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C L Bennett

Publications and source records attributed to C L Bennett.

At least 73 records · Page 4Linked to original sources
PubMed2000

Cost analyses of adjunct colony stimulating factors for acute leukemia: can they improve clinical decision making.

Colony stimulating factors reduce the duration of neutropenia following intensive chemotherapy in a variety of settings, but the advantages in the management of leukemia are inconclusive. The variations in clinical results and the high costs of granulocyte colony-stimulating factor (G-CSF) and granulocyte macrophage colony-stimulating factor (GM-CSF) have led to confusion over appropriate use for leukemia patients. In this paper, we reviewed published information on costs and cost-effectiveness of growth factors for childhood and adult leukemia patients. Medline and Healthstar databases were searched for original research articles that contain cost or cost-effectiveness analyses of G-CSF (filgrastim) and GM-SCF (sargramostim) in oncology cooperative group trials. Published manuscripts and abstracts presented at national or international oncology conferences were included. The cost of adjunct treatment was evaluated in two studies of pediatric ALL, one study of adult AML, and two studies of AML in older adults (>55 years). The use of G-CSF for children with ALL was associated with reductions in days to ANC recovery, fewer documented infections, a shorter duration of hospitalization, and small (but not significant) additional costs. In adult AML patients, benefits included a shortening of the duration of neutropenia and hospital stays, a lower incidence of infection and febrile episodes, less use of antibiotics, and cost savings of $2,230 and $2,310 in two studies and an increase if $120 in the third study. This summary suggests that economic analyses can provide useful information to assist clinical decision-making. For pediatric ALL patients, this information indicates that G-CSF use is unlikely to have significant cost implications, and its use should be based on clinical considerations. In studies of adult and older adult AML patients, both GM-CSF and G-CSF have clinical benefits and can be expected to lead to a decrease in overall costs.

Adult↗
PubMed2000

IL-1beta and TNF-alpha in prostatic secretions are indicators in the evaluation of men with chronic prostatitis.

PURPOSE: Chronic Prostatitis, or Chronic Pelvic Pain Syndrome [CPPS], is a common disorder characterized by pelvic pain and varying degrees of inflammation in expressed prostatic secretions (EPS). In search of markers to more clearly define CPPS, we compared proinflammatory cytokines interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) levels in EPS from men with CPPS, to healthy men and men with Benign Prostatic Hyperplasia (BPH). METHODS: 78 men: controls (n = 16), BPH (n = 14), CPPS IIIA [>/=10 white blood cells per high power field (WBC/hpf) in EPS] (n = 18), CPPS IIIB [<10 WBC/hpf in EPS] (n = 20), and asymptomatic inflammatory prostatitis (AIP) (n = 10) were evaluated for EPS WBC, and IL-1beta and TNF-alpha by ELISA. RESULTS: IL-1beta and TNF-alpha levels in EPS were usually detectable in men with CPPS IIIA (89% and 45%, respectively) or AIP (90%; 100%), but less often in controls (31%; 17%), BPH (57%; 15%), and CPPS IIIB (35%; 15%) respectively. IL-1beta and TNF-alpha levels were higher in CPPS IIIA versus CPPS IIIB, and in AIP versus controls or BPH (p's <0.001). Cut-points for IL-1beta and TNF-alpha discriminated AIP from controls (predictive values = 94% and 83%, respectively) and CPPS IIIA from CPPS IIIB (predictive values 84% and 100%). Overall, there was a correlation between IL-1beta and TNF-alpha (p <0.003), but no correlation between WBC and IL-1beta (p <0.1) or TNF-alpha (p <0.50). CONCLUSIONS: Cytokines are frequently present and elevated in the EPS from men with CPPS IIIA and AIP and provide a novel means for identification, characterization and potential management of men with CPPS that differs from traditional methods based on WBC.

Adult↗
PubMed1999

Thrombotic thrombocytopenic purpura associated with ticlopidine in the setting of coronary artery stents and stroke prevention.

BACKGROUND: One of the most unusual causes of thrombotic thrombocytopenic purpura (TTP), a life-threatening disease, is ticlopidine hydrochloride, an antiplatelet agent used to prevent strokes in high-risk populations or following coronary artery stent placement. Recently, Hoffman-LaRoche Pharmaceuticals, following reports of 20 deaths from ticlopidine-associated TTP, updated the information about the hematologic adverse effects of the drug. OBJECTIVES: To review our recent findings on ticlopidine-associated hematologic toxic effects, which served as the impetus for the revised warnings, and to discuss the implications of these findings. METHODS: Data were obtained from the Food and Drug Administration's MedWatch program, published phase 3 clinical trials and case reports, hematologists, and plasmapheresis centers. RESULTS: No cases of TTP have been reported in phase 3 ticlopidine trials. In contrast, postmarketing surveillance has identified serious adverse drug reactions to ticlopidine, resulting in 259 deaths, with TTP accounting for 40 of these deaths. Detailed information was available on 98 cases of ticlopidine-associated TTP. Compared with 42 patients in the coronary artery stent setting, 56 patients with ticlopidine-associated TTP in the stroke prevention setting were more likely to be women (62.5% vs 28.6%; P = .01). Before the onset of TTP in patients receiving stroke prevention therapy and patients with stent placement, ticlopidine had been used for less than 2 weeks in 5.4% and 2.4%, between 2 and 3 weeks in 17.9% and 21.4%, between 3 and 4 weeks in 30.4% and 38.1%, and between 4 and 12 weeks in 46.4% and 38.1%, respectively. Death occurred in almost 60% of all patients not receiving plasmapheresis compared with 21.9% of patients receiving plasmapheresis for stroke prevention and 14.3% of patients receiving plasmapheresis in the stent setting. CONCLUSIONS: Use of ticlopidine requires frequent physician visits and laboratory tests for at least 3 months in the stroke prevention setting, while, with short-term use in the coronary artery stent setting, adverse events are less likely to occur. These factors, as well as competition from clopidogrel bisulfate, a new antiplatelet agent, potentially limit the feasibility of ticlopidine as a stroke prevention agent, while having less impact on its use following coronary artery stent placement.

Coronary Thrombosis↗
PubMed1999

Evaluation of conflict of interest in economic analyses of new drugs used in oncology.

CONTEXT: Recent studies have found that when investigators have financial relationships with pharmaceutical or product manufacturers, they are less likely to criticize the safety or efficacy of these agents. The effects of health economics research on pharmaceutical company revenue make drug investigations potentially vulnerable to this bias. OBJECTIVE: To determine whether there is an association between pharmaceutical industry sponsorship and economic assessment of oncology drugs. DESIGN: MEDLINE and HealthSTAR databases (1988-1998) were searched for original English-language research articles of cost or cost-effectiveness analyses of 6 oncology drugs in 3 new drug categories (hematopoietic colony-stimulating factors, serotonin antagonist antiemetics, and taxanes), yielding 44 eligible articles. Two investigators independently abstracted each article based on specific criteria. MAIN OUTCOME MEASURE: Relationships between funding source and (1) qualitative cost assessment (favorable, neutral, or unfavorable) and (2) qualitative conclusions that overstated quantitative results. RESULTS: Pharmaceutical company-sponsored studies were less likely than nonprofit-sponsored studies to report unfavorable qualitative conclusions (1/20 [5%] vs 9/24 [38%]; P = .04), whereas overstatements of quantitative results were not significantly different in pharmaceutical company-sponsored (6/20 [30%]) vs nonprofit-sponsored (3/24 [13%]) studies (P = .26). CONCLUSIONS: Although we did not identify bias in individual studies, these findings indicate that pharmaceutical company sponsorship of economic analyses is associated with reduced likelihood of reporting unfavorable results.

Biomedical Research↗
PubMed1999

Identifying providers of care to individuals with human immunodeficiency virus for a mail survey using a prescription tracking database.

Unlike cancer and other illnesses for which specialists provide the majority of care for affected individuals, care of those infected with human immunodeficiency virus (HIV) is provided by generalists and many different types of specialists. To assess the utility of a prescription tracking database in identifying low experience and high-experience providers of such care regardless of specialty, we mailed a survey to 1500 physicians identified as having written prescriptions for agents used in care of HIV-infected individuals in the year before the survey. We discovered that physicians who care for patients with acquired immunodeficiency syndrome (AIDS) in the United States come from a broad range of specialties and practice in a variety of settings. Self-report of experience with AIDS care in the prior year was strongly associated with the number of HIV-related prescriptions identified in the tracking information. Response rates were consistent with those of other surveys published in medical journals. This study suggests that prescription tracking databases can be used to identify the breadth of physician/subjects who provide care for patients with HIV infection.

Databases, Factual↗
PubMed1999

Racial variation in the use of laparoscopic cholecystectomy in the Department of Veterans Affairs medical system.

BACKGROUND: While studies have found racial differences in the rates of use of established invasive cardiac and cerebrovascular procedures, no study has evaluated racial variation in the rates of adoption of new surgical procedures. For patients undergoing laparoscopic cholecystectomy, the procedure represents a new and safe option that shortens the duration of postoperative hospitalization by almost one week. In this study, we evaluated whether, in the equal access Veterans Affairs (VA) medical system, the rate of adoption of this procedure and improvements in the duration of postoperative hospitalization differed between African-American and Caucasian patients. STUDY DESIGN: Data were obtained from two sources-administrative claims files and prospectively compiled dinical data from medical records and patient interviews. In both data sets, frequency of use, length of stay, and outcomes for African-American and Caucasian patients undergoing minimally invasive and open gallbladder surgery were analyzed for the first four years of use of the procedure in the VA system (1992 to 1995). RESULTS: Analyses based on claims files indicated that, after adjustment for potentially confounding variables, African-American patients who underwent cholecystectomy in VA medical centers were 25% less likely to undergo a minimally invasive cholecystectomy during the first 4 years of use of the new procedure (adjusted odds ratio, 0.74; 95% confidence interval, 0.66-0.83). Shortening of the average postoperative length of stay from 9 days or more in the prelaparoscopic era to less than 4.5 days for patients undergoing the laparoscopic procedure occurred in the first year for Caucasian patients, but did not occur until the fourth year for African-American patients (p<0.001). The overall difference in postoperative length of stay between African-American and Caucasian patients more than doubled from 1.7 days before introduction of laparoscopic cholecystectomy to 3.8 days in the fourth year. In comparison, analyses based on nurse-compiled clinical data indicated that, after adjustment for relevant clinical factors, racial variations in the rate of laparoscopic surgery were even larger (adjusted odds ratio for laparoscopic versus open cholecystectomy for African-American versus Caucasian veterans, 0.68; 95% confidence interval, 0.55-0.84). CONCLUSIONS: Compared to Caucasian patients, African-American patients who underwent cholecystectomy in VA medical centers had an approximately 25% to 32% lower likelihood of undergoing minimally invasive cholecystectomy procedures. The differences in rates of adoption of laparoscopic surgery did not appear to be from more comorbid illnesses among African-American patients. African-American and Caucasian veterans may differ in their preference for new surgical procedures like laparoscopic cholecystectomy. Conversely, VA physicians may have been less likely to recommend laparoscopic cholecystectomies to African-American patients.

Adult↗
PubMed1999

Economic analysis of a randomized placebo-controlled phase III study of granulocyte macrophage colony stimulating factor in adult patients (> 55 to 70 years of age) with acute myelogenous leukemia. Eastern Cooperative Oncology Group (E1490).

PURPOSE: Considerable morbidity and mortality and costs occur during induction therapy for acute myeloid leukemia (AML). Colony-stimulating factors (CSFs) can shorten neutropenia, and may lower costs. We performed a cost-minimization analysis of granulocyte macrophage colony stimulating factor (GM-CSF) for AML patients > 55 to 70 years of age during an Eastern Cooperative Oncology Group Study. PATIENTS AND METHODS: Clinical data were from a randomized double-blind phase III trial of 117 AML patients. Estimates of costs were from financial accounts from seven participating institutions. Costs were reported from the third party payor perspective. Analyses were conducted utilizing a decision analytic model. The primary source of event probabilities was in-hospital care with or without an active infection. Sensitivity analyses were also reported. RESULTS: When compared to AML patients who received placebo. GM-CSF patients had fewer grade 4-5 infections (9.6% versus 36.2%, P = 0.002) and grade 3-5 infections (52% versus 70%. P = 0.07) and $2.310 in savings. Sensitivity analyses indicated that similar cost estimates applied over a range of clinical and economic assumptions. CONCLUSIONS: This analysis can serve as a template for cooperative group cost analyses. Cooperation on study methodologies may allow for results that are relevant to both clinicians and policy makers.

Aged↗
PubMed1999

The association between physician reimbursement in the US and use of hematopoietic colony stimulating factors as adjunct therapy for older patients with acute myeloid leukemia: results from the 1997 American Society of Clinical Oncology survey. Health Services Research Committee of the American Society of Clinical Oncology.

BACKGROUND/OBJECTIVES: Financial considerations play an important role in the delivery of medical care in the US. In 1996, revised guidelines from the American Society of Clinical Oncology (ASCO) indicated that granulocyte colony-stimulating factor (G-CSF) and granulocyte macrophage-colony stimulating factor (GM-CSF) were unlikely to be harmful for older acute myeloid leukemia (AML) patients and suggested that physicians could consider their use in this setting. In 1997, the ASCO health services research committee evaluated whether physician reimbursement was a primary determinant in the decision to use G-CSF and GM-CSF in this clinical situation. PATIENTS AND METHODS: A questionnaire describing clinical scenarios for a 67-year-old man with newly diagnosed de novo AML was mailed to 1500 ASCO members who practiced medical oncology and hematology. Physicians were queried about their preferences for adjunctive CSF use following induction and consolidation chemotherapy. RESULTS: Of 1020 potentially eligible respondents, returned surveys were received from 672. Following induction chemotherapy, support for CSF use was 40%, similar in magnitude for that for non-use of these agents. The most important determinant of support for CSF use was being in a fee-for-service practice (P < 0.001). CONCLUSIONS: Physicians in the US are mixed in their support for CSFs for older AML patients. Support was high in settings where CSF use was accompanied by financial profit to the physician practice, and support was low otherwise.

Age Factors↗
PubMed1999

A multi-attribute model of prostate cancer patient's preferences for health states.

Multi-attribute utility theory (MAUT) provides a way to model decisions involving trade-offs among different aspects or goals of a problem. We used MAUT to model prostate cancer patients' preferences for their own health state and we compared this model to patients' global judgments of health state utility. 57 patients with prostate cancer (mean age = 70) at two Chicago Veterans Administration health clinics were asked to evaluate health states described in terms of five health attributes affected by prostate cancer: pain, mood, sexual function, bladder and bowel function, and fatigue and energy. Each attribute had three levels that were used to form three clinically realistic health state descriptions (A = high, B = moderate, C = low). A fourth personalized health description (P) matched the patient's current health. We first measured patients' preferences using time trade-off (TTO) judgments for the three health states (A, B, and C) and for their own current health state (P). The TTO for the patient's own health state (P) was standardized by comparing it to TTO judgments for states A and C. We next constructed a multi-attribute model using the relative importance of the five attributes. The MAU scores were moderately correlated with the TTO preference judgments for the personalized state (Pearson r = 0.38, N = 57, p < 0.01). Thus, patients' preference judgments are moderately consistent and systematic. MAUT appears to be a potentially feasible method for evaluating preferences of prostate cancer patients and may prove helpful in assisting with patient decision making.

Aged↗
PubMed1999

Maximum androgen-blockade with medical or surgical castration in advanced prostate cancer: A meta-analysis of nine published randomized controlled trials and 4128 patients using flutamide.

With the recent Southwest Oncology Group (SWOG) publication of their metastatic prostate cancer clinical trial results, which concluded that orchiectomy and flutamide as maximal androgen blockade (MAB) therapy vs orchiectomy alone does not significantly improve survival (NCI 0105), and the 1989 publication from the same cooperative group indicating a 24% improvement in survival for MAB therapy with leuprolide and flutamide versus leuprolide alone (NCI 0036), clinicians may well be undecided about the likelihood of clinical benefits with flutamide in combination with medical or surgical castration. To better characterize this important therapeutic decision, we assessed the survival benefit of MAB therapy with flutamide through a meta-analysis of up-to-date information from studies reported/conducted from 1989 through 1998. All peer-reviewed published randomized controlled trials comparing treatment with flutamide plus either lutenizing hormone releasing hormone (LhRH) agonists or orchiectomy as MAB treatment with LhRH or orchiectomy alone were included. The primary objective of the study was to form a combined estimate and confidence interval for the hazard ratio (as measured by the relative risk (RR) of survival in a comparison of castration vs MAB) summarizing the effect of flutamide treatment on overall survival. Directly extracted estimates of the log hazard ratio were used if available (1 study); if not, either an estimate of the RR based on a reported P-value from a log rank test (7 studies) or a discrete proportional hazards approximation based on reconstructed annual life tables for the treatment arms (1 study) were used. Nine studies with 4128 patients with advanced prostate cancer were included in these analyses. Pooled estimates demonstrated a 10% improvement in overall survival with flutamide as MAB therapy (relative risk (RR)=0.90, 95% Confidence Interval=0.79, 1.00). The currently available updated evidence from randomized trials shows a 10% benefit in overall survival with flutamide as MAB therapy in comparison to conventional castration, almost identical to the estimate reported in the recently published Southwest Oncology Group Study (NCI 0105).

Journal Article↗
PubMed1999

Hepatic dysfunction in a population of antibody-deficient patients: prevalence, aetiology and outcome of PCR screening for hepatitis C and G viruses.

BACKGROUND AND OBJECTIVES: A group of 40 antibody-deficient patients receiving regular infusions of intravenous immunoglobulin underwent close monitoring in an attempt to identify hepatic dysfunction. The continuing risk of hepatitis virus transmission, especially hepatitis C virus via immunoglobulin products prompted this policy. We report our findings. METHODS: Screening included measurement of transaminase levels at each infusion. The patients were also tested for evidence of infection with hepatitis viruses B, C and G. RESULTS: Abnormal liver function tests were identified in 6 cases. However, a blood-borne viral aetiology was not found in any of these cases. Additional investigation allowed an alternative aetiology to be identified in most cases. One patient found to be positive for hepatitis G virus (HGV)-RNA by reverse transcriptase-polymerase chain reaction has no evidence to date of clinical problems as a result. INTERPRETATION: The results are reassuring in that definite iatrogenic hepatitis virus transmission has not been found in this cohort, despite long-term treatment with a wide range of immunoglobulin products. The source of infection of the single patient infected with HGV remains as uncertain as the pathogenic potential of this virus. However, as long as the risk of immunoglobulin-associated viral transmission continues, a strict monitoring programme such as ours should continue to facilitate prompt detection of cases with abnormal liver function. Liver dysfunction in this group requires full investigation and we cannot exclude infection with hitherto unidentified blood-borne viruses.

Adolescent↗
PubMed1999

Use of hematopoietic colony-stimulating factors: comparison of the 1994 and 1997 American Society of Clinical Oncology surveys regarding ASCO clinical practice guidelines. Health Services Research Committee of the American Society of Clinical Oncology.

PURPOSE: The American Society of Clinical Oncology (ASCO) Health Services Research Committee sought to assess whether more appropriate patterns of colony-stimulating factor (CSF) use occurred after the publication of ASCO evidence-based practice guidelines in 1994 and 1996 for patients with solid tumors or lymphoma. METHODS: In 1994 and 1997, questionnaires describing clinical scenarios were mailed to ASCO members who practiced medical oncology. Physicians were asked the extent to which they preferred to use a CSF for primary prophylaxis, secondary prophylaxis, or treatment of neutropenic complications. Multiple regression analyses were used to determine predictors of overall propensity to use CSFs and, when using a CSF, propensity to support longer schedules of CSF use. RESULTS: Decreased use of CSFs was shown in the following situations: (1) treatment for febrile neutropenia without localizing signs (39% in 1994 v 29% in 1997) or with a right lower lobe infiltrate (54% v 46%); (2) primary prophylaxis with paclitaxel for ovarian cancer (20% v 11%) or cyclophosphamide, doxorubicin, and vincristine chemotherapy for small-cell lung cancer (8.4% v 4.6%); and (3) secondary prophylaxis after afebrile neutropenia following chemotherapy for germ cell tumors (44.5% v 36.0%). One third fewer physicians supported the extended use of CSFs until an absolute neutrophil count >/= 10,000/mm(3) or a WBC count >/= 10,000/mm(3) was reached, both counts serving as criteria for stopping CSF therapy. However, we observed high rates of CSF use despite ASCO guideline recommendations against use in the following clinical situations: (1) primary prophylaxis in patients at low risk of febrile neutropenia (6% v 16%); (2) secondary prophylaxis late in the course of curative and palliative therapy (80% v 53%); and (3) treatment of afebrile and uncomplicated febrile neutropenia (30% v 60%). In 1994 and 1997, fee-for-service physicians were more likely than other physicians to prefer use of CSF support while maintaining treatment dose and schedule instead of using dose-reduction strategies, and, when using a CSF, they were more likely to support longer CSF treatment schedules (P <.05 for both scenarios). CONCLUSION: Decreased use and more appropriate use of CSFs in accordance with ASCO guideline recommendations occurred from 1994 to 1997, but there remain many opportunities to reduce CSF use with no clinical harm. Many oncologists continue to support the use of CSFs in scenarios and with scheduling criteria that the guidelines and evidence do not support. ASCO's evidence-based guidelines should be linked with formal continuous quality improvement initiatives to substantially improve the quality of supportive oncology care.

Hematopoietic Stem Cells↗
PubMed1999

The relation between physician experience and patterns of care for patients with AIDS-related Pneumocystis carinii pneumonia: results from a survey of 1,500 physicians in the United States.

STUDY OBJECTIVES: To determine whether physician experience and specialty influence the approach to care of AIDS patients with pneumonia, we surveyed physicians about their management of possible Pneumocystis carinii pneumonia (PCP) infection. DESIGN, SETTING, PARTICIPANTS: A postal survey was sent to a random sample of 1,500 internists and family physicians in the United States drawn from the American Medical Association master file who were identified by a pharmaceutical marketing company as having written prescriptions for AIDS-related agents in the previous year. MEASUREMENTS AND RESULTS: The survey had a 53% response rate. Physicians more experienced in AIDS care were more likely to advocate diagnostic bronchoscopy over initiation of empiric anti-PCP therapy for HIV-infected patients with undiagnosed pulmonary infiltrates (odds ratio [OR], 1.4 for a patient with mild severity of illness [p = 0.02]; OR, 1.7 for a severely ill patient [p < 0.001]). Physician specialty and fee-for-service reimbursement were independently associated with higher rates of bronchoscopy, with internists favoring bronchoscopy more frequently than family physicians. High-experience providers and internists also predicted better clinical outcomes for the hypothetical patients. CONCLUSIONS: Our findings extend the observations about HIV experience and PCP prophylaxis to the setting of diagnosis and treatment. Physicians with higher levels of experience with AIDS, internists, and physicians reimbursed as fee-for-service providers are more likely to support diagnostic confirmation of PCP than empiric treatment approaches.

AIDS-Related Opportunistic Infections↗
PubMed1999

Cost analysis of second-line therapies for platinum-refractory ovarian cancer: reimbursement dilemmas for Medicare patients.

Currently used options for salvage therapy for epithelial ovarian cancer include intravenously administered paclitaxel or topotecan and orally administered altretamine or etoposide. The response rates for these agents are similar (14-26%), whereas the type and incidence of adverse events differ. Under current legislation, Medicare will reimburse intravenous outpatient chemotherapy regimens only or oral regimens with a marketed intravenous formulation, despite that 89% of cancer patients prefer oral therapies. To compare the out-of-pocket costs and costs to the Medicare system, a cost minimization analysis of treatment with these agents was conducted using published phase II and phase III data. The total cost of treatment was $15,767 for paclitaxel, $18,635 for topotecan, $4477 for altretamine, and $5016 for etoposide. The out-of-pocket costs to the patient were $83, $37, $4477, and $6, respectively. Although a physician's first consideration in choosing a therapy is efficacy and toxicity, current Medicare reimbursement policies restrict patient options for cancer care. Because Medicare adopts managed care and health maintenance organizations into the management of patient care, cost effectiveness will likely become an important consideration in the treatment of cancer.

Aged↗
PubMed1999

Growth of oncology physician practice management companies.

The practice of oncology is changing dramatically, spurred on by managed care initiatives throughout the United States. As a result, physicians are faced with multiple demands from insurers, managed care organizations, and patients. In response to these demands, oncology physician practice management companies have entered the cancer market. This article describes the driving factors leading to consolidation in practice settings, the risks and benefits to oncologists of affiliating with these companies, and the organizational characteristics of four of these larger corporations. This review article is of broad interest to oncologists practicing in the United States and is meant to provide a useful reference for considering a physician practice management company as a business partner.

Humans↗
PubMed1999

The effect of reimbursement policies on the management of Medicare patients with refractory ovarian cancer.

Ovarian cancer patients who are covered by Medicare are faced with therapeutic decisions that require consideration of out-of-pocket costs for oral anticancer agents and complete reimbursement for more expensive intravenous and often more toxic medications. The response rates for oral agents such as altretamine or etoposide are similar to those for intravenous paclitaxel or topotecan (14% to 26%), but the economic considerations differ markedly. Under current legislation, Medicare will completely cover the costs for the two intravenous outpatient chemotherapy regimens, but does not provide any financial support for oral regimens that do not have associated injectable formulations. This is a matter of concern for patients, as 89% prefer oral therapies. We compared the out-of-pocket costs and costs to the Medicare system of oral and intravenous agents used for refractory ovarian cancer, using published phase II and phase III data. The total cost of treatment was $18,635 for topotecan, $15,767 for paclitaxel, $7,721 for etoposide, and $4,477 for altretamine. Conversely, out-of-pocket costs for Medicare patients without Medigap coverage were highest for altretamine, at the full cost of $4,477, whereas Medicare covered all but $83 for topotecan, $37 for paclitaxel, and $66 for etoposide. Current Medicare reimbursement policies may affect patient options for cancer care. These policies are changing and should continue to change as Medicare adopts more managed care strategies.

Antineoplastic Agents↗