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Mu H, Yang X, Li Y, Zhou B, Liu L, Zhang M, Wang Q, Chen Q, Yan L, Sun W, Pan G. Three-year follow-up study reveals improved survival rate in NSCLC patients underwent guideline-concordant diagnosis and treatment. Front Oncol 2024; 14:1382197. [PMID: 38863625 PMCID: PMC11165022 DOI: 10.3389/fonc.2024.1382197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
Background No studies in China have assessed the guideline-concordance level of the first-course of non-small cell lung cancer (NSCLC) diagnosis and treatment and its relationship with survival. This study comprehensively assesses the current status of guideline-concordant diagnosis (GCD) and guideline-concordant treatment (GCT) of NSCLC in China and explores its impact on survival. Methods First course diagnosis and treatment data for NSCLC patients in Liaoning, China in 2017 and 2018 (n=1828) were used and classified by whether they underwent GCD and GCT according to Chinese Society of Clinical Oncology (CSCO) guidelines. Pearson's chi-squared test was used to determine unadjusted associations between categorical variables of interest. Logistic models were constructed to identify variables associated with GCD and GCT. Kaplan-Meier analysis and log-rank tests were used to estimate and compare 3-year survival rates. Multivariate Cox proportional risk models were constructed to assess the risk of cancer mortality associated with guideline-concordant diagnosis and treatment. Results Of the 1828 patients we studied, 48.1% underwent GCD, and 70.1% underwent GCT. The proportions of patients who underwent both GCD and GCT, GCD alone, GCT alone and neither GCD nor GCT were 36.7%, 11.4%, 33.5% and 18.4%, respectively. Patients in advanced stage and non-oncology hospitals were significantly less likely to undergo GCD and GCT. Compared with those who underwent neither GCD nor GCT, patients who underwent both GCD and GCT, GCD alone and GCT alone had 35.2%, 26.7% and 35.7% higher 3-year survival rates; the adjusted lung cancer mortality risk significantly decreased by 29% (adjusted hazard ratio[aHR], 0.71; 95% CI, 0.53-0.95), 29% (aHR, 0.71; 95% CI, 0.50-1.00) and 32% (aHR, 0.68; 95% CI, 0.51-0.90). Conclusion The 3-year risk of death is expected to be reduced by 29% if patients with NSCLC undergo both GCD and GCT. There is a need to establish an oncology diagnosis and treatment data management platform in China to monitor, evaluate, and promote the use of clinical practice guidelines in healthcare settings.
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Affiliation(s)
- Huijuan Mu
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Institute of Chronic Diseases, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Xing Yang
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Yanxia Li
- Institute of Chronic Diseases, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Bingzheng Zhou
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
- Department of Orthopaedic Surgery and Sports Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Li Liu
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Institute of Chronic Diseases, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Minmin Zhang
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Qihao Wang
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Qian Chen
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Lingjun Yan
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Wei Sun
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Guowei Pan
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
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Mahadevan J, Appudurai R, Sothipragasam S, Kumar R, Rajasooriyar C. "Current", "heated rods", and "hot vapour": why patients refuse radiotherapy as a treatment modality for cancer in northern Sri Lanka. Support Care Cancer 2024; 32:361. [PMID: 38753165 DOI: 10.1007/s00520-024-08561-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 05/09/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE Significant proportions of patients either refuse or discontinue radiotherapy, even in the curative setting, leading to poor clinical outcomes. This study explores patient perceptions that underlie decisions to refuse/discontinue radiotherapy at a cancer care facility in northern Sri Lanka. METHODS An exploratory descriptive qualitative study was carried out among 14 purposively selected patients with cancer who refused/discontinued radiotherapy. In-depth semi-structured interviews were transcribed in Tamil, translated into English, coded, and thematically analyzed. RESULTS All participants referred to radiotherapy as "current" with several understanding the procedure to involve electricity, heat, or hot vapour. Many pointed to gaps in information provided by healthcare providers, who were perceived to focus on side effects without explaining the procedure. In the absence of these crucial details, patients relied on family members and acquaintances for information, often based on second or third-hand accounts of experiences with radiotherapy. Many felt pressured by family to refuse radiation, feared radiation, or felt ashamed to ask questions, while for others COVID-19 was an impediment. All but three participants regretted their decision, claiming they would recommend radiation to patients with cancer, especially when it is offered with curative intent. CONCLUSION Patients with cancer who refused/discontinued radiation therapy have significant information needs. While human resource deficits need to be addressed in low-resource settings like northern Sri Lanka, providing better supportive cancer care could improve clinical outcomes and save healthcare resources that would otherwise be wasted on patient preparation for radiotherapy.
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Affiliation(s)
| | - Ramalingam Appudurai
- Department of Clinical Oncology, Hospital Road, Teaching Hospital Jaffna, Jaffna, 40 000, Sri Lanka
- Tellipalai Trail Cancer Hospital, Tellipalai, Sri Lanka
| | | | - Ramya Kumar
- Department of Community and Family Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Chrishanthi Rajasooriyar
- Department of Clinical Oncology, Hospital Road, Teaching Hospital Jaffna, Jaffna, 40 000, Sri Lanka.
- Tellipalai Trail Cancer Hospital, Tellipalai, Sri Lanka.
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Nguyen DD, Satkunasivam R, Wallis CJD. Efficacy and Effectiveness: Bridging the Gap Between Clinical Trials and Real-world Practice. Eur Urol Oncol 2024; 7:25-26. [PMID: 37479643 DOI: 10.1016/j.euo.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/23/2023]
Affiliation(s)
- David-Dan Nguyen
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA; Center for Outcomes Research, Houston Methodist Hospital, Houston, USA; Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, Canada; Department of Surgical Oncology, University Health Network, Toronto, Canada.
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Mentrup F, Klein A, Lindner LH, Nachbichler S, Holzapfel BM, Albertsmeier M, Knösel T, Dürr HR. Refusal of Adjuvant Therapies and Its Impact on Local Control and Survival in Patients with Bone and Soft Tissue Sarcomas of the Extremities and Trunk. Cancers (Basel) 2024; 16:239. [PMID: 38254731 PMCID: PMC10814158 DOI: 10.3390/cancers16020239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND In soft tissue or bone sarcomas, multimodal therapeutic concepts represent the standard of care. Some patients reject the therapeutic recommendations due to several reasons. The aim of this study was to assess the impact of that rejection on both prognosis and local recurrence. METHODS Between 2012 and 2019, a total of 828 sarcoma patients were surgically treated. Chemotherapy was scheduled as a neoadjuvant, and adjuvant multi-agent therapy was performed following recommendations from an interdisciplinary tumor board. Radiotherapy, if deemed appropriate, was administered either in a neoadjuvant or an adjuvant manner. The recommended type of therapy, patient compliance, and the reasons for refusal were documented. Follow-ups included local recurrences, diagnosis of metastatic disease, and patient mortality. RESULTS Radiotherapy was recommended in 407 (49%) patients. A total of 40 (10%) individuals did not receive radiation. A reduction in overall survival and local recurrence-free survival was evident in those patients who declined radiotherapy. Chemotherapy was advised for 334 (40%) patients, 250 (75%) of whom did receive all recommended cycles. A total of 25 (7%) individuals did receive a partial course while 59 (18%) did not receive any recommended chemotherapy. Overall survival and local recurrence-free survival were reduced in patients refusing chemotherapy. Overall survival was worst for the group of patients who received no chemotherapy due to medical reasons. Refusing chemotherapy for non-medical reasons was seen in 8.8% of patients, and refusal of radiotherapy for non-medical reasons was seen in 4.7% of patients. CONCLUSIONS Divergence from the advised treatment modalities significantly impacted overall survival and local recurrence-free survival across both treatment modalities. There is an imperative need for enhanced physician-patient communication. Reducing treatment times, as achieved with hypofractionated radiotherapy and with therapy in a high-volume sarcoma center, might also have a positive effect on complying with the treatment recommendations.
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Affiliation(s)
- Franziska Mentrup
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
| | - Alexander Klein
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
| | - Lars Hartwin Lindner
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Department of Medicine III, LMU University Hospital, LMU Munich, 81377 München, Germany
| | - Silke Nachbichler
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Department of Radiation Oncology, LMU University Hospital, LMU Munich, 81377 München, Germany
| | - Boris Michael Holzapfel
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
| | - Markus Albertsmeier
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, 81377 München, Germany
| | - Thomas Knösel
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
- Institute of Pathology, LMU Munich, 81377 München, Germany
| | - Hans Roland Dürr
- Department of Orthopaedics and Trauma Surgery, Orthopaedic Oncology, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, 81377 München, Germany; (F.M.); (A.K.); (B.M.H.)
- SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377 München, Germany; (L.H.L.); (S.N.); (M.A.); (T.K.)
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Moodley Y, Bhadree S, Stopforth L, Kader S, Wexner S, van Wyk J, Neugut A, Kiran R. Patient's attitudes and perceptions around attending oncology consultations following surgery for colorectal cancer: A qualitative study. F1000Res 2023; 12:698. [PMID: 38173827 PMCID: PMC10762288 DOI: 10.12688/f1000research.134816.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 01/05/2024] Open
Abstract
Background: The oncology consultation following surgery for colorectal cancer (CRC) is usually the first step in the receipt of chemotherapy. Non-compliance with this consultation results in non-receipt of recommended chemotherapy, when appropriate, and worse clinical outcomes. This study sought to explore South African patients' attitudes and perceptions around attending scheduled oncology consultations following their CRC surgery. Methods: Semi-structured qualitative interviews were conducted with patients who had surgery for CRC at a quaternary South African hospital and who had to decide whether they would return for an oncology consultation. The "Model of health services use" informed the design of the interview guide, which included questions on factors that impact health seeking behavior. Demographics of participants, CRC disease stage, and compliance with scheduled oncology consultations were also collected. Descriptive statistics were used to analyse the quantitative data, while deductive thematic analysis was used to analyse the qualitative data. Results: Seven participants were interviewed. The median age was 60.0 years and four participants (57.1%) were female. Black African, White, and Asian participants accounted for 85.7% of the study sample. Most participants had stage III CRC (71.4%). The oncology consultation no-show rate was 14.3%. Participant's knowledge and beliefs around CRC proved to be an important predisposing factor that influenced follow-up decisions. Family support and religion were cited as important enabling factors. Travel costs to the hospital and frustrations related to the clinic appointment booking/scheduling process were cited as important disabling factors. Lastly, the participant's self-perceived need for additional oncology care also appeared to influence their decision to return for ongoing oncology consultation after the initial surgery. Conclusion: Several contextual factors can potentially influence a patient's compliance with a scheduled oncology consultation following CRC surgery. A multipronged approach which addresses these factors is required to improve compliance with oncology consultations.
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Affiliation(s)
- Yoshan Moodley
- University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Shona Bhadree
- University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Laura Stopforth
- University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Shakeel Kader
- University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | | | - Jacqueline van Wyk
- University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
- University of Cape Town, Rondebosch, Western Cape, South Africa
| | | | - Ravi Kiran
- Columbia University, New York, New York, USA
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Chen Y, Shankaran V, Hahn EE, Haupt EC, Bansal A. Underutilization or appropriate care? Assessing adjuvant chemotherapy use and survival in 3 heterogenous subpopulations with stage II/III colorectal cancer within a large integrated health system. J Manag Care Spec Pharm 2023; 29:635-646. [PMID: 37276035 PMCID: PMC10387960 DOI: 10.18553/jmcp.2023.29.6.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND: Clinical guidelines have recommended adjuvant chemotherapy (ACT) for patients with high-risk stage II colon cancer, although the survival benefit is unclear. ACT is also recommended for patients with stage III colon cancer to reduce the risk of recurrence and mortality. For stage II/III rectal cancer, however, the role of perioperative chemotherapy (PCT, adjuvant or neoadjuvant) remains controversial, resulting in substantial variation in its use in clinical practice. OBJECTIVES: To understand real-world use and predictors of ACT or PCT use and survival outcomes in 3 heterogeneous patient groups with colorectal cancer (CRC), and to inform the evidence gap between guideline-based care and clinical practice. METHODS: This retrospective cohort study included patients with an initial stage II/III CRC diagnosis between 2008 and 2013 identified from Kaiser Permanente Southern California electronic health record databases. Patients were eligible if they were aged 18-74 years at diagnosis and received primary curative surgery. We fitted mixed effects logistic regression models to evaluate predictors of ACT receipt and Cox proportional hazards models on propensity score-matched (PS-matched) samples to assess the association between ACT/PCT receipt and survival. RESULTS: We included 1,690 patients with colon cancer (stage II: 820 and stage III: 870) and 587 patients with rectal cancer (stage II: 241 and stage III: 346). We found that 65% of patients with high-risk stage II colon cancer, 15% of those with stage III colon, and 15% of those with stage II/III rectal cancer did not receive ACT/PCT. Patients with stage II colon cancer with T4 stage (odds ratio [OR] = 5.79, 95% CI = 3.33 - 10.06) and a lower comorbidity score were more likely to receive ACT (high vs low Charlson score: OR = 0.69, 95% CI = 0.55 - 0.87). Patients with stage III rectal cancer were more likely to receive PCT than those with stage II disease (OR = 7.85, 95% CI = 2.07 - 29.74). Patients with another cancer diagnosis prior to CRC diagnosis were less likely to receive PCT (OR = 0.37, 95% CI = 0.16 - 0.85). ACT/PCT use was associated with improved overall survival among patients with high-risk stage II colon cancer (PS-matched hazard ratio [HR] = 0.42, 95% CI = 0.25 - 0.70) and those with stage III CRC (stage III colon: PS-matched HR = 0.3, 95% CI = 0.25 - 0.36; stage III rectal: PS-matched HR = 0.2, 95% CI = 0.13 - 0.31). CONCLUSIONS: We found potential underuse of appropriate chemotherapy treatment in patients with high-risk stage II colon cancer and stage III CRC. Clinicians' and providers' decisions on ACT administration may not be fully guided by the risk of recurrence and 5-year survival benefits in stage II colon cancer. DISCLOSURES: This research was supported by the National Cancer Institute of the National Institutes of Health (NIH) (under R37-CA218413). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Affiliation(s)
- Yilin Chen
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle
| | - Veena Shankaran
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, and Division of Medical Oncology, University of Washington, Seattle
| | - Erin E Hahn
- Department of Health Systems Sciences, Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, CA
- Department of Research and Evaluation, Kaiser Permanente, Pasadena, CA
| | - Eric C Haupt
- Department of Research and Evaluation, Kaiser Permanente, Pasadena, CA
| | - Aasthaa Bansal
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Comparison Between Veteran and Non-Veteran Populations With Clinical Stage I Non-small Cell Lung Cancer Undergoing Surgery. Ann Surg 2023; 277:e664-e669. [PMID: 34550662 PMCID: PMC8581073 DOI: 10.1097/sla.0000000000004928] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to compare quality of care and outcomes between Veteran and non-Veteran patients undergoing surgery for clinical stage I non-small cell lung cancer (NSCLC). BACKGROUND Prior studies and the lay media have questioned the quality of care that Veterans with lung cancer receive through the VHA. We hypothesized Veterans undergoing surgery for early-stage NSCLC receive high quality care and have similar outcomes compared to the general population. METHODS We performed a retrospective cohort study of patients with clinical stage I NSCLC undergoing resection from 2006 to 2016 using a VHA dataset. Propensity score matching for baseline patient- and tumor-related variables was used to compare operative characteristics and outcomes between the VHA and the National Cancer Database (NCDB). RESULTS The unmatched cohorts included 9981 VHA and 176,304 NCDB patients. The VHA had more male, non-White patients with lower education levels, higher incomes, and higher Charlson/Deyo scores. VHA patients had inferior unadjusted 30-day mortality (VHA 2.1% vs NCDB 1.7%, P = 0.011) and median overall survival (69.0 vs 88.7 months, P < 0.001). In the propensity matched cohort of 6792 pairs, VHA patients were more likely to have minimally invasive operations (60.0% vs 39.6%, P < 0.001) and only slightly less likely to receive lobectomies (70.1% vs 70.7%, P = 0.023). VHA patients had longer lengths of stay (8.1 vs 7.1 days, P < 0.001) but similar readmission rates (7.7% vs 7.0%, P = 0.132). VHA patients had significantly better 30-day mortality (1.9% vs 2.8%, P < 0.001) and median overall survival (71.4 vs 65.2 months, P < 0.001). CONCLUSIONS Despite having more comorbidities, Veterans receive exceptional care through the VHA with favorable outcomes, including significantly longer overall survival, compared to the general population.
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Affiliation(s)
- Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO
- Division of Public Health Sciences, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO
- Division of Public Health Sciences, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Martin W. Schoen
- VA St. Louis Health Care System, St. Louis, MO
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G. Nava
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
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Moodley Y, Govender K, van Wyk J, Reddy S, Ning Y, Wexner S, Stopforth L, Bhadree S, Naidoo V, Kader S, Cheddie S, Neugut AI, Kiran RP. Predictors of treatment refusal in patients with colorectal cancer: A systematic review. Semin Oncol 2022; 49:456-464. [PMID: 36754712 PMCID: PMC10023422 DOI: 10.1053/j.seminoncol.2023.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/30/2023]
Abstract
This systematic review was conducted to investigate predictors of treatment refusal in colorectal cancer (CRC) patients. An understanding of these predictors would inform statistical models for the identification of high-risk patients who might benefit from interventions that seek to improve treatment compliance. We performed a search of PubMed and Scopus to identify potentially relevant studies on predictors of treatment refusal in CRC patients that were published between January 1, 2000 and December 31, 2021. We screened manuscripts using predefined eligibility criteria. Information on study design, study location, patient characteristics, treatments, rates and predictors of treatment refusal, and the impact of treatment refusal on mortality or survival were collected from eligible studies. Study quality was assessed using the Newcastle-Ottawa score. The overall findings of the review process were summarized using descriptive statistics and a narrative synthesis. A total of 13 studies were included in this review. Ten studies reported on refusal of CRC surgery, refusal rate: 0.25%-3.26%; three studies reported on chemotherapy refusal (one of which reported on both surgery and chemotherapy refusal), refusal rate: 7.8%-41.5%; and one study reported on refusal of any cancer treatment, refusal rate: 8.7%. The bulk of the published literature confirmed the harmful association between treatment refusal and poor survival outcomes in CRC patients. Frequently cited predictors of treatment refusal included patient demographic characteristics (age, race, gender), clinical characteristics (disease stage, comorbidity), and factors that impact access to cancer care services (healthcare insurance, facility level). Potentially high rates of treatment refusal pose a challenge to CRC control. This review has identified several factors which must be considered when attempting to reduce treatment refusal in CRC patients. Furthermore, these factors should be tested as components of predictive risk models for this important outcome.
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Affiliation(s)
- Yoshan Moodley
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Kumeren Govender
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Jacqueline van Wyk
- School of Clinical Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Health Sciences Education, University of Cape Town, Cape Town, South Africa
| | - Seren Reddy
- Department of Electronic and Computer Engineering, Durban University of Technology, Durban, South Africa
| | - Yuming Ning
- Department of Surgery, Columbia University, New York, NY, USA
| | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
| | - Laura Stopforth
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shona Bhadree
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Vasudevan Naidoo
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shakeel Kader
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Shalen Cheddie
- Gastrointestinal Cancer Research Group, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Alfred I Neugut
- Department of Medicine and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Ravi P Kiran
- Department of Surgery, Columbia University, New York, NY, USA
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9
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Pianka K, Zhao B, Lee K, Liu S, Eisenstein S, Ramamoorthy S, Lopez N. Factors associated with refusing surgery versus planned nonoperative management for rectal cancer. Surgery 2022; 172:1309-1314. [PMID: 36031444 DOI: 10.1016/j.surg.2022.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/21/2022] [Accepted: 05/30/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Increasingly, patients with rectal cancer receive nonoperative management. A growing body of retrospective evidence supporting the safety of this approach has likely contributed to its growing popularity. However, patients may also undergo nonoperative management because of refusal of surgical resection. We hypothesize that patients who refuse surgery are more likely to be from groups who traditionally face barriers accessing care. METHODS We used the National Cancer Database (2006-2017) to analyze patients with nonmetastatic rectal adenocarcinoma who underwent nonoperative management following radiation. We identified 2 groups: (1) planned nonoperative management and (2) nonoperative management because of refusal of surgery. We performed logistic regression to compare the groups along patient, socioeconomic, and facility-level factors. RESULTS In total, 9,613 and 2,039 patients were included in the planned nonoperative management and refused nonoperative management groups, respectively. Of the total study cohort (ie, planned nonoperative management + refused nonoperative management), 21% of these patients diagnosed in 2017 underwent refused nonoperative management, versus 12% in 2006. Patients who were Black (adjusted odds ratio 1.47, 95% confidence interval 1.26-1.71) or Asian/Pacific Islander (adjusted odds ratio 1.51, 95% confidence interval 1.18-1.92), age ≥65 years (adjusted odds ratio 1.55, 95% confidence interval 1.37-1.77), with more advanced disease stage (stage III adjusted odds ratio 1.30, 95% confidence interval 1.10-1.53), and government insurance (adjusted odds ratio 1.19, 95% confidence interval 1.04-1.36) were associated with increased utilization of refused nonoperative management. Conversely, lower education (adjusted odds ratio 0.62, 95% confidence interval 0.50-0.76) and female sex (adjusted odds ratio 0.88, 95% confidence interval 0.79-0.97) were associated with planned nonoperative management. CONCLUSION Our findings suggest that the refused nonoperative management group is demographically distinct. Outreach efforts to better understand the rationale behind patient decision making in rectal cancer will be paramount to ensuring appropriate implementation of nonoperative management.
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Affiliation(s)
- Kurt Pianka
- School of Medicine, University of California San Diego, La Jolla, CA
| | - Beiqun Zhao
- Department of Surgery, University of California San Diego, La Jolla, CA
| | - Katherine Lee
- Department of Surgery, University of California San Diego, La Jolla, CA
| | - Shanglei Liu
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Samuel Eisenstein
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Sonia Ramamoorthy
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | - Nicole Lopez
- Moores Cancer Center, University of California San Diego, La Jolla, CA.
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10
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Fwelo P, Yusuf ZI, Adjei A, Huynh G, Du XL. Racial and ethnic disparities in the refusal of surgical treatment in women 40 years and older with breast cancer in the USA between 2010 and 2017. Breast Cancer Res Treat 2022; 194:643-661. [PMID: 35749020 PMCID: PMC9287205 DOI: 10.1007/s10549-022-06653-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/03/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Although surgical resection is the main modality of treatment for breast cancer, some patients elect to refuse the recommended surgery. We assessed racial and ethnic differences in women 40 years and older who received or refused to receive surgical treatment for breast cancer in the USA and whether racial disparities in mortality were affected by their differences in the prevalence of refusal for surgical treatment. METHODS We studied 277,127 women with breast cancer using the Surveillance, Epidemiology, and End Results (SEER) data and performed multivariable logistic regressions to investigate the association between surgery status of breast cancer and race/ethnicity. Additionally, we performed Cox regression analyses to determine the predictors of mortality outcomes. RESULTS Of 277,127 patients with breast cancer, 1468 (0.53%) refused to receive the recommended surgical treatment in our cohort. Non-Hispanic Black women were 112% more likely to refuse the recommended surgical treatment for breast cancer compared to their non-Hispanic White counterparts [adjusted odds ratio: 2.12, 95% confidence interval (CI) 1.82-2.47]. Women who underwent breast-conserving surgery [hazards ratio (HR) 0.15, 95% CI 0.13-0.16] and mastectomy (HR 0.21, 95% CI 0.18-0.23) had lower hazard ratios of mortality as compared to women who refused the recommended treatment after adjusting for covariates. CONCLUSION Race/ethnicity was associated with refusal for the recommended surgery, especially among non-Hispanic Black women. Also, surgery refusal was associated with a higher risk of all-cause and breast cancer-related mortality. These disparities stress the need to tailor interventions aimed at raising awareness of the importance of following physician recommendations among minorities.
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Affiliation(s)
- Pierre Fwelo
- Department of Epidemiology, Human Genetics & Environmental Sciences, UTHealth School of Public Health, 7000 Fannin St., Suite 2052-4, Houston, TX, 77030, USA.
| | - Zenab I Yusuf
- Department of Epidemiology, Human Genetics & Environmental Sciences, UTHealth School of Public Health, 7000 Fannin St., Suite 2052-4, Houston, TX, 77030, USA
- Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA
| | - Abigail Adjei
- Department of Epidemiology, Human Genetics & Environmental Sciences, UTHealth School of Public Health, 7000 Fannin St., Suite 2052-4, Houston, TX, 77030, USA
| | - Gabriel Huynh
- Department of Management, Policy and Community Health, UTHealth School of Public Health, Houston, TX, USA
| | - Xianglin L Du
- Department of Epidemiology, Human Genetics & Environmental Sciences, UTHealth School of Public Health, 7000 Fannin St., Suite 2052-4, Houston, TX, 77030, USA
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11
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Hao S, Parikh AA, Snyder RA. Racial Disparities in the Management of Locoregional Colorectal Cancer. Surg Oncol Clin N Am 2021; 31:65-79. [PMID: 34776065 DOI: 10.1016/j.soc.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA.
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12
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Ronden MI, Bahce I, Hashemi SMS, Dickhoff C, de Haan PF, Becker A, Spoelstra FOB, Dahele MR, Ali R, Tiemessen MA, Tarasevych S, Maassen van den Brink K, Haasbeek CJA, Daniels JMA, van Laren M, Verbakel WFAR, Senan S. Factors influencing multi-disciplinary tumor board recommendations in stage III non-small cell lung cancer. Lung Cancer 2020; 152:149-156. [PMID: 33418430 DOI: 10.1016/j.lungcan.2020.12.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Treatment patterns in patients with stage III non-small cell lung cancer (NSCLC) vary considerably between countries, for reasons that are not well understood. We studied factors influencing treatment decision-making at thoracic multidisciplinary tumor boards (MDT's) and outcome for patients treated between 2015-2017, at a regional network comprising 5 hospitals. MATERIALS AND METHODS Details of all patients, including comorbidities, with stage III NSCLC were collected in an ethics-approved database. Weekly MDT's were conducted. The preferred radical intent treatments (RIT) for suitable patients were assumed to be concurrent chemoradiotherapy and/or surgery and other therapies were non-radical intent treatments (n-RIT). RESULTS Of 197 patients identified, 95 % were discussed at an MDT. RIT were recommended in 61 % of patients, but only 48 % finally received RIT. The estimated median OS was significantly better for patients undergoing RIT (28.3 months, CI-95 % 17.3-39.3), versus those who did not (11.2 months, CI-95 % 8.0-14.3). Patient age ≥70 years and a WHO-PS ≥2 were the most important predictors of not recommending RIT. Deaths due to progressive lung cancer within 2 years were observed in 36, 26 and 29 % of patients who received RIT, sequential chemoradiotherapy or radical radiotherapy. Corresponding comorbidity related deaths within 2 years were 3, 12 and 38 %. CONCLUSION A large number of patients who underwent MDT review were considered too old or not fit for RIT. More effective and better tolerated systemic treatments are required for patients presenting with stage III NSCLC.
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Affiliation(s)
- Merle I Ronden
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands.
| | - Idris Bahce
- Department of Pulmonology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Sayed M S Hashemi
- Department of Pulmonology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Chris Dickhoff
- Department of Surgery, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Patricia F de Haan
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Annemarie Becker
- Department of Pulmonology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Femke O B Spoelstra
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Max R Dahele
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Rania Ali
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Marian A Tiemessen
- Department of Pulmonology, Dijklander Ziekenhuis, Hoorn & Purmerend, the Netherlands
| | | | | | - Cornelis J A Haasbeek
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Johannes M A Daniels
- Department of Pulmonology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Marjolein van Laren
- Department of Pulmonology, Dijklander Ziekenhuis, Hoorn & Purmerend, the Netherlands
| | - Wilko F A R Verbakel
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands
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13
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Lee SM, Shin JS. Colorectal Cancer in Octogenarian and Nonagenarian Patients: Clinicopathological Features and Survivals. Ann Coloproctol 2020; 36:323-329. [PMID: 33207113 PMCID: PMC7714379 DOI: 10.3393/ac.2020.01.19.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 01/19/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose Elderly population will comprise a substantial proportion of colorectal cancer (CRC) patients. We examined patients older than 80 years according to their clinical and pathological characteristics to fully understand the elderly patients. Methods CRC patients, 60 years or older at diagnosis, admitted between 2009 and 2014 at our hospital were enrolled. The patients were divided into 2 groups: elderly (aged > 80 years, n = 133), and controls (aged 60 to 79 years, n = 596). Patient’s demographics, risk factors for prognosis of CRC, Clinicopathological parameters, treatment, and survival rates were compared. Results The mean ages were 83.9 and 64.8 years, respectively. Male-to-female ratio and tumor sidedness were comparable in both groups. Prognostic factors found in univariate analysis; differentiation, stage, lymphovascular invasion, and carcinoembryonic antigen showed no statistical difference. The microsatellite instability status and number of retrieved lymph nodes were also similar (17.2 vs 21.6, P = 0.505). A significant difference was found in the treatment approach for chemotherapy as the elderly patients with stage III and IV tend to have omitted adjuvant (43.6% vs. 92.8%, P < 0.001) or palliative (35.8% vs. 89.4%, P = 0.016) chemotherapy. Except in stage I, elderly patients showed significantly lower overall survival rates. Conclusion Current study shows far-elderly patients with CRC were less likely to receive standard treatments, which might have resulted in an inferior outcome. As the number of elderly patients with CRC increase, our results provide a basis for further clinical and molecular investigations of elderly CRC patients.
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Affiliation(s)
- Soo Min Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jun Sang Shin
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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14
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Song KS, Park SC, Sohn DK, Oh JH, Kim MJ, Park JW, Ryoo SB, Jeong SY, Park KJ, Oh HK, Kim DW, Kang SB. Oncologic Risk of Rectal Preservation Against Medical Advice After Chemoradiotherapy for Rectal Cancer: A Multicenter Comparative Cross-Sectional Study with Rectal Preservation as Supported by Surgeon. World J Surg 2020; 43:3216-3223. [PMID: 31410512 DOI: 10.1007/s00268-019-05128-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Rectal preservation against medical advice after neoadjuvant chemoradiotherapy for rectal cancer may increase oncologic uncertainty. This study aimed to compare the oncologic outcomes of patients undergoing rectal preservation as intended by the surgeon, and the outcomes of patients refusing rectal resection against medical advice. METHODS The study population consisted of patients in whom the rectum was preserved after neoadjuvant chemoradiotherapy for clinical stage I-III mid or low rectal cancer between May 2003 and August 2017 (n = 2883); these patients were divided into those in whom rectal preservation was intended by their surgeon (intended rectal preservation, group A, n = 41) and those in whom the rectum was not resected against medical advice (unintended rectal preservation, group B, n = 101), defined as non-operative management or local excision. RESULTS The tumor distance, age, and performance status of patients were not significantly different between the groups, while the clinical T stage before chemoradiotherapy was lower in group A than in group B (P < 0.001). During the median follow-up period of 34 months (interquartile range 18.0-72.0 months), the 3-year overall survival in group B (59.7%) was worse than that in group A (90.1%; P < 0.001), and 80.2% of group B patients had residual or unknown disease status. CONCLUSIONS This study showed that unintended rectal preservation increases oncologic risk after neoadjuvant chemoradiotherapy for rectal cancer regardless of short-term follow-up. Therefore, these findings could be shared with rectal cancer patients who choose to ignore medical advice after chemoradiotherapy to preserve their rectum.
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Affiliation(s)
- Kwang-Seop Song
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Min Jung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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15
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Kaltenmeier C, Malik J, Yazdani H, Geller DA, Medich D, Zureikat A, Tohme S. Refusal of cancer-directed treatment by colon cancer patients: Risk factors and survival outcomes. Am J Surg 2020; 220:1605-1612. [PMID: 32680623 DOI: 10.1016/j.amjsurg.2020.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023]
Abstract
AIM Surgery with or without chemotherapy represent the only curative option for patients with colon cancer. However, some patients refuse treatment despite the recommendation. This study aims to identify the incidence, risk factors and impact on survival associated with refusal. METHODS A National Cancer Data Base (NCDB) analysis between 1998 and 2012 was performed. We identified 924,290 patients with potentially treatable colon cancer. Patients who underwent treatment were compared with patients that refused. RESULTS 7152 patients refused surgery. On multivariable analysis, patients were more likely to refuse if they were older (OR = 1.14; 95% CI 1.14-1.15), female (OR = 1.20; 95% CI 1.12-1.28), African American (vs White, OR = 2.30; 95% CI 2.10-2.51) or on Medicaid (vs private, OR = 3.06; 95% CI 2.49-43.77). Overall survival was worse in patients that refused surgery [median survival 6.8 vs 24 months, Cox hazard ratio (HR) 3.41; 95%CI 3.12-3.60]. Furthermore, 11,334 patients with path. stage III disease refused adjuvant chemotherapy. CONCLUSIONS Refusal of treatment affects survival and is independently associated with several variables (gender, race, insurance status), therefore raising the concern that socioeconomic factors may drive decisions.
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Affiliation(s)
| | - Jannat Malik
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hamza Yazdani
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David A Geller
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Medich
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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16
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Eaglehouse YL, Georg MW, Shriver CD, Zhu K. Racial Comparisons in Timeliness of Colon Cancer Treatment in an Equal-Access Health System. J Natl Cancer Inst 2020; 112:410-417. [PMID: 31271431 PMCID: PMC7156930 DOI: 10.1093/jnci/djz135] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 05/14/2019] [Accepted: 07/03/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Non-Hispanic black (NHB) adults with cancer may have longer time-to-treatment than non-Hispanic whites (NHW) in the United States. Unequal access to medical care may partially account for this racial disparity. This study aimed to investigate whether there were racial differences in time-to-treatment and in treatment delays for patients diagnosed with colon cancer in the equal-access Military Health System (MHS). METHODS Patients age 18-79 years diagnosed with colon adenocarcinoma between January 1, 1998, and December 31, 2014, were identified in the Department of Defense Central Cancer Registry and the MHS Data Repository-linked databases. Median time-to-treatment (surgery and chemotherapy) and 95% confidence intervals were compared between NHBs and NHWs in multivariable quantile regression models. Odds ratios and 95% confidence intervals of receiving delayed treatment defined by guidelines for NHBs relative to NHWs were estimated using multivariable logistic regression. RESULTS Patients (n = 3067) had a mean age at diagnosis of 58.4 (12.2) years and the racial distribution was 76.7% NHW and 23.3% NHB. Median adjusted time-to-treatment was similar for NHB compared to NHW patients. The likelihood of receiving delayed treatment was similar between NHB and NHW patients. CONCLUSIONS In the MHS, there was no evidence of treatment delays for NHBs compared to NHWs, suggesting the role of equal access to medical care and insurance coverage in reducing racial disparities in colon cancer treatment.
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Affiliation(s)
- Yvonne L Eaglehouse
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
- Department of Surgery, Bethesda, MD
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda
| | - Matthew W Georg
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
- Department of Surgery, Bethesda, MD
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda
- Department of Preventive Medicine and Biostatistics, Bethesda
- F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda
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17
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Rios EM, Parma MA, Fernandez RA, Clinton TN, Reyes RM, Kaushik D, Pruthi D, Mansour AM, Mukherjee N, Gelfond J, Wheeler KM, Svatek RS. Urinary Diversion Disparity Following Radical Cystectomy for Bladder Cancer in the Hispanic Population. Urology 2020; 137:66-71. [PMID: 31883879 PMCID: PMC7063861 DOI: 10.1016/j.urology.2019.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To determine if disparities in quality of surgical care exist between Hispanics and non-Hispanics undergoing radical cystectomy for bladder cancer. MATERIALS AND METHODS An observational cohort study was conducted retrospectively on patients who underwent radical cystectomy for urothelial carcinoma of the bladder at our institution between January 2005 and July 2018. Data was collected on demographic, clinical, and pathological characteristics of patients, including self-reported ethnicity. Univariable and multivariable logistic or linear regression analyses were used to evaluate the association of ethnicity with receipt of neoadjuvant chemotherapy, utilization of laparoscopic surgery, number of lymph nodes removed, and continent urinary diversion. RESULTS We identified 507 patients in our database out of which, 136 (27%) were Hispanic and 371 (73%) were non-Hispanic. Compared to non-Hispanics, Hispanics had a higher body mass index (26.9 kg/m2 vs 28.2 kg/m2, P = .006) and lived further away from site of surgery (34 vs 96 miles, P = .02). No significant differences were observed in receipt of neoadjuvant chemotherapy, laparoscopic surgery, or number of lymph nodes removed during cystectomy between ethnicity groups. However, Hispanics were less likely than non-Hispanics to receive a continent urinary diversion on multivariable analysis (odds ratio 0.30, 95% confidence interval 0.10 - 0.92, P = .03). CONCLUSION Disparity exists in the delivery of continent urinary diversions for Hispanic patients undergoing radical cystectomy for bladder cancer. Further investigation is needed to determine the potential causes for this disparity in care delivered.
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Affiliation(s)
- Emily M Rios
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Mitchell A Parma
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Roman A Fernandez
- Department of Biostatistics, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Timothy N Clinton
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Ryan M Reyes
- Experimental Development Therapeutics Program/Urology, MD Anderson Cancer Center/UT Health Science Center, Houston, TX
| | - Dharam Kaushik
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Deepak Pruthi
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Ahmed M Mansour
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Neelam Mukherjee
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX; Experimental Development Therapeutics Program/Urology, MD Anderson Cancer Center/UT Health Science Center, Houston, TX
| | - Jon Gelfond
- Department of Biostatistics, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Karen M Wheeler
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX
| | - Robert S Svatek
- Department of Urology, University of Texas Health San Antonio (UTHSA), San Antonio, TX; Experimental Development Therapeutics Program/Urology, MD Anderson Cancer Center/UT Health Science Center, Houston, TX.
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18
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Fields AC, Lu PW, Yoo J, Irani J, Goldberg JE, Bleday R, Melnitchouk N. Treatment of stage I-III rectal cancer: Who is refusing surgery? J Surg Oncol 2020; 121:990-1000. [PMID: 32090341 DOI: 10.1002/jso.25873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Surgical resection is a cornerstone in the management of patients with rectal cancer. Patients may refuse surgical treatment for several reasons although the rate of refusal is currently unknown. METHODS The National Cancer Database was utilized to identify patients with stage I-III rectal cancer. Patients who refused surgical resection were compared to patients who underwent curative resection. RESULTS A total of 509 (2.6%) patients with stage I and 2082 (3.5%) patients with stage II/III rectal cancer refused surgery. In multivariable analysis for stage I disease, older age, Black race, and Medicaid/no insurance were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had a higher income or lived further distances from the treatment facility. In multivariable analysis for stage II/III disease, older age, Black race, insurance other than private, and rural county were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had higher Charlson comorbidity scores, lived further distances from the treatment facility, or underwent chemoradiation. There was a significant decrease in survival for patients refusing surgery compared to patients undergoing recommended surgery. CONCLUSIONS A small proportion of patients refuse surgery for rectal cancer, and this treatment decision significantly affects survival.
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Affiliation(s)
- Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pamela W Lu
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - James Yoo
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Irani
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Joel E Goldberg
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
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Laviana AA, Luckenbaugh AN, Resnick MJ. Trends in the Cost of Cancer Care: Beyond Drugs. J Clin Oncol 2020; 38:316-322. [PMID: 31804864 PMCID: PMC6994251 DOI: 10.1200/jco.19.01963] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 01/10/2023] Open
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Abstract
BACKGROUND Timing of surgery has been shown to affect outcomes in many forms of cancer, but definitive national data do not exist to determine the effect of time to surgery on survival in colon cancer. OBJECTIVE This study aimed to determine whether a delay in definitive surgery in colon cancer significantly affects survival. DATA SOURCES A retrospective cohort study using 2 independent population-based databases, The Surveillance, Epidemiology, and End Results Medicare-linked database and the National Cancer Database, was performed. STUDY SELECTION All patients had American Joint Committee on Cancer stage 1 through 3 colon cancer. Patients were more than 18 years of age in the National Cancer Database cohort and older than 66 years of age in the Medicare cohort. Patients had a minimum of 3 years of follow-up. MAIN OUTCOME MEASURES The main outcome was overall survival as a function of time between diagnosis and surgery in 4 intervals (1-2, 3-4, 5-6, >6 weeks). RESULTS The Medicare cohort demonstrated an adjusted 5-year survival of 8% to 14% higher in patients with a surgical delay between 3 and 6 weeks, with significantly lower hazard ratios in that interval. The National Cancer Database cohort demonstrated an adjusted 5-year survival of 9% to 16% higher in patients with surgery 3 to 6 weeks after diagnosis, with comparatively similar improvements in survival hazard. LIMITATIONS Because this was a retrospective study of administrative databases, with Medicare data limited to billing data, the causality of outcomes must be interpreted with caution. CONCLUSIONS The ideal timing of definitive resection in colon cancer is between 3 and 6 weeks after initial diagnosis. All efforts should be made for patients to obtain definitive surgery within this interval to achieve a modest but significant improvement in overall survival. See Video Abstract at http://links.lww.com/DCR/B76. ¿CUÁNDO DEBEN SOMETERSE LOS PACIENTES CON CÁNCER DE COLON A UNA RESECCIÓN DEFINITIVA?: Se ha demostrado que el momento de la cirugía afecta los resultados en muchas formas de cáncer, pero no existen datos nacionales definitivos para determinar el efecto del tiempo hasta la cirugía en la supervivencia en el cáncer de colon.Determinar si un retraso en la cirugía definitiva en el cáncer de colon afecta significativamente la supervivencia.Un estudio de cohorte retrospectivo que utiliza dos bases de datos independientes basadas en la población; Se realizó la base de datos vinculada a la vigilancia, la epidemiología y los resultados finales y la base de datos nacional del cáncer.Pacientes con cáncer de colon en estadíos 1 a 3 del Comité Estadounidense Conjunto sobre el Cáncer. Los pacientes tenían más de 18 años en la cohorte de la National Cancer Database y más de 66 años en la cohorte de Medicare. Los pacientes tuvieron un mínimo de 3 años de seguimiento.El resultado principal fue la supervivencia general en función del tiempo entre el diagnóstico y la cirugía en 4 intervalos (1-2, 3-4, 5-6, y mas de 6 semanas).La cohorte de Medicare demostró una supervivencia ajustada de 5 años de 8 a 14% más en pacientes con un retraso quirúrgico entre 3 a 6 semanas, con razones de riesgo significativamente más bajas en ese intervalo. La cohorte de la National Cancer Database demostró una supervivencia ajustada a 5 años de 9 a 16% más en pacientes con cirugía de 3 a 6 semanas después del diagnóstico, con mejoras comparativamente similares en el riesgo de supervivencia.Dado que este fue un estudio retrospectivo de bases de datos administrativas, con datos de Medicare limitados a datos de facturación, la causalidad de los resultados debe interpretarse con precaución.El momento ideal para la resección definitiva en el cáncer de colon es entre tres y seis semanas después del diagnóstico inicial. Se deben hacer todos los esfuerzos para que los pacientes obtengan una cirugía definitiva dentro de este intervalo para lograr una mejora modesta pero significativa en la supervivencia general. Consulte Video Resumen en http://links.lww.com/DCR/B76.
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QTc Interval-Prolonging Medications Among Patients With Lung Cancer: Implications for Clinical Trial Eligibility and Clinical Care. Clin Lung Cancer 2019; 21:21-27.e5. [PMID: 31780402 DOI: 10.1016/j.cllc.2019.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/09/2019] [Accepted: 07/25/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Concomitant medication use, including agents that prolong the corrected QT (QTc) interval, can result in the exclusion of patients with cancer from clinical trials. To estimate the potential effects on accrual, we determined the prevalence of QTc-prolonging medication prescriptions in a national patient cohort. PATIENTS AND METHODS We identified adult patients in the Veterans Affairs system with a diagnosis of lung cancer from 2003 to 2016. The use of QTc interval-prolonging medications and risk category were obtained from CredibleMeds. We calculated the prevalence of prescriptions for QTc-prolonging medications with a known or possible risk of torsade de pointes in the 3 months up to and including the date of cancer diagnosis. The rates across patient groups were compared using χ2 test. RESULTS A total of 280,068 patients were included in the present study. The mean age was 70 years, 98% were male, and 72% were white. Overall, 28.4% had been prescribed a QTc-prolonging medication, and 7.3% had been prescribed ≥2 in the 3 months before the cancer diagnosis. The most commonly prescribed QTc-prolonging medications were antimicrobial agents (14.0%), psychiatric agents (10.2%), antiemetic agents (2.6%), and cardiac medications (1.7%). Excluding the antimicrobial agents, 18.4% of the patients had been prescribed a QTc-prolonging medication. CONCLUSIONS A substantial proportion of individuals with lung cancer will be prescribed QTc-prolonging medications. These prescriptions can limit patients' eligibility for clinical trials and complicate the administration of standard cancer therapies. Further research into the actual clinical risks and optimal management of QTc-prolonging medications in cancer populations is warranted.
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Abstract
Purpose: Pancreatic cancer remains a major health concern; in the next 2 years, it will become the second leading cause of cancer deaths in the United States. Health disparities in the treatment of pancreatic cancer exist across many disciplines, including race and ethnicity, socioeconomic status (SES), and insurance. This narrative review discusses what is known about these disparities, with the goal of highlighting targets for equity promoting interventions. Methods: We performed a narrative review of health disparities in pancreatic cancer spanning greater than ten areas, including epidemiology, treatment, and outcome, using the PubMed NIH database from 2000 to 2019 in the Unites States. Results: African Americans (AAs) tend to present at diagnosis with later stage disease. AAs and Hispanics have lower rates of surgical resection, are more likely to be treated at low volume hospitals, and often experience higher rates of morbidity and mortality compared to white patients, although control for confounders is often limited. Insurance and SES also factor into the delivery of treatment for pancreatic cancer. Conclusion: Disparities by race and SES exist in the diagnosis and treatment of pancreatic cancer that are largely driven by race and SES. Improved understanding of underlying causes could inform interventions.
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Affiliation(s)
- Marcus Noel
- Department of Medicine Hematology and Oncology Division, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
| | - Kevin Fiscella
- Department of Medicine Hematology and Oncology Division, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
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Swegal WC, Herbert RJ, Eisele DW, Chang J, Bristow RE, Gourin CG. Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for laryngeal cancer. Laryngoscope 2019; 130:672-678. [PMID: 31169916 DOI: 10.1002/lary.28104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/25/2019] [Accepted: 05/20/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer. STUDY DESIGN Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data. METHODS Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume. RESULTS Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E <1 (N = 32) treated 284 patients (16.5%), with a mean O/E of 0.77 ± 0.18. Hospitals treating more than six cases with an O/E ≥1 (N = 68) treated 672 patients (39.1%), with a mean O/E of 1.17 ± 0.11. Treatment at hospitals with an O/E ≥1 was associated with improved survival (hazard ratio [HR] = 0.83 [95% confidence interval [CI]: 0.70 to 0.98]) and lower mean incremental treatment-related costs (-$3,009 [-$5,226 to -$791]) compared with hospitals with an O/E <1 (HR = 1.00 [0.80 to 1.24]) and the reference group of low-volume hospitals. CONCLUSIONS A hospital-specific O/E for NCCN treatment guideline adherence, combined with a minimum case volume criterion, is associated with survival and treatment-related costs in elderly patients with larynx cancer, and may be a feasible measure of larynx cancer quality of care. LEVEL OF EVIDENCE NA Laryngoscope, 130:672-678, 2020.
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Affiliation(s)
- Warren C Swegal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert J Herbert
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Jenny Chang
- Department of Epidemiology, University of California Irvine, Irvine, California
| | - Robert E Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange, California, U.S.A
| | - Christine G Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
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Benchetrit L, Torabi SJ, Tate JP, Mehra S, Osborn HA, Young MR, Burtness B, Judson BL. Gender disparities in head and neck cancer chemotherapy clinical trials participation and treatment. Oral Oncol 2019; 94:32-40. [PMID: 31178210 DOI: 10.1016/j.oraloncology.2019.05.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/30/2019] [Accepted: 05/09/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To characterize the representation of women in clinical trials directing the National Comprehensive Cancer Network (NCCN) guidelines for chemotherapy use in head and neck squamous cell carcinoma (HNSCC), as well as the relationship between gender and chemotherapy administration in the definitive treatment of HNSCC in the United States. METHODS A review of all HNSCC chemotherapy clinical trials cited by the 2018 NCCN guidelines was performed. Sex-based proportions were compared with the corresponding proportions in the general U.S. population of patients with HNSCC between 1985 and 2015, derived from the Surveillance, Epidemiology, and End Results (SEER) program. A second analysis using the National Cancer Database (NCDB), identified 63,544 adult patients diagnosed with stages III-IVB HNSCC between 2004 and 2014 and treated with definitive radiotherapy or chemoradiotherapy. Univariable and multivariable logistic regression analyses were used to identify predictors of chemotherapy administration. RESULTS While women comprised 26.2% of U.S. patients with HNSCC between 1985 and 2015, they comprised only 17.0% of patients analyzed in U.S. NCCN-cited chemotherapy clinical trials between 1985 and 2017. On multivariable analysis, women had decreased odds of receiving chemotherapy (Odds Ratio [OR]: 0.875; 95% Confidence Interval [CI]: 0.821-0.931; p < 0.001). CONCLUSION Women are underrepresented in HNSCC chemotherapy clinical trials cited by the national guidelines. Additionally, women are less likely than men to receive definitive chemoradiotherapy as oppose to definitive radiotherapy. Reasons for these disparities warrant further investigation as well as re-evaluation of eligibility criteria and enrollment strategies, in order to improve relevance of clinical trials to women with HNSCC.
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Affiliation(s)
- Liliya Benchetrit
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States
| | - Sina J Torabi
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States
| | - Janet P Tate
- Department of Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Saral Mehra
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States; Yale Cancer Center, New Haven, CT, United States
| | - Heather A Osborn
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States; Yale Cancer Center, New Haven, CT, United States
| | - Melissa R Young
- Yale Cancer Center, New Haven, CT, United States; Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Barbara Burtness
- Yale Cancer Center, New Haven, CT, United States; Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Benjamin L Judson
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, United States; Yale Cancer Center, New Haven, CT, United States.
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Mehta AJ, Stock S, Gray SW, Nerenz DR, Ayanian JZ, Keating NL. Factors contributing to disparities in mortality among patients with non-small-cell lung cancer. Cancer Med 2018; 7:5832-5842. [PMID: 30264921 PMCID: PMC6246958 DOI: 10.1002/cam4.1796] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 08/02/2018] [Accepted: 08/28/2018] [Indexed: 12/31/2022] Open
Abstract
Historically, non-small-cell lung cancer (NSCLC) patients who are non-white, have low incomes, low educational attainment, and non-private insurance have worse survival. We assessed whether differences in survival were attributable to sociodemographic factors, clinical characteristics at diagnosis, or treatments received. We surveyed a multiregional cohort of patients diagnosed with NSCLC from 2003 to 2005 and followed through 2012. We used Cox proportional hazard analyses to estimate the risk of death associated with race/ethnicity, annual income, educational attainment, and insurance status, unadjusted and sequentially adjusting for sociodemographic factors, clinical characteristics, and receipt of surgery, chemotherapy, and radiotherapy. Of 3250 patients, 64% were white, 16% black, 7% Hispanic, and 7% Asian; 36% of patients had incomes <$20 000/y; 23% had not completed high school; and 74% had non-private insurance. In unadjusted analyses, black race, Hispanic ethnicity, income <$60 000/y, not attending college, and not having private insurance were all associated with an increased risk of mortality. Black-white differences were not statistically significant after adjustment for sociodemographic factors, although patients with patients without a high school diploma and patients with incomes <$40 000/y continued to have an increased risk of mortality. Differences by educational attainment were not statistically significant after adjustment for clinical characteristics. Differences by income were not statistically significant after adjustment for clinical characteristics and treatments. Clinical characteristics and treatments received primarily contributed to mortality disparities by race/ethnicity and socioeconomic status in patients with NSCLC. Additional efforts are needed to assure timely diagnosis and use of effective treatment to lessen these disparities.
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Affiliation(s)
- Anish J. Mehta
- Department of MedicineBrigham and Women's HospitalBostonMassachusetts
| | - Shannon Stock
- Department of Mathematics and Computer ScienceCollege of the Holy CrossWorcesterMassachusetts
| | - Stacy W. Gray
- Department of Population SciencesCity of Hope Cancer CenterDuarteCalifornia
| | - David R. Nerenz
- Center for Health Policy and Health Services ResearchHenry Ford Health SystemDetroitMichigan
| | - John Z. Ayanian
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichigan
| | - Nancy L. Keating
- Department of MedicineBrigham and Women's HospitalBostonMassachusetts
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
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Check DK, Albers KB, Uppal KM, Suga JM, Adams AS, Habel LA, Quesenberry CP, Sakoda LC. Examining the role of access to care: Racial/ethnic differences in receipt of resection for early-stage non-small cell lung cancer among integrated system members and non-members. Lung Cancer 2018; 125:51-56. [PMID: 30429038 PMCID: PMC6242353 DOI: 10.1016/j.lungcan.2018.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 08/21/2018] [Accepted: 09/09/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To examine the role of uniform access to care in reducing racial/ethnic disparities in receipt of resection for early stage non-small cell lung cancer (NSCLC) by comparing integrated health system member patients to demographically similar non-member patients. MATERIALS AND METHODS Using data from the California Cancer Registry, we conducted a retrospective cohort study of patients from four racial/ethnic groups (White, Black, Hispanic, Asian/Pacific Islander), aged 21-80, with a first primary diagnosis of stage I or II NSCLC between 2004 and 2011, in counties served by Kaiser Permanente Northern California (KPNC) at diagnosis. Our cohort included 1565 KPNC member and 4221 non-member patients. To examine the relationship between race/ethnicity and receipt of surgery stratified by KPNC membership, we used modified Poisson regression to calculate risk ratios (RR) adjusted for patient demographic and tumor characteristics. RESULTS Black patients were least likely to receive surgery regardless of access to integrated care (64-65% in both groups). The magnitude of the black-white difference in the likelihood of surgery receipt was similar for members (RR: 0.82, 95% CI: 0.73-0.93) and non-members (RR: 0.86, 95% CI: 0.80-0.94). Among members, roughly equal proportions of Hispanic and White patients received surgery; however, among non-members, Hispanic patients were less likely to receive surgery (non-members, RR: 0.93, 95% CI: 0.86-1.00; members, RR: 0.98, 95% CI: 0.89-1.08). CONCLUSION Disparities in surgical treatment for NSCLC were not reduced through integrated health system membership, suggesting that factors other than access to care (e.g., patient-provider communication) may underlie disparities. Future research should focus on identifying such modifiable factors.
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Affiliation(s)
- Devon K Check
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Kathleen B Albers
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Kanti M Uppal
- Vacaville Medical Center, Kaiser Permanente Northern California, 1 Quality Drive, Vacaville, CA, 95688, USA.
| | - Jennifer Marie Suga
- Vallejo Medical Center, Kaiser Permanente Northern California, 975 Sereno Drive, Vallejo, CA, 94589, USA.
| | - Alyce S Adams
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Laurel A Habel
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Charles P Quesenberry
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Lori C Sakoda
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
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Guideline versus non-guideline based management of rectal cancer in octogenarians. Eur Geriatr Med 2018; 9:533-541. [PMID: 34674491 DOI: 10.1007/s41999-018-0070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/12/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE The number of octogenarians with rectal adenocarcinoma is growing. Current guidelines seem difficult to apply on octogenarians which may result in non-adherence. The aim of this retrospective cohort study is to give insight in occurrence of treatment-related complications, hospitalisations and survival among octogenarians treated according to guidelines versus octogenarians treated otherwise. METHODS 108 octogenarians with rectal adenocarcinoma were identified by screening of medical records. 22 patients were excluded for treatment process analysis because of stage IV disease or unknown stage. Baseline characteristics, diagnostic process, received treatment, motivation for deviation from guidelines, complications, hospitalisations and date of death were documented. Patients were divided in two groups depending on adherence to treatment guidelines. Differences in baseline characteristics, treatment-related complications and survival between both groups were evaluated. RESULTS Diagnosis and treatment according to guidelines occurred in 95 and 54% of the patients, respectively. When documented, patient's preference and comorbidities were major reasons to deviate from guidelines. 66% of patients who were treated according to guidelines experienced complications versus 34% of those treated otherwise (p = 0.02). After adjustment for differences in age and polypharmacy, this association was not significant. Patients treated according to the guideline had better survival 18 months after diagnosis (80 versus 56%, p = 0.02). CONCLUSIONS Treating octogenarians with rectal cancer according to guidelines seem to lead to better overall survival, but may lead to a high risk of complications. This may jeopardise quality of life. More and prospective studies in octogenarians with rectal cancer are needed to customize guidelines for these patients.
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Tohme S, Kaltenmeier C, Bou-Samra P, Varley PR, Tsung A. Race and Health Disparities in Patient Refusal of Surgery for Early-Stage Pancreatic Cancer: An NCDB Cohort Study. Ann Surg Oncol 2018; 25:3427-3435. [PMID: 30043318 DOI: 10.1245/s10434-018-6680-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 01/05/2023]
Abstract
AIM To identify factors associated with refusal of surgery in patients with early-stage pancreatic cancer and estimate the impact of this decision on survival. METHODS Using the National Cancer Data Base, 26,358 patients were identified with potentially resectable tumors (pretreatment clinical stage I: T1 or T2 N0M0). Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact on survival. RESULTS Of early-stage patients who were recommended surgery, 7.8% (N = 992) refused surgery for resectable early-stage pancreatic cancer. On multivariable analysis, patients were more likely to refuse surgery if they were older [odds ratio (OR) = 1.18; 95% confidence interval (CI) 1.16-1.19], female (OR = 1.52; 95% CI 1.33-1.73), African American (vs White, OR = 1.79; 95% CI 1.37-2.34), on Medicare/Medicaid (vs private, OR = 2.75; 95% CI 1.54-4.92) or had higher Charlson-Deyo score (2 vs 0, OR = 1.33; 95% CI 1.03-1.72). Patients were also significantly more likely to refuse surgery if they were seen at a center that is not an academic/research program (OR 1.9; 95% CI 1.6-2.27). Patients who were recommended surgery but refused had significantly worse survival than those with stage I who received surgery [median survival 6.8 vs 24 months, Cox hazard ratio (HR) 3.41; 95% CI 3.12-3.60]. CONCLUSIONS The percentage of patients refusing surgery for operable early-stage pancreatic cancer has been decreasing in the last decade but remains a significant issue that affects survival. Disparities in refusal of surgery are independently associated with several variables including gender, race, and insurance. To mitigate national disparities in surgical care, future studies should focus on exploring potential reasons for refusal and developing communication interventions.
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Affiliation(s)
- Samer Tohme
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Patrick Bou-Samra
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick R Varley
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Ferguson MK, Demchuk C, Wroblewski K, Huisingh-Scheetz M, Thompson K, Farnan J, Acevedo J. Does Race Influence Risk Assessment and Recommendations for Lung Resection? A Randomized Trial. Ann Thorac Surg 2018; 106:1013-1017. [PMID: 29902464 DOI: 10.1016/j.athoracsur.2018.04.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/18/2018] [Accepted: 04/02/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Racial disparities in use of surgical therapy for lung cancer exist in the United States. Videos of standardized patients (SPs) can help identify factors that influence physicians' surgical risk estimation. We hypothesized that physician race and SP race in videos influence surgeon decision making. METHODS Four race-neutral clinical vignettes representing lung resection candidates were paired with risk-level concordant short silent videos of SPs. Vignette/video combinations were classified as low or high risk. Trainees and practicing thoracic surgeons read a race-neutral vignette, provided an initial estimate of the percentage risk of major surgical complications, viewed a video randomized to a black or white SP, provided a final estimate of risk, and scored the likelihood that they would recommend operative therapy. Changes in risk estimates were assessed. RESULTS Participants included 113 surgeons (38 practicing surgeons, 75 trainees); of these, 76 were white non-Hispanic (67%), and 37 were other self-identified racial categories. Percentage changes between initial and final risk estimates were not significantly related to patient race (p = 0.11) or surgeon race (white versus other; p = 0.52). Videos of black SPs were associated with a similar likelihood of recommending an operation compared with that of videos of white SPs (p = 0.90). Physician race (white versus other) was not related to the likelihood of recommending surgical intervention (p = 0.79). CONCLUSIONS Neither patient nor physician race was significantly associated with risk estimation or surgical recommendations. These findings do not provide an explanation for documented racial disparities in lung cancer therapy. Further investigation is needed to identify the mechanism underlying these disparities.
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Affiliation(s)
- Mark K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois; Comprehensive Cancer Center, University of Chicago, Chicago, Illinois.
| | - Carley Demchuk
- The University of Illinois College of Medicine, Chicago, Illinois
| | - Kristen Wroblewski
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | | | | | - Jeanne Farnan
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Julissa Acevedo
- Center for Research Informatics, University of Chicago, Chicago, Illinois
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Heins MJ, de Jong JD, Spronk I, Ho VKY, Brink M, Korevaar JC. Adherence to cancer treatment guidelines: influence of general and cancer-specific guideline characteristics. Eur J Public Health 2018; 27:616-620. [PMID: 28013246 DOI: 10.1093/eurpub/ckw234] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Guideline adherence remains a challenge in clinical practice, despite guidelines' ascribed potential to improve patient outcomes. We studied the level of adherence to recommendations from Dutch national cancer treatment guidelines, and the influence of general and cancer-specific guideline characteristics on adherence. Methods Based on data from a national cancer registry, adherence was evaluated for 15 treatment recommendations for breast, colorectal, prostate and lung cancer, and melanoma. Recommendations were selected by representatives of the medical specialist associations responsible for developing and implementing the guidelines. We used multivariable multilevel analysis to calculate mean adherence and variation between individual hospitals. Results Mean adherence to the different treatment recommendations ranged from 40 to 99%. Adherence differed only slightly between older and newer guidelines and between recommendations with low, moderate or high levels of evidence (range 79-84% and 77-91%, respectively), while adherence differed more between recommendations for different cancer types (range 54-99%), different treatment modalities (adherence ranged from 40 to 92%) or recommendations that advised against or recommended in favour of particular treatment (adherence ranged from 75 to 98%). Conclusion We found significant variation in adherence between different cancer treatment guidelines. While some guideline characteristics that seem to explain this variation may be considered difficult to modify, the potential for variance across cancer types and treatment modalities suggests that adherence could be further improved. At the same time, these results warrant tailored strategies for the improvement of adherence to clinical practice guidelines.
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Affiliation(s)
- Marianne J Heins
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Judith D de Jong
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Inge Spronk
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Vincent K Y Ho
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Mirian Brink
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Joke C Korevaar
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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Vyfhuis MA, Bhooshan N, Molitoris J, Bentzen SM, Feliciano J, Edelman M, Burrows WM, Nichols EM, Suntharalingam M, Donahue J, Nagib M, Carr SR, Friedberg J, Badiyan S, Simone CB, Feigenberg SJ, Mohindra P. Clinical outcomes of black vs. non-black patients with locally advanced non–small cell lung cancer. Lung Cancer 2017; 114:44-49. [DOI: 10.1016/j.lungcan.2017.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 12/25/2022]
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Soneji S, Tanner NT, Silvestri GA, Lathan CS, Black W. Racial and Ethnic Disparities in Early-Stage Lung Cancer Survival. Chest 2017; 152:587-597. [PMID: 28450031 PMCID: PMC5812758 DOI: 10.1016/j.chest.2017.03.059] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/24/2017] [Accepted: 03/27/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Black patients with lung cancer diagnosed at early stages-for which surgical resection offers a potential cure-experience worse overall survival than do their white counterparts. We undertook a population-based study to estimate the racial and ethnic disparity in death from competing causes and assessed its contribution to the gap in overall survival among patients with early-stage lung cancer. METHODS We collected survival time data for 105,121 Hispanic, non-Hispanic Asian, non-Hispanic black, and non-Hispanic white patients with early-stage (IA, IB, IIA, and IIB) lung cancer diagnosed between 2004 and 2013 from the Surveillance, Epidemiology, and End-Results registries. We modeled survival time using competing risk regression and included as covariates sex, age at diagnosis, race/ethnicity, stage at diagnosis, histologic type, type of surgical resection, and radiation sequence. RESULTS Adjusting for demographic, clinical, and treatment characteristics, non-Hispanic blacks experienced worse overall survival compared with non-Hispanic whites (adjusted hazard ratio [aHR], 1.05; 95% CI, 1.02-1.08), whereas Hispanics and non-Hispanic Asians experienced better overall survival (aHR, 0.93; 95% CI, 0.89-0.98; and aHR, 0.82; 95% CI, 0.79-0.86, respectively). Worse survival from competing causes of death, such as cardiovascular disease and other cancers-rather than from lung cancer itself-led to the disparity in overall survival among non-Hispanic blacks (adjusted relative risk, 1.07; 95% CI, 1.02-1.12). CONCLUSIONS Narrowing racial and ethnic disparities in survival among patients with early-stage lung cancer will rely on more than just equalizing access to surgical resection and will need to include better management and treatment of smoking-related comorbidities and diseases.
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Affiliation(s)
- Samir Soneji
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; Geisel School of Medicine at Dartmouth, Lebanon, NH; Norris Cotton Cancer Center, Lebanon, NH.
| | - Nichole T Tanner
- Medical University of South Carolina Thoracic Oncology Research Group and Division of Pulmonary Critical Care Medicine; Ralph H. Johnson Veterans Affairs Hospital and Health Equity and Rural Outreach Innovation Center, Charleston, SC
| | - Gerard A Silvestri
- Medical University of South Carolina Thoracic Oncology Research Group and Division of Pulmonary Critical Care Medicine
| | - Christopher S Lathan
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - William Black
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Radiology, Geisel School of Medicine at Dartmouth, Lebanon, NH; Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH; Geisel School of Medicine at Dartmouth, Lebanon, NH; Norris Cotton Cancer Center, Lebanon, NH
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Partin MR, Gravely AA, Burgess JF, Haggstrom DA, Lillie SE, Nelson DB, Nugent SM, Shaukat A, Sultan S, Walter LC, Burgess DJ. Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow-up for abnormal colorectal cancer screening test results. Cancer 2017; 123:3502-3512. [PMID: 28493543 DOI: 10.1002/cncr.30765] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patient, physician, and environmental factors were identified, and the authors examined the contribution of these factors to demographic and health variation in colonoscopy follow-up after a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) screening. METHODS In total, 76,243 FOBT/FIT-positive patients were identified from 120 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011 and were followed for 6 months. Patient demographic (race/ethnicity, sex, age, marital status) and health characteristics (comorbidities), physician characteristics (training level, whether primary care provider) and behaviors (inappropriate FOBT/FIT screening), and environmental factors (geographic access, facility type) were identified from VHA administrative records. Patient behaviors (refusal, private sector colonoscopy use) were estimated with statistical text mining conducted on clinic notes, and follow-up predictors and adjusted rates were estimated using hierarchical logistic regression. RESULTS Roughly 50% of individuals completed a colonoscopy at a VHA facility within 6 months. Age and comorbidity score were negatively associated with follow-up. Blacks were more likely to receive follow-up than whites. Environmental factors attenuated but did not fully account for these differences. Patient behaviors (refusal, private sector colonoscopy use) and physician behaviors (inappropriate screening) fully accounted for the small reverse race disparity and attenuated variation by age and comorbidity score. Patient behaviors (refusal and private sector colonoscopy use) contributed more to variation in follow-up rates than physician behaviors (inappropriate screening). CONCLUSIONS In the VHA, blacks are more likely to receive colonoscopy follow-up for positive FOBT/FIT results than whites, and follow-up rates markedly decline with advancing age and comorbidity burden. Patient and physician behaviors explain race variation in follow-up rates and contribute to variation by age and comorbidity burden. Cancer 2017;123:3502-12. Published 2017. This article is a US Government work and is in the public domain in the USA.
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Affiliation(s)
- Melissa R Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amy A Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - James F Burgess
- Center for Healthcare Organization and Implementation Research, Boston Veterans Affairs Healthcare System, Boston, Massachusetts.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - David A Haggstrom
- Veterans Affairs Health Services Research & Development Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sarah E Lillie
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David B Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Sean M Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Aasma Shaukat
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Shahnaz Sultan
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Louise C Walter
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California
| | - Diana J Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Bao H, Xu N, Li Z, Ren H, Xia H, Li N, Yu H, Wei J, Jiang C, Liu L. Effect of laparoscopic gastrectomy on compliance with adjuvant chemotherapy in patients with gastric cancer. Medicine (Baltimore) 2017; 96:e6839. [PMID: 28538373 PMCID: PMC5457853 DOI: 10.1097/md.0000000000006839] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This study was designed to investigate the effect of laparoscopic gastrectomy on adjuvant chemotherapy in patients with gastric cancer.Patients with gastric cancer who underwent radical gastrectomy at our institution from January 2008 to January 2015 with R0 resection, as determined by a pathological examination, were included in this study. According to the surgical approach, patients were divided into the laparoscopic gastrectomy (LG) group and open gastrectomy (OG) group. Short-term and long-term outcomes were compared between the 2 groups.Of the 206 patients enrolled in the study, 114 patients were included in the LG group and 92 patients were included in the OG group. There was no significant difference in patients' general data, including age, sex, medical comorbidities, and pathological staging, between the 2 groups. However, patients in the LG group had less intraoperative blood loss, fewer postoperative complications, and a shorter hospital stay compared with patients in the OG group. There was no significant difference in the start time of adjuvant chemotherapy between the groups. However, compared with OG, LG had the following advantages: patients received more cycles of adjuvant chemotherapy, more patients received a full dose of on-schedule adjuvant chemotherapy, and more patients completed ≥75% of the planned dose. Long-term survival and disease-free survival rates were higher in the LG than in the OG.In summary, LG can improve compliance with adjuvant chemotherapy and long-term outcomes in patients with gastric cancer.
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Affiliation(s)
- Huizheng Bao
- Jilin Cancer Hospital, Changchun, Jilin, People's Republic of China
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Ahmed HZ, Liu Y, O'Connell K, Ahmed MZ, Cassidy RJ, Gillespie TW, Patel P, Pillai RN, Behera M, Steuer CE, Owonikoko TK, Ramalingam SS, Curran WJ, Higgins KA. Guideline-concordant Care Improves Overall Survival for Locally Advanced Non-Small-cell Lung Carcinoma Patients: A National Cancer Database Analysis. Clin Lung Cancer 2017; 18:706-718. [PMID: 28601387 DOI: 10.1016/j.cllc.2017.04.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current evidence-based guideline-concordant care (GCC) for locally advanced non-small-cell lung cancer (NSCLC) patients with good performance status is concurrent chemoradiation. In this study we evaluated factors associated with lack of GCC and its effects on overall survival (OS). PATIENTS AND METHODS Unresectable stage III NSCLC patients, diagnosed from 2005 to 2013 with a Charlson-Deyo score of 0, were identified from the National Cancer Database. Primary outcomes were receipt of GCC, defined as concurrent chemoradiation (thoracic radiotherapy, starting within 2 weeks of chemotherapy, to at least 60 Gy), and OS. Multivariable logistic regression modeling identified variables associated with non-GCC. Cox proportional hazard modeling was used to examine OS. RESULTS Twenty-three percent of patients (n = 10,476) received GCC. Uninsured patients were more likely to receive non-GCC (odds ratio [OR], 1.54; P < .001) compared with privately insured patients. Other groups with greater odds of receiving non-GCC included: patients treated in the western, southern, or northeastern United States (ORs, 1.39, 1.37, and 1.19, respectively; all Ps < .001) compared with the Midwest; adenocarcinoma histology (OR, 1.48; P < .001) compared with squamous cell carcinoma; and women (OR, 1.08; P = .002). Those who received non-GCC had higher death rates compared with those who received GCC (hazard ratio [HR], 1.42; P < .001). The uninsured (HR, 1.53; P < .001), patients treated in the western, southern, or northeastern United States (HRs, 1.56, 1.41, and 1.34, respectively; P < .001), adenocarcinomas (HR, 1.39; P < .001), and women (HR, 1.44; P < .001) also all had lower OS for non-GCC versus GCC. CONCLUSION Socioeconomic factors, including lack of insurance and geography, are associated with non-GCC. Patient- and disease-specific factors, including increasing adenocarcinoma histology and sex, are also associated with non-GCC. Non-GCC diminishes OS.
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Affiliation(s)
- Hiba Z Ahmed
- Emory University School of Medicine, Atlanta, GA; Emory University Rollins School of Public Health, Atlanta, GA
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Kelli O'Connell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maaz Z Ahmed
- Emory University School of Medicine, Atlanta, GA
| | - Richard J Cassidy
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Theresa W Gillespie
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Pretesh Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Rathi N Pillai
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Madhusmita Behera
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Conor E Steuer
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Taofeek K Owonikoko
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Suresh S Ramalingam
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
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Abstract
BACKGROUND Following oncologic resection, adjuvant chemotherapy is associated with decreased recurrence and improved survival in stage 3 colon cancer. However, there is controversy regarding its use in stage 2 colon cancer with high-risk features (tumor depth T4, poorly differentiated, positive margin, and/or inadequate lymph node retrieval). Consensus guidelines recommend no adjuvant chemotherapy in the absence of these high-risk features (low-risk stage 2). OBJECTIVE This study aimed to examine hospital characteristics associated with poor risk-adjusted, stage-specific guideline compliance for the use of adjuvant chemotherapy in stage 3 and low-risk stage 2 colon cancer. DESIGN This was a retrospective study. Stepwise logistic regression was used to identify patient and hospital factors associated with administration of adjuvant chemotherapy. Hierarchical regression models were used to calculate risk- and reliability-adjusted rates of chemotherapy use and observed-to-expected ratios in each hospital's stage 2 low-risk and stage 3 patients. SETTINGS Data were retrieved from the National Cancer Database. PATIENTS Patients selected were adults treated with oncologic resection for stage 2 to 3 colon cancer between 2004 and 2010. MAIN OUTCOME MEASURES The primary outcome measured was receipt of adjuvant chemotherapy. RESULTS A total of 167,345 patients were identified at 1395 hospitals. The mean overall risk-adjusted adjuvant chemotherapy rate was 65.3% for stage 3 and 15.2% for low-risk stage 2. Analysis of low outlier hospitals for stage 3 colon cancer, where adjuvant chemotherapy was underutilized, demonstrated that 62.8% were low-volume centers and 51.4% were community centers. Of high outlier hospitals for stage 2 low-risk disease, where adjuvant chemotherapy was overutilized, 87.2% were low-volume hospitals and 67.2% were community centers. LIMITATIONS Selection bias and the inability to compare specific chemotherapy regimens were limitations of this study. CONCLUSIONS Following oncologic resection, administration of adjuvant chemotherapy for low-risk stage 2 and stage 3 disease varies substantially among hospitals in the United States. Outlier hospitals were most likely to be low-volume community centers.
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Chemotherapy treatment decision-making experiences of older adults with cancer, their family members, oncologists and family physicians: a mixed methods study. Support Care Cancer 2016; 25:879-886. [PMID: 27830393 PMCID: PMC5266767 DOI: 10.1007/s00520-016-3476-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/26/2016] [Indexed: 12/03/2022]
Abstract
Purpose Although comorbidities, frailty, and functional impairment are common in older adults (OA) with cancer, little is known about how these factors are considered during the treatment decision-making process by OAs, their families, and health care providers. Our aim was to better understand the treatment decision process from all these perspectives. Methods A mixed methods multi-perspective longitudinal study using semi-structured interviews and surveys with 29 OAs aged ≥70 years with advanced prostate, breast, colorectal, or lung cancer, 24 of their family members,13 oncologists, and 15 family physicians was conducted. The sample was stratified on age (70–79 and 80+). All interviews were analyzed using thematic analysis. Results There was no difference in the treatment decision-making experience based on age. Most OAs felt that they should have the final say in the treatment decision, but strongly valued their oncologists’ opinion. “Trust in my oncologist” and “chemotherapy as the last resort to prolong life” were the most important reasons to accept treatment. Families indicated a need to improve communication between them, the patient and the specialist, particularly around goals of treatment. Comorbidity and potential side-effects did not play a major role in the treatment decision-making for patients, families, or oncologists. Family physicians reported no involvement in decisions but desired to be more involved. Conclusion This first study using multiple perspectives showed neither frailty nor comorbidity played a role in the treatment decision-making process. Efforts to improve communication were identified as an opportunity that may enhance quality of care. Condensed abstract In a mixed methods study multiple perspective study with older adults with cancer, their family members, their oncologist and their family physician we explored the treatment decision making process and found that most older adults were satisfied with their decision. Comorbidity, functional status and frailty did not impact the older adult’s or their family members’ decision. Electronic supplementary material The online version of this article (doi:10.1007/s00520-016-3476-8) contains supplementary material, which is available to authorized users.
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Loehrer AP, Song Z, Haynes AB, Chang DC, Hutter MM, Mullen JT. Impact of Health Insurance Expansion on the Treatment of Colorectal Cancer. J Clin Oncol 2016; 34:4110-4115. [PMID: 27863191 DOI: 10.1200/jco.2016.68.5701] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Purpose Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. Lack of insurance coverage has been associated with more advanced disease at presentation, more emergent admissions at time of colectomy, and lower survival relative to privately insured patients. The 2006 Massachusetts health care reform serves as a unique natural experiment to assess the impact of insurance expansion on colorectal cancer care. Methods We used the Hospital Cost and Utilization Project State Inpatient Databases to identify patients with colorectal cancer with government-subsidized or self-pay (GSSP) or private insurance admitted to a hospital between 2001 and 2011 in Massachusetts (n = 17,499) and three control states (n = 144,253). Difference-in-differences models assessed the impact of the 2006 Massachusetts coverage expansion on resection of colorectal cancer, controlling for confounding factors and secular trends. Results Before the 2006 Massachusetts reform, government-subsidized or self-pay patients had significantly lower rates of resection for colorectal cancer compared with privately insured patients in both Massachusetts and the control states. The Massachusetts insurance expansion was associated with a 44% increased rate of resection (rate ratio = 1.44; 95% CI, 1.23 to 1.68; P < .001), a 6.21 percentage point decreased probability of emergent admission (95% CI, -11.88 to -0.54; P = .032), and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34 to 14.91; P = .019) compared with the control states. Conclusion The 2006 Massachusetts health care reform, a model for the Affordable Care Act, was associated with increased rates of resection and decreased probability of emergent resection for colorectal cancer. Our findings suggest that insurance expansion may help improve access to care for patients with colorectal cancer.
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Affiliation(s)
| | - Zirui Song
- All authors: Massachusetts General Hospital, Boston, MA
| | - Alex B Haynes
- All authors: Massachusetts General Hospital, Boston, MA
| | - David C Chang
- All authors: Massachusetts General Hospital, Boston, MA
| | | | - John T Mullen
- All authors: Massachusetts General Hospital, Boston, MA
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Rankin N, McGregor D, Stone E, Butow P, Young J, White K, Shaw T. Evidence-practice gaps in lung cancer: A scoping review. Eur J Cancer Care (Engl) 2016; 27:e12588. [DOI: 10.1111/ecc.12588] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2016] [Indexed: 12/24/2022]
Affiliation(s)
- N.M. Rankin
- Sydney Catalyst Translational Cancer Research Center; University of Sydney; Camperdown NSW Australia
| | - D. McGregor
- Sydney Catalyst Translational Cancer Research Center; University of Sydney; Camperdown NSW Australia
- Research in Implementation Science and eHealth (RISe); Faculty of Health Sciences; University of Sydney; Sydney NSW Australia
| | - E. Stone
- Sydney Catalyst Translational Cancer Research Center; University of Sydney; Camperdown NSW Australia
- Department of Thoracic Medicine; St Vincent's Hospital; Darlinghurst NSW Australia
| | - P.N. Butow
- Sydney Catalyst Translational Cancer Research Center; University of Sydney; Camperdown NSW Australia
- Psycho-Oncology Co-operative Research Group; School of Psychology; University of Sydney; Sydney NSW Australia
- Centre for Medical Psychology & Evidence-based Decision-Making; University of Sydney; Sydney NSW Australia
| | - J.M. Young
- Sydney Catalyst Translational Cancer Research Center; University of Sydney; Camperdown NSW Australia
- Royal Prince Alfred Institute of Academic Surgery; Sydney Local Health District; Camperdown NSW Australia
- School of Public Health; University of Sydney; Sydney NSW Australia
| | - K. White
- Sydney Catalyst Translational Cancer Research Center; University of Sydney; Camperdown NSW Australia
- Cancer Nursing Research Unit; University of Sydney; Sydney NSW Australia
| | - T. Shaw
- Sydney Catalyst Translational Cancer Research Center; University of Sydney; Camperdown NSW Australia
- Research in Implementation Science and eHealth (RISe); Faculty of Health Sciences; University of Sydney; Sydney NSW Australia
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Erb CT, Su KW, Soulos PR, Tanoue LT, Gross CP. Surveillance Practice Patterns after Curative Intent Therapy for Stage I Non-Small-Cell Lung Cancer in the Medicare Population. Lung Cancer 2016; 99:200-7. [PMID: 27565940 PMCID: PMC5003420 DOI: 10.1016/j.lungcan.2016.07.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/24/2016] [Accepted: 07/17/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Recurrence after treatment for non-small cell lung cancer (NSCLC) is common, and routine imaging surveillance is recommended by evidence-based guidelines. Little is known about surveillance patterns after curative intent therapy for early stage NSCLC. We sought to understand recent practice patterns for surveillance of stage I NSCLC in the first two years after curative intent therapy in the Medicare population. MATERIALS AND METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database we selected patients diagnosed with stage I NSCLC between 1998 and 2008. We studied adherence to surveillance guidelines based on specialty society recommendations for chest radiography and computed tomography (CT) scanning. We also tracked the use of Positron Emission Tomography (PET) scans, which are not recommended for surveillance. We calculated the percent of patients who received guideline-adherent surveillance imaging and used logistic regression to determine associations between patient and provider factors and guideline adherence. RESULTS Overall, 61.4% of patients received guideline-adherent surveillance during the initial 2 years after treatment. Use of CT scans in the first year after treatment increased from 47.4% in 1998-78.5% in 2008, and PET use increased from 5.8% to 28.9%. Adherence with surveillance imaging was associated with younger age, higher income, more comorbidities, access to primary care, and receipt of SBRT as the primary treatment. CONCLUSIONS Adherence to specialty society guidelines for surveillance after treatment for stage I NSCLC was poor in this population of Medicare beneficiaries, with less than two-thirds of patients receiving recommended imaging, and almost 30% receiving non-recommended PET scans.
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Affiliation(s)
- Christopher T Erb
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Kevin W Su
- Yale University School of Medicine, New Haven, CT, United States
| | - Pamela R Soulos
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT, United States
| | - Lynn T Tanoue
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Cary P Gross
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT, United States.
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Effects of Implementation of Lung Cancer Screening at One Veterans Affairs Medical Center. Chest 2016; 150:1023-1029. [PMID: 27568228 DOI: 10.1016/j.chest.2016.08.1431] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/06/2016] [Accepted: 08/01/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lung cancer screening recommendations have been developed, but none are focused on veterans. We report the results of the lung cancer screening program at our Veterans Affairs medical center and compare them with historic results. METHODS All veterans between 55 and 74 years who were current smokers or quit within the past 15 years and had at least a 30-pack-year smoking history were invited to receive an annual low-dose chest CT scan beginning in December 2013. Demographics, CT scan results, and pathologic data of screened patients were recorded retrospectively. Overall results during the screening period were compared with results in veterans who received diagnoses from January 2011 to December 2013 (prescreening period). RESULTS From December 2013 through December 2014 (screening period), 1,832 patients obtained a screening CT scan. Their mean age was 65 years. A lung nodule was present in 439 of 1,832 patients (24%). Lung cancer was diagnosed in 55 of 1,832 screened patients (3.0%). During the prescreening period, 37% of every lung cancer detected at our center (30 of 82) was stage I or stage II. After implementation of the screening program that percentage rose to 60% (52 of 87; P < .01). During the screening period, 55 of the 87 diagnosed lung cancers (63%) were detected through the screening program. The number of lung cancers detected per month rose from 2.4 to 6.7 after implementation of the screening program (P < .01). CONCLUSIONS Implementation of lung cancer screening in the veteran population leads to detection of an increased number and proportion of early-stage lung cancers. Lung cancer screening in veterans may also increase the rate of lung cancer diagnoses in the immediate postimplementation period.
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Ortiz SE, Kawachi I, Boyce AM. The medicalization of obesity, bariatric surgery, and population health. Health (London) 2016; 21:498-518. [DOI: 10.1177/1363459316660858] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This article examines how the medicalization of obesity validates the use of bariatric surgery to treat obesity in the United States and how expansions in access to bariatric surgery normalize surgical procedures as disease treatment and prevention tools. Building on this discussion, the article poses two questions for population health regarding health technology: (1) to what extent does bariatric surgery treat obesity in the United States while diverting attention away from the ultimate drivers of the epidemic and (2) to what extent does bariatric surgery improve outcomes for some groups in the US population while simultaneously generating disparities? We conduct a brief, historical analysis of the American Medical Association’s decision to reclassify obesity as a disease through internal documents, peer-reviewed expert reports, and major media coverage. We use medicalization theory to show how this decision by the American Medical Association channels increased focus on obesity into the realm of medical intervention, particularly bariatric surgery, and use this evidence to review research trends on bariatric surgery. We propose research questions that investigate the population health dimensions of bariatric surgery in the United States and note key areas of future research. Our objective is to generate a discourse that considers bariatric surgery beyond the medical realm to better understand how technological interventions might work collectively with population-level obesity prevention efforts and how, in turn, population health approaches may improve bariatric surgery outcomes.
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Affiliation(s)
- Selena E Ortiz
- The Pennsylvania State University, USA
- Harvard University, USA
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Sineshaw HM, Wu XC, Flanders WD, Osarogiagbon RU, Jemal A. Variations in Receipt of Curative-Intent Surgery for Early-Stage Non-Small Cell Lung Cancer (NSCLC) by State. J Thorac Oncol 2016; 11:880-9. [PMID: 26980472 DOI: 10.1016/j.jtho.2016.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous studies reported racial and socioeconomic disparities in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) in the United States. We examined variation in receipt of surgery and whether the racial disparity varies by state. METHODS Patients in whom stage I or II NSCLC was diagnosed from 2007 to 2011 were identified from 38 state and the District of Columbia population-based cancer registries compiled by the North American Association of Central Cancer Registries. Percentage of patients receiving curative-intent surgery was calculated for each registry. Adjusted risk ratios were generated by using modified Poisson regression to control for sociodemographic (e.g., age, sex, race, insurance) and clinical (e.g., grade, stage) factors. Non-Hispanic (NH) whites and Massachusetts were used as references for comparisons because they had the lowest uninsured rates. RESULTS In all registries combined, 66.4% of patients with early-stage NSCLC (73,475 of 110,711) received curative-intent surgery. Receipt of curative-intent surgery for early-stage NSCLC varied substantially by state, ranging from 52.2% to 56.1% in Wyoming, Louisiana, and New Mexico to 75.2% to 77.2% in Massachusetts, New Jersey, and Utah. In a multivariable analysis, the likelihood of receiving curative-intent surgery was significantly lower in all but nine states/registries compared with Massachusetts, ranging from 7% lower in California to 25% lower in Wyoming. Receipt of curative-intent surgery for early-stage NSCLC was lower for NH blacks than for NH whites in every state, although statistically significant in Florida and Texas. CONCLUSIONS Receipt of curative-intent surgery for early-stage NSCLC varies substantially across states in the United States, with northeastern states generally showing the highest rates. Further, receipt of treatment appeared to be lower in NH blacks than in NH whites in every state, although statistically significant in Florida and Texas.
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Affiliation(s)
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - W Dana Flanders
- American Cancer Society, Atlanta, Georgia; Rollins School of Public Health, Emory University, Atlanta, Georgia
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Iwamoto M, Nakamura F, Higashi T. Monitoring and evaluating the quality of cancer care in Japan using administrative claims data. Cancer Sci 2015; 107:68-75. [PMID: 26495806 PMCID: PMC4724820 DOI: 10.1111/cas.12837] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/08/2015] [Accepted: 10/18/2015] [Indexed: 11/29/2022] Open
Abstract
The importance of measuring the quality of cancer care has been well recognized in many developed countries, but has never been successfully implemented on a national level in Japan. We sought to establish a wide‐scale quality monitoring and evaluation program for cancer by measuring 13 process‐of‐care quality indicators (QI) using a registry‐linked claims database. We measured two QI on pre‐treatment testing, nine on adherence to clinical guidelines on therapeutic treatments, and two on supportive care, for breast, prostate, colorectal, stomach, lung, liver and cervical cancer patients who were diagnosed in 2011 from 178 hospitals. We further assessed the reasons for non‐adherence for patients who did not receive the indicated care in 26 hospitals. QI for pretreatment testing were high in most hospitals (above 80%), but scores on adjuvant radiation and chemoradiation therapies were low (20–37%), except for breast cancer (74%). QI for adjuvant chemotherapy and supportive care were more widely distributed across hospitals (45–68%). Further analysis in 26 hospitals showed that most of the patients who did not receive adjuvant chemotherapy had clinically valid reasons for not receiving the specified care (above 70%), but the majority of the patients did not have sufficient reasons for not receiving adjuvant radiotherapy (52–69%) and supportive care (above 80%). We present here the first wide‐scale quality measurement initiative of cancer patients in Japan. Patients without clinically valid reasons for non‐adherence should be examined further in future to improve care.
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Affiliation(s)
- Momoko Iwamoto
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
| | - Fumiaki Nakamura
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahiro Higashi
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
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Becerra AZ, Probst CP, Tejani MA, Aquina CT, González MG, Hensley BJ, Noyes K, Monson JR, Fleming FJ. Opportunity lost: Adjuvant chemotherapy in patients with stage III colon cancer remains underused. Surgery 2015; 158:692-9. [DOI: 10.1016/j.surg.2015.03.057] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/16/2015] [Accepted: 03/17/2015] [Indexed: 12/24/2022]
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Nadpara PA, Madhavan SS, Tworek C. Disparities in Lung Cancer Care and Outcomes among Elderly in a Medically Underserved State Population-A Cancer Registry-Linked Database Study. Popul Health Manag 2015; 19:109-19. [PMID: 26086239 DOI: 10.1089/pop.2015.0027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite availability of guidelines for lung cancer care, variations in lung cancer care among the elderly exist across the nation and are a cause for concern in rural and medically underserved areas. Therefore, the purpose of this study was to evaluate the patterns of lung cancer care and associated health outcomes among elderly residing in a rural and medically underserved area. The authors identified 1924 elderly lung cancer patients from the West Virginia Cancer Registry-Medicare linked database (2002-2007) and categorized them by receipt of guideline-concordant (appropriate and timely) care using guidelines from the American College of Chest Physicians, British Thoracic Society, and the RAND Corporation. Hierarchical generalized logistic models were constructed to identify variables associated with receipt of guideline-concordant care. Kaplan-Meier analysis and log-rank test were used to compare 3-year survival outcomes. Multivariate Cox proportional hazards models were constructed to estimate lung cancer mortality risk associated with nonreceipt of guideline-concordant care. Although guideline-concordant appropriate care was received by fewer than half of all patients (46.5%), of those receiving care, 78.7% received it in a timely manner. Delays in diagnosis and treatment varied significantly. Survival outcomes significantly improved with appropriate care (799 vs. 366 days; P≤0.05), but did not improve with timely care. This study highlights the critical need to address disparities in receipt of guideline-concordant lung cancer care among the elderly residing in rural and medically underserved areas. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern. (Population Health Management 2016;19:109-119).
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Affiliation(s)
- Pramit A Nadpara
- 1 Virginia Commonwealth University , School of Pharmacy, Department of Pharmacotherapy & Outcomes Science, Richmond, Virginia
| | - S Suresh Madhavan
- 2 West Virginia University , School of Pharmacy, Department of Pharmaceutical Systems & Policy, Morgantown, West Virginia
| | - Cindy Tworek
- 2 West Virginia University , School of Pharmacy, Department of Pharmaceutical Systems & Policy, Morgantown, West Virginia
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Hanly P, Céilleachair AÓ, Skally M, O'Neill C, Sharp L. Direct costs of radiotherapy for rectal cancer: a microcosting study. BMC Health Serv Res 2015; 15:184. [PMID: 25934169 PMCID: PMC4494796 DOI: 10.1186/s12913-015-0845-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 04/24/2015] [Indexed: 11/10/2022] Open
Abstract
Background Radiotherapy provides significant benefits in terms of reducing risk of local recurrence and death from rectal cancer. Despite this, up-to-date cost estimates for radiotherapy are lacking, potentially inhibiting policy and decision-making. Our objective was to generate an up-to-date estimate of the cost of traditional radiotherapy for rectal cancer and model the impact of a range of potential efficiency improvements. Methods Microcosting methods were used to estimate total direct radiotherapy costs for long- (assumed at 45-50 Gy in 25 daily fractions over a 5 week period) and short-courses (assumed at 25 Gy in 5 daily fractions over a one week period). Following interviews and on-site visits to radiotherapy departments in two designated cancer centers, a radiotherapy care pathway for a typical rectal cancer patient was developed. Total direct costs were derived by applying fixed and variable unit costs to resource use within each care phase. Costs included labor, capital, consumables and overheads. Sensitivity analyses were performed. Results Radiotherapy treatment was estimated to cost between €2,080 (5-fraction course) and €3,609 (25-fraction course) for an average patient in 2012. Costs were highest in the treatment planning phase for the short-course (€1,217; 58% of total costs), but highest in the radiation treatment phase for the long-course (€1,974: 60% of total costs). By simultaneously varying treatment time, capacity utilization rates and linear accelerator staff numbers, the base cost fell by 20% for 5-fractions: (€1,660) and 35% for 25-fractions: (€2,354). Conclusions Traditional radiotherapy for rectal cancer is relatively inexpensive. Moreover, significant savings may be achievable through service organization and provision changes. These results suggest that a strong economic argument can be made for expanding the use of radiotherapy in rectal cancer treatment.
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Affiliation(s)
- Paul Hanly
- School of Business, National College of Ireland, Dublin, Ireland.
| | | | - Máiréad Skally
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - Ciaran O'Neill
- J.E. Cairnes School of Business and Economics, National University of Ireland, Galway, Ireland.
| | - Linda Sharp
- Research Department, National Cancer Registry Ireland, Cork, Ireland.
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Kehl KL, Lamont EB, McNeil BJ, Bozeman SR, Kelley MJ, Keating NL. Comparing a medical records-based and a claims-based index for measuring comorbidity in patients with lung or colon cancer. J Geriatr Oncol 2015; 6:202-10. [DOI: 10.1016/j.jgo.2015.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 11/19/2014] [Accepted: 01/20/2015] [Indexed: 11/28/2022]
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Nadpara PA, Madhavan SS, Tworek C, Sambamoorthi U, Hendryx M, Almubarak M. Guideline-concordant lung cancer care and associated health outcomes among elderly patients in the United States. J Geriatr Oncol 2015; 6:101-10. [PMID: 25604094 PMCID: PMC4450093 DOI: 10.1016/j.jgo.2015.01.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 11/26/2014] [Accepted: 01/04/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES In the United States (US), the elderly carry a disproportionate burden of lung cancer. Although evidence-based guidelines for lung cancer care have been published, lack of high quality care still remains a concern among the elderly. This study comprehensively evaluates the variations in guideline-concordant lung cancer care among elderly in the US. MATERIALS AND METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2002-2007), we identified elderly patients (aged ≥65 years) with lung cancer (n = 42,323) and categorized them by receipt of guideline-concordant care, using evidence-based guidelines from the American College of Chest Physicians. A hierarchical generalized logistic model was constructed to identify variables associated with receipt of guideline-concordant care. Kaplan-Meier analysis and Log Rank test were used for estimation and comparison of the three-year survival. Multivariate Cox proportional hazards model was constructed to estimate lung cancer mortality risk associated with receipt of guideline-discordant care. RESULTS Only less than half of all patients (44.7%) received guideline-concordant care in the study population. The likelihood of receiving guideline-concordant care significantly decreased with increasing age, non-white race, higher comorbidity score, and lower income. Three-year median survival time significantly increased (exceeded 487 days) in patients receiving guideline-concordant care. Adjusted lung cancer mortality risk significantly increased by 91% (HR = 1.91, 95% CI: 1.82-2.00) among patients receiving guideline-discordant care. CONCLUSION This study highlights the critical need to address disparities in receipt of guideline-concordant lung cancer care among elderly. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern.
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Affiliation(s)
- Pramit A Nadpara
- Virginia Commonwealth University, School of Pharmacy, Department of Pharmacotherapy & Outcomes Science, Richmond, VA 23298-0533, USA.
| | - S Suresh Madhavan
- West Virginia University, School of Pharmacy, Department of Pharmaceutical Systems & Policy, Morgantown, WV 26506-9500, USA
| | - Cindy Tworek
- West Virginia University, School of Pharmacy, Department of Pharmaceutical Systems & Policy, Morgantown, WV 26506-9500, USA
| | - Usha Sambamoorthi
- West Virginia University, School of Pharmacy, Department of Pharmaceutical Systems & Policy, Morgantown, WV 26506-9500, USA
| | - Michael Hendryx
- Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN 47405, USA
| | - Mohammed Almubarak
- West Virginia University, School of Medicine, Morgantown, WV 26506-9600, USA
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Decision Making in Lung Cancer – How Applicable are the Guidelines? Clin Oncol (R Coll Radiol) 2015; 27:125-31. [DOI: 10.1016/j.clon.2014.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/21/2014] [Indexed: 11/21/2022]
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