Association of Nonadherence to Cancer Screening Examinations With Mortality From Unrelated Causes: A Secondary Analysis of the PLCO Cancer Screening Trial

Associations between Missed Colonoscopy Appointments and Multiple Prior Adherence Behaviors in an Integrated Healthcare System: An Observational Study

BACKGROUND

Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments.

OBJECTIVE

To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018.

MAIN MEASURES

Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments.

KEY RESULTS

The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5-1.8) for outpatient appointments, 1.9 (1.7-2.1) for gastroenterology appointments, and 3.1 (2.9-3.4) for adherence with bowel preparation kits, respectively.

CONCLUSIONS

Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available.

Relationship Between Age, Comorbidity, and the Prevalence of Erectile Dysfunction

BACKGROUND

Erectile dysfunction (ED) increases with age. Remarkably, the relationship between age and the risk of ED has only been described in crude categories, such as risk for men aged 50-59 yr, without taking comorbidities into account.

OBJECTIVE

To understand how the risk of patient-reported ED varies according to age and comorbidity status.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included a cohort of 17 250 patients with prostate cancer who completed the International Index of Erectile Function erectile function domain (IIEF-EF) questionnaire before any prostate treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We created a logistic regression model to predict the probability of ED using age and comorbidities such as cardiovascular disease, diabetes, and hypertension as predictors. We used age as a nonlinear term to allow a curvilinear relationship between age and ED.

RESULTS AND LIMITATIONS

The prevalence of patient-reported ED among men without any comorbidities increased from 10% to 79% from the age of 40 and 80 yr. The risk of ED increased sharply with comorbidity: the probability of ED for 50- and 75-yr-old individuals was 20% and 68% for healthy men, but 41% and 85% for those with hypertension, obesity, and diabetes. Men with several comorbidities have the same risk of ED as that of healthy men 15-25 yr older. Limitations include a healthier-than-average patient group and lack of information about some comorbidities and the severity of comorbidities.

CONCLUSIONS

Our results allow us to better understand how the risk of ED changes with age and comorbidities. Further research should evaluate the impact of other risk factors not considered in the present study and should take risk factor severity into account.

PATIENT SUMMARY

Our study shows how the probability of erectile dysfunction (ED) changes with increasing age, analyzed alone and when taking into account the presence of other risk factors for this condition (eg, diabetes, high blood pressure, and cardiovascular disease). Our results help in better understanding the probability of ED for men with and without comorbidities.

Cost-effectiveness of risk-stratified endoscopic screening for esophageal cancer in high-risk areas of China: a modeling study

BACKGROUND AND AIMS

Risk-stratified endoscopic screening (RSES) has been suggested to improve screening efficiency. We aimed to assess the cost-effectiveness of RSES and identify the optimal risk-score thresholds for once in a lifetime esophageal cancer (EC) screening in high-risk areas of China.

METHODS

From a healthcare system perspective, a Markov model was constructed to compare the cost-effectiveness of 13 RSES strategies (under different score thresholds for EC risk), universal endoscopic screening strategy, and no screening. Six cohorts of 100,000 participants with different screening ages (40-65 years) were followed up to age 77 years. The incremental cost-effectiveness ratio (ICER), that is, incremental costs per quality-adjusted life-year (QALY) gained, was the primary outcome.

RESULTS

Compared with no screening, as the score threshold was lowered, additionally gained QALYs increased, with 49 to 172 QALYs and 329 to 1147 QALYs gained from screening performed at 40 and 65 years, respectively. RSES in all age scenarios had ICERs less than the gross domestic product (GDP) per capita, and 11 RSES strategies with score thresholds of 3 to 13 had lower ICERs than universal endoscopic screening. At a willingness-to-pay threshold of the GDP per capita (U.S.$10,276/QALY), RSES at score thresholds of 8 or 9 and universal endoscopic screening were the most cost-effective strategies at ages <55 and ≥55 years, respectively.

CONCLUSIONS

RSES is cost-effective, and score thresholds of 8 or 9 should be considered for screening ages <55 years. For individuals aged ≥55 years, universal endoscopic screening is the optimal strategy.

Adherence with protocol medication use and mortality from unrelated causes in a prevention trial

Several studies have shown that non-adherence to medication use is associated with lower use of preventive services and increased mortality. We aimed to study the relationship between initial adherence to medication use and mortality in the Prostate Cancer Prevention Trial (PCPT). The PCPT randomized men age 55 and over to a finasteride or placebo arm. Duration of treatment was seven years, followed by end-of-study prostate biopsy. Extended follow-up for mortality was performed by linkage to the National Death Index. Non-adherence was defined as taking under 80% of required pills during the first or second 6-month trial period. Proportional hazards models were used to assess the relationship between adherence and all-cause mortality (excluding prostate cancer deaths). Three models were developed as follows: Model I (controlling for demographics and trial arm), Model II (Model I factors plus specific medical conditions), Model III (Model II factors plus lifestyle factors). Of 18,667 men included in the analysis, 3082 (16.5%) were non-adherent. The most common reasons for non-adherence were side effects (33.9%) and forgetting to take pills (22%). Through 5 and 10 years of follow-up, 178 (5.9%) and 483 (15.7%) non-adherent men died versus 581 (3.7%) and 1887 (12.1%) adherent men. Hazard ratios (HRs) at 5 years were 1.62 (95% CI: 1.37-1.91), 1.55 (95% CI: 1.30-1.83) and 1.49 (95% CI: 1.25-1.76) for Models I-III. HRs at ten years were lower but still statistically significant. Non-adherence to taking protocol medications was associated with increased mortality from unrelated conditions.

Factors Associated With Lung Cancer Screening Adherence Among Patients With Negative Baseline CT Results in a Community Health Care Setting

PURPOSE

Lung cancer screening (LCS) decreases lung cancer mortality; however, that reduction depends upon screening adherence. The purpose of this study was to determine factors associated with adherence rate for LCS among patients with negative baseline CT results in a multi-integrated health care network.

METHODS

A retrospective analysis was conducted among patients with negative baseline CT results in a multi-integrated health care network LCS program between January 2015 and January 2020. The two outcomes were adherence for the first and second subsequent LCS studies. Negative baseline result was defined as a Lung CT Screening Reporting and Data System score 0, 1, or 2. Adherence was defined as undergoing a follow-up study within 11 to 15 months of a prior scan. Multivariable logistic regression was used to determine significant predictors of adherence, adjusting for patient demographics, median household income (on the basis of geocoding ZIP codes from the US Census Bureau), smoking history, screening sites, and provider specialty.

RESULTS

A total of 30.7% (512 of 1,668) and 16.3% (270 of 1,660) of patients were adherent for the first two annual subsequent screens, respectively. First-year adherence was higher among former smokers and varied by site and provider specialty. Second-year adherence was higher among former smokers and varied by site, provider specialty, and pack-years smoked.

CONCLUSIONS

Adherence to LCS in a multihospital integrated health care network was poor and even lower at year 2. The identified factors associated with adherence may serve as targets to increase LCS adherence and decrease lung cancer mortality.

Association Between Receipt of Cancer Screening and All-Cause Mortality in Older Adults

IMPORTANCE

Guidelines recommend against routine breast and prostate cancer screenings in older adults with less than 10 years' life expectancy. One study using a claims-based prognostic index showed that receipt of cancer screening itself was associated with lower mortality, suggesting that the index may misclassify individuals when used to inform cancer screening, but this finding was attributed to residual confounding because the index did not account for functional status.

OBJECTIVE

To examine whether cancer screening remains significantly associated with all-cause mortality in older adults after accounting for both comorbidities and functional status.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included individuals older than 65 years who were eligible for breast or prostate cancer screening and who participated in the 2004 Health and Retirement Study. Data were linked to Medicare claims from 2001 to 2015. Data analysis was conducted from January to November 2020.

MAIN OUTCOMES AND MEASURES

A Cox model was used to estimate the association between all-cause mortality over 10 years and receipt of screening mammogram or prostate-specific antigen (PSA) test, adjusting for variables in a prognostic index that included age, sex, comorbidities, and functional status. Potential confounders (ie, education, income, marital status, geographic region, cognition, self-reported health, self-care, and self-perceived mortality risk) of the association between cancer screening and mortality were also tested.

RESULTS

The breast cancer screening cohort included 3257 women (mean [SD] age, 77.8 [7.5] years); the prostate cancer screening cohort included 2085 men (mean [SD] age, 76.1 [6.8] years). Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.60-0.74). A weaker, but still statistically significant, association was found for screening PSA (aHR 0.88; 95% CI, 0.78-0.99). None of the potential confounders attenuated the association between screening and mortality except for cognition, which attenuated the aHR for mammogram from 0.67 (95% CI, 0.60-0.74) to 0.73 (95% CI, 0.64-0.82) and the aHR for PSA from 0.88 (95% CI, 0.78-0.99) to 0.92 (95% CI, 0.80-1.05), making PSA screening no longer statistically significant.

CONCLUSIONS AND RELEVANCE

In this study, cognition attenuated the observed association between cancer screening and mortality among older adults. These findings suggest that existing mortality prediction algorithms may be missing important variables that are associated with receipt of cancer screening and long-term mortality. Relying solely on algorithms to determine cancer screening may misclassify individuals as having limited life expectancy and stop screening prematurely. Screening decisions need to be individualized and not solely dependent on life expectancy prediction.

Vitamin K intake and breast cancer incidence and death: results from a prospective cohort study

BACKGROUND & AIMS

Vitamin K prevents growth and metastasis of certain cancers, but there is little evidence regarding the association between dietary vitamin K and breast cancer incidence and death. We sought to examine whether intakes of total vitamin K, phylloquinone (vitamin K1) and menaquinones (MKs) (vitamin K2) may influence risks of breast cancer incidence and death in the US population.

METHODS

Herein, 2286 breast cancer cases and 207 breast cancer deaths were identified during 702,748 person-years of follow-up. Cox regression and competing risk regression were used to estimate multivariable-adjusted hazards ratios (HRs) and 95% confidence intervals (95% CIs) by dietary vitamin K intake quintile (Q) for risk of breast cancer incidence and mortality.

RESULTS

After adjustment for confounders, the total MK intake was associated with an increased risk of breast cancer (HR Q5 vs Q1, 1.26; 95% CI, 1.05 to 1.52; P_trend, 0.01) and death from breast cancer (HR Q5 vs Q1, 1.71; 95% CI, 0.97 to 3.01; P_trend, 0.04). Non-linear positive dose-response associations with risks of breast cancer incidence and death were found for total MKs intake (P_{non-linearity}<0.05). No statistically significant associations were observed between the intake of total vitamin K and phylloquinone and breast cancer.

CONCLUSIONS

The present study suggests that total MK intake was associated with an altered risk of the occurrence and death of breast cancer in the general US population. If our findings are replicated in other epidemiological studies, reducing dietary intake of menaquinones may offer a novel strategy for breast cancer prevention.

Long-term anti-inflammatory diet in relation to improved breast cancer prognosis: a prospective cohort study

Inflammation-modulating nutrients and inflammatory markers are established cancer risk factors, however, evidence regarding the association between post-diagnosis diet-associated inflammation and breast cancer survival is relatively sparse. We aimed to examine the association between post-diagnosis dietary inflammatory index (DII®) and risks of all-cause and breast cancer-specific mortality. A total of 1064 female breast cancer survivors in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) Trial prospective cohort, were included in this analysis if they had completed the diet history questionnaire (DHQ). Energy-adjusted DII (E-DIITM) scores were calculated based on food and supplement intake. Cox regression and competing risk models were used to estimate multivariable-adjusted hazards ratios (HRs) and 95% confidence intervals (95% CIs) by E-DII tertile (T) for all-cause and breast cancer-specific mortality. With median follow-up of 14.6 years, there were 296 (27.8%) deaths from all causes and 100 (9.4%) breast cancer-specific death. The E-DII was associated with all-cause mortality (HR T3 vs T1, 1.34; 95% CI, 1.01-1.81; P trend, 0.049, Table 2) and breast cancer mortality (HR T3 vs T1, 1.47; 95% CI, 0.89-2.43; P trend, 0.13; multivariable-adjusted HR for 1-unit increment: 1.10; 95% CI: 1.00-1.22). Non-linear positive dose-response associations with mortality from all causes were identified for E-DII scores (P non-linearity < 0.05). The post-diagnosis E-DII was statistically significantly associated with mortality risk among breast cancer survivors. Long-term anti-inflammatory diet might be a means of improving survival of breast cancer survivors.

Other- and all-cause Mortality among women with breast cancer

BACKGROUND

Advances in early detection and treatment of breast cancer (BrCA) have led to better survival. Consequently, more women with BrCA now die from non-BrCA causes. We investigated all-cause and other-cause (non-BrCA) survival among women with BrCA.

METHODS

From the Prostate, Lung, Colorectal and Ovarian (PCLO) cohort, we selected women diagnosed with BrCA from 1994-2014. To compare survival of cases to non-cases, we used exposure density sampling. We computed standard mortality ratios (SMRs) and performed Cox proportional hazards models with matched case-control sets, controlling for demographics (Model I) and additional covariates (Model II). We also examined survival by stage within BrCA cases.

RESULTS

Among 78,215 women enrolled in PLCO, there were 1211 in-situ and 4790 invasive BrCA cases. 15-year survival rates were 97.1 % (BrCA-specific) and 77.2 % (other-cause) among in-situ and 86.4 % (BrCA-specific) and 73.4 % (other-cause) among invasive cases. For other-cause mortality, in-situ cases had lower risk in models I (HR = 0.74; 95 % CI:0.62-0.89) and II (HR = 0.75; 95 % CI:0.62-0.92) versus controls. All-cause mortality HRs for in-situ cases were 0.83 (95 % CI:0.70-0.99) and 0.85 (95 % CI:0.70-1.02) in Models I and II, respectively. Other-cause mortality was similar among invasive cases and controls. Within BrCA cases, higher stage was associated with increased other-cause mortality; HRs were 1.2 (95 % CI:1.1-1.5) and 1.7 (95 % CI:1.2-2.3) for stage II and III/IV versus stage I (Model II).

DISCUSSION

Mortality from other causes exceeded that of BrCA in both in-situ and invasive cases, highlighting the importance of managing patients' chronic conditions during and following cancer treatment.