Economic Essays on Burden, Survivorship and Health Literacy - A Focus on HPV-Related Head and Neck Cancer
Coughlan, James Diarmuid
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Our understanding of cancer and the role of specific agents in its cause continues to evolve. Head and Neck Cancers (HNC) in the developed world were traditionally associated with excessive smoking and drinking. Since 2000, the Human Papilloma Virus (HPV) has been linked with a subset of HNC in the oropharynx region and the prevalence of these has increased markedly among males aged 40-65 years of age. As with any emerging epidemic it is important to gain an understanding of the causes and effects to help inform a policy response. In this thesis, I examine issues around the characterisation of disease burden; cancer survivorship and health literacy supported by a range of empirical analyses to help provide insights into the development of a policy response to HPV-related HNC. In characterising the economic burden of HPV-related HNC in the United States, the absence of a consensus on or accepted guidelines for Cost-of-illness (COI) studies has seen a range of methods deployed in the literature. Four commonly used approaches to estimating the direct medical expenditures on HNC using the Medical Expenditure Panel Survey (MEPS) highlight the impact choice of method has on characterising disease burden. The range of average annual (2003-2008) direct medical expenditures for adults with HNC in the US was $754 million to $3.18billion; variations in confidence intervals around estimates are evident. The range underscores the importance of adopting robust approaches to burden estimation if the urgency of a policy response is to be accurately communicated. As HPV-related HNC has a good prognosis, clinical trials are focused on deintensification of treatment with the view of improving the quality of life of survivors. These facts prompted an examination of service use among cancer survivors. The thesis examines healthcare utilisation of cancer survivors in general in Ireland using The Irish Longitudinal Study of Ageing (TILDA). Count and bivariate probit regression analyses are used to estimate the relationships between service utilisation among cancer survivors relative to those with no history of diagnosed cancer, controlling for a range of covariates. Emphasis is given to the role of time since diagnosis among cancer survivors to highlight how the impact of cancer on service utilisation varies as survivors move from active treatment to what might be called the survival phase. The implications of this in planning services for highly survivable cancers such as HPV-related HNC are explored. Communication will be central to any policy response to an emerging epidemic. The absence of a health literate population has the potential to compromise the effectiveness of any policy response. An examination of health literacy, as a public health or health inequality issue is examined within an Irish context to ascertain how literacy might best be enhanced as a precursor to policies aimed at addressing HPV-related cancer. The empirical analysis demonstrates that Irish policy-makers ought to take a public health (rather than a health inequalities) perspective in respect of health literacy. Finally, policy recommendations are proffered informed by the analyses undertaken to address the emerging epidemic of HPV-related HNC. These recommendations emphasis the importance of a broad multidisciplinary response.