Cancer Patients In Singapore Research Articles

Valuation of the EORTC Quality of Life Utility Core 10 Dimensions (QLU-C10D) in a Multi-ethnic Asian Setting: How Does Having Cancer Matter?

The aim of the study was to develop and compare utility value sets for the EORTC QLU-C10D, a cancer-specific utility instrument based on the EORTC QLQ-C30, using the preferences of the general public and cancer patients in Singapore, and to assess their measurement properties. A total of 600 individuals from the general public were recruited using a multi-stage random sampling, along with 626 cancer patients with clinically confirmed diagnoses from outpatient clinics of the largest tertiary cancer hospital. Each participant valued 16 pairs of EORTC QLU-C10D health states using a discrete choice experiment (DCE). Conditional logit models were used to analyze the DCE responses of the general public and cancer patients separately. Utility values were assessed for known-group validity and responsiveness in the cancer patients by comparing mean values across subgroups of patients and calculating standardized response means using longitudinal EORTC QLQ-C30 data, respectively. Physical functioning and pain had the most impact on utility for both cancer patients and general public groups. Worst health state utility values were -0.821 and -0.463 for the general public and cancer patients, respectively. Cancer patients' values were lower for mild-to-moderate health states but higher for moderately-to-highly impaired states compared with the general public's values. Both value sets discriminated between patients with differing characteristics and responded equally well to improved health status, but the cancer patients' value set was slightly more responsive to deteriorated health. EORTC QLU-C10D value sets based on the preferences of the Singaporean general public and cancer patients exhibited differences in values but similar psychometric properties.

AB035. Validation of EORTC brain cancer module (EORTC QLQ-BN20) for assessment of health-related quality of life in glioma patients in Singapore.

Existing international data has shown that glioma patients suffer from poorer health-related quality of life (HRQoL). The European Organization for Research and Treatment of Cancer (EORTC) brain cancer-specific Quality of Life Questionnaire (QLQ-BN20) was developed to be together with EORTC Core Quality of Life Questionnaire (QLQ-C30) for cancer patients, highlighting issues particularly relevant to brain tumor patients. It has since been translated and validated across numerous cohorts. However, its psychometric properties have yet to be examined in Singapore. This study aimed to validate the use of QLQ-BN20 in a nationally representative sample of glioma patients in Singapore. Eighty-seven patients who had undergone neurosurgery for glioma from six hospitals in Singapore completed three self-reported measures of HRQoL (the EuroQol EQ-5D-5L, EORTC QLQ-C30, and EORTC QLQ-BN20). Descriptive statistics summarized their characteristics and scores on the questionnaires. Psychometric properties of QLQ-BN20 examined included convergent and discriminant validity, internal consistency (Cronbach's alpha), and construct validity (Spearman's correlation). Clinical validity of QLQ-BN20 was determined based on whether QLQ-BN20 scores could differentiate patients with good and poor functional status as measured by Karnofsky Performance Scale and Barthel's Index. The QLQ-BN20 was demonstrated to have good convergent validity (item-own scale correlation >0.70) and discriminant validity (item-own scale correlation higher than item-other scale correlation). There is high internal consistency, both overall (α=0.88) and within multi-item subscales (α=0.74-0.88). Conceptually similar subscales between different tools were more strongly correlated. For instance, the QLQ-C30 physical functioning subscale and the QLQ-BN20 motor dysfunction subscale (r=-0.65, P<0.001), and the QLQ-C30 cognitive functioning subscale and the QLQ-BN20 cognitive deficits subscale (r=-0.51, P<0.001). QLQ-BN20 was also able to distinguish between functional statuses of patients (P<0.05). This study supports the validity and reliability of the EORTC QLQ-BN20 among patients with glioma in Singapore. There is good convergent and discriminant validity, internal consistency, construct validity, and clinical validity. The QLQ-BN20 is a valuable supplement to the QLQ-C30. Hence, we recommend expanding its use for all glioma patients and possibly brain cancer patients in Singapore.

Cost-effectiveness analysis of add-on pertuzumab to trastuzumab biosimilar and chemotherapy as neoadjuvant treatment for human epidermal growth receptor 2-positive early breast cancer patients in Singapore

ABSTRACT Objectives The Asian PEONY trial showed that add-on pertuzumab to trastuzumab and chemotherapy significantly improved pathological complete response in the neoadjuvant treatment of patients with human epidermal growth factor receptor 2-positive (HER2+) early breast cancer (EBC). This study evaluated the cost-effectiveness of pertuzumab as an add-on therapy to trastuzumab and chemotherapy for neoadjuvant treatment of patients with HER2+ EBC in Singapore. Methods A six-state Markov model was developed from the Singapore healthcare system perspective, with a lifetime time horizon. Model outputs were: costs; life-years (LYs); quality-adjusted LYs (QALYs); incremental cost-effectiveness ratios (ICERs). Sensitivity/scenario analyses explored model uncertainties. Results The base case projected the addition of pertuzumab to be associated with improved outcomes by 0.277 LYs and 0.271 QALYs, increased costs by S$1,387, and an ICER of S$5,121/QALY. The ICER was most sensitive to the pCR rate, and the probabilistic sensitivity analysis showed that add-on pertuzumab had an 81.3% probability of being cost-effective at a willingness-to-pay threshold of S$45,000/QALY gained. Conclusions This model demonstrated that the long-term clinical impact of early pertuzumab use, particularly the avoidance of metastatic disease and thus avoidance of higher costs and mortality rates, make neoadjuvant pertuzumab a cost-effective option in the management of patients with HER2+ breast cancer in Singapore.

END-OF-LIFE HOSPITALIZATION SPENDING IN THE LAST SIX MONTHS OF LIFE AMONG CANCER PATIENTS

Abstract End-of-life care may constitute a vast proportion of health care expenditure globally. In the US, one-quarter of all medicare spending goes towards healthcare for people near the end of life. This is especially true for cancer patients. Our study aimed to estimate hospital spending in cancer patients in the last six months of life. Patients with cancer who died between June 2015 to December 2016 (n=653) were extracted from Singapore’s electronic medical records. A two-part model was used to estimate hospitalization spending. In the last month of life, we found that 85% of the patients did not have chemotherapy, 43% had good quality care, and 31% had palliative care. The average total hospitalization spending in the last six months of life was S$59,180. Further analysis by month from death revealed that spending increased sharply by 62%, from $7,591 in the sixth month of life to $12,315 in the last month of life. Decedents who received chemotherapy in the last month of life spent $6,925 more on hospitalization expenditure than those who did not ($17,915 vs $10,990). Among decedents seen by a palliative doctor, hospital expenditures in the last month were $8,745 higher compared to those who did not ($16,119 vs $7,374). The study depicted the huge hospitalization spending during the end-of-life for cancer patients in Singapore. Expenditure on end-of-life care can be further reduced with investment in community-based services and integrated care across the community and acute sectors, where hospital-to-home services and earlier palliative care can provide potential cost-effective solutions.

Characteristics of unplanned hospitalisations among cancer patients in Singapore

Cancer is a pervasive global problem with significant healthcare utilisation and cost. Emergency departments (EDs) see large numbers of patients with oncologic emergencies and act as "gate-keepers" to subsequent hospital admissions. A proportion of such hospital admissions are rapidly discharged within 2 days and may be potentially avoidable. Over a 6-month period, we conducted a retrospective audit of active cancer patients presenting to the ED with subsequent admission to the Department of Medical Oncology. Our aims were to identify independent factors associated with a length of stay ≤2 days; and characterise the clinical and resource needs of these short admissions. Among all medical oncology admissions, 24.4% were discharged within 2 days. Compared to longer stayers, patients with short admissions were significantly younger (P=0.010), had lower National Early Warning Scores (NEWS) (P=0.006), and had a lower proportion of gastrointestinal and hepatobiliary cancers (P=0.005). Among short admissions, common presenting medical problems were infections (n=144, 36.3%), pain (n=116, 29.2%), gastrointestinal complaints (n=85, 21.4%) and respiratory complaints (n=76, 19.1%). These admissions required investigations and treatments already available at the ED. Short admissions have low resource needs and may be managed in the ED. This may help save valuable inpatient bed-days and reduce overall healthcare costs.

End-of-life cost trajectories and the trade-off between treatment costs and life-extension: Findings from the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cohort study

Background: Few studies have assessed how patient preferences influence end-of-life costs. Aim: To estimate mean monthly healthcare costs in 2019 Singapore Dollars (SGD) at five time points within the last year of life and identify how patients’ preferences for the trade-off between treatment cost containment and life-extension and other factors affect these costs. Design: Mean monthly costs were quantified in the last 1, 3, 6, 9, and 12-months before death. Univariate and multivariate analyses were conducted. Setting/participants: Billing records for 286 deceased participants in the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cancer cohort study in Singapore. Results: Mean monthly costs were $5140 (95% CI: $4750; $5520) in the 12-months before death and rose to $8350 (95% CI: $7110; $9590) 1-month before death. Participants preferring higher cost containment/less life-extension defied the trend of increasing costs closer to death (mean monthly costs of $4630 (95% CI: $3690; $ 5580) and $4850 (95% CI: $2850; $6850) (12-months and 1-month before death respectively). Participants preferring lower cost containment/more life-extension had costs that were $1050 (95% CI: $49; $2051) and $5220 (95% CI: $2320; $8130) higher than those preferring lower costs/less life-extension 12-months and 1-month before death respectively. Conclusions: On average, cancer patients in Singapore can expect to spend $61,680 in the last year of life. Of broader relevance is that patient preferences and other observable factors clearly influence these costs, suggesting that policymakers and patients can better predict and budget for end-of-life costs by considering these factors.

Effects of housing value and medical subsidy on treatment and outcomes of breast cancer patients in Singapore: A retrospective cohort study

BackgroundSocioeconomic status (SES) is likely to affect survival in breast cancer patients. Housing value is a reasonable surrogate for SES in Singapore where most residents own their own homes, which could be public (subsidised) or private housing. We evaluated effects of housing value and enhanced medical subsidies on patients’ presentation, treatment choices, compliance and survival in a setting of good access to healthcare. MethodsA retrospective analysis of breast cancer patients treated in a tertiary hospital cluster from 2000 to 2016 was performed. Individual-level Housing value Index (HI) was derived from each patient's address and then grouped into 3 tiers: HI(high)(minimal subsidy), HI(med)(medium subsidy) and HI(low)(high subsidy). Cox regression was performed to evaluate the associations between overall survival (OS) and cancer-specific survival (CSS) with HI and various factors. FindingsWe studied a multiracial cohort of 15,532 Stage 0–IV breast cancer patients. Median age was 53.7 years and median follow-up was 7.7 years. Patients with lower HI presented with more advanced disease and had lower treatment compliance. On multivariable analysis, compared to HI(high) patients, HI(med) patients had decreased OS (HR=1.14, 95% CI 1.05–1.23) and CSS (HR=1.15, 95% CI 1.03–1.27), and HI(low) patients demonstrated reduced OS (HR=1.16, 95% CI 1.01–1.33). Ten-year non-cancer mortality was higher in lower HI-strata. Enhanced medical subsidy approximately halved treatment noncompliance rates but its receipt was not an independent prognostic factor for survival. InterpretationDespite good healthcare access, lower-HI patients have poorer survival from both cancer and non-cancer causes, possibly due to delayed health-seeking and poorer treatment compliance. Enhanced subsidies may mitigate socioeconomic disadvantages. FundingNone.

Supporting the Supporters: What are the Unmet Needs and Quality of Life of Caregivers of Cancer Patients in Singapore?

Supporting the Supporters: What are the Unmet Needs and Quality of Life of Caregivers of Cancer Patients in Singapore?

A qualitative approach in determining the patient-centered information and supportive care needs of cancer patients in Singapore

ObjectivesTo qualitatively interpret the information and supportive care needs perceived by cancer patients undergoing treatment in order to get a deeper appreciation of patients’ needs and concerns. The intended outcome...

Information sources and online information seeking behaviours of cancer patients in Singapore.

The aim of this study was to investigate the prevalence of Internet usage among cancer patients in seeking health-related information and the type of information sought. Sources of information received from, preferences for information sources and the perceived usefulness of information from these sources were also examined in this study. A self-administered questionnaire was used to evaluate the information needs of patients undergoing cancer treatment. The questionnaire also evaluated the current source and preferred source of information as well as their online information seeking behaviours. A total of 411 patients with cancer were recruited from an ambulatory cancer centre. The patients’ physicians and healthcare specialists comprised a large majority of the patients’ information sources; they were also the most preferred source of information. 59.1% of the respondents used the Internet to search for cancer-related information, namely diagnosis and treatment options, side effects of treatment and complementary and alternative therapy; demonstrating the importance of the above information. Physicians (60.3%) and healthcare specialists (26.5%) were the largest and most preferred sources of information for cancer patients in our study. It was not uncommon for cancer patients to use the Internet to search for additional information demonstrating the need to integrate this tool more effectively for knowledge transfer for those patients who want it. It is important for healthcare professionals to help cancer patients by directing them to sources of quality information (including websites). In addition, the provision of guidelines on how to evaluate health information on the Internet would be helpful to cancer patients.

AOL-5 - Current situation and perspectives of Medical Oncology in Singapore

Cancer is the number one killer disease in Singapore and almost 1 in 3 Singaporeans will develop cancer in their lifetime. Singaporeans are one of the longest living males and females globally thus, cancer rates are expected to further increase with our ageing population. We will face challenges in terms of right siting resources and managing rising healthcare costs, especially with the high cost of newer immunotherapy agents and other therapies. There has been investments in cancer research in Singapore over the decades, but has this translated into benefit for cancer patients in Singapore? This talk will discuss the state of medical oncology in Singapore and how it is meeting the needs of the people of Singapore.

Under-Treatment and Poorer Survival Outcomes in Elderly Breast Cancer Patients in Singapore: A Comparison with Younger Patients in a Tertiary Institution

Introduction: The numbers of elderly patients with breast cancers are increasing with an ageing population, yet clinical research on these patients is still lacking. This study aims to examine the differences between elderly patients and their younger counterparts, with a view to optimize management plans for the former. Methods: Patients ≥ 40 years old with histologically proven breast cancer between 1991 and 2008 were identified from our database, and grouped according to age for analyses: old elderly (≥75 years), young elderly (65 to 74 years) and young (40 to 64 years). Clinicopathologic characteristics, treatment and survival rates were compared across the 3 groups. Results: There were 103 (11.53%) old elderly, 147 (16.5%) young elderly and 643 (72.0%) young patients. The 2 elderly groups presented at later stages, received less adjuvant or palliative chemotherapy (P < 0.001), and less adjuvant radiotherapy (P < 0.001), compared to the younger patients. Both breast cancer specific survival (CSS) and overall survival (OS) in the old elderly (CSS: 64.7% (95% confidence interval [CI]: 53.4% - 73.8%), OS: 46.4% (95% CI: 35.6% - 56.4%)) and young elderly group (CSS: 82.4% (95% CI: 74.4% - 88.0%) OS: 78.6% (95% CI: 70.4% - 84.8%)) were lower than the young patient group (CSS: 84.9% (95% CI: 81.6% - 87.7%), OS: 83.4% (95% CI: 80.0% - 86.3%)) at 5 years. Conclusion: Our findings showed that clinicopathologic characteristics of elderly breast cancer patients differed from their younger counterparts. Poorer survival outcomes among our elderly patients may be the result of their under-treatment.

Prevalence and determinants of adherence to oral adjuvant endocrine therapy among breast cancer patients in Singapore

Objective:The success of oral adjuvant endocrine therapy (OAET) is greatly influenced by patients’ level of adherence to treatment. The objective of this study is to measure the prevalence and determinants of adherence to OAET among breast cancer patients in Singapore.Methods:A cross-sectional survey of patients supplemented by analysis of their prescription records was used to collect data. Adherence to OAET was assessed using the Morisky Medication Adherence Scale-4 items and evaluation of refill gaps. Univariate and multivariate analyses were done to evaluate the association between patients’ characteristics and adherence to OAET.Results:A total of 157 women who have started OAET at least 6 months before the time of interview participated in the study, of which less than half (64 patients, 40.8%) of the patients had high adherence. Univariate analysis identified patients who were 57 years or older (P = 0.027), unemployed (P = 0.027), on aromatase inhibitors (P = 0.023), on three or more concurrent medications (P = 0.001), and had one or more comorbidities (P = 0.000) to be significantly more adherent. However, only the number of comorbidities was found to be an independent predictor of adherence in a multiple logistic regression analysis (adjusted odds ratio = 2.60; 95% confidence interval = 1.208–5.593; P = 0.015). Forgetfulness was the main reason for nonadherence mentioned by 63 (67.7%) of the 93 nonadherent patients.Conclusions:Low level of OAET adherence was found in this study, and forgetfulness was cited as the main reason for nonadherence. Patients were generally receptive to the implementation of various strategies to assist them with their medication-taking behavior

Improved Survival of Advanced Lung Cancer in Singapore Over the Past Decade

We reviewed changes in clinical characteristics, treatment and survival of lung cancer patients in Singapore over the past decade. We reviewed all primary lung cancer cases from January 2004 to December 2013. Basic demographic, clinical and treatment data were extracted from the database. Overall survival (OS) was calculated using Kaplan-Meier method; survival curves were compared using log-rank test. Linear regression trend lines were estimated using least squares approach, and Cox regression analyses were performed to identify prognostic factors. Among 6006 lung cancer patients, the median age was 68 years old, 65% were males, 88% were Chinese, 92% had non-small-cell lung cancer and 76% had advanced stage IIIB/IV. There were proportionally more adenocarcinomas diagnosed over the years, while that of squamous cell carcinoma (SCC) and small-cell-lung cancer (SCLC) have remained stable. The median OS of all patients increased from 9.2 months in 2004 to 11.5 months in 2013. This survival improvement was statistically significant among patients with stage IIIB/IV (6.7 to 8.7 months; P = 0.005) and adenocarcinoma (12.7 to 15.4 months; P = 0.041). There was no improvement in median OS for SCC or SCLC. The use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKI) (hazard ratio [HR] 0.68; 95% CI, 0.63 to 0.73) and pemetrexed (HR, 0.69; 95% CI, 0.63 to 0.76) were significantly associated with improved OS. Survival of patients with advanced stage IIIB/IV lung adenocarcinoma has improved over the past decade, and is potentially associated with the use of EGFR TKI and pemetrexed.

Method Development for Detection of E545A Mutation PIK3CA Gene in Breast Cancer Patients Using Tm Shift SYBR Green I qPCR

E545A is one of the point mutations, and its frequency is high in PIK3CA gene (3.8%), particularly breast cancer patients in Singapore (13.8%) and Mexico (11.5%). In addition to induce breast cancer, the mutation also caused resistance of anti-HER2 in HER2 cancer subtype. The tremendous effect of this mutation was not supported by affordable detection method. This study aimed to develop a feasible and sensitive method of E545A detection. The developing method used Tm and Ct to identify samples. Based on optimization, the best condition was obtained at optimization 2 at annealing temperature of 65°C. At this condition, Tm and Ct of each sample were (a) exon 9 (78.4°C and 13.005±0.007) and (b) E5454A (80.4°C and 10.07±0.1). This method also demonstrated good precision as observed in variance coefficient of intra and inter assay (0). Thus, method for E5454A detection mutation was successfully developed.

Impact of PARP inhibitor expanded access program on the uptake of genetic testing in newly diagnosed or recurrent ovarian cancer patients in Singapore

Impact of PARP inhibitor expanded access program on the uptake of genetic testing in newly diagnosed or recurrent ovarian cancer patients in Singapore

A culturally adapted survivorship programme for Asian early stage breast cancer patients in Singapore: A randomized, controlled trial.

As cancer mortality rates improve in Singapore, there is an increasing need to improve the transition to posttreatment survivorship care. This study aimed to evaluate the effectiveness of a psychoeducation group (PEG) intervention program compared with usual care to reduce distress for physical symptom and psychological aspects in Asian breast cancer survivors who have completed adjuvant chemotherapy. This was a randomized, controlled trial comprising 72 Asian early stage breast cancer survivors who were randomized into the PEG (n=34) or the control (n=38) arm. The participants in the PEG arm underwent a weekly multidisciplinary PEG program delivered in a group format over 3weeks coupled with cultural adaptation. Both arms were assessed at baseline and 2months after intervention using the Rotterdam Symptom Checklist, Beck Anxiety Inventory, and EORTC QLQ-C30. A satisfaction questionnaire was also conducted among those survivors who have participated in the PEG program. Effective sizes were calculated using Cohen d. The mean age±SD of all participants was 53.0±8.9years, with the majority being Chinese (84.7%) and Malay (6.9%), and clinical characteristics were well balanced in both arms. Compared to the control arm, the PEG arm showed a significantly greater reduction in physical symptom distress (d=0.76, P=.01) and fatigue (d=0.49, P=.04). The 82.4% of the participants in the intervention group responded to the satisfaction questionnaire, and the majority (92.9%) agreed that the overall duration of the PEG intervention program was appropriate. A culturally adapted PEG program was effective in reducing physical symptom distress in Asian breast cancer survivors. (ClinicalTrials.gov: NCT02600299).

Psychometric properties and measurement equivalence of the English and Chinese versions of the Beck Anxiety Inventory in patients with breast cancer.

There is a lack of psychometric data for both the English and Chinese versions of Beck Anxiety Inventory (BAI) to support its usage among breast cancer patients. This study examined the psychometric properties and measurement equivalence of the English and Chinese versions of BAI among breast cancer patients in Singapore. Patients were recruited from two major cancer centers in Singapore. The criterion and construct validity of BAI was assessed by its correlation strength with (1) the emotional functioning subdomain of EORTC QLQ-C30 and (2) constructs related to anxiety, namely fatigue, dyspnea, and quality of life. The known-group validity was assessed according to the patients' breast cancer stage, religious beliefs, and emotional functioning levels. The internal consistency of the BAI domains was evaluated using Cronbach's alpha coefficient. Regression analysis was performed to compare the BAI total and domain scores between the two language versions. Data from 244 patients (144 English-speaking and 100 Chinese-speaking) were analyzed. For both language versions, the BAI total scores correlated moderately with the EORTC QLQ-C30 emotional functioning subdomain (r=-0.655 and -0.601). Correlations with fatigue, quality of life, and dyspnea were moderate (|r|=0.456-0.606). Patients with poorer emotional functioning reported higher anxiety levels, establishing known-group validity. All BAI domains demonstrated satisfactory internal consistencies (α=0.74-0.87), except for the panic domain (α=0.57-0.61). Possible measurement equivalence between the language versions was established. Both English and Chinese versions of BAI are valid, reliable, and possibly equivalent for future use.

Effects of High Doses of Vitamin C on Cancer Patients in Singapore: Nine Cases.

Introduction Intravenous high-dose vitamin C therapy is widely used in naturopathic and integrative oncology; however, a study reviewing its effects has never been performed in Singapore. This article serves to document administration of supportive vitamin C therapy for cancer patients in Singapore. The clinical response of 9 cancer patients of differing stages to the regular administration of large doses (25-100 g/d) of intravenous vitamin C (IVC; ascorbic acid) is outlined. Tumor pathology and patient health were verified by doctors who do not practice vitamin C treatment. Cases suggesting survival beyond prognosis, improvement in quality of life, safe coadministration with and improved tolerance of conventional therapy, and deterioration in clinical condition following withdrawal of vitamin C therapy are documented clinically. Some patients experience the Jarisch-Herxheimer reaction-the release of endotoxin from microorganism death resulting in pimples, fever, and body odor-for a few hours after the therapy, but these are resolved quickly with no lasting effects. Randomized trials of IVC therapy are recommended because it has minimal side effects and has shown promising results.

Preferences for end-of-life care among community-dwelling older adults and patients with advanced cancer: A discrete choice experiment

Singapore is in the midst of several healthcare reforms in efforts to finance and deliver health services for a rapidly aging population. The primary focus of these reforms is to make healthcare services, including those at the end of life (EOL), affordable. Given the increasingly high health care costs at the EOL, policy makers need to consider how best to allocate resources. One strategy is to allocate resources based on the preferences of sub-populations most likely to be affected. This paper thus aims to quantify preferences for EOL care both among community dwelling older adults (CDOAs) and among patients with a life-limiting illness. A discrete choice experiment was administered to CDOAs and advanced cancer patients in Singapore and willingness to pay (WTP) for specific EOL improvements was estimated. We find that patients have a higher WTP for nearly all EOL attributes compared with CDOAs. We also show that, for both groups, moderate life extension is not the most important consideration; WTP for one additional life year is lower than common thresholds for cost-effectiveness. Irrespective of whose preference are considered, the results highlight the importance of pain management and supporting home deaths at the EOL, perhaps at the expense of public funding for costly but only marginally effective treatments.