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Hassett MJ, Tramontano AC, Uno H, Ritzwoller DP, Punglia RS. Geospatial Disparities in the Treatment of Curable Breast Cancer Across the US. JAMA Oncol 2022; 8:445-449. [PMID: 35084444 PMCID: PMC8796059 DOI: 10.1001/jamaoncol.2021.7337] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Patient factors help explain disparities in breast cancer treatments and outcomes. OBJECTIVE To determine the extent to which geospatial variation in initial breast cancer care can be attributed to region vs patient factors with the aim of guiding quality improvement efforts. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective population-based cohort study from January 1, 2007, through December 31, 2016, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database that included 31 571 patients diagnosed with stage I to III breast cancer from 2007 through 2013. Five metrics of care delivery were defined: stage I at diagnosis, chemotherapy receipt, radiation therapy receipt, endocrine therapy (ET) initiation (year 1), and ET continuation (years 3-5). Data analysis was performed from January to June 2021. EXPOSURES Stage I diagnosis and treatment with chemotherapy, radiation therapy, or ET. MAIN OUTCOMES AND MEASURES For each metric, total variance was attributed proportionally to 4 domains-random, patient factors (eg, age, race and ethnicity, socioeconomic status), region (health service area [HSA]), and unexplained-using hierarchical multivariable modeling. RESULTS Of 31 571 total patients (median [IQR] age, 71 [68-75] years), 19 391 (61.4%) had stage I disease at diagnosis. Among eligible patients, 17 297 of 21 190 (81.6%) received radiation therapy, 7204 of 9903 (72.8%) received chemotherapy, 13 115 of 26 855 (48.8%) initiated ET, and 13 944 of 26 855 (52.1%) continued ET. Geospatial density (ie, heat) maps highlight regional performance patterns. For all 5 metrics, region/HSA explained more observed variation (24%-48%) than patient factors (1%-4%); the largest share of variation was unexplained (35%-54%). The metrics with the largest proportion of total variance attributed to region/HSA were ET initiation and continuation (28% and 39%, respectively). CONCLUSIONS AND RELEVANCE In this cohort study, there was substantial unexplained geospatial variation in initial breast cancer care. The variance attributed to region/HSA was multifold larger than that explained by patient factors. The importance of patient factors such as race and ethnicity notwithstanding, future quality improvement efforts should focus on reducing unwarranted geospatial variation, especially including optimizing the delivery of ET in low-performing regions.
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Affiliation(s)
- Michael J. Hassett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Angela C. Tramontano
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Harvard Medical School, Boston, Massachusetts,Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Rinaa S. Punglia
- Harvard Medical School, Boston, Massachusetts,Department of Radiation Oncology, Brigham & Women’s Hospital, Boston, Massachusetts
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Lodde G, Forschner A, Hassel J, Wulfken LM, Meier F, Mohr P, Kähler K, Schilling B, Loquai C, Berking C, Hüning S, Schatton K, Gebhardt C, Eckardt J, Gutzmer R, Reinhardt L, Glutsch V, Nikfarjam U, Erdmann M, Stang A, Kowall B, Roesch A, Ugurel S, Zimmer L, Schadendorf D, Livingstone E. Factors Influencing the Adjuvant Therapy Decision: Results of a Real-World Multicenter Data Analysis of 904 Melanoma Patients. Cancers (Basel) 2021; 13:2319. [PMID: 34065995 PMCID: PMC8151445 DOI: 10.3390/cancers13102319] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022] Open
Abstract
Adjuvant treatment of melanoma patients with immune-checkpoint inhibition (ICI) and targeted therapy (TT) significantly improved recurrence-free survival. This study investigates the real-world situation of 904 patients from 13 German skin cancer centers with an indication for adjuvant treatment since the approval of adjuvant ICI and TT. From adjusted log-binomial regression models, we estimated relative risks for associations between various influence factors and treatment decisions (adjuvant therapy yes/no, TT vs. ICI in BRAF mutant patients). Of these patients, 76.9% (95% CI 74-80) opted for a systemic adjuvant treatment. The probability of starting an adjuvant treatment was 26% lower in patients >65 years (RR 0.74, 95% CI 68-80). The most common reasons against adjuvant treatment given by patients were age (29.4%, 95% CI 24-38), and fear of adverse events (21.1%, 95% CI 16-28) and impaired quality of life (11.9%, 95% CI 7-16). Of all BRAF-mutated patients who opted for adjuvant treatment, 52.9% (95% CI 47-59) decided for ICI. Treatment decision for TT or ICI was barely associated with age, gender and tumor stage, but with comorbidities and affiliated center. Shortly after their approval, adjuvant treatments have been well accepted by physicians and patients. Age plays a decisive role in the decision for adjuvant treatment, while pre-existing autoimmune disease and regional differences influence the choice between TT or ICI.
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Affiliation(s)
- Georg Lodde
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
| | - Andrea Forschner
- Department of Dermatology, University Hospital Tuebingen, 72076 Tuebingen, Germany; (A.F.); (J.E.)
| | - Jessica Hassel
- Department of Dermatology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Lena M. Wulfken
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Venereology and Allergology, University Hospital Hannover Medical School, 30625 Hannover, Germany; (L.M.W.); (R.G.)
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, 01307 Dresden, Germany; (F.M.); (L.R.)
| | - Peter Mohr
- Department of Dermatology, Elbe Kliniken Stade-Buxtehude, 21614 Buxtehude, Germany;
| | - Katharina Kähler
- Department of Dermatology, Venereology and Allergology, University Hospital Kiel, 24105 Kiel, Germany;
| | - Bastian Schilling
- Department of Dermatology, Venereology and Allergology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (B.S.); (V.G.)
| | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, 55131 Mainz, Germany; (C.L.); (U.N.)
| | - Carola Berking
- Department of Dermatology, University Hospital Erlangen, CCC-Comprehensive Cancer Center Erlangen-EMN, Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Deutsches Zentrum Immuntherapie (DZI), 91054 Erlangen, Germany; (C.B.); (M.E.)
| | - Svea Hüning
- Department of Dermatology, Klinikum Dortmund gGmbH, 44137 Dortmund, Germany;
| | - Kerstin Schatton
- Department of Dermatology, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany;
| | - Christoffer Gebhardt
- Department of Dermatology, Venereology and Allergology, University Hospital Hamburg, 20246 Hamburg, Germany;
| | - Julia Eckardt
- Department of Dermatology, University Hospital Tuebingen, 72076 Tuebingen, Germany; (A.F.); (J.E.)
| | - Ralf Gutzmer
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Venereology and Allergology, University Hospital Hannover Medical School, 30625 Hannover, Germany; (L.M.W.); (R.G.)
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, 01307 Dresden, Germany; (F.M.); (L.R.)
| | - Valerie Glutsch
- Department of Dermatology, Venereology and Allergology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (B.S.); (V.G.)
| | - Ulrike Nikfarjam
- Department of Dermatology, University Hospital Mainz, 55131 Mainz, Germany; (C.L.); (U.N.)
| | - Michael Erdmann
- Department of Dermatology, University Hospital Erlangen, CCC-Comprehensive Cancer Center Erlangen-EMN, Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Deutsches Zentrum Immuntherapie (DZI), 91054 Erlangen, Germany; (C.B.); (M.E.)
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, 45122 Essen, Germany; (A.S.); (B.K.)
| | - Bernd Kowall
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, 45122 Essen, Germany; (A.S.); (B.K.)
| | - Alexander Roesch
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
- German Consortium for Translational Cancer Research (DKTK), Partner Site Essen and German Cancer Research Center (DKFZ), 45147 Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
| | - Dirk Schadendorf
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
- German Consortium for Translational Cancer Research (DKTK), Partner Site Essen and German Cancer Research Center (DKFZ), 45147 Essen, Germany
| | - Elisabeth Livingstone
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
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The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041384. [PMID: 33546168 PMCID: PMC7913122 DOI: 10.3390/ijerph18041384] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/15/2022]
Abstract
One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.
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Merchant SJ, Kong W, Gyawali B, Hanna TP, Chung W, Nanji S, Patel SV, Booth CM. First-Line Palliative Chemotherapy for Esophageal and Gastric Cancer: Practice Patterns and Outcomes in the General Population. JCO Oncol Pract 2021; 17:e1537-e1550. [PMID: 33449833 DOI: 10.1200/op.20.00397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Clinical trials have shown that palliative chemotherapy (PC) improves survival in patients with incurable esophageal and gastric cancer; however, outcomes achieved in routine practice are unknown. We describe treatment patterns and outcomes among patients treated in the general population of Ontario, Canada. METHODS The Ontario Cancer Registry was used to identify patients with esophageal or gastric cancer from 2007 to 2016, and data were linked to other health administrative databases. Patients who received curative-intent surgery or radiotherapy were excluded. Factors associated with the receipt of PC were determined using logistic regression. First-line PC regimens were categorized, and trends over time were reported. Survival was determined using the Kaplan-Meier method. RESULTS The cohort included 9,848 patients; 22% (2,207 of 9,848) received PC. Patients receiving PC were younger (mean age, 63 v 74 years; P < .0001) and more likely male (71% v 65%; P < .0001). Thirty-seven percent of non-PC patients saw a medical oncologist in consultation. Over the study period, utilization of PC increased (from 11% in 2007 to 19% in 2016; P < .0001), whereas the proportion of patients receiving triplet regimens decreased (65% in 2007 to 56% in 2016; P = .04). In the PC group, the median overall and cancer-specific survival from treatment initiation was 7.2 months. CONCLUSION One fifth of patients with incurable esophageal and gastric cancer in the general population receive PC. Median survival of patients treated in routine practice is inferior to that in clinical trials. Only one third of patients not treated with PC had consultation with a medical oncologist. Further work is necessary to understand low utilization of PC and medical oncology consultation in this patient population.
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Affiliation(s)
- Shaila J Merchant
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Weidong Kong
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Timothy P Hanna
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Wiley Chung
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
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