Preventive care in prostate cancer patients: following diagnosis and for five-year survivors

Vaccination uptake among post-treatment cancer survivors: A multi-vaccine scoping review

BACKGROUND

Our goal was to provide an overview of uptake rates across vaccine types and factors associated with vaccine uptake among cancer survivor populations.

METHODS

A literature search was conducted using Ovid MEDLINE® ALL (Wolters Kluwer), Embase (Elsevier) and CINAHL Complete (EBSCO) databases and according to PRISMA guidelines. Eligible articles were limited to those examining vaccination uptake among cancer survivors who had completed treatment, reported factors associated with uptake (e.g., barriers and facilitators), and published in English between 2011 and 2021. Two independent reviewers screened citations for inclusion and two performed data abstraction, verified by an arbiter.

RESULTS

The search returned 4,215 total articles, and 271 duplicates were removed. During abstract/title screening, 212 articles were identified. Following full-text screening, 47 articles/abstracts were found to meet inclusion criteria, 16 articles/abstracts were removed, and 31 studies were included in the review. Among the 31 studies, participant age ranged from 9 years to adults of all ages. Vaccine types included: influenza (n = 18), human papillomavirus (n = 10), pneumococcal (n = 8), hepatitis A/B (n = 1), shingles (n = 1), measles (n = 1), tetanus/diphtheria (n = 1), and haemophilus influenza B (n = 1). Vaccine uptake varied greatly across studies, vaccine types, and participant populations. Factors affecting vaccination uptake included sociodemographic variables and social determinants of health, health beliefs/attitudes/knowledge, provider recommendation, and cancer treatment/clinical variables.

CONCLUSIONS

Our findings highlight the need for further examining factors associated with vaccine uptake, the need for clinical guidelines that specifically address vaccination among cancer survivors, and potential targets for multi-level interventions to improve vaccination rates among cancer survivor populations.

Pain management for post-treatment survivors of complex cancers: a qualitative study of opioids and cannabis

Aim: We aimed to understand experiences with opioids and cannabis for post-treatment cancer survivors. Patients & methods: We conducted seven focus groups among head and neck and lung cancer survivors, using standard qualitative methodology to explore themes around 1) post-treatment pain and 2) utilization, perceived benefits and perceived harms of cannabis and opioids. Results & conclusion: Survivors (N = 25) experienced addiction fears, stigma and access challenges for both products. Opioids were often perceived as critical for severe pain. Cannabis reduced pain and anxiety for many survivors, suggesting that anxiety screening, as recommended in guidelines, would improve traditional pain assessment. Opioids and cannabis present complex harms and benefits for post-treatment survivors who must balance pain management and minimizing side effects.

Racial and Ethnic Disparities in Survival Among People With Second Primary Cancer in the US

Importance

Comprehensive data for racial and ethnic disparities after second primary cancers (SPCs) are lacking despite the growing burden of SPCs.

Objective

To quantify racial and ethnic disparities in survival among persons with SPCs.

Design, Setting, and Participants

This population-based, retrospective cohort study used data from 18 Surveillance, Epidemiology, and End Results registries in the US for persons diagnosed with the most common SPCs at age 20 years or older from January 1, 2000, to December 31, 2013 (with follow-up through December 31, 2018). Data were analyzed between January and April 2023.

Exposure

Race and ethnicity (Hispanic, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, and non-Hispanic White).

Main Outcomes and Measures

The main outcomes were 5-year relative survival and cause-specific survival. Cause-specific hazard ratios (HRs) were calculated for death from cancer or cardiovascular disease (CVD) in each racial and ethnic minority population compared with the White population overall and stratified by SPC type, with adjustment for sex, year and age at SPC diagnosis, and prior cancer type and stage (baseline model) and additionally for county attributes (household income, urbanicity), SPC characteristics (stage, subtype), and treatment.

Results

Among 230 370 persons with SPCs (58.4% male), 4.5% were Asian or Pacific Islander, 9.6% were Black, 6.4% were Hispanic, and 79.5% were White. A total of 109 757 cancer-related deaths (47.6%) and 18 283 CVD-related deaths (7.9%) occurred during a median follow-up of 54 months (IQR, 12-93 months). In baseline models, compared with the White population, the risk of cancer-related death overall was higher in the Black (HR, 1.21; 95% CI, 1.18-1.23) and Hispanic (HR, 1.10; 95% CI, 1.07-1.13) populations but lower in the Asian or Pacific Islander population (HR, 0.93; 95% CI, 0.90-0.96). When stratified by 13 SPC types, the risk of cancer-related death was higher for 10 SPCs in the Black population, with the highest HR for uterine cancer (HR, 1.87; 95% CI, 1.63-2.15), and for 7 SPCs in the Hispanic population, most notably for melanoma (HR, 1.46; 95% CI, 1.21-1.76). For CVD-related death, the overall HR was higher in the Black population (HR, 1.41; 95% CI, 1.34-1.49), with elevated risks evident for 11 SPCs, but lower in the Asian or Pacific Islander (HR, 0.75; 95% CI, 0.69-0.81) and Hispanic (HR, 0.90; 95% CI, 0.84-0.96) populations than in the White population. After further adjustments for county attributes and SPC characteristics and treatment, HRs were reduced for cancer-related death and for CVD-related death and associations in the same direction remained.

Conclusions and Relevance

In this cohort study of SPC survivors, the Black population had the highest risk of both death from cancer and death from CVD, and the Hispanic population had a higher risk of death from cancer than the White population. Attenuations in HRs after adjustment for potentially modifiable factors highlight opportunities to reduce survival disparities among persons with multiple primary cancers.

Safety of opioid prescribing among older cancer survivors

BACKGROUND

Cancer survivors receive more long-term opioid therapy (LTOT) than people without cancer, but the safety of LTOT prescribing is unknown.

METHODS

Opioid-naive adults aged ≥66 years who had been diagnosed in 2008-2015 with breast, lung, head and neck, or colorectal cancer were identified with data from Surveillance, Epidemiology, and End Results cancer registries linked with Medicare claims. Survivors with 1 or more LTOT episodes (≥90 consecutive days) occurring ≥1 year after their cancer diagnosis and before censoring at hospice entry, another cancer diagnosis, 6 months before death, or December 2016 were included. The safety of prescribing during the first 90 days of the first LTOT episode was measured during follow-up. As a positive safety indicator, the proportion of survivors with concurrent nonopioid pain management was measured. Indicators of less safe prescribing were the proportion of survivors with a high average daily opioid dose (≥90 morphine milligram equivalents) and the proportion of survivors with concurrent benzodiazepine dispensing. Multivariable logistic regression analyses were conducted to identify clinical predictors of each safety outcome.

RESULTS

In all, 3628 cancer survivors received LTOT during follow-up (median duration, 4.9 months; interquartile range, 3.5-8.0 months). Seventy-two percent of the survivors received multimodal pain management concurrently with LTOT. Eight percent of the survivors had high-dose opioid prescriptions; 25% of the survivors received benzodiazepines during LTOT. Multivariable analyses identified variations in safety measures by multiple clinical factors, although none were consistently significant across outcomes.

CONCLUSIONS

To improve safe LTOT prescribing for survivors, efforts should focus on increasing multimodal pain management and reducing inappropriate benzodiazepine prescribing. Different clinical predictors of each outcome suggest different drivers of safe prescribing.

Health care access and utilization among adult cancer survivors: Results from the National Institutes of Health "All of Us" Research Program

Background

Many cancer survivors face financial difficulties that prevent them from receiving appropriate health care. Racial/ethnic disparities in receipt of health care have been reported among cancer survivors, but recent data for important racial/ethnic subgroups of the US population are lacking.

Methods

To learn more about barriers to healthcare access faced by cancer survivors, we analyzed data from the NIH “All of Us” Research Program. Data were analyzed about demographic factors and other personal characteristics, personal medical history of cancer, healthcare utilization, and access to care.

Results

As of November 2020, a total of 5426 participants had a history of cancer (excluding skin cancer). About 88.2% were non‐Hispanic White; 3.9% were Black, African American, or African; 1.3% were Asian; 4.1% were Hispanic, Latino, or Spanish; and 1.2% reported more than one race. Just over one‐half had an annual income of $75,000 or greater. The majority of the participants (71.7%) were college graduates or had an advanced degree. About 47.0%% had private health insurance, 41.0% had Medicare, 6.0% had Medicaid, and the remainder had military, Veterans Affairs, other insurance, or no health insurance. Frequently cited reasons for delayed care in the past 12 months were “had to pay out of pocket for some or all of the procedures,” “deductible was too high/or could not afford the deductible,” “couldn't afford the copay,” “couldn't get time off work,” and “were nervous about seeing a health care provider.”

Discussion

A minority of cancer survivors who participated in the NIH “All of Us” Program had difficulty paying for health care in the past 12 months. Of particular concern are minorities such as African American and Hispanic cancer survivors along with those who are low income.

Many cancer survivors face financial problems that prevent them from receiving timely and recommended health care. A minority of cancer survivors who participated in the NIH “All of Us” Research Program had difficulty paying for health care in the past 12 months. Of particular concern are minorities such as African American and Hispanic cancer survivors along with those who are low income.

A cross-sectional study of factors associated with influenza vaccination in Korean cancer survivors

OBJECTIVE

To investigate factors associated with influenza vaccination in cancer survivors.

METHODS

Study subjects were 1,945 Korean adult cancer survivors. Through medical record review and self-administered questionnaires, social and medical information was collected. Influenza vaccination was defined as ever having received a flu vaccine between one year before cancer diagnosis and the survey date. Multiple logistic regression analysis was used to evaluate factors associated with influenza vaccination.

RESULTS

Overall, 60.8% of study subjects had received an influenza vaccination. Younger survivors had a significantly lower vaccination rate than did the elderly survivors (80.22% vs. 54.73%). In younger survivors, longer time elapsed since cancer diagnosis, lifestyle modification counselling during cancer treatment, adequate physical exercise (≥150 min/week) and complementary medication use were positively associated with vaccination, whereas extra-pulmonary cancers, multimodality (≥3) cancer treatment and higher educational achievement were inversely associated. In elderly survivors, fewer factors had a positive (adequate physical exercise) or inverse (multimodality cancer treatment and current smoking) association with influenza vaccination.

CONCLUSION

Influenza vaccination rate was suboptimal, especially among younger cancer survivors. Targeted strategies are necessary to improve influenza vaccination in cancer survivors with consideration of individual characteristics such as age, lifestyle, cancer treatment modality, cancer type and education level.

Associations between shared care and patient experiences among older cancer survivors

PURPOSE

Cancer survivors have unique medical care needs. "Shared care," delivered by both oncologists and primary care providers (PCPs), may better address these needs. Little information is available on differences in outcomes among survivors receiving shared care versus oncologist-led or PCP-led care. This study compared experiences of care for survivors receiving shared care, oncologist-led, PCP-led, or other care patterns.

METHODS

We used SEER-CAHPS data, including NCI's SEER registry data, Medicare claims, and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses. Medicare Fee-for-Service beneficiaries age ≥ 65 years in SEER-CAHPS with breast, cervical, colorectal, lung, renal, or prostate cancers or hematologic malignancies who responded to a Medicare CAHPS survey ≥ 18 months post-diagnosis were included. CAHPS measures included ratings of overall care, personal doctor, specialist physician, health plan, prescription drug plan, and five composite scores. Survivorship care patterns were identified using proportions of oncologist, PCP, and other physician encounters. Multivariable regressions examined associations between care patterns and CAHPS outcomes.

RESULTS

Among 10,132 survivors, 15% received shared care, 10% oncologist-led, 33% PCP-led, and 42% other. Compared with shared care, we found no significant differences in experiences of care except for getting needed drugs (lower scores for PCP-led and other care patterns). Sensitivity analyses using different patterns of care definitions similarly showed no associations between survivorship care pattern and experience of care.

CONCLUSIONS

Within the limitations of the study dataset, survivors age 65+ receiving shared care reported similar experiences of care to those receiving oncologist-led, PCP-led, and other patterns of care.

IMPLICATIONS FOR CANCER SURVIVORS

Shared care may not provide survivor-perceived benefits compared with other care patterns.

Factors associated with pneumococcal vaccination uptake by cancer survivors

PURPOSE

This study aimed to evaluate factors associated with pneumococcal vaccination uptake (PVU) of cancer survivors.

METHODS

A total of 2032 Korean adult cancer survivors diagnosed between June of 1975 and February of 2018 have participated. Information on PVU status and selected variables were collected through self-administered questionnaires and medical record review. Factors associated PVU were investigated using multiple logistic regression analysis.

RESULTS

PVU rate markedly differed by age strata and cancer sites: 73.9% for elderly (≥ 65 years) survivors and 34.6% for younger (< 65 years) survivors and 73.4% for lung cancer survivors and 42.1% for non-lung cancer survivors. Regular physical exercise was associated with higher PVU in both age groups: Odds ratio (OR) and 95% confidence interval (CI) were 1.52 (1.20, 1.94) for younger and 1.78 (1.09, 2.90) for elderly survivors. Complementary medication use was positively associated with PVU with borderline significance in both age groups. However, the association of PVU with other factors differed between the two age groups. In younger survivors, a positive association with PVU was evident for longer time lapse after cancer diagnosis, chronic disease, and living with spouse/or partner, while cancer stage, educational achievement, and alcohol use were inversely associated PVU. On the other hand, multi-modality (≥ 3) cancer treatment was inversely associated with PVU only in elderly survivors.

CONCLUSIONS

PVU of Korean cancer survivors was suboptimal in younger survivors and non-lung cancer survivors. Factors associated with PVU differed between younger and elderly survivors, and more diverse factors were identified for younger survivors.

IMPLICATIONS FOR CANCER SURVIVORS

In order to promote adherence to PVU in cancer survivors, careful consideration of high-risk factors for non-immunization within cancer survivorship context would be necessary together with free-of-charge vaccination policy.

Incidence and Predictors of Diabetes Mellitus after a Diagnosis of Early-Stage Breast Cancer in the Elderly Using Real-World Data

PURPOSE

The incidence and predictors of diabetes (DM) in patients with breast cancer (BC) were evaluated. We compared DM incidence and physician access in BC patients to matched controls.

METHODS

We identified women with stage I-III BC diagnosed from 2005 to 2013 in the SEER-Medicare database, with ≥ 2 years of follow-up after diagnosis, without previous DM claims. Incident DM was determined by ≥ 1 DM claims after BC diagnosis. Multivariable analysis was used to identify factors associated with incident DM. Age- and race-matched non-cancer controls were obtained from a 5% random sample and assigned an index date. Physician and PCP visits per-patient-per-year were compared between cases and controls in the two-year period prior to and after the index date.

RESULTS

Among 14,506 eligible BC patients, 3234 (22.3%) developed DM versus 16.5% of controls. Among BC patients, factors associated with incident DM included race (Black OR 1.63 95% CI 1.39-1.93, Hispanic OR 3.03 95% CI 1.92-4.81; vs. Caucasians), SES (Quintile 0 vs. Quintile 4 OR 1.55 95% CI 1.33-1.78), and receipt of chemotherapy (vs. none OR 1.19 95% CI 1.08-1.31). Among cases and controls, respectively, median physician visits per-patient-per-year were 19 and 17 prior to the index date, and 46 and 19 after the index date; median PCP visits were 2 for both groups in both periods.

CONCLUSION

About 22% of BC patients developed DM, more than controls in the same period. While there were differences in healthcare access, there weren't differences in PCP access between groups. This represents an opportunity for better comorbidity management in BC patients.

Screening utilization among cancer survivors: a meta-analysis

Background

Studies have been published showing both increased and decreased utilization of cancer screening services in cancer survivors compared with cancer-free counterparts. This study synthesizes existing evidence in a meta-analysis.

Methods

A systematic literature review was conducted in August 2016. Studies were included if they compared the utilization of screening services for cervical, breast and colorectal cancer among adulthood cancer survivors to cancer-free controls. Random effects meta-analyses were conducted to pool estimates.

Results

Of 3538 studies, 19 fulfilled the inclusion criteria. Cancer survivors were more likely to utilize screening services for breast cancer (odds ratio (OR) = 1.27, 95% confidence interval (CI): 1.13-1.42, P < 0.001), colorectal cancer (OR = 1.25, 95% CI: 1.15-1.37, P < 0.001) and cervical cancer (OR = 1.38, 95% CI: 1.08-1.75, P < 0.001) than cancer-free controls.

Conclusions

Overall, cancer survivors were more likely to utilize cancer screening services when compared with cancer-free controls. Future studies should evaluate, whether the utilization of screening services translates into prolonged survival.

Continuity of Care, Follow-Up Care, and Outcomes among Breast Cancer Survivors

This retrospective cohort study examined the effects of care continuity on the utilization of follow-up services and outcome of breast cancer patients (stages I-III) in the post-treatment phase of care. Propensity score matching and generalized estimation equations were used in the analysis of data obtained from national longitudinal databases. The continuity of care index (COCI) was calculated separately for primary care physicians (PCP) and oncologists. Our results revealed that breast cancer survivors with a higher oncology COCI were more likely than those with a lower oncology COCI to use mammography or breast ultrasound during the follow-up period (OR = 1.26, 95% CI: 1.19-1.32; OR = 1.12, 95% CI: 1.06-1.18; respectively). In terms of health outcomes, a higher oncology COCI was associated with a lower likelihood of hospitalization (OR = 0.78, 95% CI: 0.71-0.85) and emergency department use (OR = 0.88, 95% CI: 0.82-0.95). A higher PCP COCI was also associated with a lower likelihood of hospitalization (OR = 0.77, 95% CI: 0.70-0.85) and emergency department use (OR = 0.75, 95% CI: 0.68-0.82). Overall, this study determined that ambulatory care continuity is positively associated with the likelihood of using recommended follow-up care services and negatively associated with adverse health events among breast cancer survivors.

Racial and socioeconomic disparities in adherence to preventive health services for ovarian cancer survivors

PURPOSE

To examine ovarian cancer survivors' adherence to evidence-based guidelines for preventive health care.

METHODS

A case-control, retrospective study of Medicare fee-for-service beneficiaries diagnosed with stage I, II, or III epithelial ovarian cancer from 2001 to 2010 using the Surveillance, Epidemiology, and End Results-Medicare database. Survivors were matched 1:1 to non-cancer controls from the 5% Medicare Beneficiary file on age, race, state of residence, and follow-up time. Receipt of flu vaccination, mammography, and bone density tests were examined in accordance with national guidelines. Adherence was assessed starting 1 year after cancer diagnosis, across 2 years of claims. Interaction with the health care system, including outpatient and cancer surveillance visits, was tested as a potential mechanism for receipt of services.

RESULTS

2437 survivors met the eligibility criteria (mean age, 75; 90% white). Ovarian cancer survivors were more likely to be adherent to flu vaccination (5 percentage points (pp); < 0.001) and mammography guidelines (10 pp.; < 0.001) compared to non-cancer controls, but no differences were found for bone density test guidelines (- 1 pp.; NS). Black women were less likely to be adherent to flu vaccination and bone density tests compared with white women. Women dually eligible for Medicare and Medicaid were less likely to be adherent compared to those without such support. Adherence was not influenced by measures of outpatient visits.

CONCLUSION

Ovarian cancer survivors are receiving preventive services with the same or better adherence than their matched counterparts. Minority and dual-eligible survivors received preventive services at a lower rate than white survivors and those with higher income. The number of outpatient visits was not associated with increased preventive health visits.

IMPLICATIONS FOR CANCER SURVIVORS

Ovarian cancer survivors are receiving adequate follow-up care to be adherent to preventive health measures. Efforts to improve care coordination post-treatment may help reduce minority and low SES disparities.

Building Personalized Cancer Follow-up Care Pathways in the United States: Lessons Learned From Implementation in England, Northern Ireland, and Australia

There is a global need to transform cancer follow-up care to address the needs of cancer survivors while efficiently using the health care system to limit the effects of provider shortages, gaps in provider knowledge, and already overburdened clinics; improve the mental health of clinicians; and limit costs to health care systems and patients. England, Northern Ireland, and Australia are implementing an approach that triages patients to personalized follow-up care pathways depending on the types and levels of resources needed for patients' long-term care that has been shown to meet patients' needs, more efficiently use the health care system, and reduce costs. This article discusses lessons learned from these implementation efforts, identifying the necessary components of these care models and barriers and facilitators to implementation of this care. Specifically, the United States and other countries looking to transform follow-up care should consider how to develop six key principles of this care: algorithms to triage patients to pathways; methods to assess patient issues to guide care; remote monitoring systems; methods to support patients in self-management; ways to coordinate care and information exchange between oncology, primary care, specialists, and patients; and methods to engage all stakeholders and secure their ongoing buy-in. Next steps to advance this work in the United States are discussed.

Cardiovascular Care Among Cancer Survivors in the United States

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of mortality among cancer survivors, but whether survivors receive routine cardiovascular monitoring and preventive care has not been well studied. This study uses a population-based dataset to examine this question.

METHODS

Data from the National Health Interview Survey were used to identify 13 266 cancer survivors who completed surveys from 2011 to 2015. Prevalence of CVD and associated risk factors, patterns of doctor visitation, and receipt of CVD preventive care were examined. We used multivariable logistic regression analysis to examine factors associated with the receipt of preventive care for survivors with and without CVD risk factors.

RESULTS

CVD risk factors were prevalent in older cancer survivors 65 years and older (56.9% with hyperlipidemia, 66.8% with hypertension) and younger survivors younger than 50 years (35.4% obese, 30.3% current smokers). Rates of blood pressure, cholesterol, and glucose monitoring were high, but rates of lifestyle modification were lower (54.8% moderate exercise, 47.1% smoking cessation attempts among smokers). Although 71.5% of survivors at 2 years or less from diagnosis saw both general and specialist doctors, only 51.6% of survivors at 5 or more years saw both, and 43.5% saw only a general doctor. On multivariable analysis, receipt of CVD preventive care was strongly associated with general doctor visitation for those with and without CVD risk factors.

CONCLUSIONS

CVD and associated risk factors are prevalent among both older and younger cancer survivors across the United States. This study identifies areas for improvement related to lifestyle modification in survivors, and also highlights the importance of care transition to the primary care provider for long-term survivors.

Ten-Year Trends in Preventive Service Use Before and After Prostate Cancer Diagnosis: A Comparison with Noncancer Controls

CONTEXT

Few studies have assessed the longer-term quality of preventive care in prostate cancer (PCa) survivors.

OBJECTIVE

To compare the rates of preventive services among PCa survivors five years before and after diagnosis, to men without PCa.

DESIGN

Men enrolled in Kaiser Permanente Southern California with newly diagnosed PCa (2002-2008) were matched 1:1 to men without a PCa diagnosis on age, race, and timing of prostate-specific antigen test (N = 31,180). The use of preventive services, including colorectal cancer screening, diabetes tests, lipid panels, and influenza and pneumococcal vaccinations was assessed 5 years before and after diagnosis (or index date for controls).

MAIN OUTCOME MEASURES

Relative rates (RRs) of use were calculated for cases and controls separately and compared using Poisson regression, adjusting for comorbidities and outpatient utilization in 2014.

RESULTS

Overall, the rates of preventive services were lower among men with PCa vs men without PCa. However, in the 5 years after diagnosis, rates of preventive service use for all services were greater among PCa survivors vs men without PCa (colorectal cancer: RR = 1.05, 95% confidence interval [CI] = 1.01-1.10; lipids: RR = 1.10, 95% CI = 1.08-1.11; hemoglobin A_1C: RR = 1.17, 95% CI = 1.14-1.19; glucose: RR = 1.24, 95% CI = 1.23-1.26; influenza vaccine: RR = 1.05, 95% CI = 1.03-1.07; pneumococcal vaccine: RR = 1.03, 95% CI = 0.97-1.09).

CONCLUSION

Delivery of preventive care improved after PCa diagnosis, with survivors receiving comparable preventive care to men without PCa during the five years following diagnosis.

Care Coordination and Transitions of Care

Care coordination and effective transitions of care are essential for high-quality care in cancer survivors. Aspects of care that require coordination include cancer surveillance, managing the effects of cancer and its treatment, and preventive care, including screening for new cancers, with the clinician responsible for each aspect of care clearly defined. There are many barriers to transitioning and coordinating care across cancer specialists and primary care physicians; possible solutions include survivorship care plans and certain care models. Improving these areas, along with survivorship care training and education, may lead to more effective care coordination and transitions in the future.

Racial disparities in the utilization of preventive health services among older women with early-stage endometrial cancer enrolled in Medicare

To assess differences in the receipt of preventive health services by race/ethnicity among older women with endometrial cancer enrolled in Medicare, we conducted a retrospective population-based cohort study of women diagnosed with endometrial cancer from 2001 to 2011 in the Surveillance Epidemiology and End Results (SEER)-Medicare database. Women with stage I or II endometrial cancer of epithelial origin were included. The exposure was race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, and NH Asian/Pacific Islander [PI]). The services examined were receipt of influenza vaccination and screening tests for diabetes mellitus, hyperlipidemia, and breast cancer. We used multivariate logistic regression to estimate odds ratios with 95% confidence intervals (CI) adjusted for age, region, and year of diagnosis. A total of 13,054 women were included. In the 2 years after diagnosis, receipt of any influenza vaccine ranged from 45% among NH Black women to 67% among NH White women; receipt of a mammogram ranged from 65% among NH Black women to 74% among NH White women. Relative to NH White women, NH Black women had a lower likelihood of receiving both influenza vaccination (adjusted odds ratio [aOR] 0.40, 95% CI 0.33-0.44) and screening mammography (aOR 0.64, 95% CI 0.52-0.79). Hispanic women also were less likely to receive influenza vaccination than NH White women (aOR 0.61, 95% CI 0.51-0.72). There were no significant differences across racial groups for diabetes or cholesterol screening services. Among older women with early-stage endometrial cancer, racial disparities exist in the utilization of some preventive services.

Who Treats Patients with Diabetes and Compensated Cirrhosis

Background

Increasingly, patients with multiple chronic conditions are being managed in patient-centered medical homes (PCMH) that coordinate primary and specialty care. However, little is known about the types of providers treating complex patients with diabetes and compensated cirrhosis.

Objective

We examined the mix of physician specialties who see patients dually-diagnosed with diabetes and compensated cirrhosis.

Design

Retrospective cross-sectional study using 2000–2013 MarketScan^® Commercial Claims and Encounters and Medicare Supplemental Databases.

Patients

We identified 22,516 adults (≥ 18 years) dually-diagnosed with diabetes and compensated cirrhosis. Patients with decompensated cirrhosis, HIV/AIDS, or liver transplantation prior to dual diagnosis were excluded.

Main Measures

Physician mix categories: patients were assigned to one of four physician mix categories: primary care physicians (PCP) with no gastroenterologists (GI) or endocrinologists (ENDO); GI/ENDO with no PCP; PCP and GI/ENDO; and neither PCP nor GI/ENDO. Health care utilization: annual physician visits and health care expenditures were assessed by four physician mix categories.

Key Results

Throughout the 14 years of study, 92% of patients visited PCPs (54% with GI/ENDO and 39% with no GI/ENDO). The percentage who visited PCPs without GI/ENDO decreased 22% (from 63% to 49%), while patients who also visited GI/ENDO increased 71% (from 25% to 42%).

Conclusions

This is the first large nationally representative study to document the types of physicians seen by patients dually-diagnosed with diabetes and cirrhosis. A large proportion of these complex patients only visited PCPs, but there was a trend toward greater specialty care. The trend toward co-management by both PCPs and GI/ENDOs suggests that PCMH initiatives will be important for these complex patients. Documenting patterns of primary and specialty care is the first step toward improved care coordination.

A head and neck cancer intervention for use in survivorship clinics: a protocol for a feasibility study

BACKGROUND

Head and neck cancer survivors commonly experience severe long-term toxicities, late-occurring symptoms, and significant risks of the second primary malignancy and comorbid illnesses. With multiple simultaneous health issues, these complex cancer survivors often do not receive comprehensive health care that addresses their needs. A tool is needed to streamline and standardize comprehensive care for this cohort.

METHODS/DESIGN

We designed the Head and Neck Survivorship Tool: Assessment and Recommendations (HN-STAR) to address health care challenges for head and neck cancer survivors. HN-STAR is an electronic platform that aims to simplify the provision of personalized care in cancer survivorship clinics. It uses an algorithmic approach to integrate patient-reported outcomes, clinical details, and evidence-based guidelines to standardize comprehensive care provided in routine survivorship visits. It has four integrated components: (1) a simplified treatment summary, which pulls treatment details from a clinical database or can be completed manually using a streamlined form; (2) an online self-assessment for patients to report their own symptoms; (3) an interactive discussion guide presenting all relevant information to the provider during the clinic visit; and (4) a survivorship care plan generated at the end of each visit that reflects decisions made during the visit. By using a modifiable electronic platform, HN-STAR provides a method for incorporating survivorship care plans into clinical practice and for disseminating evidence on symptom management and preventive care. This is a study to assess the feasibility of a future multi-site, randomized clinical trial of HN-STAR. We will enroll head and neck cancer survivors who are followed in one of two nurse practitioner-led survivorship clinics. We will implement HN-STAR for one routine survivorship visits. We will assess (1) usability and feasibility outcomes of HN-STAR from the perspective of key stakeholders and (2) the planned outcomes intended for the larger trial. We will collect usability and feasibility data from online surveys of survivors and their providers. Our findings will inform whether it is feasible to advance HN-STAR to trial. If so, we will adapt HN-STAR and the study design of the trial in response to feedback from survivors and providers. The long-term goal is to determine if such an intervention will lead to improved and simplified comprehensive survivorship care.

DISCUSSION

This feasibility study will evaluate implementation of HN-STAR into clinical practice in terms of usability, practicality, and clinical flow in two distinct clinical settings. This study will also provide critical baseline data to characterize this vulnerable population. Findings from this study will inform a multicenter randomized trial of HN-STAR, aimed at standardizing and streamlining the delivery of evidence-guided comprehensive care for head and neck cancer survivors. Ultimately, if found effective, the modular structure of HN-STAR could permit its expansion to survivors of other complex cancers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02571673.

Lack of health maintenance examinations and risk in myeloma patients

Health maintenance (HM) practices are essential to prevent illness, promote well-being, and maximize health. Patients with multiple myeloma (MM) are at increased risk for cardiovascular disease and cancers, yet, research on HM practices and preventative care of MM survivors has limited report. The study comprised a descriptive, correlational, and cross-sectional online survey design. Survey of patients with MM was carried out through the International Myeloma Foundation (IMF) and the Association of Cancer Online Resources (ACOR) e-mail list services. The members of the IMF and ACOR e-mail list services were surveyed, of which 237 patients responded. The modified Medical Expenditure Preventive Survey-Preventive Care questionnaire was used; it included items that ask patients regarding their healthcare practices that relate to dental care, cancer prevention, addiction, lifestyles, sensory screening, immunizations, cardiovascular, endocrine, psychosocial, and bone health. Descriptive statistics, Pearson's chi-square, and Spearman's rho correlation coefficient were obtained. In this study, men had statistically significant inferior global health maintenance scores than women (P = 0.002). Being employed (P = 0.054) and married or partnered (P = 0.017) were significantly correlated with better health maintenance patterns among male respondents. In contrast, no statistically significant correlations between sociodemographic factors and health maintenance patterns were found in women. Patients with MM, particularly men, require continued education and close monitoring of health maintenance practices. These findings are consistent with publications looking at gender disparities in healthcare utilization in the United States. Studies show that men, in general, are less likely to seek preventative healthcare screenings. Healthcare providers must incorporate health maintenance promotion during clinic visits.

Moving survivorship care plans forward: focus on care coordination

After completing treatment for cancer, the coordination of oncology and primary care presents a challenge for cancer survivors. Many survivors need continued oncology follow-up, and all survivors require primary care. Coordinating the shared care of a cancer survivor, or facilitating an informed handoff from oncology to primary care, is essential for cancer survivors. Survivorship care plans are personalized documents that summarize cancer treatment and outline a plan of recommended ongoing care, with the goal of facilitating the coordination of post-treatment care. Despite their face validity, five trials have failed to demonstrate the effectiveness of survivorship care plans. We posit that these existing trials have critical shortcomings and do not adequately address whether survivorship care plans improve care coordination. Moving forward, we propose four criteria for future trials of survivorship care plans: focusing on high-needs survivor populations, tailoring the survivorship care plan to the care setting, facilitating implementation of the survivorship care plan in clinical practice, and selecting appropriate trial outcomes to assess care coordination. When trials meet these criteria, we can finally assess whether survivorship care plans help cancer survivors receive optimal oncology and primary care.

Comorbid condition care quality in cancer survivors: role of primary care and specialty providers and care coordination

PURPOSE

The purpose of this study is to investigate provider specialty, care coordination, and cancer survivors' comorbid condition care.

METHODS

This retrospective cross-sectional Surveillance, Epidemiology, and End Results (SEER)-Medicare study included cancer survivors diagnosed in 2004, 2-3 years post-cancer diagnosis, in fee-for-service Medicare. We examined (1) provider specialties (primary care providers (PCPs), oncology specialists, other specialists) visited post-hospitalization, (2) role of provider specialties in chronic and acute condition management, and (3) an ambulatory care coordination measure. Outcome measures covered (1) visits post-hospitalization for nine conditions, (2) chronic disease management (lipid profile, diabetic eye exam, diabetic monitoring), and (3) acute condition management (electrocardiogram (EKG) for congestive heart failure (CHF), imaging for CHF, EKG for transient ischemic attack, cholecystectomy, hip fracture repair).

RESULTS

Among 8661 cancer survivors, patients were more likely to visit PCPs than oncologists or other specialists following hospitalizations for 8/9 conditions. Patients visiting a PCP (vs. not) were more likely to receive recommended care for 3/3 chronic and 1/5 acute condition indicators. Patients visiting a nother specialist (vs. not) were more likely to receive recommended care for 3/3 chronic and 2/5 acute condition indicators. Patients visiting an oncology specialist (vs. not) were more likely to receive recommended care on 2/3 chronic indicators and less likely to receive recommended care on 1/5 acute indicators. Patients at greatest risk for poor coordination were more likely to receive appropriate care on 4/6 indicators.

CONCLUSIONS

PCPs are central to cancer survivors' non-cancer comorbid condition care quality. Implications for Cancer Survivors PCP involvement in cancer survivors' care should be promoted.

Cancer survivors' perspectives on delivery of survivorship care by primary care physicians: an internet-based survey

BACKGROUND

Helping cancer survivors to transition from active treatment to long-term survivorship requires coordinated efforts by both oncologists and primary care physicians (PCPs). This study aims to evaluate cancer survivors' perspectives on PCP-delivered survivorship care.

METHODS

We conducted an Internet-based cross-sectional survey of cancer survivors via www.OncoLink.org . Regression analyses were used to identify factors associated with perception of PCP-delivered survivorship care.

RESULTS

The 352 respondents rated overall PCP-delivered survivorship care as 60 out of 100 (SD = 23). The areas of care most strongly endorsed were general care (62 %), psychosocial support (65 %), and holistic care (68 %). Survivors were less likely to perceive their PCPs as knowledgeable about cancer follow-up (43 %), late or long-term effects of cancer therapy (45 %), and diagnosis and treatment of symptoms related to cancer or cancer therapy (42 %). While 72 % of survivors reported satisfaction with their PCP's care overall, only 41 % felt that their PCPs and oncologists communicated well with one another. In a multivariate regression analysis, higher trust in PCP (p < 0.001), non-white race (p = 0.001), living in the United States (p = 0.007), and visiting a PCP two or more times per year (p = 0.009) were significantly associated with higher ratings of PCP-delivered survivorship care.

CONCLUSIONS

While cancer survivors in general are satisfied with care delivery by PCPs, they perceived that their PCPs have limited abilities in performing cancer-specific follow-up and late effect monitoring and treatment. Better education of family physicians about survivorship issues and improved communication between PCPs and oncologists are needed to improve PCPs' delivery of survivorship care.

Changes in Medication Management After a Diagnosis of Cancer Among Medicare Beneficiaries With Diabetes

PURPOSE

A new cancer diagnosis commonly initiates a cascade of health care decisions that have potentially important consequences for management of other chronic conditions such as diabetes. We sought to determine whether a new cancer diagnosis is associated with changes in medication adherence among Medicare beneficiaries with diabetes, and whether the relationship is affected by life expectancy and generosity of drug coverage.

METHODS

The study population was drawn from a 5% random sample of Medicare beneficiaries with diabetes enrolled in Medicare Part D in 2007 and 2008. Patients had cancer newly diagnosed between January and December 2007 (n = 4,348) and were compared with a cancer-free control group (N = 28,507) assigned a pseudo-diagnosis date. Adherence (proportion of days covered [PDC]) with oral hypoglycemic agents, renin-angiotensin-aldosterone system inhibitors, and statins was tracked for 6 months before and after the diagnosis date. Multivariable regression models assessed the independent impact of a cancer diagnosis, life expectancy (proxy measure: died 7 to 12 months after index date), and coverage generosity (proxy measure: low-income subsidy recipient) on PDC, controlling for individual characteristics.

RESULTS

Relatively larger declines in medication adherence (3 to 5 percentage points; P < .001) were observed overall for patients with cancer versus controls. Short life expectancy was associated with between 8% and 11% lower PDC (P < .001) in the cancer subgroup relative to controls. Low-income subsidy status had no differential effect on changes in drug adherence.

CONCLUSION

A cancer diagnosis among patients with diabetes reduced adherence with evidence-based medications, particularly if patients' life expectancy was short.

Quality of preventive care before and after prostate cancer diagnosis

OBJECTIVE

To examine if the use of general preventive services were diminished in a cohort of men following their diagnosis of prostate cancer.

PATIENTS AND METHODS

16,604 men enrolled in Kaiser Permanente Southern California who were newly diagnosed with prostate cancer from January 1, 2002 through December 31, 2009 were passively followed through electronic medical records to determine the use of preventive services, including screening for colorectal cancer (colonoscopy and/or fecal occult blood tests (FOBT)), tests for diabetes (glucose and hemoglobin A1c) and heart disease (serum cholesterol, high density lipoprotein (HDL) and triglycerides) and vaccinations (influenza and pneumococcal). Preventive service use was compared in the two years prior to and following prostate cancer diagnosis using matched odds ratios (MOR) and 95% confidence intervals (CI) in 2013.

RESULTS

Men were more likely to receive a flu vaccine (MOR: 2.70, 95% CI: 2.52-2.90), lipid tests (MOR: 1.51, 95% CI: 1.42-1.61), diabetes tests (MOR: 2.13, 95% CI: 2.00-2.26) and screening for colorectal cancer (MOR: 1.80, 95% CI: 1.71-1.89) in the two years after prostate cancer diagnosis compared to before. Men with advanced disease at diagnosis were more likely to receive all types of preventive services after diagnosis when compared to men with localized disease.

CONCLUSIONS

Once diagnosed with prostate cancer in this setting, no less attention was paid to general preventive care, although there remains room for improvement in pneumococcal vaccination and colon cancer screening rates. The delivery of high-quality continuing care after diagnosis is critical for aging cancer patients.

Summing it up: an integrative review of studies of cancer survivorship care plans (2006-2013)

In 2006, the Institute of Medicine recommended that cancer survivors who are completing primary treatment receive a survivorship care plan (SCP) based on face validity. The state of scientific knowledge regarding the SCP is unclear. The authors conducted an integrative review of existing evidence regarding SCPs. The MEDLINE/PubMed database, the Excerpta Medica Database (EMBASE), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database were searched for relevant studies published between 2006 and 2013 using a combination of keywords: "survivors," "survivorship," "care plans," "care planning," "treatment summaries," and "cancer." Articles were included if they 1) reported results from an empirical study, 2) included cancer survivors who were diagnosed at age ≥ 18 years, 3) related to SCP, and 4) were published in English. In total, 781 records were retrieved; 77 were identified as duplicates, and 665 were abstracts or presentations that did not relate to SCPs for adults or were not empirical, which left 42 articles for inclusion in this review. Studies regarding SCP fell into 3 categories: 1) content (n=14), 2) dissemination and implementation (n=14), and 3) survivor and provider outcomes (n=14). SCPs have been endorsed and are associated with improved knowledge, but SCP use remains sporadic. Only 4 studies were randomized controlled trials (RCTs) that avoided many biases associated with observational studies. Other limitations included cross-sectional or pre-SCP-post-SCP ("pre-post") designs, limited generalizability caused by a lack of sample diversity, and a lack of systematic testing of data-collection tools. The quantity and quality of SCP research are limited. SCPs have been endorsed, but evidence of improved outcomes associated with SCP is limited. Future research that addresses the methodological concerns of extant studies is needed regarding SCP use, content, and outcomes.

Health services utilisation in breast cancer survivors in Taiwan

Surveillance guidelines for breast cancer survivors recommend regular history and physical and mammography, and against routine imaging for detecting distant metastasis. Stage 0, I, II breast cancer cases treated at a major cancer center were identified from the Taiwan Cancer Registry. We used multivariable negative binomial and logistic regression analyses on institutional claims data to examine factors contributing to utilisation patterns of surveillance visits and tests in disease-free survivors. The mean number of surveillance visits during months 13 to 60 after cancer treatment initiation was 18.5 (SD 8.2) among the 2,090 breast cancer survivors followed for at least five years. After adjusting for patient and disease factors, the number of visits was the highest among patients mainly followed by medical oncologists compared to surgeons and radiation oncologists. Patient cohorts treated in more recent years had lower number of visits associated with care coordination effort, the adjusted mean being 19.2 visits for the 2002 cohort, and 16.3 visits for the 2008 cohort (p < 0.0001). Although imaging tests were highly utilised, there was a significant decrease in tumor marker testing from the 2002 to the 2008 treatment cohort (adjusted rate 99.4% to 35.1% respectively, p < 0.0001) in association with an institutional guideline change.

Influenza vaccination and associated factors among Korean cancer survivors : a cross-sectional analysis of the Fourth & Fifth Korea National Health and Nutrition Examination Surveys

Influenza vaccination is important for cancer survivors, a population with impaired immunity. This study was designed to assess influenza vaccination patterns among Korean cancer survivors. In this cross-sectional analysis, data were obtained from standardized questionnaires from 943 cancer survivors and 41,233 non-cancer survivors who participated in the Fourth and Fifth Korea National Health and Nutrition Examination Surveys (2007-2011). We identified the adjusted influenza vaccination rates and assessed factors associated with influenza vaccination using multivariate logistic regression. Cancer survivors tended to have a higher adjusted influenza vaccination rate than the general population. The rates for influenza vaccination in specific cancer types such as stomach, hepatic, colon, and lung cancers were significantly higher than non-cancer survivors. Among all cancer survivors, those with chronic diseases, elderly subjects, and rural dwellers were more likely to receive influenza vaccination; those with cervical cancer were less likely to receive influenza vaccination. Cancer survivors were more likely to receive influenza vaccinations than non-cancer survivors, but this was not true for particular groups, especially younger cancer survivors. Cancer survivors represent a sharply growing population; therefore, immunization against influenza among cancer survivors should be concerned as their significant preventative healthcare services.

Comprehensive long-term care of patients with lung cancer: development of a novel thoracic survivorship program

BACKGROUND

Recent advances have improved the likelihood of long-term survival for patients with lung cancer. However, little attention has been given to the growing need for dedicated survivorship care for these patients. To address this unmet need, we developed a unique follow-up care model.

METHODS

In 2006, we convened a multidisciplinary working group to design a thoracic survivorship program (TSP) that provides follow-up by a nurse practitioner (NP) trained in survivorship care. Patients with early-stage lung cancer who were disease free for at least 1 year after resection were eligible for the program, which incorporates a standardized approach to cancer surveillance. Data on symptoms and outcomes were prospectively collected. Real-time electronic medical documentation was developed to optimize communication with primary physicians.

RESULTS

Data were analyzed for the initial phase of the program, which comprised 655 patients. Ninety-two percent of eligible survivors who remained disease free chose to continue their care in the TSP, rather than receive follow-up with their thoracic surgeon. Clinically significant posttreatment symptoms were common, including fatigue (46%), anxiety (32%), chronic pain (25%), dyspnea (14%), and depression (12%). The majority of recurrences (72%) and second primary cancers (91%) in this cohort were identified by scheduled chest computed tomography at TSP visits.

CONCLUSIONS

Survivorship care for patients with lung cancer, delivered in our NP-led TSP, is feasible, effective, and well accepted by patients. Through the implementation of a uniform self-sustaining patient-centered system, the TSP model improves on the variation of physician-led follow-up care.

It's who you know: patient-sharing, quality, and costs of cancer survivorship care

PURPOSE

Cancer survivors frequently receive care from a large number of physicians, creating challenges for coordination. We sought to explore whether cancer survivors whose providers have more patients in common (e.g., shared patients) tend to have higher quality and lower cost care.

METHODS

We performed a retrospective cohort study of 8,661 patients diagnosed with loco-regional breast, prostate, or colorectal cancer. We examined survivorship care from days 366 to 1,095 following their cancer diagnosis. Our primary independent variable was "care density," a novel metric of the extent to which a patient's providers share patients with one another. Our outcome measures were health care utilization, quality metrics, and costs.

RESULTS

In adjusted analyses, we found that patients with high care density--indicating high levels of patient-sharing among their providers--had significantly lower rates of hospitalization (OR 0.87, 95% CI 0.75-1.00) and higher odds of an eye examination for diabetes (OR 1.31, 95% CI 1.03-1.66) compared to patients with low care density. High care density was not associated with emergency department visits, avoidable outcomes, lipid profile following an angina diagnosis, or odds of glycosylated hemoglobin testing for diabetes. Patients with high care density had significantly lower total costs of care over 24 months (beta coefficient -$2,116, 95% CI -$3,107 to -$1,125) along with lower inpatient and outpatient costs.

CONCLUSION

Cancer survivors treated by physicians who share more patients with one another tend to have some higher aspects of quality and lower cost care.

IMPLICATIONS OF CANCER SURVIVORS

If validated, care density may be a useful indicator for monitoring care coordination among cancer survivors and potentially targeting interventions that seek to improve care delivery.

Provision and discussion of survivorship care plans among cancer survivors: results of a nationally representative survey of oncologists and primary care physicians

PURPOSE

Survivorship care planning should involve discussions between providers and cancer survivors to address survivors' needs and optimize adherence. We examined the frequency and factors associated with oncologists' and primary care physicians' (PCPs) reports of provision of written survivorship care plans (SCPs) and discussion of survivorship care recommendations with survivors.

METHODS

A nationally representative sample of 1,130 oncologists and 1,020 PCPs was surveyed about survivorship care practices with survivors. Logistic regression models predicted multilevel factors associated with providing SCPs or discussing recommendations with survivors.

RESULTS

Although a majority of oncologists (64%) reported always/almost always discussing survivorship care recommendations with survivors, fewer also discussed who survivors should see for cancer-related and other follow-up care (32%); fewer still also provided a written SCP to the survivor (< 5%). Survivorship care recommendations and provider responsibility were not regularly discussed by PCPs and survivors (12%). Oncologists who reported detailed training about late and long-term effects of cancer were more likely to provide written SCPs (odds ratio [OR], 1.73; 95% CI, 1.22 to 2.44) and discuss survivorship care planning with survivors (OR, 2.02; 95% CI, 1.51 to 2.70). PCPs who received SCPs from oncologists were 9× more likely (95% CI, 5.74 to 14.82) to report survivorship discussions with survivors.

CONCLUSION

A minority of both PCPs and oncologists reported consistently discussing and providing SCPs to cancer survivors. Training and knowledge specific to survivorship care and coordinated care between PCPs and oncologists were associated with increased survivorship discussions with survivors. These nationally representative data provide a useful benchmark to assess implementation of new efforts to improve the follow-up care of survivors.

Oncologists' and primary care physicians' awareness of late and long-term effects of chemotherapy: implications for care of the growing population of survivors

PURPOSE

The population of cancer survivors is large and growing. Yet after successful completion of treatment, many experience chemotherapy-related late or long-term effects (LEs). The extent to which physicians are aware of LEs is unknown.

METHODS

We conducted a nationally representative survey of 1,130 oncologists and 1,072 primary care providers (PCPs). Respondents were asked to select the LEs they had either observed or seen reported for five chemotherapy agents used to treat breast and colon cancers. We described and compared oncologists' and PCPs' awareness of the specified LEs. Using multivariate logistic regression models, we determined predictors of physicians' awareness of the main LEs associated with the agents.

RESULTS

Almost all oncologists (95%) reported awareness of cardiac dysfunction as an LE of doxorubicin and peripheral neuropathy as an LE of paclitaxel (97%) and oxaliplatin (97%). These LEs were reported by 55%, 27%, and 22% of PCPs, respectively. Most oncologists reported awareness of premature menopause (71%) and secondary malignancies (62%) as LEs of cyclophosphamide, compared with only 15% and 17% of PCPs, respectively. Main LEs associated with all four agents were identified by 65% of oncologists and only 6% of PCPs.

CONCLUSION

Although more than half of PCPs were aware of cardiac dysfunction as an LE of doxorubicin, awareness of other LEs was limited. Because PCPs may not be directly exposed to chemotherapy-related LEs, oncologists must communicate this information to PCPs as patients transition to primary care settings. Education for all providers caring for the growing population of cancer survivors is needed.

Health disparities and the cancer survivor

Disparities on the basis of race and ethnicity have been described in a variety of survivorship outcomes, including late and long-term effects of treatment, surveillance and health maintenance, and psychosocial outcomes. However, the current body of literature is limited in scope and additional research is needed to better define and address disparities among cancer survivors.

Role of oncologists and primary care physicians in providing follow-up care to non-Hodgkin lymphoma survivors within 5 years of diagnosis: a population-based study

PURPOSE

The growing population of non-Hodgkin lymphoma (NHL) survivors living longer with high physical and psychological treatment burden, in combination with the projected shortage of medical professionals, necessitates redesigning cancer follow-up care. This study examined follow-up care patterns, factors associated with follow-up care, and attitudes towards follow-up care among NHL survivors.

METHODS

We surveyed survivors of aggressive NHL 2 to 5 years post-diagnosis (N = 363) using a population-based sample from the Los Angeles County Surveillance Epidemiology and End Results registry.

RESULTS

Most survivors (82 %) received cancer-related follow-up care in the past year from an oncologist. History of recurrence, more comorbidities, more symptoms, and a shorter survivor-oncologist relationship were associated with high-frequency care with the oncologist [(≥5 visits in the past year), p < 0.05]. Many survivors followed up by oncologists (71 %) also saw a primary care provider (PCP) and 47 % also saw both a PCP and other specialists. Factors associated with seeing a PCP in addition to an oncologist included more symptoms, more health information needs, no history of recurrence, perceived excellent quality of cancer follow-up care, and fewer visits with the oncologist (p < 0.05). Survivors generally reported high reassurance from, and low negative anticipation towards, follow-up care.

CONCLUSIONS

The high proportion of NHL survivors receiving care from multiple physicians, and the sizable proportion (∼30 %) who have not recently seen a PCP, suggests that coordinating care across specialties is critical to ensure comprehensive, non-duplicative care. Understanding factors associated with cancer-related follow-up is a first step towards more effective, efficient, patient-centered care.

Physician visits and preventive care among Asian American and Pacific Islander long-term survivors of colorectal cancer, USA, 1996-2006

PURPOSE

Published literature on receipt of preventive healthcare services among Asian American and Pacific Islander (API) cancer survivors is scarce. We describe patterns in receipt of preventive services among API long-term colorectal cancer (CRC) survivors.

METHODS

Surveillance, Epidemiology, and End Results registry-Medicare data were used to identify 9,737 API and white patients who were diagnosed with CRC during 1996-2000 and who survived 5 or more years beyond their diagnoses. We examined receipt of vaccines, mammography (females), bone densitometry (females), and cholesterol screening among the survivors and how the physician specialties they visited for follow-up care correlated to services received.

RESULTS

APIs were less likely than whites to receive mammography (52.0 vs. 69.3 %, respectively; P < 0.0001) but more likely to receive influenza vaccine, cholesterol screening, and bone densitometry. These findings remained significant in our multivariable model, except for receipt of bone densitometry. APIs visited PCPs only and both PCPs and oncologists more frequently than whites (P < 0.0001). Women who visited both PCPs and oncologists compared with PCPs only were more likely to receive mammography (odds ratio = 1.40; 95 % confidence interval, 1.05-1.86).

CONCLUSIONS

Visits to both PCPs and oncologists were associated with increased use of mammography. Although API survivors visited these specialties more frequently than white survivors, API women may need culturally appropriate outreach to increase their use of this test.

IMPLICATIONS FOR CANCER SURVIVORS

Long-term cancer survivors need to be aware of recommended preventive healthcare services, as well as who will manage their primary care and cancer surveillance follow-up.

Racial/Ethnic disparities in health care receipt among male cancer survivors

OBJECTIVES

We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.

METHODS

We identified men aged 18 years and older from the 2006-2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).

RESULTS

In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).

CONCLUSIONS

Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.

Quality of care for comorbid conditions during the transition to survivorship: differences between cancer survivors and noncancer controls

PURPOSE

Building on previous research documenting differences in preventive care quality between cancer survivors and noncancer controls, this study examines comorbid condition care.

METHODS

Using data from the Surveillance, Epidemiology, and End Results (SEER) -Medicare database, we examined comorbid condition quality of care in patients with locoregional breast, prostate, or colorectal cancer diagnosed in 2004 who were age ≥ 66 years at diagnosis, who had survived ≥ 3 years, and who were enrolled in fee-for-service Medicare. Controls were frequency matched to cases on age, sex, race, and region. Quality of care was assessed from day 366 through day 1,095 postdiagnosis using published indicators of chronic (n = 10) and acute (n = 19) condition care. The proportion of eligible cancer survivors and controls who received recommended care was compared by using Fisher's exact tests. The chronic and acute indicators, respectively, were then combined into single logistic regression models for each cancer type to compare survivors' care receipt to that of controls, adjusting for clinical and sociodemographic variables and controlling for within-patient variation.

RESULTS

The sample matched 8,661 cancer survivors to 17,322 controls (mean age, 75 years; 65% male; 85% white). Colorectal cancer survivors were less likely than controls to receive appropriate care on both the chronic (odds ratio [OR], 0.88; 95% CI, 0.81 to 0.95) and acute (OR, 0.72; 95% CI, 0.61 to 0.85) indicators. Prostate cancer survivors were more likely to receive appropriate chronic care (OR, 1.28; 95% CI, 1.19 to 1.38) but less likely to receive quality acute care (OR, 0.75; 95% CI, 0.65 to 0.87). Breast cancer survivors received care equivalent to controls on both the chronic (OR, 1.06; 95% CI, 0.96 to 1.17) and acute (OR, 0.92; 95% CI, 0.76 to 1.13) indicators.

CONCLUSION

Because we found differences by cancer type, research exploring factors associated with these differences in care quality is needed.

Eight ways to stay healthy after cancer: an evidence-based message

PURPOSE

Since 1999, in conjunction with the internationally known and award-winning Your Disease Risk ( yourdiseaserisk.org ) risk assessment tool, the "Eight Ways to Stay Healthy and Prevent Cancer" message campaign has provided an evidence-based, but user-friendly, approach to cancer prevention. The scientific evidence behind the campaign is robust and while not a complete list, provides a great deal of benefit in the reduction of cancer risk. With 12 million cancer survivors in the United States, there is a need for a parallel set of recommendations that oncologists and primary care providers may routinely use for individuals following a cancer diagnosis focused on improving the quantity and quality of life after diagnosis. With increasing survival rates and many cancer survivors dying from noncancer causes, survivorship care necessarily focuses on more than just risk of cancer recurrence and cancer-related mortality.

METHODS

To provide a foundation for living a healthy life after a cancer diagnosis, we developed a set of evidence-based health messages for cancer survivors. "Cancer Survivors' Eight Ways to Stay Healthy After Cancer," published by the Siteman Cancer Center at Washington University School of Medicine and Barnes Jewish Hospital, documents both the evidence supporting the recommendations as well as tips for implementing them.

RESULTS

The one-line summary messages are: (1) don't smoke, (2) avoid secondhand smoke, (3) exercise regularly, (4) avoid weight gain, (5) eat a healthy diet, (6) drink alcohol in moderation, if at all, (7) stay connected with friends, family, and other survivors, (8) get screening tests and go to your regular checkups.

CONCLUSIONS

The cancer survivors' eight ways are the foundation for an evidence-based health promotion program for survivors.

Cancer research network: using integrated healthcare delivery systems as platforms for cancer survivorship research

INTRODUCTION

Much progress has been made in cancer survivorship research, but there are still many unanswered questions that can and need to be addressed by collaborative research consortia.

METHODS

Since 1999, the National Cancer Institute-funded HMO Cancer Research Network (CRN) has engaged in a wide variety of research focusing on cancer survivorship. With a focus on thematic topics in cancer survivorship, we describe how the CRN has contributed to research in cancer survivorship and the resources it offers for future collaborations.

RESULTS

We identified the following areas of cancer survivorship research: surveillance for and predictors of recurrences, health care delivery and care coordination, health care utilization and costs, psychosocial outcomes, cancer communication and decision making, late effects of cancer and its treatment, use of and adherence to adjuvant therapies, and lifestyle and behavioral interventions following cancer treatment.

CONCLUSIONS

With over a decade of experience using cancer data in community-based settings, the CRN investigators and their collaborators are poised to generate evidence in cancer survivorship research.

IMPLICATIONS FOR CANCER SURVIVORS

Collaborative research within these settings can improve the quality of care for cancer survivors within and beyond integrated health care delivery systems.

Leveraging epidemiology and clinical studies of cancer outcomes: recommendations and opportunities for translational research

As the number of cancer survivors continues to grow, research investigating the factors that affect cancer outcomes, such as disease recurrence, risk of second malignant neoplasms, and the late effects of cancer treatments, becomes ever more important. Numerous epidemiologic studies have investigated factors that affect cancer risk, but far fewer have addressed the extent to which demographic, lifestyle, genomic, clinical, and psychosocial factors influence cancer outcomes. To identify research priorities as well as resources and infrastructure needed to advance the field of cancer outcomes and survivorship research, the National Cancer Institute sponsored a workshop titled "Utilizing Data from Cancer Survivor Cohorts: Understanding the Current State of Knowledge and Developing Future Research Priorities" on November 3, 2011, in Washington, DC. This commentary highlights recent findings presented at the workshop, opportunities to leverage existing data, and recommendations for future research, data, and infrastructure needed to address high priority clinical and research questions. Multidisciplinary teams that include epidemiologists, clinicians, biostatisticians, and bioinformaticists will be essential to facilitate future cancer outcome studies focused on improving clinical care of cancer patients, identifying those at high risk of poor outcomes, and implementing effective interventions to ultimately improve the quality and duration of survival.

Linking Medicare, Medicaid, and cancer registry data to study the burden of cancers in West Virginia

OBJECTIVE

Develop the WVCR-Linked dataset by combining the West Virginia Cancer Registry (WVCR) with Medicare, Medicaid, and other data sources. Determine health care utilization, costs, and overall burden of four major cancers among the elderly in a rural and medically underserved state population, and to compare them with national estimates.

METHOD

We extracted personal identifiers from the West Virginia Cancer Registry (WVCR) data file for individuals ≥ 65 years of age with an incident diagnosis of any cancer between January 1, 2002 and December 31, 2007. We linked the extracted data with Medicare and Medicaid administrative data using deterministic record linkage procedures. We updated missing vital status information by linking the National Death Index (NDI) data file. The updated WVCR-Linked dataset was enriched by links to the U.S. decennial census (2000) file and the Area Resource File.

RESULTS

We identified 42,333 individuals, of which 41,574 (98.2%) and 6,031 (14.3%) individuals were matched with Medicare and Medicaid administrative data files, respectively. The NDI data added or updated vital status information for 3,295 (7.8%) individuals in the WVCR-Linked dataset.

CONCLUSION

The WVCR-Linked dataset is a comprehensive dataset offering many opportunities to understand factors related to cancer treatment patterns, costs, and outcomes in a rural and medically underserved elderly Appalachian population. Following our example, non-participant states in the Surveillance, Epidemiology and End Results (SEER) program can build a powerful dataset to identify and target cancer disparities, and to improve cancer-related outcomes for their elderly and dual-eligible citizens.

Cancer Survivorship Care: Don't Let the Perfect Be the Enemy of the Good

It has now been more than 5 years since the Institute of Medicine (IOM) laid out its bold vision of comprehensive survivorship care. Although there is clearly more attention paid to this phase of the cancer journey than previously, implementation of the IOM recommendations has proved difficult. In this article, we review some of the challenges to providing survivorship care and discuss efforts to prioritize the most essential elements.

Adult cancer survivors discuss follow-up in primary care: 'not what i want, but maybe what i need'

BACKGROUND Nearly one-third of office visits for cancer are handled by primary care physicians. Yet, few studies examine patient perspectives on these physicians' roles in their cancer follow-up care or their care preferences. METHODS We explored survivor preferences through qualitative, semistructured, in-depth interviews drawing on patients recruited from 2 National Cancer Institute-designated comprehensive cancer centers and 6 community hospitals. We recruited a purposive sample of early-stage breast and prostate cancer survivors aged 47 to 80 years, stratified by age, race, and length of time from and location of cancer treatment. Survivors were at least 2 years beyond completion of their active cancer treatment RESULTS Forty-two survivors participated in the study. Most participants expressed strong preferences to receive follow-up care from their cancer specialists (52%). They described the following barriers to the primary care physician's engagement in follow-up care: (1) lack of cancer expertise, (2) limited or no involvement with original cancer care, and (3) lack of care continuity. Only one-third of participants (38%) believed there was a role for primary care in cancer follow-up care and suggested the following opportunities: (1) performing routine cancer-screening tests, (2) supplementing cancer and cancer-related specialist care, and (3) providing follow-up medical care when "enough time has passed" or the survivors felt that they could reintegrate into the noncancer population. CONCLUSION Survivors have concerns about seeing their primary care physician for cancer-related follow-up care. Research interventions to address these issues are necessary to enhance the quality of care received by cancer survivors.