Economic evaluations of psychosocial interventions in cancer: A systematic review

Objective: Although the effectiveness of many psychosocial interventions for people with cancer has been established, one barrier to implementation in routine clinical care is a lack of data on cost-effectiveness. We conducted a systematic review to assess the cost-effectiveness of psychosocial interventions for improving psychological adjustment among people with cancer. Methods: Systematic review of the literature, study appraisal, and narrative synthesis. Results: Eight studies involving 1,668 patients were identified. Four of these reported outcomes in a cost per quality adjusted life year (QALY) framework. Six studies reported psychosocial interventions to be cost-effective for improving health-related quality of life, mood, pain, distress, or fear of cancer progression, compared to usual care. Of the six psychosocial interventions identified as cost-effective, three were cognitive behavioural therapy based interventions, one was a nurse-delivered telephone follow-up plus educational group program, one was a group-based exercise and psychosocial intervention, and one was a series of 10 face-to-face or telephone-based individual support sessions delivered by a nurse. The quality of studies according to the CHEC-list criteria was good overall; however, some studies were limited by their choice of outcome measure and omission of important categories of costs. Conclusions: Several psychosocial interventions, particularly those based on cognitive behavioural therapy, have been demonstrated to represent good value for money in cancer care. Future research should include a clear definition of the economic question, inclusion of all relevant costs, and consideration of utility-based quality of life measures for QALY estimation. Systematic review registration: PROSPERO Registration Number: CRD42014006370

Economic evaluations of psychosocial interventions in cancer: A systematic review

Objective: Although the effectiveness of many psychosocial interventions for people with cancer has been established, one barrier to implementation in routine clinical care is a lack of data on cost-effectiveness. We conducted a systematic review to assess the cost-effectiveness of psychosocial interventions for improving psychological adjustment among people with cancer. Methods: Systematic review of the literature, study appraisal, and narrative synthesis. Results: Eight studies involving 1,668 patients were identified. Four of these reported outcomes in a cost per quality adjusted life year (QALY) framework. Six studies reported psychosocial interventions to be cost-effective for improving health-related quality of life, mood, pain, distress, or fear of cancer progression, compared to usual care. Of the six psychosocial interventions identified as cost-effective, three were cognitive behavioural therapy based interventions, one was a nurse-delivered telephone follow-up plus educational group program, one was a group-based exercise and psychosocial intervention, and one was a series of 10 face-to-face or telephone-based individual support sessions delivered by a nurse. The quality of studies according to the CHEC-list criteria was good overall; however, some studies were limited by their choice of outcome measure and omission of important categories of costs. Conclusions: Several psychosocial interventions, particularly those based on cognitive behavioural therapy, have been demonstrated to represent good value for money in cancer care. Future research should include a clear definition of the economic question, inclusion of all relevant costs, and consideration of utility-based quality of life measures for QALY estimation. Systematic review registration: PROSPERO Registration Number: CRD42014006370

Cost-Effectiveness of Skin Surveillance Through a Specialized Clinic for Patients at High Risk of Melanoma

Purpose Clinical guidelines recommend that people at high risk of melanoma receive regular surveillance to improve survival through early detection. A specialized High Risk Clinic in Sydney, Australia was found to be effective for this purpose; however, wider implementation of this clinical service requires evidence of cost-effectiveness and data addressing potential overtreatment of suspicious skin lesions. Patients and Methods A decision-analytic model was built to compare the costs and benefits of specialized surveillance compared with standard care over a 10-year period, from a health system perspective. A high-risk standard care cohort was obtained using linked population data, comprising the Sax Institute’s 45 and Up cohort study, linked to Medicare Benefits Schedule claims data, the cancer registry, and hospital admissions data. Benefits were measured in quality-adjusted life-years gained. Sensitivity analyses were undertaken for all model parameters. Results Specialized surveillance through the High Risk Clinic was both less expensive and more effective than standard care. The mean saving was A$6,828 (95$5,564 to $8,092) per patient, and the mean quality-adjusted life-year gain was 0.31 (95% CI, 0.27 to 0.35). The main drivers of the differences were detection of melanoma at an earlier stage resulting in less extensive treatment and a lower annual mean excision rate for suspicious lesions in specialized surveillance (0.81; 95% CI, 0.72 to 0.91) compared with standard care (2.55; 95% CI, 2.34 to 2.76). The results were robust when tested in sensitivity analyses. Conclusion Specialized surveillance was a cost-effective strategy for the management of individuals at high risk of melanoma. There were also fewer invasive procedures in specialized surveillance compared with standard care in the community

Improving subjective perception of personal cancer risk: systematic review and meta-analysis of educational interventions for people with cancer or at high risk of cancer

BACKGROUND: Newly diagnosed patients with cancer require education about the disease, the available treatments and potential consequences of treatment. Greater understanding of cancer risk has been found to be associated with greater health-related quality of life, improved psychological adjustment and greater health-related behaviours. The aim of this sytematic review was to assess the effectiveness of educational interventions in improving subjective cancer risk perception and to appraise the quality of the studies. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and prospective observational studies. Eligible studies were identified via Medline, PsycINFO, AMED, CINAHL and Embase databases. After screening titles and abstracts, two reviewers independently assessed the eligibility of 206 full-text articles. RESULTS: Forty papers were included in the review; the majority of studies were conducted among breast cancer patients (n = 29) and evaluated the effect of genetic counselling on personal perceived risk (n = 25). Pooled results from RCTs (n = 12) showed that, both in the short and long term, educational interventions did not significantly influence risk perception level (standardised mean difference 0.05, 95% CI -0.24-0.34; p = 0.74) or accuracy (odds ratio = 1.96, 95% CI: 0.61-6.25; p = 0.26). Only one RCT reported a short-term difference in risk ratings (p = 0.01). Of prospective observational studies (n = 28), many did demonstrate changes in the level of perceived risk and improved risk accuracy and risk ratings in both the short and long term. However, only one (of three) observational studies reported a short-term difference in risk ratings (p < = 0.003). CONCLUSION: Further development and investigation of educational interventions using good quality, RCTs are warranted

Validity and repeatability of the EPIC physical activity questionnaire: a validation study using accelerometers as an objective measure

<p>Abstract</p> <p>Background</p> <p>A primary aim of the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study is to examine the association between total physical activity levels (comprising occupational, household and recreational activity) and the incidence of cancer. We examined the validity and long-term repeatability of total physical activity measurements estimated from the past-year recall EPIC questionnaire, using accelerometers as an objective reference measure.</p> <p>Methods</p> <p>Participants included 100 men and 82 women aged 50–65 years. Criterion validity was assessed by comparing the physical activity estimates from the EPIC questionnaire with total activity estimated from the average of three separate 7-day accelerometer periods during the same (past-year) period. Long-term repeatability of the EPIC questionnaire was assessed by comparing the responses from the baseline and 10-month administrations. Past-year EPIC estimates were also compared with the Friedenreich Lifetime Total Physical Activity Questionnaire to examine whether recent activity reflected lifetime activity.</p> <p>Results</p> <p>Accelerometer total metabolic equivalent (MET)-hours/week were positively associated with a total physical activity index (Spearman rank correlation ρ = 0.29, 95% confidence interval (CI) 0.15, 0.42) and with non-occupational activity estimated in MET-hours/week (ρ = 0.21, 95% CI 0.07, 0.35). Stratified analyses suggested stronger correlations for non-occupational activity for participants who were male, had a lower BMI, were younger, or were not full-time workers, although the differences in correlations between groups were not statistically significant. The weighted kappa coefficient for repeatability of the total physical activity index was 0.62 (95% CI 0.53, 0.71). Spearman correlations for repeatability of components of activity were 0.65 (95% CI 0.55, 0.72) for total non-occupational, 0.58 (95% CI 0.48, 0.67) for recreational and 0.73 (95% CI 0.66, 0.79) for household activity. When past-year activity was compared to lifetime estimates of activity, there was fair agreement for non-occupational (ρ = 0.26) activity, which was greater for household activity (ρ = 0.46) than for recreational activity (ρ = 0.21).</p> <p>Conclusion</p> <p>Our findings suggest that the EPIC questionnaire has acceptable measurement characteristics for ranking participants according to their level of total physical activity. The questionnaire should be able to identify the presence or absence of reasonably strong aetiological associations when either recent or long-term activity is the responsible factor.</p

Identifying challenges to implementation of clinical practice guidelines for sentinel lymph node biopsy in patients with melanoma in Australia: Protocol paper for a mixed methods study

Introduction Sentinel lymph node biopsy (SLNB) is a diagnostic procedure developed in the 1990s. It is currently used to stage patients with primary cutaneous melanoma, provide prognostic information and guide management. The Australian Clinical Practice Guidelines state that SLNB should be considered for patients with cutaneous melanoma >1mm in thickness (or >0.8mm with high-risk pathology features). Until recently, sentinel lymph node (SLN) status was used to identify patients who might benefit from a completion lymph node dissection, a procedure that is no longer routinely recommended. SLN status is now also being used to identify patients who might benefit from systemic adjuvant therapies such as anti-programmed cell death 1 (PD1) checkpoint inhibitor immunotherapy or BRAFdirected molecular targeted therapy, treatments that have significantly improved relapse-free survival for patients with resected stage III melanoma and improved overall survival of patients with unresectable stage III and stage IV melanoma. Australian and international data indicate that approximately half of eligible patients receive an SLNB. Methods and analysis This mixed-methods study seeks to understand the structural, contextual and cultural factors affecting implementation of the SLNB guidelines. Data collection will include: (1) cross-sectional questionnaires and semistructured interviews with general practitioners and dermatologists; (2) semistructured interviews with other healthcare professionals involved in the diagnosis and early definitive care of melanoma patients and key stakeholders including researchers, representatives of professional colleges, training organisations and consumer melanoma groups; and (3) documentary analysis of documents from government, health services and non-government organisations. Descriptive analyses and multivariable regression models will be used to examine factors related to SLNB practices and attitudes. Qualitative data will be analysed using thematic analysis.This work was funded by the Melanoma Centre of Research Excellence grant (1135285) from the Australian National Health and Medical Research Council (NHMRC). RLM received funding from an NHMRC Translating Research into Practice Fellowship (1150989). AEC received an NHMRC Career Development Fellowship (1147843) and Cancer Institute NSW Career Development Fellowship (15/CDF/1-14)

Identifying the 'Active Ingredients' of an Effective Psychological Intervention to Reduce Fear of Cancer Recurrence: A Process Evaluation

Purpose: Psychological interventions targeting fear of cancer recurrence (FCR) are effective in reducing fear and distress. Process evaluations are an important, yet scarce adjunct to published intervention trials, despite their utility in guiding the interpretation of study outcomes and optimizing intervention design for broader implementation. Accordingly, this paper reports the findings of a process evaluation conducted alongside a randomized controlled trial of a psychological intervention for melanoma patients. Methods: Men and women with a history of Stage 0–II melanoma at high-risk of developing new primary disease were recruited via High Risk Melanoma Clinics across Sydney, Australia and randomly allocated to receive the psychological intervention (n = 80) or usual care (n = 84). Intervention participants received a tailored psycho-educational resource and three individual psychotherapeutic sessions delivered via telehealth. Qualitative and quantitative data on intervention context, processes, and delivery (reach, dose, and fidelity), and mechanisms of impact (participant responses, moderators of outcome) were collected from a range of sources, including participant surveys, psychotherapeutic session audio-recordings, and clinical records. Results: Almost all participants reported using the psycho-educational resource (97%), received all intended psychotherapy sessions (96%), and reported high satisfaction with both intervention components. Over 80% of participants would recommend the intervention to others, and a small proportion (4%) found discussion of melanoma-related experiences confronting. Perceived benefits included enhanced doctor-patient communication, talking more openly with family members about melanoma, and improved coping. Of potential moderators, only higher FCR severity at baseline (pre-intervention) was associated with greater reductions in FCR severity (primary outcome) at 6-month follow-up (primary endpoint). Conclusions: Findings support the acceptability and feasibility of a psychological intervention to reduce FCR amongst individuals at high risk of developing another melanoma. Implementation into routine melanoma care is an imperative next step, with FCR screening recommended to identify those most likely to derive the greatest psychological benefit.This work was supported by a Cancer Institute NSW Translational Program Grant (GM, SWM, 05/TPG/1-01 and 10/TPG/1-02) and a Beyond Blue Project Grant (NK, 630575). NK was the recipient of a National Heart Foundation of Australia Future Leader Fellowship (101229). MD received a PhD scholarship through a Cancer Institute NSW Fellowship to AC and a Sydney Catalyst Top-Up Research Scholar Award. PB was supported by a National Health and Medical Research Council (NHMRC) of Australia Senior Principal Research Fellowship (1022582). ST received an NHMRC Postgraduate Scholarship. RM was supported by an NHMRC Investigator Grant (1194703) and University of Sydney Robinson Fellowship. AC was supported by an NHMRC Career Development Fellowship (1147843). The study protocol was reviewed and endorsed by two National Clinical Trials Groups; the Psycho-oncology Co-operative Research Group (PoCoG), and the Australian and New Zealand Melanoma Trials Group (ANZMTG/MASC)

Experiences of Patient-Led Surveillance, Including Patient-Performed Teledermoscopy, in the MEL-SELF Pilot Randomized Controlled Trial: Qualitative Interview Study

Current clinician-led melanoma surveillance models require frequent routinely scheduled clinic visits, with associated travel, cost, and time burden for patients. Patient-led surveillance is a new model of follow-up care that could reduce health care use such as clinic visits and medical procedures and their associated costs, increase access to care, and promote early diagnosis of a subsequent new melanoma after treatment of a primary melanoma. Understanding patient experiences may allow improvements in implementation. Objective: This study aims to explore patients’ experiences and perceptions of patient-led surveillance during the 6 months of participation in the MEL-SELF pilot randomized controlled trial. Patient-led surveillance comprised regular skin self-examination, use of a mobile dermatoscope to image lesions of concern, and a smartphone app to track and send images to a teledermatologist for review, in addition to usual care. Methods: Semistructured interviews were conducted with patients previously treated for melanoma localized to the skin in New South Wales, Australia, who were randomized to the patient-led surveillance (intervention group) in the trial. Thematic analysis was used to analyze the data with reference to the technology acceptance model. Results: We interviewed 20 patients (n=8, 40% women and n=12, 60% men; median age 62 years). Patients who were more adherent experienced benefits such as increased awareness of their skin and improved skin self-examination practice, early detection of melanomas, and opportunities to be proactive in managing their clinical follow-up. Most participants experienced difficulty in obtaining clear images and technical problems with the app. These barriers were overcome or persevered by participants with previous experience with digital technology and with effective help from a skin check partner (such as a spouse, sibling, or friend). Having too many or too few moles decreased perceived usefulness

Germline variants are associated with increased primary melanoma tumor thickness at diagnosis

Germline genetic variants have been identified, which predispose individuals and families to develop melanoma. Tumor thickness is the strongest predictor of outcome for clinically localized primary melanoma patients. We sought to determine whether there is a heritable genetic contribution to variation in tumor thickness. If confirmed, this will justify the search for specific genetic variants influencing tumor thickness. To address this, we estimated the proportion of variation in tumor thickness attributable to genome-wide genetic variation (variant-based heritability) using unrelated patients with measured primary cutaneous melanoma thickness. As a secondary analysis, we conducted a genome-wide association study (GWAS) of tumor thickness. The analyses utilized 10 604 individuals with primary cutaneous melanoma drawn from nine GWAS datasets from eight cohorts recruited from the general population, primary care and melanoma treatment centers. Following quality control and filtering to unrelated individuals with study phenotypes, 8125 patients were used in the primary analysis to test whether tumor thickness is heritable. An expanded set of 8505 individuals (47.6% female) were analyzed for the secondary GWAS meta-analysis. Analyses were adjusted for participant age, sex, cohort and ancestry. We found that 26.6% (SE 11.9%, P = 0.0128) of variation in tumor thickness is attributable to genome-wide genetic variation. While requiring replication, a chromosome 11 locus was associated (P < 5 × 10-8) with tumor thickness. Our work indicates that sufficiently large datasets will enable the discovery of genetic variants associated with greater tumor thickness, and this will lead to the identification of host biological processes influencing melanoma growth and invasion.E.M. was supported by the Malaysian Ministry of Higher Education and Universiti Sains Malaysia to study for a PhD at the University of Leeds. A.E.C. was supported by a National Health and Medical Research Council (NHMRC) of Australia Career Development Fellowship (1147843). K.K. was supported by an NHMRC Career Development Fellowship (1125290). M.M.I. was supported by Cancer Research UK (c588/a19167) and the NIH (ca083115). R.A.S. and G.V.L. are supported by NHMRC Practitioner Fellowships; R.A.S. and J.F.T. also acknowledge support from an NHMRC program grant. D.C.W., S.M. and N.K.H were supported by NHMRC Research Fellowships (1058522, 1155413, 1154543 and 1117663). We thank Nicholas G. Martin for assistance with access to data from the Q-MEGA cohort and with manuscript writing. This work was conducted using the UK Biobank Resource (application number 25331)