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Publication Abstract

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 :-

Date: 2014 Apr 01

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.British Journal of Cancer advance online publication, 1 April 2014; doi:10.1038/bjc.2014.173 www.bjcancer.com.

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: 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: 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: 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 :-

Date: 2014 Mar 27

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: 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 :-

Date: 2014 Mar 26

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. © 2014 American Cancer Society.

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: To assess the relationship between healthcare system performance on nationally endorsed prostate cancer quality of care measures and prostate cancer treatment outcomes. METHODS: This is a retrospective cohort study including 48,050 men from Surveillance Epidemiology and End Results - Medicare linked data who were diagnosed with localized prostate cancer between 2004 and 2009 and followed through 2010. Based on a composite quality measure, we categorized the healthcare 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 healthcare system-level quality of care with outcomes using multivariable logistic and Cox regression. RESULTS: Patients who underwent prostatectomy in 3-star versus 1-star healthcare systems had a lower risk of perioperative complications (odds ratio 0.80, 95% confidence interval [CI] 0.64-1.00). However, these patients were more likely to undergo a procedure addressing treatment-related morbidity (e.g., 11.3% vs. 7.8% treated for sexual morbidity, p=0.043). Among patients undergoing radiotherapy, star-ranking was not associated with treatment-related morbidity. Among all patients, star-ranking was not significantly associated with all-cause mortality (Hazard Ratio [HR] 0.99, 95% CI 0.84-1.15) or secondary cancer therapy (HR 1.04, 95% CI 0.91-1.20). CONCLUSION: We found no consistent associations between healthcare system quality and outcomes, which questions how meaningful these measures ultimately are for patients. Thus, future studies should focus on the development of more discriminative quality measures.

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 :-

Date: 2014 Mar 24

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: 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: 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 :-

Date: 2014 Mar 19

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: 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 :-

Date: 2014 Mar 18

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: 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 :-

Date: 2014 Mar 18

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. J. Surg. Oncol. © 2014 Wiley Periodicals, Inc.

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 :-

Date: 2014 Mar 15

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

Title: Treatment of Diffuse Large B-Cell Lymphoma (DLBCL) in the Elderly: Regimens without Anthracyclines are Common and Not Futile.

Journal: Leuk Lymphoma :-

Date: 2014 Mar 14

Abstract: Abstract Anthracycline-containing regimens (ACR) are recommended for DLBCL patients. However, over 40% of elderly patients do not receive ACR, possibly due to expected toxicities. We characterized treatment choices and compared the 3-year overall survival rates (OS) of 8,262 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 rituximab, 6% had non-ACR with rituximab (non-ACR-R), 4% had rituximab 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 were highest in ACR-R (65%), followed by ACR without rituximab (55%) and non-ACR-R (44%). After adjusting patient covariates, ACR-R had the best survival (63%). However, OS was comparable between non-ACR-R (52%) and ACR without rituximab (52%). Non-ACR-R could be considered for patients who are poor candidates for ACR.

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 :-

Date: 2014 Mar 11

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: 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 the Androgen Deprivation Therapy on the Risk of Coronary Heart Disease 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 ADT and three separate endpoints: coronary artery disease (CAD), acute myocardial infarction (AMI), and sudden cardiac death (SCD), in a large United States contemporary cohort of PCa patients. MATERIALS AND METHODS: Overall, 140,474 patients diagnosed with non-metastatic PCa 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. Ten-year CAD, AMI, and SCD rates were estimated. Competing-risks regression analyses tested the association between the type of ADT (GnRH agonists vs. bilateral orchiectomy) 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 orchiectomy), 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 orchiectomy (all P≥0.7), was associated with higher risk of CAD, AMI, and SCD. CONCLUSIONS: The administration of GnRH agonists, but not orchiectomy, is still associated with a significantly increased risk of CAD, AMI, and, especially, SCD in patients with non-metastatic PCa. Alternative forms of ADT should be considered in patients at higher risk of CV events.

Authors: Marks MA, Engels EA

Title: Venous Thromboembolism and Cancer Risk among Elderly Adults in the U.S.

Journal: Cancer Epidemiol Biomarkers Prev :-

Date: 2014 Mar 08

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 odds ratios (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%CI 1.12-1.23), stomach (1.19, 1.09-1.30), small intestine (1.42, 1.17-1.71), colon (1.25, 1.18-1.31), gallbladder (1.39, 1.16-1.67), pancreas (1.53, 1.43-1.64), soft tissue (1.43, 1.21-1.68), ovary (1.35, 1.22-1.50), and kidney/renal pelvis (1.34, 1.23-1.46), and melanoma (1.17, 1.08- 1.27), non-Hodgkin lymphoma (1.27, 1.20- 1.35), myeloma (1.48, 1.35-1.63), and acute myeloid leukemia (1.35, 1.19-1.54). Strongest risks were observed within 1 year of VTE diagnosis, but risk were elevated more than 6 years after VTE for colon cancer (OR 1.24, 95%CI 1.12-1.37), pancreatic cancer (1.33, 1.15-1.54), and myeloma (1.35, 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 co-morbidities, and smoking cannot be excluded as explanations, longer-term elevations for select cancers suggest that some VTEs may be caused by cancer precursors.

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

Title: Balancing cardiovascular and cancer death among patients with small renal mass: modification by cardiovascular 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. PATIENTS AND METHODS: Patients with localized 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 cardiovascular-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 tumor size. RESULTS: A total of 754 (10.5%) patients deferred therapy, 1849 (25.8%) patients underwent PN, and 4574 (63.7%) patients underwent RN. Patients at high CV risk who deferred therapy experienced 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: HR 0.59 (95%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 small renal masses at 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. Cancer 2014;120:702-710. © 2013 American Cancer Society.

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 :-

Date: 2014 Mar 01

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

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

Journal: Br J Cancer :-

Date: 2014 Feb 25

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.British Journal of Cancer advance online publication, 25 February 2014; doi:10.1038/bjc.2014.68 www.bjcancer.com.

Authors: Gandaglia G, Karakiewicz PI, Briganti A, Trinh Q, 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 :-

Date: 2014 Feb 22

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. 8-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 vs. 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 to observation (P=0.7). In patients with high-risk disease, the 8-year CSM rates for IMRT vs. observation were 5.8 vs. 10.5%, respectively (P<0.001). The corresponding NNT was 21. When high-risk patients were stratified according to age (<73 vs. ≥73), and CCI (≤1 vs. >1) the 8-year CSM rates for IMRT vs. observation were 4.3 vs. 9.4% and 6.9 vs. 11.9% and 5.3 vs. 11.4% and 6.1 vs. 10.1%, respectively (all P<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 :-

Date: 2014 Feb 19

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 65years 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: 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 :-

Date: 2014 Feb 18

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: 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: 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 :-

Date: 2014 Feb 12

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

Title: Variation in use of active surveillance among men undergoing expectant management for early-stage prostate cancer.

Journal: J Urol :-

Date: 2014 Feb 08

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

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: 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: 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: 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 3(1):124-33

Date: 2014 Feb

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 12months 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 1000person-months) was significantly higher than for those receiving a single neurotoxic agent (7.76 per 1000person-months) or a non-neurotoxic agent (5.19 per 1000person-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: 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: 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 :-

Date: 2014 Jan 30

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: 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 :-

Date: 2014 Jan 29

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: 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 :-

Date: 2014 Jan 28

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. Cancer 2013. © 2013 American Cancer Society.

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 to initial observation, in patients with locally advanced prostate cancer (PCa). PATIENTS AND METHODS: Overall, 1,382 patients with locally advanced PCa treated with RP or initial observation between 1995 and 2009 within the Surveillance, Epidemiology, and End Results (SEER)-Medicare were identified. Patients were matched using propensity-score methodology. Ten-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 vs. 19.3% for patients treated with RP vs. observation, respectively (P<0.001). The corresponding 10-year NNT was 13. The 10-year CSM rates for the same respective treatment groups were 8.9 vs. 13.9% for Gleason score ≤7, 16.8 vs. 27.8% for Gleason score 8-10, 10.1 vs. 15.8% for clinical stage T3a, and 17.0 vs. 29.3% 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 favorable CSM 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 higher risk of CSM compared to those treated with radiotherapy (P=0.03). CONCLUSIONS: RP leads to a significant survival advantage compared to observation in patients with locally advanced disease. The highest benefit was observed in patients with T3b/T4 and Gleason score 8-10 disease.

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 :-

Date: 2014 Jan 17

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. Cancer 2013. © 2013 American Cancer Society.

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 :-

Date: 2014 Jan 16

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: 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: 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: 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: 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: 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

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: 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: 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: 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: 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 :-

Date: 2013 Dec 07

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: 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 :-

Date: 2013 Dec 06

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 (<4mo after RP, n = 419) vs. delayed (4-12mo 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: 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: 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: Karl A, Adejoro O, Saigal C, Konety B, the 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 :-

Date: 2013 Nov 14

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

Title: Determinants of Practice Patterns and Quality Gaps in Lung Cancer Staging and Diagnosis.

Journal: Chest :-

Date: 2013 Nov 07

Abstract: BACKGROUND: Guidelines recommend mediastinal lymph node sampling as the first invasive diagnostic procedure in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases. METHODS: Retrospective cohort of 15,316 patients with lung cancer with regional spread without metastatic disease in the SEER or Texas Cancer Registry Medicare-linked databases. Patients were categorized based on the sequencing of invasive diagnostic tests performed: A) Evaluation consistent with guidelines, mediastinal sampling done first; B) Evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling performed but not as part of the first invasive test; C) Evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling never done; and D) 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 TBNA among pulmonologists. RESULTS: Only 21% of patients had a diagnostic evaluation consistent with guidelines. Only 56% of NSCLC patients 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, U.S. trained, had seen more lung cancer patients, and was a pulmonologist or thoracic surgeon who had graduated more recently. More recent pulmonary graduates were also more likely to perform transbronchial needle aspiration (p<0.001). CONCLUSION: 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 :-

Date: 2013 Nov 07

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: 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: 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: 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: 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: 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: 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: 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: 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 :-

Date: 2013 Oct 19

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: 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: 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:

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: 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: 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: 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. Copyright © 2013 John Wiley & Sons, Ltd.

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: 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: 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: Yabroff KR, 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: 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: 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: 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: 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: 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 :-

Date: 2013 Jun 28

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: 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: 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 :-

Date: 2013 Jun 20

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: 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: 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: 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: 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: 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: 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: 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: 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: 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: 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 colorectal cancer were more likely to be up to date with colorectal cancer screening as compared with individuals with no family history of cancer (odds ratio = 2.77, 95% confidence interval (2.20, 3.49)) but were less likely to have a body mass index <25 kg/m(2) (odds ratio = 0.80, 95% confidence interval (0.67, 0.94)).Conclusion:Innovative methods are needed to encourage those with a moderate-to-strong familial risk for breast cancer and colorectal cancer to increase their physical activity levels, strive to maintain a healthy weight, quit smoking, and reduce alcohol use.Genet Med 2013:15(3):212-221.

Authors: Tran TV, Nguyen D, Chan K, Nguyen TN

Title: The association of self-rated health and lifestyle behaviors among foreign-born Chinese, Korean, and Vietnamese Americans.

Journal: Qual Life Res 22(2):243-52

Date: 2013 Mar

Abstract: PURPOSE: This study employed the 2009 California Health Interview Survey to examine the association of self-rated heath status and lifestyle behavior variables such as smoking at least 100 cigarettes or more in an entire lifetime, alcohol consumption, and physical activity level among foreign-born Chinese, Korean, and Vietnamese Americans aged 18 and older. METHODS: The total study sample consisted of 3,023 foreign-born adult Chinese (n = 812), Korean (n = 857), and Vietnamese (n = 1,354) Americans. Logistic regression via Stata 12 was employed. Odds ratios (OR) along with confidence intervals (CI) were reported in the results. RESULTS: Results revealed that smoking at least 100 cigarettes or more in an entire lifetime had a negative association with good health status (OR = 0.74, 95 % CI = 0.59, 0.94), while alcohol consumption had a positive association with good health status (OR = 1.20, 95 % CI = 1.00, 1.44). Moderate physical activity (OR = 1.26, 95 % CI = 1.05, 1.50) and vigorous physical activity (OR = 1.68, 95 % CI = 1.31, 2.15) had a similar positive association with good self-rated health status. The results also revealed that the predicted probability of self-rated health status based on ethnicity and lifestyle variables was more favorable for foreign-born Chinese Americans than their Korean and Vietnamese American counterparts. CONCLUSIONS: This study's results corroborated the findings reported in previous research on the association of lifestyle behaviors and health status. Regardless of racial or ethnic backgrounds, good lifestyles have an important role in the prevention of poor health status. However, health education and lifestyle intervention programs should take cultural differences among racial and ethnic populations into consideration.

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

Title: Rate of early/missed colorectal cancers after colonoscopy in older patients with or without inflammatory bowel disease in the United States.

Journal: Am J Gastroenterol 108(3):444-9

Date: 2013 Mar

Abstract: OBJECTIVES: Patients with inflammatory bowel disease (IBD) have an increased risk for colorectal cancer (CRC). Previous studies on early/missed CRCs after colonoscopy excluded IBD patients. The aim of this study was to compare the rate of early/missed CRCs after colonoscopy among IBD and non-IBD patients, and identify factors associated with early/missed CRCs. METHODS: All patients in the Surveillance, Epidemiology and End-Results Medicare-linked database who were 67 years or older at colonoscopy during 1998-2005 and those who were subsequently diagnosed with CRC within 36 months were identified. CRCs diagnosed within 6 months of colonoscopy were categorized as detected CRCs; CRCs diagnosed 6-36 months after colonoscopy were categorized as early/missed CRCs. The rate of early/missed CRCs was calculated as number of early/missed CRCs divided by number of detected and early/missed CRCs. The χ(2) test and multivariate logistic regression were used in statistical analysis. RESULTS: Of 55,008 CRC patients (304 Crohn's disease; 544 ulcerative colitis (UC)), the rate of early/missed CRCs was 5.8% for non-IBD patients, 15.1% for Crohn's, and 15.8% for UC (P<0.001). Compared with older non-IBD patients, early/missed CRCs among older IBD patients were less likely right-sided (both P<0.05). In multivariate logistic regression, the risk of early/missed CRCs was three times as high for IBD patients (Crohn's odds ratio (OR), 3.07; 95% confidence interval (CI) 2.23-4.21; UC OR, 3.05; 95% CI, 2.44-3.81). Sensitivity analyses confirmed the robustness of this finding. CONCLUSIONS: Older IBD patients had a higher rate of early/missed CRCs after colonoscopy. Our finding supports intensive surveillance colonoscopy for older IBD patients as recommended by guidelines.

Authors: Banegas MP, Yabroff KR

Title: Out of pocket, out of sight? An unmeasured component of the burden of cancer.

Journal: J Natl Cancer Inst 105(4):252-3

Date: 2013 Feb 20

Abstract:

Authors: Morgans AK, Smith MR, O'Malley AJ, Keating NL

Title: Bone density testing among prostate cancer survivors treated with androgen-deprivation therapy.

Journal: Cancer 119(4):863-70

Date: 2013 Feb 15

Abstract: BACKGROUND: Androgen-deprivation therapy (ADT) causes bone loss and fractures. Guidelines recommend bone density testing before and during ADT to characterize fracture risk. The authors of the current report assessed bone density testing among men who received ADT for ≥ 1 year. METHODS: Surveillance, Epidemiology, and End Results/Medicare data were used to identify 28,960 men aged > 65 years with local/regional prostate cancer diagnosed from 2001 to 2007 who were followed through 2009 and who received ≥ 1 year of continuous ADT. Bone density testing was documented in the 18-month period beginning 6 months before ADT initiation. Logistic regression was used to identify the factors associated with bone density testing. RESULTS: Among men who received ≥ 1 year of ADT, 10.2% had a bone density assessment from 6 months before starting ADT through 1 year after. Bone density testing increased over time (14.5% of men who initiated ADT in 2007-2008 vs 6% of men who initiated ADT in 2001-2002; odds ratio for 2007-2008 vs 2001-2002, 2.29; 95% confidence interval, 1.83-2.85). Less bone density testing was observed among men aged ≥ 85 years versus men ages 66 to 69 years (odds ratio, 0.76; 95% confidence interval, 0.65-0.89), among black men versus white men (odds ratio, 0.72; 95% confidence interval, 0.61-0.86), and among men in areas with lower educational attainment (P < .001). Men who visited a medical oncologist and/or a primary care provider in addition to a urologist had higher odds of testing than men who only consulted a urologist (P < .001). CONCLUSIONS: Few men who received ADT for prostate cancer underwent bone density testing, particularly older men, black men, and those living in areas with low educational attainment. Visiting a medical oncologist was associated with increased odds of testing. Interventions are needed to increase bone density testing among men who receive long-term ADT. Data on bone density testing for nonmilitary populations of prostate cancer survivors in the United States who have received long-term androgen-deprivation therapy (ADT) have not been published. The current analysis of Surveillance, Epidemiology, and End Results/Medicare data suggests that few prostate cancer survivors who receive long-term ADT undergo bone density testing; and several key populations, including African Americans and older men, have considerably lower rates of bone density screening.

Authors: Zafar SY, Malin JL, Grambow SC, Abbott DH, Kolimaga JT, Zullig LL, Weeks JC, Ayanian JZ, Kahn KL, Ganz PA, Catalano PJ, West DW, Provenzale D, Cancer Care Outcomes Research & Surveillance CanCORS Consortium

Title: Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study.

Journal: Cancer 119(4):854-62

Date: 2013 Feb 15

Abstract: BACKGROUND: The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer. METHODS: Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy. RESULTS: Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy. CONCLUSIONS: The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

Authors: Gross CP, Long JB, Ross JS, Abu-Khalaf MM, Wang R, Killelea BK, Gold HT, Chagpar AB, Ma X

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

Journal: JAMA Intern Med 173(3):220-6

Date: 2013 Feb 11

Abstract: BACKGROUND: Little is known about the cost to Medicare of breast cancer screening or whether regional-level screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women. METHODS: Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screening-related cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs. RESULTS: In the United States, the annual costs to fee-for-service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were $1.08 billion and $1.36 billion, respectively. For women 75 years or older, annual screening-related expenditures exceeded $410 million. Age-standardized screening-related cost per beneficiary varied more than 2-fold across regions (from $42 to $107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.78 [95% CI, 1.40-2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs ($151 vs $115; P = .20). CONCLUSIONS: The cost to Medicare of breast cancer screening exceeds $1 billion annually in the fee-for-service program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes.

Authors: Chen AB, Cronin A, Weeks JC, Chrischilles EA, Malin J, Hayman JA, Schrag D

Title: Palliative radiation therapy practice in patients with metastatic non-small-cell lung cancer: a Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study.

Journal: J Clin Oncol 31(5):558-64

Date: 2013 Feb 10

Abstract: PURPOSE: Randomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression. RESULTS: Of 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associated with younger age at diagnosis and receipt of chemotherapy and surgery to metastatic sites. Among patients receiving palliative bone RT, only 6% received single-fraction treatment. Among patients receiving palliative chest RT, 42% received more than 20 fractions. Patients treated in integrated networks were more likely to receive lower doses and fewer fractions to the bone and chest. CONCLUSION: When palliative RT is used in patients with metastatic NSCLC, a substantial proportion of patients receive a greater number of treatments and higher doses than supported by current evidence, suggesting an opportunity to improve care delivery.

Authors: Malin JL, Weeks JC, Potosky AL, Hornbrook MC, Keating NL

Title: Medical oncologists' perceptions of financial incentives in cancer care.

Journal: J Clin Oncol 31(5):530-5

Date: 2013 Feb 10

Abstract: PURPOSE: The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised about financial incentives associated with the chemotherapy concession in oncology practices and their impact on treatment recommendations. METHODS: The objective of this study was to measure the physician-reported effects of prescribing chemotherapy or growth factors or making referrals to other cancer specialists, hospice, or hospital admissions on medical oncologists' income. US medical oncologists involved in the care of a population-based cohort of patients with lung or colorectal cancer from the Cancer Care Outcomes Research and Surveillance (CanCORS) study were surveyed regarding their perceptions of the impact of prescribing practices or referrals on their income. RESULTS: Although most oncologists reported that their incomes would be unaffected, compared with salaried oncologists, physicians in fee-for-service practice, and those paid a salary with productivity incentives were more likely to report that their income would increase from administering chemotherapy (odds ratios [ORs], 7.05 and 7.52, respectively; both P < .001) or administering growth factors (ORs, 5.60 and 6.03, respectively; both P < .001). CONCLUSION: A substantial proportion of oncologists who are not paid a fixed salary report that their incomes increase when they administer chemotherapy and growth factors. Further research is needed to understand the impact of these financial incentives on both the quality and cost of care.

Authors: Halasz LM, Weeks JC, Neville BA, Taback N, Punglia RS

Title: Use of stereotactic radiosurgery for brain metastases from non-small cell lung cancer in the United States.

Journal: Int J Radiat Oncol Biol Phys 85(2):e109-16

Date: 2013 Feb 01

Abstract: PURPOSE: The indications for treatment of brain metastases from non-small cell lung cancer (NSCLC) with stereotactic radiosurgery (SRS) remain controversial. We studied patterns, predictors, and cost of SRS use in elderly patients with NSCLC. METHODS AND MATERIALS: Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we identified patients with NSCLC who were diagnosed with brain metastases between 2000 and 2007. Our cohort included patients treated with radiation therapy and not surgical resection as initial treatment for brain metastases. RESULTS: We identified 7684 patients treated with radiation therapy within 2 months after brain metastases diagnosis, of whom 469 (6.1%) cases had billing codes for SRS. Annual SRS use increased from 3.0% in 2000 to 8.2% in 2005 and varied from 3.4% to 12.5% by specific SEER registry site. After controlling for clinical and sociodemographic characteristics, we found SRS use was significantly associated with increasing year of diagnosis, specific SEER registry, higher socioeconomic status, admission to a teaching hospital, no history of participation in low-income state buy-in programs (a proxy for Medicaid eligibility), no extracranial metastases, and longer intervals from NSCLC diagnosis. The average cost per patient associated with radiation therapy was 2.19 times greater for those who received SRS than for those who did not. CONCLUSIONS: The use of SRS in patients with metastatic NSCLC increased almost 3-fold from 2000 to 2005. In addition, we found significant variations in SRS use across SEER registries and socioeconomic quartiles. National practice patterns in this study suggested both a lack of consensus and an overall limited use of the approach among elderly patients before 2008.

Authors: Jensen RE, Arora NK, Bellizzi KM, Rowland JH, Hamilton AS, Aziz NM, Potosky AL

Title: Health-related quality of life among survivors of aggressive non-Hodgkin lymphoma.

Journal: Cancer 119(3):672-80

Date: 2013 Feb 01

Abstract: BACKGROUND: Non-Hodgkin lymphoma (NHL) is the fifth most common cancer among men and women. Patients with aggressive NHL receive intense medical treatments that can significantly compromise health-related quality of life (HRQOL). However, knowledge of HRQOL and its correlates among survivors of aggressive NHL is limited. METHODS: Self-reported data on HRQOL (physical and mental function, anxiety, depression, and fatigue) were analyzed for 319 survivors of aggressive NHL. Survivors 2 to 5 years postdiagnosis were selected from the Los Angeles County Cancer Registry. Bivariate and multivariable methods were used to assess the influence of sociodemographic, clinical, and cognitive health-appraisal factors on survivors' HRQOL. RESULTS: After accounting for other covariates, marital status was associated with all HRQOL outcomes (P < .05). Younger survivors reported worse mental function and higher levels of depression, anxiety, and fatigue (P < .01). Survivors who had more comorbid conditions or lacked private health insurance reported worse physical and mental function and higher levels of depression and fatigue (P < .05). Survivors who experienced a recurrence reported worse physical function and higher levels of depression and fatigue (P < .05). With the exception of a nonsignificant association between perceived control and physical function, greater perceptions of personal control and health competence were associated significantly with more positive HRQOL outcomes (P < .01). CONCLUSIONS: The current results indicated that survivors of aggressive NHL who are younger, are unmarried, lack private insurance, or experience greater illness burden may be at risk for poorer HRQOL. Cognitive health-appraisal factors were strongly related to HRQOL, suggesting potential benefits of interventions focused on these mutable factors for this population.

Authors: Neuman HB, O'Connor ES, Weiss J, Loconte NK, Greenblatt DY, Greenberg CC, Smith MA

Title: Surgical treatment of colon cancer in patients aged 80 years and older : analysis of 31,574 patients in the SEER-Medicare database.

Journal: Cancer 119(3):639-47

Date: 2013 Feb 01

Abstract: BACKGROUND: Age-related disparities in colon cancer treatment exist, with older patients being less likely to receive recommended therapy. However, to the authors' knowledge, few studies to date have focused on receipt of surgery. The objective of the current study was to describe patterns of surgery in patients aged ≥ 80 years with colon cancer and examine outcomes with and without colectomy. METHODS: Medicare beneficiaries aged ≥ 80 years with colon cancer who were diagnosed between 1992 and 2005 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Multivariable logistic regression analysis was used to assess factors associated with nonoperative management. Kaplan-Meier survival analysis determined 1-year overall and colon cancer-specific survival. RESULTS: Of 31,574 patients, 80% underwent colectomy. Approximately 46% were diagnosed during an urgent/emergent hospital admission, with decreased 1-year overall survival (70% vs 86% for patients diagnosed during an elective admission) noted among these individuals. Factors found to be most predictive of nonoperative management included older age, black race, more hospital admissions, use of home oxygen, use of a wheelchair, being frail, and having dementia. For both operative and nonoperative patients, the 1-year overall survival rate was lower than the colon cancer-specific survival rate (operative patients: 78% vs 89%; nonoperative patients: 58% vs 78%). CONCLUSIONS: The majority of older patients with colon cancer undergo surgery, with improved outcomes noted compared with nonoperative management. However, many patients who are not selected for surgery die of unrelated causes, reflecting good surgical selection. Patients undergoing surgery during an urgent/emergent admission have an increased short-term mortality risk. Because the earlier detection of colon cancer may increase the percentage of older patients undergoing elective surgery, the findings of the current study may have policy implications for colon cancer screening and suggest that age should not be the only factor driving cancer screening recommendations.

Authors: Vest MT, Herrin J, Soulos PR, Decker RH, Tanoue L, Michaud G, Kim AW, Detterbeck F, Morgensztern D, Gross CP

Title: Use of new treatment modalities for non-small cell lung cancer care in the Medicare population.

Journal: Chest 143(2):429-35

Date: 2013 Feb 01

Abstract: BACKGROUND: Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as video-assisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare beneficiaries with stage I NSCLC are unknown. METHODS: We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment. RESULTS: The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0). CONCLUSION: From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation.

Authors: Arasu VA, Joe BN, Lvoff NM, Leung JW, Brenner RJ, Flowers CI, Moore DH, Sickles EA

Title: Response.

Journal: Radiology 266(2):685-6

Date: 2013 Feb

Abstract:

Authors: Catalano PJ, Ayanian JZ, Weeks JC, Kahn KL, Landrum MB, Zaslavsky AM, Lee J, Pendergast J, Harrington DP, Cancer Care Outcomes Research Surveillance Consortium

Title: Representativeness of participants in the cancer care outcomes research and surveillance consortium relative to the surveillance, epidemiology, and end results program.

Journal: Med Care 51(2):e9-15

Date: 2013 Feb

Abstract: BACKGROUND: The research goals of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium are to determine how characteristics and beliefs of patients, providers, and health care organizations influence the treatments and outcomes of individuals with newly diagnosed lung and colorectal cancers. As CanCORS results will inform national policy, it is important to know how they generalize to the United States population with these cancers. RESEARCH DESIGN: This study assessed the representativeness of the CanCORS cohort of 10,547 patients with lung cancer (LC) or colorectal cancer (CRC) enrolled between 2003 and 2005. We compared characteristics (sex, race, age, and disease stage) with the Surveillance, Epidemiology, and End Results (SEER) population of 234,464 patients with new onset of these cancers during the CanCORS recruitment period. RESULTS: The CanCORS sample is well matched to the SEER Program for both cancers. In CanCORS, 41% LC/47% CRC were female versus 47% LC/49% CRC in SEER. African American, Hispanic, and Asian cases differed by no more than 5 percentage points between CanCORS and SEER. The SEER population is slightly older, with the percentage of patients older than 75 years 33.1% LC/37.3% CRC in SEER versus 26.9% LC/29.4% in CanCORS, and also has a slightly higher proportion of early stage patients. We also found that the CanCORS cohort was representative within specific SEER regions that map closely to CanCORS sites. CONCLUSIONS: This study demonstrates that the CanCORS Consortium was successful in enrolling a demographically representative sample within the CanCORS regions.

Authors: Chando S, Tiro JA, Harris TR, Kobrin S, Breen N

Title: Effects of socioeconomic status and health care access on low levels of human papillomavirus vaccination among Spanish-speaking Hispanics in California.

Journal: Am J Public Health 103(2):270-2

Date: 2013 Feb

Abstract: Little is known about the effect of language preference, socioeconomic status, and health care access on human papillomavirus (HPV) vaccination. We examined these factors in Hispanic parents of daughters aged 11 to 17 years in California (n = 1090). Spanish-speaking parents were less likely to have their daughters vaccinated than were English speakers (odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.31, 0.98). Adding income and access to multivariate analyses made language nonsignificant (OR = 0.68; 95% CI = 0.35, 1.29). This confirms that health care use is associated with language via income and access. Low-income Hispanics, who lack access, need information about free HPV vaccination programs.

Authors: Kamineni A, Anderson ML, White E, Taplin SH, Porter P, Ballard-Barbash R, Malone K, Buist DS

Title: Body mass index, tumor characteristics, and prognosis following diagnosis of early-stage breast cancer in a mammographically screened population.

Journal: Cancer Causes Control 24(2):305-12

Date: 2013 Feb

Abstract: PURPOSE: Many studies suggest increased body mass index (BMI) is associated with worse breast cancer outcomes, but few account for variability in screening, access to treatment, and tumor differences. We examined the association between BMI and risk of breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality, and evaluated whether tumor characteristics differ by BMI among a mammographically screened population with access to treatment. METHODS: Using a retrospective cohort study design, we followed 485 women aged ≥40 years diagnosed with stage I/II breast cancer within 24 months of a screening mammogram occurring between 1988 and 1993 for 10-year outcomes. BMI before diagnosis was categorized as normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). Tumor marker expression was assessed via immunohistochemistry using tissue collected before adjuvant treatment. Medical records were abstracted to identify treatment, recurrence, and mortality. We used Cox proportional hazards to separately model the hazard ratios (HR) of our three outcomes by BMI while adjusting for age, stage, and tamoxifen use. RESULTS: Relative to normal-weight women, obese women experienced increased risk of recurrence (HR 2.43; 95 % CI 1.34-4.41) and breast cancer death (HR 2.41; 95 % CI 1.00-5.81) within 10 years of diagnosis. There was no association between BMI and all-cause mortality. Obese women had significantly faster growing tumors, as measured by Ki-67. CONCLUSIONS: Our findings add to the growing evidence that obesity may contribute to poorer breast cancer outcomes, and also suggest that increased tumor proliferation among obese women is a pathway that explains part of their excess risk of adverse outcomes.

Authors: Kim PH, Pinheiro LC, Atoria CL, Eastham JA, Sandhu JS, Elkin EB

Title: Trends in the use of incontinence procedures after radical prostatectomy: a population based analysis.

Journal: J Urol 189(2):602-8

Date: 2013 Feb

Abstract: PURPOSE: Urinary incontinence is a frequent complication of radical prostatectomy with a detrimental impact on quality of life. We identified predictors and trends in the use of procedures for post-prostatectomy incontinence. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results) cancer registry data linked with Medicare claims, we identified men 66 years old or older who were treated with radical prostatectomy in 2000 to 2007. The primary outcome was performance of an incontinence procedure. Demographic and clinical predictors of incontinence surgery were evaluated by multivariable regression analysis. RESULTS: Of 16,348 men treated with radical prostatectomy 1,057 (6%) had undergone at least 1 incontinence procedure by a median of 20 months after the procedure, including 61% who underwent the first incontinence procedure within 2 years of prostatectomy. Older age and residence in the South were associated with greater probability of an incontinence procedure. Black men and those living in nonmetropolitan areas were less likely than their peers to undergo an incontinence procedure. Of men treated with any incontinence procedure 15% underwent more than 1 type. Of those treated with bulking agents 39% also received a urethral sling or artificial urinary sphincter and 13% who received a sling also had an artificial urinary sphincter. In 34% of the men who underwent any incontinence surgery artificial urinary sphincter placement was the only procedure performed. CONCLUSIONS: In this population based cohort of older men with prostate cancer only 6% underwent an incontinence procedure after prostatectomy. This low rate may reflect the underuse of potentially beneficial procedures.

Authors: Matushansky I, Dela Cruz F, Insel BJ, Hershman DL, Neugut AI

Title: Chemotherapy use in elderly patients with soft tissue sarcoma: a population-based study.

Journal: Cancer Invest 31(2):83-91

Date: 2013 Feb

Abstract: Adjuvant chemotherapy for soft tissue sarcoma (STS) remains controversial while improvement in survival has never been conclusively demonstrated for metastatic STS. We identified individuals in SEER-Medicare with resected or metastatic STS, 1991-2007. Of 2,382 patients with resected STS, 106 (4.5%) received chemotherapy. High tumor grade, larger tumor size, and malignant fibrous histiocytoma subtype were associated with chemotherapy receipt. Of 365 patients with metastatic STS, 118 (32.4%) received chemotherapy. Younger age, fewer comorbidities, and being married were associated with chemotherapy receipt. Consistent with clinical trials, we found minimal use of chemotherapy. Clinical factors were associated with chemotherapy receipt in nonmetastatic STS.

Authors: Okechukwu CA, Dutra LM, Bacic J, El Ayadi A, Emmons KM

Title: Home matters: work and household predictors of smoking and cessation among blue-collar workers.

Journal: Prev Med 56(2):130-4

Date: 2013 Feb

Abstract: OBJECTIVE: This study examined the joint influence of work- and household-related variables on smoking behavior among a population representative sample of blue-collar workers with live-in partners. METHODS: The study used data on 1389 blue-collar workers from the Tobacco Use Supplement to the United States Current Population Survey 2002 to 2003 longitudinal overlap sample. Unadjusted and adjusted logistical regression analyses, which employed sampling and replicate weights to account for sampling design, were run to estimate independent and joint effects of the predictors. RESULTS: In adjusted analyses, partner smoking (OR=4.97, 95%CI=3.02-8.18) and complete and partial home smoking policy (OR=0.16, 95%CI=0.09-0.29 and OR=0.39, 95%CI=0.23-0.68, respectively) were significant predictors of smoking status, but worksite smoking policies and presence of a young child under 5 in the household were not (p>0.05). Baseline complete home smoking ban was a significant predictor of subsequent cessation (OR=3.49, 95%CI=1.19-10.23), while partner smoking status, workplace smoking policy, and the presence of a young child in the home did not predict cessation (p>0.05). CONCLUSION: Household-related variables were significant predictors of smoking status and cessation among blue-collar workers. Current efforts to decrease smoking in this group, which are mostly focused on work-related risk factors, should consider how to incorporate household risk factors.

Authors: Rajan SS, Carpenter WR, Stearns SC, Lyman GH

Title: Short-term costs associated with primary prophylactic G-CSF use during chemotherapy.

Journal: Am J Manag Care 19(2):150-9

Date: 2013 Feb

Abstract: BACKGROUND: Chemotherapy is vital for breast cancer treatment, but early-onset toxicities like neutropenia hinder its administration. Neutropenia also increases costs due to hospitalizations and aggressive systemic antibiotic administration. Primary prophylactic (PP) use of granulocyte colony-stimulating factor (G-CSF) helps prevent neutropenia. However, evidence supporting the cost-effectiveness of PPG-CSF is inconclusive, and American Society of Clinical Oncology guidelines state the need for performing cost analyses in high-risk groups like the elderly. OBJECTIVES: To examine the effect of PPG-CSF administration on neutropenia hospitalization costs and overall Medicare costs during the year following chemotherapy initiation. METHODS: A retrospective observational study of patients newly diagnosed with breast cancer between 1994 and 2002 was performed using the linked SEER-Medicare database. To account for the nonrandom nature of observational data, a covariate matching technique was used to preprocess the data before performing parametric analysis estimating the effect of PPG-CSF on costs. RESULTS: Administration of PPG-CSF during the first course of chemotherapy was associated with a 57% increase in overall Medicare costs during the study period, despite a drop in neutropenia hospitalization costs. Forty-two percent of the increase in costs was due to increase in chemotherapy costs during the year after chemotherapy initiation. CONCLUSIONS: A significant part of the increase in immediate medical costs in breast cancer patients receiving PPG-CSF is due to improved chemotherapy administration. It is important to determine whether these short-term cost increases lead to long-term health benefits and savings. Cost analyses with longer follow-ups are crucial for chronic diseases like breast cancer.

Authors: Revels SL, Banerjee M, Yin H, Sonnenday CJ, Birkmeyer JD

Title: Racial disparities in surgical resection and survival among elderly patients with poor prognosis cancer.

Journal: J Am Coll Surg 216(2):312-9

Date: 2013 Feb

Abstract: BACKGROUND: Reports indicate that black patients have lower survival after the diagnosis of a poor prognosis cancer, compared with white patients. We explored the extent to which this disparity is attributable to the underuse of surgery. STUDY DESIGN: Using the Surveillance, Epidemiology, and End Results program and Medicare database, we identified 57,364 patients, ages 65 years and older, with a new diagnosis of nonmetastatic liver, lung, pancreatic, and esophageal cancer, from 2000 to 2005. We evaluated racial differences in resection rates after adjustment for patient, tumor, and hospital characteristics using hierarchical logistic regression. Cox proportional hazards regression was used to assess racial differences in survival after adjusting for patient, tumor, and hospital characteristics, and receipt of surgery. RESULTS: Compared with white patients, black patients were less likely to undergo surgery for liver (adjusted odds ratio [aOR] = 0.49; 95% CI, 0.29-0.83), lung (aOR = 0.62; 95% CI, 0.56-0.69), pancreas (aOR = 0.53; 95% CI, 0.41-0.70), and esophagus cancers (aOR = 0.64; 95% CI, 0.42-0.99). Hospitals varied in their surgery rates among patients with potentially resectable disease. However, resection rates were consistently lower for black patients, regardless of the resection rate of the treating hospital. Although there were no racial differences in overall survival with liver and esophageal cancer, black patients experienced poorer survival for lung (adjusted hazard ratio = 1.05; 95% CI, 1.00-1.10) and pancreas cancer (adjusted hazard ratio = 1.15; 95% CI, 1.03-1.30). In both instances, there were no residual racial disparities in overall survival after adjusting for use of surgery. CONCLUSIONS: Black patients are less likely to undergo surgery after diagnosis of a poor prognosis cancer. Our findings suggest that surgery is an important predictor of overall mortality, and that efforts to reduce racial disparities will require stakeholders to gain a better understanding of why elderly black patients are less likely to get to the operating room.

Authors: Wang SY, Kuntz KM, Tuttle TM, Jacobs DR Jr, Kane RL, Virnig BA

Title: The association of preoperative breast magnetic resonance imaging and multiple breast surgeries among older women with early stage breast cancer.

Journal: Breast Cancer Res Treat 138(1):137-47

Date: 2013 Feb

Abstract: To evaluate the association between preoperative breast magnetic resonance imaging (MRI) utilization and the rate of multiple surgeries, and to investigate the extent of any variation of rates of multiple surgeries among physicians. We identified patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007 in the Surveillance, Epidemiology, and End Results-Medicare database. Using diagnosis and procedure codes, we defined that the initial treatment episode had ended when a gap in surgery occurred at least 90 days after primary surgery. Surgical procedures of partial mastectomy or mastectomy during the initial treatment period were calculated to identify patients who received multiple surgeries. Multilevel logistic regression models were used to identify patient- and physician-level predictors of multiple surgeries. Of 45,453 women with early stage breast cancer who were treated by 2,595 surgeons during the study period, 9,462 patients (20.8 %) received multiple breast surgeries; of these patients, 8,318 (87.9 %) underwent one additional surgery, 988 (10.4 %) received two additional surgeries, and 156 (1.6 %) received three or more additional surgeries. Among 2,997 (6.6 % of the entire cohort) women who underwent preoperative breast MRI evaluation, 770 received multiple breast surgeries. After we adjusted for patient and tumor characteristics associated with multiple surgeries, we found that the rate of multiple surgeries was not significantly different between the two groups with or without preoperative breast MRI. Furthermore, the median odds ratio of 2.0, corresponding with the median value of the relative odds of receiving multiple surgeries between two randomly chosen physicians after controlling for other confounders, indicated a large individual surgeon effect. Substantial variation was observed in the rates of multiple surgeries in women aged 66 and older with early stage breast cancer. Evidence does not support that preoperative breast MRI reduces the incidence of multiple surgeries.

Authors: Wei F, Moore PC, Green AL

Title: Geographic variability in human papillomavirus vaccination among U.S. young women.

Journal: Am J Prev Med 44(2):154-7

Date: 2013 Feb

Abstract: BACKGROUND: Little information is available on geographic disparity of human papillomavirus (HPV) vaccination among women aged 18-26 years in the U.S. Genital HPV is the most common sexually transmitted infection in the U.S. Persistent HPV infection with oncogenic types can cause cervical cancer. PURPOSE: This study utilized data collected from the 2010 National Health Interview Survey (NHIS). It identified geographic variability and other factors contributing to the disparities in HPV vaccine series initiation in a nationally representative sample of women aged 18-26 years. METHODS: The study utilized data collected from 1867 women who participated in the Cancer Control Module Supplement of the 2012 NHIS. A multivariable logistic regression model was used to assess characteristics associated with initiation of the HPV series. Analyses were performed in 2012. RESULTS: After adjusting for other characteristics, women living in the West and North Central/Midwest had 54% and 20% greater odds of initiating the HPV series, respectively, compared with those living in the Northeast. Other factors associated with HPV series initiation were younger age, Hispanic background, being single/never married, childlessness, a history of HPV, and current alcohol use. Factors correlated with failure to initiate the HPV series were: not having insurance, living below the 200% poverty level, not being a high school graduate, not currently using hormone-based birth control, most recent Pap >1 year ago, no regular provider, last clinic visit ≥12 months ago, and never having received the hepatitis B vaccine. CONCLUSIONS: Results demonstrate disparity in HPV vaccine uptake by region of residence in the U.S. among young women. Further research is needed to understand the factors contributing to this geographic disparity. Evaluation of vaccination policies and practices associated with higher coverage regions might help characterize effective methods to improve HPV vaccination among women aged 18-26 years.

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 :-

Date: 2013 Jan 04

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=40 724). 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: Guadagnolo BA, Liao KP, Elting L, Giordano S, Buchholz TA, Shih YC

Title: Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States.

Journal: J Clin Oncol 31(1):80-7

Date: 2013 Jan 01

Abstract: PURPOSE: Our goal was to evaluate use and associated costs of radiation therapy (RT) in the last month of life among those dying of cancer. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare linked databases to analyze claims data for 202,299 patients dying as a result of lung, breast, prostate, colorectal, and pancreas cancers from 2000 to 2007. Logistic regression modeling was used to conduct adjusted analyses of potential impacts of demographic, health services, and treatment-related variables on receipt of RT and treatment with greater than 10 days of RT. Costs were calculated in 2009 dollars. RESULTS: Among the 15,287 patients (7.6%) who received RT in the last month of life, its use was associated with nonclinical factors such as race, gender, income, and hospice care. Of these patients, 2,721 (17.8%) received more than 10 days of treatment. Nonclinical factors that were associated with greater likelihood of receiving more than 10 days of RT in the last 30 days of life included: non-Hispanic white race, no receipt of hospice care, and treatment in a freestanding, versus a hospital-associated facility. Hospice care was associated with 32% decrease in total costs of care in the last month of life among those receiving RT. CONCLUSION: Although utilization of RT overall was low, almost one in five of patients who received RT in their final 30 days of life spent more than 10 of those days receiving treatment. More research is needed into physician decision making regarding use of RT for patients with end-stage cancer.

Authors: Mahnken JD, Keighley JD, Girod DA, Chen X, Mayo MS

Title: Identifying incident oral and pharyngeal cancer cases using Medicare claims.

Journal: BMC Oral Health 13(1):1-

Date: 2013 Jan 01

Abstract: BACKGROUND: Baseline and trend data for oral and pharyngeal cancer incidence is limited. A new algorithm was derived using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to create an algorithm to identify incident cases of oral and pharyngeal cancer using Medicare claims. METHODS: Using a split-sample approach, Medicare claims' procedure and diagnosis codes were used to generate a new algorithm to identify oral and pharyngeal cancer cases and validate its operating characteristics. RESULTS: The algorithm had high sensitivity (95%) and specificity (97%), which varied little by age group, sex, and race and ethnicity. CONCLUSION: Examples of the utility of this algorithm and its operating characteristics include using it to derive baseline and trend estimates of oral and pharyngeal cancer incidence. Such measures could be used to provide incidence estimates where they are lacking or to serve as comparator estimates for tumor registries.

Authors:

Title: Stat bite distribution of 5-year breast cancer risk in the Breast Cancer Surveillance Consortium (BCSC) estimated with the BCSC risk calculator

Journal: J Natl Cancer Inst 105(1):5-

Date: 2013 Jan

Abstract:

Authors: Armstrong K, Handorf EA, Chen J, Bristol Demeter MN

Title: Breast cancer risk prediction and mammography biopsy decisions: a model-based study.

Journal: Am J Prev Med 44(1):15-22

Date: 2013 Jan

Abstract: BACKGROUND: Controversy continues about screening mammography, in part because of the risk of false-negative and false-positive mammograms. Pre-test breast cancer risk factors may improve the positive and negative predictive value of screening. PURPOSE: To create a model that estimates the potential impact of pre-test risk prediction using clinical and genomic information on the reclassification of women with abnormal mammograms (BI-RADS3 and BI-RADS4 [Breast Imaging-Reporting and Data System]) above and below the threshold for breast biopsy. METHODS: The current study modeled 1-year breast cancer risk in women with abnormal screening mammograms using existing data on breast cancer risk factors, 12 validated breast cancer single-nucleotide polymorphisms (SNPs), and probability of cancer given the BI-RADS category. Examination was made of reclassification of women above and below biopsy thresholds of 1%, 2%, and 3% risk. The Breast Cancer Surveillance Consortium data were collected from 1996 to 2002. Data analysis was conducted in 2010 and 2011. RESULTS: Using a biopsy risk threshold of 2% and the standard risk factor model, 5% of women with a BI-RADS3 mammogram had a risk above the threshold, and 3% of women with BI-RADS4A mammograms had a risk below the threshold. The addition of 12 SNPs in the model resulted in 8% of women with a BI-RADS3 mammogram above the threshold for biopsy and 7% of women with BI-RADS4A mammograms below the threshold. CONCLUSIONS: The incorporation of pre-test breast cancer risk factors could change biopsy decisions for a small proportion of women with abnormal mammograms. The greatest impact comes from standard breast cancer risk factors.

Authors: Cook LS, Nelson HE, Cockburn M, Olson SH, Muller CY, Wiggins CL

Title: Comorbidities and endometrial cancer survival in Hispanics and non-Hispanic whites.

Journal: Cancer Causes Control 24(1):61-9

Date: 2013 Jan

Abstract: PURPOSE: We investigated comorbidities and endometrial cancer survival by ethnicity because Hispanic whites (HWs) have worse survival than non-Hispanic whites (NHWs). METHODS: An endometrial cancer cohort (1992-2004) established with the Surveillance, Epidemiology and End Results-Medicare-linked database (n = 3,286) was followed through 2007. Endometrial cancer-specific and other cause mortality were evaluated with multivariate hazard ratios (mHRs). RESULTS: HWs were more likely than NHWs to have regional/distant disease (31.7 vs. 24.8 %), diabetes (31.7 vs. 11.0 %), and hypertension (49.4 vs. 37.6 %). HWs had poorer endometrial cancer-specific survival than NHWs (age-adjusted HR = 1.28; 95% CI 1.01-1.61), but not after adjustment for tumor characteristics and treatment (mHR = 1.02; 95% CI 0.81-1.29). In contrast, even after adjustment for cancer-related factors, other cause mortality in HWs was elevated (mHR = 1.27; 95% CI 1.01-1.59), but not after further adjustment for comorbid conditions (mHR = 1.07; 95% CI 0.85-1.35). CONCLUSIONS: Comorbidities, particularly diabetes, were more common in HWs than in NHWs and impacted other cause mortality. Improving diabetes management may be an effective means of improving other cause mortality. This may be particularly true for HWs, given their particularly high prevalence of diabetes.

Authors: Crivello ML, Ruth K, Sigurdson ER, Egleston BL, Evers K, Wong YN, Boraas M, Bleicher RJ

Title: Advanced imaging modalities in early stage breast cancer: preoperative use in the United States Medicare population.

Journal: Ann Surg Oncol 20(1):102-10

Date: 2013 Jan

Abstract: BACKGROUND: Guidelines for breast cancer staging exist, but adherence remains unknown. This study evaluates patterns of imaging in early stage breast cancer usually reserved for advanced disease. METHODS: Surveillance Epidemiology, and End Results data linked to Medicare claims from 1992-2005 were reviewed for stage I/II breast cancer patients. Claims were searched for preoperative performance of computed tomography (CT), positron emission tomography (PET), bone scans, and brain magnetic resonance imaging (MRI) ("advanced imaging"). RESULTS: There were 67,874 stage I/II breast cancer patients; 18.8% (n=12,740) had preoperative advanced imaging. The proportion of patients having CT scans, PET scans, and brain MRI increased from 5.7% to 12.4% (P<0.0001), 0.8% to 3.4% (P<0.0001) and 0.2% to 1.1% (P=0.008), respectively, from 1992 to 2005. Bone scans declined from 20.1% to 10.7% (P<0.0001). "Breast cancer" (174.x) was the only diagnosis code associated with 62.1% of PET scans, 37.7% of bone scans, 24.2% of CT, and 5.1% of brain MRI. One or more symptoms or metastatic site was suggested for 19.6% of bone scans, 13.0% of CT, 13.0% of PET, and 6.2% of brain MRI. Factors associated (P<0.05) with use of all modalities were urban setting, breast MRI and ultrasound. Breast MRI was the strongest predictor (P<0.0001) of bone scan (odds ratio [OR] 1.63, 95% confidence interval [CI] 1.44-1.86), Brain MRI (OR 1.74, 95% CI 1.15-2.63), CT (OR 2.42, 95% CI 2.12-2.76), and PET (OR 5.71, 95% CI 4.52-7.22). CONCLUSIONS: Aside from bone scans, performance of advanced imaging is increasing in early stage Medicare breast cancer patients, with limited rationale provided by coded diagnoses. In light of existing guidelines and increasing scrutiny about health care costs, greater reinforcement of current indications is warranted.

Authors: Forsythe LP, Alfano CM, George SM, McTiernan A, Baumgartner KB, Bernstein L, Ballard-Barbash R

Title: Pain in long-term breast cancer survivors: the role of body mass index, physical activity, and sedentary behavior.

Journal: Breast Cancer Res Treat 137(2):617-30

Date: 2013 Jan

Abstract: Although pain is common among post-treatment breast cancer survivors, studies that are longitudinal, identify a case definition of clinically meaningful pain, or examine factors contributing to pain in survivors are limited. This study describes longitudinal patterns of pain in long-term breast cancer survivors, evaluating associations of body mass index (BMI), physical activity, sedentary behavior with mean pain severity and above-average pain. Women newly diagnosed with stages 0-IIIA breast cancer (N = 1183) were assessed, on average, 6 months (demographic/clinical characteristics), 30 months (demographics), 40 months (demographics, pain), 5 years (BMI, physical activity, and sedentary behavior), and 10 years (demographics, pain, BMI, physical activity, and sedentary behavior) post-diagnosis. This analysis includes survivors who completed pain assessments 40 months post-diagnosis (N = 801), 10 years post-diagnosis (N = 563), or both (N = 522). Above-average pain was defined by SF-36 bodily pain scores ≥1/2 standard deviation worse than age-specific population norms. We used multiple regression models to test unique associations of BMI, physical activity, and sedentary behavior with pain adjusting for demographic and clinical factors. The proportion of survivors reporting above-average pain was higher at 10 years than at 40 months (32.3 vs. 27.8 %, p < 0.05). Approximately one-quarter of survivors reported improved pain, while 9.0 % maintained above-average pain and 33.1 % reported worsened pain. Cross-sectionally at 10 years, overweight and obese survivors reported higher pain than normal-weight survivors and women meeting physical activity guidelines were less likely to report above-average pain than survivors not meeting these guidelines (p < 0.05). Longitudinally, weight gain (>5 %) was positively associated, while meeting physical activity guidelines was inversely associated, with above-average pain (OR, 95 % CI = 1.76, 1.03-3.01 and 0.40, 0.20-0.84, respectively) (p < 0.05). Weight gain and lack of physical activity place breast cancer survivors at risk for pain long after treatment ends. Weight control and exercise interventions should be tested for effects on long-term pain in these women.

Authors: Goulart BH, Reyes CM, Fedorenko CR, Mummy DG, Satram-Hoang S, Koepl LM, Blough DK, Ramsey SD

Title: Referral and treatment patterns among patients with stages III and IV non-small-cell lung cancer.

Journal: J Oncol Pract 9(1):42-50

Date: 2013 Jan

Abstract: PURPOSE: Little is known about how referrals to different cancer specialists influence cancer care for non-small-cell lung cancer (NSCLC). Among Medicare enrollees, we identified factors of patients and their primary care physician that were associated with referrals to cancer specialists, and how the types of cancer specialists seen correlated with delivery of guideline-based therapies (GBTs). METHODS: Data from patients with stages III and IV NSCLC included in the SEER-Medicare database were linked to their physicians in the American Medical Association Masterfile database. Using logistic regression, we (1) identified patient and physician factors that were associated with referrals to cancer specialists (medical oncologists, radiation oncologists, and surgeons); (2) identified the types of referral to cancer specialists that predicted greater likelihood of receiving GBT (per National Comprehensive Cancer Network guidelines). RESULTS: A total of 28,977 patients with NSCLC diagnosed from January 1, 2000 to December 31, 2005 met eligibility criteria. Younger age, white race, higher income, and primary physician specialty other than family practice predicted higher likelihood of referrals to medical oncologists (P < .01 for all predictors). Seeing the three types of cancer specialists predicted higher likelihood of GBT (stage IIIA: odds ratio [OR] = 20.6; P < .001; IIIB: OR = 77.2; P < .001; and IV: OR = 1.2; P = .011), compared with seeing a medical oncologist only. Use of GBTs increased over the study period (42% to 48% from 2000 to 2005; P < .001). CONCLUSION: Referrals to all types of cancer specialists increased the likelihood of treatment with standard therapies, particularly in stage III patients. However, racial and income disparities still prevent optimal referrals to cancer specialists.

Authors: Haggstrom DA, Klabunde CN, Smith JL, Yuan G

Title: Variation in primary care physicians' colorectal cancer screening recommendations by patient age and comorbidity.

Journal: J Gen Intern Med 28(1):18-24

Date: 2013 Jan

Abstract: BACKGROUND: Screening patterns among primary care physicians (PCPs) may be influenced by patient age and comorbidity. Colorectal cancer (CRC) screening has little benefit among patients with limited life expectancy. OBJECTIVE: To characterize the extent to which PCPs modify their recommendations for CRC screening based upon patients' increasing age and/or worsening comorbidity DESIGN: Cross-sectional, nationally representative survey. PARTICIPANTS: The study comprised primary care physicians (n = 1,266) including general internal medicine, family practice, and obstetrics-gynecology physicians. MAIN MEASURES: Physician CRC screening recommendations among patients of varying age and comorbidity were measured based upon clinical vignettes. Independent variables in adjusted models included physician and practice characteristics. KEY RESULTS: For an 80-year-old patient with unresectable non-small cell lung cancer (NSCLC), 25 % of PCPs recommended CRC screening. For an 80-year-old patient with ischemic cardiomyopathy (New York Heart Association, Class II), 71 % of PCPs recommended CRC screening. PCPs were more likely to recommend fecal occult blood testing than colonoscopy as the preferred screening modality for a healthy 80-year-old, compared to healthy 50- or 65-year-old patients (19 % vs. 5 % vs. 2 % p < 0.001). For an 80-year-old with unresectable NSCLC, PCPs who were an obstetrics-gynecology physician were more likely to recommend CRC screening, while those with a full electronic medical record were less likely to recommend screening. CONCLUSIONS: PCPs consider comorbidity when screening older patients for CRC and may change the screening modality from colonoscopy to FOBT. However, a sizable proportion of PCPs would recommend screening for patients with advanced cancer who would not benefit. Understanding the mechanisms underlying these patterns will facilitate the design of future medical education and policy interventions to reduce unnecessary care.

Authors: Jacobs BL, Zhang Y, Skolarus TA, Wei JT, Montie JE, Schroeck FR, Hollenbeck BK

Title: Certificate of need legislation and the dissemination of robotic surgery for prostate cancer.

Journal: J Urol 189(1):80-5

Date: 2013 Jan

Abstract: PURPOSE: The uncertainty about the incremental benefit of robotic prostatectomy and its higher associated costs makes it an ideal target for state based certificate of need laws, which have been enacted in several states. We studied the relationship between certificate of need laws and market level adoption of robotic prostatectomy. MATERIALS AND METHODS: We used SEER (Surveillance, Epidemiology, and End Results)-Medicare data from 2003 through 2007 to identify men 66 years old or older treated with prostatectomy for prostate cancer. Using data from the American Health Planning Association, we categorized Health Service Areas according to the stringency of certificate of need regulations (ie low vs high stringency) presiding over that market. We assessed our outcomes (probability of adopting robotic prostatectomy and propensity for robotic prostatectomy use in adopting Health Service Areas) using Cox proportional hazards and Poisson regression models, respectively. RESULTS: Compared to low stringency markets, high stringency markets were more racially diverse (54% vs 15% nonwhite, p <0.01), and had similar population densities (886 vs 861 people per square mile, p = 0.97) and median incomes ($42,344 vs $39,770, p = 0.56). In general, both market types had an increase in the adoption and utilization of robotic prostatectomy. However, the probability of robotic prostatectomy adoption (p = 0.22) did not differ based on a market's certificate of need stringency and use was lower in high stringency markets (p <0.01). CONCLUSIONS: State based certificate of need regulations were ineffective in constraining robotic surgery adoption. Despite decreased use in high stringency markets, similar adoption rates suggest that other factors impact the diffusion of robotic prostatectomy.

Authors: Jacobs BL, Zhang Y, Tan HJ, Ye Z, Skolarus TA, Hollenbeck BK

Title: Hospitalization trends after prostate and bladder surgery: implications of potential payment reforms.

Journal: J Urol 189(1):59-65

Date: 2013 Jan

Abstract: PURPOSE: Hospital stays have decreased for patients undergoing surgery for urological cancer. However, there are concerns that patients are being discharged from the hospital prematurely. We examined associations between hospital stay and short-term outcomes for a low risk procedure (prostatectomy) and high risk procedure (cystectomy). MATERIALS AND METHODS: We used SEER (Surveillance, Epidemiology and End Results)-Medicare data from 1992 through 2005 to identify 46,781 prostatectomy and 9,035 cystectomy cases. We assessed our main outcome (adjusted likelihood of hospital readmission within 30 days) using a logistic regression model. Secondary outcomes included mortality rates and discharge disposition. RESULTS: In comparing patients from 1992 to 1993, to 2004 to 2005, hospital stay decreased approximately 3 days for both surgeries (relative decrease of more than 50% for prostatectomy and 21% for cystectomy). Hospital readmission rates were 4.5% and 25.2% for prostatectomy and cystectomy, respectively, and remained stable with time. Skilled nursing/intermediate care use was stable for patients who underwent prostatectomy (approximately 1%), but increased from 8.2% (95% CI 5.4-11.4) to 18.9% (95% CI 16.8-21.3) for those treated with cystectomy. Use of home care increased from 8.1% (95% CI 7.3-9.0) to 11.1% (95% CI 10.1-12.1) and from 34.2% (95% CI 29.7-38.7) to 47.5% (95% CI 44.5-50.1) for prostatectomy and cystectomy cases, respectively. CONCLUSIONS: Reductions in hospital stay were more dramatic for patients who underwent prostatectomy and were associated with stable short-term outcomes. Conversely, smaller reductions in hospitalization for patients undergoing cystectomy were met with substantial increases in the use of post-acute care. Going forward, close surveillance of how imminent policy reforms affect patterns and quality of care will be necessary.

Authors: Khanna A, Hu JC, Gu X, Nguyen PL, Lipsitz S, Palapattu GS

Title: Certificate of need programs, intensity modulated radiation therapy use and the cost of prostate cancer care.

Journal: J Urol 189(1):75-9

Date: 2013 Jan

Abstract: PURPOSE: Certificate of need programs are a primary mechanism to regulate the use and cost of health care services at the state level. The effect of certificate of need programs on the use of intensity modulated radiation therapy and the increasing costs of prostate cancer care is unknown. We compared the use of intensity modulated radiation therapy and change in prostate cancer health care costs in regions with vs without active certificate of need programs. MATERIALS AND METHODS: This population based, observational study using SEER (Surveillance, Epidemiology, and End Results)-Medicare linked data from 2002 through 2009 was comprised of 13,814 men treated for prostate cancer in 3 regions with active certificate of need programs (CON Yes) vs 44,541 men treated for prostate cancer in 9 regions without active certificate of need programs (CON No). We assessed intensity modulated radiation therapy use relative to other prostate cancer definitive therapies and overall prostate cancer health care costs with respect to certificate of need status. RESULTS: In propensity score adjusted analyses, intensity modulated radiation therapy use increased from 2.3% to 46.4% of prostate cancer definitive therapies in CON Yes regions vs 11.3% to 41.7% in CON No regions from 2002 to 2009. Furthermore, we observed greater intensity modulated radiation therapy use with time in CON Yes vs No regions (p <0.001). Annual cost growth did not differ between CON Yes vs No regions (p = 0.396). CONCLUSIONS: Certificate of need programs were not effective in limiting intensity modulated radiation therapy use or attenuating prostate cancer health care costs. There remains an unmet need to control the rapid adoption of new, more expensive therapies for prostate cancer that have limited cost and comparative effectiveness data.

Authors: Kim S, Moore DF, Shih W, Lin Y, Li H, Shao YH, Shen S, Lu-Yao GL

Title: Severe genitourinary toxicity following radiation therapy for prostate cancer--how long does it last?

Journal: J Urol 189(1):116-21

Date: 2013 Jan

Abstract: PURPOSE: Radiation therapy is a common treatment for localized prostate cancer but long-term data are sparse on treatment related toxicity compared to observation. We evaluated the time course of grade 2-4 genitourinary toxicities in men treated with primary radiation or observation for T1-T2 prostate cancer. MATERIALS AND METHODS: We performed a population based cohort study using Medicare claims data linked to SEER (Surveillance, Epidemiology and End Results) data. Cumulative incidence functions for time to first genitourinary event were calculated based on the competing risks model with death before any genitourinary event as a competing event. The generalized estimating equation method was used to evaluate the risk ratios of recurrent events. RESULTS: Of the study patients 60,134 received radiation therapy and 25,904 underwent observation. The adjusted risk ratio for genitourinary toxicity was 2.49 (95% CI 2.00-3.11) for 10 years and thereafter. Patients who had required prior procedures for obstruction/stricture, including transurethral prostate resection, before radiation therapy were at significantly increased risk for genitourinary toxicity (risk ratio 2.78, 95% CI 2.56-2.94). CONCLUSIONS: This study demonstrates that the increased risk of grade 2-4 genitourinary toxicities attributable to radiation therapy persists 10 years after treatment and thereafter. Patients who required prior procedures for obstruction/stricture were at higher risk for genitourinary toxicity than those without these preexisting conditions.

Authors: Lillard DR, Molloy E, Sfekas A

Title: Smoking initiation and the iron law of demand

Journal: J Health Econ 32(1):114-27

Date: 2013 Jan

Abstract: We show, with three longitudinal datasets, that cigarette taxes and prices affect smoking initiation decisions. Evidence from longitudinal studies is mixed but generally find that initiation does not vary with price or tax. We show that the lack of statistical significance partly results because of limited policy variation in the time periods studied, truncated behavioral windows, or mis-assignment of price and tax rates in retrospective data (which occurs when one has no information about respondents' prior state or region of residence). Our findings highlight issues relevant to initiation behavior generally, particularly those for which individuals' responses to policy changes may be noisy or small in magnitude.

Authors: Lin CC, Virgo KS

Title: Association between the availability of medical oncologists and initiation of chemotherapy for patients with stage III colon cancer.

Journal: J Oncol Pract 9(1):27-33

Date: 2013 Jan

Abstract: PURPOSE: Although the number of medical oncologists (MOs) has steadily increased over time, and adjuvant chemotherapy provides significant survival benefit for patients with stage III colon cancer, many patients still do not receive chemotherapy. Uneven geographic distribution of MOs may contribute to decreasing access to cancer care. This study explored the association of MO availability by hospital service area (HSA) of patient residence and access to chemotherapy treatment. METHODS: Using the linked SEER-Medicare database, the study identified 9,262 patients who were age ≥66 years and underwent colectomy for stage III colon cancer diagnosed from 2000 to 2005. MOs were identified by physician specialty codes. HSAs are geographic areas that are relatively self-contained with respect to routine hospital care. Multivariate logistic regression was used to investigate the association between MO availability by HSA of patient residence and initiation of chemotherapy. RESULTS: Within 3 months after colectomy, 5,622 patients (60.7%) initiated chemotherapy. Adjusting for clinical and patient characteristics, patients residing in an HSA with ≥ one MO had an increased likelihood of initiating chemotherapy within 3 months after colectomy compared with those living in areas with no MOs (one to two MOs: OR, 1.451 [P < .01]; three to eight MOs: OR, 1.497 [P < .01]; ≥ nine MOs: OR, 1.322 [P < .01]). CONCLUSION: Results suggest that the availability of ≥ one MO within the HSA in which a patient resides was associated with greater access to chemotherapy after surgery.

Authors: Miller JW, Sabatino SA, Thompson TD, Breen N, White MC, Ryerson AB, Taplin S, Ballard-Barbash R

Title: Breast MRI use uncommon among U.S. women.

Journal: Cancer Epidemiol Biomarkers Prev 22(1):159-66

Date: 2013 Jan

Abstract: BACKGROUND: The goal of breast cancer screening is to reduce breast cancer mortality. Mammography is the standard screening method for detecting breast cancer early. Breast MRI is recommended to be used in conjunction with mammography for screening subsets of women at high risk for breast cancer. We offer the first study to provide national estimates of breast MRI use among women in the United States. METHODS: We analyzed data from women who responded to questions about having a breast MRI on the 2010 National Health Interview Survey. We assessed report of having a breast MRI and reasons for it by sociodemographic characteristics and access to health care and computed five-year and lifetime breast cancer risk using the Gail model. RESULTS: Among 11,222 women who responded, almost 5% reported ever having a breast MRI and 2% reported having an MRI within the 2 years preceding the survey. Less than half of the women who reported having a breast MRI were at increased risk. Approximately 60% of women reported having the breast MRI for diagnostic reasons. Women who ever had a breast MRI were more likely to be older, Black, and insured and to report a usual source of health care as compared with women who reported no MRI. CONCLUSIONS: Breast MRI use may be underused or overused in certain subgroups of women. IMPACT: As access to health care improves, the use of breast MRI and the appropriateness of its use for breast cancer detection will be important to monitor.

Authors: Parsons HM, Begun JW, McGovern PM, Tuttle TM, Kuntz KM, Virnig BA

Title: Hospital characteristics associated with maintenance or improvement of guideline-recommended lymph node evaluation for colon cancer.

Journal: Med Care 51(1):60-7

Date: 2013 Jan

Abstract: BACKGROUND: Over the past 20 years, surgical practice organizations have recommended the identification of ≥12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines. RESEARCH DESIGN: Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (≥12) lymph node evaluation compared with initial evaluation levels (1996-1998) using χ tests and multivariate logistic regression analysis, adjusting for patient case-mix. RESULTS: We identified 228 hospitals that performed ≥6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n=60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance. CONCLUSIONS: Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.

Authors: Presley CJ, Raldow AC, Cramer LD, Soulos PR, Long JB, Yu JB, Makarov DV, Gross CP

Title: A new approach to understanding racial disparities in prostate cancer treatment

Journal: J Geriatr Oncol 4(1):1-8

Date: 2013 Jan

Abstract: Abstract Objective:Previous studies addressing racial disparities in treatment for early-stage prostate cancer have focused on the etiology of undertreatment of black men. Our objective was to determine whether racial disparities are attributable to undertreatment, overtreatment, or both.Methods:Using the SEER-Medicare dataset, we identified men 67-84years-old diagnosed with localized prostate cancer from 1998 to 2007. We stratified men into clinical benefit groups using tumor aggressiveness and life expectancy. Low-benefit was defined as low-risk tumors and life expectancy <10years; high-benefit as moderate-risk tumors and life expectancy ≥10years; all others were intermediate-benefit. Logistic regression modeled the association between race and treatment (radical prostatectomy or radiotherapy) across benefit groups.Results:Of 68,817 men (9.8% black and 90.2% white), 56.2% of black and 66.3% of white men received treatment (adjusted odds ratio (OR)=0.65; 95% CI, 0.62-0.69). The percent of low-, intermediate-, and high-benefit men who received treatment was 56.7%, 68.4%, and 79.6%, respectively (P=<0.001). In the low-benefit group, 51.9% of black vs. 57.2% of white patients received treatment (OR=0.74; 95% CI, 0.67-0.81) compared to 57.2% vs. 69.6% in the intermediate-benefit group (OR=0.64; 95% CI, 0.59-0.70). Racial disparity was largest in the high-benefit group (64.2% of black vs. 81.4% of white patients received treatment; OR=0.57; 95% CI, 0.48-0.68). The interaction between race and clinical benefit was significant (P<0.001).Conclusion:Racial disparities were largest among men most likely to benefit from treatment. However, a substantial proportion of both black and white men with a low clinical benefit received treatment, indicating a high level of overtreatment.

Authors: Quon JL, Yu JB, Soulos PR, Gross CP

Title: The relation between age and androgen deprivation therapy use among men in the Medicare population receiving radiation therapy for prostate cancer.

Journal: J Geriatr Oncol 4(1):9-18

Date: 2013 Jan

Abstract: OBJECTIVES: Neoadjuvant and concurrent androgen deprivation therapy (ncADT) is recommended for men with high-risk prostate cancer, but not low-risk cancer or short life expectancy. It is unclear whether the use of ncADT among older men in the community setting is aligned with the potential for clinical benefit. MATERIALS AND METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare database to assess patterns of ncADT use among men diagnosed with prostate cancer during 2004-2007 who received radiation therapy. Men were stratified according to tumor risk groups and life expectancy. We used logistic regression to identify factors associated with ncADT use within each risk group. RESULTS: There were 10,686 men in the sample (mean age 74.2 years; 83.4% white). The use of ncADT was 80.7%, 54.1%, and 27.8% in the high-, intermediate-, and low-risk groups, respectively. Men with a life expectancy<5 years had higher rates of ncADT use than men with a life expectancy≥10 years in all risk groups. Within each risk group, advancing age was associated with higher likelihood of receiving ncADT (odds ratio for men aged 80-84 compared to 67-69=1.93 (95% CI 1.37-2.70); 1.51 (95% CI 1.22-1.87); and 1.71 (95% CI 1.14-2.57) for high-, intermediate-, and low-risk groups, respectively). CONCLUSION: ncADT use is not consistent with guideline recommendations and is more frequent among men who are older, have shorter life expectancy, and are less likely to benefit from therapy.

Authors: Sathiakumar N, Delzell E, Morrisey MA, Falkson C, Yong M, Chia V, Blackburn J, Arora T, Kilgore ML

Title: Mortality following bone metastasis and skeletal-related events among patients 65 years and above with lung cancer: A population-based analysis of U.S. Medicare beneficiaries, 1999-2006.

Journal: Lung India 30(1):20-6

Date: 2013 Jan

Abstract: BACKGROUND: To quantify the impact of bone metastasis and skeletal-related events (SREs) on mortality among older patients with lung cancer. MATERIALS AND METHODS: Using the linked Surveillance, Epidemiology and End Results-Medicare database, we identified patients aged 65 years or older diagnosed with lung cancer between July 1, 1999 and December 31, 2005 and followed them to determine deaths through December 31, 2006. We classified patients as having possible bone metastasis and SREs using discharge diagnoses from inpatient claims and diagnoses paired with procedure codes from outpatient claims. We used Cox regression to estimate mortality hazards ratios (HR) among patients with bone metastasis with or without SRE, compared to patients without bone metastasis. RESULTS: Among 126,123 patients with lung cancer having a median follow-up of 0.6 years, 24,820 (19.8%) had bone metastasis either at lung cancer diagnosis (9,523, 7.6%) or during follow-up (15,297, 12.1%). SREs occurred in 12,665 (51%) patients with bone metastasis. The HR for death was 2.4 (95% CI = 2.4-2.5) both for patients with bone metastasis but no SRE and for patients with bone metastasis plus SRE, compared to patients without bone metastasis. CONCLUSIONS: Having a bone metastasis, as indicated by Medicare claims, was associated with mortality among patients with lung cancer. We found no difference in mortality between patients with bone metastasis complicated by SRE and patients with bone metastasis but without SRE.

Authors: Singh A, Kuo YF, Goodwin JS

Title: Many patients who undergo surgery for colorectal cancer receive surveillance colonoscopies earlier than recommended by guidelines.

Journal: Clin Gastroenterol Hepatol 11(1):65-72.e1

Date: 2013 Jan

Abstract: BACKGROUND & AIMS: Patients treated with surgery for colorectal cancer (CRC) should undergo colonoscopy examinations 1, 4, and 9 years later, to check for cancer recurrence. We investigated the use patterns of surveillance colonoscopies among Medicare patients. METHODS: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify patients who underwent curative surgery for colorectal cancer from 1992 to 2005 and analyzed the timing of the first 3 colonoscopies after surgery. Early surveillance colonoscopy was defined as a colonoscopy, for no reason other than surveillance, within 3 months to 2 years after a colonoscopy examination with normal results. RESULTS: Approximately 32.1% and 27.3% of patients with normal results from their first and second colonoscopies, respectively, underwent subsequent surveillance colonoscopies within 2 years (earlier than recommended). Of patients who were older than 80 years at their first colonoscopy, 23.6% underwent a repeat procedure within 2 years for no clear indication. In multivariable analysis, early surveillance colonoscopy was not associated with sex, race, or patients' level of education. There was significant regional variation in early surveillance colonoscopies among the Surveillance, Epidemiology, and End Results regions. There was a significant trend toward reduced occurrence of second early surveillance colonoscopies. CONCLUSIONS: Many Medicare enrollees who have undergone curative resection for colorectal cancer undergo surveillance colonoscopy more frequently than recommended by the guidelines. Reducing overuse could free limited resources for appropriate colonoscopy examinations of inadequately screened populations.

Authors: Sun M, Bianchi M, Trinh QD, Hansen J, Abdollah F, Hanna N, Tian Z, Shariat SF, Montorsi F, Perrotte P, Karakiewicz PI

Title: Comparison of partial vs radical nephrectomy with regard to other-cause mortality in T1 renal cell carcinoma among patients aged ≥75 years with multiple comorbidities.

Journal: BJU Int 111(1):67-73

Date: 2013 Jan

Abstract: OBJECTIVE: To quantify the effect of partial nephrectomy (PN) vs radical nephrectomy (RN) on other-cause mortality (OCM) in elderly patients with localized renal cell carcinoma (RCC) and/or multiple comorbidities. METHODS: Using the Surveillance, Epidemiology, and End Results Medicare-linked database, patients with T1 RCC, aged ≥75 years, or who had ≥2 comorbidities, were identified (1988-2005). To adjust for inherent differences between treatment types, propensity-based matched analyses were performed. Competing-risks regression analyses for prediction of OCM were assessed according to treatment type. The effect of PN and RN on OCM was examined in three sub-groups: patients aged ≥75 years; patients with ≥2 comorbidities; and patients aged ≥75 years with ≥2 comorbidities. RESULTS: After propensity-based matched analyses and adjustment for all covariates, PN was found to exert a protective effect relative to RN with respect to OCM in all patients (hazard ratio [HR]: 0.84, P = 0.048). In subanalyses, no difference was recorded between PN and RN in patients who were aged ≥75 years (HR: 0.83, P = 0.2), with ≥2 baseline comorbidities at diagnosis (HR: 0.83, P = 0.1), or in patients who were aged ≥75 years and who had ≥2 baseline comorbidities (HR: 0.77, P = 0.2). CONCLUSIONS: Some elderly patients and/or those with multiple comorbidities at diagnosis may not benefit from PN with respect to OCM. After rigorous patient selection, alternative treatment options could be considered.

Authors: Zhang S, Ivy JS, Diehl KM, Yankaskas BC

Title: The association of breast density with breast cancer mortality in African American and white women screened in community practice.

Journal: Breast Cancer Res Treat 137(1):273-83

Date: 2013 Jan

Abstract: The effect of breast density on survival outcomes for American women who participate in screening remains unknown. We studied the role of breast density on both breast cancer and other cause of mortality in screened women. Data for women with breast cancer, identified from the community-based Carolina Mammography Registry, were linked with the North Carolina cancer registry and NC death tapes for this study. Cause-specific Cox proportional hazards models were developed to analyze the effect of several covariates on breast cancer mortality-namely, age, race (African American/White), cancer stage at diagnosis (in situ, local, regional, and distant), and breast density (BI-RADS( ® ) 1-4). Two stratified Cox models were considered controlling for (1) age and race, and (2) age and cancer stage, respectively, to further study the effect of density. The cumulative incidence function with confidence interval approximation was used to quantify mortality probabilities over time. For this study, 22,597 screened women were identified as having breast cancer. The non-stratified and stratified Cox models showed no significant statistical difference in mortality between dense tissue and fatty tissue, while controlling for other covariate effects (p value = 0.1242, 0.0717, and 0.0619 for the non-stratified, race-stratified, and cancer stage-stratified models, respectively). The cumulative mortality probability estimates showed that women with dense breast tissues did not have significantly different breast cancer mortality than women with fatty breast tissue, regardless of age (e.g., 10-year confidence interval of mortality probabilities for whites aged 60-69 white: 0.056-0.090 vs. 0.054-0.083). Aging, African American race, and advanced cancer stage were found to be significant risk factors for breast cancer mortality (hazard ratio >1.0). After controlling for cancer incidence, there was not a significant association between mammographic breast density and mortality, adjusting for the effects of age, race, and cancer stage.

Authors:

Title: Evaluating costs with unmeasured confounding: a sensitivity analysis for the treatment effect

Journal: 7(4):2062-80

Date: 2013

Abstract: Estimates of the effects of treatment on cost from observational studies are subject to bias if there are unmeasured confounders. It is therefore advisable in practice to assess the potential magnitude of such biases. We derive a general adjustment formula for loglinear models of mean cost and explore special cases under plausible assumptions about the distribution of the unmeasured confounder. We assess the performance of the adjustment by simulation, in particular, examining robustness to a key assumption of conditional independence between the unmeasured and measured covariates given the treatment indicator. We apply our method to SEER-Medicare cost data for a stage II/III muscle-invasive bladder cancer cohort. We evaluate the costs for radical cystectomy vs. combined radiation/chemotherapy, and find that the significance of the treatment effect is sensitive to plausible unmeasured Bernoulli, Poisson and Gamma confounders.

Authors: Buchanan ND, King JB, Rodriguez JL, White A, Trivers KF, Forsythe LP, Kent EE, Rowland JH, Sabatino SA

Title: Changes among US Cancer Survivors: Comparing Demographic, Diagnostic, and Health Care Findings from the 1992 and 2010 National Health Interview Surveys.

Journal: ISRN Oncol 2013:238017-

Date: 2013

Abstract: Background. Differences in healthcare and cancer treatment for cancer survivors in the United States (US) have not been routinely examined in nationally representative samples or studied before and after important Institute of Medicine (IOM) recommendations calling for higher quality care provision and attention to comprehensive cancer care for cancer survivors. Methods. To assess differences between survivor characteristics in 1992 and 2010, we conducted descriptive analyses of 1992 and 2010 National Health Interview Survey (NHIS) data. Our study sample consisted of 1018 self-reported cancer survivors from the 1992 NHIS and 1718 self-reported cancer survivors from the 2010 NHIS who completed the Cancer Control (CCS) and Cancer Epidemiology (CES) Supplements. Results. The prevalence of reported survivors increased from 1992 to 2010 (4.2% versus 6.3%). From 1992 to 2010, there was an increase in long-term cancer survivors and a drop in multiple malignancies, and surgery remained the most widely used treatment. Significantly fewer survivors (<10 years after diagnosis) were denied insurance coverage. Survivors continue to report low participation in counseling or support groups. Conclusions. As the prevalence of cancer survivors continues to grow, monitoring differences in survivor characteristics can be useful in evaluating the effects of policy recommendations and the quality of clinical care.

Authors: Butler EN, Chawla N, Lund J, Harlan LC, Warren JL, Yabroff KR

Title: Patterns of colorectal cancer care in the United States and Canada: a systematic review.

Journal: J Natl Cancer Inst Monogr 2013(46):13-35

Date: 2013

Abstract: Colorectal cancer is the third most common cancer in the United States and Canada. Given the high incidence and increased survival of colorectal cancer patients, prevalence is increasing over time in both countries. Using MEDLINE, we conducted a systematic review of the literature published between 2000 and 2010 to describe patterns of colorectal cancer care. Specifically we examined data sources used to obtain treatment information and compared patterns of cancer-directed initial care, post-diagnostic surveillance care, and end-of-life care among colorectal cancer patients diagnosed in the United States and Canada. Receipt of initial treatment for colorectal cancer was associated with the anatomical position of the tumor and extent of disease at diagnosis, in accordance with consensus-based guidelines. Overall, care trends were similar between the United States and Canada; however, we observed differences with respect to data sources used to measure treatment receipt. Differences were also present between study populations within country, further limiting direct comparisons. Findings from this review will allow researchers, clinicians, and policy makers to evaluate treatment receipt by patient, clinical, or system characteristics and identify emerging trends over time. Furthermore, comparisons between health-care systems in the United States and Canada can identify disparities in care, allow the evaluation of different models of care, and highlight issues regarding the utility of existing data sources to estimate national patterns of care.

Authors: Chawla N, Butler EN, Lund J, Warren JL, Harlan LC, Yabroff KR

Title: Patterns of colorectal cancer care in Europe, Australia, and New Zealand.

Journal: J Natl Cancer Inst Monogr 2013(46):36-61

Date: 2013

Abstract: Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.

Authors: Cronin KA, Miglioretti DL, Krapcho M, Yu B, Geller BM, Carney PA, Onega T, Feuer EJ, Breen N, Ballard-Barbash R

Title: Appendix - CEBP Focus on Cancer Surveillance: Bias Associated With Self-Report of Prior Screening Mammography.

Journal: :-

Date: 2013

Abstract:

Authors: Douglass D, Islam N, Baranowski J, Chen TA, Subar AF, Zimmerman TP, Baranowski T

Title: Simulated adaptations to an adult dietary self-report tool to accommodate children: impact on nutrient estimates.

Journal: J Am Coll Nutr 32(2):92-7

Date: 2013

Abstract: OBJECTIVE: To simulate the effect of child-friendly (CF) adaptations of the National Cancer Institute's Automated Self-Administered 24-Hour Dietary Recall (ASA24) on estimates of nutrient intake. METHOD: One hundred twenty children, 8-13 years old, entered their previous day's intake using the ASA24 and completed an interviewer-administered recall using the Nutrition Data System for Research (NDSR). Based on a hypothesis that proposed adaptations to the ASA24 will not significantly affect mean nutrient estimates, ASA24 data were manipulated postadministration to simulate a CF version in which 2 categories of data collection were removed: (1) foods not likely to be consumed by children (45%) based on previous analyses of national dietary data and (2) food detail questions (probes) to which children are unlikely to know the answers (46%), based on our experience. RESULTS: Mean estimates of select nutrients between the beta version of ASA24 and the simulated CF recall showed no significant differences, indicating that the food and probe elimination did not significantly affect results. However, a comparison of total sugar and vitamin C assessments between the original ASA24, the CF version, and NDSR showed that the daily nutrient totals for both nutrients were significantly higher in the self-administered methods (both ASA24 and CF version) than in NDSR (interviewer-administered), which warrants a review of different methods for obtaining information about foods that are sources of these nutrients. CONCLUSION: The simulation of CF adaptations showed that it is feasible to implement, thereby reducing CF response burden without significantly affecting the results.

Authors: Duggan C, Ballard-Barbash R, Baumgartner RN, Baumgartner KB, Bernstein L, McTiernan A

Title: Associations between null mutations in GSTT1 and GSTM1, the GSTP1 Ile(105)Val polymorphism, and mortality in breast cancer survivors.

Journal: Springerplus 2:450-

Date: 2013

Abstract: PURPOSE: Here we assessed associations between null mutations in glutathione-S-transferase (GST)T1 and GSTM1 genes, and the rs1695 polymorphism in GSTP1 (Ile(105)Val), and risk of breast cancer-specific (n=45) and all-cause (n=99) mortality in a multiethnic, prospective cohort of 533 women diagnosed with stage I-IIIA breast cancer in 1995-1999, enrolled in the Health, Eating, Activity, and Lifestyle (HEAL) Study. METHODS: We measured the presence of the null mutation in GSTT1 and GSTM1, and the rs1695 polymorphism in GSTP1 by polymerase chain reaction. We assessed associations between breast-cancer specific and all-cause mortality using Cox proportional hazards models. RESULTS: Participants with ER-negative tumors were more likely to be GSTT1 null (χ(2)=4.52; P=0.03), and African American women were more likely to be GSTM1 null (χ(2)=34.36; P<0.0001). Neither GSTM1 nor GSTT1 null mutations were associated with breast cancer-specific or all-cause mortality. In a model adjusted for body mass index, race/ethnicity, tumor stage and treatment received at diagnosis, the variant Val allele of rs1695 was associated with increased risk of all-cause (HR=1.81, 95% CI 1.16-2.82, P=0.008), but not breast cancer-specific mortality. The GSTT1 null mutation was associated with significantly higher levels of C-reactive protein. CONCLUSIONS: GSTM1 and GSTT1 null genotypes had no effect on outcome; however the variant allele of rs1695 appears to confer increased risk for all-cause mortality in breast-cancer survivors. Given the limited sample size of most studies examining associations between GST polymorphisms with breast cancer survival, and the lack of women undergoing more contemporary treatment protocols (treated prior to 1999), it may be helpful to re-examine this issue among larger samples of women diagnosed after the late 1990s, who all received some form of chemotherapy or radiotherapy.

Authors: Fishman PA, Hornbrook MC, Ritzwoller DP, O'Keeffe-Rosetti MC, Lafata JE, Salloum RG

Title: The challenge of conducting comparative effectiveness research in cancer: the impact of a fragmented U.S. health-care system.

Journal: J Natl Cancer Inst Monogr 2013(46):99-105

Date: 2013

Abstract: Comparative effectiveness research (CER) can make important contributions to the transformation of US health care by filling gaps left by tightly controlled clinical trials. However, without comprehensive and comparable data that reflect the diversity of the US health-care system, CER's value will be diminished. We document the limits of observational CER by examining the age at diagnosis, disease stage, and select measures of health-care use among individuals diagnosed with incident cancer aged 65 or older from four large health maintenance organizations (HMOs) relative to seniors identified through the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the period 1999-2007. Aged individuals in the HMOs were younger, diagnosed at earlier stages, and more likely to receive care in inpatient settings than individuals in the linked SEER-Medicare data. These differences highlight the need for comprehensive and comparable datasets that reflect the diversity of US health care to support CER that can inform health-care reform in the United States.

Authors: Francisci S, Yabroff KR, Gigli A, Mariotto A, Mezzetti M, Lipscomb J

Title: Advancing the science of cancer cost measurement: challenges and opportunities.

Journal: Ann Ist Super Sanita 49(1):73-8

Date: 2013

Abstract: OBJECTIVES: Cancer accounts for a major proportion of national health expenditures, which are expected to increase in the future. This paper aims to identify major challenges with estimating cancer related costs, and discuss international comparisons, and recommendations for future research. METHODS: It starts from the experience of an international workshop aimed at comparing cancer burden evaluation methods, improving results comparability, discussing strengths and criticisms of different approaches. RESULTS: Three methodological themes necessary to inform the analysis are identified and discussed: data availability; costs definition; epidemiological measures. CONCLUSIONS: Cost evaluation is applied to cancer control interventions and is relevant for public health planners. Despite their complexity, international comparisons are fundamental to improve, generalize and extend cost evaluation to different contexts.

Authors: Gigli A, Warren JL, Yabroff KR, Francisci S, Stedman M, Guzzinati S, Giusti F, Miccinesi G, Crocetti E, Angiolini C, Mariotto A

Title: Initial treatment for newly diagnosed elderly colorectal cancer patients: patterns of care in Italy and the United States.

Journal: J Natl Cancer Inst Monogr 2013(46):88-98

Date: 2013

Abstract: Cancer is a major component of health-care expenditures in most developed countries. The costs of cancer care are expected to increase due to rising incidence (as the population ages) and increasing use of targeted anticancer therapies. However, epidemiological analysis of patterns of care may be required prior to empirically well-grounded cost analyses. Additionally, comparisons of care between health-care delivery systems and countries can identify opportunities to improve practice. They can also increase understanding of patient outcomes and economic consequences of differences in policies related to cancer screening, treatment, and programs of care. In this study, we compared patterns of colorectal cancer treatment during the first year following diagnosis in two cohorts of elderly patients from some areas of Italy and the United States using cancer registry linked to administrative data. We evaluated hospital use, initial treatments (surgery, chemotherapy, and radiation), and timeliness of surgery and adjuvant therapy, taking into account patient characteristics and clinical features, such as stage at diagnosis and the cancer subsite. We observed greater use of adjuvant chemotherapy in stage III and IV colon cancer patients and adjuvant therapy in all stages of rectal cancer patients in the US cohort. We found a higher rate of open surgeries in the Italian cohort, a similar rate of hospitalization, but a higher number of hospital days in the Italian cohort. However, in spite of structural differences between the United States and Italy in health-care organization and delivery as well as in data collection, patterns of care and the timing of care in the year after diagnosis are generally similar among patients within stage of disease at diagnosis. Comparative studies of the costs associated with patterns of cancer care will be important for future research.

Authors: Griffiths RI, O'Malley CD, Herbert RJ, Danese MD

Title: Misclassification of incident conditions using claims data: impact of varying the period used to exclude pre-existing disease.

Journal: BMC Med Res Methodol 13:32-

Date: 2013

Abstract: BACKGROUND: Estimating the incidence of medical conditions using claims data often requires constructing a prevalence period that predates an event of interest, for instance the diagnosis of cancer, to exclude those with pre-existing conditions from the incidence risk set. Those conditions missed during the prevalence period may be misclassified as incident conditions (false positives) after the event of interest.Using Medicare claims, we examined the impact of selecting shorter versus longer prevalence periods on the incidence and misclassification of 12 relatively common conditions in older persons. METHODS: The source of data for this study was the National Cancer Institute's Surveillance, Epidemiology, and End Results cancer registry linked to Medicare claims. Two cohorts of women were included: 33,731 diagnosed with breast cancer between 2000 and 2002, who had ≥ 36 months of Medicare eligibility prior to cancer, the event of interest; and 101,649 without cancer meeting the same Medicare eligibility criterion. Cancer patients were followed from 36 months before cancer diagnosis (prevalence period) up to 3 months after diagnosis (incidence period). Non-cancer patients were followed for up to 39 months after the beginning of Medicare eligibility. A sham date was inserted after 36 months to separate the prevalence and incidence periods. Using 36 months as the gold standard, the prevalence period was then shortened in 6-month increments to examine the impact on the number of conditions first detected during the incidence period. RESULTS: In the breast cancer cohort, shortening the prevalence period from 36 to 6 months increased the incidence rates (per 1,000 patients) of all conditions; for example: hypertension 196 to 243; diabetes 34 to 76; chronic obstructive pulmonary disease 29 to 46; osteoarthritis 27 to 36; congestive heart failure 20 to 36; osteoporosis 22 to 29; and cerebrovascular disease 13 to 21. Shortening the prevalence period has less impact on those without cancer. CONCLUSIONS: Selecting a short prevalence period to rule out pre-existing conditions can, through misclassification, substantially inflate estimates of incident conditions. In incidence studies based on Medicare claims, selecting a prevalence period of ≥24 months balances the need to exclude pre-existing conditions with retaining the largest possible cohort.

Authors: Islam NG, Dadabhoy H, Gillum A, Baranowski J, Zimmerman T, Subar AF, Baranowski T

Title: Digital food photography: dietary surveillance and beyond

Journal: Proc Food Sci 2:122-8

Date: 2013

Abstract: The method used for creating a database of approximately 20,000 digital images of multiple portion sizes of foods linked to the USDA's Food and Nutrient Database for Dietary Studies (FNDDS) is presented. The creation of this database began in 2002 and its development has spanned 10 years. Initially the images were intended to be used as a kid-friendly aid for estimating portion size in the context of a computerized 24-hour dietary recall for 8-15 year old children. In 2006, Baylor College of Medicine, Westat, and the National Cancer Institute initiated a collaboration that resulted in the expansion of this image database in preparation for the release of the web-based Automated Self- Administered 24 Hour Dietary Recall (ASA24) for adults (now also available for use by children - ASA24-Kids). Researchers in the US and overseas have capitalized on these digital images for purposes including, but not limited, to dietary assessment.

Authors: Kent EE, Alfano CM, Smith AW, Bernstein L, McTiernan A, Baumgartner KB, Ballard-Barbash R

Title: The roles of support seeking and race/ethnicity in posttraumatic growth among breast cancer survivors.

Journal: J Psychosoc Oncol 31(4):393-412

Date: 2013

Abstract: Posttraumatic growth (PTG) after cancer can minimize the emotional impact of disease and treatment; however, the facilitators of PTG, including support seeking, are unclear. The authors examined the role of support seeking on PTG among 604 breast cancer survivors ages 40 to 64 from the Health Eating, Activity, and Lifestyle (HEAL) Study. Multivariable linear regression was used to examine predictors of support seeking (participation in support groups and confiding in health care providers) as well as the relationship between support seeking and PTG. Support program participation was moderate (61.1%) compared to the high rates of confiding in health professionals (88.6%), and African Americans were less likely to report participating than non-Hispanic Whites (odds ratio = .14, confidence intervals [0.08, 0.23]). The mean (SD) PTG score was 48.8 (27.4) (range 0-105). Support program participation (β = 10.4) and confiding in health care providers (β = 12.9) were associated (p < .001) with higher PTG. In analyses stratified by race/ethnicity, PTG was significantly higher in non-Hispanic Whites and African American support program participants (p < .01), but not significantly higher in Hispanics/Latinas. Confiding in a health care provider was only associated with PTG for non-Hispanic Whites (p = .02). Support program experiences and patient-provider encounters should be examined to determine which attributes facilitate PTG in diverse populations.

Authors: Lipscomb J, Yabroff KR, Hornbrook MC, Gigli A, Francisci S, Krahn M, Gatta G, Trama A, Ritzwoller DP, Durand-Zaleski I, Salloum R, Chawla N, Angiolini C, Crocetti E, Giusti F, Guzzinati S, Mezzetti M, Miccinesi G, Mariotto A

Title: Comparing cancer care, outcomes, and costs across health systems: charting the course.

Journal: J Natl Cancer Inst Monogr 2013(46):124-30

Date: 2013

Abstract:

Authors: Oster NV, Carney PA, Allison KH, Weaver DL, Reisch LM, Longton G, Onega T, Pepe M, Geller BM, Nelson HD, Ross TR, Tosteson AN, Elmore JG

Title: Development of a diagnostic test set to assess agreement in breast pathology: practical application of the Guidelines for Reporting Reliability and Agreement Studies (GRRAS).

Journal: BMC Womens Health 13:3-

Date: 2013

Abstract: BACKGROUND: Diagnostic test sets are a valuable research tool that contributes importantly to the validity and reliability of studies that assess agreement in breast pathology. In order to fully understand the strengths and weaknesses of any agreement and reliability study, however, the methods should be fully reported. In this paper we provide a step-by-step description of the methods used to create four complex test sets for a study of diagnostic agreement among pathologists interpreting breast biopsy specimens. We use the newly developed Guidelines for Reporting Reliability and Agreement Studies (GRRAS) as a basis to report these methods. METHODS: Breast tissue biopsies were selected from the National Cancer Institute-funded Breast Cancer Surveillance Consortium sites. We used a random sampling stratified according to woman's age (40-49 vs. ≥50), parenchymal breast density (low vs. high) and interpretation of the original pathologist. A 3-member panel of expert breast pathologists first independently interpreted each case using five primary diagnostic categories (non-proliferative changes, proliferative changes without atypia, atypical ductal hyperplasia, ductal carcinoma in situ, and invasive carcinoma). When the experts did not unanimously agree on a case diagnosis a modified Delphi method was used to determine the reference standard consensus diagnosis. The final test cases were stratified and randomly assigned into one of four unique test sets. CONCLUSIONS: We found GRRAS recommendations to be very useful in reporting diagnostic test set development and recommend inclusion of two additional criteria: 1) characterizing the study population and 2) describing the methods for reference diagnosis, when applicable.

Authors: Owonikoko TK, Ragin C, Chen Z, Kim S, Behera M, Brandes JC, Saba NF, Pentz R, Ramalingam SS, Khuri FR

Title: Real-world effectiveness of systemic agents approved for advanced non-small cell lung cancer: a SEER-Medicare analysis.

Journal: Oncologist 18(5):600-10

Date: 2013

Abstract: OBJECTIVES: Disparity exists between patients with lung cancer enrolled in clinical trials and patients treated in the community setting. This study assessed the real-world effectiveness of cytotoxic agents that became available for the treatment of non-small cell lung cancer (NSCLC) in the last 2 decades. METHODS: We employed the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database for patients diagnosed with stage IIIB/IV NSCLC between 1988 and 2005 to assess the effectiveness of newly approved agents. Effectiveness of specific agents was assessed at time periods immediately following the approval of the agent for NSCLC: baseline, 1988-1994; platinum, 1995-1999; docetaxel, 1999-2003; pemetrexed and bevacizumab, 2004-2005. Significant associations between specific drug treatment and survival improvement were determined using the Kaplan-Meier method, Cox proportional hazard model, and propensity score analyses. Significant differences were established by log-rank test. RESULTS: This analysis employed data from 143,548 patients by sex (58% male, 42% female), cancer stage (35% stage IIIB, 65% stage IV), and age (12% 20-64 years, 22% 65-69 years, 45% 70-79 years, 22% 80 years and older). There was temporal improvement in survival for patients treated with newly approved chemotherapy (1-year survival rates: 32.41% in 1988-1994, 32.95% in 1995-1998, 37.40% in 1999-2003, and 39.55% in 2004-2005). Patients treated with a newly approved drug during the relevant treatment era had a significant reduction in the risk of death when compared with patients treated with chemotherapy other than the newly approved agent (hazard ratios [95% confidence interval] were 0.76 [0.71-0.81] for platinum, 0.73 [0.70-0.75] for docetaxel, 0.40 [0.37-0.44] for pemetrexed, and 0.33 [0.27-0.40] for bevacizumab; p < .001). Propensity score adjustment did not significantly alter these results. CONCLUSIONS: Currently approved drugs for the treatment of advanced NSCLC are associated with improved survival in the U.S. Medicare patient population. Our findings support the effectiveness of these agents in the real-world oncology practice.

Authors: Shariff-Marco S, Breen N, Stinchcomb DG, Klabunde CN

Title: Multilevel predictors of colorectal cancer screening use in California.

Journal: Am J Manag Care 19(3):205-16

Date: 2013

Abstract: BACKGROUND: Screening can detect colorectal cancer (CRC) early, yet its uptake needs to be improved. Social determinants of health (SDOH) may be linked to CRC screening use but are not well understood. OBJECTIVES: To examine geographic variation in CRC screening and the extent to which multilevel SDOH explain its use in California, the most populous and racially/ethnically diverse state in the United States. STUDY DESIGN: Analysis of individual and neighborhood data on 20,626 adult respondents aged >50 years from the 2005 California Health Interview Survey. METHODS: We used multilevel logistic regression models to estimate the effects of individual characteristics and area-level segregation, socioeconomic status (SES), and healthcare resources at 2 different geographic levels on CRC screening use. RESULTS: We confirmed that individual-level factors (eg, race/ethnicity, income, insurance) were strong predictors and found that area-level healthcare resources were associated with CRC screening. Primary care shortage in the Medical Service Study Area was associated with CRC screening for any modality (odds ratio [OR] = 0.89; 95% confidence interval [CI], 0.80-1.00). County-level HMO penetration (OR = 1.85; 95% CI, 1.47-2.33) and primary care shortage (OR = 0.73; 95% CI, 0.53-0.99) were associated with CRC screening with flexible sigmoidoscopy. CONCLUSIONS: Contextual factors including locality, primary care resources, and HMO membership are important determinants of CRC screening uptake; SES and segregation did not explain variation in screening behavior. More studies of contextual factors and varying geographic scales are needed to further elucidate their impact on CRC screening uptake.

Authors: Smith AW, Cronin KA, Bowles H, Willis G, Jacobs DR Jr, Ballard-Barbash R, Troiano RP

Title: Reproducibility of physical activity recall over fifteen years: longitudinal evidence from the CARDIA study.

Journal: BMC Public Health 13:180-

Date: 2013

Abstract: BACKGROUND: To examine the benefits of physical activity (PA) on diseases with a long developmental period, it is important to determine reliability of long-term PA recall. METHODS: We investigated 15-year reproducibility of PA recall. Participants were 3605 White and African-American adults in the Coronary Artery Risk Development in Young Adults study, aged 33-45 at the time of recall assessment. Categorical questions assessed PA before and during high school (HS) and overall PA level at Baseline, with the same timeframes recalled 15 years later. Moderate- and vigorous-intensity scores were calculated from reported months of participation in specific activities. RESULTS: HS PA recall had higher reproducibility than overall PA recall (weighted kappa = 0.43 vs. 0.21). Correlations between 15-year recall and Baseline reports of PA were r = 0.29 for moderate-intensity scores, and r = 0.50 for vigorous-intensity. Recall of vigorous activities had higher reproducibility than moderate-intensity activities. Regardless of number of months originally reported for specific activities, most participants recalled either no activity or activity during all 12 months. CONCLUSION: PA recall from the distant past is moderately reproducible, but poor at the individual level, among young and middle aged adults.

Authors: Smith AW, Parsons HM, Kent EE, Bellizzi K, Zebrack BJ, Keel G, Lynch CF, Rubenstein MB, Keegan TH, AYA HOPE Study Collaborative Group

Title: Unmet Support Service Needs and Health-Related Quality of Life among Adolescents and Young Adults with Cancer: The AYA HOPE Study.

Journal: Front Oncol 3:75-

Date: 2013

Abstract: Introduction: Cancer for adolescents and young adults (AYA) differs from younger and older patients; AYA face medical challenges while navigating social and developmental transitions. Research suggests that these patients are under or inadequately served by current support services, which may affect health-related quality of life (HRQOL). Methods: We examined unmet service needs and HRQOL in the National Cancer Institute's Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) study, a population-based cohort (n = 484), age 15-39, diagnosed with cancer 6-14 months prior, in 2007-2009. Unmet service needs were psychosocial, physical, spiritual, and financial services where respondents endorsed that they needed, but did not receive, a listed service. Linear regression models tested associations between any or specific unmet service needs and HRQOL, adjusting for demographic, medical, and health insurance variables. Results: Over one-third of respondents reported at least one unmet service need. The most common were financial (16%), mental health (15%), and support group (14%) services. Adjusted models showed that having any unmet service need was associated with worse overall HRQOL, fatigue, physical, emotional, social, and school/work functioning, and mental health (p's < 0.0001). Specific unmet services were related to particular outcomes [e.g., needing pain management was associated with worse overall HRQOL, physical and social functioning (p's < 0.001)]. Needing mental health services had the strongest associations with worse HRQOL outcomes; needing physical/occupational therapy was most consistently associated with poorer functioning across domains. Discussion: Unmet service needs in AYAs recently diagnosed with cancer are associated with worse HRQOL. Research should examine developmentally appropriate, relevant practices to improve access to services demonstrated to adversely impact HRQOL, particularly physical therapy and mental health services.

Authors: Thornton LE, Cameron AJ, McNaughton SA, Waterlander WE, Sodergren M, Svastisalee C, Blanchard L, Liese AD, Battersby S, Carter MA, Sheeshka J, Kirkpatrick SI, Sherman S, Cowburn G, Foster C, Crawford DA

Title: Does the availability of snack foods in supermarkets vary internationally?

Journal: Int J Behav Nutr Phys Act 10:56-

Date: 2013

Abstract: BACKGROUND: Cross-country differences in dietary behaviours and obesity rates have been previously reported. Consumption of energy-dense snack foods and soft drinks are implicated as contributing to weight gain, however little is known about how the availability of these items within supermarkets varies internationally. This study assessed variations in the display of snack foods and soft drinks within a sample of supermarkets across eight countries. METHODS: Within-store audits were used to evaluate and compare the availability of potato chips (crisps), chocolate, confectionery and soft drinks. Displays measured included shelf length and the proportion of checkouts and end-of-aisle displays containing these products. Audits were conducted in a convenience sample of 170 supermarkets across eight developed nations (Australia, Canada, Denmark, Netherlands, New Zealand, Sweden, United Kingdom (UK), and United States of America (US)). RESULTS: The mean total aisle length of snack foods (adjusted for store size) was greatest in supermarkets from the UK (56.4 m) and lowest in New Zealand (21.7 m). When assessed by individual item, the greatest aisle length devoted to chips, chocolate and confectionery was found in UK supermarkets while the greatest aisle length dedicated to soft drinks was in Australian supermarkets. Only stores from the Netherlands (41%) had less than 70% of checkouts featuring displays of snack foods or soft drinks. CONCLUSION: Whilst between-country variations were observed, overall results indicate high levels of snack food and soft drinks displays within supermarkets across the eight countries. Exposure to snack foods is largely unavoidable within supermarkets, increasing the likelihood of purchases and particularly those made impulsively.

Authors: Ward BW, Schiller JS

Title: Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010.

Journal: Prev Chronic Dis 10:E65-

Date: 2013

Abstract: Preventing and ameliorating chronic conditions has long been a priority in the United States; however, the increasing recognition that people often have multiple chronic conditions (MCC) has added a layer of complexity with which to contend. The objective of this study was to present the prevalence of MCC and the most common MCC dyads/triads by selected demographic characteristics. We used respondent-reported data from the 2010 National Health Interview Survey (NHIS) to study the US adult civilian noninstitutionalized population aged 18 years or older (n = 27,157). We categorized adults as having 0 to 1, 2 to 3, or 4 or more of the following chronic conditions: hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, chronic obstructive pulmonary disease, or current asthma. We then generated descriptive estimates and tested for significant differences. Twenty-six percent of adults have MCC; the prevalence of MCC has increased from 21.8% in 2001 to 26.0% in 2010. The prevalence of MCC significantly increased with age, was significantly higher among women than men and among non-Hispanic white and non-Hispanic black adults than Hispanic adults. The most common dyad identified was arthritis and hypertension, and the combination of arthritis, hypertension, and diabetes was the most common triad. The findings of this study contribute information to the field of MCC research. The NHIS can be used to identify population subgroups most likely to have MCC and potentially lead to clinical guidelines for people with more common MCC combinations.

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

Title: Urinary incontinence and health-related quality of life among older Americans with and without cancer: a cross-sectional study.

Journal: BMC Cancer 13:377-

Date: 2013

Abstract: BACKGROUND: Few studies have investigated the impact of urinary incontinence (UI) on health-related quality of life (HRQOL) among cancer survivors. UI is prevalent in the general population and can be both an indicator of cancer and a side effect of cancer treatment. UI and cancer diagnoses have been associated with decreases in HRQOL. This study evaluates the prevalence of UI and the impact on HRQOL among older cancer survivors. METHODS: The prevalence of UI among cancer survivors (breast, prostate, bladder, colorectal, lung, and endometrial/uterine cancers) and those without cancer was estimated using the SEER-MHOS database. Factors associated with UI were investigated using logistic regression and the impact of UI on SF-36 scores was determined using linear regression. RESULTS: Over 36% of SEER-MHOS beneficiaries without cancer reported UI and higher prevalence was noted among cancer survivors (37%-54% depending on cancer type). History of bladder, breast, endometrial/uterine, or prostate cancer was associated with higher prevalence of UI. UI was independently associated with both lower physical component scores (PCS) (-1.27; 95%CI:-1.34,-1.20) and mental component scores (MCS) (-1.75; 95%CI -1.83, -1.68). A suggested decreasing trend in the prevalence of UI was associated with a longer time since cancer diagnosis. CONCLUSIONS: UI was highly prevalent, especially in bladder, endometrial/uterine, and prostate cancer survivors. Improved recognition of UI risk among cancer survivors will help clinicians better anticipate and mediate the effect of UI on individuals' HRQOL.

Authors: Yabroff KR, Borowski L, Lipscomb J

Title: Economic studies in colorectal cancer: challenges in measuring and comparing costs.

Journal: J Natl Cancer Inst Monogr 2013(46):62-78

Date: 2013

Abstract: Estimates of the costs associated with cancer care are essential both for assessing burden of disease at the population level and for conducting economic evaluations of interventions to prevent, detect, or treat cancer. Comparisons of cancer costs between health systems and across countries can improve understanding of the economic consequences of different health-care policies and programs. We conducted a structured review of the published literature on colorectal cancer (CRC) costs, including direct medical, direct nonmedical (ie, patient and caregiver time, travel), and productivity losses. We used MEDLINE to identify English language articles published between 2000 and 2010 and found 55 studies. The majority were conducted in the United States (52.7%), followed by France (12.7%), Canada (10.9%), the United Kingdom (9.1%), and other countries (9.1%). Almost 90% of studies estimated direct medical costs, but few studies estimated patient or caregiver time costs or productivity losses associated with CRC. Within a country, we found significant heterogeneity across the studies in populations examined, health-care delivery settings, methods for identifying incident and prevalent patients, types of medical services included, and analyses. Consequently, findings from studies with seemingly the same objective (eg, costs of chemotherapy in year following CRC diagnosis) are difficult to compare. Across countries, aggregate and patient-level estimates vary in so many respects that they are almost impossible to compare. Our findings suggest that valid cost comparisons should be based on studies with explicit standardization of populations, services, measures of costs, and methods with the goal of comparability within or between health systems or countries. Expected increases in CRC prevalence and costs in the future highlight the importance of such studies for informing health-care policy and program planning.

Authors: Yabroff KR, Francisci S, Mariotto A, Mezzetti M, Gigli A, Lipscomb J

Title: Advancing comparative studies of patterns of care and economic outcomes in cancer: challenges and opportunities.

Journal: J Natl Cancer Inst Monogr 2013(46):1-6

Date: 2013

Abstract:

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

Title: Epidemiology and outcomes of previously undiagnosed diabetes in older women with breast cancer: an observational cohort study based on SEER-Medicare.

Journal: BMC Cancer 12(1):613-

Date: 2012 Dec 22

Abstract: BACKGROUND: In breast cancer, diabetes diagnosed prior to cancer (previously diagnosed) is associated with advanced cancer stage and increased mortality. However, in the general population, 40% of diabetes is undiagnosed until glucose testing, and evidence suggests one consequence of increased evaluation and management around breast cancer diagnosis is the increased detection of previously undiagnosed diabetes. Biological factors - for instance, higher insulin levels due to untreated disease - and others underlying the association between previously diagnosed diabetes and breast cancer could differ in those whose diabetes remains undiagnosed until cancer. Our objectives were to identify factors associated with previously undiagnosed diabetes in breast cancer, and to examine associations between previously undiagnosed diabetes and cancer stage, treatment patterns, and mortality. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare, we identified women diagnosed with breast cancer and diabetes between 01/2001 and 12/2005. Diabetes was classified as previously diagnosed if it was identified within Medicare claims between 24 and 4 months before cancer diagnosis, and previously undiagnosed if it was identified from 3 months before to ≤ 3 months after cancer. Patients were followed until 12/2007 or death, whichever came first. Multivariate analyses were performed to examine risk factors for previously undiagnosed diabetes and associations between undiagnosed (compared to previously diagnosed) diabetes, cancer stage, treatment, and mortality. RESULTS: Of 2,418 patients, 634 (26%) had previously undiagnosed diabetes; the remainder had previously diagnosed diabetes. The mean age was 77.8 years, and 49.4% were diagnosed with in situ or stage I disease. Age > 80 years (40% of the cohort) and limited health system contact (primary care physician and/or preventive services) prior to cancer were associated with higher adjusted odds of previously undiagnosed diabetes. Previously undiagnosed diabetes was associated with higher adjusted odds of advanced stage (III/IV) cancer (Odds Ratio = 1.37: 95% Confidence Interval (CI) 1.05 - 1.80; P = 0.02), and a higher adjusted mortality rate due to causes other than cancer (Hazard Ratio = 1.29; 95% CI 1.02 - 1.63; P = 0.03). CONCLUSIONS: In breast cancer, previously undiagnosed diabetes is associated with advanced stage cancer and increased mortality. Identifying biological factors would require further investigation.

Authors: Bleicher RJ, Ruth K, Sigurdson ER, Ross E, Wong YN, Patel SA, Boraas M, Topham NS, Egleston BL

Title: Preoperative delays in the US Medicare population with breast cancer.

Journal: J Clin Oncol 30(36):4485-92

Date: 2012 Dec 20

Abstract: PURPOSE: Although no specific delay threshold after diagnosis of breast cancer has been demonstrated to affect outcome, delays can cause anxiety, and surgical waiting time has been suggested as a quality measure. This study was performed to determine the interval from presentation to surgery in Medicare patients with nonmetastatic invasive breast cancer who did not receive neoadjuvant chemotherapy and factors associated with a longer time to surgery. METHODS: Medicare claims linked to Surveillance, Epidemiology, and End Results data were reviewed for factors associated with delay between the first physician claim for a breast problem and first therapeutic surgery. RESULTS: Between 1992 and 2005, 72,586 Medicare patients with breast cancer had a median interval (delay) between first physician visit and surgery of 29 days, increasing from 21 days in 1992 to 32 days in 2005. Women (29 days v 24 days for men; P < .001), younger patients (29 days; P < .001), blacks and Hispanics (each 37 days; P < .001), patients in the northeast (33 days; P < .001), and patients in large metropolitan areas (32 days; P < .001) had longer delays. Patients having breast conservation and mastectomies had adjusted median delays of 28 and 30 days, respectively, with simultaneous reconstruction adding 12 days. Preoperative components, including imaging modalities, biopsy type, and clinician visits, were also each associated with a specific additional delay. CONCLUSION: Waiting times for breast cancer surgery have increased in Medicare patients, and measurable delays are associated with demographics and preoperative evaluation components. If such increases continue, periodic assessment may be required to rule out detrimental effects on outcomes.

Authors: Chen J, Long JB, Hurria A, Owusu C, Steingart RM, Gross CP

Title: Incidence of heart failure or cardiomyopathy after adjuvant trastuzumab therapy for breast cancer.

Journal: J Am Coll Cardiol 60(24):2504-12

Date: 2012 Dec 18

Abstract: OBJECTIVES: The purpose of this study was to estimate heart failure (HF) and cardiomyopathy (CM) rates after adjuvant trastuzumab therapy and chemotherapy in a population of older women with early-stage breast cancer. BACKGROUND: Newer biologic therapies for breast cancer such as trastuzumab have been reported to increase HF and CM in clinical trials, especially in combination with anthracycline chemotherapy. Elderly patients, however, typically have a higher prevalence of cardiovascular risk factors and have been underrepresented in trastuzumab clinical trials. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data from 2000 through 2007, we identified women 67 to 94 years of age with early-stage breast cancer. We calculated 3-year incidence rates of HF or CM for the following mutually exclusive treatment groups: trastuzumab (with or without nonanthracycline chemotherapy), anthracycline plus trastuzumab, anthracycline (without trastuzumab and with or without nonanthracycline chemotherapy), other nonanthracycline chemotherapy, or no adjuvant chemotherapy or trastuzumab therapy. HF or CM events were ascertained from administrative Medicare claims. Poisson regression was used to quantify risk of HF or CM, adjusting for sociodemographic factors, cancer characteristics, and cardiovascular conditions. RESULTS: We identified 45,537 older women (mean age: 76.2 years, standard deviation: 6.2 years) with early-stage breast cancer. Adjusted 3-year HF or CM incidence rates were higher for patients receiving trastuzumab (32.1 per 100 patients) and anthracycline plus trastuzumab (41.9 per 100 patients) compared with no adjuvant therapy (18.1 per 100 patients, p < 0.001). Adding trastuzumab to anthracycline therapy added 12.1, 17.9, and 21.7 HF or CM events per 100 patients over 1, 2, and 3 years of follow-up, respectively. CONCLUSIONS: HF or CM are common complications after trastuzumab therapy for older women, with higher rates than those reported from clinical trials.

Authors: Griffiths RI, Gleeson ML, Mikhael J, Dreyling MH, Danese MD

Title: Comparative effectiveness and cost of adding rituximab to first-line chemotherapy for elderly patients diagnosed with diffuse large B-cell lymphoma.

Journal: Cancer 118(24):6079-88

Date: 2012 Dec 15

Abstract: BACKGROUND: Clinical trials indicate that rituximab improves the survival of patients with diffuse large B-cell lymphoma (DLBCL). Economic models using multiple data sources, including clinical trials for survival outcomes, have projected cost offsets/savings and favorable cost-effectiveness associated with rituximab. In this study, the authors evaluated survival and cost impacts of adding rituximab to first-line chemotherapy for DLBCL using a single database that reflects routine clinical practice among elderly patients in the United States. METHODS: By using Surveillance, Epidemiology, and End Results (SEER) data linked to Medicare, the authors identified 5484 elderly patients who were diagnosed with DLBCL between January 1999 and December 2005 who had claims through December 2007. Included patients began chemotherapy with or without rituximab within 180 days of diagnosis. Multivariate analyses were conducted to estimate the impact of rituximab on mortality and costs to Medicare. The cost per life-year gained of rituximab was calculated using cost and survival estimates from the multivariate analyses. RESULTS: The mean patient age was 76 years, 43% of patients had stage III or IV disease, and 64% received rituximab. In a Cox regression model, rituximab resulted in lower 4-year all-cause mortality (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.61-0.74) and cancer mortality, and the incremental cumulative survival was 0.37 years. In least-squares regression, rituximab resulted in higher 4-year total costs ($23,097; 95% CI, $19,129-$27,298), immunochemotherapy costs ($12,069; 95% CI, $10,687-$13,634), other cancer costs ($7655; 95% CI, $5067-$10,489), and noncancer costs ($3461; 95% CI, $1319-$5650). The cost per life-year gained was $62,424. CONCLUSIONS: In routine clinical practice, rituximab was associated with survival benefits comparable to those observed in clinical trials. However, these benefits did not translate into the previously reported cost savings.

Authors: Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Malin JL, Earle CC, Weeks JC

Title: Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study.

Journal: J Clin Oncol 30(35):4387-95

Date: 2012 Dec 10

Abstract: PURPOSE: National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death. PATIENTS AND METHODS: We studied 1,231 patients with stage IV lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium, a population- and health system-based prospective cohort study, who died during the 15-month study period but survived at least 1 month. Our main outcome measure was the aggressiveness of EOL care received. RESULTS: Nearly half of patients received at least one marker of aggressive EOL care, including chemotherapy in the last 14 days of life (16%), intensive care unit care in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%). Patients who had EOL discussions with their physicians before the last 30 days of life were less likely to receive aggressive measures at EOL, including chemotherapy (P = .003), acute care (P < .001), or any aggressive care (P < .001). Such patients were also more likely to receive hospice care (P < .001) and to have hospice initiated earlier (P < .001). CONCLUSION: Early EOL discussions are prospectively associated with less aggressive care and greater use of hospice at EOL.

Authors: Chang CM, Warren JL, Engels EA

Title: Chronic fatigue syndrome and subsequent risk of cancer among elderly US adults.

Journal: Cancer 118(23):5929-36

Date: 2012 Dec 01

Abstract: BACKGROUND: The cause of chronic fatigue syndrome (CFS) is unknown but is thought to be associated with immune abnormalities or infection. Because cancer can arise from similar conditions, associations between CFS and cancer were examined in a population-based case-control study among the US elderly. METHODS: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare registry data, approximately 1.2 million cancer cases and 100,000 controls (age range, 66-99 years; 1992-2005) were evaluated. CFS was identified in the period more than 1 year prior to selection, using linked Medicare claims. Unconditional logistic regression was used to estimate the odds ratios (ORs) comparing the CFS prevalence in cases and controls, adjusting for age, sex, and selection year. All statistical tests were 2-sided. RESULTS: CFS was present in 0.5% of cancer cases overall and 0.5% of controls. CFS was associated with an increased risk of non-Hodgkin lymphoma (NHL) (OR = 1.29, 95% confidence interval [CI] = 1.16-1.43, P = 1.7 × 10(-6) ). Among NHL subtypes, CFS was associated with diffuse large B cell lymphoma (OR = 1.34, 95% CI = 1.12-1.61), marginal zone lymphoma (OR = 1.88, 95% CI = 1.38-2.57), and B cell NHL not otherwise specified (OR = 1.51, 95% CI = 1.03-2.23). CFS associations with NHL overall and NHL subtypes remained elevated after excluding patients with medical conditions related to CFS or NHL, such as autoimmune conditions. CFS was also associated, although not after multiple comparison adjustment, with cancers of the pancreas (OR = 1.25, 95% CI = 1.07-1.47), kidney (OR = 1.27, 95% CI = 1.07-1.49), breast (OR = 0.85, 95% CI = 0.74-0.98), and oral cavity and pharynx (OR = 0.70, 95% CI = 0.49-1.00). CONCLUSIONS: Chronic immune activation or an infection associated with CFS may play a role in explaining the increased risk of NHL.

Authors: Shirvani SM, Jiang J, Chang JY, Welsh JW, Gomez DR, Swisher S, Buchholz TA, Smith BD

Title: Comparative effectiveness of 5 treatment strategies for early-stage non-small cell lung cancer in the elderly.

Journal: Int J Radiat Oncol Biol Phys 84(5):1060-70

Date: 2012 Dec 01

Abstract: PURPOSE: The incidence of early-stage non-small cell lung cancer (NSCLC) among older adults is expected to increase because of demographic trends and computed tomography-based screening; yet, optimal treatment in the elderly remains controversial. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort spanning 2001-2007, we compared survival outcomes associated with 5 strategies used in contemporary practice: lobectomy, sublobar resection, conventional radiation therapy, stereotactic ablative radiation therapy (SABR), and observation. METHODS AND MATERIALS: Treatment strategy and covariates were determined in 10,923 patients aged ≥ 66 years with stage IA-IB NSCLC. Cox regression, adjusted for patient and tumor factors, compared overall and disease-specific survival for the 5 strategies. In a second exploratory analysis, propensity-score matching was used for comparison of SABR with other options. RESULTS: The median age was 75 years, and 29% had moderate to severe comorbidities. Treatment distribution was lobectomy (59%), sublobar resection (11.7%), conventional radiation (14.8%), observation (12.6%), and SABR (1.1%). In Cox regression analysis with a median follow-up time of 3.2 years, SABR was associated with the lowest risk of death within 6 months of diagnosis (hazard ratio [HR] 0.48; 95% confidence interval [CI] 0.38-0.63; referent is lobectomy). After 6 months, lobectomy was associated with the best overall and disease-specific survival. In the propensity-score matched analysis, survival after SABR was similar to that after lobectomy (HR 0.71; 95% CI 0.45-1.12; referent is SABR). Conventional radiation and observation were associated with poor outcomes in all analyses. CONCLUSIONS: In this population-based experience, lobectomy was associated with the best long-term outcomes in fit elderly patients with early-stage NSCLC. Exploratory analysis of SABR early adopters suggests efficacy comparable with that of surgery in select populations. Evaluation of these therapies in randomized trials is urgently needed.

Authors: Chang Y, Schechter CB, van Ravesteyn NT, Near AM, Heijnsdijk EA, Adams-Campbell L, Levy D, de Koning HJ, Mandelblatt JS

Title: Collaborative modeling of the impact of obesity on race-specific breast cancer incidence and mortality.

Journal: Breast Cancer Res Treat 136(3):823-35

Date: 2012 Dec

Abstract: Obesity affects multiple points along the breast cancer control continuum from prevention to screening and treatment, often in opposing directions. Obesity is also more prevalent in Blacks than Whites at most ages so it might contribute to observed racial disparities in mortality. We use two established simulation models from the Cancer Intervention and Surveillance Modeling Network (CISNET) to evaluate the impact of obesity on race-specific breast cancer outcomes. The models use common national data to inform parameters for the multiple US birth cohorts of Black and White women, including age- and race-specific incidence, competing mortality, mammography characteristics, and treatment effectiveness. Parameters are modified by obesity (BMI of ≥ 30 kg/m(2)) in conjunction with its age-, race-, cohort- and time-period-specific prevalence. We measure age-standardized breast cancer incidence and mortality and cases and deaths attributable to obesity. Obesity is more prevalent among Blacks than Whites until age 74; after age 74 it is more prevalent in Whites. The models estimate that the fraction of the US breast cancer cases attributable to obesity is 3.9-4.5 % (range across models) for Whites and 2.5-3.6 % for Blacks. Given the protective effects of obesity on risk among women <50 years, elimination of obesity in this age group could increase cases for both the races, but decrease cases for women ≥ 50 years. Overall, obesity accounts for 4.4-9.2 % and 3.1-8.4 % of the total number of breast cancer deaths in Whites and Blacks, respectively, across models. However, variations in obesity prevalence have no net effect on race disparities in breast cancer mortality because of the opposing effects of age on risk and patterns of age- and race-specific prevalence. Despite its modest impact on breast cancer control and race disparities, obesity remains one of the few known modifiable risks for cancer and other diseases, underlining its relevance as a public health target.

Authors: Epstein AJ, Johnson SJ

Title: Physician response to financial incentives when choosing drugs to treat breast cancer.

Journal: Int J Health Care Finance Econ 12(4):285-302

Date: 2012 Dec

Abstract: This paper considers physician agency in choosing drugs to treat metastatic breast cancer, a clinical setting in which patients have few protections from physicians' rent seeking. Physicians have explicit financial incentives attached to each potential drug treatment, with profit margins ranging more than a hundred fold. SEER-Medicare claims and Medispan pricing data were formed into a panel of 4,503 patients who were diagnosed with metastatic breast cancer and treated with anti-cancer drugs from 1992 to 2002. We analyzed the effects of product attributes, including profit margin, randomized controlled trial citations, FDA label, generic status, and other covariates on therapy choice. Instruments and drug fixed effects were used to control for omitted variables and possible measurement error associated with margin. We find that increasing physician margin by 10% yields between an 11 and 177% increase in the likelihood of drug choice on average across drugs. Physicians were more likely to use drugs with which they had experience, had more citations, and were FDA-approved to treat breast cancer. Oncologists are susceptible to financial incentives when choosing drugs, though other factors play a large role in their choice of drug.

Authors: Erinosho TO, Berrigan D, Thompson FE, Moser RP, Nebeling LC, Yaroch AL

Title: Dietary intakes of preschool-aged children in relation to caregivers' race/ethnicity, acculturation, and demographic characteristics: results from the 2007 California Health Interview Survey.

Journal: Matern Child Health J 16(9):1844-53

Date: 2012 Dec

Abstract: Few studies have examined the influence of acculturation on dietary behaviors of young children while controlling for other demographic variables. The purpose of this study was to assess reported dietary intakes of preschool-aged children (3-5 years) and subsequent associations with caregivers' race/ethnicity, acculturation and demographic characteristics, using data from the 2007 California Health Interview Survey (CHIS). Analysis was restricted to Hispanic and non-Hispanic white caregivers and their preschool-aged children (n = 1,105). Caregivers' acculturation was assessed using place of birth, duration of United States residence, and language spoken at home. Proxy-reports by caregivers to a dietary screener were used to estimate children's intakes of fruit, 100% fruit juice, vegetables, sweets, and sugar-sweetened beverages consumed. In multivariate analyses, Hispanic caregivers reported their children consumed fewer servings of vegetables than did the children of non-Hispanic white caregivers; there were no other statistically significant differences in children's dietary intakes by caregivers' race/ethnicity. Caregivers' acculturation was associated with caregiver-reported consumption of sweets by children (β = 0.09, 95%CI = 0.01-0.18). Demographic characteristics that were associated with reported dietary intakes of children included caregivers' age, education, and geographic region of residence. In contrast to past studies of acculturation and diet in older children and adults, this study suggests that for 3-5 year olds, caregivers' level of acculturation does not play as strong a role in the dietary intakes of the younger children under their care.

Authors: Fenton JJ, Miglioretti DL

Title: Why we need more breast cancer screening trials.

Journal: Evid Based Med 17(6):169-70

Date: 2012 Dec

Abstract:

Authors: Halpern MT, Holden DJ

Title: Disparities in timeliness of care for U.S. Medicare patients diagnosed with cancer.

Journal: Curr Oncol 19(6):e404-13

Date: 2012 Dec

Abstract: BACKGROUND: Timeliness of care (rapid initiation of treatment after definitive diagnosis) is a key component of high-quality cancer treatment. The present study evaluated factors influencing timeliness of care for U.S. Medicare enrollees. METHODS: Data for Medicare enrollees diagnosed with breast, colorectal, lung, or prostate cancer while living in U.S. seer (Surveillance, Epidemiology and End Results) regions in 2000-2002 were analyzed. Patients were classified as experiencing delayed treatment if the interval between diagnosis and treatment was greater than the 95th percentile for each cancer site. The impacts of patient sociodemographic, clinical, and area-based factors on the likelihood of delayed treatment were analyzed using multivariate logistic regression. RESULTS: Black patients (compared with white patients) and patients initially treated with radiation therapy or chemotherapy (rather than surgery) had a greater likelihood of treatment delays across all four cancer sites. Hispanic status, dual Medicare-Medicaid status, location of initial treatment (inpatient vs. outpatient), and stage at diagnosis also affected timeliness of care for some cancer sites. Surprisingly, area-based factors reflecting availability of cancer care services were not significantly associated with timeliness of care or were associated with greater delays in areas with greater numbers of service providers. CONCLUSIONS: Multiple factors affected receipt of timely cancer care for members of the study population, all of whom had coverage of medical care services through Medicare. Because delays in treatment initiation can increase morbidity, decrease quality of life, shorten survival, and result in greater costs, prospective studies and tailored interventions are needed to address those factors among at-risk patient groups.

Authors: Henderson LM, Hubbard RA, Onega TL, Zhu W, Buist DS, Fishman P, Tosteson AN

Title: Assessing health care use and cost consequences of a new screening modality: the case of digital mammography.

Journal: Med Care 50(12):1045-52

Date: 2012 Dec

Abstract: BACKGROUND: Full-field digital mammography (FFDM) has largely replaced screen-film mammography (SFM) for breast cancer screening, but how this affects downstream breast-related use and costs is unknown. OBJECTIVES: To compare breast-related health care use and costs among Medicare beneficiaries undergoing SFM versus FFDM from 1999 to 2005. DESIGN: Retrospective cohort study. SUBJECTS: Medicare-enrolled women aged 66 and older with mammograms in Breast Cancer Surveillance Consortium registries. MEASURES: Subsequent follow-up with additional imaging or breast biopsy within 12 months was ascertained through Medicare claims. Associated mean costs were estimated by screening modality and year, adjusting for confounding factors, and clustering within mammography facilities using Generalized Estimating Equations. RESULTS: Among 138,199 women, 332,324 SFM and 22,407 FFDM mammograms were analyzed. Approximately 6.5% of SFM and 9.0% of FFDM had positive findings. In 2001, subsequent imaging was higher among FFDM versus SFM (127.5 vs. 97.4 follow-up mammography claims per 1000 index mammograms), whereas subsequent biopsy was lower among FFDM versus SFM (19.2 vs. 24.9 per 1000 index mammograms) with differences decreasing over time. From 2001 to 2004, mammography subsequent to FFDM had higher mean costs than SFM ($82.60 vs. $64.31 in 2001). The only cost differences between SFM and FFDM for ultrasound or biopsy were in 2001. CONCLUSIONS: Subsequent breast-related health care use differed early in FFDM introduction, but diminished over time with differences attributable to higher recall rates for additional imaging and lower rates of biopsy in those undergoing FFDM versus SFM. Remaining cost differences are because of higher reimbursement rates for FFDM versus SFM.

Authors: Hubbard RA, Zhu W, Onega TL, Fishman P, Henderson LM, Tosteson AN, Buist DS

Title: Effects of digital mammography uptake on downstream breast-related care among older women.

Journal: Med Care 50(12):1053-9

Date: 2012 Dec

Abstract: BACKGROUND: Digital mammography is the dominant modality for breast cancer screening in the United States. No previous studies have investigated as to how introducing digital mammography affects downstream breast-related care. OBJECTIVE: Compare breast-related health care use after a screening mammogram before and after introduction of digital mammography. RESEARCH DESIGN AND SUBJECTS: Longitudinal study of screening mammograms from 14 radiology facilities contributing data to the Breast Cancer Surveillance Consortium performed 1 year before and 4 years after each facility introduced digital mammography, along with linked Medicare claims. We included 30,211 mammograms for women aged 66 years and older without breast cancer. MEASURES: Rates of false-positive recall and short-interval follow-up were based on radiologists' assessments and recommendations; rates of follow-up mammography, ultrasound, and breast biopsy use were based on Medicare claims. RESULTS: False-positive recall rates increased after the introduction of digital mammography. Follow-up mammography use was significantly higher across all 4 years after a facility began using digital mammography compared with the year before [year 1 odds ratio (OR) = 1.7, 95% confidence interval (CI), 1.4-2.1]. Among women with false-positive mammography results, use of ultrasound decreased significantly in the second through fourth years after digital mammography began (year 2 OR = 0.4, 95% CI, 0.3-0.6). CONCLUSIONS: Introduction of a new technology led to changes in health care use that persisted for at least 4 years. Comparative effectiveness research on new technologies should consider not only diagnostic performance but also downstream utilization attributable to this apparent learning curve.

Authors: Jacobs BL, Zhang Y, Skolarus TA, Wei JT, Montie JE, Schroeck FR, Hollenbeck BK

Title: Managed care and the diffusion of intensity-modulated radiotherapy for prostate cancer.

Journal: Urology 80(6):1236-42

Date: 2012 Dec

Abstract: OBJECTIVE: To better understand associations between managed care penetration in health care markets and the adoption of intensity-modulated radiotherapy (IMRT). METHODS: We used Surveillance, Epidemiology, and End Results-Medicare data to identify men diagnosed with prostate cancer between 2001 and 2007 who were treated with radiotherapy (n = 55,162). We categorized managed care penetration in Health Service Areas (HSAs) as low (<3%), intermediate (3%-10%), and high (>10%), and assessed our main outcomes (ie, probability of IMRT adoption, which is the ability of a health care market to deliver IMRT, and IMRT utilization in HSA markets) using a Cox proportional hazards model and Poisson regression model, respectively. RESULTS: Compared with markets with low managed care penetration, populations in highly penetrated HSAs were more racially diverse (25% vs 15% non-white, P <.01), densely populated (2110 vs 145 people/square mile, P <.01), and wealthier (median income, $48,500 vs $31,900, P <.01). The probability of IMRT adoption was greatest in markets with the highest managed care penetration (eg, 0.82 [high] vs 0.72 [low] in 2007, P = .05). Among adopting markets, the use of IMRT increased in all HSA categories. However, relative to markets with low managed care penetration, IMRT use was constrained in markets with the highest penetration (0.69 [high] vs 0.76 [low] in 2007, P <.01). CONCLUSION: Markets with higher managed care penetration demonstrated a greater propensity for acquiring IMRT technology. However, after adopting IMRT, more highly penetrated markets had roughly 7% slower growth in IMRT use during the study period. These findings provide insight into the implications of delivery system reforms for cancer-related technologies.

Authors: Jayadevappa R, Malkowicz SB, Chhatre S, Johnson JC, Gallo JJ

Title: The burden of depression in prostate cancer.

Journal: Psychooncology 21(12):1338-45

Date: 2012 Dec

Abstract: OBJECTIVE: We sought to analyze the prevalence and incremental burden of depression among elderly with prostate cancer. METHODS: We adopted a retrospective cohort design using the Surveillance, Epidemiology and End Results-Medicare linked database between 1995 and 2003. Patients with prostate cancer diagnosed between 1995 and 1998 were identified and followed retrospectively for 1 year pre-diagnosis and up to 8 years post diagnosis. In this cohort of patients with prostate cancer, depression during treatment phase (1 year after diagnosis of prostate cancer) or in the follow-up phase was identified using the International Classification of Diseases-Ninth Revision depression-related codes. Poisson, general linear (log-link) and Cox regression models were used to determine the association between depression status during treatment and follow-up phases and outcomes-health resource utilization, cost and mortality. RESULTS: Of the 50,147 patients newly diagnosed with prostate cancer, 4285 (8.54%) had a diagnosis of depression. A diagnosis of depression during treatment phase was associated with higher odds of emergency room visits (odds ratio (OR) = 4.45, 95% CI = 4.13, 4.80), hospitalizations (OR = 3.22, CI = 3.08, 3.37), outpatient visits (OR = 1.71, CI = 1.67, 1.75) and excess risk of death over the course of the follow-up interval (hazard ratio = 2.82, CI = 2.60, 3.06). Health care costs associated with depression remained elevated compared with costs for men without depression, over the course of the follow-up. CONCLUSIONS: Depression during the treatment phase was associated with significant health resource utilization, costs and mortality among men with prostate cancer. These findings emphasize the need to effectively identify and treat depression in the setting of prostate cancer.

Authors: Klabunde CN, Willis GB, McLeod CC, Dillman DA, Johnson TP, Greene SM, Brown ML

Title: Improving the quality of surveys of physicians and medical groups: a research agenda.

Journal: Eval Health Prof 35(4):477-506

Date: 2012 Dec

Abstract: Because health care providers have a central role in implementing guidelines, health care reform, and new standards of care and technologies, surveying them about their practices and perspectives is vital for health services and policy research. In November 2010, the National Cancer Institute convened a workshop to review and discuss current methodologies in designing and fielding large-scale surveys of physicians and medical groups. This report summarizes key issues and future directions for four topic areas addressed in the workshop: sample frames for surveying physicians and medical groups; points of contact and response modes; response incentives; and questionnaire design and burden. Recommendations were made for improving sample frame databases, optimizing mixed-mode surveys, and studying use of incentives with gatekeepers and in medical group settings. There is particular need for empirical assessment of factors that motivate or impede participation of physicians, other types of clinicians, and medical groups in survey research.

Authors: Kutikov A, Egleston BL, Canter D, Smaldone MC, Wong YN, Uzzo RG

Title: Competing risks of death in patients with localized renal cell carcinoma: a comorbidity based model.

Journal: J Urol 188(6):2077-83

Date: 2012 Dec

Abstract: PURPOSE: Multiple risks compete with cancer as the primary cause of death. These factors must be considered against the benefits of treatment. We constructed a model of competing causes of death to help contextualize treatment trade-off analyses in patients with localized renal cell carcinoma. MATERIALS AND METHODS: We identified 6,655 individuals 66 years old or older with localized renal cell carcinoma in the linked SEER (Surveillance, Epidemiology and End Results)-Medicare data set for 1995 to 2005. We used Fine and Gray competing risks proportional hazards regression to predict probabilities of competing mortality outcomes. Prognostic markers included race, gender, tumor size, age and the Charlson comorbidity index score. RESULTS: At a median followup of 43 months, age and comorbidity score strongly correlated with patient mortality and were most predictive of nonkidney cancer death, as measured by concordance statistics. Patients with localized, node negative kidney cancer had a low 3 (4.7%), 5 (7.5%) and 10-year (11.9%) probability of cancer specific death but a significantly higher overall risk of death from competing causes within 3 (10.9%), 5 (20.1%) and 10 years (44.4%) of renal cell carcinoma diagnosis, depending on comorbidity score. CONCLUSIONS: Informed treatment decisions regarding patients with solid tumors must integrate not only cancer related variables but also factors that predict noncancer death. We established a comorbidity based predictive model that may assist in patient counseling by allowing quantification and comparison of competing risks of death in patients 66 years old or older with localized renal cell carcinoma who elect to proceed with surgery.

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

Title: Does primary androgen-deprivation therapy delay the receipt of secondary cancer therapy for localized prostate cancer?

Journal: Eur Urol 62(6):966-72

Date: 2012 Dec

Abstract: BACKGROUND: Despite evidence that shows no survival advantage, many older patients receive primary androgen-deprivation therapy (PADT) shortly after the diagnosis of localized prostate cancer (PCa). OBJECTIVE: This study evaluates whether the early use of PADT affects the subsequent receipt of additional palliative cancer treatments such as chemotherapy, palliative radiation therapy, or intervention for spinal cord compression or bladder outlet obstruction. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal population-based cohort study consists of Medicare patients aged ≥ 66 yr diagnosed with localized PCa from 1992 to 2006 in areas covered by the Surveillance Epidemiology and End Results (SEER) program. SEER-Medicare linked data through 2009 were used to identify the use of PADT and palliative cancer therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Instrumental variable analysis methods were used to minimize confounding effects. Confidence intervals were derived from the bootstrap estimates. RESULTS AND LIMITATIONS: This study includes 29 775 men who did not receive local therapy for T1-T2 PCa within the first year of cancer diagnosis. Among low-risk patients (Gleason score 2-7 in 1992-2002 and Gleason score 2-6 in 2003-2006) with a median age of 78 yr and a median follow-up of 10.3 yr, PADT was associated with a 25% higher use of chemotherapy (hazard ratio [HR]: 1.25; 95% confidence interval [CI], 1.08-1.44) and a borderline higher use of any palliative cancer treatment (HR: 1.07; 95% CI, 0.97-1.19) within 10 yr of diagnosis in regions with high PADT use compared with regions with low PADT use. Because this study was limited to men >65 yr, the results may not be applicable to younger patients. CONCLUSIONS: Early treatment of low-risk, localized PCa with PADT does not delay the receipt of subsequent palliative therapies and is associated with an increased use of chemotherapy.

Authors: Meissner HI, Klabunde CN, Breen N, Zapka JM

Title: Breast and colorectal cancer screening: U.S. primary care physicians' reports of barriers.

Journal: Am J Prev Med 43(6):584-9

Date: 2012 Dec

Abstract: BACKGROUND: Primary care physicians (PCPs) play a key role in performing and referring patients for cancer screening. Understanding barriers to test use is critical to developing strategies that promote adherence to clinical guidelines, but current literature does not distinguish the extent to which barriers may be similar or unique across screening modalities. PURPOSE: To describe PCPs' self-reported perceptions of barriers to screening for breast and colorectal cancer (CRC) and compare the top three barriers associated with these screening modalities. METHODS: Cross-sectional data analyzed in 2011 from a nationally representative survey of 2478 PCPs in the U.S. in 2006-2007. RESULTS: PCPs reported greater barriers for CRC screening than for mammography. Lack of patient follow-through to complete recommended screening and the inability to pay for tests were the main barriers perceived by PCPs for both types of screening. Another major barrier cited was that patients do not perceive CRC as a threat. This was a lesser concern for the well-diffused message about the need for mammography. CONCLUSIONS: This is the first national study to provide a comparison of physician-perceived barriers to breast and CRC screening. Study results suggest that efforts to improve use of cancer screening, and CRC screening in particular, will require interventions at physician, practice, and health-system levels.

Authors: Morgan TM, Barocas DA, Keegan KA, Cookson MS, Chang SS, Ni S, Clark PE, Smith JA Jr, Penson DF

Title: Volume outcomes of cystectomy--is it the surgeon or the setting?

Journal: J Urol 188(6):2139-44

Date: 2012 Dec

Abstract: PURPOSE: Hospital volume and surgeon volume are each associated with outcomes after complex oncological surgery. However, the interplay between hospital and surgeon volume, and their impact on these outcomes has not been well characterized. We studied the relationship between surgeon and hospital volume, and overall mortality after radical cystectomy. MATERIALS AND METHODS: The SEER (Surveillance, Epidemiology and End Results)-Medicare linked database was used to identify 7,127 patients with urothelial carcinoma of the bladder who underwent radical cystectomy from 1992 to 2006. Hospital volume and surgeon volume were expressed by tertile. The primary outcome measure was overall survival. Covariates included age, Charlson comorbidity index, stage, grade, node count, node density, number of positive nodes, urinary diversion and year of surgery. Multivariate analyses using generalized linear multilevel models were used to determine the independent association between hospital and surgeon volume and survival. RESULTS: When hospital volume or surgeon volume was included in the multivariate model, a significant volume-survival relationship was observed for each. However, when both were in the model, hospital volume attenuated the impact of surgeon volume on mortality while the significant hospital volume-mortality relationship persisted (HR 1.18, 95% CI 1.08-1.30, p <0.01). In addition, the adjusted 3-year probability of survival was significantly correlated with hospital volume in each distinct surgeon volume stratum while survival was not correlated with surgeon volume in each hospital volume stratum. CONCLUSIONS: After adjustment for patient and disease characteristics, the relationship between surgeon volume and survival after radical cystectomy is accounted for by hospital volume. In contrast, hospital volume remained an independent predictor of survival, suggesting that structure and process characteristics of high volume hospitals drive long-term outcomes after radical cystectomy.

Authors: Oran B, Weisdorf DJ

Title: Survival for older patients with acute myeloid leukemia: a population-based study.

Journal: Haematologica 97(12):1916-24

Date: 2012 Dec

Abstract: BACKGROUND: Acute myeloid leukemia is the second most common leukemia among United States adults with a median age of 69 years. We investigated recent clinical practices related to treatments and disease outcomes in older patients with acute myeloid leukemia in the United States. DESIGN AND METHODS: In this retrospective cohort study, we used Surveillance, Epidemiology, and End Results program data from 2000 through 2007 linked to Medicare enrollment and utilization data in the United States. RESULTS: Among 5,480 patients with acute myeloid leukemia (median age 78 years, range 65-93), 38.6% received leukemia therapy within three months of diagnosis (treated group). Practice changed with 16.3% of treated patients receiving hypomethylating agents after 2004 when those agents became available. Median survival was two months in the untreated group versus six months in the treated group (P<0.01) with the biggest improvements seen in those aged 65-69 years (10 months vs. 4 months; P<0.01) and 70-74 years (8 months vs. 3 months; P<0.01). In 46 patients receiving allogeneic hematopoietic cell transplantation (0.8%), the median survival from diagnosis was 22 months. CONCLUSIONS: Therapy for leukemia improves overall survival in older acute myeloid leukemia patients. Based on their comorbidities, most patients up to 80 years of age should be considered for treatment. New therapies including hypomethylating agents and allogeneic hematopoietic cell transplantation are promising and must be compared with other chemotherapy regimens.

Authors: Rengan R, Mitra N, Liao K, Armstrong K, Vachani A

Title: Effect of HIV on survival in patients with non-small-cell lung cancer in the era of highly active antiretroviral therapy: a population-based study.

Journal: Lancet Oncol 13(12):1203-9

Date: 2012 Dec

Abstract: BACKGROUND: HIV-infected patients with lung cancer have been reported to have poorer survival than uninfected patients. Whether this outcome holds true in the era of highly active antiretroviral therapy (HAART) is unclear. We examined the effect of HIV infection on clinical outcome in patients with lung cancer who are also receiving HAART. METHODS: Patients diagnosed with non-small-cell lung cancer (NSCLC) from Jan 1, 2000, to Dec 31, 2005, with or without HIV infection were identified by querying the Surveillance, Epidemiology, and End Results registry and the Medicare lung cancer database. Survival analysis by stage and treatment delivered comparing the HIV-infected patients with uninfected controls was done with Kaplan-Meier and Cox models with propensity score adjustments. FINDINGS: 71,976 patients with NSCLC were identified as uninfected controls and 322 patients with NSCLC were identified in the HIV group; median age was 75 years for both groups. Median overall survival for all stages was 7·0 months (95% CI 7·0-7·0) for uninfected controls versus 8·0 months (6·0-10·0) for the HIV group (p=0·16); for those with stage I/II disease it was 37·0 months (36·0-39·0) versus 43·0 months (26·0-58·0; p=0·37); for those with stage IIIA/IIIB disease it was 7·0 months (7·0-7·0) versus 3·0 months (2·0-8·0; p=0·051); and for those with stage IV disease it was 3·0 months for both groups (95% CI 3·0-3·0 for controls; 2·0-5·0 for HIV group; p=0·77). After propensity score adjustment, the survival difference in stage IIIA/IIIB was no longer seen (hazard ratio 0·88; 95% CI 0·71-1·09). The median survival for HIV infected patients with stage I or II NSCLC who underwent surgical resection was 58·0 months (95% CI 57·0-60·0) for uninfected controls versus 50·0 months (42·0 to unestimable) for the HIV group (p=0·88). INTERPRETATION: We noted no significant difference in clinical outcome between patients with HIV and uninfected controls with NSCLC. Survival after curative surgical resection in early-stage patients was similar in HIV-infected individuals and uninfected controls. These data suggest that HIV status should not affect therapeutic decision making in NSCLC. FUNDING: US National Cancer Institute (award number UC2CA148310).

Authors: Shaikh WR, Geller A, Alexander G, Asgari MM, Chanange GJ, Dusza S, Eide MJ, Fletcher SW, Goulart JM, Halpern AC, Landow S, Marghoob AA, Quigley EA, Weinstock MA

Title: Developing an interactive web-based learning program on skin cancer: the learning experiences of clinical educators.

Journal: J Cancer Educ 27(4):709-16

Date: 2012 Dec

Abstract: Web-based learning in medical education is rapidly growing. However, there are few firsthand accounts on the rationale for and development of web-based learning programs. We present the experience of clinical educators who developed an interactive online skin cancer detection and management course in a time-efficient and cost-efficient manner without any prior skills in computer programming or technical construction of web-based learning programs. We review the current state of web-based learning including its general advantages and disadvantages as well as its specific utility in dermatology. We then detail our experience in developing an interactive online skin cancer curriculum for primary care clinicians. Finally, we describe the main challenges faced and lessons learned during the process. This report may serve medical educators who possess minimal computer programming and web design skills but want to employ the many strengths of web-based learning without the huge costs associated with hiring a professional development team.

Authors: Smaldone MC, Egleston B, Uzzo RG, Kutikov A

Title: Does partial nephrectomy result in a durable overall survival benefit in the Medicare population?

Journal: J Urol 188(6):2089-94

Date: 2012 Dec

Abstract: PURPOSE: We assessed whether the impact of partial nephrectomy and radical nephrectomy on overall mortality differed by patient age in a Medicare population undergoing surgery for T1a renal cell carcinoma. MATERIALS AND METHODS: Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified patients older than 66 years who underwent partial nephrectomy or radical nephrectomy for T1a (4 cm or smaller) renal cell carcinoma from 1995 to 2007. The effects of procedure type on overall mortality by age were assessed using time dependent Cox proportional hazards models adjusted by propensity score based weighting. RESULTS: A total of 5,496 patients (mean age 74.2 ± 5.6 years, 55.9% male) who underwent partial nephrectomy (1,665; 30.3%) or radical nephrectomy (3,831; 69.7%) for 4 cm or smaller renal cell carcinoma (mean tumor size 2.8 ± 0.9 cm) were identified. After adjustment, a statistically significant survival benefit for partial nephrectomy compared to radical nephrectomy was observed at 1 year (age 68, HR 1.6, CI 1.2-2.3; age 75, HR 1.5, CI 1.1-1.9; age 85, HR 1.7, CI 1.1-2.5) and 3 years (age 68, HR 1.4, CI 1.03-2.0; age 75, HR 1.3, CI 1.1-1.6; age 85, HR 1.5, CI 1.02-2.3), while these trends became insignificant in patients younger than 68 and older than 85 years. However, the survival benefit decreased with time, and little significant benefit with partial nephrectomy was observed at 5 and 10 years after surgery regardless of age (66 years or older). CONCLUSIONS: Lacking strong evidence regarding a long-term survival benefit, the decision to perform partial nephrectomy in elderly patients should be individualized, and placed in the context of baseline renal function, expected surgical morbidity and competing risks to survival.

Authors: Villaseñor A, Ballard-Barbash R, Baumgartner K, Baumgartner R, Bernstein L, McTiernan A, Neuhouser ML

Title: Prevalence and prognostic effect of sarcopenia in breast cancer survivors: the HEAL Study.

Journal: J Cancer Surviv 6(4):398-406

Date: 2012 Dec

Abstract: PURPOSE: This study aimed to determine the prevalence of sarcopenia and examine whether sarcopenia was associated with overall and breast-cancer-specific mortality in a cohort of women diagnosed with breast cancer (stages I-IIIA). METHODS: A total of 471 breast cancer patients from western Washington State and New Mexico who participated in the prospective Health, Eating, Activity, and Lifestyle Study were included in this study. Appendicular lean mass was measured using dual X-ray absorptiometry scans at study inception, on average, 12 months after diagnosis. Sarcopenia was defined as two standard deviations below the young healthy adult female mean of appendicular lean mass divided by height squared (<5.45 kg/m(2)). Total and breast-cancer-specific mortality data were obtained from Surveillance Epidemiology and End Results registries. Multivariable Cox proportional hazard models assessed the associations between sarcopenia and mortality. RESULTS: Median follow-up was 9.2 years; 75 women were classified as sarcopenic, and among 92 deaths, 46 were attributed to breast cancer. In multivariable models that included age, race-ethnicity/study site, treatment type, comorbidities, waist circumference, and total body fat percentage, sarcopenia was independently associated with overall mortality (hazard ratio (HR) = 2.86; 95 % CI, 1.67-4.89). Sarcopenic women had increased risk of breast-cancer-specific mortality, although the association was not statistically significant (HR = 1.95, 95 % CI, 0.87-4.35). CONCLUSION: Sarcopenia is associated with an increased risk of overall mortality in breast cancer survivors and may be associated with breast-cancer-specific mortality. The development of effective interventions to maintain and/or increase skeletal muscle mass to improve prognosis in breast cancer survivors warrants further study. IMPLICATIONS FOR CANCER SURVIVORS: Such interventions may help breast cancer patients live longer.

Authors: Wallace PM, Suzuki R

Title: Regional, racial, and gender differences in colorectal cancer screening in middle-aged African-Americans and Whites.

Journal: J Cancer Educ 27(4):703-8

Date: 2012 Dec

Abstract: African-Americans have higher incidence and mortality from colorectal cancer than non-African-Americans. Early detection with colorectal cancer (CRC) screening reduces untimely death because the test can detect abnormalities and precancerous polyps in the colon and rectum. However, African-Americans aged 50 and older continue to have low CRC screening adherence. A retrospective analysis was conducted on data from the 2010 National Health Interview Survey to examine trends in self-reported CRC screening by geographic region, race, and gender. African-Americans, particularly men, were less likely to have been screened for colon cancer compared to all races and genders in this study. Individuals in the south were more likely to receive CRC screening than other regions. Colon cancer education and interventions are needed among low-adherent groups to promote the benefits of early detection with CRC screening.

Authors: Williams SB, Amarasekera CA, Gu X, Lipsitz SR, Nguyen PL, Hevelone ND, Kowalczyk KJ, Hu JC

Title: Influence of surgeon and hospital volume on radical prostatectomy costs.

Journal: J Urol 188(6):2198-202

Date: 2012 Dec

Abstract: PURPOSE: While higher radical prostatectomy hospital and surgeon volume are associated with better outcomes, the effect of provider volume on health care costs remains unclear. We performed a population based study to characterize the effect of surgeon and hospital volume on radical prostatectomy costs. MATERIALS AND METHODS: We used SEER (Surveillance, Epidemiology and End Results)-Medicare linked data to identify 11,048 men who underwent radical prostatectomy from 2003 to 2009. We categorized hospital and surgeon radical prostatectomy volume into tertiles (low, intermediate, high) and assessed costs from radical prostatectomy until 90 days postoperatively using propensity adjusted analyses. RESULTS: Higher surgeon volume at intermediate volume hospitals (surgeon volume low $9,915; intermediate $10,068; high $9,451; p = 0.021) and high volume hospitals (surgeon volume low $11,271; intermediate $10,638; high $9,529; p = 0.002) was associated with lower radical prostatectomy costs. Extrapolating nationally, selective referral to high volume radical prostatectomy surgeons at high and intermediate volume hospitals netted more than $28.7 million in cost savings. Conversely, higher hospital volume was associated with greater radical prostatectomy costs for low volume surgeons (hospital volume low $9,685; intermediate $9,915; high $11,271; p = 0.010) and intermediate volume surgeons (hospital volume low $9,605; intermediate $10,068; high $10,638; p = 0.029). High volume radical prostatectomy surgeon costs were not affected by varying hospital volume, and among low volume hospitals radical prostatectomy costs did not differ by surgeon volume. CONCLUSIONS: Selective referral to high volume radical prostatectomy surgeons operating at intermediate and high volume hospitals nets significant cost savings. However, higher radical prostatectomy hospital volume was associated with greater costs for low and intermediate volume radical prostatectomy surgeons.

Authors: Yabroff KR, Dowling E, Rodriguez J, Ekwueme DU, Meissner H, Soni A, Lerro C, Willis G, Forsythe LP, Borowski L, Virgo KS

Title: The Medical Expenditure Panel Survey (MEPS) experiences with cancer survivorship supplement.

Journal: J Cancer Surviv 6(4):407-19

Date: 2012 Dec

Abstract: INTRODUCTION: The prevalence of cancer survivorship in the USA is expected to increase in the future because the US population is increasing in size and is aging and because survival following diagnosis is improving for many types of cancer. Medical care costs associated with cancer are also projected to increase dramatically. However, currently available data for estimating medical care costs and other important aspects of the burden of cancer, including time spent receiving medical care, productivity loss due to morbidity for patients and their families, and financial hardship, are limited, particularly in the population under the age of 65. METHODS: We describe selected publicly available data sources for estimating the burden of cancer in the USA and a new collaborative effort to improve the quality of these data: the nationally representative Medical Expenditure Panel Survey (MEPS) Experiences with Cancer Survivorship Supplement. CONCLUSIONS: Data from this effort can be used to address key gaps in cancer survivorship research related to medical care costs, employment patterns, financial hardship, and other aspects of the burden of illness for cancer survivors and their families. IMPLICATIONS FOR CANCER SURVIVORS: Research using the MEPS Experiences with Cancer Survivorship Supplement can inform efforts by health care policy makers, healthcare systems, providers, and employers to improve the cancer survivorship experience in the USA.

Authors: Smith RA, Kerlikowske K, Miglioretti DL, Kalager M

Title: Clinical decisions. Mammography screening for breast cancer.

Journal: N Engl J Med 367(21):e31-

Date: 2012 Nov 22

Abstract:

Authors: Feuer EJ, Lee M, Mariotto AB, Cronin KA, Scoppa S, Penson DF, Hachey M, Cynkin L, Carter GA, Campbell D, Percy-Laurry A, Zou Z, Schrag D, Hankey BF

Title: The Cancer Survival Query System: making survival estimates from the Surveillance, Epidemiology, and End Results program more timely and relevant for recently diagnosed patients.

Journal: Cancer 118(22):5652-62

Date: 2012 Nov 15

Abstract: BACKGROUND: Population-based cancer registries that include patient follow-up generally provide information regarding net survival (ie, survival associated with the risk of dying of cancer in the absence of competing risks). However, registry data also can be used to calculate survival from cancer in the presence of competing risks, which is more clinically relevant. METHODS: Statistical methods were developed to predict the risk of death from cancer and other causes, as well as natural life expectancy if the patient did not have cancer based on a profile of prognostic factors including characteristics of the cancer, demographic factors, and comorbid conditions. The Surveillance, Epidemiology, and End Results (SEER) Program database was used to calculate the risk of dying of cancer. Because the risks of dying of cancer versus other causes are assumed to be independent conditional on the prognostic factors, a wide variety of independent data sources can be used to calculate the risk of death from other causes. Herein, the risk of death from other causes was estimated using SEER and Medicare claims data, and was matched to the closest fitting portion of the US life table to obtain a "health status-adjusted age." RESULTS: A nomogram was developed for prostate cancer as part of a Web-based Cancer Survival Query System that is targeted for use by physicians and patients to obtain information on a patient's prognosis. More nomograms currently are being developed. CONCLUSIONS: Nomograms of this type can be used as one tool to assist cancer physicians and their patients to better understand their prognosis and to weigh alternative treatment and palliative strategies.

Authors: Reeve BB, Stover AM, Jensen RE, Chen RC, Taylor KL, Clauser SB, Collins SP, Potosky AL

Title: Impact of diagnosis and treatment of clinically localized prostate cancer on health-related quality of life for older Americans: a population-based study.

Journal: Cancer 118(22):5679-87

Date: 2012 Nov 15

Abstract: BACKGROUND: Few studies have measured longitudinal changes in health-related quality of life (HRQOL) among patients with prostate cancer starting before their cancer diagnosis or have provided simultaneous comparisons with a matched noncancer cohort. In the current study, the authors addressed these gaps by providing unique estimates of the effects of a cancer diagnosis on HRQOL accounting for the confounding effects of ageing and comorbidity. METHODS: Data from the Surveillance, Epidemiology, and End Results registry were linked with Medicare Health Outcomes Survey (MHOS) data. Eligible patients (n = 445) were Medicare beneficiaries aged ≥65 years from 1998 to 2003 whose first prostate cancer diagnosis occurred between their baseline and follow-up MHOS. By using propensity score matching, 2225 participants without cancer were identified from the MHOS data. Analysis of covariance models were used to estimate changes in HRQOL as assessed with the Medical Outcomes Study Short Form-36 survey and the activities of daily living scale. RESULTS: Before diagnosis, patients with prostate cancer reported HRQOL similar to that of men without cancer. After diagnosis, men with prostate cancer experienced significant decrements in physical, mental, and social aspects of their lives relative to controls, especially within the first 6 months after diagnosis. For men who were surveyed beyond 1 year after diagnosis, HRQOL was similar to that for controls. However, an increased risk for major depressive disorder was observed among men who received either conservative management or external beam radiation. CONCLUSIONS: The current findings illustrated the time-sensitive nature of decline in HRQOL after a cancer diagnosis and enhanced understanding of the impact of prostate cancer diagnosis and treatment on physical, mental, and social well being among older men.

Authors: Salloum RG, Hornbrook MC, Fishman PA, Ritzwoller DP, O'Keeffe Rossetti MC, Elston Lafata J

Title: Adherence to surveillance care guidelines after breast and colorectal cancer treatment with curative intent.

Journal: Cancer 118(22):5644-51

Date: 2012 Nov 15

Abstract: BACKGROUND: Evidence-based guidelines recommend routine surveillance, including office visits and testing, to detect new and recurrent disease among survivors of breast and colorectal cancer. The extent to which surveillance practice is consistent with guideline recommendations or may vary by age is not known. METHODS: Cohorts of adult patients diagnosed with breast (n = 6205) and colorectal (n = 2297) cancer between 2000 and 2008 and treated with curative intent in 4 geographically diverse managed care environments were identified via tumor registries. Kaplan-Meier estimates were used to describe time to initial and subsequent receipt of surveillance services. Cox proportional hazards models evaluated the relation between patient characteristics and receipt of metastatic screening. RESULTS: Within 18 months of treatment, 87.2% of breast cancer survivors received recommended mammograms, with significantly higher rates noted for patients aged 50 years to 65 years. Among survivors of colorectal cancer, only 55.0% received recommended colon examinations, with significantly lower rates for those aged ≥ 75 years. The majority of breast (64.7%) and colorectal (73.3%) cancer survivors received nonrecommended metastatic disease testing. In patients with breast cancer, factors associated with metastatic disease testing include white race (hazards ratio [HR], 1.13), comorbidities (HR, 1.17), and younger age (HR, 1.13; 1.15; 1.13 for age groups: <50, 50-64, and 65-74 respectively). In those with colorectal cancer, these factors included younger age (HR, 1.31; 1.25 for age groups: <50 and 50-64 respectively) and comorbidities (HR, 1.10). CONCLUSIONS: Among an insured population, wide variation regarding the use of surveillance care was found by age and relative to guideline recommendations. Breast cancer survivors were found to have high rates of both guideline-recommended recurrence testing and non-guideline-recommended metastatic testing. Only approximately 50% of colorectal cancer survivors received recommended tests but greater than 67% received metastatic testing.

Authors: Bittner Fagan H, Sifri R, Wender R, Schumacher E, Reed JF 3rd

Title: Weight status and perception of colorectal cancer risk.

Journal: J Am Board Fam Med 25(6):792-7

Date: 2012 Nov-Dec

Abstract: BACKGROUND: Obesity increases the risk of many cancers including colorectal cancer (CRC). METHODS: This is secondary data analysis of the 2010 National Health Interview Survey data. A total of 9360 obese and overweight participants, aged 50 to 80 years, were analyzed according to their perception of their personal cancer risk. RESULTS: Having a perception of increased risk for cancer was associated with higher CRC screening rates. However, when compared with their normal-weight counterparts, overweight and obese individuals did not perceive themselves as being at an increased risk for cancer in general or for CRC specifically. Subgroup analysis revealed one notable exception. Obese black women appeared to recognize themselves as being at higher risk for CRC. CONCLUSIONS: Most obese and overweight individuals fail to recognize their increased cancer risk. Individuals who perceive themselves as being at increased risk for cancer, especially CRC, are more likely to have undergone CRC screening. Unfortunately, obese and overweight individuals do not seem to recognize the increased cancer risk conferred by their body weight. Education is needed so that obese and overweight individuals are aware that their excess body weight is a risk factor for cancer.

Authors: Kent EE, Arora NK, Rowland JH, Bellizzi KM, Forsythe LP, Hamilton AS, Oakley-Girvan I, Beckjord EB, Aziz NM

Title: Health information needs and health-related quality of life in a diverse population of long-term cancer survivors.

Journal: Patient Educ Couns 89(2):345-52

Date: 2012 Nov

Abstract: OBJECTIVE: To investigate health information needs and their association with health-related quality of life (HRQOL) in a diverse, population-based sample of long-term cancer survivors. METHODS: We analyzed health information needs from 1197 cancer survivors 4-14 years post-diagnosis drawn from two cancer registries in California. Multivariable regression models were used to identify factors associated with endorsement of total number and different categories of needs. The relationship between number of needs and HRQOL and effect modification by confidence for obtaining information was examined. RESULTS: Survivors reported a high prevalence of unmet information needs in the following categories: side effects & symptoms: 75.8%; tests & treatment: 71.5%; health promotion: 64.5%; interpersonal & emotional: 60.2%; insurance: 39.0%; and sexual functioning & fertility: 34.6%. Survivors who were younger, non-White, and did not receive but wanted a written treatment summary reported a higher number of needs. Number of information needs was inversely related to mental well-being, particularly for those with low confidence for obtaining information (P<0.05). CONCLUSION: These patterns suggest disparities in access to important health information in long-term survivors and that affect HRQOL. PRACTICE IMPLICATIONS: Findings suggest a need for tailored interventions to equip survivors with comprehensive health information and to bolster skills for obtaining information.

Authors: Moy KL, Sallis JF, Trinidad DR, Ice CL, McEligot AJ

Title: Health behaviors of native Hawaiian and Pacific Islander adults in California.

Journal: Asia Pac J Public Health 24(6):961-9

Date: 2012 Nov

Abstract: Smoking, diet and physical activity are associated with chronic diseases, but representative prevalence data on these behaviors for Native Hawaiian and Pacific Islander (NHPI) adults are scarce. Data from the 2005 California Health Interview Survey were analyzed for self-identified NHPI and non-Hispanic white (NHW) adults. Ethnic and NHPI gender differences were examined for socio-demographic variables, obesity and health behaviors. Compared to NHW, NHPI displayed higher prevalence of obesity (p<0.001), smoking (p<0.05) and consumption of unhealthy foods and beverages (p<0.05). NHPI males were more likely than females to smoke (p<0.001). NHPI adults appear to be at higher risk for chronic disease than NHW due to obesity, smoking and intake of unhealthy foods and beverages. Culturally-specific health promotion interventions are needed to reduce risks among the underrepresented NHPI population.

Authors: Onega T, Smith M, Miglioretti DL, Carney PA, Geller BA, Kerlikowske K, Buist DS, Rosenberg RD, Smith RA, Sickles EA, Haneuse S, Anderson ML, Yankaskas B

Title: Radiologist agreement for mammographic recall by case difficulty and finding type.

Journal: J Am Coll Radiol 9(11):788-94

Date: 2012 Nov

Abstract: PURPOSE: The aim of this study was to assess agreement of mammographic interpretations by community radiologists with consensus interpretations of an expert radiology panel to inform approaches that improve mammographic performance. METHODS: From 6 mammographic registries, 119 community-based radiologists were recruited to assess 1 of 4 randomly assigned test sets of 109 screening mammograms with comparison studies for no recall or recall, giving the most significant finding type (mass, calcifications, asymmetric density, or architectural distortion) and location. The mean proportion of agreement with an expert radiology panel was calculated by cancer status, finding type, and difficulty level of identifying the finding at the patient, breast, and lesion level. Concordance in finding type between study radiologists and the expert panel was also examined. For each finding type, the proportion of unnecessary recalls, defined as study radiologist recalls that were not expert panel recalls, was determined. RESULTS: Recall agreement was 100% for masses and for examinations with obvious findings in both cancer and noncancer cases. Among cancer cases, recall agreement was lower for lesions that were subtle (50%) or asymmetric (60%). Subtle noncancer findings and benign calcifications showed 33% agreement for recall. Agreement for finding responsible for recall was low, especially for architectural distortions (43%) and asymmetric densities (40%). Most unnecessary recalls (51%) were asymmetric densities. CONCLUSIONS: Agreement in mammographic interpretation was low for asymmetric densities and architectural distortions. Training focused on these interpretations could improve the accuracy of mammography and reduce unnecessary recalls.

Authors: Reeve BB, Stover AM, Alfano CM, Smith AW, Ballard-Barbash R, Bernstein L, McTiernan A, Baumgartner KB, Piper BF

Title: The Piper Fatigue Scale-12 (PFS-12): psychometric findings and item reduction in a cohort of breast cancer survivors.

Journal: Breast Cancer Res Treat 136(1):9-20

Date: 2012 Nov

Abstract: Brief, valid measures of fatigue, a prevalent and distressing cancer symptom, are needed for use in research. This study's primary aim was to create a shortened version of the revised Piper Fatigue Scale (PFS-R) based on data from a diverse cohort of breast cancer survivors. A secondary aim was to determine whether the PFS captured multiple distinct aspects of fatigue (a multidimensional model) or a single overall fatigue factor (a unidimensional model). Breast cancer survivors (n = 799; stages in situ through IIIa; ages 29-86 years) were recruited through three SEER registries (New Mexico, Western Washington, and Los Angeles, CA) as part of the Health, Eating, Activity, and Lifestyle (HEAL) study. Fatigue was measured approximately 3 years post-diagnosis using the 22-item PFS-R that has four subscales (Behavior, Affect, Sensory, and Cognition). Confirmatory factor analysis was used to compare unidimensional and multidimensional models. Six criteria were used to make item selections to shorten the PFS-R: scale's content validity, items' relationship with fatigue, content redundancy, differential item functioning by race and/or education, scale reliability, and literacy demand. Factor analyses supported the original 4-factor structure. There was also evidence from the bi-factor model for a dominant underlying fatigue factor. Six items tested positive for differential item functioning between African-American and Caucasian survivors. Four additional items either showed poor association, local dependence, or content validity concerns. After removing these 10 items, the reliability of the PFS-12 subscales ranged from 0.87 to 0.89, compared to 0.90-0.94 prior to item removal. The newly developed PFS-12 can be used to assess fatigue in African-American and Caucasian breast cancer survivors and reduces response burden without compromising reliability or validity. This is the first study to determine PFS literacy demand and to compare PFS-R responses in African-Americans and Caucasian breast cancer survivors. Further testing in diverse populations is warranted.

Authors: Schneider EB, Hyder O, Wolfgang CL, Hirose K, Choti MA, Makary MA, Herman JM, Cameron JL, Pawlik TM

Title: Patient readmission and mortality after surgery for hepato-pancreato-biliary malignancies.

Journal: J Am Coll Surg 215(5):607-15

Date: 2012 Nov

Abstract: BACKGROUND: The incidence and associated risk factors for readmission after hepato-pancreato-biliary surgery are poorly characterized. The objective of the current study was to compare readmission after pancreatic vs hepatobiliary surgical procedures, as well as to identify potential factors associated with higher readmission within 30 days of discharge. STUDY DESIGN: Using Surveillance, Epidemiology and End Results-Medicare linked data from 1986-2005, we identified 9,957 individuals aged 66 years and older who underwent complex hepatic, biliary, or pancreatic procedures for cancer treatment and were eligible for analysis. In-hospital morbidity, mortality, and 30-day readmission were examined. RESULTS: Primary surgical treatment consisted of a pancreatic (46.7%), hepatic (50.0%), or biliary (3.4%) procedure. Mean patient age was 72.6 years and most patients were male (53.2%). The number of patients with multiple preoperative comorbidities increased over time (patients with Elixhauser's comorbidity score >13: 1986-1990, 47.0% vs 2001-2005, 62.9%; p < 0.001). Pancreatic operations had higher inpatient mortality vs hepatobiliary procedures (9.2% vs 7.3%; p < 0.001). Mean length of stay after pancreatic procedures was longer compared with hepatobiliary procedures (19.7 vs 10.3 days; p < 0.001). The proportion of patients readmitted after a pancreatic (1986-1990, 17.7%; 1991-1995, 16.1%; 1996-2000, 18.6%; 2001-2005, 19.6%; p = 0.15) or hepatobiliary (1986-1990, 14.3%; 1991-1995, 14.1%; 1996-2000, 15.2%; 2001-2005, 15.5%; p = 0.69) procedure did not change over time. Factors associated with increased risk of readmission included preoperative Elixhauser comorbidities >13 (odds ratio = 1.90) and prolonged index hospital stay ≥10 days (odds ratio = 1.54; both p < 0.05). During the readmission, additional morbidity and mortality were 46.5% and 8.0%, respectively. CONCLUSIONS: Although the incidence of readmission did not change across the time periods examined, readmission was higher among patients undergoing a pancreatic procedure vs a hepatobiliary procedure. Other factors associated with risk of readmission included number of patient comorbidities and prolonged hospital stay. Readmission was associated with additional short-term morbidity and mortality.

Authors: Sun M, Abdollah F, Hansen J, Trinh QD, Bianchi M, Tian Z, Briganti A, Shariat SF, Montorsi F, Perrotte P, Karakiewicz PI

Title: Is a treatment delay in radical prostatectomy safe in individuals with low-risk prostate cancer?

Journal: J Sex Med 9(11):2961-9

Date: 2012 Nov

Abstract: INTRODUCTION: Many patients diagnosed with localized prostate cancer (PCa) are presented with several treatment modalities, which may require time to understand these options before making an informed decision regarding treatment. AIM: The aim of this study was to compare the effect of radical prostatectomy (RP) delay on postoperative functional outcomes and mortality in a North American population-based cohort. METHODS: Overall, 17,153 men treated with RP for non-metastatic clinical stage T1-2, low-grade PCa between years 1995 and 2005 within the U.S. Surveillance, Epidemiology, and End Results Medicare-linked database were abstracted. MAIN OUTCOME MEASURES: The effect of treatment delay (from PCa diagnosis to RP of >3 months) on pathological upstaging at surgery (≥pT3) and postoperative functional outcomes (urinary incontinence and erectile dysfunction) was examined using logistic regression analyses. The 10-year PCa mortality rates were computed using cumulative incidence rates. RESULTS: Overall, 2,576 (15%) patients underwent RP > 3 months after diagnosis. A treatment delay of >3 months was associated with a 24% and 33% higher rate of erectile dysfunction diagnosis and procedure, respectively (both P ≤ 0.001). Treatment delay was also associated with 6% higher rate of urinary incontinence procedure (P = 0.01). Furthermore, a dose-response effect was detected with respect to increasing durations of RP delay (≤3 vs. 3-5 vs. 5-9 vs. ≥9 months) the rates of erectile dysfunction and urinary incontinence diagnoses/procedures. Treatment delay was not associated with pathological upstaging and PCa mortality. CONCLUSIONS: Customarily, the timing of RP following biopsy is dictated by tumor aggressiveness. In general, patients with more unfavorable characteristics are operated sooner. This may obliterate the potential detriments of delayed RP. The treatment delay between biopsy and RP may result in more extensive periprostatic tissue resection and may adversely affect postoperative continence and erectile function.

Authors: Wang R, Gross CP, Frick K, Xu X, Long J, Raza A, Galili N, Zikria J, Guan Y, Ma X

Title: The impact of hypomethylating agents on the cost of care and survival of elderly patients with myelodysplastic syndromes.

Journal: Leuk Res 36(11):1370-5

Date: 2012 Nov

Abstract: During 2004-2006, two hypomethylating agents (HMAs) were approved for the treatment of myelodysplastic syndromes (MDS) in the United States. We assessed the impact of HMAs on the cost of care and survival of MDS patients, by constructing a cohort of patients who were diagnosed during 2001-2007 (n=6556, age ≥66.5 years) and comparable non-cancer controls. We assessed MDS patients' and controls' Medicare expenditures to derive MDS-related cost. We evaluated the two-year survival of patients as a group and by major subtypes. Taking into account the survival probabilities of MDS, the expected MDS-related 5-year cost was $63,223 (95% confidence interval: $59,868-66,432 in 2009 dollars), higher than the reported comparable cost for any of the 18 most prevalent cancers in the United States. Compared with MDS patients diagnosed in the earlier period (January 2001-June 2004) who received no HMAs, patients diagnosed later (July 2004-December 2007) who received HMAs had a significantly higher 24-month cost ($97,977 vs. $42,628 in 2009 dollars) and an improved 24-month survival (especially among patients with refractory anemia or refractory anemia with excess blasts). The magnitude of the cost of care underscores a need for comparative cost-effectiveness studies to reduce the clinical and economic burden of MDS.

Authors: Weaver KE, Forsythe LP, Reeve BB, Alfano CM, Rodriguez JL, Sabatino SA, Hawkins NA, Rowland JH

Title: Mental and physical health-related quality of life among U.S. cancer survivors: population estimates from the 2010 National Health Interview Survey.

Journal: Cancer Epidemiol Biomarkers Prev 21(11):2108-17

Date: 2012 Nov

Abstract: BACKGROUND: Despite extensive data on health-related quality of life (HRQOL) among cancer survivors, we do not yet have an estimate of the percentage of survivors with poor mental and physical HRQOL compared with population norms. HRQOL population means for adult-onset cancer survivors of all ages and across the survivorship trajectory also have not been published. METHODS: Survivors (N = 1,822) and adults with no cancer history (N = 24,804) were identified from the 2010 National Health Interview Survey. The PROMIS® Global Health Scale was used to assess HRQOL. Poor HRQOL was defined as 1 SD or more below the PROMIS® population norm. RESULTS: Poor physical and mental HRQOL were reported by 24.5% and 10.1% of survivors, respectively, compared with 10.2% and 5.9% of adults without cancer (both P < 0.0001). This represents a population of approximately 3.3 million and 1.4 million U.S. survivors with poor physical and mental HRQOL. Adjusted mean mental and physical HRQOL scores were similar for breast, prostate, and melanoma survivors compared with adults without cancer. Survivors of cervical, colorectal, hematologic, short-survival, and other cancers had worse physical HRQOL; cervical and short-survival cancer survivors reported worse mental HRQOL. CONCLUSION: These data elucidate the burden of cancer diagnosis and treatment among U.S. survivors and can be used to monitor the impact of national efforts to improve survivorship care and outcomes. IMPACT: We present novel data on the number of U.S. survivors with poor HRQOL. Interventions for high-risk groups that can be easily implemented are needed to improve survivor health at a population level.

Authors: Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, Schrag D

Title: Patients' expectations about effects of chemotherapy for advanced cancer.

Journal: N Engl J Med 367(17):1616-25

Date: 2012 Oct 25

Abstract: BACKGROUND: Chemotherapy for metastatic lung or colorectal cancer can prolong life by weeks or months and may provide palliation, but it is not curative. METHODS: We studied 1193 patients participating in the Cancer Care Outcomes Research and Surveillance (CanCORS) study (a national, prospective, observational cohort study) who were alive 4 months after diagnosis and received chemotherapy for newly diagnosed metastatic (stage IV) lung or colorectal cancer. We sought to characterize the prevalence of the expectation that chemotherapy might be curative and to identify the clinical, sociodemographic, and health-system factors associated with this expectation. Data were obtained from a patient survey by professional interviewers in addition to a comprehensive review of medical records. RESULTS: Overall, 69% of patients with lung cancer and 81% of those with colorectal cancer did not report understanding that chemotherapy was not at all likely to cure their cancer. In multivariable logistic regression, the risk of reporting inaccurate beliefs about chemotherapy was higher among patients with colorectal cancer, as compared with those with lung cancer (odds ratio, 1.75; 95% confidence interval [CI], 1.29 to 2.37); among nonwhite and Hispanic patients, as compared with non-Hispanic white patients (odds ratio for Hispanic patients, 2.82; 95% CI, 1.51 to 5.27; odds ratio for black patients, 2.93; 95% CI, 1.80 to 4.78); and among patients who rated their communication with their physician very favorably, as compared with less favorably (odds ratio for highest third vs. lowest third, 1.90; 95% CI, 1.33 to 2.72). Educational level, functional status, and the patient's role in decision making were not associated with such inaccurate beliefs about chemotherapy. CONCLUSIONS: Many patients receiving chemotherapy for incurable cancers may not understand that chemotherapy is unlikely to be curative, which could compromise their ability to make informed treatment decisions that are consonant with their preferences. Physicians may be able to improve patients' understanding, but this may come at the cost of patients' satisfaction with them. (Funded by the National Cancer Institute and others.).

Authors: Bellizzi KM, Smith A, Schmidt S, Keegan TH, Zebrack B, Lynch CF, Deapen D, Shnorhavorian M, Tompkins BJ, Simon M, Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) Study Collaborative Group

Title: Positive and negative psychosocial impact of being diagnosed with cancer as an adolescent or young adult.

Journal: Cancer 118(20):5155-62

Date: 2012 Oct 15

Abstract: BACKGROUND: The objective of this study was to explore the psychosocial impact of cancer on newly diagnosed adolescent and young adult (AYA) cancer patients. METHODS: This was a population-based, multicenter study of 523 newly diagnosed AYA survivors (ages 15-39 years) of germ cell cancer (n = 204), non-Hodgkin lymphoma (n = 131), Hodgkin lymphoma (n = 142), acute lymphocytic leukemia (n = 21), or sarcoma (n = 25) from 7 National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) registries. Age at diagnosis was categorized into 3 groups (ages 15-20 years, 21-29 years, and 30-39 years). RESULTS: Respondents (43% response rate), on average (±standard deviation), were aged 29 = 6.7 years, and most patients (80.1%) were not receiving treatment at the time the completed the survey. With modest differences between the age groups, the most prevalent areas of life impacted in a negative way were financial, body image, control over life, work plans, relationship with spouse/significant other, and plans for having children. Endorsement of positive life impact items also was evident across the 3 age groups, particularly with regard to relationships, future plans/goals, and health competence. CONCLUSIONS: The current results indicated that there will be future need for interventions targeting financial assistance, body image issues, relationships, and helping AYAs to attain their education objectives.

Authors: O'Neill CB, Atoria CL, O'Reilly EM, LaFemina J, Henman MC, Elkin EB

Title: Costs and trends in pancreatic cancer treatment.

Journal: Cancer 118(20):5132-9

Date: 2012 Oct 15

Abstract: BACKGROUND: Pancreatic cancer poses a substantial morbidity and mortality burden in the United States, and predominantly affects older adults. The objective of this study was to estimate the direct medical costs of pancreatic cancer treatment in a population-based cohort of Medicare beneficiaries, and the contribution of different treatment modalities and health care services to the total cost of care and trends in costs over time. METHODS: In the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, pancreatic cancer patients were identified who were aged 66 years or older and who were diagnosed from 2000 to 2007. Total direct medical costs were estimated from Medicare payments overall and within categories of care. Costs attributable to pancreatic cancer were estimated by subtracting the costs of medical care in a matched cohort of cancer-free beneficiaries. RESULTS: A total of 15,037 patients were identified, of whom 97% were observed from diagnosis until death. Mean total direct medical costs were $65,500. Mean total costs were greater for patients with resectable locoregional disease ($134,700) than for those with unresectable locoregional or distant disease ($65,300 and $49,000, respectively). Hospitalizations and cancer-directed procedures collectively accounted for the largest fraction of health care costs. The total cost of care appeared to increase slightly over the study period (P = .05). The mean costs attributable to pancreatic cancer were $61,700. CONCLUSIONS: Despite poor prognosis and short survival, the economic burden of pancreatic cancer in the elderly is substantial. Demographic trends, greater use of targeted therapies, and possible implementation of screening strategies are likely to impact treatment patterns and costs in the future.

Authors:

Title: Dietary assessment methodology

Journal: :5-46

Date: 2012 Oct 11

Abstract:

Authors: Albert JM, Pan IW, Shih YC, Jiang J, Buchholz TA, Giordano SH, Smith BD

Title: Effectiveness of radiation for prevention of mastectomy in older breast cancer patients treated with conservative surgery.

Journal: Cancer 118(19):4642-51

Date: 2012 Oct 01

Abstract: BACKGROUND: A recent clinical trial concluded that radiation therapy (RT) does not lower the risk of mastectomy and, thus, may be omitted in older women with stage I, estrogen receptor (ER)-positive breast cancer who undergo conservative surgery (CS). However, it is not known whether this finding applies to patients outside of clinical trials. Accordingly, we used the Surveillance, Epidemiology, and End Results-Medicare observational cohort to determine the effect of RT on the risk of mastectomy among older women with stage I, ER-positive breast cancer. METHODS: The authors identified 7403 women ages 70 to 79 years who underwent CS between 1992 and 2002. Claims were used to determine RT status and to identify women who underwent mastectomy subsequent to initial treatment. The Kaplan-Meier method was used to estimate the risk of subsequent mastectomy, and Cox regression analysis was used to determine the effect of RT adjusted for clinical-pathologic covariates. RESULTS: At a median follow-up of 7.3 years, the risk of subsequent mastectomy within 10 years of diagnosis was 3.2% for patients who received RT versus 6.3% for patients who did not receive RT (P < .001). In adjusted analyses, RT was associated with a lower risk of mastectomy (hazard ratio, 0.33; 95% confidence interval, 0.22-0.48; P < .001). RT provided no benefit for patients ages 75 to 79 years without high-grade tumors who had a pathologic lymph node assessment (P = .80); however, for all other subgroups, RT was associated with an absolute reduction in risk of mastectomy that ranged from 4.3% to 9.8% at 10 years. CONCLUSIONS: Outside of a clinical trial, the receipt of RT after CS was associated with a greater likelihood of ultimate breast preservation for most older women with early breast cancer.

Authors: Samper-Ternent R, Asem H, Zhang DD, Kuo YF, Hatch SS, Freeman JL, Berenson AB

Title: The effect of postoperative beam, implant, and combination radiation therapy on GI and bladder toxicities in female Medicare beneficiaries with stage I uterine cancer.

Journal: J Geriatr Oncol 3(4):344-350

Date: 2012 Oct 01

Abstract: OBJECTIVE: Determine the risk of late gastrointestinal (GI) and bladder toxicities in women treated for Stage I uterine cancer with postoperative beam, implant, or combination radiation. METHODS: The Surveillance, Epidemiology, and End Results (SEER) tumor registry and Medicare claims were used to estimate the risk of developing late GI and bladder toxicities by type of radiation received. Bladder and GI diagnoses were identified 6-60 months after cancer diagnosis. Cox-proportional hazard models were used to estimate risk of any late GI or bladder toxicity due to type of radiation received. RESULTS: A total of 3,024 women with uterine cancer diagnosed from 1992-2005 were identified for analysis with a mean age of 73.9 (Standard Deviation (SD) ± 6.5). Bladder and GI toxicities occurred most frequently in the combination group, and least in the implant group. After controlling for demographic characteristics, tumor grade, diagnosis year, SEER region, comorbidities, prior GI and bladder diagnosis, and chemotherapy, women receiving implant radiation had a 21% absolute decrease in GI toxicities compared to women receiving combination radiation (Hazard Ratio (HR) 0.79, 95% confidence interval (CI) 0.68-0.92). No differences were observed between those receiving beam and combination in GI (HR 1.01 (0.89-1.14)) and bladder (HR 0.95 (0.80-1.11)) toxicities. CONCLUSIONS: Older women receiving combined radiation had the highest rates of GI and bladder toxicities, while women receiving implant radiation alone had the lowest rates. When selecting type of radiation for a patient, these toxicities should be considered. Counseling older women surviving cancer on late toxicities due to radiation must be a priority for physicians caring for them.

Authors: Carlos RC, Buist DS, Wernli KJ, Swan JS

Title: Patient-centered outcomes in imaging: quantifying value.

Journal: J Am Coll Radiol 9(10):725-8

Date: 2012 Oct

Abstract: The Patient-Centered Outcomes Research Institute was created in response to a mandate to conduct comparative effectiveness research in clinical care to inform decision making. The institute will be funded by the Patient-Centered Outcomes Research Trust Fund, through congressional set-asides, and by Medicare and private health insurers, through a per beneficiary fee. The institute is governed by a board with a broad stakeholder constitution. Key committees set the national agenda for patient-centered outcomes research, the agenda for funding priorities, and communication and dissemination of the evidence with the goal of increasing the rate of implementation of the evidence into policy. In imaging, patient-centered outcomes go beyond the traditional metrics of patient satisfaction. Instead, these outcomes need to encompass the benefits and harms, focus on outcomes relevant to patients, and provide information to inform decision making. Therefore, radiologists need to be involved as stakeholders in the design, conduct, and dissemination of this research.

Authors: Guadagnolo BA, Xu Y, Zagars GK, Cormier JN, Pollock RE, Feig BW, Giordano S, Buchholz TA, Shih YC

Title: A population-based study of the quality of care in the diagnosis of large (≥5 cm) soft tissue sarcomas.

Journal: Am J Clin Oncol 35(5):455-61

Date: 2012 Oct

Abstract: PURPOSE: The aim of this study was to assess preoperative biopsy utilization for patients with soft tissue sarcoma (STS) of ≥5 cm in size and whether or not preoperative biopsy was associated with fewer surgical procedures to adequately treat these tumors. METHODS: We identified 899 patients from the Surveillance, Epidemiology, and End Results-Medicare database with a diagnosis of STS and who underwent surgical resection of their tumors between 1992 and 2006. We used diagnosis and procedure codes from claims data to identify which patients had a biopsy performed and the corresponding number of surgical procedures for each patient. Multivariate logistic regression analyses were carried out to assess the influence of patient, tumor, and sociodemographic characteristics on performance of biopsy and the likelihood of multiple STS operations. RESULTS: Only 40.6% of patients with tumors of ≥5 cm in size underwent biopsy as part of initial management of their STS. In multivariate analysis, biopsy utilization varied significantly by sex, tumor size, grade, and geographic region. After adjusting for patient, tumor, and sociodemographic characteristics, receipt of a biopsy was the only factor significantly associated with reduced likelihood of multiple STS operations (odds ratio=0.34, 95% confidence interval, 0.24-0.49). CONCLUSION: Preoperative biopsy utilization among Medicare beneficiaries undergoing surgery for STS of ≥5 cm in size is low. Performance of a biopsy for patients with soft tissue tumors of ≥5 cm in size is associated with a decreased likelihood of a patient undergoing multiple surgeries for treatment of STS.

Authors: James TA, Mace JL, Virnig BA, Geller BM

Title: Preoperative needle biopsy improves the quality of breast cancer surgery.

Journal: J Am Coll Surg 215(4):562-8

Date: 2012 Oct

Abstract: BACKGROUND: Percutaneous needle biopsy has the potential to provide a preoperative diagnosis of breast cancer, which helps to optimize surgical planning; however, its use remains an area of unexplained clinical variation. The purposes of this study were to perform a statewide assessment of diagnostic biopsy methods for women diagnosed with breast cancer and to evaluate the impact of biopsy method on the quality of breast cancer surgery. STUDY DESIGN: Vermont cancer registries were combined with Medicare data to identify women diagnosed with breast cancer between 1998 and 2006. Demographics, margin status, surgical evaluation of axillary nodes, and total number of operations were correlated to biopsy method. RESULTS: Percutaneous needle biopsy (PNB) was the initial biopsy method in 713 (62.8%) patients, and it increased significantly over the study period. Patients living in urban settings were more likely to receive PNB (70.6%) than patients living in rural areas (57.5%). Breast cancer surgery performance metrics including margin status, number of operations, and performance of axillary evaluation significantly favored PNB over open biopsy (OB). CONCLUSIONS: The quality of breast cancer surgery as measured by initial margin status, total number of operations, and axillary evaluation improved with preoperative PNB; however, the use of PNB varied considerably. The potential impact of PNB on the quality of patient care and health care costs is substantial. Emphasis should be placed on understanding the barriers to the use of preoperative PNB and developing strategies to expand its use in the management of breast cancer.

Authors: Kepka D, Berkowitz Z, Yabroff KR, Roland K, Saraiya M

Title: Human papillomavirus vaccine practices in the USA: do primary care providers use sexual history and cervical cancer screening results to make HPV vaccine recommendations?

Journal: Sex Transm Infect 88(6):433-5

Date: 2012 Oct

Abstract: OBJECTIVES: Guidelines recommend against the use of Papanicolaou (Pap) or human papillomavirus (HPV) testing when determining eligibility for the HPV vaccine. Optimally, the HPV vaccine should be administered before sexual initiation. Guidelines recommend that age-eligible women with past exposure to HPV should still be vaccinated. Little is known about how primary care providers (PCPs) use sexual history and HPV and Pap tests in their HPV vaccine recommendations. METHODS: Data from the 2007 Cervical Cancer Screening Supplement (CCSS) administered with the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to assess HPV vaccination recommendations. The CCSS investigates cervical cancer screening practices, HPV testing and HPV vaccine recommendations among PCPs. A summary measure of compliance with guidelines was defined as rarely or never using the number of sexual partners and HPV tests and Pap tests to determine vaccine receipt. A total of 421 PCPs completed the CCSS in 2007. RESULTS: Among NAMCS and NHAMCS providers who recommend the HPV vaccine, only 53% (95% CI 42% to 63%) reported making guideline-consistent recommendations. The majority reported sometimes to always recommending the HPV vaccine to women with a history of an abnormal Pap result (85%; 95% CI 75% to 91%) and a positive HPV test (79%; 95% CI 70% to 86%). CONCLUSIONS: A large proportion of providers report practices that are inconsistent with guidelines. Providers may also be recommending the vaccine to women who may receive little benefit from the vaccine. Provider and system-level efforts to improve guideline-consistent practices are needed.

Authors: Maxwell AE, Crespi CM, Alano RE, Sudan M, Bastani R

Title: Health risk behaviors among five Asian American subgroups in California: identifying intervention priorities.

Journal: J Immigr Minor Health 14(5):890-4

Date: 2012 Oct

Abstract: This analysis assessed the prevalence of excess body weight, physical inactivity and alcohol and tobacco use in Asian American subgroups. Using 2005 California Health Interview Survey data, we estimated the prevalence of body mass index (BMI) categories using both standard and World Health Organization-proposed Asian-specific categories, physical inactivity, and alcohol and tobacco use for Chinese (n = 1,285), Japanese (n = 421), Korean (n = 620), Filipino (n = 659) and Vietnamese (n = 480) Americans in California. About 80% of Japanese and Filipino American men and 70% of Korean American men were "increased/high risk" by Asian-specific BMI categories. Most Asian American subgroups were more likely to walk for transportation than non-Hispanic whites, but less likely to report other physical activities. Highest smoking and binge drinking prevalences were among Korean, Vietnamese and Filipino American men and Japanese and Korean American women. These results suggest risk profiles for each Asian American subgroup to consider when setting priorities for health promotion programs.

Authors: Mazor KM, Rogers HJ, Williams AE, Roblin DW, Gaglio B, Field TS, Greene SM, Han PK, Costanza ME

Title: The Cancer Message Literacy Tests: psychometric analyses and validity studies.

Journal: Patient Educ Couns 89(1):69-75

Date: 2012 Oct

Abstract: OBJECTIVE: To examine the psychometric properties of two new health literacy tests, and to evaluate score validity. METHODS: Adults aged 40-71 completed the Cancer Message Literacy Test-Listening (CMLT-Listening), the Cancer Message Literacy Test-Reading (CMLT-Reading), the REALM, the Lipkus numeracy test, a brief knowledge test (developed for this study) and five brief cognitive tests. Participants also self-reported educational achievement, current health, reading ability, ability to understand spoken information, and language spoken at home. RESULTS: Score reliabilities were good (CMLT-Listening: alpha=.84) to adequate (CMLT-Reading: alpha=.75). Scores on both CMLT tests were positively and significantly correlated with scores on the REALM, numeracy, cancer knowledge and the cognitive tests. Mean CMLT scores varied as predicted according to educational level, language spoken at home, self-rated health, self-reported reading, and self-rated ability to comprehend spoken information. CONCLUSION: The psychometric findings for both tests are promising. Scores appear to be valid indicators of comprehension of spoken and written health messages about cancer prevention and screening. PRACTICE IMPLICATIONS: The CMLT-Listening will facilitate research into comprehension of spoken health messages, and together with the CMLT-Reading will allow researchers to examine the unique contributions of listening and reading comprehension to health-related decisions and behaviors.

Authors: Okechukwu C, Bacic J, Cheng KW, Catalano R

Title: Smoking among construction workers: the nonlinear influence of the economy, cigarette prices, and antismoking sentiment.

Journal: Soc Sci Med 75(8):1379-86

Date: 2012 Oct

Abstract: Little research has been conducted on the influence of macroeconomic environments on smoking among blue-collar workers, a group with high smoking prevalence and that is especially vulnerable to the effects of changing economic circumstances. Using data from 52,418 construction workers in the Tobacco Use Supplement to the United States Current Population Survey, we examined the association of labor market shock, cigarette prices, and state antismoking sentiments with smoking status and average number of cigarettes smoked daily. Data analysis included the use of multiple linear and logistic regressions, which employed the sampling and replicate weights to account for sampling design. Unemployed, American-Indian, lower-educated and lower-income workers had higher smoking rates. Labor market shock had a quadratic association, which was non-significant for smoking status and significant for number of cigarettes. The association of cigarette prices with smoking status became non-significant after adjusting for state-level antismoking sentiment. State-level antismoking sentiment had significant quadratic association with smoking status among employed workers and significant quadratic association with number of cigarettes for all smokers. The study highlights how both workplace-based smoking cessation interventions and antismoking sentiments could further contribute to disparities in smoking by employment status.

Authors: Reid RJ, McBride CM, Alford SH, Price C, Baxevanis AD, Brody LC, Larson EB

Title: Association between health-service use and multiplex genetic testing.

Journal: Genet Med 14(10):852-9

Date: 2012 Oct

Abstract: PURPOSE: The objective of this work was to examine whether offers of multiplex genetic testing increase health-care utilization among healthy patients aged 25-40 years. The identification of genetic variants associated with common disease is accelerating rapidly. "Multiplex tests" that give individuals feedback on large panels of genetic variants have proliferated. Availability of these test results may prompt consumers to use more health-care services. METHODS: A total of 1,599 continuously insured adults aged 25-40 years were surveyed and offered a multiplex genetic susceptibility test for eight common health conditions. Health-care utilization from automated records was compared in 12-month pre- and posttest periods among persons who completed a baseline survey only (68.7%), those who visited a study website but opted not to test (17.8%), and those who chose the multiplex genetic susceptibility test (13.6%). RESULTS: In the pretest period, persons choosing genetic testing used an average of 1.02 physician visits per quarter as compared with 0.93 and 0.82 for the baseline-only and Web-only groups, respectively (P < 0.05). There were no statistically significant differences by group in the pretest use of any common medical tests or procedures associated with four common health conditions. When changes in physician and medical test/procedure use in the posttest period were compared among the groups, no statistically significant differences were observed for any utilization category. CONCLUSIONS: Persons offered and completing multiplex genetic susceptibility testing used more physician visits before testing, but testing was not associated with subsequent changes in use. This study supports the supposition that multiplex genetic testing offers can be provided directly to the patients in such a way that use of health services is not inappropriately increased.

Authors: Taplin SH, Yabroff KR, Zapka J

Title: A multilevel research perspective on cancer care delivery: the example of follow-up to an abnormal mammogram.

Journal: Cancer Epidemiol Biomarkers Prev 21(10):1709-15

Date: 2012 Oct

Abstract: In 1999, researchers and policy makers recognized the challenge of creating an integrated patient-centered cancer care process across the many types of care from risk assessment through end of life. More than a decade later, there has been limited progress toward that goal even though the standard reductionist approach to health services and medical research has resulted in major advances in tests, procedures, and individualized patient approaches to care. In this commentary, we propose that considering an entire care process within its multilevel context may increase progress toward an integrated experience and improvements in the quality of care. As an illustrative case, we describe the multilevel context of care delivery for the process of follow-up to an abnormal screening mammogram. By taking a multilevel perspective on this process, we identify a rich set of options for intervening and improving follow-up to abnormalities and, therefore, outcomes of screening. We propose that taking this multilevel perspective when designing interventions may improve the quality of cancer care in an effective and sustainable way.

Authors: Wisnivesky JP, Bonomi M, Lurslurchachai L, Mhango G, Halm EA

Title: Radiotherapy and chemotherapy for elderly patients with stage I-II unresected lung cancer.

Journal: Eur Respir J 40(4):957-64

Date: 2012 Oct

Abstract: Radiotherapy (RT) is the standard therapy for unresected stage I-II nonsmall cell lung cancer (NSCLC). Using population-based data, we compared survival and toxicity among unresected elderly patients treated with combined chemoradiotherapy (CRT) or RT alone. Using the Surveillance, Epidemiology and End Results (SEER) registry (National Cancer Institute, Bethesda, MD, USA) we identified 3,006 cases of unresected stage I-II NSCLC. We used propensity score methods to compare survival and rates of toxicity of patients treated with RT versus CRT. Overall, 844 (28%) patients received CRT. Adjusted analyses showed that CRT was associated with improved survival (hazard ratio 0.85, 95% CI 0.78-0.94). Combination therapy was also associated with better survival among stage I patients treated with intermediate complexity RT (HR 0.80, 95% CI 0.70-0.90); however, no difference in survival was observed among patients treated with complex RT. In stage II patients, CRT was associated with improved survival regardless of the RT technique (HR 0.61-0.72). CRT was associated with increased odds of toxicity. Despite increased toxicity, CRT may improve survival of elderly unresected patients with stage II disease as well as stage I NSCLC treated with intermediate RT complexity. Randomised trials are needed to clarify the balance of benefits and risk of CRT in unresected patients.

Authors: Yaroch AL, Tooze J, Thompson FE, Blanck HM, Thompson OM, Colón-Ramos U, Shaikh AR, McNutt S, Nebeling LC

Title: Evaluation of three short dietary instruments to assess fruit and vegetable intake: the National Cancer Institute's food attitudes and behaviors survey.

Journal: J Acad Nutr Diet 112(10):1570-7

Date: 2012 Oct

Abstract: BACKGROUND: Fruit and vegetable (F/V) intake assessment tools that are valid, reliable, brief, and easy to administer and code are vital to the field of public health nutrition. OBJECTIVE: To evaluate three short F/V intake screeners (ie, a 2-item serving tool, a 2-item cup tool, and a 16-item F/V intake screener) among adults using multiple 24-hour dietary recalls (24-hour recalls) as the reference instrument and evaluate test-retest reliability of the screeners across a 2- to 3-week time period. DESIGN: Validity and reliability study. PARTICIPANTS/SETTING: Two hundred forty-four adults for the validity study and 335 adults for test-retest reliability. STATISTICAL ANALYSES PERFORMED: Median values for F/V intakes were calculated for the screeners and 24-hour recalls. The Wilcoxon signed rank test was used to compare screeners with the 24-hour recalls. Deattenuated Pearson correlations were reported for validity and intraclass correlation coefficient used for reliability. RESULTS: The estimated median daily servings/cups of F/V for the 2-item serving screener was lower, for the 2-item cup screener was equivalent for men but higher for women, and for the 16-item F/V intake screener were about the same when compared with 24-hour recall values. The deattenuated correlations comparing the 24-hour recalls with the screeners were positive but weak for the 2-item serving screener, and were positive and moderate in strength for the 2-item cup and 16-item F/V intake screeners. The test-retest intraclass correlation coefficients were all positive and fairly strong for all of the screeners. CONCLUSIONS: Although dietary screeners offer a more cost-effective, less burdensome way to obtain gross estimates to rank individuals with regard to F/V intake, these methods are not recommended for assessing precise intake levels.

Authors: Zhang X, Martinez-Donate AP, Kuo D, Jones NR

Title: "How is smoking handled in your home?": agreement between parental reports on home smoking bans in the United States, 1995-2007.

Journal: Nicotine Tob Res 14(10):1170-9

Date: 2012 Oct

Abstract: INTRODUCTION: Home smoking bans significantly reduce secondhand smoke exposure among children, but parents may offer discordant reports on whether there is a home smoking ban. The purpose of this study was to examine national trends in (a) parental discordance/concordance in the reporting of home smoking bans and (b) correlates of discordant/concordant reports among two-parent households with underage children from 1995 to 2007. METHODS: Data from the 1995/1996, 1998/1999, 2001/2002, 2003, and 2006/2007 Tobacco Use Supplement of the U.S. Current Population Survey were used to estimate prevalence rates and multinomial logistic regression models of discordant/concordant parental smoking ban reports by survey period. RESULTS: Overall, the percentage of households in which the 2 parents gave discordant reports on a complete home smoking ban decreased significantly from 12.7% to 2.8% from 1995 to 2007 (p < .001). Compared with households where both parents reported a complete smoking ban, discordant reports were more likely to be obtained from households with current smokers (p < .01) across survey periods. Compared with households where both parents reported the lack of a complete home smoking ban, discordant reports were more likely among households with college graduates, no current smokers, and parents with Hispanic ethnicity (p < .05). CONCLUSIONS: Parental concordance on the existence of a home smoking ban increased from 1995 to 2007. This suggests estimates of home smoking bans based on just one parent may be more reliable now than they were in the past. Interventions to improve the adoption and enforcement of home smoking bans should target households with current smoker parents.

Authors: Dansky Ullmann C, Harlan LC, Shavers VL, Stevens JL

Title: A population-based study of therapy and survival for patients with head and neck cancer treated in the community.

Journal: Cancer 118(18):4452-61

Date: 2012 Sep 15

Abstract: BACKGROUND: The objective of this study was to examine patterns of care and survival in a population-based sample of patients with head and neck cancer (HNC) who were treated in the community or in hospitals that had residency training programs. METHODS: Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program were used to sample 1317 patients aged ≥20 years with invasive squamous HNC who were diagnosed during 2004 and who had vital status available through 2008. RESULTS: Treatment and survival were influenced by tumor site and disease stage. Patients who had stage I/II cancer of the oral cavity generally underwent surgery; patients with stage III oral cavity disease underwent surgery and received radiation; and patients with stage IV oral cavity disease underwent surgery and received chemoradiation. Patients with early stage cancer of the oropharynx either underwent surgery or received radiation and chemotherapy, and patients with late/unstaged oropharyngeal disease primarily received radiation and chemotherapy. Patients with early stage cancer of the larynx mainly received radiation alone, and patients with late stage laryngeal disease generally received chemoradiation. Cisplatin-based regimens were used most frequently. Overall, taxanes were used in 32% of regimens, and cetuximab was used in <3% of regimens. Patients aged ≥50 years, those with a Charlson comorbidity score ≥1, those with stage IV disease, and those with cancer located in the oral cavity or larynx had poorer survival. Although facilities with residency training programs treated more black patients and more patients with late stage disease, when adjusted for other factors, survival rates were similar to those reported in facilities with no such programs. CONCLUSIONS: Therapy generally followed accepted standards for 2004. Findings in particular tumor sites and stages may reflect the variability that still exists for the treatment of HNC. The use of taxanes and cetuximab is expected to increase based on new evidence of benefit. Reducing treatment-related toxicities and long-term functional deficits will be critical and especially important with the increase in human papillomavirus-related cancers. In addition, further attempts to improve survival for older patients are needed.

Authors: Wisnivesky JP, Halm EA, Bonomi M, Smith C, Mhango G, Bagiella E

Title: Postoperative radiotherapy for elderly patients with stage III lung cancer.

Journal: Cancer 118(18):4478-85

Date: 2012 Sep 15

Abstract: BACKGROUND: The potential role of postoperative radiation therapy (PORT) for patients who have completely resected, stage III nonsmall cell lung cancer (NSCLC) with N2 disease remains controversial. By using population-based data, the authors of this report compared the survival of a concurrent cohort of elderly patients who had N2 disease treated with and without PORT. METHODS: By using the Surveillance, Epidemiology, and End Results (SEER) registry linked to Medicare records, 1307 patients were identified who had stage III NSCLC with N2 lymph node involvement diagnosed between 1992 and 2005. Propensity scoring methods and instrumental variable analysis were used to compare the survival of patients who did and did not receive PORT after controlling for selection bias. RESULTS: Overall, 710 patients (54%) received PORT. Propensity score analysis indicated that PORT was not associated with improved survival in patients with N2 disease (hazard ratio [HR], 1.11; 95% confidence interval [CI], 0.97-1.27). Analyses that were limited to patients who did or did not receive chemotherapy, who received intermediate-complexity or high-complexity radiotherapy planning, or adjusted for time trends produced similar results. The instrumental variable estimator for the absolute improvement in 1-year and 3-year survival with PORT was -0.04 (95% CI, -0.15 to 0.08) and -0.08 (95% CI, -0.24 to 0.15), respectively. CONCLUSIONS: The current data suggested that PORT is not associated with improved survival for elderly patients with N2 disease. These findings have important clinical implications, because SEER data indicate that a large percentage of elderly patients currently receive PORT despite the lack of definitive evidence about its effectiveness. The potential effectiveness of PORT should be evaluated further in randomized controlled trials.

Authors: Abdollah F, Sun M, Schmitges J, Thuret R, Tian Z, Shariat SF, Briganti A, Jeldres C, Perrotte P, Montorsi F, Karakiewicz PI

Title: Competing-risks mortality after radiotherapy vs. observation for localized prostate cancer: a population-based study.

Journal: Int J Radiat Oncol Biol Phys 84(1):95-103

Date: 2012 Sep 01

Abstract: PURPOSE: Contemporary patients with localized prostate cancer (PCa) are more frequently treated with radiotherapy. However, there are limited data on the effect of this treatment on cancer-specific mortality (CSM). Our objective was to test the relationship between radiotherapy and survival in men with localized PCa and compare it with those treated with observation. METHODS: A population-based cohort identified 68,797 men with cT1-T2 PCa treated with radiotherapy or observation between the years 1992 and 2005. Propensity-score matching was used to minimize potential bias related to treatment assignment. Competing-risks analyses tested the effect of treatment type (radiotherapy vs. observation) on CSM, after accounting to other-cause mortality. All analyses were carried out within PCa risk, baseline comorbidity status, and age groups. RESULTS: Radiotherapy was associated with more favorable 10-year CSM rates than observation in patients with high-risk PCa (8.8 vs. 14.4%, hazard ratio [HR]: 0.59, 95% confidence interval [CI]: 0.50-0.68). Conversely, the beneficial effect of radiotherapy on CSM was not evident in patients with low-intermediate risk PCa (3.7 vs. 4.1%, HR: 0.91, 95% CI: 0.80-1.04). Radiotherapy was beneficial in elderly patients (5.6 vs. 7.3%, HR: 0.70, 95% CI: 0.59-0.80). Moreover, it was associated with improved CSM rates among patients with no comorbidities (5.7 vs. 6.5%, HR: 0.81, 95% CI: 0.67-0.98), one comorbidity (4.6 vs. 6.0%, HR: 0.87, 95% CI: 0.75-0.99), and more than two comorbidities (4.2 vs. 5.0%, HR: 0.79, 95% CI: 0.65-0.96). CONCLUSIONS: Radiotherapy substantially improves CSM in patients with high-risk PCa, with little or no benefit in patients with low-/intermediate-risk PCa relative to observation. These findings must be interpreted within the context of the limitations of observational data.

Authors: Sanoff HK, Carpenter WR, Freburger J, Li L, Chen K, Zullig LL, Goldberg RM, Schymura MJ, Schrag D

Title: Comparison of adverse events during 5-fluorouracil versus 5-fluorouracil/oxaliplatin adjuvant chemotherapy for stage III colon cancer: a population-based analysis.

Journal: Cancer 118(17):4309-20

Date: 2012 Sep 01

Abstract: BACKGROUND: In clinical trials, combined 5-fluorouracil (5FU) plus oxaliplatin improves the survival of patients who have resected, stage III colon cancer with manageable toxicity. However, the tolerability of this in the general population of patients with colon cancer is uncertain. METHODS: Adverse outcomes were compared in patients with stage III colon cancer who received either 5FU or 5FU/oxaliplatin within 120 days of undergoing resection versus a control group of patients with stage II colon cancer who did not receive chemotherapy in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database and in data from the New York State Cancer Registry linked to Medicare and Medicaid. Hospitalizations, emergency room (ER) visits, and outpatient adverse events (AEs) were measured in claims from 30 days to 9 months after patients underwent resection. Multiple logistic regression was used to calculate adjusted odds ratios of events by treatment. Propensity score matching was used to minimize selection bias. RESULTS: Adverse outcomes were more frequent for chemotherapy recipients. AE rates were higher in patients who received 5FU/oxaliplatin (81%) compared with patients who received 5FU alone (72%), in the SEER-Medicare data. The effect of oxaliplatin on AEs was greater in older patients: The odds ratio was 2.10 (95% confidence interval, 1.53-2.87) for patients aged ≥ 75 years versus 1.75 (95% confidence interval, 1.39-2.21) for patients aged <75 years. ER use was high in Medicaid patients (83% of those who received chemotherapy), but neither ER use nor hospitalization was increased by oxaliplatin. The 60-day mortality rate was 1% to 3% for patients who received 5FU alone and 1% to 2% for patients who received combined 5FU/oxaliplatin. CONCLUSIONS: The incremental harms of adjuvant chemotherapy with 5FU/oxaliplatin versus 5FU alone were modest in patients with stage III colon cancer who were insured by Medicare and Medicaid. The additional harms in patients aged ≥ 75 years largely were restricted to outpatient events and did not extend to an increased rate of hospitalization or early death.

Authors: Abdollah F, Schmitges J, Sun M, Jeldres C, Tian Z, Briganti A, Shariat SF, Perrotte P, Montorsi F, Karakiewicz PI

Title: Comparison of mortality outcomes after radical prostatectomy versus radiotherapy in patients with localized prostate cancer: a population-based analysis.

Journal: Int J Urol 19(9):836-5

Date: 2012 Sep

Abstract: OBJECTIVES: To compare the mortality outcomes of radical prostatectomy and radiotherapy as treatment modalities for patients with localized prostate cancer. METHODS: Our cohort consisted of 68 665 patients with localized prostate cancer, treated with radical prostatectomy or radiotherapy, between 1992 and 2005. Propensity-score matching was used to minimize potential bias related to treatment assignment. Competing-risks analyses tested the effect of treatment type on cancer-specific mortality, after accounting for other-cause mortality. All analyses were stratified according to prostate cancer risk groups, baseline Charlson Comorbidity Index and age. RESULTS: For patients treated with radical prostatectomy versus radiotherapy, the 10-year cancer-specific mortality rates were 1.4 versus 3.9% in low-intermediate risk prostate cancer and 6.8 versus 11.5% in high-risk prostate cancer, respectively. Rates were 2.4 versus 5.9% in patients with Charlson Comorbidity Index of 0, 2.4 versus 5.1% in patients with Charlson Comorbidity Index of 1, and 2.9 versus 5.2% in patients with Charlson Comorbidity Index of ≥2. Rates were 2.1 versus 5.0% in patients aged 65-69 years, 2.8 versus 5.5% in patients aged 70-74 years, and 2.9 versus 7.6% in patients aged 75-80 years (all P < 0.001). At multivariable analyses, radiotherapy was associated with less favorable cancer-specific mortality in all categories (all P < 0.001). CONCLUSIONS: Patients treated with radical prostatectomy fare substantially better than those treated with radiotherapy. Patients with high-risk prostate cancer benefit the most from radical prostatectomy. Conversely, the lowest benefit was observed in patients with low-intermediate risk prostate cancer and/or multiple comorbidities. An intermediate benefit was observed in the other examined categories.

Authors: Bonomi MR, Smith CB, Mhango G, Wisnivesky JP

Title: Outcomes of elderly patients with stage IIIB-IV non-small cell lung cancer admitted to the intensive care unit.

Journal: Lung Cancer 77(3):600-4

Date: 2012 Sep

Abstract: BACKGROUND: Although the prognosis of elderly patients with stage IIIB and IV non-small cell lung cancer (NSCLC) is poor, it remains a common cause of cancer related admissions to the intensive care unit (ICU). The objective was to evaluate short and long-term outcomes of a population-based sample of elderly patients with advanced NSCLC who require ICU care. METHODS: Using combined data from the Surveillance, Epidemiology and End Results registry and Medicare files, we identified 1134 patients >65 years of age with stage IIIB and IV NSCLC admitted to an ICU with a diagnosis of respiratory, cardiac, or neurologic complications, renal failure, or sepsis. We assessed rates and predictors of death during hospitalization. The Kaplan-Meier method was used to estimate mortality rates at 90 days and 1 year post hospital discharge. RESULTS: In-hospital mortality was 33% (95% CI: 30-36%). The 90-day and 1-year mortality rate was 71% and 90%, respectively. Patients with an admitting diagnosis of sepsis had the highest rate of in-hospital mortality (59%). Of those who were alive at discharge, 52% were transferred to a skilled nursing facility, 6% to hospice, and 42% returned home. CONCLUSION: We found that one-third of elderly patients with advanced NSCLC admitted to the ICU do not survive hospitalization. Among survivors, most patients required continued institutionalization with a very low likelihood of surviving >1 year from discharge. This data should help patients, families, and health care providers of elderly patients with advanced NSCLC make decisions regarding ICU utilization.

Authors: Carney PA, Abraham L, Cook A, Feig SA, Sickles EA, Miglioretti DL, Geller BM, Yankaskas BC, Elmore JG

Title: Impact of an educational intervention designed to reduce unnecessary recall during screening mammography.

Journal: Acad Radiol 19(9):1114-20

Date: 2012 Sep

Abstract: RATIONALE AND OBJECTIVES: The aim of this study was to describe the impact of a tailored Web-based educational program designed to reduce excessive screening mammography recall. MATERIALS AND METHODS: Radiologists enrolled in one of four mammography registries in the United States were invited to take part and were randomly assigned to receive the intervention or to serve as controls. The controls were offered the intervention at the end of the study, and data collection included an assessment of their clinical practice as well. The intervention provided each radiologist with individual audit data for his or her sensitivity, specificity, recall rate, positive predictive value, and cancer detection rate compared to national benchmarks and peer comparisons for the same measures; profiled breast cancer risk in each radiologist's respective patient populations to illustrate how low breast cancer risk is in population-based settings; and evaluated the possible impact of medical malpractice concerns on recall rates. Participants' recall rates from actual practice were evaluated for three time periods: the 9 months before the intervention was delivered to the intervention group (baseline period), the 9 months between the intervention and control groups (T1), and the 9 months after completion of the intervention by the controls (T2). Logistic regression models examining the probability that a mammogram was recalled included indication of intervention versus control and time period (baseline, T1, and T2). Interactions between the groups and time period were also included to determine if the association between time period and the probability of a positive result differed across groups. RESULTS: Thirty-one radiologists who completed the continuing medical education intervention were included in the adjusted model comparing radiologists in the intervention group (n = 22) to radiologists who completed the intervention in the control group (n = 9). At T1, the intervention group had 12% higher odds of positive mammographic results compared to the controls, after controlling for baseline (odds ratio, 1.12; 95% confidence interval, 1.00-1.27; P = .0569). At T2, a similar association was found, but it was not statistically significant (odds ratio, 1.10; 95% confidence interval, 0.96 to 1.25). No associations were found among radiologists in the control group when comparing those who completed the continuing medical education intervention (n = 9) to those who did not (n = 10). In addition, no associations were found between time period and recall rate among radiologists who set realistic goals. CONCLUSIONS: This study resulted in a null effect, which may indicate that a single 1-hour intervention is not adequate to change excessive recall among radiologists who undertook the intervention being tested.

Authors: Cheng YJ, Wang MC

Title: Estimating propensity scores and causal survival functions using prevalent survival data.

Journal: Biometrics 68(3):707-16

Date: 2012 Sep

Abstract: This article develops semiparametric approaches for estimation of propensity scores and causal survival functions from prevalent survival data. The analytical problem arises when the prevalent sampling is adopted for collecting failure times and, as a result, the covariates are incompletely observed due to their association with failure time. The proposed procedure for estimating propensity scores shares interesting features similar to the likelihood formulation in case-control study, but in our case it requires additional consideration in the intercept term. The result shows that the corrected propensity scores in logistic regression setting can be obtained through standard estimation procedure with specific adjustments on the intercept term. For causal estimation, two different types of missing sources are encountered in our model: one can be explained by potential outcome framework; the other is caused by the prevalent sampling scheme. Statistical analysis without adjusting bias from both sources of missingness will lead to biased results in causal inference. The proposed methods were partly motivated by and applied to the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data for women diagnosed with breast cancer.

Authors: Choi WW, Gu X, Lipsitz SR, D'Amico AV, Williams SB, Hu JC

Title: The effect of minimally invasive and open radical prostatectomy surgeon volume.

Journal: Urol Oncol 30(5):569-76

Date: 2012 Sep

Abstract: OBJECTIVE: To determine the effect of minimally invasive radical prostatectomy (MIRP) surgeon volume on outcomes, and correlate with those of open radical prostatectomy retropubic (ORP). METHODS AND MATERIALS: Observational population-based study of 8,831 men undergoing MIRP and ORP by 1,457 low, medium, and high volume surgeons from SEER-Medicare linked data from 2003 to 2007. After stratifying by surgeon ORP and MIRP volume, the following outcomes were studied: length of stay, transfusions, post-operative 30-day and anastomotic stricture complications, and use of additional cancer therapies. RESULTS: Men undergoing MIRP with high and medium vs. low volume surgeons were less likely to require additional cancer therapies (4.5% and 4.7% vs. 7%, P = 0.020). Similarly, men undergoing ORP with high vs. medium and low volume surgeons were less likely to require additional cancer therapies (5.7% vs. 6.8% and 7.1%, P = 0.044). Men undergoing ORP with high vs. medium and low volume surgeons experienced shorter lengths of stay (2.9 vs. 3.3 and 3.6 days, P < 0.001), and fewer transfusions (15.4% vs. 21.3% and 22.7%, P = 0.017), 30-day complications (18.4% vs. 25.6% and 25.7%, P < 0.001), and anastomotic strictures (10.1% vs. 15.6% and 16.3%, P = 0.003). However, MIRP surgeon volume did not affect these outcomes. CONCLUSIONS: Men undergoing MIRP or ORP with high volume surgeons were less likely to require additional cancer therapies. Additionally, patients of high volume ORP surgeons were more likely to experience shorter hospital stays, fewer transfusions, 30-day complications, and anastomotic strictures, while MIRP surgeon volume did not affect these peri-operative outcomes.

Authors: Cook AJ, Elmore JG, Zhu W, Jackson SL, Carney PA, Flowers C, Onega T, Geller B, Rosenberg RD, Miglioretti DL

Title: Mammographic interpretation: radiologists' ability to accurately estimate their performance and compare it with that of their peers.

Journal: AJR Am J Roentgenol 199(3):695-702

Date: 2012 Sep

Abstract: OBJECTIVE: The purposes of this study were to determine whether U.S. radiologists accurately estimate their own interpretive performance of screening mammography and to assess how they compare their performance with that of their peers. SUBJECTS AND METHODS: Between 2005 and 2006, 174 radiologists from six Breast Cancer Surveillance Consortium registries completed a mailed survey. The radiologists' estimated and actual recall, false-positive, and cancer detection rates and positive predictive value of biopsy recommendation (PPV(2)) for screening mammography were compared. Radiologists' ratings of their performance as lower than, similar to, or higher than that of their peers were compared with their actual performance. Associations with radiologist characteristics were estimated with weighted generalized linear models. RESULTS: Although most radiologists accurately estimated their cancer detection and recall rates (74% and 78% of radiologists), fewer accurately estimated their false-positive rate (19%) and PPV(2) (26%). Radiologists reported having recall rates similar to (43%) or lower than (31%) and false-positive rates similar to (52%) or lower than (33%) those of their peers and similar (72%) or higher (23%) cancer detection rates and similar (72%) or higher (38%) PPV(2). Estimation accuracy did not differ by radiologist characteristics except that radiologists who interpreted 1000 or fewer mammograms annually were less accurate at estimating their recall rates. CONCLUSION: Radiologists perceive their performance to be better than it actually is and at least as good as that of their peers. Radiologists have particular difficulty estimating their false-positive rates and PPV(2).

Authors: Dunton GF, Berrigan D, Ballard-Barbash R, Perna F, Graubard BI, Atienza AA

Title: Differences in the intensity and duration of adolescents' sports and exercise across physical and social environments.

Journal: Res Q Exerc Sport 83(3):376-82

Date: 2012 Sep

Abstract: We used data from the American Time Use Survey (years 2003-06) to analyze whether the intensity and duration of high school students' (ages 15-18 years) sports and exercise bouts differed across physical and social environments. Boys' sports and exercise bouts were more likely to reach a vigorous intensity when taking place at school and with friends/acquaintances/other people; whereas girls' sports and exercise bouts were more likely to reach a vigorous intensity when outdoors and alone. For boys and girls, bout durations were greater at school and with friends/acquaintances/other people than in other environments. Overall, environmental influences on the intensity but not duration of sports and exercise bouts appear to differ between boys and girls.

Authors: Jarman MP, Bowling JM, Dickens P, Luken K, Yankaskas BC

Title: Factors facilitating acceptable mammography services for women with disabilities.

Journal: Womens Health Issues 22(5):e421-8

Date: 2012 Sep

Abstract: BACKGROUND: Prior research has described general barriers to breast cancer screening for women with disabilities (WWD). We explored specific accommodations described as necessary by WWD who have accessed screening services, and the presence of such accommodations in community-based screening programs. METHODS: We surveyed WWD in the Carolina Mammography Registry to determine what accommodations were needed when accessing breast screening services, and whether or not these needs were met. The sample of 1,348 WWD was identified through a survey of limitations, with a response rate of 45.5% (4,498/9,885). Of the 1,348 WWD eligible for the second survey, 739 responded for a response rate of 54.8%. RESULTS: The most frequently needed accommodations were an accessible changing area with a bench (60.0%), oral description of the procedure by the technologist (60.5%), and handicapped/accessible parking (27.6%). Handicapped parking was the need most likely to go unmet (3.1%). CONCLUSION: Most needs are being met by radiology facilities and staff, and the few needs going unmet are related to the physical/built environment. Overall, for WWD who are in screening, the mammography system seems to be more accessible than generally perceived.

Authors: Keegan TH, Lichtensztajn DY, Kato I, Kent EE, Wu XC, West MM, Hamilton AS, Zebrack B, Bellizzi KM, Smith AW, AYA HOPE Study Collaborative Group

Title: Unmet adolescent and young adult cancer survivors information and service needs: a population-based cancer registry study.

Journal: J Cancer Surviv 6(3):239-50

Date: 2012 Sep

Abstract: PURPOSE: We described unmet information and service needs of adolescent and young adult (AYA) cancer survivors (15-39 years of age) and identified sociodemographic and health-related factors associated with these unmet needs. METHODS: We studied 523 AYAs recruited from seven population-based cancer registries, diagnosed with acute lymphocytic leukemia, Hodgkin's lymphoma, non-Hodgkin's lymphoma, germ cell cancer, or sarcoma in 2007-2008. Participants completed surveys a median of 11 months from diagnosis. Multivariable logistic regression analyses were used to estimate associations between unmet (information and service) needs and sociodemographic and health-related factors. RESULTS: More than half of AYAs had unmet information needs relating to their cancer returning and cancer treatments. AYAs needing services, but not receiving them, ranged from 29 % for in-home nursing to 75 % for a support group. The majority of AYAs who needed a pain management expert, physical/occupational therapist, mental health worker, or financial advice on paying for health care did not receive services. In multivariable analyses, older participants, men, participants of non-white race/ethnicity, and participants who reported less than excellent general health or fair/poor quality of care were more likely to report unmet information needs. Factors associated with both unmet service and information needs included physical health or emotional problems interfering with social activities or having ≥3 physical treatment-related symptoms. CONCLUSIONS: Recently diagnosed AYA cancer survivors have substantial unmet information needs varying by demographic and health-related factors. IMPLICATIONS FOR CANCER SURVIVORS: We identified subgroups of AYA cancer survivors with high unmet needs that can be targeted for interventions and referrals.

Authors: Kim AW, Detterbeck FC, Boffa DJ, Decker RH, Soulos PR, Cramer LD, Gross CP

Title: Characteristics associated with the use of nonanatomic resections among Medicare patients undergoing resections of early-stage lung cancer.

Journal: Ann Thorac Surg 94(3):895-901

Date: 2012 Sep

Abstract: BACKGROUND: Racial disparities in access to surgical resection for treatment of early-stage non-small-cell lung cancer (NSCLC) are well documented. However it is unclear how race, clinical, and hospital characteristics affect the surgical approach among patients undergoing resection. METHODS: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)/Medicare linked database, we identified patients 67 years of age or older diagnosed with stage I NSCLC who underwent surgical resection from 2000 to 2007. Surgical approach was categorized as lobectomy or segmentectomy (anatomic) versus wedge resection (nonanatomic). We used logistic regression to identify the association between demographic, clinical, and hospital factors and the use of nonanatomic resections. RESULTS: There were 8,986 patients in the sample (mean age, 75 years; 53% women); 12.8% underwent nonanatomic resection. The use of nonanatomic resection increased significantly, from 11.0% in 2000 to 15.9% in 2007 (p=0.008). In multivariable analysis, race was not associated with the receipt of nonanatomic resection. Factors associated with the use of nonanatomic resections included age greater than 80 years (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.15-1.98), T1a primary tumor status, chronic obstructive pulmonary disease (COPD) (OR, 1.81; 95% CI, 1.55-2.12), and volume of hospital lung resections performed (highest versus lowest hospital volume, OR, 1.58; 95% CI, 1.23-2.04). More nonanatomic resections were performed in 2007 than in 2000 (OR, 1.73; 95% CI, 1.27-2.37). After stratifying by tumor size, the temporal trend in the use of nonanatomic resection remained significant only among patients with tumors greater than 3 cm. CONCLUSIONS: Since 2000, the use of nonanatomic resections in stage I NSCLC has increased, most significantly among patients with larger tumors. After adjusting for clinical factors, there was no relation between race and type of surgical resection.

Authors: Koebnick C, Smith N, Huang K, Martinez MP, Clancy HA, Kushi LH

Title: The prevalence of obesity and obesity-related health conditions in a large, multiethnic cohort of young adults in California.

Journal: Ann Epidemiol 22(9):609-16

Date: 2012 Sep

Abstract: PURPOSE: To identify population groups that are most susceptible to obesity-related health conditions at young age. METHODS: For this population-based cross-sectional study, measured weight and height, diagnosis, laboratory, and drug prescription information were extracted from electronic medical records of 1,819,205 patients aged 20 to 39 years enrolled in two integrated health plans in California in 2007 through 2009. RESULTS: Overall, 29.9% of young adults were obese. Extreme obesity (body mass index [BMI] ≥ 40 kg/m(2)) was observed in 6.1% of women and 4.5% of men. The adjusted relative risk (RR) for diabetes, hypertension, dyslipidemia, and the metabolic syndrome increased sharply for those individuals with a BMI of 40 or greater, with the sharpest increase in the adjusted RR for hypertension and the metabolic syndrome. The association between weight class and dyslipidemia, hypertension, and the metabolic syndrome but not diabetes was stronger among 20.0- to 29.9-year-olds compared with 30.0- to 39.9-year-olds (P for interaction < .05). For example, compared with their normal weight counterparts of the same age group, young adults with a BMI of 40.0 to 49.9, 50.0 to 59.9, and 60 or greater kg/m(2) had a RR for hypertension of 11.73, 19.88, and 30.47 (95% confidence interval [CI], 26.39-35.17) at 20 to 29 years old, and 9.31, 12.41, and 15.43 (95% CI, 14.32-16.63) at 30 to 39 years old. CONCLUSIONS: Although older individuals were more likely to be extremely obese, the association between obesity-related health conditions was stronger in younger individuals. Hispanics and Blacks are also more likely to be obese, including extremely obese, putting them at an elevated risk for premature cardiovascular disease and some cancers relative to non-Hispanic Whites.

Authors: Kwan ML, Haque R, Lee VS, Joanie Chung WL, Avila CC, Clancy HA, Quinn VP, Kushi LH

Title: Validation of AJCC TNM staging for breast tumors diagnosed before 2004 in cancer registries.

Journal: Cancer Causes Control 23(9):1587-91

Date: 2012 Sep

Abstract: PURPOSE: American Joint Committee on Cancer (AJCC) Tumor (T), Nodal (N), and Metastatic (M) staging is commonly used in clinical practice for treatment decisions, yet before 2004, Surveillance Epidemiology and End Results (SEER)-affiliated cancer registries did not routinely include TNM staging defined by AJCC criteria, reporting instead SEER Summary Staging. METHODS: We developed and validated an algorithm to determine AJCC TNM staging from Extent of Disease information for 17,133 female breast cancer cases diagnosed from 1988 to 2003 in the cancer registries of Kaiser Permanente Northern and Southern California. Test characteristics (percent agreement, Cohen's kappa, sensitivity, specificity) were calculated to compare derived TNM with gold-standard TNM available in the registry. RESULTS: Agreement for TNM variables was excellent (range 0.91-1.00 for percent agreement and Cohen's kappa). The sensitivity and specificity, respectively, of the algorithm for AJCC TNM Version 6 staging were as follows: Stage 0 (0.99, 1.00), Stage I (0.97, 0.98), Stage II (0.91, 0.96), Stage III (0.69, 0.99), and Stage IV (0.92, 1.00). Stage III had lower sensitivity due to reclassification of supraclavicular lymph node positivity from M1 (Stage IV) to N3 (Stage IIIC) in AJCC Version 6. CONCLUSIONS: Derived AJCC staging for breast tumors diagnosed before 2004 is feasible and accurate using cancer registry data.

Authors: Mobley LR, Kuo TM, Watson L, Gordon Brown G

Title: Geographic disparities in late-stage cancer diagnosis: multilevel factors and spatial interactions.

Journal: Health Place 18(5):978-90

Date: 2012 Sep

Abstract: In 2009 in the United States, breast cancer was the most common cancer in women, and colorectal cancer was the third most common cancer in both men and women. Currently, over 40% of these cancers are diagnosed at an advanced stage, which results in higher morbidity and mortality than would obtain with optimal cancer screening utilization. To provide information that might improve these cancer outcomes we use spatial analysis to answer questions related to both Why and Where disparities in late-stage cancer diagnoses are observed. In examining Why, we include state level characteristics reflecting characteristics of states' cancer control planning, insurance markets and managed care environments to help model the spatial heterogeneity from place to place. To answer questions related to Where disparities are observed, we generate county level predictions of late-stage cancer rates from a random-intercept multilevel model estimated on the population data from 11 pooled SEER Registries. The findings allow for comparisons across states that reveal logical starting points for a national effort to control cancer.

Authors: Parsons HM, Tuttle TM, Kuntz KM, Begun JW, McGovern PM, Virnig BA

Title: Quality of care along the cancer continuum: does receiving adequate lymph node evaluation for colon cancer lead to comprehensive postsurgical care?

Journal: J Am Coll Surg 215(3):400-11

Date: 2012 Sep

Abstract: BACKGROUND: Among surgically treated patients with colon cancer, lower long-term mortality has been demonstrated in those with 12 or more lymph nodes evaluated. We examined whether patients receiving adequate lymph node evaluation were also more likely to receive comprehensive postsurgical care, leading to lower mortality. STUDY DESIGN: We used the 1992 to 2007 Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify surgically treated American Joint Committee on Cancer (AJCC) stage III colon cancer patients. We used chi-square analyses and logistic regression to evaluate the association between adequate (≥12) lymph node evaluation and receipt of postsurgical care (adjuvant chemotherapy, surveillance colonoscopy, CT scans, and CEA testing) and Cox proportional hazards regression to evaluate 10-year all-cause mortality, adjusting for postsurgical care. RESULTS: Among 17,906 surgically treated stage III colon cancer patients, adequate (≥12) lymph node evaluation was not associated with receiving comprehensive postsurgical care after adjustment for patient and tumor characteristics (p > 0.05 for all). Initially, adequate lymph node evaluation was associated with lower all-cause mortality (hazard ratio [HR] 0.88; 95% CI [0.85 to 0.91]), but among 3-year survivors, the impact of adequate lymph node evaluation on lower mortality was diminished (HR 0.94; 95% CI [0.88 to 1.01]). However, receiving comprehensive postsurgical care was associated with continued lower mortality in 3-year survivors. CONCLUSIONS: Adequate lymph node evaluation for colon cancer was associated with lower mortality among all patients. However, among 3-year survivors, the association between lymph node evaluation and lower hazard of death was no longer significant, while postsurgical care remained strongly associated with lower long-term mortality, indicating that postsurgical care may partially explain the relationship between lymph node evaluation and mortality.

Authors: Pesko MF, Kruger J, Hyland A

Title: Cigarette price minimization strategies used by adults.

Journal: Am J Public Health 102(9):e19-21

Date: 2012 Sep

Abstract: We used multivariate logistic regressions to analyze data from the 2006 to 2007 Tobacco Use Supplement of the Current Population Survey, a nationally representative sample of adults. We explored use of cigarette price minimization strategies, such as purchasing cartons of cigarettes, purchasing in states with lower after-tax cigarette prices, and purchasing on the Internet. Racial/ethnic minorities and persons with low socioeconomic status used these strategies less frequently at last purchase than did White and high-socioeconomic-status respondents.

Authors: Roetzheim RG, Ferrante JM, Lee JH, Chen R, Love-Jackson KM, Gonzalez EC, Fisher KJ, McCarthy EP

Title: Influence of primary care on breast cancer outcomes among Medicare beneficiaries.

Journal: Ann Fam Med 10(5):401-11

Date: 2012 Sep-Oct

Abstract: PURPOSE: We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes. METHODS: Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations. RESULTS: Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis. CONCLUSIONS: Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

Authors: Ulmer WD, Prasad SM, Kowalczyk KJ, Gu X, Dodgion C, Lipsitz S, Palapattu GS, Choueiri TK, Hu JC

Title: Factors associated with the adoption of minimally invasive radical prostatectomy in the United States.

Journal: J Urol 188(3):775-80

Date: 2012 Sep

Abstract: PURPOSE: Minimally invasive radical prostatectomy has supplanted radical retropubic prostatectomy in popularity despite the absence of strong comparative effectiveness data demonstrating its superiority. We examined the influence of patient, surgeon and hospital characteristics on the use of minimally invasive radical prostatectomy vs radical retropubic prostatectomy. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results)-Medicare linked data we identified 11,732 men who underwent radical prostatectomy from 2003 to 2007. We assessed the contribution of patient, surgeon and hospital characteristics to the likelihood of undergoing minimally invasive radical prostatectomy vs radical retropubic prostatectomy using multilevel logistic regression mixed models. RESULTS: Patient factors (36.7%) contributed most to the use of minimally invasive radical prostatectomy vs radical retropubic prostatectomy, followed by surgeon (19.1%) and hospital (11.8%) factors. Among patient specific factors Asian race (OR 1.86, 95% CI 1.27-2.72, p = 0.001), clinically organ confined tumors (OR 2.71, 95% CI 1.60-4.57, p <0.001) and obtaining a second opinion from a urologist (OR 3.41, 95% CI 2.67-4.37, p <0.001) were associated with the highest use of minimally invasive radical prostatectomy while lower income was associated with decreased use of minimally invasive radical prostatectomy. Among surgeon and hospital specific factors, higher surgeon volume (OR 1.022, 95% CI 1.015-1.028, p <0.001), surgeon age younger than 50 years (OR 2.68, 95% CI 1.69-4.24, p <0.001) and greater hospital bed size (OR 1.001, 95% CI 1.001-1.002, p <0.001) were associated with increased use of minimally invasive radical prostatectomy, while solo or 2 urologist practices were associated with decreased use of minimally invasive radical prostatectomy (OR 0.48, 95% CI 0.27-0.86, p = 0.013). CONCLUSIONS: The adoption of minimally invasive radical prostatectomy vs radical retropubic prostatectomy is multifactorial, and associated with specific patient, surgeon and hospital related factors. Obtaining a second opinion from another urologist was the strongest factor associated with opting for minimally invasive radical prostatectomy.

Authors: Yasmeen S, Hubbard RA, Romano PS, Zhu W, Geller BM, Onega T, Yankaskas BC, Miglioretti DL, Kerlikowske K

Title: Risk of advanced-stage breast cancer among older women with comorbidities.

Journal: Cancer Epidemiol Biomarkers Prev 21(9):1510-9

Date: 2012 Sep

Abstract: BACKGROUND: Comorbidities have been suggested influencing mammography use and breast cancer stage at diagnosis. We compared mammography use, and overall and advanced-stage breast cancer rates, among female Medicare beneficiaries with different levels of comorbidity. METHODS: We used linked Breast Cancer Surveillance Consortium (BCSC) and Medicare claims data from 1998 through 2006 to ascertain comorbidities among 149,045 female Medicare beneficiaries ages 67 and older who had mammography. We defined comorbidities as either "unstable" (life-threatening or difficult to control) or "stable" (age-related with potential to affect daily activity) on the basis of claims within 2 years before each mammogram. RESULTS: Having undergone two mammograms within 30 months was more common in women with stable comorbidities (86%) than in those with unstable (80.3%) or no (80.9%) comorbidities. Overall rates of advanced-stage breast cancer were lower among women with no comorbidities [0.5 per 1,000 mammograms, 95% confidence interval (CI), 0.3-0.8] than among those with stable comorbidities (0.8; 95% CI, 0.7-0.9; P = 0.065 compared with no comorbidities) or unstable comorbidities (1.1; 95% CI, 0.9-1.3; P = 0.002 compared with no comorbidities). Among women having undergone two mammograms within 4 to 18 months, those with unstable and stable comorbidities had significantly higher advanced cancer rates than those with no comorbidities (P = 0.004 and P = 0.03, respectively). CONCLUSIONS: Comorbidities were associated with more frequent use of mammography but also higher risk of advanced-stage disease at diagnosis among the subset of women who had the most frequent use of mammography. IMPACT: Future studies need to examine whether specific comorbidities affect clinical progression of breast cancer.

Authors: Zapka J, Klabunde CN, Taplin S, Yuan G, Ransohoff D, Kobrin S

Title: Screening colonoscopy in the US: attitudes and practices of primary care physicians.

Journal: J Gen Intern Med 27(9):1150-8

Date: 2012 Sep

Abstract: BACKGROUND: Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery. OBJECTIVE: Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns. DESIGN: Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007. PARTICIPANTS: 1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists. MAIN MEASURES: Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics. RESULTS: The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering. CONCLUSIONS: PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.

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 :-

Date: 2012 Aug 23

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: Gierach GL, Ichikawa L, Kerlikowske K, Brinton LA, Farhat GN, Vacek PM, Weaver DL, Schairer C, Taplin SH, Sherman ME

Title: Relationship between mammographic density and breast cancer death in the Breast Cancer Surveillance Consortium.

Journal: J Natl Cancer Inst 104(16):1218-27

Date: 2012 Aug 22

Abstract: BACKGROUND: Women with elevated mammographic density have an increased risk of developing breast cancer. However, among women diagnosed with breast cancer, it is unclear whether higher density portends reduced survival, independent of other factors. METHODS: We evaluated relationships between mammographic density and risk of death from breast cancer and all causes within the US Breast Cancer Surveillance Consortium. We studied 9232 women diagnosed with primary invasive breast carcinoma during 1996-2005, with a mean follow-up of 6.6 years. Mammographic density was assessed using the Breast Imaging Reporting and Data System (BI-RADS) density classification. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by Cox proportional hazards regression; women with scattered fibroglandular densities (BI-RADS 2) were the referent group. All statistical tests were two-sided. RESULTS: A total of 1795 women died, of whom 889 died of breast cancer. In multivariable analyses (adjusted for site, age at and year of diagnosis, American Joint Committee on Cancer stage, body mass index, mode of detection, treatment, and income), high density (BI-RADS 4) was not related to risk of death from breast cancer (HR = 0.92, 95% CI = 0.71 to 1.19) or death from all causes (HR = 0.83, 95% CI = 0.68 to 1.02). Analyses stratified by stage and other prognostic factors yielded similar results, except for an increased risk of breast cancer death among women with low density (BI-RADS 1) who were either obese (HR = 2.02, 95% CI = 1.37 to 2.97) or had tumors of at least 2.0 cm (HR = 1.55, 95% CI = 1.14 to 2.09). CONCLUSIONS: High mammographic breast density was not associated with risk of death from breast cancer or death from any cause after accounting for other patient and tumor characteristics. Thus, risk factors for the development of breast cancer may not necessarily be the same as factors influencing the risk of death after breast cancer has developed.

Authors: Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, Hsia J, Morton J, Palipudi KM, Asma S, GATS Collaborative Group

Title: Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys.

Journal: Lancet 380(9842):668-79

Date: 2012 Aug 18

Abstract: BACKGROUND: Despite the high global burden of diseases caused by tobacco, valid and comparable prevalence data for patterns of adult tobacco use and factors influencing use are absent for many low-income and middle-income countries. We assess these patterns through analysis of data from the Global Adult Tobacco Survey (GATS). METHODS: Between Oct 1, 2008, and March 15, 2010, GATS used nationally representative household surveys with comparable methods to obtain relevant information from individuals aged 15 years or older in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam). We compared weighted point estimates and 95% CIs of tobacco use between these 14 countries and with data from the 2008 UK General Lifestyle Survey and the 2006-07 US Tobacco Use Supplement to the Current Population Survey. All these surveys had cross-sectional study designs. FINDINGS: In countries participating in GATS, 48·6% (95% CI 47·6-49·6) of men and 11·3% (10·7-12·0) of women were tobacco users. 40·7% of men (ranging from 21·6% in Brazil to 60·2% in Russia) and 5·0% of women (0·5% in Egypt to 24·4% in Poland) in GATS countries smoked a tobacco product. Manufactured cigarettes were favoured by most smokers (82%) overall, but smokeless tobacco and bidis were commonly used in India and Bangladesh. For individuals who had ever smoked daily, women aged 55-64 years at the time of the survey began smoking at an older age than did equivalently aged men in most GATS countries. However, those individuals who had ever smoked daily and were aged 25-34-years when surveyed started to do so at much the same age in both sexes. Quit ratios were very low (<20% overall) in China, India, Russia, Egypt, and Bangladesh. INTERPRETATION: The first wave of GATS showed high rates of smoking in men, early initiation of smoking in women, and low quit ratios, reinforcing the view that efforts to prevent initiation and promote cessation of tobacco use are needed to reduce associated morbidity and mortality. FUNDING: Bloomberg Philanthropies' Initiative to Reduce Tobacco Use, Bill and Melinda Gates Foundation, Brazilian and Indian Governments.

Authors: Albert JM, Liu DD, Shen Y, Pan IW, Shih YC, Hoffman KE, Buchholz TA, Giordano SH, Smith BD

Title: Nomogram to predict the benefit of radiation for older patients with breast cancer treated with conservative surgery.

Journal: J Clin Oncol 30(23):2837-43

Date: 2012 Aug 10

Abstract: PURPOSE: The role of radiation therapy (RT) after conservative surgery (CS) remains controversial for older patients with breast cancer. Guidelines based on recent clinical trials have suggested that RT may be omitted in selected patients with favorable disease. However, it is not known whether this recommendation should extend to other older women. Accordingly, we developed a nomogram to predict the likelihood of long-term breast preservation with and without RT. METHODS: We used Surveillance, Epidemiology, and End Results-Medicare data to identify 16,092 women age 66 to 79 years treated with CS between 1992 and 2002, using claims to identify receipt of RT and subsequent mastectomy. Time to mastectomy was estimated using the Kaplan-Meier method. Cox proportional hazards models determined the effect of covariates on mastectomy-free survival (MFS). A nomogram was developed to predict 5- and 10-year MFS, given associated risk factors, and bootstrap validation was performed. RESULTS: With a median follow-up of 7.2 years, the overall 5- and 10-year MFS rates were 98.1% (95% CI, 97.8% to 98.3%) and 95.4% (95% CI, 94.9% to 95.8%), respectively. In multivariate analysis, age, race, tumor size, estrogen receptor status, and receipt of RT were predictive of time to mastectomy and were incorporated into the nomogram. Nodal status was also included given a significant interaction with RT. The resulting nomogram demonstrated good accuracy in predicting MFS, with a bootstrap-corrected concordance index of 0.66. CONCLUSION: This clinically useful tool predicts 5- and 10-year MFS among older women with early breast cancer using readily available clinicopathologic factors and can aid individualized clinical decision making by estimating predicted benefit from RT.

Authors: Centers for Disease Control and Prevention (CDC)

Title: Vital signs: walking among adults--United States, 2005 and 2010.

Journal: MMWR Morb Mortal Wkly Rep 61(31):595-601

Date: 2012 Aug 10

Abstract: BACKGROUND: Physical activity has numerous health benefits, including improving weight management. The 2008 Physical Activity Guidelines for Americans recommend ≥150 minutes/week of moderate-intensity aerobic physical activity (e.g., brisk walking) for substantial health benefits. Walking is the most commonly reported physical activity by U.S. adults. METHODS: CDC used data from the 2005 and 2010 National Health Interview Surveys to assess changes in prevalence of walking (defined as walking for transportation or leisure in at least one bout of 10 minutes or more in the preceding 7 days) by sex, age group, race/ethnicity, education, body mass index category, walking assistance status, region, and physician-diagnosed chronic disease. CDC also assessed the association between walking and meeting the aerobic physical activity guideline. RESULTS: Overall, walking prevalence increased significantly from 55.7% in 2005 to 62.0% in 2010. Significantly higher walking prevalence was observed in most demographic and health characteristic categories examined. In 2010, the adjusted odds ratio of meeting the aerobic physical activity guideline among walkers, compared with non-walkers, was 2.95 (95% confidence interval = 2.73-3.19). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: To sustain increases in the prevalence of walking, communities can implement evidence-based strategies such as creating or enhancing access to places for physical activity, or using design and land use policies and practices that emphasize mixed-use communities and pedestrian-friendly streets. The impact of these strategies on both walking and physical activity should be monitored systematically at the national, state, and local levels. Public health efforts to promote walking as a way to meet physical activity guidelines can help improve the health of U.S. residents.

Authors: Hu YY, Kwok AC, Jiang W, Taback N, Loggers ET, Ting GV, Lipsitz SR, Weeks JC, Greenberg CC

Title: High-cost imaging in elderly patients with stage IV cancer.

Journal: J Natl Cancer Inst 104(15):1164-72

Date: 2012 Aug 08

Abstract: BACKGROUND: Medicare expenditures for high-cost diagnostic imaging have risen faster than those for total cancer care and have been targeted for potential cost reduction. We sought to determine recent and long-term patterns in high-cost diagnostic imaging use among elderly (aged ≥65 years) patients with stage IV cancer. METHODS: We identified claims within the Surveillance, Epidemiology, and End Results (SEER)-Medicare database with computed tomography, magnetic resonance imaging, positron emission tomography, and nuclear medicine scans between January 1994 and December 2009 for patients diagnosed with stage IV breast, colorectal, lung, or prostate cancer between January 1995 and December 2006 (N = 100,594 patients). The proportion of these patients imaged and rate of imaging per-patient per-month of survival were calculated for each phase of care in patients diagnosed between January 2002 and December 2006 (N = 55,253 patients). Logistic regression was used to estimate trends in imaging use in stage IV patients diagnosed between January 1995 and December 2006, which were compared with trends in imaging use in early-stage (stages I and II) patients with the same tumor types during the same period (N = 192,429 patients). RESULTS: Among the stage IV patients diagnosed between January 2002 and December 2006, 95.9% underwent a high-cost diagnostic imaging procedure, with a mean number of 9.79 (SD = 9.77) scans per patient and 1.38 (SD = 1.24) scans per-patient per-month of survival. After the diagnostic phase, 75.3% were scanned again; 34.3% of patients were scanned in the last month of life. Between January 1995 and December 2006, the proportion of stage IV cancer patients imaged increased (relative increase = 4.6%, 95% confidence interval [CI] = 3.7% to 5.6%), and the proportion of early-stage cancer patients imaged decreased (relative decrease = -2.5%, 95% CI = -3.2% to -1.9%). CONCLUSIONS: Diagnostic imaging is used frequently in patients with stage IV disease, and its use increased more rapidly over the decade of study than that in patients with early-stage disease.

Authors: Yabroff KR, Warren JL

Title: High-cost imaging in elderly patients with stage IV cancer: challenges for research, policy, and practice.

Journal: J Natl Cancer Inst 104(15):1113-4

Date: 2012 Aug 08

Abstract:

Authors: Dinan MA, Curtis LH, Carpenter WR, Biddle AK, Abernethy AP, Patz EF Jr, Schulman KA, Weinberger M

Title: Stage migration, selection bias, and survival associated with the adoption of positron emission tomography among medicare beneficiaries with non-small-cell lung cancer, 1998-2003.

Journal: J Clin Oncol 30(22):2725-30

Date: 2012 Aug 01

Abstract: PURPOSE: Previous studies have linked the use of positron emission tomography (PET) with improved outcomes among patients with non-small-cell lung cancer (NSCLC). However, this association may be confounded by PET-induced stage migration and selection bias. We examined the association between PET use and overall survival among Medicare beneficiaries with NSCLC. PATIENTS AND METHODS: Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER) -Medicare data was used to characterize changes in overall survival, stage-specific survival, and stage distribution among Medicare beneficiaries with NSCLC between 1998 and 2003. RESULTS: A total of 97,007 patients with NSCLC diagnosed between 1998 and 2003 met the study criteria. Two-year and 4-year survival remained unchanged, despite widespread adoption of PET. The proportion of patients staged with advanced disease increased from 44% to 50%. Upstaging of disease was accompanied by stage-specific improved survival, with 2-year survival of stage IV disease increasing from 8% to 11% between 1998 and 2003. PET was more likely to be administered to patients with less advanced disease (stages I through IIIA) and greater overall survival. CONCLUSION: Overall survival among Medicare beneficiaries with NSCLC was unchanged between 1998 and 2003, despite widespread adoption of PET. The association between PET use and increased survival likely reflects an artifact of selection bias and consequent stage migration.

Authors: Arasu VA, Joe BN, Lvoff NM, Leung JW, Brenner RJ, Flowers CI, Moore DH, Sickles EA

Title: Benefit of semiannual ipsilateral mammographic surveillance following breast conservation therapy.

Journal: Radiology 264(2):371-7

Date: 2012 Aug

Abstract: PURPOSE: To compare cancer recurrence outcomes on the basis of compliant semiannual versus noncompliant annual ipsilateral mammographic surveillance following breast conservation therapy (BCT). MATERIALS AND METHODS: A HIPAA-compliant retrospective review was performed of post-BCT examinations from 1997 through 2008 by using a deidentified database. The Committee on Human Research did not require institutional review board approval for this study, which was considered quality assurance. Groups were classified according to compliance with institutional post-BCT protocol, which recommends semiannual mammographic examinations of the ipsilateral breast for 5 years. A compliant semiannual examination was defined as an examination with an interval of 0-9 months, although no examination had intervals less than 3 months. A noncompliant annual examination was defined as an examination with an interval of 9-18 months. Cancer recurrence outcomes were compared on the basis of the last examination interval leading to diagnosis. RESULTS: Initially, a total of 10 750 post-BCT examinations among 2329 asymptomatic patients were identified. Excluding initial mammographic follow-up, there were 8234 examinations. Of these, 7169 examinations were semiannual with 94 recurrences detected and 1065 examinations were annual with 15 recurrences detected. There were no differences in demographic risk factors or biopsy rates. Recurrences identified at semiannual intervals were significantly less advanced than those identified at annual intervals (stage I vs stage II, P = .04; stage 0 + stage I vs stage II, P = .03). Nonsignificant findings associated with semiannual versus annual intervals included smaller tumor size (mean, 11.7 vs 15.3 mm; P = .15) and node negativity (98% vs 91%, P = .28). CONCLUSION: Results suggest that a semiannual interval is preferable for ipsilateral mammographic surveillance, allowing detection of a significantly higher proportion of cancer recurrences at an earlier stage than noncompliant annual surveillance.

Authors: Boyd CA, Branch DW, Sheffield KM, Han Y, Kuo YF, Goodwin JS, Riall TS

Title: Hospital and medical care days in pancreatic cancer.

Journal: Ann Surg Oncol 19(8):2435-42

Date: 2012 Aug

Abstract: BACKGROUND: Little is known about resource utilization (number of days in the hospital or medical care) between diagnosis and death in patients with pancreatic cancer. METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we identified 25,476 patients with pancreatic cancer (1992-2005). Hospital and medical care days per person-month from the time of diagnosis were described, stratified by stage, treatment, and survival duration. RESULTS: Hospital/medical care days vary by length of survival and treatment strategy in patients with pancreatic cancer. For all stages, patients were in the hospital a mean of 6.4 days and received medical care a total of 9.0 days in the first month after diagnosis, decreasing to 1.7 and 3.7 days per month, respectively, by the end of the first year. Hospital/medical care days per month of life were higher in patients with shorter survival but increased sharply at the end of life in all patients, regardless of duration of survival. In patients with locoregional disease, resection was associated with a higher number of hospital/medical care days during the first 4 months after diagnosis, but fewer at the end of the first year. For distant disease, hospital days were similar but days in medical care were higher for patients receiving chemotherapy, increasing especially at the end of life. CONCLUSIONS: This study is the first to quantify hospital/medical care days in patients with pancreatic cancer by stage, treatment, and survival. This information will provide realistic expectations and allow for treatment decisions based on patient preferences.

Authors: Cross DS, Ritter M, Reding DJ

Title: Historical prostate cancer screening and treatment outcomes from a single institution.

Journal: Clin Med Res 10(3):97-105

Date: 2012 Aug

Abstract: OBJECTIVE: To quantify outcomes of individuals diagnosed and treated for prostate cancer in a single institution. DESIGN: Retrospective electronic chart abstraction. SETTING: Marshfield Clinic, the largest private multispecialty group practice in Wisconsin, and one of the largest in the United States, provides health care services annually to approximately 385,000 unique patients through 1.8 million annual patient encounters. PARTICIPANTS: Individuals within the Marshfield Clinic cancer registry who had been diagnosed with prostate cancer between 1960 and 2009. METHODS: Electronic chart abstraction from the cancer registry and the electronic medical record was conducted (N=6,181). Data abstracted included age at diagnosis; stage and grade of tumor; prostate specific antigen (PSA) values before, at, and after diagnosis; initial cancer treatment; follow-up time; subsequent cancer treatments; evidence of metastasis; age of death; and cause of death, if known. RESULTS: The average age of prostate cancer diagnosis has decreased from 70-71 years in the 1960's and 1970's to an average age at diagnosis of 67 years in the 2000's (P<0.001). This decrease in age occurred within the decades of implementation of PSA screening. Approximately 74% of men diagnosed with prostate cancer within the PSA screening era had at least one PSA test, and the presence of a PSA test did not appear to change treatment outcome. Age, grade, and stage were the biggest predictors of prostate cancer outcome. There was no difference in event-free survival between current treatment types (radical prostatectomy, brachytherapy, photon treatment, or intensity-modulated radiation therapy) (2003 or later) when stratified by age (greater than 85%, 5-year event-free survival P=0.85); however, more events occurred with older external beam radiation treatment regimens (1993-2003) (70% to 75%, 5-year event-free survival P=0.001). CONCLUSION: Individuals diagnosed and treated for prostate cancer within the Marshfield Clinic comprehensive care setting follow national trends with a decreased age of diagnosis since the advent of PSA screening. Outcomes for individuals treated within the Clinic system are also comparable to national trends.

Authors: Eide MJ, Tuthill JM, Krajenta RJ, Jacobsen GR, Levine M, Johnson CC

Title: Validation of claims data algorithms to identify nonmelanoma skin cancer.

Journal: J Invest Dermatol 132(8):2005-9

Date: 2012 Aug

Abstract: Health maintenance organization (HMO) administrative databases have been used as sampling frames for ascertaining nonmelanoma skin cancer (NMSC). However, because of the lack of tumor registry information on these cancers, these ascertainment methods have not been previously validated. NMSC cases arising from patients served by a staff model medical group and diagnosed between 1 January 2007 and 31 December 2008 were identified from claims data using three ascertainment strategies. These claims data cases were then compared with NMSC identified using natural language processing (NLP) of electronic pathology reports (EPRs), and sensitivity, specificity, positive and negative predictive values were calculated. Comparison of claims data-ascertained cases with the NLP demonstrated sensitivities ranging from 48 to 65% and specificities from 85 to 98%, with ICD-9-CM ascertainment demonstrating the highest case sensitivity, although the lowest specificity. HMO health plan claims data had a higher specificity than all-payer claims data. A comparison of EPR and clinic log registry cases showed a sensitivity of 98% and a specificity of 99%. Validation of administrative data to ascertain NMSC demonstrates respectable sensitivity and specificity, although NLP ascertainment was superior. There is a substantial difference in cases identified by NLP compared with claims data, suggesting that formal surveillance efforts should be considered.

Authors: Fenton JJ, Zhu W, Balch S, Smith-Bindman R, Lindfors KK, Hubbard RA

Title: External validation of Medicare claims codes for digital mammography and computer-aided detection.

Journal: Cancer Epidemiol Biomarkers Prev 21(8):1344-7

Date: 2012 Aug

Abstract: BACKGROUND: While Medicare claims are a potential resource for clinical mammography research or quality monitoring, the validity of key data elements remains uncertain. Claims codes for digital mammography and computer-aided detection (CAD), for example, have not been validated against a credible external reference standard. METHODS: We matched Medicare mammography claims for women who received bilateral mammograms from 2003 to 2006 to corresponding mammography data from the Breast Cancer Surveillance Consortium (BCSC) registries in four U.S. states (N = 253,727 mammograms received by 120,709 women). We assessed the accuracy of the claims-based classifications of bilateral mammograms as either digital versus film and CAD versus non-CAD relative to a reference standard derived from BCSC data. RESULTS: Claims data correctly classified the large majority of film and digital mammograms (97.2% and 97.3%, respectively), yielding excellent agreement beyond chance (κ = 0.90). Claims data correctly classified the large majority of CAD mammograms (96.6%) but a lower percentage of non-CAD mammograms (86.7%). Agreement beyond chance remained high for CAD classification (κ = 0.83). From 2003 to 2006, the predictive values of claims-based digital and CAD classifications increased as the sample prevalences of each technology increased. CONCLUSION: Medicare claims data can accurately distinguish film and digital bilateral mammograms and mammograms conducted with and without CAD. IMPACT: The validity of Medicare claims data regarding film versus digital mammography and CAD suggests that these data elements can be useful in research and quality improvement.

Authors: Laiyemo AO, Doubeni C, Pinsky PF, Doria-Rose VP, Sanderson AK 2nd, Bresalier R, Weissfeld J, Schoen RE, Marcus PM, Prorok PC, Berg CD

Title: Factors associated with inadequate colorectal cancer screening with flexible sigmoidoscopy.

Journal: Cancer Epidemiol 36(4):395-9

Date: 2012 Aug

Abstract: BACKGROUND AND STUDY AIM: Inadequate colorectal cancer screening wastes limited endoscopic resources. We examined patients factors associated with inadequate flexible sigmoidoscopy (FSG) screening at baseline screening and repeat screening 3-5 years later in 10 geographically-dispersed screening centers participating in the ongoing Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. METHODS: A total of 64,554 participants (aged 55-74) completed baseline questionnaires and underwent FSG at baseline. Of these, 39,385 participants returned for repeat screening. We used logistic regression models to assess factors that are associated with inadequate FSG (defined as a study in which the depth of insertion of FSG was <50 cm or visual inspection was limited to <90% of the mucosal surface but without detection of a polyp or mass). RESULTS: Of 7084 (11%) participants with inadequate FSG at baseline, 6496 (91.7%) had <50 cm depth of insertion (75.3% due to patient discomfort) and 500 (7.1%) participants had adequate depth of insertion but suboptimal bowel preparation. Compared to 55-59 year age group, advancing age in 5-year increments (odds ratios (OR) from 1.08 to 1.51) and female sex (OR = 2.40; 95% confidence interval (CI): 2.27-2.54) were associated with inadequate FSG. Obesity (BMI > 30 kg/m(2)) was associated with reduced odds (OR = 0.67; 95% CI: 0.62-0.72). Inadequate FSG screening at baseline was associated with inadequate FSG at repeat screening (OR = 6.24; 95% CI: 5.78-6.75). CONCLUSIONS: Sedation should be considered for patients with inadequate FSG or an alternative colorectal cancer screening method should be recommended.

Authors: National Cancer Institute

Title: Cancer Trends Progress Report - 2011/2012 Update

Journal: :-

Date: 2012 Aug

Abstract:

Authors: Pocobelli G, Chubak J, Hanson N, Drescher C, Resta R, Urban N, Buist DS

Title: Prophylactic oophorectomy rates in relation to a guideline update on referral to genetic counseling.

Journal: Gynecol Oncol 126(2):229-35

Date: 2012 Aug

Abstract: OBJECTIVE: We sought to determine whether prophylactic oophorectomy rates changed after the introduction of a 2007 health plan clinical guideline recommending systematic referral to a genetic counselor for women with a personal or family history suggestive of an inherited susceptibility to breast/ovarian cancer. METHODS: We conducted a retrospective cohort study of female members of Group Health, an integrated delivery system in Washington State. Subjects were women aged ≥ 35 years during 2004-2009 who reported a personal or family history consistent with an inherited susceptibility to breast/ovarian cancer. Personal and family history information was collected on a questionnaire completed when the women had a mammogram. We ascertained oophorectomies from automated claims data and determined whether surgeries were prophylactic by medical chart review. Rates were age-adjusted and age-adjusted incidence rate ratios (IRR) and 95% confidence intervals (CI) were computed using Poisson regression. RESULTS: Prophylactic oophorectomy rates were relatively unchanged after compared to before the guideline change, 1.0 versus 0.8/1000 person-years, (IRR=1.2; 95% CI: 0.7-2.0), whereas bilateral oophorectomy rates for other indications decreased. Genetic counseling receipt rates doubled after the guideline change (95% CI: 1.7-2.4) from 5.1 to 10.2/1000 person-years. During the study, bilateral oophorectomy rates were appreciably greater in women who saw a genetic counselor compared to those who did not regardless of whether they received genetic testing as part of their counseling. CONCLUSION: A doubling in genetic counseling receipt rates lends support to the idea that the guideline issuance contributed to sustained rates of prophylactic oophorectomies in more recent years.

Authors: Romaire MA, Bowles EJ, Anderson ML, Buist DS

Title: Comparative effectiveness of mailed reminder letters on mammography screening compliance.

Journal: Prev Med 55(2):127-30

Date: 2012 Aug

Abstract: OBJECTIVE: Reminder letters are effective at prompting women to schedule mammograms. Less well studied are reminders addressing multiple preventive service recommendations. We compared the effectiveness of a mammogram-specific reminder sent when a woman was due for a mammogram to a reminder letter addressing multiple preventive services and sent on a woman's birthday on mammography receipt. METHODS: The study included 48,583 women 52-74 years enrolled in Group Health Cooperative, a health plan in Washington State. From 2005 to 2009, women were mailed 88,605 mammogram-specific or birthday letters. In this one group pretest-posttest study, we modeled the odds of obtaining a screening mammogram after receiving a letter by reminder type using logistic regression, controlling for demographic and healthcare use characteristics and stratifying by whether women were overdue or up-to-date with mammography at the mailing. RESULTS: Among women up-to-date with screening, birthday letters were negatively associated with mammography receipt compared to mammogram-specific letters (birthday letters with 1-2 recommendations: OR=0.73; 95% CI:0.68-0.79; 3 recommendations: OR=0.74; 95% CI:0.69-0.78; 4-8 recommendations: OR=0.62 95% CI:0.55-0.68) after. Among overdue women, birthday letters with 4-8 recommendations were negatively associated with mammography receipt. CONCLUSIONS: Transitioning from mammogram-specific reminder letters to multiple preventive service birthday letters was associated with decreased mammography receipt.

Authors: Smaldone MC, Kutikov A, Egleston B, Simhan J, Canter DJ, Teper E, Viterbo R, Chen DY, Greenberg RE, Uzzo RG

Title: Assessing performance trends in laparoscopic nephrectomy and nephron-sparing surgery for localized renal tumors.

Journal: Urology 80(2):286-91

Date: 2012 Aug

Abstract: OBJECTIVE: To assess the impact of laparoscopy on usage of partial nephrectomy (PN) by comparing national usage trends in patients undergoing surgery for localized renal tumors. METHODS: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we retrospectively examined trends in procedure usage from 1995 to 2007 for patients undergoing surgery for localized (stage I/II) renal masses. Procedures were classified as open radical nephrectomy (ORN), laparoscopic radical nephrectomy (LRN), open partial nephrectomy (OPN), and laparoscopic partial nephrectomy (LPN). Patients were further stratified by tumor size (≤4 cm, >4- ≤7 cm, >7 cm). Data were primarily analyzed using logistic regressions. RESULTS: Patients (n = 11,689, mean age 74.4 ± 5.7 years, 56% male) with a mean tumor size of 4.7 ± 3.3 cm met the inclusion criteria. From 1995 to 2007, ORN rates decreased and for each year successive year patients were more likely to be treated with OPN (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.14-1.19), LRN (OR 1.44, CI 1.41-1.47), and LPN (OR 1.75, CI 1.68-1.83). Although the increased usage of OPN (7.5% vs 13.6%, P < .001) and LPN (0% vs 14.2%, P < .001) reached statistical significance, this was offset by a marked increase in LRN over the same time period (3.0% vs 43.0%, P < .001). CONCLUSION: Despite increasing emphasis on nephron preservation, PN usage rates remain low. Compared with a 40% increase in LRN, use of PN increased by only 20% from 1995 to 2007. As a result, 72% of identified Medicare beneficiaries with localized tumors were managed with radical nephrectomy (RN) in 2007. The trade-off of minimally invasive surgery for nephron preservation may have adverse long-term consequences.

Authors: Soulakova JN, Hartman AM, Liu B, Willis GB, Augustine S

Title: Reliability of adult self-reported smoking history: data from the tobacco use supplement to the current population survey 2002-2003 cohort.

Journal: Nicotine Tob Res 14(8):952-60

Date: 2012 Aug

Abstract: INTRODUCTION: This study examined the reliability of self-reported smoking history measures. The key measures of interest were time since completely quitting smoking among former smokers; age at which fairly regular smoking was initiated among former and current smokers; the number of cigarettes smoked per day and the number of years of daily smoking among former smokers; and never smoking. Another goal was to examine sociodemographic factors and interview method as potential predictors of the odds of strict agreement in responses. METHODS: Data from the 2002-2003 Tobacco Use Supplement to the Current Population Survey were examined. Descriptive analysis was performed to detect discrepant data patterns, and intraclass and Pearson correlations and kappa coefficients were used to assess reporting consistency over the 12-month interval. Multiple logistic regression models with replicate weights were built and fitted to identify factors influencing the logit of agreement for each measure of interest. RESULTS: All measures revealed at least moderate levels of overall agreement. However, upon closer examination, a few measures also showed some considerable differences in absolute value. The highest percentage of these differences was observed for former smokers' reports of the number of years smoking every day. Conclusions: Overall, the data suggest that self-reported smoking history characteristics are reliable. The logit of agreement over a 12-month period is shown to depend on a few sociodemographic characteristics as well as their interactions with each other and with interview method.

Authors: Subar AF, Kirkpatrick SI, Mittl B, Zimmerman TP, Thompson FE, Bingley C, Willis G, Islam NG, Baranowski T, McNutt S, Potischman N

Title: The Automated Self-Administered 24-hour dietary recall (ASA24): a resource for researchers, clinicians, and educators from the National Cancer Institute.

Journal: J Acad Nutr Diet 112(8):1134-7

Date: 2012 Aug

Abstract:

Authors: Baxter NN, Warren JL, Barrett MJ, Stukel TA, Doria-Rose VP

Title: Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty.

Journal: J Clin Oncol 30(21):2664-9

Date: 2012 Jul 20

Abstract: PURPOSE: We designed this study to evaluate the association of colonoscopy with colorectal cancer (CRC) death in the United States by site of CRC and endoscopist specialty. METHODS: We designed a case-control study using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. We identified patients (cases) diagnosed with CRC age 70 to 89 years from January 1998 through December 2002 who died as a result of CRC by 2007. We selected three matched controls without cancer for each case. Controls were assigned a referent date (date of diagnosis of the case). Colonoscopy performed from January 1991 through 6 months before the diagnosis/referent date was our primary exposure. We compared exposure to colonoscopy in cases and controls by using conditional logistic regression controlling for covariates, stratified by site of CRC. We determined endoscopist specialty by linkage to the American Medical Association (AMA) Masterfile. We assessed whether the association between colonoscopy and CRC death varied with endoscopist specialty. RESULTS: We identified 9,458 cases (3,963 proximal [41.9%], 4,685 distal [49.5%], and 810 unknown site [8.6%]) and 27,641 controls. In all, 11.3% of cases and 23.7% of controls underwent colonoscopy more than 6 months before diagnosis. Compared with controls, cases were less likely to have undergone colonoscopy (odds ratio [OR], 0.40; 95% CI, 0.37 to 0.43); the association was stronger for distal (OR, 0.24; 95% CI, 0.21 to 0.27) than proximal (OR, 0.58; 95% CI, 0.53 to 0.64) CRC. The strength of the association varied with endoscopist specialty. CONCLUSION: Colonoscopy is associated with a reduced risk of death from CRC, with the association considerably and consistently stronger for distal versus proximal CRC. The overall association was strongest if colonoscopy was performed by a gastroenterologist.

Authors: Sanoff HK, Carpenter WR, Stürmer T, Goldberg RM, Martin CF, Fine JP, McCleary NJ, Meyerhardt JA, Niland J, Kahn KL, Schymura MJ, Schrag D

Title: Effect of adjuvant chemotherapy on survival of patients with stage III colon cancer diagnosed after age 75 years.

Journal: J Clin Oncol 30(21):2624-34

Date: 2012 Jul 20

Abstract: PURPOSE: Few patients 75 years of age and older participate in clinical trials, thus whether adjuvant chemotherapy for stage III colon cancer (CC) benefits this group is unknown. METHODS: A total of 5,489 patients ≥ 75 years of age with resected stage III CC, diagnosed between 2004 and 2007, were selected from four data sets containing demographic, stage, treatment, and survival information. These data sets included SEER-Medicare, a linkage between the New York State Cancer Registry (NYSCR) and its Medicare programs, and prospective cohort studies Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) and the National Comprehensive Cancer Network. Data sets were analyzed in parallel using covariate adjusted and propensity score (PS) matched proportional hazards models to evaluate the effect of treatment on survival. PS trimming was used to mitigate the effects of selection bias. RESULTS: Use of adjuvant therapy declined with age and comorbidity. Chemotherapy receipt was associated with a survival benefit of comparable magnitude to clinical trials results (SEER-Medicare PS-matched mortality, hazard ratio [HR], 0.60; 95% CI, 0.53 to 0.68). The incremental benefit of oxaliplatin over non-oxaliplatin-containing regimens was also of similar magnitude to clinical trial results (SEER-Medicare, HR, 0.84; 95% CI, 0.69 to 1.04; NYSCR-Medicare, HR, 0.82, 95% CI, 0.51 to 1.33) in two of three examined data sources. However, statistical significance was inconsistent. The beneficial effect of chemotherapy and oxaliplatin did not seem solely attributable to confounding. CONCLUSION: The noninvestigational experience suggests patients with stage III CC ≥ 75 years of age may anticipate a survival benefit from adjuvant chemotherapy. Oxaliplatin offers no more than a small incremental benefit. Use of adjuvant chemotherapy after the age of 75 years merits consideration in discussions that weigh individual risks and preferences.

Authors: Aiello Bowles EJ, Boudreau DM, Chubak J, Yu O, Fujii M, Chestnut J, Buist DSM

Title: Patient-reported discontinuation of endocrine therapy and related adverse effects among women with early-stage breast cancer

Journal: J Oncol Pract :-

Date: 2012 Jul 17

Abstract: Background: Approximately 20% to 50% of women diagnosed with hormone receptor-positive breast cancer discontinue endocrine therapy early; most reports come from automated pharmacy data or small self-report evaluations. We conducted a larger self-report evaluation of endocrine therapy discontinuation associated with patient characteristics and therapy-related adverse effects.Methods: We surveyed 538 women from a single health plan who were diagnosed with early-stage breast cancer from 2002 to 2008 and received endocrine therapy. Women reported adverse effects and reasons for discontinuation via mailed survey; tumor characteristics were obtained via registry linkage. We classified women as discontinuers if they self-reported stopping therapy and their self-reported duration of tamoxifen plus aromatase inhibitor (AI) use was < 5 years, and nondiscontinuers if they self-reported ≥ 5 years use or current use. We estimated odds ratios (ORs) with 95% CIs for discontinuation versus continuation by using logistic regression adjusted for age and year of diagnosis.Results: Among 538 women, 98 (18.2%) discontinued endocrine therapy early. Women with positive lymph nodes (v negative) were significantly less likely to discontinue therapy (odds ratio [OR] = 0.54; 95% CI, 0.31 to 0.93). Almost all women (94%) experienced adverse effects. Experiencing headaches was associated with discontinuation of AIs (OR = 4.16; 95% CI, 2.16 to 8.01) and tamoxifen (OR = 2.34; 95% CI, 1.24 to 4.41); few other individual adverse effects were related to discontinuation despite most discontinuers reporting they "did not like adverse effects" (AIs: 66.7%, tamoxifen: 59.1%).Conclusion: Few individual adverse effects or patient characteristics were significantly associated with endocrine therapy discontinuation, yet adverse effects were prevalent and were the most common reason women reported for discontinuing therapy.

Authors: Doubeni CA, Laiyemo AO, Major JM, Schootman M, Lian M, Park Y, Graubard BI, Hollenbeck AR, Sinha R

Title: Socioeconomic status and the risk of colorectal cancer: an analysis of more than a half million adults in the National Institutes of Health-AARP Diet and Health Study.

Journal: Cancer 118(14):3636-44

Date: 2012 Jul 15

Abstract: BACKGROUND: No previous prospective US study has examined whether the incidence of colorectal cancer (CRC) is disproportionately high in low socioeconomic status (SES) populations of both men and women. This study examined the relationship between both individual and area-level SES and CRC incidence, overall and by tumor location. METHODS: Data were obtained from the ongoing prospective National Institutes of Health-AARP Diet and Health Study of persons (50-71 years old) who resided in 6 US states and 2 metropolitan areas at baseline in 1995-1996. Incident CRCs were ascertained from tumor registries through December 2006. SES was measured by self-reported education and census-tract socioeconomic deprivation. Baseline and follow-up questionnaires collected detailed information on individual-level CRC risk factors including family history and health behaviors. RESULTS: Among 506,488 participants analyzed, 7676 were diagnosed with primary invasive colorectal adenocarcinomas: 44.6% [corrected] in the right colon, 26.7% in the left colon, and 25.9% in the rectum. The overall incidence of CRC was significantly higher among people who had low educational level or lived in low-SES neighborhoods, relative to respective highest-SES groups, even after accounting for other risk factors. These associations were stronger in the rectum than in left or right colon. In the right colon, there were no significant SES differences by either SES measure after accounting for covariates. CONCLUSIONS: SES, assessed by either individual-level education or neighborhood measures, was associated with risk of CRC even after accounting for other risk factors. The relationship between SES and CRC was strongest in the rectum and weakest in the right colon.

Authors: Ehdaie B, Atoria CL, Gupta A, Feifer A, Lowrance WT, Morris MJ, Scardino PT, Eastham JA, Elkin EB

Title: Androgen deprivation and thromboembolic events in men with prostate cancer.

Journal: Cancer 118(13):3397-406

Date: 2012 Jul 01

Abstract: BACKGROUND: Androgen deprivation therapy (ADT) improves prostate cancer outcomes in specific clinical settings, but is associated with adverse effects, including cardiac complications and possibly thromboembolic complications. The objective of this study was to estimate the impact of ADT on thromboembolic events (TEs) in a population-based cohort. METHODS: In the linked Surveillance, Epidemiology and End Results-Medicare database, we identified men older than 65 who were diagnosed with nonmetastatic prostate cancer between 1999 and 2005. Medical or surgical ADT was identified by Medicare claims for gonadotropin-releasing hormone agonists or bilateral orchiectomy at any time following diagnosis. TEs included deep venous thrombosis, pulmonary embolism, and arterial embolism. The impact of ADT on the risk of any TE and on total number of events was estimated, controlling for patient and tumor characteristics. RESULTS: Of 154,611 patients with prostate cancer, 58,466 (38%) received ADT. During a median follow-up of 52 months, 15,950 men had at least 1 TE, including 8829 (55%) who had ADT and 7121 (45%) with no ADT. ADT was associated with increased risk of a TE (adjusted hazard ratio = 1.56; 95% confidence interval, 1.50-1.61; P < .0001), and duration of ADT was associated with the total number of events (P < .0001). CONCLUSIONS: In this population-based cohort, ADT was associated with increased risk of a TE, and longer durations of ADT were associated with more TEs. Men with intermediate- and low-risk prostate cancer should be assessed for TE risk factors before starting ADT and counseled regarding the risks and benefits of this therapy.

Authors: Parsons HM, Harlan LC, Lynch CF, Hamilton AS, Wu XC, Kato I, Schwartz SM, Smith AW, Keel G, Keegan TH

Title: Impact of cancer on work and education among adolescent and young adult cancer survivors.

Journal: J Clin Oncol 30(19):2393-400

Date: 2012 Jul 01

Abstract: PURPOSE: To examine the impact of cancer on work and education in a sample of adolescent and young adult (AYA) patients with cancer. PATIENTS AND METHODS: By using the Adolescent and Young Adult Health Outcomes and Patient Experience Study (AYA HOPE)-a cohort of 463 recently diagnosed patients age 15 to 39 years with germ cell cancer, Hodgkin's lymphoma, non-Hodgkin's lymphoma, sarcoma, and acute lymphocytic leukemia from participating Surveillance, Epidemiology, and End Results (SEER) cancer registries-we evaluated factors associated with return to work/school after cancer diagnosis, a belief that cancer had a negative impact on plans for work/school, and reported problems with work/school after diagnosis by using descriptive statistics, χ(2) tests, and multivariate logistic regression. RESULTS: More than 72% (282 of 388) of patients working or in school full-time before diagnosis had returned to full-time work or school 15 to 35 months postdiagnosis compared with 34% (14 of 41) of previously part-time workers/students, 7% (one of 14) of homemakers, and 25% (five of 20) of unemployed/disabled patients (P < .001). Among full-time workers/students before diagnosis, patients who were uninsured (odds ratio [OR], 0.21; 95% CI, 0.07 to 0.67; no insurance v employer-/school-sponsored insurance) or quit working directly after diagnosis (OR, 0.15; 95% CI, 0.06 to 0.37; quit v no change) were least likely to return. Very intensive cancer treatment and quitting work/school were associated with a belief that cancer negatively influenced plans for work/school. Finally, more than 50% of full-time workers/students reported problems with work/studies after diagnosis. CONCLUSION: Although most AYA patients with cancer return to work after cancer, treatment intensity, not having insurance, and quitting work/school directly after diagnosis can influence work/educational outcomes. Future research should investigate underlying causes for these differences and best practices for effective transition of these cancer survivors to the workplace/school after treatment.

Authors: Abdollah F, Sun M, Schmitges J, Thuret R, Bianchi M, Shariat SF, Briganti A, Jeldres C, Perrotte P, Montorsi F, Karakiewicz PI

Title: Survival benefit of radical prostatectomy in patients with localized prostate cancer: estimations of the number needed to treat according to tumor and patient characteristics.

Journal: J Urol 188(1):73-83

Date: 2012 Jul

Abstract: PURPOSE: The benefit of active treatment for prostate cancer is a subject of continuous debate. We assessed the relationship between treatment type (radical prostatectomy vs observation) and cancer specific mortality in a large, population based cohort. MATERIALS AND METHODS: We examined the records of 44,694 patients treated with radical prostatectomy or observation between 1992 and 2005 in the SEER (Surveillance, Epidemiology and End Results)-Medicare linked database. Patients were matched by propensity score. Competing risks analysis was done to test the effect of treatment type on cancer specific mortality after accounting for other cause mortality. The number needed to treat was calculated. All analysis was stratified by prostate cancer risk group, baseline Charlson comorbidity index and patient age. RESULTS: For patients treated with radical prostatectomy vs observation the 10-year cancer specific mortality rate was 5.2% vs 12.8% for high risk prostate cancer, 1.4% vs 3.8% for low-intermediate risk prostate cancer, 2.4% vs 5.8% for a Charlson comorbidity index of 0, 2.3% vs 6.4% for a comorbidity index of 1, 2.5% vs 5.4% for a comorbidity index of 2 or greater, 2.0% vs 4.6% at ages 65 to 69, 2.6% vs 5.6% at ages 70 to 74 and 2.7% vs 8.1% at ages 75 to 80 years (each p <0.001). The corresponding number need to treat was 13, 42, 29, 24, 34, 38, 33 and 19, respectively. On multivariable analysis radical prostatectomy was an independent predictor of more favorable cancer specific mortality in all categories (each p <0.001). CONCLUSIONS: Patients with high risk prostate cancer benefit the most from radical prostatectomy. The lowest benefit was observed in patients with low-intermediate risk prostate cancer. An intermediate benefit was observed when patients were classified by Charlson comorbidity index and age category.

Authors: Coups EJ, Stapleton JL, Hudson SV, Medina-Forrester A, Goydos JS, Natale-Pereira A

Title: Skin cancer screening among Hispanic adults in the United States: results from the 2010 National Health Interview Survey.

Journal: Arch Dermatol 148(7):861-3

Date: 2012 Jul

Abstract:

Authors: Doria-Rose VP, White MC, Klabunde CN, Nadel MR, Richards TB, McNeel TS, Rodriguez JL, Marcus PM

Title: Use of lung cancer screening tests in the United States: results from the 2010 National Health Interview Survey.

Journal: Cancer Epidemiol Biomarkers Prev 21(7):1049-59

Date: 2012 Jul

Abstract: BACKGROUND: Before evidence of efficacy, lung cancer screening was being ordered by many physicians. The National Lung Screening Trial (NLST), which showed a 20% reduction in lung cancer mortality among those randomized to receive low-dose computed tomography (LDCT), will likely lead to increased screening use. METHODS: We estimated the prevalence of chest X-ray and CT use in the United States using data from the 2010 National Health Interview Survey (NHIS). Subjects included 15,537 NHIS respondents aged ≥40 years without prior diagnosis of lung cancer. Estimates of the size of the U. S. population by age and smoking status were calculated. Multivariate logistic regression examined predictors of test use adjusting for potential confounders. RESULTS: Twenty-three percent of adults reported chest X-ray in the previous year and 2.5% reported chest X-ray specifically to check for lung cancer; corresponding numbers for chest CT were 7.5% and 1.3%. Older age, black race, male gender, smoking, respiratory disease, personal history of cancer, and having health insurance were associated with test use. Approximately, 8.7 million adults in the United States would be eligible for LDCT screening according to NLST eligibility criteria. CONCLUSIONS AND IMPACT: Monitoring of trends in the use of lung screening tests will be vital to assess the impact of NLST and possible changes in lung cancer screening recommendations and insurance coverage in the future. Education of patients by their physicians, and of the general public, may help ensure that screening is used appropriately, in those most likely to benefit.

Authors: Geller BM, Bogart A, Carney PA, Elmore JG, Monsees BS, Miglioretti DL

Title: Is confidence of mammographic assessment a good predictor of accuracy?

Journal: AJR Am J Roentgenol 199(1):W134-41

Date: 2012 Jul

Abstract: OBJECTIVE: Interpretive accuracy varies among radiologists, especially in mammography. This study examines the relationship between radiologists' confidence in their assessments and their accuracy in interpreting mammograms. MATERIALS AND METHODS: In this study, 119 community radiologists interpreted 109 expert-defined screening mammography examinations in test sets and rated their confidence in their assessment for each case. They also provided a global assessment of their ability to interpret mammograms. Positive predictive value (PPV) and negative predictive value (NPV) were modeled as functions of self-rated confidence on each examination using log-linear regression estimated with generalized estimating equations. Reference measures were cancer status and expert-defined need for recall. Effect modification by weekly mammography volume was examined. RESULTS: Radiologists who self-reported higher global interpretive ability tended to interpret more mammograms per week (p = 0.08), were more likely to specialize (p = 0.02) and to have completed a fellowship in breast or women's imaging (p = 0.05), and had a higher PPV for cancer detection (p = 0.01). Examinations for which low-volume radiologists were "very confident" had a PPV of 2.93 times (95% CI, 2.01-4.27) higher than examinations they rated with neutral confidence. Trends of increasing NPVs with increasing confidence were significant for low-volume radiologists relative to noncancers (p = 0.01) and expert nonrecalls (p < 0.001). A trend of significantly increasing NPVs existed for high-volume radiologists relative to expert nonrecall (p = 0.02) but not relative to noncancer status (p = 0.32). CONCLUSION: Confidence in mammography assessments was associated with better accuracy, especially for low-volume readers. Asking for a second opinion when confidence in an assessment is low may increase accuracy.

Authors: Goddard KA, Knaus WA, Whitlock E, Lyman GH, Feigelson HS, Schully SD, Ramsey S, Tunis S, Freedman AN, Khoury MJ, Veenstra DL

Title: Building the evidence base for decision making in cancer genomic medicine using comparative effectiveness research.

Journal: Genet Med 14(7):633-42

Date: 2012 Jul

Abstract: The clinical utility is uncertain for many cancer genomic applications. Comparative effectiveness research (CER) can provide evidence to clarify this uncertainty. The aim of this study was to identify approaches to help stakeholders make evidence-based decisions and to describe potential challenges and opportunities in using CER to produce evidence-based guidance. We identified general CER approaches for genomic applications through literature review, the authors' experiences, and lessons learned from a recent, seven-site CER initiative in cancer genomic medicine. Case studies illustrate the use of CER approaches. Evidence generation and synthesis approaches used in CER include comparative observational and randomized trials, patient-reported outcomes, decision modeling, and economic analysis. Significant challenges to conducting CER in cancer genomics include the rapid pace of innovation, lack of regulation, and variable definitions and evidence thresholds for clinical and personal utility. Opportunities to capitalize on CER methods in cancer genomics include improvements in the conduct of evidence synthesis, stakeholder engagement, increasing the number of comparative studies, and developing approaches to inform clinical guidelines and research prioritization. CER offers a variety of methodological approaches that can address stakeholders' needs and help ensure an effective translation of genomic discoveries.

Authors: Griffiths RI, Gleeson ML, Danese MD, O'Hagan A

Title: Inverse probability weighted least squares regression in the analysis of time-censored cost data: an evaluation of the approach using SEER-Medicare.

Journal: Value Health 15(5):656-63

Date: 2012 Jul-Aug

Abstract: OBJECTIVES: To assess the accuracy and precision of inverse probability weighted (IPW) least squares regression analysis for censored cost data. METHODS: By using Surveillance, Epidemiology, and End Results-Medicare, we identified 1500 breast cancer patients who died and had complete cost information within the database. Patients were followed for up to 48 months (partitions) after diagnosis, and their actual total cost was calculated in each partition. We then simulated patterns of administrative and dropout censoring and also added censoring to patients receiving chemotherapy to simulate comparing a newer to older intervention. For each censoring simulation, we performed 1000 IPW regression analyses (bootstrap, sampling with replacement), calculated the average value of each coefficient in each partition, and summed the coefficients for each regression parameter to obtain the cumulative values from 1 to 48 months. RESULTS: The cumulative, 48-month, average cost was $67,796 (95% confidence interval [CI] $58,454-$78,291) with no censoring, $66,313 (95% CI $54,975-$80,074) with administrative censoring, and $66,765 (95% CI $54,510-$81,843) with administrative plus dropout censoring. In multivariate analysis, chemotherapy was associated with increased cost of $25,325 (95% CI $17,549-$32,827) compared with $28,937 (95% CI $20,510-$37,088) with administrative censoring and $29,593 ($20,564-$39,399) with administrative plus dropout censoring. Adding censoring to the chemotherapy group resulted in less accurate IPW estimates. This was ameliorated, however, by applying IPW within treatment groups. CONCLUSION: IPW is a consistent estimator of population mean costs if the weight is correctly specified. If the censoring distribution depends on some covariates, a model that accommodates this dependency must be correctly specified in IPW to obtain accurate estimates.

Authors: Kaphingst KA, McBride CM, Wade C, Alford SH, Reid R, Larson E, Baxevanis AD, Brody LC

Title: Patients' understanding of and responses to multiplex genetic susceptibility test results.

Journal: Genet Med 14(7):681-7

Date: 2012 Jul

Abstract: PURPOSE: Examination of patients' responses to direct-to-consumer genetic susceptibility tests is needed to inform clinical practice. This study examined patients' recall and interpretation of, and responses to, genetic susceptibility test results provided directly by mail. METHODS: This observational study had three prospective assessments (before testing, 10 days after receiving results, and 3 months later). Participants were 199 patients aged 25-40 years who received free genetic susceptibility testing for eight common health conditions. RESULTS: More than 80% of the patients correctly recalled their results for the eight health conditions. Patients were unlikely to interpret genetic results as deterministic of health outcomes (mean = 6.0, s.d. = 0.8 on a scale of 1-7, 1 indicating strongly deterministic). In multivariate analysis, patients with the least deterministic interpretations were white (P = 0.0098), more educated (P = 0.0093), and least confused by results (P = 0.001). Only 1% talked about their results with a provider. CONCLUSION: Findings suggest that most patients will correctly recall their results and will not interpret genetics as the sole cause of diseases. The subset of those confused by results could benefit from consultation with a health-care provider, which could emphasize that health habits currently are the best predictors of risk. Providers could leverage patients' interest in genetic tests to encourage behavior changes to reduce disease risk.

Authors: Martin MY, Sanders S, Griffin JM, Oster RA, Ritchie C, Phelan SM, Atienza AA, Kahn K, van Ryn M

Title: Racial variation in the cancer caregiving experience: a multisite study of colorectal and lung cancer caregivers.

Journal: Cancer Nurs 35(4):249-56

Date: 2012 Jul-Aug

Abstract: BACKGROUND: As cancer care shifts from hospital to outpatient settings, the number of cancer caregivers continues to grow. However, little is known about the cancer caregiving experience. This gap in knowledge is especially evident for racially diverse caregivers. OBJECTIVE: This study, part of a multisite study of care recipients with either lung or colorectal cancer and their caregivers, examined the caregiving experiences of African American (AA) and white caregivers. METHODS: Caregivers were identified by cancer patients in the Cancer Care Outcomes Research and Surveillance consortium. Caregivers completed a self-administered, mailed questionnaire that assessed their characteristics and experiences. Analysis of covariance was used to compare racial groups by objective burden and caregiving resources while controlling for covariates. RESULTS: Despite greater preparedness for the caregiving role (P = .006), AA caregivers reported more weekly hours caregiving than whites did (26.5 ± 3.1 vs 18.0 ± 1.7; P = .01). In later phases of caregiving, AAs reported having more social support (P = .02), spending more hours caregiving (31.9 ± 3.5 vs 16.9 ± 1.9; P < .001), and performing more instrumental activities of daily living on behalf of their care recipient (P = .021). CONCLUSION: Racial differences in the caregiving experience exist. IMPLICATIONS FOR PRACTICE: Nurses play a key role in educating cancer patients and their caregivers on how to effectively cope with and manage cancer. Because AA caregivers seem to spend more time in the caregiving role and perform more caregiving tasks, AA caregivers may benefit from interventions tailored to their specific caregiving experience.

Authors: Mazor KM, Roblin DW, Williams AE, Greene SM, Gaglio B, Field TS, Costanza ME, Han PK, Saccoccio L, Calvi J, Cove E, Cowan R

Title: Health literacy and cancer prevention: two new instruments to assess comprehension.

Journal: Patient Educ Couns 88(1):54-60

Date: 2012 Jul

Abstract: OBJECTIVES: Ability to understand spoken health information is an important facet of health literacy, but to date, no instrument has been available to quantify patients' ability in this area. We sought to develop a test to assess comprehension of spoken health messages related to cancer prevention and screening to fill this gap, and a complementary test of comprehension of written health messages. METHODS: We used the Sentence Verification Technique to write items based on realistic health messages about cancer prevention and screening, including media messages, clinical encounters and clinical print materials. Items were reviewed, revised, and pre-tested. Adults aged 40-70 participated in a pilot administration in Georgia, Hawaii, and Massachusetts. RESULTS: The Cancer Message Literacy Test-Listening is self-administered via touchscreen laptop computer. No reading is required. It takes approximately 1 hour. The Cancer Message Literacy Test-Reading is self-administered on paper. It takes approximately 10min. CONCLUSIONS: These two new tests will allow researchers to assess comprehension of spoken health messages, to examine the relationship between listening and reading literacy, and to explore the impact of each form of literacy on health-related outcomes. PRACTICE IMPLICATIONS: Researchers and clinicians now have a means of measuring comprehension of spoken health information.

Authors: Pronk NP, Krebs-Smith SM, Galuska DA, Liu B, Kushner RF, Troiano RP, Clauser SB, Ballard-Barbash R, Smith AW

Title: Knowledge of energy balance guidelines and associated clinical care practices: the U.S. National Survey of Energy Balance Related Care among Primary Care Physicians.

Journal: Prev Med 55(1):28-33

Date: 2012 Jul

Abstract: OBJECTIVE: To assess primary care physicians' (PCPs) knowledge of energy balance related guidelines and the association with sociodemographic characteristics and clinical care practices. METHOD: As part of the 2008 U.S. nationally representative National Survey of Energy Balance Related Care among Primary Care Physicians (EB-PCP), 1776 PCPs from four specialties who treated adults (n=1060) or children and adolescents (n=716) completed surveys on sociodemographic information, knowledge of energy balance guidelines, and clinical care practices. RESULTS: EB-PCP response rate was 64.5%. For PCPs treating children, knowledge of guidelines for healthy BMI percentile, physical activity, and fruit and vegetables intake was 36.5%, 27.0%, and 62.9%, respectively. For PCPs treating adults, knowledge of guidelines for overweight, obesity, physical activity, and fruit and vegetables intake was 81.4%, 81.3%, 70.9%, and 63.5%, respectively. Generally, younger, female physicians were more likely to exhibit correct knowledge. Knowledge of weight-related guidelines was associated with assessment of body mass index (BMI) and use of BMI-for-age growth charts. CONCLUSION: Knowledge of energy balance guidelines among PCPs treating children is low, among PCPs treating adults it appeared high for overweight and obesity-related clinical guidelines and moderate for physical activity and diet, and was mostly unrelated to clinical practices among all PCPs.

Authors: Spayne MC, Gard CC, Skelly J, Miglioretti DL, Vacek PM, Geller BM

Title: Reproducibility of BI-RADS breast density measures among community radiologists: a prospective cohort study.

Journal: Breast J 18(4):326-33

Date: 2012 Jul-Aug

Abstract: Using data from the Vermont Breast Cancer Surveillance System (VBCSS), we studied the reproducibility of Breast Imaging Reporting and Data System (BI-RADS) breast density among community radiologists interpreting mammograms in a cohort of 11,755 postmenopausal women. Radiologists interpreting two or more film-screen screening or bilateral diagnostic mammograms for the same woman within a 3- to 24-month period during 1996-2006 were eligible. We observed moderate-to-substantial overall intra-rater agreement for use of BI-RADS breast density in clinical practice, with an overall intra-radiologist percent agreement of 77.2% (95% confidence interval (CI), 74.5-79.5%), an overall simple kappa of 0.58 (95% CI, 0.55-0.61), and an overall weighted kappa of 0.70 (95% CI, 0.68-0.73). Agreement exhibited by individual radiologists varied widely, with intra-radiologist percent agreement ranging from 62.1% to 87.4% and simple kappa ranging from 0.19 to 0.69 across individual radiologists. Our findings underscore the need for additional evaluation of the BI-RADS breast density categorization system in clinical practice.

Authors: Sun M, Abdollah F, Bianchi M, Trinh QD, Shariat SF, Jeldres C, Tian Z, Hansen J, Briganti A, Graefen M, Montorsi F, Perrotte P, Karakiewicz PI

Title: Conditional survival of patients with urothelial carcinoma of the urinary bladder treated with radical cystectomy.

Journal: Eur J Cancer 48(10):1503-11

Date: 2012 Jul

Abstract: AIM OF STUDY: To examine the impact of survival probability according to duration of survivorship following radical cystectomy (RC) in patients diagnosed with urothelial carcinoma of the urinary bladder (UCUB). METHODS: Overall, 4991 UCUB patients who underwent RC were abstracted. The cumulative survival estimates were used to generate conditional survival rates. Cox regression analyses were performed for prediction of cancer-specific mortality (CSM), according to duration of survivorship. RESULTS: The five-year CSM-free survival rate was 63.9% at RC, and increased to 71.0%, 77.5%, 81.7%, 85.9% and 86.3% in patients who survived ≥ 1, 2, 3, 4 and 5 years, respectively. Patients with pT2-4 disease benefitted from the highest increase in survivorship two years after RC. The same findings were recorded according to patients' nodal status. CONCLUSION: The survival of the first two years after RC markedly improves individual patient prognosis. The prognostic gains differ according to patient and tumour characteristics.

Authors: Waters EA, McNeel TS, Stevens WM, Freedman AN

Title: Use of tamoxifen and raloxifene for breast cancer chemoprevention in 2010.

Journal: Breast Cancer Res Treat 134(2):875-80

Date: 2012 Jul

Abstract: Two selective estrogen receptor modulators, tamoxifen and raloxifene, have been shown in randomized clinical trials to reduce the risk of developing primary invasive breast cancer in high-risk women. In 1998, the U.S. Food and Drug Administration (FDA) used these studies as a basis for approving tamoxifen for primary breast chemoprevention in both premenopausal and postmenopausal women at high risk. In 2007, the FDA approved raloxifene for primary breast cancer chemoprevention for postmenopausal women. Data from the year 2010 National Health Interview Survey were analyzed to estimate the prevalence of tamoxifen and raloxifene use for chemoprevention of primary breast cancers among U.S. women. Prevalence of use of chemopreventive agents for primary tumors was 20,598 (95 % CI, 518-114,864) for U.S. women aged 35-79 for tamoxifen. Prevalence was 96,890 (95 % CI, 41,277-192,391) for U.S. women aged 50-79 for raloxifene. Use of tamoxifen and raloxifene for prevention of primary breast cancers continues to be low. In 2010, women reporting medication use for breast cancer chemoprevention were primarily using the more recently FDA approved drug raloxifene. Multiple possible explanations for the low use exist, including lack of awareness and/or concern about side effects among primary care physicians and patients.

Authors: Williams SB, Lei Y, Nguyen PL, Gu X, Lipsitz SR, Yu HY, Kowalczyk KJ, Hu JC

Title: Comparative effectiveness of cryotherapy vs brachytherapy for localised prostate cancer.

Journal: BJU Int 110(2 Pt 2):E92-8

Date: 2012