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Kapoor A, Labonte AJ, Winter MR, Segal JB, Silliman RA, Katz JN, Losina E, Berlowitz D. Risk of venous thromboembolism after total hip and knee replacement in older adults with comorbidity and co-occurring comorbidities in the Nationwide Inpatient Sample (2003-2006). BMC Geriatr 2010; 10:63. [PMID: 20846450 PMCID: PMC2949673 DOI: 10.1186/1471-2318-10-63] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Accepted: 09/17/2010] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Venous thromboembolism is a common, fatal, and costly injury which complicates major surgery in older adults. The American College of Chest Physicians recommends high potency prophylaxis regimens for individuals undergoing total hip or knee replacement (THR or TKR), but surgeons are reluctant to prescribe them due to fear of excess bleeding. Identifying a high risk cohort such as older adults with comorbidities and co-occurring comorbidities who might benefit most from high potency prophylaxis would improve how we currently perform preoperative assessment. METHODS Using the Nationwide Inpatient Sample, we identified older adults who underwent THR or TKR in the U.S. between 2003 and 2006. Our outcome was VTE, including any pulmonary embolus or deep venous thrombosis. We performed multivariate logistic regression analyses to assess the effects of comorbidities on VTE occurrence. Comorbidities under consideration included coronary artery disease, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and cerebrovascular disease. We also examined the impact of co-occurring comorbidities on VTE rates. RESULTS CHF increased odds of VTE in both the THR cohort (OR = 3.08 95% CI 2.05-4.65) and TKR cohort (OR = 2.47 95% CI 1.95-3.14). COPD led to a 50% increase in odds in the TKR cohort (OR = 1.49 95% CI 1.31-1.70). The data did not support synergistic effect of co-occurring comorbidities with respect to VTE occurrence. CONCLUSIONS Older adults with CHF undergoing THR or TKR and with COPD undergoing TKR are at increased risk of VTE. If confirmed in other datasets, these older adults may benefit from higher potency prophylaxis.
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Schonberg MA, Marcantonio ER, Li D, Silliman RA, Ngo L, McCarthy EP. Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival. J Clin Oncol 2010; 28:2038-45. [PMID: 20308658 PMCID: PMC2860406 DOI: 10.1200/jco.2009.25.9796] [Citation(s) in RCA: 302] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Few data are available on breast cancer characteristics, treatment, and survival for women age 80 years or older. PATIENTS AND METHODS We used the linked Surveillance, Epidemiology and End Results-Medicare data set from 1992 to 2003 to examine tumor characteristics, treatments (mastectomy, breast-conserving surgery [BCS] with radiation therapy or alone, or no surgery), and outcomes of women age 80 years or older (80 to 84, 85 to 89, > or = 90 years) with stage I/II breast cancer compared with younger women (age 67 to 79 years). We used Cox proportional hazard models to examine the impact of age on breast cancer-related and other causes of death. Analyses were performed within stage, adjusted for tumor and sociodemographic characteristics, treatments received, and comorbidities. Results In total, 49,616 women age 67 years or older with stage I/II disease were included. Tumor characteristics (grade, hormone receptivity) were similar across age groups. Treatment with BCS alone increased with age, especially after age 80. The risk of dying from breast cancer increased with age, significantly after age 80. For stage I disease, the adjusted hazard ratio of dying from breast cancer for women age > or = 90 years compared with women age 67 to 69 years was 2.6 (range, 2.0 to 3.4). Types of treatments received were significantly associated with age and comorbidity, with age as the stronger predictor (26% of women age > or = 80 years without comorbidity received BCS alone or no surgery compared with 6% of women age 67 to 79 years). CONCLUSION Women age > or = 80 years have breast cancer characteristics similar to those of younger women yet receive less aggressive treatment and experience higher mortality from early-stage breast cancer. Future studies should focus on identifying tumor and patient characteristics to help target treatments to the oldest women most likely to benefit.
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Lash TL, Cronin-Fenton D, Ahern TP, Rosenberg CL, Lunetta KL, Silliman RA, Hamilton-Dutoit S, Garne JP, Ewertz M, Sørensen HT, Pedersen L. Breast cancer recurrence risk related to concurrent use of SSRI antidepressants and tamoxifen. Acta Oncol 2010; 49:305-12. [PMID: 20156115 DOI: 10.3109/02841860903575273] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Up to one-quarter of breast cancer patients suffer clinically significant depression in the year after diagnosis, which may respond to intervention. About half may be prescribed a psychotropic medication, such as a selective serotonin reuptake inhibitor (SSRI), while completing breast cancer therapy. Cytochrome P-450 2D6 (CYP2D6) metabolizes SSRIs and also metabolizes tamoxifen to more active forms. Therefore, concurrent use of SSRIs may reduce tamoxifen's effectiveness at preventing breast cancer recurrence. The SSRI citalopram has limited potency to inhibit CYP2D6 activity, so has been recommended for breast cancer patients taking tamoxifen. This study provides epidemiologic evidence to support this recommendation. MATERIAL AND METHODS We conducted a case-control study of breast cancer recurrence nested in the population of female residents of Denmark who were diagnosed with non-metastatic estrogen-receptor positive breast cancers between 1994 and 2001 and who took tamoxifen for at least one year. We ascertained complete prescription histories by linking cases' and controls' civil registration numbers to the Danish national prescription registry. We estimated the association between SSRI use while taking tamoxifen and risk of recurrent breast cancer. RESULTS About the same proportion of recurrent cases (37 of 366) and matched controls (35 of 366) received at least one prescription for citalopram or its s-stereoisomer while taking tamoxifen (adjusted odds ratio = 1.1, 95% confidence interval = 0.7, 1.7). Breast cancer patients taking other SSRIs were also at no increased risk of recurrence (adjusted odds ratio = 0.9, 95% confidence interval = 0.5, 1.8). DISCUSSION Breast cancer patients with indications for an SSRI may be prescribed citalopram - and possibly other SSRI - without adversely affecting the outcome of adjuvant therapy with tamoxifen.
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Silliman RA. When cancer in older adults is undermanaged: the breast cancer story. J Am Geriatr Soc 2010; 57 Suppl 2:S259-61. [PMID: 20122024 DOI: 10.1111/j.1532-5415.2009.02506.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Age is the most important risk factor for breast cancer; age is also a risk factor for undermanagement of breast cancer. One thousand eight hundred fifty-nine women aged 65 and older with early-stage breast cancer were studied, and it was found that undermanagement is a risk factor for recurrence and for dying of breast cancer. Although conservative treatment is probably warranted in patients with tumors having excellent prognostic characteristics and in women with limited life expectancies, standard treatment is needed for the majority of older women if the disproportionate burden of breast cancer in this age group is to be reduced. Better strategies are needed for identifying those most likely to benefit from standard treatment and from systematic surveillance for recurrence. In this regard, collaboration between oncologists and primary care physicians is essential for achieving high-quality care and outcomes in this vulnerable group of patients.
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Bosco JL, Silliman RA. Abstract PR-08: Body mass index and breast cancer outcomes in older breast cancer survivors. Cancer Prev Res (Phila) 2010. [DOI: 10.1158/1940-6207.prev-09-pr-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Obesity may increase the risk of breast cancer and decrease survival in postmenopausal women through higher levels of circulating estrogen. The mortality risk is greater in younger women, but studies of women ≥ 65 years are limited. Consenting women ≥ 65 years at incident diagnosis of stage I (tumor ≥ 1 cm), stage II, or stage IIIA primary breast cancer from Los Angeles, Minnesota, North Carolina, or Rhode Island were interviewed by telephone 3 months (baseline) after their definitive surgery (N=658) and were followed annually for 9 years unless death, loss to follow-up, or refusal to continue participation occurred. BMI was calculated using weight (kilograms [kg]) and height (meters [m]) reported at baseline (BMI 25–29 kg/m2 = overweight; BMI ≥ 30 kg/m2 = obese). Women with a healthy BMI (< 25 kg/m2) comprised the reference group. Recurrence was collected during follow-up interviews. Death was confirmed by a Social Security Death Index search through March 2009 and date and cause of death were collected from the National Death Index through 2004. Demographic characteristics (age, race, marital status, education, geographic location, and Charlson Comorbidity Index [CCI]) were collected at baseline. Breast cancer tumor (stage, histologic grade, estrogen receptor expression) and treatment (primary therapy, adjuvant chemotherapy receipt, adjuvant tamoxifen receipt) characteristics were collected from medical records. Of our cohort, 34% were overweight and 21% were obese (mean BMI, 25.7 kg/m2). The majority of overweight women were 70–74 years old (29%), had a CCI of 0 (62%), and completed college or higher (53%); obese women were mostly 65–69 years (34%), had a CCI of 2 (13%) and only completed up to high school (40%). Women who were overweight (Odds Ratio [OR]=1.5; 95% Confidence Interval [CI]=0.8, 2.7) or obese (OR=1.6; 95% CI=0.8, 3.1) had an increased the risk of recurrence compared with women with a healthy BMI. Being overweight was not associated with breast cancer-specific mortality or allcause mortality. Obese women had nearly a twofold increased risk of dying from breast cancer (OR=1.9; 95%CI=0.7, 5.0); obesity was weakly associated with the risk of dying from any cause (OR=1.2; 95%CI=0.7, 1.8). Weight at baseline and 6 years later were consistently reported by the women in our study. Since women do not tend to overestimate their weight, our results conservatively estimate the effect of obesity on breast cancer outcomes. Unlike many previous studies, we had detailed information regarding primary and adjuvant treatment, which are important in estimating the risk of breast cancer recurrence and mortality. Although our data are compatible with a 20–30% decreased risk of breast cancer outcomes, our findings suggest higher body mass after breast cancer diagnosis is associated with negative outcomes in older women. Achieving or maintaining a healthy BMI after definitive surgery may improve breast cancer prognosis.
Citation Information: Cancer Prev Res 2010;3(1 Suppl):PR-08.
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Clough-Gorr KM, Rakowski W, Clark M, Silliman RA. The Getting-Out-of-Bed (GoB) scale: a measure of motivation and life outlook in older adults with cancer. J Psychosoc Oncol 2010; 27:454-68. [PMID: 19813135 DOI: 10.1080/07347330903182911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To develop and evaluate the psychometric properties of a measure of motivation and life outlook (Getting-Out-of-Bed [GoB]). DESIGN Secondary analysis of baseline and 6-month data from a longitudinal follow-up study of older breast cancer survivors. PARTICIPANTS Women (N = 660) diagnosed with primary breast cancer stage I-IIIA disease, age >or=65 years, and permission to contact from an attending physician in four geographic regions in the United States (city-based Los Angeles, California; statewide in Minnesota, North Carolina, and Rhode Island). MEASUREMENT Data were collected over 6-months of follow-up from consenting patients' medical records and telephone interviews with patients. Data collected included the 4-item GoB, health-related quality of life (HRQoL), breast cancer, sociodemographic, and health-related characteristics. RESULTS Factor analysis produced, as hypothesized, one principal component with eigen values of 2.74(baseline) and 2.91(6-months) which explained 68.6%(baseline) and 72.7%(6-months) of total variance. In further psychometric analyses, GoB exhibited good construct validity (divergent: low nonstatistically significant correlations with unrelated constructs; convergent: moderate statistically significant correlations with related constructs; discriminant: distinguished high HRQoL groups with a high level of significance), excellent internal reliability (Cronbach's alpha 0.84(baseline), 0.87(6-months)), and produced stable measurements over 6-months. Women with GoB scores >or=50 at baseline were more likely at 6-months to have good HRQoL, good self-perceived health, and report regular exercise, indicating good predictive ability. CONCLUSION GoB demonstrated overall good psychometric properties in this sample of older breast cancer survivors, suggestive of a promising tool for assessing motivation and life outlook in older adults. Nevertheless, because it was developed and initially evaluated in a select sample, using measures with similar but not exact content overlap further evaluation is needed before it can be recommended for widespread use.
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Clough-Gorr KM, Stuck AE, Thwin SS, Silliman RA. Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up. J Clin Oncol 2009; 28:380-6. [PMID: 20008637 DOI: 10.1200/jco.2009.23.5440] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To evaluate geriatric assessment (GA) domains in relation to clinically important outcomes in older breast cancer survivors. METHODS Six hundred sixty women diagnosed with primary breast cancer in four US geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island) were selected with disease stage I to IIIA, age >or= 65 years at date of diagnosis, and permission from attending physician to contact. Data were collected over 7 years of follow-up from consenting patients' medical records, telephone interviews, physician questionnaires, and the National Death Index. Outcomes included self-reported treatment tolerance and all-cause mortality. Four GA domains were described by six individual measures, as follows: sociodemographic by adequate finances; clinical by Charlson comorbidity index (CCI) and body mass index; function by number of physical function limitations; and psychosocial by the five-item Mental Health Index (MHI5) and Medical Outcomes Study Social Support Survey (MOS-SSS). Associations were evaluated using t tests, chi(2) tests, and regression analyses. RESULTS In multivariable regression including age and stage, three measures from two domains (clinical and psychosocial) were associated with poor treatment tolerance; these were CCI >or= 1 (odds ratio [OR] = 2.49; 95% CI, 1.18 to 5.25), MHI5 score less than 80 (OR = 2.36; 95% CI, 1.15 to 4.86), and MOS-SSS score less than 80 (OR = 3.32; 95% CI, 1.44 to 7.66). Four measures representing all four GA domains predicted mortality; these were inadequate finances (hazard ratio [HR] = 1.89; 95% CI, 1.24 to 2.88; CCI >or= 1 (HR = 1.38; 95% CI, 1.01 to 1.88), functional limitation (HR = 1.40; 95% CI, 1.01 to 1.93), and MHI5 score less than 80 (HR = 1.34; 95% CI, 1.01 to 1.85). In addition, the proportion of women with these outcomes incrementally increased as the number of GA deficits increased. CONCLUSION This study provides longitudinal evidence that GA domains are associated with poor treatment tolerance and predict mortality at 7 years of follow-up, independent of age and stage of disease.
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Clough-Gorr KM, Ganz PA, Silliman RA. Older breast cancer survivors: factors associated with self-reported symptoms of persistent lymphedema over 7 years of follow-up. Breast J 2009; 16:147-55. [PMID: 19968661 DOI: 10.1111/j.1524-4741.2009.00878.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Lymphedema of the arm is a common complication of breast cancer with symptoms that can persist over long periods of time. For older women (over 50% of breast cancer cases) it means living with the potential for long-term complications of persistent lymphedema in conjunction with the common diseases and disabilities of aging over survivorship. We identified women > or =65 years diagnosed with primary stage I-IIIA breast cancer. Data were collected over 7 years of follow-up from consenting patients' medical records and telephone interviews. Data collected included self-reported symptoms of persistent lymphedema, breast cancer characteristics, and selected sociodemographic and health-related characteristics. The overall prevalence of symptoms of persistent lymphedema was 36% over 7 years of follow-up. Having stage II or III (OR = 1.77, 95% CI: 1.07-2.93) breast cancer and having a BMI >30 (OR = 3.04, 95% CI: 1.69-5.45) were statistically significantly predictive of symptoms of persistent lymphedema. Women > or =80 years were less likely to report symptoms of persistent lymphedema when compared to younger women (OR = 0.44, 95% CI: 0.18-0.95). Women with symptoms of persistent lymphedema consistently reported worse general mental health and physical function. Symptoms of persistent lymphedema were common in this population of older breast cancer survivors and had a noticeable effect on both physical function and general mental health. Our findings provide evidence of the impact of symptoms of persistent lymphedema on the quality of survivorship of older women. Clinical and research efforts focused on risk factors for symptoms of persistent lymphedema in older breast cancer survivors may lead to preventative and therapeutic measures that help maintain their health and well-being over increasing periods of survivorship.
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Gold HT, Thwin SS, Buist DSM, Field TS, Wei F, Yood MU, Lash TL, Quinn VP, Geiger AM, Silliman RA. Delayed radiotherapy for breast cancer patients in integrated delivery systems. THE AMERICAN JOURNAL OF MANAGED CARE 2009; 15:785-789. [PMID: 19895182 PMCID: PMC2916649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To identify factors associated with delayed radiotherapy (RT) in older women with early-stage breast cancer. METHODS We studied 541 women age >or=65 years diagnosed with early-stage breast cancer in 1990-1994 at 5 integrated healthcare delivery systems and treated with breast-conserving surgery and RT, but not chemotherapy. We examined whether demographic, tumor, or treatment characteristics were associated with RT delays of >8 weeks postsurgery using chi(2) tests and multivariable logistic regression. RESULTS Seventy-six women (14%) had delayed RT, with a median delay of 14 weeks. Even though they had insurance and access to care, nonwhite and Hispanic women were much more likely than white women to have delayed RT (odds ratio = 3.3; 95% confidence interval = 1.7, 10) in multivariable analyses that controlled for demographic and clinical variables. CONCLUSIONS Timely RT should be facilitated through physician and patient education, navigation, and notification programs to improve quality of care. Queues for RT appointments should be evaluated on an ongoing basis to ensure adequate access. Future research should examine modifiable barriers to RT timeliness and whether delays impact long-term outcomes.
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Bosco JLF, Lash TL, Prout MN, Buist DSM, Geiger AM, Haque R, Wei F, Silliman RA. Breast cancer recurrence in older women five to ten years after diagnosis. Cancer Epidemiol Biomarkers Prev 2009; 18:2979-83. [PMID: 19843686 DOI: 10.1158/1055-9965.epi-09-0607] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Little is known about the risk of recurrence >5 years after diagnosis among older breast cancer survivors. A community-based population of women >or=65 years diagnosed with early-stage breast cancer who survived disease free for 5 years was followed for 5 additional years or until a diagnosis of breast cancer recurrence, second primary, death, or loss to follow-up. These 5-year disease-free survivors (N = 1,277) had primary breast cancers that were node negative (77%) and estrogen receptor positive or unknown (86%). Five percent (n = 61) developed a recurrence between 5 and 10 years after diagnosis: 25% local, 9.8% regional, and 66% distant. Women who were node positive [hazard ratio (HR), 3.9; 95% confidence interval (95% CI), 1.5-10], had poorly differentiated tumors (HR, 2.5; 95% CI, 0.9-6.6), or who received breast conserving surgery without radiation therapy (HR, 2.4; 95% CI, 1.0-5.8) had higher recurrence rates compared with node negative, well differentiated, and receipt of mastectomy, respectively. Not receiving adjuvant tamoxifen, compared with receiving adjuvant tamoxifen, was also positively associated with late recurrence among women with estrogen receptor-positive/unknown tumors. Although relatively few women experience a late recurrence, most recurrences present as advanced disease, which is difficult to treat in older women. This study of late recurrence emphasizes that the risk, although small, is not negligible even in this group at high risk of death due to competing causes.
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Buist DSM, Chubak J, Prout M, Yood MU, Bosco JLF, Thwin SS, Gold HT, Owusu C, Field TS, Quinn VP, Wei F, Silliman RA. Referral, receipt, and completion of chemotherapy in patients with early-stage breast cancer older than 65 years and at high risk of breast cancer recurrence. J Clin Oncol 2009; 27:4508-14. [PMID: 19687341 DOI: 10.1200/jco.2008.18.3459] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Some women with early-stage breast cancer are at higher risk of recurrence and can benefit from chemotherapy. We describe patterns of referral, receipt, and completion of chemotherapy among older women at high risk of recurrence. PATIENTS AND METHODS A total of 2,124 women age 65 years or older who were diagnosed with early-stage breast cancer between 1990 and 1994 and 1996 to 1999 were included; 1,090 of these were at high risk of recurrence. We reviewed medical records to categorize chemotherapy outcomes as follows: did not discuss or were not referred to a medical oncologist (n = 133); discussed and/or referred to a medical oncologist but received no chemotherapy (n = 742); received an incomplete chemotherapy course (n = 29), or received a completed chemotherapy course (n = 186). RESULTS Overall, 19.7% of high-risk women received any chemotherapy, and 86.5% of these women completed their chemotherapy courses. Just greater than 10% of high-risk women did not have a discussion about chemotherapy as part of breast cancer treatment documented in the medical record; these women also received fewer diagnostic assessments of their initial tumors. CONCLUSION Individuals who receive chemotherapy for early-stage breast cancer are a select subgroup of patients at high risk of recurrence. This study identifies characteristics of women who were referred for and who received chemotherapy, and this study plays an important role in understanding generalizability of studies that examine chemotherapy treatment effectiveness. Outcomes after breast cancer could continue to be improved with increased receipt of chemotherapy among older women at high risk of breast cancer recurrence.
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Ahern TP, Bosco JL, Silliman RA, Yood MU, Field TS, Wei F, Lash TL. Potential misinterpretations caused by collapsing upper categories of comorbidity indices: An illustration from a cohort of older breast cancer survivors. Clin Epidemiol 2009; 1:93-100. [PMID: 20865090 PMCID: PMC2943165 DOI: 10.2147/clep.s5757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Comorbidity indices summarize complex medical histories into concise ordinal scales, facilitating stratification and regression in epidemiologic analyses. Low subject prevalence in the highest strata of a comorbidity index often prompts combination of upper categories into a single stratum ('collapsing'). OBJECTIVE We use data from a breast cancer cohort to illustrate potential inferential errors resulting from collapsing a comorbidity index. METHODS Starting from a full index (0, 1, 2, 3, and ≥4 comorbidities), we sequentially collapsed upper categories to yield three collapsed categorizations. The full and collapsed categorizations were applied to analyses of (1) the association between comorbidity and all-cause mortality, wherein comorbidity was the exposure; (2) the association between older age and all-cause mortality, wherein comorbidity was a candidate confounder or effect modifier. RESULTS COLLAPSING THE INDEX ATTENUATED THE ASSOCIATION BETWEEN COMORBIDITY AND MORTALITY (RISK RATIO, FULL VERSUS DICHOTOMIZED CATEGORIZATION: 4.6 vs 2.1), reduced the apparent magnitude of confounding by comorbidity of the age/mortality association (relative risk due to confounding, full versus dichotomized categorization: 1.14 vs 1.09), and obscured modification of the association between age and mortality on both the absolute and relative scales. CONCLUSIONS Collapsing categories of a comorbidity index can alter inferences concerning comorbidity as an exposure, confounder and effect modifier.
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Bosco JLF, Silliman RA, Thwin SS, Geiger AM, Buist DSM, Prout MN, Yood MU, Haque R, Wei F, Lash TL. A most stubborn bias: no adjustment method fully resolves confounding by indication in observational studies. J Clin Epidemiol 2009; 63:64-74. [PMID: 19457638 DOI: 10.1016/j.jclinepi.2009.03.001] [Citation(s) in RCA: 258] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 02/20/2009] [Accepted: 03/02/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of methods that control for confounding by indication, we compared breast cancer recurrence rates among women receiving adjuvant chemotherapy with those who did not. STUDY DESIGN AND SETTING In a medical record review-based study of breast cancer treatment in older women (n=1798) diagnosed between 1990 and 1994, our crude analysis suggested that adjuvant chemotherapy was positively associated with recurrence (hazard ratio [HR]=2.6; 95% confidence interval [CI]=1.9, 3.5). We expected a protective effect, so postulated that the crude association was confounded by indications for chemotherapy. We attempted to adjust for this confounding by restriction, multivariable regression, propensity scores (PSs), and instrumental variable (IV) methods. RESULTS After restricting to women at high risk for recurrence (n=946), chemotherapy was not associated with recurrence (HR=1.1; 95% CI=0.7, 1.6) using multivariable regression. PS adjustment yielded similar results (HR=1.3; 95% CI=0.8, 2.0). The IV-like method yielded a protective estimate (HR=0.9; 95% CI=0.2, 4.3); however, imbalances of measured factors across levels of the IV suggested residual confounding. CONCLUSION Conventional methods do not control for unmeasured factors, which often remain important when addressing confounding by indication. PS and IV analysis methods can be useful under specific situations, but neither method adequately controlled confounding by indication in this study.
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Oates DJ, Silliman RA. Health literacy: improving patient understanding. ONCOLOGY (WILLISTON PARK, N.Y.) 2009; 23:376-379. [PMID: 19476268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Schonberg MA, Silliman RA, Marcantonio ER. Weighing the benefits and burdens of mammography screening among women age 80 years or older. J Clin Oncol 2009; 27:1774-80. [PMID: 19255318 DOI: 10.1200/jco.2008.19.9877] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To examine outcomes of mammography screening among women > or = 80 years to inform decision making. PATIENTS AND METHODS We conducted a cohort study of 2,011 women without a history of breast cancer who were age > or = 80 years between 1994 and 2004 and who received care at one academic primary care clinic or two community health centers in Boston, MA. Medical record data were abstracted on all screening and diagnostic mammograms, breast ultrasounds and biopsies performed, all breast cancers diagnosed through December 31, 2006, and on sociodemographics. Date and cause of death were confirmed using the National Death Index. RESULTS The majority of patients (78.6%) were non-Hispanic white and 51.4% (n = 1,034) had been screened with mammography since age 80 years. Among women who were screened, eight were diagnosed with ductal carcinoma in situ, 16 with early stage disease (1.5%), two with late stage disease, and one died as a result of breast cancer. Many (110; 11%) experienced a false-positive screening mammogram that led to 19 benign breast biopsies, eight refused work-up, and three experienced a false-negative screening mammogram; 97 were screened within 2 years of their death from other causes. There were no significant differences in the rate, stage, recurrence rate, or deaths due to breast cancer between women who were screened and those who were not screened. CONCLUSION The majority of women > or = 80 years are screened with mammography yet few benefit. Meanwhile, 12.5% experience a burden from screening. The data from this study can be used to inform elderly women's decision making and potentially lead to more rational use of screening.
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Clough-Gorr KM, Fink AK, Silliman RA. Challenges associated with longitudinal survivorship research: attrition and a novel approach of reenrollment in a 6-year follow-up study of older breast cancer survivors. J Cancer Surviv 2008; 2:95-103. [DOI: 10.1007/s11764-008-0049-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 02/22/2008] [Indexed: 11/25/2022]
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Lash TL, Ahern TP, Cronin-Fenton D, Garne JP, Hamilton-Dutoit S, Kvistgaard ME, Rosenberg CL, Silliman RA, Sørensen HT. Modification of Tamoxifen Response: What Have We Learned? J Clin Oncol 2008; 26:1764-5; author reply 1765-6. [DOI: 10.1200/jco.2007.15.5432] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Field TS, Doubeni C, Fox MP, Buist DSM, Wei F, Geiger AM, Quinn VP, Lash TL, Prout MN, Yood MU, Frost FJ, Silliman RA. Under utilization of surveillance mammography among older breast cancer survivors. J Gen Intern Med 2008; 23:158-63. [PMID: 18060463 PMCID: PMC2359172 DOI: 10.1007/s11606-007-0471-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Revised: 08/09/2007] [Accepted: 11/13/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND Annual surveillance mammography is recommended for follow-up of women with a history of breast cancer. We examined surveillance mammography among breast cancer survivors who were enrolled in integrated healthcare systems. METHODS Women in this study were 65 or older when diagnosed with early stage invasive breast cancer (N = 1,762). We assessed mammography use during 4 years of follow-up, using generalized estimating equations to account for repeated measurements. RESULTS Eighty-two percent had mammograms during the first year after treatment; the percentage declined to 68.5% in the fourth year of follow-up. Controlling for age and comorbidity, women who were at higher risk of recurrence by being diagnosed at stage II or receiving breast-conserving surgery (BCS) without radiation therapy were less likely to have yearly mammograms (compared to stage I, odds ratio [OR] for stage IIA 0.72, confidence interval [CI] 0.59, 0.87, OR for stage IIB 0.75, CI 0.57, 1.0; compared to BCS with radiation, OR 0.58, CI 0.43, 0.77). Women with visits to a breast cancer surgeon or oncologist were more likely to receive mammograms (OR for breast cancer surgeon 6.0, CI 4.9, 7.4, OR for oncologist 7.4, CI 6.1, 9.0). CONCLUSIONS Breast cancer survivors who are at greater risk of recurrence are less likely to receive surveillance mammograms. Women without a visit to an oncologist or breast cancer surgeon during a year have particularly low rates of mammography. Improvements to surveillance care for breast cancer survivors may require active participation by primary care physicians and improvements in cancer survivorship programs by healthcare systems.
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Clough-Gorr KM, Silliman RA. Translation Requires Evidence: Does Cancer-Specific CGA Lead to Better Care and Outcomes? ONCOLOGY (WILLISTON PARK, N.Y.) 2008; 22:925-928. [PMID: 20798779 PMCID: PMC2927829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Owusu C, Buist DSM, Field TS, Lash TL, Thwin SS, Geiger AM, Quinn VP, Frost F, Prout M, Yood MU, Wei F, Silliman RA. Predictors of tamoxifen discontinuation among older women with estrogen receptor-positive breast cancer. J Clin Oncol 2007; 26:549-55. [PMID: 18071188 DOI: 10.1200/jco.2006.10.1022] [Citation(s) in RCA: 242] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Five years of adjuvant tamoxifen therapy for estrogen receptor (ER) -positive breast cancer is more effective than 2 years of use. However, information on tamoxifen discontinuation is scanty. We sought to identify predictors of tamoxifen discontinuation among older women with breast cancer. PATIENTS AND METHODS Within six health care delivery systems, we identified women >or= 65 years old diagnosed with stage I to IIB ER-positive or indeterminant breast cancer between 1990 and 1994 who had filled a prescription for adjuvant tamoxifen. We observed them for 5 years after initial tamoxifen prescription. We used automated pharmacy records to validate tamoxifen prescription information abstracted from medical records. The primary end point was tamoxifen discontinuation, operationalized as ever discontinuing tamoxifen during 5 years of follow-up. We used Cox proportional hazards to identify predictors of tamoxifen discontinuation. RESULTS Of 961 women who were prescribed tamoxifen, 49% discontinued tamoxifen before the completion of 5 years. Discontinuers were more likely to be aged 75 to less than 80 years (v < 70 years; hazard ratio [HR] = 1.41; 95% CI, 1.06 to 1.87), be aged >or= 80 years (HR = 2.02; 95% CI, 1.53 to 2.66), have an increase in Charlson Comorbidity Index at 3 years from diagnosis (HR = 1.52; 95% CI, 1.18 to 1.95), have an increase in the number of cardiopulmonary comorbidities at 3 years (HR = 1.75; 95% CI, 1.34 to 2.28), have indeterminant ER status (v ER-positive status; HR = 1.36; 95% CI, 1.00 to 1.85), and have received breast-conserving surgery (BCS) without radiotherapy (v mastectomy; HR = 1.62; 95% CI, 1.18 to 2.22). CONCLUSION Attention to nonadherence among older women at risk of discontinuation, particularly those receiving BCS without radiotherapy, might improve breast cancer outcomes for these women.
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Yood MU, Owusu C, Buist DSM, Geiger AM, Field TS, Thwin SS, Lash TL, Prout MN, Wei F, Quinn VP, Frost FJ, Silliman RA. Mortality impact of less-than-standard therapy in older breast cancer patients. J Am Coll Surg 2007; 206:66-75. [PMID: 18155570 DOI: 10.1016/j.jamcollsurg.2007.07.015] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Revised: 05/16/2007] [Accepted: 07/17/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to compare the rates of all-cause and breast cancer-specific mortality after breast-conserving surgery (BCS) only, BCS plus radiation therapy (RT), mastectomy, and the receipt of adjuvant tamoxifen in a large population-based cohort of older women with early-stage disease. STUDY DESIGN This cohort study was conducted within six US integrated health-care delivery systems. Automated administrative databases, medical records, and tumor registries were used to identify women aged 65 years or older who received BCS or mastectomy to treat stage I or II breast cancer diagnosed from January 1, 1990, through December 31, 1994. We compared cause-specific 10-year mortality rates across treatment categories by fitting Cox proportional hazards models adjusted for demographics and tumor characteristics. RESULTS We identified 1,837 women having operations for stage I or II breast cancer. Compared with women receiving mastectomy, those receiving BCS without RT were twice as likely to die of breast cancer (adjusted hazards ratio [HR]=2.19, 95% confidence interval [CI], 1.51 to 3.18). Breast cancer mortality rates were similar between women receiving BCS plus RT and women receiving mastectomy (adjusted HR=1.08, 95% CI, 0.79 to 1.48). In the subset of 886 chemotherapy-naive women treated with tamoxifen, those treated with tamoxifen for less than 1 year had a substantially higher breast cancer mortality rate than those exposed 5 years or more (adjusted HR=6.26, 95% CI, 3.10 to 12.64). CONCLUSIONS Our findings indicate that older women receiving BCS alone have higher rates of breast cancer death than those receiving BCS + RT or mastectomy and that the survival benefit from tamoxifen increases with increasing duration of treatment.
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Caruso LB, Clough-Gorr KM, Silliman RA. Improving Quality of Care for Urban Older People with Diabetes Mellitus and Cardiovascular Disease. J Am Geriatr Soc 2007; 55:1656-62. [PMID: 17714460 DOI: 10.1111/j.1532-5415.2007.01320.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The management of older patients with chronic medical conditions dominates medical practice. Cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) in patients aged 65 and older have reached epidemic proportions. Using elements of the Chronic Care Model (CCM), a quality improvement project was undertaken to restructure the Geriatric Ambulatory Practice at Boston Medical Center, Boston's safety net hospital, to improve the quality of care for CVD and diabetes mellitus. Two hundred eighty-three eligible patients who had CVD, DM, or both were identified. The 39-month project period was divided into a 12-month baseline period and three follow-up periods. The multifaceted intervention consisted of development of a disease registry that centralized clinical information, implementation of an electronic medical record, patient education, physician education regarding evidence-based guidelines, feedback of provider-specific and practice data to physicians, and implementation of a foot examination protocol. Clinical measures included glycosylated hemoglobin, a diabetic foot examination, lipid profile, and blood pressure measurement. These were collected at baseline and at each patient visit for the entire project period. The average age of all patients was 76; 64% were female, 64% were African American, 72% had Medicare, and 22% had state subsidized medical insurance. Patients in all disease groups showed significant improvement in all clinical measures over time, independent of the frequency of visits. Using the CCM as a quality improvement framework can improve clinical measures for older urban minority populations with CVD and DM.
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Buist DSM, Ichikawa L, Prout MN, Yood MU, Field TS, Owusu C, Geiger AM, Quinn VP, Wei F, Silliman RA. Receipt of appropriate primary breast cancer therapy and adjuvant therapy are not associated with obesity in older women with access to health care. J Clin Oncol 2007; 25:3428-36. [PMID: 17687148 DOI: 10.1200/jco.2007.11.4918] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Many studies have reported body mass index (BMI) increases the risk of breast cancer recurrence and breast cancer-specific mortality. Few studies have reported or examined whether breast cancer treatment differs by BMI. The purpose of this study was to examine the association between BMI at breast cancer diagnosis and receipt of appropriate primary tumor therapy and adjuvant therapy. METHODS We identified 897 women age >or= 65 years diagnosed with stage I or II breast cancer from 1990 to 1999 at five health care organizations. We used medical records to confirm demographics, tumor characteristics, treatment, comorbid conditions, and to calculate BMI at diagnosis (< 25 kg/m(2), n = 328; 25 to < 30 kg/m(2), n = 305; 30 to < 35 kg/m(2), n = 188; >or= 35 kg/m(2), n = 76). We defined primary therapy based on National Guidelines as receiving breast-conserving surgery with radiation therapy and axillary node dissection, simple mastectomy with axillary node dissection, or modified radical mastectomy (73% overall); adjuvant therapy was defined as receipt of hormonal therapy, chemotherapy, or both (60% overall). RESULTS The median BMI was 26.7 kg/m(2) (range, 14.6 to 61.2). The proportion of women receiving primary therapy and adjuvant therapy was lowest for women less than 25 kg/m(2) (69% and 56%, respectively) and greatest for obese I (78% and 64%, respectively). There were no differences in receipt of primary or adjuvant treatment across BMI in univariate or multivariable models (after adjusting for age, stage, comorbidity, diagnosis year, and hormone receptor positivity). CONCLUSION Receipt of appropriate primary therapy and adjuvant therapy is not associated with BMI in older women with access to health care. Additional research in larger samples and more diverse settings is needed.
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Owusu C, Lash TL, Silliman RA. Effectiveness of adjuvant tamoxifen therapy among older women with early stage breast cancer. Breast J 2007; 13:374-82. [PMID: 17593042 DOI: 10.1111/j.1524-4741.2007.00445.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To investigate the effectiveness of adjuvant tamoxifen in older women with early-stage breast cancer. Between 1997 and 1999, women > or = 65 years old at diagnosis with stage I-IIIa breast cancer were recruited from four geographic regions of the United States and followed prospectively for 5 years after diagnosis. Data sources included tumor registries, medical records review, and telephone interviews. The primary end points were breast cancer-specific and overall survival ascertained by matching identifying data with the National Death Index and Social Security Administration master death file. Tamoxifen prescription was operationalized as tamoxifen prescribed by 6 months after diagnosis. Survival analysis was undertaken using Kaplan-Meier curves and Cox proportional hazards modeling. We studied 689 women whose average age was 74.2 years at diagnosis (SD = 6.3, range 65-96 years). The median follow-up was 67 months (range 3.5-88 months). Of the 689 patients, 519 (76%) were prescribed tamoxifen. The 5-year breast cancer-specific survival was 93% (95% CI = 90-95) and 89% (95% CI = 83-94) for the ever tamoxifen and never tamoxifen groups, respectively. The ratio of adjusted breast cancer mortality hazards was 0.61 (95% CI = 0.31-1.12) for the ever tamoxifen group versus the never tamoxifen group. Similarly, the 5-year overall survival was 81% (95% CI = 76-85) and 70% (95% CI = 61-78) for the ever tamoxifen and never tamoxifen groups, respectively, with an adjusted hazard ratio of 0.53 (95% CI = 0.37-0.77). Adjuvant tamoxifen is associated with improvement in 5-year breast cancer-specific and overall survival in older women with early-stage breast cancer.
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Thwin SS, Clough-Gorr KM, McCarty MC, Lash TL, Alford SH, Buist DSM, Enger SM, Field TS, Frost F, Wei F, Silliman RA. Automated inter-rater reliability assessment and electronic data collection in a multi-center breast cancer study. BMC Med Res Methodol 2007; 7:23. [PMID: 17577410 PMCID: PMC1919388 DOI: 10.1186/1471-2288-7-23] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Accepted: 06/18/2007] [Indexed: 12/05/2022] Open
Abstract
Background The choice between paper data collection methods and electronic data collection (EDC) methods has become a key question for clinical researchers. There remains a need to examine potential benefits, efficiencies, and innovations associated with an EDC system in a multi-center medical record review study. Methods A computer-based automated menu-driven system with 658 data fields was developed for a cohort study of women aged 65 years or older, diagnosed with invasive histologically confirmed primary breast cancer (N = 1859), at 6 Cancer Research Network sites. Medical record review with direct data entry into the EDC system was implemented. An inter-rater and intra-rater reliability (IRR) system was developed using a modified version of the EDC. Results Automation of EDC accelerated the flow of study information and resulted in an efficient data collection process. Data collection time was reduced by approximately four months compared to the project schedule and funded time available for manuscript preparation increased by 12 months. In addition, an innovative modified version of the EDC permitted an automated evaluation of inter-rater and intra-rater reliability across six data collection sites. Conclusion Automated EDC is a powerful tool for research efficiency and innovation, especially when multiple data collection sites are involved.
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