs. The top three perceived barriers among NCI-CCs and non-NCI-CCs were limited institutional budgets (57.9% vs 59.0%; p=0.92), poor reimbursements (55.3% vs 43.6%; p=0.31), and lack of adequately trained palliative care physicians and nurses (52.6% vs 43.6%; p=0.43). Both NCI-CCs and non-NCI-CCs favourably rated their palliative care services (89.7% vs 71.8%; p=0.04) with no major changes since 2009.ConclusionCC executives endorse integration of palliative care, with greater willingness to invest in palliative care among NCI-CCs. Resource limitation continues to be a major barrier.

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.

Screening for colorectal cancer is cost-effective, but many U.S. women are nonadherent, and the cost-effectiveness of web-based tailored screening interventions is unknown. A randomized controlled trial, COBRA (Increasing Colorectal and Breast Cancer Screening), was the source of information for the economic evaluation. COBRA compared screening among a Usual Care group to: (i) tailored Phone Counseling intervention; (ii) tailored Web intervention; and (iii) tailored Web + Phone intervention groups. A sample of 1,196 women aged 50 to 75 who were nonadherent to colorectal cancer screening were recruited from Indiana primary care clinics during 2013 to 2015. Screening status was obtained through medical records at recruitment with verbal confirmation at consent, and at 6-month follow-up via medical record audit and participant self-report. A "best sample" analysis and microcosting from the patient and provider perspectives were applied to estimate the costs and effects of the interventions. Statistical uncertainty was analyzed with nonparametric bootstrapping and net benefit regression analysis. The per participant cost of implementing the Phone Counseling, Web-based, and Web + Phone Counseling interventions was $277, $314, and $336, respectively. The incremental cost per person screened for the Phone Counseling compared with no intervention was $995, while the additional cost of Web and the Web + Phone compared with Phone Counseling did not yield additonal persons screened. Tailored Phone Counseling significantly increased colorectal cancer screening rates compared with Usual Care. Tailored Web interventions did not improve the screening rate compared with the lower cost Phone Counseling intervention.

Oropharyngeal cancer (OPC) incidence is rising among men in the US. Comprehensive assessments of nationwide trends in OPC incidence and mortality by demographics, tumor characteristics at diagnosis, and geography are lacking.We examined secular trends in OPC incidence and mortality rates in all 50 US states and the District of Columbia (DC).In this cross-sectional study, we used the US Cancer Statistics data set to examine OPC incidence trends from 2001 through 2017. Observed and incidence-based mortality trends were evaluated using data from the National Center for Health Statistics and Surveillance Epidemiology and End Results program, respectively. Data analysis was conducted from January to April 2021.Nationwide, 260 182 OPC cases were identified; 209 297 (80%) occurred in men, 168 674 (65%) with regional stage, and 142 068 (55%) in the Southeast and Midwest regions, during 2001 to 2017. Incidence of OPC increased nationally 2.7% per year among men, with a notable (over 3% per year) rise among non-Hispanic White men and in men aged 65 years and older. Overall, among women, the annual percentage change was 0.5% (95% CI, -0.28% to 1.22%). Among men, with a 3.1% per year rise (95% CI, 2.4% to 3.8%), regional-stage OPC incidence increased nearly 2-fold. Among women, regional-stage OPC incidence increased 1.0% per year (95% CI, 0.3% to 1.7%). Among men, OPC incidence increased in all states and regions except Alaska, DC, and Wyoming. Among men, the most pronounced increases (more than 3.5% per year) were clustered in the Southeast and Midwest regions. Among women, a rise of more than 2% per year was also concentrated in the Southeast and Midwest regions. Among men, OPC incidence-based mortality increased 2.1% per year (95% CI, 1.0% to 3.2%) overall in recent years (from 2006 to 2017). In contrast, among women, the annual percentage change in OPC incidence-based mortality was -1.2% (95% CI, -2.5% to 0.1%).The findings of this cross-sectional study suggest that the incidence of OPC has continued to increase nationally among men in the US, with rapid increases among the elderly population. The notable rise in regional-stage OPC and the concurrent recent rise in mortality among men is troubling and calls for urgent improvements in prevention. Distinct geographic patterns with notable rises in the Midwest and Southeast regions imply the need for improved and targeted prevention as well as future studies to understand etiological reasons for geographic disparities.

Importance In the US, safety concern has been identified as a primary barrier to initiating the human papillomavirus (HPV) vaccine. It is unclear if the public's sentiment concerning HPV vaccine safety aligns with postmarketing vaccine safety surveillance data. Objective To perform a parallel assessment of trends in HPV vaccine safety concerns and HPV vaccine adverse event (AE) reporting. Design, Setting, and Participants This study was a cross-sectional analysis of the National Immunization Survey (NIS) and Vaccine Adverse Event Reporting System (VAERS). Participants in the NIS were adolescents aged 13 to 17 years. AEs were reported to VAERS by patients, health care clinicians, or other sources. Statistical analysis was performed from October 2020 to May 2021. Main Outcomes and Measures Secular trends in HPV vaccine safety concerns and spontaneous AE reporting for HPV vaccination from 2015 to 2018. Results Caregivers of 39 364 unvaccinated adolescents with a mean (SD) age of 15.57 (0.08) years (26 996 White adolescents [62.9%], 22 707 male adolescents [56.1%], 11 392 privately insured [62.6%], and 32 674 above the poverty level [79.3%]) reported their reasons for not initiating the HPV vaccine series in the 2015-2018 NIS. Citing safety concerns as the primary reason for not initiating the HPV vaccine series increased from 13.0% (95% CI, 12.1%-14.0%) in 2015 to 23.4% (95% CI, 21.8%-25.0%) in 2018 (P for trend

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.

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.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.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.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.

OBJECTIVE: To describe disparities in patterns of hospice use and end-of-life costs among ovarian cancer patients. METHODS: Using Texas Cancer Registry-Medicare data, ovarian cancer patients deceased 2005–2012 with >12 months of continuous Medicare coverage before death were included. Descriptive statistics and multivariable logistic regressions were used to evaluate patterns of hospice use. Cost and resource utilization was obtained from Medicare claims and analyzed using a non-parametric Mann-Whitney test. RESULTS: 2,331 patients were assessed: 1,788 (77%) white, 359 (15%) Hispanic, 158 (7%) black and 26 (1%) other. 1,756 (75%) enrolled in hospice prior to death but only 1,580 (68%) died with hospice. 176 (10%) of 1756 patients unenrolled and died without hospice. 346 (20%) unenrolled from hospice multiple times. From 2008–2012, patients were less likely to unenroll from hospice prior to death. Black patients were more likely to unenroll from hospice prior to death (OR 2.07 [1.15–3.73]; p=0.02) compared to white patients. The median amount paid by Medicare during the last six months of life was $38,530 for those in hospice compared to $49,942 if never enrolled in hospice (p

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

Background: Colorectal cancer mortality could be decreased with risk-appropriate cancer screening. We examined the efficacy of three tailored interventions compared with usual care for increasing screening adherence. Methods: Women (n = 1,196) ages 51 to 74, from primary care networks and nonadherent to colorectal cancer guidelines, were randomized to (1) usual care, (2) tailored Web intervention, (3) tailored phone intervention, or (4) tailored Web + phone intervention. Average-risk women could select either stool test or colonoscopy, whereas women considered at higher than average risk received an intervention that supported colonoscopy. Outcome data were collected at 6 months by self-report, followed by medical record confirmation (attrition of 23%). Stage of change for colorectal cancer screening (precontemplation or contemplation) was assessed at baseline and 6 months. Results: The phone (41.7%, P < 0.0001) and combined Web + phone (35.8%, P < 0.001) interventions significantly increased colorectal cancer screening by stool test compared with usual care (11.1%), with ORs ranging from 5.4 to 6.8 in models adjusted for covariates. Colonoscopy completion did not differ between groups except that phone significantly increased colonoscopy completion compared with usual care for participants in the highest tertile of self-reported fear of cancer. Conclusions: A tailored phone with or without a Web component significantly increased colorectal cancer screening compared with usual care, primarily through stool testing, and phone significantly increased colonoscopy compared with usual care but only among those with the highest levels of baseline fear. Impact: This study supports tailored phone counseling with or without a Web program for increasing colorectal cancer screening in average-risk women.

Screening for colorectal and breast cancer is considered cost effective, but limited evidence exists on cost-effectiveness of screening promotion interventions that simultaneously target both cancers. Increasing Colorectal and Breast Cancer Screening (Project COBRA), a randomized controlled trial conducted in the community, examined the cost-effectiveness of an innovative tailored web-based intervention compared with tailored telephone counseling and usual care. Screening status at 6 months was obtained by participant surveys plus medical record reviews. Cost was prospectively measured from the patient and provider perspectives using time logs and project invoices. Relative efficiency of the interventions was quantified by the incremental cost-effectiveness ratios. Nonparametric bootstrapping and net benefit regression analysis were used to assess statistical uncertainty of the results. The average cost per participant to implement the Phone counseling, Web-based, and Web + Phone counseling interventions were $277, $314, and $337, respectively. Comparing Phone counseling with usual care resulted in an additional cost of $300 (95% confidence interval [CI]: $283–$320) per cancer screening test and $421 (95% CI: $400–$441) per additional person screened in the target population. Phone counseling alone was more cost-effective than the Web + Phone intervention. Web-based intervention alone was more costly but less effective than the Phone counseling. When simultaneously promoting screening for both colorectal and breast cancer the Web-based intervention was less cost-effective compared with Phone and Web + Phone strategies. The results suggest that targeting multiple cancer screening may improve the cost-effectiveness of cancer screening interventions. Prevention Relevance: This study informs researchers, decision makers, healthcare providers, and payers about the improved cost-effectiveness of targeting multiple cancer screenings for cancer early detection programs.

INTRODUCTION: HPV vaccination is both a clinically and cost-effective way to prevent HPV-related cancers. Increased focus on preventing HPV infection and HPV-related cancers has motivated development of strategies to increase adolescent vaccination rates. This analysis estimates the average cost associated with implementing programs aimed at increasing HPV vaccination from the perspective of the clinic decision makers. As providers and healthcare organizations consider vaccination initiatives, it is important for them to understand the costs associated with implementing these programs. METHODS: Healthcare provider assessment and feedback, reminders, and education; and parent education/reminder strategies were implemented in a large pediatric clinic network between October 2015 and February 2018 to improve HPV vaccination rates. A micro-costing method was used in 2018 to prospectively estimate program implementation costs with the clinic as the unit of analysis. A sensitivity analysis assessed the effects of variability in levels of participation. RESULTS: Assessment and feedback reports and provider education were implemented among 51 clinics at average per clinic cost of $786 and $368 respectively. Electronic vaccination reminders were delivered to providers and parents at a per clinic cost of $824. The parent education implementation cost was $2,126 per clinic. CONCLUSION: The four complimentary HPV evidence-based strategies were delivered at a total cost of $157,534 or $4,749 per clinic, including staff training and participant recruitment, reaching 155,000 HPV vaccine eligible adolescents.

The sudden onset of the coronavirus (SARS-CoV-2) pandemic has resulted in tremendous loss of human life and economy in more than 210 countries and territories around the world. While self-protections such as wearing mask, sheltering in place and quarantine polices and strategies are necessary for containing virus transmission, tens of millions people in the U.S. have lost their jobs due to the shutdown of businesses. Therefore, how to reopen the economy safely while the virus is still circulating in population has become a problem of significant concern and importance to elected leaders and business executives. In this study, mathematical modeling is employed to quantify the profit generation and the infection risk simultaneously from the point of view of a business entity. Specifically, an ordinary differential equation model was developed to characterize disease transmission and infection risk. An algebraic equation is proposed to determine the net profit that a business entity can generate after reopening and take into account the costs associated of several protection/quarantine guidelines. All model parameters were calibrated based on various data and information sources. Sensitivity analyses and case studies were performed to illustrate the use of the model in practice., Comment: 15 pages, 15 figures, 2 tables

Summary Background Human papillomavirus (HPV) vaccine uptake among US adolescents is primarily dependent on the intent of their parents. To the best of our knowledge, an analysis quantifying parental intent to initiate and complete the HPV vaccine series in the USA at both the national and state level has not been done. We aim to estimate parental intent to initiate and complete the HPV vaccine series at the national-level and state-level and to identify reasons for lack of intent to initiate and complete the vaccine series. Methods This cross-sectional study uses data from the adolescent component of the 2017–18 National Immunization Survey (NIS-Teen). Study participants were parents or caregivers of US adolescents aged 13–17 years, who were most knowledgeable about the immunisation status of the adolescents. The primary outcome was parental intent to vaccinate the adolescent in the next 12 months. The secondary outcomes were (1) the prevalence of reasons given for lack of intent to initiate and complete the HPV vaccine series, and (2) the relationship between receiving a recommendation from a health-care provider to vaccinate and intent to initiate the vaccination series. We computed national-level and state-level estimates for parental lack of intent to initiate and to complete the vaccine series; population-level estimates were derived using survey weights. A survey design-adjusted Wald F test was used for bivariate analysis. A multivariate logistic regression model was used to examine the association between health-care provider recommendation and parental intent to initiate the series. Analyses were stratified by history of health-care provider recommendation to initiate the HPV vaccine series. Findings In 2017–18, the parent or caregiver of 82 297 US adolescents aged 13–17 years completed the NIS-Teen survey. 30 558 (37·1%) were unvaccinated and 9073 (10·8%) received only one HPV vaccine dose. Parents of 58·0% (17 171/29 086) of unvaccinated adolescents with data available on parental intent had no intention to initiate the HPV vaccine series. More than 65% of parents of unvaccinated adolescents in Idaho, Kansas, Michigan, Montana, Nebraska, North Dakota, Oklahoma, and Utah had no intention to initiate the HPV vaccine series. Parents of 23·5% (2166/9072) of initiators with data available on parental intent had no intention to complete the HPV vaccine series. More than 30% of parents in Arkansas, Florida, Georgia, Hawaii, Idaho, Utah, and West Virginia did not intend to complete the HPV vaccine series, whereas in the District of Columbia (11·2% [22/166]) and Rhode Island (20·4% [21/112]) parental lack of intent was relatively low (both regions have an HPV vaccine mandate). The most common reason for lack of intent among parents to initiate the vaccine for unvaccinated adolescents was safety concerns (22·8% [4182/16 455]); lack of a recommendation from a health-care provider (22·2% [440/1944]) was the most frequently cited reason for absence of intent to complete the series among parents of adolescents who received only one HPV vaccine dose. Receipt of a recommendation from a health-care provider was associated with greater odds of parental intent to initiate the HPV vaccine series (odds ratio 1·11, 95% CI 1·01–1·22). 45·5% (13 156/29 086) of parents of unvaccinated adolescents had reportedly received an HPV vaccine recommendation. Parents of 60·6% (7938/13 156) of unvaccinated adolescents with a recommendation from a health-care provider and data available on parental intent had no intention to initiate the series. Interpretation Lack of parental intent to initiate and complete the HPV vaccine series for adolescents is a major public health concern in the USA. Combating vaccine safety concerns and strong recommendations from health-care providers could improve the currently suboptimal HPV vaccination coverage. Funding US National Cancer Institute.

Study objective To examine the risks and compare the occurrences of major long-term side effects (sexual dysfunction, bone fractures, diabetes, cardiovascular morbidity, acute myocardial infarction [MI], and dementia) in patients with prostate cancer who received androgen-deprivation therapy (ADT) with those who did not. Design Propensity score-matched retrospective cohort study using Medicare claims data. Data source National Cancer Institute's Surveillance, Epidemiology, and End Results Program-Medicare linked database. Patients A total of 201,797 patients 66 years or older who were diagnosed with any stage of prostate cancer between 1992 and 2009; of these, 94,528 patients received ADT; 107,269 patients did not. Measurements and main results We identified receipt of ADT and number of claims for ADT, and ascertained the long-term treatment-related side effects that occurred during 19 years of follow-up, from 1992-2010, from Medicare claims data. Cox proportional hazards models were used to estimate the incidences and hazard ratios (HRs) of newly developed side effects. Among all potential long-term side effects, the risk of bone fractures was highest (HR 1.39, 95% confidence interval [CI] 1.35-1.43), followed by diabetes (HR 1.21, 95% CI 1.18-1.24), dementia (HR 1.16, 95% CI 1.13-1.20), coronary heart disease (HR 1.12, 95% CI 1.09-1.14), and acute MI (HR 1.11, 95% CI 1.08-1.15) in those who received ADT compared with those who did not. The HRs for bone fractures and diabetes increased steadily as the number of ADT doses increased, indicating a linear trend in the dose-response relationship. Compared with patients who received active surveillance, ADT was associated with a 12% increased risk of sexual dysfunction (HR 1.12, 95% CI 1.05-1.20). The HR for sexual dysfunction increased to 1.68 (95% CI 1.59-1.77) when ADT was combined with radiation therapy and to 3.54 (95% CI 3.26-3.85) when ADT was combined with radiation and surgery. Conclusion The results of this study demonstrated that in men with prostate cancer, receipt of ADT was associated with higher risks of bone fractures, diabetes, dementia, coronary heart disease, acute MI, and sexual dysfunction than in those who did not receive ADT.

Objective A comparative assessment of treatment alternatives for T1N0 anal canal cancer has never been conducted. We compared the outcomes associated with the treatment alternatives-chemoradiotherapy (CRT), radiotherapy (RT), and surgery or ablation techniques (surgery/ablation)-for T1N0 anal canal cancer. Materials and methods This retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results (SEER) registries linked with Medicare longitudinal data (SEER-Medicare database). Analysis included 190 patients who were treated for T1N0 anal canal cancer using surgery/ablation (n=44), RT (n=50), or CRT (n=96). The outcomes were reported in terms of survival and hazards ratios using Kaplan-Meier and Cox proportional hazards modeling, respectively; lifetime costs; and cost-effectiveness measured in terms of incremental cost-effectiveness ratio, that is, the ratio of the difference in costs between the 2 alternatives to the difference in effectiveness between the same 2 alternatives. Results There was no significant difference in the survival duration between the treatment groups as predicted by the Kaplan-Meier curves. After adjusting for patient characteristics and propensity score, the hazard ratio of death for the patients who received CRT compared with surgery/ablation was 1.742 (95% confidence interval, 0.793-3.829) and RT was 2.170 (95% confidence interval, 0.923-5.101); however, the relationship did not reach statistical significance. Surgery/ablation resulted in lower lifetime cost than RT or CRT. The incremental cost-effectiveness ratio associated with CRT compared with surgery/ablation was $142,883 per life year gained. Conclusions There was no statistically significant difference in survival among the treatment alternatives for T1N0 anal canal cancer. Given that surgery/ablation costs less than RT or CRT and might be cost-effective compared with RT and CRT, it is crucial to explore this finding further in this era of limited health care resources.

Objective To determine the lifetime and phase-specific cost of anal cancer management and the economic burden of anal cancer care in elderly (66 y and older) patients in the United States. Patients and methods For this study, we used Surveillance Epidemiology and End Results-Medicare linked database (1992 to 2009). We matched newly diagnosed anal cancer patients (by age and sex) to noncancer controls. We estimated survival time from the date of diagnosis until death. Lifetime and average annual cost by stage and age at diagnosis were estimated by combining survival data with Medicare claims. The average lifetime cost, proportion of patients who were elderly, and the number of incident cases were used to estimate the economic burden. Results The average lifetime cost for patients with anal cancer was US$50,150 (N=2227) (2014 US dollars). The average annual cost in men and women was US$8025 and US$5124, respectively. The overall survival after the diagnosis of cancer was 8.42 years. As the age and stage at diagnosis increased, so did the cost of cancer-related care. The anal cancer-related lifetime economic burden in Medicare patients in the United States was US$112 million. Conclusions Although the prevalence of anal cancer among the elderly in the United States is small, its economic burden is considerable.

Background Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality. Objectives To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1. Methods Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step. Results After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%). Conclusions In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.

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 P < 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.

Rationale Mobile stroke units speed treatment for acute ischemic stroke, thereby possibly improving outcomes. Aim To compare mobile stroke unit and standard management clinical outcomes, healthcare utilization, and cost-effectiveness in tissue plasminogen activator-eligible acute ischemic stroke patients calling 911. Sample size 693. Eighty percent power with 0.05 type I error rate to detect a difference of 0.09 in mean utility-weighted modified Rankin scale between groups. Design Phase III, multicenter, prospective cluster-randomized (mobile stroke unit versus standard management weeks) comparative effectiveness study in tissue plasminogen activator-eligible patients. Outcomes Primary: Ninety-day mean utility-weighted modified Rankin scale. Coprimary: cost-effectiveness based on EQ5D quality of life and one year poststroke costs. Analysis Two-sample t-test and linear regression adjusting for covariates; incremental cost-effectiveness ratio and net benefit regression. Results As of March 2017, 288 tissue plasminogen activator-eligible patients have been enrolled (173 in the mobile stroke unit arm and 115 in the standard management arm). Two new centers start in early 2017 with target end of recruitment September 2019. Conclusion This is the first randomized study to test for disability, healthcare utilization, and cost-effectiveness of a mobile stroke unit. The progress of the study suggests that it is feasible. Management of tissue plasminogen activator eligible acute ischemic stroke patients by a mobile stroke unit could potentially result in less disability and healthcare utilization, and be cost effective. Mobile stroke units are very costly. This trial may determine if the fixed cost can be justified by a reduction in disability and healthcare utilization. Clinical Trial Registration NCT02190500.

Regular screening is considered the most effective method to reduce the mortality and morbidity associated with breast cancer. Nevertheless, contradictory evidence about screening mammograms has led to periodic changes and considerable variations among different screening guidelines. This study is the first to examine the immediate impact of the 2009 US Preventive Services Task Force (USPSTF) guideline modification on physician recommendation of mammograms. The study included visits by women aged 40 years and older without prior breast cancer from the National Ambulatory and Medical Care Survey 2008-2010. Bivariate and multiple logistic regressions were used to determine the factors associated with mammography recommendation. Approximately 29,395 visits were included and mammography was recommended during 1350 visits; 50-64-year-old women had 72% higher odds, and 65-74-year-old women had twice the odds of getting a mammogram recommendation compared with 40-49-year-old women in 2009. However, there was no difference in recommendation by age groups in 2008 and 2010. Obstetricians and gynecologists did not modify their recommendation behavior in 2009, unlike all other specialists who reduced their recommendation for 40-49-year-old women in 2009. Other characteristics associated with mammogram recommendations were certain patient comorbidities, physician specialty and primary care physician status, health maintenance organization status of the clinic, and certain visit characteristics. This study demonstrated a temporary effect of the USPSTF screening guideline change on mammogram recommendation. However, in light of conflicting recommendations by different guidelines, the physicians erred toward the more rigorous guidelines and did not permanently reduce their mammogram recommendation for women aged 40-49 years.

Objective To determine the mean cervical cancer medical care costs for patients enrolled in commercial insurance in Texas. Cost is represented by insurer and patient payments for care. Methods We estimated the mean medical care costs during the first 2years after the index diagnosis date for patients with cervical cancer (cases). Cases were identified using claims-based International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9), diagnosis codes and matched to controls without a claims-based ICD-9 code for cancer using a 2-step propensity score matching method. Index dates for the cases were randomly assigned to potential controls, and cases and controls were matched by index date. Data for cancer cases and controls were obtained from the de-identified 2011–2014 U.S. MarketScan databases. A generalized linear model was employed to compute the cost for censored months during the 2-year follow-up period. Differential costs were assessed by subtracting the medical costs incurred by controls from those incurred by cases. Results During 2011–2014, 475 commercially insured Texas patients with newly diagnosed cervical cancer met the inclusion criteria. The first-year and second-year mean medical costs were $60,828 and $37,721 for cases and $9982 and $10,066 for controls, respectively. The differential costs of cervical cancer for the first and second years were $50,846 and $27,656, respectively. The major correlates of higher monthly cervical cancer costs were higher Charlson Comorbidity Index score during 6months period prior to diagnosis, higher healthcare costs between 6months and 3months prior to diagnosis, and residence in the western region of Texas. Costs for cervical cancer patients decreased steeply between month 1 and month 5 after diagnosis and then were stable, while costs for the control group were stable throughout the follow-up period. Conclusions Mean direct medical costs associated with cervical cancer in Texas were substantial. These data will serve as key cost parameters in models of costs associated with human papillomavirus (HPV)-related cancers in Texas and the economic evaluation of HPV vaccination dissemination in Texas.

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

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.

INTRODUCTION: Adherence to breast and colorectal cancer screening reduce mortality from these cancers, yet screening rates remain suboptimal. This 2 X 2 RCT compared three theory-based interventions to usual care to simultaneously increase breast and colon cancer screening in women who were non adherent to both at study entry. STUDY DESIGN: RCT. SETTING/PARTICIPANTS: Women (N=692) who were non-adherent to both breast and colon cancer screening and aged 51–75 years were recruited. Enrollment, intervention delivery, and data collection were completed between 2013 and 2017 and data analyzed in 2018. INTERVENTION: The randomized intervention included four groups: three intervention arms (personally tailored messages using a web-based intervention, phone delivery by a trained navigator, or both) compared to usual care. Women at average risk for colon cancer were allowed to select either colonoscopy or stool test as their preferred colon cancer screening. Mammography was promoted for breast cancer screening. MAIN OUTCOME MEASURES: Outcome data at 6 months included self-report and medical records for screening activity. RESULTS: All intervention arms significantly increased receipt of either a mammogram or stool test compared with control (web: p

No study has investigated the cost and effectiveness of androgen deprivation therapy (ADT) and other curative treatment therapies among the Medicare population, and no study has taken into consideration the long-term side effects associated with ADT.To examine if adding ADT was cost-effective when accounting for ADT-related long-term side effects in men with prostate cancer.For this cost-utility analysis, we used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to estimate and compare patient survival, costs from a health payer's perspective, and cost-effectiveness of 3 treatment modalities for advanced prostate cancer patients, including radiation therapy, radiation plus ADT, and active surveillance. We also estimated quality-adjusted life-years (QALYs) by assigning appropriate health state utility values obtained from the literature for each phase of care and for long-term side effects. Propensity score matching was used to control for bias and confounding that were inherent to the observational study design.Adding ADT to radiation therapy increased median patient survival by 0.71 years. The incremental cost-effectiveness ratio (ICER) for radiation plus ADT versus radiation alone was $63,049 and $295,995 per mean life-year gained for radiation compared with active surveillance, respectively. Treatment-associated adverse side effects substantially reduced QALYs gained. Compared with radiation only, the incremental cost of radiation plus ADT was $127,900 per mean QALY and was nearly 80% cost-effective at a willingness-to-pay threshold of $210,000 per QALY.Despite ADT-associated costs and long-term side effects, compared with radiation alone, radiation plus ADT was cost-effective at $127,900 per QALY.This research was supported in part by the Cancer Prevention Research Institute of Texas (grant nos. RP130051 and RP170668). The authors declare that there are no conflicts of interest.

Background The incidence of oropharyngeal cancer (OPC) is rapidly increasing. This study aimed to describe the temporal trends and projection of OPC incidence. Methods Incidence data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database and trends were calculated using the joinpoint regression model. Results The incidence of OPC in the US population significantly increased by 1.94% (95% confidence interval [CI], 1.65%-2.23%) per year from 2000 to 2015. OPC was projected to increase continuously over the next 30 years, with more than half of projected new OPC cases being found in non-Hispanic white men aged 55-69 years. By 2045, OPC will become the third most common cancer in 55-69-year-old non-Hispanic white men in the United States. Conclusions The incidence of OPC is expected to increase substantially in the US population, particularly among middle-aged non-Hispanic white men. Our projections may have implications for policy makers.

Background Patients with inflammatory bowel disease (IBD) are at elevated risk of developing anal cancer. However, it remains unclear whether the increased risk manifests from immunosuppressant use or location of the disease (inflammation). We aimed to examine whether the risk of anal cancer in IBD patients is attributable to immunosuppression or the disease’s location by comparing IBD patients with rheumatoid arthritis (RA) and diverticulitis patients, respectively. Methods We conducted a retrospective cohort study using the US Optum® commercial claims database (2008–2018). We estimated the risk of anal cancer in the IBD cohort compared to the RA cohort (to examine risk attributable to immunosuppressant use) and the diverticulitis cohort (to examine risk attributable to similar disease location). Disease cohorts and index dates were identified using a combination of ICD diagnosis codes and prescription drug use. Patients 18 years and older and with a minimum of 12 months of continuous insurance enrollment were included. All three cohorts were mutually exclusive; we excluded persons with HIV/AIDS or organ transplant. We estimated hazard ratios (HRs) using Cox proportional regression, adjusting for age at diagnosis, comorbidity, risk factors for HPV infection (smoking, obesity, genital wart, substance abuse, alcoholism), and prescription drug use. Analyses were stratified by sex. Results The study included 70,314 patients with IBD, 164,991 with RA, and 129,558 with diverticulitis. In men, the adjusted hazard ratio (aHR) of developing anal cancer was 6.78 (95% CI, 3.40–13.55) comparing IBD to RA, and was 2.68 (95% CI, 0.99–7.30) comparing IBD to diverticulitis. Among women, the risk of developing anal cancer was significantly higher in IBD compared to RA (aHR 2.70; 95% CI, 1.36–5.35), but not different compared to diverticulitis (aHR 0.70; 95% CI, 0.20–2.44). The factors associated with a higher risk of anal cancer in both men and women were age at diagnosis, history of genital wart, corticosteroid use, and immunosuppressant use. Conclusion We found a significantly elevated risk of anal cancer in IBD patients than RA patients. However, anal cancer risk was not significantly different when comparing IBD patients to diverticulitis patients. These results indicate that the location of the disease is more strongly associated with anal cancer incidence than the treatment of autoimmune disease.

Objective To evaluate the risk of thromboembolic and pulmonary toxicities associated with hematopoietic growth factor (HGF) use (i.e., erythropoietin-stimulating agent [ESA] and/or colony-stimulating factor [CSF]) in a community-dwelling cohort of elderly patients with advanced ovarian cancer. Methods We studied 8,188 women, 65 years and older from the Surveillance, Epidemiology and End Results-Medicare linked database, diagnosed from January 1, 2000 to December 31, 2009. Patients were categorized into five groups: no chemotherapy and no ESA/CSF ( n = 2,616), chemotherapy but no ESA/CSF ( n = 1,854), ESA only ( n = 1,313), CSF only ( n = 743), and ESA + CSF ( n = 1,662). We reported the cumulative incidence of toxicities for 2, 6, and greater than 6 months, and the incidence density for the overall follow-up. Cox-proportional hazards regression was performed to determine risk of toxicities. Results Of the 5,572 patients receiving chemotherapy, 66.7% ( n = 3,718) received HGF supportive treatment, 29.8% received ESA + CSF, 23.6% received ESA only, and 13.3% received CSF only. Patients who received chemotherapy and also ESA + CSF had a 14.1% cumulative incidence of thromboembolic event (TEE) at 6 months of follow-up compared with 8.0% in those who received chemotherapy without growth factor and 3.2% in those with neither chemotherapy nor growth factor. Those with chemotherapy who received ESA + CSF had a significantly higher risk of TEE (adjusted hazard ratio, 1.22; 95% confidence interval, 1.01–1.47) as compared with patients with chemotherapy and no ESA/CSF, although patients aged 85 years and older may experience up to a five-fold increased risk. The risk of pulmonary toxicities did not significantly differ by HGF use. Conclusions An increased risk of TEEs was observed in elderly patients with ovarian cancer who received ESA + CSF. The risk–benefit ratio for administering HGF should be carefully evaluated, especially among those 85 years and older.