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Publication Abstract

Authors: Freedman DM, Wu J, Daugherty SE, Kuncl RW, Enewold LR, Pfeiffer RM

Title: The risk of amyotrophic lateral sclerosis after cancer in U.S. elderly adults: A population-based prospective study.

Journal: Int J Cancer 135(7):1745-50

Date: 2014 Oct 01

Abstract: Although epidemiologic studies have examined the risk of amyotrophic lateral sclerosis (ALS) in relation to cancer, none have been large population-based studies using incident ALS and adjusting for medical surveillance. Addressing those limitations, all first primary cancer cases from the Surveillance, Epidemiology and End Results (SEER) Program (1992-2005), linked to Medicare claims data were used. Cases were followed from cancer diagnosis until the earliest date of ALS diagnosis, a break in Medicare claims data, death, age 85 or December 31, 2005. A comparison group from a 5% random Medicare sample in the SEER areas who were cancer-free and censored as above, or until a cancer diagnosis were selected. ALS outcomes were derived from medical claims. The proportional hazards models to estimate ALS hazard ratios (HRs), using age as the time scale, adjusting for sex, race and physician visits, and stratifying the baseline hazard on birth year and SEER registry were used. A total of 303 ALS cases were ascertained in cancer patients (2,154,062 person-years) compared with 246 ALS cases (2,467,634 person-years) in the reference population. There was no overall relationship between cancer and ALS (HR = 0.99; 95% CI = 0.81-1.22), nor by gender or race. Except for an elevated ALS risk in the first year after a leukemia diagnosis, the relationship between site-specific cancers and ALS was null after correcting for multiple comparisons. Having a cancer diagnosis was not associated with an overall risk of incident ALS. The short-term ALS risk after leukemia may reflect screening or reporting errors.

Authors: García-Albéniz X, Logan RW, Schrag D, Hernán MA

Title: Evaluation of the Duplication of Staging CT Scans for Localized Colon Cancer in a Medicare Population.

Journal: Med Care :-

Date: 2014 Sep 15

Abstract: BACKGROUND:: To quantify and characterize duplicated tests performed during the staging of localized colon cancer in the Medicare population. METHODS:: We used the SEER-Medicare linked database to select patients diagnosed with localized colon cancer between the years 1996 and 2009. We considered a patient as adequately staged after having received a colonoscopy, an abdominal computed tomography (CT) scan, and a pelvic CT scan. Abdominal and pelvic CT scans performed between complete staging and first cancer-directed treatment, if not ordered due to an acute condition, were considered duplicates. We characterized the institutions providing the tests and evaluated the association with survival using a weighted pooled logistic regression adjusted by baseline and time-varying confounders. RESULTS:: Of 36,291 patients with a complete staging, 2680 (7.4%) had at least 1 duplicated test. Patients receiving a duplicate had a higher comorbidity score, were more symptomatic, and had more visits to the emergency department and clinical evaluations. They also were treated with surgery less frequently and had worse survival (hazard ratio 1.22, 95% confidence interval, 1.16-1.28). The type of institution involved in the staging (nonprofit/government centers, proprietary centers, free-standing facilities) was not associated with receiving duplicated tests. CONCLUSIONS:: We found a low frequency of duplicated abdominal or pelvic CT scans in the staging of colon cancer in the Medicare population.

Authors: Chen AB, Li L, Cronin A, Schrag D

Title: Comparative Effectiveness of Intensity-Modulated Versus 3D Conformal Radiation Therapy Among Medicare Patients with Stage III Lung Cancer.

Journal: J Thorac Oncol :-

Date: 2014 Sep 12

Abstract: INTRODUCTION:: The clinical benefit of intensity-modulated radiation therapy (IMRT) compared to 3D conformal radiation (3D-RT) has not been well established for locally advanced non-small-cell lung cancer (NSCLC). METHODS:: Using SEER-Medicare, we identified Medicare beneficiaries diagnosed with stage III NSCLC who received potentially curative (≥ 25 fractions) thoracic IMRT or 3D-RT from 2002-2009. Overall survival and number of hospital days within 90 days of radiation were analyzed using Cox proportional hazard and negative binomial regression models, respectively. Propensity score adjustment was used to control for clinical and demographic variables associated with outcomes. RESULTS:: IMRT comprised an increasing proportion of conformal thoracic radiation for NSCLC, rising from 3.0% in 2002 to 26.8% in 2009. Use of IMRT varied significantly by year of diagnosis, facility type, and geographic region and was more likely to be used among patients receiving chemotherapy or with higher comorbidity scores. Among patients receiving potentially curative treatment, there was no difference in overall survival (propensity adj HR .99, p = 0.83) or number of hospital days in the 90 days following radiation start (propensity adj HR 1.15, p = 0.23). CONCLUSIONS:: When radiation is used to treat locally advanced NSCLC, IMRT is increasingly preferred to 3D-RT. However, among patients receiving potentially curative radiation there was no significant difference in overall survival or time spent hospitalized following treatment.

Authors: Penn DC, Chang Y, Meyer AM, DeFilippo Mack C, Sanoff HK, Stitzenberg KB, Carpenter WR

Title: Provider-based research networks may improve early access to innovative colon cancer treatment for African Americans treated in the community.

Journal: Cancer :-

Date: 2014 Sep 10

Abstract: BACKGROUND: African American (AA) patients with colon cancer (CC) experience worse outcomes than whites partly due to differential treatment. The National Cancer Institute's Community Clinical Oncology Program (CCOP), a provider-based research network, adopts and diffuses innovative CC treatments quickly. The authors hypothesized that CCOP participation would lessen racial differences in the receipt of oxaliplatin, an innovative treatment for CC, among patients with stage III CC in the community. METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors performed a population-based retrospective cohort study of AA and white individuals aged ≥66 years who were diagnosed with AJCC stage III CC from 2003 through 2005. Generalized estimating equations were used to calculate the odds of receiving an oxaliplatin-containing regimen. Predicted probabilities of oxaliplatin receipt for race-CCOP combinations were calculated. The absolute difference in oxaliplatin receipt between races was estimated using the interaction contrast ratio. RESULTS: Of 2971 included individuals, 36% received oxaliplatin, 29.5% were CCOP-affiliated, and 7.6% were AA. On multivariate analysis, early diffusion of oxaliplatin was not found to be associated with race or CCOP participation. The probability of receiving oxaliplatin for AAs participating in a CCOP (0.46) was nearly double that of AAs who were not participating in a CCOP (0.25; P <.05). For white individuals, the probabilities of receiving oxaliplatin did not differ by CCOP participation. For oxaliplatin receipt, the joint effects assessment suggested a greater benefit of CCOP participation among AAs (interaction contrast ratio, 1.7). CONCLUSIONS: Among older patients with stage III CC, there is a differential impact of race on oxaliplatin receipt depending on CCOP participation. AAs treated by CCOPs were more likely to receive oxaliplatin than AAs treated elsewhere. Provider-based research networks may facilitate early access to innovative treatment for AAs with stage III CC. Cancer 2014. © 2014 American Cancer Society.

Authors: Jarosek SL, Virnig BA, Chu H, Elliott SP

Title: Propensity-weighted Long-term Risk of Urinary Adverse Events After Prostate Cancer Surgery, Radiation, or Both.

Journal: Eur Urol :-

Date: 2014 Sep 09

Abstract: BACKGROUND: Prostate cancer is the second most common cancer in men and has high survivorship, yet little is known about the long-term risk of urinary adverse events (UAEs) after treatment. OBJECTIVE: To compare the long-term UAE incidence across treatment and control groups. DESIGN, SETTING, AND PARTICIPANTS: Using a matched-cohort design, we identified elderly men treated with external-beam radiotherapy (EBRT; n=44 318), brachytherapy (BT; n=14 259), EBRT+BT (n=11 835), radical prostatectomy (RP; n=26 970), RP+EBRT (n=1557), or cryotherapy (n=2115) for non-metastatic prostate cancer and 144 816 non-cancer control individuals from the population-based Surveillance, Epidemiology, and End Results-Medicare linked data from 1992-2007 with follow-up through 2009. OUTCOME MEASURES AND STATISTICAL ANALYSIS: The incidence of treated UAEs and time from cancer treatment to first UAE were analyzed in terms of propensity-weighted survival. RESULTS: Median follow-up was 4.14 yr. At 10 yr, all treatment groups experienced higher propensity-weighted cumulative UAE incidence than the control group (16.1%; hazard risk [HR] 1.0), with the highest incidence for RP+EBRT (37.8%; HR 3.19, 95% confidence interval [CI] 2.79-3.66), followed by BT+EBRT (28.4%; HR 1.97, CI 1.85-2.10), RP (26.6%; HR 2.44, CI 2.34-2.55), cryotherapy (23.4%; HR 1.56, CI 1.30-1.87), BT (19.8%; HR 1.43, CI 1.33-1.53), and EBRT (19.7%; HR 1.11, CI 1.07-1.16). Bladder outlet obstruction was the most common event. CONCLUSIONS: Men undergoing RP, RP+EBRT, and BT+EBRT experienced the highest UAE risk at 10 yr, although UAEs accrued differently over extended follow-up. The significant background UAE rate among non-cancer control individuals yields a risk attributable to prostate cancer treatment that is 17% lower than prior estimates. PATIENT SUMMARY: We show that treatment for prostate cancer, especially combinations of two treatments such as radiation and surgery, carries a significant risk of urinary adverse events such as urethral stricture. This risk increases with time since treatment, emphasizing that treatments have long-term effects.

Authors: Ritch CR, Graves AJ, Keegan KA, Ni S, Bassett JC, Chang SS, Resnick MJ, Penson DF, Barocas DA

Title: Increasing use of observation among men at low risk for prostate cancer mortality.

Journal: J Urol :-

Date: 2014 Sep 04

Abstract: PURPOSE: There are growing concerns regarding the overtreatment of localized prostate cancer. It is also relatively unknown whether there has been increased uptake of observational strategies for disease management. We assessed the temporal trend in use of observation for clinically localized prostate cancer, particularly among men with low-risk disease, who were young and healthy enough to undergo treatment. MATERIALS AND METHODS: We conducted a retrospective cohort study using the Surveillance Epidemiology, and End Results cancer registry linked to Medicare claims (SEER-Medicare database) in 66,499 men with localized prostate cancer between 2004 and 2009. The main outcome was use of observation within one year following diagnosis. We performed multivariable analysis to develop a predictive model for use of observation adjusting for diagnosis year, age, risk and comorbidity. RESULTS: Observation was used in 12,007 men (18%) with a slight increase over time from 17% to 20%. However, there was marked increase in the use of observation from 18% in 2004 to 29% in 2009 for men with low-risk disease. Men 66-69 years old, with low-risk disease and no comorbidities, had twice the odds of undergoing observation in 2009 versus 2004 (OR = 2.12; 95% CI = 1.73-2.59). In addition to the diagnosis year, age, risk group, comorbidity and race were independent predictors of undergoing observation (all P<.001). CONCLUSIONS: We identified increasing use of observation for low-risk prostate cancer between 2004 and 2009, even among men young and healthy enough for treatment, suggesting growing acceptance of surveillance in this group of patients.

Authors: Gupta A, Atoria CL, Ehdaie B, Shariat SF, Rabbani F, Herr HW, Bochner BH, Elkin EB

Title: Risk of Fracture After Radical Cystectomy and Urinary Diversion for Bladder Cancer.

Journal: J Clin Oncol :-

Date: 2014 Sep 02

Abstract: PURPOSE: Radical cystectomy and urinary diversion may cause chronic metabolic acidosis, leading to long-term bone loss in patients with bladder cancer. However, the risk of fractures after radical cystectomy has not been defined. We assessed whether radical cystectomy and intestinal urinary diversion are associated with increased risk of fracture. PATIENTS AND METHODS: Population-based study using SEER-Medicare-linked data from 2000 through 2007 for patients with stage 0-III bladder cancer. We evaluated the association between radical cystectomy and risk of fracture at any site, controlling for patient and disease characteristics. RESULTS: The cohort included 50,520 patients, of whom 4,878 had cystectomy and urinary diversion. The incidence of fracture in the cystectomy group was 6.55 fractures per 100 person-years, compared with 6.39 fractures per 100 person-years in those without cystectomy. Cystectomy was associated with a 21% greater risk of fracture (adjusted hazard ratio, 1.21; 95% CI, 1.10 to 1.32) compared with no cystectomy, controlling for patient and disease characteristics. There was no evidence of an interaction between radical cystectomy and age, sex, comorbidity score, or cancer stage. CONCLUSION: Patients with bladder cancer who have radical cystectomy and urinary diversion are at increased risk of fracture.

Authors: Wang YR, Cangemi JR, Loftus Jr EV, Picco MF

Title: Use of Surveillance Colonoscopy in Medicare Patients with Inflammatory Bowel Disease prior to Colorectal Cancer Diagnosis.

Journal: Digestion 90(1):58-62

Date: 2014 Sep 02

Abstract: Background: Patients with longstanding inflammatory bowel disease (IBD) involving large intestine proximal to rectum are considered to be at increased risk for colorectal cancer (CRC). One prior study showed low utilization of surveillance colonoscopy in patients with ≥8 years of ulcerative colitis (UC) in the USA. Aims: To study use of surveillance colonoscopy among Medicare beneficiaries with IBD in the 2-year period prior to CRC diagnosis. Data and Methods: Our study sample included Medicare beneficiaries in the SEER-Medicare-linked database who were diagnosed with CRC during 2001-2005 and had ≥3 physician visits with ICD-9 diagnosis code for IBD prior to CRC diagnosis. Medicare beneficiaries aged >85 years without Part B coverage or enrolled in HMOs were excluded. Colonoscopy performed within 6-30 months prior to CRC diagnosis was defined as surveillance colonoscopy. The χ(2) test and multivariate logistic regression were used in statistical analysis. Results: Of 241 Medicare beneficiaries with IBD and diagnosed with CRC, 92 (38%) patients underwent ≥1 surveillance colonoscopy in the 2 years prior to cancer diagnosis. The use of surveillance colonoscopy was similar between Crohn's disease (28/86, 33%) and UC (64/155, 41%). In multivariate logistic regression, older age (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.94-0.99) was negative associated with surveillance colonoscopy use and personal history of colon polyp (OR 2.73, 95% CI 1.09-6.87) was positively associated with surveillance colonoscopy use. Conclusions: Use of surveillance colonoscopy was low among Medicare beneficiaries with IBD in the 2 years prior to CRC diagnosis. © 2014 S. Karger AG, Basel.

Authors: Wong J, Xu B, Yeung HN, Roeland EJ, Martinez ME, Le QT, Mell LK, Murphy JD

Title: Age disparity in palliative radiation therapy among patients with advanced cancer.

Journal: Int J Radiat Oncol Biol Phys 90(1):224-30

Date: 2014 Sep 01

Abstract: PURPOSE/OBJECTIVE: Palliative radiation therapy represents an important treatment option among patients with advanced cancer, although research shows decreased use among older patients. This study evaluated age-related patterns of palliative radiation use among an elderly Medicare population. METHODS AND MATERIALS: We identified 63,221 patients with metastatic lung, breast, prostate, or colorectal cancer diagnosed between 2000 and 2007 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Receipt of palliative radiation therapy was extracted from Medicare claims. Multivariate Poisson regression analysis determined residual age-related disparity in the receipt of palliative radiation therapy after controlling for confounding covariates including age-related differences in patient and demographic covariates, length of life, and patient preferences for aggressive cancer therapy. RESULTS: The use of radiation decreased steadily with increasing patient age. Forty-two percent of patients aged 66 to 69 received palliative radiation therapy. Rates of palliative radiation decreased to 38%, 32%, 24%, and 14% among patients aged 70 to 74, 75 to 79, 80 to 84, and over 85, respectively. Multivariate analysis found that confounding covariates attenuated these findings, although the decreased relative rate of palliative radiation therapy among the elderly remained clinically and statistically significant. On multivariate analysis, compared to patients 66 to 69 years old, those aged 70 to 74, 75 to 79, 80 to 84, and over 85 had a 7%, 15%, 25%, and 44% decreased rate of receiving palliative radiation, respectively (all P<.0001). CONCLUSIONS: Age disparity with palliative radiation therapy exists among older cancer patients. Further research should strive to identify barriers to palliative radiation among the elderly, and extra effort should be made to give older patients the opportunity to receive this quality of life-enhancing treatment at the end of life.

Authors: Silverman D, Ruth K, Sigurdson ER, Egleston BL, Goldstein LJ, Wong YN, Boraas M, Bleicher RJ

Title: Skin involvement and breast cancer: are t4b lesions of all sizes created equal?

Journal: J Am Coll Surg 219(3):534-44

Date: 2014 Sep

Abstract: BACKGROUND: Nonmetastatic, noninflammatory, invasive breast cancers with skin involvement (SI) are classified as T4b, regardless of size. This study evaluated disease-specific survival (DSS) to determine whether size should be considered for these lesions rather than grouping them all into stage III. STUDY DESIGN: Surveillance, Epidemiology, and End Results data linked to Medicare claims were reviewed. Skin involved and non-SI tumors were reclassified using the American Joint Committee on Cancer, 7(th) edition groupings using tumor size and nodal involvement alone without considering SI (neostage). Disease-specific survival was adjusted for demographics, histology, and treatment using competing risk methods with propensity score-based weighting and bootstrap standard errors. RESULTS: Among 924 SI patients diagnosed between 1992 and 2005, tumors were 0.1 to 2.0 cm, 2.1 to 5.0 cm, and >5.0 cm in 11.6%, 51.1%, and 37.3% of patients, respectively. There were no nodal metastases in 22.3%, 1 to 3 positive nodes in 31.7%, 4 to 9 positive in 28.6%, and ≥10 positive in 17.4% of patients. For SI patients, adjusted 5-year DSS was 95.8% (95% CI, 95.6-96.0) for neostage I, declining progressively to 36.4% (95% CI, 33.8-39.2) for neostage IIIC patients. Adjusted 5-year DSS for SI and non-SI tumors (n = 66,185) was similar for neostage I, IIA, and IIB, and markedly lower for IIIA and IIIC. Adjusted DSS for SI IIIA was similar to non-SI IIIC. CONCLUSIONS: Noninflammatory SI breast cancers have widely varied DSS that differs by tumor size and nodal involvement and therefore should not all be stage III. Skin involvement should be subordinate to T and N groupings to classify SI with non-SI lesions having similar prognoses.

Authors: White AJ, Reeve BB, Chen RC, Stover AM, Irwin DE

Title: Coexistence of urinary incontinence and major depressive disorder with health-related quality of life in older Americans with and without cancer.

Journal: J Cancer Surviv 8(3):497-507

Date: 2014 Sep

Abstract: PURPOSE: This study evaluates the prevalence and factors associated with major depressive disorder (MDD) in a population of cancer survivors and the impact of co-occurring MDD and urinary incontinence (UI) on health-related quality of life (HRQOL). METHODS: The prevalence of MDD risk among cancer survivors (breast, prostate, bladder, colorectal, lung, and endometrial/uterine cancers) and those without cancer was estimated using the Surveillance, Epidemiology and End Results Program-Medicare Health Outcomes Survey (SEER-MHOS) linked database (n = 9,282 with cancer/n = 289,744 without cancer). Risk for MDD was measured using three items from the Diagnostic Interview Schedule, and HRQOL was measured by the SF-36. UI was defined as self-reported leakage of urine causing a problem in previous 6 months. Factors associated with MDD were investigated using logistic regression, and the impact of co-occurring MDD and UI on HRQOL scores was determined using linear regression. RESULTS: The prevalence of MDD risk ranged from 19.2 % for prostate to 34.1 % for lung. Lung cancer diagnosis was associated with risk of MDD. Being ≥5 years from diagnosis was associated with decreased risk of MDD (prevalence odds ratio (POR) = 0.82, 95 % confidence interval (95 % CI) 0.71, 0.95). The coexistence of both UI and MDD was associated with a decrease across HRQOL subscales; including 40 points on role-emotional (RE) score. CONCLUSIONS: Cancer survivors reporting co-occurrence of UI and MDD experienced significant decrements in HRQOL. IMPLICATIONS OF CANCER SURVIVORS: Understanding the combined effect of UI and MDD may help clinicians to better recognize and alleviate their effects on cancer survivors' HRQOL.

Authors: Ezer N, Smith CB, Galsky MD, Mhango G, Gu F, Gomez J, Strauss GM, Wisnivesky J

Title: Cisplatin vs. carboplatin-based chemoradiotherapy in patients >65years of age with stage III non-small cell lung cancer.

Journal: Radiother Oncol :-

Date: 2014 Aug 20

Abstract: BACKGROUND AND PURPOSE: Combined chemoradiotherapy (CRT) is considered the standard care for unresectable stage III non-small cell lung cancer (NSCLC). There have been limited data comparing outcomes of carboplatin vs. cisplatin-based CRT, particularly in elderly. MATERIAL AND METHODS: From the Surveillance, Epidemiology and End Results-Medicare registry, we identified 1878 patients >65years of age with unresected stage III NSCLC that received concurrent CRT between 2002 and 2009. We fitted a propensity score model predicting use of cisplatin-based therapy and compared adjusted overall and lung-cancer specific survival of carboplatin- vs. cisplatin-treated patients. Rates of severe toxicity requiring hospital admission were compared in propensity score adjusted analyses. RESULTS: Overall 1552 (83%) received carboplatin (77% in combination with paclitaxel) and 17% cisplatin (67% in combination with etoposide). Adjusted cox models showed similar overall (hazard ratio [HR]: 0.98; 95% confidence interval [CI]: 0.86-1.12) and lung cancer-specific (HR: 0.99; 95% CI: 0.84-1.17) survival among patients treated with carboplatin vs. cisplatin. Adjusted rates of neutropenia (odds ratio [OR]: 0.35; 95% CI: 0.21-0.61), anemia (OR: 0.67; 95% CI: 0.51-0.89), and thrombocytopenia (OR: 0.51; 95% CI: 0.31-0.85) were lower among carboplatin-treated patients; other toxicities were not different between groups. CONCLUSION: Carboplatin-based CRT is associated with similar long-term survival but lower rates of toxicity. These findings suggest carboplatin may be the most appropriate chemotherapeutic agent for elderly stage III patients.

Authors: Goldenberg D, Mackley H, Koch W, Bann DV, Schaefer EW, Hollenbeak CS

Title: Age and stage as determinants of treatment for oral cavity and oropharyngeal cancers in the elderly.

Journal: Oral Oncol :-

Date: 2014 Aug 18

Abstract: BACKGROUND: We investigate treatment selection for oral cavity and oropharyngeal (OC&OP) cancers to understand factors that influence treatment selection. METHODS: We studied 7023 patients, ⩾66years, diagnosed with a first primary OC&OP cancer using SEER-Medicare data. Multinomial logistic regression was to model treatment selection, controlling for other factors. RESULTS: Most patients with OC cancer were treated with surgery alone (56.5%); most patients with OP cancer were treated with chemotherapy and radiation (28.9%). Age, stage and site were the most important predictors of treatment selection. As age increased from 70 to 81 (the interquartile range), treatment shifted toward surgery alone (OR=1.26; CI: 1.08-1.46) and no treatment (OR=1.5, 95% CI: 1.25-1.80), and away from combined surgery, radiation and treatments involving chemotherapy. CONCLUSIONS: Age, stage, and site are the most important determinants of treatment selection for patients with OC&OP cancers. Increasing age and stage drive treatment toward non-surgical options and no treatment at all.

Authors: Ravi P, Karakiewicz PI, Roghmann F, Gandaglia G, Choueiri TK, Menon M, McKay RR, Nguyen PL, Sammon JD, Sukumar S, Varda B, Chang SL, Kibel AS, Sun M, Trinh QD

Title: Mental health outcomes in elderly men with prostate cancer.

Journal: Urol Oncol :-

Date: 2014 Aug 18

Abstract: OBJECTIVE: To examine the burden of mental health issues (MHI), namely anxiety, depressive disorders, and suicide, in a population-based cohort of older men with localized prostate cancer and to evaluate associations with primary treatment modality. PATIENTS AND METHODS: A total of 50,856 men, who were 65 years of age or older with clinically localized prostate cancer diagnosed between 1992 and 2005 and without a diagnosis of mental illness at baseline, were abstracted from the Surveillance, Epidemiology, and End Results-Medicare database. The primary outcome of interest was the development of MHI (anxiety, major depressive disorder, depressive disorder not elsewhere classified, neurotic depression, adjustment disorder with depressed mood, and suicide) after the diagnosis of prostate cancer. RESULTS: A total of 10,389 men (20.4%) developed MHI during the study period. Independent risk factors for MHI included age≥75 years (hazard ratio [HR] = 1.29); higher comorbidity (Charlson comorbidity index≥3, HR = 1.63); rural hospital location (HR = 1.14); being single, divorced, or widowed (HR = 1.12); later year of diagnosis (HR = 1.05); and urinary incontinence (HR = 1.47). Black race (HR = 0.79), very high-income status (HR = 0.87), and definitive treatment (radical prostatectomy [RP], HR = 0.79; radiotherapy [RT], HR= 0.85, all P<0.001) predicted a lower risk of MHI. The rates of MHI at 10 years were 29.7%, 29.0%, and 22.6% in men undergoing watchful waiting (WW), RT, and RP, respectively. CONCLUSION: Older men with localized prostate cancer had a significant burden of MHI. Men treated with RP or RT were at a lower risk of developing MHI, compared with those undergoing WW, with median time to development of MHI being significantly greater in those undergoing RP compared with those undergoing RT or WW.

Authors: van Hees F, Zauber AG, Klabunde CN, Goede SL, Lansdorp-Vogelaar I, van Ballegooijen M

Title: The Appropriateness of More Intensive Colonoscopy Screening Than Recommended in Medicare Beneficiaries: A Modeling Study.

Journal: JAMA Intern Med :-

Date: 2014 Aug 18

Abstract: Importance: Many Medicare beneficiaries undergo more intensive colonoscopy screening than recommended. Whether this is favorable for beneficiaries and efficient from a societal perspective is uncertain. Objective: To determine whether more intensive colonoscopy screening than recommended is favorable for Medicare beneficiaries (ie, whether it results in a net health benefit) and whether it is efficient from a societal perspective (ie, whether the net health benefit justifies the additional resources required). Design, Setting, and Participants: Microsimulation modeling study of 65-year-old Medicare beneficiaries at average risk for colorectal cancer (CRC) and with an average life expectancy who underwent a screening colonoscopy at 55 years with negative results. Interventions: Colonoscopy screening as recommended by guidelines (ie, at 65 and 75 years) vs scenarios with a shorter screening interval (5 or 3 instead of 10 years) or in which screening was continued to 85 or 95 years. Main Outcomes and Measures: Quality-adjusted life-years (QALYs) gained (measure of net health benefit); additional colonoscopies required per additional QALY gained and additional costs per additional QALY gained (measures of efficiency). Results: Screening previously screened Medicare beneficiaries more intensively than recommended resulted in only small increases in CRC deaths prevented and life-years gained. In comparison, the increases in colonoscopies performed and colonoscopy-related complications experienced were large. As a result, all scenarios of more intensive screening than recommended resulted in a loss of QALYs, rather than a gain (ie, a net harm). The only exception was shortening the screening interval from 10 to 5 years, which resulted in 0.7 QALYs gained per 1000 beneficiaries. However, this scenario was inefficient because it required no less than 909 additional colonoscopies and an additional $711 000 per additional QALY gained. Results in previously unscreened beneficiaries were slightly less unfavorable, but conclusions were identical. Conclusions and Relevance: Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.

Authors: Kwan SW, Mortell KE, Hippe DS, Brunner MC

Title: An Economic Analysis of Sublobar Resection versus Thermal Ablation for Early-Stage Non-Small-Cell Lung Cancer.

Journal: J Vasc Interv Radiol :-

Date: 2014 Aug 14

Abstract: PURPOSE: To compare medical costs for a matched-pair cohort of Medicare patients with early-stage non-small-cell lung cancer (NSCLC) who underwent treatment with sublobar resection or thermal ablation. MATERIALS AND METHODS: Patients at least 65 years of age with stage IA/IB NSCLC treated with sublobar resection or thermal ablation from 2007 to 2009 were identified from Surveillance, Epidemiology, and End Results/Medicare-linked data and matched by propensity scores. The primary outcome of interest, cost from the payer's perspective, was derived from Medicare claims data. A partitioned inverse probability-weighted estimator was used to calculate mean and median treatment-related costs and costs at 1, 3, 12, 18, and 24 months after treatment. Baseline characteristics, Kaplan-Meier survival curves, and calculated cost variables were compared between the two groups. RESULTS: The final matched cohort of 128 patients had similar baseline characteristics and overall survival (P = .52). Patients who underwent ablation had significantly lower treatment-related costs than those who underwent sublobar resection (P < .001). The difference in median treatment-related cost was $16,105. At 1 month, 3 months, and 12 months after treatment, cumulative costs remained significantly different (P ≤ .011). Lower cost associated with ablations performed in the outpatient setting was a major contributor to the differences between the two treatment modalities, although inpatient ablations maintained a small cost advantage over sublobar resections. CONCLUSIONS: Among matched Medicare patients with stage I NSCLC, thermal ablation resulted in significantly lower treatment-related costs and cumulative medical costs 1 month, 3 months, and 12 months after treatment compared with sublobar resection.

Authors: Yang YX, French B, Localio AR, Brensinger CM, Lewis JD

Title: Minimal benefit of earlier-than-recommended repeat colonoscopy among US Medicare enrollees following a negative colonoscopy.

Journal: Aliment Pharmacol Ther :-

Date: 2014 Aug 14

Abstract: BACKGROUND: A large proportion of US Medicare beneficiaries undergo earlier-than-recommended follow-up colonoscopies after negative screening colonoscopy. Such practice entails substantial cost and added risk. AIMS: To compare the risk of colorectal cancer (CRC) associated with varying follow-up colonoscopy intervals following a negative colonoscopy, and to determine whether the potential benefit of a shorter colonoscopy follow-up interval would differ by gender. METHODS: We conducted a weighted cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database (1991-2006) among 932 370 Medicare enrollees who are representative of the entire US elderly population. We compared the cumulative incidence of CRC among patients who underwent follow-up colonoscopies at different intervals following a negative colonoscopy. The primary outcome was incident CRC. RESULTS: The eligible study cohort (n = 480 864) included 106 924 patients who underwent ≥1 colonoscopy. Men were more likely to require polypectomy during their initial colonoscopy than women. Compared to the recommended 9-10 year follow-up colonoscopy interval, an interval of 5-6 years was associated with the largest CRC cumulative risk reduction [i.e. 0.17% (95% CI: 0.009-0.32%)]. The magnitude of risk reduction associated with shorter colonoscopy follow-up intervals was not significantly different between men and women. CONCLUSIONS: Among elderly individuals who undergo a negative colonoscopy, the magnitude of reduction in the cumulative CRC risk afforded by earlier-than-recommended follow-up colonoscopy is quite small, and probably cannot justify the risk and cost of increased colonoscopy frequency. In addition, there are insufficient differences between men and women to warrant gender-specific recommendations.

Authors: de Vries S, Jeffe DB, Davidson NO, Deshpande AD, Schootman M

Title: Postoperative 30-day mortality in patients undergoing surgery for colorectal cancer: development of a prognostic model using administrative claims data.

Journal: Cancer Causes Control :-

Date: 2014 Aug 08

Abstract: PURPOSE: To develop a prognostic model to predict 30-day mortality following colorectal cancer (CRC) surgery using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data and to assess whether race/ethnicity, neighborhood, and hospital characteristics influence model performance. METHODS: We included patients aged 66 years and older from the linked 2000-2005 SEER-Medicare database. Outcome included 30-day mortality, both in-hospital and following discharge. Potential prognostic factors included tumor, treatment, sociodemographic, hospital, and neighborhood characteristics (census-tract-poverty rate). We performed a multilevel logistic regression analysis to account for nesting of CRC patients within hospitals. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) for discrimination and the Hosmer-Lemeshow goodness-of-fit test for calibration. RESULTS: In a model that included all prognostic factors, important predictors of 30-day mortality included age at diagnosis, cancer stage, and mode of presentation. Race/ethnicity, census-tract-poverty rate, and hospital characteristics were independently associated with 30-day mortality, but they did not influence model performance. Our SEER-Medicare model achieved moderate discrimination (AUC = 0.76), despite suboptimal calibration. CONCLUSIONS: We developed a prognostic model that included tumor, treatment, sociodemographic, hospital, and neighborhood predictors. Race/ethnicity, neighborhood, and hospital characteristics did not improve model performance compared with previously developed models.

Authors: Schroeck FR, Kaufman SR, Jacobs BL, Hollenbeck BK

Title: Receipt of "Best Care" According to Current Quality of Care Measures and Outcomes Among men with Prostate Cancer.

Journal: J Urol :-

Date: 2014 Aug 06

Abstract: PURPOSE: We evaluated whether prostate cancer patients receiving "Best Care" according to a set of five nationally endorsed quality measures had decreased treatment related morbidity and improved cancer control. METHODS: In this retrospective cohort study, we included 38,055 men from the Surveillance Epidemiology and End Results-Medicare database treated for localized prostate cancer between 2004 and 2010. For each patient, we determined whether he received "Best Care", defined as care adherent to all applicable measures. We measured associations of "Best Care" with need for interventions addressing treatment related morbidity and with need for secondary cancer therapy using Cox proportional hazards models. RESULTS: Only 3,412 men (9.0%) received "Best Care". Five years after treatment, these men had a similar likelihood as men who did not receive "Best Care" to undergo procedures for urinary morbidity (e.g., 10.7% vs. 12.9%, p=0.338, for the subset of men who underwent prostatectomy) and secondary cancer therapy (e.g., 40.9% vs. 37.3%, p=0.522, for the subset of men who underwent prostatectomy for high-risk prostate cancer). However, they were more likely to have a procedure for sexual morbidity (e.g., 17.3% vs. 10.8%, p<0.001, for men who underwent prostatectomy). Similar trends were observed among men treated with radiotherapy. CONCLUSIONS: Overall, men receiving "Best Care" did not fare better with regards to treatment related morbidity and cancer control. Collectively, our findings suggest that the current process of care measures are not tightly linked to outcomes and that further research is needed to identify better measures that are meaningful and important to patients.

Authors: Black DM, Jiang J, Kuerer HM, Buchholz TA, Smith BD

Title: Racial disparities in adoption of axillary sentinel lymph node biopsy and lymphedema risk in women with breast cancer.

Journal: JAMA Surg 149(8):788-96

Date: 2014 Aug 01

Abstract: IMPORTANCE: Racial disparities exist in many aspects of breast cancer care. Sentinel lymph node biopsy (SLNB) was developed to replace axillary lymph node dissection (ALND) for staging early breast cancer to minimize complications. Racial disparities in the use of SLNB remain incompletely characterized, and their effect on lymphedema risk is not known. OBJECTIVE: To determine racial differences in SLNB use among patients with pathologically node-negative breast cancer during the period when SLNB became the preferred method for axillary staging as well as whether such differences affect lymphedema risk. DESIGN, SETTING, AND PARTICIPANTS: A retrospective study was conducted using the Surveillance, Epidemiology, and End Results-Medicare-linked database from 2002 through 2007 to identify cases of incident, nonmetastatic, pathologically node-negative breast cancer in women aged 66 years or older. MAIN OUTCOMES AND MEASURES: Sentinel lymph node biopsy use and 5-year cumulative incidence of lymphedema by race. RESULTS: Of 31 274 women identified, 1767 (5.6%) were black, 27 856 (89.1%) were white, and 1651 (5.3%) were of other or unknown race. Sentinel lymph node biopsy was performed in 73.7% of white patients and 62.4% of black patients (P < .001). The use of SLNB increased by year for both black and white patients (P < .001); however, a fixed disparity of approximately 12 percentage points in SLNB use persisted through 2007. In adjusted analysis, black patients were significantly less likely than white patients to undergo SLNB (odds ratio, 0.67; 95% CI, 0.60-0.75; P < .001). Overall, the 5-year cumulative lymphedema risk was 8.2% in whites and 12.3% in blacks (hazard ratio [HR], 1.43; 95% CI, 1.23-1.67; P < .001). When stratified by type of axillary surgery, 5-year lymphedema risk was 6.8% in whites undergoing SLNB (HR, 1 [reference]), 8.8% in blacks undergoing SLNB (HR, 1.28; 95% CI, 1.02-1.60; P = .03), 12.2% in whites undergoing ALND (1.79; 1.63-1.96; P < .001), and 18.0% in blacks undergoing ALND (2.76; 2.25-3.39; P < .001). CONCLUSIONS AND RELEVANCE: Although SLNB use increased in both black and white patients with pathologically node-negative breast cancer from 2002 through 2007, the rates of SLNB remained lower in black than white patients during this entire period by approximately 12 percentage points. This racial disparity in SLNB use contributed to racial disparities in lymphedema risk. Improvements in the dissemination of new techniques are needed to avoid disparities in breast cancer care and patient outcomes, particularly in disadvantaged groups.

Authors: Lipitz-Snyderman A, Sepkowitz KA, Elkin EB, Pinheiro LC, Sima CS, Son CH, Atoria CL, Bach PB

Title: Long-term central venous catheter use and risk of infection in older adults with cancer.

Journal: J Clin Oncol 32(22):2351-6

Date: 2014 Aug 01

Abstract: PURPOSE: Long-term central venous catheters (CVCs) are often used in patients with cancer to facilitate venous access to administer intravenous fluids and chemotherapy. CVCs can also be a source of bloodstream infections, although this risk is not well understood. We examined the impact of long-term CVC use on infection risk, independent of other risk factors such as chemotherapy, in a population-based cohort of patients with cancer. PATIENTS AND METHODS: We conducted a retrospective analysis using SEER-Medicare data for patients age > 65 years diagnosed from 2005 to 2007 with invasive colorectal, head and neck, lung, or pancreatic cancer, non-Hodgkin lymphoma, or invasive or noninvasive breast cancer. Cox proportional hazards regression was used to examine the relationship between CVC use and infections, with CVC exposure as a time-dependent predictor. We used multivariable analysis and propensity score methods to control for patient characteristics. RESULTS: CVC exposure was associated with a significantly elevated infection risk, adjusting for demographic and disease characteristics. For patients with pancreatic cancer, risk of infections during the exposure period was three-fold greater (adjusted hazard ratio [AHR], 2.93; 95% CI, 2.58 to 3.33); for those with breast cancer, it was six-fold greater (AHR, 6.19; 95% CI, 5.42 to 7.07). Findings were similar when we accounted for propensity to receive a CVC and limited the cohort to individuals at high risk of infections. CONCLUSION: Long-term CVC use was associated with an increased risk of infections for older adults with cancer. Careful assessment of the need for long-term CVCs and targeted strategies for reducing infections are critical to improving cancer care quality.

Authors: Agaku IT, Ayo-Yusuf OA, Vardavas CI

Title: A comparison of cessation counseling received by current smokers at US dentist and physician offices during 2010-2011.

Journal: Am J Public Health 104(8):e67-75

Date: 2014 Aug

Abstract: OBJECTIVES: We compared patient-reported receipt of smoking cessation counseling from US dentists and physicians. METHODS: We analyzed the 2010 to 2011 Tobacco Use Supplement of the Current Population Survey to assess receipt of smoking cessation advice and assistance by a current smoker from a dentist or physician in the past 12 months. RESULTS: Current adult smokers were significantly less likely to be advised to quit smoking during a visit to a dentist (31.2%) than to a physician (64.8%). Among physician patients who were advised to quit, 52.7% received at least 1 form of assistance beyond the simple advice to quit; 24.5% of dental patients received such assistance (P < .05). Approximately 9.4 million smokers who visited a dentist in 2010 to 2011 did not receive any cessation counseling. CONCLUSIONS: Our results indicate a need for intensified efforts to increase dentist involvement in cessation counseling. System-level changes, coupled with regular training, may enhance self-efficacy of dentists in engaging patients in tobacco cessation counseling.

Authors: Curtin GM, Sulsky SI, Van Landingham C, Marano KM, Graves MJ, Ogden MW, Swauger JE

Title: Primary measures of dependence among menthol compared to non-menthol cigarette smokers in the United States.

Journal: Regul Toxicol Pharmacol 69(3):451-66

Date: 2014 Aug

Abstract: Previously published studies provide somewhat inconsistent evidence on whether menthol in cigarettes is associated with increased dependence. The National Health and Nutrition Examination Survey, National Survey on Drug Use and Health, National Health Interview Survey, and Tobacco Use Supplement to the Current Population Survey collect data on current cigarette type preference and primary measures of dependence, and thus allow examination of whether menthol smokers are more dependent than non-menthol smokers. Analyses based on combined data from multiple administrations of each of these four nationally representative surveys, using three definitions for current smokers (i.e., smoked ⩾1day, ⩾10days and daily during the past month), consistently demonstrate that menthol smokers do not report smoking more cigarettes per day than non-menthol smokers. Moreover, two of the three surveys that provide data on time to first cigarette after waking indicate no difference in urgency to smoke among menthol compared to non-menthol smokers, while the third suggests menthol smokers may experience a greater urgency to smoke; estimates from all three surveys indicate that menthol versus non-menthol smokers do not report a higher Heaviness of Smoking Index. Collectively, these findings indicate no difference in dependence among U.S. smokers who use menthol compared to non-menthol cigarettes.

Authors: DuGoff EH, Bekelman JE, Stuart EA, Armstrong K, Pollack CE

Title: Surgical Quality Is More Than Volume: The Association between Changing Urologists and Complications for Patients with Localized Prostate Cancer.

Journal: Health Serv Res 49(4):1165-83

Date: 2014 Aug

Abstract: OBJECTIVES: To examine the association of changing urologists on surgical complications in men with prostate cancer. DATA SOURCES/STUDY SETTING: Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005. STUDY DESIGN: A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy. METHODS: Subjects were classified as having "changed urologists" if they had a different urologist who diagnosed their cancer from the one who performed their surgery. "Doubly robust" propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence. PRINCIPAL FINDINGS: Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76-0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment. CONCLUSIONS: Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.

Authors: Gourin CG, Dy SM, Herbert RJ, Blackford AL, Quon H, Forastiere AA, Eisele DW, Frick KD

Title: Treatment, survival, and costs of laryngeal cancer care in the elderly.

Journal: Laryngoscope 124(8):1827-35

Date: 2014 Aug

Abstract: OBJECTIVES/HYPOTHESIS: To examine associations between treatment and volume with survival and costs in elderly patients with laryngeal squamous cell cancer (SCCA). STUDY DESIGN: Retrospective cross-sectional analysis of Surveillance, Epidemiology, and End Results-Medicare data. METHODS: We evaluated 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 using cross-tabulations, multivariate logistic and generalized linear regression modeling, and survival analysis. RESULTS: Chemoradiation was significantly associated with supraglottic tumors (relative risk ratio: 2.6, 95% confidence interval [CI]: 1.7-4.0), additional cancer-directed treatment (odds ratio [OR]: 1.8, 95% CI: 1.2-2.7), and a reduced likelihood of surgical salvage (OR: 0.3, 95% CI: 0.2-0.6). Surgery with postoperative radiation was associated with significantly improved survival (hazard ratio [HR]: 0.7, 95% CI: 0.6-0.9), after controlling for patient and tumor variables including salvage. High-volume care was not associated with survival for nonoperative treatment but was associated with improved survival (HR: 0.7, 95% CI: 0.5-0.8) among surgical patients. Initial treatment and 5-year overall costs for chemoradiation were higher than for all other treatment categories. High-volume care was associated with significantly lower costs of care for surgical patients but was not associated with differences in costs of care for nonoperative treatment. CONCLUSIONS: Chemoradiation in elderly patients with laryngeal cancer was associated with increased costs, additional cancer-directed treatment, and a reduced likelihood of surgical salvage. Surgery with postoperative radiation was associated with improved survival in this cohort, and high-volume hospital surgical care was associated with improved survival and lower costs. These findings have implications for improving the quality of laryngeal cancer treatment at a time of both rapid growth in the elderly population and diminishing healthcare resources. LEVEL OF EVIDENCE: 2cLaryngoscope, 124:1827-1835, 2014.

Authors: Karl A, Adejoro O, Saigal C, Konety B, Urologic Diseases in America Project

Title: General adherence to guideline recommendations on initial diagnosis of bladder cancer in the United States and influencing factors.

Journal: Clin Genitourin Cancer 12(4):270-7

Date: 2014 Aug

Abstract: BACKGROUND: Because international guidelines recommend best practices regarding staging of incident bladder cancer, we determined the adherence to such recommendations in the United States, performing a large retrospective database analysis. PATIENTS AND METHODS: Patients with the diagnosis of urothelial cancer were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between 1992 and 2007. Staging procedures were identified and analyzed. As reference for published recommendations, we used the American Urological Association (AUA), European Association of Urology (EAU), and National Comprehensive Cancer Network (NCCN) guidelines. Based on these sources, recommended initial staging of bladder cancer was analyzed. Of all 56,130 patients, 6148 (10.9%) had a cytologic examination, 29,677 (52.9%) had a standard urinalysis, 2882 (5.1%) underwent intravenous pyelography (IVP), 6950 (12.4%) underwent retrograde pyelography (RPG), and 8145 (14.5%) had computed tomography/magnetic resonance imaging (CT/MRI). RESULTS: There was a significant trend over the years to a higher use of cytologic analysis, standard urinalysis, and CT/MRI. We observed a significant trend toward a lower rate of IVP and a stable use of RPG. The limitation of our study is that claims data are designed for payment processing, not quality measurement. CONCLUSION: Despite published recommendations on the initial diagnosis of bladder cancer, our data show that less than half of the included patients received all the elements thought to be required for an initial diagnosis of bladder cancer as recommended by guidelines. Greater adherence to recommendations may ensure optimal treatment strategies. Appropriate treatment is critical to patient outcomes, because evidence-based therapeutic management can be practiced only if an accurate assessment of the disease takes place at the time of initial diagnosis.

Authors: Killelea BK, Long JB, Chagpar AB, Ma X, Wang R, Ross JS, Gross CP

Title: Evolution of breast cancer screening in the Medicare population: clinical and economic implications.

Journal: J Natl Cancer Inst 106(8):-

Date: 2014 Aug

Abstract: BACKGROUND: Newer approaches to mammography, including digital image acquisition and computer-aided detection (CAD), and adjunct imaging (e.g., magnetic resonance imaging [MRI]) have diffused into clinical practice. The impact of these technologies on screening-related cost and outcomes remains undefined, particularly among older women. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we constructed two cohorts of women without a history of breast cancer and followed each cohort for 2 years. We compared the use and cost of screening mammography including digital mammography and CAD, adjunct procedures including breast ultrasound, MRI, and biopsy between the period of 2001 and 2002 and the period of 2008 and 2009 using χ(2) and t test. We also assessed the change in breast cancer stage and incidence rates using χ(2) and Poisson regression. All statistical tests were two-sided. RESULTS: There were 137150 women (mean age = 76.0 years) in the early cohort (2001-2002) and 133097 women (mean age = 77.3 years) in the later cohort (2008-2009). The use of digital image acquisition for screening mammography increased from 2.0% in 2001 and 2002 to 29.8% in 2008 and 2009 (P < .001). CAD use increased from 3.2% to 33.1% (P < .001). Average screening-related cost per capita increased from $76 to $112 (P < .001), with annual national fee-for-service Medicare spending increasing from $666 million to $962 million. There was no statistically significant change in detection rates of early-stage tumors (2.45 vs 2.57 per 1000 person-years; P = .41). CONCLUSIONS: Although breast cancer screening-related costs increased substantially from 2001 through 2009 among Medicare beneficiaries, a clinically significant change in stage at diagnosis was not observed.

Authors: Olszewski AJ, Winer ES, Castillo JJ

Title: Improved survival with rituximab-based chemoimmunotherapy in older patients with extranodal diffuse large B-cell lymphoma.

Journal: Leuk Res 38(8):866-73

Date: 2014 Aug

Abstract: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we investigated the relative benefits of adding rituximab to CHOP chemotherapy in diffuse large B-cell lymphoma (DLBCL) of extranodal origin, and found similar advantage for nodal and extranodal lymphomas. Hazard ratio for overall survival was 0.64 for nodal, and 0.70 for extranodal DLBCL. Hazard ratios for lymphoma-related death were 0.62 and 0.57, respectively. The advantage was largest for DLBCL of the spleen, liver and lung. Conversely, it was not evident for thyroid or testicular lymphomas. Compared with nodal DLBCL, spleen was the only site with significantly better prognosis after R-CHOP.

Authors: Parmar AD, Vargas GM, Tamirisa NP, Sheffield KM, Riall TS

Title: Trajectory of care and use of multimodality therapy in older patients with pancreatic adenocarcinoma.

Journal: Surgery 156(2):280-9

Date: 2014 Aug

Abstract: INTRODUCTION: Multimodality therapy with chemotherapy and operative resection is recommended for patients with locoregional pancreatic cancer but is not received by many patients. OBJECTIVE: To evaluate patterns in the use and timing of chemotherapy and resection and factors associated with receipt of multimodality therapy in older patients with locoregional pancreatic cancer. METHODS: We used Surveillance, Epidemiology, and End Results-linked Medicare data (1992-2007) to identify patients with locoregional pancreatic adenocarcinoma. Multimodality therapy was defined as receipt of both chemotherapy and pancreatic resection. Logistic regression was used to determine factors independently associated with receipt of multimodality therapy. Log-rank tests were used to identify differences in survival for patients stratified by type and timing of treatment. RESULTS: We identified 10,505 patients with pancreatic adenocarcinoma. 5,358 patients (51.0%) received either chemotherapy or surgery, with 1,166 patients (11.1%) receiving both modalities. Resection alone was performed in 1,138 patients (10.8%), and chemotherapy alone was given to 3,054 (29.1%) patients. In patients undergoing resection as the initial treatment modality, 49.4% never received chemotherapy; 97.4% of patients who underwent chemotherapy as the initial treatment modality never underwent resection. The use of multimodality therapy increased from 7.4% of patients in 1992-1995 to 13.8% of patients in 2004-2007 (P < .0001). The 2-year survival was 41.0% for patients receiving multimodality therapy, 25.1% with resection alone, and 12.5% with chemotherapy alone (P < .0001). Of the patients receiving multimodality therapy, chemotherapy was delivered in the adjuvant setting in 93.1% and in the neoadjuvant setting in 6.9%, with similar 2-year survival with either approach (neoadjuvant vs adjuvant, 46.9% vs 40.6%; P = .16). Year of diagnosis, white race, less comorbidity, and no vascular invasion were independently associated with receipt of multimodality therapy. CONCLUSION: Only half of older patients with locoregional pancreatic cancer receive any treatment, and fewer than one quarter of treated patients receive multimodality therapy. Nearly all patients receiving chemotherapy as the initial treatment modality did not undergo resection, whereas half of those undergoing resection first received chemotherapy. When multimodality therapy is used, the vast majority of patients had chemotherapy in the adjuvant setting with a similar survival, regardless of approach.

Authors: Ryu SY, Crespi CM, Maxwell AE

Title: Colorectal cancer among Koreans living in South Korea versus California: incidence, mortality, and screening rates.

Journal: Ethn Health 19(4):406-23

Date: 2014 Aug

Abstract: OBJECTIVES: This study compared trends in colorectal cancer (CRC) incidence and mortality rates among Koreans in South Korea and Korean Americans and non-Hispanic whites in California between 1999 and 2009, and examined CRC screening rates and socio-demographic correlates of CRC screening in the two Korean populations. DESIGN: Age-standardized CRC incidence and mortality rates of Koreans in South Korea and Korean Americans and non-Hispanic whites in California for the years 1999-2009 were obtained from annual reports of cancer statistics and modeled using joinpoint regression. Using 2009 data from the Korean National Health and Nutrition Examination Survey and the California Health Interview Survey, we estimated and compared CRC screening rates and test modalities. We used multiple logistic regression to examine socio-demographic correlates of completion of CRC screening according to the guidelines among the two Korean populations. RESULTS: CRC incidence and mortality rates among South Koreans increased during 1999-2009 but more slowly during the late 2000s. In California, CRC incidence increased among Korean American females but decreased among non-Hispanic whites. About 37% of South Koreans and 60% of Korean Americans reported completion of CRC screening according to guidelines in 2009. Among South Koreans, married status, higher income, and private health insurance were associated with CRC screening, adjusting for other factors. Among Korean Americans, having health insurance was associated with CRC screening. CONCLUSION: Despite almost identical CRC screening guidelines in South Korea and the USA and substantially higher screening rates among Korean Americans as compared to South Koreans, disparities remain in both populations with respect to CRC statistics. Thus, efforts to promote primary and secondary prevention of CRC in both Korean populations are critically important in both countries.

Authors: Satram-Hoang S, Reyes C, Hoang KQ, Momin F, Skettino S

Title: Treatment practice in the elderly patient with chronic lymphocytic leukemia-analysis of the combined SEER and Medicare database.

Journal: Ann Hematol 93(8):1335-44

Date: 2014 Aug

Abstract: The median age at diagnosis of chronic lymphocytic leukemia (CLL) is 72, but patients enrolled in randomized trials are often a decade younger. Therapy selection and outcomes in the older, comorbid population are less understood. We evaluated treatment patterns and outcomes among 2,985 first primary CLL patients from the linked Surveillance, Epidemiology, and End Results-Medicare database. There were 151 chlorambucil (CLB), 594 rituximab monotherapy (R-mono), 696 rituximab + intravenous chemotherapy (R + IV Chemo), and 1,544 IV chemo-only patients. Patients administered CLB and R-mono were the oldest and had the highest comorbidity burden while patients receiving R + IV Chemo were the youngest and had the lowest comorbidity burden (p < 0.0001). In the multivariate survival analysis, receipt of R + IV Chemo was associated with significantly lower mortality risk vs. IV Chemo-only (hazard ratio (HR) = 0.73; 95 % confidence interval (CI) 0.62-0.87) and a non-significant mortality risk reduction with R-mono vs. CLB (HR = 0.47; 95 % CI: 0.21-1.05). Older age and increasing comorbidity score were significantly associated with higher mortality. These findings suggest that chemoimmunotherapy is more effective than chemotherapy in an elderly population with a high prevalence of comorbidity, and this extends the conclusions from clinical trials in younger, medically fit patients.

Authors: Schootman M, Lian M, Pruitt SL, Deshpande AD, Hendren S, Mutch M, Jeffe DB, Davidson N

Title: Hospital and geographic variability in thirty-day all-cause mortality following colorectal cancer surgery.

Journal: Health Serv Res 49(4):1145-64

Date: 2014 Aug

Abstract: OBJECTIVE: To assess hospital and geographic variability in 30-day mortality after surgery for CRC and examine the extent to which sociodemographic, area-level, clinical, tumor, treatment, and hospital characteristics were associated with increased likelihood of 30-day mortality in a population-based sample of older CRC patients. DATA SOURCES/STUDY SETTING: Linked Surveillance Epidemiology End Results (SEER) and Medicare data from 47,459 CRC patients aged 66 years or older who underwent surgical resection between 2000 and 2005, resided in 13,182 census tracts, and were treated in 1,447 hospitals. STUDY DESIGN: An observational study using multilevel logistic regression to identify hospital- and patient-level predictors of and variability in 30-day mortality. DATA COLLECTION/EXTRACTION METHODS: We extracted sociodemographic, clinical, tumor, treatment, hospital, and geographic characteristics from Medicare claims, SEER, and census data. PRINCIPAL FINDINGS: Of 47,459 CRC patients, 6.6 percent died within 30 days following surgery. Adjusted variability in 30-day mortality existed across residential census tracts (predicted mortality range: 2.7-12.3 percent) and hospitals (predicted mortality range: 2.5-10.5 percent). Higher risk of death within 30 days was observed for CRC patients age 85+ (12.7 percent), census-tract poverty rate >20 percent (8.0 percent), two or more comorbid conditions (8.8 percent), stage IV at diagnosis (15.1 percent), undifferentiated tumors (11.6 percent), and emergency surgery (12.8 percent). CONCLUSIONS: Substantial, but similar variability was observed across census tracts and hospitals in 30-day mortality following surgery for CRC in patients 66 years and older. Risk of 30-day mortality is driven not only by patient and hospital characteristics but also by larger social and economic factors that characterize geographic areas.

Authors: Shankaran V, Mummy D, Koepl L, Bansal A, Mirick DK, Yu E, Morlock R, Ogale S, Ramsey SD

Title: Survival and lifetime costs associated with first-line bevacizumab use in older patients with metastatic colorectal cancer.

Journal: Oncologist 19(8):892-9

Date: 2014 Aug

Abstract: INTRODUCTION: The objective of this study was to investigate clinical effectiveness and incremental lifetime costs associated with first-line bevacizumab in older patients with metastatic colorectal cancer (mCRC). METHODS: Patients diagnosed with mCRC in 2004-2007 were identified from the Surveillance, Epidemiology, and End Results-Medicare database and stratified by first-line treatment (no chemotherapy [CTx], CTx alone, CTx plus bevacizumab). The impact of first-line bevacizumab on survival was investigated using a propensity score adjusted multivariate Cox proportional hazards model. Mean lifetime costs for each cohort were calculated using Medicare claims for all services rendered between diagnosis and end of follow-up, adjusting for death and censoring. RESULTS: A total of 4,414 patients (mean age: 77.3 years) were identified, of whom 15% received first-line bevacizumab. Among first-line-treated patients, bevacizumab receipt was associated with improved overall survival (hazard ratio: 0.85 [95% confidence interval: 0.75-0.97]; p = .013), and this benefit was limited to patients who received >1 month of bevacizumab therapy. Median and mean survival were greatest in patients treated with CTx plus bevacizumab relative to CTx alone (CTx plus bevacizumab median 19.4 months [mean 28.0 months] vs. CTx alone median 15.1 months [mean 22.9 months]; p < .001), as were mean lifetime costs (mean per patient cost $143,284 vs. $111,280). Compared with CTx alone, CTx plus bevacizumab was associated with a 5.1-month increase in mean survival and a $32,004 increase in mean lifetime treatment costs, with an incremental cost of $75,303 per life-year gained. CONCLUSION: Bevacizumab use is associated with longer survival than CTx alone in older patients treated in real-world clinical settings, at an incremental cost of $75,303 per life-year gained.

Authors: Wang SY, Wang R, Yu JB, Ma X, Xu X, Kim SP, Soulos PR, Saraf A, Gross CP

Title: Understanding regional variation in Medicare expenditures for initial episodes of prostate cancer care.

Journal: Med Care 52(8):680-7

Date: 2014 Aug

Abstract: OBJECTIVES: To evaluate the contributions of patient and treatment factors to overall expenditures and regional variation for initial treatment of localized prostate cancer (CaP) in the Medicare program. RESEARCH DESIGN: Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 47,517 beneficiaries with localized CaP during 2005-2009 and matched noncancer controls. We employed hierarchical generalized linear models to estimate risk-standardized cancer-related expenditures for each hospital referral region. To identify key contributors to the variation, we sequentially added patient characteristics, treatment intensity (the percentage of patients receiving curative treatments), ancillary procedures (biopsy, hormone therapy, and imaging), and specific treatment modalities into the model. We categorized the expenditures according to the type of services to identify their relative impact on the expenditure variations. RESULTS: The mean expenditure on CaP-related care per CaP beneficiary was $15,900, including $1800 on surgery, $11,200 on radiotherapy, and $1900 on ancillary procedures. The expenditure difference between quintiles 5 and 1 was $6200. Patient characteristics explained 8.4% of this difference. Treatment intensity and treatment modalities accounted for an additional 21.2% and 31.2% of the variation, respectively. Between the highest and lowest expenditure quintiles, the difference in radiotherapy expenditure was $5000, whereas that in surgery or ancillary procedures was <$200. CONCLUSIONS: There is substantial geographic variation in CaP expenditures, and the specific modality of radiotherapy is the most important contributor to this variation. Efforts to address the CaP care costs, such as bundled payment development, require targeting both treatment intensity and use of costly modalities.

Authors: Rajan SS, Cai Y, Yi M, Tsai CL, Du XL

Title: Use of Hematopoietic Growth Factors in Elderly Lung Cancer Patients Receiving Chemotherapy: A SEER-Medicare-based Study.

Journal: Am J Clin Oncol :-

Date: 2014 Jul 25

Abstract: OBJECTIVES:: Hematopoietic growth factors (HGFs) are essential for successful completion of chemotherapy in lung cancer patients. However, because of their adverse effects, clinical guidelines recommend their use in only selective clinical scenarios. This study, for the first time, explores patient characteristics and temporal trends associated with HGF utilization among elderly lung cancer patients receiving chemotherapy. METHODS:: This is a retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data containing 80,940 patients, aged 65 years and older, diagnosed with stage I to IV lung cancer between 1992 and 2009, and who received chemotherapy. Descriptive statistics and logistic regressions were used to examine the characteristics associated with 2 types of HGFs-colony stimulating factors (CSFs) and erythropoiesis-stimulating agents (ESAs). RESULTS:: Twenty-five percent of the patients received CSFs and 42% received ESAs. Temporal variations were most predictive of HGF utilization, with an increase from 2.6% in 1992 to 47.3% in 2009 for CSFs and 1.3% to 30.5% for ESAs. Higher chemotherapy-based risk profiles increased the odds of HGF receipt 2 to 3 times (P<0.0001). Even after controlling for relevant clinical characteristics, unexplained sociodemographic associations persisted, suggesting lack of compliance with HGF guidelines. CONCLUSIONS:: There has been a significant increase in the use of HGFs over time. Although chemotherapy-based risk profiles were significant predictors of HGF receipt, the study results suggest possible lack of compliance with treatment guidelines, which should be investigated. Given the high cost of HGFs, future studies are also needed to determine cost-effectiveness of these drugs among lung cancer patients.

Authors: Zhang Y, Hollenbeck BK, Schroeck FR, Jacobs BL

Title: Managed Care and the Dissemination of Robotic Prostatectomy.

Journal: Surg Innov :-

Date: 2014 Jul 21

Abstract: Objective. Robotic prostatectomy has rapidly disseminated over the past decade. How managed care, thought by many to be a barrier to new technology, influences the dissemination of robotics is unknown. We sought to better understand the relationship between a market's managed-care penetration and the dissemination of robotic prostatectomy. Methods. We used SEER-Medicare data from 2003 through 2007 to identify men ≥66 years of age treated with radical prostatectomy for prostate cancer. We categorized Health Service Areas (HSAs) according to the degree of managed-care penetration (ie, low vs high). We assessed adoption of robotic prostatectomy and utilization among adopting HSAs using Cox proportional-hazards and Poisson regression models, respectively. Results. Compared with markets with little managed care, highly penetrated markets had more racial diversity (24% vs 15% nonwhite, P < .01), higher population densities (1987 vs 422 people/square mile, P < .01), and higher median incomes ($49 374 vs $36 236, P < .01). Robotic prostatectomy adoption and utilization increased over time in both HSA categories. Compared with low managed-care markets, those with high managed care adopted robotic prostatectomy more rapidly (eg, probability 0.37 [low] vs 0.52 [high] in 2007; P < .01). However, the postadoption utilization of robotic prostatectomy was constrained in these highly penetrated markets (eg, probability 0.66 [low] vs 0.52 [high] in 2007; P < .01). Conclusions. High managed-care penetration was associated with more rapid robotic prostatectomy adoption. However, once adopted, utilization increased more slowly in these markets. Understanding this paradox is important as more technologies are unveiled in an increasingly cost-conscious health care environment.

Authors: Daskivich TJ, Lai J, Dick AW, Setodji CM, Hanley JM, Litwin MS, Saigal C, on behalf of the Urologic Diseases in America Project

Title: Variation in treatment associated with life expectancy in a population-based cohort of men with early-stage prostate cancer.

Journal: Cancer :-

Date: 2014 Jul 17

Abstract: BACKGROUND: Men with major comorbidities are at risk for overtreatment of prostate cancer due to uncertainty regarding their life expectancy. We sought to characterize life expectancy and treatment in a population-based cohort of men with differing ages and comorbidity burdens at diagnosis. METHODS: We sampled 96,032 men aged ≥66 years with early-stage prostate cancer who had Gleason scores ≤7 and were diagnosed during 1991 to 2007 from the Surveillance, Epidemiology, and End Results-Medicare database. We calculated cumulative incidence of other-cause mortality and determined treatment patterns among subgroups defined by age and Charlson comorbidity index scores. RESULTS: Overall, life expectancy was <10 years (10-year other-cause mortality rate, >50%) for 50,049 of 96,032 men (52%). Life expectancy differed by age and comorbidity score and was <10 years for men ages 66 to 69 years with Charlson scores ≥2, for men ages 70 to 74 years with Charlson scores ≥1, and for all men ages 75 to 79 years and ≥80 years. Among those who had a life expectancy <10 years, treatment was aggressive (surgery, radiation, or brachytherapy) for 68% of men aged 66 to 69 years, 69% of men aged 70 to 74 years, 57% of men aged 75 to 79 years, and 24% of men aged ≥80 years. Among these men, aggressive treatment was predominantly radiation therapy (50%, 53%, 63%, and 69%, respectively) and less frequently was surgery (30%, 25%, 13%, and 9%, respectively). Multivariate models revealed little variation in the probability of aggressive treatment by comorbidity status within age subgroups despite substantial differences in mortality. CONCLUSIONS: Men aged <80 years at diagnosis who have life expectancies <10 years often receive aggressive treatment for low-risk and intermediate-risk prostate cancer, mostly with radiation therapy. [See related editorial on pages 000-000, this issue.] Cancer 2014. © 2014 American Cancer Society.

Authors: Carmona R, Gulaya S, Murphy JD, Rose BS, Wu J, Noticewala S, McHale MT, Yashar CM, Vaida F, Mell LK

Title: Validated Competing Event Model for the Stage I-II Endometrial Cancer Population.

Journal: Int J Radiat Oncol Biol Phys 89(4):888-98

Date: 2014 Jul 15

Abstract: PURPOSE/OBJECTIVES(S): Early-stage endometrial cancer patients are at higher risk of noncancer mortality than of cancer mortality. Competing event models incorporating comorbidity could help identify women most likely to benefit from treatment intensification. METHODS AND MATERIALS: 67,397 women with stage I-II endometrioid adenocarcinoma after total hysterectomy diagnosed from 1988 to 2009 were identified in Surveillance, Epidemiology, and End Results (SEER) and linked SEER-Medicare databases. Using demographic and clinical information, including comorbidity, we sought to develop and validate a risk score to predict the incidence of competing mortality. RESULTS: In the validation cohort, increasing competing mortality risk score was associated with increased risk of noncancer mortality (subdistribution hazard ratio [SDHR], 1.92; 95% confidence interval [CI], 1.60-2.30) and decreased risk of endometrial cancer mortality (SDHR, 0.61; 95% CI, 0.55-0.78). Controlling for other variables, Charlson Comorbidity Index (CCI) = 1 (SDHR, 1.62; 95% CI, 1.45-1.82) and CCI >1 (SDHR, 3.31; 95% CI, 2.74-4.01) were associated with increased risk of noncancer mortality. The 10-year cumulative incidences of competing mortality within low-, medium-, and high-risk strata were 27.3% (95% CI, 25.2%-29.4%), 34.6% (95% CI, 32.5%-36.7%), and 50.3% (95% CI, 48.2%-52.6%), respectively. With increasing competing mortality risk score, we observed a significant decline in omega (ω), indicating a diminishing likelihood of benefit from treatment intensification. CONCLUSION: Comorbidity and other factors influence the risk of competing mortality among patients with early-stage endometrial cancer. Competing event models could improve our ability to identify patients likely to benefit from treatment intensification.

Authors: Javid SH, Varghese TK, Morris AM, Porter MP, He H, Buchwald D, Flum DR, Collaborative to Improve Native Cancer Outcomes (CINCO)

Title: Guideline-concordant cancer care and survival among American Indian/Alaskan Native patients.

Journal: Cancer 120(14):2183-90

Date: 2014 Jul 15

Abstract: BACKGROUND: American Indians/Alaskan Natives (AI/ANs) have the worst 5-year cancer survival of all racial/ethnic groups in the United States. Causes for this disparity are unknown. The authors of this report examined the receipt of cancer treatment among AI/AN patients compared with white patients. METHODS: This was a retrospective cohort study of 338,204 patients who were diagnosed at age ≥65 years with breast, colon, lung, or prostate cancer between 1996 and 2005 in the Surveillance, Epidemiology, and End Results-Medicare database. Nationally accepted guidelines for surgical and adjuvant therapy and surveillance were selected as metrics of optimal, guideline-concordant care. Treatment analyses compared AI/ANs with matched whites. RESULTS: Across cancer types, AI/ANs were less likely to receive optimal cancer treatment and were less likely to undergo surgery (P ≤ .025 for all cancers). Adjuvant therapy rates were significantly lower for AI/AN patients with breast cancer (P < .001) and colon cancer (P = .001). Rates of post-treatment surveillance also were lower among AI/ANs and were statistically significantly lower for AI/AN patients with breast cancer (P = .002) and prostate cancer (P < .001). Nonreceipt of optimal cancer treatment was associated with significantly worse survival across cancer types. Disease-specific survival for those who did not undergo surgery was significantly lower for patients with breast cancer (hazard ratio [HR], 0.62), colon cancer (HR, 0.74), prostate cancer (HR, 0.52), and lung cancer (HR, 0.36). Survival rates also were significantly lower for those patients who did not receive adjuvant therapy for breast cancer (HR, 0.56), colon cancer (HR, 0.59), or prostate cancer (HR, 0.81; all 95% confidence intervals were <1.0). CONCLUSIONS: Fewer AI/AN patients than white patients received guideline-concordant cancer treatment across the 4 most common cancers. Efforts to explain these differences are critical to improving cancer care and survival for AI/AN patients. Cancer 2014;120:2183-2190. © 2014 American Cancer Society.

Authors: Zheng Z, Onukwugha E, Hanna N, Bikov K, Seal B, Mullins CD

Title: Cost-Effectiveness of Second-Line Chemotherapy/Biologics among Elderly Metastatic Colon Cancer Patients.

Journal: Adv Ther :-

Date: 2014 Jul 15

Abstract: INTRODUCTION: Advancements in chemotherapy treatment have improved the clinical management of metastatic colon cancer (mCC) patients. An increasing number of elderly mCC patients receive various combinations of regimens in second-line chemotherapy/biologics treatment (Tx2) after first-line treatment (Tx1) to prolong survival and/or palliate symptoms, but these regimens have higher costs. This analysis investigated the survival benefit and incremental cost associated with Tx2 among elderly mCC patients. METHODS: Elderly (aged ≥66 years) SEER-Medicare patients diagnosed with mCC in 2003-2007 were identified and followed until death or the end of 2009. Cox regression and partitioned least squares regression were utilized to obtain the survival benefit and incremental cost associated with Tx2 within a 5-year study period. A time-varying model was used to reduce bias due to sequential ordering of Tx1 and Tx2. The regressions controlled for patient demographic characteristics, clinical variables, and a proxy for poor performance. Bootstrapping was used to generate 95% confidence intervals (CI). RESULTS: Of the 3,266 elderly mCC patients who received Tx1, 2,744 (84%) died within the observation period; 1,440 (44%) received Tx2. The survival benefit associated with receipt of Tx2 was 0.33 years (95% CI 0.19-0.43), and the associated incremental cost was $40,888 (95% CI 3,044-44,324). The incremental cost-effectiveness ratio (ICER) for Tx2 was $123,903 per life year gained (95% CI 9,600-216,082). CONCLUSION: The estimated survival benefit of receiving second-line chemotherapy/biologics was about 4 months, which is consistent with evidence from clinical trials. This improved survival was associated with an ICER that exceeds the traditional threshold.

Authors: Hoffman KE, Niu J, Shen Y, Jiang J, Davis JW, Kim J, Kuban DA, Perkins GH, Shah JB, Smith GL, Volk RJ, Buchholz TA, Giordano SH, Smith BD

Title: Physician Variation in Management of Low-Risk Prostate Cancer: A Population-Based Cohort Study.

Journal: JAMA Intern Med :-

Date: 2014 Jul 14

Abstract: Importance: Up-front treatment of older men with low-risk prostate cancer can cause morbidity without clear survival benefit; however, most such patients receive treatment instead of observation. The impact of physicians on the management approach is uncertain. Objective: To determine the impact of physicians on the management of low-risk prostate cancer with up-front treatment vs observation. Design, Setting, and Participants: Retrospective cohort of men 66 years and older with low-risk prostate cancer diagnosed from 2006 through 2009. Patient and tumor characteristics were obtained from the Surveillance, Epidemiology, and End Results cancer registries. The diagnosing urologist, consulting radiation oncologist, cancer-directed therapy, and comorbid medical conditions were determined from linked Medicare claims. Physician characteristics were obtained from the American Medical Association Physician Masterfile. Mixed-effects models were used to evaluate management variation and factors associated with observation. Main Outcomes and Measures: No cancer-directed therapy within 12 months of diagnosis (observation). Results: A total of 2145 urologists diagnosed low-risk prostate cancer in 12 068 men, of whom 80.1% received treatment and 19.9% were observed. The case-adjusted rate of observation varied widely across urologists, ranging from 4.5% to 64.2% of patients. The diagnosing urologist accounted for 16.1% of the variation in up-front treatment vs observation, whereas patient and tumor characteristics accounted for 7.9% of this variation. After adjustment for patient and tumor characteristics, urologists who treat non-low-risk prostate cancer (adjusted odds ratio [aOR], 0.71 [95% CI, 0.55-0.92]; P = .01) and graduated in earlier decades (P = .004) were less likely to manage low-risk disease with observation. Treated patients were more likely to undergo prostatectomy (aOR, 1.71 [95% CI, 1.45-2.01]; P < .001), cryotherapy (aOR, 28.2 [95% CI, 19.5-40.9]; P < .001), brachytherapy (aOR, 3.41 [95% CI, 2.96-3.93]; P < .001), or external-beam radiotherapy (aOR, 1.31 [95% CI, 1.08-1.58]; P = .005) if their urologist billed for that treatment. Case-adjusted rates of observation also varied across consulting radiation oncologists, ranging from 2.2% to 46.8% of patients. Conclusions and Relevance: Rates of management of low-risk prostate cancer with observation varied widely across urologists and radiation oncologists. Patients whose diagnosis was made by urologists who treated prostate cancer were more likely to receive up-front treatment and, when treated, more likely to receive a treatment that their urologist performed. Public reporting of physicians' cancer management profiles would enable informed selection of physicians to diagnose and manage prostate cancer.

Authors: Lu-Yao GL, Albertsen PC, Moore DF, Shih W, Lin Y, DiPaola RS, Yao SL

Title: Fifteen-Year Survival Outcomes Following Primary Androgen-Deprivation Therapy for Localized Prostate Cancer.

Journal: JAMA Intern Med :-

Date: 2014 Jul 14

Abstract: Importance: One in 6 American men will be diagnosed as having prostate cancer during their lifetime. Although there are no data to support the use of primary androgen-deprivation therapy (ADT) for early-stage prostate cancer, primary ADT has been widely used for localized prostate cancer, especially among older patients. Objective: To determine the long-term survival impact of primary ADT in older men with localized (T1/T2) prostate cancer. Design, Setting, and Participants: This was a population-based cohort study of 66 717 Medicare patients 66 years or older diagnosed from 1992 through 2009 who received no definitive local therapy within 180 days of prostate cancer diagnosis. The study was conducted in predefined US geographical areas covered by the Surveillance, Epidemiology, and End Results (SEER) Program. Instrumental variable analysis was used to assess the impact of primary ADT and control for potential biases associated with unmeasured confounding variables. The instrumental variable comprised combined health services areas with various usage rates of primary ADT. The analysis compared survival outcomes in the top tertile areas with those in the bottom tertile areas. Main Outcomes and Measures: Prostate cancer-specific survival and overall survival. Results: With a median follow-up of 110 months, primary ADT was not associated with improved 15-year overall or prostate cancer-specific survival following the diagnosis of localized prostate cancer. Among patients with moderately differentiated cancers, the 15-year overall survival was 20.0% in areas with high primary ADT use vs 20.8% in areas with low use (difference: 95% CI, -2.2% to 0.4%), and the 15-year prostate cancer survival was 90.6% in both high- and low-use areas (difference: 95% CI, -1.1% to 1.2%). Among patients with poorly differentiated cancers, the 15-year cancer-specific survival was 78.6% in high-use areas vs 78.5%, in low-use areas (difference: 95% CI, -1.8% to 2.4%), and the 15-year overall survival was 8.6% in high-use areas vs 9.2% in low-use areas (difference: 95% CI, -1.5% to 0.4%). Conclusions and Relevance: Primary ADT is not associated with improved long-term overall or disease-specific survival for men with localized prostate cancer. Primary ADT should be used only to palliate symptoms of disease or prevent imminent symptoms associated with disease progression.

Authors: Sulsky SI, Fuller WG, Van Landingham C, Ogden MW, Swauger JE, Curtin GM

Title: Evaluating the association between menthol cigarette use and the likelihood of being a former versus current smoker.

Journal: Regul Toxicol Pharmacol 70(1):231-241

Date: 2014 Jul 11

Abstract: Menthol in cigarettes has been examined for its potential to affect smoking dependence, measured primarily as number of cigarettes smoked per day and time to first cigarette after waking; the ability to quit smoking constitutes an additional measure of dependence. Successful quitting among menthol compared to non-menthol cigarette smokers is difficult to determine from the literature, due in part to the various definitions of quitting used by researchers. Nevertheless, intervention and follow-up studies of smoking cessation treatments generally indicate no differences in quitting success among menthol compared to non-menthol smokers, while cross-sectional studies suggest some differences within race/ethnicity groups. The association between menthol cigarette use and likelihood of being a former versus current smoker was examined based on data from the National Health Interview Survey and Tobacco Use Supplement to the Current Population Survey. Analyses stratified by race/ethnicity and limited to smokers who had quit at least one year prior to survey participation provided inconsistent results with regard to menthol cigarette use and quitting, both within surveys (i.e., comparing race/ethnicity groups) and between surveys (i.e., same race/ethnicity group across surveys). Evidence suggesting the existence or direction of an association between menthol in cigarettes and quitting depended on the data source.

Authors: Hu JC, Williams SB, Carter SC, Eggener SE, Prasad S, Chamie K, Trinh QD, Sun M, Nguyen PL, Lipsitz SR

Title: Population-based assessment of prostate-specific antigen testing for prostate cancer in the elderly.

Journal: Urol Oncol :-

Date: 2014 Jul 10

Abstract: OBJECTIVES: To perform a population-based analysis to characterize the effect of prostate-specific antigen (PSA) testing on oncologic outcomes in men diagnosed with prostate cancer. MATERIALS AND METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare-linked data to identify 98,883 men diagnosed with prostate cancer from 1996 to 2007. We stratified frequency of PSA testing as none, 1 to 2, 3 to 5, and≥6 tests in the 5 years before prostate cancer diagnosis. We used propensity scoring methods to assess the effect of frequency of PSA testing on likelihood of (1) metastases at diagnosis and (2) overall mortality and prostate cancer-specific mortality. RESULTS: In adjusted analyses, the likelihood of being diagnosed with metastatic prostate cancer decreased with greater frequency of PSA testing (none, 10.6; 1-2, 8.3; 3-5, 3.7; and≥6, 2.5 events per 100 person years, P<0.001). Additionally, greater frequency of PSA testing was associated with improved overall survival and prostate cancer-specific survival (P<0.001 for both). CONCLUSIONS: Greater frequency of PSA testing in men 70 years of age or older in the 5 years before prostate cancer diagnosis is associated with lower likelihood of being diagnosed with metastatic prostate cancer and improved overall and prostate cancer-specific survival.

Authors: Onwudiwe NC, Kwok Y, Onukwugha E, Sorkin JD, Zuckerman IH, Shaya FT, Daniel Mullins C

Title: Cardiovascular event-free survival after adjuvant radiation therapy in breast cancer patients stratified by cardiovascular risk.

Journal: Cancer Med :-

Date: 2014 Jul 10

Abstract: The objective of this study was to estimate the risk of a cardiovascular event or death associated with modern radiation in a population of elderly female breast cancer patients with varying baseline cardiovascular risk. The data used for this analysis are from the linked Surveillance, Epidemiology, and End-Results (SEER)-Medicare database. The retrospective cohort study included women aged 66 years and older with stage 0-III breast cancer diagnosed between 2000 and 2005. Women were grouped as low, intermediate, or high cardiovascular risk based on the presence of certain clinical diagnoses. The risk for the combined outcome of a hospitalization for a cardiovascular event or death within 6 months and 24 months of diagnosis was estimated using a multivariable Cox model. The median follow-up time was 24 months. Among the 91,612 women with American Joint Committee on Cancer (AJCC) stage 0-III breast cancer: 39,555 (43.2%) were treated with radiation therapy and 52,057 (56.8%) were not. The receipt of radiation therapy in the first 6 months was associated with a statistically significant increased risk for the combined outcome in women categorized as high risk (HR = 1.510; 95% CI, 1.396-1.634) or intermediate risk (HR = 1.415; 95% CI, 1.188-1.686) but not low risk (HR = 1.027; 95% CI, 0.798-1.321). Women with a prior medical history of cardiovascular disease treated with radiation therapy are at increased risk for an event and should be monitored for at least 6 months following treatment with radiation therapy.

Authors: Chhatre S, Metzger DS, Malkowicz SB, Woody G, Jayadevappa R

Title: Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer.

Journal: Cancer :-

Date: 2014 Jul 09

Abstract: BACKGROUND: Substance use disorder in patients with cancer has implications for outcomes. The objective of this study was to analyze the effects of the type and timing of substance use on outcomes in elderly Medicare recipients with advanced prostate cancer. METHODS: This was an observational cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 2000 to 2009. Among men who were diagnosed with advanced prostate cancer between 2001 and 2004, we identified those who had a claim for substance use disorder in the year before cancer diagnosis, 1 year after cancer diagnosis, and an additional 4 years after diagnosis. The outcomes investigated were use of health services, costs, and mortality. RESULTS: The prevalence of substance use disorder was 10.6%. The category drug psychoses and related had greater odds of inpatient hospitalizations (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.9-2.8), outpatient hospital visits (OR, 2.6; 95% CI, 1.9-3.6), and emergency room visits (OR, 1.7; 95% CI, 1.2-2.4). Substance use disorder in the follow-up phase was associated with greater odds of inpatient hospitalizations (OR, 2.0; 95% CI, 1.8-2.2), outpatient hospital visits (OR, 2.0; 95% CI, 1.7-2.4), and emergency room visits (OR, 1.7; 95% CI, 1.5-2.1). Compared with men who did not have substance use disorder, those in the category drug psychoses and related had 70% higher costs, and those who had substance use disorder during the follow-up phase had 60% higher costs. The hazard of all-cause mortality was highest for patients in the drug psychoses and related category (hazard ratio, 1.3; 95% CI, 1.1-1.7) and the substance use disorder in treatment phase category (hazard ratio, 1.5; 95% CI, 1.3-1.7). CONCLUSIONS: The intersection of advanced prostate cancer and substance use disorder may adversely affect outcomes. Incorporating substance use screening and treatments into prostate cancer care guidelines and coordination of care is desirable. Cancer 2014. © 2014 American Cancer Society.

Authors: Prasad SM, Eggener SE, Lipsitz SR, Irwin MR, Ganz PA, Hu JC

Title: Effect of Depression on Diagnosis, Treatment, and Mortality of Men With Clinically Localized Prostate Cancer.

Journal: J Clin Oncol :-

Date: 2014 Jul 07

Abstract: PURPOSE: Although demographic, clinicopathologic, and socioeconomic differences may affect treatment and outcomes of prostate cancer, the effect of mental health disorders remains unclear. We assessed the effect of previously diagnosed depression on outcomes of men with newly diagnosed prostate cancer. PATIENTS AND METHODS: We performed a population-based observational cohort study using Surveillance, Epidemiology, and End Results-Medicare linked data of 41,275 men diagnosed with clinically localized prostate cancer from 2004 to 2007. We identified 1,894 men with a depressive disorder in the 2 years before the prostate cancer diagnosis and determined its effect on treatment and survival. RESULTS: Men with depressive disorder were older, white or Hispanic, unmarried, resided in nonmetropolitan areas and areas of lower median income, and had more comorbidities (P <.05 for all), but there was no variation in clinicopathologic characteristics. In adjusted analyses, men with depressive disorder were more likely to undergo expectant management for low-, intermediate-, and high-risk disease (P ≤ .05, respectively). Conversely, depressed men were less likely to undergo definitive therapy (surgery or radiation) across all risk strata (P <.01, respectively). Depressed men experienced worse overall mortality across risk strata (low: relative risk [RR], 1.86; 95% CI, 1.48 to 2.33; P <.001; intermediate: RR, 1.25; 95% CI, 1.06 to 1.49; P = .01; high: RR, 1.16; 95% CI, 1.03 to 1.32; P = .02). CONCLUSION: Men with intermediate- or high-risk prostate cancer and a recent diagnosis of depression are less likely to undergo definitive treatment and experience worse overall survival. The effect of depression disorders on prostate cancer treatment and survivorship warrants further study, because both conditions are relatively common in men in the United States.

Authors: Ulahannan SV, Duffy AG, McNeel TS, Kish JK, Dickie LA, Rahma OE, McGlynn KA, Greten TF, Altekruse SF

Title: Earlier presentation and application of curative treatments in hepatocellular carcinoma.

Journal: Hepatology :-

Date: 2014 Jul 04

Abstract: Purpose: To assess the use of curative therapies for hepatocellular carcinomas (HCC) in the population. Methods: HCC treatment patterns were examined in SEER 18 registries (28% of U.S.). Joinpoint regression analyses were performed to assess 2000-2010 incidence trends by tumor size, count and receipt of potentially curative treatments (transplantation, resection and ablation). SEER-Medicare data enabled evaluation of treatment patterns including receipt of sorafenib or TACE by HCC-associated co-morbidities. Results: Diagnoses of tumors ≤5.0 cm in diameter significantly increased during 2000- 2010, surpassing diagnosis of larger tumors. Overall, 23% of cases received potentially curative treatment. Joinpoint models indicated incidence rates of treatment with curative intent increased 17.6% per year during 2000-2005, then declined by -2.9% per year during 2005-2010 (P< 0.001). Among HCC cases with a single tumor ≤5.0 cm and no extension beyond the liver, use of ablative therapy significantly increased during 2000-2010. Use of invasive surgery for single tumors, regardless of size, significantly increased during the initial years of the decade then plateaued. The group most likely to receive curative treatment in the SEER-Medicare cases was patients with one, small tumor confined to the liver (657 of 1597 cases, 41%), with no difference in treatment by hepatic co-morbidity status (P=0.24). A higher proportion of cases with reported liver-associated co-morbidities were, however diagnosed with tumors ≤5.0 cm in diameter (1745 0f 2464, 71%) compared to patients with no reported co-morbidities (996 of 2596, 38%, P<0.001). Conclusion: Although more HCC patients were diagnosed with early disease over time, the use of curative treatments in this patient group has recently plateaued. Efforts to identify and treat more eligible candidates for curative therapy could be beneficial. (Hepatology 2014;).

Authors: Chawla N, Yabroff KR, Mariotto A, McNeel TS, Schrag D, Warren JL

Title: Limited validity of diagnosis codes in Medicare claims for identifying cancer metastases and inferring stage.

Journal: Ann Epidemiol :-

Date: 2014 Jul 03

Abstract: PURPOSE: Researchers are using diagnosis codes from health claims to identify metastatic disease in cancer patients. The validity of this approach has not been established. METHODS: We used the linked 2005-2007 Surveillance, Epidemiology and End Results (SEER)-Medicare data to assess the validity of metastasis codes at diagnosis from claims compared with stage reported by SEER cancer registries. The cohort included 80,052 incident breast, lung, and colorectal cancer patients aged 65 years and older. Using gold-standard SEER data, we evaluated sensitivity, specificity, positive predictive value, and negative predictive value of claims-based stage, survival by stage classification, and patient factors associated with stage misclassification using multivariable regression. RESULTS: For patients with a registry report of distant metastatic cancer, the sensitivity, specificity, and positive predictive value of claims never simultaneously exceeded 80% for any cancer: lung (42.7%, 94.8%, and 88.1%), breast (51.0%, 98.3%, and 65.8%), and colorectal (72.8%, 93.8%, and 68.5%). Misclassification of stage from Medicare claims was significantly associated with inaccurate estimates of stage-specific survival (P < .001). In adjusted analysis, patients who were older, black, or living in low-income areas were more likely to have their stage misclassified in claims. CONCLUSIONS: Diagnosis codes in Medicare claims have limited validity for inferring cancer stage and metastatic disease.

Authors: Curtin GM, Sulsky SI, Van Landingham C, Marano KM, Graves MJ, Ogden MW, Swauger JE

Title: Patterns of menthol cigarette use among current smokers, overall and within demographic strata, based on data from four U.S. government surveys.

Journal: Regul Toxicol Pharmacol 70(1):189-196

Date: 2014 Jul 02

Abstract: The National Health and Nutrition Examination Survey, National Survey on Drug Use and Health, National Health Interview Survey and Tobacco Use Supplement to the Current Population Survey provide estimates of the proportions of U.S. smokers who currently use menthol cigarettes, overall and within demographic strata. Among adult past-month, regular and daily smokers, menthol cigarette use ranges from 26% to 30%, with statistically higher proportions of female versus male smokers (8-11 percentage points higher) currently using menthol cigarettes. Compared to adult smokers overall, statistically higher proportions of non-Hispanic Black smokers (72-79%) and statistically lower proportions of non-Hispanic White smokers (19-22%) currently use menthol cigarettes, with no differences among smokers of other race/ethnicity groups (18-20% to 28-30%, depending on the survey). Higher proportions of younger adult past-month, regular and daily smokers (aged 18-25years) currently use menthol cigarettes compared to older adult smokers (aged 26-29years and/or ⩾30years); however, differences are small in magnitude, with the vast majority of adult smokers (70-75%) who currently use menthol cigarettes being aged ⩾30years. Comparisons between youth and adult smokers are provided, although data for youth smokers are less available and provide less consistent patterns of menthol cigarette use.

Authors: Barcenas CH, Niu J, Zhang N, Zhang Y, Buchholz TA, Elting LS, Hortobagyi GN, Smith BD, Giordano SH

Title: Risk of hospitalization according to chemotherapy regimen in early-stage breast cancer.

Journal: J Clin Oncol 32(19):2010-7

Date: 2014 Jul 01

Abstract: PURPOSE: To compare the risk of hospitalization between patients with early-stage breast cancer who received different chemotherapy regimens. PATIENT AND METHODS: We identified 3,567 patients older than age 65 years from the SEER/Texas Cancer Registry-Medicare database and 9,327 patients younger than age 65 years from the MarketScan database who were diagnosed with early-stage breast cancer between 2003 and 2007. The selection was nonrandomized and nonprospectively collected. We categorized patients according to the regimens they received: docetaxel (T) and cyclophosphamide (C), doxorubicin (A) and C, TAC, AC + T, dose-dense AC + paclitaxel (P) or AC + weekly P. We compared the rates of chemotherapy-related hospitalizations that occurred within 6 months of chemotherapy initiation and used multivariable logistic regression analysis to identify the factors associated with these hospitalizations. RESULTS: Among patients younger than age 65 years, the hospitalization rates ranged from 6.2% (dose-dense AC + P) to 10.0% (TAC), and those who received TAC and AC + T had significantly higher rates of hospitalization than did patients who received TC. Among patients older than age 65 years, these rates ranged from 12.7% (TC) to 24.2% (TAC) and the rates of hospitalization of patients who received TAC, AC + T, AC, or AC + weekly P were higher than those of patients who received TC. CONCLUSION: TAC and AC + T were associated with the highest risk of hospitalization in patients younger than age 65 years. Among patients older than age 65 years, all regimens (aside from dose-dense AC + P) were associated with a higher risk of hospitalization than TC. Results may be affected by selection biases where less aggressive regimens are offered to frailer patients.

Authors: Shen C, Shih YC, Xu Y, Yao JC

Title: Octreotide long-acting repeatable use among elderly patients with carcinoid syndrome and survival outcomes: A population-based analysis.

Journal: Cancer 120(13):2039-49

Date: 2014 Jul 01

Abstract: BACKGROUND: Octreotide long-acting repeatable (LAR) is indicated for the treatment of carcinoid syndrome and diarrhea related to VIPoma, and may delay tumor growth in patients with neuroendocrine tumors (NETs). To the authors' knowledge, the pattern of octreotide LAR use in clinical practice and its impact on survival outcomes has not been well documented. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, the authors identified patients with NET aged ≥ 65 years who were diagnosed between July 1999 and December 2007. Patients with US Food and Drug Administration-approved indications for octreotide LAR were identified from Medicare claims. Multivariate logistic regression was performed to ascertain factors associated with octreotide LAR use, whereas the Cox proportional hazards model was used to evaluate the impact of octreotide LAR on survival. RESULTS: Among those with Food and Drug Administration-approved indications, 245 of 4848 patients with distant-stage disease (51%) and 81 of 807 patients with local/regional disease (10%) initiated treatment with octreotide LAR within 6 months of diagnosis. Multivariate logistic regression indicated that among those with distant-stage disease, older age (≥ 80 years vs 65-69 years) (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.23-0.81), female sex (OR, 0.62; 95% CI, 0.40-0.97), and living in the South (vs Northeast) (OR, 0.36; 95% CI, 0.18-0.72) were associated with a lower likelihood of using octreotide LAR. The multivariate proportional hazards model showed that octreotide LAR provided a significant 5-year survival benefit for patients with distant-stage disease (hazards ratio, 0.61; P ≤ .001), whereas this survival benefit was not shown for the patients with local/regional stage (hazards ratio, 0.88; P = .563). CONCLUSIONS: The results of this retrospective study suggest a possible survival benefit for the use of octreotide LAR in elderly patients with distant-stage NET with carcinoid syndrome. The results of the current study also suggest that octreotide LAR is underused in this population despite recommended guidelines. Cancer 2014;120:2039-2049. © 2014 American Cancer Society.

Authors: Evan Pollack C, Wang H, Bekelman JE, Weissman G, Epstein AJ, Liao K, Dugoff EH, Armstrong K

Title: Physician social networks and variation in rates of complications after radical prostatectomy.

Journal: Value Health 17(5):611-8

Date: 2014 Jul

Abstract: OBJECTIVES: Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy. METHODS: In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. RESULTS: Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications. CONCLUSIONS: Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.

Authors: Fenton JJ, Zhu W, Balch S, Smith-Bindman R, Fishman P, Hubbard RA

Title: Distinguishing screening from diagnostic mammograms using medicare claims data.

Journal: Med Care 52(7):e44-51

Date: 2014 Jul

Abstract: BACKGROUND: Medicare claims data may be a fruitful data source for research or quality measurement in mammography. However, it is uncertain whether claims data can accurately distinguish screening from diagnostic mammograms, particularly when claims are not linked with cancer registry data. OBJECTIVES: To validate claims-based algorithms that can identify screening mammograms with high positive predictive value (PPV) in claims data with and without cancer registry linkage. RESEARCH DESIGN: Development of claims-derived algorithms using classification and regression tree analyses within a random half-sample of bilateral mammogram claims with validation in the remaining half-sample. SUBJECTS: Female fee-for-service Medicare enrollees aged 66 years and older, who underwent bilateral mammography from 1999 to 2005 within Breast Cancer Surveillance Consortium (BCSC) registries in 4 states (CA, NC, NH, and VT), enabling linkage of claims and BCSC mammography data (N=383,730 mammograms obtained from 146,346 women). MEASURES: Sensitivity, specificity, and PPV of algorithmic designation of a "screening" purpose of the mammogram using a BCSC-derived reference standard. RESULTS: In claims data without cancer registry linkage, a 3-step claims-derived algorithm identified screening mammograms with 97.1% sensitivity, 69.4% specificity, and a PPV of 94.9%. In claims that are linked to cancer registry data, a similar 3-step algorithm had higher sensitivity (99.7%), similar specificity (62.7%), and higher PPV (97.4%). CONCLUSIONS: Simple algorithms can identify Medicare claims for screening mammography with high predictive values in Medicare claims alone and in claims linked with cancer registry data.

Authors: Gandaglia G, Abdollah F, Hu J, Kim S, Briganti A, Sammon JD, Becker A, Roghmann F, Graefen M, Montorsi F, Perrotte P, Karakiewicz PI, Trinh QD, Sun M

Title: Is robot-assisted radical prostatectomy safe in men with high-risk prostate cancer? Assessment of perioperative outcomes, positive surgical margins, and use of additional cancer treatments.

Journal: J Endourol 28(7):784-91

Date: 2014 Jul

Abstract: Abstract Introduction: Despite a rapid dissemination of robot-assisted radical prostatectomy (RARP) over open radical prostatectomy (ORP), to date no study has compared perioperative outcomes between the two approaches in patients with high-risk prostate cancer (PCa). The aim of our study was to evaluate the safety and feasibility of RARP in this setting. Patients and Methods: Overall, 1,512 patients with high-risk PCa within the Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database diagnosed between 2008 and 2009 were abstracted. Patients were treated with RARP or ORP. Postoperative complications, blood transfusions, prolonged length of stay (pLOS), positive surgical margins, and additional cancer therapy rates were compared. Propensity-score matched analyses and logistic regression models fitted with generalized estimating equations for clustering among hospitals were performed. Results: Overall, 706 (46.7%) and 806 (53.3%) patients underwent ORP and RARP, respectively. Following propensity-matched analyses, 706 patients remained. No differences were observed in complications (P=0.6), positive surgical margins (P=0.4), or additional therapy after surgery (P=0.2) between patients treated with RARP and ORP; however, RARP was associated with lower rates of transfusions and shorter hospitalization (all P<0.001). In multivariable analyses, patients undergoing RARP were less likely to receive a blood transfusion (P=0.002) or to experience pLOS (P<0.001) compared with men treated with ORP. Conclusions: RARP and ORP have comparable complications, positive surgical margins, and additional cancer therapy rates in high-risk PCa. RARP is associated with lower rates of blood transfusions and shorter hospital stays. These findings suggest that RARP is safe and feasible even in this clinical scenario.

Authors: Guadagnolo BA, Liao KP, Giordano SH, Elting LS, Buchholz TA, Shih YC

Title: Increasing use of advanced radiation therapy technologies in the last 30 days of life among patients dying as a result of cancer in the United States.

Journal: J Oncol Pract 10(4):e269-76

Date: 2014 Jul

Abstract: PURPOSE: We sought to analyze trends in radiation therapy (RT) technology use and costs in the last 30 days of life for patients dying as a result of cancer. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare and Texas Cancer Registry-Medicare databases to analyze claims data for 13,488 patients dying as a result of lung, breast, prostate, colorectal, melanoma, and pancreas cancers from 2000 to 2009. Logistic regression modeling was used to conduct adjusted analyses regarding influence of demographic, clinical, and health services variables on receipt of types of RT. Costs were calculated in 2009 US dollars. RESULTS: The proportion of patients treated with two-dimensional RT decreased from 74.9% of those receiving RT in the last 30 days of life in 2000 to 32.7% in 2009 (P < .001). Those receiving three-dimensional RT increased from 27.2% in 2000 to 58.5% in 2009 (P < .001). The proportion of patients treated with intensity-modulated radiation therapy in the last 30 days of life increased from 0% in 2000 to 6.2% in 2009 (P < .001), and those undergoing stereotactic radiosurgery increased from 0% in 2000 to 5.0% in 2009 (P < .001). The adjusted mean costs of per-patient RT services delivered in the last 30 days of life were higher in the years 2007 to 2009. CONCLUSION: Among patients receiving RT in the last month of life, there was a shift away from the simplest technique toward more advanced RT technologies. Studies are needed to ascertain whether these technology shifts improve palliative outcomes and quality of life for patients dying as a result of cancer who receive RT services.

Authors: Hershman DL, Neugut AI, Shim JJ, Glied S, Tsai WY, Wright JD

Title: Erythropoiesis-stimulating agent use after changes in medicare reimbursement policies.

Journal: J Oncol Pract 10(4):264-9

Date: 2014 Jul

Abstract: PURPOSE: Since 2004, concerns about the safety of erythropoiesis-stimulating agents (ESAs) have resulted in label changes and restrictions on their use. We examined changes in ESA use and blood transfusions over time. METHODS: The SEER-Medicare database was used to identify patients age ≥ 65 years with breast, lung, prostate, ovary, or colon cancer, diagnosed between 2000 and 2007, who had a chemotherapy claim after their cancer diagnosis. We calculated the mean number of ESA claims per patient per year. Follow-up claims were available through 2008. We used multivariable logistic regression models to analyze the association of ESA use and extended ESA use with clinical and demographic variables. RESULTS: Among 121,169 patients identified, 46,063 (38%) received an ESA. ESA use increased from 12.4% to 16.2% by 2006 and then decreased to 7.9% by 2008. Similarly, the mean number of ESA claims per patient decreased steadily over the entire timeframe. The annual percentage of patients undergoing transfusion remained relatively constant (9% to 10%). In a Cox proportional hazards time-dependent model, ESA use was positively associated with black race (odds ratio [OR], 1.11; 95% CI, 1.07 to 1.15), metropolitan location (OR, 1.17; 95% CI, 1.13 to 1.21), metastatic disease (OR, 1.39; 95% CI, 1.35 to 1.41), female sex (OR, 1.17; 95% CI, 1.14 to 1.20), > one comorbidity (OR, 1.29; 95% CI, 1.25 to 1.32), and tumor type. The number of denied claims increased over time. CONCLUSION: Our study demonstrated a rapid decline in the percentage of patients treated with ESAs after changes to reimbursement policy, but not after warnings about use. Reimbursement restrictions of other overused or off-label drugs may help reduce health care expenditures.

Authors: Javid SH, He H, Korde LA, Flum DR, Anderson BO

Title: Predictors and outcomes of completion axillary node dissection among older breast cancer patients.

Journal: Ann Surg Oncol 21(7):2172-80

Date: 2014 Jul

Abstract: BACKGROUND: The role of completion axillary lymph node dissection (ALND) for older women who had sentinel lymph node-positive (SLN+) invasive breast cancer is unclear. We examined factors predictive of ALND and the association between ALND, adjuvant chemotherapy administration, and survival. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we reviewed records of women age >65 diagnosed with stage I/II breast cancer from 1998-2005. Adjusted Cox proportional hazards and multivariate logistic regression were used to identify patient and disease variables associated with ALND, and assess association between ALND and all-cause and breast cancer-specific survival. RESULTS: Among SLN+ patients, 88 % underwent ALND. Earlier diagnosis year, greater nodal involvement, younger age, registry location, and larger tumor size were all associated with a significantly higher likelihood of ALND. The ALND in SLN+ patients was not significantly associated with 5-year breast cancer-specific survival (hazard ratio [HR] 1.22, 95 % confidence interval [CI] 0.76-1.96). The SLN+ patients who underwent ALND were more likely to receive adjuvant chemotherapy (odds ratio [OR] 1.8, 95 % CI 1.45-2.24). However, younger age (OR 18.0, 95 % CI 14.4-23.9), estrogen receptor-negative (ER-) status (OR 4.2, 95 % CI 3.4-5.3), and fewer comorbidities (OR 2.6, 95 % CI 1.7-4.0) were all more strongly linked to receipt of chemotherapy. CONCLUSIONS: ALND for older patients with SLN+ breast cancer is not associated with improved 5-year all-cause or breast cancer-specific survival. Younger age, fewer comorbidities, and estrogen receptor-negative (ER-) status were more strongly associated with receipt of chemotherapy than ALND. Consideration should be given to omitting ALND in older patients, particularly if findings of ALND will not influence adjuvant therapy decisions.

Authors: Patel HD, Kates M, Pierorazio PM, Allaf ME

Title: Race and sex disparities in the treatment of older patients with T1a renal cell carcinoma: a comorbidity-controlled competing-risks model.

Journal: Urol Oncol 32(5):576-83

Date: 2014 Jul

Abstract: OBJECTIVES: Recognizing population-level disparities for the treatment of patients with renal cell carcinoma (RCC) would inform clinical practice and health policy. Few studies, reporting conflicting results, have investigated race and sex disparities specifically among patients with small renal masses. METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results-Medicare database (1995-2007) was queried for patients with localized T1a RCC undergoing radical nephrectomy, partial nephrectomy (PN), or deferred therapy (DT). Demographics, comorbidity, and treatment approach were assessed. Multivariable logistic regression models evaluated predictors of DT and then PN among those receiving surgery. Cox proportional hazards model evaluated survival differences for whites vs. blacks and women vs. men. RESULTS: A total of 6,092 white and 617 black patients with T1a RCC met the inclusion criteria. Blacks were twice as likely to defer therapy compared with whites (odds ratio = 1.95, 95% CI: 1.52-2.51) and had worse overall survival (hazard ratio = 1.36, 95% CI: 1.19-1.56). However, cancer-specific survival (CSS) was similar (P = 0.429). The greatest discrepancy was among healthy (Charlson comorbidity index≤1) blacks who had a much higher rate of DT compared with their white counterparts. Women were found to have decreased use of PN compared with men (odds ratio = 0.84, 95% CI: 0.74-0.96) and better CSS (hazard ratio = 0.74, 95% CI: 0.58-0.94), but there were no differences by race. CONCLUSIONS: The differential use of DT by race instead of purely by age and comorbidity is concerning but has not led to a significant difference in CSS. Women are less likely to undergo PN compared with men, but they also have a notably improved CSS.

Authors: Penn DC, Stitzenberg KB, Cobran EK, Godley PA

Title: Provider-based research networks demonstrate greater hospice use for minority patients with lung cancer.

Journal: J Oncol Pract 10(4):e182-90

Date: 2014 Jul

Abstract: PURPOSE: The Community Clinical Oncology Program (CCOP) and Minority-Based Community Clinical Oncology Program (MBCCOP) are provider-based research networks (PBRN) that improve minority enrollment in cancer-focused clinical trials. We hypothesized that affiliation with a PBRN may also mitigate racial differences in hospice enrollment for patients with lung cancer. METHODS: We used the SEER-Medicare data, linked to the National Cancer Institute's CCOP program data, to identify all patients (≥ age 65 years) with lung cancer, diagnosed from 2001 to 2007. We defined clinical treatment settings as CCOP, MBCCOP, academic, or community-affiliated and used multivariable logistic regression analysis to determine factors associated with hospice enrollment. RESULTS: Forty-one thousand eight hundred eighty-five (55.1%) patients with lung cancer enrolled in hospice before death. Approximately 55% of CCOP, 57% of MBCCOP, 57% of academic, and 52% of community patients enrolled. Patients who were more likely to enroll were female (odds ratio [OR], 1.36; 95% CI, 1.31 to 1.40); ≥ age 79 years (OR, 1.11; 95%CI, 1.06 to 1.16); white; lived in more educated areas; had minimal comorbidities; and had distant disease. Asian and black patients in academic (41.1% and 50.4%, respectively) and community practices (35.2% and 43.4%, respectively) were less likely to enroll in hospice compared with white patients (academic, 58.8%; community, 53.1%). However, hospice enrollment was equivalent for black and white patients in MBCCOP (59.5% v 57.2%) and CCOP (52.2% v 56.3%) practices. CONCLUSION: Minority patients with lung cancer receiving treatment in cancer-focused PBRN- affiliated practices have greater hospice enrollment than those treated in academic and community practices.

Authors: Pruitt SL, Leonard T, Zhang S, Schootman M, Halm EA, Gupta S

Title: Physicians, clinics, and neighborhoods: multiple levels of influence on colorectal cancer screening.

Journal: Cancer Epidemiol Biomarkers Prev 23(7):1346-55

Date: 2014 Jul

Abstract: BACKGROUND: We (i) described variability in colorectal cancer (CRC) test use across multiple levels, including physician, clinic, and neighborhood; and (ii) compared the performance of novel cross-classified models versus traditional hierarchical models. METHODS: We examined multilevel variation in CRC test use among patients not up-to-date with screening in a large, urban safety net health system (2011-2012). Outcomes included: (i) fecal occult blood test (FOBT) or (ii) colonoscopy and were ascertained using claims data during a 1-year follow-up. We compared Bayesian (i) cross-classified four-level logistic models nesting patients within separate, nonoverlapping "levels" (physicians, clinics, and census tracts) versus (ii) three hierarchical two-level models using deviance information criterion. Models were adjusted for covariates (patient sociodemographic factors, driving time to clinic, and census tract poverty rate). RESULTS: Of 3,195 patients, 157 (4.9%) completed FOBT and 292 (9.1%) completed colonoscopy during the study year. Patients attended 19 clinics, saw 177 physicians, and resided in 332 census tracts. Significant variability was observed across all levels in both hierarchical and cross-classified models that was unexplained by measured covariates. For colonoscopy, variance was similar across all levels. For FOBT, physicians, followed by clinics, demonstrated the largest variability. Model fit using cross-classified models was superior or similar to 2-level hierarchical models. CONCLUSIONS: Significant and substantial variability was observed across neighborhood, physician, and clinic levels in CRC test use, suggesting the importance of factors at each of these levels on CRC testing. IMPACT: Future multilevel research and intervention should consider the simultaneous influences of multiple levels, including clinic, physician, and neighborhood. Cancer Epidemiol Biomarkers Prev; 23(7); 1346-55. ©2014 AACR.

Authors: Shaikh RA, Siahpush M, Singh GK

Title: Socioeconomic, demographic and smoking-related correlates of the use of potentially reduced exposure to tobacco products in a national sample.

Journal: Tob Control 23(4):353-8

Date: 2014 Jul

Abstract: BACKGROUND AND AIM: In recent years, new non-traditional, potentially reduced exposure products (PREPs), claiming to contain fewer harmful chemicals than the traditional products, have been introduced in the market. Little is known about socioeconomic, demographic and smoking-related determinants of the likelihood of using these products among smokers. The aim of this study was to examine these determinants. METHODS: Data from the 2006-2007 Tobacco Use Supplement to the Current Population Survey was used. We limited the analysis to current smokers (n=40724). Multivariate logistic regression analyses were conducted to estimate the association between covariates and the probability of the use of PREPs. RESULTS: We found that younger age, lower education, higher nicotine addiction and having an intention to quit are associated with higher likelihood of the use of PREPs. The likelihood of using these products was found to be higher among respondents who are unemployed or have a service, production, sales or farming occupation than those with a professional occupation. Smokers living in the midwest, south or west, were found to have a greater likelihood of the use of PREPs than those living in the northeast. CONCLUSIONS: Because there is little evidence to suggest that PREPs are less harmful that other tobacco products, their marketing as harm-minimising products should be regulated. Smokers, in particular those who are younger, have a lower socioeconomic status, and are more nicotine-dependent, should be the target of educational programmes that reveal the actual harm of PREPs.

Authors: Wernli KJ, Hubbard RA, Johnson E, Chubak J, Kamineni A, Green BB, Rutter CM

Title: Patterns of colorectal cancer screening uptake in newly eligible men and women.

Journal: Cancer Epidemiol Biomarkers Prev 23(7):1230-7

Date: 2014 Jul

Abstract: BACKGROUND: We describe patterns of colorectal cancer screening uptake in a U.S. insured population as individuals become newly eligible for screening at age 50 and assess temporal trends and patient characteristics with screening uptake. METHODS: We identified a cohort of 81,223 men and women who were members of Group Health and turned 50 years old from 1996 to 2010. We ascertained receipt of colorectal cancer screening within five years. Time to screening was estimated by year of cohort entry using cumulative incidence curves and Cox proportional hazards models-estimated patient characteristics associated with screening uptake. RESULTS: Stool-based screening tests were the most common, 72% of first screening tests. The proportion of individuals initiating colorectal cancer screening via colonoscopy increased from 8% in 1996 to 1998 to 33% in 2008 to 2010. Patient factors associated with increased colorectal cancer screening were: turning 50 more recently (2008-2010; Ptrend < 0.0001) or Asian race [HR, 1.14; 95% confidence interval (CI), 1.10-1.19]. Patient factors associated with decreased screening were: being a woman (HR, 0.70; 95% CI, 0.68-0.72), Native American (HR, 0.68; 95% CI, 0.60-0.78), or Pacific Islander race (HR, 0.82; 95% CI, 0.72-0.95), and having prevalent diabetes (HR, 0.78; 95% CI, 0.75-0.82) and higher body mass index (Ptrend < 0.0001). CONCLUSIONS: Patient characteristics associated with initiation of colorectal cancer screening in a newly eligible population are similar to characteristics associated with overall screening participation in all age-eligible adults. Our results identify patient populations to target in outreach programs. IMPACT: Disparities in receipt of colorectal cancer screening are evident from onset of an age-eligible cohort, identifying key groups for future interventions for screening. Cancer Epidemiol Biomarkers Prev; 23(7); 1230-7. ©2014 AACR.

Authors: Yabroff KR, Guy GP Jr, Ekwueme DU, McNeel T, Rozjabek HM, Dowling E, Li C, Virgo KS

Title: Annual patient time costs associated with medical care among cancer survivors in the United States.

Journal: Med Care 52(7):594-601

Date: 2014 Jul

Abstract: BACKGROUND: Although patient time costs are recommended for inclusion in cost-effectiveness analyses, these data are not routinely collected. We used nationally representative data and a medical service-based approach to estimate the annual patient time costs among cancer survivors. METHODS: We identified adult 6699 cancer survivors and 86,412 individuals without a cancer history ages 18 years or more from 2008-2011 Medical Expenditure Panel Survey (MEPS). Service use was categorized as hospitalizations, emergency room use, provider visits, ambulatory surgery, chemotherapy, and radiation therapy. Service time estimates were applied to frequencies for each service category and the US median wage rate in 2011 was used to value time. We evaluated the association between cancer survivorship and service use frequencies and patient time costs with multivariable regression models, stratified by age group (18-64 and 65+ y). Sensitivity analyses evaluated different approaches for valuing time. RESULTS: Cancer survivors were more likely to have hospitalizations, emergency room visits, ambulatory surgeries, and provider visits in the past year than individuals without a cancer history in adjusted analyses (P<0.05). Annual patient time was higher for cancer survivors than individuals without a cancer history among those aged 18-64 years (30.2 vs. 13.6 h; P<0.001) and 65+ years (55.1 vs. 36.6 h; P<0.001), as were annual patient time costs (18-64 y: $500 vs. $226; P<0.001 and 65+ y: $913 vs. $607; P<0.001). CONCLUSIONS: Cancer survivors had greater annual medical service use and patient time costs than individuals without a cancer history. This medical service-based approach for estimating annual time costs can also be applied to other conditions.

Authors: Walling AM, Weeks JC, Kahn KL, Tisnado D, Keating NL, Dy SM, Arora NK, Mack JW, Pantoja PM, Malin JL

Title: Symptom Prevalence in Lung and Colorectal Cancer Patients.

Journal: J Pain Symptom Manage :-

Date: 2014 Jun 25

Abstract: CONTEXT.: Relatively few data are available about symptoms among cancer patients. OBJECTIVES: To describe the prevalence and severity of symptoms among a large, representative cohort of newly diagnosed cancer patients. METHODS: We collected survey data about symptoms (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, diarrhea) from 5422 patients with incident lung and colorectal cancer from the diverse, nationally representative Cancer Care Outcomes Research and Surveillance (CanCORs) Consortium cohort. We described the prevalence of any symptoms and moderate/severe symptoms approximately four to six months following diagnosis. We used logistic regression to identify patient and clinical characteristics associated with symptoms, and calculated adjusted proportions of patients with symptoms. RESULTS: In total, 5067 (93.5%) patients reported at least one symptom in the four weeks before their survey, with 51% reporting at least one moderate/severe symptom. Lung cancer patients reported more symptoms than colorectal cancer patients. Patients who received treatment or had more comorbidities were more likely to report symptoms. For example, after adjustment, patients who received chemotherapy during the six weeks before the survey were more likely than others to report at least one symptom (97.3% vs. 90.8%, P<0.001), and at least one moderate/severe symptom (56.8% vs. 46.2%, P<0.001). After adjustment, early vs. late stage patients did not differ in reports of at least one symptom (93.6% vs. 93.4%, P=0.853) and differed only slightly in reports of at least one moderate/severe symptom (53.3% vs. 49.6%, P=0.009). CONCLUSION: Most recently diagnosed lung and colorectal cancer patients have cancer-related symptoms regardless of stage, and more than half have at least one moderate/severe symptom.

Authors: Olszewski AJ, Shafqat H, Ali S

Title: Disparate survival outcomes after front-line chemoimmunotherapy in older patients with follicular, nodal marginal zone and small lymphocytic lymphoma.

Journal: Leuk Lymphoma :1-19

Date: 2014 Jun 23

Abstract: Abstract Using the SEER-Medicare data (1996-2010), we compared survival and toxicity outcomes in 6,993 patients older than 65 years with follicular (FL), nodal marginal zone (NMZL) and small lymphocytic lymphoma (SLL) receiving front-line therapy with rituximab, RCHOP, RCVP or rituximab/fludarabine-containing regimens within 3 years from diagnosis. We demonstrated significant heterogeneity by histology after various regimens in multivariable survival models. Compared with RCHOP, overall survival was inferior with fludarabine-based regimens in FL (hazard ratio, HR, 1.53, P=0.0001) and NMZL (HR 1.88, P=0.0018). Analogous associations were evident for cumulative incidence of lymphoma-related death (HR 1.37, P=0.017, and 1.87, P=0.026, respectively). Conversely, in SLL outcomes were similar with any regimen. In NMZL and SLL, survival was not significantly different after single-agent rituximab compared with multi-agent combinations. The choice of front-line chemotherapy may thus impact survival in older patients with indolent lymphomas, and the heterogeneity by histology should be accounted for in clinical trials.

Authors: Veenstra CM, Epstein AJ, Liao K, Morris AM, Pollack CE, Armstrong KA

Title: The effect of care setting in the delivery of high-value colon cancer care.

Journal: Cancer :-

Date: 2014 Jun 20

Abstract: BACKGROUND: The effect of care setting on value of colon cancer care is unknown. METHODS: A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File. RESULTS: Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P<.001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P<.001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P<.001). CONCLUSIONS: Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers. Cancer 2014. © 2014 American Cancer Society.

Authors: Cooke CR, Feemster LC, Wiener RS, O'Neil ME, Slatore CG

Title: Aggressiveness of intensive care use among patients with lung cancer in the SEER-Medicare registry.

Journal: Chest :-

Date: 2014 Jun 19

Abstract: ABSTRACT: Background:Approximately 65% of elderly patients with lung cancer who are admitted to the intensive care unit (ICU) will die within six months. Efforts to improve end of life care for this population must first understand the patient factors that underlie admission to the ICU Methods:We performed a retrospective cohort study examining all fee-for-service inpatient claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry for elderly patients (age > 65) diagnosed with lung cancer between 1992 and 2005 who were hospitalized for reasons other than resection of their lung cancer. We calculated yearly rates of ICU admission per 1000 hospitalizations via room and board codes or ICD-9-CM and DRG codes for mechanical ventilation, stratified rates by receipt of mechanical ventilation and ICU type (medical/surgical/cardiac vs. intermediate), and compared these rates over time. Results:A total of 175,756 patients with lung cancer in SEER were hospitalized for a reason other than surgical resection of their tumor during the study period, 49,373 (28%) of whom had at least one ICU stay. The rate of ICU admission per 1000 hospitalizations increased over the study period from 140.7 in 1992 to 201.7 in 2005 (p<0.001). The majority of the increase in ICU admissions (per 1000 hospitalizations) between 1992 and 2005 occurred among patients who were not mechanically ventilated (118.2 to 173.3, p<0.001), in intermediate ICUs (20.0 to 61.9, p<0.001), but increased only moderately in medical/surgical/cardiac units (120.7 to 139.9 p<0.001). Conclusions:ICU admission for patients with lung cancer increased over time, mostly among patients without mechanical ventilation who were largely cared for in intermediate ICUs. Background: Approximately 65% of elderly patients with lung cancer who are admitted to the intensive care unit (ICU) will die within six months. Efforts to improve end of life care for this population must first understand the patient factors that underlie admission to the ICU. Methods: We performed a retrospective cohort study examining all fee-for-service inpatient claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry for elderly patients (age > 65) diagnosed with lung cancer between 1992 and 2005 who were hospitalized for reasons other than resection of their lung cancer. We calculated yearly rates of ICU admission per 1000 hospitalizations via room and board codes or ICD-9-CM and DRG codes for mechanical ventilation, stratified rates by receipt of mechanical ventilation and ICU type (medical/surgical/cardiac vs. intermediate), and compared these rates over time. Results: A total of 175,756 patients with lung cancer in SEER were hospitalized for a reason other than surgical resection of their tumor during the study period, 49,373 (28%) of whom had at least one ICU stay. The rate of ICU admission per 1000 hospitalizations increased over the study period from 140.7 in 1992 to 201.7 in 2005 (p<0.001). The majority of the increase in ICU admissions (per 1000 hospitalizations) between 1992 and 2005 occurred among patients who were not mechanically ventilated (118.2 to 173.3, p<0.001), in intermediate ICUs (20.0 to 61.9, p<0.001), but increased only moderately in medical/surgical/cardiac units (120.7 to 139.9 p<0.001). Conclusions: ICU admission for patients with lung cancer increased over time, mostly among patients without mechanical ventilation who were largely cared for in intermediate ICUs.

Authors: Fairfield KM, Murray K, LaChance JA, Wierman HR, Earle CC, Trimble EL, Warren JL

Title: Intraperitoneal chemotherapy among women in the Medicare population with epithelial ovarian cancer.

Journal: Gynecol Oncol :-

Date: 2014 Jun 18

Abstract: BACKGROUND: Intraperitoneal combined with intravenous chemotherapy (IV/IP) for primary treatment of epithelial ovarian cancer results in a substantial survival advantage for women who are optimally debulked surgically, compared with standard IV only therapy (IV). Little is known about the use of this therapy in the Medicare population. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 4665 women aged 66 and older with epithelial ovarian cancer diagnosed between 2005-2009, with their Medicare claims. We defined receipt of any IV/IP chemotherapy when there was claims evidence of any receipt of such treatment within 12months of the date of diagnosis. We used descriptive statistics to examine factors associated with treatment and health services use. RESULTS: Among 3561 women with Stage III or IV epithelial ovarian cancer who received any chemotherapy, only 124 (3.5%) received IV/IP chemotherapy. The use of IV/IP chemotherapy did not increase over the period of the study. In this cohort, younger women, those with fewer comorbidities, whites, and those living in Census tracts with higher income were more likely to receive IV/IP chemotherapy. Among women who received any IV/IP chemotherapy, we did not find an increase in acute care services (hospitalizations, emergency department visits, or ICU stays). CONCLUSION: During the period between 2005 and 2009, few women in the Medicare population living within observed SEER areas received IV/IP chemotherapy, and the use of this therapy did not increase. We observed marked racial and sociodemographic differences in access to this therapy.

Authors: Patel HD, Kates M, Pierorazio PM, Gorin MA, Jayram G, Ball MW, Hyams ES, Allaf ME

Title: Comorbidities and causes of death in the management of localized T1a kidney cancer.

Journal: Int J Urol :-

Date: 2014 Jun 16

Abstract: OBJECTIVE: The objectives of the present study were analyze specific comorbidities associated with survival and actual causes of death for patients with small renal masses, and to suggest a simplified measure associated with decreased overall survival specific to this population. METHODS: The Surveillance, Epidemiology and End Results-Medicare database (1995-2007) was queried to identify patients with localized T1a kidney cancer undergoing partial nephrectomy, radical nephrectomy or deferring therapy. We explored independent associations of specific comorbidities with causes of death, and developed a simplified cardiovascular index. Cox proportional hazards, and Fine and Gray competing risks regression were used. RESULTS: Of 7177 Medicare beneficiaries in the study population, 754 (10.5%) deferred therapy, 1849 (25.8%) underwent partial nephrectomy and 4574 (63.7%) underwent radical nephrectomy with none of the selected comorbidities identified in 3682 (51.3%) patients. Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival. The cardiovascular index provided good survival risk stratification, and reclassified 1427 (41%) patients with a score ≥1 on the Charlson Comorbidity Index to a 0 on the cardiovascular index with minimal concession of 5-year survival. CONCLUSIONS: Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival among Medicare beneficiaries with small renal masses. The cardiovascular index could serve as a clinically useful prognostic aid when advising older patients that are borderline candidates for surgery or active surveillance.

Authors: Stover AM, Mayer DK, Muss H, Wheeler SB, Lyons JC, Reeve BB

Title: Quality of life changes during the pre- to postdiagnosis period and treatment-related recovery time in older women with breast cancer.

Journal: Cancer 120(12):1881-9

Date: 2014 Jun 15

Abstract: BACKGROUND: Health care providers have little population-based evidence about health-related quality of life (HRQOL) changes, from the pre- to postdiagnosis period, and treatment-related recovery time for women aged 65 years and older diagnosed with breast cancer. METHODS: Older women with and without breast cancer completed self-reports of HRQOL at baseline and 2 years later as part of annual Medicare Health Outcomes Surveys (MHOS). MHOS was linked to Surveillance, Epidemiology, and End Results registries, which were used to categorize women with breast cancer by treatment type (breast-conserving surgery, breast-conserving surgery plus radiation, mastectomy) and time since diagnosis at follow-up. Each cancer case diagnosed in 1998 through 2007 (N = 542) was matched to 5 women without cancer (N = 2710) using propensity score matching. Analysis of covariance models examined changes in HRQOL, adjusting for demographics and initial functioning. RESULTS: Older women within 6 months of diagnosis had greater declines than women without cancer in SF-36 Physical (-5.8 vs -1.8) and Mental (-3.6 vs -0.7) Component Summary scores, General Health (-12.3 vs -4.6), Vitality (-11.0 vs -2.2), Bodily Pain (-8.5 vs -2.1), Social Functioning (-15.1 vs -3.3), Role-Physical (-26.5 vs -3.9), and Role-Emotional (-13.1 vs -3.1) scores (all P < .05). By approximately 1 year, women with and without breast cancer had similar HRQOL. Comparable declines in Physical Component Summary and Role-Physical occurred across treatment types. CONCLUSIONS: Women aged 65 years and older diagnosed with breast cancer should be counseled that survivors within 6 months of diagnosis are vulnerable to HRQOL declines, compared to women without breast cancer, but that decrements generally wane after 12 months.

Authors: Cooper GS, Xu F, Schluchter MD, Koroukian SM, Barnholtz Sloan JS

Title: Diverticulosis and the Risk of Interval Colorectal Cancer.

Journal: Dig Dis Sci :-

Date: 2014 Jun 14

Abstract: BACKGROUND: Diverticulosis, a prevalent condition at screening colonoscopy, has been associated with colorectal cancers that develop after a clearing colonoscopy, or interval cancers. AIMS: To quantify the overall risk of diverticulosis in the development of interval cancers and examine this association in relevant subgroups. METHODS: Using a linked database containing SEER tumor registry data and Medicare claims, we identified patients aged ≥69 years with colorectal cancer who underwent colonoscopy within 6 months of diagnosis. Patients with an additional colonoscopy from 36 to 6 months prior to cancer diagnosis were characterized as having interval cancers. We compared characteristics of patients with interval cancers and detected cancers according to a diagnosis of diverticulosis not associated with a colonoscopy procedure from 1991 through the date of the most recent colonoscopy in both univariate and multivariate models. RESULTS: A previous diagnosis of diverticulosis was documented in 14,452 (26.9 %) patients with detected cancers compared to 2,905 (69.3 %) patients with interval cancers (p < 0.001); these results were consistent in multivariable analysis. Moreover, the association was found as well in the proximal colon (OR 2.88, 95 % CI 2.66, 3.12), distal colon (OR 3.56, 95 % CI 3.09, 4.11), and rectum (OR 4.07, 95 % CI 3.34, 4.95). The vast majority of diverticulosis diagnoses were without complications such as hemorrhage or diverticulitis. CONCLUSIONS: Diverticulosis was strongly associated with interval colorectal cancers in all segments of the colon. Given its known predominance in the left colon, the findings argue against impaired visualization of lesions at colonoscopy as the only pathogenic factor.

Authors: Ehdaie B, Atoria CL, Lowrance WT, Herr HW, Bochner BH, Donat SM, Dalbagni G, Elkin EB

Title: Adherence to surveillance guidelines after radical cystectomy: A population-based analysis.

Journal: Urol Oncol :-

Date: 2014 Jun 13

Abstract: OBJECTIVES: Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database. METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics. RESULTS: Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60-0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68-0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70-2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27-1.82). We also observed significant geographic variability in adherence. CONCLUSION: Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.

Authors: Ekwueme DU, Yabroff KR, Guy GP Jr, Banegas MP, de Moor JS, Li C, Han X, Zheng Z, Soni A, Davidoff A, Rechis R, Virgo KS, Centers for Disease Control and Prevention (CDC)

Title: Medical costs and productivity losses of cancer survivors--United States, 2008-2011.

Journal: MMWR Morb Mortal Wkly Rep 63(23):505-10

Date: 2014 Jun 13

Abstract: The number of persons in the United States with a history of cancer has increased from 3 million in 1971 to approximately 13.4 million in 2012, representing 4.6% of the population. Given the advances in early detection and treatment of cancer and the aging of the U.S. population, the number of cancer survivors is projected to increase by >30% during the next decade, to approximately 18 million. Cancer survivors face many challenges with medical care follow-up, managing the long-term and late effects of treatments, monitoring for recurrence, and an increased risk for additional cancers. These survivors also face economic challenges, including limitations in work and daily activities, obtaining health insurance coverage and accessing health care, and increasing medical care costs. To estimate annual medical costs and productivity losses among male and female cancer survivors and persons without a cancer history, CDC, along with other organizations, analyzed data from the 2008-2011 Medical Expenditure Panel Survey (MEPS), sponsored by the Agency for Healthcare Research and Quality. The results indicate that the economic burden of cancer survivorship is substantial among all survivors. For male cancer survivors, during 2008-2011, average annual medical costs and productivity losses resulting from health problems per person and adjusted to 2011 dollars were significantly higher among cancer survivors than among persons without a cancer history, by $4,187 and $1,459, respectively; for females, the estimated annual costs per person were $3,293 and $1,330 higher among cancer survivors than among persons without a cancer history, respectively. These findings suggest the need to develop and evaluate health and employment intervention programs aimed at improving outcomes for cancer survivors and their families.

Authors: Lairson DR, Parikh RC, Cormier JN, Chan W, Du XL

Title: Cost-Utility Analysis of Chemotherapy Regimens in Elderly Patients with Stage III Colon Cancer.

Journal: Pharmacoeconomics :-

Date: 2014 Jun 12

Abstract: BACKGROUND: Chemotherapy prolongs survival for stage III colon cancer patients but community-level evidence on the effectiveness and cost effectiveness of treatment for elderly patients is limited. Comparisons were between patients receiving no chemotherapy, 5-fluorouracil (5-FU), and FOLFOX (5-FU + oxaliplatin). METHODS: A retrospective cohort study was conducted using the Surveillance Epidemiology, and End Results (SEER)-Medicare linked database. Patients (≥65 years) with American Joint Committee on Cancer stage III colon cancer at diagnosis in 2004-2009 were identified. The 3-way propensity score matched sample included 3,534 patients. Effectiveness was measured in life-years and quality-adjusted life-years (QALYs). Medicare costs (2010 US dollars) were estimated from diagnosis until death or end of study. RESULTS: FOLFOX patients experienced 6.06 median life-years and 4.73 QALYs. Patients on 5-FU had 5.75 median life-years and 4.50 median QALYs, compared to 3.42 and 2.51, respectively, for the no chemotherapy patients. Average total healthcare costs ranged from US$85,422 for no chemotherapy to US$168,628 for FOLFOX. Incremental cost-effectiveness ratios (ICER) for 5-FU versus no chemotherapy were US$17,131 per life-year gained and US$20,058 per QALY gained. ICERs for FOLFOX versus 5-FU were US$139,646 per life-year gained and US$188,218 per QALY gained. Results appear to be sensitive to age, suggesting that FOLFOX performs better for patients 65-69 and 80+ years old while 5-FU appears most effective and cost effective for the age groups 70-74 and 75-79 years. CONCLUSION: FOLFOX appears more effective and cost effective than other strategies for colon cancer treatment of older patients. Results were sensitive to age, with ICERs exhibiting a U-shaped pattern.

Authors: Odejide OO, Cronin AM, Davidoff AJ, LaCasce AS, Abel GA

Title: Limited Stage Diffuse Large B-Cell Lymphoma: Comparative Effectiveness of Treatment Strategies in a Large Cohort of Elderly Patients.

Journal: Leuk Lymphoma :1-27

Date: 2014 Jun 10

Abstract: Abstract Optimal treatment for limited stage DLBCL in the elderly is controversial. Using the Surveillance Epidemiology and End Results-Medicare database, we compared overall survival (OS), time to second-line therapy (surrogate for recurrence), and adverse events in elderly patients diagnosed with stage I or II DLBCL in 1999-2009, who received either abbreviated rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) plus radiation or 6-8 cycles of RCHOP alone. Of 874 patients, 359 received abbreviated RCHOP with radiation, and 515 received a full course of RCHOP. In propensity score-adjusted analyses, OS was similar in both groups (HR 1.02, 95 CI 0.76,1.38). Abbreviated RCHOP with radiation was associated with lower risk of second-line therapy (HR 0.71, 95% CI 0.53,0.94) and lower odds of febrile neutropenia (OR 0.27, 95% CI 0.15,0.50). While the two treatments resulted in similar survival, our data suggest that abbreviated RCHOP with radiation may be better tolerated than a full course of RCHOP.

Authors: Agaku IT, Odukoya OO, Olufajo O, Filippidis FT, Vardavas CI

Title: Support for smoke-free cars when children are present: a secondary analysis of 164,819 U.S. adults in 2010/2011.

Journal: Eur J Pediatr :-

Date: 2014 Jun 03

Abstract: Comprehensive smoke-free legislations prohibiting smoking in indoor areas of workplaces, bars, and restaurants have been adopted in most of the USA; however, limited efforts have focused on regulating secondhand smoke (SHS) exposure in the family car. The objective of this study was to identify the determinants and national/state-specific population support for smoke-free cars, in the presence of any occupant in general, but particularly when children are present. National data of US adults aged ≥18 years (n = 164,819) were obtained from the 2010/2011 Tobacco Use Supplement of the Current Population Survey. Among all US adults, a significantly greater proportion supported smoke-free cars when it was specified that the occupant was a child compared to when not specified (93.4 vs. 73.7 %, p < 0.05). Age, race/ethnicity, gender, current tobacco use, marital status, and the existence of household smoke-free regulations all mediated population support for smoke-free cars. Conclusion: While differences within the US population were noted, this study however showed overwhelming support for smoke-free car policies, particularly when children are present. Policies which prohibit smoking in indoor or confined areas such as cars may benefit public health by protecting nonsmoking children and adults from involuntary SHS exposure.

Authors: Falchook AD, Salloum RG, Hendrix LH, Chen RC

Title: Use of bone scan during initial prostate cancer workup, downstream procedures, and associated Medicare costs.

Journal: Int J Radiat Oncol Biol Phys 89(2):243-8

Date: 2014 Jun 01

Abstract: PURPOSE: For patients with a high likelihood of having metastatic disease (high-risk prostate cancer), bone scan is the standard, guideline-recommended test to look for bony metastasis. We quantified the use of bone scans and downstream procedures, along with associated costs, in patients with high-risk prostate cancer, and their use in low- and intermediate-risk patients for whom these tests are not recommended. METHODS AND MATERIALS: Patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed with prostate cancer from 2004 to 2007 were included. Prostate specific antigen (PSA), Gleason score, and clinical T stage were used to define D'Amico risk categories. We report use of bone scans from the date of diagnosis to the earlier of treatment or 6 months. In patients who underwent bone scans, we report use of bone-specific x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans, and bone biopsy within 3 months after bone scan. Costs were estimated using 2012 Medicare reimbursement rates. RESULTS: In all, 31% and 48% of patients with apparent low- and intermediate-risk prostate cancer underwent a bone scan; of these patients, 21% underwent subsequent x-rays, 7% CT, and 3% MRI scans. Bone biopsies were uncommon. Overall, <1% of low- and intermediate-risk patients were found to have metastatic disease. The annual estimated Medicare cost for bone scans and downstream procedures was $11,300,000 for low- and intermediate-risk patients. For patients with apparent high-risk disease, only 62% received a bone scan, of whom 14% were found to have metastasis. CONCLUSIONS: There is overuse of bone scans in patients with low- and intermediate-risk prostate cancers, which is unlikely to yield clinically actionable information and results in a potential Medicare waste. However, there is underuse of bone scans in high-risk patients for whom metastasis is likely.

Authors: Guy GP Jr, Yabroff KR, Ekwueme DU, Smith AW, Dowling EC, Rechis R, Nutt S, Richardson LC

Title: Estimating the health and economic burden of cancer among those diagnosed as adolescents and young adults.

Journal: Health Aff (Millwood) 33(6):1024-31

Date: 2014 Jun 01

Abstract: Adolescent and young adult cancer survivors-those who were ages 15-39 at their first cancer diagnosis-have important health limitations. These survivors are at risk for higher health care expenditures and lost productivity, compared to adults without a history of cancer. Using Medical Expenditure Panel Survey data, we present nationally representative estimates of the economic burden among people who were diagnosed with cancer in adolescence or young adulthood. Our findings demonstrate that surviving cancer at this age is associated with a substantial economic burden. Compared to adults without a history of cancer, adolescent and young adult cancer survivors had excess annual medical expenditures of $3,170 per person and excess annual productivity losses of $2,250 per person. Multifaceted prevention strategies, including education and sustained intervention programs to ensure access to lifelong risk-based follow-up care, may be effective ways to improve the economic outcomes associated with cancer survivorship in this population.

Authors: Tosteson AN, Fryback DG, Hammond CS, Hanna LG, Grove MR, Brown M, Wang Q, Lindfors K, Pisano ED

Title: Consequences of false-positive screening mammograms.

Journal: JAMA Intern Med 174(6):954-61

Date: 2014 Jun 01

Abstract: IMPORTANCE: False-positive mammograms, a common occurrence in breast cancer screening programs, represent a potential screening harm that is currently being evaluated by the US Preventive Services Task Force. OBJECTIVE: To measure the effect of false-positive mammograms on quality of life by measuring personal anxiety, health utility, and attitudes toward future screening. DESIGN, SETTING, AND PARTICIPANTS: The Digital Mammographic Imaging Screening Trial (DMIST) quality-of-life substudy telephone survey was performed shortly after screening and 1 year later at 22 DMIST sites and included randomly selected DMIST participants with positive and negative mammograms. EXPOSURE: Mammogram requiring follow-up testing or referral without a cancer diagnosis. MAIN OUTCOMES AND MEASURES: The 6-question short form of the Spielberger State-Trait Anxiety Inventory state scale (STAI-6) and the EuroQol EQ-5D instrument with US scoring. Attitudes toward future screening as measured by women's self-report of future intention to undergo mammographic screening and willingness to travel and stay overnight to undergo a hypothetical new type of mammography that would identify as many cancers with half the false-positive results. RESULTS: Among 1450 eligible women invited to participate, 1226 (84.6%) were enrolled, with follow-up interviews obtained in 1028 (83.8%). Anxiety was significantly higher for women with false-positive mammograms (STAI-6, 35.2 vs 32.7), but health utility scores did not differ and there were no significant differences between groups at 1 year. Future screening intentions differed by group (25.7% vs 14.2% more likely in false-positive vs negative groups); willingness to travel and stay overnight did not (9.9% vs 10.5% in false-positive vs negative groups). Future screening intention was significantly increased among women with false-positive mammograms (odds ratio, 2.12; 95% CI, 1.54-2.93), younger age (2.78; 1.5-5.0), and poorer health (1.63; 1.09-2.43). Women's anticipated high-level anxiety regarding future false-positive mammograms was associated with willingness to travel overnight (odds ratio, 1.94; 95% CI, 1.28-2.95). CONCLUSIONS AND RELEVANCE: False-positive mammograms were associated with increased short-term anxiety but not long-term anxiety, and there was no measurable health utility decrement. False-positive mammograms increased women's intention to undergo future breast cancer screening and did not increase their stated willingness to travel to avoid a false-positive result. Our finding of time-limited harm after false-positive screening mammograms is relevant for clinicians who counsel women on mammographic screening and for screening guideline development groups.

Authors: Basu A

Title: Estimating person-centered treatment (PeT) effects using instrumental variables: an application to evaluating prostate cancer treatments

Journal: J Appl Econ 29(4):671-91

Date: 2014 Jun-Jul

Abstract: This paper builds on the methods of local instrumental variables developed by Heckman and Vytlacil (1999, 2001, 2005) to estimate person-centered treatment (PeT) effects that are conditioned on the person's observed characteristics and averaged over the potential conditional distribution of unobserved characteristics that lead them to their observed treatment choices. PeT effects are more individualized than conditional treatment effects from a randomized setting with the same observed characteristics. PeT effects can be easily aggregated to construct any of the mean treatment effect parameters and, more importantly, are well suited to comprehend individual-level treatment effect heterogeneity. The paper presents the theory behind PeT effects, and applies it to study the variation in individual-level comparative effects of prostate cancer treatments on overall survival and costs. Copyright © 2013 John Wiley & Sons, Ltd.

Authors: Becker A, Ravi P, Roghmann F, Trinh QD, Tian Z, Larouche A, Kim S, Shariat SF, Kluth L, Dahlem R, Fisch M, Graefen M, Eichelberg C, Karakiewicz PI, Sun M

Title: Laparoscopic radical nephrectomy vs laparoscopic or open partial nephrectomy for T1 renal cell carcinoma: comparison of complication rates in elderly patients during the initial phase of adoption.

Journal: Urology 83(6):1285-91

Date: 2014 Jun

Abstract: OBJECTIVE: To assess postoperative complication profiles and 30-day mortality (30 dM) in older patients undergoing either laparoscopic radical nephrectomy (LRN) compared with open partial nephrectomy (OPN) or laparoscopic partial nephrectomy (LPN) for early stage renal cell carcinoma. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare linked database, 2277 patients aged>65 years with T1 renal cell carcinoma, who underwent LRN, OPN, or LPN were identified (1992-2005). Surgical and medical complications and 30 dM after nephrectomy were abstracted. Bivariate and multivariate logistic regression analyses were performed. RESULTS: Relative to LRN, the rate of surgical complications was higher for OPN (28% vs 20%; P<.001) and LPN (29% vs 20%; P=.01). These differences persisted after multivariate adjustment for patient and tumor characteristics (OPN: odds ratio, 1.6; 95% confidence interval, 1.28-1.91; P<.001; LPN: odds ratio, 1.6; 95% confidence interval, 1.13-2.39; P=.01). Specifically, relative to LRN, OPN was associated with a 7% higher rate of genitourinary complications (13% vs 20%; P<.001). Similarly, relative to LRN, LPN was associated with a 7% higher rate of genitourinary complications (13% vs 20%; P=.001) and with a 4% higher rate of hemorrhagic complications (8% vs 4%; P=.02). No statistically significant differences were recorded for all other surgical and/or medical complication types and 30 dM (all P≥.2). CONCLUSION: The complication and 30-dM rates were not different between LRN, OPN, and LPN groups. Exceptions include genitourinary complications that favor LRN relative to OPN and LPN and hemorrhagic complications that favor LRN relative to LPN. It is doubtful that these results should discourage the use of partial nephrectomy relative to LRN in older patients.

Authors: Bradley CJ, Dahman B, Anscher M

Title: Prostate cancer treatment and survival: evidence for men with prevalent comorbid conditions.

Journal: Med Care 52(6):482-9

Date: 2014 Jun

Abstract: BACKGROUND: The absence of evidence-based guidelines for prostate cancer treatment led the Institute of Medicine to include localized prostate cancer treatment among the 25 most important topics for comparative effectiveness research. OBJECTIVE: This study compared prostate cancer treatment and survival in men with and without prevalent comorbid conditions. RESEARCH DESIGN: The sample comprised elderly men, aged 66 years and older, extracted from SEER-Medicare data, between 2004 and 2009 (N=73,563). Treatment and survival for men with at least 1 of 4 prevalent comorbid conditions were compared with men who did not have any of the 12 Charlson comorbid conditions. The sample was stratified by comorbid condition and low-risk, intermediate-risk, and high-risk disease. RESULTS: Over half of men received some form of cancer-directed treatment, irrespective of comorbid condition. Men who have congestive heart failure (CHF) or multiple comorbid conditions were less likely to be treated, whereas men with diabetes were more likely to be treated. With the exception of men with CHF, men with comorbid conditions and low-risk disease received no survival benefit from any type of treatment. CONCLUSIONS: Most men received treatment, particularly radiation therapy, regardless of comorbid condition. The evidence suggests more caution should be used when treating men with low-risk disease and comorbid conditions as they are at risk for adverse events and additional medical costs, without a survival benefit.

Authors: Bright BC, Soulakova JN

Title: Evidence of telescoping in regular smoking onset age.

Journal: Nicotine Tob Res 16(6):717-24

Date: 2014 Jun

Abstract: INTRODUCTION: We examined the evidence of telescoping bias in self-reports of regular smoking onset age. Since the exact year of the onset was not available, the discrepancy (termed shift) in self-reports was explored. The study was targeted at establishing the relationships between the prevalence and the magnitude of shifting and respondent and survey characteristics and identifying the key factors contributing to forward and backward shifting. METHODS: The 2002-2003 Tobacco Use Supplement to the Current Population Survey was administered using phone and in-person interviews to the same respondents in 2002 and 2003. The regular smoking onset age, reported by current and former smokers during both years, was used. All statistical analyses incorporated replicate weights to adjust for the complex survey design. RESULTS: In our sample, about 31.6% (31.8%) of respondents forwardly (backwardly) shifted the smoking onset age, with the mean magnitude of discrepancy about 2.7 years (both directions). The elapsed time since the onset was shown to be the most important considered predictor of prevalence of shifting. The prevalence of forward (backward) shifting tends to increase (decrease) as elapsed time increases. Furthermore, the discrepancy in forwardly shifted responses tends to increase, on average, with elapsed time. CONCLUSIONS: The findings indicate that both forward and backward shifting may be prevalent in reports on smoking onset age. The extent of shifting depends on elapsed time since the onset (and therefore, the respondent's age) and other respondent and survey characteristics. The findings are consistent with presence of both forward and backward telescoping biases.

Authors: Davidoff AJ, Gardner LD, Zuckerman IH, Hendrick F, Ke X, Edelman MJ

Title: Validation of disability status, a claims-based measure of functional status for cancer treatment and outcomes studies.

Journal: Med Care 52(6):500-10

Date: 2014 Jun

Abstract: BACKGROUND: In prior research, we developed a claims-based prediction model for poor patient disability status (DS), a proxy measure for performance status, commonly used by oncologists to summarize patient functional status and assess ability of a patient to tolerate aggressive treatment. In this study, we implemented and validated the DS measure in 4 cohorts of cancer patients: early and advanced non-small cell lung cancers (NSCLC), stage IV estrogen receptor-negative (ER-) breast cancer, and myelodysplastic syndromes (MDS). DATA AND METHODS: SEER-Medicare data (1999-2007) for the 4 cohorts of cancer patients. Bivariate and multivariate logistic regression tested the association of the DS measure with designated cancer-directed treatments: early NSCLC (surgery), advanced NSCLC (chemotherapy), stage IV ER- breast cancer (chemotherapy), and MDS (erythropoiesis-stimulating agents). Treatment model fit was compared across model iterations. RESULTS: In both unadjusted and adjusted results, predicted poor DS was strongly associated with a lower likelihood of cancer treatment receipt in all 4 cohorts [early NSCLC (N=20,280), advanced NSCLC (N=31,341), stage IV ER- breast cancer (N=1519), and MDS (N=6058)] independent of other patient, contextual, and disease characteristics, as well as the Charlson Comorbidity Index. Inclusion of the DS measure into models already controlling for other variables did not significantly improve model fit across the cohorts. CONCLUSIONS: The DS measure is a significant independent predictor of cancer-directed treatment. Small changes in model fit associated with both DS and the Charlson Comorbidity Index suggest that unobserved factors continue to play a role in determining cancer treatments.

Authors: Freedman RA, Vaz-Luis I, Barry WT, Lii H, Lin NU, Winer EP, Keating NL

Title: Patterns of chemotherapy, toxicity, and short-term outcomes for older women receiving adjuvant trastuzumab-based therapy.

Journal: Breast Cancer Res Treat 145(2):491-501

Date: 2014 Jun

Abstract: Limited data are available regarding patterns of chemotherapy receipt and treatment-related toxicities for older women receiving adjuvant trastuzumab-based therapy. We used surveillance, epidemiology and end results (SEER)-Medicare data to identify patients ≥66 years with stage I-III breast cancer treated during 2005-2009, who received trastuzumab-based therapy. We examined patterns of chemotherapy receipt, and using multivariable logistic regression, we examined associations of age and comorbidity with non-standard chemotherapy. In propensity-weighted cohorts of women receiving standard and non-standard trastuzumab-based therapy, we also examined rates of (1) hospital events during the first 6 months of chemotherapy and (2) short-term survival. Among 2,106 women, 29.7 % were aged ≥76 and 66 % had a comorbidity score = 0. Overall, 31.3 % of women received non-standard chemotherapy. Compared to patients aged 66-70, older patients more often received non-standard chemotherapy [adjusted odds ratio (OR) = 4.1, 95 % confidence interval (CI) = 3.40-4.92 (ages 76-80); OR = 15.3, 95 %CI = 9.92-23.67 (age ≥ 80)]. However, comorbidity was not associated with receipt of non-standard chemotherapy. After propensity score adjustment, hospitalizations were more frequent in the standard (vs. non-standard) group (adjusted OR = 1.7, 95 % CI = 1.29-2.24). With a median follow-up of 2.8 years, 276 deaths occurred; the adjusted hazard ratio (HR) for death was lower in standard versus non-standard treated women (HR = 0.69, 95 % CI = 0.52-0.91). Among a population-based cohort of older women receiving trastuzumab, nearly one-third received non-standard chemotherapy, with the highest rates among the oldest women. Non-standard chemotherapy was associated with fewer toxicity-related hospitalizations but worse survival. Further exploration of treatment toxicities and outcomes for older women with HER2-positive breast cancer is warranted.

Authors: Houssami N, Abraham LA, Onega T, Collins LC, Sprague BL, Hill DA, Miglioretti DL

Title: Accuracy of screening mammography in women with a history of lobular carcinoma in situ or atypical hyperplasia of the breast.

Journal: Breast Cancer Res Treat 145(3):765-73

Date: 2014 Jun

Abstract: Women with lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), atypical ductal hyperplasia (ADH), or atypical hyperplasia (AH) are at increased breast cancer (BC) risk. We investigated the accuracy and outcomes of mammography screening in women with histology-proven LCIS, ALH, ADH, or AH history who had screening through Breast Cancer Surveillance Consortium-affiliated mammography facilities. Screens from two cohorts, defined by LCIS/ALH or ADH/AH history, were compared to two cohorts without such history mammogram-matched for age-group, breast density, family history, screen-year, and mammography registry. Overall 359 BCs (277 invasive BC) occurred within 1 year from screening among 52,380 screens. In the LCIS/ALH cohort [versus comparator screens] cancer incidence rates, cancer detection rates (CDR), and interval cancer rates (ICR) were significantly higher (all P < 0.001); although ICR was 4.4/1,000 screens [versus 0.9/1,000; P < 0.001] the proportion that were interval cancers did not differ between compared cohorts (P = 0.43); screening sensitivity was 76.1 % [versus 82.3 %; P = 0.43], however, specificity was significantly lower at 85.1 % [versus 90.7 %; P < 0.0001]. In the ADH/AH cohort [versus comparator] cancer rates and CDR were significantly higher (P < 0.001); although ICR was 2.6/1,000 screens [versus 0.9/1,000; P = 0.002] the proportion that were interval cancers did not differ between cohorts (P = 0.74); screening sensitivity was 81.0 % [versus 82.6 %; P = 0.74] and specificity was lower at 86.2 % [versus 90.2 %; P < 0.0001]. Mammography screening sensitivity in LCIS/ALH and ADH/AH cohorts did not significantly differ from that of matched screens, however, specificity was lower, and ICRs were higher (reflecting underlying cancer rates). Adjunct screening may be of value in these women if it reduces ICR without substantially reducing specificity.

Authors: Huang KH, Kaplan AL, Carter SC, Lipsitz SR, Hu JC

Title: The impact of radical prostatectomy operative time on outcomes and costs.

Journal: Urology 83(6):1265-71

Date: 2014 Jun

Abstract: OBJECTIVE: To examine the impact of radical prostatectomy (RP) operative time on outcomes and cost, we performed a population-based assessment of operative time as a predictor of outcomes. Although operative time has been used as a metric to evaluate RP surgeon learning curves, the effect of RP operative times on outcomes remains understudied. MATERIALS AND METHODS: We used US Surveillance, Epidemiology, and End Results-Medicare linked data to identify 7534 men aged≥66 years diagnosed with prostate cancer during 2003-2007 who underwent RP for localized prostate cancer through 2009. We categorized RP operative time into quartiles (short, intermediate, long, and very long) and used propensity score analyses to assess its impact on perioperative complications, mortality, length of hospitalization, readmissions, emergency room visits, and costs. RESULTS: Quartiles ranged from 0 to 172 minutes for short, 173 to 214 minutes for intermediate, 215 to 268 minutes for long, and ≥269 minutes for very long RP operative times. After propensity score adjustment, longer operative time was associated with more surgery-related complications (short, 12.0%; intermediate, 12.3%; long, 14.4%; and very long, 22.8%; P<.001), longer median (interquartile range) length of stay in days (short, 2 [2-3]; intermediate, 2 [2-3]; long, 2 [1-3]; and very long, 2 [1-3]; P<.001), and higher median costs (short, $10,647; intermediate, $10,957; long, $11,405; and very long, $11,966; P<.001). CONCLUSION: Longer RP operative time is associated with more complications, longer lengths of hospital stay, and higher costs. Increasing operative efficiency may reduce complications, length of stay, and health-care costs.

Authors: Keegan TH, Tao L, DeRouen MC, Wu XC, Prasad P, Lynch CF, Shnorhavorian M, Zebrack BJ, Chu R, Harlan LC, Smith AW, Parsons HM, AYA HOPE Study Collaborative Group

Title: Medical care in adolescents and young adult cancer survivors: what are the biggest access-related barriers?

Journal: J Cancer Surviv 8(2):282-92

Date: 2014 Jun

Abstract: PURPOSE: Adolescent and young adult (AYA) cancer survivors experience barriers to utilizing healthcare, but the determinants of cancer-related medical care of AYAs has not been fully explored. METHODS: We studied factors associated with medical care utilization among 465 AYA cancer survivors in the AYA Health Outcomes and Patient Experience Study, a cohort of 15 to 39 year olds recently diagnosed with germ cell cancer, lymphoma, sarcoma, or acute lymphocytic leukemia. Descriptive statistics and multivariate logistic regression methods were used. RESULTS: Most AYA cancer survivors (95%), who were 15-35 months post diagnosis, received medical care in the past 12 months and 17% were undergoing cancer treatment. In multivariate analyses, compared with AYAs with no cancer-related medical visits in the previous year, AYAs receiving cancer-related care were more likely to currently have health insurance (odds ratio (OR) = 4.9; 95% confidence interval (CI) = 1.7-13.8) or have had health insurance in the past year (OR = 4.0; 95% CI = 0.99-16.3). Cancer recurrence, lacking employment, and negative changes in self-reported general health were associated with ongoing cancer treatment versus other cancer-related medical care. Eleven percent of all AYAs and 25% of AYAs who did not receive medical care in the past 12 months lost health insurance between the initial and follow-up surveys. CONCLUSION: AYA cancer survivors with health insurance were much more likely to receive cancer-related medical care than those without insurance. IMPLICATIONS FOR CANCER SURVIVORS: Despite the need for post-treatment medical care, lacking health insurance is a barrier to receiving any medical care among AYAs.

Authors: Schmocker RK, Caretta-Weyer H, Weiss JM, Ronk K, Havlena J, Loconte NK, Decker M, Smith MA, Greenberg CC, Neuman HB

Title: Determining breast cancer axillary surgery within the surveillance epidemiology and end results-Medicare database.

Journal: J Surg Oncol 109(8):756-9

Date: 2014 Jun

Abstract: BACKGROUND: Use of sentinel lymph node biopsy (SLNB) is under-reported by cancer registries' "Scope of Regional Lymph Node Surgery" variable. In 2011, the Surveillance Epidemiology and End Results (SEER) Program recommended against its use to determine extent of axillary surgery, leaving a gap in the utilization of claims data for breast cancer research. The objective was to develop an algorithm using SEER registry and claims data to classify extent of axillary surgery for breast cancer. METHODS: We analyzed data for 24,534 breast cancer patients. CPT codes and number of examined lymph nodes classified the extent of axillary surgery. The final algorithm was validated by comparing the algorithm derived extent of axillary surgery to direct chart review for 100 breast cancer patients treated at our breast center. RESULTS: Using the algorithm, 13% had no axillary surgery, 56% SLNB and 31% axillary lymph node dissection (ALND). SLNB was performed in 77% of node negative patients and ALND in 72% of node positive. In our validation study, concordance between algorithm and direct chart review was 97%. CONCLUSIONS: Given recognized inaccuracies in cancer registries' "Scope of Regional Lymph Node Surgery" variable, these findings have high utility for health services researchers studying breast cancer treatment.

Authors: Spencer BA, Shim JJ, Hershman DL, Zacharia BE, Lim EA, Benson MC, Neugut AI

Title: Metastatic epidural spinal cord compression among elderly patients with advanced prostate cancer.

Journal: Support Care Cancer 22(6):1549-55

Date: 2014 Jun

Abstract: BACKGROUND: A recent randomized trial demonstrated that for metastatic epidural spinal cord compression (MESCC), a complication of advanced prostate cancer, surgical decompression may be more effective than external beam radiation therapy (RT). We investigated predictors of MESCC, its treatment, and its impact on hospital length of stay for patients with advanced prostate cancer. METHODS: We used the SEER-Medicare database to identify patients >65 years with stage IV (n = 14,800) prostate cancer. We used polytomous logistic regression to compare those with and without MESCC and those hospitalized for treatment with surgical decompression and/or RT. RESULTS: MESCC developed in 711 (5 %) of patients, among whom 359 (50 %) received RT and 107 (15 %) underwent surgery ± RT. Median survival was 10 months. MESCC was more likely among patients who were black (OR 1.75, 95 %CI 1.39-2.19 vs. white) and had high-grade tumors (OR 3.01, 95 %CI 1.14-7.94), and less likely in those younger; with prior hormonal therapy (OR 0.73, 95 %CI 0.62-0.86); or with osteoporosis (OR 0.63, 95 %CI 0.47-0.83). Older patients were less likely to undergo either RT or surgery, as were those with ≥1 comorbidity. Patients with high-grade tumors were more likely to undergo RT (OR 1.92, 95 %CI 1.25-2.96). Those who underwent RT or surgery spent an additional 11 and 29 days, respectively, hospitalized. CONCLUSIONS: We found that black men with metastatic prostate cancer are more likely to develop MESCC than whites. RT was more commonly utilized for treatment than surgery, but the elderly and those with comorbidities were unlikely to receive either treatment.

Authors: Tong L, Ahn C, Symanski E, Lai D, Du XL

Title: Effects of newly developed chemotherapy regimens, comorbidities, chemotherapy-related toxicities on the changing patterns of the leading causes of death in elderly patients with colorectal cancer.

Journal: Ann Oncol 25(6):1234-42

Date: 2014 Jun

Abstract: BACKGROUND: Abundant evidences have shown that newly developed chemotherapy regimens improved 5-year survival rate of colorectal cancer (CRC) patients over the past two decades. However, their impact on risk of death from leading causes among elderly patients is still poorly understood. PATIENTS AND METHODS: A retrospective cohort study of 69 718 elderly CRC patients with their first primary tumors in 1992-2009, identified from the 12 areas of Surveillance, Epidemiology, and End Results-Medicare linked database with their Medicare claims up to 2010. Multivariate Cox regression models were used to assess the effect of newly developed chemotherapy regimens, comorbidities, and chemotherapy related toxicities on cause-specific death and their temporal patterns among elderly CRC patients. RESULTS: The leading causes of death among CRC patients were CRC, circulation disorders, and secondary cancers, which accounted for 51.4%, 25%, and 4.6% of all-cause death, respectively. Patients diagnosed in more recent diagnostic time periods were significantly less likely to die of CRC [period 2: 5-year hazard ratio = 0.94, 95% confidence interval (CI) 0.90-0.97; period 3: 0.86, 0.83-0.90], circulation disorders (period 2: 0.94, 0.88-1.00; period 3: 0.80, 0.75-0.87), and more likely to die of secondary cancer (period 3: 1.42, 1.20-1.68) compared with those diagnosed in period 1. Charlson comorbidities index and the selected pre-existing comorbidities were significantly associated with increased 5-year risk of death from all three leading causes. Both hematological and gastric toxicity were associated with reduced risk of death from CRC and circulation disorders. The association between diagnostic time period and risk reduction in death from CRC depended on chemotherapy treatment (P < 0.0001). Subgroup analyses showed that the chemotherapy-dependent significant risk reduction was seen in patients with stage II-III CRC, patients without comorbidities, and patients without toxicities (P < 0.0001 for all). CONCLUSION: The newly developed chemotherapy regimens were associated with the decreased risk of mortality from CRC.

Authors: Weiss JM, Schumacher J, Allen GO, Neuman H, Lange EO, Loconte NK, Greenberg CC, Smith MA

Title: Adjuvant chemotherapy for stage II right-sided and left-sided colon cancer: analysis of SEER-medicare data.

Journal: Ann Surg Oncol 21(6):1781-91

Date: 2014 Jun

Abstract: BACKGROUND: Survival benefit from adjuvant chemotherapy is established for stage III colon cancer; however, uncertainty exists for stage II patients. Tumor heterogeneity, specifically microsatellite instability (MSI), which is more common in right-sided cancers, may be the reason for this observation. We examined the relationship between adjuvant chemotherapy and overall 5-year mortality for stage II colon cancer by location (right- vs left-side) as a surrogate for MSI. METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified Medicare beneficiaries from 1992 to 2005 with AJCC stage II (n = 23,578) and III (n = 17,148) primary adenocarcinoma of the colon who underwent surgery for curative intent. Overall 5-year mortality was examined with Kaplan-Meier survival analysis and Cox proportional hazards regression with propensity score weighting. RESULTS: It was found that 18 % of stage II patients (n = 2941) with right-sided cancer and 22 % (n = 1693) with left-sided cancer received adjuvant chemotherapy. After adjustment, overall 5-year survival benefit from chemotherapy was observed only for stage III patients (right-sided: hazard ratio [HR], 0.64; 95 % CI, 0.59-0.68; p < .001 and left-sided: HR, 0.61; 95 % CI, 0.56-0.68; p < .001). No survival benefit was observed for stage II patients with either right-sided (HR, 0.97; 95 % CI, 0.87-1.09; p = .64) or left-sided cancer (HR, 0.97; 95 % CI, 0.84-1.12; p = .68). CONCLUSIONS: Among Medicare patients with stage II colon cancer, a substantial number receive adjuvant chemotherapy. Adjuvant chemotherapy did not improve overall 5-year survival for either right- or left-sided colon cancers. Our results reinforce existing guidelines and should be considered in treatment algorithms for older adults with stage II colon cancer.

Authors: Snyder RA, Penson DF, Ni S, Koyama T, Merchant NB

Title: Trends in the use of evidence-based therapy for resectable gastric cancer.

Journal: J Surg Oncol :-

Date: 2014 May 30

Abstract: BACKGROUND AND OBJECTIVES: Two pivotal randomized controlled trials (RCTs), the Intergroup (INT-0116) and Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trials, demonstrated a survival benefit of multimodality therapy in patients with resectable gastric cancer. The purpose of this study was to determine utilization rates of these treatment regimens in the United States and to identify factors associated with receipt of evidence-based care. METHODS: We performed a retrospective cohort study of patients with Stage IB-IV (M0) gastric adenocarcinoma who underwent resection from 1991 to 2009 using the linked SEER-Medicare database. RESULTS: Only 19.1% of patients received post-operative chemoradiation therapy (CRT), and 1.9% received peri-operative chemotherapy; most patients underwent surgery alone (60.9%). Patients with more advanced stage, younger age, and fewer comorbidities were more likely to receive evidence-based care. We found no association between National Cancer Institute (NCI) designation and delivery of multimodality therapy. However, patients who underwent medical oncology consultation were much more likely to receive evidence-based treatment (OR 3.10, 95% CI 2.35-4.09). CONCLUSIONS: Rates of peri-operative chemotherapy and post-operative CRT in patients with resected gastric cancer remain remarkably low, despite high-quality RCT evidence demonstrating their benefit. Furthermore, NCI designation does not appear to be associated with administration of evidence-based treatment. J. Surg. Oncol. © 2014 Wiley Periodicals, Inc.

Authors: Anderson LA, Atman AA, McShane CM, Titmarsh GJ, Engels EA, Koshiol J

Title: Common infection-related conditions and risk of lymphoid malignancies in older individuals.

Journal: Br J Cancer 110(11):2796-803

Date: 2014 May 27

Abstract: BACKGROUND: Chronic antigenic stimulation may initiate non-Hodgkin (NHL) and Hodgkin lymphoma (HL) development. Antecedent, infection-related conditions have been associated, but evidence by lymphoproliferative subtype is limited. METHODS: From the US SEER-Medicare database, 44,191 NHL, 1832 HL and 200,000 population-based controls, frequency-matched to all SEER cancer cases, were selected. Logistic regression models, adjusted for potential confounders, compared infection-related conditions in controls with HL and NHL patients and by the NHL subtypes diffuse large B-cell, T-cell, follicular and marginal zone lymphoma (MZL). Stratification by race was undertaken. RESULTS: Respiratory tract infections were broadly associated with NHL, particularly MZL. Skin infections were associated with a 15-28% increased risk of NHL and with most NHL subtypes, particularly cellulitis with T-cell lymphoma (OR 1.36, 95%CI 1.24-1.49). Only herpes zoster remained associated with HL following Bonferroni correction (OR 1.55, 95% CI 1.28-1.87). Gastrointestinal and urinary tract infections were not strongly associated with NHL or HL. In stratified analyses by race, sinusitis, pharyngitis, bronchitis and cellulitis showed stronger associations with total NHL in blacks than whites (P<0.001). CONCLUSIONS: Infections may contribute to the aetiologic pathway and/or be markers of underlying immune modulation. Precise elucidation of these mechanisms may provide important clues for understanding how immune disturbance contributes to lymphoma.

Authors: Blanch-Hartigan D, Forsythe LP, Alfano CM, Smith T, Nekhlyudov L, Ganz PA, Rowland JH

Title: Provision and discussion of survivorship care plans among cancer survivors: results of a nationally representative survey of oncologists and primary care physicians.

Journal: J Clin Oncol 32(15):1578-85

Date: 2014 May 20

Abstract: PURPOSE: Survivorship care planning should involve discussions between providers and cancer survivors to address survivors' needs and optimize adherence. We examined the frequency and factors associated with oncologists' and primary care physicians' (PCPs) reports of provision of written survivorship care plans (SCPs) and discussion of survivorship care recommendations with survivors. METHODS: A nationally representative sample of 1,130 oncologists and 1,020 PCPs was surveyed about survivorship care practices with survivors. Logistic regression models predicted multilevel factors associated with providing SCPs or discussing recommendations with survivors. RESULTS: Although a majority of oncologists (64%) reported always/almost always discussing survivorship care recommendations with survivors, fewer also discussed who survivors should see for cancer-related and other follow-up care (32%); fewer still also provided a written SCP to the survivor (< 5%). Survivorship care recommendations and provider responsibility were not regularly discussed by PCPs and survivors (12%). Oncologists who reported detailed training about late and long-term effects of cancer were more likely to provide written SCPs (odds ratio [OR], 1.73; 95% CI, 1.22 to 2.44) and discuss survivorship care planning with survivors (OR, 2.02; 95% CI, 1.51 to 2.70). PCPs who received SCPs from oncologists were 9× more likely (95% CI, 5.74 to 14.82) to report survivorship discussions with survivors. CONCLUSION: A minority of both PCPs and oncologists reported consistently discussing and providing SCPs to cancer survivors. Training and knowledge specific to survivorship care and coordinated care between PCPs and oncologists were associated with increased survivorship discussions with survivors. These nationally representative data provide a useful benchmark to assess implementation of new efforts to improve the follow-up care of survivors.

Authors: Quek RG, Master VA, Portier KM, Ward KC, Lin CC, Virgo KS, Lipscomb J

Title: Association of reimbursement policy and urologists׳ characteristics with the use of medical androgen deprivation therapy for clinically localized prostate cancer.

Journal: Urol Oncol :-

Date: 2014 May 16

Abstract: OBJECTIVES: Physician characteristics and changes in drug reimbursement rates have been shown to influence practice patterns regardless of clinical guidelines, patient, clinical, or sociodemographic factors. We concurrently examined the association between urologists׳ characteristics and non-evidence-based use of primary medical androgen deprivation therapy (ADT) for clinically localized patients with prostate cancer, before and after the 2003 Medicare Modernization Act׳s reductions in ADT reimbursement rates. METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results-Medicare-linked database and the American Medical Association Physician Masterfile are used in a retrospective analysis of 12,255 patients diagnosed between 2001 and 2007 with clinical stage T1-T2, low- to intermediate-grade prostate cancer, and the 1,863 urologists who treated them. Logistic multilevel regression analyses are used to evaluate the association of urologists׳ characteristics on ADT use among patients within 6 months of diagnosis. RESULTS: Overall, 3,866 (32%) patients received non-evidence-based ADT. After adjusting for patient and urologist characteristics, patients treated by urologists with no medical school affiliations, compared with those treated by urologists with major medical school affiliations, are significantly more likely to receive non-evidence-based medical ADT (odds ratio = 2.35; 95% CI: 1.71-3.23; P<0.0001). Non-US-trained urologists are also more likely to prescribe non-evidence-based medical ADT (odds ratio = 1.64; 95% CI: 1.33-2.04; P<0.0001). CONCLUSIONS: Patients treated by non-medical school-affiliated or non-US-trained urologists or both are significantly more likely to receive non-evidence-based ADT before and after the passage of the Medicare Modernization Act. Better strategies to encourage evidence-based ADT use on clinically localized patients with prostate cancer may be of benefit especially among non-medical school-affiliated or non-US-trained urologists or both.

Authors: Onega T, Beaber EF, Sprague BL, Barlow WE, Haas JS, Tosteson AN, D Schnall M, Armstrong K, Schapira MM, Geller B, Weaver DL, Conant EF

Title: Breast cancer screening in an era of personalized regimens: A conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level.

Journal: Cancer :-

Date: 2014 May 15

Abstract: Breast cancer screening holds a prominent place in public health, health care delivery, policy, and women's health care decisions. Several factors are driving shifts in how population-based breast cancer screening is approached, including advanced imaging technologies, health system performance measures, health care reform, concern for "overdiagnosis," and improved understanding of risk. Maximizing benefits while minimizing the harms of screening requires moving from a "1-size-fits-all" guideline paradigm to more personalized strategies. A refined conceptual model for breast cancer screening is needed to align women's risks and preferences with screening regimens. A conceptual model of personalized breast cancer screening is presented herein that emphasizes key domains and transitions throughout the screening process, as well as multilevel perspectives. The key domains of screening awareness, detection, diagnosis, and treatment and survivorship are conceptualized to function at the level of the patient, provider, facility, health care system, and population/policy arena. Personalized breast cancer screening can be assessed across these domains with both process and outcome measures. Identifying, evaluating, and monitoring process measures in screening is a focus of a National Cancer Institute initiative entitled PROSPR (Population-based Research Optimizing Screening through Personalized Regimens), which will provide generalizable evidence for a risk-based model of breast cancer screening, The model presented builds on prior breast cancer screening models and may serve to identify new measures to optimize benefits-to-harms tradeoffs in population-based screening, which is a timely goal in the era of health care reform. Cancer 2014. © 2014 American Cancer Society.

Authors: Daskivich TJ, Lai J, Dick AW, Setodji CM, Hanley JM, Litwin MS, Saigal C, the Urologic Diseases in America Project

Title: Comparative effectiveness of aggressive versus nonaggressive treatment among men with early-stage prostate cancer and differing comorbid disease burdens at diagnosis.

Journal: Cancer :-

Date: 2014 May 13

Abstract: BACKGROUND: This study sought to compare the effectiveness of aggressive versus nonaggressive treatment in reducing cancer-specific mortality for older men with early-stage prostate cancer across differing comorbid disease burdens at diagnosis. METHODS: In total, the authors sampled 140,553 men aged ≥66 years with early-stage prostate cancer who were diagnosed between 1991 and 2007 from the Surveillance, Epidemiology, and End Results-Medicare database. Propensity-adjusted competing-risks regression analysis was used to compare the risk of cancer-specific mortality between men who received aggressive versus nonaggressive treatment among comorbidity subgroups. RESULTS: In propensity-adjusted competing-risks regression analysis, aggressive treatment was associated with a significantly lower risk of cancer-specific mortality among men who had Charlson scores of 0, 1, and 2 but not among men who had Charlson scores ≥3 (subhazard ratio, 0.85; 95% confidence interval, 0.62-1.18). The absolute reduction in 15-year cancer-specific mortality between men who received aggressive versus nonaggressive treatment was 6.1%, 4.3%, 3.9%, and 0.9% for men with Charlson scores of 0, 1, 2, and ≥3, respectively. Among men who had well-differentiated and moderately-differentiated tumors, aggressive treatment again was associated with a lower risk of cancer-specific mortality for those who had Charlson scores of 0, 1, and 2 but not for those who had Charlson scores ≥3 (subhazard ratio, 1.14; 95% confidence interval, 0.70-1.89). The absolute reduction in 15-year cancer-specific mortality between men who received aggressive versus nonaggressive treatment was 3.8%, 3%, 1.9%, and -0.5% for men with Charlson scores of 0, 1, 2, and ≥3, respectively. CONCLUSIONS: The cancer-specific survival benefit from aggressive treatment for early-stage prostate cancer diminishes with increasing comorbidity at diagnosis. Men with Charlson scores ≥3 garner no survival benefit from aggressive treatment. Cancer 2014. © 2014 American Cancer Society.

Authors: Gandaglia G, Sammon JD, Chang SL, Choueiri TK, Hu JC, Karakiewicz PI, Kibel AS, Kim SP, Konijeti R, Montorsi F, Nguyen PL, Sukumar S, Menon M, Sun M, Trinh QD

Title: Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era.

Journal: J Clin Oncol 32(14):1419-26

Date: 2014 May 10

Abstract: PURPOSE: Given the lack of randomized trials comparing robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP), we sought to re-examine the outcomes of these techniques using a cohort of patients treated in the postdissemination era. PATIENTS AND METHODS: Overall, data from 5,915 patients with prostate cancer treated with RARP or ORP within the SEER-Medicare linked database diagnosed between October 2008 and December 2009 were abstracted. Postoperative complications, blood transfusions, prolonged length of stay (pLOS), readmission, additional cancer therapies, and costs of care within the first year after surgery were compared between the two surgical approaches. To decrease the effect of unmeasured confounders, instrumental variable analysis was performed. Multivariable logistic regression analyses were then performed. RESULTS: Overall, 2,439 patients (41.2%) and 3,476 patients (58.8%) underwent ORP and RARP, respectively. In multivariable analyses, patients undergoing RARP had similar odds of overall complications, readmission, and additional cancer therapies compared with patients undergoing ORP. However, RARP was associated with a higher probability of experiencing 30- and 90-day genitourinary and miscellaneous medical complications (all P ≤ .02). Additionally, RARP led to a lower risk of experiencing blood transfusion and of having a pLOS (all P < .001). Finally, first-year reimbursements were greater for patients undergoing RARP compared with ORP (P < .001). CONCLUSION: RARP and ORP have comparable rates of complications and additional cancer therapies, even in the postdissemination era. Although RARP was associated with lower risk of blood transfusions and a slightly shorter length of stay, these benefits do not translate to a decrease in expenditures.

Authors: Yeung HN, Mitchell WM, Roeland EJ, Xu B, Mell LK, Le QT, Murphy JD

Title: Palliative Radiation Before Hospice: The Long and the Short of It.

Journal: J Pain Symptom Manage :-

Date: 2014 May 10

Abstract: CONTEXT: Randomized data support shorter radiotherapy courses for management of cancer-related symptoms in the palliative setting. OBJECTIVES: The purpose of this study was to evaluate the length of palliative radiotherapy before hospice enrollment among the elderly U.S. population, with a further focus on factors that influence the duration of radiation and the length of survival on hospice, including whether the duration of radiation was associated with length of survival on hospice. METHODS: A total of 6982 patients with breast, prostate, lung, or colorectal cancer who received a course of radiotherapy within 30 days before hospice enrollment were identified within the Surveillance, Epidemiology, and End Results-Medicare-linked database. The primary end points included the duration of palliative radiotherapy and the time from hospice enrollment through death (hospice duration). Multivariate linear regression and multivariate Cox models evaluated factors associated with the length of radiotherapy course and hospice duration. RESULTS: The median length of palliative radiotherapy was 14 days, and the median hospice duration was 13 days. The course of palliative radiotherapy was longer than hospice duration in 48% of the patients. Breast and lung cancer were associated with longer courses of radiotherapy and shorter stays on hospice. Patients treated in freestanding radiation centers had longer courses of radiotherapy. For these groups, a longer radiotherapy course was not associated with longer hospice duration. CONCLUSION: This study found relatively long courses of radiotherapy before short lengths of survival on hospice. Future research is needed to identify barriers to shorter radiotherapy courses.

Authors: Etzioni DA, Young-Fadok TM, Cima RR, Wasif N, Madoff RD, Naessens JM, Habermann EB

Title: Patient survival after surgical treatment of rectal cancer: Impact of surgeon and hospital characteristics.

Journal: Cancer :-

Date: 2014 May 06

Abstract: BACKGROUND: Surgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood. METHODS: We used data from the Surveillance, Epidemiology, and End Results-Medicare database to analyze the outcomes of patients aged 65 years and older undergoing operative treatment for nonmetastatic rectal cancer, diagnosed in the United States between 1998 and 2007. These data were linked to a registry to identify whether the treating surgeon was a board-certified colorectal surgeon versus a noncolorectal surgeon. Hospital volume and hospital certification as a National Cancer Institute-designated Comprehensive Cancer Centers were also analyzed. The primary outcome of interest was long-term survival. RESULTS: Our data source yielded 6432 patients. Initial analysis demonstrated improved long-term survival in patients treated by higher-volume colorectal surgeons, higher-volume hospitals, teaching hospitals, and National Cancer Institute (NCI)-designated Comprehensive Cancer Centers. Based on an iterative approach to modeling the interactions between these various factors, we found a robust effect of surgeon subspecialty status, hospital volume, and NCI designation. Surgeon volume was not distinctly associated with long-term survival. CONCLUSIONS: Patients treated for rectal cancer by board-certified colorectal surgeons in centers that are higher volume and/or NCI-designated Comprehensive Cancer Centers experience better overall survival. These differences persist after adjustment for a broad range of patient and contextual risk factors, including surgeon volume. Patients and payers can use these results to identify surgeons and hospitals where outcomes are most favorable. Cancer 2014. © 2014 American Cancer Society.

Authors: Hu M, Jacobs BL, Montgomery JS, He C, Ye J, Zhang Y, Brathwaite J, Morgan TM, Hafez KS, Weizer AZ, Gilbert SM, Lee CT, Lavieri MS, Helm JE, Hollenbeck BK, Skolarus TA

Title: Sharpening the focus on causes and timing of readmission after radical cystectomy for bladder cancer.

Journal: Cancer 120(9):1409-16

Date: 2014 May 01

Abstract: BACKGROUND: Readmissions after radical cystectomy are common, burdensome, and poorly understood. For these reasons, the authors conducted a population-based study that focused on the causes of and time to readmission after radical cystectomy. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, at total of 1782 patients who underwent radical cystectomy from 2003 through 2009 were identified. A piecewise exponential model was used to examine reasons for readmission as well as patient and clinical factors associated with the timing of readmission. RESULTS: One in 4 patients (25.5%) were readmitted within 30 days of discharge after radical cystectomy. Compared with patients without readmission, those readmitted were similar with regard to age, sex, and race. Readmitted patients had more complications (33.8% vs 13.9%; P< .001) and were more likely to have been discharged to skilled nursing facilities from their index admission (P< .001). The average time to readmission and subsequent length of stay were 11.5 days and 6.7 days, respectively. The majority of readmissions (67.4%) occurred within 2 weeks of discharge, 66.8% had emergency department charges, and 25.9% involved intensive care unit use. Although the spectrum of reasons for readmission varied over the 4 weeks after discharge, the most common included infection (51.4%), failure to thrive (36.3%), and urinary (33.2%) and gastrointestinal (23.1%) etiologies; 95.8% of patients had ≥ 1 of these diagnosis groups present at the time of readmission. CONCLUSIONS: Readmissions after radical cystectomy are common and time-dependent. Interventions to prevent and reduce the readmission burden after cystectomy likely need to focus on the first 2 weeks after discharge, take into consideration the spectrum of reasons for readmission, and target high-risk individuals.

Authors: VanderWalde NA, Meyer AM, Deal AM, Layton JB, Liu H, Carpenter WR, Weissler MC, Hayes DN, Fleming ME, Chera BS

Title: Effectiveness of chemoradiation for head and neck cancer in an older patient population.

Journal: Int J Radiat Oncol Biol Phys 89(1):30-7

Date: 2014 May 01

Abstract: PURPOSE: The purpose of this study was to compare chemoradiation therapy (CRT) with radiation therapy (RT) only in an older patient population with head and neck squamous cell carcinoma (HNSCC). METHODS AND MATERIALS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1992-2007), we identified a retrospective cohort of nonmetastatic HNSCC patients and divided them into treatment groups. Comparisons were made between CRT and RT cohorts. Propensity scores for CRT were estimated from covariates associated with receipt of treatment using multivariable logistic regression. Standardized mortality ratio weights (SMRW) were created from the propensity scores and used to balance groups on measured confounders. Multivariable and SMR-weighted Cox proportional hazard models were used to estimate the hazard ratio (HR) of death for receipt of CRT versus RT among the whole group and for separate patient and tumor categories. RESULTS: The final cohort of 10,599 patients was 68% male and 89% white. Median age was 74 years. Seventy-four percent were treated with RT, 26% were treated with CRT. Median follow-up points for CRT and RT survivors were 4.6 and 6.3 years, respectively. On multivariable analysis, HR for death with CRT was 1.13 (95% confidence interval [CI]: 1.07-1.20; P<.01). Using the SMRW model, the HR for death with CRT was 1.08 (95% CI: 1.02-1.15; P=.01). CONCLUSIONS: Although the addition of chemotherapy to radiation has proven efficacious in many randomized controlled trials, it may be less effective in an older patient population treated outside of a controlled trial setting.

Authors: Carter SC, Lipsitz S, Shih YC, Nguyen PL, Trinh QD, Hu JC

Title: Population-based determinants of radical prostatectomy operative time.

Journal: BJU Int 113(5b):E112-8

Date: 2014 May

Abstract: OBJECTIVES: To determine factors that influence radical prostatectomy (RP) operative times. Operative time assessment is inherent to defining surgeon learning curves and evaluating quality of care. SUBJECTS/PATIENTS AND METHODS: Population-based observational cohort study using USA Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data of men diagnosed with prostate cancer during 2003-2007 who underwent robot-assisted radical prostatectomy (RARP, 3458 men) and retropubic RP (RRP, 6993) through to 2009. We obtained median operative time using anaesthesia administrative data for RP and used median regression to assess the contribution of patient, surgeon, and hospital factors to operative times. RESULTS: The median RARP operative time decreased from 315 to 247 min from 2003 to 2008-2009 (P < 0.001), while the median RRP operative time remained similar (195 vs 197 min, P = 0.90). In adjusted analysis, RARP vs RRP (parameter estimate [PE] 70.9; 95% confidence interval [CI] 58, 84; P < 0.001) and obesity (PE 15; 95% CI 7, 23; P < 0.001) were associated with longer operative times while higher surgeon volumes were associated with shorter operative times (P < 0.001). RPs performed by surgeons employed by group (parameter estimate [PE] -22.76; 95% CI -38, -7.49; P = 0.004) and non-government (PE -35.59; 95% CI -68.15, -3.03; P = 0.032) vs government facilities and non-profit vs government hospital ownership (PE -21.85; 95% CI -32.28, -11.42; P < 0.001) were associated with shorter operative times. CONCLUSIONS: During our study period, RARP operative times decreased by 68 min while RRP operative times remained stagnant. Higher surgeon volume was associated with shorter operative times, and selective referral or improved efficiency to the level of high-volume surgeons would net almost $15 million (USA dollars) in annual savings.

Authors: Cummings KC 3rd, Patel M, Htoo PT, Bakaki PM, Cummings LC, Koroukian S

Title: A comparison of the effects of epidural analgesia versus traditional pain management on outcomes after gastric cancer resection: a population-based study.

Journal: Reg Anesth Pain Med 39(3):200-7

Date: 2014 May-Jun

Abstract: BACKGROUND AND OBJECTIVES: Epidural analgesia may increase survival after cancer surgery by reducing recurrence. This population-based study compared survival and treated recurrence after gastric cancer resection between patients receiving epidurals and those who did not. METHODS: We used the linked federal Surveillance, Epidemiology, and End Results Program/Medicare database to identify patients aged 66 years or older with nonmetastatic gastric carcinoma diagnosed 1996 to 2005 who underwent resection. Exclusions included diagnosis at autopsy, no Medicare Part B, familial cancer syndrome, emergency surgery, and laparoscopic procedures. Epidurals were identified by Current Procedural Terminology codes. Treated recurrence was defined as chemotherapy greater than or equal to 16 months and/or radiation greater than or equal to 12 months after surgery. Recurrence was compared by conditional logistic regression. Survival was compared via marginal Cox proportional hazards regression model. RESULTS: We identified 2745 patients, 766 of whom had epidural codes. Patients receiving epidurals were more likely to have regional disease, be white, and live in areas with relatively high socioeconomic status. Overall treated recurrence was 25.6% (27.5% epidural and 24.9% nonepidural). In the adjusted logistic regression, there was no difference in recurrence (odds ratio, 1.40; 95% confidence interval [CI], 0.96-2.05). Median survival did not differ: 28.1 months (95% CI, 24.8-32.3) in the epidural versus 27.4 months (95% CI, 24.8-30.0) in the nonepidural groups. The marginal Cox models showed no association between epidural use and mortality (adjusted hazard ratio, 0.93; 95% CI, 0.84-1.03). CONCLUSIONS: There was no difference between groups regarding treated recurrence or survival. Whether this is true or simply a result of insufficient power is unclear. Prospective studies are needed to provide stronger evidence.

Authors: Fehniger J, Livaudais-Toman J, Karliner L, Kerlikowske K, Tice JA, Quinn J, Ozanne E, Kaplan CP

Title: Perceived versus objective breast cancer risk in diverse women.

Journal: J Womens Health (Larchmt) 23(5):420-7

Date: 2014 May

Abstract: BACKGROUND: Prior research suggests that women do not accurately estimate their risk for breast cancer. Estimating and informing women of their risk is essential for tailoring appropriate screening and risk reduction strategies. METHODS: Data were collected for BreastCARE, a randomized controlled trial designed to evaluate a PC-tablet based intervention providing multiethnic women and their primary care physicians with tailored information about breast cancer risk. We included women ages 40-74 visiting general internal medicine primary care clinics at one academic practice and one safety net practice who spoke English, Spanish, or Cantonese, and had no personal history of breast cancer. We collected baseline information regarding risk perception and concern. Women were categorized as high risk (vs. average risk) if their family history met criteria for referral to genetic counseling or if they were in the top 5% of risk for their age based on the Gail or Breast Cancer Surveillance Consortium Model (BCSC) breast cancer risk model. RESULTS: Of 1,261 participants, 25% (N=314) were classified as high risk. More average risk than high risk women had correct risk perception (72% vs. 18%); 25% of both average and high risk women reported being very concerned about breast cancer. Average risk women with correct risk perception were less likely to be concerned about breast cancer (odds ratio [OR]=0.3; 95% confidence interval [CI]=0.2-0.4) while high risk women with correct risk perception were more likely to be concerned about breast cancer (OR=5.1; 95%CI=2.7-9.6). CONCLUSIONS: Many women did not accurately perceive their risk for breast cancer. Women with accurate risk perception had an appropriate level of concern about breast cancer. Improved methods of assessing and informing women of their breast cancer risk could motivate high risk women to apply appropriate prevention strategies and allay unnecessary concern among average risk women.

Authors: Gandaglia G, Karakiewicz PI, Briganti A, Trinh QD, Schiffmann J, Tian Z, Kim SP, Nguyen PL, Graefen M, Montorsi F, Sun M, Abdollah F

Title: Intensity-modulated radiation therapy leads to survival benefit only in patients with high-risk prostate cancer: a population-based study.

Journal: Ann Oncol 25(5):979-86

Date: 2014 May

Abstract: BACKGROUND: During the last years, there has been a rapid adoption of intensity-modulated radiation therapy (IMRT) in patients with prostate cancer (PCa), despite the lack of randomized trials evaluating its effectiveness. The aim of our study was to evaluate the survival benefit associated with IMRT in patients with PCa. PATIENTS AND METHODS: Overall, 42 483 patients with PCa treated with IMRT or initial observation between 2001 and 2007 within the Surveillance, Epidemiology, and End Results (SEER)-Medicare were evaluated. Patients in both treatment arms were matched using propensity-score methodology. After propensity-score matching, 19 064 patients remained in our analyses. Eight-year cancer-specific mortality (CSM) rates were estimated, and the number needed to treat (NNT) was calculated. Competing risks regression analyses tested the relationship between treatment type and CSM. RESULTS: Overall, the 8-year CSM rates were 3.4% and 4.1% for patients treated with IMRT versus initial observation, respectively (P < 0.001). The corresponding 8-year NNT was 142. In patients with low/intermediate-risk disease, IMRT was not associated with lower CSM rates compared with observation (P = 0.7). In patients with high-risk disease, the 8-year CSM rates for IMRT versus observation were 5.8% versus 10.5%, respectively (P < 0.001). The corresponding NNT was 21. When high-risk patients were stratified according to age (<73 versus ≥73), and Charlson comorbidity index (≤1 versus >1) the 8-year CSM rates for IMRT versus observation were 4.3% versus 9.4% and 6.9% versus 11.9% and 5.3% versus 11.4% and 6.1% versus 10.1%, respectively (all Ps < 0.001). The corresponding NNTs were 19, 21, 16, and 25, respectively. In multivariate analyses, the protective effect of IMRT was more evident in high-risk patients with younger age and lower comorbidities. CONCLUSIONS: IMRT leads to a survival advantage only in patients with high-risk disease. Conversely, patients with low/intermediate-risk disease did not benefit from IMRT at 8-year follow-up.

Authors: Garg G, Yee C, Schwartz K, Mutch DG, Morris RT, Powell MA

Title: Patterns of care, predictors, and outcomes of chemotherapy in elderly women with early-stage uterine carcinosarcoma: a population-based analysis.

Journal: Gynecol Oncol 133(2):242-9

Date: 2014 May

Abstract: OBJECTIVE: To examine the patterns of care, predictors, and impact of chemotherapy on survival in elderly women diagnosed with early-stage uterine carcinosarcoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify women 65 years or older diagnosed with stage I-II uterine carcinosarcomas from 1991 through 2007. Multivariable logistic regression and Cox-proportional hazards models were used for statistical analysis. RESULTS: A total of 462 women met the eligibility criteria; 374 had stage I, and 88 had stage II uterine carcinosarcomas. There were no appreciable differences over time in the percentages of women administered chemotherapy for early stage uterine carcinosarcoma (14.7% in 1991-1995, 14.9% in 1996-2000, and 17.9% in 2001-2007, P=0.67). On multivariable analysis, the factors positively associated with receipt of chemotherapy were younger age at diagnosis, higher disease stage, residence in the eastern part of the United States, and lack of administration of external beam radiation (P<0.05). In the adjusted Cox-proportional hazards regression models, administration of three or more cycles of chemotherapy did not reduce the risk of death in stage I patients (HR: 1.45, 95% CI: 0.83-2.39) but was associated with non-significant decreased mortality in stage II patients (HR: 0.83, 95% CI: 0.32-1.95). CONCLUSIONS: Approximately 15-18% of elderly patients diagnosed with early-stage uterine carcinosarcoma were treated with chemotherapy. This trend remained stable over time, and chemotherapy was not associated with any significant survival benefit in this patient population.

Authors: Huo J, Lairson DR, Du XL, Chan W, Buchholz TA, Guadagnolo AA

Title: Survival and cost-effectiveness of hospice care for metastatic melanoma patients.

Journal: Am J Manag Care 20(5):366-73

Date: 2014 May

Abstract: Objectives We analyzed the association of hospice use with survival and healthcare costs among patients diagnosed with metastatic melanoma. Methods We used the Surveillance, Epidemiology, and End Results (SEER)- Medicare-linked databases to identify patients 65 years or older with metastatic melanoma who died between 2000 and 2009. We analyzed claims data to ascertain cancer treatment utilization and costs. Survival, end-of-life costs, and incremental cost-effectiveness ratio were evaluated using propensity score methods. Costs were analyzed from the payer perspective in 2009 dollars.Result Of 862 patients, 225 (26%) received no hospice care, 523 (61%) received 1 to 3 days of hospice care, and 114 (13%) received 4 or more days of hospice care. The median survival time was 6.1 months for patients with no hospice care, 6.5 months for patients enrolled in hospice for 1 to 3 days, and 10.2 months for patients enrolled for 4 or more days (P < .001). The hazard ratio for survival among patients with 4 or more days of hospice use was 0.66; 95% confidence interval, 0.54-0.81, P <.0001 in the propensity score-matched model. Patients with 4 or more days of hospice care incurred lower end-of-life costs than the comparison groups ($14,594 vs $22,647 for the 1-to-3-days hospice care, and $28,923 for patients with no hospice care; P <.0001). Conclusions Patients diagnosed with metastatic melanoma who enrolled in 4 or more days of hospice care had longer survival than those who had 1 to 3 days of hospice or no hospice care, and this longer overall survival was accompanied by lower end-of-life costs.

Authors: Kizilbash SH, Ward KC, Liang JJ, Jaiyesimi I, Lipscomb J

Title: Survival outcomes in patients with early stage, resected pancreatic cancer - a comparison of gemcitabine- and 5-fluorouracil-based chemotherapy and chemoradiation regimens.

Journal: Int J Clin Pract 68(5):578-89

Date: 2014 May

Abstract: PURPOSE: We conducted a comparative survival analysis between patients with resected pancreatic cancer who received adjuvant treatment with either gemcitabine- or 5-fluorouracil-based chemotherapy and chemoradiation regimens. PATIENTS AND METHODS: The Surveillance, Epidemiology and End Results (SEER)-Medicare database was used to identify patients with pancreatic cancer diagnosed from 1998 to 2005 who received curative surgery and adjuvant chemotherapy with either 5-fluorouracil or gemcitabine. These groups were subdivided by treatment with radiotherapy. Patients were followed until death, study end-point or a maximum of 5 years after diagnosis. RESULTS: Three hundred and fifty-nine patients received 5-fluorouracil and 346 received gemcitabine. Compared with chemoradiation with 5-fluorouracil, outcomes for patients who received chemoradiation with gemcitabine did not differ. Patients who received gemcitabine without radiation had increased hazards (poorly differentiated tumours: HR = 1.50, p = 0.01; moderately differentiated tumours, HR = 1.28, p = 0.11). However, outcomes of patients who received 5-fluorouracil without radiation varied with tumour grade. In moderately differentiated tumours, patients had better outcomes with 5-fluorouracil when compared with chemoradiation with 5-fluorouracil (HR = 0.42, p = 0.02). In poorly differentiated tumours, the opposite was true (HR 2.10, p = 0.09). CONCLUSION: Patients with low-grade resected pancreatic cancer may have better outcomes with 5-fluorouracil-based chemotherapy without radiation when compared with 5-fluorouracil with radiation.

Authors: Marks MA, Engels EA

Title: Venous thromboembolism and cancer risk among elderly adults in the United States.

Journal: Cancer Epidemiol Biomarkers Prev 23(5):774-83

Date: 2014 May

Abstract: BACKGROUND: Few studies have evaluated cancer risk following venous thromboembolism (VTE). Both VTE and cancer disproportionately affect older adults. METHODS: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we evaluated 1.2 million cancer cases and 200,000 controls (66-99 years old, 1992-2005). VTEs occurring before selection were identified using Medicare claims. Logistic regression was used to estimate ORs. RESULTS: VTE was present in 2.5% of cases and 2.2% of controls. VTE was associated with risk of cancers of the lung [OR = 1.18; 95% confidence interval (CI), 1.12-1.23], stomach (OR = 1.19; 95% CI, 1.09-1.30), small intestine (OR = 1.42; 95% CI, 1.17-1.71), colon (OR = 1.25; 95% CI, 1.18-1.31), gallbladder (OR = 1.39; 95% CI, 1.16-1.67), pancreas (OR = 1.53; 95% CI, 1.43-1.64), soft tissue (OR = 1.43; 95% CI, 1.21-1.68), ovary (OR = 1.35; 95% CI, 1.22-1.50), and kidney/renal pelvis (OR = 1.34; 95% CI, 1.23-1.46), and melanoma (OR = 1.17; 95% CI, 1.08-1.27), non-Hodgkin lymphoma (OR = 1.27; 95% CI, 1.20- 1.35), myeloma (OR = 1.48; 95% CI, 1.35-1.63), and acute myeloid leukemia (OR = 1.35; 95% CI, 1.19-1.54). Strongest risks were observed within 1 year of VTE diagnosis, but risks were elevated more than 6 years after VTE for colon cancer (OR = 1.24; 95% CI, 1.12-1.37), pancreatic cancer (OR = 1.33; 95% CI, 1.15-1.54), and myeloma (OR = 1.35; 95% CI, 1.10-1.66). Few differences in risk were observed by VTE subtype. Cancers of the lung, stomach, and pancreas were more likely to have distant metastases within one year after VTE. CONCLUSION: Among elderly adults, cancer risk is elevated following VTE diagnosis. IMPACT: Short-term associations with cancer are likely driven by enhanced screening following VTE and reverse causation. While obesity, other comorbidities, and smoking cannot be excluded as explanations, longer-term elevations for select cancers suggest that some VTEs may be caused by cancer precursors.

Authors: Ost DE, Niu J, Elting LS, Buchholz TA, Giordano SH

Title: Determinants of practice patterns and quality gaps in lung cancer staging and diagnosis.

Journal: Chest 145(5):1097-1113

Date: 2014 May

Abstract: BACKGROUND: Guidelines recommend mediastinal lymph node sampling as the fi rst invasive diagnostic procedure in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases. METHODS: Patients were a retrospective cohort of 15,316 patients with lung cancer with regional spread without metastatic disease in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) or Texas Cancer Registry Medicare-linked databases. Patients were categorized based on the sequencing of invasive diagnostic tests performed: (1) evaluation consistent with guidelines, mediastinal sampling done fi rst; (2) evaluation inconsistent with guidelines, non-small cell lung cancer (NSCLC) present, mediastinal sampling performed but not as part of the fi rst invasive test; (3) evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling never done; and (4) evaluation inconsistent with guidelines, small cell lung cancer. The primary outcome was whether guideline-consistent care was delivered. Secondary outcomes included whether patients with NSCLC ever had mediastinal sampling and use of transbronchial needle aspiration (TBNA) among pulmonologists. RESULTS: Only 21% of patients had a diagnostic evaluation consistent with guidelines. Only 56% of patients with NSCLC had mediastinal sampling prior to treatment. There was significant regional variability in guideline-consistent care (range, 12%-29%). Guideline-consistent care was associated with lower patient age, metropolitan areas, and if the physician ordering or performing the test was male, trained in the United States, had seen more patients with lung cancer, and was a pulmonologist or thoracic surgeon who had graduated more recently. More recent pulmonary graduates were also more likely to perform TBNA ( P < .001). CONCLUSIONS: Guideline-consistent care varied regionally and was associated with physician-level factors, suggesting that a lack of effective physician training may be contributing to the quality gaps observed.

Authors: Tan HJ, Wolf JS Jr, Ye Z, Hafez KS, Miller DC

Title: Population level assessment of hospital based outcomes following laparoscopic versus open partial nephrectomy during the adoption of minimally invasive surgery.

Journal: J Urol 191(5):1231-7

Date: 2014 May

Abstract: PURPOSE: The comparative outcomes of laparoscopic and open partial nephrectomy remain incompletely defined. Therefore, we used population based data to examine resource use and short-term outcomes among patients with kidney cancer treated with laparoscopic vs open partial nephrectomy. MATERIALS AND METHODS: Using linked SEER (Surveillance, Epidemiology, and End Results)-Medicare data we identified patients with kidney cancer treated with laparoscopic or open partial nephrectomy from 2000 through 2007. We then used Medicare claims to identify several postoperative outcomes including intensive care unit care, length of stay, rehospitalizations, operative mortality and postoperative complications. We fit multivariate logistic regression models to estimate the association between each outcome and surgical approach (ie laparoscopic partial nephrectomy vs open partial nephrectomy), adjusting for patient and tumor characteristics. RESULTS: We identified 651 (28%) and 1,670 (72%) patients treated with laparoscopic partial nephrectomy and open partial nephrectomy, respectively. Compared to those who underwent open partial nephrectomy, patients treated with laparoscopic partial nephrectomy had a 34% lower probability of requiring intensive care unit time (20.0% vs 30.2%, p <0.001) and shorter median length of stay (3 vs 5 days, p <0.001), with no differences observed in the likelihood of rehospitalization or operative mortality. While the frequency of postoperative complications was similar (35.5% vs 36.1%, p = 0.829), patients treated with laparoscopic partial nephrectomy had a nearly twofold greater probability of genitourinary complications and postoperative hemorrhage (p <0.001). CONCLUSIONS: At a population level the patients with kidney cancer treated with laparoscopic partial nephrectomy experienced a shorter and less intense hospitalization, supporting the benefits of laparoscopy. However, the greater likelihood of procedure related complications highlights the need for continued efforts aimed at ensuring the safe adoption and application of this advanced surgical technique.

Authors: Zheng Z, Hanna N, Onukwugha E, Bikov KA, Mullins CD

Title: Hospital center effect for laparoscopic colectomy among elderly stage I-III colon cancer patients.

Journal: Ann Surg 259(5):924-9

Date: 2014 May

Abstract: OBJECTIVE: To investigate hospital-level variation in short-term laparoscopic colectomy outcomes among stage I-III elderly colon cancer patients. BACKGROUND: Surgical outcomes are associated with patient and surgeon characteristics. If outcomes are also impacted by the hospital where the surgery occurs, there is a hospital center effect (HCE). METHODS: Surveillance, Epidemiology, and End Results (SEER)-Medicare data was used to identify stage I-III colon cancer patients treated with laparoscopic colectomies. Multilevel regressions were utilized to study potential HCE for length of stay (LOS), 30-day rehospitalization, and in-hospital mortality, adjusting for patient, surgeon, and hospital-level characteristics. To quantify HCE, we calculated the median instantaneous rate ratio (MIRR) for LOS and median odds ratio (MOR) for in-hospital mortality and 30-day rehospitalization. Sensitivity analyses were conducted for high volume/medical school affiliated hospitals and colorectal surgeons. RESULTS: The multilevel analyses based on 4617 patients from 465 hospitals documented statistically significant HCEs for LOS (MIRR = 1.35; P < 0.001) and in-hospital mortality (MOR = 1.69; P = 0.032), but no HCE for 30-day rehospitalization. Sensitivity analyses confirmed our findings. HCE was significant for LOS in all sensitivity analyses and was significant for in-hospital mortality for high volume/medical school affiliated hospitals. CONCLUSIONS: HCE exists for LOS and in-hospital mortality of laparoscopic colectomy, which suggests that the choice of hospital affects outcomes independently of other confounding variables. Reducing the variation in outcomes associated with HCE may improve the quality of cancer care.

Authors: Dallo FJ, Kindratt TB

Title: Disparities in Preventive Health Behaviors Among Non-Hispanic White Men: Heterogeneity Among Foreign-Born Arab and European Americans.

Journal: Am J Mens Health :-

Date: 2014 Apr 29

Abstract: The objectives of this study were to estimate and compare the age-adjusted prevalence of not receiving a flu vaccine, pneumonia vaccine, or prostate cancer screening among U.S.- and foreign-born White men by region of birth (Europe/Russia and the Arab Nations) and examine these associations while controlling for potential confounders. Twelve years of restricted data from the National Health Interview Survey (NHIS) including 91,636 U.S.- and foreign-born men were used. Chi-squares were used to compare descriptive statistics, and odds ratios (ORs; 95% confidence intervals [CIs]) were used for inferential statistics. In crude and adjusted analyses, foreign-born Arab American men were less likely to report receiving a flu (OR = 0.38; 95% CI = 0.21, 0.67) and pneumonia (OR = 0.33; 95% CI = 0.16, 0.70) vaccine compared with U.S.-born White men. There were no statistically significant differences for PSA testing between Arab American and White men. This national study examining uptake of flu and pneumonia vaccines suggests estimates are lower for foreign-born Arab American men compared with U.S.-born White men. Future studies should collect qualitative data that assesses the cultural context surrounding prevention and screening behaviors among Arab Americans.

Authors: Arvold ND, Wang Y, Zigler C, Schrag D, Dominici F

Title: Hospitalization burden and survival among older glioblastoma patients.

Journal: Neuro Oncol :-

Date: 2014 Apr 28

Abstract: BACKGROUND: Half of all glioblastoma patients are at least 65 years old. The frequency and duration of hospitalization from disease- and treatment-related morbidity in this population are unknown. METHODS: We performed a retrospective cohort study among patients aged 65 years and older with glioblastoma diagnosed between 1999 and 2007 using SEER-Medicare linked data. Diagnoses and procedures were identified using administrative claims data. Logistic regression was performed to identify predictors of high hospitalization burden. RESULTS: Among the 5029 patients in the cohort, 52% were ages 65-74, and 52% were male. Twenty-six percent of patients underwent extensive resection, 72% received radiotherapy, and 18% received temozolomide. Median survival was 4.9 months. Among all patients, 21% were hospitalized at least 30 cumulative days between diagnosis and death, and 22% of all patients spent at least one-fourth of their remaining lives as inpatients. Higher comorbidity score (adjusted hazard ratio [AHR], 1.72; 95% CI, 1.42-2.07) and black race (AHR, 1.56; 95% CI, 1.11-2.18) were associated with an increased risk of being hospitalized for at least 25% of remaining life, whereas radiation (AHR, 0.49; 95% CI, 0.42-0.58), temozolomide (AHR, 0.31; 95% CI, 0.23-0.42), and extensive surgery (AHR, 0.83; 95% CI, 0.69-0.99) were associated with a decreased risk. CONCLUSIONS: These data highlight the burden of hospitalization faced by a large proportion of older glioblastoma patients. In the setting of short survival, strategies to reduce the amount of time these patients spend hospitalized are urgently needed, to help maintain quality of life at the end of life.

Authors: Yong C, Onukwugha E, Mullins CD, Seal B, Hussain A

Title: The use of health services among elderly patients with stage IV prostate cancer in the initial period following diagnosis.

Journal: J Geriatr Oncol :-

Date: 2014 Apr 26

Abstract: OBJECTIVE: Information regarding variability in the type and extent of health services used by elderly patients with advanced prostate cancer (PCa) in the initial period following diagnosis is limited. We evaluated health services utilization among elderly men with stage IV PCa with (M1) and without (M0) distant metastasis during the year following diagnosis. METHODS: We evaluated patients aged 66 and older with incident stage IV PCa during 2005-2007 using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Measures included skilled nursing facility (SNF) stay, hospice stay, and hospitalization. Multivariable logistic regression models were estimated to determine the association between M1 PCa and each health service. Poisson regression was used to assess hospital length of stay. RESULTS: The final sample included 3379 patients (20% M0; 80% M1). In the year following diagnosis, M1 patients had greater use of SNF (M0: 8%; M1: 22%), hospice (M0: 5%; M1: 20%), and hospitalization (M0: 43%; M1: 61%). Compared to M0 patients, M1 patients had statistically significantly higher adjusted odds of SNF use (OR=1.89; 95% CI=1.38-2.59), hospice use (OR=3.22; 95% CI=2.19-4.72), and hospitalization (OR=1.45; 95% CI=1.20-1.75). Among those hospitalized, M1 patients had 24% longer length of stay (p<0.01). CONCLUSIONS: There is 2- to 3-fold greater use of SNF and hospice, and higher hospitalization among M1 compared to M0 patients. Elderly patients with advanced PCa face significant clinical burden within the first year after their diagnosis. Greater understanding of the relationship between clinical disease burden and health services utilization can improve healthcare delivery in this population.

Authors: Tien YY, Link BK, Brooks JM, Wright K, Chrischilles E

Title: Treatment of diffuse large B-cell lymphoma in the elderly: regimens without anthracyclines are common and not futile.

Journal: Leuk Lymphoma :-

Date: 2014 Apr 22

Abstract: Anthracycline-containing regimens (ACRs) are recommended for patients with diffuse large B-cell lymphoma (DLBCL). However, over 40% of elderly patients do not receive ACRs, possibly due to expected toxicities. We characterized treatment choices and compared the 3-year overall survival (OS) rates of 8262 Medicare beneficiaries diagnosed with DLBCL in 2000-2006 identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Of the cohort, 45% had ACR with rituximab (ACR-R), 13% had ACR without R, 6% had non-ACR with R (non-ACR-R), 4% had R monotherapy, 3% had non-ACR and 29% had no systemic therapy. Patients not receiving ACR were older and/or had more comorbidities. The unadjusted OS was highest in ACR-R (65%), followed by ACR without R (55%) and non-ACR-R (44%). After adjusting patient covariates, ACR-R showed the best survival (63%). However, OS was comparable between non-ACR-R (52%) and ACR without R (52%). Non-ACR-R could be considered for patients who are poor candidates for ACR.

Authors: Huo J, Lairson DR, Du XL, Chan W, Jiang J, Buchholz TA, Guadagnolo BA

Title: Hospital Case Volume is Associated With Improved Survival for Patients With Metastatic Melanoma.

Journal: Am J Clin Oncol :-

Date: 2014 Apr 21

Abstract: OBJECTIVES:: Hospital case volume has been shown to be a predictor of patient mortality for treatment for various cancers. The influence of hospital case volume on malignant melanoma survival and treatment utilization is unknown. METHODS:: We used the Surveillance, Epidemiology, and End Results-Medicare linked databases to identify patients aged 65 years or older diagnosed with metastatic melanoma between 2000 and 2009. We analyzed claims data to ascertain cancer treatment variation by hospital case volume. Overall survival was evaluated using propensity score methods. RESULTS:: Among 1438 patients, 612 (42.6%) were treated in low-volume hospitals (≤5 patients) after receiving their diagnosis, 479 (33.3%) were treated in intermediate-volume hospitals (6 to 10 patients), and 347 (24.1%) were treated in high-volume hospitals (>10 patients). In Cox proportional hazards models, treatment in a high-volume hospital after propensity score adjustment was associated with a significant improvement in survival when adjusting for other characteristics (intermediate volume: hazard ratio [HR]=0.70, P=0.0007; high volume: HR=0.63, P<0.0001). Patients treated in high-volume hospitals were less likely to receive chemotherapy, surgery, and/or radiation therapy after a metastatic melanoma diagnosis. CONCLUSIONS:: For patients diagnosed with metastatic melanoma, being treated in a high-volume hospital was associated with an improvement in survival and lower utilization of chemotherapy, immunotherapy, surgery, and radiation therapy.

Authors: Haynes AB, You YN, Hu CY, Eng C, Kopetz ES, Rodriguez-Bigas MA, Skibber JM, Cantor SB, Chang GJ

Title: Postoperative chemotherapy use after neoadjuvant chemoradiotherapy for rectal cancer: Analysis of Surveillance, Epidemiology, and End Results-Medicare data, 1998-2007.

Journal: Cancer 120(8):1162-70

Date: 2014 Apr 15

Abstract: BACKGROUND: Neoadjuvant chemoradiotherapy followed by tumor resection and postoperative chemotherapy is the standard of care for patients with clinical stage II or III adenocarcinoma of the rectum. Significant variation exists in the receipt of postoperative chemotherapy after resection in this population. The objective of this study was to determine the demographic and clinicopathologic factors associated with the initiation of postoperative chemotherapy in elderly patients with rectal cancer and to identify potential targets for reducing treatment variation. METHODS: A retrospective cohort study was performed of patients with rectal cancer ages 66 to 80 years who received neoadjuvant chemoradiotherapy and underwent radical resection in the Surveillance, Epidemiology, and End Results-linked Medicare database (1998-2007). Multivariate logistic regression was used to assess chemotherapy use in relation to patient, tumor, and treatment response characteristics. RESULTS: Among 1492 patients who met the study criteria, 61.5% received adjuvant therapy with 5-fluorouracil. Pathologic stage was the strongest determinant of whether patients received postoperative chemotherapy (48.3% of patients with stage I disease, 59.6% of patients with stage II disease, and 77.6% of patients with stage III disease). Increasing age and postoperative readmission also were associated significantly with a decreased rate of adjuvant therapy initiation. CONCLUSIONS: Although standard treatment guidelines for locally advanced rectal cancer include postoperative chemotherapy for all patients after neoadjuvant chemoradiotherapy and radical resection, greater than 1 in 3 patients failed to receive adjuvant therapy. Despite the absence of established evidence, treatment decisions appear to be influenced by the findings at surgical pathology.

Authors: Wright JD, Ananth CV, Tsui J, Glied SA, Burke WM, Lu YS, Neugut AI, Herzog TJ, Hershman DL

Title: Comparative effectiveness of upfront treatment strategies in elderly women with ovarian cancer.

Journal: Cancer 120(8):1246-54

Date: 2014 Apr 15

Abstract: BACKGROUND: Observational studies comparing neoadjuvant chemotherapy to primary surgery for advanced-stage ovarian cancer are limited by strong selection bias. Multiple methods were used to control for confounding and selection bias to estimate the effect of primary treatment on survival for ovarian cancer. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify women ≥ 65 years of age with stage II-IV epithelial ovarian cancer who survived > 6 months from the date of diagnosis and received treatment from 1991 through 2007. Traditional regression analysis, propensity score-based analysis, and an instrumental variable analysis (IVA) using geographic location as an instrument were used to compare survival between neoadjuvant chemotherapy and primary surgery. RESULTS: A total of 9587 patients with stage II-IV ovarian cancer were identified. Use of primary surgery decreased from 63.2% in 1991 to 49.5% by 2007, whereas primary chemotherapy increased from 19.7% in 1991 to 31.8% in 2007 (P < .0001). In the observational cohort survival (hazard ratio [HR] = 1.27; 95% confidence interval [CI] = 1.19-1.35) was inferior for patients treated with neoadjuvant chemotherapy; both median survival (15.8 versus 28.8 months) and 2-year survival (36% versus 56%) were lower in the neoadjuvant chemotherapy group compared to those who underwent surgery. In the IVA, primary treatment had minimal effect on overall survival (HR = 1.04; 95% CI = 0.67-1.60). The median survival for patients with a value of the instrument less than the median (24.0 months, 95% CI = 23.0-25.0) and greater than or equal to median value of the IV (24.0 months, 95% CI = 23.0-26.0) were similar. CONCLUSIONS: Use of neoadjuvant therapy has increased over time. Survival with neoadjuvant chemotherapy did not differ significantly from primary surgery in elderly women in the United States.

Authors: Onukwugha E, Yong C, Mullins CD, Seal B, McNally D, Hussain A

Title: Skeletal-related events and mortality among older men with advanced prostate cancer.

Journal: J Geriatr Oncol :-

Date: 2014 Apr 14

Abstract: OBJECTIVE: Skeletal-related events (SREs) are defined as a cluster of events including clinical diagnoses and treatment. Using claims data, the burden of SREs as a group has been reported among patients with cancer. We investigate the mortality impact of subcomponents of SREs, a topic that has received limited attention among older men. MATERIALS AND METHODS: We analyzed prostate cancer (PCa) and all-cause mortality among men diagnosed with metastatic PCa from 2000 to 2007 using Surveillance, Epidemiology, and End Results data linked with 1999-2009 Medicare data. We created three measures of pathological fracture (PF), spinal cord compression (SCC), and bone surgery (BS) that differed in the use of claims-based bone metastasis information. We reported covariate-adjusted hazard ratios (HRs) using the full sample and a propensity score-matched sample (PSMS). RESULTS: Application of inclusion/exclusion criteria resulted in 7062 men in the full sample (1776 in the PSMS). PCa-specific (all-cause mortality) was 54% (80%) at a median follow-up of 609days. SRE prevalence ranged from 9.7% to 17.1% across the measures. In a PCa mortality model, the HR associated with an SRE ranged from 1.07 (0.98-1.16) to 1.31 (1.18-1.45). The HRs for SCC and PF were statistically significant and positively associated with PCa-specific mortality. The results for BS depended on the measure. Results for SCC and BS, but not for PF, were preserved using a PSMS. CONCLUSIONS: The relationship between SREs and mortality among older men with metastatic PCa was driven by SCC and depended on the definition used to measure SREs.

Authors: Corley DA, Jensen CD, Marks AR, Zhao WK, Lee JK, Doubeni CA, Zauber AG, de Boer J, Fireman BH, Schottinger JE, Quinn VP, Ghai NR, Levin TR, Quesenberry CP

Title: Adenoma detection rate and risk of colorectal cancer and death.

Journal: N Engl J Med 370(14):1298-306

Date: 2014 Apr 03

Abstract: BACKGROUND: The proportion of screening colonoscopic examinations performed by a physician that detect one or more adenomas (the adenoma detection rate) is a recommended quality measure. However, little is known about the association between this rate and patients' risks of a subsequent colorectal cancer (interval cancer) and death. METHODS: Using data from an integrated health care delivery organization, we evaluated the associations between the adenoma detection rate and the risks of colorectal cancer diagnosed 6 months to 10 years after colonoscopy and of cancer-related death. With the use of Cox regression, our estimates of attributable risk were adjusted for the demographic characteristics of the patients, indications for colonoscopy, and coexisting conditions. RESULTS: We evaluated 314,872 colonoscopies performed by 136 gastroenterologists; the adenoma detection rates ranged from 7.4 to 52.5%. During the follow-up period, we identified 712 interval colorectal adenocarcinomas, including 255 advanced-stage cancers, and 147 deaths from interval colorectal cancer. The unadjusted risks of interval cancer according to quintiles of adenoma detection rates, from lowest to highest, were 9.8, 8.6, 8.0, 7.0, and 4.8 cases per 10,000 person-years of follow-up, respectively. Among patients of physicians with adenoma detection rates in the highest quintile, as compared with patients of physicians with detection rates in the lowest quintile, the adjusted hazard ratio for any interval cancer was 0.52 (95% confidence interval [CI], 0.39 to 0.69), for advanced-stage interval cancer, 0.43 (95% CI, 0.29 to 0.64), and for fatal interval cancer, 0.38 (95% CI, 0.22 to 0.65). Each 1.0% increase in the adenoma detection rate was associated with a 3.0% decrease in the risk of cancer (hazard ratio, 0.97; 95% CI, 0.96 to 0.98). CONCLUSIONS: The adenoma detection rate was inversely associated with the risks of interval colorectal cancer, advanced-stage interval cancer, and fatal interval cancer. (Funded by the Kaiser Permanente Community Benefit program and the National Cancer Institute.).

Authors: Luo J, Lin HC, He K, Hendryx M

Title: Diabetes and prognosis in older persons with colorectal cancer.

Journal: Br J Cancer 110(7):1847-54

Date: 2014 Apr 02

Abstract: BACKGROUND: Epidemiological studies have reported that diabetes significantly increases overall mortality in patients with colorectal cancer. However, it is unclear whether diabetes increases colorectal cancer-specific mortality. We used the US Surveillance Epidemiology and End Results (SEER) database linked with Medicare claims data to assess the influence of pre-existing diabetes on prognosis of patients with colorectal cancer. METHODS: Data from 61,213 patients aged 67 or older with colorectal cancer diagnosed between 2003 and 2009 were extracted and prospectively followed through the date of death or the end of 2012 if the patient was still alive. Diabetes cases with and without complications were identified based on an algorithm developed for the Chronic Condition Data Warehouse (CCW). Cox models were used to estimate hazard ratios (HRs) for total mortality. The proportional subdistribution hazards model proposed by Fine and Gray was used to estimate HRs for colorectal cancer-specific mortality. RESULTS: Compared with patients without diabetes, colorectal cancer patients with pre-existing diabetes had significantly higher risk of overall mortality (HR=1.20, 95 % confidence interval (95% CI): 1.17-1.23). The HR for overall mortality was more pronounced for patients who had diabetes with complications (HR=1.50, 95% CI: 1.42-1.58). However, diabetes was not associated with increased colorectal cancer-specific mortality after accounting for non-colorectal cancer outcomes as competing risk. CONCLUSIONS: Pre-existing diabetes increased risk of total mortality among patients with colorectal cancer, especially among cancer patients who had diabetes with complications. The increased risk of total mortality associated with diabetes was primarily explained by increased cardiovascular-specific mortality, not by increased colorectal cancer-specific mortality.

Authors: Fung C, Pandya C, Guancial E, Noyes K, Sahasrabudhe DM, Messing EM, Mohile SG

Title: Impact of Bladder Cancer on Health Related Quality of Life in 1,476 Older Americans: A Cross-Sectional Study.

Journal: J Urol :-

Date: 2014 Apr 01

Abstract: PURPOSE: The impact of bladder cancer diagnosis on health related quality of life is poorly understood. We compared health related quality of life measures in patients before and after bladder cancer diagnosis. MATERIALS AND METHODS: We performed a cross-sectional study in 1,476 patients 65 years old or older with bladder cancer in the SEER-MHOS linkage database between 1998 and 2007 to assess differences in physical and mental component summary scores in 620 and 856 who completed a survey before and after bladder cancer diagnosis, respectively. To determine differences in physical and mental scores in the prediagnosis and post-diagnosis cohorts, we used ANOVA adjusting for baseline covariates. RESULTS: There were statistically significant differences in physical and mental component summary scores between the prediagnosis and post-diagnosis groups (-2.7, 95% CI -3.8, -1.7 vs -1.4, 95% CI -2.6, -0.3). In patients with nonmuscle invasive bladder cancer the physical and mental score differences were -1.9 (p <0.01) and -1.4 (p = 0.01), respectively. In those with muscle invasive bladder cancer there was a statistically and clinically significant difference in the physical but not the mental score (-5.3, p <0.01 vs -2.7, p = 0.07). This difference in the physical domain persisted up to 10 years after the diagnosis of muscle invasive bladder cancer. Patients with bladder cancer who had 4 or more comorbid medical conditions and 1 or more deficits in daily living activity were most at risk for low physical component summary scores. CONCLUSIONS: Future research into interventions to improve health related quality of life and methods to incorporate health related quality of life into decision making models are critical to improve outcomes in older patients with bladder cancer.

Authors: McShane CM, Murray LJ, Engels EA, Landgren O, Anderson LA

Title: Common community-acquired infections and subsequent risk of multiple myeloma: a population-based study.

Journal: Int J Cancer 134(7):1734-40

Date: 2014 Apr 01

Abstract: The role of bacteria and viruses as aetiological agents in the pathogenesis of cancer has been well established for several sites, including a number of haematological malignancies. Less clear is the impact of such exposures on the subsequent development of multiple myeloma (MM). Using the population-based U.S. Surveillance Epidemiology and End Results-Medicare dataset, 15,318 elderly MM and 200,000 controls were identified to investigate the impact of 14 common community-acquired infections and risk of MM. Odds ratios (ORs) and associated 95% confidence intervals (CIs) were adjusted for sex, age and calendar year of selection. The 13-month period prior to diagnosis/selection was excluded. Risk of MM was increased by 5-39% following Medicare claims for eight of the investigated infections. Positive associations were observed for several infections including bronchitis (adjusted OR 1.14, 95% CI 1.09-1.18), sinusitis (OR 1.15, 95% CI 1.10-1.20) pneumonia (OR 1.27, 95% CI 1.21-1.33), herpes zoster (OR 1.39, 95% CI 1.29-1.49) and cystitis (OR 1.09, 95% CI 1.05-1.14). Each of these infections remained significantly elevated following the exclusion of more than 6 years of claims data. Exposure to infectious antigens may therefore play a role in the development of MM. Alternatively, the observed associations may be a manifestation of an underlying immune disturbance present several years prior to MM diagnosis and thereby part of the natural history of disease progression.

Authors: Bergamo C, Sigel K, Mhango G, Kale M, Wisnivesky JP

Title: Inequalities in lung cancer care of elderly patients with schizophrenia: an observational cohort study.

Journal: Psychosom Med 76(3):215-20

Date: 2014 Apr

Abstract: OBJECTIVE: Cancer mortality is higher in individuals with schizophrenia, a finding that may be due, in part, to inequalities in care. We evaluated gaps in lung cancer diagnosis, treatment, and survival among elderly individuals with schizophrenia. METHODS: The Surveillance, Epidemiology, and End Results database linked to Medicare records was used to identify patients 66 years or older with primary non-small cell lung cancer. Lung cancer stage, diagnostic evaluation, and rates of stage-appropriate treatment were compared among patients with and without schizophrenia using unadjusted and multiple regression analyses. Survival was compared among groups using Kaplan-Meier methods. RESULTS: Of the 96,702 patients with non-small cell lung cancer in the Surveillance, Epidemiology, and End Results database, 1303 (1.3%) had schizophrenia. In comparison with the general population, patients with schizophrenia were less likely to present with late-stage disease after controlling for age, sex, marital status, race/ethnicity, income, histology, and comorbidities (odds ratio = 0.82, 95% confidence interval = 0.73-0.93) and were less likely to undergo appropriate evaluation (p < .050 for all comparisons). Adjusting for similar factors, patients with schizophrenia were also less likely to receive stage-appropriate treatment (odds ratio = 0.50, 95% confidence interval = 0.43-0.58). Survival was decreased among patients with schizophrenia (mean survival = 22.3 versus 26.3 months, p = .002); however, no differences were observed after controlling for treatment received (p = .40). CONCLUSIONS: Elderly patients with schizophrenia present with earlier stages of lung cancer but are less likely to undergo diagnostic evaluation or to receive stage-appropriate treatment, resulting in poorer outcomes. Efforts to increase treatment rates for elderly patients with schizophrenia may lead to improved survival in this group.

Authors: Bitton A, Onega T, Tosteson AN, Haas JS

Title: Toward a better understanding of patient-reported outcomes in clinical practice.

Journal: Am J Manag Care 20(4):281-3

Date: 2014 Apr

Abstract: Current shifts toward patient-centered healthcare and accountable payment options point to the more personalized production of better health, not just healthcare, as a next organizational paradigm. Transformation to a system geared toward promoting health requires us to think broadly about what it means to engage patients meaningfully, to give them a voice in their health and care, and to capture more of their varied experience and attitudes beyond the provider visit. The collection and use of patient-reported outcome data into electronic health records represents an important step forward for the transition to a more patient-centered health system. We set out an agenda for better understanding how and when patient-reported outcomes may improve patient health and care experience.

Authors: Crandley EF, Hegarty SE, Hyslop T, Wilson DD, Dicker AP, Showalter TN

Title: Treatment-related complications of radiation therapy after radical prostatectomy: comparative effectiveness of intensity-modulated versus conformal radiation therapy.

Journal: Cancer Med 3(2):397-405

Date: 2014 Apr

Abstract: Intensity-modulated radiation therapy (IMRT) is frequently utilized after prostatectomy without strong evidence for an improvement in outcomes compared to conformal radiation therapy (RT). We analyzed a large group of patients treated with RT after radical prostatectomy (RP) to compare complications after IMRT and CRT. The Surveillance, Epidemiology and End Results (SEER)-Medicare database was queried to identify male Medicare beneficiaries aged 66 years or older who underwent prostatectomy with 1+ adverse pathologic features and received postprostatectomy RT between 1995 and 2007. Chi-square test was used to compare baseline characteristics between the treatment groups. First complication events, based upon administrative procedure or diagnosis codes occurring >1 year after start of RT, were compared for IMRT versus CRT groups. Propensity score adjustment was performed to adjust for potential confounders. Multivariable Cox proportional hazards models of time to first complication were performed. A total of 1686 patients were identified who received RT after RP (IMRT = 634, CRT = 1052). Patients treated with IMRT were more likely to be diagnosed after 2004 (P < 0.001), have minimally invasive prostatectomy (P < 0.001) and have positive margins (P = 0.019). IMRT use increased over time. After propensity score adjustment, IMRT was associated with lower rate of gastrointestinal (GI) complications, and higher rate of genitourinary-incontinence complications, compared to CRT. The observed outcomes after IMRT must be considered when determining the optimal approach for postprostatectomy RT and warrant additional study.

Authors: Duggan C, Risques R, Alfano C, Prunkard D, Imayama I, Holte S, Baumgartner K, Baumgartner R, Bernstein L, Ballard-Barbash R, Rabinovitch P, McTiernan A

Title: Change in peripheral blood leukocyte telomere length and mortality in breast cancer survivors.

Journal: J Natl Cancer Inst 106(4):dju035-

Date: 2014 Apr

Abstract: BACKGROUND: Progressive telomere shortening with cell division is a hallmark of aging. Short telomeres are associated with increased cancer risk, but there are conflicting reports about telomere length and mortality in breast cancer survivors. METHODS: We measured peripheral blood leukocyte telomere length at two time points in women enrolled in a multiethnic, prospective cohort of stage I to stage IIIA breast cancer survivors diagnosed between 1995 and 1999 with a median follow-up of 11.2 years. We evaluated associations between telomere length measured at mean 6 (baseline; LTL0; n = 611) and 30 months (LTL30; n = 478) after diagnosis and the change between those time points (n = 478), with breast cancer-specific and all-cause mortality using Cox proportional hazards models adjusted for possible confounders. Statistical tests were two-sided. RESULTS: There were 135 deaths, of which 74 were due to breast cancer. Neither baseline nor 30-month telomere length was associated with either all-cause or breast cancer-specific mortality (LTL0: hazard ratio [HR] = 0.83, 95% confidence interval [CI] = 0.67 to 1.02; HR = 0.88; 95% CI = 0.67 to 1.15; LTL30: HR = 0.78, 95% CI = 0.59 to 1.05; HR = 0.86; 95% = CI = 0.58 to 1.26, respectively). However, participants whose telomeres shortened between baseline and 30 months were at a statistically significantly increased risk of breast cancer-specific (HR = 3.03; 95% CI = 1.11 to 8.18) and all-cause mortality (HR = 2.38; 95% CI = 1.28 to 4.39) compared with participants whose telomeres lengthened. When follow-up was censored at 5-years after diagnosis, LTL0 (HR = 0.66; 95% CI = 0.45 to 0.96), LTL30 (HR = 0.51; 95% CI = 0.29 to 0.92), and change in telomere length (HR = 3.45; 95% CI = 1.11 to 10.75) were statistically significantly associated with all-cause mortality. CONCLUSIONS: Telomere shortening was associated with increased risk of breast cancer-specific and all-cause mortality, suggesting that change in blood telomere length over time could be a biomarker of prognosis. Research on determinants of telomere length and change is needed.

Authors: Francis DO, Pearce EC, Ni S, Garrett CG, Penson DF

Title: Epidemiology of vocal fold paralyses after total thyroidectomy for well-differentiated thyroid cancer in a Medicare population.

Journal: Otolaryngol Head Neck Surg 150(4):548-57

Date: 2014 Apr

Abstract: OBJECTIVES: The population-level incidence of vocal fold paralysis after thyroidectomy for well-differentiated thyroid carcinoma (WDTC) is not known. This study aimed to measure longitudinal incidence of postoperative vocal fold paralyses and need for directed interventions in the Medicare population undergoing total thyroidectomy for WDTC. STUDY DESIGN: Retrospective cohort study. SETTING: US population. SUBJECTS AND METHODS: Subjects were Medicare beneficiaries. SEER-Medicare data (1991-2009) were used to identify beneficiaries who underwent total thyroidectomy for WDTC. Incident vocal fold paralyses and directed interventions were identified. Multivariate analyses were used to determine factors associated with odds of developing these surgical complications. RESULTS: Of 5670 total thyroidectomies for WDTC, 9.5% were complicated by vocal fold paralysis (8.2% unilateral vocal fold paralysis [UVFP]; 1.3% bilateral vocal fold paralysis [BVFP]). Rate of paralyses decreased 5% annually from 1991 to 2009 (odds ratio 0.95; 95% confidence interval, 0.93-0.97; P < .001). Overall, 22% of patients with vocal fold paralysis required surgical intervention (UVFP 21%, BVFP 28%). Multivariate logistic regression revealed that the odds of postthyroidectomy paralysis increased with each additional year of age, with non-Caucasian race, with particular histologic types, with advanced stage, and in particular registry regions. CONCLUSION: Annual rates of postthyroidectomy vocal fold paralyses are decreasing among Medicare beneficiaries with WDTC. High incidence in this aged population is likely due to a preponderance of temporary paralyses, which is supported by the need for directed intervention in less than a quarter of affected patients. Further population-based studies are needed to refine the population incidence and risk factors for paralyses in the aging population.

Authors: Gupta S, Sussman DA, Doubeni CA, Anderson DS, Day L, Deshpande AR, Elmunzer BJ, Laiyemo AO, Mendez J, Somsouk M, Allison J, Bhuket T, Geng Z, Green BB, Itzkowitz SH, Martinez ME

Title: Challenges and possible solutions to colorectal cancer screening for the underserved.

Journal: J Natl Cancer Inst 106(4):dju032-

Date: 2014 Apr

Abstract: Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. CRC incidence and mortality can be reduced through screening. However, in the United States, screening participation remains suboptimal, particularly among underserved populations such as the uninsured, recent immigrants, and racial/ethnic minority groups. Increasing screening rates among underserved populations will reduce the US burden of CRC. In this commentary focusing on underserved populations, we highlight the public health impact of CRC screening, list key challenges to screening the underserved, and review promising approaches to boost screening rates. We identify four key policy and research priorities to increase screening among underserved populations: 1) actively promote the message, "the best test is the one that gets done"; 2) develop and implement methods to identify unscreened individuals within underserved population groups for screening interventions; 3) develop and implement approaches for organized screening delivery; and 4) fund and enhance programs and policies that provide access to screening, diagnostic follow-up, and CRC treatment for underserved populations. This commentary represents the consensus of a diverse group of experts in cancer control and prevention, epidemiology, gastroenterology, and primary care from across the country who formed the Coalition to Boost Screening among the Underserved in the United States. The group was organized and held its first annual working group meeting in conjunction with the World Endoscopy Organization's annual Colorectal Cancer Screening Committee meeting during Digestive Disease Week 2012 in San Diego, California.

Authors: Henrikson NB, Tuzzio L, Loggers ET, Miyoshi J, Buist DS

Title: Patient and oncologist discussions about cancer care costs.

Journal: Support Care Cancer 22(4):961-7

Date: 2014 Apr

Abstract: PURPOSE: Patient out-of-pocket costs are higher for cancer care than for any other health-care sector. Oncologist-patient discussions of costs are not well understood. We conducted an exploratory interview study to examine the frequency, patterns, attitudes, and preferences of both patients and providers on discussion of treatment costs. METHODS: We conducted semi-structured telephone interviews with oncology clinicians and people receiving chemotherapy at a large nonprofit health system. Multiple investigators conducted thematic analysis using modified content analysis, grounded theory, and interaction analysis methods. RESULTS: Patient themes included the relevance of cost to their experience, preference for the doctor to be the starting point of cost discussions, but relative infrequency of discussions with doctors or other care team member. Provider themes were an emphasis on clinical benefit above costs, conviction that cost-related decisions should rest with patients, and lack of access to treatment costs. Interest in discussing costs and barriers accessing cost information were common themes from both patients and providers. CONCLUSIONS: Doctors and patients want to discuss treatment costs but lack access to them. These data support growing evidence for a provider role in discussions of cost during cancer treatment planning.

Authors: Kaplan AL, Trinh QD, Sun M, Carter SC, Nguyen PL, Shih YC, Marks LS, Hu JC

Title: Testosterone replacement therapy following the diagnosis of prostate cancer: outcomes and utilization trends.

Journal: J Sex Med 11(4):1063-70

Date: 2014 Apr

Abstract: INTRODUCTION: Late-onset hypogonadism may impair quality of life and contribute to metabolic and cardiovascular comorbidity in aging men. Testosterone replacement therapy is effective in treating hypogonadism. However, for the millions of men with a history of prostate cancer, exogenous testosterone has long been considered contraindicated, even though little data in such men are available. Clarification of this safety issue could allow treatment to be considered for a sizeable segment of the aging male population. AIM: The aim of this study is to examine population-based utilization and impact of testosterone replacement therapy in men with prostate cancer. METHODS: Using linked Surveillance, Epidemiology, and End Results-Medicare data, we identified 149,354 men diagnosed with prostate cancer from 1992 to 2007. Of those, 1181 (0.79%) men received exogenous testosterone following their cancer diagnosis. We used propensity scoring analysis to examine the effect of testosterone replacement on the use of salvage hormone therapy and overall and prostate cancer-specific mortality. MAIN OUTCOME MEASURES: We assessed overall mortality, cancer-specific mortality, and the use of salvage hormone therapy. RESULTS: Following prostate cancer diagnosis, testosterone replacement was directly related to income and educational status and inversely related to age (all P < 0.001). Men undergoing radical prostatectomy and men with well-differentiated tumors were more likely to receive testosterone (all P < 0.001). On adjusted analysis, testosterone replacement therapy was not associated with overall or cancer-specific mortality or with the use of salvage hormone therapy. CONCLUSIONS: In this population-based observational study of testosterone replacement therapy in men with a history of prostate cancer, treatment was not associated with increased overall or cancer-specific mortality. These findings suggest testosterone replacement therapy may be considered in men with a history of prostate cancer, but confirmatory prospective studies are needed.

Authors: Kirkpatrick SI, Reedy J, Kahle LL, Harris JL, Ohri-Vachaspati P, Krebs-Smith SM

Title: Fast-food menu offerings vary in dietary quality, but are consistently poor.

Journal: Public Health Nutr 17(4):924-31

Date: 2014 Apr

Abstract: OBJECTIVE: To evaluate five popular fast-food chains' menus in relation to dietary guidance. DESIGN: Menus posted on chains' websites were coded using the Food and Nutrient Database for Dietary Studies and MyPyramid Equivalents Database to enable Healthy Eating Index-2005 (HEI-2005) scores to be assigned. Dollar or value and kids' menus and sets of items promoted as healthy or nutritious were also assessed. SETTING: Five popular fast-food chains in the USA. SUBJECTS: Not applicable. RESULTS: Full menus scored lower than 50 out of 100 possible points on the HEI-2005. Scores for Total Fruit, Whole Grains and Sodium were particularly dismal. Compared with full menus, scores on dollar or value menus were 3 points higher on average, whereas kids' menus scored 10 points higher on average. Three chains marketed subsets of items as healthy or nutritious; these scored 17 points higher on average compared with the full menus. No menu or subset of menu items received a score higher than 72 out of 100 points. CONCLUSIONS: The poor quality of fast-food menus is a concern in light of increasing away-from-home eating, aggressive marketing to children and minorities, and the tendency for fast-food restaurants to be located in low-income and minority areas. The addition of fruits, vegetables and legumes; replacement of refined with whole grains; and reformulation of offerings high in sodium, solid fats and added sugars are potential strategies to improve fast-food offerings. The HEI may be a useful metric for ongoing monitoring of fast-food menus.

Authors: Kowalczyk KJ, Gu X, Nguyen PL, Lipsitz SR, Trinh QD, Lynch JH, Collins SP, Hu JC

Title: Optimal timing of early versus delayed adjuvant radiotherapy following radical prostatectomy for locally advanced prostate cancer.

Journal: Urol Oncol 32(3):303-8

Date: 2014 Apr

Abstract: OBJECTIVES: Although post-radical prostatectomy (RP) adjuvant radiation therapy (ART) benefits disease that is staged as pT3 or higher, the optimal ART timing remains unknown. Our objective is to characterize the outcomes and optimal timing of early vs. delayed ART. MATERIALS AND METHODS: From the Surveillance, Epidemiology and End Results-Medicare data from 1995 to 2007, we identified 963 men with pT3N0 disease receiving early (<4 mo after RP, n = 419) vs. delayed (4-12 mo after RP, n = 544) ART after RP. Utilizing propensity score methods, we compared overall mortality, prostate cancer-specific mortality (PCSM), bone-related events (BRE), salvage hormonal therapy utilization, and intervention for urethral stricture. We then used the maximal statistic approach to determine at what time post-RP ART had the most significant effect on outcomes of interest in men with pT3N0 disease. RESULTS: When compared with delayed ART in men with pT3 disease, early ART was associated with improved PCSM (0.47 vs. 1.02 events per 100 person-years; P = 0.038) and less salvage hormonal therapy (2.88 vs. 4.59 events per 100 person-years; P = 0.001). Delaying ART beyond 5 months is associated with worse PCSM (hazard ratio [HR] 2.3; P = 0.020), beyond 3 months is associated with more BRE (HR 1.6; P = 0.025), and beyond 4 months is associated higher rates of salvage hormonal therapy (HR 1.6; P = 0.002). ART performed after 9 months was associated with fewer urethral strictures (HR 0.6; P = 0.042). CONCLUSION: Initiating ART less than 5 months after RP for pT3 is associated with improved PCSM. Early ART is also associated with fewer BRE and less use of salvage hormonal therapy if administered earlier than 3 and 4 months after RP, respectively. However, ART administered later than 9 months after RP is associated with fewer urethral strictures. Our population-based findings complement randomized trials designed with fixed ART timing.

Authors: Lakhani NA, Saraiya M, Thompson TD, King SC, Guy GP Jr

Title: Total body skin examination for skin cancer screening among U.S. adults from 2000 to 2010.

Journal: Prev Med 61:75-80

Date: 2014 Apr

Abstract: OBJECTIVE: Melanoma incidence and mortality are increasing among United States adults. At present, routine skin cancer screening via total body skin examinations (TBSEs) by a physician is not recommended by the United States Preventive Services Task Force (USPSTF); while organizations such as the American Cancer Society recommend screening. Currently, there are limited data on the prevalence, correlates, and trends of TBSE among United States adults. METHODS: We analyzed data by race/ethnicity, age, and skin cancer risk level, among other characteristics from three different National Health Interview Survey (NHIS) cancer control supplements conducted every five years since 2000 in random United States households. High-risk status and middle-risk status were defined based on the USPSTF criteria (age, race, sunburn, and family history). RESULTS: Prevalence of having at least one TBSE increased from 14.5 in 2000 to 16.5 in 2005 to 19.8 in 2010 (P<0.0001). In 2010, screening rates were higher among the elderly, the fair-skinned, those reporting sunburn(s), and individuals with a family history of skin cancer. Approximately 104.7million (51.1%) U.S. adults are at high-risk for developing melanoma, of which 24.0% had at least one TBSE. CONCLUSIONS: TBSE rates have been increasing since 2000 both overall and among higher-risk groups. Data on screening trends could help tailor future prevention strategies.

Authors: Leppert JT, Hanley J, Wagner TH, Chung BI, Srinivas S, Chertow GM, Brooks JD, Saigal CS, Urologic Diseases in America Project

Title: Utilization of renal mass biopsy in patients with renal cell carcinoma.

Journal: Urology 83(4):774-9

Date: 2014 Apr

Abstract: OBJECTIVE: To examine the patient, tumor, and temporal factors associated with receipt of renal mass biopsy (RMB) in a contemporary nationally representative sample. METHODS: We queried the Surveillance, Epidemiology, and End Results-Medicare data set for incident cases of renal cell carcinoma diagnosed between 1992 and 2007. We tested for associations among receipt of RMB and patient and tumor characteristics, type of therapy, and procedure type. Temporal trends in receipt of RMB were characterized over the study period. RESULTS: Approximately 1 in 5 (20.7%) patients diagnosed with renal cell carcinoma (n = 24,702) underwent RMB before instituting therapy. There was a steady and modest increase in RMB utilization, with the highest utilization (30%) occurring in the final study year. Of patients who underwent radical (n = 15,666) or partial (n = 2211) nephrectomy, 17% and 20%, respectively, underwent RMB in advance of surgery. Sixty-five percent of patients who underwent ablation (n = 314) underwent RMB before or in conjunction with the procedure. Roughly half of patients (50.4%) treated with systemic therapy alone underwent RMB. Factors independently associated with use of RMB included younger age, black race, Hispanic ethnicity, tumor size <7 cm, and metastatic disease at presentation. CONCLUSION: At present, most patients who eventually undergo radical or partial nephrectomy do not undergo RMB, whereas most patients who eventually undergo ablation or systemic therapy do. The optimal use of RMB in the evaluation of kidney tumors has yet to be determined.

Authors: Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Hollingsworth JM, Shahinian VB, Hollenbeck BK

Title: Regional variation in quality of prostate cancer care.

Journal: J Urol 191(4):957-62

Date: 2014 Apr

Abstract: PURPOSE: Despite the endorsement of several quality measures for prostate cancer by the National Quality Forum and the Physician Consortium for Performance Improvement, how consistently physicians adhere to these measures has not been examined. We evaluated regional variation in adherence to these quality measures to identify targets for future quality improvement. MATERIALS AND METHODS: For this retrospective cohort study we used SEER (Surveillance, Epidemiology, and End Results)-Medicare data for 2001 to 2007 to identify 53,614 patients with newly diagnosed prostate cancer. Patients were assigned to 661 regions (Hospital Service Areas). Hierarchical generalized linear models were used to examine reliability adjusted regional adherence to the endorsed quality measures. RESULTS: Adherence at the patient level was highly variable, ranging from 33% for treatment by a high volume provider to 76% for receipt of adjuvant androgen deprivation therapy while undergoing radiotherapy for high risk cancer. In addition, there was considerable regional variation in adherence to several measures, including pretreatment counseling by a urologist and radiation oncologist (range 9% to 89%, p <0.001), avoiding overuse of bone scans in low risk cancer (range 16% to 96%, p <0.001), treatment by a high volume provider (range 1% to 90%, p <0.001) and followup with radiation oncologists (range 14% to 86%, p <0.001). CONCLUSIONS: We found low adherence rates for most established prostate cancer quality of care measures. Within most measures regional variation in adherence was pronounced. Measures with low adherence and a large amount of regional variation may be important low hanging targets for quality improvement.

Authors: Shao YH, Kim S, Moore DF, Shih W, Lin Y, Stein M, Kim IY, Lu-Yao GL

Title: Cancer-specific survival after metastasis following primary radical prostatectomy compared with radiation therapy in prostate cancer patients: results of a population-based, propensity score-matched analysis.

Journal: Eur Urol 65(4):693-700

Date: 2014 Apr

Abstract: BACKGROUND: Data regarding the difference in the clinical course from metastasis to prostate cancer-specific mortality (PCSM) following radical prostatectomy (RP) compared with radiation therapy (RT) are lacking. OBJECTIVE: To examine the association between primary treatment modality and prostate cancer-specific survival (PCSS) after metastasis. DESIGN, SETTING, AND PARTICIPANTS: We used the Surveillance Epidemiology and End Results-Medicare linked database from 1994 to 2007 for patients diagnosed with localized prostate cancer (PCa). We used cancer stage and Gleason score to stratify patients into low and intermediate-high risks. INTERVENTION: Radical prostatectomy or radiation therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Our outcome is time from onset of metastases to PCSM. Propensity score matching and Cox regression were used to analyze the PCSM hazard for the RP group compared with the RT group. RESULTS AND LIMITATIONS: Our study consisted of 66,492 men diagnosed with PCa, 51,337 men receiving RT, and 15,155 men undergoing RP within 1 yr of cancer diagnosis. During the study period, 2802 men were diagnosed as having metastatic disease. A total of 916 men with metastases were included in the propensity-matched cohort; of these men, 186 died from PCa. During the follow-up, for the low-risk patients, the adjusted PCSS after metastasis was 86.2% and 79.3% in the RP and RT groups, respectively; for the intermediate-high-risk patients, the PCSS after metastasis was 76.3% and 63.3% in the RP and RT groups, respectively. The hazard ratios estimating the risk of PCSM between the RP and RT groups were 0.64 (95% confidence interval [CI], 0.36-1.16) and 0.55 (95% CI, 0.39-0.77) for the low- and intermediate-high-risk groups, respectively. Because of the nature of observational studies, the results may be affected by residual confounders and treatment indication. CONCLUSIONS: Following the development of metastases, men who received primary RP have a longer PCSS than men who received primary RT. Our results may have implications for the timing and nature of local PCa treatment.

Authors: Shih YC, Xu Y, Dong W, Smieliauskas F, Giordano S, Shen Y

Title: First do no harm: population-based study shows non-evidence-based trastuzumab prescription may harm elderly women with breast cancer.

Journal: Breast Cancer Res Treat 144(2):417-25

Date: 2014 Apr

Abstract: Trastuzumab, although cardiotoxic, is associated with improved survival in HER2-positive breast cancer. Non-compliance with HER2 testing guidelines before prescribing trastuzumab occurs in practice; however, the clinical consequences are unclear. Using SEER-Medicare database (2000-2009), we assessed differences in baseline characteristics between women ≥ 65 with breast cancer who received and did not receive HER2 testing prior to trastuzumab prescription. We used propensity score matched-pair analysis to balance the confounders between these two groups. We assessed the differences in overall survival and 3-year rates of avoiding congestive heart failure (CHF) between women who received trastuzumab without HER2 testing (trastuzumab group) and women who had chemotherapy but did not receive trastuzumab (irrespective of testing) (chemo-only group). Based on the matched data, we used Cox regression in these assessments with double robust estimation or with stratification. Among women who received trastuzumab, 140 (4.7 %) had no documentation of HER2 testing. Breast surgery, south residential region, and an earlier year of diagnosis were predictive of no HER2 testing in multivariate logistic regression. Women in the chemo-only group had similar overall survival (HR = 1.28; P = 0.108) over an 8-year follow-up post-diagnosis and significantly higher likelihood of avoiding CHF over 3 years after the first administration of chemotherapy or trastuzumab (HR = 1.66, P = 0.036) compared to women in the trastuzumab group, using the propensity score-matched data. Non-evidence-based prescription of trastuzumab is associated with increased rates of CHF with no additional survival benefit among older women with breast cancer. Inappropriate prescriptions of targeted therapies agent can lead to detrimental health and financial consequences.

Authors: de Vries S, Jeffe DB, Pruitt SL, Davidson NO, Schootman M

Title: Patient, hospital, and geographic disparities associated with comanagement during hospitalization for colorectal cancer surgery.

Journal: J Hosp Med 9(4):226-31

Date: 2014 Apr

Abstract: BACKGROUND: Comanagement of surgical patients has increased, but information regarding detailed characteristics of patients receiving comanagement during hospitalization for colorectal cancer (CRC) surgery is lacking. OBJECTIVE: To examine the use of and characteristics associated with comanagement of patients hospitalized for CRC surgery. DESIGN: This study used a population-based cross-sectional design. SETTING: We used the linked 2000 to 2005 Surveillance, Epidemiology, and End Results and Medicare claims data. PATIENTS: We included 37,065 patients aged 66 years or older, hospitalized for definitive CRC surgery following stage I to III diagnosis. MEASUREMENTS: The outcome of interest was comanagement during hospitalization for CRC surgery, and we examined the association between several patient and hospital characteristics. Comanagement was defined as having a relevant physician (ie, internal medicine hospitalist/generalist) submit a claim for evaluation and management services on 70% or more of the days of hospitalization of the patient. RESULTS: During hospitalization for CRC surgery, 27.6% of patients were comanaged, but this percentage varied widely across hospitals (from 1.9% to 83.2%). Several patient and hospital characteristics were associated with the use of comanaged care, of which important characteristics included older age at diagnosis, presence of comorbidity, emergency surgery, and hospital volume. CONCLUSIONS: Extensive variability existed in comanagement use across patients and hospitals, likely reflecting the lack of evidence for its clinical effectiveness.

Authors: Tejada JJ, Ivy JS, King RE, Wilson JR, Ballan MJ, Kay MG, Diehl KM, Yankaskas BC

Title: Combined DES/SD model of breast cancer screening for older women, II: screening-and-treatment simulation

Journal: IIE Trans 46(7):707-727

Date: 2014 Mar 28

Abstract: In the second article of a two-article sequence, the focus is on a simulation model for screening and treatment of breast cancer in U.S. women of age 65+. The first article details a natural-history simulation model of the incidence and progression of untreated breast cancer in a representative simulated population of older U.S. women, which ultimately generates a database of untreated breast cancer histories for individuals in the simulated population. Driven by the resulting database, the screening-and-treatment simulation model is composed of discrete-event simulation (DES) and system dynamics (SD) submodels. For each individual in the simulated population, the DES submodel simulates screening policies and treatment procedures to estimate the resulting survival rates and the costs of screening and treatment. The SD submodel represents the overall structure and operation of the U.S. system for detecting and treating breast cancer. The main results and conclusions are summarized, including a final recommendation for annual screening between ages 65 and 80. A discussion is also presented on how both the natural-history and screening-and-treatment simulations can be used for performance comparisons of proposed screening policies based on overall cost-effectiveness, the numbers of life-years and quality-adjusted life-years saved, and the main components of the total cost incurred by each policy.

Authors: Drahos J, Ricker W, Parsons R, Pfeiffer RM, Warren JL, Cook MB

Title: Metabolic Syndrome Increases Risk of Barrett Esophagus in the Absence of Gastroesophageal Reflux: An Analysis of SEER-Medicare Data.

Journal: J Clin Gastroenterol :-

Date: 2014 Mar 25

Abstract: GOALS:: To evaluate the association between metabolic syndrome (MetS) and risk of Barrett esophagus (BE) using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database compared with 2 control groups-Medicare population controls and endoscopy controls. BACKGROUND:: BE principally arises as an adaptation to the proinflammatory state induced by gastroesophageal reflux disease (GERD). The relationship between obesity and BE is presumed to be mediated by GERD. However, evidence suggests central adiposity also increases risk of BE independent of GERD. Central adiposity is one risk factor defining MetS, which confers a systemic proinflammatory state-a potential GERD-independent mechanism by which obesity could increase the risk of BE. STUDY:: MetS was defined as diagnosis of at least 3 of the following conditions: obesity, elevated triglycerides, high blood pressure, and elevated fasting glucose. Multivariable logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals. RESULTS:: In 2198 incident BE cases, prior MetS was significantly associated with BE (odds ratio, 1.20; 95% confidence interval: 1.07, 1.36) compared with population controls. However, GERD status modified the association; among those without prior GERD, MetS increased risk of BE by 34%; however, no association was observed among those with a prior GERD diagnosis (P-value for effect modification <0.001). MetS was not associated with risk of BE compared with endoscopy controls. CONCLUSIONS:: MetS increased the risk of BE compared with population controls, an association driven by and confined to the non-GERD stratum. MetS may mediate an association between central adiposity and BE for those without GERD.

Authors: Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Miller DC, Montgomery JS, Weizer AZ, Hollenbeck BK

Title: Adherence to Performance Measures and Outcomes among Men Treated for Prostate Cancer.

Journal: J Urol :-

Date: 2014 Mar 25

Abstract: PURPOSE: We assessed the relationship between health care system performance on nationally endorsed prostate cancer quality of care measures and prostate cancer treatment outcomes. MATERIALS AND METHODS: This retrospective cohort study included 48,050 men from SEER-Medicare linked data diagnosed with localized prostate cancer between 2004 and 2009, and followed through 2010. Based on a composite quality measure we categorized the health care systems in which these men were treated into 1-star (bottom 20%), 2-star (middle 60%) and 3-star (top 20%) systems. We then examined the association of health care system level quality of care with outcomes using multivariable logistic and Cox regression. RESULTS: Patients who underwent prostatectomy in 3-star vs 1-star health care systems were at lower risk for perioperative complications (OR 0.80, 95% CI 0.64-1.00). However, they were more likely to undergo a procedure addressing treatment related morbidity, eg for sexual morbidity (11.3% vs 7.8%, p = 0.043). In patients who received radiotherapy star ranking was not associated with treatment related morbidity. In all patients star ranking was not significantly associated with all-cause mortality (HR 0.99, 95% CI 0.84-1.15) or secondary cancer therapy (HR 1.04, 95% CI 0.91-1.20). CONCLUSIONS: We found no consistent association between health care system quality and outcomes, which questions how meaningful these measures ultimately are for patients. Thus, future studies should focus on developing more discriminative quality measures.

Authors: Dodgion CM, Neville BA, Lipsitz SR, Schrag D, Breen E, Zinner MJ, Greenberg CC

Title: Hospital variation in sphincter preservation for elderly rectal cancer patients.

Journal: J Surg Res :-

Date: 2014 Mar 22

Abstract: BACKGROUND: The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference. RESULTS: The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation. CONCLUSIONS: Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.

Authors: Vaz-Luis I, Keating NL, Lin NU, Lii H, Winer EP, Freedman RA

Title: Duration and toxicity of adjuvant trastuzumab in older patients with early-stage breast cancer: a population-based study.

Journal: J Clin Oncol 32(9):927-34

Date: 2014 Mar 20

Abstract: PURPOSE: Few data are available regarding adjuvant trastuzumab use in older women with early-stage breast cancer. We examined rates and predictors of adjuvant trastuzumab completion and cardiac events in this population. PATIENTS AND METHODS: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify patients age ≥ 66 years with stage I to III breast cancer diagnosed between 2005 and 2009 who received trastuzumab. Completion of trastuzumab was defined as receipt of more than 270 days of therapy. We used multivariable logistic regression to examine patient, clinical, and geographic characteristics associated with trastuzumab completion. We also examined rates of hospital admissions for cardiac events. RESULTS: Among 2,028 women, most (71.2%) were younger than age 76 years and had a comorbidity score of 0 (66.8%); 85.2% received trastuzumab with chemotherapy. Overall, 1,656 women (81.7%) completed trastuzumab. Older patients and those with more comorbidity had lower odds of treatment completion (odds ratio [OR], 0.40 [95% CI, 0.30 to 0.55] for age ≥ 80 years v age 66 to 70 years; OR, 0.65 [95% CI, 0.49 to 0.88] for comorbidity score of 2 v 0). During treatment, 73 patients (3.6%) were hospitalized for cardiac events (2.6% of those who completed trastuzumab v 8.1% of those who did not; P < .001). CONCLUSION: Most older patients who initiated adjuvant trastuzumab completed therapy. Age and comorbidity were among factors that were associated with treatment completion, and rates of significant cardiac events were higher in those who did not complete therapy. Further exploration of toxicities and optimal treatments for older women with human epidermal growth factor receptor 2-positive breast cancer are warranted.

Authors: Dai H, Yan Y, Wang P, Liu P, Cao Y, Xiong L, Luo Y, Pan T, Ma X, Wang J, Yang Z, Liu X, Chen C, Huang Y, Li Y, Wang Y, Hao X, Ye Z, Chen K

Title: Distribution of mammographic density and its influential factors among Chinese women.

Journal: Int J Epidemiol :-

Date: 2014 Mar 16

Abstract: BACKGROUND:: Mammographic density (MD) has not been systematically investigated among Chinese women. Breast cancer screening programmes provided detailed information on MD in a large number of asymptomatic women. METHODS:: In the Multi-modality Independent Screening Trial (MIST), we estimated the association between MD and its influential factors using logistic regression, adjusting for age, body mass index (BMI) and study area. Differences between Chinese and other ethnic groups with respect to MD were also explored with adjustment for age and BMI. RESULTS:: A total of 28 388 women aged 45 to 65 years, who had been screened by mammography, were enrolled in the study. Of these, 49.2% were categorized as having dense breasts (BI-RADS density 3 and 4) and 50.8% as fatty breasts (BI-RADS density 1 and 2). Postmenopausal status [odds ratio (OR) = 0.66; 95% confidence interval (CI): 0.62-0.70] and higher number of live births (OR = 0.56; 95% CI: 0.46-0.68) were inversely associated with MD, whereas prior benign breast disease (OR = 1.48; 95% CI: 1.40-1.56) and later age at first birth (OR = 1.17; 95% CI: 1.08-1.27) were positively associated with MD. In comparison with the data from the Breast Cancer Surveillance Consortium, we found that women in MIST were more likely to have fatty breasts than Americans (from the Breast Cancer Surveillance Consortium) in the older age group (≥50 years) but more likely to have dense breasts in the younger age group (<50 years). CONCLUSIONS:: This study suggests that several risk factors for breast cancer were associated with breast density in Chinese women. Information on the determinants of mammographic density may provide valuable insights into breast cancer aetiology.

Authors: Carrell DS, Halgrim S, Tran DT, Buist DS, Chubak J, Chapman WW, Savova G

Title: Using natural language processing to improve efficiency of manual chart abstraction in research: the case of breast cancer recurrence.

Journal: Am J Epidemiol 179(6):749-58

Date: 2014 Mar 15

Abstract: The increasing availability of electronic health records (EHRs) creates opportunities for automated extraction of information from clinical text. We hypothesized that natural language processing (NLP) could substantially reduce the burden of manual abstraction in studies examining outcomes, like cancer recurrence, that are documented in unstructured clinical text, such as progress notes, radiology reports, and pathology reports. We developed an NLP-based system using open-source software to process electronic clinical notes from 1995 to 2012 for women with early-stage incident breast cancers to identify whether and when recurrences were diagnosed. We developed and evaluated the system using clinical notes from 1,472 patients receiving EHR-documented care in an integrated health care system in the Pacific Northwest. A separate study provided the patient-level reference standard for recurrence status and date. The NLP-based system correctly identified 92% of recurrences and estimated diagnosis dates within 30 days for 88% of these. Specificity was 96%. The NLP-based system overlooked 5 of 65 recurrences, 4 because electronic documents were unavailable. The NLP-based system identified 5 other recurrences incorrectly classified as nonrecurrent in the reference standard. If used in similar cohorts, NLP could reduce by 90% the number of EHR charts abstracted to identify confirmed breast cancer recurrence cases at a rate comparable to traditional abstraction.

Authors: Harris JP, Murphy JD, Hanlon AL, Le QT, Loo BW Jr, Diehn M

Title: A population-based comparative effectiveness study of radiation therapy techniques in stage III non-small cell lung cancer.

Journal: Int J Radiat Oncol Biol Phys 88(4):872-84

Date: 2014 Mar 15

Abstract: PURPOSE: Concerns have been raised about the potential for worse treatment outcomes because of dosimetric inaccuracies related to tumor motion and increased toxicity caused by the spread of low-dose radiation to normal tissues in patients with locally advanced non-small cell lung cancer (NSCLC) treated with intensity modulated radiation therapy (IMRT). We therefore performed a population-based comparative effectiveness analysis of IMRT, conventional 3-dimensional conformal radiation therapy (3D-CRT), and 2-dimensional radiation therapy (2D-RT) in stage III NSCLC. METHODS AND MATERIALS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify a cohort of patients diagnosed with stage III NSCLC from 2002 to 2009 treated with IMRT, 3D-CRT, or 2D-RT. Using Cox regression and propensity score matching, we compared survival and toxicities of these treatments. RESULTS: The proportion of patients treated with IMRT increased from 2% in 2002 to 25% in 2009, and the use of 2D-RT decreased from 32% to 3%. In univariate analysis, IMRT was associated with improved overall survival (OS) (hazard ratio [HR] 0.90, P=.02) and cancer-specific survival (CSS) (HR 0.89, P=.02). After controlling for confounders, IMRT was associated with similar OS (HR 0.94, P=.23) and CSS (HR 0.94, P=.28) compared with 3D-CRT. Both techniques had superior OS compared with 2D-RT. IMRT was associated with similar toxicity risks on multivariate analysis compared with 3D-CRT. Propensity score matched model results were similar to those from adjusted models. CONCLUSIONS: In this population-based analysis, IMRT for stage III NSCLC was associated with similar OS and CSS and maintained similar toxicity risks compared with 3D-CRT.

Authors: Nogueira L, Freedman ND, Engels EA, Warren JL, Castro F, Koshiol J

Title: Gallstones, cholecystectomy, and risk of digestive system cancers.

Journal: Am J Epidemiol 179(6):731-9

Date: 2014 Mar 15

Abstract: Gallstones and cholecystectomy may be related to digestive system cancer through inflammation, altered bile flux, and changes in metabolic hormone levels. Although gallstones are recognized causes of gallbladder cancer, associations with other cancers of the digestive system are poorly established. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1992-2005), which includes 17 cancer registries that cover approximately 26% of the US population, to identify first primary cancers (n = 236,850) occurring in persons aged ≥66 years and 100,000 cancer-free population-based controls frequency-matched by calendar year, age, and gender. Odds ratios and 95% confidence intervals were calculated using logistic regression analysis, adjusting for the matching factors. Gallstones and cholecystectomy were associated with increased risk of noncardia gastric cancer (odds ratio (OR) = 1.21 (95% confidence interval (CI): 1.11, 1.32) and OR = 1.26 (95% CI: 1.13, 1.40), respectively), small-intestine carcinoid (OR = 1.27 (95% CI: 1.01, 1.60) and OR = 1.78 (95% CI: 1.41, 2.25)), liver cancer (OR = 2.35 (95% CI: 2.18, 2.54) and OR = 1.26 (95% CI: 1.12, 1.41)), and pancreatic cancer (OR = 1.24 (95% CI: 1.16, 1.31) and OR = 1.23 (95% CI: 1.15, 1.33)). Colorectal cancer risk associated with gallstones and cholecystectomy decreased with increasing distance from the common bile duct (P-trend < 0.001). Hence, gallstones and cholecystectomy are associated with the risk of cancers occurring throughout the digestive tract.

Authors: Noone AM, Lund JL, Mariotto A, Cronin K, McNeel T, Deapen D, Warren JL

Title: Comparison of SEER Treatment Data With Medicare Claims.

Journal: Med Care :-

Date: 2014 Mar 15

Abstract: BACKGROUND:: The population-based Surveillance, Epidemiology, and End Results (SEER) registries collect information on first-course treatment, including surgery, chemotherapy, radiation therapy, and hormone therapy. However, the SEER program does not release data on chemotherapy or hormone therapy due to uncertainties regarding data completeness. Activities are ongoing to investigate the opportunity to supplement SEER treatment data with other data sources. METHODS:: Using the linked SEER-Medicare data, we examined the validity of the SEER data to identify receipt of chemotherapy and radiation therapy among those aged 65 and older diagnosed from 2000 to 2006 with bladder, female breast, colorectal, lung, ovarian, pancreas, or prostate cancer and hormone therapy among men diagnosed with prostate cancer at age 65 or older. Treatment collected by SEER was compared with treatment as determined by Medicare claims, using Medicare claims as the gold standard. The κ, sensitivity, specificity, positive predictive values, and negative predictive values were calculated for the receipt of each treatment modality. RESULTS:: The overall sensitivity of SEER data to identify chemotherapy, radiation, and hormone therapy receipt was moderate (68%, 80%, and 69%, respectively) and varied by cancer site, stage, and patient characteristics. The overall positive predictive value was high (>85%) for all treatment types and cancer sites except chemotherapy for prostate cancer. CONCLUSIONS:: SEER data should not generally be used for comparisons of treated and untreated individuals or to estimate the proportion of treated individuals in the population. Augmenting SEER data with other data sources will provide the most accurate treatment information.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0.

Authors: Gandaglia G, Sun M, Popa I, Schiffmann J, Abdollah F, Trinh QD, Saad F, Graefen M, Briganti A, Montorsi F, Karakiewicz PI

Title: The impact of androgen-deprivation therapy (ADT) on the risk of cardiovascular (CV) events in patients with non-metastatic prostate cancer: a population-based study.

Journal: BJU Int :-

Date: 2014 Mar 10

Abstract: OBJECTIVE: To examine and quantify the contemporary association between androgen-deprivation therapy (ADT) and three separate endpoints: coronary artery disease (CAD), acute myocardial infarction (AMI), and sudden cardiac death (SCD), in a large USA contemporary cohort of patients with prostate cancer. PATIENTS AND METHODS: In all, 140 474 patients diagnosed with non-metastatic prostate cancer between 1995 and 2009 within the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database were abstracted. Patients treated with ADT and those not receiving ADT were matched using propensity score methodology. The 10-year CAD, AMI, and SCD rates were estimated. Competing-risks regression analyses tested the association between the type of ADT (GnRH agonists vs bilateral orchidectomy) and CAD, AMI, and SCD, after adjusting for the risk of dying during follow-up. RESULTS: Overall, the 10-year rates of CAD, AMI, and SCD were 25.9%, 15.6%, and 15.8%, respectively. After stratification according to ADT status (ADT-naïve vs GnRH agonists vs bilateral orchidectomy), the CAD rates were 25.1% vs 26.9% vs 23.2%, the AMI rates were 14.8% vs 16.6% vs 14.8%, and the SCD rates were 14.2% vs 17.7% vs 16.4%, respectively. In competing-risks multivariable regression analyses, the administration of GnRH agonists (all P < 0.001), but not bilateral orchidectomy (all P ≥ 0.7), was associated with higher risk of CAD, AMI, and SCD. CONCLUSIONS: The administration of GnRH agonists, but not orchidectomy, is still associated with a significantly increased risk of CAD, AMI, and, especially, SCD in patients with non-metastatic prostate cancer. Alternative forms of ADT should be considered in patients at higher risk of CV events.

Authors: Schaefer EW, Wilson MZ, Goldenberg D, Mackley H, Koch W, Hollenbeak CS

Title: Effect of marriage on outcomes for elderly patients with head and neck cancer.

Journal: Head Neck :-

Date: 2014 Mar 04

Abstract: BACKGROUND: Beneficial effects of marriage on cancer outcomes have been observed for many cancers, but oral cavity and pharyngeal cancers have never been examined. METHODS: We used the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) Program linked with Medicare records to identify 9403 elderly patients (age ≥66 years) with oral cavity and pharyngeal cancers. We used a propensity score analysis to estimate differences in proportions (pd ) between married and unmarried patients on stage, treatment, and survival. RESULTS: For oral cavity cancers, a larger proportion of married patients presented with earlier stage (pd = 0.05; 95% confidence interval [CI], 0.02-0.08), were treated with surgery (pd = 0.06; 95% CI, 0.03-0.08), and survived 1 year (pd = 0.04; 95% CI, 0.01-0.06). Similar results were found for pharyngeal cancers for stage (pd = 0.04; 95% CI, 0.01-0.06), treatment with chemotherapy and radiation (pd = 0.04; 95% CI, 0.01-0.07), and 1-year survival (pd = 0.01; 95% CI, 0.08-0.16). CONCLUSION: Marriage is associated with earlier stage, aggressive treatment, and superior survival for patients with oral cavity and pharyngeal cancers. © 2014 Wiley Periodicals, Inc. Head Neck, 2014.

Authors: Patel HD, Kates M, Pierorazio PM, Allaf ME

Title: Balancing cardiovascular (CV) and cancer death among patients with small renal masses: modification by CV risk.

Journal: BJU Int :-

Date: 2014 Mar 03

Abstract: OBJECTIVE: To assess modification of comparative cancer survival by cardiovascular (CV) risk and treatment strategy among older patients with small renal masses (SRMs). PATIENTS AND METHODS: Patients with localised T1a renal cell carcinoma were identified in the Surveillance, Epidemiology and End Results-Medicare database (1995-2007). Patients were stratified by CV risk, using major atherosclerotic CV comorbidities identified by the Framingham Heart Study, to compare overall (OS), cancer-specific (CSS), and CV-specific survival (CVSS) for those who deferred therapy (DT) to those undergoing either partial (PN) or radical nephrectomy (RN). Cox proportional hazards and Fine and Gray competing risks regression adjusted for demographics, comorbidities, and tumour size were performed. RESULTS: In all, 754 (10.5%) patients had DT, 1849 (25.8%) patients underwent PN, and 4574 (63.7%) patients underwent RN. Patients at high CV risk who had DT had the greatest CV-to-cancer mortality rate ratio (2.89), and CV risk was generally associated with worse OS and CVSS. Patients in the high CV risk strata had no difference in CSS between treatment strategies [DT vs PN: hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.25-1.41; DT vs RN: HR 0.81, 95%CI 0.46-1.43)], while there was a 2-4 fold CSS benefit for surgery in the low CV risk strata. CONCLUSIONS: Cancer survival was comparable across treatment strategies for older patients with SRMs with high risk CV disease. Greater attention to CV comorbidity as it relates to competing risks of death and life expectancy may be deserved in selecting patients appropriate for active surveillance because patients at low CV risk might benefit from surgery.

Authors: Beadle BM, Liao KP, Elting LS, Buchholz TA, Ang KK, Garden AS, Guadagnolo BA

Title: Improved survival using intensity-modulated radiation therapy in head and neck cancers: a SEER-Medicare analysis.

Journal: Cancer 120(5):702-10

Date: 2014 Mar 01

Abstract: BACKGROUND: Intensity-modulated radiation therapy (IMRT) is a technologically advanced, and more expensive, method of delivering radiation therapy with a goal of minimizing toxicity. It has been widely adopted for head and neck cancers; however, its comparative impact on cancer control and survival remains unknown. The goal of this analysis was to compare the cause-specific survival (CSS) for patients with head and neck cancers treated with IMRT versus non-IMRT from 1999 to 2007. METHODS: CSS was determined using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database and analyzed regarding treatment details, including the use of IMRT versus non-IMRT, using claims data. Hazard ratios (HRs) were estimated by the frailty model with a propensity score matching cohort and instrumental variable analysis. RESULTS: A total of 3172 patients were identified. With a median follow-up of 40 months, patients treated with IMRT had a statistically significant improvement in CSS compared with those treated with non-IMRT (84.1% versus 66.0%; P < .001). When each anatomic subsite was analyzed separately, all respective subgroups of patients treated with IMRT had better CSS than those treated with non-IMRT. In multivariable survival analyses, patients treated with IMRT were associated with better CSS (HR = 0.72, 95% confidence interval = 0.59 to 0.90 for propensity score matching; HR = 0.60, 95% confidence interval = 0.41 to 0.88 for instrumental variable analysis). CONCLUSIONS: Patients with head and neck cancers who were treated with IMRT experienced significant improvements in CSS compared with patients treated with non-IMRT techniques. This suggests there may be benefits to IMRT in cancer outcomes, in addition to toxicity reduction, for this patient population.

Authors: Nekhlyudov L, Aziz NM, Lerro C, Virgo KS

Title: Oncologists' and primary care physicians' awareness of late and long-term effects of chemotherapy: implications for care of the growing population of survivors.

Journal: J Oncol Pract 10(2):e29-36

Date: 2014 Mar 01

Abstract: PURPOSE: The population of cancer survivors is large and growing. Yet after successful completion of treatment, many experience chemotherapy-related late or long-term effects (LEs). The extent to which physicians are aware of LEs is unknown. METHODS: We conducted a nationally representative survey of 1,130 oncologists and 1,072 primary care providers (PCPs). Respondents were asked to select the LEs they had either observed or seen reported for five chemotherapy agents used to treat breast and colon cancers. We described and compared oncologists' and PCPs' awareness of the specified LEs. Using multivariate logistic regression models, we determined predictors of physicians' awareness of the main LEs associated with the agents. RESULTS: Almost all oncologists (95%) reported awareness of cardiac dysfunction as an LE of doxorubicin and peripheral neuropathy as an LE of paclitaxel (97%) and oxaliplatin (97%). These LEs were reported by 55%, 27%, and 22% of PCPs, respectively. Most oncologists reported awareness of premature menopause (71%) and secondary malignancies (62%) as LEs of cyclophosphamide, compared with only 15% and 17% of PCPs, respectively. Main LEs associated with all four agents were identified by 65% of oncologists and only 6% of PCPs. CONCLUSION: Although more than half of PCPs were aware of cardiac dysfunction as an LE of doxorubicin, awareness of other LEs was limited. Because PCPs may not be directly exposed to chemotherapy-related LEs, oncologists must communicate this information to PCPs as patients transition to primary care settings. Education for all providers caring for the growing population of cancer survivors is needed.

Authors: Farrelly MC, Arnold KY, Juster HR, Allen JA

Title: Quantifying the effect of changes in state-level adult smoking rates on youth smoking.

Journal: J Public Health Manag Pract 20(2):E1-6

Date: 2014 Mar-Apr

Abstract: OBJECTIVE: Quantify the degree to which changes in state-level adult smoking prevalence subsequently influence youth smoking prevalence. DESIGN: Analysis of data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) collected from 1995 to 2006 and the National Youth Tobacco Survey (NYTS) collected from 1999 to 2006. SETTING AND PARTICIPANTS: Adults 25 years or older who completed the TUS-CPS and youth in middle and high school who completed the NYTS. MAIN OUTCOME MEASURES: Current smoking among middle and high school students as a function of the change in state-level adult smoking, controlling for individual-level sociodemographic characteristics and state-level tobacco control policy variables. RESULTS: Among middle school students, declines in state-level adult smoking rates are associated with lower odds of current smoking (P < .05), and each doubling of the decline in adult smoking rates is associated with a 6.0% decrease in youth smoking. Among high school students, declines in state-level adult smoking rates are not associated with current smoking. Higher cigarette prices were associated with lower odds of smoking among middle and high school students. Greater population coverage by smoke-free air laws and greater funding for tobacco control programs were associated with lower odds of current smoking among high school students but not middle school students. Compliance with youth access laws was not associated with middle or high school smoking. CONCLUSION: By quantifying the effect of changes in state-level adult smoking rates on youth smoking, this study enhances the precision with which the tobacco control community can assess the return on investment for adult-focused tobacco control programs.

Authors: Friedlander DF, Gu X, Prasad SM, Lipsitz SR, Nguyen PL, Trinh QD, Sun M, Hu JC

Title: Population-based comparative effectiveness of salvage radical prostatectomy vs cryotherapy.

Journal: Urology 83(3):653-7

Date: 2014 Mar

Abstract: OBJECTIVE: To characterize population-based practice patterns, disease-specific and overall mortality, and cost associated with salvage cryotherapy (SCT) vs salvage radical prostatectomy (SRP). METHODS: We retrospectively identified 440 men who failed primary radiation therapy and subsequently underwent SCT (n = 341, 77.5%) or SRP (n = 99, 22.5%) between 1992 and 2009 from Surveillance, Epidemiology, and End Results-Medicare linked data. Propensity score analyses were used to compare overall and prostate cancer-specific mortality and associated Medicare expenditures for SRP vs SCT. RESULTS: Men undergoing SCT were more likely to be white (P <.001), less likely to be high school graduates (P = .008), and experienced shorter median time from diagnosis to salvage therapy (44.1 vs 60.1, P <.001) and from primary radiotherapy to salvage therapy (38.7 vs 55.8 months, P <.001). In adjusted analyses, overall mortality was higher (21.6 vs 6.1 deaths/100 person years, P <.001) for SRP vs SCT. There was a trend for higher prostate cancer-specific death rates with SRP vs SCT (6.5 vs 1.4 deaths/100 person years, P = .061). Medicare expenditures for SRP vs SCT were more than 2-fold higher ($19,543 vs $8,088, P <.001). CONCLUSION: SRP vs SCT is associated with higher overall mortality and greater health care expenditures. However, longer follow-up is needed to assess long-term functional outcomes and cancer control.

Authors: Hays RD, Reeve BB, Smith AW, Clauser SB

Title: Associations of cancer and other chronic medical conditions with SF-6D preference-based scores in Medicare beneficiaries.

Journal: Qual Life Res 23(2):385-91

Date: 2014 Mar

Abstract: PURPOSE: Documenting the impact of different types of cancer on daily functioning and well-being is important for understanding burden relative to other chronic medical conditions. This study examined the impact of 10 different cancers and 13 other chronic medical conditions on health-related quality of life. METHODS: Health-related quality of life data were gathered on the Medicare Health Outcomes Survey (MHOS) between 1998 and 2002. Cancer information was ascertained using the National Cancer Institute's surveillance, epidemiology, and end results program and linked to MHOS data. RESULTS: The average SF-6D score was 0.73 (SD = 0.14). Depressive symptoms had the largest unique association with the SF-6D, followed by arthritis of the hip, chronic obstructive pulmonary disease/asthma, stroke, and sciatica. In addition, the majority of cancer types were significantly associated with the SF-6D score, with significant negative weights ranging from -0.01 to -0.02 on the 0-1 health utility scale. Distant stage of cancer was associated with large decrements in the SF-6D ranging from -0.04 (prostate) to -0.08 (female breast). CONCLUSION: A large number of chronic conditions, including cancer, are associated uniquely with decrements in health utility. The cumulative effects of comorbid conditions have substantial impact on daily functioning and well-being of Medicare beneficiaries.

Authors: Jean RA, Kallogjeri D, Strope SA, Hardin FM, Rich JT, Piccirillo JF

Title: Exploring SEER-Medicare for changes in the treatment of laryngeal cancer among elderly medicare beneficiaries.

Journal: Otolaryngol Head Neck Surg 150(3):419-27

Date: 2014 Mar

Abstract: OBJECTIVE: To explore the change in frequency of treatment, and its association with 5-year survival, among elderly Medicare enrollees with squamous cell carcinoma of the larynx (SCCL). STUDY DESIGN: Retrospective analysis of a national cancer database. SUBJECTS AND METHODS: This was an analysis of the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set of elderly patients diagnosed with SCCL between 1992 and 2007. Surgical and nonsurgical treatments were identified, and changes in frequency by year of cancer diagnosis were explored. A propensity-matched multivariate Cox proportional hazards model was used to compare the impact of treatment. RESULTS: There were 3324 cases of primary SCCL diagnosed between 1992 and 2007 studied. Most were male (n = 2605; 78%), white (n = 2845; 87%), and between 66 and 74 years of age (n = 1874; 56%). Between 1992 and 2005, there was a significant trend for increasing 5-year overall survival (43% in 1992 to 54% in 2005-2007; P < .01). There was a significant trend for decreasing frequency of surgical therapy (47% in 1992-1995 to 41% in 2005-2007; P = .03). Surgical therapy was associated with a decreased risk of overall mortality (hazard ratio, 0.76; 95% confidence interval, 0.68-0.86) in comparison to nonsurgical treatments. CONCLUSION: The analysis demonstrates an increase in survival among elderly Medicare enrollees diagnosed with SCCL between 1992 and 2007. Despite a significant trend for its decreasing use, there was a significantly decreased risk of overall mortality associated with surgical therapy.

Authors: McLaughlin VH, Trentham-Dietz A, Hampton JM, Newcomb PA, Sprague BL

Title: Lifestyle factors and the risk of a second breast cancer after ductal carcinoma in situ.

Journal: Cancer Epidemiol Biomarkers Prev 23(3):450-60

Date: 2014 Mar

Abstract: BACKGROUND: Little information exists on lifestyle factors that affect prognosis after treatment for ductal carcinoma in situ (DCIS) breast cancer. Improved understanding of the role of lifestyle factors is important to survivors wishing to reduce their risk of a second breast cancer diagnosis. METHODS: We examined the association between body mass index (BMI), physical activity, and alcohol intake, and risk of a second breast cancer diagnosis among 1,925 DCIS survivors in the Wisconsin In Situ Cohort. Exposures were self-reported during biennial patient interviews. Second breast cancer diagnoses were validated via pathology report. Cox proportional hazards regression was used to estimate the association between prediagnosis, postdiagnosis, and change in exposure levels and the risk of a second diagnosis, with adjustment for patient, tumor, and treatment factors. RESULTS: Over a mean of 6.7 years of follow-up, 162 second breast cancer diagnoses were reported, including 57 invasive events, 60 in situ events, and 45 diagnoses of unknown stage. A significant trend of increasing risk of a second diagnosis was found over increasing categories of postdiagnosis alcohol intake (Ptrend = 0.02). Among premenopausal women, increased prediagnosis BMI was associated with a reduced risk of a second diagnosis (HR = 0.93; 95% confidence interval, 0.88-0.99). CONCLUSION: DCIS survivors may reduce their risk of a second diagnosis by reducing postdiagnosis alcohol consumption. IMPACT: The population of DCIS survivors is projected to surpass one million by the year 2016. Our results suggest that these women may be able to reduce their risk of a second diagnosis through moderation of alcohol consumption.

Authors: McShane CM, Murray LJ, Engels EA, Anderson LA

Title: Community-acquired infections associated with increased risk of lymphoplasmacytic lymphoma/Waldenström macroglobulinaemia.

Journal: Br J Haematol 164(5):653-8

Date: 2014 Mar

Abstract: Emerging evidence supports the role of immune stimulation in the development of lymphoplasmacytic lymphoma/Waldenström Macroglobulinaemia (LPL/WM). Using the population-based Surveillance, Epidemiology End Results-Medicare database we investigated the exposure to 14 common community-acquired infections and subsequent risk of LPL/WM in 693 LPL/WM cases and 200 000 controls. Respiratory tract infections, bronchitis [odds ratio (OR) 1·56], pharyngitis (OR 1·43), pneumonia (OR 1·42) and sinusitis (OR 1·33) and skin infection, herpes zoster (OR 1·51) were all significantly associated with subsequent increased risk of LPL/WM. For each of these infections, the findings remained significantly elevated following the exclusion of more than 6 years of Medicare claims data prior to LPL/WM diagnosis. Our findings may support a role for infections in the development of LPL/WM or could reflect an underlying immune disturbance that is present several years prior to diagnosis and thereby part of the natural history of disease progression.

Authors: Olszewski AJ, Ali S

Title: Comparative outcomes of rituximab-based systemic therapy and splenectomy in splenic marginal zone lymphoma.

Journal: Ann Hematol 93(3):449-58

Date: 2014 Mar

Abstract: Despite diagnostic and therapeutic advances, the majority of patients with splenic marginal zone lymphoma (SMZL) are still treated with splenectomy. We analyzed survival outcomes after surgery or rituximab-based systemic therapy in the Surveillance Epidemiology and End Results-Medicare database, using inverse probability of treatment weighting to minimize treatment selection bias. From the 657 recorded cases diagnosed between 2000 and 2007, with a median age of 77 years, we selected 227 eligible patients treated with splenectomy (68 %), rituximab alone (23 %), or in combination with chemotherapy (9 %) within 2 years from diagnosis. No significant difference between the groups was observed in the cumulative incidence of lymphoma-related death (LRD) at 3 years (19.6 % with systemic therapy and 17.3 % with splenectomy; hazard ratio [HR], 1.04; 95 % confidence interval [CI], 0.56-1.92; P = 0.90) or in the overall survival (HR, 1.01; 95 % CI, 0.66-1.55; P = 0.95). The 90-day mortality after splenectomy was 7.1 %. The rates of hospitalizations, infections, transfusions, and cardiovascular or thromboembolic events were higher after combination chemoimmunotherapy than after splenectomy. Conversely, there was no significant difference in most complications between groups treated with splenectomy or rituximab alone. The cumulative incidence of LRD after single-agent rituximab at 3 years was 18.7 % (95 % CI, 8.6-31.7). In conclusion, in SMZL patients over the age of 65 years, the risk of LRD and overall survival are similar with systemic therapy or splenectomy as initial therapy. Single-agent rituximab may offer the most favorable risk/benefit ratio in this population.

Authors: Saylor PJ, Smith MR, O'Malley AJ, Keating NL

Title: Androgen-deprivation therapy and risk for biliary disease in men with prostate cancer.

Journal: Eur Urol 65(3):642-9

Date: 2014 Mar

Abstract: BACKGROUND: Androgen-deprivation therapy (ADT) by either a gonadotropin-releasing hormone (GnRH) agonist or bilateral orchiectomy improves disease-related outcomes of men with prostate cancer but has a variety of adverse metabolic effects including obesity, increased abdominal girth, increased triglycerides, and insulin resistance. Each is a risk factor for gallstone disease. Additionally, GnRH agonist treatment was recently shown in metabolomic analyses to increase plasma levels of some bile acids. OBJECTIVE: To assess the relationship between ADT and the incidence of biliary disease in men with prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: We studied 183 842 men >65 yr of age living in Surveillance, Epidemiology, and End Results regions who were diagnosed with prostate cancer from 1992 to 2007 and followed through 2009. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We calculated incidence rates for biliary disease during treatment with GnRH agonists, orchiectomy, or no therapy. We used Cox proportional hazard models to assess the association of ADT with biliary disease. RESULTS AND LIMITATIONS: Among 183 842 men with locoregional prostate cancer, 48.4% received GnRH agonist treatment and 2.2% underwent bilateral orchiectomy during follow-up. GnRH agonist treatment was associated with a significantly higher incidence of biliary disease compared with no treatment (15.7 vs 13.4 cases per 1000 person-years; p<0.001). In adjusted analyses, GnRH agonist use was associated with the risk of biliary disease (adjusted hazard ratio: 1.10; 95% confidence interval, 1.05-1.15; p<0.001). Orchiectomy was not significantly associated with biliary disease. CONCLUSIONS: GnRH agonist treatment may be associated with a greater risk of incident biliary disease.

Authors: Sen S, Wang SY, Soulos PR, Frick KD, Long JB, Roberts KB, Yu JB, Evans SB, Chagpar AB, Gross CP

Title: Examining the cost-effectiveness of radiation therapy among older women with favorable-risk breast cancer.

Journal: J Natl Cancer Inst 106(3):dju008-

Date: 2014 Mar

Abstract: BACKGROUND: Little is known about the cost-effectiveness of external beam radiation therapy (EBRT) or newer radiation therapy (RT) modalities such as intensity modulated radiation (IMRT) or brachytherapy among older women with favorable-risk breast cancer. METHODS: Using a Markov model, we estimated the cost-effectiveness of no RT, EBRT, and IMRT over 10 years. We estimated the incremental cost-effectiveness ratio (ICER) of IMRT compared with EBRT under different scenarios to determine the necessary improvement in effectiveness for newer modalities to be cost-effective. We estimated model inputs using women in the Surveillance, Epidemiology, and End Results-Medicare database fulfilling the Cancer and Leukemia Group B C9343 trial criteria. RESULTS: The incremental cost of EBRT compared with no RT was $9500 with an ICER of $44600 per quality-adjusted life year (QALY) gained. The ICERs increased with age, ranging from $38300 (age 70-74 years) to $55800 (age 80 to 94 years) per QALY. The ICERs increased to more than $63800 per QALY for women aged 70 to 74 years with an expected 10-year survival of 25%. Reduction in local recurrence by IMRT compared with EBRT did not have a substantial impact on the ICER of IMRT. IMRT would have to increase the utility of baseline state by 20% to be cost-effective (<$100000 per QALY). CONCLUSIONS: EBRT is cost-effective for older women with favorable risk breast cancer, but substantially less cost-effective for women with shorter expected survival. Newer RT modalities would have to be substantially more effective than existing therapies in improving quality of life to be cost-effective.

Authors: Smith CB, Kale M, Mhango G, Neugut AI, Hershman DL, Mandeli JP, Wisnivesky JP

Title: Comparative outcomes of elderly stage I lung cancer patients treated with segmentectomy via video-assisted thoracoscopic surgery versus open resection.

Journal: J Thorac Oncol 9(3):383-9

Date: 2014 Mar

Abstract: INTRODUCTION: Video-assisted thorcacic surgery (VATS) is considered an alternative to open lobectomy for the treatment of non-small-cell lung cancer (NSCLC). Limited data are available, however, regarding the equivalence of open versus VATS segmental resections, particularly among elderly patients. METHODS: From the Surveillance, Epidemiology, and End Results-Medicare database we identified 577 stage I NSCLC patients aged more than 65 years treated with VATS or open segmentectomy. We used propensity score methods to control for differences in the baseline characteristics of patients treated with VATS versus open segmentectomy. Outcomes included perioperative complications, need for intensive care unit, extended hospital stay, perioperative mortality, and survival. RESULTS: Overall, 27% of patients underwent VATS. VATS-treated patients had lower rates of postoperative complications (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.37-0.83), intensive care unit admissions (OR: 0.18, 95% CI: 0.12-0.28), and decreased length of stay (OR: 0.41, 95% CI: 0.21-0.81) after adjusting for propensity scores. Postoperative outcomes were not significantly different across groups after adjusting for surgeon characteristics. Overall (hazard ratio: 0.80, 95% CI: 0.60-1.06) and lung cancer-specific (hazard ratio: 0.71, 95% CI: 0.45-1.12) survival was similar across groups. CONCLUSIONS: VATS segmentectomy can be safely performed among elderly NSCLC patients and is associated with equivalent postoperative and oncologic outcomes.

Authors: Steele CB, Townsend JS, Tai E, Thomas CC

Title: Physician visits and preventive care among Asian American and Pacific Islander long-term survivors of colorectal cancer, USA, 1996-2006.

Journal: J Cancer Surviv 8(1):70-9

Date: 2014 Mar

Abstract: PURPOSE: Published literature on receipt of preventive healthcare services among Asian American and Pacific Islander (API) cancer survivors is scarce. We describe patterns in receipt of preventive services among API long-term colorectal cancer (CRC) survivors. METHODS: Surveillance, Epidemiology, and End Results registry-Medicare data were used to identify 9,737 API and white patients who were diagnosed with CRC during 1996-2000 and who survived 5 or more years beyond their diagnoses. We examined receipt of vaccines, mammography (females), bone densitometry (females), and cholesterol screening among the survivors and how the physician specialties they visited for follow-up care correlated to services received. RESULTS: APIs were less likely than whites to receive mammography (52.0 vs. 69.3 %, respectively; P < 0.0001) but more likely to receive influenza vaccine, cholesterol screening, and bone densitometry. These findings remained significant in our multivariable model, except for receipt of bone densitometry. APIs visited PCPs only and both PCPs and oncologists more frequently than whites (P < 0.0001). Women who visited both PCPs and oncologists compared with PCPs only were more likely to receive mammography (odds ratio = 1.40; 95 % confidence interval, 1.05-1.86). CONCLUSIONS: Visits to both PCPs and oncologists were associated with increased use of mammography. Although API survivors visited these specialties more frequently than white survivors, API women may need culturally appropriate outreach to increase their use of this test. IMPLICATIONS FOR CANCER SURVIVORS: Long-term cancer survivors need to be aware of recommended preventive healthcare services, as well as who will manage their primary care and cancer surveillance follow-up.

Authors: O'Neill CB, O'Neill JP, Atoria CL, Baxi SS, Henman MC, Ganly I, Elkin EB

Title: Treatment complications and survival in advanced laryngeal cancer: A population based analysis.

Journal: Laryngoscope :-

Date: 2014 Feb 27

Abstract: Objective: Primary curative treatment of advanced laryngeal cancer may include surgery or chemoradiation, although recommendations vary and both are associated with complications. We evaluated predictors and trends in the use of these modalities and compared rates of complications and overall survival in a population-based cohort of older adults. Study Design: Retrospective population-based cohort study Methods: Using SEER cancer registry data linked with Medicare claims, we identified patients over 65 with advanced laryngeal cancer diagnosed 1999-2007 who had total laryngectomy (TL) or chemoradiation (CTRT) within 6 months following diagnosis. We identified complications and estimated the impact of treatment on overall survival, using propensity score methods. Results: The proportion of patients receiving TL declined from 74% in 1999 to 26% in 2007 (p<0.0001). Almost 20% of CTRT patients had a tracheostomy following treatment and 57% had a feeding tube. TL was associated with an 18% lower risk of death, adjusting for patient and disease characteristics. The benefit of TL was greatest in patients with the highest propensity to receive surgery. Conclusion: TL remains an important treatment option in well selected older patients. However, treatment selection is complex and, factors such as functional status, patient preference, surgeon expertise and post-treatment support services should play a role in treatment decisions.

Authors: Hu JC, Gandaglia G, Karakiewicz PI, Nguyen PL, Trinh QD, Shih YC, Abdollah F, Chamie K, Wright JL, Ganz PA, Sun M

Title: Comparative Effectiveness of Robot-assisted Versus Open Radical Prostatectomy Cancer Control.

Journal: Eur Urol :-

Date: 2014 Feb 19

Abstract: BACKGROUND: Robot-assisted radical prostatectomy (RARP) remains controversial, and no improvement in cancer control outcomes has been demonstrated over open radical prostatectomy (ORP). OBJECTIVE: To examine population-based, comparative effectiveness of RARP versus ORP pertaining surgical margin status and use of additional cancer therapy. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective observational study of 5556 RARP and 7878 ORP cases from 2004 to 2009 from Surveillance Epidemiology and End Results-Medicare linked data. INTERVENTION: RARP versus ORP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation therapy [RT] or androgen deprivation therapy [ADT]) by surgical approach. RESULTS AND LIMITATIONS: In the propensity-adjusted analysis, RARP was associated with fewer positive surgical margins (13.6% vs 18.3%; odds ratio [OR]: 0.70; 95% confidence interval [CI], 0.66-0.75), largely because of fewer RARP positive margins for intermediate-risk (15.0% vs 21.0%; OR: 0.66; 95% CI, 0.59-0.75) and high-risk (15.1% vs 20.6%; OR: 0.70; 95% CI, 0.63-0.77) disease. In addition, RARP was associated with less use of additional cancer therapy within 6 mo (4.5% vs 6.2%; OR: 0.75; 95% CI, 0.69-0.81), 12 mo (OR: 0.73; 95% CI, 0.62-0.86), and 24 mo (OR: 0.67; 95% CI, 0.57-0.78) of surgery. Limitations include the retrospective nature of the study and the absence of prostate-specific antigen levels to determine biochemical recurrence. CONCLUSIONS: RARP is associated with improved surgical margin status relative to ORP for intermediate- and high-risk disease and less use of postprostatectomy ADT and RT. This has important implications for quality of life, health care delivery, and costs. PATIENT SUMMARY: Robot-assisted radical prostatectomy (RP) versus open RP is associated with fewer positive margins and better early cancer control because of less use of additional androgen deprivation and radiation therapy within 2 yr of surgery.

Authors: Eil R, Diggs BS, Wang SJ, Dolan JP, Hunter JG, Thomas CR

Title: Nomogram for predicting the benefit of neoadjuvant chemoradiotherapy for patients with esophageal cancer: a SEER-Medicare analysis.

Journal: Cancer 120(4):492-8

Date: 2014 Feb 15

Abstract: BACKGROUND: The survival impact of neoadjuvant chemoradiotherapy (CRT) on esophageal cancer remains difficult to establish for specific patients. The aim of the current study was to create a Web-based prediction tool providing individualized survival projections based on tumor and treatment data. METHODS: Patients diagnosed with esophageal cancer between 1997 and 2005 were selected from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The covariates analyzed were sex, T and N classification, histology, total number of lymph nodes examined, and treatment with esophagectomy or CRT followed by esophagectomy. After propensity score weighting, a log-logistic regression model for overall survival was selected based on the Akaike information criterion. RESULTS: A total of 824 patients with esophageal cancer who were treated with esophagectomy or trimodal therapy met the selection criteria. On multivariate analysis, age, sex, T and N classification, number of lymph nodes examined, treatment, and histology were found to be significantly associated with overall survival and were included in the regression analysis. Preoperative staging data and final surgical margin status were not available within the SEER-Medicare data set and therefore were not included. The model predicted that patients with T4 or lymph node disease benefitted from CRT. The internally validated concordance index was 0.72. CONCLUSIONS: The SEER-Medicare database of patients with esophageal cancer can be used to produce a survival prediction tool that: 1) serves as a counseling and decision aid to patients and 2) assists in risk modeling. Patients with T4 or lymph node disease appeared to benefit from CRT. This nomogram may underestimate the benefit of CRT due to its variable downstaging effect on pathologic stage. It is available at skynet.ohsu.edu/nomograms.

Authors: Filson CP, Schroeck FR, Ye Z, Wei JT, Hollenbeck BK, Miller DC

Title: Variation in Use of Active Surveillance among Men Undergoing Expectant Treatment for Early Stage Prostate Cancer.

Journal: J Urol :-

Date: 2014 Feb 08

Abstract: PURPOSE: We examined variation in active surveillance use in Medicare eligible men undergoing expectant treatment for early stage prostate cancer. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results) and Medicare data we identified 49,192 men diagnosed with localized prostate cancer from 2004 through 2007. Of 7,347 patients who did not receive treatment (ie expectant management) within 12 months of diagnosis we assessed the prevalence of active surveillance (ie repeat prostate biopsy and prostate specific antigen measurement) vs watchful waiting across health care markets. We fit multivariable logistic regression models to examine associations of active surveillance with patient demographics, cancer severity and health care market characteristics. RESULTS: During the study interval use of active surveillance vs watchful waiting increased significantly in patients treated expectantly from 9.7% in 2004 to 15.3% in 2007 (p <0.001). Active surveillance was less common in older patients, those with high risk tumors and those with more comorbidities (each p <0.001). Patients who were white and had higher socioeconomic status were more likely to receive active surveillance (each p <0.05). After adjusting for patient and tumor characteristics significant differences in the predicted probability of active surveillance persisted across health care markets (range 2.4% to 30.1%). No significant variation in active surveillance use was associated with specific health care market characteristics, including intensity of end of life care, Medicare reimbursement or provider density. CONCLUSIONS: Active surveillance has been relatively uncommon in Medicare beneficiaries with localized prostate cancer. Its use relative to watchful waiting varies based on patient demographics, tumor severity and geographic location.

Authors: Lee JK, Liles EG, Bent S, Levin TR, Corley DA

Title: Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis.

Journal: Ann Intern Med 160(3):171-

Date: 2014 Feb 04

Abstract: BACKGROUND: Performance characteristics of fecal immunochemical tests (FITs) to screen for colorectal cancer (CRC) have been inconsistent. PURPOSE: To synthesize data about the diagnostic accuracy of FITs for CRC and identify factors affecting its performance characteristics. DATA SOURCES: Online databases, including MEDLINE and EMBASE, and bibliographies of included studies from 1996 to 2013. STUDY SELECTION: All studies evaluating the diagnostic accuracy of FITs for CRC in asymptomatic, average-risk adults. DATA EXTRACTION: Two reviewers independently extracted data and critiqued study quality. DATA SYNTHESIS: Nineteen eligible studies were included and meta-analyzed. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of FITs for CRC were 0.79 (95% CI, 0.69 to 0.86), 0.94 (CI, 0.92 to 0.95), 13.10 (CI, 10.49 to 16.35), 0.23 (CI, 0.15 to 0.33), respectively, with an overall diagnostic accuracy of 95% (CI, 93% to 97%). There was substantial heterogeneity between studies in both the pooled sensitivity and specificity estimates. Stratifying by cutoff value for a positive test result or removal of discontinued FIT brands resulted in homogeneous sensitivity estimates. Sensitivity for CRC improved with lower assay cutoff values for a positive test result (for example, 0.89 [CI, 0.80 to 0.95] at a cutoff value less than 20 µg/g vs. 0.70 [CI, 0.55 to 0.81] at cutoff values of 20 to 50 µg/g) but with a corresponding decrease in specificity. A single-sample FIT had similar sensitivity and specificity as several samples, independent of FIT brand. LIMITATIONS: Only English-language articles were included. Lack of data prevented complete subgroup analyses by FIT brand. CONCLUSION: Fecal immunochemical tests are moderately sensitive, are highly specific, and have high overall diagnostic accuracy for detecting CRC. Diagnostic performance of FITs depends on the cutoff value for a positive test result. PRIMARY FUNDING SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases and National Cancer Institute.

Authors: O'Donoghue C, Eklund M, Ozanne EM, Esserman LJ

Title: Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines.

Journal: Ann Intern Med 160(3):145-

Date: 2014 Feb 04

Abstract: BACKGROUND: Controversy exists over how often and at what age mammography screening should be implemented. Given that evidence supports less frequent screening, the cost differences among advocated screening policies should be better understood. OBJECTIVE: To estimate the aggregate cost of mammography screening in the United States in 2010 and compare the costs of policy recommendations by professional organizations. DESIGN: A model was developed to estimate the cost of mammography screening in 2010 and 3 screening strategies: annual (ages 40 to 84 years), biennial (ages 50 to 69 years), and U.S. Preventive Services Task Force (USPSTF) guidelines (biennial for those aged 50 to 74 years and personalized based on risk for those younger than 50 years and based on comorbid conditions for those 75 years and older). SETTING: United States. PATIENTS: Women aged 40 to 85 years. INTERVENTION: Mammography annually, biennially, or following USPSTF guidelines. MEASUREMENTS: Cost of screening per year, using Medicare reimbursements. RESULTS: The estimated cost of mammography screening in the United States in 2010 was $7.8 billion, with approximately 70% of women screened. The simulated cost of screening 85% of women was $10.1 billion, $2.6 billion, and $3.5 billion for annual, biennial, and USPSTF guidelines, respectively. The largest drivers of cost (in order) were screening frequency, percentage of women screened, cost of mammography, percentage of women screened with digital mammography, and percentage of mammography recalls. LIMITATION: Cost estimates and assumptions used in the model were conservative. CONCLUSION: The cost of mammography varies by at least $8 billion per year on the basis of screening strategy. The USPSTF guidelines are based on the scientific evidence to date to maximize patient benefit and minimize harm but also result in far more effective use of resources. PRIMARY FUNDING SOURCE: University of California and the Safeway Foundation.

Authors: Chen RC, Carpenter WR, Hendrix LH, Bainbridge J, Wang AZ, Nielsen ME, Godley PA

Title: Receipt of guideline-concordant treatment in elderly prostate cancer patients.

Journal: Int J Radiat Oncol Biol Phys 88(2):332-8

Date: 2014 Feb 01

Abstract: PURPOSE: To examine the proportion of elderly prostate cancer patients receiving guideline-concordant treatment, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. METHODS AND MATERIALS: A total of 29,001 men diagnosed in 2004-2007 with localized prostate cancer, aged 66 to 79 years, were included. We characterized the proportion of men who received treatment concordant with the National Comprehensive Cancer Network guidelines, stratified by risk group and age. Logistic regression was used to examine covariates associated with receipt of guideline-concordant management. RESULTS: Guideline concordance was 79%-89% for patients with low- or intermediate-risk disease. Among high-risk patients, 66.6% of those aged 66-69 years received guideline-concordant management, compared with 51.9% of those aged 75-79 years. Discordance was mainly due to conservative management-no treatment or hormone therapy alone. Among the subgroup of patients aged ≤76 years with no measured comorbidity, findings were similar. On multivariable analysis, older age (75-79 vs 66-69 years, odds ratio 0.51, 95% confidence interval 0.50-0.57) was associated with a lower likelihood of guideline concordance for high-risk prostate cancer, but comorbidity was not. CONCLUSIONS: There is undertreatment of elderly but healthy patients with high-risk prostate cancer, the most aggressive form of this disease.

Authors: Ost DE, Niu J, S Elting L, Buchholz TA, Giordano SH

Title: Quality gaps and comparative effectiveness in lung cancer staging and diagnosis.

Journal: Chest 145(2):331-45

Date: 2014 Feb 01

Abstract: BACKGROUND: Guidelines recommend mediastinal lymph node sampling as the first invasive test in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases, but there are no comparative effectiveness studies on how test sequencing affects outcomes. The objective was to compare practice patterns and outcomes of diagnostic strategies in patients with lung cancer. METHODS: The study included a retrospective cohort of 15,316 patients with lung cancer with regional spread without distant metastases in the Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. If the first invasive test involved mediastinal sampling, patients were classified as receiving guideline-consistent care; otherwise, they were classified as receiving guideline-inconsistent care. We used propensity matching to compare the number of tests performed and multivariate logistic regression to compare the frequency of complications. RESULTS: Twenty-one percent of patients had guideline-consistent diagnostic evaluations. Among patients with non-small cell lung cancer, 44% never had mediastinal sampling. Patients who had guideline-consistent care required fewer tests than those with guideline-inconsistent care (P < .0001), including thoracotomies (49% vs 80%, P < .001) and CT image-guided biopsies (9% vs 63%, P < .001), although they had more transbronchial needle aspirations (37% vs 4%, P < .001). The consequence was that patients with guideline-consistent care had fewer pneumothoraxes (4.8% vs 25.6%, P < .0001), chest tubes (0.7% vs 4.9%, P < .001), hemorrhages (5.4% vs 10.6%, P < .001), and respiratory failure events (5.3% vs 10.5%, P < .001). CONCLUSIONS: Guideline-consistent care with mediastinal sampling first resulted in fewer tests and complications. We found three quality gaps: failure to sample the mediastinum first, failure to sample the mediastinum at all in patients with non-small cell lung cancer, and overuse of thoracotomy.

Authors: Smith GL, Jiang J, Buchholz TA, Xu Y, Hoffman KE, Giordano SH, Hunt KK, Smith BD

Title: Benefit of adjuvant brachytherapy versus external beam radiation for early breast cancer: impact of patient stratification on breast preservation.

Journal: Int J Radiat Oncol Biol Phys 88(2):274-84

Date: 2014 Feb 01

Abstract: PURPOSE: Brachytherapy after lumpectomy is an increasingly popular breast cancer treatment, but data concerning its effectiveness are conflicting. Recently proposed "suitability" criteria guiding patient selection for brachytherapy have never been empirically validated. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we compared women aged 66 years or older with invasive breast cancer (n=28,718) or ductal carcinoma in situ (n=7229) diagnosed from 2002 to 2007, treated with lumpectomy alone, brachytherapy, or external beam radiation therapy (EBRT). The likelihood of breast preservation, measured by subsequent mastectomy risk, was compared by use of multivariate proportional hazards, further stratified by American Society for Radiation Oncology (ASTRO) brachytherapy suitability groups. We compared 1-year postoperative complications using the χ(2) test and 5-year local toxicities using the log-rank test. RESULTS: For patients with invasive cancer, the 5-year subsequent mastectomy risk was 4.7% after lumpectomy alone (95% confidence interval [CI], 4.1%-5.4%), 2.8% after brachytherapy (95% CI, 1.8%-4.3%), and 1.3% after EBRT (95% CI, 1.1%-1.5%) (P<.001). Compared with lumpectomy alone, brachytherapy achieved a more modest reduction in adjusted risk (hazard ratio [HR], 0.61; 95% CI, 0.40-0.94) than achieved with EBRT (HR, 0.22; 95% CI, 0.18-0.28). Relative risks did not differ when stratified by ASTRO suitability group (P=.84 for interaction), although ASTRO "suitable" patients did show a low absolute subsequent mastectomy risk, with a minimal absolute difference in risk after brachytherapy (1.6%; 95% CI, 0.7%-3.5%) versus EBRT (0.8%; 95% CI, 0.6%-1.1%). For patients with ductal carcinoma in situ, EBRT maintained a reduced risk of subsequent mastectomy (HR, 0.40; 95% CI, 0.28-0.55; P<.001), whereas the small number of patients treated with brachytherapy (n=179) precluded definitive comparison with lumpectomy alone. In all patients, brachytherapy showed a higher postoperative infection risk (16.5% vs 9.9% after lumpectomy alone vs 11.4% after EBRT, P<.001); higher incidence of breast pain (22.9% vs 11.2% vs 16.7%, P<.001); and higher incidence of fat necrosis (15.3% vs 5.3% vs 7.7%, P<.001). CONCLUSIONS: In this study era, brachytherapy showed lesser breast preservation benefit compared with EBRT. Suitability criteria predicted differential absolute, but not relative, benefit in patients with invasive cancer.

Authors: Dallal CM, Tice JA, Buist DS, Bauer DC, Lacey JV Jr, Cauley JA, Hue TF, Lacroix A, Falk RT, Pfeiffer RM, Fuhrman BJ, Veenstra TD, Xu X, Brinton LA, B~FIT Research Group

Title: Estrogen metabolism and breast cancer risk among postmenopausal women: a case-cohort study within B~FIT.

Journal: Carcinogenesis 35(2):346-55

Date: 2014 Feb

Abstract: Although elevated circulating estrogens are associated with increased postmenopausal breast cancer risk, less is known regarding the role of estrogen metabolism in breast carcinogenesis. We conducted a case-cohort study within the Breast and Bone Follow-up to the Fracture Intervention Trial to assess serum estrogens and estrogen metabolites (EMs) in 407 incident breast cancer cases diagnosed during follow-up and a subcohort of 496 women. In 1992-93, women completed a baseline questionnaire and provided blood samples. Hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for geography and trial participation status, were estimated using Cox proportional hazard regression. Serum concentrations of EMs were measured by liquid chromatography-tandem mass spectrometry. EMs (quintiles, Q) were analyzed individually, as metabolic pathways (C-2, -4 or -16) and as ratios. Elevated circulating estradiol was associated with increased breast cancer risk (HRQ5vsQ1 = 1.86; 95% CI: 1.19-2.90; P trend = 0.04). An elevated ratio of the 2-hydroxylation pathway (HRQ5vsQ1 = 0.69; 95% CI: 0.46-1.05; P trend = 0.01) and 4-hydroxylation pathway (HRQ5vsQ1 = 0.61; 95% CI: 0.40-0.93; P trend = 0.004) to parent estrogens (estradiol and estrone) was inversely associated with risk. A higher ratio of the 2/16-hydroxylation pathways was associated with reduced risk (HRQ5vsQ1 = 0.60; 95% CI: 0.40-0.90; P trend = 0.002). Increased 2- or 4-hydroxylation of parent estrogens may lower risk of postmenopausal breast cancer. Analyses of metabolic pathways may help elucidate the role of estrogen metabolism in breast carcinogenesis.

Authors: Ezaz G, Long JB, Gross CP, Chen J

Title: Risk prediction model for heart failure and cardiomyopathy after adjuvant trastuzumab therapy for breast cancer.

Journal: J Am Heart Assoc 3(1):e000472-

Date: 2014 Feb

Abstract: BACKGROUND: Adjuvant trastuzumab improves survival for women with human epidermal growth factor receptor 2-positive breast cancer, but increases risk for heart failure (HF) and cardiomyopathy (CM). However, clinical trials may underestimate HF/CM risk because they enroll younger subjects with fewer cardiac risk factors. We sought to develop a clinical risk score that identifies older women with breast cancer who are at higher risk of HF or CM after trastuzumab. METHODS AND RESULTS: Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified women with breast cancer who received adjuvant trastuzumab. Using a split-sample design, we used a proportional hazards model to identify candidate predictors of HF/CM in a derivation cohort. A risk score was constructed using regression coefficients, and HF/CM rates were calculated in the validation cohort. The sample consisted of 1664 older women (mean age 73.6 years) with 3-year HF/CM rate of 19.1%. A risk score consisting of age, adjuvant chemotherapy, coronary artery disease, atrial fibrillation or flutter, diabetes mellitus, hypertension, and renal failure was able to classify HF/CM risk into low (0 to 3 points), medium (4 to 5 points), and high (≥6 points) risk strata with 3-year rates of 16.2%, 26.0%, and 39.5%, respectively. CONCLUSIONS: A 7-factor risk score was able to stratify 3-year risk of HF/CM after trastuzumab between the lowest and highest risk groups by more than 2-fold in a Medicare population. These findings will inform future research aimed at further developing a clinical risk score for HF/CM for breast cancer patients of all ages.

Authors: Jayasekera J, Onukwugha E, Bikov K, Mullins CD, Seal B, Hussain A

Title: The economic burden of skeletal-related events among elderly men with metastatic prostate cancer.

Journal: Pharmacoeconomics 32(2):173-91

Date: 2014 Feb

Abstract: BACKGROUND AND OBJECTIVE: Advanced prostate cancer patients with bone metastasis are predisposed to skeletal complications termed skeletal-related events (SREs). There is limited information available on Medicare costs associated with treating SREs. The objective of this study was to ascertain SRE-related costs among older men with metastatic prostate cancer in the US. METHODS: We analysed patients aged 66 years or older who were diagnosed with incident stage IV (M1) prostate cancer between 2000 and 2007 from the linked Surveillance, Epidemiology and End Results (SEER)-Medicare dataset. A propensity score for the incidence of an SRE was estimated using a logistic regression model including demographic and clinical baseline variables. Patients with SREs (cases) were matched to patients without SREs (controls) based on the propensity score, length of follow-up (i.e. date of prostate cancer diagnosis to last date of observation) and death. Health resource utilization cost differences between cases and controls over time were compared using generalized linear models. Healthcare costs were examined by type of SRE (pathological fracture only, pathological fracture with concurrent surgery, spinal cord compression only, spinal cord compression with concurrent surgery, and bone surgery only) and by source of care (inpatient, physician/non-institutional provider, skilled nursing facility, outpatient and hospice). All costs were adjusted to 2009 US dollars, using the medical care component of the Consumer Price Index. RESULTS: Application of the inclusion criteria resulted in 1,131 metastatic prostate cancer patients with SREs and 6,067 patients without SREs during follow-up. The average age of the sample was 79 years, and 14 % were African American. A total of 928 patients with SREs were matched to 928 patients without SREs. The average health care utilization cost of patients with SREs was US$29,696 (95 % confidence interval [CI] US$24,730-US$34,662) higher than that of the controls. The most expensive SRE group was spinal cord compression with concurrent surgery (US$82,868: 95 % CI US$67,472-US$98,264) followed by bone surgery only (US$37,496: 95 % CI US$29,684-US$45,308), pathological fracture with concurrent surgery (US$34,169: 95 % CI US$25,837-US$ 42,501), spinal cord compression only (US$25,793: 95 % CI US$20,933-US$30,653) and pathological fracture only (US$14,649: 95 % CI US$6,537-US$22,761). The largest cost difference by source of care was observed for hospitalizations (p < 0.01). CONCLUSION: Metastatic prostate cancer patients with SREs incur higher costs compared to similar patients without SREs. SRE costs among older stage IV (M1) prostate cancer patients vary by SRE type, with spinal cord compression and concurrent surgery costing at least twice as much as other SREs.

Authors: Loveland-Jones CE, Ruth K, Sigurdson ER, Egleston BL, Boraas M, Bleicher RJ

Title: Patterns of nodal staging during breast conservation surgery in the medicare patient: will the ACOSOG Z0011 trial change the pattern of care?

Journal: Breast Cancer Res Treat 143(3):571-7

Date: 2014 Feb

Abstract: ACOSOG Z0011 spares axillary dissection (AD) in breast conservation surgery (BCS) patients with T1/T2 tumors and 1-2 positive nodes. Current patterns of care and the impact of Z0011 on AD versus additional surgery rates for Medicare patients undergoing BCS are unknown. SEER data linked to Medicare claims for 1999-2005 were reviewed for women with invasive nonmetastatic breast cancer who underwent nodal staging on the same day as BCS. There were 3,280 women with T1/T2 tumors and positive nodes who underwent same-day nodal staging; 2,532 (77.2 %) of these women had 1-2 positive nodes. Assuming 25.7 % have extracapsular extension, 651 women would require AD. However, 1,881 women, or 57.4 % of those with T1/T2 tumors and positive nodes, would be spared AD. Meanwhile, among the 748 women having ≥ 3 positive nodes, 579 underwent same-day AD, but under Z0011, would now wait for permanent section. A total of 160 of these women underwent re-excision or completion mastectomy at a later date anyway, when delayed AD could be performed. The remaining 419 women with ≥ 3 positive nodes would require an additional surgery date for the sole purpose of completion AD. The Z0011 paradigm would consequently necessitate an additional surgery date for 1,070 (651 + 419) women, or 32.6 % of those with T1/T2 tumors and positive nodes. The Z0011 paradigm appears to increase the number of Medicare patients undergoing BCS who require an additional surgery date but decrease the number requiring AD to a greater extent. Future changes in the use of AD or axillary irradiation may yet modify that impact substantially.

Authors: Nuño M, Ly D, Ortega A, Sarmiento JM, Mukherjee D, Black KL, Patil CG

Title: Does 30-day readmission affect long-term outcome among glioblastoma patients?

Journal: Neurosurgery 74(2):196-5

Date: 2014 Feb

Abstract: BACKGROUND: Research on readmissions has focused mainly on the economic and resource burden it places on hospitals. OBJECTIVE: To evaluate the effect of 30-day readmission on overall survival among newly diagnosed glioblastoma multiforme (GBM) patients. METHODS: A nationwide cohort of GBM patients diagnosed between 1991 and 2007 was studied using the Surveillance, Epidemiology and End Results Medicare database. Multivariate models were used to determine factors associated with readmission and overall survival. Odds ratio, hazard ratio, 95% confidence interval, and P values were reported. Complete case and multiple imputation analyses were performed. RESULTS: Among the 2774 newly diagnosed GBM patients undergoing surgery at 442 hospitals nationwide, 437 (15.8%) were readmitted within 30 days of the index hospitalization. Although 63% of readmitted patients returned to the index hospital where surgery was performed, a significant portion (37%) were readmitted to nonindex hospitals. The median overall survival for readmitted patients (6.0 months) was significantly shorter than for nonreadmitted (7.6 months; P < .001). In a confounder-adjusted imputed model, 30-day readmission increased the hazard of mortality by 30% (hazard ratio, 1.3; P < .001). Neurological symptoms (30.2%), thromboembolic complications (19.7%), and infections (17.6%) were the leading reasons for readmission. CONCLUSION: Prior studies that have reported only the readmissions back to index hospitals are likely underestimating the true 30-day readmission rate. GBM patients who were readmitted within 30 days had significantly shorter survival than nonreadmitted patients. Future studies that attempt to decrease readmissions and evaluate the impact of reducing readmissions on patient outcomes are needed.

Authors: Saver BG, Wang CY, Dobie SA, Green PK, Baldwin LM

Title: The central role of comorbidity in predicting ambulatory care sensitive hospitalizations.

Journal: Eur J Public Health 24(1):66-72

Date: 2014 Feb

Abstract: BACKGROUND: Ambulatory care sensitive hospitalizations (ACSHs) are commonly used as measures of access to and quality of care. They are defined as hospitalizations for certain acute and chronic conditions; yet, they are most commonly used in analyses comparing different groups without adjustment for individual-level comorbidity. We present an exploration of their roles in predicting ACSHs for acute and chronic conditions. METHODS: Using 1998-99 US Medicare claims for 1 06 930 SEER-Medicare control subjects and 1999 Area Resource File data, we modelled occurrence of acute and chronic ACSHs with logistic regression, examining effects of different predictors on model discriminatory power. RESULTS: Flags for the presence of a few comorbid conditions-congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and, for acute ACSHs, dementia-contributed virtually all of the discriminative ability for predicting ACSHs. C-statistics were up to 0.96 for models predicting chronic ACSHs and up to 0.87 for predicting acute ACSHs. C-statistics for models lacking comorbidity flags were lower, at best 0.73, for both acute and chronic ACSHs. CONCLUSION: Comorbidity is far more important in predicting ACSH risk than any other factor, both for acute and chronic ACSHs. Imputations about quality and access should not be made from analyses that do not control for presence of important comorbid conditions. Acute and chronic ACSHs differ enough that they should be modelled separately. Unaggregated models restricted to persons with the relevant diagnoses are most appropriate for chronic ACSHs.

Authors: Shuch B, Hanley JM, Lai JC, Vourganti S, Setodji CM, Dick AW, Chow WH, Saigal CS, Urologic Diseases in America Project

Title: Adverse health outcomes associated with surgical management of the small renal mass.

Journal: J Urol 191(2):301-8

Date: 2014 Feb

Abstract: PURPOSE: Partial and radical nephrectomy are treatments for the small renal mass. Partial nephrectomy is considered the gold standard as it may protect against renal dysfunction compared to radical nephrectomy. However, both treatments may cause adverse health outcomes. MATERIALS AND METHODS: A matched cohort study was performed using the SEER (Surveillance, Epidemiology and End Results)-Medicare data set. Individuals treated with partial or radical nephrectomy for 4 cm or smaller nonmetastatic renal cell carcinoma were compared to 2 control groups (nonmuscle invasive bladder cancer and noncancer). A greedy algorithm matched surgical groups to controls. Medicare claims were examined for renal, cardiovascular and secondary cancer events. RESULTS: Patients who underwent partial nephrectomy (1,471) and radical nephrectomy (4,299) were matched to controls. The time to event model demonstrated an increased risk of renal events for both treatments. Compared to the bladder cancer control and noncancer control groups, radical nephrectomy hazard ratios for renal events were 2.415 (p <0.0001) and 6.211 (p <0.0001), respectively, while partial nephrectomy hazard ratios were 1.513 (p <0.0001) and 4.926 (p <0.0001), respectively. Secondary cancers were increased for partial nephrectomy and radical nephrectomy compared to both control groups (p <0.0001). Cardiovascular events were increased for both treatments compared to noncancer controls (p <0.0001), but not compared to bladder cancer controls. CONCLUSIONS: Partial nephrectomy and radical nephrectomy may lead to adverse health outcomes. Compared to controls, partial nephrectomy and radical nephrectomy are associated with worsened renal outcomes. The increase in secondary cancers and cardiovascular events with both treatments is notable, and requires further investigation. Further research should investigate if active surveillance of the appropriately selected small renal mass limits adverse health outcomes.

Authors: Sprague BL, Bolton KC, Mace JL, Herschorn SD, James TA, Vacek PM, Weaver DL, Geller BM

Title: Registry-based study of trends in breast cancer screening mammography before and after the 2009 U.S. Preventive Services Task Force recommendations.

Journal: Radiology 270(2):354-61

Date: 2014 Feb

Abstract: PURPOSE: To determine whether the 2009 U.S. Preventive Services Task Force (USPSTF) guidelines for breast cancer mammography screening were followed by changes in screening utilization in the state of Vermont. MATERIALS AND METHODS: This retrospective study was HIPAA compliant and approved by the institutional review board, with waiver of informed consent. Trends in screening mammography utilization during 1997-2011 were examined among approximately 150,000 women aged 40 years and older in the state of Vermont using statewide mammography registry data. RESULTS: The percentage of Vermont women aged 40 years and older screened in the past year declined from 45.3% in 2009% to 41.6% in 2011 (an absolute decrease of -3.7 percentage points; 95% confidence interval [CI]: -3.3, -4.1). The largest decline in utilization was among women aged 40-49 years (-4.8 percentage points; 95% CI: -4.1, -5.4), although substantial declines were also observed among women aged 50-74 years (-3.0 percentage points; 95% CI: -2.6, -3.5) and women aged 75 years and older (-3.1 percentage points; 95% CI: -2.3, -4.0). The percentage of women aged 50-74 years screened within the past 2 years declined by -3.4 percentage points (95% CI: -3.0, -3.9) from 65.4% in 2009 to 61.9% in 2011. CONCLUSION: After years of increasing screening mammography utilization in Vermont, there was a decline in screening, which coincided with the release of the 2009 USPSTF recommendations. The age-specific patterns in utilization were generally consistent with the USPSTF recommendations, although there was also evidence that the percentage of women aged 50-74 years screened in the past 2 years declined since 2009.

Authors: Sun M, Sammon JD, Becker A, Roghmann F, Tian Z, Kim SP, Larouche A, Abdollah F, Hu JC, Karakiewicz PI, Trinh QD

Title: Radical prostatectomy vs radiotherapy vs observation among older patients with clinically localized prostate cancer: a comparative effectiveness evaluation.

Journal: BJU Int 113(2):200-8

Date: 2014 Feb

Abstract: OBJECTIVE: To compare efficacy between radical prostatectomy (RP), radiotherapy and observation with respect to overall survival (OS) in patients with clinically localized prostate cancer (PCa). METHODS: Using data (1988-2005) from the Surveillance, Epidemiology, and End Results-Medicare linked database, 67 087 men with localized PCa were identified. The prevalence of the initial treatment strategy was quantified according to patients' life expectancy ([LE] <10 vs ≥10 years) at initial diagnosis and according to tumour stage. To reduce the unmeasured bias associated with treatment, we performed an instrumental variable analysis. Stratified (by stage and LE) Cox regression and competing-risks regression analyses were generated for the prediction of OS and cancer-specific mortality, respectively. RESULTS: Among patients with <10 years of LE, most were treated with radiotherapy (49%) or observation (47%). Among patients with ≥10 years of LE, most received radiotherapy (49%), followed by RP (26%). In men with <10 years of LE, RP and radiotherapy were not different with respect to OS (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.45-1.48, P = 0.499). Conversely, in men with ≥10 years of LE, RP was associated with an improved OS compared with observation (HR: 0.59, 95% CI: 0.49-0.71, P < 0.001) and radiotherapy (HR: 0.66, 95% CI: 0.56-0.79, P < 0.001). Similar results were recorded in competing-risks regression analyses. CONCLUSION: In patients with an estimated LE ≥10 years at initial diagnosis, RP was associated with improved survival compared with radiotherapy and observation, regardless of disease stage.

Authors: Titmarsh GJ, McMullin MF, McShane CM, Clarke M, Engels EA, Anderson LA

Title: Community-acquired infections and their association with myeloid malignancies.

Journal: Cancer Epidemiol 38(1):56-61

Date: 2014 Feb

Abstract: INTRODUCTION: Antigenic stimulation is a proposed aetiologic mechanism for many haematological malignancies. Limited evidence suggests that community-acquired infections may increase the risk of acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS). However, associations with other myeloid malignancies including chronic myeloid leukaemia (CML) and myeloproliferative neoplasms (MPNs) are unknown. MATERIALS AND METHODS: Using the Surveillance, Epidemiology and End Result (SEER)-Medicare database, fourteen community-acquired infections were compared between myeloid malignancy patients [AML (n=8489), CML (n=3626) diagnosed 1992-2005; MDS (n=3072) and MPNs (n=2001) diagnosed 2001-2005; and controls (200,000 for AML/CML and 97,681 for MDS/MPN]. Odds ratios (ORs) and 95% confidence intervals were adjusted for gender, age and year of selection excluding infections diagnosed in the 13-month period prior to selection to reduce reverse causality. RESULTS: Risk of AML and MDS respectively, were significantly associated with respiratory tract infections, bronchitis (ORs 1.20 [95% CI: 1.14-1.26], 1.25 [95% CI: 1.16-1.36]), influenza (ORs 1.16 [95% CI: 1.07-1.25], 1.29 [95% CI: 1.16-1.44]), pharyngitis (ORs 1.13 [95% CI: 1.06-1.21], 1.22 [95% CI: 1.11-1.35]), pneumonia (ORs 1.28 [95% CI: 1.21-1.36], 1.52 [95% CI: 1.40-1.66]), sinusitis (ORs 1.23 [95% CI: 1.16-1.30], 1.25 [95% CI: 1.15-1.36]) as was cystitis (ORs 1.13 [95% CI: 1.07-1.18], 1.26 [95% CI: 1.17-1.36]). Cellulitis (OR 1.51 [95% CI: 1.39-1.64]), herpes zoster (OR 1.31 [95% CI: 1.14-1.50]) and gastroenteritis (OR 1.38 [95% CI: 1.17-1.64]) were more common in MDS patients than controls. For CML, associations were limited to bronchitis (OR 1.21 [95% CI: 1.12-1.31]), pneumonia (OR 1.49 [95% CI: 1.37-1.62]), sinusitis (OR 1.19 [95% CI: 1.09-1.29]) and cellulitis (OR 1.43 [95% CI: 1.32-1.55]) following Bonferroni correction. Only cellulitis (OR 1.34 [95% CI: 1.21-1.49]) remained significant in MPN patients. Many infections remained elevated when more than 6 years of preceding claims data were excluded. DISCUSSION: Common community-acquired infections may be important in the malignant transformation of the myeloid lineage. Differences in the aetiology of classic MPNs and other myeloid malignancies require further exploration.

Authors: Tsai HT, Isaacs C, Fu AZ, Warren JL, Freedman AN, Barac A, Huang CY, Potosky AL

Title: Risk of cardiovascular adverse events from trastuzumab (Herceptin(®)) in elderly persons with breast cancer: a population-based study.

Journal: Breast Cancer Res Treat 144(1):163-70

Date: 2014 Feb

Abstract: Randomized controlled trials have reported a 4-5 times increased risk of heart failure (HF) in breast cancer patients receiving trastuzumab (Herceptin (®) ) compared to patients who do not receive trastuzumab. However, data regarding the cardiac effects of trastuzumab on elderly patients treated in general practice remain very limited. Using the US surveillance, epidemiology, and end results (SEER)-Medicare database, we conducted a retrospective cohort study on the cardiac effects of trastuzumab use in all incident breast cancer patients diagnosed from 1998 to 2007 who were 66 years and older, had no prior recent claims for cardiomyopathy (CM) or HF, and were followed through 2009. We defined our outcome as the first CM/HF event after diagnosis. We performed Cox-proportional hazard models with propensity score adjustment to estimate CM/HF risk associated with trastuzumab use. A total of 6,829 out of 68,536 breast cancer patients (median age: 75) had an incident CM/HF event. Patients who received trastuzumab tended to be younger, non-white, diagnosed more recently, and had a stage IV diagnosis. Trastuzumab use was associated with an increased risk of CM/HF (HR = 2.08, 95 % CI 1.77-2.44, p < 0.001). The trastuzumab-associated CM/HF risk was stronger in patients who were younger (HR = 2.52 for 66-75 years and HR = 1.44 for 76 years and older, p < 0.001) and diagnosed in recent years (HR = 2.58 for 2006-2007 vs. 1.86 for 1998-2005, p = 0.01). The twofold risk of CM/HF associated with trastuzumab remained regardless of patients' diagnosis stage, presence of hypertension, cardiovascular comorbidities, or receipt of anthracyclines, taxanes, or radiation. Trastuzumab may double CM/HF risk among elderly breast cancer patients. Our findings reinforce the need to prevent and manage cardiac risk among elderly breast cancer patients receiving trastuzumab.

Authors: Wirtz HS, Boudreau DM, Gralow JR, Barlow WE, Gray S, Bowles EJ, Buist DS

Title: Factors associated with long-term adherence to annual surveillance mammography among breast cancer survivors.

Journal: Breast Cancer Res Treat 143(3):541-50

Date: 2014 Feb

Abstract: Clinical practice guidelines recommend yearly surveillance mammography for breast cancer survivors, yet many women do not receive this service. The objective of this study was to evaluate factors related to long-term surveillance mammography adherence among breast cancer survivors. We conducted a retrospective cohort study among women ≥ 18 years, diagnosed with incident stage I or II breast cancer between 1990 and 2008. We used medical record and administrative health plan data to ascertain covariates and receipt of surveillance mammography for up to 10 years after completing breast cancer treatment. Surveillance included post-diagnosis screening exams among asymptomatic women. We used multivariable repeated measures generalized estimating equation regression models to estimate odds ratios and robust 95 % confidence intervals to examine factors related to the annual receipt of surveillance mammography. The analysis included 3,965 women followed for a median of six surveillance years; 79 % received surveillance mammograms in year 1 but decreased to 63 % in year 10. In multivariable analyses, women, who were < 40 years or 80+ years of age (compared to 50-59 years), current smokers, had greater comorbidity, were diagnosed more recently, had stage II cancer, or were treated with mastectomy or breast conserving surgery without radiation, were less likely than other women to receive surveillance mammography. Women with outpatient visits during the year to primary care providers, oncologists, or both were more likely to undergo surveillance. In this large cohort study of women diagnosed with early-stage invasive breast cancer, we found that important subgroups of women are at high risk for non-adherence to surveillance recommendations, even among younger breast cancer survivors. Efforts should be undertaken to actively engage breast cancer survivors in managing long-term surveillance care.

Authors: Zheng Z, Hanna N, Onukwugha E, Reese ES, Seal B, Mullins CD

Title: Does the type of first-line regimens influence the receipt of second-line chemotherapy treatment? An analysis of 3211 metastatic colon cancer patients.

Journal: Cancer Med 3(1):124-33

Date: 2014 Feb

Abstract: With new agents entering the market, the sequencing of first-line (Tx1), second-line (Tx2), and subsequent chemotherapy/biologics regimens are being examined. We examined how Tx1 regimens impacted the likelihood of receiving Tx2 among metastatic colon cancer (mCC) patients. Surveillance, Epidemiology and End Results (SEER)-Medicare data were used to identify elderly mCC patients between 2003 and 2007. The inverse probability weighting Cox regression method was utilized to study the relationship between receipt of Tx2 and Tx1 regimens, controlling for patient-level factors. Of the 7895 elderly patients identified, 3211 (41%) received Tx1 of which 1440 proceeded to Tx2. The impact of Tx1 on receipt of Tx2 varied by the specific regimens utilized. As compared to 5FU/LV users, IROX (Hazard Ratio [HR] = 0.03; P < 0.01) and IROX + Biologics (HR = 0.20; P < 0.01) users were less likely to receive Tx2; (oxaliplatin) OX + Biologics (HR = 1.26; P < 0.01) users were more likely to receive Tx2. Significant patient-level factors included: Hispanic ethnicity (HR = 0.67; P < 0.01); being married (HR = 0.87; P = 0.01); proxy for poor performance status (HR = 0.82; P = 0.05); each 10-year age increment (HR = 1.14; P < 0.01); and State buy-in status (HR = 1.21; P = 0.01). The specific first-line regimen does impact mCC patients' likelihood of receiving Tx2 in clinical practice. Elderly mCC patients, their health care providers, and policy makers will benefit from new evidence about the impact of sequencing of treatment lines.

Authors: Gandaglia G, Sun M, Hu JC, Novara G, Choueiri TK, Nguyen PL, Schiffmann J, Graefen M, Shariat SF, Abdollah F, Briganti A, Montorsi F, Trinh QD, Karakiewicz PI

Title: Gonadotropin-releasing Hormone Agonists and Acute Kidney Injury in Patients with Prostate Cancer.

Journal: Eur Urol :-

Date: 2014 Jan 28

Abstract: BACKGROUND: Androgen deprivation therapy (ADT) might increase the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa). OBJECTIVE: To examine the impact of ADT on AKI in a large contemporary cohort of patients with nonmetastatic PCa representing the US population. DESIGN, SETTING, AND PARTICIPANTS: Overall, 69 292 patients diagnosed with nonmetastatic PCa between 1995 and 2009 were abstracted from the Surveillance Epidemiology and End Results-Medicare database. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSES: Patient in both treatment arms (ADT vs no ADT) were matched using propensity-score methodology. Ten-year AKI rates were estimated. Competing-risks regression analyses tested the association between ADT and AKI, after adjusting for the risk of death during follow-up. RESULTS AND LIMITATIONS: Overall, the 10-yr AKI rates were 24.9% versus 30.7% for ADT-naive patients versus those treated with ADT, respectively (p<0.001). When patients were stratified according to the type of ADT, the 10-yr AKI rates were 31.1% versus 26.0% for men treated with gonadotropin-releasing hormone (GnRH) agonists and bilateral orchiectomy, respectively (p<0.001). In multivariable analyses, the administration of GnRH agonists (hazard ratio [HR]: 1.24; 95% confidence interval [CI], 1.18-1.31; p<0.001), but not bilateral orchiectomy (HR: 1.11; 95% CI, 0.96-1.29; p=0.1), was associated with the risk of experiencing AKI. Our study is limited by its retrospective design. CONCLUSIONS: ADT is associated with an increased risk of AKI in patients with nonmetastatic PCa. In particular, the administration of GnRH agonists, but not surgical castration, may substantially increase the risk of experiencing AKI. These observations should help provide physicians with better patient selection to reduce the risk of AKI. PATIENT SUMMARY: The administration of gonadotropin-releasing hormone agonists, but not bilateral orchiectomy, increases the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa). These observations should help provide physicians with better patient selection to reduce the risk of AKI in PCa patients.

Authors: Gandaglia G, Sun M, Trinh QD, Becker A, Schiffmann J, Hu JC, Briganti A, Montorsi F, Perrotte P, Karakiewicz PI, Abdollah F

Title: Survival benefit of definitive therapy in patients with clinically advanced prostate cancer: estimations of the number needed to treat based on competing-risks analysis.

Journal: BJU Int :-

Date: 2014 Jan 27

Abstract: OBJECTIVE: To describe the survival benefit associated with radical prostatectomy (RP), as compared with initial observation, in patients with locally advanced prostate cancer (PCa). PATIENTS AND METHODS: Overall, 1382 patients with locally advanced PCa treated with RP or initial observation between 1995 and 2009 were identified from the Surveillance, Epidemiology and End Results Medicare insurance programme-linked database. Patients were matched using propensity-score methodology, then 10-year cancer-specific mortality (CSM) rates were estimated and the number needed to treat (NNT) was calculated. Competing-risks regression analyses tested the relationship between treatment type and CSM. RESULTS: Overall, the 10-year CSM rates were 11.8 and 19.3% for patients treated with RP and initial observation, respectively (P < 0.001). The corresponding 10-year NNT was 13. The 10-year CSM rates for the same treatment groups were 8.9 vs 13.9%, respectively, for Gleason score ≤7, 16.8 vs 27.8%, respectively, for Gleason score 8-10, 10.1 vs 15.8%, respectively, for clinical stage T3a, and 17.0 vs 29.3%, respectively, for T3b/T4, respectively (all P ≤ 0.04). The corresponding NNTs were 20, 9, 17 and 8, respectively. In multivariable analyses, RP was an independent predictor of more favourable CSM rates in all categories (all P ≤ 0.04). In separate sensitivity analyses, no differences were recorded when patients treated with radiotherapy were compared with those receiving RP (P = 0.4). Conversely, patients undergoing initial observation had a higher risk of CSM compared with those treated with radiotherapy (P = 0.03). CONCLUSIONS: RP leads to a significant survival advantage compared with observation in patients with locally advanced disease. The highest benefit was observed in patients with T3b/T4 and Gleason score 8-10 disease.

Authors: Gandaglia G, Popa I, Abdollah F, Schiffmann J, Shariat SF, Briganti A, Montorsi F, Trinh QD, Karakiewicz PI, Sun M

Title: The Effect of Neoadjuvant Chemotherapy on Perioperative Outcomes in Patients Who Have Bladder Cancer Treated with Radical Cystectomy: A Population-based Study.

Journal: Eur Urol :-

Date: 2014 Jan 24

Abstract: BACKGROUND: Although therapeutic guidelines recommend the use of neoadjuvant chemotherapy before radical cystectomy (RC) in patients who have muscle-invasive bladder cancer (MIBC), this approach remains largely underused. One of the main reasons for this phenomenon might reside in concerns regarding the risk of morbidity and mortality associated with neoadjuvant chemotherapy. OBJECTIVE: To compare perioperative outcomes between patients receiving neoadjuvant chemotherapy and those treated with RC alone. DESIGN, SETTING, AND PARTICIPANTS: Relying on the Surveillance Epidemiology and End Results-Medicare-linked database, 3760 patients diagnosed with MIBC between 2000 and 2009 were evaluated. INTERVENTION: RC alone or RC plus neoadjuvant chemotherapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Complications occurred within 30 and 90 d after surgery. Heterologous blood transfusions (HBTs), length of stay (LoS), readmission, and perioperative mortality were compared. To decrease the effect of unmeasured confounders associated with treatment selection, propensity score-matched analyses were performed. RESULTS AND LIMITATIONS: Overall, 416 (11.1%) of patients received neoadjuvant chemotherapy. Following propensity score matching, 416 (20%) and 1664 (80%) patients treated with RC plus neoadjuvant chemotherapy and RC alone remained, respectively. The 30-d complication, readmission, and mortality rates were 66.0%, 32.2%, and 5.3%, respectively. The 90-d complication, readmission, and mortality rates were 72.5%, 46.6%, and 8.2%, respectively. When patients were stratified according to neoadjuvant chemotherapy status, no significant differences were observed in the rates of complications, HBT, prolonged LoS, readmission, and mortality between the two groups (all p ≥ 0.1). These results were confirmed in multivariate analyses, where the use of neoadjuvant chemotherapy was not associated with higher risk of 30- and 90-d complications, HBT, prolonged LoS, readmission, and mortality (all p ≥ 0.1). Our study is limited by its retrospective nature. CONCLUSIONS: The use of neoadjuvant chemotherapy is not associated with higher perioperative morbidity or mortality. These results should encourage wider use of neoadjuvant chemotherapy when clinically indicated. PATIENT SUMMARY: Chemotherapy before radical cystectomy in patients with muscle-invasive bladder cancer does not increase the risk of complications or death. The use of chemotherapy should be strongly encouraged, as recommended by clinical guidelines, given its benefits.

Authors: Gourin CG, Frick KD, Blackford AL, Herbert RJ, Quon H, Forastiere AA, Eisele DW, Dy SM

Title: Quality indicators of laryngeal cancer care in the elderly.

Journal: Laryngoscope :-

Date: 2014 Jan 15

Abstract: Objective: To examine associations between quality of care, survival, and costs in elderly patients treated for laryngeal squamous cell cancer (SCCA). Study design: Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Methods: We evaluated 2,370 patients diagnosed with laryngeal SCCA from 2004-2007 using multivariate regression and survival analysis. Using quality indicators derived from guidelines for recommended care, summary measures of quality were calculated for diagnosis, initial treatment, surveillance, treatment for recurrent disease, end-of-life care, and performance, and an overall summary measure of quality. Results: High-quality care was associated with significant differences in survival for diagnosis (HR=0.80, 95% CI [0.66-0.97]), initial treatment (HR=0.75 [0.63-0.88]), surveillance (HR=0.54 [0.44-0.66]), treatment of recurrence (HR=1.54 [1.26-1.89]), end-of-life care (HR=0.69 [0.52-0.92]), performance (HR=0.41 [0.33-0.52]), and the overall summary measure of quality (HR=0.66 [0.54-0.80]), which was significantly associated with lower mean incremental costs (-$24,958 [-$35,873- -$14,042]). There was a significant survival advantage for initial treatment with surgery and postoperative radiation (HR=0.66 [0.53-0.82]) and high-volume surgical care (HR=0.64 [0.43-0.96]), after controlling for all other variables including quality of care. Conclusions: High-quality larynx cancer care in elderly patients was associated with improved survival and reduced costs; however, high-quality care for treatment of recurrence was associated with poorer survival. These data suggest that survival outcomes in elderly patients with laryngeal cancer are not entirely explained by differences in the receipt of quality care using existing treatment and performance quality indicators, and suggest a need to develop sensitive and valid quality indicators of larynx cancer care in this population.

Authors: Panchal JM, Lairson DR, Chan W, Du XL

Title: Geographic Variation in Oxaliplatin Chemotherapy and Survival in Patients With Colon Cancer.

Journal: Am J Ther :-

Date: 2014 Jan 09

Abstract: Geographic disparity in colon cancer survival has received less attention, despite the fact that health care delivery varied across regions. To examine geographic variation in colon cancer survival and explore factors affecting this variation, including the use of oxaliplatin chemotherapy, we studied cases with resected stage-III colon cancer in 2004-2009, identified from the Surveillance, Epidemiology and End Results-Medicare linked database. Cox proportional hazard model was used to estimate the effect of oxaliplatin-containing chemotherapy on survival across regions. Propensity score adjustments were made to control for potential selection bias and confounding. Rural regions showed lowest 3-year survival, whereas big metro regions showed better 3-year survival rate than any other region (67.3% in rural regions vs. 69.5% in big metro regions). Hazard ratio for patients residing in metro region was comparable with those residing in big metro region (1.27, 95% confidence interval: 0.90-1.80). However, patients residing in urban area were exhibiting lower mortality than those in other regions, although not statistically significant. Patients who received oxaliplatin chemotherapy were 23% significantly less likely to die of cancer than those received 5-fluorouracil only chemotherapy (adjusted hazard ratio = 0.77, 95% confidence interval: 0.63-0.95). In conclusion, there were some differences in survival across geographic regions, which were not statistically significant after adjusting for sociodemographic, tumor, chemotherapy, and other treatment characteristics. Oxaliplatin chemotherapy was associated with improved survival outcomes compared with 5-fluorouracil only chemotherapy across regions. Further studies may evaluate other factors and newer chemotherapy regimens on mortality/survival of older patients.

Authors: Gandaglia G, Trinh QD, Hu JC, Schiffmann J, Becker A, Roghmann F, Popa I, Tian Z, Perrotte P, Montorsi F, Briganti A, Karakiewicz PI, Sun M, Abdollah F

Title: The impact of robot-assisted radical prostatectomy on the use and extent of pelvic lymph node dissection in the "post-dissemination" period.

Journal: Eur J Surg Oncol :-

Date: 2014 Jan 02

Abstract: INTRODUCTION: Previous series during the dissemination era of minimally invasive techniques for treatment of prostate cancer (PCa) showed a declining use of pelvic lymph node dissection (PLND). The aim of our study was to re-assess the impact of robot-assisted radical prostatectomy (RARP) on the utilization rate of PLND and its extent in the post-dissemination period. METHODS: Relying on the Surveillance Epidemiology and End Results (SEER) Medicare-linked database, 5804 patients with non-metastatic PCa undergoing open radical prostatectomy (ORP) or RARP between years 2008 and 2009 were identified. Uni- and multivariable logistic regression analyses tested the relationship between surgical approach (RARP vs. ORP) and: 1 - the rate of PLND (pNx vs. pN0-1); and 2 - the extent of PLND (limited vs. extended). RESULTS: Overall, 3357 (57.8%) patients underwent a PLND. The proportion of patients treated with PLND was significantly higher among ORP vs. RARP patients: 71.2 vs. 48.6%, respectively (P < 0.001). In addition, the median number of lymph nodes removed was significantly higher for patients treated with ORP vs. RARP: 5 vs. 4, respectively (P < 0.001). In multivariable analyses, ORP was associated with 2.7- and 1.3-fold higher odds of undergoing PLND and of receiving an extended PLND compared to RARP, respectively (both P ≤ 0.001). Stratified analyses according to disease risk classifications revealed similar trends. CONCLUSIONS: In the post-dissemination era, RARP remains associated with a decreased use of PLND and suboptimum extent. Efforts should be made to improve guideline adherence in performing a PLND whenever indicated according to tumor aggressiveness, despite surgical approach.

Authors: Onukwugha E, Yong C, Hussain A, Seal B, Mullins CD

Title: Concordance between administrative claims and registry data for identifying metastasis to the bone: an exploratory analysis in prostate cancer.

Journal: BMC Med Res Methodol 14(1):1-

Date: 2014 Jan 02

Abstract: BACKGROUND: To assess concordance between Medicare claims and Surveillance, Epidemiology, and End Results (SEER) reports of incident BM among prostate cancer (PCa) patients. The prevalence and consequences of bone metastases (BM) have been examined across tumor sites using healthcare claims data however the reliability of these claims-based BM measures has not been investigated. METHODS: This retrospective cohort study utilized linked registry and claims (SEER-Medicare) data on men diagnosed with incident stage IV M1 PCa between 2005 and 2007. The SEER-based measure of incident BM was cross-tabulated with three separate Medicare claims approaches to assess concordance. Sensitivity, specificity and positive predictive value (PPV) were calculated to assess the concordance between registry- and claims-based measures. RESULTS: Based on 2,708 PCa patients in SEER-Medicare, there is low to moderate concordance between the SEER- and claims-based measures of incident BM. Across the three approaches, sensitivity ranged from 0.48 (0.456 - 0.504) to 0.598 (0.574 - 0.621), specificity ranged from 0.538 (0.507 - 0.569) to 0.620 (0.590 - 0.650) and PPV ranged from 0.679 (0.651 - 0.705) to 0.690 (0.665 - 0.715). A comparison of utilization patterns between SEER-based and claims-based measures suggested avenues for improving sensitivity. CONCLUSION: Claims-based measures using BM ICD 9 coding may be insufficient to identify patients with incident BM diagnosis and should be validated against chart data to maximize their potential for population-based analyses.

Authors: Ma X, Wang R, Long JB, Ross JS, Soulos PR, Yu JB, Makarov DV, Gold HT, Gross CP

Title: The cost implications of prostate cancer screening in the Medicare population.

Journal: Cancer 120(1):96-102

Date: 2014 Jan 01

Abstract: BACKGROUND: Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening. METHODS: A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. RESULTS: Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11). CONCLUSIONS: Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.

Authors: Baranowski T, Islam N, Douglass D, Dadabhoy H, Beltran A, Baranowski J, Thompson D, Cullen KW, Subar AF

Title: Food Intake Recording Software System, version 4 (FIRSSt4): a self-completed 24-h dietary recall for children.

Journal: J Hum Nutr Diet 27 Suppl 1:66-71

Date: 2014 Jan

Abstract: The Food Intake Recording Software System, version 4 (firsst4), is a web-based 24-h dietary recall (24 hdr) self-administered by children based on the Automated Self-Administered 24-h recall (ASA24) (a self-administered 24 hdr for adults). The food choices in firsst4 are abbreviated to include only those reported by children in US national surveys; and detailed food probe questions are simplified to exclude those that children could not be expected to answer (e.g. questions regarding food preparation and added fats). ASA24 and firsst4 incorporate 10 000+ food images, with up to eight images per food, to assist in portion size estimation. We review the formative research conducted during the development of firsst4. When completed, firsst4 will be hosted and maintained for investigator use on the National Cancer Institute's ASA24 website.

Authors: Bulliard JL, Garcia M, Blom J, Senore C, Mai V, Klabunde C

Title: Sorting out measures and definitions of screening participation to improve comparability: the example of colorectal cancer.

Journal: Eur J Cancer 50(2):434-46

Date: 2014 Jan

Abstract: Participation is a key indicator of the potential effectiveness of any population-based intervention. Defining, measuring and reporting participation in cancer screening programmes has become more heterogeneous as the number and diversity of interventions have increased, and the purposes of this benchmarking parameter have broadened. This study, centred on colorectal cancer, addresses current issues that affect the increasingly complex task of comparing screening participation across settings. Reports from programmes with a defined target population and active invitation scheme, published between 2005 and 2012, were reviewed. Differences in defining and measuring participation were identified and quantified, and participation indicators were grouped by aims of measure and temporal dimensions. We found that consistent terminology, clear and complete reporting of participation definition and systematic documentation of coverage by invitation were lacking. Further, adherence to definitions proposed in the 2010 European Guidelines for Quality Assurance in Colorectal Cancer Screening was suboptimal. Ineligible individuals represented 1% to 15% of invitations, and variable criteria for ineligibility yielded differences in participation estimates that could obscure the interpretation of colorectal cancer screening participation internationally. Excluding ineligible individuals from the reference population enhances comparability of participation measures. Standardised measures of cumulative participation to compare screening protocols with different intervals and inclusion of time since invitation in definitions are urgently needed to improve international comparability of colorectal cancer screening participation. Recommendations to improve comparability of participation indicators in cancer screening interventions are made.

Authors: Duarte CW, Murray K, Lucas FL, Fairfield K, Miller H, Brooks P, Vary CP

Title: Improved survival outcomes in cancer patients with hereditary hemorrhagic telangiectasia.

Journal: Cancer Epidemiol Biomarkers Prev 23(1):117-25

Date: 2014 Jan

Abstract: BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder characterized by deficiency in endoglin, an angiogenic protein. The net effect of endoglin expression on cancer outcomes from animal studies has proven controversial. We evaluated whether reduced systemic endoglin levels, expected in patients diagnosed with HHT, impacted clinical outcomes for cancer. METHODS: A retrospective cohort analysis using Surveillance, Epidemiology, and End Results-Medicare was conducted to evaluate the effect of HHT on survival among patients diagnosed with breast, colorectal, lung, or prostate cancer between 2000 and 2007 (n = 540,520). We generated Kaplan-Meier survival curves and Cox models to compare the effect of HHT on all-cause survival for a composite of the four cancers, and separate models by cancer, adjusting for demographic variables, cancer type, cancer stage, and comorbidities. RESULTS: All-cause survival analysis for a composite of the four cancers showed an adjusted HR of 0.69 [95% confidence interval (CI) of 0.51-0.91; P = 0.009] for HHT, indicating significantly improved survival outcome. When stratified by cancer type, HHT diagnosis showed a significant protective effect among breast cancer patients with an adjusted HR of 0.31 (95% CI, 0.13-0.75; P = 0.009). CONCLUSIONS: There was a significant association between HHT and improved survival outcome for a composite of patients with breast, prostate, colorectal, and lung cancer, and in analysis stratified by cancer, the association was significant for HHT patients with breast cancer. IMPACT: This study supports the hypothesis that systemically educed endoglin expression is associated with improved survival outcome in multiple cancers, and suggests that anti-endoglin antibody therapy may have broad-based application.

Authors: Fortune-Greeley AK, Wheeler SB, Meyer AM, Reeder-Hayes KE, Biddle AK, Muss HB, Carpenter WR

Title: Preoperative breast MRI and surgical outcomes in elderly women with invasive ductal and lobular carcinoma: a population-based study.

Journal: Breast Cancer Res Treat 143(1):203-12

Date: 2014 Jan

Abstract: Existing evidence suggests that preoperative breast magnetic resonance imaging (MRI) might not improve surgical outcomes in the general breast cancer population. To determine if patients differentially benefit from breast MRI, we examined surgical outcomes-initial mastectomy, reoperation, and final mastectomy rates-among patients grouped by histologic type. We identified women diagnosed with early-stage breast cancer from 2004 to 2007 in the SEER-Medicare dataset. We classified patients as having invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), mixed ductal/lobular carcinoma (IDLC) or other histologic type. Medicare claims were used to identify breast MRI and definitive surgeries during the initial surgical treatment episode. We used propensity score methods to account for the differential likelihood of exposure to MRI. Of the 20,332 patients who met our inclusion criteria for this study, 12.2 % had a preoperative breast MRI. Patients with ILC as compared to other histologic groups were most likely to receive MRI [OR 2.32; 95 % CI (2.02-2.67)]. In the propensity score-adjusted analyses, breast MRI was associated with an increased likelihood of an initial mastectomy for all patients and among all histologic subgroups. Among patients with ILC, having a breast MRI was associated with lower odds of a reoperation [OR 0.59; 95 % CI (0.40-0.86)], and an equal likelihood of a final mastectomy compared to similar patients without a breast MRI. Overall and among patients with IDC and IDLC, breast MRI was not significantly associated with a likelihood of a reoperation but was associated with greater odds of a final mastectomy. Our study provides evidence in support of the targeted use of preoperative breast MRI among patients with ILC to improve surgical planning; it does not provide evidence for the routine use of breast MRI among all newly diagnosed breast cancer patients or among patients with IDC.

Authors: Jacobs BL, Zhang Y, Skolarus TA, Wei JT, Montie JE, Miller DC, Hollenbeck BK

Title: Comparative effectiveness of external-beam radiation approaches for prostate cancer.

Journal: Eur Urol 65(1):162-8

Date: 2014 Jan

Abstract: BACKGROUND: Intensity-modulated radiotherapy (IMRT) is increasingly used to treat localized prostate cancer. Although allowing for the delivery of higher doses of radiation to the prostate, its effectiveness compared with the prior standard three-dimensional conformal therapy (3D-CRT) is uncertain. OBJECTIVE: To examine the comparative effectiveness of IMRT relative to 3D-CRT. DESIGN, SETTING, AND PARTICIPANTS: We performed a population-based cohort study using Surveillance, Epidemiology, and End Results-Medicare data to identify men diagnosed with prostate cancer between 2001 and 2007 who underwent either 3D-CRT (n=6976) or IMRT (n=11 039). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed our main outcomes (ie, the adjusted use of salvage therapy with androgen-deprivation therapy [ADT] and risk of a complication requiring an intervention) using Cox proportional hazards models. RESULTS AND LIMITATIONS: The percentage of men receiving IMRT increased from 9% in 2001 to 93% in 2007. Compared with those treated with 3D-CRT, low-risk patients treated with IMRT had similar likelihoods of using salvage therapy with ADT and similar risks of having a complication requiring an intervention (all p>0.05). Conversely, a subset of higher risk patients treated with IMRT who did not receive concurrent ADT were less likely to use salvage therapy (p=0.02) while maintaining similar complication rates. Because our cohort includes Medicare beneficiaries, our findings may not be generalizable to younger patients. CONCLUSIONS: For a subset of higher risk patients, IMRT appears to show a benefit in terms of reduced salvage therapy without an increase in complications. For other patients, the risks of salvage therapy and complications are comparable between the two modalities.

Authors: Klabunde CN, Clauser SB, Liu B, Pronk NP, Ballard-Barbash R, Huang TT, Smith AW

Title: Organization of primary care practice for providing energy balance care.

Journal: Am J Health Promot 28(3):e67-80

Date: 2014 Jan-Feb

Abstract: PURPOSE: Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care. DESIGN: The study design was a nationally representative survey conducted in 2008. SETTING: The study setting was U.S. primary care practices. SUBJECTS: A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%). MEASURES: The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care. ANALYSIS: Descriptive statistics and logistic regression modeling were used. RESULTS: More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (<30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26-2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17-0.44) than others to provide energy balance care. CONCLUSION: PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.

Authors: Kwan SW, Mortell KE, Talenfeld AD, Brunner MC

Title: Thermal ablation matches sublobar resection outcomes in older patients with early-stage non-small cell lung cancer.

Journal: J Vasc Interv Radiol 25(1):1-9.e1

Date: 2014 Jan

Abstract: PURPOSE: To compare survival outcomes of sublobar resection and thermal ablation for early-stage non-small cell lung cancer (NSCLC) in older patients. MATERIALS AND METHODS: SEER-Medicare linked data for patients with a diagnosis of lung cancer from 2007-2009 were used. Patients ≥ 65 years old with stage IA or IB NSCLC who were treated with sublobar resection or thermal ablation were identified. Primary outcome was overall survival (OS), and secondary outcome was lung cancer-specific survival (LCSS). Demographic and clinical variables were compared. Unadjusted OS and LCSS curves were estimated using the Kaplan-Meier method, and multivariate analysis was performed using the Cox model. OS and LCSS curves for propensity score matched groups were also compared. RESULTS: The final unmatched study population comprised 1,897 patients. Patients who underwent sublobar resection were significantly younger (P = .006) and significantly less likely to have a comorbidity index > 1 (P = .036), a diagnosis of chronic obstructive pulmonary disease (P = .017), or adjuvant radiation therapy (P < .0001) compared with patients treated with thermal ablation. Unadjusted survival curves of unmatched groups demonstrated significantly better OS (P = .028) and LCSS (P = .0006) in the resection group. Multivariate Cox model adjusting for demographic and clinical variables found no significant difference in OS between the treatment groups (P = .555); a difference in LCSS (hazard ratio = 1.185, P = .026) persisted. Survival curves for matched groups found no significant difference in OS (P = .695) or LCSS (P = .819) between treatment groups. CONCLUSIONS: After controlling for selection bias, this study found no difference in OS between patients treated with sublobar resection and thermal ablation.

Authors: Lairson DR, Parikh RC, Cormier JN, Du XL

Title: Cost-utility analysis of platinum-based chemotherapy versus taxane and other regimens for ovarian cancer.

Journal: Value Health 17(1):34-42

Date: 2014 Jan-Feb

Abstract: OBJECTIVES: Most economic evaluations of chemotherapies for ovarian cancer patients have used hypothetical cohorts or randomized control trials, but evidence integrating real-world survival, cost, and utility data is limited. METHODS: A propensity score-matched cohort of 6856 elderly (≥65 years) ovarian cancer patients diagnosed from 1991 to 2005 from the Surveillance, Epidemiology, and End Results-Medicare data cohort were included. Treatment regimens (i.e., no chemotherapy, platinum-based only, platinum plus taxane, and other nonplatinum) were identified in the 6 months postdiagnosis. Patients were followed until death or end of study (December 2006). Effectiveness was measured in quality-adjusted life-years (QALYs), and total health care costs were measured by using a payer's perspective (2009 US dollars). Methodological and statistical uncertainties were accounted by including alternative scenarios (for utility values) and net monetary benefit approach. Incremental cost-effectiveness ratios (ICERs) were calculated, and stratified analyses were performed by tumor stages and age groups. RESULTS: On comparing the platinum-based group versus no chemotherapy, we found that the ICER was $30,073/QALY and $58,151/QALY for early- and late-stage disease, respectively, while other nonplatinum and platinum plus taxane groups were dominated (less effective and more costly). Similar results were found across alternative scenarios and age groups. For patients 85 years or older, platinum plus taxane, however, was not dominated by the platinum-based group, with an ICER of $133,892/QALY. CONCLUSIONS: Following elderly ovarian cancer patients over a lifetime using real-world longitudinal data and adjusting for quality of life, we found that treatment with platinum-based regimen was the most cost-effective treatment alternative.

Authors: Lin CC, Virgo KS

Title: Diagnosis date agreement between SEER and Medicare claims data: impact on treatment.

Journal: Med Care 52(1):32-7

Date: 2014 Jan

Abstract: BACKGROUND: A prior assessment of concordance between the diagnosis month in SEER records and Medicare claims found reasonable agreement; however, no assessment of the impact of discordance on cancer treatment ascertainment was conducted. OBJECTIVES: The aim of this study was to assess the concordance between the SEER diagnosis date (Sdx) and Medicare claim-derived diagnosis date and the impact of discordance on identification of treatment received. METHODS: The first Medicare claim date with a cancer diagnosis (Mdx) was compared with the Sdx among patients diagnosed with breast, colorectal, or lung cancer. The Mdx was considered concordant with the Sdx if the Mdx was within 16 days. Claims within 4 months after both the Mdx and Sdx were examined to collect treatment information. Treatment rate agreement was measured by κ-statistics. RESULTS: Among 50,731 breast, 51,025 colorectal, and 61,384 lung cancer patients, the Sdx and Mdx were concordant in 79%, 86%, and 73% of cases, respectively. Most discordant Mdx cases were identified in the month after the SEER diagnosis month. A small proportion of cases (7%-12%) preceded the SEER diagnosis month. Agreement for receipt of surgery was very good across all 3 cancer sites (κ>0.88) and was excellent for radiation therapy (κ>0.96). CONCLUSIONS: Although most cases were concordant for both diagnosis date and treatment ascertainment, there was still a small proportion of cases discordant for both diagnosis date and treatment identification. This study underscores the importance of examining claims in the months preceding diagnosis in the SEER-Medicare dataset to ensure patients are appropriately selected for analysis.

Authors: Lynge E, Ponti A, James T, Májek O, von Euler-Chelpin M, Anttila A, Fitzpatrick P, Frigerio A, Kawai M, Scharpantgen A, Broeders M, Hofvind S, Vidal C, Ederra M, Salas D, Bulliard JL, Tomatis M, Kerlikowske K, Taplin S, ICSN DCIS Working group

Title: Variation in detection of ductal carcinoma in situ during screening mammography: a survey within the International Cancer Screening Network.

Journal: Eur J Cancer 50(1):185-92

Date: 2014 Jan

Abstract: BACKGROUND: There is concern about detection of ductal carcinoma in situ (DCIS) in screening mammography. DCIS accounts for a substantial proportion of screen-detected lesions but its effect on breast cancer mortality is debated. The International Cancer Screening Network conducted a comparative analysis to determine variation in DCIS detection. PATIENTS AND METHODS: Data were collected during 2004-2008 on number of screening examinations, detected breast cancers, DCIS cases and Globocan 2008 breast cancer incidence rates derived from national or regional cancer registers. We calculated screen-detection rates for breast cancers and DCIS. RESULTS: Data were obtained from 15 screening settings in 12 countries; 7,176,050 screening examinations; 29,605 breast cancers and 5324 DCIS cases. The ratio between highest and lowest breast cancer incidence was 2.88 (95% confidence interval (CI) 2.76-3.00); 2.97 (95% CI 2.51-3.51) for detection of breast cancer; and 3.49 (95% CI 2.70-4.51) for detection of DCIS. CONCLUSIONS: Considerable international variation was found in DCIS detection. This variation could not be fully explained by variation in incidence nor in breast cancer detection rates. It suggests the potential for wide discrepancies in management of DCIS resulting in overtreatment of indolent DCIS or undertreatment of potentially curable disease. Comprehensive cancer registration is needed to monitor DCIS detection. Efforts to understand discrepancies and standardise management may improve care.

Authors: Menes TS, Rosenberg R, Balch S, Jaffer S, Kerlikowske K, Miglioretti DL

Title: Upgrade of high-risk breast lesions detected on mammography in the Breast Cancer Surveillance Consortium.

Journal: Am J Surg 207(1):24-31

Date: 2014 Jan

Abstract: BACKGROUND: Upgrade rates of high-risk breast lesions after screening mammography were examined. METHODS: The Breast Cancer Surveillance Consortium registry was used to identify all Breast Imaging Reporting and Data System category 4 assessments followed by needle biopsies with high-risk lesions. Follow-up was performed for all women. RESULTS: High-risk lesions were found in 957 needle biopsies, with excision documented in 53%. Most (n = 685) were atypical ductal hyperplasia (ADH), 173 were lobular neoplasia, and 99 were papillary lesions. Upgrade to cancer varied with type of lesion (18% in ADH, 10% in lobular neoplasia, and 2% in papillary lesions). In premenopausal women with ADH, upgrade was associated with family history. Cancers associated with ADH were mostly (82%) ductal carcinoma in situ, and those associated with lobular neoplasia were mostly (56%) invasive. During a further 2 years of follow-up, cancer was documented in 1% of women with follow-up surgery and in 3% with no surgery. CONCLUSIONS: Despite low rates of surgery, low rates of cancer were documented during follow-up. Benign papillary lesions diagnosed on Breast Imaging Reporting and Data System category 4 mammograms among asymptomatic women do not justify surgical excision.

Authors: Patel HD, Kates M, Pierorazio PM, Hyams ES, Gorin MA, Ball MW, Bhayani SB, Hui X, Thompson CB, Allaf ME

Title: Survival after diagnosis of localized T1a kidney cancer: current population-based practice of surgery and nonsurgical management.

Journal: Urology 83(1):126-32

Date: 2014 Jan

Abstract: OBJECTIVE: To compare overall and cancer-specific survival (CSS) of patients who undergo nonsurgical management (NSM), partial nephrectomy (PN), and radical nephrectomy (RN). NSM is being increasingly used for older patients with early-stage kidney cancer and competing risks of death. However, survival is poorly characterized for this approach compared with surgery with PN or RN. METHODS: The Surveillance, Epidemiology and End Results-Medicare database from 1995 to 2007 was used to identify patients aged 65 years or older diagnosed with localized T1a kidney cancer treated with PN, RN, or NSM. We used Cox proportional hazards regression, Fine and Gray competing risks regression, and propensity score matching to adjust for patient and tumor characteristics. RESULTS: Of 7177 Medicare beneficiaries meeting the inclusion criteria, 754 (10.5%) underwent NSM, 1849 (25.8%) PN, and 4574 (63.7%) RN, with 436 (57.8%), 389 (21.0%), and 1598 (34.9%) patients dying from any cause, respectively, at a median follow-up of 56 months. Overall survival favored PN and RN compared with NSM (hazard ratio [95% CI]: 0.40 [0.34-0.46] and 0.50 [0.45-0.56], respectively) as did CSS (hazard ratio [95% CI]: 0.42 [0.27-0.64] and 0.62 [0.46-0.85], respectively). However, there was no difference in CSS between any 2 treatment groups for younger patients (<75 years), whereas there was an excess of kidney cancer deaths for NSM patients aged 75-79 years and an attenuated difference for patients aged 80 years or older. CONCLUSION: NSM was associated with an increased risk of kidney cancer death among Medicare beneficiaries aged 75-79 years. Evolving active surveillance protocols will need to develop robust selection criteria to maximize cancer survival for older patients with kidney cancer.

Authors: Shaya FT, Breunig IM, Seal B, Mullins CD, Chirikov VV, Hanna N

Title: Comparative and cost effectiveness of treatment modalities for hepatocellular carcinoma in SEER-Medicare.

Journal: Pharmacoeconomics 32(1):63-74

Date: 2014 Jan

Abstract: BACKGROUND: The incidence of hepatocellular carcinoma (HCC) is increasing in the USA and worldwide. Several treatments are available for patients diagnosed at any disease stage. It remains unclear how medical expenditures vary across patients who remain untreated or undergo different modes of therapy. We evaluate the comparative and cost effectiveness of treatment modalities for HCC from a Medicare perspective. METHODS: The Surveillance, Epidemiology, and End Results (SEER) registries and linked Medicare database with claims from Parts A/B were used to identify Medicare enrollees with initial diagnosis of HCC between 2000 and 2007 and followed through 2009. Patients were assigned to treatment modalities based on HCC staging systems: transplant, resection, liver directed, radiation, chemotherapy or no treatment. Survival benefits and cumulative Medicare expenditures were estimated in multivariate models, stratified by initial disease stage, to control for confounding. Cost-effectiveness ratios compared costs and benefits of the modalities across initial stages. RESULTS: Cancer stages I, II, III, IV and unstaged represented 24, 9, 14, 17 and 37 % of 11,047 patients, respectively. Fewer than 40 % received any treatment. Relative to no treatment, transplant was most effective in reducing mortality, followed by resection, liver directed, and radiation or chemotherapy. Resection tended to be most cost effective in early staged and unstaged patients; transplant was least cost effective. In stage IV patients, liver directed therapy was more cost effective than chemotherapy or radiation. CONCLUSIONS: Survival benefit was attributable to all treatment modalities. More effective treatments incurred greater Medicare expenditures, but resection patients incurred the least expenditures per year of life gained.

Authors: Stout NK, Nekhlyudov L, Li L, Malin ES, Ross-Degnan D, Buist DS, Rosenberg MA, Alfisher M, Fletcher SW

Title: Rapid increase in breast magnetic resonance imaging use: trends from 2000 to 2011.

Journal: JAMA Intern Med 174(1):114-21

Date: 2014 Jan

Abstract: IMPORTANCE: Breast magnetic resonance imaging (MRI) is highly sensitive for detecting breast cancer. Low specificity, cost, and little evidence regarding mortality benefits, however, limit recommendations for its use to high-risk women. How breast MRI is actually used in community settings is unknown. OBJECTIVE: To describe breast MRI trends and indications in a community setting. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study at a not-for-profit health plan and multispecialty group medical practice in New England of 10,518 women aged 20 years and older enrolled in the health plan for at least 1 year who had at least 1 breast MRI between January 1, 2000, and December 31, 2011. MAIN OUTCOMES AND MEASURES: Breast MRI counts were obtained from claims data. Clinical indication (screening, diagnostic evaluation, staging or treatment, or surveillance) was determined using a prediction model developed from electronic medical records on a subset of participants. Breast cancer risk status was assessed using claims data and, for the subset, also through electronic medical record review. RESULTS; Breast MRI use increased more than 20-fold from 6.5 per 10,000 women in 2000 to 130.7 per 10,000 in 2009. Use then declined and stabilized to 104.8 per 10,000 by 2011. Screening and surveillance, rare indications in 2000, together accounted for 57.6% of MRI use by 2011; 30.1% had a claims-documented personal history and 51.7% a family history of breast cancer, whereas 3.5% of women had a documented genetic mutation. In the subset of women with electronic medical records who received screening or surveillance MRIs, only 21.0% had evidence of meeting American Cancer Society (ACS) criteria for breast MRI. Conversely, only 48.4% of women with documented deleterious genetic mutations received breast MRI screening. CONCLUSIONS AND RELEVANCE: Breast MRI use increased steeply over 10 years and then stabilized, especially for screening and surveillance among women with family or personal history of breast cancer; most women receiving screening and surveillance breast MRIs lacked documented evidence of meeting ACS criteria, and many women with mutations were not screened. Efforts are needed to ensure that breast MRI use and documentation are focused on those women who will benefit most.

Authors: Sun M, Becker A, Tian Z, Roghmann F, Abdollah F, Larouche A, Karakiewicz PI, Trinh QD

Title: Management of localized kidney cancer: calculating cancer-specific mortality and competing risks of death for surgery and nonsurgical management.

Journal: Eur Urol 65(1):235-41

Date: 2014 Jan

Abstract: BACKGROUND: For elderly individuals with localized renal cell carcinoma (RCC), surgical intervention remains the primary treatment option but may not benefit patients with limited life expectancy. OBJECTIVE: To calculate the trade-offs between surgical excision and nonsurgical management (NSM) with respect to competing causes of mortality. DESIGN, SETTING, AND PARTICIPANTS: Relying on a cohort of Medicare beneficiaries, all patients with nonmetastatic node-negative T1 RCC between 1988 and 2005 were abstracted. INTERVENTION: All patients were treated with partial nephrectomy (PN), radical nephrectomy (RN), or NSM. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were modeled through competing-risks regression methodologies. Instrumental variable analysis was used to account for the potential biases associated with measured and unmeasured confounders. RESULTS AND LIMITATIONS: A total of 10 595 patients were identified. In instrumental variable analysis, patients treated with PN (hazard ratio [HR]: 0.45; 95% confidence interval [CI], 0.24-0.83; p=0.01) or RN (HR: 0.58; 95% CI, 0.35-0.96; p=0.03) had a significantly lower risk of CSM than those treated with NSM. In subanalyses restricted to patients ≥ 75 yr, the instrumental variable analysis failed to detect any statistically significant difference between PN (HR: 0.48; p=0.1) or RN (HR: 0.57; p=0.1) relative to NSM with respect to CSM. Similar trends were observed in T1a RCC only. CONCLUSIONS: PN or RN is associated with a reduction of CSM among older patients diagnosed with localized RCC, compared with NSM. The same benefit failed to reach statistical significance among patients ≥ 75 yr. The harms of surgery need to be weighed against the marginal survival benefit for some patients.

Authors: Ward PR, Wong MD, Moore R, Naeim A

Title: Fall-related injuries in elderly cancer patients treated with neurotoxic chemotherapy: a retrospective cohort study.

Journal: J Geriatr Oncol 5(1):57-64

Date: 2014 Jan

Abstract: BACKGROUND: Fall-related injuries are a well-described cause of morbidity and mortality in the community-dwelling elderly population, but have not been well described in patients with cancer. Cancer treatment with chemotherapy can result in many unwanted side effects, including peripheral neuropathy if the drugs are potentially neurotoxic. Peripheral neuropathy and other side effects of chemotherapy may lead to an increased risk of fall-related injuries. METHODS: We conducted a retrospective cohort analysis using the records of 65,311 patients with breast, colon, lung, or prostate cancer treated with chemotherapy in the SEER-Medicare database from 1994 to 2007. The primary outcome was any fall-related injury defined as a traumatic fracture, dislocation, or head injury within 12 months of the first dose of chemotherapy. The sample population was divided into 3 cohorts based on whether they most frequently received a neurotoxic doublet, single agent, or a non-neurotoxic chemotherapy. Cox proportional-hazards analyses were adjusted for baseline characteristics to determine the risk of fall-related injuries among the 3 cohorts. RESULTS: The rate of fall-related injuries for patients receiving a doublet of neurotoxic chemotherapy (9.15 per 1000 person-months) was significantly higher than for those receiving a single neurotoxic agent (7.76 per 1000 person-months) or a non-neurotoxic agent (5.19 per 1000 person-months). Based on the Cox proportional-hazards model risk of fall-related injuries was highest for the cohort receiving a neurotoxic doublet after the model was adjusted for baseline characteristics. CONCLUSIONS: Among elderly patients with cancer, use of neurotoxic chemotherapy is associated with an increased risk of fall-related injuries.

Authors: Wernli KJ, DeMartini WB, Ichikawa L, Lehman CD, Onega T, Kerlikowske K, Henderson LM, Geller BM, Hofmann M, Yankaskas BC, Breast Cancer Surveillance Consortium

Title: Patterns of breast magnetic resonance imaging use in community practice.

Journal: JAMA Intern Med 174(1):125-32

Date: 2014 Jan

Abstract: IMPORTANCE: Breast magnetic resonance imaging (MRI) is increasingly used for breast cancer screening, diagnostic evaluation, and surveillance. However, we lack data on national patterns of breast MRI use in community practice. OBJECTIVE: To describe patterns of breast MRI use in US community practice during the period 2005 through 2009. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study using data collected from 2005 through 2009 on breast MRI and mammography from 5 national Breast Cancer Surveillance Consortium registries. Data included 8931 breast MRI examinations and 1,288,924 screening mammograms from women aged 18 to 79 years. MAIN OUTCOMES AND MEASURES: We calculated the rate of breast MRI examinations per 1000 women with breast imaging within the same year and described the clinical indications for the breast MRI examinations by year and age. We compared women screened with breast MRI to women screened with mammography alone for patient characteristics and lifetime breast cancer risk. RESULTS: The overall rate of breast MRI from 2005 through 2009 nearly tripled from 4.2 to 11.5 examinations per 1000 women, with the most rapid increase from 2005 to 2007 (P = .02). The most common clinical indication was diagnostic evaluation (40.3%), followed by screening (31.7%). Compared with women who received screening mammography alone, women who underwent screening breast MRI were more likely to be younger than 50 years, white non-Hispanic, and nulliparous and to have a personal history of breast cancer, a family history of breast cancer, and extremely dense breast tissue (all P < .001). The proportion of women screened using breast MRI at high lifetime risk for breast cancer (>20%) increased during the study period from 9% in 2005 to 29% in 2009. CONCLUSIONS AND RELEVANCE: Use of breast MRI for screening in high-risk women is increasing. However, our findings suggest that there is a need to improve appropriate use, including among women who may benefit from screening breast MRI.

Authors: Wernli KJ, O'Meara ES, Kerlikowske K, Miglioretti DL, Muller CY, Onega T, Sprague BL, Henderson LM, Buist DS

Title: Investigation of mammographic breast density as a risk factor for ovarian cancer.

Journal: J Natl Cancer Inst 106(1):djt341-

Date: 2014 Jan

Abstract: BACKGROUND: Endogenous hormones and growth factors that increase mammographic breast density could increase ovarian cancer risk. We examined whether high breast density is associated with ovarian cancer risk. METHODS: We conducted a cohort study of 724,603 women aged 40 to 79 years with 2,506,732 mammograms participating in the Breast Cancer Surveillance Consortium from 1995 to 2009. Incident epithelial ovarian cancer was diagnosed in 1373 women. We used partly conditional Cox regression to estimate the association between breast density and 5-year risk of incident epithelial ovarian cancer overall and stratified by 10-year age group. All statistical tests were two-sided. RESULTS: Compared with women with scattered fibroglandular densities, women with heterogeneously dense and extremely dense breast tissue had 20% and 18% increased 5-year risk of incident epithelial ovarian cancer (hazard ratio [HR] = 1.20, 95% confidence interval [CI] = 1.06 to 1.36; HR = 1.18, 95% CI = 0.93 to 1.50, respectively; P(trend) = .01). Among women aged 50 to 59 years, we observed a trend in elevated risk associated with increased breast density (P(trend) = .02); women with heterogeneously and extremely dense breast tissue had 30% (HR = 1.30; 95% CI = 1.03 to 1.64) and 65% (HR = 1.65; 95% CI = 1.12 to 2.44) increased risk, respectively, compared with women with scattered fibroglandular densities. The pattern was similar but not statistically significant at age 40 to 49 years. There were no consistent patterns of breast density and ovarian cancer risk at age 60 to 79 years. CONCLUSIONS: Dense breast tissue was associated with a modest increase in 5-year ovarian cancer risk in women aged 50 to 59 years but was not associated with ovarian cancer at ages 40 to 49 or 60 to 79 years.

Authors: Banerjee M, Filson C, Xia R, Miller DC

Title: Logic regression for provider effects on kidney cancer treatment delivery.

Journal: Comput Math Methods Med 2014:316935-

Date: 2014

Abstract: In the delivery of medical and surgical care, often times complex interactions between patient, physician, and hospital factors influence practice patterns. This paper presents a novel application of logic regression in the context of kidney cancer treatment delivery. Using linked data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program and Medicare we identified patients diagnosed with kidney cancer from 1995 to 2005. The primary endpoints in the study were use of innovative treatment modalities, namely, partial nephrectomy and laparoscopy. Logic regression allowed us to uncover the interplay between patient, provider, and practice environment variables, which would not be possible using standard regression approaches. We found that surgeons who graduated in or prior to 1980 despite having some academic affiliation, low volume surgeons in a non-NCI hospital, or surgeons in rural environment were significantly less likely to use laparoscopy. Surgeons with major academic affiliation and practising in HMO, hospital, or medical school based setting were significantly more likely to use partial nephrectomy. Results from our study can show efforts towards dismantling the barriers to adoption of innovative treatment modalities, ultimately improving the quality of care provided to patients with kidney cancer.

Authors: Becker A, Roghmann F, Ravi P, Tian Z, Kluth LA, Gandaglia G, Noldus J, Dahlem R, Schlomm T, Graefen M, Karakiewicz PI, Trinh QD, Sun M

Title: Delay in nephrectomy and cancer control outcomes in elderly patients with small renal masses.

Journal: Urol Int 92(4):455-61

Date: 2014

Abstract: OBJECTIVE: To examine the impact of nephrectomy delay on the survival of patients with small renal masses. METHODS: Relying on the Surveillance, Epidemiology, and End Results Medicare-linked database, 6,237 patients with pT1a renal cell carcinoma who underwent radical or partial nephrectomy were identified (1988-2005). Nephrectomy delay was dichotomized as ≤3 vs. >3 months. Uni- and multivariate Cox regression analyses tested the effect of delayed nephrectomy on cancer-specific mortality (CSM). In sub-analyses, various other time from diagnosis to nephrectomy cut-offs were modelled: (a) ≤1 vs. >1 month, (b) ≤2 vs. >2 months, (c) ≤4 vs. >4 months, (d) ≤6 vs. >6 months, (e) ≤12 vs. >12 months or (f) continuously coded. RESULTS: In univariate analyses, nephrectomy delay >3 months was associated with a higher risk of CSM (hazard ratio [HR]: 2.07; 95% confidence interval [CI]: 1.58-2.72; p < 0.001). However, after multivariate adjustment, a nephrectomy delay >3 months was not significantly associated with a higher risk of CSM (HR: 1.33; 95% CI: 0.96-1.86; p = 0.09). The lack of a relationship between nephrectomy delay and CSM after multivariate adjustment persisted even in various sub-analyses of other categorizations for nephrectomy delay. CONCLUSIONS: In the case of eventual nephrectomy delay among patients with small renal masses, CSM is unaffected.

Authors: Brown ML, Klabunde CN, Cronin KA, White MC, Richardson LC, McNeel TS

Title: Challenges in meeting healthy people 2020 objectives for cancer-related preventive services, National Health Interview Survey, 2008 and 2010.

Journal: Prev Chronic Dis 11:E29-

Date: 2014

Abstract: INTRODUCTION: Healthy People (HP) is the US program that formulates and tracks national health objectives for the nation. The National Health Interview Survey (NHIS) is a designated data source for setting and evaluating several HP targets in cancer. We used data from the 2008 and 2010 NHIS to provide a benchmark for national performance toward meeting HP 2020 cancer-related objectives. METHODS: HP 2020 cancer screening, provider counseling, and health care access objectives were selected. For each objective, NHIS measures for the overall population and several sociodemographic subgroups were calculated; the findings were compared with established HP 2020 targets. RESULTS: From 2008 to 2010, rates of breast and cervical cancer screening declined slightly while colorectal cancer screening rates increased by 7 percentage points. Rates of cancer screening and provider counseling were below HP targets. Meeting HP targets seems less likely for subgroups characterized by low income, no health insurance, or no usual source of care. Meeting HP targets for access to health services will require an increase of 18 percentage points in the proportion of persons under age 65 with health insurance coverage and an increase of 10 percentage points in the proportion aged 18 to 64 with a usual source of care. CONCLUSION: Whether HP objectives for cancer screening and health care access are met may depend on implementation of health care reform measures that improve access to and coordination of care. Better integration of clinical health care and community-based efforts for delivering high-quality screening and treatment services and elimination of health disparities are also needed.

Authors: Burnside ES, Lin Y, Munoz del Rio A, Pickhardt PJ, Wu Y, Strigel RM, Elezaby MA, Kerr EA, Miglioretti DL

Title: Addressing the challenge of assessing physician-level screening performance: mammography as an example.

Journal: PLoS One 9(2):e89418-

Date: 2014

Abstract: BACKGROUND: Motivated by the challenges in assessing physician-level cancer screening performance and the negative impact of misclassification, we propose a method (using mammography as an example) that enables confident assertion of adequate or inadequate performance or alternatively recognizes when more data is required. METHODS: Using established metrics for mammography screening performance-cancer detection rate (CDR) and recall rate (RR)-and observed benchmarks from the Breast Cancer Surveillance Consortium (BCSC), we calculate the minimum volume required to be 95% confident that a physician is performing at or above benchmark thresholds. We graphically display the minimum observed CDR and RR values required to confidently assert adequate performance over a range of interpretive volumes. We use a prospectively collected database of consecutive mammograms from a clinical screening program outside the BCSC to illustrate how this method classifies individual physician performance as volume accrues. RESULTS: Our analysis reveals that an annual interpretive volume of 2770 screening mammograms, above the United States' (US) mandatory (480) and average (1777) annual volumes but below England's mandatory (5000) annual volume is necessary to confidently assert that a physician performed adequately. In our analyzed US practice, a single year of data uniformly allowed confident assertion of adequate performance in terms of RR but not CDR, which required aggregation of data across more than one year. CONCLUSION: For individual physician quality assessment in cancer screening programs that target low incidence populations, considering imprecision in observed performance metrics due to small numbers of patients with cancer is important.

Authors: Forsythe LP, Kent EE, Rowland JH

Title: Survivorship

Journal: :-

Date: 2014

Abstract:

Authors: Griffiths RI, Gleeson ML, Valderas JM, Danese MD

Title: Impact of undetected comorbidity on treatment and outcomes of breast cancer.

Journal: Int J Breast Cancer 2014:970780-

Date: 2014

Abstract: Preexisting comorbidity adversely impacts breast cancer treatment and outcomes. We examined the incremental impact of comorbidity undetected until cancer. We followed breast cancer patients in SEER-Medicare from 12 months before to 84 months after diagnosis. Two comorbidity indices were constructed: the National Cancer Institute index, using 12 months of claims before cancer, and a second index for previously undetected conditions, using three months after cancer. Conditions present in the first were excluded from the second. Overall, 6,184 (10.1%) had ≥1 undetected comorbidity. Chronic obstructive pulmonary disease (38%) was the most common undetected condition. In multivariable analyses that adjusted for comorbidity detected before cancer, older age, later stage, higher grade, and poor performance status all were associated with higher odds of ≥1 undetected comorbidity. In stage I-III cancer, undetected comorbidity was associated with lower adjusted odds of receiving adjuvant chemotherapy (Odds Ratio (OR) = 0.81, 95% Confidence Interval (CI) 0.73-0.90, P < 0.0001; OR = 0.38, 95% CI 0.30-0.49, P < 0.0001; index score 1 or ≥2, respectively), and with increased mortality (Hazard Ratio (HR) = 1.45, 95% CI 1.38-1.53, P < 0.0001; HR = 2.38, 95% CI 2.18-2.60, P < 0.0001; index score 1 or ≥2). Undetected comorbidity is associated with less aggressive treatment and higher mortality in breast cancer.

Authors: Griffiths RI, Lindquist KJ, O'Malley CD, Gleeson ML, Duryea JL, Valderas JM, Danese MD

Title: Undiagnosed diabetes in breast, colorectal, lung, and prostate cancer: incidence and risk factors.

Journal: ISRN Oncol 2014:607850-

Date: 2014

Abstract: Our study describes the incidence and risk factors for undiagnosed diabetes in elderly cancer patients. Using Surveillance, Epidemiology, and End Results-Medicare data, we followed patients with breast, colorectal, lung, or prostate cancer from 24 months before to 3 months after cancer diagnosis. Medicare claims were used to exclude patients with diabetes 24 to 4 months before cancer (look-back period), identify those with diabetes undiagnosed until cancer, and construct indicators of preventive services, physician contact, and comorbidity during the look-back period. Logistic regression analyses were performed to identify factors associated with undiagnosed diabetes. Overall, 2,678 patients had diabetes undiagnosed until cancer. Rates were the highest in patients with both advanced-stage cancer and low prior primary care/medical specialist contact (breast 8.2%, colorectal 5.9%, lung 4.4%). Nonwhite race/ethnicity, living in a census tract with a higher percent of the population in poverty and a lower percent college educated, lower prior preventive services use, and lack of primary care and/or medical specialist care prior to cancer all were associated with higher (P ≤ 0.05) adjusted odds of undiagnosed diabetes. Undiagnosed diabetes is relatively common in selected subgroups of cancer patients, including those already at high risk of poor outcomes due to advanced cancer stage.

Authors: Lang K, Huang H, Sasane M, Paly VF, Hao Y, Menzin J

Title: Survival, healthcare resource use and costs among stage IV ER + breast cancer patients not receiving HER2 targeted therapy: a retrospective analysis of linked SEER-Medicare data.

Journal: BMC Health Serv Res 14:298-

Date: 2014

Abstract: BACKGROUND: Few studies have evaluated survival, treatment, resource use, and costs among women with stage IV ER + breast cancer (BC) who did not receive HER2 targeted therapy. METHODS: Using linked Surveillance, Epidemiology, and End Results (SEER) and Medicare data from 2006-2009, women aged 66+ years with an incident diagnosis of stage IV ER + BC (index date) in 2007 and no HER2 targeted therapy were identified. A comparison cohort without cancer was created from the SEER 5% Medicare sample and matched 1:1 to the study cohort based on age, sex, and race. All patients had continuous enrollment for a 12-month baseline period prior to index and were followed until the end of the study window, disenrollment, or death, whichever came first. Resource utilization and costs (by place of service, reported per patient per month, PPPM) were compared across cohorts. Treatment patterns including receipt of surgery, radiation, chemotherapy, aromatase inhibitors (AI), and non-AI hormonal therapy were evaluated for study cohort patients with at least 2 months of follow-up. Kaplan-Meier survival analysis was also conducted. RESULTS: 325 women with stage IV ER + BC without HER2 targeted therapy were identified and matched to 325 women without cancer. Mean age was 77 years for both cohorts, with average follow-up of 18 months for study patients and 26 months for comparison patients. Compared to the comparison cohort, study patients had significantly higher mortality (60.3% versus 31.1%, P < 0.001), shorter survival (survival at 36 months 28% vs. 62%) and higher resource utilization across all settings except for oral prescription drugs. Total PPPM healthcare costs were also significantly higher among study patients ($7,271 vs. $1,778, P < 0.001). Approximately 57% of study patients with 2+ months of follow-up received chemotherapy and over 62% received an AI during follow-up. Within 4 months of cancer diagnosis, surgery and radiation were received by 39% and 32% of study patients, respectively. CONCLUSIONS: We found significant excess clinical and economic burden among women with stage IV ER + breast cancer who did not receive HER2 targeted therapy. Future studies with more precise and recent data are warranted to confirm and extend these results.

Authors: Onega T, Weiss J, Kerlikowske K, Wernli K, Buist DS, Henderson LM, Goodrich M, Alford-Teaster J, Virnig B, Tosteson AN, DeMartini W, Hubbard R

Title: The influence of race/ethnicity and place of service on breast reconstruction for Medicare beneficiaries with mastectomy.

Journal: Springerplus 3:416-

Date: 2014

Abstract: Racial disparities in breast reconstruction for breast cancer are documented. Place of service has contributed to disparities in cancer care; but the interaction of race/ethnicity and place of service has not been explicitly examined. We examined whether place of service modified the effect of race/ethnicity on receipt of reconstruction. We included women with a mastectomy for incident breast cancer in SEER-Medicare from 2005-2009. Using Medicare claims, we determined breast reconstruction within 6 months. Facility characteristics included: rural/urban location, teaching status, NCI Cancer Center designation, cooperative oncology group membership, Disproportionate Share Hospital (DSH) status, and breast surgery volume. Using multivariable logistic regression, we analyzed reconstruction in relation to minority status and facility characteristics. Of the 17,958 women, 14.2% were racial/ethnic women of color and a total of 9.3% had reconstruction. Caucasians disproportionately received care at non-teaching hospitals (53% v. 42%) and did not at Disproportionate Share Hospitals (77% v. 86%). Women of color had 55% lower odds of reconstruction than Caucasians (OR = 0.45; 95% CI 0.37-0.55). Those in lower median income areas had lower odds of receiving reconstruction, regardless of race/ethnicity. Odds of reconstruction reduced at rural, non-teaching and cooperative oncology group hospitals, and lower surgery volume facilities. Facility effects on odds of reconstruction were similar in analyses stratified by race/ethnicity status. Race/ethnicity and facility characteristics have independent effects on utilization of breast reconstruction, with no significant interaction. This suggests that, regardless of a woman's race/ethnicity, the place of service influences the likelihood of reconstruction.

Authors: Price GL, Davis KL, Karve S, Pohl G, Walgren RA

Title: Survival patterns in United States (US) medicare enrollees with non-CML myeloproliferative neoplasms (MPN).

Journal: PLoS One 9(3):e90299-

Date: 2014

Abstract: PURPOSE: Non-CML myeloproliferative neoplasms (MPN) include essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis (MF). Reported median overall survival (OS) ranges from a few to several years for MF, a decade or more for ET and PV. The study objective was to compare US survival rates of ET, PV, and MF patients with matched non-MPN/non-cancer controls in a nationally representative database. PATIENTS AND METHODS: Data were taken retrospectively from the Survey, Epidemiology, and End Results (SEER)-Medicare linked database. Medicare enrollees with a new SEER MPN diagnosis between Jan 1, 2001 and Dec 31, 2007 were eligible. First MPN diagnosis was required at or after Medicare enrollment to allow for continuous follow-up. Non-MPN/non-cancer control groups were selected from Medicare separately for each MPN subtype and demographically matched to cases at a ratio of 5:1. Survival was determined starting from the case diagnosis date using the Kaplan-Meier method. RESULTS: A total of 3,364 MPN patients (n = 1,217 ET; 1,625 PV; 522 MF) met the inclusion criteria and were matched to controls. Mean age was 78.4, 76.1, and 77.4 years for ET, PV, and MF, respectively, and percent female was 63, 50, and 41. Median OS was significantly (p<0.05) lower for MPN cases vs. controls (ET: 68 vs. 101 months; PV: 65 vs. 104; MF: 24 vs. 106). CONCLUSIONS: In the US Medicare population, survival in MF patients was worse than that of patients with ET or PV and significantly worse than matched controls. Survival of patients with ET or PV was substantially inferior to matched controls. These findings have implications for the clinical management of MPN patients and underscore the need for effective therapies in all MPN subtypes.

Authors: Putila J, Guo NL

Title: Combining COPD with Clinical, Pathological and Demographic Information Refines Prognosis and Treatment Response Prediction of Non-Small Cell Lung Cancer.

Journal: PLoS One 9(6):e100994-

Date: 2014

Abstract: BACKGROUND: Accurate assessment of a patient's risk of recurrence and treatment response is an important prerequisite of personalized therapy in lung cancer. This study extends a previously described non-small cell lung cancer prognostic model by the addition of chemotherapy and co-morbidities through the use of linked SEER-Medicare data. METHODOLOGY/PRINCIPAL FINDINGS: Data on 34,203 lung adenocarcinoma and 26,967 squamous cell lung carcinoma patients were used to determine the contribution of Chronic Obstructive Pulmonary Disease (COPD) to prognostication in 30 treatment combinations. A Cox model including COPD was estimated on 1,000 bootstrap samples, with the resulting model assessed on ROC, Brier Score, Harrell's C, and Nagelkerke's R2 metrics in order to evaluate improvements in prognostication over a model without COPD. The addition of COPD to the model incorporating cancer stage, age, gender, race, and tumor grade was shown to improve prognostication in multiple patient groups. For lung adenocarcinoma patients, there was an improvement on the prognostication in the overall patient population and in patients without receiving chemotherapy, including those receiving surgery only. For squamous cell carcinoma, an improvement on prognostication was seen in both the overall patient population and in patients receiving multiple types of chemotherapy. COPD condition was able to stratify patients receiving the same treatments into significantly (log-rank p<0.05) different prognostic groups, independent of cancer stage. CONCLUSION/SIGNIFICANCE: Combining patient information on COPD, cancer stage, age, gender, race, and tumor grade could improve prognostication and prediction of treatment response in individual non-small cell lung cancer patients. This model enables refined prognosis and estimation of clinical outcome of comprehensive treatment regimens, providing a useful tool for personalized clinical decision-making.

Authors: Vilaprinyo E, Forné C, Carles M, Sala M, Pla R, Castells X, Domingo L, Rue M, Interval Cancer (INCA) Study Group

Title: Cost-effectiveness and harm-benefit analyses of risk-based screening strategies for breast cancer.

Journal: PLoS One 9(2):e86858-

Date: 2014

Abstract: The one-size-fits-all paradigm in organized screening of breast cancer is shifting towards a personalized approach. The present study has two objectives: 1) To perform an economic evaluation and to assess the harm-benefit ratios of screening strategies that vary in their intensity and interval ages based on breast cancer risk; and 2) To estimate the gain in terms of cost and harm reductions using risk-based screening with respect to the usual practice. We used a probabilistic model and input data from Spanish population registries and screening programs, as well as from clinical studies, to estimate the benefit, harm, and costs over time of 2,624 screening strategies, uniform or risk-based. We defined four risk groups, low, moderate-low, moderate-high and high, based on breast density, family history of breast cancer and personal history of breast biopsy. The risk-based strategies were obtained combining the exam periodicity (annual, biennial, triennial and quinquennial), the starting ages (40, 45 and 50 years) and the ending ages (69 and 74 years) in the four risk groups. Incremental cost-effectiveness and harm-benefit ratios were used to select the optimal strategies. Compared to risk-based strategies, the uniform ones result in a much lower benefit for a specific cost. Reductions close to 10% in costs and higher than 20% in false-positive results and overdiagnosed cases were obtained for risk-based strategies. Optimal screening is characterized by quinquennial or triennial periodicities for the low or moderate risk-groups and annual periodicity for the high-risk group. Risk-based strategies can reduce harm and costs. It is necessary to develop accurate measures of individual risk and to work on how to implement risk-based screening strategies.

Authors: Zebrack B, Kent EE, Keegan TH, Kato I, Smith AW, AYA HOPE Study Collaborative Group

Title: "Cancer sucks," and other ponderings by adolescent and young adult cancer survivors.

Journal: J Psychosoc Oncol 32(1):1-15

Date: 2014

Abstract: As part of the National Cancer Institute's AYA HOPE study, 296 adolescent and young adults (AYAs) completed an open-ended survey item asking them to describe their medical care or experience with cancer. Patient, provider, and system-level characteristics all appear to influence AYAs' perceptions of their medical care. Participants attributed levels of satisfaction with care to the availability and communication of information, the management of side-effects, and the expediency and flexibility of treatments. Struggles with health insurance and finances were evident. Findings contribute to a better understanding of AYAs' cancer treatment experiences and will inform improvements to oncology care for this population.

Authors: Warren JL, Mariotto A, Melbert D, Schrag D, Doria-Rose P, Penson D, Yabroff KR

Title: Sensitivity of Medicare Claims to Identify Cancer Recurrence in Elderly Colorectal and Breast Cancer Patients.

Journal: Med Care :-

Date: 2013 Dec 26

Abstract: BACKGROUND:: Researchers are increasingly interested in using observational data to evaluate cancer outcomes following treatment, including cancer recurrence and disease-free survival. Because population-based cancer registries do not collect recurrence data, recurrence is often imputed from health claims, primarily by identifying later cancer treatments after initial treatment. The validity of this approach has not been established. RESEARCH DESIGN:: We used the linked Surveillance, Epidemiology, and End Results-Medicare data to assess the sensitivity of Medicare claims for cancer recurrence in patients very likely to have had a recurrence. We selected newly diagnosed stage II/III colorectal (n=6910) and female breast cancer (n=3826) patients during 1994-2003 who received initial cancer surgery, had a treatment break, and then died from cancer in 1994-2008. We reviewed all claims from the treatment break until death for indicators of recurrence. We focused on additional cancer treatment (surgery, chemotherapy, radiation therapy) as the primary indicator, and used multivariate logistic regression analysis to evaluate patient factors associated with additional treatment. We also assessed metastasis diagnoses and end-of-life care as recurrence indicators. RESULTS:: Additional treatment was the first indicator of recurrence for 38.8% of colorectal patients and 35.2% of breast cancer patients. Patients aged 70 and older were less likely to have additional treatment (P < 0.05), in adjusted analyses. Over 20% of patients either had no recurrence indicator before death or had end-of-life care as their first indicator. CONCLUSIONS:: Identifying recurrence through additional cancer treatment in Medicare claims will miss a large percentage of patients with recurrences; particularly those who are older.

Authors: Simpson DR, Martínez ME, Gupta S, Hattangadi-Gluth J, Mell LK, Heestand G, Fanta P, Ramamoorthy S, Le QT, Murphy JD

Title: Racial disparity in consultation, treatment, and the impact on survival in metastatic colorectal cancer.

Journal: J Natl Cancer Inst 105(23):1814-20

Date: 2013 Dec 04

Abstract: BACKGROUND: Black patients with metastatic colorectal cancer have inferior survival compared to white patients. The purpose of this study was to examine disparity in specialist consultation and multimodality treatment and the impact that treatment inequality has on survival. METHODS: We identified 9935 non-Hispanic white and 1281 black patients with stage IV colorectal cancer aged 66 years and older from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Logistic regression models identified race-based differences in consultation rates and subsequent treatment with surgery, chemotherapy, or radiation. Multivariable Cox regression models identified potential factors that explain race-based survival differences. All statistical tests were two-sided. RESULTS: Black patients had lower rates of consultation with surgery, medical oncology, and radiation oncology. Among patients seen in consultation, black patients received less surgery directed at the primary tumor, liver- or lung-directed surgery, chemotherapy, and radiotherapy. Unadjusted survival analysis found a 15% higher chance of dying for black patients compared with white patients (hazard ratio [HR] = 1.15; 95% confidence interval (CI) = 1.08 to 1.22; P < .001). Adjustment for patient, tumor, and demographic variables marginally reduced the risk of death (HR = 1.08; 95% CI = 1.01 to 1.15; P = .03). After adjustment for differences in treatment, the increased risk of death for black patients disappeared. CONCLUSIONS: Our study shows racial disparity in specialist consultation as well as subsequent treatment with multimodality therapy for metastatic colorectal cancer, and it suggests that inferior survival for black patients may stem from this treatment disparity. Further research into the underlying causes of this inequality will improve access to treatment and survival in metastatic colorectal cancer.

Authors: Hyder O, Dodson RM, Nathan H, Schneider EB, Weiss MJ, Cameron JL, Choti MA, Makary MA, Hirose K, Wolfgang CL, Herman JM, Pawlik TM

Title: Influence of patient, physician, and hospital factors on 30-day readmission following pancreatoduodenectomy in the United States.

Journal: JAMA Surg 148(12):1095-102

Date: 2013 Dec 01

Abstract: IMPORTANCE It is not known whether hospital and surgeon volumes have an association with readmission among patients undergoing pancreatoduodenectomy. OBJECTIVE: To evaluate patient-, surgeon-, and hospital-level factors associated with readmission. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data with cases diagnosed from January 1, 1998, to December 31, 2005, and followed up until December 2007. Population-based cancer registry data were linked to Medicare data for the corresponding patients. A total of 1488 unique individuals who underwent a pancreatoduodenectomy were identified. INTERVENTIONS: Undergoing pancreatoduodenectomy at hospitals classified by volume of pancreatoduodenectomy procedures performed at the facility were either very-low, low, medium, or high volume. Undergoing pancreatoduodenectomy by surgeons classified by volume of pancreatoduodenectomy procedures performed by the surgeon were either very-low, low, medium, or high volume. MAIN OUTCOMES AND MEASURES: In-hospital morbidity, mortality, and 30-day readmission were examined. RESULTS: The median age was 74 years, and 1436 patients (96.5%) had a least 1 medical comorbidity. Patients were treated by 575 distinct surgeons at 298 distinct hospitals. Length of stay was longest (median, 17 days) and 90-day mortality highest (17.2%) at very-low-volume hospitals (P < .001). Among all pancreatoduodenectomy patients, 292 (21.3%) were readmitted within 30 days of discharge. There was no effect of surgeon volume and a modest effect of hospital volume (odds ratio for highest- vs lowest-volume quartiles, 1.85; 95% CI, 1.22-2.80; P = .02). The presence of significant preoperative medical comorbidities was associated with an increased risk for hospital readmission after pancreatoduodenectomy. A comorbidity score greater than 13 had a pronounced effect on the chance of readmission following pancreatoduodenectomy (odds ratio, 2.06; 95% CI, 1.56-2.71; P < .001). The source of variation in readmission was primarily attributable to patient-related factors (95.4%), while hospital factors accounted for 4.3% of the variability and physician factors for only 0.3%. CONCLUSIONS AND RELEVANCE: Nearly 1 in 5 patients are readmitted following pancreatoduodenectomy. While variation in readmission is, in part, attributable to differences among hospitals, the largest share of variation was found at the patient level.

Authors: Akushevich I, Kravchenko J, Ukraintseva S, Arbeev K, Kulminski A, Yashin AI

Title: Morbidity risks among older adults with pre-existing age-related diseases.

Journal: Exp Gerontol 48(12):1395-401

Date: 2013 Dec

Abstract: Multi-morbidity is common among older adults; however, for many aging-related diseases there is no information for U.S. elderly population on how earlier-manifested disease affects the risk of another disease manifested later during patient's lifetime. Quantitative evaluation of risks of cancer and non-cancer diseases for older adults with pre-existing conditions is performed using the Surveillance, Epidemiology, and End Results (SEER) Registry data linked to the Medicare Files of Service Use (MFSU). Using the SEER-Medicare data containing individual records for 2,154,598 individuals, we empirically evaluated age patterns of incidence of age-associated diseases diagnosed after the onset of earlier manifested disease and compared these patterns with those in general population. Individual medical histories were reconstructed using information on diagnoses coded in MFSU, dates of medical services/procedures, and Medicare enrollment/disenrollment. More than threefold increase of subsequent diseases risk was observed for 15 disease pairs, majority of them were i) diseases of the same organ and/or system (e.g., Parkinson disease for patients with Alzheimer disease, HR=3.77, kidney cancer for patients with renal failure, HR=3.28) or ii) disease pairs with primary diseases being fast-progressive cancers (i.e., lung, kidney, and pancreas), e.g., ulcer (HR=4.68) and melanoma (HR=4.15) for patients with pancreatic cancer. Lower risk of subsequent disease was registered for 20 disease pairs, mostly among patients with Alzheimer's or Parkinson's disease, e.g., decreased lung cancer risk among patients with Alzheimer's (HR=0.64) and Parkinson's (HR=0.60) disease. Synergistic and antagonistic dependences in geriatric disease risks were observed among US elderly confirming known and detecting new associations of wide spectrum of age-associated diseases. The results can be used in optimization of screening, prevention and treatment strategies of chronic diseases among U.S. elderly population.

Authors: Boltz MM, Hollenbeak CS, Schaefer E, Goldenberg D, Saunders BD

Title: Attributable costs of differentiated thyroid cancer in the elderly Medicare population.

Journal: Surgery 154(6):1363-70

Date: 2013 Dec

Abstract: BACKGROUND: Little is known about costs associated with differentiated thyroid cancer (DTC) and follow-up care. This study used data from the Surveillance Epidemiology and End Results (SEER) database to examine cumulative costs attributable to disease stage and treatment options of DTC in elderly patients over 5 years. METHODS: We identified 2,823 patients aged >65 years with DTC and 5,646 noncancer comparison cases from SEER Medicare data between 1995 and 2005. Cumulative costs were obtained by estimating average costs/patient in each month up to 60 months after diagnosis. We performed multivariate analyses of costs by fitting each monthly cost to linear models, controlling for demographics and comorbidities. Marginal effects of covariates were obtained by summing coefficients over 60 months. RESULTS: Cumulative costs were $17,669/patient the first year and $48,989/patient 5 years after diagnosis. Regional disease was associated with higher costs at 1 year ($9,578) and 5 years ($8,902). Distant disease was associated with 1-year costs of $28,447 and 5-year costs of $20,103. Patients undergoing surgery and radiation had a decrease in cost of $722 at 5 years. CONCLUSION: DTC in the elderly is associated with significant economic burden largely attributable to patient demographics, stage of disease, and treatment modalities.

Authors: Caretta-Weyer H, Greenberg CG, Wilke LG, Weiss J, LoConte NK, Decker M, Steffens NM, Smith MA, Neuman HB

Title: Impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial on clinical management of the axilla in older breast cancer patients: a SEER-medicare analysis.

Journal: Ann Surg Oncol 20(13):4145-52

Date: 2013 Dec

Abstract: BACKGROUND: American College of Surgeons Oncology Group (ACOSOG) Z0011 demonstrated that eligible breast cancer patients with positive sentinel lymph nodes (SLN) could be spared an axillary lymph node dissection (ALND) without sacrificing survival or local control. Although heralded as a ''practice-changing trial,'' some argue that the stringent inclusion criteria limit the trial's clinical significance. The objective was to assess the potential impact of ACOSOG Z0011 on axillary surgical management of Medicare patients and examine current practice patterns. METHODS: Medicare beneficiaries aged C66 years with nonmetastatic invasive breast cancer diagnosed from 2001 to 2007 were identified from the Surveillance, Epidemiology and End Results-Medicare database (n = 59,431). Eligibility for ACOSOG Z0011 was determined: SLN mapping, tumor\5 cm, no neoadjuvant treatment, breast conservation; number of positive nodes was determined. Actual surgical axillary management for eligible patients was assessed. RESULTS: Twelve percent (6,942/59,431) underwent SLN mapping and were node positive. Overall, 2,637 patients (4.4 % (2,637/59,431) of the total cohort, but 38 % (2,637/6,942) of patients with SLN mapping and positive nodes) met inclusion criteria for ACOSOG Z0011, had 1 or 2 positive lymph nodes, and could have been spared an ALND. Of these 2,637 patients, 46 % received a completion ALND and 54 % received only SLN biopsy. CONCLUSIONS: Widespread implementation of ACOSOG Z0011 trial results could potentially spare 38 % of older breast cancer patients who undergo SLN mapping with positive lymph nodes an ALND. However, 54 % of these patients are already managed with SLN biopsy alone, lessening the impact of this trial on clinical practice in older breast cancer patients.

Authors: Charlton ME, Lin C, Jiang D, Stitzenberg KB, Halfdanarson TR, Pendergast JF, Chrischilles EA, Wallace RB

Title: Factors associated with use of preoperative chemoradiation therapy for rectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium.

Journal: Am J Clin Oncol 36(6):572-9

Date: 2013 Dec

Abstract: PURPOSE: Preoperative (preop) chemoradiation therapy (CRT) improves local control and reduces toxicity more than postoperative (postop) CRT for the treatment of stages II/III rectal cancer, but studies suggest that many patients still receive postop CRT. We examined patient beliefs and clinical and provider characteristics associated with receipt of recommended therapy. METHODS: We identified stages II/III rectal cancer patients who had primary site resection and CRT among subjects in the Cancer Care Outcomes Research and Surveillance Consortium, a population-based and health system-based prospective cohort of newly diagnosed colorectal cancer patients from 2003 to 2005. Patient surveys and abstracted medical records were used to construct variables and determine sequence of CRT and surgery. Logistic regression was used to model the association between predictors and receipt of preop CRT. RESULTS: Of the 201 patients, 66% received preop and 34% received postop CRT. Those visiting a medical oncologist and/or radiation oncologist before a surgeon had a 96% (95% confidence interval, 92%-100%) predicted probability of receiving preop CRT, compared with 48% (95% confidence interval, 41%-55%) for those visiting a surgeon first. Among those visiting a surgeon first, documentation of recommended staging procedures was associated with receiving preop CRT. CONCLUSIONS: Sequence of provider visits and documentation of recommended staging procedures were important predictors of receiving preop CRT. Initial multidisciplinary evaluation led to better adherence to CRT guidelines. Further evaluation of provider characteristics, referral patterns, and related health system processes should be undertaken to inform targeted interventions to reduce variation from recommended care.

Authors: Folse HJ, Green LE, Kress A, Allman R, Dinh TA

Title: Cost-effectiveness of a genetic test for breast cancer risk.

Journal: Cancer Prev Res (Phila) 6(12):1328-36

Date: 2013 Dec

Abstract: Genetic testing of seven single-nucleotide polymorphisms (7SNP) can improve estimates of risk of breast cancer relative to the Gail risk test alone, for the purpose of recommending MRI screening for women at high risk. A simulation of breast cancer and health care processes was used to conduct a virtual trial comparing the use of the 7SNP test with the Gail risk test to categorize patients by risk. Average-risk patients received annual mammogram, whereas high-risk patients received annual MRI. Cancer incidence was based on Surveillance, Epidemiology, and End Results data and validated to Cancer Prevention Study II Nutrition Cohort data. Risk factor values were drawn from National Health and Nutrition Examination Survey (NHANES-4) and Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial data. Mammogram characteristics were derived from Breast Cancer Surveillance Consortium data. The test was most cost-effective when given to patients at an intermediate lifetime risk of breast cancer. For patients with a risk of 16% to 28%, it resulted in a 1.91% reduction in cancer deaths, saving 0.005 quality-adjusted life years per person at a cost of $163,264 per QALY. These results were sensitive to the age at which the test is given, the discount rate, and the costs of the genetic test and MRI. The cost effectiveness of using the 7SNP test for patients with intermediate Gail risk is similar to that of other recommended strategies, including annual MRI for patients with a lifetime risk greater than 20% or BRCA1/2 mutations.

Authors: Lee JY, Moore PC, Steliga MA

Title: Do HIV-infected non-small cell lung cancer patients receive guidance-concordant care?

Journal: Med Care 51(12):1063-8

Date: 2013 Dec

Abstract: BACKGROUND: The incidence of lung cancer cases among HIV-infected individuals is increasing with time. It is unclear whether HIV-infected individuals receive the same care for lung cancer as immunocompetent patients because of comorbidities, the potential for interaction between antiretroviral agents and cancer chemotherapy, and concerns regarding complications related to treatment or infection. OBJECTIVES: The objective of this study was to assess the effect of HIV infection on receipt of guidance-concordant care, and its impact on overall survival among non-small cell lung cancer Medicare beneficiaries. DESIGN: The study design was a matched case-control design where each HIV patient was matched by age group, sex, race, and lung cancer stage at diagnosis with 20 controls randomly selected among those who were not HIV infected. SUBJECTS: The patients included in this study were Medicare beneficiaries diagnosed with non-small cell lung cancer between 1998 and 2007, who qualified for Medicare on the basis of age and were 65 years of age or older at the time of lung cancer diagnosis. HIV infection status was based on Medicare claims data. A total of 174 HIV cases and 3480 controls were included in the analysis. MEASURES: Odds ratios for receiving guidance-concordant care and hazard ratios for overall survival were estimated. RESULTS: HIV infection was not independently associated with the receipt of guidance-concordant care. Among stage I/II patients, median survival times were 26 and 43 months, respectively, for those with and without HIV infection (odds ratio=1.48, P=0.021). CONCLUSIONS: HIV infection was not associated with receipt of guidance-concordant care but reduced survival in early-stage patients.

Authors: Mariotto AB, Wang Z, Klabunde CN, Cho H, Das B, Feuer EJ

Title: Life tables adjusted for comorbidity more accurately estimate noncancer survival for recently diagnosed cancer patients.

Journal: J Clin Epidemiol 66(12):1376-85

Date: 2013 Dec

Abstract: OBJECTIVES: To provide cancer patients and clinicians with more accurate estimates of a patient's life expectancy with respect to noncancer mortality, we estimated comorbidity-adjusted life tables and health-adjusted age. STUDY DESIGN AND SETTING: Using data from the Surveillance Epidemiology and End Results-Medicare database, we estimated comorbidity scores that reflect the health status of people who are 66 years of age and older in the year before cancer diagnosis. Noncancer survival by comorbidity score was estimated for each age, race, and sex. Health-adjusted age was estimated by systematically comparing the noncancer survival models with US life tables. RESULTS: Comorbidity, cancer status, sex, and race are all important predictors of noncancer survival; however, their relative impact on noncancer survival decreases as age increases. Survival models by comorbidity better predicted noncancer survival than the US life tables. The health-adjusted age and national life tables can be consulted to provide an approximate estimate of a person's life expectancy, for example, the health-adjusted age of a black man aged 75 years with no comorbidities is 67 years, giving him a life expectancy of 13 years. CONCLUSION: The health-adjusted age and the life tables adjusted by age, race, sex, and comorbidity can provide important information to facilitate decision making about treatment for cancer and other conditions.

Authors: Nathan H, Hyder O, Mayo SC, Hirose K, Wolfgang CL, Choti MA, Pawlik TM

Title: Surgical therapy for early hepatocellular carcinoma in the modern era: a 10-year SEER-medicare analysis.

Journal: Ann Surg 258(6):1022-7

Date: 2013 Dec

Abstract: OBJECTIVE: We sought to quantify the use of and analyze factors predictive of receipt of surgical therapy for early hepatocellular carcinoma (HCC). BACKGROUND: The incidence of HCC is increasing, and the options for surgical therapy for early HCC have expanded, but the use of surgical therapy for early HCC has not been examined in a modern cohort. METHODS: A retrospective cohort study was performed using data from the 1998-2007 Surveillance, Epidemiology, and End Results-Medicare linked database. Data were analyzed for patients 66 years of age and older with early HCC (tumors ≤5 cm without metastatic disease, nodal metastasis, extrahepatic extension, or major vascular invasion). Both Surveillance, Epidemiology, and End Results and Medicare data were used to ascertain receipt of therapy as well as comorbidity burden and other patient and hospital variables. Multivariable logistic regression models were used to analyze factors associated with receipt of therapy. RESULTS: Our selection criteria identified 1745 patients for this study. Most patients had tumors between 2 and 5 cm in size (n = 1440, 83%). Solitary tumors (n = 1121, 64%) were more common than multiple tumors (n = 624, 36%). A total of 820 patients (47%) with early HCC received no surgical therapy. Among 741 patients with solitary, unilobar tumors and microscopic confirmation of HCC, 246 (33%) received no surgical therapy. Of 535 patients with no liver-related comorbidities, 273 (51%) did not receive surgical therapy. In multivariable analysis, patient age, income, tumor factors, liver-related comorbidities, and hospital factors were associated with receipt of surgical therapy. CONCLUSIONS: Although some patients with early HCC may not be candidates for surgical therapy, these data suggest that there is a significant missed opportunity to improve survival of patients with early HCC through the use of surgical therapy.

Authors: Neuman HB, Weiss JM, Schrag D, Ronk K, Havlena J, LoConte NK, Smith MA, Greenberg CC

Title: Patient demographic and tumor characteristics influencing oncologist follow-up frequency in older breast cancer survivors.

Journal: Ann Surg Oncol 20(13):4128-36

Date: 2013 Dec

Abstract: BACKGROUND: Although recommendations for breast cancer follow-up frequency exist, current follow-up guidelines are standardized, without consideration of individual patient characteristics. Some studies suggest oncologists are using these characteristics to tailor follow-up recommendations, but it is unclear how this is translating into practice. The objective of this study was to examine current patterns of oncologist breast cancer follow-up and determine the association between patient and tumor characteristics and follow-up frequency. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify stage I-III breast cancer patients diagnosed 2000-2007 (n = 39,241). Oncologist follow-up visits were defined using Medicare specialty provider codes and the linked AMA Masterfile. Multinomial logistic regression determined the association between patient and tumor characteristics and oncologist follow-up visit frequency. RESULTS: Younger age (p < 0.001), positive nodes (p < 0.001), estrogen receptor/progesterone receptor positivity (p < 0.001), and increasing treatment intensity (p < 0.001) were most strongly associated with more frequent follow-up. However, after accounting for these characteristics, significant variation in follow-up frequency was observed. In addition to patient factors, the number and types of oncologists involved in follow-up were associated with follow-up frequency (p < 0.001). Types of oncologists providing follow-up varied, with medical oncologists the sole providers of follow-up for 19-51 % of breast cancer survivors. Overall, 58 % of patients received surgical oncology, and 51 % undergoing radiation received radiation oncology follow-up, usually in combination with medical oncology. CONCLUSIONS: Significant variation in breast cancer follow-up frequency exists. Developing follow-up guidelines tailored for patient, tumor, and treatment characteristics while also providing guidance on who should provide follow-up has the potential to increase clinical efficiency.

Authors: Nurgalieva ZZ, Franzini L, Morgan R, Vernon SW, Liu CC, Du XL

Title: Surveillance mammography use after treatment of primary breast cancer and racial disparities in survival.

Journal: Med Oncol 30(4):691-

Date: 2013 Dec

Abstract: Racial and ethnic minority patients continue to die disproportionately from breast cancer compared with their white counterparts, even after adjusting for insurance status and income. No studies have examined whether surveillance mammography reduces racial disparities in survival among elderly breast cancer survivors following active treatment for breast cancer. This study included 28,117 cases diagnosed with primary breast cancer at age 66 years and over, identified from SEER data during 1992-2005. Kaplan-Meier methods and Cox regression models were used for survival analysis. A higher proportion of whites received surveillance mammograms during the surveillance period compared with nonwhites: 71.7% of African-Americans, 72.5% of Hispanics, and 69.3% of Asians had mammograms compared with 74.9% of whites. In propensity-score-adjusted analysis, women who had a mammogram within 2 years were less likely (hazard ratio 0.84; 95% CI 0.78-0.82) to die from any cause compared with women who did not have any mammograms during this time period. The hazard ratio of cancer-specific mortality elevated for Hispanics compared with whites (hazard ratio 1.5; 95% CI 0.6-3.2) and was reduced after adjusting for surveillance mammography (hazard ratio 1.4; 95% CI 0.5-2.9). Similar pattern in the reduction in disease-specific hazard ratio was observed for blacks: After controlling for patient and tumor characteristics, hazard ratio was elevated but not significantly different from that in whites (hazard ratio 2.0; 95% CI 0.9-3.7), and hazard ratio adjusting for surveillance mammography further reduced the point estimate (hazard ratio 1.5; 95% CI 0.7-2.8). Asian and Pacific Islanders and Hispanics appeared to have lower risks of all-cause mortality compared with whites after controlling for patient and tumor characteristics and surveillance mammogram received. Our findings indicates that while surveillance mammograms and physician visits may play a contributory role in achieving equal outcomes for breast cancer-specific mortality for women with breast cancer, searching for other factors that might help achieve national goals to eliminate racial disparities in healthcare, and outcomes is warranted.

Authors: Reese ES, Onukwugha E, Hanna N, Seal BS, Mullins CD

Title: Clinical and demographic characteristics associated with the receipt of chemotherapy treatment among 7951 elderly metastatic colon cancer patients.

Journal: Cancer Med 2(6):907-15

Date: 2013 Dec

Abstract: Among older individuals diagnosed with metastatic colon cancer (mCC) there is limited evidence available that describes the characteristics associated with advancing to second- and subsequent lines of treatment with chemotherapy/biologics. Our objective was to describe the trends and lines of treatment received among elderly mCC patients. Elderly beneficiaries diagnosed with mCC from 2003 to 2007 were identified in the Surveillance, Epidemiology and End Results (SEER)-Medicare dataset. Beneficiaries were followed up until death or censoring. Treatment lines were classified in combinations of chemotherapies and biologics. Modified Poisson regression was used to predict receipt of lines of treatment. Analyses controlled for age, race/ethnicity, gender, marital status, state buy-in during diagnosis year, SEER-registry site, Charlson comorbidity index (CCI), poor performance indicators, surgery of primary site, and surgery of regional/distal sites. Among 7951 Medicare beneficiaries identified with mCC, 3266 initiated therapy. Of these, 1440 advanced to second-line treatment. Of these, 274 advanced to a subsequent-line treatment. Surgeries of the primary tumor site and of the regional/distal sites and marital status were the most significant variables associated with advancing through second- and subsequent-line treatments. Greater than 80 years of age, African American race, SEER-registry area, less than 6 months state buy-in assistance in mCC diagnosis year, and having poor performance indicators were inversely associated with receipt of second- or subsequent-line treatments. Among elderly individuals diagnosed with mCC, we identified demographic, clinical, and regional factors associated with receipt of second- and subsequent-line chemotherapy/biologics. Additional research is warranted to understand the role of physician versus patient preferences as well as geographic differences explaining why patients advance through lines of chemotherapy.

Authors: Schroeck FR, Kaufman SR, Jacobs BL, Zhang Y, Weizer AZ, Montgomery JS, Gilbert SM, Strope SA, Hollenbeck BK

Title: The impact of technology diffusion on treatment for prostate cancer.

Journal: Med Care 51(12):1076-84

Date: 2013 Dec

Abstract: BACKGROUND: The use of local therapy for prostate cancer may increase because of the perceived advantages of new technologies such as intensity-modulated radiotherapy (IMRT) and robotic prostatectomy. OBJECTIVE: To examine the association of market-level technological capacity with receipt of local therapy. DESIGN: Retrospective cohort. SUBJECTS: Patients with localized prostate cancer who were diagnosed between 2003 and 2007 (n=59,043) from the Surveillance Epidemiology and End Results-Medicare database. MEASURES: We measured the capacity for delivering treatment with new technology as the number of providers offering robotic prostatectomy or IMRT per population in a market (hospital referral region). The association of this measure with receipt of prostatectomy, radiotherapy, or observation was examined with multinomial logistic regression. RESULTS: For each 1000 patients diagnosed with prostate cancer, 174 underwent prostatectomy, 490 radiotherapy, and 336 were observed. Markets with high robotic prostatectomy capacity had higher use of prostatectomy (146 vs. 118 per 1000 men, P=0.008) but a trend toward decreased use of radiotherapy (574 vs. 601 per 1000 men, P=0.068), resulting in a stable rate of local therapy. High versus low IMRT capacity did not significantly impact the use of prostatectomy (129 vs. 129 per 1000 men, P=0.947) and radiotherapy (594 vs. 585 per 1000 men, P=0.579). CONCLUSIONS: Although there was a small shift from radiotherapy to prostatectomy in markets with high robotic prostatectomy capacity, increased capacity for both robotic prostatectomy and IMRT did not change the overall rate of local therapy. Our findings temper concerns that the new technology spurs additional therapy of prostate cancer.

Authors: Veluswamy RR, Mhango G, Bonomi M, Neugut AI, Hershman DL, Aldridge MD, Wisnivesky JP

Title: Adjuvant treatment for elderly patients with early-stage lung cancer treated with limited resection.

Journal: Ann Am Thorac Soc 10(6):622-8

Date: 2013 Dec

Abstract: OBJECTIVES: Limited resection is commonly used for treating older patients with early-stage non-small cell lung cancer (NSCLC) who cannot tolerate lobectomy. However, parenchymal-sparing procedures leave patients at increased risk of recurrence. The role of postoperative radiotherapy (PORT) and chemotherapy after limited resection is not established. METHODS: We identified 1,929 patients with stage I-II (≤ 5 cm in size) NSCLC who underwent limited resection (wedge or segmentectomy) from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Using propensity score methods, we compared toxicity and survival of patients treated with limited resection alone, PORT, adjuvant chemotherapy, or PORT and chemotherapy. We conducted secondary analysis stratifying the sample by size (>2-5 cm), stage (IA vs. IB/IIA), and type of limited resection (wedge resection vs. segmentectomy). MEASUREMENTS AND MAIN RESULTS: Overall, 1,656 (85.8%), 159 (8.3%), 74 (3.8%), and 40 (2.1%) patients were treated with limited resection alone, PORT, adjuvant chemotherapy, or PORT and chemotherapy, respectively. Adjusted analysis using inverse probability weighting showed that PORT (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.45-1.69), adjuvant chemotherapy (HR, 1.48; 95% CI, 1.36-1.61), and PORT and chemotherapy (HR, 1.73; 95% CI, 1.61-1.86) were associated with worse survival compared with limited resection alone. Similar results were obtained in secondary analyses. Compared with limited resection alone, the adjusted odds ratios for toxicity were 1.97 (95% CI, 1.6-2.4), 3.15 (95% CI, 2.58-3.85), 2.59 (95% CI, 2.0-3.4) for PORT, chemotherapy, and PORT and chemotherapy, respectively. CONCLUSIONS: PORT and adjuvant chemotherapy are not beneficial and appear to be associated with increased toxicity and worse survival after limited resection in elderly patients with early-stage NSCLC. Alternative strategies should be explored to improve local control.

Authors: Chavez-MacGregor M, Zhang N, Buchholz TA, Zhang Y, Niu J, Elting L, Smith BD, Hortobagyi GN, Giordano SH

Title: Trastuzumab-related cardiotoxicity among older patients with breast cancer.

Journal: J Clin Oncol 31(33):4222-8

Date: 2013 Nov 20

Abstract: PURPOSE: The use of trastuzumab in the adjuvant setting improves outcomes but is associated with cardiotoxicity manifested as congestive heart failure (CHF). The rates and risk factors associated with trastuzumab-related CHF among older patients are unknown. PATIENTS AND METHODS: Breast cancer patients at least 66 years old with full Medicare coverage, diagnosed with stage I-III breast cancer between 2005 and 2009, and treated with chemotherapy were identified in the SEER-Medicare and in the Texas Cancer Registry-Medicare databases. The rates and risk factors associated with CHF were evaluated. Chemotherapy, trastuzumab use, comorbidities, and CHF were identified using International Classification of Diseases, version 9, and Healthcare Common Procedure Coding System codes. Analyses included descriptive statistics and Cox proportional hazards models. RESULTS: In total, 9,535 patients were included, of whom 2,203 (23.1%) received trastuzumab. Median age of the entire cohort was 71 years old. Among trastuzumab users, the rate of CHF was 29.4% compared with 18.9% in nontrastuzumab users (P < .001). Trastuzumab users were more likely to develop CHF than nontrastuzumab users (hazard ratio [HR], 1.95; 95% CI, 1.75 to 2.17). Among trastuzumab-treated patients, older age (age > 80 years; HR, 1.53; 95% CI, 1.16 to 2.10), coronary artery disease (HR, 1.82; 95% CI, 1.34 to 2.48), hypertension (HR, 1.24; 95% CI, 1.02 to 1.50), and weekly trastuzumab administration (HR, 1.33; 95% CI, 1.05 to 1.68) increased the risk of CHF. CONCLUSION: In this large cohort of older breast cancer patients, the rates of trastuzumb-related CHF are higher than those reported in clinical trials. Among patients treated with trastuzumab, those with cardiac comorbidities and older age may be at higher risk. Further studies need to confirm the role that the frequency of administration plays in the development of trastuzumab-related CHF.

Authors: Cho H, Klabunde CN, Yabroff KR, Wang Z, Meekins A, Lansdorp-Vogelaar I, Mariotto AB

Title: Comorbidity-adjusted life expectancy: a new tool to inform recommendations for optimal screening strategies.

Journal: Ann Intern Med 159(10):667-76

Date: 2013 Nov 19

Abstract: BACKGROUND: Many guidelines recommend considering health status and life expectancy when making cancer screening decisions for elderly persons. OBJECTIVE: To estimate life expectancy for elderly persons without a history of cancer, taking into account comorbid conditions. DESIGN: Population-based cohort study. SETTING: A 5% sample of Medicare beneficiaries in selected geographic areas, including their claims and vital status information. PARTICIPANTS: Medicare beneficiaries aged 66 years or older between 1992 and 2005 without a history of cancer (n = 407 749). MEASUREMENTS: Medicare claims were used to identify comorbid conditions included in the Charlson index. Survival probabilities were estimated by comorbidity group (no, low/medium, and high) and for the 3 most prevalent conditions (diabetes, chronic obstructive pulmonary disease, and congestive heart failure) by using the Cox proportional hazards model. Comorbidity-adjusted life expectancy was calculated based on comparisons of survival models with U.S. life tables. Survival probabilities from the U.S. life tables providing the most similar survival experience to the cohort of interest were used. RESULTS: Persons with higher levels of comorbidity had shorter life expectancies, whereas those with no comorbid conditions, including very elderly persons, had favorable life expectancies relative to an average person of the same chronological age. The estimated life expectancy at age 75 years was approximately 3 years longer for persons with no comorbid conditions and approximately 3 years shorter for those with high comorbidity relative to the average U.S. population. LIMITATIONS: The cohort was limited to Medicare fee-for-service beneficiaries aged 66 years or older living in selected geographic areas. Data from the Surveillance, Epidemiology, and End Results cancer registry and Medicare claims lack information on functional status and severity of comorbidity, which might influence life expectancy in elderly persons. CONCLUSION: Life expectancy varies considerably by comorbidity status in elderly persons. Comorbidity-adjusted life expectancy may help physicians tailor recommendations for stopping or continuing cancer screening for individual patients.

Authors: O'Meara ES, Zhu W, Hubbard RA, Braithwaite D, Kerlikowske K, Dittus KL, Geller B, Wernli KJ, Miglioretti DL

Title: Mammographic screening interval in relation to tumor characteristics and false-positive risk by race/ethnicity and age.

Journal: Cancer 119(22):3959-67

Date: 2013 Nov 15

Abstract: BACKGROUND: Biennial screening mammography retains most of the benefits of annual breast cancer screening with reduced harms. Whether screening guidelines based on race/ethnicity and age would be more effective than age-based guidelines is unknown. METHODS: Mammography data from the Breast Cancer Surveillance Consortium were linked to pathology and tumor databases. The authors identified women aged 40 to 74 years who underwent annual, biennial, or triennial screening mammography between 1994 and 2008. Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (95% CI) of adverse tumor characteristics among 14,396 incident breast cancer cases and 10-year cumulative risks of false-positive recall and biopsy recommendation among 1,276,312 noncases. RESULTS: No increased risk of adverse tumor characteristics associated with biennial versus annual screening were noted in white women, black women, Hispanic women aged 40 to 49 years, or Asian women aged 50 to 74 years. Hispanic women aged 50 to 74 years who screened biennially versus annually were found to have an increased risk of late-stage disease (OR, 1.6; 95% CI, 1.0-2.5) and large tumors (OR, 1.6; 95% CI, 1.1-2.4). Asian women aged 40 to 49 years who underwent biennial screening had an elevated risk of positive lymph nodes (OR, 3.1; 95% CI, 1.3-7.1). No elevated risks were associated with triennial versus biennial screening. Cumulative false-positive risks decreased markedly with a longer screening interval. CONCLUSIONS: The authors found limited evidence of elevated risks of adverse tumor characteristics with biennial versus annual screening, whereas cumulative false-positive risks were lower. However, elevated risks of late-stage disease in Hispanic women and lymph node-positive disease in younger Asian women who screened less often than annually warrant consideration and replication.

Authors: Bertrand KA, Tamimi RM, Scott CG, Jensen MR, Pankratz V, Visscher D, Norman A, Couch F, Shepherd J, Fan B, Chen YY, Ma L, Beck AH, Cummings SR, Kerlikowske K, Vachon CM

Title: Mammographic density and risk of breast cancer by age and tumor characteristics.

Journal: Breast Cancer Res 15(6):R104-

Date: 2013 Nov 04

Abstract: INTRODUCTION: Understanding whether mammographic density (MD) is associated with all breast tumor subtypes and whether the strength of association varies by age is important for utilizing MD in risk models. METHODS: Data were pooled from six studies including 3414 women with breast cancer and 7199 without who underwent screening mammography. Percent MD was assessed from digitized film-screen mammograms using a computer-assisted threshold technique. We used polytomous logistic regression to calculate breast cancer odds according to tumor type, histopathological characteristics, and receptor (estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor (HER2)) status by age (<55, 55-64, and ≥65 years). RESULTS: MD was positively associated with risk of invasive tumors across all ages, with a two-fold increased risk for high (>51%) versus average density (11-25%). Women ages <55 years with high MD had stronger increased risk of ductal carcinoma in situ (DCIS) compared to women ages 55-64 and ≥65 years (Page-interaction = 0.02). Among all ages, MD had a stronger association with large (>2.1 cm) versus small tumors and positive versus negative lymph node status (P's < 0.01). For women ages <55 years, there was a stronger association of MD with ER-negative breast cancer than ER-positive tumors compared to women ages 55-64 and ≥65 years (Page-interaction = 0.04). MD was positively associated with both HER2-negative and HER2-positive tumors within each age group. CONCLUSION: MD is strongly associated with all breast cancer subtypes, but particularly tumors of large size and positive lymph nodes across all ages, and ER-negative status among women ages <55 years, suggesting high MD may play an important role in tumor aggressiveness, especially in younger women.

Authors: Arora NK, Jensen RE, Sulayman N, Hamilton AS, Potosky AL

Title: Patient-physician communication about health-related quality-of-life problems: are non-Hodgkin lymphoma survivors willing to talk?

Journal: J Clin Oncol 31(31):3964-70

Date: 2013 Nov 01

Abstract: PURPOSE: To investigate non-Hodgkin lymphoma (NHL) survivors' willingness to discuss health-related quality-of-life (HRQOL) problems with their follow-up care physician. PATIENTS AND METHODS: Willingness to discuss HRQOL problems (physical, daily, emotional, social, and sexual functioning) was examined among 374 NHL survivors, 2 to 5 years postdiagnosis. Survivors were asked if they would bring up HRQOL problems with their physician and indicate reasons why not. Logistic regression models examined the association of patient sociodemographics, clinical characteristics, follow-up care variables, and current HRQOL scores with willingness to discuss HRQOL problems. RESULTS: Overall, 94%, 82%, 76%, 43%, and 49% of survivors would initiate discussions of physical, daily, emotional, social, and sexual functioning, respectively. Survivors who indicated their physician "always" spent enough time with them or rated their care as "excellent" were more willing to discuss HRQOL problems (P < .05). Survivors reporting poorer physical health were less willing to discuss their daily functioning problems (P < .001). Men were more willing to discuss sexual problems than women (P < .001). One in three survivors cited "nothing can be done" as a reason for not discussing daily functioning problems, and at least one in four cited "this was not their doctor's job" and a preference to "talk to another clinician" as reasons for not discussing emotional, social, and sexual functioning. CONCLUSION: NHL survivors' willingness to raise HRQOL problems with their physician varied by HRQOL domain. For some domains, even when survivors were experiencing problems, they may not discuss them. To deliver cancer care for the whole patient, interventions that facilitate survivor-clinician communication about survivors' HRQOL are needed.

Authors: Parmar AD, Sheffield KM, Han Y, Vargas GM, Guturu P, Kuo YF, Goodwin JS, Riall TS

Title: Evaluating comparative effectiveness with observational data: endoscopic ultrasound and survival in pancreatic cancer.

Journal: Cancer 119(21):3861-9

Date: 2013 Nov 01

Abstract: BACKGROUND: A previous observational study reported that endoscopic ultrasound (EUS) is associated with improved survival in older patients with pancreatic cancer. The objective of this study was to reevaluate this association using different statistical methods to control for confounding and selection bias. METHODS: Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2007) was used to identify patients with locoregional pancreatic cancer. Two-year survival in patients who did and did not receive EUS was compared by using standard Cox proportional hazards models, propensity score methodology, and instrumental variable analysis. RESULTS: EUS was associated with improved survival in both unadjusted (hazard ratio [HR] = 0.67, 95% confidence interval [CI] = 0.63-0.72) and standard regression analyses (HR = 0.78, 95% CI = 0.73-0.84) which controlled for age, sex, race, marital status, tumor stage, SEER region, Charlson comorbidity, year of diagnosis, education, preoperative biliary stenting, chemotherapy, radiation, and pancreatic resection. Propensity score adjustment, matching, and stratification did not attenuate this survival benefit. In an instrumental variable analysis, the survival benefit was no longer observed (HR = 1.00, 95% CI = 0.73-1.36). CONCLUSIONS: These results demonstrate the need to exercise caution in using administrative data to infer causal mortality benefits with diagnostic and/or treatment interventions in cancer research.

Authors: Beadle BM, Liao KP, Chambers MS, Elting LS, Buchholz TA, Kian Ang K, Garden AS, Guadagnolo BA

Title: Evaluating the impact of patient, tumor, and treatment characteristics on the development of jaw complications in patients treated for oral cancers: a SEER-Medicare analysis.

Journal: Head Neck 35(11):1599-605

Date: 2013 Nov

Abstract: BACKGROUND: Jaw complications, including osteoradionecrosis, are significant sequelae of radiation therapy (RT) for oral cancers. This study identifies the impact of patient, tumor, and treatment characteristics on the development of jaw complications in patients treated with RT. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients treated with RT for oral cancers from 1999 to 2007. Jaw complications were identified by International Classification of Diseases 9th revision (ICD-9) diagnosis codes and/or related procedures using Current Procedural Terminology (CPT) and ICD-9 codes. RESULTS: A total of 1848 patients were identified. With a median follow-up of 2.5 years, 297 patients (16.1%) developed jaw complications: 226 patients had a diagnosis, 41 patients had a procedure, and 30 patients had both. On multivariate analysis, female sex, lack of chemotherapy use, and fewer comorbidities were associated with a statistically significant increase in jaw complications. CONCLUSIONS: Even with modern techniques, jaw complications are a notable and potentially devastating side effect of RT for oral cancers.

Authors: Bianchi M, Becker A, Abdollah F, Trinh QD, Hansen J, Tian Z, Shariat SF, Perrotte P, Karakiewicz PI, Sun M

Title: Rates of open versus laparoscopic and partial versus radical nephrectomy for T1a renal cell carcinoma: a population-based evaluation.

Journal: Int J Urol 20(11):1064-71

Date: 2013 Nov

Abstract: OBJECTIVES: To examine the trends of open and laparoscopic partial nephrectomy and radical nephrectomy according to sociodemographic and tumor characteristics. METHODS: Using the Surveillance, Epidemiology, and End Results Medicare-linked database, 6024 patients diagnosed with T1a renal cell carcinoma were abstracted. Multivariable logistic regression analyses were used for prediction of open radical nephrectomy, open partial nephrectomy, laparoscopic radical nephrectomy and laparoscopic partial nephrectomy. Covariates comprised of patient age, baseline comorbidity status, sex, race, marital status, socioeconomic status, population density, Surveillance, Epidemiology and End Results registry, tumor size, and year of diagnosis. RESULTS: Open radical nephrectomy decreased from 89% in 1988 to 66% in 2005 (P < 0.001), whereas open partial nephrectomy increased from 7% to 29% (P < 0.001). Meanwhile, utilization of either laparoscopic radical nephrectomy or laparoscopic partial nephrectomy remained low. Treatment utilization differed according to Surveillance, Epidemiology, and End Results registries (P < 0.001). Increasing patient age, female sex, low socioeconomic status and unmarried status (all P ≤ 0.003) were predictors of open radical nephrectomy. The utilization rates of laparoscopic radical nephrectomy or laparoscopic partial nephrectomy varied minimally according to the examined characteristics. Older patients or women were significantly more likely to undergo laparoscopic radical nephrectomy, even after adjustment for all covariates (both P ≤ 0.02). CONCLUSIONS: The rising utilization rates of radical nephrectomy are encouraging. Nevertheless, disparities of treatment type still exist. It is of concern that older and female patients are less likely to undergo nephron-sparing surgery, and to have a radical nephrectomy by the laparoscopic approach instead.

Authors: Buist DS, Bosco JL, Silliman RA, Gold HT, Field T, Yood MU, Quinn VP, Prout M, Lash TL, Breast Cancer Outcomes in Older Women (BOW) Investigators

Title: Long-term surveillance mammography and mortality in older women with a history of early stage invasive breast cancer.

Journal: Breast Cancer Res Treat 142(1):153-63

Date: 2013 Nov

Abstract: Annual surveillance mammograms in older long-term breast cancer survivors are recommended, but this recommendation is based on little evidence and with no guidelines on when to stop. Surveillance mammograms should decrease breast cancer mortality by detecting second breast cancer events at an earlier stage. We examined the association between surveillance mammography beyond 5 years after diagnosis on breast cancer-specific mortality in a cohort of women aged ≥ 65 years diagnosed 1990-1994 with early stage breast cancer. Our cohort included women who survived disease free for ≥ 5 years (N = 1,235) and were followed from year 6 through death, disenrollment, or 15 years after diagnosis. Asymptomatic surveillance mammograms were ascertained through medical record review. We used Cox proportional hazards regression stratified by follow-up year to calculate the association between time-varying surveillance mammography and breast cancer-specific and other-than-breast mortality adjusting for site, stage, primary surgery type, age and time-varying Charlson Comorbidity Index. The majority (85 %) of the 1,235 5-year breast cancer survivors received ≥ 1 surveillance mammogram in years 5-9 (yearly proportions ranged from 48 to 58 %); 82 % of women received ≥ 1 surveillance mammogram in years 10-14. A total of 120 women died of breast cancer and 393 women died from other causes (average follow-up 7.3 years). Multivariable models and lasagna plots suggested a modest reduction in breast cancer-specific mortality with surveillance mammogram receipt in the preceding year (IRR 0.82, 95 % CI 0.56-1.19, p = 0.29); the association with other-cause mortality was 0.95 (95 % CI 0.78-1.17, p = 0.64). Among older breast cancer survivors, surveillance mammography may reduce breast cancer-specific mortality even after 5 years of disease-free survival. Continuing surveillance mammography in older breast cancer survivors likely requires physician-patient discussions similar to those recommended for screening, taking into account comorbid conditions and life-expectancy.

Authors: Carlsson SV, Ehdaie B, Atoria CL, Elkin EB, Eastham JA

Title: Risk of incisional hernia after minimally invasive and open radical prostatectomy.

Journal: J Urol 190(5):1757-62

Date: 2013 Nov

Abstract: PURPOSE: The number of radical prostatectomies has increased. Many urologists have shifted from the open surgical approach to minimally invasive techniques. It is not clear whether the risk of post-prostatectomy incisional hernia varies by surgical approach. MATERIALS AND METHODS: In the linked Surveillance, Epidemiology and End Results (SEER)-Medicare data set we identified men 66 years old or older who were treated with minimally invasive or open radical prostatectomy for prostate cancer diagnosed from 2003 to 2007. The main study outcome was incisional hernia repair, as identified in Medicare claims after prostatectomy. We also examined the frequency of umbilical, inguinal and other hernia repairs. RESULTS: We identified 3,199 and 6,795 patients who underwent minimally invasive and open radical prostatectomy, respectively. The frequency of incisional hernia repair was 5.3% at a median 3.1-year followup in the minimally invasive group and 1.9% at a 4.4-year median followup in the open group, corresponding to an incidence rate of 16.1 and 4.5/1,000 person-years, respectively. Compared to the open technique, the minimally invasive procedure was associated with more than a threefold increased risk of incisional hernia repair when controlling for patient and disease characteristics (adjusted HR 3.39, 95% CI 2.63-4.38, p<0.0001). Minimally invasive radical prostatectomy was associated with an attenuated but increased risk of any hernia repair compared with open radical prostatectomy (adjusted HR 1.48, 95% CI 1.29-1.70, p<0.0001). CONCLUSIONS: Minimally invasive radical prostatectomy was associated with a significantly increased risk of incisional hernia compared with open radical prostatectomy. This is a potentially remediable complication of prostate cancer surgery that warrants increased vigilance with respect to surgical technique.

Authors: Carney PA, Bogart A, Sickles EA, Smith R, Buist DS, Kerlikowske K, Onega T, Miglioretti DL, Rosenberg R, Yankaskas BC, Geller BM

Title: Feasibility and acceptability of conducting a randomized clinical trial designed to improve interpretation of screening mammography.

Journal: Acad Radiol 20(11):1389-98

Date: 2013 Nov

Abstract: PURPOSE: To describe recruitment, enrollment, and participation in a study of US radiologists invited to participate in a randomized controlled trial of two continuing medical education (CME) interventions designed to improve interpretation of screening mammography. METHODS: We collected recruitment, consent, and intervention-completion information as part of a large study involving radiologists in California, Oregon, Washington, New Mexico, New Hampshire, North Carolina, and Vermont. Consenting radiologists were randomized to receive either a 1-day live, expert-led educational session; to receive a self-paced DVD with similar content; or to a control group (delayed intervention). The impact of the interventions was assessed using a preintervention-postintervention test set design. All activities were institutional review board approved and HIPAA compliant. RESULTS: Of 403 eligible radiologists, 151 of 403 (37.5%) consented to participate in the trial and 119 of 151 (78.8%) completed the preintervention test set, leaving 119 available for randomization to one of the two intervention groups or to controls. Female radiologists were more likely than male radiologists to consent to and complete the study (P = .03). Consenting radiologists who completed all study activities were more likely to have been interpreting mammography for 10 years or less compared to radiologists who consented and did not complete all study activities or did not consent at all. The live intervention group was more likely to report their intent to change their clinical practice as a result of the intervention compared to those who received the DVD (50% versus 17.6%, P = .02). The majority of participants in both interventions groups felt the interventions were a useful way to receive CME mammography credits. CONCLUSIONS: Community radiologists found interactive interventions designed to improve interpretative mammography performance acceptable and useful for clinical practice. This suggests CME credits for radiologists should, in part, be for examining practice skills.

Authors: Dittus K, Geller B, Weaver DL, Kerlikowske K, Zhu W, Hubbard R, Braithwaite D, O'Meara ES, Miglioretti DL, Breast Cancer Surveillance Consortium

Title: Impact of mammography screening interval on breast cancer diagnosis by menopausal status and BMI.

Journal: J Gen Intern Med 28(11):1454-62

Date: 2013 Nov

Abstract: BACKGROUND: Controversy remains regarding the frequency of screening mammography. Women with different risks for developing breast cancer because of body mass index (BMI) may benefit from tailored recommendations. OBJECTIVE: To determine the impact of mammography screening interval for women who are normal weight (BMI < 25), overweight (BMI 25-29.9), or obese (BMI ≥ 30), stratified by menopausal status. DESIGN: Two cohorts selected from the Breast Cancer Surveillance Consortium. Patient and mammography data were linked to pathology databases and tumor registries. PARTICIPANTS: The cohort included 4,432 women aged 40-74 with breast cancer; the false-positive analysis included a cohort of 553,343 women aged 40-74 without breast cancer. MAIN MEASURES: Stage, tumor size and lymph node status by BMI and screening interval (biennial vs. annual). Cumulative probability of false-positive recall or biopsy by BMI and screening interval. Analyses were stratified by menopausal status. KEY RESULTS: Premenopausal obese women undergoing biennial screening had a non-significantly increased odds of a tumor size > 20 mm relative to annual screeners (odds ratio [OR] = 2.07; 95 % confidence interval [CI] 0.997 to 4.30). Across all BMI categories from normal to obese, postmenopausal women with breast cancer did not present with higher stage, larger tumor size or node positive tumors if they received biennial rather than annual screening. False-positive recall and biopsy recommendations were more common among annually screened women. CONCLUSION: The only negative outcome identified for biennial vs. annual screening was a larger tumor size (> 20 mm) among obese premenopausal women. Since annual mammography does not improve stage at diagnosis compared to biennial screening and false-positive recall/biopsy rates are higher with annual screening, women and their primary care providers should weigh the harms and benefits when deciding on annual versus biennial screening.

Authors: Hagiwara M, Hackshaw MD, Oster G

Title: Economic burden of selected adverse events in patients aged ≥65 years with metastatic renal cell carcinoma.

Journal: J Med Econ 16(11):1300-6

Date: 2013 Nov

Abstract: OBJECTIVE: To estimate the costs of adverse events (AEs) in patients aged ≥65 years with metastatic renal cell carcinoma (mRCC). METHODS: Retrospective study using the linked Surveillance, Epidemiology and End Results (SEER) Medicare database. Study subjects consisted of persons in SEER-Medicare, aged ≥65 years, with evidence of newly diagnosed mRCC between January 1, 2007 and December 31, 2007. Adverse events of interest consisted of Grade 3 or 4 toxicities that have been reported with frequency ≥5% in randomized controlled trials of sunitinib, sorafenib, bevacizumab, and pazopanib (i.e., targeted therapies for mRCC), and included abdominal pain, back pain, diarrhea, dyspnea, extremity pain, fatigue/asthenia, hand-foot syndrome, hypertension, lymphopenia, nausea/vomiting, neutropenia, proteinuria, and thrombocytopenia. Patients in SEER-Medicare with these events were identified based on ICD-9-CM diagnosis codes on Medicare claims. For each AE of interest, costs were tallied among evented patients over 30 days, beginning with the date of each patient's first mention of the AE, and were compared with those of non-evented patients over a similar 30-day period beginning with an identical 'shadow' index date. Total costs were compared on an unadjusted basis and with adjustment for differences in baseline characteristics using a generalized linear model. RESULTS: A total of 881 patients with mRCC met study entry criteria; 60% of these patients had Medicare claims with mention of one or more AEs of interest. Events occurring with frequency >20% included abdominal pain, dyspnea, and fatigue/asthenia; 10-20% of study subjects had encounters for back pain, extremity pain, and nausea/vomiting. Mean (standard deviation) total cost of care over 30 days was substantially higher among patients with AEs ($13,944 [$14,529]) compared with those without mention of these events ($1878 [$5264]). Adjusting for differences in baseline characteristics, the mean (95% confidence interval) difference in costs between evented and non-evented patients was $12,410 ($9217-$16,522). Study limitations include problems in event ascertainment due to inaccuracies in ICD-9-CM coding on Medicare claims data, and restriction of the study population to patients with metastatic involvement at initial diagnosis of RCC. CONCLUSIONS: Costs of care are substantially higher in patients aged ≥65 years with mRCC who experience AEs commonly associated with sunitinib, sorafenib, bevacizumab, and pazopanib. Efforts to prevent and/or better manage these events potentially can reduce healthcare costs.

Authors: Hong JC, Murphy JD, Wang SJ, Koong AC, Chang DT

Title: Chemoradiotherapy before and after surgery for locally advanced esophageal cancer: a SEER-Medicare analysis.

Journal: Ann Surg Oncol 20(12):3999-4007

Date: 2013 Nov

Abstract: PURPOSE: The optimal combination and timing of therapy for esophageal cancer remains controversial. The Surveillance, Epidemiology, and End Results (SEER)-Medicare registry was used to assess neoadjuvant and adjuvant therapy. METHODS: Patients diagnosed with nonmetastatic T3+ or N1+ esophageal adenocarcinoma (ACA) or squamous cell carcinoma (SCC) from 1995 to 2002 who underwent surgical resection within 6 months of diagnosis were studied. Medicare data defined preoperative chemoradiotherapy (preCRT), preoperative radiotherapy (preRT), postoperative CRT (postCRT), chemotherapy and surgery (CT + S), and surgery alone. RESULTS: Of 419 eligible patients, 126 received preCRT, 55 preRT, 40 postCRT, 29 CT + S, and 169 surgery alone. PreCRT yielded median overall survival (OS) of 37 months, greater than surgery alone (17 months, p = 0.002) and postCRT (17 months, p = 0.06). PreRT (20 months, p = 0.20), postCRT (p = 0.88), and CT + S (20 months, p = 0.42) were not associated with OS benefit versus surgery alone. For SCC, preCRT improved survival versus surgery alone (p = 0.01), with a trend for ACA (p = 0.07). ACA (22 months) had greater OS than SCC (17 months) (p = 0.03). ACA, younger age, and married status were associated with increased OS. Adjusting for these, preCRT had longer OS versus surgery alone (p = 0.02) and postCRT (p = 0.03). Chemotherapy agents and surgical approach did not affect OS. CONCLUSIONS: In the SEER-Medicare cohort, preCRT significantly improved survival versus surgery alone and postCRT for locally advanced esophageal cancer, particularly for SCC. PreRT, postCRT, and CT + S were not associated with longer survival.

Authors: Howell EA, Egorova N, Hayes MP, Wisnivesky J, Franco R, Bickell N

Title: Racial disparities in the treatment of advanced epithelial ovarian cancer.

Journal: Obstet Gynecol 122(5):1025-32

Date: 2013 Nov

Abstract: OBJECTIVE: To examine whether treatment with guideline-recommended care (surgery and chemotherapy) is associated with mortality differences between black and white women with advanced epithelial ovarian cancer. METHODS: We conducted an observational cohort study using the Surveillance, Epidemiology, and End Results (SEER) linked to Medicare claims for 1995-2007. We evaluated long-term survival for 4,695 black and white women with stage III or stage IV epithelial ovarian cancer with Kaplan-Meier analysis and Cox regression, and then in patients matched by propensity score to create two similar cohorts for comparison. We investigated the association between race, stage, and survival among women who were treated with guideline-recommended care and those who received incomplete treatment. RESULTS: Black women with advanced epithelial ovarian cancer were more likely to die than white women (unadjusted hazard ratio [HR] 1.27; 95% confidence interval [CI] 1.10-1.46). Black women were less likely than white women to receive guideline-recommended care (54% compared with 68%; P<.001), and women who did not receive recommended treatment had lower survival rates than women who received recommended care. Cox proportional hazards models demonstrated no differences in black women compared with white women regarding mortality among women who were treated with guideline-recommended care (adjusted HR 1.04; 95% CI 0.85-1.26), or among women who received incomplete treatment (adjusted HR 1.09; 95% CI 0.89-1.34). The survival analysis of patients matched by propensity score confirmed these analyses. CONCLUSIONS: Differences in rates of treatment with guideline-recommended care are associated with black-white mortality disparities among women with advanced epithelial ovarian cancer. LEVEL OF EVIDENCE: III.

Authors: Hyder O, Dodson RM, Nathan H, Herman JM, Cosgrove D, Kamel I, Geschwind JF, Pawlik TM

Title: Referral patterns and treatment choices for patients with hepatocellular carcinoma: a United States population-based study.

Journal: J Am Coll Surg 217(5):896-906

Date: 2013 Nov

Abstract: BACKGROUND: Patterns of care of physician specialists may differ for patients with hepatocellular carcinoma (HCC). Reasons underlying variations are poorly understood. One source of variation may be disparate referral rates to specialists, leading to differences in cancer-directed treatments. STUDY DESIGN: Surveillance, Epidemiology, and End Results (SEER)-linked Medicare database was queried for patients with HCC, diagnosed between 1998 and 2007, who consulted 1 or more physicians after diagnosis. Visit and procedure records were abstracted from Medicare billing records. Factors associated with specialist consult and subsequent treatment were examined. RESULTS: There were 6,752 patients with HCC identified; 1,379 (20%) patients had early-stage disease. Median age was 73 years; the majority were male (66%), white (60%), and from the West region (56%). After diagnosis, referral to a specialist varied considerably (hepatology/gastroenterology, 60%; medical oncology, 62%; surgery, 56%; interventional radiology [IR], 33%; radiation oncology, 9%). Twenty-two percent of patients saw 1 specialist; 39% saw 3 or more specialists. Time between diagnosis and visitation with a specialist varied (surgery, 37 days vs IR, 55 days; p = 0.04). Factors associated with referral to a specialist included younger age (odds ratio [OR] 2.16), Asian race (OR 1.49), geographic region (Northeast OR 2.10), and presence of early-stage disease (OR 2.21) (all p < 0.05). Among patients with early-stage disease, 77% saw a surgeon, while 50% had a consultation with medical oncologist. Receipt of therapy among patients with early-stage disease varied (no therapy, 30%; surgery, 39%; IR, 9%; chemotherapy, 23%). Factors associated with receipt of therapy included younger age (OR 2.48) and early-stage disease (OR 2.20). CONCLUSIONS: After HCC diagnosis, referral to a specialist varied considerably. Both clinical and nonclinical factors were associated with consultation. Disparities in referral to a specialist and subsequent therapy need to be better understood to ensure all HCC patients receive appropriate care.

Authors: Kowalczyk KJ, Harbin AC, Choueiri TK, Hevelone ND, Lipsitz SR, Trinh QD, Tina Shih YC, Hu JC

Title: Use of surveillance imaging following treatment of small renal masses.

Journal: J Urol 190(5):1680-5

Date: 2013 Nov

Abstract: PURPOSE: With the increasing incidence of small renal masses, there is greater use of ablation, nephron sparing surgery and surveillance compared to radical nephrectomy. However, patterns of care in the use of posttreatment imaging remain uncharacterized. The purpose of this study is to determine the rate of posttreatment imaging after various treatments for small renal mass. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results)-Medicare data during 2005 to 2009, we identified 1,682 subjects diagnosed with small renal mass and treated with open partial nephrectomy (330), minimally invasive partial nephrectomy (160), open radical nephrectomy (404), minimally invasive radical nephrectomy (535), thermal ablation (212) and surveillance (42). Use of imaging was compared within 24 months of treatment and multivariate regression models were constructed to identify factors associated with increased imaging use. RESULTS: On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy (OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent. CONCLUSIONS: Subjects undergoing nephron sparing surgery undergo more posttreatment imaging compared to open radical nephrectomy. Although possibly associated with lower morbidity, thermal ablation is associated with significantly greater use of imaging compared to other small renal mass treatments. This may increase costs and radiation exposure, although further study is needed for confirmation.

Authors: Onitilo AA, Engel JM, James TA, Aiello Bowles EJ, McCahill LE, Feigelson HS

Title: Reply to: Should initial mastectomy rates increase?

Journal: J Am Coll Surg 217(5):960-2

Date: 2013 Nov

Abstract:

Authors: Parikh AA, Ni S, Koyama T, Pawlik TM, Penson D

Title: Trends in the multimodality treatment of resectable colorectal liver metastases: an underutilized strategy.

Journal: J Gastrointest Surg 17(11):1938-46

Date: 2013 Nov

Abstract: OBJECTIVE: Advances in multimodality therapy have led to increased survival for patients with metastatic colorectal cancer, but the impact on patients undergoing resection for colorectal liver metastases is unclear. The purpose of this study was to evaluate patterns of treatment for resectable colorectal liver metastases in the USA over the last two decades. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, 1,926 patients who underwent hepatic resection for colorectal liver metastasis between 1991 and 2007 were included and divided into two cohorts: period 1 (1991-2000) and period 2 (2001-2007). Demographic data, treatment patterns, and outcomes of the two periods were compared by univariate methods. Multivariable regression models were constructed to predict the use of perioperative chemotherapy, postoperative complications, and 90-day mortality following liver resection. RESULTS: The overall use of perioperative chemotherapy was 33 % and did not differ between periods, but shifted from postoperative to preoperative over time. By multivariable analysis, older age, black race, stage III primary cancer, and metachronous disease were predictive of lesser likelihood of chemotherapy use. The use of preoperative chemotherapy was not associated with any increase in perioperative morbidity or mortality. CONCLUSIONS: Despite increased survival and widespread recommendations for the use of multimodality therapy, the overall resection rate and use of perioperative chemotherapy for resectable colorectal liver metastases remain underutilized and have not increased over time. Efforts to investigate barriers to the widespread use of multimodality therapy for these patients are warranted.

Authors: Prasad SM, Gu X, Kowalczyk KJ, Lipsitz SR, Nguyen PL, Hu JC

Title: Morbidity and costs of salvage vs. primary radical prostatectomy in older men.

Journal: Urol Oncol 31(8):1477-82

Date: 2013 Nov

Abstract: OBJECTIVES: Salvage radical prostatectomy (RP) is performed with curative intent following post-radiotherapy recurrence for prostate cancer. While single-center salvage RP outcomes appear promising, little is known about outcomes in the community setting in elderly men. We sought to evaluate utilization, outcomes, and costs of salvage RP vs. primary RP in older men. MATERIALS AND METHODS: Surveillance, Epidemiology and End Results-Medicare linked data from 1992 to 2007 was used to identify 18,317 men aged 65 years or older who underwent RP from 2002 to 2007. Propensity score analyses were used to compare outcomes and costs for primary vs. salvage RP. RESULTS: Salvage RP was rare, accounting for 0.5% of RP. Men undergoing salvage vs. primary RP were older, white, and less likely to undergo CT, bone scan and prostate biopsy preoperatively (P < 0.05 for all). In adjusted analyses, salvage vs. primary RP was associated with increased 30-day complications (60.1% vs. 22.7%, P < 0.01), lengths of stay (mean 7 vs. 3 days, P < 0.01), and hospital readmissions within 30 days (30.4% vs. 5.7%, P < 0.01). The odds of death within 90 days were higher for salvage vs. primary RP (OR 26.7, 95% CI 12.9-55.1, P < 0.01). The median expenditure for salvage RP within 6 months postoperatively was almost twice that for primary RP (US$30,881 vs. US$12,431, P < 0.01). CONCLUSIONS: Metastatic workup was performed less frequently before salvage vs. primary RP, and morbidity and mortality for salvage RP was high relative to primary RP. Given the morbidity and high cost of salvage RP, guidelines for patient selection and selective referral may optimize outcomes, especially in older men.

Authors: Rodriguez HP, Herrera AP, Wang Y, Jacobson DM

Title: Local health department assurance of services and the health of California's seniors.

Journal: J Public Health Manag Pract 19(6):550-61

Date: 2013 Nov-Dec

Abstract: OBJECTIVE: To examine the extent to which local health department (LHD) assurance of select services known to promote and protect the health of older adults is associated with more favorable population health indicators among seniors. DESIGN: Data from the California Health Interview Survey (CHIS: 2003, 2005, and 2007) were linked with the 2005 wave of the National Association of County and City Health Officials profile survey and the Area Resource File to assess the association of LHD assurance and senior health indicators. Assurance was measured by an index of 5 services, either directly provided or contracted by LHDs: cancer screening, injury prevention, comprehensive primary care, home health care, and chronic disease prevention. Multilevel regression models estimated the association of LHD assurance of services and each of 6 older adult health indicators, controlling for individual, LHD, and county characteristics that included key social determinants of health, such as poverty. SETTING: Fifty-seven California counties. PARTICIPANTS: 33,154 older adults (age 65 and older). MAIN OUTCOME MEASURES: Colorectal cancer screening, mammography, healthy eating, physical activity, and multiple falls among older adults. RESULTS: Local health departments provided or contracted a median of 2 of the 5 services. In adjusted analyses, LHD assurance of services was generally unassociated with the seniors' health behaviors, screening, and falls. Greater LHD expenditures per capita were associated with significantly better mammography screening rates (adjusted odds ratio [AOR] = 1.22, P < 0.01) compared to jurisdictions in the bottom one-third of per capita LHD spending. Greater county-level poverty (a social determinant of health) was associated with greater junk food consumption (AOR = 1.14, P < 0.01) and worse fruit and vegetable consumption (AOR = 0.97, P < 0.01). Highly impoverished counties were consistently in the bottom quartile of performance across all indicators. CONCLUSIONS: The LHD's assurance of select services known to promote and protect the health of older adults does not appear to translate into higher rates of colorectal cancer screening, mammography, healthy eating, physical activity, and fewer falls among seniors. County-level poverty is most strongly associated with older adult health, underscoring a key barrier to address in local senior health improvement efforts.

Authors: Roetzheim RG, Lee JH, Ferrante JM, Gonzalez EC, Chen R, Fisher KJ, Love-Jackson K, McCarthy EP

Title: The influence of dermatologist and primary care physician visits on melanoma outcomes among Medicare beneficiaries.

Journal: J Am Board Fam Med 26(6):637-47

Date: 2013 Nov-Dec

Abstract: BACKGROUND: Ambulatory visits to dermatologists and primary care physicians (PCPs) may improve melanoma outcomes through early detection. We sought to measure the effect of dermatologist and PCP visits on melanoma stage at diagnosis and mortality. METHODS: We used data from the database linking Surveillance Epidemiology and End Results (SEER) and Medicare data (1994 to 2005) to examine patterns of dermatologist and PCP ambulatory visits before diagnosis for 18,884 Medicare beneficiaries with invasive melanoma or unknown stage at diagnosis. Visits were assessed during the 2-year time interval before the month of diagnosis. We examined whether dermatologist and PCP visits were associated with diagnosis of thinner melanomas (defined as local stage tumors having Breslow thickness <1 mm) and lower melanoma mortality. RESULTS: Medicare beneficiaries visiting both a dermatologist and PCP before diagnosis had greater odds of diagnosis of a thin melanoma (adjusted odds ratio, 1.26; 95% confidence interval, 1.12-1.41) and lower melanoma mortality (adjusted hazard ratio 0.66, 95% confidence interval, 0.57-0.76) compared with those without such visits. The mortality findings were attenuated once stage at diagnosis was adjusted for in the multivariable model. CONCLUSION: Improved melanoma outcomes among Medicare beneficiaries may depend on adequate access and use of dermatologist and PCP services.

Authors: Ryu SY, Crespi CM, Maxwell AE

Title: What factors explain disparities in mammography rates among Asian-American immigrant women? A population-based study in California.

Journal: Womens Health Issues 23(6):e403-10

Date: 2013 Nov-Dec

Abstract: BACKGROUND: The purpose of this study was to compare rates of screening mammography among immigrant women in five Asian-American ethnic groups in California, and ascertain the extent to which differences in mammography rates among these groups are attributable to differences in known correlates of cancer screening. METHODS: Using 2009 data from the California Health Interview Survey, we compared the rates of mammography among Chinese, Filipino, Japanese, Korean, and Vietnamese immigrants 40 years and older. To assess the impact of Asian ethnicity on participation in screening, we performed multiple logistic regression analysis with models that progressively adjusted for acculturation, sociodemographic characteristics, access to health care, and breast cancer risk factors, and examined the predicted probabilities of screening after adjusting for these factors. FINDINGS: Participation in screening mammography differed according to ethnicity, with Filipina and Vietnamese Americans having the highest rates and Korean Americans having the lowest rates of lifetime and recent (past 2 years) screening. These differences decreased substantially after adjusting for acculturation, sociodemographic factors, and risk factors of breast cancer, but differences remained, most notably for Korean Americans, who continued to have the lowest predicted probability of screening even after adjustment for these factors. CONCLUSIONS: This analysis draws attention to low mammography screening rates among Asian-American immigrants, especially recent immigrants who lack health insurance. Given that their breast cancer incidence is rising with length of stay in the United States, it is important to increase regular mammography screening in these groups.

Authors: Schroeck FR, Kaufman SR, Jacobs BL, Skolarus TA, Miller DC, Weizer AZ, Montgomery JS, Wei JT, Shahinian VB, Hollenbeck BK

Title: Technology diffusion and diagnostic testing for prostate cancer.

Journal: J Urol 190(5):1715-20

Date: 2013 Nov

Abstract: PURPOSE: While the dissemination of robotic prostatectomy and intensity modulated radiotherapy may fuel the increased use of prostatectomy and radiotherapy, these new technologies may also have spillover effects related to diagnostic testing for prostate cancer. Therefore, we examined the association of regional technology penetration with the receipt of prostate specific antigen testing and prostate biopsy. MATERIALS AND METHODS: In this retrospective cohort study we included 117,857 men 66 years old or older from the 5% sample of Medicare beneficiaries living in Surveillance, Epidemiology and End Results (SEER) areas from 2003 to 2007. Regional technology penetration was measured as the number of providers performing robotic prostatectomy or intensity modulated radiotherapy per population in a health care market, ie hospital referral region. We assessed the association of technology penetration with the prostate specific antigen testing rate and prostate biopsy using generalized estimating equations. RESULTS: High technology penetration was associated with an increased rate of prostate specific antigen testing (442 vs 425/1,000 person-years, p<0.01) and a similar rate of prostate biopsy (10.1 vs 9.9/1,000 person-years, p=0.69). The impact of technology penetration on prostate specific antigen testing and prostate biopsy was much less than the effect of age, race and comorbidity, eg the prostate specific antigen testing rate per 1,000 person-years was 485 vs 373 for men with only 1 vs 3+ comorbid conditions (p<0.01). CONCLUSIONS: Increased technology penetration is associated with a slightly higher rate of prostate specific antigen testing and no change in the prostate biopsy rate. Collectively, our findings temper concerns that adopting new technology accelerates diagnostic testing for prostate cancer.

Authors: Shahinian VB, Kuo YF

Title: Patterns of bone mineral density testing in men receiving androgen deprivation for prostate cancer.

Journal: J Gen Intern Med 28(11):1440-6

Date: 2013 Nov

Abstract: BACKGROUND: Practice guidelines recommend bone mineral density (BMD) monitoring for men on androgen deprivation therapy (ADT) for prostate cancer, but single center studies suggest this is underutilized. OBJECTIVE: We examined determinants of BMD testing in men receiving ADT in a large population-based cohort of men with prostate cancer. DESIGN: Retrospective cohort study. PARTICIPANTS: We used the Surveillance, Epidemiology and End-Results (SEER)-Medicare database to identify 84,036 men with prostate cancer initiating ADT from 1996 through 2008. MAIN MEASURES: Rates of BMD testing within the period 12 months prior to 3 months after initiation of ADT were assessed and compared to matched controls without cancer and to men with prostate cancer not receiving ADT. A logistic regression model was performed predicting use of BMD testing, adjusted for patient demographics, indications for ADT use, year of diagnosis and specialty of the physician involved in the care of the patient. KEY RESULTS: Rates of BMD testing increased steadily over time in men receiving ADT, diverging from the control groups such that by 2008, 11.5 % of men were receiving BMD testing versus 4.4 % in men with prostate cancer not on ADT and 3.8 % in the non-cancer controls. In the logistic regression model, year of diagnosis, race/ethnicity, indications for ADT use and geographic region were significant predictors of BMD testing. Patients with only a urologist involved in their care were significantly less likely to receive BMD testing as compared to those with both a urologist and a primary care physician (PCP) (odds ratio 0.71, 95 % confidence interval 0.64-0.80). CONCLUSIONS: There has been a sharp increase in rates of BMD testing among men receiving ADT for prostate cancer over time, beyond rates noted in contemporaneous controls. Absolute rates of BMD testing remain low, however, but are higher in men who have a PCP involved in their care.

Authors: Shirvani SM, Jiang J, Gomez DR, Chang JY, Buchholz TA, Smith BD

Title: Intensity modulated radiotherapy for stage III non-small cell lung cancer in the United States: predictors of use and association with toxicities.

Journal: Lung Cancer 82(2):252-9

Date: 2013 Nov

Abstract: BACKGROUND: Intensity modulated radiotherapy for stage III lung cancer has become commonplace in the United States in the absence of randomized controlled trials. We used a large, population-based database to determine which factors led to increased utilization of IMRT and to evaluate associations of IMRT with toxicities. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare records identified 3986 individuals aged 66 years or older diagnosed with stage III lung cancer between 2001 and 2007 and treated with IMRT or 3D conformal radiotherapy. Predictors of IMRT use were determined using logistic regression. Associations of IMRT use with diagnosis codes for radiation-related toxicities were evaluated with multivariate proportional hazards regression and propensity-score matching. RESULTS: Among the 3986 patients studied, the median age was 75 years, 54.1% were male, and 62% had IIIA disease. Two hundred and fifty seven (6.5%) patients received IMRT, with use increasing from 0.5% in 2001 to 14.7% in 2007 (P < 0.001). Key predictors of IMRT delivery included increasing year of diagnosis and treatment in a freestanding center (odds ratio, 2.10; 95% confidence interval [CI], 1.59-2.77, P < 0.001); tumor size, stage, and number of radiotherapy fractions delivered were not associated with IMRT use. IMRT use was not associated with a higher burden of lung or esophagus toxicities when compared to 3DCRT. CONCLUSION: These findings suggest that practice environment strongly influenced adoption of IMRT for lung cancer. Patient and tumor factors were not significant predictors of IMRT use. Esophagus and lung toxicity rates were similar between IMRT and 3DCRT.

Authors: Sigel K, Lurslurchachai L, Bonomi M, Mhango G, Bergamo C, Kale M, Halm E, Wisnivesky J

Title: Effectiveness of radiation therapy alone for elderly patients with unresected stage III non-small cell lung cancer.

Journal: Lung Cancer 82(2):266-70

Date: 2013 Nov

Abstract: PURPOSE: Chemoradiotherapy is the standard of care for unresectable stage III non-small cell lung cancer (NSCLC). Elderly patients, who are often considered unfit for combined chemoradiotherapy, frequently receive radiation therapy (RT) alone. Using population-based data, we evaluated the effectiveness and tolerability of lone RT in unresected elderly stage III NSCLC patients. METHODS AND MATERIALS: Using the Surveillance, Epidemiology and End Results (SEER) registry linked to Medicare records we identified 10,376 cases of unresected stage III NSCLC that were not treated with chemotherapy, diagnosed between 1992 and 2007. We used logistic regression to determine propensity scores for RT treatment using patients' pre-treatment characteristics. We then compared survival of patients who underwent lone RT vs. no treatment using a Cox regression model adjusting for propensity scores. The adjusted odds for toxicity among patients treated with and without RT were also estimated. RESULTS: Overall, 6468 (62%) patients received lone RT. Adjusted analyses showed that RT was associated with improved overall survival in unresected stage III NCSLC (hazard ratio [HR]: 0.76; 95% confidence interval [CI]: 0.74-0.79) after controlling for propensity scores. RT treated patients had an increased adjusted risk of hospitalization for pneumonitis (odds ratio [OR]: 89, 95% CI: 12-636), and esophagitis (OR: 8, 95% CI: 3-21). CONCLUSIONS: These data suggest that use of RT alone may improve the outcomes of elderly patients with unresected stage III NSCLC. Severe toxicity, however, was considerably higher in the RT treated group. The potential risks and benefits of RT should be carefully discussed with eligible elderly NSCLC patients.

Authors: Smith-Gagen J, Carrillo JE, Ang A, Pérez-Stable EJ

Title: Practices that reduce the Latina survival disparity after breast cancer.

Journal: J Womens Health (Larchmt) 22(11):938-46

Date: 2013 Nov

Abstract: OBJECTIVES: Latina breast cancer patients are 20 percent more likely to die within 5 years after diagnosis compared with white women, even though they have a lower incidence of breast cancer, lower general mortality rates, and some better health behaviors. Existing data only examine disparities in the utilization of breast cancer care; this research expands the study question to which utilization factors drive the shorter survival in Latina women compared with white women. METHODS: This longitudinal linked Surveillance Epidemiology and End Results (SEER)-Medicare cohort study examined early stage breast cancer patients diagnosed between 1992 and 2000 and followed for 5-11 years after diagnosis (N=44,999). Modifiable utilization factors included consistent visits to primary care providers and to specialists after diagnosis, consistent post-diagnosis mammograms, and receipt of initial care consistent with current standards of care. RESULTS: Of the four utilization factors potentially driving this disparity, a lack of consistent post-diagnosis mammograms was the strongest driver of the Latina breast cancer survival disparity. Consistent mammograms attenuated the hazard of death from 23% [hazard ratio, HR, (95% confidence interval, 95%CI)=1.23 (1.1,1.4)] to a nonsignificant 12% [HR (95%CI)=1.12 (0.7,1.3)] and reduced the excess hazard of death in Latina women by 55%. Effect modification identified that visits to primary care providers have a greater protective impact on the survival of Latina compared to white women [HR (95%CI)=0.9 (0.9,0.9)]. CONCLUSIONS: We provide evidence that undetected new or recurrent breast cancers due to less consistent post-diagnosis mammograms contribute substantially to the long-observed Latina survival disadvantage. Interventions involving primary care providers may be especially beneficial to this population.

Authors: Stover AM, Reeve BB, Piper BF, Alfano CM, Smith AW, Mitchell SA, Bernstein L, Baumgartner KB, McTiernan A, Ballard-Barbash R

Title: Deriving clinically meaningful cut-scores for fatigue in a cohort of breast cancer survivors: a Health, Eating, Activity, and Lifestyle (HEAL) Study.

Journal: Qual Life Res 22(9):2279-92

Date: 2013 Nov

Abstract: PURPOSE: To empirically determine clinically meaningful cut-scores on the 0-10 response scale of the revised Piper Fatigue Scale (PFS-R) and its shorter version (PFS-12). Breast cancer survivors were classified (i.e., none, mild, moderate, or severe fatigue) based on the cut-scores, and relationships between these cut-scores and decrements in health-related quality of life (HRQOL) were examined. METHODS: A total of 857 breast cancer survivors, stages in situ-IIIa, from the Health, Eating, Activity, and Lifestyle (HEAL) Study were eligible. Survivors completed the PFS-R, SF-36, and a sexual health scale approximately 3 years after diagnosis. Multivariate analysis of covariance was used to examine five fatigue severity cut-score models, controlling for demographics, clinical characteristics, comorbidity, and antidepressant use. Multivariate regression was used to examine HRQOL decrements by cut-score category. RESULTS: Analyses supported two similar fatigue severity cut-score models for the PFS-R and PFS-12: Model A.) none (0), mild (1-3), moderate (4-6), and severe (7-10); and Model D.) none (0), mild (1-2), moderate (3-5), and severe (6-10). For every threshold increase in fatigue severity, clinically meaningful decrements in physical, mental, and sexual health scores were observed, supporting construct validity of the fatigue cut-scores. CONCLUSION: Standardized fatigue cut-scores may enhance interpretability and comparability across studies and populations and guide treating planning.

Authors: Strope SA, Chang SH, Chen L, Sandhu G, Piccirillo JF, Schootman M

Title: Survival impact of followup care after radical cystectomy for bladder cancer.

Journal: J Urol 190(5):1698-703

Date: 2013 Nov

Abstract: PURPOSE: Due to substantial variation in patient followup after radical cystectomy for bladder cancer, we sought to understand the effect of urine and laboratory tests, physician visits and imaging on overall survival. MATERIALS AND METHODS: We analyzed a cohort of patients treated in the fee for service Medicare population from 1992 through 2007 using Surveillance Epidemiology and End Results (SEER)-Medicare data. Using propensity score analysis, we assessed the relationship between time and geography standardized expenditures on followup care and overall survival during 3 postoperative periods, including perioperative (0 to 3 months), early followup (4 to 6 months) and later followup (7 to 24 months). Using instrumental variable analysis, we assessed the overall survival impact of the quantity of followup care by category, including physician visits, imaging, and laboratory and urine tests. RESULTS: We found no improvement in survival due to followup care in the perioperative and early followup periods. Receiving followup care during later followup was associated with improved survival in the low, middle and high expenditure tertiles (HR 0.23, 95% CI 0.15-0.35, HR 0.27, 95% CI 0.18-0.40 and HR 0.47, 95% CI 0.31-0.71, respectively). Instrumental variable analysis suggested that only physician visits and urine testing improved survival (HR 0.96, 0.93-0.99 and 0.95, 0.91-0.99, respectively). CONCLUSIONS: Followup care after radical cystectomy in the later followup period was associated with improved survival. Physician visits and urine tests were associated with this improved survival. Our results suggest that aspects of followup care significantly improve patient outcomes but imaging could be done more judiciously after cystectomy.

Authors: Wang SY, Virnig BA, Tuttle TM, Jacobs DR Jr, Kuntz KM, Kane RL

Title: Variability of preoperative breast MRI utilization among older women with newly diagnosed early-stage breast cancer.

Journal: Breast J 19(6):627-36

Date: 2013 Nov-Dec

Abstract: While magnetic resonance imaging (MRI) is frequently used following breast cancer diagnosis, routine use of breast MRI for preoperative evaluation remains contentious. We identified factors associated with preoperative breast MRI utilization and investigated the variation among physicians. We used the surveillance, epidemiology, and end Results (SEER)-Medicare linked database to analyze the preoperative breast MRI utilization among patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007. Multilevel logistic regression models were used to identify patient- and physician-level predictors of preoperative MRI utilization. Of 56,743 women with early-stage breast cancer who were treated with surgery and evaluated by a preoperative mammogram and/or ultrasound during the study period, 8.7% (n = 4,913) received preoperative breast MRI. While patient and tumor characteristics did predict preoperative breast MRI utilization, they explained only 15.4% of the variation in utilization rates. Differences in preoperative breast MRI utilization across physicians were large, after controlling patient-level factors and physicians' volumes. Accounting for clustering of patients within individual physicians (n = 3,144), the multilevel logistic regression models explained 36.4% of variation. The median odds ratio of 3.2, corresponding with the median value of the relative odds of receiving preoperative breast MRI between two randomly chosen physicians, indicated a large individual physician effect. Our study found that preoperative breast MRI has been adopted rapidly and variably. Although patient characteristics were associated with preoperative breast MRI utilization, physician practice was a major determinant of whether women received preoperative breast MRI. Future studies should evaluate whether routine use of preoperative breast MRI in newly diagnosed early-stage breast cancer improves clinical outcomes.

Authors: Wood WA, Chai X, Weisdorf D, Martin PJ, Cutler C, Inamoto Y, Wolff D, Pavletic SZ, Pidala J, Palmer JM, Arora M, Arai S, Jagasia M, Storer B, Lee SJ, Mitchell S

Title: Comorbidity burden in patients with chronic GVHD.

Journal: Bone Marrow Transplant 48(11):1429-36

Date: 2013 Nov

Abstract: Chronic GVHD (cGVHD) is associated with mortality, disability and impaired quality of life. Understanding the role of comorbidity in patients with cGVHD is important both for prognostication and potentially for tailoring treatments based on mortality risks. In a prospective cohort study of patients with cGVHD (n=239), we examined the performance of two comorbidity scales, the Functional Comorbidity Index (FCI) and the Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI). Both scales detected a higher number of comorbidities at cGVHD cohort enrollment than pre-hematopoietic cell transplant (HCT) (P<0.001). Higher HCT-CI scores at the time of cGVHD cohort enrollment were associated with higher non-relapse mortality (HR: 1.21:1.04-1.42, P=0.01). For overall mortality, we detected an interaction with platelet count. Higher HCT-CI scores at enrollment were associated with an increased risk of overall mortality when the platelet count was ≤ 100,000/μL (HR: 2.01:1.20-3.35, P=0.01), but not when it was >100,000/μL (HR: 1.05:0.90-1.22, P=0.53). Comorbidity scoring may help better to predict survival outcomes in patients with cGVHD. Further studies to understand vulnerability unrelated to cGVHD activity in this patient population are needed.

Authors: Guy GP Jr, Ekwueme DU, Yabroff KR, Dowling EC, Li C, Rodriguez JL, de Moor JS, Virgo KS

Title: Economic burden of cancer survivorship among adults in the United States.

Journal: J Clin Oncol 31(30):3749-57

Date: 2013 Oct 20

Abstract: PURPOSE: To present nationally representative estimates of the impact of cancer survivorship on medical expenditures and lost productivity among adults in the United States. METHODS: Using the 2008 to 2010 Medical Expenditure Panel Survey, we identified 4,960 cancer survivors and 64,431 individuals without a history of cancer age ≥ 18 years. Direct medical costs were measured using annual health care expenditures and examined by source of payment and service type. Indirect morbidity costs were estimated from lost productivity as a result of employment disability, missed work days, and lost household productivity. We evaluated the economic burden of cancer survivorship by estimating excess costs among cancer survivors, stratified by time since diagnosis (recently diagnosed [≤ 1 year] and previously diagnosed [> 1 year]), compared with individuals without a history of cancer using multivariable regression models stratified by age (18 to 64 and ≥ 65 years), controlling for age, sex, race/ethnicity, education, and comorbidities. RESULTS: In 2008 to 2010, the annual excess economic burden of cancer survivorship among recently diagnosed cancer survivors was $16,213 per survivor age 18 to 64 years and $16,441 per survivor age ≥ 65 years. Among previously diagnosed cancer survivors, the annual excess burden was $4,427 per survivor age 18 to 64 years and $4,519 per survivor age ≥ 65 years. Excess medical expenditures composed the largest share of the economic burden among cancer survivors, particularly among those recently diagnosed. CONCLUSION: The economic impact of cancer survivorship is considerable and is also high years after a cancer diagnosis. Efforts to reduce the economic burden caused by cancer will be increasingly important given the growing population of cancer survivors.

Authors: Forsythe LP, Parry C, Alfano CM, Kent EE, Leach CR, Haggstrom DA, Ganz PA, Aziz N, Rowland JH

Title: Use of survivorship care plans in the United States: associations with survivorship care.

Journal: J Natl Cancer Inst 105(20):1579-87

Date: 2013 Oct 16

Abstract: BACKGROUND: Survivorship care plans (SCPs), including a treatment summary and follow-up plan, intend to promote coordination of posttreatment cancer care; yet, little is known about the provision of these documents by oncologists to primary care physicians (PCPs). This study compared self-reported oncologist provision and PCP receipt of treatment summaries and follow-up plans, characterized oncologists who reported consistent provision of these documents to PCPs, and examined associations between PCP receipt of these documents and survivorship care. METHODS: A nationally representative sample of medical oncologists (n = 1130) and PCPs (n = 1020) were surveyed regarding follow-up care for breast and colon cancer survivors. All statistical tests were two-sided. Multivariable regression models identified factors associated with oncologist provision of treatment summaries and SCPs to PCPs (always/almost always vs less frequent). RESULTS: Nearly half of oncologists reported always/almost always providing treatment summaries, whereas 20.2% reported always/almost always providing SCPs (treatment summary + follow-up plan). Approximately one-third of PCPs indicated always/almost always receiving treatment summaries; 13.4% reported always/almost always receiving SCPs. Oncologists who reported training in late- and long-term effects of cancer and use of electronic medical records were more likely to report SCP provision (P < .05). PCP receipt of SCPs was associated with better PCP-reported care coordination, physician-physician communication, and confidence in survivorship care knowledge compared to receipt of neither treatment summaries nor SCPs (P < .05). CONCLUSIONS: Providing SCPs to PCPs may enhance survivorship care coordination, physician-physician communication, and PCP confidence. However, considerable progress will be necessary to achieve implementation of sharing SCPs among oncologists and PCPs.

Authors: Kent EE, Forsythe LP, Yabroff KR, Weaver KE, de Moor JS, Rodriguez JL, Rowland JH

Title: Are survivors who report cancer-related financial problems more likely to forgo or delay medical care?

Journal: Cancer 119(20):3710-7

Date: 2013 Oct 15

Abstract: BACKGROUND: Financial problems caused by cancer and its treatment can substantially affect survivors and their families and create barriers to seeking health care. METHODS: The authors identified cancer survivors diagnosed as adults (n=1556) from the nationally representative 2010 National Health Interview Survey. Using multivariable logistic regression analyses, the authors report sociodemographic, clinical, and treatment-related factors associated with perceived cancer-related financial problems and the association between financial problems and forgoing or delaying health care because of cost. Adjusted percentages using the predictive marginals method are presented. RESULTS: Cancer-related financial problems were reported by 31.8% (95% confidence interval, 29.3%-34.5%) of survivors. Factors found to be significantly associated with cancer-related financial problems in survivors included younger age at diagnosis, minority race/ethnicity, history of chemotherapy or radiation treatment, recurrence or multiple cancers, and shorter time from diagnosis. After adjustment for covariates, respondents who reported financial problems were more likely to report delaying (18.3% vs 7.4%) or forgoing overall medical care (13.8% vs 5.0%), prescription medications (14.2% vs 7.6%), dental care (19.8% vs 8.3%), eyeglasses (13.9% vs 5.8%), and mental health care (3.9% vs 1.6%) than their counterparts without financial problems (all P<.05). CONCLUSIONS: Cancer-related financial problems are not only disproportionately represented in survivors who are younger, members of a minority group, and have a higher treatment burden, but may also contribute to survivors forgoing or delaying medical care after cancer.

Authors: Quek RG, Master VA, Ward KC, Lin CC, Virgo KS, Portier KM, Lipscomb J

Title: Determinants of the combined use of external beam radiotherapy and brachytherapy for low-risk, clinically localized prostate cancer.

Journal: Cancer 119(20):3619-28

Date: 2013 Oct 15

Abstract: BACKGROUND: Prostate cancer treatment choices have been shown to vary by physician and patient characteristics. For patients with low-risk, clinically localized prostate cancer, the authors examined the impact of their clinical, sociodemographic, and radiation oncologists' (RO) characteristics on the likelihood that the patients would receive combined external beam radiotherapy and brachytherapy, a treatment regimen that is at variance with clinical guidelines. METHODS: The Surveillance, Epidemiology and End Results (SEER)-Medicare linked database and the American Medical Association Physician Masterfile were used in a retrospective analysis of 5531 patients with low-risk, clinically localized prostate cancer who were diagnosed between 2004 and 2007, and the 708 ROs who treated them. Hierarchical logistic regression analyses were used to evaluate the relationship between patient and RO characteristics and the use of combined therapy within 6 months of diagnosis. RESULTS: Overall, 356 patients (6.4%) received combined therapy. Nonclinical factors were found to be associated with combined therapy. After adjusting for patient and RO characteristics, the odds of receiving combined therapy for patients residing in Georgia were found to be significantly greater than for all other SEER regions. Black patients were significantly less likely to receive combined therapy (odds ratio, 0.62; 95% confidence interval, 0.40-0.96 [P= .03]) compared with white patients. In addition, ROs accounted for 36.6% of the variation in patients receiving combined therapy. CONCLUSIONS: Geographic and sociodemographic factors were found to be significantly associated with guideline-discordant combined therapy for patients diagnosed with low-risk, clinically localized prostate cancer. Which RO a patient consults is important in determining whether they receive combined therapy.

Authors: Gupta S, Halm EA, Rockey DC, Hammons M, Koch M, Carter E, Valdez L, Tong L, Ahn C, Kashner M, Argenbright K, Tiro J, Geng Z, Pruitt S, Skinner CS

Title: Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial.

Journal: JAMA Intern Med 173(18):1725-32

Date: 2013 Oct 14

Abstract: IMPORTANCE: Colorectal cancer (CRC) screening saves lives, but participation rates are low among underserved populations. Knowledge on effective approaches for screening the underserved, including best test type to offer, is limited. OBJECTIVE: To determine (1) if organized mailed outreach boosts CRC screening compared with usual care and (2) if FIT is superior to colonoscopy outreach for CRC screening participation in an underserved population. DESIGN, SETTING, AND PARTICIPANTS: We identified uninsured patients, not up to date with CRC screening, age 54 to 64 years, served by the John Peter Smith Health Network, Fort Worth and Tarrant County, Texas, a safety net health system. INTERVENTIONS: Patients were assigned randomly to 1 of 3 groups. One group was assigned to fecal immunochemical test (FIT) outreach, consisting of mailed invitation to use and return an enclosed no-cost FIT (n = 1593). A second was assigned to colonoscopy outreach, consisting of mailed invitation to schedule a no-cost colonoscopy (n = 479). The third group was assigned to usual care, consisting of opportunistic primary care visit-based screening (n = 3898). In addition, FIT and colonoscopy outreach groups received telephone follow-up to promote test completion. MAIN OUTCOME MEASURES: Screening participation in any CRC test within 1 year after randomization. RESULTS: Mean patient age was 59 years; 64% of patients were women. The sample was 41% white, 24% black, 29% Hispanic, and 7% other race/ethnicity. Screening participation was significantly higher for both FIT (40.7%) and colonoscopy outreach (24.6%) than for usual care (12.1%) (P < .001 for both comparisons with usual care). Screening was significantly higher for FIT than for colonoscopy outreach (P < .001). In stratified analyses, screening was higher for FIT and colonoscopy outreach than for usual care, and higher for FIT than for colonoscopy outreach among whites, blacks, and Hispanics (P < .005 for all comparisons). Rates of CRC identification and advanced adenoma detection were 0.4% and 0.8% for FIT outreach, 0.4% and 1.3% for colonoscopy outreach, and 0.2% and 0.4% for usual care, respectively (P < .05 for colonoscopy vs usual care advanced adenoma comparison; P > .05 for all other comparisons). Eleven of 60 patients with abnormal FIT results did not complete colonoscopy. CONCLUSIONS AND REVELANCE: Among underserved patients whose CRC screening was not up to date, mailed outreach invitations resulted in markedly higher CRC screening compared with usual care. Outreach was more effective with FIT than with colonoscopy invitation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01191411.

Authors: Fu AZ, Tsai HT, Marshall JL, Freedman AN, Potosky AL

Title: Utilization of bevacizumab in US elderly patients with colorectal cancer receiving chemotherapy.

Journal: J Oncol Pharm Pract :-

Date: 2013 Oct 11

Abstract: OBJECTIVE: /st>Bevacizumab, the first FDA-approved anti-angiogenesis agent, has been used for metastatic colorectal cancer since 2004. This study evaluated the utilization of bevacizumab among elderly metastatic colorectal cancer patients in the United States. METHODS: /st>Using Surveillance and Epidemiology and End RESULTS: (SEER)-Medicare data, this retrospective cohort study consisted of individuals aged 65 years or older with a colorectal cancer diagnosis between 2005 and 2009, who received chemotherapy any time through 2010. This included patients with newly diagnosed metastatic colorectal cancer and patients who progressed from initially diagnosed earlier-stage disease. We ascertained comorbid conditions using ICD-9 codes and conducted logistic regression to identify patients' characteristics associated with bevacizumab use. RESULT: A total of 8645 patients were identified (mean age 74 years; 52% male); 57% of patients received bevacizumab with initially diagnosed metastatic colorectal cancer and 44% of patients with treated progressive or recurrent disease. After adjusting for other covariates, we found that patients aged ≥80 years were less likely to receive bevacizumab compared with those aged 65-69 years (odds ratio (OR), 0.64 (95% confidence interval (CI): 0.57-0.73)), or if they had evidence of comorbid cardiomyopathy/congestive heart failure (OR, 0.82 (CI: 0.70-0.95)) or arrhythmic disorder (OR, 0.85 (CI: 0.75-0.96)). Adoption of bevacizumab into practice was rapid following its approval, and the use increased from 36% to 40% from 2005 to 2010 (p = 0.013). There were significant regional variations in bevacizumab use. CONCLUSIONS: /st>Despite rapid uptake since its original approval, there appears to be low use of bevacizumab in elderly metastatic colorectal cancer patients in the United States. Regional variations and the strong effects of age and comorbidity suggest lack of consensus among oncologists regarding benefits and risks of bevacizumab in elderly patients.

Authors: Ferrante JM, Lee JH, McCarthy EP, Fisher KJ, Chen R, Gonzalez EC, Love-Jackson K, Roetzheim RG

Title: Primary care utilization and colorectal cancer incidence and mortality among Medicare beneficiaries: a population-based, case-control study.

Journal: Ann Intern Med 159(7):437-46

Date: 2013 Oct 01

Abstract: BACKGROUND: Utilization of primary care may decrease colorectal cancer (CRC) incidence and death through greater receipt of CRC screening tests. OBJECTIVE: To examine the association of primary care utilization with CRC incidence, CRC deaths, and all-cause mortality. DESIGN: Population-based, case-control study. SETTING: Medicare program. PARTICIPANTS: Persons aged 67 to 85 years diagnosed with CRC between 1994 and 2005 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions matched with control patients (n = 205,804 for CRC incidence, 54,160 for CRC mortality, and 121,070 for all-cause mortality). MEASUREMENTS: Primary care visits in the 4- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality, and all-cause mortality. RESULTS: Compared with persons having 0 or 1 primary care visit, persons with 5 to 10 visits had lower CRC incidence (adjusted odds ratio [OR], 0.94 [95% CI, 0.91 to 0.96]) and mortality (adjusted OR, 0.78 [CI, 0.75 to 0.82]) and lower all-cause mortality (adjusted OR, 0.79 [CI, 0.76 to 0.82]). Associations were stronger in patients with late-stage CRC diagnosis, distal lesions, and diagnosis in more recent years when there was greater Medicare screening coverage. Ever receipt of CRC screening and polypectomy mediated the association of primary care utilization with CRC incidence. LIMITATION: This study used administrative data, which made it difficult to identify potential confounders and prevented examination of the content of primary care visits. CONCLUSION: Medicare beneficiaries with higher utilization of primary care have lower CRC incidence and mortality and lower overall mortality. Increasing and promoting access to primary care in the United States for Medicare beneficiaries may help decrease the national burden of CRC. PRIMARY FUNDING SOURCE: American Cancer Society.

Authors: Hershman DL, Wright JD, Lim E, Buono DL, Tsai WY, Neugut AI

Title: Contraindicated use of bevacizumab and toxicity in elderly patients with cancer.

Journal: J Clin Oncol 31(28):3592-9

Date: 2013 Oct 01

Abstract: PURPOSE: Drugs are approved on the basis of randomized trials conducted in selected populations. However, once approved, these treatments are usually expanded to patients ineligible for the trial. PATIENTS AND METHODS: We used the SEER-Medicare database to identify subjects older than 65 years with metastatic breast, lung, and colon cancer, diagnosed between 2004 and 2007 and undergoing follow-up to 2009, who received bevacizumab. We defined a contraindication as having at least two billing claims before bevacizumab for thrombosis, cardiac disease, stroke, hemorrhage, hemoptysis, or GI perforation. We defined toxicity as first development of one of these conditions after therapy. RESULTS: Among 16,085 metastatic patients identified, 3,039 (18.9%) received bevacizumab. Receipt of bevacizumab was associated with white race, later year of diagnosis, tumor type, and decreased comorbid conditions. Of patients who received bevacizumab, 1,082 (35.5%) had a contraindication. In multivariate analysis, receipt of bevacizumab with a contraindication was associated with black race (odds ratio [OR] = 2.6; 95% CI, 1.4 to 4.9), increased age, comorbidity, later year of diagnosis, and lower socioeconomic status. Patients with lung (OR = 1.7; 95% CI, 1.1 to 2.4) and colon cancer (OR = 1.4; 95% CI, 1.1 to 1.9) were more likely to have a contraindication. In the group with no contraindication, 30% had a complication after bevacizumab; black patients were more likely to have a complication than were white patients (OR = 1.9; 95% CI, 1.21 to 2.93). CONCLUSION: Our study demonstrates widespread use of bevacizumab among patients who had contraindications. Black patients were less likely to receive the drug, but those who did were more likely to have a contraindication. Efforts to understand toxicity and efficacy in populations excluded from clinical trials are needed.

Authors: Hong JC, Kruser TJ, Gondi V, Mohindra P, Cannon DM, Harari PM, Bentzen SM

Title: Risk of cerebrovascular events in elderly patients after radiation therapy versus surgery for early-stage glottic cancer.

Journal: Int J Radiat Oncol Biol Phys 87(2):290-6

Date: 2013 Oct 01

Abstract: PURPOSE: Comprehensive neck radiation therapy (RT) has been shown to increase cerebrovascular disease (CVD) risk in advanced-stage head-and-neck cancer. We assessed whether more limited neck RT used for early-stage (T1-T2 N0) glottic cancer is associated with increased CVD risk, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. METHODS AND MATERIALS: We identified patients ≥66 years of age with early-stage glottic laryngeal cancer from SEER diagnosed from 1992 to 2007. Patients treated with combined surgery and RT were excluded. Medicare CPT codes for carotid interventions, Medicare ICD-9 codes for cerebrovascular events, and SEER data for stroke as the cause of death were collected. Similarly, Medicare CPT and ICD-9 codes for peripheral vascular disease (PVD) were assessed to serve as an internal control between treatment groups. RESULTS: A total of 1413 assessable patients (RT, n=1055; surgery, n=358) were analyzed. The actuarial 10-year risk of CVD was 56.5% (95% confidence interval 51.5%-61.5%) for the RT cohort versus 48.7% (41.1%-56.3%) in the surgery cohort (P=.27). The actuarial 10-year risk of PVD did not differ between the RT (52.7% [48.1%-57.3%]) and surgery cohorts (52.6% [45.2%-60.0%]) (P=.89). Univariate analysis showed an increased association of CVD with more recent diagnosis (P=.001) and increasing age (P=.001). On multivariate Cox analysis, increasing age (P<.001) and recent diagnosis (P=.002) remained significantly associated with a higher CVD risk, whereas the association of RT and CVD remained not statistically significant (HR=1.11 [0.91-1.37,] P=.31). CONCLUSIONS: Elderly patients with early-stage laryngeal cancer have a high burden of cerebrovascular events after surgical management or RT. RT and surgery are associated with comparable risk for subsequent CVD development after treatment in elderly patients.

Authors: Sigel K, Crothers K, Dubrow R, Krauskopf K, Jao J, Sigel C, Moskowitz A, Wisnivesky J

Title: Prognosis in HIV-infected patients with non-small cell lung cancer.

Journal: Br J Cancer 109(7):1974-80

Date: 2013 Oct 01

Abstract: BACKGROUND: We conducted a population-based study to evaluate whether non-small cell lung cancer (NSCLC) prognosis was worse in HIV-infected compared with HIV-uninfected patients. METHODS: Using the Surveillance, Epidemiology and End Results (SEER) registry linked to Medicare claims, we identified 267 HIV-infected patients and 1428 similar controls with no evidence of HIV diagnosed with NSCLC between 1996 and 2007. We used conditional probability function (CPF) analyses to compare survival by HIV status accounting for an increased risk of non-lung cancer death (competing risks) in HIV-infected patients. We used multivariable CPF regression to evaluate lung cancer prognosis by HIV status adjusted for confounders. RESULTS: Stage at presentation and use of stage-appropriate lung cancer treatment did not differ by HIV status. Median survival was 6 months (95% confidence interval (CI): 5-8 months) among HIV-infected NSCLC patients compared with 20 months (95% CI: 17-23 months) in patients without evidence of HIV. Multivariable CPF regression showed that HIV was associated with a greater risk of lung cancer-specific death after controlling for confounders and competing risks. CONCLUSION: NSCLC patients with HIV have a poorer prognosis than patients without evidence of HIV. NSCLC may exhibit more aggressive behaviour in the setting of HIV.

Authors: Trantham LC, Nielsen ME, Mobley LR, Wheeler SB, Carpenter WR, Biddle AK

Title: Use of prostate-specific antigen testing as a disease surveillance tool following radical prostatectomy.

Journal: Cancer 119(19):3523-30

Date: 2013 Oct 01

Abstract: BACKGROUND: Prostate-specific antigen (PSA) testing is recommended every 6 to 12 months for the first 5 years following radical prostatectomy as a means to detect potential disease recurrence. Despite substantial research on factors affecting treatment decisions, recurrence, and mortality, little is known about whether men receive guideline-concordant surveillance testing or whether receipt varies by year of diagnosis, time since treatment, or other individual characteristics. METHODS: Surveillance testing following radical prostatectomy among elderly men was examined using Surveillance, Epidemiology, and End Results cancer registry data linked to Medicare claims. Multivariate logistic regression was used to examine the effect of demographic, tumor, and county-level characteristics on the odds of receiving surveillance testing within a given 1-year period following treatment. RESULTS: Overall, receipt of surveillance testing was high, with 96% of men receiving at least one test the first year after treatment and approximately 80% receiving at least one test in the fifth year after treatment. Odds of not receiving a test declined with time since treatment. Nonmarried men, men with less-advanced disease, and non-Hispanic blacks and Hispanics had higher odds of not receiving a surveillance test. Year of diagnosis did not affect the receipt of surveillance tests. CONCLUSIONS: Most men receive guideline-concordant surveillance PSA testing after prostatectomy, although evidence of a racial disparity between non-Hispanic whites and some minority groups exists. The decline in surveillance over time suggests the need for well-designed long-term surveillance plans following radical prostatectomy. Cancer 2013;119:3523-3530.. © 2013 American Cancer Society.

Authors:

Title: The unmet need in chronic lymphocytic leukemia: impact of comorbidity burden on treatment patterns and outcomes in elderly patients

Journal: J Cancer Ther 4(8):-

Date: 2013 Oct

Abstract: Introduction: Chronic lymphocytic leukemia (CLL) is a disease of the elderly. Elderly patients often have increased comorbidity burden and loss of organ reserve that may impact their ability to tolerate cancer therapy. We described realworld characteristics of typical CLL patients and identified factors predictive of receiving treatment. Methods: A retrospective cohort analysis of 8343 first primary CLL patients was performed using the linked Surveillance, Epidemiology, and End Results-Medicare database. Patients were diagnosed from 1/1/1998 to 12/31/2007, >66 years, and continuously enrolled in Medicare Parts A and B in the year prior to diagnosis. Comorbidity was examined using the National Cancer Institute comorbidity index and the Cumulative Illness Rating Scale. Cox and Logistic regression modeling assessed patient characteristics predictive of receiving treatment within the first year after diagnosis. Results: Median follow-up time from diagnosis was 782 days. During the study time period, there were 3366 (40%) treated patients and 4977 (60%) untreated. Even among those diagnosed with advanced stage (n = 4213), 57% were not treated. Treated patients were younger at diagnosis compared to untreated (76 vs. 79; p < 0.0001). In general, as age increased, the incidence and severity of comorbidities increased. In multivariate regression analyses, the treatment rate was significantly lower among patients >80 years, females, and with early stage disease; and significantly decreased with increasing comorbidity burden. Conclusions: Age, gender, comorbidity and stage were predictive of receiving treatment. Among patients with advanced stage, 57% were not being treated possibly due to older age and/or higher comorbidity burden.

Authors: Caprario LC, Kent DM, Strauss GM

Title: Effects of chemotherapy on survival of elderly patients with small-cell lung cancer: analysis of the SEER-Medicare database

Journal: 8(10):-

Date: 2013 Oct

Abstract: Introduction: This retrospective cohort study was designed to analyze factors associated with administration of chemotherapy and to examine the impact of chemotherapy on survival among elderly patients with small-cell lung cancer (SCLC) in the community.Methods: Elderly patients aged 65 years and older with SCLC diagnosed between 1992 and 2001 were selected from the Surveillance, Epidemiology, and End Results-Medicare database. Logistic regression was used to evaluate which covariates influenced receipt of chemotherapy. Cox proportional hazards regression was used to examine the influence of clinical and demographic variables on survival. The independent effect of chemotherapy on survival was determined using propensity scores and quantile regression.Results: In the final cohort of 10,428 patients, 67.1% received chemotherapy, 39.1% received radiation, 3.4% received surgery, and 21.8% received no treatment. The most common chemotherapy regimens included etoposide combined with either cisplatin or carboplatin. Patients aged 85 years and older were significantly less likely to receive chemotherapy compared with patients aged 65 to 69 years (odds ratio 0.17; 95% confidence interval 0.14-0.21). Median survival for all patients was 7 months. Factors associated with improved survival were being female, black race, having limited-stage disease, receiving any treatment, and having a lower comorbidity score. Quantile regression demonstrated that chemotherapy provided a 6.5-month improvement in median survival (95% confidence interval 6.3-6.6; p<0.001).Conclusions: Statistically significant differences in the receipt of chemotherapy exist among elderly patients with SCLC. Chemotherapy is associated with a greater than 6-month improvement in median survival among elderly patients with SCLC, even in patients over the age of 80 years.

Authors: Freedman RA, He Y, Winer EP, Keating NL

Title: Racial/Ethnic differences in receipt of timely adjuvant therapy for older women with breast cancer: are delays influenced by the hospitals where patients obtain surgical care?

Journal: Health Serv Res 48(5):1669-83

Date: 2013 Oct

Abstract: OBJECTIVE: To examine whether hospitals where patients obtain care explain racial/ethnic differences in treatment delay. DATA SOURCE: Surveillance, Epidemiology, and End Results data linked with Medicare claims. STUDY DESIGN: We examined delays in adjuvant chemotherapy or radiation for women diagnosed with stage I-III breast cancer during 1992-2007. We used multivariable logistic regression to assess the probability of delay by race/ethnicity and included hospital fixed effects to assess whether hospitals explained disparities. PRINCIPAL FINDINGS: Among 54,592 women, black (11.9 percent) and Hispanic (9.9 percent) women had more delays than whites (7.8 percent, p < .0001). After adjustment, black (vs. white) women had higher odds of delay (odds ratio = 1.25, 95 percent confidence interval = 1.10-1.42), attenuated somewhat by including hospital fixed effects (OR = 1.17, 95 percent CI = 1.02-1.33). CONCLUSIONS: Hospitals are the important contributors to racial disparities in treatment delay.

Authors: Hyder O, Dodson RM, Weiss M, Cosgrove DP, Herman JM, Geschwind JF, Kamel IR, Pawlik TM

Title: Trends and patterns of utilization in post-treatment surveillance imaging among patients treated for hepatocellular carcinoma.

Journal: J Gastrointest Surg 17(10):1774-83

Date: 2013 Oct

Abstract: BACKGROUND: Little is known about the patterns of utilization of surveillance imaging after treatment of hepatocellular carcinoma (HCC). We sought to define population-based patterns of surveillance and investigate if intensity of surveillance impacted outcome following HCC treatment. METHODS: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients with HCC diagnosed between 1998 and 2007 who underwent resection, ablation, or intra-arterial therapy (IAT). The association between imaging frequency and long-term survival was analyzed. RESULTS: Of the 1,467 patients, most underwent ablation only (41.5%), while fewer underwent liver resection only (29.6 %) or IAT only (18.3%). Most patients had at least one CT scan (92.7%) during follow-up, while fewer had an MRI (34.1%). A temporal trend was noted with more frequent surveillance imaging obtained in post-treatment year 1 (2.5 scans/year) vs. year 5 (0.9 scans/year; P = 0.01); 34.5% of alive patients had no imaging after 2 years. Frequency of surveillance imaging correlated with procedure type (total number of scans/5 years, resection, 4.7; ablation, 4.9; IAT, 3.7; P < 0.001). Frequency of surveillance imaging was not associated with a survival benefit (three to four scans/year, 49.5 months vs. two scans/year, 71.7 months vs. one scan/year, 67.6 months; P = 0.01) CONCLUSION: Marked heterogeneity exists in how often surveillance imaging is obtained following treatment of HCC. Higher intensity imaging does not confer a survival benefit.

Authors: Kasahara Y, Kawai M, Tsuji I, Tohno E, Yokoe T, Irahara M, Tangoku A, Ohuchi N

Title: Harms of screening mammography for breast cancer in Japanese women.

Journal: Breast Cancer 20(4):310-5

Date: 2013 Oct

Abstract: BACKGROUND: The US Preventative Services Task Force assesses the efficacy of breast cancer screening by the sum of its benefits and harms, and recommends against routine screening mammography because of its relatively great harms for women aged 40-49 years. Assessment of the efficacy of screening mammography should take into consideration not only its benefits but also its harms, but data regarding those harms are lacking for Japanese women. METHODS: In 2008 we collected screening mammography data from 144,848 participants from five Japanese prefectures by age bracket to assess the harms [false-positive results, performance of unnecessary additional imaging, fine-needle aspiration cytology (FNA), and biopsy and its procedures]. RESULTS: The rate of cancer detected in women aged 40-49 years was 0.28%. The false-positive rate (9.6%) and rates of additional imaging by mammography (5.8%) and ultrasound (7.3%) were higher in women aged 40-49 years than in the other age brackets. The rates of FNA (1.6%) and biopsy (0.7%) were also highest in women aged 40-49 years. However, they seemed to be lower than the rates reported by the Breast Cancer Surveillance Consortium (BCSC) and other studies in the US. CONCLUSIONS: The results, although preliminary, indicate the possibility that the harms of screening mammography for Japanese women are less than those for American women.

Authors: Miller PE, McKinnon RA, Krebs-Smith SM, Subar AF, Chriqui J, Kahle L, Reedy J

Title: Sugar-sweetened beverage consumption in the U.S.: novel assessment methodology.

Journal: Am J Prev Med 45(4):416-21

Date: 2013 Oct

Abstract: BACKGROUND: Sugar-sweetened beverage (SSB) consumption has been linked with poor diet quality, weight gain, and increased risk for obesity, diabetes, and cardiovascular disease. Previous studies have been hampered by inconsistent definitions and a failure to capture all types of SSBs. PURPOSE: To comprehensively examine total SSB consumption in the U.S. using an all-encompassing definition that includes beverages calorically sweetened after purchase in addition to presweetened beverages. METHODS: Data from the 2005-2008 National Health and Nutrition Examination Survey (N=17,078) were analyzed in September 2012 and used to estimate calories (kilocalories) of added sugars from SSBs and to identify top sources of SSBs. RESULTS: On average, Americans aged ≥2 years consumed 171 kcal (8% of total kcal) per day from added sugars in SSBs; the top sources were soda, fruit drinks, tea, coffee, energy/sports drinks, and flavored milks. Male adolescents (aged 12-19 years) had the highest mean intakes (293 kcal/day; 12% of total kcal). CONCLUSIONS: Americans consume more calories from added sugars in beverages than previously reported. The methodology presented in this paper allows for more-comprehensive estimates than those previously used regarding the extent to which SSBs provide calories from added sugars.

Authors: Owens CL, Peterson D, Kamineni A, Buist DS, Weinmann S, Ross TR, Williams AE, Stark A, Adams KF, Field TS

Title: Effects of transitioning from conventional methods to liquid-based methods on unsatisfactory Papanicolaou tests: results from a multicenter US study.

Journal: Cancer Cytopathol 121(10):568-75

Date: 2013 Oct

Abstract: BACKGROUND: Papanicolaou (Pap) testing has transitioned from conventional preparations (CPs) to liquid-based preparations (LBPs) because of the perceived superiority of LBPs. Many studies conclude that LBPs reduce unsatisfactory Pap tests; however, some believe that the evidence substantiating this claim is weak. The authors studied the effect of the transition from CPs to LBPs on the proportion of unsatisfactory Pap tests in 4 health care systems in the United States participating in the National Institutes of Health-funded Screening Effectiveness and Research in Community-Based Healthcare (SEARCH) project. METHODS: The study cohort consisted of 548,174 women ages 21 to 65 years who had 1443,725 total Pap tests between 2000 and 2010. Segmented regression analysis was used to estimate the effect of adopting LBPs on the proportion of unsatisfactory Pap tests after adjusting for age. RESULTS: Three sites that implemented SurePath LBP experienced significant reductions in unsatisfactory Pap tests (estimated effect: site 1, -2.46%; 95% confidence interval [CI], -1.47%, -3.45%; site 2, -1.78%; 95% CI, -1.54%, -2.02%; site 3, -8.25%; 95% CI, -7.33%, -9.17%). The fourth site that implemented ThinPrep LBP did not experience a reduction in unsatisfactory Pap tests. The relative risk of an unsatisfactory Pap test in women aged ≥ 50 years increased after the transition to LBPs (SurePath: relative risk, 2.1; 95% CI, 1.9-2.2; ThinPrep: relative risk, 1.7; 95% CI, 1.5-2.0). CONCLUSIONS: The observed changes in the proportion of unsatisfactory Pap tests varied across the participating sites and depended on the type of LBP technology, the age of women, and the rates before the implementation of this technology.

Authors: Perencevich M, Ojha RP, Steyerberg EW, Syngal S

Title: Racial and ethnic variations in the effects of family history of colorectal cancer on screening compliance.

Journal: Gastroenterology 145(4):775-81.e2

Date: 2013 Oct

Abstract: BACKGROUND & AIMS: Individuals with a family history of colorectal cancer (CRC) have a higher risk of developing CRC than the general population, and studies have shown that they are more likely to undergo CRC screening. We assessed the overall and race- and ethnicity-specific effects of a family history of CRC on screening. METHODS: We analyzed data from the 2009 California Health Interview Survey to estimate overall and race- and ethnicity-specific odds ratios (ORs) for the association between family history of CRC and CRC screening. RESULTS: The unweighted and weighted sample sizes were 23,837 and 8,851,003, respectively. Individuals with a family history of CRC were more likely to participate in any form of screening (OR, 2.3; 95% confidence limit [CL], 1.7, 3.1) and in colonoscopy screening (OR, 2.7; 95% CL, 2.2, 3.4) than those without a family history, but this association varied among racial and ethnic groups. The magnitude of the association between family history and colonoscopy screening was highest among Asians (OR, 6.1; 95% CL, 3.1, 11.9), lowest among Hispanics (OR, 1.4; 95% CL, 0.67, 2.8), and comparable between non-Hispanic whites (OR, 3.1; 95% CL, 2.6, 3.8) and non-Hispanic blacks (OR 2.6; 95% CL, 1.2, 5.7) (P for interaction < .001). CONCLUSIONS: The effects of family history of CRC on participation in screening vary among racial and ethnic groups, and have the lowest effects on Hispanics, compared with other groups. Consequently, interventions to promote CRC screening among Hispanics with a family history should be considered.

Authors: Ritzwoller DP, Carroll N, Delate T, O'Keeffe-Rossetti M, Fishman PA, Loggers ET, Aiello Bowles EJ, Elston-Lafata J, Hornbrook MC

Title: Validation of electronic data on chemotherapy and hormone therapy use in HMOs.

Journal: Med Care 51(10):e67-73

Date: 2013 Oct

Abstract: BACKGROUND: Most data regarding medical care for cancer patients in the United States comes from Surveillance, Epidemiology and End Results-linked Medicare analyses of individuals aged 65 years or older and typically excludes Medicare Advantage enrollees. OBJECTIVES: To assess the accuracy of chemotherapy and hormone therapy treatment data available through the Cancer Research Network's Virtual Data Warehouse (VDW). RESEARCH DESIGN: Retrospective, longitudinal cohort study. Medical record-abstracted, tumor registry-indicated treatments (gold standard) were compared with VDW-indicated treatments derived from health maintenance organization pharmacy, electronic medical record, and claim-based data systems. SUBJECTS: Enrollees aged 18 years and older diagnosed with incident breast, colorectal, lung, or prostate cancer from 2000 through 2007. MEASURES: Sensitivity, specificity, and positive predictive value were computed at 6 and 12 months after cancer diagnosis. RESULTS: Approximately 45% of all cancer cases (total N=23,800) were aged 64 years or younger. Overall chemotherapy sensitivity/specificities across the 3 health plans for incident breast, colorectal, lung, and prostate cancer cases were 95%/90%, 95%/93%, 93%/93%, and 85%/77%, respectively. With the exception of prostate cancer cases, overall positive predictive value ranged from 86% to 89%. Small variations in chemotherapy data accuracy existed due to cancer site and data source, whereas greater variation existed in hormone therapy capture across sites. CONCLUSIONS: Strong concordance exists between gold standard tumor registry measures of chemotherapy receipt and Cancer Research Network VDW data. Health maintenance organization VDW data can be used for a variety of studies addressing patterns of cancer care and comparative effectiveness research that previously could only be conducted among elderly Surveillance, Epidemiology and End Results-Medicare populations.

Authors: Willis GB, Smith T, Lee HJ

Title: Do additional recontacts to increase response rate improve physician survey data quality?

Journal: Med Care 51(10):945-8

Date: 2013 Oct

Abstract: BACKGROUND: Although response rates for physician surveys have been decreasing, it is not clear whether this trend is associated with an increase in survey nonresponse bias. One means for assessing potential bias is to conduct a level-of-effort analysis that compares data estimates for respondents interviewed during the first recruitment contact to respondents interviewed at later recontact cycles. METHODS: We compared early and later responders within the Survey of Physician Attitudes Regarding the Care of Cancer Survivors with respect to both demographic characteristics and aggregate survey responses to items on survivor care knowledge, attitudes, and practices. RESULTS: Accumulating additional completions across each of 4 respondent contact attempts improved weighted response rates (35.0%, 46.9%, 52.3%, and 57.6%, respectively). However, the majority of estimates for analyzed variables remained relatively unchanged over additional cycles of recontact. CONCLUSIONS: We conclude that additional respondent recontact attempts, especially beyond a single recontact, had little influence on key data distributions, suggesting that these were ineffective in reducing nonresponse bias. Further, the conduct of additional recruitment recontacts was an inefficient means for increasing statistical power. For the conduct of physician surveys, a practice that may in some cases be cost-effective, while also controlling total survey error, is to establish a larger initial sample; to either eliminate nonresponse follow-up or to limit this to one recontact; and to accept a somewhat lower final overall survey response rate.

Authors: Wood WA, Deal AM, Reeve BB, Abernethy AP, Basch E, Mitchell SA, Shatten C, Hie Kim Y, Whitley J, Serody JS, Shea T, Battaglini C

Title: Cardiopulmonary fitness in patients undergoing hematopoietic SCT: a pilot study.

Journal: Bone Marrow Transplant 48(10):1342-9

Date: 2013 Oct

Abstract: Hematopoietic cell transplantation (HCT) is a life-saving treatment for patients with high-risk hematological malignancies. Prognostic measures to determine fitness for HCT are needed to inform decision-making and interventions. VO(2peak) is obtained by measuring gas exchange during cycle ergometry and has not been studied as a prognostic factor in HCT. Thirty-two autologous and allogeneic HCT patients underwent VO(2peak) and 6 Minute Walk (6MW) testing before HCT, and provided weekly symptom and health-related quality of life (HRQOL) assessments before HCT and concluding at Day 100. Twenty-nine patients completed pre-HCT testing. Pre-HCT VO(2peak) was positively correlated with pre-HCT 6MW (r=0.65, P<0.001) and negatively correlated with number of chemotherapy regimens and months of chemotherapy. Patients with lower VO(2peak) reported higher symptom burden and inferior HRQOL at baseline and during early post-HCT period. Patients with pre-HCT VO(2peak) <16 mL/kg/min had higher risk of mortality post HCT (entire cohort: hazard ratio (HR) 9.1 (1.75-47.0), P=0.01; allogeneic HCT patients only: HR 6.70 (1.29-34.75), P=0.02) and more hospitalized days before Day 100 (entire cohort: median 33 vs 19, P=0.003; allogeneic HCT patients only: median 33 vs 21, P=0.004). VO(2peak) pre-HCT is feasible and might predict symptom severity, HRQOL and mortality. Additional studies are warranted.

Authors: Chirikov VV, Mullins CD, Hanna N, Breunig IM, Seal B, Shaya FT

Title: Multispecialist Care and Mortality in Hepatocellular Carcinoma.

Journal: Am J Clin Oncol :-

Date: 2013 Sep 21

Abstract: PURPOSE:: Multidisciplinary physician care has increased for many cancers yet little evidence exists for hepatocellular carcinoma (HCC). The purpose of this study was to explore the association between multispecialist care and mortality in HCC. METHODS:: Treated patients with an HCC primary diagnosis from 2000 to 2007 were studied using Surveillance, Epidemiology, and End Results-Medicare data. A surrogate variable for multidisciplinary care was defined-multispecialist care-as the number of disciplines among surgeons, radiology oncologist, intervention radiologist, hematologist/medical oncologist, gastroenterologist, and generalist in the pretreatment period. Multivariate survival analysis was conducted and adjusted for selection and survival bias. RESULTS:: Of 3588 treated HCC patients, 1434 (40%) saw 1, 1343 (37%) saw 2, and 811 (23%) saw 3 or more specialists. Patients with multispecialist care received treatment that differed from patients who saw a single specialist. In propensity score-adjusted survival analysis, patients who saw 3 or more specialist types were associated with 10% (P=0.04) reduced mortality, compared with those who saw 1 specialist. When stratified by treatment received, patients on chemotherapy who saw 3 or more specialist types were associated with 28% (P=0.002) reduced mortality, compared with those who saw 1 specialist. CONCLUSIONS:: Multispecialist care for treated HCC patients was associated with reduced mortality, particularly among chemotherapy recipients. While adjusting for selection and survival bias, our study is limited in capturing a causal relationship between coordinated multidisciplinary care and mortality. Our findings may provide support for the development of coordinated care delivery models but should be confirmed through more rigorous examination in future studies.

Authors: Levin TR, Corley DA

Title: Colorectal-cancer screening--coming of age.

Journal: N Engl J Med 369(12):1164-6

Date: 2013 Sep 19

Abstract:

Authors: Hou N, Hong S, Wang W, Olopade OI, Dignam JJ, Huo D

Title: Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density.

Journal: J Natl Cancer Inst 105(18):1365-72

Date: 2013 Sep 18

Abstract: BACKGROUND: Although studies have demonstrated a positive association between hormone replacement therapy (HRT) and breast cancer risk, this association may vary by patient factors. METHODS: We analyzed 1642824 screening mammograms with 9300 breast cancer cases in postmenopausal women aged 45 years or older derived from the Breast Cancer Surveillance Consortium, a longitudinal registry of mammography screening in the United States. Multiple imputation methods were used to accommodate missing data for HRT use (14%) and other covariables. We performed logistic regression to estimate odds ratios (ORs) for breast cancer associated with HRT use within strata of race/ethnicity, age, body mass index (BMI), and breast density, with two-way interaction terms between HRT use and each key covariable of interest. P values for assessing possible interactions were computed from Wald z statistics. All statistical tests were two-sided. RESULTS: HRT use was associated with greater than 20% increased risk in white (OR = 1.21; 95% CI = 1.14 to 1.28), Asian (OR = 1.58; 95% CI = 1.18 to 2.11), and Hispanic women (OR = 1.35; 95% CI = 1.09 to 1.67) but not black women (OR = 0.91; 95% CI = 0.72 to 1.14; P interaction = .04). In women with low/normal BMI and extremely dense breasts, HRT use was associated with the highest breast cancer risk (OR = 1.49; 95% CI = 1.21 to 1.83), compared with nonusers. In overweight/obese women with less-dense breasts, no excess risk was associated with HRT use (adjusted ORs = 0.96 to 1.03). CONCLUSIONS: The impact of HRT use on breast cancer risk varies according to race/ethnicity, BMI, and breast density. This risk stratification could help in advising HRT use for the relief of menopausal symptoms.

Authors: Schairer C, Li Y, Frawley P, Graubard BI, Wellman RD, Buist DS, Kerlikowske K, Onega TL, Anderson WF, Miglioretti DL

Title: Risk factors for inflammatory breast cancer and other invasive breast cancers.

Journal: J Natl Cancer Inst 105(18):1373-84

Date: 2013 Sep 18

Abstract: BACKGROUND: We investigated risk factors for inflammatory breast cancer (IBC), a rare, aggressive, and poorly understood breast cancer that is characterized by diffuse breast skin erythema and edema. METHODS: We included 617 IBC case subjects in a nested case-control study from the Breast Cancer Surveillance Consortium database (1994-2009). We also included 1151 noninflammatory, locally advanced, invasive breast cancers with chest wall/breast skin involvement (LABC), 7600 noninflammatory invasive case subjects without chest wall/breast skin involvement (BC), and 93 654 control subjects matched to case subjects on age and year at diagnosis and mammography registry. We present estimates of rate ratios (RRs) and 95% confidence intervals (CI) from conditional logistic regression analyses for each case group vs control subjects based on multiply imputed datasets. RESULTS: First-degree family history of breast cancer and high mammographic breast density increased risk of IBC, LABC, and BC. High body mass index (BMI) increased IBC risk irrespective of menopausal status and estrogen receptor (ER) expression; rate ratios for BMI 30 and greater vs BMI less than 25 were 3.90 (95% CI = 1.50 to 10.14) in premenopausal women and 3.70 (95% CI = 1.98 to 6.94) in peri/postmenopausal women not currently using hormones. BMI 30 and greater slightly increased risk of ER-positive BC (RR = 1.40; 95% CI = 1.11 to 1.76). Statistically significant reductions in risk of ER-negative IBC with older age at first birth and of ER-positive IBC with higher education were not seen for LABC and BC of the same ER status. CONCLUSIONS: Different associations with BMI, age at first birth, and education between IBC and/or LABC and BC suggest a distinct etiology for IBC.

Authors: Dowling EC, Chawla N, Forsythe LP, de Moor J, McNeel T, Rozjabek HM, Ekwueme DU, Yabroff KR

Title: Lost productivity and burden of illness in cancer survivors with and without other chronic conditions.

Journal: Cancer 119(18):3393-401

Date: 2013 Sep 15

Abstract: BACKGROUND: Cancer survivors may experience long-term and late effects from treatment that adversely affect health and limit functioning. Few studies examine lost productivity and disease burden in cancer survivors compared with individuals who have other chronic conditions or by cancer type. METHODS: We identified 4960 cancer survivors and 64,431 other individuals from the 2008-2010 Medical Expenditure Panel Survey and compared multiple measures of disease burden, including health status and lost productivity, between conditions and by cancer site for cancer survivors. All analyses controlled for the effects of age, sex, race/ethnicity, and number of comorbid conditions. RESULTS: Overall, in adjusted analyses in multiple models, cancer survivors with another chronic disease (heart disease or diabetes) experienced higher levels of burden compared with individuals with a history of cancer only, chronic disease only, and neither cancer, heart disease, nor diabetes across multiple measures (P < .05). Among cancer survivors, individuals with short survival cancers and multiple cancers consistently had the highest levels of burden across multiple measures (P < .0001). CONCLUSIONS: Cancer survivors who have another chronic disease experience more limitations and higher levels of burden across multiple measures. Limitations are particularly severe in cancer survivors with short survival cancer and multiple cancers.

Authors: Sheets NC, Hendrix LH, Allen IM, Chen RC

Title: Trends in the use of postprostatectomy therapies for patients with prostate cancer: a surveillance, epidemiology, and end results Medicare analysis.

Journal: Cancer 119(18):3295-301

Date: 2013 Sep 15

Abstract: BACKGROUND: For patients with adverse pathologic factors (positive surgical margins, extracapsular extension, or seminal vesicle invasion) on prostatectomy pathology, the use and timing of postsurgical treatments are controversial. The goal of the current study was to examine patterns of care in patients with a pathologic indication for postprostatectomy radiotherapy (RT) using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. METHODS: A total of 3460 men treated with radical prostatectomy for localized prostate cancer between 2000 and 2006 with at least 1 adverse pathologic factor and at least 3 years of claims data after surgery were included. Medicare claims through December 31, 2009 were examined. Rates of postprostatectomy hormonal therapy, RT, or both were examined. Logistic regression analysis examined potential factors associated with the receipt and timing of RT. RESULTS: Within 3 years after surgery, 1076 patients (31%) received some form of further therapy, including 850 (25%) who received RT. Receipt of RT was < 35% in all subgroups including every year of study. Fewer than one-half of patients who received RT (43%) did so within 6 months of surgery. On multivariate analysis, pathologic T classification and tumor grade were associated with receipt of RT within 6 months or 3 years of surgery, as were younger age, geographic region, and population density. CONCLUSIONS: Rates of postprostatectomy RT remain low and the timing of RT has not appreciably changed since the publication of the randomized trials supporting the use of adjuvant RT. The use of hormone therapy is almost as common as RT, despite a relative lack of evidence supporting its use in this setting.

Authors: Arem H, Reedy J, Sampson J, Jiao L, Hollenbeck AR, Risch H, Mayne ST, Stolzenberg-Solomon RZ

Title: The Healthy Eating Index 2005 and risk for pancreatic cancer in the NIH-AARP study.

Journal: J Natl Cancer Inst 105(17):1298-305

Date: 2013 Sep 04

Abstract: BACKGROUND: Dietary pattern analyses characterizing combinations of food intakes offer conceptual and statistical advantages over food- and nutrient-based analyses of disease risk. However, few studies have examined dietary patterns and pancreatic cancer risk and none focused on the 2005 Dietary Guidelines for Americans. We used the Healthy Eating Index 2005 (HEI-2005) to estimate the association between meeting those dietary guidelines and pancreatic cancer risk. METHODS: We calculated the HEI-2005 score for 537 218 men and women in the National Institutes of Health-American Association of Retired Persons Diet and Health Study using responses to food frequency questionnaires returned in 1995 and 1996. We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of pancreatic cancer according to HEI-2005 quintiles and explored effect modification by known risk factors. P interaction values were calculated using the Wald test. All statistical tests were two-sided. RESULTS: We identified 2383 incident, exocrine pancreatic cancer cases (median = 10.5 years follow-up). Comparing participants who met the most dietary guidelines (Q5) with those who met the fewest guidelines (Q1), we observed a reduced risk of pancreatic cancer (HR = 0.85, 95% CI = 0.74 to 0.97). Among men there was an interaction by body mass index (P interaction = .03), with a hazard ratio of 0.72 (95% CI = 0.59 to 0.88) comparing Q5 vs Q1 in overweight/obese men (body mass index ≥ 25 kg/m(2)) but no association among normal weight men. CONCLUSIONS: Our findings support the hypothesis that consuming a high-quality diet, as scored by the HEI-2005, may reduce the risk of pancreatic cancer.

Authors: Chamie K, Litwin MS, Bassett JC, Daskivich TJ, Lai J, Hanley JM, Konety BR, Saigal CS, Urologic Diseases in America Project

Title: Recurrence of high-risk bladder cancer: a population-based analysis.

Journal: Cancer 119(17):3219-27

Date: 2013 Sep 01

Abstract: BACKGROUND: Patients with bladder cancer are apt to develop multiple recurrences that require intervention. The recurrence, progression, and bladder cancer-related mortality rates were examined in a cohort of individuals with high-grade non-muscle-invasive bladder cancer. METHODS: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, subjects were identified who had a diagnosis of high-grade, non-muscle-invasive disease in 1992 to 2002 and who were followed until 2007. Multivariate competing-risks regression analyses were then used to examine recurrence, progression, and bladder cancer-related mortality rates. RESULTS: Of 7410 subjects, 2897 (39.1%) experienced a recurrence without progression, 2449 (33.0%) experienced disease progression, of whom 981 succumbed to bladder cancer. Using competing-risks regression analysis, the 10-year recurrence, progression, and bladder cancer-related mortality rates were found to be 74.3%, 33.3%, and 12.3%, respectively. Stage T1 was the only variable associated with a higher rate of recurrence. Women, black race, undifferentiated grade, and stage Tis and T1 were associated with a higher risk of progression and mortality. Advanced age (≥ 70) was associated with a higher risk of bladder cancer-related mortality. CONCLUSIONS: Nearly three-fourths of patients diagnosed with high-risk bladder cancer will recur, progress, or die within 10 years of their diagnosis. Even though most patients do not die of bladder cancer, the vast majority endures the morbidity of recurrence and progression of their cancer. Increasing efforts should be made to offer patients intravesical therapy with the goal of minimizing the incidence of recurrences. Furthermore, the high recurrence rate seen during the first 2 years of diagnosis warrants an intense surveillance schedule.

Authors: Bonito A, Horowitz N, McCorkle R, Chagpar AB

Title: Do healthcare professionals discuss the emotional impact of cancer with patients?

Journal: Psychooncology 22(9):2046-50

Date: 2013 Sep

Abstract: BACKGROUND: It is known that cancer may affect patients' emotions and their relationships with other people and that those with strong emotional support may enjoy improved outcomes. We sought to determine the frequency with which healthcare professionals discuss the impact of cancer on patients' emotions and relationships with others. METHODS: Data regarding healthcare professionals' discussions of the emotional impact of cancer and relevant covariates were obtained from the 2010 National Health Interview Survey. Statistical analyses were performed using sudaan software (Research Triangle Institute, Raleigh, NC, USA). RESULTS: Of the 2074 people with a prior diagnosis of cancer surveyed, 701 (33.8%) claimed that a doctor, nurse, or other healthcare professional had discussed with them 'how cancer could affect their emotions or relationships with others'. Of these, 586 (84.5%) reported that they were 'very satisfied' with how well their emotional and social needs were met; 73.4% of those who had not had this discussion reported being very satisfied. Patients with leukemia/lymphoma, younger patients, African Americans, and those with a lower degree of education were most likely to report having discussions about emotional issues. Gender was not correlated with these discussions (30.6% in men vs. 33.3% in women). On multivariate analysis, age, race, and cancer type remained independent significant predictors of having a discussion regarding the emotional impact of cancer. CONCLUSION: Only a third of cancer patients discussed the emotional impact of a cancer diagnosis with their healthcare professional. Age, race, and type of malignancy affect the likelihood of having these discussions.

Authors: Brown ER, Kincheloe J, Breen N, Olson JL, Portnoy B, Lee SJ

Title: States' use of local population health data: comparing the Behavioral Risk Factor Surveillance System and independent state health surveys.

Journal: J Public Health Manag Pract 19(5):444-50

Date: 2013 Sep-Oct

Abstract: OBJECTIVES: To identify and compare key features of independent comprehensive state health surveys (SHS) with those of the Behavioral Risk Factor Surveillance System (BRFSS) for addressing the need for statewide and local population health data. METHODS: We developed inclusion criteria, systematically collected information about federal and SHS that met these criteria, and obtained supplemental information from SHS leaders. RESULTS: We identified comprehensive independent SHS in 11 states and BRFSS surveys in all 50 states. The independent SHS meet important statewide and local data needs, filling 3 key health data gaps in the BRFSS: lack of adequate data on special populations such as children, lack of data on specific localities, and limited depth and scope of health topics surveyed on key issues such as health insurance coverage. Unlike BRFSS, independent SHS have limited comparability with each other. CONCLUSIONS: The BRFSS and independent SHS each meet some key state and local data needs but result in data gaps and inefficient use of resources. Surveys could more effectively and efficiently meet future needs for comparable data to monitor health care reform and address health disparities if they were coordinated across states and at the national, state, and local levels.

Authors: Cheung WY, Aziz N, Noone AM, Rowland JH, Potosky AL, Ayanian JZ, Virgo KS, Ganz PA, Stefanek M, Earle CC

Title: Physician preferences and attitudes regarding different models of cancer survivorship care: a comparison of primary care providers and oncologists.

Journal: J Cancer Surviv 7(3):343-54

Date: 2013 Sep

Abstract: PURPOSE: New strategies for delivering cancer follow-up care are needed. We surveyed primary care providers (PCPs) and oncologists to assess how physician attitudes toward and self-efficacy with cancer follow-up affect preferences for different cancer survivorship models. METHODS: The survey of physician attitudes regarding the care of cancer survivors was mailed to a randomly selected national sample of PCPs and oncologists to evaluate their perspectives regarding physician roles, knowledge about survivorship care processes, and views on cancer surveillance. Multinomial logistic regression models were constructed to examine how physician attitudes towards, and self-efficacy with, their own skills affected preferences for different cancer survivorship care models. RESULTS: Of 3,434 physicians identified, a total of 2,026 participants provided eligible responses: 938 PCPs and 1,088 oncologists. Most PCPs (51 %) supported a PCP/shared care model; whereas, the majority of specialists (59 %) strongly endorsed an oncologist-based model (p < 0.001). Less than a quarter of PCPs and oncologists preferred specialized survivor clinics. A significant proportion of oncologists (87 %) did not feel that PCPs should take on the primary role of cancer follow-up. Most PCPs believed that they were better able to perform breast and colorectal cancer follow-up (57 %), detect recurrent cancers (74 %), and offer psychosocial support (50 %), but only a minority (32 %) was willing to assume primary responsibility. PCPs already involved with cancer surveillance (43 %) were more likely to prefer a PCP/shared care than oncologist-based survivorship model (OR, 2.08; 95 % CI, 1.34-3.23). CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: PCPs and oncologists have different preferences for models of cancer survivorship care. Prior involvement with cancer surveillance was one of the strongest predictors of PCPs' willingness to assume this responsibility.

Authors: Jarvis MJ, Cohen JE, Delnevo CD, Giovino GA

Title: Dispelling myths about gender differences in smoking cessation: population data from the USA, Canada and Britain.

Journal: Tob Control 22(5):356-60

Date: 2013 Sep

Abstract: OBJECTIVES: Based mainly on findings from clinical settings, it has been claimed that women are less likely than men to quit smoking successfully. If true, this would have important implications for tobacco control interventions. The authors aimed to test this possibility using data from general population surveys. METHODS: The authors used data from major national surveys conducted in 2006-2007 in the USA (Tobacco Use Supplement to the Current Population Survey), Canada (Canadian Tobacco Use Monitoring Survey) and the UK (General Household Survey) to estimate rates of smoking cessation by age in men and women. RESULTS: The authors found a pattern of gender differences in smoking cessation which was consistent across countries. Below age 50, women were more likely to have given up smoking completely than men, while among older age groups, men were more likely to have quit than women. Across all age groups, there was relatively little difference in cessation between the sexes. CONCLUSIONS: Conclusions about gender differences in smoking cessation should be based on evidence from the general population rather than from atypical clinical samples. This study has found convincing evidence that men in general are not more likely to quit smoking successfully than women.

Authors: Klabunde CN, Willis GB, Casalino LP

Title: Facilitators and barriers to survey participation by physicians: a call to action for researchers.

Journal: Eval Health Prof 36(3):279-95

Date: 2013 Sep

Abstract: Surveys of health care providers are a well-established tool for obtaining information about the organization and delivery of care as well as about provider knowledge and attitudes. However, declining response rates to provider surveys are a widely acknowledged concern. Although a number of studies have identified specific methods for increasing response rates in health care provider-and particularly physician-surveys, few have addressed the more fundamental question of what motivates or deters providers from survey participation. We briefly review theoretical perspectives concerning why providers choose to participate in surveys, and what is known about facilitators and barriers to participation. We then describe several research designs (i.e., focus groups, key informant interviews, diary and office workflow studies, surveying the surveyors, and follow-back studies of respondents/nonrespondents) for obtaining empirical data on facilitators and barriers to survey participation, particularly by physicians and medical groups. Researchers must begin to build an evidence base for understanding provider decisions concerning survey participation.

Authors: Mazor KM, Gaglio B, Nekhlyudov L, Alexander GL, Stark A, Hornbrook MC, Walsh K, Boggs J, Lemay CA, Firneno C, Biggins C, Blosky MA, Arora NK

Title: Assessing patient-centered communication in cancer care: stakeholder perspectives.

Journal: J Oncol Pract 9(5):e186-93

Date: 2013 Sep

Abstract: PURPOSE: Patient-centered communication is critical to quality cancer care. Effective communication can help patients and family members cope with cancer, make informed decisions, and effectively manage their care; suboptimal communication can contribute to care breakdowns and undermine clinician-patient relationships. The study purpose was to explore stakeholders' views on the feasibility and acceptability of collecting self-reported patient and family perceptions of communication experiences while receiving cancer care. The results were intended to inform the design, development, and implementation of a structured and generalizable patient-level reporting system. METHODS: This was a formative, qualitative study that used semistructured interviews with cancer patients, family members, clinicians, and leaders of health care organizations. The constant comparative method was used to identify major themes in the interview transcripts. RESULTS: A total of 106 stakeholders were interviewed. Thematic saturation was achieved. All stakeholders recognized the importance of communication and endorsed efforts to improve communication during cancer care. Patients, clinicians, and leaders expressed concerns about the potential consequences of reports of suboptimal communication experiences, such as damage to the clinician-patient relationship, and the need for effective improvement strategies. Patients and family members would report good communication experiences in order to encourage such practices. Practical and logistic issues were identified. CONCLUSION: Patient reports of their communication experiences during cancer care could increase understanding of the communication process, stimulate improvements, inform interventions, and provide a basis for evaluating changes in communication practices. This qualitative study provides a foundation for the design and pilot testing of such a patient reporting system.

Authors: Meyer AM, Reeder-Hayes KE, Liu H, Wheeler SB, Penn D, Weiner BJ, Carpenter WR

Title: Differential receipt of sentinel lymph node biopsy within practice-based research networks.

Journal: Med Care 51(9):812-8

Date: 2013 Sep

Abstract: BACKGROUND: Practice-based research networks (PBRNs) are promising for accelerating not only research, but also dissemination of research-based evidence into broader community practice. Sentinel lymph node biopsy (SLNB) is an innovation in breast cancer care associated with equivalent survival and lower morbidity, as compared with standard axillary lymph node dissection. We examined the diffusion of SLNB into practice and whether affiliation with the Community Clinical Oncology Program (CCOP), a cancer-focused PBRN, was associated with more rapid uptake of SLNB. RESEARCH DESIGN: Surveillance Epidemiology and End Results-Medicare data were used to study women diagnosed with stage I or II breast cancer in the years 2000-2005 and undergoing breast-conserving surgery with axillary staging (n=6226). The primary outcome was undergoing SLNB. CCOP affiliation of the surgical physician was ascertained from NCI records. Multivariable generalized linear modeling with generalized estimating equations was used to measure association between CCOP exposure and undergoing SLNB, controlling for potential confounders. RESULTS: Women treated by a CCOP physician had significantly higher odds of receiving SLNB compared with women treated by a non-CCOP physician (OR 2.68; 95% CI, 1.35-5.34). The magnitude of this association was larger than that observed among patients treated by physicians operating in medical school-affiliated hospitals (OR 1.76; 95% CI, 1.30-2.39). CONCLUSIONS: Women treated by CCOP-affiliated physicians were more likely to undergo SLNB irrespective of the hospital's medical school affiliation, suggesting that the CCOP PBRN may play a role in the rapid adoption of research-based innovation in community practice.

Authors: Miller PE, Cross AJ, Subar AF, Krebs-Smith SM, Park Y, Powell-Wiley T, Hollenbeck A, Reedy J

Title: Comparison of 4 established DASH diet indexes: examining associations of index scores and colorectal cancer.

Journal: Am J Clin Nutr 98(3):794-803

Date: 2013 Sep

Abstract: BACKGROUND: Multiple diet indexes have been developed to capture the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and examine relations with health outcomes but have not been compared within the same study population to our knowledge. OBJECTIVE: We compared 4 established DASH indexes and examined associations with colorectal cancer. DESIGN: Scores were generated from a food-frequency questionnaire in the NIH-AARP Diet and Health Study (n = 491,841). Separate indexes defined by Dixon (7 food groups, saturated fat, and alcohol), Mellen (9 nutrients), Fung (7 food groups and sodium), and Günther (8 food groups) were used. HRs and 95% CIs for colorectal cancer were generated by using Cox proportional hazard models. RESULTS: From 1995 through 2006, 6752 incident colorectal cancer cases were ascertained. In men, higher scores were associated with reduced colorectal cancer incidence by comparing highest to lowest quintiles for all indexes as follows: Dixon (HR: 0.77; 95% CI: 0.69, 0.87), Mellen (HR: 0.78; 95% CI: 0.71, 0.86), Fung (HR: 0.75; 95% CI: 0.68, 0.83), and Günther (HR: 0.81; 95% CI: 0.74, 0.90). Higher scores in women were inversely associated with colorectal cancer incidence by using methods defined by Mellen (HR: 0.79; 95% CI: 0.68, 0.91), Fung (HR: 0.84; 95% CI: 0.73, 0.96), and Günther (HR: 0.84; 95% CI: 0.73.0.97) but not Dixon (HR: 1.01; 95% CI: 0.80, 1.28). CONCLUSION: The consistency in findings, particularly in men, suggests that all indexes capture an underlying construct inherent in the DASH dietary pattern, although the specific index used can affect results.

Authors: Murphy JD, Nelson LM, Chang DT, Mell LK, Le QT

Title: Patterns of care in palliative radiotherapy: a population-based study.

Journal: J Oncol Pract 9(5):e220-7

Date: 2013 Sep

Abstract: PURPOSE: Approximately one half of the radiotherapy (RT) prescribed in the United States is delivered with palliative intent. The purpose of this study was to investigate the patterns of delivery of palliative RT across the United States. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare linked database, 51,610 patients were identified with incident stage IV breast, prostate, lung, or colorectal cancer diagnosed between 2000 and 2007 and observed through 2009. Multivariate logistic regression determined predictors of palliative RT. RESULTS: Forty-one percent of the study population received palliative RT, including 53% of patients with lung cancer, followed by those with breast (42%), prostate (40%), and colorectal cancers (12%). Multivariate analysis revealed that older patients (P<.001) and those with higher Charlson comorbidity scores (P<.001) were less likely to receive palliative RT. Black patients with prostate cancer were 20% less likely (P<.001), and black patients with colorectal cancer were 28% less likely (P<.001), than white patients to receive palliative RT. Among those treated with RT, 23% of patients with lung cancer died within 2 weeks of completing treatment, followed by those with colorectal (12%), breast (11%), and prostate cancers (8%). In addition to tumor site, significant predictors (P<.05) of death within 2 weeks of receiving RT included increased age, increased comorbidity, and male sex. CONCLUSION: Inequality in the receipt of palliative RT exists among the elderly and patients with comorbid conditions and varies with race. In addition, a significant number of patients die shortly after receiving RT. Understanding these patterns of care, along with further research into the underlying causes, will improve access and quality of palliative RT.

Authors: Robin Yabroff K, Short PF, Machlin S, Dowling E, Rozjabek H, Li C, McNeel T, Ekwueme DU, Virgo KS

Title: Access to preventive health care for cancer survivors.

Journal: Am J Prev Med 45(3):304-12

Date: 2013 Sep

Abstract: BACKGROUND: Access to health care, particularly effective primary and secondary preventive care, is critical for cancer survivors, in order to minimize the adverse sequelae of cancer and its treatment. PURPOSE: The goal of the study was to evaluate the association between cancer survivorship and access to primary and preventive health care. METHODS: Cancer survivors (n=4960) and individuals without a cancer history (n=64,431) aged ≥ 18 years, from the 2008-2010 Medical Expenditure Panel Survey (MEPS), were evaluated. Multiple measures of access and preventive services use were compared. The association between cancer survivorship and access and preventive services was evaluated with multivariate logistic regression models, stratified by age group (18-64 years and ≥ 65 years), controlling for the effects of age, gender, race/ethnicity, education, marital status, and comorbidities. Data were analyzed in 2013. RESULTS: Cancer survivors aged ≥ 65 years had equivalent or greater access and preventive services use than individuals without a cancer history, in adjusted analyses. However, among those aged 18-64 years with private health insurance, cancer survivors were more likely than other individuals to have a usual source of care and to use preventive services, whereas uninsured or publicly insured cancer survivors were generally less likely to have a usual source of care and to use preventive services than were uninsured or publicly insured adults without a cancer history. CONCLUSIONS: Although access and preventive care use in cancer survivors is generally equivalent or greater compared to that of other individuals, disparities for uninsured and publicly insured cancer survivors aged 18-64 years suggest that improvements in survivor care are needed.

Authors: Shankaran V, Mummy D, Koepl L, Blough D, Yim YM, Yu E, Ramsey S

Title: Adverse events associated with bevacizumab and chemotherapy in older patients with metastatic colorectal cancer.

Journal: Clin Colorectal Cancer 12(3):204-213.e1

Date: 2013 Sep

Abstract: BACKGROUND: The safety of bevacizumab in older mCRC patients is poorly understood. The purpose of this analysis was to determine the prevalence, incidence, and risk factors for treatment-related AEs in older bevacizumab recipients. PATIENTS AND METHODS: Patients age ≥65 were identified from SEER-Medicare and categorized by mCRC diagnosis pre and post bevacizumab approval (2001-2003 vs. 2005-2007). Preexisting conditions known to increase bevacizumab-related AE risk were identified in the year before diagnosis. Factors associated with bevacizumab receipt were identified using logistic regression. Incidence rates for all AEs and specific serious AEs were determined. Risk factors for first AE were determined by competing risks regression. RESULTS: Of 6821 patients, 3282 (48%) were diagnosed in 2005-2007 of whom 19% received first-line bevacizumab. Likelihood of bevacizumab receipt was lower in patients age ≥ 75 (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.36-0.47), nonwhite patients (OR, 0.67; 95% CI, 0.55-0.81), patients with higher comorbidity index (OR, 0.52; 95% CI, 0.43-0.62), and patients with preexisting cerebrovascular disease (OR, 0.49; 95% CI, 0.33-0.73). AE incidence rate was not increased among first-line bevacizumab recipients relative to first-line chemotherapy recipients. In a competing risk regression adjusting for potential confounders, bevacizumab receipt (2005-2007) was not associated with an increased risk of first AE compared with chemotherapy alone (2001-2007) (hazard ratio, 0.97; 95% CI, 0.87-1.08). CONCLUSION: In an older mCRC population, bevacizumab receipt was less likely in older (age ≥ 75) nonwhite patients with preexisting cerebrovascular comorbidities. First-line bevacizumab was not associated with increased AE incidence or risk of first AE compared with chemotherapy alone.

Authors: Wirtz HS, Buist DS, Gralow JR, Barlow WE, Gray S, Chubak J, Yu O, Bowles EJ, Fujii M, Boudreau DM

Title: Frequent antibiotic use and second breast cancer events.

Journal: Cancer Epidemiol Biomarkers Prev 22(9):1588-99

Date: 2013 Sep

Abstract: BACKGROUND: Antibiotic use may be associated with higher breast cancer risk and breast cancer mortality, but no study has evaluated the relation between antibiotic use and second breast cancer events (SBCE). METHODS: We conducted a retrospective cohort study among women ≥18 years, diagnosed with incident stage I/II breast cancer during 1990-2008. Antibiotic use and covariates were obtained from health plan administrative databases and medical record review. Frequent antibiotic use was defined as ≥4 antibiotic dispensings in any moving 12-month period after diagnosis. Our outcome was SBCE defined as recurrence or second primary breast cancer. We used multivariable Cox proportional hazards models to estimate HR and 95% confidence intervals (CI), accounting for competing risks. RESULTS: A total of 4,216 women were followed for a median of 6.7 years. Forty percent were frequent antibiotic users and 558 (13%) had an SBCE. Results are suggestive of a modest increased risk of SBCE (HR, 1.15; 95% CI, 0.88-1.50) among frequent antibiotic users compared with nonusers. Any potential increased risk was not supported when we evaluated recent use and past use. We observed no dose-response trends for SBCE with increasing duration of antibiotic use nor did we find evidence for altered SBCE risk in the antibiotic classes studied. CONCLUSIONS: Frequent antibiotic use may be associated with modestly elevated risk of SBCEs, but the association was not significant. IMPACT: Additional investigation by antibiotic class and underlying indication are important next steps given the high prevalence of frequent antibiotic use and growing number of breast cancer survivors.

Authors: Fisher KJ, Lee JH, Ferrante JM, McCarthy EP, Gonzalez EC, Chen R, Love-Jackson K, Roetzheim RG

Title: The effects of primary care on breast cancer mortality and incidence among Medicare beneficiaries.

Journal: Cancer 119(16):2964-72

Date: 2013 Aug 15

Abstract: BACKGROUND: Primary care physician (PCP) services may have an impact on breast cancer mortality and incidence, possibly through greater use of screening mammography. METHODS: The authors conducted a retrospective, 1:1 matching case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database to examine use of PCP services and their association with breast cancer mortality and incidence. SEER cases representing the 3 outcomes of interest (breast cancer mortality, all-cause mortality among women diagnosed with breast cancer, and breast cancer incidence) were matched to unaffected controls from the 5% Medicare random sample. Conditional logistic regression was used to examine associations between physician visits and breast cancer outcomes while controlling for other covariates. RESULTS: Women who had 2 or more PCP visits during the 24-month assessment interval had lower odds of breast cancer mortality, all-cause mortality, and late-stage breast cancer diagnosis compared with women who had no PCP visits or 1 PCP visit while adjusting for other covariates, including mammography and non-PCP visits. Women who had 5 to 10 PCP visits had 0.69 times the odds of breast cancer mortality (95% confidence interval, 0.63-0.75), 0.83 times the odds of death from any cause having been diagnosed with breast cancer (95% confidence interval, 0.79-0.87), and 0.67 times the odds of a late-stage breast cancer diagnosis (95% confidence interval, 0.61-0.73) compared with those who had no PCP visits or 1 PCP visit. CONCLUSIONS: The current findings suggest that PCPs play an important role in reducing breast cancer mortality among the Medicare population. Further research is needed to better understand the impact of primary care on breast cancer and other cancers that are amendable to prevention or early detection.

Authors: Shuch B, Hanley J, Lai J, Vourganti S, Kim SP, Setodji CM, Dick AW, Chow WH, Saigal C, Urologic Diseases in America Project

Title: Overall survival advantage with partial nephrectomy: a bias of observational data?

Journal: Cancer 119(16):2981-9

Date: 2013 Aug 15

Abstract: BACKGROUND: Partial nephrectomy (PN) and radical nephrectomy (RN) are standard treatments for a small renal mass. Retrospective studies suggest an overall survival (OS) advantage, however a randomized phase 3 trial suggests otherwise. The effects of both surgical modalities on OS were evaluated compared with controls. METHODS: A matched cohort study was performed using the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset. Individuals treated with PN or RN for localized renal cell carcinoma (RCC) measuring ≤4 cm were compared with 2 control groups (non-muscle-invasive bladder cancer (BCC) and noncancer controls (NCC). Using a greedy algorithm, RCC groups were matched with controls by demographics and comorbidities. OS for surgical groups and controls were compared. The cause of death was evaluated for cancer groups when differences in OS were noted. RESULTS: Patients undergoing PN and RN were matched with controls. All cancer groups had >95% 10-year cancer-specific survival (CSS). Median OS was similar between RN (9.05 years) and BCC (8.67 years; P = .067) and NCC (8.77 years; P = .49). Median OS was improved for PN (10.45 years) compared with BCC (8.75 years; P<.001) and NCC controls (8.76 years; P<.001). A multivariate Cox hazards model demonstrated that PN improved OS compared with NCC (hazard ratio, 1.257; P<.001) and BCC (hazard ratio, 1.364; P<.001). CONCLUSIONS: RN patients had similar OS compared with controls, suggesting that this treatment modality does not compromise survival. Patients undergoing PN had improved OS compared with controls, suggesting possible selection bias. The apparent survival advantage conferred by PN in SEER-Medicare case series is likely the result of selection bias involving unmeasured confounders.

Authors: Fenton JJ, Onega T, Zhu W, Balch S, Smith-Bindman R, Henderson L, Sprague BL, Kerlikowske K, Hubbard RA

Title: Validation of a Medicare Claims-based Algorithm for Identifying Breast Cancers Detected at Screening Mammography.

Journal: Med Care :-

Date: 2013 Aug 06

Abstract: BACKGROUND:: The breast cancer detection rate is a benchmark measure of screening mammography quality, but its computation requires linkage of mammography interpretive performance information with cancer incidence data. A Medicare claims-based measure of detected breast cancers could simplify measurement of this benchmark and facilitate mammography quality assessment and research. OBJECTIVES:: To validate a claims-based algorithm that can identify with high positive predictive value (PPV) incident breast cancers that were detected at screening mammography. RESEARCH DESIGN:: Development of a claims-derived algorithm using classification and regression tree analyses within a random half-sample of Medicare screening mammography claims followed by validation of the algorithm in the remaining half-sample using clinical data on mammography results and cancer incidence from the Breast Cancer Surveillance Consortium (BCSC). SUBJECTS:: Female fee-for-service Medicare enrollees aged 68 years and older who underwent screening mammography from 2001 to 2005 within BCSC registries in 4 states (CA, NC, NH, and VT), enabling linkage of claims and BCSC mammography data (N=233,044 mammograms obtained by 104,997 women). MEASURES:: Sensitivity, specificity, and PPV of algorithmic identification of incident breast cancers that were detected by radiologists relative to a reference standard based on BCSC mammography and cancer incidence data. RESULTS:: An algorithm based on subsequent codes for breast cancer diagnoses and treatments and follow-up mammography identified incident screen-detected breast cancers with 92.9% sensitivity [95% confidence interval (CI), 91.0%-94.8%], 99.9% specificity (95% CI, 99.9%-99.9%), and a PPV of 88.0% (95% CI, 85.7%-90.4%). CONCLUSIONS:: A simple claims-based algorithm can accurately identify incident breast cancers detected at screening mammography among Medicare enrollees. The algorithm may enable mammography quality assessment using Medicare claims alone.

Authors: Cho H, Mariotto AB, Mann BS, Klabunde CN, Feuer EJ

Title: Assessing non-cancer-related health status of US cancer patients: other-cause survival and comorbidity prevalence.

Journal: Am J Epidemiol 178(3):339-49

Date: 2013 Aug 01

Abstract: With advances in prevention, screening, and treatment, cancer patients are living longer; hence, non-cancer-related health status will likely play a larger role in determining their life expectancy. In this study, we present a novel method for characterizing non-cancer--related health status of cancer patients using population-based cancer registry data. We assessed non-cancer-related health status in the context of survival from other causes of death and prevalence of comorbidities. Data from the Surveillance, Epidemiology, and End Results program (2000-2006) were used to analyze cancer patients' survival probabilities by cause of death. Other-cause survival was estimated using a left-truncated survival method with the hazard of death due to other causes characterized as a function of age. Surveillance, Epidemiology, and End Results data linked to Medicare claims (1992-2005) were used to quantify comorbidity prevalence. Relative to the US population, survival from a non-cancer-related death was higher for patients diagnosed with early stage breast and prostate cancer but lower for lung cancer patients at all stages. Lung cancer patients had worse comorbidity status than did other cancer patients. The present study represents the first attempt to evaluate the non-cancer-related health status of US cancer patients by cancer site (breast, prostate, colorectal, and lung) and stage. The findings provide insight into non-cancer-related health issues among cancer patients and their risk of dying from other causes.

Authors: Barile JP, Reeve BB, Smith AW, Zack MM, Mitchell SA, Kobau R, Cella DF, Luncheon C, Thompson WW

Title: Monitoring population health for Healthy People 2020: evaluation of the NIH PROMIS® Global Health, CDC Healthy Days, and satisfaction with life instruments.

Journal: Qual Life Res 22(6):1201-11

Date: 2013 Aug

Abstract: PURPOSE: Healthy People 2020 identified health-related quality of life and well-being (WB) as indicators of population health for the next decade. This study examined the measurement properties of the NIH PROMIS(®) Global Health Scale, the CDC Healthy Days items, and associations with the Satisfaction with Life Scale. METHODS: A total of 4,184 adults completed the Porter Novelli's HealthStyles mailed survey. Physical and mental health (9 items from PROMIS Global Scale and 3 items from CDC Healthy days measure), and 4 WB factor items were tested for measurement equivalence using multiple-group confirmatory factor analysis. RESULTS: The CDC items accounted for similar variance as the PROMIS items on physical and mental health factors; both factors were moderately correlated with WB. Measurement invariance was supported across gender and age; the magnitude of some factor loadings differed between those with and without a chronic medical condition. CONCLUSIONS: The PROMIS, CDC, and WB items all performed well. The PROMIS items captured a broad range of functioning across the entire continuum of physical and mental health, while the CDC items appear appropriate for assessing burden of disease for chronic conditions and are brief and easily interpretable. All three measures under study appear to be appropriate measures for monitoring several aspects of the Healthy People 2020 goals and objectives.

Authors: Bostean G, Crespi CM, McCarthy WJ

Title: Associations among family history of cancer, cancer screening and lifestyle behaviors: a population-based study.

Journal: Cancer Causes Control 24(8):1491-503

Date: 2013 Aug

Abstract: PURPOSE: Some cancers are largely preventable through modification of certain behavioral risk factors and preventive screening, even among those with a family history of cancer. This study examined the associations between (1) family cancer history and cancer screening, (2) family history and cancer preventive lifestyle behaviors, and (3) cancer screening and lifestyle behaviors. METHODS: Data were from the 2009 California Health Interview Survey (n = 12,603). Outcomes included screening for breast cancer (BC) and colorectal cancer (CRC) and six cancer preventive lifestyle behaviors, based on World Cancer Research Fund recommendations. Multivariate logistic regression analyses, stratified by gender and race-ethnicity, examined associations. Predicted probabilities of cancer screening by family cancer history, race-ethnicity, and sex were computed. RESULTS: Family history of site-specific cancer-CRC for men and women, and BC for women-was associated with higher probability of cancer screening for most groups, especially for CRC, but was largely unrelated to other lifestyle behaviors. In the few cases in which family history was significantly associated with lifestyle-for example, physical activity among White and Latino males, smoking among White and Asian females-individuals with a family history had lower odds of adherence to recommendations than those with no family history. Greater overall adherence to lifestyle recommendations was associated with higher odds of up-to-date CRC screening among White and Asian males, and lower odds among Asian females (no significant association with BC screening); this relationship did not vary by family cancer history. CONCLUSION: The fact that family history of cancer is not associated with better lifestyle behaviors may reflect shared behavioral risks within families, or the lack of knowledge about how certain lifestyle behaviors impact personal cancer risk. Findings can inform interventions aimed at lifestyle behavioral modification for individuals at increased cancer risk due to family history.

Authors: Gancayco J, Soulos PR, Khiani V, Cramer LD, Ross JS, Genao I, Tinetti M, Gross CP

Title: Age-based and sex-based disparities in screening colonoscopy use among medicare beneficiaries.

Journal: J Clin Gastroenterol 47(7):630-6

Date: 2013 Aug

Abstract: BACKGROUND: The use of screening colonoscopy among older persons is controversial due to variability in life expectancy and sex-based differences in colorectal cancer incidence. We assessed the relation between sex, age, and receipt of screening colonoscopy overall and within strata of life expectancy. METHODS: We used Medicare data to identify beneficiaries during the years 2001 to 2005 who had not undergone a colonoscopy in the prior 3 years. Medicare claims were used to identify screening colonoscopy use; life expectancy was estimated using a life table approach. We used Poisson regression to examine sex and age differences in screening colonoscopy, adjusted for patient demographic characteristics. RESULTS: Our sample consisted of 161,229 patients (61.9% female; mean age 76.9 y). The screening colonoscopy rates for females and males were 16.9 and 24.4 screening colonoscopies per 1000 person-years, respectively (P<0.001). The screening colonoscopy rate was highest for patients with the longest life expectancy (10 to 15 y: 27.2 screening colonoscopies per 1000 person-years) compared with 3.4 per 1000 person-years in the life expectancy <5-year group. Within specific life expectancy categories, older patients had significantly lower screening rates; in the 10- to 15-year life expectancy category, patients 75 to 79 years old had a lower rate (21.9 screening colonoscopies per 1000 person-years) than patients 68 to 69 years old (34.1 screening colonoscopies per 1000 person-years; P<0.001). CONCLUSIONS: In a large cohort of Medicare beneficiaries, there was evidence of screening colonoscopy use even among patients with a short life expectancy. After accounting for life expectancy, females and older persons were less likely to undergo screening colonoscopy.

Authors: Hyder O, Dodson RM, Mayo SC, Schneider EB, Weiss MJ, Herman JM, Wolfgang CL, Pawlik TM

Title: Post-treatment surveillance of patients with colorectal cancer with surgically treated liver metastases.

Journal: Surgery 154(2):256-65

Date: 2013 Aug

Abstract: BACKGROUND: Little is known about current surveillance patterns after treatment of colorectal liver metastasis (CRLM) or whether the intensity of surveillance correlates with outcome. We sought to define current population-based patterns of surveillance and investigate whether intensity of surveillance impacted outcome. METHODS: We queried the Surveillance, Epidemiology, and End Results-linked Medicare database for patients with CRLM diagnosed between 1991 and 2005 who underwent liver resection and/or tumor ablation. Frequency of post-treatment abdominal computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) was recorded for ≤ 5 years after treatment. The association between frequency of imaging with secondary interventions and long-term survival were analyzed. RESULTS: We identified 1,739 patients with CRLM treated with surgery; median age was 73 years, and the majority were male (52.6%). CRLM treatment consisted of liver resection (61%), ablation (32%), or both simultaneously (6%). CT (97%) was utilized more often for post-treatment surveillance compared with MRI (7%) and PET (18%). A temporal trend was noted with more frequent surveillance imaging obtained in post-treatment year 1 (2.4 scans/year) versus year 5 (0.6 scans/year; P = .01); 66% of living patients had no imaging after 2 years. Frequency of surveillance imaging correlated with procedure type (total number of scans/5 years: resection, 5.0; ablation, 4.6; resection and ablation, 6.2; P = .01). Other factors associated with a greater frequency of surveillance included younger age at diagnosis, geographic location in the South, and CRLM directed surgery in 2000 through 2005 (all P < .05). Overall survival did not differ by intensity of surveillance imaging (3-4 scans/yr, 43 months vs 2 scans/yr, 57 months vs 1 scan/yr, 54 months; P = .08). CONCLUSION: Marked heterogeneity exists in how often surveillance imaging is obtained after treatment of CRLM. Intensity of imaging does not affect time to second procedure or median survival duration. Surveillance guidelines for CRLM need to be refocused to provide the best value for healthcare resources.

Authors: Jinkins LJ, Parmar AD, Han Y, Duncan CB, Sheffield KM, Brown KM, Riall TS

Title: Current trends in preoperative biliary stenting in patients with pancreatic cancer.

Journal: Surgery 154(2):179-89

Date: 2013 Aug

Abstract: BACKGROUND: Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy. METHODS: Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992-2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients. RESULTS: Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001). CONCLUSION: Use of preoperative biliary stenting doubled between 1992 and 2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.

Authors: Kaplan AL, Hu JC

Title: Use of testosterone replacement therapy in the United States and its effect on subsequent prostate cancer outcomes.

Journal: Urology 82(2):321-6

Date: 2013 Aug

Abstract: OBJECTIVE: To assess utilization trends and determine the effect of testosterone replacement therapy on outcomes in men who subsequently developed prostate cancer. METHODS: We used linked Surveillance, Epidemiology, and End Results-Medicare data to identify 149,354 men diagnosed with prostate cancer from 1992 to 2007. Of those, 2,237 men (1.5%) underwent testosterone replacement therapy before their prostate cancer diagnosis. Propensity scoring methods were used to assess cancer-specific outcomes of testosterone replacement vs no replacement therapy. RESULTS: Testosterone replacement was associated with older age at cancer diagnosis, nonwhite race, and higher comorbidity (P <.001). No testosterone vs testosterone before the prostate cancer diagnosis was associated with higher grade (34% vs 30%, P <.0001) and more T4 (6.5% vs 4.3%, P <.0001) tumors. Mortality was decreased in men with ≥2 prostate-specific antigen (PSA) tests in the year before their cancer diagnosis. No significant difference was found between groups in overall survival, cancer-specific survival, or use of salvage androgen-deprivation therapy after initial treatment. CONCLUSION: Through our observational study design, we show that testosterone use was low throughout the study period. Testosterone use was not associated with aggressive prostate cancer and did not affect overall or disease-specific mortality. Although our findings support growing evidence that testosterone replacement is safe with respect to prostate cancer, confirmatory prospective studies are needed.

Authors: Kent EE, Sender LS, Morris RA, Grigsby TJ, Montoya MJ, Ziogas A, Anton-Culver H

Title: Multilevel socioeconomic effects on quality of life in adolescent and young adult survivors of leukemia and lymphoma.

Journal: Qual Life Res 22(6):1339-51

Date: 2013 Aug

Abstract: PURPOSE: Cancer registry survival analyses have shown that adolescent and young adult patients with low socioeconomic status (SES) have reduced survival compared to those with higher SES. The objective of this study was to determine whether neighborhood- (nSES) and/or individual-level SES (iSES) also predicted current quality of life in adolescent and young adult survivors. METHODS: The Socioeconomics and Quality of Life study surveyed adolescent and young adult survivors of leukemia and lymphoma at least one year post-diagnosis using population-based ascertainment. Factor analysis was used to create a multidimensional age-relevant iSES score and compared with a preexisting census-block-group derived nSES score. Four quality of life domains were assessed: physical health, psychological and emotional well-being, social relationships, and life skills. Nested multivariable linear regression models were run to test the associations between both SES measures and quality of life and to compare the explanatory power of nSES and iSES. RESULTS: Data from 110 individuals aged 16-40 were included in the final analysis. After adjustment for sociodemographic confounders, low nSES was associated only with poorer physical health, whereas low iSES was related to poorer quality of life in all four domains with iSES accounting for an additional 14, 12, 25, and 10 % of the variance, respectively. CONCLUSIONS: Measures of SES at the individual as compared to the neighborhood level may be stronger indicators of outcomes in adolescents and young adults, which has important implications for SES measurement in the context of cancer surveillance.

Authors: Killelea BK, Long JB, Chagpar AB, Ma X, Soulos PR, Ross JS, Gross CP

Title: Trends and clinical implications of preoperative breast MRI in Medicare beneficiaries with breast cancer.

Journal: Breast Cancer Res Treat 141(1):155-63

Date: 2013 Aug

Abstract: While there has been increasing interest in the use of preoperative breast magnetic resonance imaging (MRI) for women with breast cancer, little is known about trends in MRI use, or the association of MRI with surgical approach among older women. Using the Surveillance, Epidemiology and End Results-Medicare database, we identified a cohort of women diagnosed with breast cancer from 2000 to 2009 who underwent surgery. We used Medicare claims to identify preoperative breast MRI and surgical approach. We evaluated temporal trends in MRI use according to age and type of surgery, and identified factors associated with MRI. We assessed the association between MRI and surgical approach: breast-conserving surgery (BCS) versus mastectomy, bilateral versus unilateral mastectomy, and use of contralateral prophylactic mastectomy. Among the 72,461 women in our cohort, 10.1 % underwent breast MRI. Preoperative MRI use increased from 0.8 % in 2000-2001 to 25.2 % in 2008-2009 (p < 0.001). Overall, 43.3 % received mastectomy and 56.7 % received BCS. After adjustment for clinical and demographic factors, MRI was associated with an increased likelihood of having a mastectomy compared to BCS (adjusted odds ratio = 1.21, 95 % CI 1.14-1.28). Among women who underwent mastectomy, MRI was significantly associated with an increased likelihood of having bilateral cancer diagnosed (9.7 %) and undergoing bilateral mastectomy (12.5 %) compared to women without MRI (3.7 and 4.1 %, respectively, p < 0.001 for both). In conclusion, the use of preoperative breast MRI has increased substantially among older women with breast cancer and is associated with an increased likelihood of being diagnosed with bilateral cancer, and more invasive surgery.

Authors: Kowalczyk KJ, Choueiri TK, Hevelone ND, Trinh QD, Lipsitz SR, Nguyen PL, Lynch JH, Hu JC

Title: Comparative effectiveness, costs and trends in treatment of small renal masses from 2005 to 2007.

Journal: BJU Int 112(4):E273-80

Date: 2013 Aug

Abstract: What's known on the subject? and what does the study add?: Retrospective data have suggested an increased survival benefit for patients undergoing partial nephrectomy compared to radical nephrectomy, possibly as a result of the avoidance of long-term renalin sufficiency and subsequent sequelae. However, recent level-one evidence has questioned this benefit. Both retrospective studies and randomized controlled trials are not without limitations. There are few population-based data available with respect to the outcomes of partial nephrectomy vs radical nephrectomy. Additionally, there are no population-based studies analyzing the surgical approach (minimally-invasive vs open), as well as other modalities, such as ablation and surveillance. Finally, there is very little information available on the potential differences in cost for each approach. The present study comprises the first comprehensive population-based analysis of the trends, outcomes and costs of all treatment modalities for T1a renal masses from 2005 to 2007. OBJECTIVE: To perform a comprehensive analysis of the outcomes and costs for treatments for small renal masses (SRM) using a population-based approach. Partial nephrectomy may be associated with improved survival, although level-one evidence has questioned this survival advantage. PATIENTS AND METHODS: Using Surveillance, Epidemiology and End Results-Medicare data, we identified 1682 subjects who were diagnosed with SRM from 2005 to 2007. Treatment included open radical nephrectomy (ORN; n = 404), minimally-invasive radical nephrectomy (MIRN; n = 535), open partial nephrectomy (OPN; n = 330), minimally-invasive partial nephrectomy (MIPN; n = 160), ablation (n = 211) and surveillance (n = 42). Postoperative complications, renal insufficiency diagnosis, overall mortality, cancer-specific mortality and postoperative costs were compared. Covariates were balanced before outcomes analysis using propensity score methods. RESULTS: Although the use of nephron-sparing surgery (NSS) increased over the study period, radical nephrectomy remained the predominant approach for SRM in 2007. Minimally-invasive approaches had shorter lengths of stay (P < 0.001), whereas open approaches had more overall complications, respiratory complications and intensive care unit admissions (all P < 0.003). MIRN and ORN were associated with more peri-operative medical complications, acute renal failure, haemodialysis use and long-term chronic renal insufficiency diagnosis vs NSS (all P < 0.001). Ablation, MIRN and ORN were associated with the highest overall mortality rates (P < 0.001), whereas MIRN and ORN were associated with the highest cancer-specific mortality rates (P < 0.001). Treatment costs were lowest for surveillance ($2911) followed by ablation ($10730), MIRN ($15373), MIPN ($15695), OPN ($16986) and ORN ($17803). CONCLUSIONS: Although not the predominant treatment approach for SRM over the study period, the use of NSS increased and was associated with improved survival, fewer complications and less renal insufficiency. Minimally-invasive approaches confer lower costs.

Authors: Locher JL, Bonner JA, Carroll WR, Caudell JJ, Allison JJ, Kilgore ML, Ritchie CS, Tajeu GS, Yuan Y, Roth DL

Title: Patterns of prophylactic gastrostomy tube placement in head and neck cancer patients: a consideration of the significance of social support and practice variation.

Journal: Laryngoscope 123(8):1918-25

Date: 2013 Aug

Abstract: OBJECTIVES/HYPOTHESIS: The purpose of this study was to examine factors associated with prophylactic placement of feeding tubes in head and neck cancer patients receiving radiation therapy as a part of treatment using multilevel models that account for patient-, physician-, and institution-level sources of variation. STUDY DESIGN: A retrospective analysis using binary logistic regression and hierarchical linear models was run to evaluate independent predictors of prophylactic feeding tube placement. METHODS: Surveillance, Epidemiology, and End Results-Medicare data were used. Head and neck cancer patients diagnosed with locoregionally advanced stage disease from 2000 to 2005 were included in this study (N = 8,306). RESULTS: Across all models, prophylactic gastrostomy tube placement was found to be more likely in patients who had cancer of the larynx or oropharynx compared with those with cancer of the nasopharynx or oral cavity; who had regional instead of local cancer; who did not receive surgery as a part of treatment, but did receive chemotherapy; and who were divorced, separated, or widowed. Additionally, although practice variation was observed to occur, its overall contribution in predicting prophylactic gastrostomy tube placement was minimal. CONCLUSIONS: As health care enters an era of patient-centered care, further investigation of the potential role of social support (or lack of social support) in influencing treatment decisions of head and neck cancer patients and providers is warranted.

Authors: Mack CD, Glynn RJ, Brookhart MA, Carpenter WR, Meyer AM, Sandler RS, Stürmer T

Title: Calendar time-specific propensity scores and comparative effectiveness research for stage III colon cancer chemotherapy.

Journal: Pharmacoepidemiol Drug Saf 22(8):810-8

Date: 2013 Aug

Abstract: PURPOSE: Nonexperimental studies of treatment effectiveness provide an important complement to randomized trials by including heterogeneous populations. Propensity scores (PSs) are common in these studies but may not adequately capture changes in channeling experienced by innovative treatments. We use calendar time-specific (CTS) PSs to examine the effect of oxaliplatin during dissemination from off-label to widespread use. METHODS: Stage III colon cancer patients aged 65+ years initiating chemotherapy between 2003 and 2006 were examined using cancer registry data linked with Medicare claims. Two PS approaches for receipt of oxaliplatin versus 5-flourouricil were constructed using logistic models with key components of age, sex, substage, grade, census-level income, and comorbidities: (i) a conventional, year-adjusted PS and (ii) a CTS PS constructed and matched separately within 1-year intervals, then combined. We compared PS-matched hazard ratios (HRs) for mortality using Cox models. RESULTS: Oxaliplatin use increased significantly; 8% (n = 86) of patients received it in the first time period versus 52% (n = 386) in the last. Channeling by comorbidities, income, and age appeared to change over time. The CTS PS improved covariate balance within calendar time strata and yielded an attenuated estimated benefit of oxaliplatin (HR = 0.75) compared with the conventional PS (HR = 0.69). CONCLUSION: In settings where prescribing patterns have changed and calendar time acts as a confounder, a CTS PS can characterize changes in treatment choices and estimating separate PSs within specific calendar time periods may result in enhanced confounding control. To increase validity of comparative effectiveness research, researchers should carefully consider drug lifecycles and effects of innovative treatment dissemination over time.

Authors: Shahidi NC, Homayoon B, Cheung WY

Title: Factors associated with suboptimal colorectal cancer screening in US immigrants.

Journal: Am J Clin Oncol 36(4):381-7

Date: 2013 Aug

Abstract: BACKGROUND: Our objectives were to: (1) compare colorectal cancer screening (CRCS) among US born citizens (USBs), naturalized citizens (NACs), and noncitizens (NOCs) and (2) evaluate clinical factors and potential barriers associated with CRCS in these populations. METHODS: Screening-eligible patients were identified from the 2007 California Health Interview Survey. Up-to-date CRCS was defined as a fecal occult blood test within 1 year, a sigmoidoscopy within 5 years, or a colonoscopy within 10 years. Using logistic regression, we determined the effects of immigrant status on CRCS. Stratified analyses based on location of residence, health insurance status, and English proficiency were conducted. RESULTS: A total of 30,434 average-risk adults aged 50 years or older completed the survey. Only 67% of USBs, 61% of NACs, and 46% of NOCs underwent CRCS. Advanced age, male sex, high-income earners, nonsmokers, and those who were married or visited their physicians frequently were more likely to receive CRCS (all P < 0.05). Compared with USBs, both NACs and NOCs showed decreased odds of CRCS (odds ratio 0.88, 95% confidence interval, 0.74-1.06 and odds ratio 0.68, 95% confidence interval, 0.53-0.88, respectively; P = 0.011). Stratified analyses revealed that the associations between immigrants and decreased CRCS were more prominent for those who lived in rural areas, lacked insurance, or were not English proficient. CONCLUSIONS: CRCS remains suboptimal, especially in new US immigrants. Improving health care access and mitigating language barriers may minimize this disparity.

Authors: Sprague BL, McLaughlin V, Hampton JM, Newcomb PA, Trentham-Dietz A

Title: Disease-free survival by treatment after a DCIS diagnosis in a population-based cohort study.

Journal: Breast Cancer Res Treat 141(1):145-54

Date: 2013 Aug

Abstract: Randomized trials have demonstrated the efficacy of radiation and tamoxifen in reducing risk of second events after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS), but the comparative effectiveness of mastectomy, BCS, and adjuvant treatments have not been established in community practice. We examined disease-free survival (DFS) among 1,676 DCIS cases diagnosed during 1995-2006 in the population-based Wisconsin In Situ Cohort study. Information on patient and tumor characteristics, treatments, and second breast cancer events were collected via a comprehensive review of data from patient interviews, the statewide cancer registry, and pathology reports. Breast cancer DFS was evaluated according to treatment while adjusting for patient and tumor characteristics. After an average of 7.1 years of follow-up, 143 second breast cancer events occurred. Overall 5-year DFS was similar among women treated with ipsilateral mastectomy (95.6 %; 95 % CI 93.5-97.0) compared to women treated with BCS and radiation (94.8 %; 95 % CI 92.8-96.1), though women receiving BCS without radiation experienced poorer overall DFS (87.0 %; 95 % CI 80.6-91.5). Women treated with tamoxifen in addition to BCS and radiation had a similar risk of a second breast event, although the hazard ratio (HR) suggested a potential benefit (0.70, 95% CI 0.41-1.19). Women treated with BCS, radiation, and tamoxifen had comparable risk of a second event as those treated with ipsilateral mastectomy (HR = 1.20; 95 % CI 0.71-2.02). In this population-based sample, the use of BCS with radiation and tamoxifen resulted in high DFS rates comparable to those achieved by ipsilateral mastectomy.

Authors: Stott-Miller M, Chen C, Schwartz SM

Title: Type II diabetes and metabolic syndrome in relation to head and neck squamous cell carcinoma risk: a SEER-Medicare database study.

Journal: Cancer Epidemiol 37(4):428-33

Date: 2013 Aug

Abstract: BACKGROUND: Diabetes and metabolic syndrome have been found to increase the risk of various cancers. Previous studies indicated that diabetes may increase the risk of head and neck squamous cell carcinoma (HNSCC). Metabolic syndrome has not been investigated as a risk factor. We tested whether type II diabetes or metabolic syndrome were associated with HNSCC using a very large database of medical administrative records, providing the ability to investigate relatively weak effects and stratify by subgroups. METHODS: We identified persons diagnosed with HNSCC between 1994 and 2007 in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. We selected controls from a 5% sample of Medicare beneficiaries and frequency matched to cases on sex and duration of enrollment. We estimated odds ratios (OR) and 95% confidence intervals (CI) for the association between type II diabetes/metabolic syndrome and HNSCC, adjusted for potential confounders, among 14,022 cases and 42,066 controls. RESULTS: We observed a very weak inverse association between type II diabetes and HNSCC (OR=0.92; 95% CI, 0.88-0.96) and a moderate inverse association for metabolic syndrome (OR=0.81; 95% CI, 0.78-0.85). Associations were modified by tobacco use, with null results for type II diabetes among never users (OR=1.00; 95% CI, 0.95-1.06) and inverse associations among ever users (OR=0.80; 95% CI, 0.75-0.86). CONCLUSIONS: We observed moderate inverse associations between metabolic syndrome and HNSCC and weak inverse associations between type II diabetes and HNSCC, which was contrary to the evidence to date. Inadequate control for confounding factors, such as overweight/obesity, may have influenced results.

Authors: Subar AF, Midthune D, Tasevska N, Kipnis V, Freedman LS

Title: Checking for completeness of 24-h urine collection using para-amino benzoic acid not necessary in the Observing Protein and Energy Nutrition study.

Journal: Eur J Clin Nutr 67(8):863-7

Date: 2013 Aug

Abstract: BACKGROUND/OBJECTIVES: The orally administered para-amino benzoic acid (PABA) is known to have near 100% excretion in urine and is used as a measure of 24-h urine collection completeness (referred to as PABAcheck). The purpose was to examine the effect of including urine collections deemed incomplete based on PABAcheck in a dietary measurement error study. SUBJECTS/METHODS: The Observing Protein and Energy Nutrition (OPEN) study was conducted in 1999-2000 and included 484 men and women aged 40-69 years. A food frequency questionnaire and 24-h dietary recalls were evaluated using recovery biomarkers that included urinary nitrogen and potassium from two 24-h urine collections. Statistical modeling determined the measurement error properties of dietary assessment instruments. In the original analyses, PABAcheck was used as a measure of complete urine collection; incomplete collections were either excluded or adjusted to acceptable levels. The OPEN data were reanalyzed including all urine collections and by using criteria based on self-reported missing voids to assess the differences. RESULTS: Means and coefficients of variation for biomarker-based protein and potassium intakes, and measurement error model-based correlations and attenuation factors were similar regardless of whether PABAcheck or missed voids were considered. CONCLUSION: PABAcheck may not be required in large population-based biomarker studies. However, until there are more analyses evaluating the necessity of a PABAcheck, it is recommended that PABA be given to all participants, but not necessarily analyzed. Then, PABAcheck could be used selectively as a marker of completeness among the collections in which low levels of biomarker are detected or for which noncompliance is suspected.

Authors: Welzel TM, Graubard BI, Quraishi S, Zeuzem S, Davila JA, El-Serag HB, McGlynn KA

Title: Population-attributable fractions of risk factors for hepatocellular carcinoma in the United States.

Journal: Am J Gastroenterol 108(8):1314-21

Date: 2013 Aug

Abstract: OBJECTIVES: Risk factors for hepatocellular carcinoma (HCC) include hepatitis B and C viruses (HBV, HCV), excessive alcohol consumption, rare genetic disorders and diabetes/obesity. The population attributable fractions (PAF) of these factors, however, have not been investigated in population-based studies in the United States. METHODS: Persons ≥68 years diagnosed with HCC (n=6,991) between 1994 and 2007 were identified in the SEER-Medicare database. A 5% random sample (n=255,702) of persons residing in SEER locations were selected for comparison. For each risk factor, odds ratios (ORs), 95% confidence intervals (95% CI) and PAFs were calculated. RESULTS: As anticipated, the risk of HCC was increased in relationship to each factor: HCV (OR 39.89, 95% CI: 36.29-43.84), HBV (OR 11.17, 95% CI: 9.18-13.59), alcohol-related disorders (OR 4.06, 95% CI: 3.82-4.32), rare metabolic disorders (OR 3.45, 95% CI: 2.97-4.02), and diabetes and/or obesity (OR 2.47, 95% CI: 2.34-2.61). The PAF of all factors combined was 64.5% (males 65.6%; females 62.2%). The PAF was highest among Asians (70.1%) and lowest among black persons (52.4%). Among individual factors, diabetes/obesity had the greatest PAF (36.6%), followed by alcohol-related disorders (23.5%), HCV (22.4%), HBV (6.3%) and rare genetic disorders (3.2%). While diabetes/obesity had the greatest PAF among both males (36.4%) and females (36.7%), alcohol-related disorders had the second greatest PAF among males (27.8%) and HCV the second greatest among females (28.1%). Diabetes/obesity had the greatest PAF among whites (38.9%) and Hispanics (38.1%), while HCV had the greatest PAF among Asians (35.4%) and blacks (34.9%). The second greatest PAF was alcohol-related disorders in whites (25.6%), Hispanics (30.1%) and blacks (and 18.5%) and HBV in Asians (28.5%). CONCLUSIONS: The dominant risk factors for HCC in the United States among persons ≥68 years differ by sex and race/ethnicity. Overall, eliminating diabetes/obesity could reduce the incidence of HCC more than the elimination of any other factor.

Authors: Winner M, Mooney SJ, Hershman DL, Feingold DL, Allendorf JD, Wright JD, Neugut AI

Title: Incidence and predictors of bowel obstruction in elderly patients with stage IV colon cancer: a population-based cohort study.

Journal: JAMA Surg 148(8):715-22

Date: 2013 Aug

Abstract: IMPORTANCE: Research has been limited on the incidence, mechanisms, etiology, and treatment of symptoms that require palliation in patients with terminal cancer. Bowel obstruction (BO) is a common complication of advanced abdominal cancer, including colon cancer, for which small, single-institution studies have suggested an incidence rate of 15% to 29%. Large population-based studies examining the incidence or risk factors associated with BO in cancer are lacking. OBJECTIVE: To investigate the incidence and risk factors associated with BO in patients with stage IV colon cancer. DESIGN AND SETTING: Retrospective cohort, population-based study of patients in the Surveillance, Epidemiology, and End Results and Medicare claims linked databases who were diagnosed as having stage IV colon cancer from January 1, 1991, through December 31, 2005. PATIENTS: Patients 65 years or older with stage IV colon cancer (n = 12 553). MAIN OUTCOMES AND MEASURES: Time to BO, defined by inpatient hospitalization for BO. We used Cox proportional hazards regression models to determine associations between BO and patient, prior treatment, and tumor features. RESULTS: We identified 1004 patients with stage IV colon cancer subsequently hospitalized with BO (8.0%). In multivariable analysis, proximal tumor site (hazard ratio, 1.22 [95% CI, 1.07-1.40]), high tumor grade (1.34 [1.16-1.55]), mucinous histological type (1.27 [1.08-1.50]), and nodal stage N2 (1.52 [1.26-1.84]) were associated with increased risk of BO, as was the presence of obstruction at cancer diagnosis (1.75 [1.47-2.04]). A more recent diagnosis was associated with decreased risk of subsequent obstruction (hazard ratio, 0.84 [95% CI, 0.72-0.98]). CONCLUSIONS AND RELEVANCE: In this large population of patients with stage IV colon cancer, BO after diagnosis was less common (8.0%) than previously reported. Risk was associated with site and histological type of the primary tumor. Future studies will explore management and outcomes in this serious, common complication.

Authors: Silber JH, Rosenbaum PR, Clark AS, Giantonio BJ, Ross RN, Teng Y, Wang M, Niknam BA, Ludwig JM, Wang W, Even-Shoshan O, Fox KR

Title: Characteristics associated with differences in survival among black and white women with breast cancer.

Journal: JAMA 310(4):389-97

Date: 2013 Jul 24

Abstract: IMPORTANCE: Difference in breast cancer survival by race is a recognized problem among Medicare beneficiaries. OBJECTIVE: To determine if racial disparity in breast cancer survival is primarily attributable to differences in presentation characteristics at diagnosis or subsequent treatment. DESIGN, SETTING, AND PATIENTS: Comparison of 7375 black women 65 years and older diagnosed between 1991 to 2005 and 3 sets of 7375 matched white control patients selected from 99,898 white potential controls, using data for 16 US Surveillance, Epidemiology and End Results (SEER) sites in the SEER-Medicare database. All patients received follow-up through December 31, 2009, and the black case patients were matched to 3 white control populations on demographics (age, year of diagnosis, and SEER site), presentation (demographics variables plus patient comorbid conditions and tumor characteristics such as stage, size, grade, and estrogen receptor status), and treatment (presentation variables plus details of surgery, radiation therapy, and chemotherapy). MAIN OUTCOMES AND MEASURES: 5-Year survival. RESULTS: The absolute difference in 5-year survival (blacks, 55.9%; whites, 68.8%) was 12.9% (95% CI, 11.5%-14.5%; P < .001) in the demographics match. This difference remained unchanged between 1991 and 2005. After matching on presentation characteristics, the absolute difference in 5-year survival was 4.4% (95% CI, 2.8%-5.8%; P < .001) and was 3.6% (95% CI, 2.3%-4.9%; P < .001) lower for blacks than for whites matched also on treatment. In the presentation match, fewer blacks received treatment (87.4% vs 91.8%; P < .001), time from diagnosis to treatment was longer (29.2 vs 22.8 days; P < .001), use of anthracyclines and taxols was lower (3.7% vs 5.0%; P < .001), and breast-conserving surgery without other treatment was more frequent (8.2% vs 7.3%; P = .04). Nevertheless, differences in survival associated with treatment differences accounted for only 0.81% of the 12.9% survival difference. CONCLUSIONS AND RELEVANCE: In the SEER-Medicare database, differences in breast cancer survival between black and white women did not substantially change among women diagnosed between 1991 and 2005. These differences in survival appear primarily related to presentation characteristics at diagnosis rather than treatment differences.

Authors: Parry C, Kent EE, Forsythe LP, Alfano CM, Rowland JH

Title: Can't see the forest for the care plan: a call to revisit the context of care planning.

Journal: J Clin Oncol 31(21):2651-3

Date: 2013 Jul 20

Abstract:

Authors: Tice JA, O'Meara ES, Weaver DL, Vachon C, Ballard-Barbash R, Kerlikowske K

Title: Benign breast disease, mammographic breast density, and the risk of breast cancer.

Journal: J Natl Cancer Inst 105(14):1043-9

Date: 2013 Jul 17

Abstract: BACKGROUND: Benign breast disease and high breast density are prevalent, strong risk factors for breast cancer. Women with both risk factors may be at very high risk. METHODS: We included 42818 women participating in the Breast Cancer Surveillance Consortium who had no prior diagnosis of breast cancer and had undergone at least one benign breast biopsy and mammogram; 1359 women developed incident breast cancer in 6.1 years of follow-up (78.1% invasive, 21.9% ductal carcinoma in situ). We calculated hazard ratios (HRs) using Cox regression analysis. The referent group was women with nonproliferative changes and average density. All P values are two-sided. RESULTS: Benign breast disease and breast density were independently associated with breast cancer. The combination of atypical hyperplasia and very high density was uncommon (0.6% of biopsies) but was associated with the highest risk for breast cancer (HR = 5.34; 95% confidence interval [CI] = 3.52 to 8.09, P < .001). Proliferative disease without atypia (25.6% of biopsies) was associated with elevated risk that varied little across levels of density: average (HR = 1.37; 95% CI = 1.11 to 1.69, P = .003), high (HR = 2.02; 95% CI = 1.68 to 2.44, P < .001), or very high (HR = 2.05; 95% CI = 1.54 to 2.72, P < .001). Low breast density (4.5% of biopsies) was associated with low risk (HRs <1) for all benign pathology diagnoses. CONCLUSIONS: Women with high breast density and proliferative benign breast disease are at very high risk for future breast cancer. Women with low breast density are at low risk, regardless of their benign pathologic diagnosis.

Authors: Mandelblatt J, van Ravesteyn N, Schechter C, Chang Y, Huang AT, Near AM, de Koning H, Jemal A

Title: Which strategies reduce breast cancer mortality most? Collaborative modeling of optimal screening, treatment, and obesity prevention.

Journal: Cancer 119(14):2541-8

Date: 2013 Jul 15

Abstract: BACKGROUND: US breast cancer mortality is declining, but thousands of women still die each year. METHODS: Two established simulation models examine 6 strategies that include increased screening and/or treatment or elimination of obesity versus continuation of current patterns. The models use common national data on incidence and obesity prevalence, competing causes of death, mammography characteristics, treatment effects, and survival/cure. Parameters are modified based on obesity (defined as BMI  ≥  30 kg/m(2) ). Outcomes are presented for the year 2025 among women aged 25+ and include numbers of cases, deaths, mammograms and false-positives; age-adjusted incidence and mortality; breast cancer mortality reduction and deaths averted; and probability of dying of breast cancer. RESULTS: If current patterns continue, the models project that there would be about 50,100-57,400 (range across models) annual breast cancer deaths in 2025. If 90% of women were screened annually from ages 40 to 54 and biennially from ages 55 to 99 (or death), then 5100-6100 fewer deaths would occur versus current patterns, but incidence, mammograms, and false-positives would increase. If all women received the indicated systemic treatment (with no screening change), then 11,400-14,500 more deaths would be averted versus current patterns, but increased toxicity could occur. If 100% received screening plus indicated therapy, there would be 18,100-20,400 fewer deaths. Eliminating obesity yields 3300-5700 fewer breast cancer deaths versus continuation of current obesity levels. CONCLUSIONS: Maximal reductions in breast cancer deaths could be achieved through optimizing treatment use, followed by increasing screening use and obesity prevention.

Authors: Walker GV, Giordano SH, Williams M, Jiang J, Niu J, MacKinnon J, Anderson P, Wohler B, Sinclair AH, Boscoe FP, Schymura MJ, Buchholz TA, Smith BD

Title: Muddy water? Variation in reporting receipt of breast cancer radiation therapy by population-based tumor registries.

Journal: Int J Radiat Oncol Biol Phys 86(4):686-93

Date: 2013 Jul 15

Abstract: PURPOSE: To evaluate, in the setting of breast cancer, the accuracy of registry radiation therapy (RT) coding compared with the gold standard of Medicare claims. METHODS AND MATERIALS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified 73,077 patients aged ≥66 years diagnosed with breast cancer in the period 2001-2007. Underascertainment (1 - sensitivity), sensitivity, specificity, κ, and χ(2) were calculated for RT receipt determined by registry data versus claims. Multivariate logistic regression characterized patient, treatment, and geographic factors associated with underascertainment of RT. Findings in the SEER-Medicare registries were compared with three non-SEER registries (Florida, New York, and Texas). RESULTS: In the SEER-Medicare registries, 41.6% (n=30,386) of patients received RT according to registry coding, versus 49.3% (n=36,047) according to Medicare claims (P<.001). Underascertainment of RT was more likely if patients resided in a newer SEER registry (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.60-1.80; P<.001), rural county (OR 1.34, 95% CI 1.21-1.48; P<.001), or if RT was delayed (OR 1.006/day, 95% CI 1.006-1.007; P<.001). Underascertainment of RT receipt in SEER registries was 18.7% (95% CI 18.6-18.8%), compared with 44.3% (95% CI 44.0-44.5%) in non-SEER registries. CONCLUSIONS: Population-based tumor registries are highly variable in ascertainment of RT receipt and should be augmented with other data sources when evaluating quality of breast cancer care. Future work should identify opportunities for the radiation oncology community to partner with registries to improve accuracy of treatment data.

Authors: Mack JW, Chen K, Boscoe FP, Gesten FC, Roohan PJ, Weeks JC, Schymura MJ, Schrag D

Title: Underuse of hospice care by Medicaid-insured patients with stage IV lung cancer in New York and California.

Journal: J Clin Oncol 31(20):2569-79

Date: 2013 Jul 10

Abstract: PURPOSE: Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare. PATIENTS AND METHODS: Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results-Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use. RESULTS: Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients. CONCLUSION: Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.

Authors: Stokes WA, Hendrix LH, Royce TJ, Allen IM, Godley PA, Wang AZ, Chen RC

Title: Racial differences in time from prostate cancer diagnosis to treatment initiation: a population-based study.

Journal: Cancer 119(13):2486-93

Date: 2013 Jul 01

Abstract: BACKGROUND: Timely delivery of care has been identified by the Institute of Medicine as an indicator for quality health care, and treatment delay is a potentially modifiable obstacle that can contribute to the disparities among African American (AA) and Caucasian patients in prostate cancer recurrence and mortality. Using the Surveillance, Epidemiologic and End Results (SEER)-Medicare linked database, we compared time from diagnosis to treatment in AA and Caucasian prostate cancer patients. METHODS: A total of 2506 AA and 21,454 Caucasian patients diagnosed with localized prostate cancer from 2004 through 2007 and treated within 12 months were included. Linear regression was used to assess potential differences in time to treatment between AA and Caucasian patients, after adjusting for sociodemographic and clinical covariates. RESULTS: Time from diagnosis to definitive (prostatectomy and radiation) treatment was longer for AA patients in all risk groups, and most pronounced in high-risk cancer (96 versus 105 days, P < .001). On multivariate analysis, racial differences to any and definitive treatment persisted (β = 7.3 and 7.6, respectively, for AA patients). Delay to definitive treatment was longer in high-risk (versus low-risk) disease and in more recent years. CONCLUSIONS: AA patients with prostate cancer experienced longer time from diagnosis to treatment than Caucasian patients with prostate cancer. AA patients appear to experience disparities across all aspects of this disease process, and together these factors in receipt of care plausibly contribute to the observed differences in rates of recurrence and mortality among AA and Caucasian patients with prostate cancer.

Authors: Akushevich I, Kravchenko J, Ukraintseva S, Arbeev K, Yashin AI

Title: Time trends of incidence of age-associated diseases in the US elderly population: Medicare-based analysis.

Journal: Age Ageing 42(4):494-500

Date: 2013 Jul

Abstract: OBJECTIVES: time trends of age-adjusted incidence rates of 19 ageing-related diseases were evaluated for 1992-2005 period with the National Long Term Care Survey and the Surveillance, Epidemiology and End Results Registry data both linked to Medicare data (NLTCS-Medicare and SEER-Medicare, respectively). METHODS: the rates were calculated using individual medical histories (34,077 individuals from NLTCS-Medicare and 199,418 from SEER-Medicare) reconstructed using information on diagnoses coded in Medicare data, dates of medical services/procedures and Medicare enrolment/disenrolment. Results: increases of incidence rates were dramatic for renal disease [the average annual percent change (APC) is 8.56%, 95% CI = 7.62, 9.50%], goiter (APC = 6.67%, 95% CI = 5, 90, 7, 44%), melanoma (APC = 6.15%, 95% CI = 4.31, 8.02%) and Alzheimer's disease (APC = 3.96%, 95% CI = 2.67, 5.26%), and less prominent for diabetes and lung cancer. Decreases of incidence rates were remarkable for angina pectoris (APC = -6.17%, 95% CI = -6.96, -5.38%); chronic obstructive pulmonary disease (APC = -5.14%, 95% CI = -6.78,-3.47%), and ulcer (APC = -5.82%, 95% CI = -6.77,-4.86%) and less dramatic for carcinomas of colon and prostate, stroke, hip fracture and asthma. Incidence rates of female breast carcinoma, myocardial infarction, Parkinson's disease and rheumatoid arthritis were almost stable. For most diseases, an excellent agreement was observed for incidence rates between NLTCS-Medicare and SEER-Medicare. A sensitivity analysis proved the stability of the evaluated time trends. CONCLUSION: time trends of the incidence of diseases common in the US elderly population were evaluated. The results show dramatic increase in incidence rates of melanoma, goiter, chronic renal and Alzheimer's disease in 1992-2005. Besides specifying widely recognised time trends on age-associated diseases, new information was obtained for trends of asthma, ulcer and goiter among the older adults in the USA.

Authors: Bekelman JE, Suneja G, Guzzo T, Pollack CE, Armstrong K, Epstein AJ

Title: Effect of practice integration between urologists and radiation oncologists on prostate cancer treatment patterns.

Journal: J Urol 190(1):97-101

Date: 2013 Jul

Abstract: PURPOSE: National attention has focused on whether urology-radiation oncology practice integration, known as integrated prostate cancer centers, contributes to the use of intensity modulated radiation therapy, a common and expensive prostate cancer treatment. MATERIALS AND METHODS: We examined prostate cancer treatment patterns before and after conversion of a urology practice to an integrated prostate cancer center in July 2006. Using the SEER (Statistics, Epidemiology and End Results)-Medicare database, we identified patients 65 years old or older in 1 statewide registry diagnosed with nonmetastatic prostate cancer between 2004 and 2007. We classified patients into 3 groups, including 1--those seen by integrated prostate cancer center physicians (exposure group), 2--those living in the same hospital referral region who were not seen by integrated prostate cancer center physicians (hospital referral region control group) and 3--those living elsewhere in the state (state control group). We compared changes in treatment among the 3 groups, adjusting for patient, clinical and socioeconomic factors. RESULTS: Compared with the 8.1 ppt increase in adjusted intensity modulated radiation therapy use in the state control group, the use of this therapy increased 20.3 ppts (95% CI 13.4, 27.1) in the integrated prostate cancer center group and 19.2 ppts (95% CI 9.6, 28.9) in the hospital referral region control group. Androgen deprivation therapy, for which Medicare reimbursement decreased sharply, similarly decreased in integrated prostate cancer center and hospital referral region controls. Prostatectomy decreased significantly in the integrated prostate cancer center group. CONCLUSIONS: Coincident with the conversion of a urology group practice to an integrated prostate cancer center, we observed an increase in intensity modulated radiation therapy and a decrease in androgen deprivation therapy in patients seen by integrated prostate cancer center physicians and those seen in the surrounding health care market that were not observed in the remainder of the state.

Authors: Breunig IM, Shaya FT, Hanna N, Seal B, Chirikov VV, Daniel Mullins C

Title: Transarterial chemoembolization treatment: association between multiple treatments, cumulative expenditures, and survival.

Journal: Value Health 16(5):760-8

Date: 2013 Jul-Aug

Abstract: OBJECTIVES: To examine cumulative survival and Medicaid-paid expenses associated with multiple courses of transarterial chemoembolization (TACE) as primary treatment for hepatocellular carcinoma (HCC). METHODS: Medicare enrollees diagnosed with primary HCC from 2000 to 2007, ever treated with TACE, but not transplant/resection, followed through 2009 by using the Surveillance, Epidemiology and End-Results Program and linked Medicare databases. Cumulative all-cause/HCC-related survival was estimated by using multivariate Cox proportional hazards models stratified by the total number of TACE treatments. Multivariate weighted Cox regressions estimated the average risk of mortality faced with nonproportional hazards. Lin's inverse probability-weighted least squares regression method estimated cumulative Medicare expenditures adjusted for censoring and covariates. RESULTS: Of 1228 patients, 34% were stage 1, 16% stage 2, 19% stage 3, 6% stage 4, and 26% unstaged. About 44% were aged 65 to 75 years, 69% were men, and 72% were Caucasian. Over half (57%) of the patients received one course, 24% two, 11% three, and 8% four courses of TACE. One-course patients incurred an average $74,788 (95% confidence interval [CI] $71,890-$77,686), two-course patients $101,126 (95% CI $94,395-$107,856), three-course patients $111,776 (95% CI $101,931-$121,621), and four-plus-course patients $148,878 (95% CI $136,346-$161,409). One-course patients lived (all-cause) an average 1.86 (95% CI 1.82-1.90), two-course patients 2.09 (95% CI 2.05-2.13), three-course patients 2.81 (95% CI 2.66-2.97), and four-plus-course patients 3.06 (95% CI 2.95-3.18) years after diagnosis. Average risk of all-cause mortality was not significantly different between one/two courses or three/four-plus courses. CONCLUSIONS: Cumulative Medicare expenditures nearly doubled from one-course to four-plus-course patients. On average, four-plus-course patients lived over one more year than did one-course patients. Physician/patient decisions should be balanced with consideration of efficient use of limited resources, but payer's intervention in physician discretion may not be important in this setting.

Authors: Dodgion CM, Neville BA, Lipsitz SR, Hu YY, Schrag D, Breen E, Greenberg CC

Title: Do older Americans undergo stoma reversal following low anterior resection for rectal cancer?

Journal: J Surg Res 183(1):238-45

Date: 2013 Jul

Abstract: OBJECTIVE: For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR). DESIGN: SEER-Medicare-linked analysis from 1991-2007. SETTINGS AND PARTICIPANTS: A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma. MAIN OUTCOME MEASURES: (1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal. RESULTS: Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age <80 y (P < 0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P < 0.001), neoadjuvant radiation (P < 0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P < 0.0001). CONCLUSIONS: Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.

Authors: Han PK, Kobrin S, Breen N, Joseph DA, Li J, Frosch DL, Klabunde CN

Title: National evidence on the use of shared decision making in prostate-specific antigen screening.

Journal: Ann Fam Med 11(4):306-14

Date: 2013 Jul-Aug

Abstract: PURPOSE: Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making-a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making. METHODS: A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics. RESULTS: Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%-90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%-43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared decision making. CONCLUSIONS: Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in nonscreened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening.

Authors: Harel O, Chung H, Miglioretti D

Title: Latent class regression: inference and estimation with two-stage multiple imputation.

Journal: Biom J 55(4):541-53

Date: 2013 Jul

Abstract: Latent class regression (LCR) is a popular method for analyzing multiple categorical outcomes. While nonresponse to the manifest items is a common complication, inferences of LCR can be evaluated using maximum likelihood, multiple imputation, and two-stage multiple imputation. Under similar missing data assumptions, the estimates and variances from all three procedures are quite close. However, multiple imputation and two-stage multiple imputation can provide additional information: estimates for the rates of missing information. The methodology is illustrated using an example from a study on racial and ethnic disparities in breast cancer severity.

Authors: Imayama I, Alfano CM, Neuhouser ML, George SM, Wilder Smith A, Baumgartner RN, Baumgartner KB, Bernstein L, Wang CY, Duggan C, Ballard-Barbash R, McTiernan A

Title: Weight, inflammation, cancer-related symptoms and health related quality of life among breast cancer survivors.

Journal: Breast Cancer Res Treat 140(1):159-76

Date: 2013 Jul

Abstract: Maintaining weight is important for better prognosis of breast cancer survivors. The associations between weight and cancer-related symptoms are not known. We examined associations among weight, weight change, inflammation, cancer-related symptoms, and health-related quality of life (HRQOL) in a cohort of stage 0-IIIA breast cancer survivors. Participants were recruited on average 6 months (2-12 months) after diagnosis. Height, weight, and C-reactive protein (CRP) were assessed at approximately 30 months post-diagnosis; cancer-related symptoms (chest wall and arm symptoms, vasomotor symptoms, urinary incontinence, vaginal symptoms, cognition/mood problems, sleep, sexual interest/function), and HRQOL (SF-36) were assessed at approximately 40 months post-diagnosis. Weight was measured at baseline in a subset. Data on 661 participants were evaluable for body mass index (BMI); 483 were evaluable for weight change. We assessed associations between BMI (<25.0, 25.0-29.9, ≥30.0 kg/m2), post-diagnosis weight change (lost ≥5 %, weight change <5 %, gained ≥5 %), and CRP (tertile) with cancer-related symptoms and HRQOL using analysis of covariance. Higher symptoms scores indicate more frequent or severe symptoms. Higher HRQOL scores indicate better HRQOL. Compared with those with BMI <25 kg/m2, women with BMI ≥30 kg/m2 had the following scores: increased for arm symptoms (+25.0 %), urinary incontinence (+40.0 %), tendency to nap (+18.9 %), and poorer physical functioning (−15.6 %, all p < 0.05). Obese women had lower scores in trouble falling asleep (−9.9 %; p < 0.05). Compared with weight change <5 %, participants with ≥5 % weight gain had lower scores in physical functioning (−7.2 %), role-physical (−15.5 %) and vitality (−11.2 %), and those with weight loss ≥5 % had lower chest wall (−33.0 %) and arm symptom scores (−35.5 %, all p < 0.05). Increasing CRP tertile was associated with worse scores for chest wall symptoms, urinary incontinence, physical functioning, role-physical, vitality and physical component summary scores (all P trend < 0.05). Future studies should examine whether interventions to maintain a healthy weight and reduce inflammation could alleviate cancer-related symptoms and improve HRQOL.

Authors: Keating NL, O'Malley AJ, Freedland SJ, Smith MR

Title: Does comorbidity influence the risk of myocardial infarction or diabetes during androgen-deprivation therapy for prostate cancer?

Journal: Eur Urol 64(1):159-66

Date: 2013 Jul

Abstract: BACKGROUND: Androgen-deprivation therapy (ADT) for prostate cancer (PCa) may be associated with cardiovascular disease and diabetes. Some data suggest that men with certain conditions may be more susceptible to developing cardiovascular disease than others. OBJECTIVE: To assess whether the risk of myocardial infarction (MI) or diabetes during ADT is modified by specific baseline comorbidities. DESIGN, SETTING, AND PARTICIPANTS: We conducted a population-based observational study of 185 106 US men ≥66 yr of age diagnosed with local/regional PCa from 1992 to 2007. We assessed comorbidities monthly over the follow-up period. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cox proportional hazards models with time-varying variables assessing incident diabetes or MI. RESULTS AND LIMITATIONS: A total of 49.9% of the men received ADT during follow-up. Among men with no comorbidities, ADT was associated with an increase in the adjusted hazard of MI (adjusted hazard ratio [AHR]: 1.09; 95% confidence interval [CI], 1.02-1.16) and diabetes (AHR: 1.33; 95% CI, 1.27-1.39). Risks of MI and diabetes were similarly increased among men with and without specific comorbid illnesses (p>0.10 for all interactions, with one exception). Previous MI, congestive heart failure, peripheral arterial disease, stroke, hypertension, chronic obstructive pulmonary disease, and renal disease were associated with new MI and diabetes, and obesity and rheumatologic disease were also associated with diabetes. Limitations include the observational study design, reliance on administrative data to ascertain outcomes, and lack of information on risk factors such as smoking and family history. CONCLUSIONS: Traditional risk factors for MI and diabetes were also associated with developing these conditions during ADT but did not significantly modify the risk attributable to ADT. Strategies to screen and prevent diabetes and cardiovascular disease in men with PCa should be similar to the strategies recommended for the general population.

Authors: King BA, Babb SD, Tynan MA, Gerzoff RB

Title: National and state estimates of secondhand smoke infiltration among U.S. multiunit housing residents.

Journal: Nicotine Tob Res 15(7):1316-21

Date: 2013 Jul

Abstract: INTRODUCTION: Multiunit housing (MUH) residents are susceptible to secondhand smoke (SHS), which can infiltrate smoke-free living units from nearby units and shared areas where smoking is permitted. This study assessed the prevalence and characteristics of MUH residency in the United States, and the extent of SHS infiltration in this environment at both the national and state levels. METHODS: National and state estimates of MUH residency were obtained from the 2009 American Community Survey. Assessed MUH residency characteristics included sex, age, race/ethnicity, and poverty status. Estimates of smoke-free home rule prevalence were obtained from the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The number of MUH residents who have experienced SHS infiltration was determined by multiplying the estimated number of MUH residents with smoke-free homes by the range of self-reported SHS infiltration (44%-46.2%) from peer-reviewed studies of MUH residents. RESULTS: One-quarter of U.S. residents (25.8%, 79.2 million) live in MUH (state range: 10.1% in West Virginia to 51.7% in New York). Nationally, 47.6% of MUH residents are male, 53.3% are aged 25-64 years, 48.0% are non-Hispanic White, and 24.4% live below the poverty level. Among MUH residents with smoke-free home rules (62.7 million), an estimated 27.6-28.9 million have experienced SHS infiltration (state range: 26,000-27,000 in Wyoming to 4.6-4.9 million in California). CONCLUSIONS: A considerable number of Americans reside in MUH and many of these individuals experience SHS infiltration in their homes. Prohibiting smoking in MUH would help protect MUH residents from involuntary SHS exposure.

Authors: Klabunde CN, Han PK, Earle CC, Smith T, Ayanian JZ, Lee R, Ambs A, Rowland JH, Potosky AL

Title: Physician roles in the cancer-related follow-up care of cancer survivors.

Journal: Fam Med 45(7):463-74

Date: 2013 Jul-Aug

Abstract: BACKGROUND AND OBJECTIVES: Information about primary care physicians' (PCPs) and oncologists' involvement in cancer-related follow-up care, and care coordination practices, is lacking but essential to improving cancer survivors' care. This study assesses PCPs' and oncologists' self-reported roles in providing cancer-related follow-up care for survivors who are within 5 years of completing cancer treatment. METHODS: In 2009, the National Cancer Institute and the American Cancer Society conducted a nationally representative survey of PCPs (n=1,014) and medical oncologists (n=1,125) (response rate=57.6%, cooperation rate=65.1%). Mailed questionnaires obtained information on physicians' roles in providing cancer-related follow-up care to early-stage breast and colon cancer survivors, personal and practice characteristics, beliefs about and preferences for follow-up care, and care coordination practices. RESULTS: More than 50% of PCPs reported providing cancer-related follow-up care for survivors, mainly by co-managing with an oncologist. In contrast, more than 70% of oncologists reported fulfilling these roles by providing the care themselves. In adjusted analyses, PCP co-management was associated with specialty, training in late or long-term effects of cancer, higher cancer patient volume, favorable attitudes about PCP care involvement, preference for a shared model of survivorship care, and receipt of treatment summaries from oncologists. Among oncologists, only preference for a shared care model was associated with co-management with PCPs. CONCLUSIONS: PCPs and oncologists differ in their involvement in cancer-related follow-up care of survivors, with co-management more often reported by PCPs than by oncologists. Given anticipated national shortages of PCPs and oncologists, study results suggest that improved communication and coordination between these providers is needed to ensure optimal delivery of follow-up care to cancer survivors.

Authors: Palmer NR, Geiger AM, Felder TM, Lu L, Case LD, Weaver KE

Title: Racial/Ethnic disparities in health care receipt among male cancer survivors.

Journal: Am J Public Health 103(7):1306-13

Date: 2013 Jul

Abstract: OBJECTIVES: We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors. METHODS: We identified men aged 18 years and older from the 2006-2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years). RESULTS: In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively). CONCLUSIONS: Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.

Authors: VanderWalde NA, Meyer A, Liu H, Tyree SD, Zullig LL, Carpenter WR, Shores CD, Weissler MC, Hayes DN, Fleming M, Chera BS

Title: Patterns of care in older patients with squamous cell carcinoma of the head and neck: a Surveillance, Epidemiology, and End Results-Medicare analysis.

Journal: J Geriatr Oncol 4(3):262-70

Date: 2013 Jul

Abstract: Background: There is growing evidence in the literature that older patients may not benefit from more intensive therapy for head and neck squamous cell carcinoma (HNSCC). A growing number of patients with HNSCC are age 65 years or older; however, much of the evidence base informing treatment decisions is based on substantially younger and healthier clinical trial populations. The purpose of this study was to assess the patterns of care of older HNSCC patients to better understand how age is associated with treatment decisions.Methods: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (1992-2007), we identified patients with non-metastatic HNSCC (n = 10,867) and categorized them by treatment: surgery vs. non-surgery and chemoradiotherapy (CRT) vs. radiotherapy (RT). Multivariate logistic regression models were used to identify variables associated with the receipt of surgery and CRT.Results: Increasing age was associated with decreased odds of receiving CRT (OR = 0.94; 95% CI 0.93-0.94) but not surgery (OR 1.00; 95% CI 0.99-1.00). Co-morbidity and race were not associated with receipt of either surgery or CRT. Utilization of CRT increased while surgery decreased between 1992 and 2007.Conclusion: Age may influence the receipt of CRT for older HNSCC patients. There has been an increasing trend in the receipt of CRT and a decrease in primary surgery.

Authors: Winner M, Mooney SJ, Hershman DL, Feingold DL, Allendorf JD, Wright JD, Neugut AI

Title: Management and outcomes of bowel obstruction in patients with stage IV colon cancer: a population-based cohort study.

Journal: Dis Colon Rectum 56(7):834-43

Date: 2013 Jul

Abstract: BACKGROUND: Bowel obstruction is a common complication of late-stage abdominal cancer, especially colon cancer, which has been investigated predominantly in small, single-institution studies. OBJECTIVE: We used a large, population-based data set to explore the surgical treatment of bowel obstruction and its outcomes after hospitalization for obstruction among patients with stage IV colon cancer. DESIGN: This was a retrospective cohort study. SETTING AND PATIENTS: We identified 1004 patients aged 65 years or older in the Surveillance, Epidemiology and End Results-Medicare database diagnosed with stage IV colon cancer January 1, 1991 to December 31, 2005, who were later hospitalized for bowel obstruction. MAIN OUTCOME MEASURES: We describe outcomes after hospitalization and analyzed the associations between surgical treatment of obstruction and outcomes. RESULTS: Hospitalization for bowel obstruction occurred a median of 7.4 months after colon cancer diagnosis, and median survival after obstruction was approximately 2.5 months. Median hospitalization for obstruction was about 1 week and in-hospital mortality was 12.7%. Between discharge and death, 25% of patients were readmitted to the hospital at least once for obstruction, and, on average, patients lived 5 days out of the hospital for every day in the hospital between obstruction diagnosis and death. Survival was 3 times longer in those whose obstruction claims suggested an adhesive obstruction origin. In multivariable models, surgical compared with nonsurgical management was not associated with prolonged survival (p = 0.134). LIMITATIONS: Use of an administrative database did not allow determination of quality of life or relief of obstruction as an outcome, nor could nonsurgical interventions, eg, endoscopic stenting or octreotide, be assessed. CONCLUSIONS: In this population-based study of patients with stage IV colon cancer who had bowel obstruction, overall survival following obstruction was poor irrespective of treatment. Universally poor outcomes suggest that a diagnosis of obstruction in the setting of advanced colon cancer should be considered a preterminal event.

Authors: Wright JD, Deutsch I, Wilde ET, Ananth CV, Neugut AI, Lewin SN, Siddiq Z, Herzog TJ, Hershman DL

Title: Uptake and outcomes of intensity-modulated radiation therapy for uterine cancer.

Journal: Gynecol Oncol 130(1):43-8

Date: 2013 Jul

Abstract: OBJECTIVE: While intensity-modulated radiation therapy (IMRT) allows more precise radiation planning, the technology is substantially more costly than conformal radiation and, to date, the benefits of IMRT for uterine cancer are not well defined. We examined the use of IMRT and its effect on late toxicity for uterine cancer. METHODS: Women with uterine cancer treated from 2001 to 2007 and registered in the SEER-Medicare database were examined. We investigated the extent and predictors of IMRT administration. The incidence of acute and late-radiation toxicities was compared for IMRT and conformal radiation. RESULTS: We identified a total of 3555 patients including 328 (9.2%) who received IMRT. Use of IMRT increased rapidly and reached 23.2% by 2007. In a multivariable model, residence in the western U.S. and receipt of chemotherapy were associated with receipt of IMRT. Women who received IMRT had a higher rate of bowel obstruction (rate ratio=1.41; 95% CI, 1.03-1.93), but other late gastrointestinal and genitourinary toxicities as well as hip fracture rates were similar between the cohorts. After accounting for other characteristics, the cost of IMRT was $14,706 (95% CI, $12,073 to $17,339) greater than conformal radiation. CONCLUSION: The use of IMRT for uterine cancer is increasing rapidly. IMRT was not associated with a reduction in radiation toxicity, but was more costly.

Authors: Yao N, Mackley HB, Anderson RT, Recht A

Title: Survival after partial breast brachytherapy in elderly patients with nonmetastatic breast cancer.

Journal: Brachytherapy 12(4):293-302

Date: 2013 Jul-Aug

Abstract: BACKGROUND: Despite growing utilization of accelerated partial breast irradiation using brachytherapy (APBI-Brachy) for elderly breast cancer patients, there are limited data from randomized Phase III trials to support its routine use. This study uses population-based data to examine whether APBI-Brachy results in comparable survival rates compared with whole breast irradiation (WBI). METHODS: A sample of 29,647 female patients diagnosed with nonmetastatic breast cancer in 2002-2007 treated with breast-conserving surgery and radiotherapy was identified in the Surveillance, Epidemiology, and End Results Program-Medicare data set. Log-rank tests, Cox proportional hazards models, instrumental variable analysis, and subgroup analysis were used to study the comparative effectiveness of APBI-Brachy and WBI. RESULTS: During a median followup of 3.6 and 4.8 years, 123 (7.7%) and 3438 (13.6%) patients died after APBI-Brachy and WBI, respectively. Recurrence-free survival (p = 0.9711) and overall survival rates (p = 0.0551) did not differ significantly between the two radiation modalities. After accounting for tumor characteristics, patient characteristics, community factors, and comorbidities, the recurrence-free survival (hazard ratio, 1.05; 95% confidence interval, 0.90-1.23; p = 0.5125) and overall survival (hazard ratio, 0.87; 95% confidence interval, 0.72-1.04; p = 0.1332) rates were still not significantly different between patients treated with APBI-Brachy and WBI. CONCLUSION: Partial breast brachytherapy and WBI resulted in similar recurrence-free and overall survival rates in this cohort of elderly breast cancer patients, even after adjustment for the more favorable characteristics of patients in the former group. These findings will need to be confirmed by the randomized trials comparing these modalities.

Authors: Jacobs BL, Zhang Y, Schroeck FR, Skolarus TA, Wei JT, Montie JE, Gilbert SM, Strope SA, Dunn RL, Miller DC, Hollenbeck BK

Title: Use of advanced treatment technologies among men at low risk of dying from prostate cancer.

Journal: JAMA 309(24):2587-95

Date: 2013 Jun 26

Abstract: IMPORTANCE: The use of advanced treatment technologies (ie, intensity-modulated radiotherapy [IMRT] and robotic prostatectomy) for prostate cancer is increasing. The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain. OBJECTIVE: To assess the use of advanced treatment technologies, compared with prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer. DESIGN, SETTING, AND PATIENTS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified a retrospective cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (n = 23,633), EBRT (n = 3926), robotic prostatectomy (n = 5881), open radical prostatectomy (n = 6123), or observation (n = 16,384). Follow-up data were available through December 31, 2010. MAIN OUTCOMES AND MEASURES: The use of advanced treatment technologies among men unlikely to die from prostate cancer, as assessed by low-risk disease (clinical stage ≤T2a, biopsy Gleason score ≤6, and prostate-specific antigen level ≤10 ng/mL), high risk of noncancer mortality (based on the predicted probability of death within 10 years in the absence of a cancer diagnosis), or both. RESULTS: In our cohort, the use of advanced treatment technologies increased from 32% (95% CI, 30%-33%) to 44% (95% CI, 43%-46%) among men with low-risk disease (P < .001) and from 36% (95% CI, 35%-38%) to 57% (95% CI, 55%-59%) among men with high risk of noncancer mortality (P < .001). The use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% (95% CI, 23%-28%) to 34% (95% CI, 31%-37%) (P < .001). Among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13% (95% CI, 12%-14%), or 129.2 per 1000 patients diagnosed with prostate cancer, to 24% (95% CI, 24%-25%), or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001). CONCLUSION AND RELEVANCE: Among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of noncancer mortality, or both, the use of advanced treatment technologies has increased.

Authors: Goldin GH, Sheets NC, Meyer AM, Kuo TM, Wu Y, Stürmer T, Godley PA, Carpenter WR, Chen RC

Title: Comparative effectiveness of intensity-modulated radiotherapy and conventional conformal radiotherapy in the treatment of prostate cancer after radical prostatectomy.

Journal: JAMA Intern Med 173(12):1136-43

Date: 2013 Jun 24

Abstract: IMPORTANCE: Comparative effectiveness research of prostate cancer therapies is needed because of the development and rapid clinical adoption of newer and costlier treatments without proven clinical benefit. Radiotherapy is indicated after prostatectomy in select patients who have adverse pathologic features and in those with recurrent disease. OBJECTIVES: To examine the patterns of use of intensity-modulated radiotherapy (IMRT), a newer, more expensive technology that may reduce radiation dose to adjacent organs compared with the older conformal radiotherapy (CRT) in the postprostatectomy setting, and to compare disease control and morbidity outcomes of these treatments. DESIGN AND SETTING: Data from the Surveillance, Epidemiology, and End Results-Medicare-linked database were used to identify patients with a diagnosis of prostate cancer who had received radiotherapy within 3 years after prostatectomy. PARTICIPANTS: Patients who received IMRT or CRT. MAIN OUTCOMES AND MEASURES: The outcomes of 457 IMRT and 557 CRT patients who received radiotherapy between 2002 and 2007 were compared using their claims through 2009. We used propensity score methods to balance baseline characteristics and estimate adjusted incidence rate ratios (RRs) and their 95% CIs for measured outcomes. RESULTS: Use of IMRT increased from zero in 2000 to 82.1% in 2009. Men who received IMRT vs CRT showed no significant difference in rates of long-term gastrointestinal morbidity (RR, 0.95; 95% CI, 0.66-1.37), urinary nonincontinent morbidity (0.93; 0.66-1.33), urinary incontinence (0.98; 0.71-1.35), or erectile dysfunction (0.85; 0.61-1.19). There was no significant difference in subsequent treatment for recurrent disease (RR, 1.31; 95% CI, 0.90-1.92). CONCLUSIONS AND RELEVANCE: Postprostatectomy IMRT and CRT achieved similar morbidity and cancer control outcomes. The potential clinical benefit of IMRT in this setting is unclear. Given that IMRT is more expensive, its use for postprostatectomy radiotherapy may not be cost-effective compared with CRT, although formal analysis is needed.

Authors: Virgo KS, Lerro CC, Klabunde CN, Earle C, Ganz PA

Title: Barriers to breast and colorectal cancer survivorship care: perceptions of primary care physicians and medical oncologists in the United States.

Journal: J Clin Oncol 31(18):2322-36

Date: 2013 Jun 20

Abstract: PURPOSE: High-quality, well-coordinated cancer survivorship care is needed yet barriers remain owing to fragmentation in the United States health care system. This article is a nationwide survey of barriers perceived by primary care physicians (PCPs) and medical oncologists (MOs) regarding breast and colorectal cancer survivorship care beyond 5 years after treatment. METHODS: The Survey of Physician Attitudes Regarding the Care of Cancer Survivors was mailed out in 2009 to a nationally-representative sample (n = 3,596) of US PCPs and MOs. Ten physician-perceived cancer survivorship care barriers/concerns were compared between the two provider types. Using weighted multinomial logistic regression, we modeled each barrier, adjusting for physician demographics, reimbursement, training, and practice characteristics. RESULTS: We received responses from 2,202 physicians (1,072 PCPs; 1,130 MOs; 65.1% cooperation rate). In adjusted patient-related barriers models, MOs were more likely than PCPs to report patient language barriers (odds ratio, [OR], 1.72; 95% CI, 1.22 to 2.42), insurance restrictions impeding test/treatment use (OR, 1.42; 95% CI, 1.03 to 1.96), and patients requesting more aggressive testing (OR, 4.08; 95% CI, 2.73 to 6.10). In adjusted physician-related barriers models, PCPs were more likely to report inadequate training (OR, 3.06; 95% CI, 2.03 to 4.61) and ordering additional tests/treatments because of malpractice concerns (OR, 1.87; 95% CI, 1.20 to 2.93). MOs were more likely to report uncertainty regarding general preventive care responsibility (often/always: OR, 1.97; 95% CI, 1.13 to 3.43; sometimes: OR, 2.16; 95% CI, 1.60 to 2.93). CONCLUSION: MOs and PCPs perceive different cancer follow-up care barriers/concerns to be problematic. Resolving inadequate training, malpractice-driven test ordering, and preventive-care responsibility concerns may require continuing education, explicit guidelines, and survivorship care plans. Reviewing care plans with survivors may also reduce patients' requests for unnecessary testing.

Authors: Williams WW, Lu PJ, Saraiya M, Yankey D, Dorell C, Rodriguez JL, Kepka D, Markowitz LE

Title: Factors associated with human papillomavirus vaccination among young adult women in the United States.

Journal: Vaccine 31(28):2937-46

Date: 2013 Jun 19

Abstract: BACKGROUND: Human papillomavirus (HPV) vaccination is recommended to protect against HPV-related diseases. OBJECTIVE: To estimate HPV vaccine coverage and assess factors associated with vaccine awareness, initiation and receipt of 3 doses among women age 18-30 years. METHODS: Data from the 2010 National Health Interview Survey were analyzed to assess associations of HPV vaccination among women age 18-26 (n=1866) and 27-30 years (n=1028) with previous HPV exposure, cervical cancer screening and selected demographic, health care and behavioral characteristics using bivariate analysis and multivariable logistic regression. RESULTS: Overall, 23.2% of women age 18-26 and 6.7% of women age 27-30 years reported receiving at least 1 dose of HPV vaccine. In multivariable analyses among women age 18-26 years, not being married, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, influenza vaccination in the past year, and receipt of other recommended vaccines were associated with HPV vaccination. One-third of unvaccinated women age 18-26 years (n=490) were interested in receiving HPV vaccine. Among women who were not interested in receiving HPV vaccine (n=920), the main reasons reported included: not needing the vaccine (41.3%); concerns about safety of the vaccine (12.5%); not knowing enough about the vaccine (11.9%); not being sexually active (8.2%); a doctor not recommending the vaccine (7.6%); and already having HPV (2.7%). Among women with health insurance, 10 or more physician contacts within the past year and no contraindications, 74.5% reported not receiving HPV vaccine. CONCLUSIONS: HPV vaccination coverage among women age 18-26 years remains low. Opportunities to vaccinate are missed. Healthcare providers can play an important role in educating young women about HPV and encouraging vaccination. Successful public health and educational interventions will need to address physician attitudes and practice patterns and other factors that influence vaccination behaviors.

Authors: Smith AW, Bellizzi KM, Keegan TH, Zebrack B, Chen VW, Neale AV, Hamilton AS, Shnorhavorian M, Lynch CF

Title: Health-related quality of life of adolescent and young adult patients with cancer in the United States: the Adolescent and Young Adult Health Outcomes and Patient Experience study.

Journal: J Clin Oncol 31(17):2136-45

Date: 2013 Jun 10

Abstract: PURPOSE: Adolescents and young adults (AYAs) diagnosed with cancer face numerous physical, psychosocial, and practical challenges. This article describes the health-related quality of life (HRQOL) and associated demographic and health-related characteristics of this developmentally diverse population. PATIENTS AND METHODS: Data are from the Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) study, a population-based cohort of 523 AYA patients with cancer, ages 15 to 39 years at diagnosis from 2007 to 2009. Comparisons are made by age group and with general and healthy populations. Multiple linear regression models evaluated effects of demographic, disease, health care, and symptom variables on multiple domains of HRQOL using the Pediatric Quality of Life Inventory (PedsQL) and the Short-Form Health Survey 12 (SF-12). RESULTS: Overall, respondents reported significantly worse HRQOL across both physical and mental health scales than did general and healthy populations. The greatest deficits were in limitations to physical and emotional roles, physical and social functioning, and fatigue. Teenaged patients (ages 15 to 17 years) reported worse physical and work/school functioning than patients 18 to 25 years old. Regression models showed that HRQOL was worse for those in treatment, with current/recent symptoms, or lacking health insurance at any time since diagnosis. In addition, sarcoma patients, Hispanic patients, and those with high school or lower education reported worse physical health. Unmarried patients reported worse mental health. CONCLUSION: Results suggest that AYAs with cancer have major decrements in several physical and mental HRQOL domains. Vulnerable subgroups included Hispanic patients, those with less education, and those without health insurance. AYAs also experienced higher levels of fatigue that were influenced by current symptoms and treatment. Future research should explore ways to address poor functioning in this understudied group.

Authors: Glasgow RE, Doria-Rose VP, Khoury MJ, Elzarrad M, Brown ML, Stange KC

Title: Comparative effectiveness research in cancer: what has been funded and what knowledge gaps remain?

Journal: J Natl Cancer Inst 105(11):766-73

Date: 2013 Jun 05

Abstract:

Authors:

Title: Do Higher Tobacco Taxes Reduce Adult Smoking? New Evidence of the Effect of Recent Cigarette Tax Increases on Adult Smoking

Journal: :-

Date: 2013 Jun 01

Abstract: There is a general consensus among policymakers that raising tobacco taxes reduces cigarette consumption. However, evidence that tobacco taxes reduce adult smoking is relatively sparse. In this paper, we extend the literature in two ways: using data from the Current Population Survey Tobacco Use Supplements we focus on recent, large tax changes, which provide the best opportunity to empirically observe a response in cigarette consumption, and employ a novel paired difference-in-differences technique to estimate the association between tax increases and cigarette consumption. Estimates indicate that, for adults, the association between cigarette taxes and either smoking participation or smoking intensity is negative, small, and not usually statistically significant. Our evidence suggests that increases in cigarette taxes are associated with small decreases in cigarette consumption and that it will take sizable tax increases, on the order of 100%, to decrease smoking by as much as 5%. (JEL I18, I12)

Authors: Forsythe LP, Kent EE, Weaver KE, Buchanan N, Hawkins NA, Rodriguez JL, Ryerson AB, Rowland JH

Title: Receipt of psychosocial care among cancer survivors in the United States.

Journal: J Clin Oncol 31(16):1961-9

Date: 2013 Jun 01

Abstract: PURPOSE: Given the importance of psychosocial care for cancer survivors, this study used population-based data to characterize survivors who reported a discussion with health care provider(s) about the psychosocial effects of cancer and who reported using professional counseling or support groups (PCSG) and tested associations between receipt of psychosocial care and satisfaction with care. PATIENTS AND METHODS: We examined survivors of adult cancers from the 2010 National Health Interview Survey (N = 1,777). Multivariable logistic regression models examined factors associated with receipt of and satisfaction with psychosocial care. RESULTS: Most survivors (55.1%) reported neither provider discussions nor use of PCSG; 31.4% reported provider discussion only, 4.4% reported use of PCSG only, and 8.9% reported both. Non-Hispanic blacks (v non-Hispanic whites), married survivors, survivors of breast cancer (v prostate or less prevalent cancers), those treated with chemotherapy, and survivors reporting past research study/clinical trial participation were more likely to report provider discussion(s) (P < .01). Hispanics (v non-Hispanic whites), survivors age 40 to 49 years (v ≤ 39 years), survivors of breast cancer (v melanoma or less prevalent cancers), those diagnosed ≤ 1 year ago (v > 5 years ago), survivors treated with radiation, and past research participants were more likely to report use of PCSG (P < .05). Survivors reporting any psychosocial care were more likely to be "very satisfied" with how their needs were met (P < .001). CONCLUSION: Many survivors do not report a discussion with providers about the psychosocial effects of cancer, which reflects a missed opportunity to connect survivors to psychosocial services. These data can benchmark the success of efforts to improve access to cancer-related psychosocial care.

Authors: Lund JL, Stürmer T, Sanoff HK, Brookhart A, Sandler RS, Warren JL

Title: Determinants of adjuvant oxaliplatin receipt among older stage II and III colorectal cancer patients.

Journal: Cancer 119(11):2038-47

Date: 2013 Jun 01

Abstract: BACKGROUND: Controversy exists regarding adjuvant oxaliplatin treatment among older patients with stage II and III colorectal cancer (CRC). This study sought to identify patient/tumor, physician, hospital, and geographic factors associated with oxaliplatin use among older patients. METHODS: Individuals diagnosed at age > 65 with stage II or III CRC from 2004 through 2007 undergoing surgical resection and receiving adjuvant chemotherapy were identified using the Surveillance, Epidemiology and End Results program (SEER)-Medicare database, which includes patient/tumor and hospital characteristics. Physician information was obtained from the American Medical Association. Poisson regression was used to identify independent predictors of oxaliplatin receipt. The discriminatory ability of each category of characteristics to predict oxaliplatin receipt was assessed by comparing the area under the receiver operating curve from logistic regression models. RESULTS: We identified 4388 individuals who underwent surgical resection at 773 hospitals and received chemotherapy from 1517 physicians. Adjuvant oxaliplatin use was higher among stage III (colon = 56%, rectum = 51%) compared to stage II patients (colon = 37%, rectum = 35%). Overall, patients who were older; diagnosed before 2006; separated, divorced, or widowed; living in a higher poverty census tract or in the East or Midwest; or with higher levels of comorbidity were less likely to receive oxaliplatin. Patient factors and calendar year accounted for most of the variation in oxaliplatin receipt (area under the curve = 75.8%). CONCLUSIONS: Adjuvant oxaliplatin use increased rapidly from 2004 through 2007 despite uncertainties regarding its effectiveness in older patients. Physician and hospital characteristics had little influence on adjuvant oxaliplatin receipt among older patients.

Authors: Rowland JH, Kent EE, Forsythe LP, Loge JH, Hjorth L, Glaser A, Mattioli V, Fosså SD

Title: Cancer survivorship research in Europe and the United States: where have we been, where are we going, and what can we learn from each other?

Journal: Cancer 119 Suppl 11:2094-108

Date: 2013 Jun 01

Abstract: The growing number of cancer survivors worldwide has led to of the emergence of diverse survivorship movements in the United States and Europe. Understanding the evolution of cancer survivorship within the context of different political and health care systems is important for identifying the future steps that need to be taken and collaborations needed to promote research among and enhance the care of those living after cancer. The authors first review the history of survivorship internationally and important related events in both the United States and Europe. Lessons learned from survivorship research are then broadly discussed, followed by examination of the infrastructure needed to sustain and advance this work, including platforms for research, assessment tools, and vehicles for the dissemination of findings. Future perspectives concern the identification of collaborative opportunities for investigators in Europe and the United States to accelerate the pace of survivorship science going forward.

Authors: Tooze JA, Troiano RP, Carroll RJ, Moshfegh AJ, Freedman LS

Title: A measurement error model for physical activity level as measured by a questionnaire with application to the 1999-2006 NHANES questionnaire.

Journal: Am J Epidemiol 177(11):1199-208

Date: 2013 Jun 01

Abstract: Systematic investigations into the structure of measurement error of physical activity questionnaires are lacking. We propose a measurement error model for a physical activity questionnaire that uses physical activity level (the ratio of total energy expenditure to basal energy expenditure) to relate questionnaire-based reports of physical activity level to true physical activity levels. The 1999-2006 National Health and Nutrition Examination Survey physical activity questionnaire was administered to 433 participants aged 40-69 years in the Observing Protein and Energy Nutrition (OPEN) Study (Maryland, 1999-2000). Valid estimates of participants' total energy expenditure were also available from doubly labeled water, and basal energy expenditure was estimated from an equation; the ratio of those measures estimated true physical activity level ("truth"). We present a measurement error model that accommodates the mixture of errors that arise from assuming a classical measurement error model for doubly labeled water and a Berkson error model for the equation used to estimate basal energy expenditure. The method was then applied to the OPEN Study. Correlations between the questionnaire-based physical activity level and truth were modest (r = 0.32-0.41); attenuation factors (0.43-0.73) indicate that the use of questionnaire-based physical activity level would lead to attenuated estimates of effect size. Results suggest that sample sizes for estimating relationships between physical activity level and disease should be inflated, and that regression calibration can be used to provide measurement error-adjusted estimates of relationships between physical activity and disease.

Authors: Zhu J, Sharma DB, Chen AB, Johnson BE, Weeks JC, Schrag D

Title: Comparative effectiveness of three platinum-doublet chemotherapy regimens in elderly patients with advanced non-small cell lung cancer.

Journal: Cancer 119(11):2048-60

Date: 2013 Jun 01

Abstract: BACKGROUND: Randomized trials report equivalent efficacy among various combinations of platinum-based regimens in advanced non-small cell lung cancer (NSCLC). Their relative effectiveness and comparability based on squamous versus nonsquamous histology is uncertain. METHODS: The authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data to identify first-line chemotherapy agents administered to Medicare beneficiaries with stage IIIB or IV NSCLC diagnosed from 2000 to 2007. Overall survival was compared between patients who received the 3 most common regimens: carboplatin-paclitaxel, carboplatin-gemcitabine, and carboplatin-docetaxel. Stratified analyses distinguished between the outcomes of patients with squamous versus nonsquamous cell histology. Multivariable Cox proportional hazards models and propensity score analyses facilitated adjustment for imbalance in measurable patient characteristics. RESULTS: Of the 15,318 patients who received first-line chemotherapy, 43.1% received carboplatin-paclitaxel, 14.3% received carboplatin-gemcitabine, 8.5% received carboplatin-docetaxel, and 34.1% received other regimens. The median survival was 8.0 months (interquartile range [IQR], 3.5-17.4 months) for carboplatin-paclitaxel, 7.3 months (IQR, 3.4-15.2 months) for carboplatin-gemcitabine, and 7.5 months (IQR, 3.2-16.0 months) for carboplatin-docetaxel. Both multivariable and propensity score-adjusted Cox models demonstrated a slight inferiority associated with carboplatin-gemcitabine or carboplatin-docetaxel versus carboplatin-paclitaxel, with a hazard ratio of 1.10 (95% confidence interval, 1.04-1.15) and 1.09 (95% confidence interval, 1.02-1.16), respectively, in propensity score-stratified models. Among the subgroup of 2063 patients with squamous carcinoma, propensity score-stratified analyses had a higher risk of death (hazard ratio, 1.20; 95% confidence interval, 1.07-1.35) associated with carboplatin-gemcitabine versus carboplatin-paclitaxel. CONCLUSIONS: Carboplatin-paclitaxel was associated with slightly better survival compared with carboplatin-gemcitabine or carboplatin-docetaxel within the Medicare population with advanced NSCLC, and this was most pronounced for patients who had squamous cell histology.

Authors: Austin S, Martin MY, Kim Y, Funkhouser EM, Partridge EE, Pisu M

Title: Disparities in use of gynecologic oncologists for women with ovarian cancer in the United States.

Journal: Health Serv Res 48(3):1135-53

Date: 2013 Jun

Abstract: OBJECTIVE: To examine disparities in utilization of gynecologic oncologists (GOs) across race and other sociodemographic factors for women with ovarian cancer. DATA SOURCES: Obtained SEER-Medicare linked dataset for 4,233 non-Hispanic White, non-Hispanic African American, Hispanic of any race, and Non-Hispanic Asian women aged ≥ 66 years old diagnosed with ovarian cancer during 2000-2002 from 17 SEER registries. Physician specialty was identified by linking data to the AMA master file using Unique Physician Identification Numbers. STUDY DESIGN: Retrospective claims data analysis for 1999-2006. Logistic regression models were used to analyze the association between GO utilization and race/ethnicity in the initial, continuing, and final phases of care. PRINCIPAL FINDINGS: GO use decreased from the initial to final phase of care (51.4-28.8 percent). No racial/ethnic differences were found overall and by phase of cancer care. Women >70 years old and those with unstaged disease were less likely to receive GO care compared to their counterparts. GO use was lower in some SEER registries compared to the Atlanta registry. CONCLUSIONS: GO use for the initial ovarian cancer treatment or for longer term care was low but not different across racial/ethnic groups. Future research should identify factors that affect GO utilization and understand why use of these specialists remains low.

Authors: Bekelman JE, Handorf EA, Guzzo T, Evan Pollack C, Christodouleas J, Resnick MJ, Swisher-McClure S, Vaughn D, Ten Have T, Polsky D, Mitra N

Title: Radical cystectomy versus bladder-preserving therapy for muscle-invasive urothelial carcinoma: examining confounding and misclassification biasin cancer observational comparative effectiveness research.

Journal: Value Health 16(4):610-8

Date: 2013 Jun

Abstract: OBJECTIVES: Radical cystectomy (RC) is the standard treatment for muscle-invasive urothelial carcinoma of the bladder. Trimodality bladder-preserving therapy (BPT) is an alternative to RC, but randomized comparisons of RC versus BPT have proven infeasible. To compare RC versus BPT, we undertook an observational cohort study using registry and administrative claims data from the Surveillance, Epidemiology and End Results-Medicare database. METHODS: We identified patients age 65 years or older diagnosed between 1995 and 2005 who received RC (n = 1426) or BPT (n = 417). We examined confounding and stage misclassification in the comparison of RC and BPT by using multivariable adjustment, propensity score-based adjustment, instrumental variable (IV) analysis, and simulations. RESULTS: Patients who received BPT were older and more likely to have comorbid disease. After propensity score adjustment, BPT was associated with an increased hazard of death from any cause (hazard ratio [HR] 1.26; 95% confidence interval [CI] 1.05-1.53) and from bladder cancer (HR 1.31; 95% CI 0.97-1.77). Using the local area cystectomy rate as an instrument, IV analysis demonstrated no differences in survival between BPT and RC (death from any cause HR 1.06; 95% CI 0.78-1.31; death from bladder cancer HR 0.94; 95% CI 0.55-1.18). Simulation studies for stage misclassification yielded results consistent with the IV analysis. CONCLUSIONS: Survival estimates in an observational cohort of patients who underwent RC versus BPT differ by analytic method. Multivariable and propensity score adjustment revealed greater mortality associated with BPT relative to RC, while IV analysis and simulation studies suggest that the two treatments are associated with similar survival outcomes.

Authors: Berry MF, Worni M, Pietrobon R, D'Amico TA, Akushevich I

Title: Variability in the treatment of elderly patients with stage IIIA (N2) non-small-cell lung cancer.

Journal: J Thorac Oncol 8(6):744-52

Date: 2013 Jun

Abstract: INTRODUCTION: : We evaluated treatment patterns of elderly patients with stage IIIA (N2) non-small-cell lung cancer (NSCLC). METHODS: : The use of surgery, chemotherapy, and radiation for patients with stage IIIA (T1-T3N2M0) NSCLC in the Surveillance, Epidemiology, and End Results-Medicare database from 2004 to 2007 was analyzed. Treatment variability was assessed using a multivariable logistic regression model that included treatment, patient, tumor, and census track variables. Overall survival was analyzed using the Kaplan-Meier approach and Cox proportional hazard models. RESULTS: : The most common treatments for 2958 patients with stage IIIA (N2) NSCLC were radiation with chemotherapy (n = 1065, 36%), no treatment (n = 534, 18%), and radiation alone (n = 383, 13%). Surgery was performed in 709 patients (24%): 235 patients (8%) had surgery alone, 40 patients (1%) had surgery with radiation, 222 patients had surgery with chemotherapy (8%), and 212 patients (7%) had surgery, chemotherapy, and radiation. Younger age (p < 0.0001), lower T-status (p < 0.0001), female sex (p = 0.04), and living in a census track with a higher median income (p = 0.03) predicted surgery use. Older age (p < 0.0001) was the only factor that predicted that patients did not get any therapy. The 3-year overall survival was 21.8 ± 1.5% for all patients, 42.1 ± 3.8% for patients that had surgery, and 15.4 ± 1.5% for patients that did not have surgery. Increasing age, higher T-stage and Charlson Comorbidity Index, and not having surgery, radiation, or chemotherapy were all risk factors for worse survival (all p values < 0.001). CONCLUSIONS: : Treatment of elderly patients with stage IIIA (N2) NSCLC is highly variable and varies not only with specific patient and tumor characteristics but also with regional income level.

Authors: Davidoff AJ, Weiss SR, Baer MR, Ke X, Hendrick F, Zeidan A, Gore SD

Title: Patterns of erythropoiesis-stimulating agent use among Medicare beneficiaries with myelodysplastic syndromes and consistency with clinical guidelines.

Journal: Leuk Res 37(6):675-80

Date: 2013 Jun

Abstract: Erythropoiesis-stimulating agents (ESA) are used commonly to reduce symptomatic anemia in patients with myelodysplastic syndromes (MDS). We assessed population-based patterns of ESA use relative to treatment guidelines using data from the Surveillance, Epidemiology, and End Results (SEER) registries, with linked Medicare claims providing detailed treatment data from 2001 through 2005. The study found widespread use (62%) of ESA in Medicare beneficiaries with MDS. Similar ESA use rates regardless of risk status, low frequency (45%) of serum erythropoietin determination prior to ESA initiation, and high prevalence (60.4%) of short-duration ESA episodes suggest clinically important discrepancies between actual practice and guideline-recommended therapy.

Authors: Dinan MA, Curtis LH, Carpenter WR, Biddle AK, Abernethy AP, Patz EF Jr, Schulman KA, Weinberger M

Title: Variations in use of PET among Medicare beneficiaries with non-small cell lung cancer, 1998-2007.

Journal: Radiology 267(3):807-17

Date: 2013 Jun

Abstract: PURPOSE: To explore demographic and regional factors associated with the use of positron emission tomography (PET) in patients with non-small cell lung cancer (NSCLC) and to determine whether their associations with PET use has changed over time. MATERIALS AND METHODS: The Office of Human Research Ethics at the University of North Carolina and the institutional review board of the Duke University Health System approved (with waiver of informed consent) this retrospective analysis of Surveillance Epidemiology and End Results Medicare data for Medicare beneficiaries given a diagnosis of NSCLC between 1998 and 2007. The primary outcome was change in the number of PET examinations 2 months before to 4 months after diagnosis, examined according to year and sociodemographic subgroup. PET use was compared between demographic and geographic subgroups and between early (1998-2000) and late (2005-2007) cohorts by using χ(2) tests. Factors associated with use of PET during the study period were further examined by using logit and linear probability multivariable regression analyses. RESULTS: The final cohort included 46 544 patients with 46 935 cases of NSCLC. By 2005, more than half of patients underwent one or more PET examinations, regardless of demographic subgroup. In multivariable logistic regression analysis, patients who underwent PET were more likely to be married, nonblack, and younger than 80 years and to live in census tracts with higher education levels or in the Northeast (P < .001 for all). Living within 40 miles of a PET facility was initially associated with undergoing PET (P < .001), but this association disappeared by 2007. Imaging rates increased more rapidly in patients who were nonblack (P ≤ .01), patients who were younger than 81 years (P < .001), and patients who lived in the Northeast and South (P < .001). CONCLUSION: PET imaging among Medicare beneficiaries with NSCLC was initially concentrated among nonblack patients younger than 81 years. Despite widespread adoption among all subgroups, differences within demographic subgroups remained.

Authors: Du XL, Cai Y, Symanski E

Title: Association between chemotherapy and cognitive impairments in a large cohort of patients with colorectal cancer.

Journal: Int J Oncol 42(6):2123-33

Date: 2013 Jun

Abstract: No population-based study has been conducted on the relationship between chemotherapy and the risk of cognitive impairments in patients with colorectal cancer. This study aimed to determine this association in a large population-based cohort of patients. We studied 72,374 men and women who were diagnosed with stages I-III colorectal cancer at age ≥ 65 years from 1991 through 2002 from 16 regions in the Surveillance, Epidemiology and End Results program who were free of cognitive impairments at baseline with up to 17 years of follow-up and also studied 15,921 matched cohorts based on the propensity of receiving chemotherapy. The cumulative incidence of drug-induced dementia at 5 years was 16.2 cases per 1,000 persons for the chemotherapy group and 12.4 cases per 1,000 persons for the no chemotherapy group. Overall, patients who received chemotherapy were 24% significantly more likely to develop drug-induced dementia compared to those without chemotherapy after adjusting for patient and tumor characteristics (hazard ratio 1.24, 95% confidence interval 1.05-1.47). The significantly increased risk was only observed in those without mood disorder who received chemotherapy in the entire cohort (1.26, 1.06-1.50) and in the matched cohort (1.29, 1.04-1.59). The risk of developing Alzheimer's disease, vascular dementia or other dementias was significantly lower in patients receiving chemotherapy compared to those without chemotherapy regardless of mood disorder status. In conclusion, there was a significant association between chemotherapy and the risk of developing drug-induced dementia in patients with colorectal cancer without mood disorder, but chemotherapy was associated with a decreased risk of other dementias.

Authors: George SM, Smith AW, Alfano CM, Bowles HR, Irwin ML, McTiernan A, Bernstein L, Baumgartner KB, Ballard-Barbash R

Title: The association between television watching time and all-cause mortality after breast cancer.

Journal: J Cancer Surviv 7(2):247-52

Date: 2013 Jun

Abstract: PURPOSE: Sedentary time is a rapidly emerging independent risk factor for mortality in the general population, but its prognostic effect among cancer survivors is unknown. In a multiethnic, prospective cohort of breast cancer survivors, we hypothesized that television watching time would be independently associated with an increased risk of death from any cause. METHODS: The Health, Eating, Activity, and Lifestyle Study cohort included 687 women diagnosed with local or regional breast cancer. On average 30 (±4) months postdiagnosis, women completed self-report assessments on time spent sitting watching television/videos in a typical day in the previous year. Multivariate Cox proportional hazards models were used to estimate hazard ratios (HR) and 95 % confidence intervals (CI) for death from any cause (n = 89) during the 7 years of follow-up. RESULTS: Television time (top tertile vs. bottom tertile) was positively related to risk of death (HR, 1.94; 95 % CI, 1.02, 3.66, p trend = 0.024), but the association was attenuated and not statistically significant after adjustment for aerobic moderate-vigorous intensity physical activity (HR, 1.70; 95 % CI, 0.89, 3.22, p trend = 0.14) and all covariates (HR, 1.39; 95 % CI, 0.69, 2.82, p trend = 0.48). CONCLUSION: In this first published investigation on this topic, we did not observe a statistically significant multivariate-adjusted association between television watching time and risk of death among women diagnosed with breast cancer. IMPLICATIONS FOR CANCER SURVIVORS: These results begin an evidence base on this topic that can be built upon to inform lifestyle recommendations for this expanding, aging population.

Authors: In H, Jiang W, Lipsitz SR, Neville BA, Weeks JC, Greenberg CC

Title: Variation in the utilization of reconstruction following mastectomy in elderly women.

Journal: Ann Surg Oncol 20(6):1872-9

Date: 2013 Jun

Abstract: BACKGROUND: Regardless of their age, women who choose to undergo postmastectomy reconstruction report improved quality of life as a result. However, actual use of reconstruction decreases with increasing age. Whereas this may reflect patient preference and clinical factors, it may also represent age-based disparity. METHODS: Women aged 65 years or older who underwent mastectomy for DCIS/stage I/II breast cancer (2000-2005) were identified in the SEER-Medicare database. Overall and institutional rates of reconstruction were calculated. Characteristics of hospitals with higher and lower rates of reconstruction were compared. Pseudo-R² statistics utilizing a patient-level logistic regression model estimated the relative contribution of institution and patient characteristics. RESULTS: A total of 19,234 patients at 716 institutions were examined. Overall, 6 % of elderly patients received reconstruction after mastectomy. Institutional rates ranged from zero to >40 %. Whereas 53 % of institutions performed no reconstruction on elderly patients, 5.6 % performed reconstructions on more than 20 %. Although patient characteristics (%ΔR² = 70 %), and especially age (%ΔR² = 34 %), were the primary determinants of reconstruction, institutional characteristics also explained some of the variation (%ΔR² = 16 %). This suggests that in addition to appropriate factors, including clinical characteristics and patient preferences, the use of reconstruction among older women also is influenced by the institution at which they receive care. CONCLUSIONS: Variation in the likelihood of reconstruction by institution and the association with structural characteristics suggests unequal access to this critical component of breast cancer care. Increased awareness of a potential age disparity is an important first step to improve access for elderly women who are candidates and desire reconstruction.

Authors: Kaplan JR, Kowalczyk KJ, Borza T, Gu X, Lipsitz SR, Nguyen PL, Friedlander DF, Trinh QD, Hu JC

Title: Patterns of care and outcomes of radiotherapy for lymph node positivity after radical prostatectomy.

Journal: BJU Int 111(8):1208-14

Date: 2013 Jun

Abstract: OBJECTIVE: To evaluate the use and outcomes of adjuvant radiation therapy (ART) for men with lymph node (LN)-positive disease after radical prostatectomy (RP) using a population-based approach. PATIENTS AND METHODS: Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 1995 to 2007 was used to identify 577 men with LN metastases discovered during RP and absence of distant metastases, of which 177 underwent ART ≤1 year of RP. Propensity score models were used to compare overall mortality and prostate cancer-specific mortality (PCSM) for men that did and those that did not receive ART. RESULTS: Men in both groups received adjuvant androgen-deprivation therapy at similar rates after propensity weighting adjustments (33.6% vs 33.7%, P = 0.977). ART was not associated with differences in overall (5.09 vs 3.77 events per 100 person-years, P = 0.153) or PCSM (2.89 vs 1.31, P = 0.090) relative to men who did not receive ART. CONCLUSIONS: ART after RP in men with LN-positive prostate cancer was not associated with improved overall or disease-specific survival, in contrast to previous single-centre studies. Prospective randomised studies are needed to assess the effectiveness of ART in this patient population.

Authors: Kent EE, Smith AW, Keegan TH, Lynch CF, Wu XC, Hamilton AS, Kato I, Schwartz SM, Harlan LC

Title: Talking About Cancer and Meeting Peer Survivors: Social Information Needs of Adolescents and Young Adults Diagnosed with Cancer.

Journal: J Adolesc Young Adult Oncol 2(2):44-52

Date: 2013 Jun

Abstract: PURPOSE: Limited research exists on the social information needs of adolescents and young adults (AYAs, aged 15-39 at diagnosis) with cancer. METHODS: The Adolescent and Young Adult Health Outcomes and Patient Experiences (AYA HOPE) Study recruited 523 patients to complete surveys 6-14 months after cancer diagnosis. Participants reported information needs for talking about their cancer experience with family and friends (TAC) and meeting peer survivors (MPS). Multiple logistic regression was used to examine factors associated with each need. RESULTS: Approximately 25% (118/477) and 43% (199/462) of participants reported a TAC or MPS need respectively. Participants in their 20s (vs. teenagers) were more likely to report a MPS need (p=0.03). Hispanics (vs. non-Hispanic whites) were more likely to report a TAC need (p=0.01). Individuals who did not receive but reported needing support groups were about 4 and 13 times as likely to report TAC and MPS needs respectively (p<0.05). Participants reporting high symptom burden were more likely to report TAC and MPS needs (p<0.01), and those reporting fair/poor quality of care were more likely to report a TAC need (p<0.01). Those reporting that cancer had an impact on several key relationships with family and friends were more likely to report social information needs. CONCLUSION: Social information needs are higher in AYAs diagnosed in their 20s, in Hispanics, among those reporting high symptom burden and/or lower quality of care, and in individuals not in support groups. Efforts should be made to develop interventions for AYAs in most need of social information and support.

Authors: Margerison-Zilko C, Cubbin C

Title: Socioeconomic disparities in tobacco-related health outcomes across racial/ethnic groups in the United States: national health interview survey 2010.

Journal: Nicotine Tob Res 15(6):1161-5

Date: 2013 Jun

Abstract: INTRODUCTION: Existing research documents strong inverse socioeconomic gradients in current smoking and lung cancer morbidity and mortality; these gradients appear stronger among non-Hispanic Whites and Blacks compared with Hispanics. We sought to examine a broader range of outcomes across the tobacco use continuum, examining socioeconomic gradients separately among the 3 largest racial/ethnic groups in the United States. METHODS: We used data from the 2010 National Health Interview Survey (n = 17,284) Cancer Control Supplement to calculate prevalences and means for outcomes across the tobacco use continuum by educational attainment and income separately among non-Hispanic Black, Hispanic/Latino, and non-Hispanic White adults. RESULTS: Findings demonstrate that current smoking, age at initiation, cigarettes per day, years quit, and secondhand smoke all exhibit strong inverse educational gradients and moderately strong inverse income gradients, especially among Whites and Blacks. Hispanics/Latinos generally have more favorable outcomes along the tobacco use continuum and less evident socioeconomic gradients. CONCLUSIONS: Educational attainment is strongly associated with indicators across the tobacco use continuum among non-Hispanic Whites and Blacks. More research is needed to determine whether policies and programs to increase educational attainment may also reduce tobacco-related health disparities.

Authors: Mason C, Alfano CM, Smith AW, Wang CY, Neuhouser ML, Duggan C, Bernstein L, Baumgartner KB, Baumgartner RN, Ballard-Barbash R, McTiernan A

Title: Long-term physical activity trends in breast cancer survivors.

Journal: Cancer Epidemiol Biomarkers Prev 22(6):1153-61

Date: 2013 Jun

Abstract: BACKGROUND: Physical activity is associated with reduced mortality and higher quality of life in breast cancer survivors; however, limited data on the prevalence of activity and long-term trends after diagnosis are available. METHODS: A multiethnic cohort of 631 women (18-64 years) with stage 0 to IIIA breast cancer was followed for 10 years. Recreational aerobic activity (MET-h/wk) was ascertained for the year before diagnosis (baseline), 24 months, 5 years, and 10 years after enrollment. Women were classified according to U.S. physical activity guidelines (≥150 min/wk moderate or ≥75 min/wk vigorous activity). The OR for meeting guidelines at 5 and 10 years according to baseline factors was estimated using logistic regression. The change in MET-h/wk was predicted using linear regression. RESULTS: Prediagnosis, 34% of women met physical activity guidelines; 34.0%, 39.5%, and 21.4% met guidelines at 24 months, 5 years, and 10 years after enrollment, respectively. Less than 8% of survivors met guidelines at all follow-up periods. Over 10 years, recreational aerobic activity decreased by a mean ± SD of 4.3 ± 16.2 MET-h/wk. Meeting guidelines pre-diagnosis was strongly associated with meeting guidelines at 5 years [OR (95% confidence interval; CI): 2.76 (1.85-4.1)] and 10 years [OR (95% CI): 3.35 (2.13-5.28)]. No other demographic or prognostic factors were significantly associated with the 10-year change in MET-h/wk. CONCLUSION: The vast majority of early breast cancer survivors do not meet national exercise recommendations 10 years postdiagnosis. IMPACT: Physical activity levels are low in breast cancer survivors across the 10 years postdiagnosis; nonetheless, the predictors of activity in this population remain poorly understood.

Authors: Meyers J, Yu Y, Kaye JA, Davis KL

Title: Medicare fee-for-service enrollees with primary acute myeloid leukemia: an analysis of treatment patterns, survival, and healthcare resource utilization and costs.

Journal: Appl Health Econ Health Policy 11(3):275-86

Date: 2013 Jun

Abstract: BACKGROUND: Acute myeloid leukemia (AML) is the most common form of acute leukemia affecting adults, with incidence increasing with patient age. Previous studies have found that older AML patients, constituting the majority of the AML population, generally have poor outcomes, high healthcare expenditures, and median survival of <3 months. Because up-to-date information on treatment patterns, survival trends, and costs of care for elderly AML patients are lacking in the literature, we examined Medicare fee-for-service enrollees with primary AML to update these estimates and report on changes in treatment for this population. OBJECTIVE: The primary objective of this study was to examine real-world data on treatment patterns, survival, and costs in elderly patients with primary AML. Factors associated with receipt of chemotherapy and with mortality also were assessed. METHODS: This is a retrospective database analysis using the Surveillance, Epidemiology, and End Results cancer registry and linked Medicare claims. Patients aged 65 years and older, who were newly diagnosed with AML between 1 January 1997 and 31 December 2007 were selected if they had no previous neoplasm or hematological disease. Patients were followed until death or to the end of the observation period (31 December 2007). Study measures included chemotherapy and supportive care (SC) received, survival time, and all-cause healthcare utilization and costs accrued from AML diagnosis until death or observation period end. Regression analyses assessed factors associated with receipt of chemotherapy (logistic) and mortality among chemotherapy and SC users (Cox). RESULTS: Of the 4,058 patients meeting the inclusion criteria, 43 % received chemotherapy; 57 % received SC only. Among patients receiving chemotherapy, 69.1 % died within 1 year; median survival was 7.0 months. Among patients receiving only SC, 95.0 % died within 1 year; median survival was 1.5 months. The most significant factors associated with receipt of chemotherapy were patient age [odds ratio (OR) = 0.420 among patients 75-84 years and 0.099 among patients 85+ years, compared with patients aged 65-74 years) and Charlson Comorbidity Index (CCI) score (OR = 0.614 for patients with a CCI = 2 or 3 and 0.707 for patients with a CCI >3, compared with patients with a CCI = 0) (all P < 0.001). The most significant factors associated with mortality among patients receiving chemotherapy were patient age [hazard ratio (HR) = 1.321 among patients 75-84 years and 1.832 among patients 85+ years, compared with patients aged 65-74 years] and CCI score (OR = 1.287 for patients with a CCI = 2 or 3 and 1.220 for patients with a CCI >3, compared with patients with a CCI = 0) (all P < 0.01). Mean (standard deviation) all-cause healthcare costs were $96,078 ($109,072); the largest component was inpatient utilization (76.3 %). CONCLUSIONS: Younger patients with fewer comorbidities were more likely to receive chemotherapy and had longer survival. AML is associated with a substantial economic burden, and treatment outcomes appear to be suboptimal, with limited therapy options currently available.

Authors: Oberstein PE, Hershman DL, Khanna LG, Chabot JA, Insel BJ, Neugut AI

Title: Uptake and patterns of use of gemcitabine for metastatic pancreatic cancer: a population-based study.

Journal: Cancer Invest 31(5):316-22

Date: 2013 Jun

Abstract: Gemcitabine was approved for advanced pancreatic cancer in 1996. We investigated uptake and predictors of its use. We identified 3,231 individuals > 65 years in the SEER-Medicare database with stage IV pancreatic adenocarcinoma, diagnosed between 1998-2005, who survived > 30 days. Of these, 54% received chemotherapy, 93% with gemcitabine. Gemcitabine nonreceipt was associated with advanced age and unmarried (OR: 0.65, 95% CI: 0.55-0.76). Diagnosis in 2004-2005 versus 1998-2000 was more likely to receive gemcitabine (OR: 1.51, 95% CI: 1.23-1.84) as were higher SES patients (highest versus lowest quintile, OR: 2.14, 95% CI: 1.60-2.85). Gemcitabine was rapidly adopted among elderly advanced pancreatic cancer patients; several factors are associated with use.

Authors: Onega T, Anderson ML, Miglioretti DL, Buist DS, Geller B, Bogart A, Smith RA, Sickles EA, Monsees B, Bassett L, Carney PA, Kerlikowske K, Yankaskas BC

Title: Establishing a gold standard for test sets: variation in interpretive agreement of expert mammographers.

Journal: Acad Radiol 20(6):731-9

Date: 2013 Jun

Abstract: RATIONALE AND OBJECTIVES: Test sets for assessing and improving radiologic image interpretation have been used for decades and typically evaluate performance relative to gold standard interpretations by experts. To assess test sets for screening mammography, a gold standard for whether a woman should be recalled for additional workup is needed, given that interval cancers may be occult on mammography and some findings ultimately determined to be benign require additional imaging to determine if biopsy is warranted. Using experts to set a gold standard assumes little variation occurs in their interpretations, but this has not been explicitly studied in mammography. MATERIALS AND METHODS: Using digitized films from 314 screening mammography exams (n = 143 cancer cases) performed in the Breast Cancer Surveillance Consortium, we evaluated interpretive agreement among three expert radiologists who independently assessed whether each examination should be recalled, and the lesion location, finding type (mass, calcification, asymmetric density, or architectural distortion), and interpretive difficulty in the recalled images. RESULTS: Agreement among the three expert pairs for recall/no recall was higher for cancer cases (mean 74.3 ± 6.5) than for noncancers (mean 62.6 ± 7.1). Complete agreement on recall, lesion location, finding type and difficulty ranged from 36.4% to 42.0% for cancer cases and from 43.9% to 65.6% for noncancer cases. Two of three experts agreed on recall and lesion location for 95.1% of cancer cases and 91.8% of noncancer cases, but all three experts agreed on only 55.2% of cancer cases and 42.1% of noncancer cases. CONCLUSION: Variability in expert interpretive is notable. A minimum of three independent experts combined with a consensus should be used for establishing any gold standard interpretation for test sets, especially for noncancer cases.

Authors: Panchal JM, Lairson DR, Chan W, Du XL

Title: Geographic variation and sociodemographic disparity in the use of oxaliplatin-containing chemotherapy in patients with stage III colon cancer.

Journal: Clin Colorectal Cancer 12(2):113-21

Date: 2013 Jun

Abstract: This study examined the geographic variation and sociodemographic disparities in the use of oxaliplatin chemotherapy, which has not been widely studied in the past. Our results suggest that chemotherapy use varies across geographic regions. Patterns of use that relate specifically to oxaliplatin-containing chemotherapy can inform providers and researchers how newer regimens are being used as standard chemotherapy in a real-world setting. BACKGROUND: According to the National Cancer Comprehensive Network (NCCN), oxaliplatin with 5-fluorouracil and leucovorin (5-FU/LV) is the recommended adjuvant chemotherapy for patients with resected stage III colon cancer. Age and race are considered strong predictors of chemotherapy receipt, whereas geographic disparity has received minimal attention. The purpose of this study was to examine geographic variation and sociodemographic disparity in the use of chemotherapy in patients with stage III colon cancer, focusing specifically on oxaliplatin. METHODS: A retrospective cohort of 4106 Medicare patients was identified from the Surveillance, Epidemiology and End Results (SEER)/Medicare linked database. Descriptive statistics show how oxaliplatin-containing chemotherapy was used in various geographic regions among different age and racial groups. Multiple logistic regression analysis was performed to examine the relationship between receipt of oxaliplatin-containing chemotherapy and geographic region while adjusting for other sociodemographic and tumor characteristics. RESULTS: Only 49% of the patients with stage III disease received adjuvant chemotherapy within 3 to 6 months of colon cancer-specific surgery. Patients aged 66 to 70 years were 78% more likely to receive chemotherapy than were those aged 80 years and older (P<.001). Patients in less urban regions were approximately 42% less likely to receive oxaliplatin chemotherapy than those residing in a big metro region (odds ratio [OR], 0.58; P=.008). CONCLUSION: Chemotherapy use varies across geographic regions, especially for new chemotherapy drugs like oxaliplatin. Further research is needed to identify the causes of this geographic disparity and ways to provide high-quality cancer care to all patients according to their preferences and needs.

Authors: Reilly CM, Bruner DW, Mitchell SA, Minasian LM, Basch E, Dueck AC, Cella D, Reeve BB

Title: A literature synthesis of symptom prevalence and severity in persons receiving active cancer treatment.

Journal: Support Care Cancer 21(6):1525-50

Date: 2013 Jun

Abstract: PURPOSE: Patients with cancer experience acute and chronic symptoms caused by their underlying disease or by the treatment. While numerous studies have examined the impact of various treatments on symptoms experienced by cancer patients, there are inconsistencies regarding the symptoms measured and reported in treatment trials. This article presents a systematic review of the research literature of the prevalence and severity of symptoms in patients undergoing cancer treatment. METHODS: A systematic search for studies of persons receiving active cancer treatment was performed with the search terms of "multiple symptoms" and "cancer" for studies involving patients over the age of 18 years and published in English during the years 2001 to 2011. Search outputs were reviewed independently by seven authors, resulting in the synthesis of 21 studies meeting criteria for generation of an Evidence Table reporting symptom prevalence and severity ratings. RESULTS: Data were extracted from 21 multi-national studies to develop a pooled sample of 4,067 cancer patients in whom the prevalence and severity of individual symptoms was reported. In total, the pooled sample across the 21 studies was comprised of 62% female, with a mean age of 58 years (range 18 to 97 years). A majority (62%) of these studies assessed symptoms in homogeneous samples with respect to tumor site (predominantly breast and lung cancer), while 38% of the included studies utilized samples with mixed diagnoses and treatment regimens. Eighteen instruments and structured interviews were including those measuring single symptoms, multi-symptom inventories, and single symptom items drawn from HRQOL or health status measures. The MD Anderson Symptom Inventory was the most commonly used instrument in the studies analyzed (n = 9 studies; 43%), while the Functional Assessment of Cancer Therapy, Hospital Anxiety and Depression Subscale, Medical Outcomes Survey Short Form-36, and Symptom Distress Scale were each employed in two studies. Forty-seven symptoms were identified across the 21 studies which were then categorized into 17 logical groupings. Symptom prevalence and severity were calculated across the entire cohort and also based upon sample sizes in which the symptoms were measured providing the ability to rank symptoms. CONCLUSIONS: Symptoms are prevalent and severe among patients with cancer. Therefore, any clinical study seeking to evaluate the impact of treatment on patients should consider including measurement of symptoms. This study demonstrates that a discrete set of symptoms is common across cancer types. This set may serve as the basis for defining a "core" set of symptoms to be recommended for elicitation across cancer clinical trials, particularly among patients with advanced disease.

Authors: Roen EL, Roubidoux MA, Joe AI, Russell TR, Soliman AS

Title: Adherence to screening mammography among American Indian women of the Northern Plains.

Journal: Breast Cancer Res Treat 139(3):897-905

Date: 2013 Jun

Abstract: Breast cancer is a burden for American Indian (AI) women who have younger age at diagnosis and higher stage of disease. Rural areas also have had less access to screening mammography. An Indian Health Service Mobile Women's Health Unit (MWHU) was implemented to improve mammogram screening of AI women in the Northern Plains. Our purpose was to determine the past adherence to screening mammography at a woman's first presentation to the MWHU for mammogram screening. Date of the most recent prior non-MWHU mammogram was obtained from mammography records. Adherence to screening guidelines was defined as the prior mammogram occurring 1-2 years before the first MWHU visit among women >41 years, and was the main outcome, whereas, age and clinic site were predictors. Adherence was compared with national data of the Breast Cancer Surveillance Consortium (BCSC). Among 1,771 women >41 years, adherence to screening mammography guidelines was 48.01 % among >65 years, 42.05 % among 50-64 years, 33.43 % among 41-49 years, and varied with clinic site (25.23-65.93 %). Age (p < 0.0001) and clinic site (p < 0.0001) were associated with adherence. Overall, adherence to screening mammography guidelines was found in 39.86 % (706/1771) of MWHU women versus 74.34 % (747,095/1,004,943) of BCSC women. The majority (60.14 %) of women at first presentation to the MWHU had not had mammograms in the previous 2 years, lower screening adherence than nationally (25.66 %). Adherence was lowest among women ages 41-49, and varied with clinic site. Findings suggest disparities in mammography screening among these women.

Authors: Sacco JE, Dodd KW, Kirkpatrick SI, Tarasuk V

Title: Voluntary food fortification in the United States: potential for excessive intakes.

Journal: Eur J Clin Nutr 67(6):592-7

Date: 2013 Jun

Abstract: BACKGROUND: Historically, the voluntary addition of micronutrients to foods in the United States has been regarded as an important means to lessen problems of nutrient inadequacy. With expanding voluntary food fortification and widespread supplement use, it is important to understand how voluntary food fortification has an impact on the likelihood of excessive usual intakes. Our objective was to investigate whether individuals in the United States with greater frequency of exposure to micronutrients from voluntarily fortified foods (vFF) are more likely to have usual intakes approaching or exceeding the respective tolerable upper intake levels (UL). SUBJECTS/METHODS: The National Cancer Institute method was applied to data from the 2007-2008 National Health and Nutrition Examination Survey (NHANES) to estimate the joint distribution of usual intake from both vFF and non-vFF sources for 12 nutrients and determine the probability of consuming these nutrients from vFF on a given day. For each nutrient, we estimated the distribution of usual intake from all food sources by quintile of probability of consuming vFF and compared the distributions with ULs. RESULTS: An increased probability of consuming zinc, retinol, folic acid, selenium and copper from vFF was associated with a greater risk of intakes above the UL among children. Among adults, increased probability of consuming calcium and iron from vFF was associated with a greater risk of intakes above the UL among some age/sex groups. CONCLUSION: The high nutrient exposures associated with vFF consumption in some population subgroups suggest a need for more careful weighing of the risks and benefits of uncontrolled food fortification.

Authors: Weaver KE, Foraker RE, Alfano CM, Rowland JH, Arora NK, Bellizzi KM, Hamilton AS, Oakley-Girvan I, Keel G, Aziz NM

Title: Cardiovascular risk factors among long-term survivors of breast, prostate, colorectal, and gynecologic cancers: a gap in survivorship care?

Journal: J Cancer Surviv 7(2):253-61

Date: 2013 Jun

Abstract: PURPOSE: Individuals diagnosed with high survival cancers will often die of cardiovascular disease (CVD) rather than a recurrence of their cancer, yet CVD risk factors may be overlooked during survivorship care. We assess the prevalence of CVD risk factors among long-term cancer survivors and compare results to survey data from the general population in the same geographic region. We also characterize how often at-risk survivors discuss CVD-related health behaviors with their health care providers. METHODS: Survivors (n = 1,582) of breast, prostate, colorectal, and gynecologic cancers, 4-14 years after diagnosis, were recruited from two California cancer registries for a cross-sectional mail survey. We assessed CVD risk factors, including smoking, body mass index, physical inactivity, hypercholesterolemia, hypertension, and diabetes, as well as report of discussions with health care providers about diet, exercise, smoking, and lifestyle change assistance. RESULTS: With the exception of current smoking, CVD risk factors were more common among survivors than the general adult population. Of survivors, 62.0 % were overweight or obese, 55.0 % reported hypertension, 20.7 % reported diabetes, 18.1 % were inactive, and 5.1 % were current smokers. Compared to white, non-Hispanic survivors, Hispanic (b = 0.37, p = 0.007) and African-American (b = 0.66, p < 0.0001), but not Asian, survivors reported significantly more risk factors. One in three survivors with one or more risk factors for CVD did not report a health promotion discussion with their health care providers. CONCLUSIONS: CVD risk factors are common among long-term survivors, but many at-risk survivors may not discuss lifestyle prevention with their health care team. Primary care and oncology should work together to deliver optimal survivorship care that addresses CVD risk factors, as well as prevalent disease. IMPLICATIONS FOR CANCER SURVIVORS: Cardiovascular disease may compromise cancer survivors' long-term health and well-being, yet cardiovascular risk factors may be overlooked during survivorship care. We document that CVD risk factors are common among cancers survivors, yet nearly a third of survivors do not report health promotion discussions with their medical teams. Survivors should be aware of their cardiovascular risk factors and initiate discussions with their medical teams about health promotion topics, if appropriate.

Authors: Wright JD, Neugut AI, Lewin SN, Lu YS, Herzog TJ, Hershman DL

Title: Trends in hospital volume and patterns of referral for women with gynecologic cancers.

Journal: Obstet Gynecol 121(6):1217-25

Date: 2013 Jun

Abstract: OBJECTIVE: To estimate trends in hospital volume and referral patterns for women with uterine and ovarian cancer. METHODS: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify women aged 65 years or older with ovarian and uterine cancer who underwent surgery from 2000 to 2007. "Volume creep," when a greater number of patients undergo surgery at the same hospitals, and "market concentration," when a similar overall number of patients undergo a procedure but at a smaller number of hospitals, were analyzed. RESULTS: Among 4,522 patients with ovarian cancer, mean hospital volume increased from 3.1 cases during 2000-2001 to 3.4 cases during 2006-2007 (P=.62) suggesting minimal volume creep. Similarly, there was little evidence of market concentration. In 2000-2001, 37.8% of women were treated at the top decile by volume hospitals compared with 41.4% in 2006-2007 (P=.14). In 2006-2007, 201 (63.2%) of the hospitals had an ovarian cancer surgery volume of two or fewer cases. Among 9,908 women with uterine cancer, the mean hospital volume increased slightly from 4.5 in 2000-2001 to 5.4 in 2006-2007 (P=.10). The percentage of patients treated at the top decile by volume of hospitals increased from 40.4% in 2000-2001 to 44.7% in 2006-2007 (P<.001). In 2006-2007, 243 (49.3%) of the hospitals had a uterine cancer surgery volume of two or fewer cases. CONCLUSION: There have been only modest changes in the referral patterns of women with ovarian and uterine cancer. A large number of hospitals have a very low procedural volume.

Authors: Austin SR, Wong YN, Uzzo RG, Beck JR, Egleston BL

Title: Why Summary Comorbidity Measures Such As the Charlson Comorbidity Index and Elixhauser Score Work.

Journal: Med Care :-

Date: 2013 May 23

Abstract: BACKGROUND:: Comorbidity adjustment is an important component of health services research and clinical prognosis. When adjusting for comorbidities in statistical models, researchers can include comorbidities individually or through the use of summary measures such as the Charlson Comorbidity Index or Elixhauser score. We examined the conditions under which individual versus summary measures are most appropriate. METHODS:: We provide an analytic proof of the utility of comorbidity summary measures when used in place of individual comorbidities. We compared the use of the Charlson and Elixhauser scores versus individual comorbidities in prognostic models using a SEER-Medicare data example. We examined the ability of summary comorbidity measures to adjust for confounding using simulations. RESULTS:: We devised a mathematical proof that found that the comorbidity summary measures are appropriate prognostic or adjustment mechanisms in survival analyses. Once one knows the comorbidity score, no other information about the comorbidity variables used to create the score is generally needed. Our data example and simulations largely confirmed this finding. CONCLUSIONS:: Summary comorbidity measures, such as the Charlson Comorbidity Index and Elixhauser scores, are commonly used for clinical prognosis and comorbidity adjustment. We have provided a theoretical justification that validates the use of such scores under many conditions. Our simulations generally confirm the utility of the summary comorbidity measures as substitutes for use of the individual comorbidity variables in health services research. One caveat is that a summary measure may only be as good as the variables used to create it.

Authors: Cooper GS, Kou TD, Barnholtz Sloan JS, Koroukian SM, Schluchter MD

Title: Use of colonoscopy for polyp surveillance in Medicare beneficiaries.

Journal: Cancer 119(10):1800-7

Date: 2013 May 15

Abstract: BACKGROUND: Professional society guidelines recommend follow-up colonoscopy for patients with resected colonic adenomas. However, adherence to guideline recommendations in routine clinical practice has not been well characterized. METHODS: The authors used a population-based sample of Medicare beneficiaries to identify all patients aged ≥70 years who had a claim for colonoscopy with polypectomy or hot biopsy during the period from 2001 to 2004. Medicare claims through 2009 identified colonoscopy within the following 5 years as well as fecal occult blood testing, sigmoidoscopy, and barium enema. RESULTS: In total, 12,771 patients were included. At 5 years, 45.7% of patients underwent another colonoscopy, and 32.3% of procedures included a polypectomy. The rates of fecal occult blood testing, flexible sigmoidoscopy, and barium enema at 5 years were 54%, 3.8%, and 2.9%, respectively. There was a marked decrease in repeat colonoscopy at 1 year, 3 years, and 5 years with more recent years of index procedures. Other predictors of undergoing repeat colonoscopy were younger age, African American race, and a colonoscopy before the index examination. There was no association with physician specialty. The decreasing use of colonoscopy with time was maintained in a multivariable analysis. CONCLUSIONS: In a sample of elderly Medicare beneficiaries, there was under use of follow-up colonoscopy at 5 years after polypectomy, and <50% of patients received a repeat examination. In particular, the use of this procedure decreased over the 4-year study period. Coupled with other data indicating the overuse of follow-up colonoscopy in patients without polyps, there appeared to be significant discordance between guidelines and actual practice.

Authors: Sharma A, Schwartz SM, Méndez E

Title: Hospital volume is associated with survival but not multimodality therapy in Medicare patients with advanced head and neck cancer.

Journal: Cancer 119(10):1845-52

Date: 2013 May 15

Abstract: BACKGROUND: Given the complexity of management of advanced head and neck squamous cell carcinoma (HNSCC), this study hypothesized that high hospital volume would be associated with receiving National Comprehensive Cancer Network (NCCN) guideline therapy and improved survival in patients with advanced HNSCC. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients with advanced HNSCC. Treatment modalities and survival were determined using Medicare data. Hospital volume was determined by the number of patients with HNSCC treated at each hospital. RESULTS: There were 1195 patients with advanced HNSCC who met inclusion criteria. In multivariable analyses, high hospital volume was not associated with receiving multimodality therapy per NCCN guidelines (odds ratio = 1.02, 95% confidence interval = 0.66-1.60), but showed a nearly significant inverse association with survival in a model adjusted for National Cancer Institute-designated cancer center status, age, sex, race, socioeconomic status, marital status, comorbidity, year of diagnosis, tumor site, and tumor stage (hazard ratio = 0.85, 95% confidence interval = 0.69-1.04). CONCLUSIONS: Medicare patients with advanced HNSCC treated at high-volume hospitals were not more likely to receive NCCN guideline therapy, but had nearly statistically significant better survival, when compared with patients treated at low-volume hospitals. These results suggest that features of high-volume hospitals other than delivery of NCCN guideline therapy influence survival. Cancer 2013. © 2013 American Cancer Society.

Authors: Caswell JL, Kerlikowske K, Shepherd JA, Cummings SR, Hu D, Huntsman S, Ziv E

Title: High mammographic density in women of Ashkenazi Jewish descent.

Journal: Breast Cancer Res 15(3):R40-

Date: 2013 May 13

Abstract: INTRODUCTION: Percent mammographic density (PMD) adjusted for age and body mass index is one of the strongest risk factors for breast cancer and is known to be approximately 60% heritable. Here we report a finding of an association between genetic ancestry and adjusted PMD. METHODS: We selected self-identified Caucasian women in the California Pacific Medical Center Research Institute Cohort whose screening mammograms placed them in the top or bottom quintiles of age-adjusted and body mass index-adjusted PMD. Our final dataset included 474 women with the highest adjusted PMD and 469 with the lowest genotyped on the Illumina 1 M platform. Principal component analysis (PCA) and identity-by-descent analyses allowed us to infer the women's genetic ancestry and correlate it with adjusted PMD. RESULTS: Women of Ashkenazi Jewish ancestry, as defined by the first principal component of PCA and identity-by-descent analyses, represented approximately 15% of the sample. Ashkenazi Jewish ancestry, defined by the first principal component of PCA, was associated with higher adjusted PMD (P = 0.004). Using multivariate regression to adjust for epidemiologic factors associated with PMD, including age at parity and use of postmenopausal hormone therapy, did not attenuate the association. CONCLUSIONS: Women of Ashkenazi Jewish ancestry, based on genetic analysis, are more likely to have high age-adjusted and body mass index-adjusted PMD. Ashkenazi Jews may have a unique set of genetic variants or environmental risk factors that increase mammographic density.

Authors: Kerlikowske K, Zhu W, Hubbard RA, Geller B, Dittus K, Braithwaite D, Wernli KJ, Miglioretti DL, O'Meara ES, Breast Cancer Surveillance Consortium

Title: Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy.

Journal: JAMA Intern Med 173(9):807-16

Date: 2013 May 13

Abstract: IMPORTANCE: Controversy exists about the frequency women should undergo screening mammography and whether screening interval should vary according to risk factors beyond age. OBJECTIVE: To compare the benefits and harms of screening mammography frequencies according to age, breast density, and postmenopausal hormone therapy (HT) use. DESIGN: Prospective cohort. SETTING: Data collected January 1994 to December 2008 from mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries. PARTICIPANTS: Data were collected prospectively on 11,474 women with breast cancer and 922,624 without breast cancer who underwent mammography at facilities that participate in the BCSC. MAIN OUTCOMES AND MEASURES: We used logistic regression to calculate the odds of advanced stage (IIb, III, or IV) and large tumors (>20 mm in diameter) and 10-year cumulative probability of a false-positive mammography result by screening frequency, age, breast density, and HT use. The main predictor was screening mammography interval. RESULTS: Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively). CONCLUSIONS AND RELEVANCE: Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

Authors: Huo J, Du XL, Lairson DR, Chan W, Jiang J, Buchholz TA, Guadagnolo BA

Title: Utilization of Surgery, Chemotherapy, Radiation Therapy, and Hospice at the End of Life for Patients Diagnosed With Metastatic Melanoma.

Journal: Am J Clin Oncol :-

Date: 2013 May 02

Abstract: OBJECTIVES:: To examine the patterns of utilization of radiation therapy, chemotherapy, surgery, and hospice at the end-of-life care for patients diagnosed with metastatic melanoma. METHODS:: We identified 816 Medicare beneficiaries toward who were 65 years of age or older, with pathologically confirmed metastatic malignant melanoma between January 1, 2000, and December 31, 2007. We evaluated trends and associations between sociodemographic and health service characteristics and the use of hospice care, chemotherapy, surgery, and radiation therapy. RESULTS:: We found increasing use of surgery for patients with metastatic melanoma from 13% in 2000 to 30% in 2007 (P=0.03 for trend), and no significant fluctuation in the use of chemotherapy (P=0.43) or radiation therapy (P=0.46). Older patients were less likely to receive radiation therapy or chemotherapy. The use of hospice care increased from 61% in 2000 to 79% in 2007 (P=0.07 for trend). Enrollment in short-term (1 to 3 d) hospice care use increased, whereas long-term hospice care (≥4 d) remained stable. Patients living in the SEER (Surveillance, Epidemiology and End Results) northeast and south regions were less likely to undergo surgery. Patients enrolled in long-term hospice care used significantly less chemotherapy, surgery, and radiation therapy. CONCLUSIONS:: Surgery and hospice care use increased over the years of this study, whereas the use of chemotherapy and radiation therapy remained consistent for patients diagnosed with metastatic melanoma.

Authors: Brooks GA, Li L, Sharma DB, Weeks JC, Hassett MJ, Yabroff KR, Schrag D

Title: Regional variation in spending and survival for older adults with advanced cancer.

Journal: J Natl Cancer Inst 105(9):634-42

Date: 2013 May 01

Abstract: BACKGROUND: Medicare spending varies substantially across the United States. We evaluated the association between mean regional spending and survival in advanced cancer. METHODS: We identified 116 523 subjects with advanced cancer from 2002 to 2007, using Surveillance, Epidemiology and End Results (SEER)-Medicare linked data. Subjects were aged 65 years and older with non-small cell lung, colon, breast, prostate, or pancreas cancer. Of these subjects, 61 083 had incident advanced-stage cancer (incident cohort) and 98 935 had death from cancer (decedent cohort); 37% of subjects were included in both cohorts. Subjects were linked to one of 80 hospital referral regions within SEER areas. We estimated mean regional spending in both cohorts. We assessed the primary outcome, survival, in the incident cohort; the exposure measure was the quintile of regional spending in the decedent cohort. Survival in quintiles 2 through 5 was compared with that in quintile 1 (lowest spending quintile) using Cox regression models. RESULTS: From quintile 1 to 5, mean regional spending increased by 32% and 41% in the incident and decedent cohorts (incident cohort: $28 854 to $37 971; decedent cohort: $27 446 to $38 630). The association between spending and survival varied by cancer site and quintile; hazard ratios ranged from 0.92 (95% confidence interval [CI] = 0.82 to 1.04, pancreas cancer quintile 5) to 1.24 (95% CI = 1.11 to 1.39, breast cancer quintile 3). In most cases, differences in survival between quintile 1 and quintiles 2 through 5 were not statistically significant. CONCLUSION: There is substantial regional variation in Medicare spending for advanced cancer, yet no consistent association between mean regional spending and survival.

Authors: Carney PA, Parikh J, Sickles EA, Feig SA, Monsees B, Bassett LW, Smith RA, Rosenberg R, Ichikawa L, Wallace J, Tran K, Miglioretti DL

Title: Diagnostic mammography: identifying minimally acceptable interpretive performance criteria.

Journal: Radiology 267(2):359-67

Date: 2013 May

Abstract: PURPOSE: To develop criteria to identify thresholds for the minimally acceptable performance of physicians interpreting diagnostic mammography studies. MATERIALS AND METHODS: In an institutional review board-approved HIPAA-compliant study, an Angoff approach was used to set criteria for identifying minimally acceptable interpretive performance for both workup after abnormal screening examinations and workup of a breast lump. Normative data from the Breast Cancer Surveillance Consortium (BCSC) was used to help the expert radiologist identify the impact of cut points. Simulations, also using data from the BCSC, were used to estimate the expected clinical impact from the recommended performance thresholds. RESULTS: Final cut points for workup of abnormal screening examinations were as follows: sensitivity, less than 80%; specificity, less than 80% or greater than 95%; abnormal interpretation rate, less than 8% or greater than 25%; positive predictive value (PPV) of biopsy recommendation (PPV2), less than 15% or greater than 40%; PPV of biopsy performed (PPV3), less than 20% or greater than 45%; and cancer diagnosis rate, less than 20 per 1000 interpretations. Final cut points for workup of a breast lump were as follows: sensitivity, less than 85%; specificity, less than 83% or greater than 95%; abnormal interpretation rate, less than 10% or greater than 25%; PPV2, less than 25% or greater than 50%; PPV3, less than 30% or greater than 55%; and cancer diagnosis rate, less than 40 per 1000 interpretations. If underperforming physicians moved into the acceptable range after remedial training, the expected result would be (a) diagnosis of an additional 86 cancers per 100,000 women undergoing workup after screening examinations, with a reduction in the number of false-positive examinations by 1067 per 100,000 women undergoing this workup, and (b) diagnosis of an additional 335 cancers per 100,000 women undergoing workup of a breast lump, with a reduction in the number of false-positive examinations by 634 per 100,000 women undergoing this workup. CONCLUSION: Interpreting physicians who fall outside one or more of the identified cut points should be reviewed in the context of an overall assessment of all their performance measures and their specific practice setting to determine if remedial training is indicated.

Authors: Chia VM, O'Malley CD, Danese MD, Lindquist KJ, Gleeson ML, Kelsh MA, Griffiths RI

Title: Prevalence and incidence of comorbidities in elderly women with ovarian cancer.

Journal: Gynecol Oncol 129(2):346-52

Date: 2013 May

Abstract: OBJECTIVE: Studies suggest comorbidity plays an important role in ovarian cancer. We characterized the epidemiology of comorbid conditions in elderly U.S. women with ovarian cancer. METHODS: Women with ovarian cancer age ≥66 years, and matched cancer-free women, were identified using the National Cancer Institute's Surveillance, Epidemiology, and End Results registry linked to Medicare claims. Prevalence before diagnosis/index date and 3- and 12-month incidence rates (per 1000 person-years) after diagnosis/index date were estimated for 34 chronic and acute conditions across a broad range of diagnostic categories. RESULTS: There were 5087 each of women with ovarian cancer and cancer-free women. The prevalence of most conditions was similar between cancer and cancer-free patients, but exceptions included hypertension (51.8% and 43.5%, respectively), osteoarthritis (13.4% and 17.3%, respectively), and cerebrovascular disease (8.0% and 9.8%, respectively). In contrast, 3- and 12-month incidence rates (per 1000 person years) of most conditions were significantly higher in cancer than in cancer-free patients: hypertension (177.3 and 47.4, respectively); thromboembolic event (145.3 and 5.5, respectively); congestive heart failure (113.3 and 28.6, respectively); infection (664.4 and 55.2, respectively); and anemia (408.3 and 33.1, respectively) at 12 months. CONCLUSIONS: Comorbidities were common among elderly women. After cancer diagnosis, women with ovarian cancer had a much higher incidence of comorbidities than cancer-free women. The high incidence of some of these comorbidities may be related to the cancer or its treatment, but others may have been prevalent but undiagnosed until the cancer diagnosis. The presence of comorbidities may affect treatment decisions.

Authors: Chubak J, Rutter CM, Kamineni A, Johnson EA, Stout NK, Weiss NS, Doria-Rose VP, Doubeni CA, Buist DS

Title: Measurement in comparative effectiveness research.

Journal: Am J Prev Med 44(5):513-9

Date: 2013 May

Abstract: Comparative effectiveness research (CER) on preventive services can shape policy and help patients, their providers, and public health practitioners select regimens and programs for disease prevention. Patients and providers need information about the relative effectiveness of various regimens they may choose. Decision makers need information about the relative effectiveness of various programs to offer or recommend. The goal of this paper is to define and differentiate measures of relative effectiveness of regimens and programs for disease prevention. Cancer screening is used to demonstrate how these measures differ in an example of two hypothetical screening regimens and programs. Conceptually and algebraically defined measures of relative regimen and program effectiveness also are presented. The measures evaluate preventive services that range from individual tests through organized, population-wide prevention programs. Examples illustrate how effective screening regimens may not result in effective screening programs and how measures can vary across subgroups and settings. Both regimen and program relative effectiveness measures assess benefits of prevention services in real-world settings, but each addresses different scientific and policy questions. As the body of CER grows, a common lexicon for various measures of relative effectiveness becomes increasingly important to facilitate communication and shared understanding among researchers, healthcare providers, patients, and policymakers.

Authors: Daye D, Keller B, Conant EF, Chen J, Schnall MD, Maidment AD, Kontos D

Title: Mammographic parenchymal patterns as an imaging marker of endogenous hormonal exposure: a preliminary study in a high-risk population.

Journal: Acad Radiol 20(5):635-46

Date: 2013 May

Abstract: RATIONALE AND OBJECTIVES: Parenchymal texture patterns have been previously associated with breast cancer risk, yet their underlying biological determinants remain poorly understood. Here, we investigate the potential of mammographic parenchymal texture as a phenotypic imaging marker of endogenous hormonal exposure. MATERIALS AND METHODS: A retrospective cohort study was performed. Digital mammography (DM) images in the craniocaudal (CC) view from 297 women, 154 without breast cancer and 143 with unilateral breast cancer, were analyzed. Menopause status was used as a surrogate of cumulative endogenous hormonal exposure. Parenchymal texture features were extracted and mammographic percent density (MD%) was computed using validated computerized methods. Univariate and multivariable logistic regression analysis was performed to assess the association between texture features and menopause status, after adjusting for MD% and hormonally related confounders. The receiver operating characteristic (ROC) area under the curve (AUC) of each model was estimated to evaluate the degree of association between the extracted mammographic features and menopause status. RESULTS: Coarseness, gray-level correlation, and fractal dimension texture features have a significant independent association with menopause status in the cancer-affected population; skewness and fractal dimension exhibit a similar association in the cancer-free population (P < .05). The ROC AUC of the logistic regression model including all texture features was 0.70 (P < .05) for cancer-affected and 0.63 (P < .05) for cancer-free women. Texture features retained significant association with menopause status (P < .05) after adjusting for MD%, age at menarche, ethnicity, contraception use, hormone replacement therapy, parity, and age at first birth. CONCLUSION: Mammographic texture patterns may reflect the effect of endogenous hormonal exposure on the breast tissue and may capture such effects beyond mammographic density. Differences in texture features between pre- and postmenopausal women are more pronounced in the cancer-affected population, which may be attributed to an increased association to breast cancer risk. Texture features could ultimately be incorporated in breast cancer risk assessment models as markers of hormonal exposure.

Authors: Feigelson HS, James TA, Single RM, Onitilo AA, Aiello Bowles EJ, Barney T, Bakerman JE, McCahill LE

Title: Factors associated with the frequency of initial total mastectomy: results of a multi-institutional study.

Journal: J Am Coll Surg 216(5):966-75

Date: 2013 May

Abstract: BACKGROUND: Several previous studies have reported conflicting data on recent trends in use of initial total mastectomy (TM); the factors that contribute to TM variation are not entirely clear. Using a multi-institution database, we analyzed how practice, patient, and tumor characteristics contributed to variation in TM for invasive breast cancer. STUDY DESIGN: We collected detailed clinical and pathologic data about breast cancer diagnosis, initial, and subsequent breast cancer operations performed on all female patients from 4 participating institutions from 2003 to 2008. We limited this analysis to 2,384 incident cases of invasive breast cancer, stages I to III, and excluded patients with clinical indications for mastectomy. Predictors of initial TM were identified with univariate analyses and random effects multivariable logistic regression models. RESULTS: Initial TM was performed on 397 (16.7%) eligible patients. Use of preoperative MRI more than doubled the rate of TM (odds ratio [OR] = 2.44; 95% CI, 1.58-3.77; p < 0.0001). Increasing tumor size, high nuclear grade, and age were also associated with increased rates of initial TM. Differences by age and ethnicity were observed, and significant variation in the frequency of TM was seen at the individual surgeon level (p < 0.001). Our results were similar when restricted to tumors <20 mm. CONCLUSIONS: We identified factors associated with initial TM, including preoperative MRI and individual surgeon, that contribute to the current debate about variation in use of TM for the management of breast cancer. Additional evaluation of patient understanding of surgical options and outcomes in breast cancer and the impact of the surgeon provider is warranted.

Authors: Hamilton AS, Miller MF, Arora NK, Bellizzi KM, Rowland JH

Title: Predictors of use of complementary and alternative medicine by non-hodgkin lymphoma survivors and relationship to quality of life.

Journal: Integr Cancer Ther 12(3):225-35

Date: 2013 May

Abstract: HYPOTHESES: This study hypothesized that non-Hodgkin lymphoma (NHL) patients who used complementary and alternative medicine (CAM) would have higher health-related quality of life (HRQOL) and a greater perceived sense of control than nonusers. However, since CAM may predict HRQOL, and perceived control may be both associated with CAM use as well as being an independent predictor of HRQOL, the authors also sought to test whether perceived control mediated the relationship between CAM use and HRQOL. STUDY DESIGN: This was a cross-sectional study design. NHL survivors diagnosed between June 1, 1998 and August 31, 2001 were selected from the population-based SEER (Surveillance, Epidemiology, and End Results) cancer registry for Los Angeles County and were mailed a survey in 2003 that assessed CAM use and predictors of CAM use. The response rate was 54.8%; 319 provided complete data for analysis. METHODS: Categories of CAM were defined according to the National Center for Complementary and Alternative Medicine guidelines. The authors measured survivors' cancer-related control using the Perceived Personal Control scale, a 4-question scale that was adapted from previously validated scales. HRQOL was measured using the mental component summary and physical component summary scores from the SF-36 v2.0. Bivariate and multivariable logistic and linear regression models were used to assess factors associated with CAM use and the association of CAM use with psychosocial health outcomes, respectively. RESULTS: Sixty-one percent of respondents reported using at least one CAM modality within the past 4 weeks, and 40% did so after excluding personal prayer and support groups. Younger age and higher education were significantly associated with greater CAM use as were higher perception of cancer-related control (P = .004) and more positive mental functioning (P = .016). Perception of control significantly mediated the association between CAM use and mental functioning (P < .001). CONCLUSIONS: CAM use may be related to more positive mental health-related quality of life by increasing patients' perception of perceived control over their health; however, cause and effect cannot be determined. Physicians should be aware that cancer survivors have a need to take an active role in improving their health.

Authors: Houssami N, Abraham LA, Kerlikowske K, Buist DS, Irwig L, Lee J, Miglioretti DL

Title: Risk factors for second screen-detected or interval breast cancers in women with a personal history of breast cancer participating in mammography screening.

Journal: Cancer Epidemiol Biomarkers Prev 22(5):946-61

Date: 2013 May

Abstract: BACKGROUND: Women with a personal history of breast cancer (PHBC) have increased risk of an interval cancer. We aimed to identify risk factors for second (ipsilateral or contralateral) screen-detected or interval breast cancer within 1 year of screening in PHBC women. METHODS: Screening mammograms from women with history of early-stage breast cancer at Breast Cancer Surveillance Consortium-affiliated facilities (1996-2008) were examined. Associations between woman-level, screen-level, and first cancer variables and the probability of a second breast cancer were modeled using multinomial logistic regression for three outcomes [screen-detected invasive breast cancer, interval invasive breast cancer, or ductal carcinoma in situ (DCIS)] relative to no second breast cancer. RESULTS: There were 697 second breast cancers, of these 240 were interval cancers, among 67,819 screens in 20,941 women. In separate models for women with DCIS or invasive first cancer, first breast cancer surgery predicted all three second breast cancer outcomes (P < 0.001), and high ORs for second breast cancers (between 1.95 and 4.82) were estimated for breast conservation without radiation (relative to mastectomy). In women with invasive first breast cancer, additional variables predicted risk (P < 0.05) for at least one of the three outcomes: first-degree family history, dense breasts, longer time between mammograms, young age at first breast cancer, first breast cancer stage, and adjuvant systemic therapy for first breast cancer; and risk of interval invasive breast cancer was highest in women <40 years at first breast cancer (OR, 3.41; 1.34-8.70), those with extremely dense breasts (OR, 2.55; 1.4-4.67), and those treated with breast conservation without radiation (OR, 2.67; 1.53-4.65). CONCLUSION: Although the risk of a second breast cancer is modest, our models identify risk factors for interval second breast cancer in PHBC women. IMPACT: Our findings may guide discussion and evaluations of tailored breast screening in PHBC women, and incorporating this information into clinical decision-making warrants further research.

Authors: Keller BM, Nathan DL, Gavenonis SC, Chen J, Conant EF, Kontos D

Title: Reader variability in breast density estimation from full-field digital mammograms: the effect of image postprocessing on relative and absolute measures.

Journal: Acad Radiol 20(5):560-8

Date: 2013 May

Abstract: RATIONALE AND OBJECTIVES: Mammographic breast density, a strong risk factor for breast cancer, may be measured as either a relative percentage of dense (ie, radiopaque) breast tissue or as an absolute area from either raw (ie, "for processing") or vendor postprocessed (ie, "for presentation") digital mammograms. Given the increasing interest in the incorporation of mammographic density in breast cancer risk assessment, the purpose of this study is to determine the inherent reader variability in breast density assessment from raw and vendor-processed digital mammograms, because inconsistent estimates could to lead to misclassification of an individual woman's risk for breast cancer. MATERIALS AND METHODS: Bilateral, mediolateral-oblique view, raw, and processed digital mammograms of 81 women were retrospectively collected for this study (N = 324 images). Mammographic percent density and absolute dense tissue area estimates for each image were obtained from two radiologists using a validated, interactive software tool. RESULTS: The variability of interreader agreement was not found to be affected by the image presentation style (ie, raw or processed, F-test: P > .5). Interreader estimates of relative and absolute breast density are strongly correlated (Pearson r > 0.84, P < .001) but systematically different (t-test, P < .001) between the two readers. CONCLUSION: Our results show that mammographic density may be assessed with equal reliability from either raw or vendor postprocessed images. Furthermore, our results suggest that the primary source of density variability comes from the subjectivity of the individual reader in assessing the absolute amount of dense tissue present in the breast, indicating the need to use standardized tools to mitigate this effect.

Authors: Kuykendal AR, Hendrix LH, Salloum RG, Godley PA, Chen RC

Title: Guideline-discordant androgen deprivation therapy in localized prostate cancer: patterns of use in the medicare population and cost implications.

Journal: Ann Oncol 24(5):1338-43

Date: 2013 May

Abstract: Background Androgen deprivation therapy (ADT) in localized prostate cancer improves overall survival and is recommended by National Comprehensive Cancer Network guidelines in certain situations. However, ADT is without benefit in other situations and can actually cause harm. This study examines recent trends in the ADT use and quantifies the cost of guideline-discordant ADT. Patients and methods Patients, aged 66-80 years, in the Surveillance Epidemiology and End Results-Medicare database with non-metastatic prostate cancer diagnosed between 2004 and 2007 were included for analysis. Prostate-specific antigen, Gleason score, and stage were used to define D'Amico risk categories. Logistic regression was used to examine factors associated with guideline-discordant ADT. Annual direct cost was estimated using 2011 Medicare reimbursement for ADT. Results Of 28 654 men included, 12.4% received guideline-discordant ADT. In low-risk patients, 14.9% received discordant ADT, mostly due to simultaneous ADT with radiation. Discordant use was seen in 7.3% of intermediate and 14.9% of high-risk patients, mostly from ADT as primary therapy. The odds of receiving guideline-discordant ADT decreased over time (2007 versus 2004; OR 0.69; 95% CI 0.62-0.76). The estimated annual direct cost from discordant ADT is $42 000 000. Conclusion Approximately one in eight patients received ADT discordant with published guidelines. Elimination of discordant use would result in substantial savings.

Authors: Lund JL, Stürmer T, Harlan LC, Sanoff HK, Sandler RS, Brookhart MA, Warren JL

Title: Identifying specific chemotherapeutic agents in Medicare data: a validation study.

Journal: Med Care 51(5):e27-34

Date: 2013 May

Abstract: BACKGROUND: Large health care databases are increasingly used to examine the dissemination and benefits and harms of chemotherapy treatment in routine practice, particularly among patients excluded from trials (eg, the elderly). Misclassification of chemotherapy could bias estimates of frequency and association, warranting an updated assessment. METHODS: We evaluated the validity of Medicare claims to identify receipt of chemotherapy and specific agents delivered to elderly stage II/III colorectal (CRC), in situ/early-stage breast, non-small-cell lung, and ovarian cancer patients using the National Cancer Institute's Patterns of Care studies (POC) as the gold standard. The POC collected data on chemotherapy treatment by reabstracting hospital records, contacting physicians, and reviewing medical records. Patients' POC data were linked and compared with their Medicare claims for 2 to 12 months postdiagnosis. κ, sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific agents. RESULTS: Sensitivity and specificity of Medicare claims to identify any chemotherapy were high across all cancer sites. We found substantial variation in validity across agents, by site and administration modality. Capecitabine, an oral CRC treatment, was identified in claims with high specificity (98%) but low sensitivity (47%), whereas oxaliplatin, an intravenously administered CRC agent had higher sensitivity (75%) and similar specificity (97%). CONCLUSIONS: Receipt of chemotherapy and specific intravenous agents can be identified using Medicare claims, showing improvement from prior reports; yet, variation exists. Future studies should assess newly approved agents and the impact of coverage decisions for these agents under the Medicare Part D program.

Authors: Neuman HB, Weiss JM, Leverson G, O'Connor ES, Greenblatt DY, Loconte NK, Greenberg CC, Smith MA

Title: Predictors of short-term postoperative survival after elective colectomy in colon cancer patients ≥ 80 years of age.

Journal: Ann Surg Oncol 20(5):1427-35

Date: 2013 May

Abstract: BACKGROUND: Individuals ≥ 80 years of age represent an increasing proportion of colon cancer diagnoses. Selecting these patients for elective surgery is challenging because of diminished overall health, functional decline, and limited data to guide decisions. The objective was to identify overall health measures that are predictive of poor survival after elective surgery in these oldest-old colon cancer patients. METHODS: Medicare beneficiaries ≥ 80 years who underwent elective colectomy for stage I-III colon cancer from 1992-2005 were identified from the Surveillance, Epidemiology and End Results(SEER)-Medicare database. Kaplan-Meier survival analysis determined 90-day and 1-year overall survival. Multivariable logistic regression assessed factors associated with short-term postoperative survival. RESULTS: Overall survival for the 12,979 oldest-old patients undergoing elective colectomy for colon cancer was 93.4 and 85.7 %, at 90 days and 1 year. Older age, male gender, frailty, increased hospitalizations in prior year, and dementia were most strongly associated with decreased survival. In addition, AJCC stage III (vs stage I) disease and widowed (vs married) were highly associated with decreased survival at 1 year. Although only 4.4 % of patients were considered frail, this had the strongest association with mortality, with an odds ratio of 8.4 (95 % confidence interval, 6.4-11.1). CONCLUSIONS: Although most oldest-old colon cancer patients do well after elective colectomy, a significant proportion (6.6 %) die by postoperative day 90 and frailty is the strongest predictor. The ability to identify frailty through billing claims is intriguing and suggests the potential to prospectively identify, through the electronic medical record, patients at highest risk of decreased survival.

Authors: Olszewski AJ, Castillo JJ

Title: Comparative outcomes of oncologic therapy in gastric extranodal marginal zone (MALT) lymphoma: analysis of the SEER-Medicare database.

Journal: Ann Oncol 24(5):1352-9

Date: 2013 May

Abstract: BACKGROUND: Therapy for gastric marginal zone (MALT) lymphoma is largely based on single-arm trials. This observational study compared survival with radiotherapy, rituximab and combination chemoimmunotherapy in this disease. PATIENTS AND METHODS: Gastric MALT lymphoma cases diagnosed between 1997 and 2007 were selected from the Surveillance, Epidemiology and End Results-Medicare database. Propensity score analysis and competing risk models were used to compare survival in patients with stage IE treated with radiation or chemotherapy, and in patients of all stages treated with rituximab alone or with chemoimmunotherapy. RESULTS: Among 1134 patients, 21% underwent radiation and 24% chemotherapy as initial treatment. In the balanced cohort of 347 patients with stage IE, radiotherapy alone was associated with a better cause-specific survival [hazard ratio (HR) 0.27, P < 0.001]. Patients receiving systemic therapy had better survival if it incorporated rituximab (HR 0.53, P = 0.017). After adjustment for confounding, the outcomes of those who received rituximab alone or combination chemoimmunotherapy were not statistically different (P = 0.14). CONCLUSIONS: In elderly patients with stage IE gastric MALT lymphoma, radiotherapy was associated with lower risk of lymphoma-related death than chemotherapy. In those requiring systemic treatment, addition of cytotoxic chemotherapy to rituximab in the first-line regimen was not associated with improved survival.

Authors: Pruitt SL, Harzke AJ, Davidson NO, Schootman M

Title: Do diagnostic and treatment delays for colorectal cancer increase risk of death?

Journal: Cancer Causes Control 24(5):961-77

Date: 2013 May

Abstract: BACKGROUND: Using 1998-2005 SEER-Medicare data, we examined the effect of diagnostic and treatment delays on all-cause and colorectal cancer (CRC)-specific death among US adults aged ≥ 66 years with invasive colon or rectal cancer. We hypothesized that longer delays would be associated with a greater risk of death. METHODS: We defined diagnostic and treatment delays, respectively, as days between (1) initial medical consult for CRC symptoms and pathologically confirmed diagnosis (maximum: 365 days) and (2) pathologically confirmed diagnosis and treatment (maximum: 120 days). Cases (CRC deaths) and controls (deaths due to other causes or censored) were matched on survival time. Logistic regression analyses adjusted for sociodemographic, tumor, and treatment factors. RESULTS: Median diagnostic delays were 60 (colon) and 40 (rectal) days and treatment delays were 13 (colon) and 16 (rectal) days in 10,663 patients. Colon cancer patients with the longest diagnostic delays (8-12 months vs. 14-59 days) had higher odds of all-cause (aOR: 1.31 CI: 1.08-1.58), but not CRC-specific death. Colon cancer patients with the shortest treatment delays (<1 vs. 1-2 weeks) had higher odds of all-cause (aOR: 1.23 CI: 1.01-1.49), but not CRC-specific death. Among rectal cancer patients, delays were not associated with risk of all-cause or CRC-specific death. CONCLUSIONS: Longer delays of up to 1 year after symptom onset and 120 days for treatment did not increase odds of CRC-specific death. There may be little clinical benefit in detecting and treating existing symptomatic disease earlier. Screening prior to symptom onset must remain the primary goal to reduce CRC incidence, morbidity, and mortality.

Authors: Shao YH, Moore DF, Shih W, Lin Y, Jang TL, Lu-Yao GL

Title: Fracture after androgen deprivation therapy among men with a high baseline risk of skeletal complications.

Journal: BJU Int 111(5):745-52

Date: 2013 May

Abstract: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Receipt of androgen deprivation therapy (ADT) has been associated with an increased risk of skeletal-associated complications, such as a decrease in bone mineral density and an increase in fracture risk. Many men with pre-existing health conditions receive ADT as their primary treatment because they are considered to be inappropriate candidates for attempted curative treatments. However, several chronic health conditions, such as diabetes, rheumatoid disease and chronic liver disease, are strong predictors for osteoporosis and fractures. We undertook the present study aiming to quantify the impact of treating men with ADT who carry known risk factors for skeletal complications. Among these high-risk men, more than 58% develop at least one fracture after ADT within the 12 years of follow-up. Men who sustained a fracture within 48 months experienced an almost 40% higher risk of mortality than those who did not. Our findings suggest that treating men with a high fracture risk at baseline with long-term ADT may have serious adverse consequences. OBJECTIVE: To quantify the impact of androgen deprivation therapy (ADT) in men with a high baseline risk of skeletal complications and evaluate the risk of mortality after a fracture. PATIENTS AND METHODS: We studied 75994 men, aged ≥ 66 years, with localized prostate cancer from the Surveillance, Epidemiology and End Results-Medicare linked data. Cox proportional hazard models were employed to evaluate the risk. RESULTS: Men with a high baseline risk of skeletal complications have a higher probability of receiving ADT than those with a low risk (52.1% vs 38.2%, P < 0.001). During the 12-year follow-up, more than 58% of men with a high risk and 38% of men with a low risk developed at least one fracture after ADT. The dose effect of ADT is stronger among men who received ADT only compared to those who received ADT with other treatments. In the high-risk group, the fracture rate increased by 19.9 per 1000 person-years (from 52.9 to 73.0 person-years) for men who did not receive ADT compared to those who received 18 or more doses of gonadotropin-releasing hormone agonist among men who received ADT only, and by 14.2 per 1000 person-years (from 45.2 to 59.4 person-years) among men who received ADT and other treatments. Men experiencing a fracture had a 1.38-fold higher overall mortality risk than those who did not (95% CI, 1.34-1.43). CONCLUSIONS: Men with a high baseline risk of skeletal complications developed more fractures after ADT. The mortality risk is 40% higher after experiencing a fracture. Consideration of patient risk before prescribing ADT for long-term use may reduce both fracture risk and fracture-associated mortality.

Authors: Spencer BA, Insel BJ, Hershman DL, Benson MC, Neugut AI

Title: Racial disparities in the use of palliative therapy for ureteral obstruction among elderly patients with advanced prostate cancer.

Journal: Support Care Cancer 21(5):1303-11

Date: 2013 May

Abstract: OBJECTIVES: Palliative issues are an important but understudied issue for patients with advanced cancer. Ureteral obstruction is a complication of advanced prostate cancer, usually relieved with placement of retrograde ureteral stent (RUS) or percutaneous nephrostomy (PCN) to palliate symptoms associated with obstructive uropathy and/or renal failure. We investigated predictors of receipt of RUS and PCN and their association with survival for older advanced prostate cancer patients. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients aged 65 or older with stage IV (n = 10,848) or recurrent (n = 7,872) prostate cancer. We used multivariable analysis to compare those with ureteral obstruction treated with RUS or PCN to those not treated and to analyze the association between RUS, PCN, and survival. RESULTS: Sixteen percent (n = 2,958) of the sample developed ureteral obstruction. Compared to no treatment, African Americans were more likely to undergo placement of PCN [odds ratio 1.48, 95 % confidence intervals (CI) 1.03-2.13] than Whites, but equally likely to receive a stent. Subjects of >80 years were less likely to undergo RUS (ages 80-84, 0.41, 95 % CI 0.27-0.63; ages ≥85, 0.30, 95 % CI 0.16-0.54) compared to patients 65-69 years. Subjects who received a PCN were 55 % more likely to die than those who were untreated. There was no difference in survival among those receiving RUS vs untreated. Nine percent of subjects received RUS or PCN within 30 days of dying. CONCLUSIONS: This is the first population-based study to demonstrate a racial disparity in the palliative treatment of advanced prostate cancer. Reasons for disparate care need to be determined so that interventions may be developed.

Authors: Trowbridge MJ, Huang TT, Botchwey ND, Fisher TR, Pyke C, Rodgers AB, Ballard-Barbash R

Title: Public health and the green building industry: partnership opportunities for childhood obesity prevention.

Journal: Am J Prev Med 44(5):489-95

Date: 2013 May

Abstract:

Authors: Wang YR, Cangemi JR, Loftus EV Jr, Picco MF

Title: Increased odds of interval left-sided colorectal cancer after flexible sigmoidoscopy compared with colonoscopy in older patients in the United States: a population-based analysis of the SEER-Medicare linked database, 2001-2005.

Journal: Mayo Clin Proc 88(5):471-8

Date: 2013 May

Abstract: OBJECTIVES: To compare the proportion of interval left-sided colorectal cancers (CRCs) after flexible sigmoidoscopy vs colonoscopy in older patients and to identify factors associated with interval CRC. PATIENTS AND METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare-linked database, we studied patients 67 years or older with left-sided CRC who had at least one lower endoscopy performed within the previous 36 months between July 1, 2001, and December 31, 2005. The CRCs diagnosed within 6 months of lower endoscopy were defined as detected CRCs; CRCs diagnosed 6 to 36 months after lower endoscopy were defined as interval CRCs. The proportion of interval CRCs was calculated as number of interval CRCs divided by number of detected and interval CRCs. The χ(2) test and a multivariate logistic regression model were used in the statistical analysis. RESULTS: Of 15,484 older patients with left-sided CRC, the proportion of interval CRCs after flexible sigmoidoscopy was 8.8% compared with 2.5% after colonoscopy (P<.001). This difference was similar across left colon locations and largest in the descending colon (17.1% vs 3.5%; P<.001). In multivariate logistic regression, the odds of interval CRC after flexible sigmoidoscopy was 3 times as high as that after colonoscopy (odds ratio, 3.52; 95% CI, 2.66-4.65). CONCLUSION: In older patients with left-sided CRC, the odds of interval CRC after flexible sigmoidoscopy was 3 times as high as that after colonoscopy. Whether this finding reflects differences in bowel preparation quality, sedation use, or depth of insertion warrants future research.

Authors: Wang YR, Cangemi JR, Loftus EV Jr, Picco MF

Title: Risk of colorectal cancer after colonoscopy compared with flexible sigmoidoscopy or no lower endoscopy among older patients in the United States, 1998-2005.

Journal: Mayo Clin Proc 88(5):464-70

Date: 2013 May

Abstract: OBJECTIVE: To determine whether the risk of colorectal cancer (CRC) decreases after colonoscopy compared with sigmoidoscopy or no lower endoscopy. PATIENTS AND METHODS: Patients 67 to 80 years old in the 5% random Medicare sample of the Surveillance, Epidemiology and End Results and Medicare-linked database were grouped into those who underwent colonoscopy or flexible sigmoidoscopy from January 1, 1998, through December 31, 2002, and those who did not undergo lower endoscopy. We excluded patients with inflammatory bowel disease, history of colon polyps, or family history of CRC. All patients were followed up until the diagnosis of CRC or carcinoma in situ, death, or December 31, 2005. The risk of CRC after colonoscopy was compared with the risk after sigmoidoscopy or no lower endoscopy. The multivariate Cox proportional hazards model was used in statistical analysis. RESULTS: In the colonoscopy group (n=12,266), 58 CRCs (0.5%) were diagnosed during follow-up compared with 66 CRCs (1.0%) in the sigmoidoscopy group (n=6402) and 634 (1.5%) in the control group (n=41,410) (all P<.001). In the sigmoidoscopy group, 771 patients (12.0%) underwent colonoscopy within the next 12 months. In multivariate Cox regressions, colonoscopy was associated with a decreased risk of distal CRC (hazard ratio [HR], 0.266; 95% CI, 0.161-0.437) and proximal CRC (HR, 0.451; 95% CI, 0.305-0.666); sigmoidoscopy was associated with a decreased risk of distal CRC (HR, 0.409; 95% CI, 0.207-0.809) but not proximal CRC. CONCLUSION: Among older patients, the risk of distal CRC decreased after both colonoscopy and sigmoidoscopy; the risk of proximal CRC decreased after colonoscopy but not sigmoidoscopy.

Authors: Connelly-Frost A, Shantakumar S, Kobayashi MG, Li H, Li L

Title: Older renal cell cancer patients experience increased rates of venous thromboembolic events: a retrospective cohort study of SEER-Medicare data.

Journal: BMC Cancer 13(1):209-

Date: 2013 Apr 27

Abstract: BACKGROUND: Venous thromboembolic co-morbidities can have a significant impact on treatment response, treatment options, quality of life, and ultimately, survival from cancer. The extent of venous thromboembolic co-morbidity among older renal cell cancer patients is poorly described in the literature. It is important to understand the scope of venous thromboembolic events, before and after diagnosis, in order to offer renal cell cancer patients optimal care and improved quality of life. METHODS: The main goal of this study was to estimate and describe the incidence of venous thromboembolic events before and after renal cell cancer diagnosis. SEER-Medicare linked data (1991--2003) was utilized for this retrospective cohort analysis (n = 11,950) of older renal cell cancer patients (>= 65 years). Incidence rates and proportions in addition to multivariable Cox proportional hazard and logistic regression models were utilized to describe the incidence and relative risk of venous thromboembolic events. RESULTS: We observed that in the 12 months after diagnosis, 8.3% of renal cell cancer patients experienced a deep venous thrombosis, 2.4% experienced a pulmonary embolism, and 3.9% experienced other thromboembolic events. Nearly 70% of venous thromboembolic events occurred in the first 90 days after renal cell cancer diagnosis. Renal cell cancer patients were 2--4 times more likely to have a venous thromboembolic event in the 12 months after cancer diagnosis than non-cancer patients followed during the same time frame. Recent history of a venous event substantially increased the risk of that same event in the 12 months after diagnosis (HR = 5.2-18.8). CONCLUSION: Venous thromboembolic events are common and serious co-morbidities that should be closely monitored in older renal cell cancer patients, particularly during the first 3 months following diagnosis and among those with a recent history of a venous thromboembolic event.

Authors: Kadakia A, Rajan SS, Abughosh S, Du XL, Johnson ML

Title: CMF-Regimen Preferred as First-course Chemotherapy for Older and Sicker Women With Breast Cancer: Findings From a SEER-Medicare-based Population Study.

Journal: Am J Clin Oncol :-

Date: 2013 Apr 19

Abstract: OBJECTIVE:: The objective of this study was to determine the sociodemographic and clinical characteristics associated with Cyclophosphamide, Methotrexate, and 5-Fluorouracil (CMF) utilization as a first-course chemotherapy regimen among female Medicare patients with early-stage breast cancer. METHODS:: A longitudinal study was conducted with women 66 years and older, diagnosed with stage I to III breast cancer from 1993 to 2004, and receiving chemotherapy using the Surveillance, Epidemiology, and End Result-Medicare data. First-course CMF chemotherapy was defined as chemotherapy initiation within 6 months of breast cancer diagnosis, with at least 1 claim of CMF each within 1 year of diagnosis. Logistic regression was used to perform the analysis. RESULTS:: Older and sicker women, living in census tracts with lower average education, and diagnosed with advanced stage, hormone receptor-negative tumors have a higher probability of CMF administration. Receipt of lymph node dissection and nonreceipt of radiation therapy were also associated with CMF administration. CMF administration has declined over the years and has significant regional variation. CONCLUSIONS:: Reduction in CMF use overtime indicates the increased use of newer and more effective systemic therapies among breast cancer patients. In spite of the reduction in CMF use over time, CMF is more frequently administered to older and sicker women, possibly because of higher risk of anthracycline-induced toxicities in these patients. Clinical guidelines have no recommendations for CMF administration in breast cancer patients with certain clinical characteristics. Hence, it is important to understand if the associations observed in this study can be clinically justified in order to reduce unjustified use of less-effective regimens.

Authors:

Title: Health technology assessment (HTA) of surveillance of women aged less than 50 years at elevated risk of breast cancer

Journal: :-

Date: 2013 Apr 18

Abstract:

Authors: Brower V

Title: Breast density legislation fueling controversy.

Journal: J Natl Cancer Inst 105(8):510-1

Date: 2013 Apr 17

Abstract:

Authors: McMillen RC, Winickoff JP, Wilson K, Tanski S, Klein JD

Title: A dual-frame sampling methodology to address landline replacement in tobacco control research.

Journal: Tob Control :-

Date: 2013 Apr 17

Abstract: OBJECTIVES: We assessed the comparability of self-reported smoking prevalence estimates from a dual-frame survey with those from two large-scale, national surveys. METHODS: The Social Climate Survey of Tobacco Control (SCS-TC) obtained self-reported current smoking status via a dual-frame methodology in the fall of 2010. One frame used random digit dialling procedures and consisted of households with a landline telephone; the other frame consisted of a population-based probability-based online panel. Current smoking prevalence was compared with national estimates from the 2010 National Health Interview Survey (NHIS) and the 2009-2010 National Health and Nutrition Examination Survey (NHANES). RESULTS: 18.3% (95% CI 17.0% to 19.6%) of SCS-TC respondents reported current smoking. NHIS and NHANES estimates found 19.4% (95% CI 18.8% to 20.1%) and 20.3% (95% CI 18.7% to 22.1%), respectively, reporting current smoking. CONCLUSIONS: Prevalence estimates for cigarette smoking obtained from the dual-frame SCS-TC are comparable to those from other national surveys. A mixed-mode approach may be a useful strategy to transition cross-sectional surveys with established trend data to newer dual-frame designs to maintain compatibility with surveys from previous years and to include the growing number of households that do not have landline telephones.

Authors: Fenton JJ, Xing G, Elmore JG, Bang H, Chen SL, Lindfors KK, Baldwin LM

Title: Short-term outcomes of screening mammography using computer-aided detection: a population-based study of medicare enrollees.

Journal: Ann Intern Med 158(8):580-7

Date: 2013 Apr 16

Abstract: BACKGROUND: Computer-aided detection (CAD) has rapidly diffused into screening mammography practice despite limited and conflicting data on its clinical effect. OBJECTIVE: To determine associations between CAD use during screening mammography and the incidence of ductal carcinoma in situ (DCIS) and invasive breast cancer, invasive cancer stage, and diagnostic testing. DESIGN: Retrospective cohort study. SETTING: Medicare program. PARTICIPANTS: Women aged 67 to 89 years having screening mammography between 2001 and 2006 in U.S. SEER (Surveillance, Epidemiology and End Results) regions (409 459 mammograms from 163 099 women). MEASUREMENTS: Incident DCIS and invasive breast cancer within 1 year after mammography, invasive cancer stage, and diagnostic testing within 90 days after screening among women without breast cancer. RESULTS: From 2001 to 2006, CAD prevalence increased from 3.6% to 60.5%. Use of CAD was associated with greater DCIS incidence (adjusted odds ratio [OR], 1.17 [95% CI, 1.11 to 1.23]) but no difference in invasive breast cancer incidence (adjusted OR, 1.00 [CI, 0.97 to 1.03]). Among women with invasive cancer, CAD was associated with greater likelihood of stage I to II versus III to IV cancer (adjusted OR, 1.27 [CI, 1.14 to 1.41]). In women without breast cancer, CAD was associated with increased odds of diagnostic mammography (adjusted OR, 1.28 [CI, 1.27 to 1.29]), breast ultrasonography (adjusted OR, 1.07 [CI, 1.06 to 1.09]), and breast biopsy (adjusted OR, 1.10 [CI, 1.08 to 1.12]). LIMITATION: Short follow-up for cancer stage, potential unmeasured confounding, and uncertain generalizability to younger women. CONCLUSION: Use of CAD during screening mammography among Medicare enrollees is associated with increased DCIS incidence, the diagnosis of invasive breast cancer at earlier stages, and increased diagnostic testing among women without breast cancer. PRIMARY FUNDING SOURCE: Center for Healthcare Policy and Research, University of California, Davis.

Authors: Yi M, Xu J, Liu P, Chang GJ, Du XL, Hu CY, Song Y, He J, Ren Y, Wei Y, Yang J, Hunt KK, Li X

Title: Comparative analysis of lifestyle factors, screening test use, and clinicopathologic features in association with survival among Asian Americans with colorectal cancer.

Journal: Br J Cancer 108(7):1508-14

Date: 2013 Apr 16

Abstract: BACKGROUND: Colorectal cancer (CRC) diagnoses and disease-specific survival (DSS) vary between ethnic groups in the United States. However, few studies have assessed differences among Asian subgroups. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients with invasive CRC between 1988 and 2008. Differences in clinicopathologic features, and DSS rates were compared among Asian subgroups. The California Health Interview Survey was used to examine risk factors and screening patterns for CRC. RESULTS: The study included 359 374 patients with 8.4% Asian. Patients in all Asian subgroups were younger (median: 68 years) at diagnosis than non-Hispanic white (NHW) patients (median: 72 years). Most Asian subgroups, except Hawaiians, had better DSS than NHW patients although Asian subgroups had more advanced disease than NHW. Indian/Pakistani patients had a higher 5-year DSS than other Asian subgroups. Obesity proportions were lower in Asian subgroups (<50.2%) than in NHW (59.8%). Vietnamese men and Korean women had the lowest proportions of CRC screening. Advance tumour stages were highly associated with worse DSS in each ethnicity group. High tumour grades were associated with worse DSS in NHW, Filipino, and Chinese. Older age at diagnosis was associated with worse DSS in most ethnicity groups except Hawaiian and Vietnamese. CONCLUSION: Disparities exist between Asians and NHW with CRC, and among various Asian subgroups. Differences in cancer clinicopathologic features, patients' behavioural habits, lifestyle, and screening patterns may explain some differences in CRC survival observed among ethnic groups.

Authors: Clough-Gorr KM, Thwin SS, Bosco JL, Silliman RA, Buist DS, Pawloski PA, Quinn VP, Prout MN

Title: Incident malignancies among older long-term breast cancer survivors and an age-matched and site-matched nonbreast cancer comparison group over 10 years of follow-up.

Journal: Cancer 119(8):1478-85

Date: 2013 Apr 15

Abstract: BACKGROUND: Of the approximately 2.4 million American women with a history of breast cancer, 43% are aged ≥ 65 years and are at risk for developing subsequent malignancies. METHODS: Women from 6 geographically diverse sites included 5-year breast cancer survivors (N = 1361) who were diagnosed between 1990 and 1994 at age ≥ 65 years with stage I or II disease and a comparison group of women without breast cancer (N = 1361). Women in the comparison group were age-matched and site-matched to breast cancer survivors on the date of breast cancer diagnosis. Follow-up began 5 years after the index date (survivor diagnosis date or comparison enrollment date) until death, disenrollment, or through 15 years after the index date. Data were collected from medical records and electronic sources (cancer registry, administrative, clinical, National Death Index). Analyses included descriptive statistics, crude incidence rates, and Cox proportional hazards regression models for estimating the risk of incident malignancy and were adjusted for death as a competing risk. RESULTS: Survivors and women in the comparison group were similar: >82% were white, 55% had a Charlson Comorbidity Index of 0, and ≥ 73% had a body mass index ≤ 30 kg/m(2) . Of all 306 women (N = 160 in the survivor group, N = 146 in the comparison group) who developed a first incident malignancy during follow-up, the mean time to malignancy was similar (4.37 ± 2.81 years vs 4.03 ± 2.76 years, respectively; P = .28), whereas unadjusted incidence rates were slightly higher in survivors (1882 vs 1620 per 100,000 person years). The adjusted hazard of developing a first incident malignancy was slightly elevated in survivors in relation to women in the comparison group, but it was not statistically significant (hazard ratio, 1.17; 95% confidence interval, 0.94-1.47). CONCLUSIONS: Older women who survived 5 years after an early stage breast cancer diagnosis were not at an elevated risk for developing subsequent incident malignancies up to 15 years after their breast cancer diagnosis.

Authors: Yang Y, Mauldin PD, Ebeling M, Hulsey TC, Liu B, Thomas MB, Camp ER, Esnaola NF

Title: Effect of metabolic syndrome and its components on recurrence and survival in colon cancer patients.

Journal: Cancer 119(8):1512-20

Date: 2013 Apr 15

Abstract: BACKGROUND: Although epidemiologic studies suggest that metabolic syndrome (MetS) increases the risk of colorectal cancer, its effect on cancer mortality remains controversial. METHODS: The authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1998-2006) to conduct a retrospective cohort study of 36,079 patients with colon cancer to determine the independent effect of MetS and its components on overall survival (OS) and recurrence-free rates (RFRs). Data on MetS and its components were ascertained from Medicare claims. OS and RFRs in patients with and without MetS and its components were compared using multivariate Cox models. RESULTS: MetS had no apparent effect on OS or RFR. Both elevated glucose/diabetes mellitus (DM) and elevated hypertension were associated with worse OS (adjusted hazard ratio [aHR], 1.17 [95% confidence interval, 1.13-1.21] and 1.08 [95% confidence interval, 1.03-1.12], respectively) and worse RFRs (aHR, 1.25 [95% confidence interval, 1.16-1.34] and 1.22 [95% confidence interval, 1.12-1.33], respectively). In contrast, dyslipidemia was associated with improved survival (aHR, 0.77; 95% confidence interval, 0.75-0.80) and reduced recurrence (aHR, 0.71; 95% confidence interval, 0.66-0.75). These effects were consistent for both men and women and were more pronounced in patients with early stage disease. CONCLUSIONS: MetS had no apparent effect on colon cancer outcomes, probably because of the combined adverse effects of elevated glucose/DM and hypertension and the protective effect of dyslipidemia in patients with nonmetastatic disease. The authors concluded that patients who have early stage colon cancer with elevated glucose/DM and/or hypertension may benefit from more intensive surveillance and/or broader use of adjuvant therapy and that trials to define the benefits of low-fat diets, insulin-lowering agents, and statins on recurrence/survival in patients with nonmetastatic colon cancer are warranted.

Authors: Cooper GS, Kou TD, Rex DK

Title: Complications following colonoscopy with anesthesia assistance: a population-based analysis.

Journal: JAMA Intern Med 173(7):551-6

Date: 2013 Apr 08

Abstract: IMPORTANCE: Deep sedation for endoscopic procedures has become an increasingly used option but, because of impairment in patient response, this technique also has the potential for a greater likelihood of adverse events. The incidence of these complications has not been well studied at a population level. DESIGN: Population-based study. SETTING AND PARTICIPANTS: Using a 5% random sample of cancer-free Medicare beneficiaries who resided in one of the regions served by a SEER (Surveillance, Epidemiology, and End Results) registry, we identified all procedural claims for outpatient colonoscopy without polypectomy from January 1, 2000, through November 30, 2009. INTERVENTION: Colonoscopy without polypectomy, with or without the use of deep sedation (identified by a concurrent claim for anesthesia services). MAIN OUTCOME MEASURES: The occurrence of hospitalizations for splenic rupture or trauma, colonic perforation, and aspiration pneumonia within 30 days of the colonoscopy. RESULTS: We identified a total of 165 527 procedures in 100 359 patients, including 35 128 procedures with anesthesia services (21.2%). Selected postprocedure complications were documented after 284 procedures (0.17%) and included aspiration (n = 173), perforation (n = 101), and splenic injury (n = 12). (Some patients had >1 complication.) Overall complications were more common in cases with anesthesia assistance (0.22% [95% CI, 0.18%-0.27%]) than in others (0.16% [0.14%-0.18%]) (P < .001), as was aspiration (0.14% [0.11%-0.18%] vs 0.10% [0.08%-0.12%], respectively; P = .02). Frequencies of perforation and splenic injury were statistically similar. Other predictors of complications included age greater than 70 years, increasing comorbidity, and performance of the procedure in a hospital setting. In multivariate analysis, use of anesthesia services was associated with an increased complication risk (odds ratio, 1.46 [95% CI, 1.09-1.94]). CONCLUSIONS AND RELEVANCE: Although the absolute risk of complications is low, the use of anesthesia services for colonoscopy is associated with a somewhat higher frequency of complications, specifically, aspiration pneumonia. The differences may result in part from uncontrolled confounding, but they may also reflect the impairment of normal patient responses with the use of deep sedation.

Authors: Bikov KA, Mullins CD, Seal B, Onukwugha E, Hanna N

Title: Algorithm for Identifying Chemotherapy/Biological Regimens for Metastatic Colon Cancer in SEER-Medicare.

Journal: Med Care :-

Date: 2013 Apr 01

Abstract: BACKGROUND:: Metastatic colon cancer (mCC) patients often receive multiple lines of chemotherapy/biological treatment (TX), yet subsequent TX lines have not been sufficiently examined using SEER-Medicare data. We developed an algorithm that identifies the number and type of TX lines received by mCC patients. METHODS:: The algorithm rules for detecting TX lines were developed a priori and applied to SEER-Medicare data for 7951 elderly mCC patients, diagnosed in 2003-2007 and followed through 2009. Statistical analysis estimated the relationship between the number of treatments received and patient characteristics. Sensitivity analyses examined how results changed when different algorithm rules were used. RESULTS:: Only 41% (3266) of mCC patients received any chemotherapy/biologics treatment; 1440 (18% of all, 44% of treated) and 274 (3% of all, 8% of treated) received second-line and third-line treatment, respectively. Initial and subsequent treatment regimens varied widely. Results were robust to alterations in the algorithm. CONCLUSIONS:: The number of drugs used to treat cancer patients has increased during the past decade. Patients may have several TX lines with complex regimens. More guidance is needed with regard to identifying and studying these interventions using SEER-Medicare data. By proposing 1 approach to categorizing TX lines for mCC patients, we hope to empower the scientific community and to advance the use of SEER-Medicare data for health outcomes research.

Authors: Laz TH, Rahman M, Berenson AB

Title: Human papillomavirus vaccine uptake among 9-17 year old males in the United States: the National Health Interview Survey, 2010.

Journal: Hum Vaccin Immunother 9(4):874-8

Date: 2013 Apr 01

Abstract: In 2009, a quadrivalent HPV vaccine was approved and "permissively" recommended for US males aged 9 to 26 y to protect against genital warts. The purpose of this study was to examine parental awareness and HPV vaccine uptake among 9-17 y old males during the first year following this recommendation. Data from the 2010 National Health Interview Survey (NHIS) were obtained to assess vaccination status (n = 2973) of this age group. Univariate logistic regression analysis was performed to examine correlates of parental awareness and uptake of the HPV vaccine. Overall, 55% of parents with sons were aware of the HPV vaccine. The likelihood of parental awareness was lower among minorities and adolescents with low family incomes, and higher among adolescents with insurance, higher parental education, and those who had a well-child check up and dental examination in the past year than their counterparts. Only 2.0% and 0.5% of 9-17 y old males initiated (≥ 1 dose) and completed (≥ 3 doses) the vaccine series, respectively. Adolescents with a Hispanic origin (odds ratio (OR) 2.03, 95% confidence interval (CI) 1.09-3.78), low family income (OR 2.89, 95% CI 1.48 -5.57), and history of influenza vaccination in the past year (OR 1.89, 95% CI 1.11 -3.22) were more likely than their counterparts to initiate the HPV vaccine. On the other hand, adolescents with private insurance (OR 0.44, 95% CI 0.20 -0.94) and those who had college educated parents (OR 0.45, 95% CI 0.22 -0.89) were less likely to initiate the vaccine. This study showed that very few adolescent males received any doses of HPV vaccine during the first year following its recommendation for this gender. Thus, interventional programs are needed to improve vaccine uptake among adolescent males.

Authors: Ma J, Ward EM, Smith R, Jemal A

Title: Annual number of lung cancer deaths potentially avertable by screening in the United States.

Journal: Cancer 119(7):1381-5

Date: 2013 Apr 01

Abstract: BACKGROUND: The National Lung Screening Trial (NLST), which was conducted between 2002 and 2009, demonstrated that screening with low-dose computed tomography (LDCT) reduced lung cancer mortality by 20% among screening-eligible populations compared with chest x-ray. In this article, the authors provide an estimate of the annual number of lung cancer deaths that can be averted by screening, assuming the screening regimens adopted in the NLST are fully implemented in the United States. METHODS: The annual number of lung cancer deaths that can be averted by screening was estimated as a product of the screening effect, the US population size (obtained from the 2010 US Census data), the prevalence of screening eligibility (estimated using the 2010 National Health Interview Survey [NHIS] data), and the lung cancer mortality rates among screening-eligible populations (estimated using the NHIS data from 2000-2004 and the third National Health and Nutrition Examination Survey linked mortality files). Analyses were performed separately by sex, age, and smoking status, with Poisson regression analysis used for mortality rate estimation. Uncertainty of the estimates of the number of avertable lung cancer deaths was quantified by simulation. RESULTS: Approximately 8.6 million Americans (95% confidence interval [95% CI], 8.0 million-9.2 million), including 5.2 million men (95% CI, 4.8 million-5.7 million) and 3.4 million women (95% CI, 3.0 million -3.8 million), were eligible for lung cancer screening in 2010. If the screening regimen adopted in the NLST was fully implemented among these screening-eligible US populations, a total of 12,250 (95% CI, 10,170-15,671) lung cancer deaths (8990 deaths in men and 3260 deaths in women) would be averted each year. CONCLUSIONS: The data from the current study indicate that LDCT screening could potentially avert approximately 12,000 lung cancer deaths per year in the United States. Further studies are needed to estimate the number of avertable lung cancer deaths and the cost-effectiveness of LDCT screening under different scenarios of risk, various screening frequencies, and various screening uptake rates.

Authors: Roberts KB, Soulos PR, Herrin J, Yu JB, Long JB, Dostaler E, Gross CP

Title: The adoption of new adjuvant radiation therapy modalities among Medicare beneficiaries with breast cancer: clinical correlates and cost implications.

Journal: Int J Radiat Oncol Biol Phys 85(5):1186-92

Date: 2013 Apr 01

Abstract: PURPOSE: New radiation therapy modalities have broadened treatment options for older women with breast cancer, but it is unclear how clinical factors, geographic region, and physician preference affect the choice of radiation therapy modality. METHODS AND MATERIALS: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women diagnosed with stage I-III breast cancer from 1998 to 2007 who underwent breast-conserving surgery. We assessed the temporal trends in, and costs of, the adoption of intensity modulated radiation therapy (IMRT) and brachytherapy. Using hierarchical logistic regression, we evaluated the relationship between the use of these new modalities and patient and regional characteristics. RESULTS: Of 35,060 patients, 69.9% received conventional external beam radiation therapy (EBRT). Although overall radiation therapy use remained constant, the use of IMRT increased from 0.0% to 12.6% from 1998 to 2007, and brachytherapy increased from 0.7% to 9.0%. The statistical variation in brachytherapy use attributable to the radiation oncologist and geographic region was 41.4% and 9.5%, respectively (for IMRT: 23.8% and 22.1%, respectively). Women undergoing treatment at a free-standing radiation facility were significantly more likely to receive IMRT than were women treated at a hospital-based facility (odds ratio for IMRT vs EBRT: 3.89 [95% confidence interval, 2.78-5.45]). No such association was seen for brachytherapy. The median radiation therapy cost per treated patient increased from $5389 in 2001 to $8539 in 2007. CONCLUSIONS: IMRT and brachytherapy use increased substantially from 1998 to 2007; overall, radiation therapy costs increased by more than 50%. Radiation oncologists played an important role in treatment choice for both types of radiation therapy, whereas geographic region played a bigger role in the use of IMRT than brachytherapy.

Authors: Ballard-Barbash R, Siddiqi SM, Berrigan DA, Ross SA, Nebeling LC, Dowling EC

Title: Trends in research on energy balance supported by the National Cancer Institute.

Journal: Am J Prev Med 44(4):416-23

Date: 2013 Apr

Abstract: Over the past decade, the body of research linking energy balance to the incidence, development, progression, and treatment of cancer has grown substantially. No prior NIH portfolio analyses have focused on energy balance within one institute. This portfolio analysis describes the growth of National Cancer Institute (NCI) grant research on energy balance-related conditions and behaviors from 2004 to 2010 following the release of an NCI research priority statement in 2003 on energy balance and cancer-related research. Energy balance grants from fiscal years (FY) 2004 to 2010 were identified using multiple search terms and analyzed between calendar years 2008 and 2010. Study characteristics related to cancer site, design, population, and energy balance area (physical activity, diet, and weight) were abstracted. From FY2004 to FY2010, the NCI awarded 269 energy balance-relevant grants totaling $518 million. In FY2010, 4.2% of NCI's total research project grants budget was allocated to energy balance research, compared to 2.1% in FY2004. The NCI more than doubled support for investigator-initiated research project grants (R01) and increased support for cooperative agreement (U01, U54) and exploratory research (R21) grants. In the portfolio, research examining energy balance areas in combination accounted for 41.6%, and observational and interventional studies were equally represented (38.3% and 37.2%, respectively). Breast cancer was the most commonly studied cancer. Inclusion of minorities rose, and funding specific to cancer survivors more than doubled. From FY2004 to FY2010, NCI's investment in energy balance and related health behavior research showed growth in funding and diversity of mechanisms, topics, and disciplines-growth that reflects new directions in this field.

Authors: Batina NG, Trentham-Dietz A, Gangnon RE, Sprague BL, Rosenberg MA, Stout NK, Fryback DG, Alagoz O

Title: Variation in tumor natural history contributes to racial disparities in breast cancer stage at diagnosis.

Journal: Breast Cancer Res Treat 138(2):519-28

Date: 2013 Apr

Abstract: Black women tend to be diagnosed with breast cancer at a more advanced stage than whites and subsequently experience elevated breast cancer mortality. We sought to determine whether there are racial differences in tumor natural history that contribute to these disparities. We used the University of Wisconsin Breast Cancer Simulation Model, a validated member of the National Cancer Institute's Cancer Intervention and Surveillance Modeling Network, to evaluate the contribution of racial differences in tumor natural history to observed disparities in breast cancer incidence. We fit eight natural history parameters in race-specific models by calibrating to the observed race- and stage-specific 1975-2000 U.S. incidence rates, while accounting for known racial variation in population structure, underlying risk of breast cancer, screening mammography utilization, and mortality from other causes. The best fit models indicated that a number of natural history parameters must vary between blacks and whites to reproduce the observed stage-specific incidence patterns. The mean of the tumor growth rate parameter was 63.6 % higher for blacks than whites (0.18, SE 0.04 vs. 0.11, SE 0.02). The fraction of tumors considered highly aggressive based on their tendency to metastasize at a small size was 2.2 times greater among blacks than whites (0.41, SE 0.009 vs. 0.019, SE 0.008). Based on our simulation model, breast tumors in blacks grow faster and are more likely to metastasize earlier than tumors in whites. These differences suggest that targeted prevention and detection strategies that go beyond equalizing access to mammography may be needed to eliminate breast cancer disparities.

Authors: Chen F, Wang Z, Bhattacharyya T

Title: Convergence of outcomes for hip fracture fixation by nails and plates.

Journal: Clin Orthop Relat Res 471(4):1349-55

Date: 2013 Apr

Abstract: BACKGROUND: Recent popularity of intramedullary nails over sliding hip screws for treatment of intertrochanteric fractures is concerning given the absence of evidence for clinical superiority for nailing yet the presence of reimbursement differences. QUESTIONS/PURPOSES: We describe the change in outcomes of both procedures across a 15-year span and address the role of reimbursements in the setting of shifting patterns in use. METHODS: A 5% sample of Medicare enrollees from 1993 to 2007 was used. Cohorts were generated along diagnostic and procedure codes. Trends in device use by hospital type, surgical times, and rate of revision surgeries were compared. Historic reimbursements were examined. RESULTS: Since 2005, intramedullary nail fixation has become the more common treatment in government, nonprofit, and for-profit hospitals. Before 1999, intramedullary nailing required 36 minutes longer to perform than plate-and-screw fixation on average, and had higher revision surgery rates (hazard ratio, 2.48; CI, 1.37-4.48) and 1-year mortality (hazard ratio, 1.42; CI, 1.01-1.99). These differences were not significant since 2000. Reimbursement differences have been consistently in favor of intramedullary nails. CONCLUSION: Intramedullary nailing of intertrochanteric fractures has become as safe and efficient as the sliding hip screws, but has been more popular since 2006. Reimbursements were favorable for intramedullary nails in times of low and high use. These results argue against the reimbursement difference as the sole driving force for use of intramedullary nails. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Authors: Fernandez FG, Crabtree TD, Liu J, Meyers BF

Title: Incremental risk of prior coronary arterial stents for pulmonary resection.

Journal: Ann Thorac Surg 95(4):1212-20

Date: 2013 Apr

Abstract: BACKGROUND: Many patients requiring lung cancer resection have concomitant coronary artery disease. Preoperative coronary artery stenting has been associated with increased risk of cardiac events after noncardiac surgery. Our aim was to determine the incidence of major adverse cardiac events (MACE) in patients undergoing pulmonary resection for lung cancer after percutaneous coronary stenting. METHODS: This study uses Surveillance, Epidemiology, and End Results-Medicare data (1998 to 2005). Patients undergoing lung cancer resection within 1 year after coronary stenting were compared with patients without preoperative coronary intervention. The incidence and predictors of MACE within 30 days after surgery were determined. RESULTS: Five hundred nineteen patients underwent lung cancer resection after coronary stenting (stent), and 21,892 patients underwent lung cancer resection without a preceding coronary intervention (no stent). The stent group had higher comorbidity scores (p<0.0001) and more males (66% versus 50%; p<0.0001). There were no differences in age (74 versus 74 years), tumor size (33.7 versus 33.6 mm), stage (53% versus 54% stage I), and resections of lobectomy or greater (83% versus 80%) between stent and no-stent groups (all p>0.05). Thirty-day MACE and mortality rates were 9.3% and 7.7% in the stent group and 4.9% and 4.6% in the no-stent group (both p<0.0001). Multivariable predictors of MACE were coronary stent, age, male sex, comorbidity score, tumor size, and stage. CONCLUSIONS: Patients undergoing lung cancer surgery within 1 year of coronary stenting are at high risk for perioperative MACE. The presence of a coronary stent should be an important component of risk assessment before resection for lung cancer.

Authors: Goldman LE, Walker R, Hubbard R, Kerlikowske K, Breast Cancer Surveillance Consortium

Title: Timeliness of abnormal screening and diagnostic mammography follow-up at facilities serving vulnerable women.

Journal: Med Care 51(4):307-14

Date: 2013 Apr

Abstract: BACKGROUND: Whether timeliness of follow-up after abnormal mammography differs at facilities serving vulnerable populations, such as women with limited education or income, in rural areas, and racial/ethnic minorities is unknown. METHODS: We examined receipt of diagnostic evaluation after abnormal mammography using 1998-2006 Breast Cancer Surveillance Consortium-linked Medicare claims. We compared whether time to recommended breast imaging or biopsy depended on whether women attended facilities serving vulnerable populations. We characterized a facility by the proportion of mammograms performed on women with limited education or income, in rural areas, or racial/ethnic minorities. RESULTS: We analyzed 30,874 abnormal screening examinations recommended for follow-up imaging across 142 facilities and 10,049 abnormal diagnostic examinations recommended for biopsy across 114 facilities. Women at facilities serving populations with less education or more racial/ethnic minorities had lower rates of follow-up imaging (4%-5% difference, P<0.05), and women at facilities serving more rural and low-income populations had lower rates of biopsy (4%-5% difference, P<0.05). Women undergoing biopsy at facilities serving vulnerable populations had longer times until biopsy than those at facilities serving nonvulnerable populations (21.6 vs. 15.6 d; 95% confidence interval for mean difference 4.1-7.7). The proportion of women receiving recommended imaging within 11 months and biopsy within 3 months varied across facilities (interquartile range, 85.5%-96.5% for imaging and 79.4%-87.3% for biopsy). CONCLUSIONS: Among Medicare recipients, follow-up rates were slightly lower at facilities serving vulnerable populations, and among those women who returned for diagnostic evaluation, time to follow-up was slightly longer at facilities that served vulnerable population. Interventions should target variability in follow-up rates across facilities, and evaluate effectiveness particularly at facilities serving vulnerable populations.

Authors: Guenther PM, Casavale KO, Reedy J, Kirkpatrick SI, Hiza HA, Kuczynski KJ, Kahle LL, Krebs-Smith SM

Title: Update of the Healthy Eating Index: HEI-2010.

Journal: J Acad Nutr Diet 113(4):569-80

Date: 2013 Apr

Abstract: The Healthy Eating Index (HEI) is a measure of diet quality in terms of conformance with federal dietary guidance. Publication of the 2010 Dietary Guidelines for Americans prompted an interagency working group to update the HEI. The HEI-2010 retains several features of the 2005 version: (a) it has 12 components, many unchanged, including nine adequacy and three moderation components; (b) it uses a density approach to set standards, eg, per 1,000 calories or as a percentage of calories; and (c) it employs least-restrictive standards; ie, those that are easiest to achieve among recommendations that vary by energy level, sex, and/or age. Changes to the index include: (a) the Greens and Beans component replaces Dark Green and Orange Vegetables and Legumes; (b) Seafood and Plant Proteins has been added to capture specific choices from the protein group; (c) Fatty Acids, a ratio of polyunsaturated and monounsaturated to saturated fatty acids, replaces Oils and Saturated Fat to acknowledge the recommendation to replace saturated fat with monounsaturated and polyunsaturated fatty acids; and (d) a moderation component, Refined Grains, replaces the adequacy component, Total Grains, to assess overconsumption. The HEI-2010 captures the key recommendations of the 2010 Dietary Guidelines and, like earlier versions, will be used to assess the diet quality of the US population and subpopulations, evaluate interventions, research dietary patterns, and evaluate various aspects of the food environment.

Authors: Han PK, Klabunde CN, Noone AM, Earle CC, Ayanian JZ, Ganz PA, Virgo KS, Potosky AL

Title: Physicians' beliefs about breast cancer surveillance testing are consistent with test overuse.

Journal: Med Care 51(4):315-23

Date: 2013 Apr

Abstract: BACKGROUND: Overuse of surveillance testing for breast cancer survivors is an important problem but its extent and determinants are incompletely understood. The objectives of this study were to determine the extent to which physicians' breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs. METHODS: During 2009-2010, a cross-sectional survey of US medical oncologists and primary care physicians (PCPs) was carried out. Physicians responded to a clinical vignette ascertaining beliefs about appropriate breast cancer surveillance testing. Multivariable analyses examined the extent to which test beliefs were consistent with overuse and associated with physician and practice characteristics and physician perceptions, attitudes, and practices. RESULTS: A total of 1098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). Eighty-four percent of PCPs [95% confidence interval (CI), 81.4%-86.5%] and 72% of oncologists (95% CI, 69.8%-74.7%) reported beliefs consistent with blood test overuse, whereas 50% of PCPs (95% CI, 47.3%-53.8%) and 27% of oncologists (95% CI, 23.9%-29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care. CONCLUSIONS: Beliefs consistent with breast cancer surveillance test overuse are common, greater for PCPs and blood tests than for oncologists and imaging tests, and associated with practice characteristics and perceived self-efficacy and ambiguity about testing. These results suggest modifiable targets for efforts to reduce surveillance test overuse.

Authors: Hollenbeak CS, Boltz MM, Schaefer EW, Saunders BD, Goldenberg D

Title: Recurrence of differentiated thyroid cancer in the elderly.

Journal: Eur J Endocrinol 168(4):549-56

Date: 2013 Apr

Abstract: OBJECTIVE: Data from the Surveillance Epidemiology and End Results Medicare-linked database were used to estimate the incidence of and risk factors associated with recurrent thyroid cancer, and to assess the impact of recurrence on mortality following diagnosis, controlling for mortality as a competing risk. DESIGN: We identified 2883 patients over 65 years of age diagnosed with a single, primary well-differentiated thyroid cancer between 1995 and 2007. A recurrence was considered if the patient had evidence of I-131 therapy, imaging for metastatic thyroid carcinoma, or complete thyroidectomy beyond 6 months of diagnosis. Competing risk regressions were performed using Cox proportional hazards models with 1- and 2-year landmarks. RESULTS: Recurrence was observed in 1117 (39%) of the 2883 patients in the cohort. Age, stage, and treatment status were significant risk factors for developing recurrent disease (P<0.0001). Patients with recurrent disease had a higher risk of all-cause mortality within 10 years of diagnosis than patients with no recurrence at 1- and 2-year landmarks. Patients with follicular histology and a recurrence were less likely to die from cancer (hazard ratio 0.54; P=0.03) than patients with no recurrence. CONCLUSIONS: The rate of recurrence of well-differentiated thyroid carcinomas in this sample of elderly patients was 39%. Extent of disease and older age negatively impacted the risk of recurrence from differentiated thyroid cancer. In these data, patients with follicular histology and a recurrence were less likely to die, suggesting that mortality and recurrence are competing risks. These data should be taken into account with individualized treatment strategies for elderly patients with recurrent malignant thyroid disease.

Authors: Homayoon B, Shahidi NC, Cheung WY

Title: Impact of asian ethnicity on colorectal cancer screening: a population-based analysis.

Journal: Am J Clin Oncol 36(2):167-73

Date: 2013 Apr

Abstract: OBJECTIVES: Although research shows that African Americans and Hispanics frequently receive less colorectal cancer screening (CRCS) than whites, few studies have focused on CRCS among Asians. The aims of this study were to compare CRCS between Asians and whites and to evaluate for clinical predictors of CRCS. METHODS: From the 2007 California Health Interview Survey, we identified all Asian and white respondents who were eligible for CRCS. Logistic regression was performed to evaluate for differences in CRCS. We used stratified and interaction analyses to examine whether associations between race and CRCS were modified by insurance status, birthplace, or language skills, while controlling for other confounders. RESULTS: Baseline characteristics were similar between Asians and whites. Only 58% of Asians and 66% of whites reported undergoing up-to-date CRCS (P < 0.01). In multivariate analyses, visiting a physician more than 5 times produced the highest odds of being up-to-date with screening. When compared with whites, Asians had decreased odds of being up-to-date with screening. Stratified analyses showed that this disparity existed mainly in the insured, but not in the uninsured, and it was not modified by place of birth or English language proficiency. CONCLUSIONS: Despite its ability to reduce mortality, CRCS is suboptimal in our US population-based cohort of Asians when compared with whites. A contributing factor to this problem for the Chinese and Koreans may be a lack of awareness regarding CRCS, whereas the source of the problem in the Vietnamese seems to be related to healthcare access.

Authors: Hubbard RA, Zhu W, Horblyuk R, Karliner L, Sprague BL, Henderson L, Lee D, Onega T, Buist DS, Sweet A

Title: Diagnostic imaging and biopsy pathways following abnormal screen-film and digital screening mammography.

Journal: Breast Cancer Res Treat 138(3):879-87

Date: 2013 Apr

Abstract: The transition from screen-film to digital mammography may have altered diagnostic evaluation of women following a positive screening examination. This study compared the use and timeliness of diagnostic imaging and biopsy for women screened with screen-film or digital mammography. Data were obtained from 35,321 positive screening mammograms on 32,087 women aged 40-89 years, from 22 breast cancer surveillance consortium facilities in 2005-2008. Diagnostic pathways were classified by their inclusion of diagnostic mammography, ultrasound, magnetic resonance imaging, and biopsy. We compared time to resolution and frequency of diagnostic pathways by patient characteristics, screening exam modality, and radiology facility. Between-facility differences were evaluated by computing the proportion of mammograms receiving follow-up with a particular pathway for each facility and examining variation in these proportions across facilities. Multinomial logistic regression adjusting for age, calendar year, and facility compared odds of follow-up with each pathway. The median time to resolution of a positive screening mammogram was 10 days. Compared to screen-film mammograms, digital mammograms were more frequently followed by only a single diagnostic mammogram (46 vs. 36 %). Pathways following digital screening mammography were also less likely to include biopsy (16 vs. 20 %). However, in adjusted analyses, most differences were not statistically significant (p = 0.857 for mammography only; p = 0.03 for biopsy). Substantial variability in diagnostic pathway frequency was seen across facilities. For instance, the frequency of evaluation with diagnostic mammography alone ranged from 23 to 55 % across facilities. Differences in evaluation of positive digital and screen-film screening mammograms were minor, and appeared to be largely attributable to substantial variation between radiology facilities. To guide health systems in their efforts to eliminate practices that do not contribute to effective care, we need further research to identify the causes of this variation and the best evidence-based approach for follow-up.

Authors: Lu PJ, Williams WW, Li J, Dorell C, Yankey D, Kepka D, Dunne EF

Title: Human papillomavirus vaccine initiation and awareness: U.S. young men in the 2010 National Health Interview Survey.

Journal: Am J Prev Med 44(4):330-8

Date: 2013 Apr

Abstract: BACKGROUND: In 2009, the quadrivalent human papillomavirus (HPV) vaccine was licensed by the U.S. Food and Drug Administration for use in men/boys aged 9-26 years. In 2009, the Advisory Committee on Immunization Practices (ACIP) provided a permissive recommendation allowing HPV vaccine administration to this group. PURPOSE: To assess HPV vaccination initiation and coverage, evaluate awareness of HPV and HPV vaccine, and identify factors independently associated with such awareness among men aged 18-26 years. METHODS: Data from the 2010 National Health Interview Survey were analyzed in 2011. RESULTS: In 2010, HPV vaccination initiation among men aged 18-26 years was 1.1%. Among the 1741 men interviewed in this age group, nearly half had heard of HPV (51.8%). Overall, about one third of these men had heard of the HPV vaccine (34.8%). Factors independently associated with a higher likelihood of awareness of both HPV and HPV vaccine among men aged 18-26 years included having non-Hispanic white race/ethnicity; a higher education level; a U.S. birthplace; more physician contacts; private health insurance; received other vaccines; and reported risk behaviors related to sexually transmitted diseases, including HIV. CONCLUSIONS: HPV vaccination initiation among men aged 18-26 years in 2010 was low. HPV and HPV vaccine awareness were also low, and messages in this area directed to men are needed. Since ACIP published a recommendation for routine use of HPV4 among men/boys in December 2011, continued monitoring of HPV vaccination uptake among men aged 18-26 years is useful for evaluating the vaccination campaigns, and planning and implementing strategies to increase coverage.

Authors: McCarthy AM, Armstrong K, Handorf E, Boghossian L, Jones M, Chen J, Demeter MB, McGuire E, Conant EF, Domchek SM

Title: Incremental impact of breast cancer SNP panel on risk classification in a screening population of white and African American women.

Journal: Breast Cancer Res Treat 138(3):889-98

Date: 2013 Apr

Abstract: Breast cancer risk prediction remains imperfect, particularly among non-white populations. This study examines the impact of including single-nucleotide polymorphism (SNP) alleles in risk prediction for white and African American women undergoing screening mammogram. Using a prospective cohort study, standard risk information and buccal swabs were collected at the time of screening mammography. A 12 SNP panel was performed by deCODE genetics. Five-year and lifetime risks incorporating SNPs were calculated by multiplying estimated Breast Cancer Risk Assessment Tool (BCRAT) risk by the total genetic risk ratio. Concordance between the BCRAT and the combined model (BCRAT + SNPs) in identifying high-risk women was measured using the kappa statistic. SNP data were available for 810 women (39 % African American, 55 % white). The mean BCRAT 5-year risk was 1.71 % for whites and 1.18 % for African Americans. Mean genetic risk ratios were 1.09 in whites and 1.29 in African Americans. Among whites, three SNPs had higher frequencies, and among African Americans, seven SNPs had higher and four had lower high-risk allele frequencies than previously reported. Agreement between the BCRAT and the combined model was relatively low for identifying high-risk women (5-year κ = 0.54, lifetime κ = 0.36). Addition of SNPs had the greatest effect among African Americans, with 12.4 % identified as having high-5-year risk by BCRAT, but 33 % by the combined model. A greater proportion of African Americans were reclassified as having high-5-year risk than whites using the combined model (21 vs. 10 %). The addition of SNPs to the BCRAT reclassifies the high-risk status of some women undergoing screening mammography, particularly African Americans. Further research is needed to determine the clinical validity and utility of the SNP panel for use in breast cancer risk prediction, particularly among African Americans for whom these risk alleles have generally not been validated.

Authors: Mooney SJ, Winner M, Hershman DL, Wright JD, Feingold DL, Allendorf JD, Neugut AI

Title: Bowel obstruction in elderly ovarian cancer patients: a population-based study.

Journal: Gynecol Oncol 129(1):107-12

Date: 2013 Apr

Abstract: PURPOSE: Bowel obstruction is a common pre-terminal event in abdominal/pelvic cancer that has mainly been described in small single-institution studies. We used a large, population-based database to investigate the incidence, management, and outcomes of obstruction in ovarian cancer patients. PATIENTS AND METHODS: We identified patients with stages IC-IV ovarian cancer, aged 65 years or older, in the Surveillance, Epidemiology and End Results (SEER)-Medicare database diagnosed between January 1, 1991 and December 31, 2005. We modeled predictors of inpatient hospitalization for bowel obstruction after cancer diagnosis, categorized management of obstruction, and analyzed the associations between treatment for obstruction and outcomes. RESULTS: Of 8607 women with ovarian cancer, 1518 (17.6%) were hospitalized for obstruction subsequent to cancer diagnosis. Obstruction at cancer diagnosis (HR=2.17, 95%CI: 1.86-2.52) and mucinous tumor histology (HR=1.45, 95%CI: 1.15-1.83) were associated with increased risk of subsequent obstruction. Surgical management of obstruction was associated with lower 30-day mortality (13.4% in women managed surgically vs. 20.2% in women managed non-surgically), but equivalent survival after 30 days and equivalent rates of post-obstruction chemotherapy. Median post-obstruction survival was 382 days in women with obstructions of adhesive origin and 93 days in others. CONCLUSION: In this large-scale, population-based assessment of patients with advanced ovarian cancer, nearly 20% of women developed bowel obstruction after cancer diagnosis. While obstruction due to adhesions did not signal the end of life, all other obstructions were pre-terminal events for the majority of patients regardless of treatment.

Authors: O'Shaughnessy MJ, Jarosek SL, Virnig BA, Konety BR, Elliott SP

Title: Factors associated with reduction in use of neoadjuvant androgen suppression therapy before radical prostatectomy.

Journal: Urology 81(4):745-51

Date: 2013 Apr

Abstract: OBJECTIVE: To determine whether the prescribing patterns for nonindicated androgen suppression therapy (AST), using neoadjuvant AST as the model, changed according to the prevailing clinical evidence, changes in reimbursement, or evidence of increased harm from treatment. MATERIALS AND METHODS: We identified 34,976 men with prostate cancer who had undergone radical prostatectomy within 12 months of diagnosis from the Surveillance, Epidemiology, and End Results-Medicare data set (1992-2007), and their clinical and demographic parameters were assessed. We measured the Medicare claims for receipt of AST before radical prostatectomy and calculated the annual rates of neoadjuvant AST, which were adjusted for confounding variables using multivariate logistic regression analysis, and compared them with the prevailing published clinical data on the outcomes of neoadjuvant AST, changes in reimbursement, or published data on clinical harm from treatment. RESULTS: The use of neoadjuvant AST increased from 7.8% in 1992 to a peak of 17.6% in 1996 and then decreased steadily to 4.6% in 2007. This rate change was significant on multivariate regression analysis, with a single join point in 1996 (P <.001), and corresponded to published data showing improved surgical margin rates and pathologic downstaging in the early 1990s and data showing no improvement in disease recurrence or overall survival beginning in 1997. Changes in reimbursement and evidence of harm from AST were not associated with the decreased use of neoadjuvant AST. CONCLUSION: Using neoadjuvant AST as the model for the nonindicated use of AST, physicians reduced AST use in response to high-level evidence showing a lack of benefit, despite the high reimbursement. This suggests that physicians adapt to emerging evidence and use evidence-based practice.

Authors: Roland KB, Benard VB, Soman A, Breen N, Kepka D, Saraiya M

Title: Cervical cancer screening among young adult women in the United States.

Journal: Cancer Epidemiol Biomarkers Prev 22(4):580-8

Date: 2013 Apr

Abstract: BACKGROUND: Cervical cancer screening guidelines have evolved significantly in the last decade for young adult women, with current recommendations promoting later initiation and longer intervals. METHODS: Using self-reported cross-sectional National Health Interview Survey (NHIS) 2000-2010 data, trends in Papanicolaou (Pap) testing among women ages 18-29 years were examined. NHIS 2010 data were used to investigate age at first Pap test (N = 2,198), time since most recent Pap test (n = 1,622), and predictors of Pap testing within the last 12 months (n = 1,622). RESULTS: The percentage of 18-year-olds who reported ever having a Pap test significantly decreased from 49.9% in 2000 to 37.9% in 2010. Mean age at first Pap test in 2010 was significantly younger for non-Hispanic black women (16.9 years), women < high school education (16.9 years), women who received the HPV vaccine (17.1 years), and women who have ever given birth (17.3 years). The majority reported their last Pap test within the previous 12 months (73.1%). Usual source of healthcare (OR, 2.31) and current birth control use (OR, 1.64) significantly increased chances of having a Pap test within the previous 12 months. CONCLUSIONS: From 2000 to 2010, there was a gradual decline in Pap test initiation among 18-year-olds; however, in 2010, many women reported ≤12 months since last screening. Evidence-based guidelines should be promoted, as screening young adult women for cervical cancer more frequently than recommended can cause considerable harms. IMPACT: A baseline of cervical cancer screening among young adult women in the United States to assess adherence to evidence-based screening guidelines.

Authors: Rosales M, Gonzalez P

Title: Mammography screening among Mexican, Central-American, and South-American women.

Journal: J Immigr Minor Health 15(2):225-33

Date: 2013 Apr

Abstract: Cancer and cancer screening disparities exist across Latino subgroups; however the reasons for these disparities are not fully known. This study examines (1) mammography screening among Latinas born in Mexico, Central-America and South-America and (2) the impact of birthplace and acculturation on mammography screening. Data were derived from the California Health Interview Survey 2007. Analyses included 1,675 Latina women 40 years of age and older. Multivariate logistic regression examined predictors of mammography screening. Mexican and Central-American women were less likely to report ever receiving a mammogram while Mexican women were less likely to report a recent mammogram. Low-acculturated women were less likely to report ever receiving a mammogram and less likely to report recent mammography. Different screening patterns across Latina subgroups were observed. Differences in screening patterns and the factors associated with screening highlight the need for unique intervention strategies tailored specifically to Latinas.

Authors: Schneider EB, Haider AH, Hyder O, Efron JE, Lidor AO, Pawlik TM

Title: Assessing short- and long-term outcomes among black vs white Medicare patients undergoing resection of colorectal cancer.

Journal: Am J Surg 205(4):402-8

Date: 2013 Apr

Abstract: BACKGROUND: We sought to identify differences among black and white Medicare-insured patients with colorectal cancer who underwent resection. METHODS: Surveillance, Epidemiology and End Results-Medicare (SEER-Medicare) linked inpatient data from 1986 to 2005 were examined. Differences in short- and long-term outcomes among black vs white patients were investigated. RESULTS: There were 125,676 (92.4%) white and 9,891 (7.6%) black patients who met the criteria. Black patients were younger (75.5 vs 77.2 years; P < .001) but had more comorbidities than did white patients (mean Charlson comorbidity index score 3.99 vs 3.87; P < .001). Black patients demonstrated greater odds of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.30 to 1.56) and readmission within 30 days (OR, 1.26; 95% CI, 1.18 to 1.34). Comparing 1986 to 1990 vs 2001 to 2005, black patients had greater odds of 30-day readmission (OR, 1.12 vs 1.31) but reduced odds of index in-hospital mortality (OR, 1.84 vs 1.28). Black patients had worse long-term survival after colorectal surgery (hazard ratio [HR], 1.21; 95% CI, 1.17 to 1.25; P < .001). CONCLUSIONS: Black patients with colorectal cancer demonstrated increased risk of mortality and readmission after controlling for age, sex, and comorbidities. Although black vs white differences in perioperative mortality decreased over time, disparities in readmission and long-term survival persisted.

Authors: Villaseñor A, Ballard-Barbash R, Ambs A, Bernstein L, Baumgartner K, Baumgartner R, Ulrich CM, Hollis BW, McTiernan A, Neuhouser ML

Title: Associations of serum 25-hydroxyvitamin D with overall and breast cancer-specific mortality in a multiethnic cohort of breast cancer survivors.

Journal: Cancer Causes Control 24(4):759-67

Date: 2013 Apr

Abstract: PURPOSE: Despite limited evidence on the association of vitamin D with outcomes in breast cancer survivors, some clinicians advise breast cancer patients to use vitamin D supplements. More evidence is needed to inform these recommendations. METHODS: In the Health, Eating, Activity, and Lifestyle study, we examined associations of post-treatment serum concentrations of 25-hydroxyvitamin D (25(OH)D) on overall and breast cancer-specific mortality in 585 breast cancer survivors from western Washington State, New Mexico, and Los Angeles County. 25(OH)D was measured in stored blood collected 2 years post-enrollment. Outcomes were ascertained from the Surveillance, Epidemiology, and End Results registries and medical records. Cox proportional hazards models were fit to assess associations of serum 25(OH)D with overall and breast cancer-specific mortality. RESULTS: After a median follow-up of 9.2 years; 110 women died, including 48 from breast cancer. Standard cut points classified 211 (31.6 %) women as serum 25(OH)D deficient (<20 ng/mL), 189 (32.2 %) as insufficient (20-30 ng/mL), and 185 (36.2 %) as sufficient (>30 ng/mL). Compared to women with deficient 25(OH)D, those in the sufficient ranges had a decreased risk of overall mortality (age-adjusted HR = 0.58; 95 % CI 0.36-0.96); however, multivariate adjustments attenuated the association (HR = 0.90; 95 % CI 0.50-1.61). No association was found between serum 25(OH)D and breast cancer-specific mortality (sufficient: HR = 1.21; 95 % CI 0.52-2.80) in multivariate models. CONCLUSION: In this breast cancer cohort, higher serum 25(OH)D may be associated with improved survival, but results were not statistically significant and must be interpreted with caution. The potential prognostic effect of vitamin D from diet, supplements, or both should be evaluated in future larger studies with additional endpoints from breast cancer patients.

Authors: Zandberg DP, Huang TY, Ke X, Baer MR, Gore SD, Smith SW, Davidoff AJ

Title: Treatment and outcomes for chronic myelomonocytic leukemia compared to myelodysplastic syndromes in older adults.

Journal: Haematologica 98(4):584-90

Date: 2013 Apr

Abstract: Prior studies have investigated patients' characteristics, treatments, and outcomes for older adults with myelodysplastic syndromes, but most failed to distinguish chronic myelomonocytic leukemia. Recognizing potentially important differences between the diseases, we undertook a population-based comparison of baseline characteristics, treatments, and outcomes between older adults with chronic myelomonocytic leukemia and myelodysplastic syndromes. The patients' data were obtained from Surveillance Epidemiology and End Results registry data from 2001-2005, linked to Medicare claims. Baseline characteristics, treatment (red blood cell transfusions, hematopoietic growth factors, hypomethylating agents, chemotherapy or transplantation), progression to acute myeloid leukemia, and overall survival were compared using bivariate techniques. Multivariate logistic regression estimated differences in treatments received. Cox proportional hazard models estimated the effects of chronic myelomonocytic leukemia relative to myelodysplastic syndromes on progression-free survival. A larger proportion of patients with chronic myelomonocytic leukemia (n=792), compared to patients with myelodysplastic syndromes (n=7,385), failed to receive any treatment (25% versus 15%; P<0.0001), or only received red blood cell transfusions (19.8% versus 16.7%; P=0.037). A larger percentage of patients with chronic myelomonocytic leukemia progressed to acute myeloid leukemia (42.6% versus 15.5%, respectively; P<0.0001), with shorter time to progression. Chronic myelomonocytic leukemia patients had a shorter median survival (13.3 versus 23.3 months; P<0.0001) and lower 3-year survival rate (19% versus 36%; P<0.0001). Adjusted estimates, controlling for baseline characteristics and selected treatments, indicate that chronic myelomonocytic leukemia was associated with an increased risk of progression to acute myeloid leukemia or death (HR 2.22; P<0.0001), compared to myelodysplastic syndromes. In conclusion, chronic myelomonocytic leukemia is less frequently treated in older adults and is associated with worse outcomes, even after controlling for the patients' baseline characteristics and selected treatments. Our data suggest the need for continued evaluation of the biological differences between these diseases and clinical trials targeting chronic myelomonocytic leukemia.

Authors: de Moor JS, Mariotto AB, Parry C, Alfano CM, Padgett L, Kent EE, Forsythe L, Scoppa S, Hachey M, Rowland JH

Title: Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care.

Journal: Cancer Epidemiol Biomarkers Prev 22(4):561-70

Date: 2013 Apr

Abstract: BACKGROUND: Cancer survivors represent a growing population, heterogeneous in their need for medical care, psychosocial support, and practical assistance. To inform survivorship research and practice, this manuscript will describe the prevalent population of cancer survivors in terms of overall numbers and prevalence by cancer site and time since diagnosis. METHODS: Incidence and survival data from 1975-2007 were obtained from the Surveillance, Epidemiology, and End Results Program and population projections from the United States Census Bureau. Cancer prevalence for 2012 and beyond was estimated using the Prevalence Incidence Approach Model, assuming constant future incidence and survival trends but dynamic projections of the U.S. population. RESULTS: As of January 1, 2012, approximately 13.7 million cancer survivors were living in the United States with prevalence projected to approach 18 million by 2022. Sixty-four percent of this population have survived 5 years or more; 40% have survived 10 years or more; and 15% have survived 20 years or more after diagnosis. Over the next decade, the number of people who have lived 5 years or more after their cancer diagnosis is projected to increase approximately 37% to 11.9 million. CONCLUSIONS: A coordinated agenda for research and practice is needed to address cancer survivors' long-term medical, psychosocial, and practical needs across the survivorship trajectory. IMPACT: Prevalence estimates for cancer survivors across the survivorship trajectory will inform the national research agenda as well as future projections about the health service needs of this population.

Authors: Snyder CF, Frick KD, Herbert RJ, Blackford AL, Neville BA, Wolff AC, Carducci MA, Earle CC

Title: Quality of care for comorbid conditions during the transition to survivorship: differences between cancer survivors and noncancer controls.

Journal: J Clin Oncol 31(9):1140-8

Date: 2013 Mar 20

Abstract: PURPOSE: Building on previous research documenting differences in preventive care quality between cancer survivors and noncancer controls, this study examines comorbid condition care. METHODS: Using data from the Surveillance, Epidemiology, and End Results (SEER) -Medicare database, we examined comorbid condition quality of care in patients with locoregional breast, prostate, or colorectal cancer diagnosed in 2004 who were age ≥ 66 years at diagnosis, who had survived ≥ 3 years, and who were enrolled in fee-for-service Medicare. Controls were frequency matched to cases on age, sex, race, and region. Quality of care was assessed from day 366 through day 1,095 postdiagnosis using published indicators of chronic (n = 10) and acute (n = 19) condition care. The proportion of eligible cancer survivors and controls who received recommended care was compared by using Fisher's exact tests. The chronic and acute indicators, respectively, were then combined into single logistic regression models for each cancer type to compare survivors' care receipt to that of controls, adjusting for clinical and sociodemographic variables and controlling for within-patient variation. RESULTS: The sample matched 8,661 cancer survivors to 17,322 controls (mean age, 75 years; 65% male; 85% white). Colorectal cancer survivors were less likely than controls to receive appropriate care on both the chronic (odds ratio [OR], 0.88; 95% CI, 0.81 to 0.95) and acute (OR, 0.72; 95% CI, 0.61 to 0.85) indicators. Prostate cancer survivors were more likely to receive appropriate chronic care (OR, 1.28; 95% CI, 1.19 to 1.38) but less likely to receive quality acute care (OR, 0.75; 95% CI, 0.65 to 0.87). Breast cancer survivors received care equivalent to controls on both the chronic (OR, 1.06; 95% CI, 0.96 to 1.17) and acute (OR, 0.92; 95% CI, 0.76 to 1.13) indicators. CONCLUSION: Because we found differences by cancer type, research exploring factors associated with these differences in care quality is needed.

Authors: Brawarsky P, Neville BA, Fitzmaurice GM, Earle C, Haas JS

Title: Surveillance after resection for colorectal cancer.

Journal: Cancer 119(6):1235-42

Date: 2013 Mar 15

Abstract: BACKGROUND: Professional societies recommend posttreatment surveillance for colorectal cancer (CRC) survivors. This study describes the use of surveillance over time, with a particular focus on racial/ethnic disparities, and also examines the role of area characteristics, such as capacity for CRC screening, on surveillance. METHODS: Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify individuals aged 66 to 85 years who were diagnosed with CRC from 1993 to 2005 and treated with surgery. The study examined factors associated with subsequent receipt of a colonoscopy, carcinoembryonic antigen (CEA) testing, primary care (PC) visits, and a composite measure of overall surveillance. RESULTS: Of eligible subjects, 61.0% had a colonoscopy, 68.0% had CEA testing, 77.1% had PC visits, and 43.0% received overall surveillance. After adjustment, blacks were less likely than whites to undergo colonoscopy (odds ratio [OR] 0.76, 95% confidence interval [CI] = 0.69-0.83) and to receive CEA testing and overall surveillance, whereas white/Hispanic rates did not differ. Rates for all outcomes increased from 1993 to 2005, but black/white disparities remained. Individuals in areas with greatest capacity for CRC screening were more likely (OR = 1.09, 95% CI = 1.02-1.18) to receive colonoscopy, and those in areas with the greatest percentage of blacks were less likely (OR = 0.89, 95% CI = 0.83-0.95) to receive colonoscopy. Those living in areas with shortage of PC were less likely to receive PC visits (OR = 0.55, 95% CI = 0.48-0.64) and overall surveillance (OR = 0.83, 95% CI = 0.71-0.98). CONCLUSIONS: Many CRC survivors do not get recommended surveillance, and black/white disparities in rates of surveillance have not improved. Characteristics of the area where an individual lives contribute to the use of surveillance.

Authors: Cott Chubiz JE, Lee JM, Gilmore ME, Kong CY, Lowry KP, Halpern EF, McMahon PM, Ryan PD, Gazelle GS

Title: Cost-effectiveness of alternating magnetic resonance imaging and digital mammography screening in BRCA1 and BRCA2 gene mutation carriers.

Journal: Cancer 119(6):1266-76

Date: 2013 Mar 15

Abstract: BACKGROUND: Current clinical guidelines recommend earlier, more intensive breast cancer screening with both magnetic resonance imaging (MRI) and mammography for women with breast cancer susceptibility gene (BRCA) mutations. Unspecified details of screening schedules are a challenge for implementing guidelines. METHODS: A Markov Monte Carlo computer model was used to simulate screening in asymptomatic women who were BRCA1 and BRCA2 mutation carriers. Three dual-modality strategies were compared with digital mammography (DM) alone: 1) DM and MRI alternating at 6-month intervals beginning at age 25 years (Alt25), 2) annual MRI beginning at age 25 years with alternating DM added at age 30 years (MRI25/Alt30), and 3) DM and MRI alternating at 6-month intervals beginning at age 30 years (Alt30). Primary outcomes were quality-adjusted life years (QALYs), lifetime costs (in 2010 US dollars), and incremental cost-effectiveness (dollars per QALY gained). Additional outcomes included potential harms of screening, and lifetime costs stratified into component categories (screening and diagnosis, treatment, mortality, and patient time costs). RESULTS: All 3 dual-modality screening strategies increased QALYs and costs. Alt30 screening had the lowest incremental costs per additional QALY gained (BRCA1, $74,200 per QALY; BRCA2, $215,700 per QALY). False-positive test results increased substantially with dual-modality screening and occurred more frequently in BRCA2 carriers. Downstream savings in both breast cancer treatment and mortality costs were outweighed by increases in up-front screening and diagnosis costs. The results were influenced most by estimates of breast cancer risk and MRI costs. CONCLUSIONS: Alternating MRI and DM screening at 6-month intervals beginning at age 30 years was identified as a clinically effective approach to applying current guidelines, and was more cost-effective in BRCA1 gene mutation carriers compared with BRCA2 gene mutation carriers.

Authors: Braithwaite D, Zhu W, Hubbard RA, O'Meara ES, Miglioretti DL, Geller B, Dittus K, Moore D, Wernli KJ, Mandelblatt J, Kerlikowske K, Breast Cancer Surveillance Consortium

Title: Screening outcomes in older US women undergoing multiple mammograms in community practice: does interval, age, or comorbidity score affect tumor characteristics or false positive rates?

Journal: J Natl Cancer Inst 105(5):334-41

Date: 2013 Mar 06

Abstract: Background Uncertainty exists about the appropriate use of screening mammography among older women because comorbid illnesses may diminish the benefit of screening. We examined the risk of adverse tumor characteristics and false positive rates according to screening interval, age, and comorbidity. Methods From January 1999 to December 2006, data were collected prospectively on 2993 older women with breast cancer and 137 949 older women without breast cancer who underwent mammography at facilities that participated in a data linkage between the Breast Cancer Surveillance Consortium and Medicare claims. Women were aged 66 to 89 years at study entry to allow for measurement of 1 year of preexisting illnesses. We used logistic regression analyses to calculate the odds of advanced (IIb, III, IV) stage, large (>20 millimeters) tumors, and 10-year cumulative probability of false-positive mammography by screening frequency (1 vs 2 years), age, and comorbidity score. The comorbidity score was derived using the Klabunde approximation of the Charlson score. All statistical tests were two-sided. Results Adverse tumor characteristics did not differ statistically significantly by comorbidity, age, or interval. Cumulative probability of a false-positive mammography result was higher among annual screeners than biennial screeners irrespective of comorbidity: 48.0% (95% confidence interval [CI] = 46.1% to 49.9%) of annual screeners aged 66 to 74 years had a false-positive result compared with 29.0% (95% CI = 28.1% to 29.9%) of biennial screeners. Conclusion Women aged 66 to 89 years who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of a false-positive recommendation than annual screeners, regardless of comorbidity.

Authors: Yager SS, Chen L, Cheung WY

Title: Sex-based Disparities in Colorectal Cancer Screening.

Journal: Am J Clin Oncol :-

Date: 2013 Mar 04

Abstract: PURPOSE:: Research suggests that recurrence and survival from colorectal cancer are worse in men than in women but the causes for this are unclear. Our aims were to (1) assess for sex differences in colorectal cancer screening (CRCS) within a large, contemporary population-based sample in California; and (2) examine the impact of income, education, and insurance status on sex differences in CRCS. METHODS:: Screening-eligible patients were identified from the 2007 US California Health Interview Survey. Up-to-date, CRCS was defined as fecal occult blood test within 1 year, flexible sigmoidoscopy within 5 years, or colonoscopy within 10 years. Logistic regression models were constructed to evaluate the relationship between sex and CRCS. Stratified analyses on the basis of self-reported income (low vs. high), education (≤ high school vs. > high school), and health insurance status (insured vs. uninsured) were performed to determine if sex differences in screening were modified by these parameters. RESULTS:: In total, 11,260 men and 17,705 women were identified: mean ages were 65 and 66 years, respectively, and 63% were white in both the sexes. In the entire cohort, only two thirds of men and women reported undergoing up-to-date CRCS. Women had decreased odds of CRCS than men, after adjusting for potential confounders. Stratified analyses indicated that sex disparities in CRCS persisted among the insured, educated, and high-income earners. CONCLUSIONS:: Women are less likely to undergo CRCS than men, but poor health care access is associated with low CRCS in both the sexes. Conventional strategies aimed at improving health care access should also include sex-specific interventions that raise awareness about preventive care to most effectively optimize CRCS.

Authors: Duggan C, Wang CY, Neuhouser ML, Xiao L, Smith AW, Reding KW, Baumgartner RN, Baumgartner KB, Bernstein L, Ballard-Barbash R, McTiernan A

Title: Associations of insulin-like growth factor and insulin-like growth factor binding protein-3 with mortality in women with breast cancer.

Journal: Int J Cancer 132(5):1191-200

Date: 2013 Mar 01

Abstract: Elevated circulating insulin-like growth factor-1 (IGF-1), a breast epithelial cell mitogen, is associated with breast cancer development. However, its association with breast cancer survival is not established. Circulating concentrations of IGF-1 are controlled via binding proteins, including IGF Binding Protein-3 (IGFBP-3), that may modulate the association of IGF-1 with breast-cancer outcomes. We measured IGF-1 and IGFBP-3 concentrations in serum from 600 women enrolled in the health, eating, activity, and lifestyle (HEAL) study, a multiethnic, prospective cohort study of women diagnosed with stage I-IIIA breast cancer. We evaluated the association between IGF-1 and IGFBP-3, and as a ratio, modeled using quintile cut-points, with risk of breast cancer-specific (n = 42 deaths) and all-cause mortality (n = 87 deaths) using Cox proportional hazards models. In models adjusted for body mass index, ethnicity, tamoxifen use at time of blood draw, treatment received at diagnosis and IGFBP-3, women in the highest quintile of IGF-1 level had an increased risk of all-cause mortality (Hazard Ratio (HR) = 3.10, 95% CI 1.21-7.93, p = 0.02), although no dose-response association was evident. The IGF-1/IGFBP-3 ratio, an indicator of free IGF-I levels, was significantly associated with increasing risk of all-cause mortality (HR = 2.83, 95% CI 1.25-6.36 p(trend) = 0.01, upper vs. lower quintile) in a fully adjusted model. In conclusion, high serum levels of IGF-1 and the IGF-1/IGFBP-3 ratio were associated with increased risk of all-cause mortality in women with breast cancer. These results need to be confirmed in larger breast cancer survivor cohorts.

Authors: Guadagnolo BA, Huo J, Liao KP, Buchholz TA, Das P

Title: Changing trends in radiation therapy technologies in the last year of life for patients diagnosed with metastatic cancer in the United States.

Journal: Cancer 119(5):1089-97

Date: 2013 Mar 01

Abstract: BACKGROUND: Our goal was to investigate utilization trends for advanced radiation therapy (RT) technologies, such as intensity-modulated radiation therapy (IMRT) and stereotactic radiosurgery (SRS), in the last year of life among patients diagnosed with metastatic cancer. METHODS: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare linked databases to analyze claims data in the last 12 months of life for 64,525 patients diagnosed with metastatic breast, colorectal, lung, pancreas, and prostate cancers from 2000 to 2007. Logistic regression modeling was conducted to analyze potential demographic, health services, and treatment-related variables' influences on receipt of advanced RT. RESULTS: Among the 19,161 (29.7%) patients who received radiation therapy, there was a significant decrease in the proportion of patients who received the simplest radiation technique (ie, 2D-radiation therapy) (P < .0001), and significant increases in the proportions of patients receiving more advanced radiation techniques (ie, IMRT, and SRS; P < .0001 for all curves); although the rates for use of IMRT and SRS in 2007 remained under 5%. On multivariate analyses, receipt of RT varied significantly by non-clinical characteristics such as race, marital status, neighborhood income, and SEER region. Patients who received hospice care in the last year of life were more likely to receive radiation therapy (OR = 1.35, 95% CI = 1.30-1.40) but less likely to be treated with IMRT (OR = 0.76, 95% CI = 0.62-0.92). CONCLUSIONS: Although the proportion of patients receiving RT in the last year of life for metastatic cancer did not change for most of the past decade, we observed significant trends toward more advanced radiation techniques.

Authors: Billmeier SE, Ayanian JZ, He Y, Jaklitsch MT, Rogers SO

Title: Predictors of nursing home admission, severe functional impairment, or death one year after surgery for non-small cell lung cancer.

Journal: Ann Surg 257(3):555-63

Date: 2013 Mar

Abstract: OBJECTIVE: To assess factors associated with nursing home admission, severe functional impairment, or death 1 year after surgery for stage I-IIIa non-small cell lung cancer. BACKGROUND: Patients perceive long-term disability to be one of the most undesirable complications of lung cancer treatment. METHODS: A multiregional cohort was surveyed 12 months after surgery. Logistic regression was used to determine adjusted predictors of long-term disability. Recursive partitioning was used to create a risk index based on preoperative factors. RESULTS: Of the 1007 patients, 146 (15%) were admitted to a nursing home or died by 1 year after surgery, with higher risk among patients 80 years or older, those with severe comorbidities, and those with stage II-IIIa disease (all Ps ≤ 0.01). Among 759 survivors who completed the follow-up survey, 51 (7%) were admitted to a nursing home or reported inability to get out of bed, dress or wash themselves, or perform usual activities. Patients with moderate comorbidities (P < 0.001) or lack of high school diploma (P = 0.03) were more likely to experience nursing home admission or severe functional impairment. The risk of nursing home admission, severe functional impairment, or death was low (16%) for patients younger than 75 years and for those 75 years or older with stage I disease, intermediate (33%) for patients 75 years or older with stage II-IIIa disease and no or mild comorbidities, and high (60%) for those 75 years or older with stage II-IIIa disease and moderate or severe comorbidities. CONCLUSIONS: Patients' risk of long-term disability should be incorporated in preoperative counseling.

Authors: Chien LC, Schootman M, Pruitt SL

Title: The modifying effect of patient location on stage-specific survival following colorectal cancer using geosurvival models.

Journal: Cancer Causes Control 24(3):473-84

Date: 2013 Mar

Abstract: Colorectal cancer (CRC) is the third leading cause of cancer death in the US, and stage at diagnosis is the primary prognostic factor. To date, the interplay between geographic place and individual characteristics such as cancer stage with CRC survival is unexplored. We used a Bayesian geosurvival statistical model to evaluate whether the spatial patterns of CRC survival at the census tract level varies by stage at diagnosis (in situ/local, regional, distant), controlling for patient characteristics, surveillance test use, and treatment using linked 1991-2005 SEER-Medicare data of patients ≥ 66 years old in two US metropolitan areas. The spatial pattern of survival varied by stage at diagnosis for both cancer sites and registries. Significant spatial effects were identified in all census tracts for colon cancer and the majority of census tracts for rectal cancer. Geographic disparities appeared to be highest for distant-stage rectal cancer. Compared to those with in situ/local stage in the same census tracts, patients with distant-stage cancer were at most 7.73 times and 4.69 times more likely to die of colon and rectal cancer, respectively. Moreover, frailty areas for CRC at in situ/local stage more likely have a higher relative risk at regional stage, but not at distant stage. We identified geographic areas with excessive risk of CRC death and demonstrated that spatial patterns varied by both cancer type and cancer stage. More research is needed to understand the moderating pathways between geographic and individual-level factors on CRC survival.

Authors: Chukmaitov A, Bradley CJ, Dahman B, Siangphoe U, Warren JL, Klabunde CN

Title: Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications.

Journal: Gastrointest Endosc 77(3):436-46

Date: 2013 Mar

Abstract: BACKGROUND AND OBJECTIVE: Serious GI adverse events in the outpatient setting were examined by polypectomy technique, endoscopist volume, and facility type (ambulatory surgery center and hospital outpatient department). DESIGN: Retrospective follow-up study. SETTING: Ambulatory surgery and hospital discharge datasets from Florida (1997-2004) were used. PATIENTS: A total of 2,315,126 outpatient colonoscopies performed in patients of all ages and payers were examined. MAIN OUTCOME: Thirty-day hospitalizations because of colonic perforations and GI bleeding, measured as cumulative and specific outcomes, were investigated. RESULTS: Compared with simple colonoscopy, the adjusted risks of cumulative adverse events were greater with the use of cold forceps (1.21 [95% CI, 1.01-1.44]), ablation (3.75 [95% CI, 2.97-4.72]), hot forceps (5.63 [95% CI, 4.97-6.39]), snares (7.75 [95% CI, 6.95-8.64]), or complex colonoscopy (8.83 [95% CI, 7.70-10.12]). Low-volume endoscopists had higher risks of adverse events (1.18 [95% CI, 1.07-1.30]). A higher risk of adverse events was associated with procedures performed in ambulatory surgery centers (1.27 [95% CI, 1.16-1.40]). Important findings were also reported for the analyses stratified by specific outcomes and procedures. LIMITATION: The study was constrained by limitations inherent in administrative data pertaining to a single state. CONCLUSIONS: As the complexity of polypectomy increases, a higher risk of adverse events is reported. Using lower risk procedures when clinically appropriate or referring patients to high-volume endoscopists can reduce the rates of perforations and GI bleeding. Given the large number of colonoscopies performed in the United States, it is critical that the rates of adverse events be considered when choosing procedures.

Authors: Fouad MN, Lee JY, Catalano PJ, Vogt TM, Zafar SY, West DW, Simon C, Klabunde CN, Kahn KL, Weeks JC, Kiefe CI

Title: Enrollment of patients with lung and colorectal cancers onto clinical trials.

Journal: J Oncol Pract 9(2):e40-7

Date: 2013 Mar

Abstract: PURPOSE: Only 2% to 5% of adult patients with cancer enroll onto clinical trials. We assessed simultaneously characteristics of patients and their physicians that may be independently associated with participation. METHODS: CanCORS, a National Cancer Institute (NCI) -funded population-based observational cohort study of newly diagnosed patients with lung and colorectal cancers, sampled patients across five geographic areas, five health care delivery systems, and 15 Veterans Administration hospitals. We linked patient survey and medical record data with physician survey data to examine correlates of trial enrollment. RESULTS: Among 9,901 patients, 5.3% enrolled onto trials. Of the 9,901 patients, we linked 6,506 patients to one medical oncologist, surgeon, or radiation oncologist (physicians, N = 1,325) who responded to the physician survey and was considered their primary cancer clinician decision maker. Patient age, race, disease stage, geographic region, and health insurance were independently associated with trial enrollment. Physician factors independently associated with patient trial enrollment were being a medical oncologist, practicing at an NCI-designated cancer center, taking the lead in discussing trials with patients, and receiving increased income from trial enrollment. After simultaneously adjusting for patient and physician characteristics, only being a physician practicing at an NCI-designated cancer center (odds ratio [OR], 1.65; 95% CI, 1.19 to 2.27) and patient female sex (OR, 1.36; 95% CI, 1.10 to 1.68), age > 70 versus < 50 years (OR, 0.28; 95% CI, 0.16 to 0.48), and advanced disease (OR, 1.85; 95% CI, 1.45 to 2.37) remained independently associated with trial enrollment. CONCLUSION: Both practice environment and patient clinical and demographic characteristics are associated with cancer clinical trial enrollment; simultaneous intervention may be required when trying to increase enrollment rates.

Authors: George SM, Alfano CM, Wilder Smith A, Irwin ML, McTiernan A, Bernstein L, Baumgartner KB, Ballard-Barbash R

Title: Sedentary behavior, health-related quality of life, and fatigue among breast cancer survivors.

Journal: J Phys Act Health 10(3):350-8

Date: 2013 Mar

Abstract: BACKGROUND: Many cancer survivors experience declines in health-related quality of life (HRQOL) and increases in fatigue as a result of cancer and its treatment. Exercise is linked to improvements in these outcomes, but little is known about the role of sedentary behavior. In a large, ethnically-diverse cohort of breast cancer survivors, we examined the relationship between sedentary time, HRQOL, and fatigue, and examined if that relationship differed by recreational moderate-vigorous physical activity (MVPA) level. METHODS: Participants were 710 women diagnosed with stage 0-IIIA breast cancer in the Health, Eating, Activity, and Lifestyle Study. Women completed questionnaires at approximately 30-months postdiagnosis (sedentary time; recreational MVPA) and 41-months postdiagnosis (HRQOL; fatigue). In multivariate models, we regressed these outcomes linearly on quartiles of daily sedentary time, and a variable jointly reflecting sedentary time quartiles and MVPA categories (0; >0 to <9; ≥9 MET-hrs/wk). RESULTS: Sedentary time was not independently related to subscales or summary scores of HRQOL or fatigue. In addition, comparisons of women with high vs. low (Q4:Q1) sedentary time by MVPA level did not result in significant differences in HRQOL or fatigue. CONCLUSION: In this breast cancer survivor cohort, self-reported sedentary time was not associated with HRQOL or fatigue, 3.5 years postdiagnosis.

Authors: Harvey JA, Gard CC, Miglioretti DL, Yankaskas BC, Kerlikowske K, Buist DS, Geller BA, Onega TL, Breast Cancer Surveillance Consortium

Title: Reported mammographic density: film-screen versus digital acquisition.

Journal: Radiology 266(3):752-8

Date: 2013 Mar

Abstract: PURPOSE: To test the hypothesis that American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) categories for breast density reported by radiologists are lower when digital mammography is used than those reported when film-screen (FS) mammography is used. MATERIALS AND METHODS: This study was institutional review board approved and HIPAA compliant. Demographic data, risk factors, and BI-RADS breast density categories were collected from five mammography registries that were part of the Breast Cancer Surveillance Consortium. Active, passive, or waiver of consent was obtained for all participants. Women aged 40 years and older who underwent at least two screening mammographic examinations less than 36 months apart between January 1, 2000, and December 31, 2009, were included. Women with prior breast cancer, augmentation, or use of agents known to affect density were excluded. The main sample included 89 639 women with both FS and digital mammograms. The comparison group included 259 046 women with two FS mammograms and 87 066 women with two digital mammograms. BI-RADS density was cross-tabulated according to the order in which the two types of mammogram were acquired and by the first versus second interpretation. RESULTS: Regardless of acquisition method, the percentage of women with a change in density from one reading to the next was similar. Breast density was lower in 19.8% of the women who underwent FS before digital mammography and 17.1% of those who underwent digital before FS mammography. Similarly, lower density classifications were reported on the basis of the second mammographic examination regardless of acquisition method (15.8%-19.8%). The percentage of agreement between density readings was similar regardless of mammographic types paired (67.3%-71.0%). CONCLUSION: The study results showed no difference in reported BI-RADS breast density categories according to acquisition method. Reported BI-RADS density categories may be useful in the development of breast cancer risk models in which FS, digital, or both acquisition methods are used.

Authors: Hubbard RA, Miglioretti DL

Title: A semiparametric censoring bias model for estimating the cumulative risk of a false-positive screening test under dependent censoring.

Journal: Biometrics 69(1):245-53

Date: 2013 Mar

Abstract: False-positive test results are among the most common harms of screening tests and may lead to more invasive and expensive diagnostic testing procedures. Estimating the cumulative risk of a false-positive screening test result after repeat screening rounds is, therefore, important for evaluating potential screening regimens. Existing estimators of the cumulative false-positive risk are limited by strong assumptions about censoring mechanisms and parametric assumptions about variation in risk across screening rounds. To address these limitations, we propose a semiparametric censoring bias model for cumulative false-positive risk that allows for dependent censoring without specifying a fixed functional form for variation in risk across screening rounds. Simulation studies demonstrated that the censoring bias model performs similarly to existing models under independent censoring and can largely eliminate bias under dependent censoring. We used the existing and newly proposed models to estimate the cumulative false-positive risk and variation in risk as a function of baseline age and family history of breast cancer after 10 years of annual screening mammography using data from the Breast Cancer Surveillance Consortium. Ignoring potential dependent censoring in this context leads to underestimation of the cumulative risk of false-positive results. Models that provide accurate estimates under dependent censoring are critical for providing appropriate information for evaluating screening tests.

Authors: Lee JK, Levin TR, Corley DA

Title: The road ahead: what if gastroenterologists were accountable for preventing colorectal cancer?

Journal: Clin Gastroenterol Hepatol 11(3):204-7

Date: 2013 Mar

Abstract:

Authors: Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM

Title: Is repeat prostate biopsy associated with a greater risk of hospitalization? Data from SEER-Medicare.

Journal: J Urol 189(3):867-70

Date: 2013 Mar

Abstract: PURPOSE: We recently reported an increasing risk over time of hospitalization among Medicare participants after undergoing an initial prostate biopsy. Less is known about the relative risks of repeat prostate biopsies, which are frequently performed in prostate cancer screening and in active surveillance programs. We determined whether repeat biopsies are associated with an increased risk of hospitalization compared to the initial biopsy. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results)-Medicare linked data from 1991 to 2007 we identified 13,883 men who underwent a single prostate biopsy and 3,640 who had multiple biopsies. The 30-day hospitalization rates were compared between these groups, and with a randomly selected control population of 134,977. ICD-9 codes were then used to examine the frequency of serious infectious and noninfectious urological complications as the primary diagnosis for hospital admissions. RESULTS: Initial and repeat biopsies were associated with a significantly increased risk of hospitalization within a 30-day period compared to randomly selected controls (p <0.0001). However, the repeat biopsy session was not associated with a greater risk of infectious (OR 0.81, 95% 0.49-1.32, p = 0.39) or serious noninfectious urological complications (OR 0.94, 95% CI 0.54-1.62, p = 0.82) compared to the initial biopsy. CONCLUSIONS: Each biopsy was associated with a significant risk of complications compared to randomly selected controls. However, the repeat biopsy procedure itself was not associated with a greater risk of serious complications requiring hospital admission compared to the initial biopsy.

Authors: Mazor KM, Greene SM, Roblin D, Lemay CA, Firneno CL, Calvi J, Prouty CD, Horner K, Gallagher TH

Title: More than words: patients' views on apology and disclosure when things go wrong in cancer care.

Journal: Patient Educ Couns 90(3):341-6

Date: 2013 Mar

Abstract: OBJECTIVE: Guidelines on apology and disclosure after adverse events and errors have been in place for over 5 years. This study examines whether patients consider recommended responses to be appropriate and desirable, and whether clinicians' actions after adverse events are consistent with recommendations. METHODS: Patients who believed that something had gone wrong during their cancer care were identified. During in-depth interviews, patients described the event, clinicians' responses, and their reactions. RESULTS: 78 patients were interviewed. Patients' valued apology and expressions of remorse, empathy and caring, explanation, acknowledgement of responsibility, and efforts to prevent recurrences, but these key elements were often missing. For many patients, actions and evidence of clinician learning were most important. CONCLUSION: Patients' reports of apology and disclosure when they believe something has gone wrong in their care suggest that clinicians' responses continue to fall short of expectations. PRACTICE IMPLICATIONS: Clinicians preparing to talk with patients after an adverse event or medical error should be aware that patients expect their actions to be congruent with their words of apology and caring. Healthcare systems need to support clinicians throughout the disclosure process, and facilitate both system and individual learning to prevent recurrences.

Authors: McLeod CC, Klabunde CN, Willis GB, Stark D

Title: Health care provider surveys in the United States, 2000-2010: a review.

Journal: Eval Health Prof 36(1):106-26

Date: 2013 Mar

Abstract: Surveys of health care providers (e.g., physicians and other health care professionals) are an important tool for assessing health care practices and the settings in which care is delivered. Although multiple methods are used to increase survey data quality, little is known about which methods are most commonly implemented. We reviewed 117 large surveys described in literature published between 2000 and 2010, examining descriptions of survey design features, survey implementation, and response rates. Despite wide variation, the typical provider survey selected practicing physicians as respondents, used the American Medical Association Masterfile as sample frame, included mail as both mode of initial contact and questionnaire administration mode, and offered monetary incentives to respondents. Our review revealed inconsistency of documentation concerning procedures used, and a variety of response rate calculation methods, such that it was difficult to determine practices that maximize response rate. We recommend that reports provide more comprehensive documentation concerning key methodological features to improve assessment of survey data quality.

Authors: Nurgalieva ZZ, Franzini L, Morgan RO, Vernon SW, Liu CC, Du XL

Title: Impact of timing of adjuvant chemotherapy initiation and completion after surgery on racial disparities in survival among women with breast cancer.

Journal: Med Oncol 30(1):419-

Date: 2013 Mar

Abstract: While large differences by race/ethnicity in breast cancer survival are well established, it is unknown whether differences in quality of chemotherapy delivered explain the racial/ethnic disparities in survival among black, Hispanic, Asian, and white women with breast cancer. We evaluated factors associated with time to initiation of adjuvant chemotherapy and chemotherapy completion and examined outcomes data among women with breast cancer. Patients who initiated chemotherapy later than 3 months after surgery were 1.8 times more likely to die of breast cancer (95 % CI 1.3-2.5) compared with those who initiated chemotherapy less than a month after surgery, even after controlling for known confounders or controlling for race/ethnicity. Women who completed chemotherapy had significantly higher survival compared with those who have not completed chemotherapy. Despite correcting for chemotherapy initiation and completion and known predictors of outcome, African American women still had worse disease-specific survival than their Caucasian counterparts. While a complete and timely adjuvant treatment among various ethnic populations would help to reduce racial disparities in survival, there are still other factors to be identified that may explain the remaining differences in survival between ethnic women with breast cancer.

Authors: Sabatino SA, Thompson TD, Smith JL, Rowland JH, Forsythe LP, Pollack L, Hawkins NA

Title: Receipt of cancer treatment summaries and follow-up instructions among adult cancer survivors: results from a national survey.

Journal: J Cancer Surviv 7(1):32-43

Date: 2013 Mar

Abstract: PURPOSE: The purpose of this study is to examine reporting of treatment summaries and follow-up instructions among cancer survivors. METHODS: Using the 2010 National Health Interview Survey, we created logistic regression models among cancer survivors not in treatment (n = 1,345) to determine characteristics associated with reporting treatment summaries and written follow-up instructions, adjusting for sociodemographic, access, and cancer-related factors. Findings are presented for all survivors and those recently diagnosed (≤4 years). We also examined unadjusted associations between written instructions and subsequent surveillance and screening. RESULTS: Among those recently diagnosed, 38 % reported receiving treatment summaries and 58 % reported written instructions. Among all survivors, approximately one third reported summaries and 44 % reported written instructions. After adjustment, lower reporting of summaries was associated with cancer site, race, and number of treatment modalities among those recently diagnosed, and white vs. black or Hispanic race/ethnicity, breast vs. colorectal cancer, >10 vs. ≤5 years since diagnosis, no clinical trials participation, and better than fair health among all survivors. For instructions, lower reporting was associated with no trials participation and lower income among those recently diagnosed, and increasing age, white vs. black race, lower income, >10 vs. ≤5 years since diagnosis, 1 vs. ≥2 treatment modalities, no trials participation, and at least good vs. fair/poor health among all survivors. Written instructions were associated with reporting provider recommendations for breast and cervical cancer surveillance, and recent screening mammograms. CONCLUSION: Many recently diagnosed cancer survivors did not report receiving treatment summaries and written follow-up instructions. Opportunities exist to examine associations between use of these documents and recommended care and outcomes, and to facilitate their adoption. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivors who have completed therapy should ask their providers for treatment summaries and written follow-up instructions, and discuss with them how their cancer and therapy impact their future health care.

Authors: Satram-Hoang S, Lee L, Yu S, Guduru SR, Gunuganti AR, Reyes C, McKenna E

Title: Comparative effectiveness of chemotherapy in elderly patients with metastatic colorectal cancer.

Journal: J Gastrointest Cancer 44(1):79-88

Date: 2013 Mar

Abstract: PURPOSE: Treatment advances have improved outcomes in clinical trials of patients with metastatic colorectal cancer (mCRC). Less is known about these effects for patients in real-world settings. This study evaluated treatment patterns and survival in older, demographically diverse patients with mCRC. METHODS: A retrospective cohort analysis was performed for 4,250 patients from January 1, 2000 to December 31, 2007 using linked Surveillance, Epidemiology, and End Results-Medicare database. Patients were ≥ 66 years, enrolled in Medicare parts A and B, and received first-line treatment with fluorouracil and leucovorin (5-FU/LV), capecitabine (CAP), 5-FU/LV plus oxaliplatin (FOLFOX), or CAP and oxaliplatin (CAPOX). Cox regression with backward elimination and propensity score-weighted Cox regression estimated relative risk of death. Date of last follow-up was December 2009. Statistical comparisons were made between 5-FU/LV vs. CAP and FOLFOX vs. CAPOX. RESULTS: Compared to 5-FU/LV, patients treated with CAP were older (mean age 78 vs. 76; P<0.0001) and more likely female (61 vs. 54 %; P=0.0017), while patients receiving CAPOX and FOLFOX were similar in age (mean age 74 vs. 73; P=0.0924). Complications requiring medical resource utilization following initiation of therapy were significantly higher among patients administered with 5-FU/LV (54 %) vs. CAP (17 %; P<0.0001) and FOLFOX (75 %) vs. CAPOX (57 %; P<0.0001). The multivariate analysis revealed no significant differences in survival between 5-FU/LV and CAP and between FOLFOX and CAPOX. CONCLUSIONS: Overall survival was comparable between CAP and 5-FU/LV and between CAPOX and FOLFOX with fewer complications requiring medical resource utilization associated with CAP and CAPOX, thus confirming clinical trial results.

Authors: Schonberg MA, Breslau ES, McCarthy EP

Title: Targeting of mammography screening according to life expectancy in women aged 75 and older.

Journal: J Am Geriatr Soc 61(3):388-95

Date: 2013 Mar

Abstract: OBJECTIVES: To examine receipt of mammography screening according to life expectancy in women aged 75 and older. DESIGN: Population-based survey. SETTING: United States. PARTICIPANTS: Community dwelling U.S. women aged 75 and older who participated in the 2008 or 2010 National Health Interview Survey. MEASUREMENTS: Using a previously developed and validated index, women were categorized according to life expectancy (>9, 5-9, <5 years). Receipt of mammography screening in the past 2 years was examined according to life expectancy, adjusting for sociodemographic characteristics, access to care, preventive orientation (e.g., receipt of influenza vaccination), and receipt of a clinician recommendation for screening. RESULTS: Of 2,266 respondents, 27.1% had a life expectancy of greater than 9 years, 53.4% had a life expectancy of 5 to 9 years, and 19.5% had a life expectancy of less than 5 years. Overall, 55.7% reported receiving mammography screening in the past 2 years. Life expectancy was strongly associated with receipt of screening (P < .001), yet 36.1% of women with less than 5 years life expectancy were screened, and 29.2% of women with more than 9 years life expectancy were not screened. A clinician recommendation for screening was the strongest predictor of screening independent of life expectancy. Higher educational attainment, age, receipt of influenza vaccination, and history of benign breast biopsy were also independently associated with being screened. CONCLUSION: Despite uncertainty of benefit, many women aged 75 and older are screened with mammography. Life expectancy is strongly associated with receipt of screening, which may reflect clinicians and patients appropriately considering life expectancy in screening decisions, but 36% of women with short life expectancies are still screened, suggesting that new interventions are needed to further improve targeting of screening according to life expectancy. Decision aids and guidelines encouraging clinicians to consider patient life expectancy in screening decisions may improve care.

Authors: Sigel K, Mhango G, Cohen J, Halm EA, Mandeli J, Strauss G, Wisnivesky J

Title: Outcomes after adjuvant platinum-based chemotherapy in elderly NSCLC patients with T4 disease.

Journal: Ann Surg Oncol 20(3):1013-9

Date: 2013 Mar

Abstract: BACKGROUND: The postoperative management of elderly patients with T4, N0-1, M0 non-small cell lung cancer (NSCLC) remains controversial. The objective of this study was to evaluate the association of adjuvant chemotherapy with survival and toxicity among these patients. METHODS: Using surveillance, epidemiology and end results registry data linked to Medicare claims, we identified 389 elderly patients with resected T4, N0-1, M0 NSCLC diagnosed between 1992 and 2007. We compared survival of patients treated with and without platinum-based chemotherapy using a Cox regression adjusting for propensity scores for chemotherapy use and use of radiotherapy. We used logistic regression to assess the risk of adverse events in patients receiving chemotherapy. RESULTS: No benefit was noted in overall survival with adjuvant chemotherapy after PS adjustment for both N0 (hazard ratio 0.78, 95% confidence interval 0.50-1.23) and N1 (hazard ratio 1.01, 95% confidence interval 0.67-1.53) cancers. Patients receiving adjuvant chemotherapy experienced severe adverse events more frequently than patients who did not receive chemotherapy. CONCLUSIONS: Use of adjuvant chemotherapy in elderly patients with T4, N0-1, M0 NSCLC was not associated with a survival advantage and was associated with higher rates of severe toxicity.

Authors: Spencer BA, McBride RB, Hershman DL, Buono D, Herr HW, Benson MC, Gupta-Mohile S, Neugut AI

Title: Adjuvant intravesical bacillus calmette-guérin therapy and survival among elderly patients with non-muscle-invasive bladder cancer.

Journal: J Oncol Pract 9(2):92-8

Date: 2013 Mar

Abstract: PURPOSE: National guidelines recommend adjuvant intravesical Bacillus Calmette-Guérin (BCG) therapy for higher-risk non-muscle-invasive bladder cancer (NMIBC). Although a survival benefit has not been demonstrated, randomized trials have shown reduced recurrence and delayed progression after its use. We investigated predictors of BCG receipt and its association with survival for older patients with NMIBC. PATIENTS AND METHODS: We identified individuals with NMIBC registered in the Surveillance, Epidemiology, and End Results-Medicare database from 1991 to 2003. We used logistic regression to compare those treated with BCG within 6 months of initial diagnosis with those not treated, adjusting for demographic and clinical factors. Cox proportional hazards modeling was used to analyze the association between BCG and overall survival (OS) and bladder cancer-specific survival (BCSS) for the entire cohort and within tumor grades. RESULTS: Of 23,932 patients with NMIBC identified, 22% received adjuvant intravesical BCG. Predictors of receipt were stages Tis and T1, higher grade, and urban residence. Age > 80 years, fewer than two comorbidities, and not being married were associated with decreased use. In the survival analysis, BCG use was associated with better OS (hazard ratio [HR], 0.87; 95% CI, 0.83 to 0.92) in the entire cohort and BCSS among higher-grade cancers (poorly differentiated: HR, 0.78; 95% CI, 0.72 to 0.85; undifferentiated: HR, 0.66; 95% CI, 0.56 to 0.77). CONCLUSION: Despite guidelines recommending its use, BCG is administered to less than one quarter of eligible patients. This large population-based study found improved OS and BCSS were associated with use of adjuvant intravesical BCG among older patients with NMIBC. Better-designed clinical trials focusing on higher-grade cancers are needed to confirm these findings.

Authors: Strauss JA, Chao CR, Kwan ML, Ahmed SA, Schottinger JE, Quinn VP

Title: Identifying primary and recurrent cancers using a SAS-based natural language processing algorithm.

Journal: J Am Med Inform Assoc 20(2):349-55

Date: 2013 Mar-Apr

Abstract: OBJECTIVE: Significant limitations exist in the timely and complete identification of primary and recurrent cancers for clinical and epidemiologic research. A SAS-based coding, extraction, and nomenclature tool (SCENT) was developed to address this problem. MATERIALS AND METHODS: SCENT employs hierarchical classification rules to identify and extract information from electronic pathology reports. Reports are analyzed and coded using a dictionary of clinical concepts and associated SNOMED codes. To assess the accuracy of SCENT, validation was conducted using manual review of pathology reports from a random sample of 400 breast and 400 prostate cancer patients diagnosed at Kaiser Permanente Southern California. Trained abstractors classified the malignancy status of each report. RESULTS: Classifications of SCENT were highly concordant with those of abstractors, achieving κ of 0.96 and 0.95 in the breast and prostate cancer groups, respectively. SCENT identified 51 of 54 new primary and 60 of 61 recurrent cancer cases across both groups, with only three false positives in 792 true benign cases. Measures of sensitivity, specificity, positive predictive value, and negative predictive value exceeded 94% in both cancer groups. DISCUSSION: Favorable validation results suggest that SCENT can be used to identify, extract, and code information from pathology report text. Consequently, SCENT has wide applicability in research and clinical care. Further assessment will be needed to validate performance with other clinical text sources, particularly those with greater linguistic variability. CONCLUSION: SCENT is proof of concept for SAS-based natural language processing applications that can be easily shared between institutions and used to support clinical and epidemiologic research.

Authors: Townsend JS, Steele CB, Richardson LC, Stewart SL

Title: Health behaviors and cancer screening among Californians with a family history of cancer.

Journal: Genet Med 15(3):212-21

Date: 2013 Mar

Abstract: Purpose:The purpose of this study was to compare health behaviors and cancer screening among Californians with and without a family history of cancer.Methods:We analyzed data from the 2005 California Health Interview Survey to ascertain cancer screening test use and to estimate the prevalence of health behaviors that may reduce the risk of cancer. We used logistic regression to control for demographic factors and health-care access.Results:Women with a family history of breast or ovarian cancer were more likely to be up to date with mammography as compared with women with no family history of cancer (odds ratio = 1.69, 95% confidence interval (1.39, 2.04)); their health behaviors were similar to other women. Men and women with a family history of colore