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Assessing the Financial Toxicity Associated with Treatment Options for Resectable Pancreatic Cancer
Marcelo Cerullo*, Faiz Gani, Joseph K. Canner, Timothy M. Pawlik
Surgery, Johns Hopkins Hospital, Baltimore, MD

Background: Patients often carry the rising burden of out-of-pocket healthcare costs associated with cancer care. The high costs of different therapies, sometimes referred to as “financial toxicity,” and the relative benefit associated with these treatments have been poorly studied. We therefore sought to characterize and compare the overall costs relative to survival benefit of the treatment options most commonly employed for resectable pancreatic cancer.
Methods: The Truven Health MarketScan database was used to identify commercially insured patients who underwent a pancreatic resection (pancreaticoduodenectomy, partial/distal pancreatectomy, or total pancreatectomy) between January 01, 2010 and December 31, 2012. Total costs for inpatient surgery, outpatient chemotherapy, and outpatient radiation therapy were calculated for each patient and adjusted to 2012 dollars. Generalized linear models were constructed to predict the mean costs for each treatment group. Overall survival (OS) was estimated using the Kaplan-Meier method and multivariable Cox proportional hazards regression analysis was performed to calculate the survival benefit for each treatment modality.
Results: Among the 3,395 patients identified, 1,788 (52.7%) underwent surgery only, 655 (19.3%) underwent surgery+chemotherapy, 140 (4.1%) underwent surgery+radiation therapy and 812 (23.9%) surgery+chemotherapy+radiation therapy. The average total cost for treatment was ,201 (95%CI: ,936-,416). Patients who underwent surgery alone incurred a mean cost of ,785 (95%CI: ,846 - ,084) while the costs for treatment modalities involving surgery+chemotherapy were higher (surgery+chemotherapy: ,237 [95%CI: ,295-,178]; surgery+chemotherapy+radiation therapy: ,663 [95%CI: ,366-,959]; both p<0.05, Figure 1). Median OS was 20.1 months (95%CI: 19.1-21.4 months). Upon stratification by nodal status, patients with nodal metastasis who were treated with surgery+chemotherapy+radiation therapy had a longer OS compared with surgery alone (HR=0.76, 95%CI: 0.61-0.95, p=0.01). In contrast, despite a mean increased cost of up ,668, administration of adjuvant chemotherapy or radiation did not translate into a survival benefit among patients without nodal disease (p>0.05).
Conclusions: Total costs of care relative to improvement in survival vary significantly by treatment modality and tumor characteristics. Future studies should seek to investigate not only the efficacy of different treatment modalities, but also target areas of excess spending to reduce the cost of care for pancreatic cancer.

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