Colon cancer treatment in rural North and South Carolina

The Effect of Rural Residence on Cancer-Related Self-Efficacy With UK Cancer Survivors Following Treatment

PURPOSE

To examine rural and urban differences in cancer-related self-efficacy with UK cancer survivors following treatment.

METHODS

A cross-sectional postal survey with posttreatment cancer survivors in the East Midlands of England. The survey collected data on demographics and cancer-related self-efficacy using the Cancer Survivors Self-Efficacy Scale. Rural-urban residence was determined using Office for National Statistics classifications. Linear Regression models were developed using a Directed Acyclic Graph that determined confounding variables. When the model deviated from normal the outcome variable was transformed using the Box-Cox transformation.

FINDINGS

Of those surveyed, 227 responded, of whom 58% were female and 45% lived in a rural area. A linear regression model showed a significant increase in cancer-related self-efficacy in cancer survivors living in rural areas compared to urban residents (0.76, 95% CI: 0.25-1.27), although the residual plot deviated from a normal distribution. A model of the effect of rural living on a Box-Cox transformed outcome variable confirmed an increased cancer-related self-efficacy score in rural regions (9.06, 95% CI: 2.97-15.14). Rural living remained significant (7.98, 95% CI: 1.78-14.19) after adjustment for the respondents' income. Similarly adjusting for deprivation led to a significant increase in cancer-related self-efficacy in rural regions (8.64, 95% CI: 2.48-14.79).

CONCLUSION

This study has important implications when considering the impact of location of residence on cancer-related self-efficacy in cancer survivorship. The role of deprivation had some impact for sample respondents in both the urban and rural environment and merits further analysis.

Evaluating the Effectiveness, Efficiency and Safety of Telemedicine for Urological Care in the Male Prisoner Population

Introduction

We reviewed the safety and effectiveness of our hospital's urologic telemedicine (TM) program that has been utilized for the Iowa prisoner population for over a decade.

Methods

A retrospective review of TM visits of male prisoners from 2007 to 2014 was performed. Effectiveness of TM visits was assessed by 1) concordance of TM and in-person diagnoses, 2) compliance with radiologic and medication orders and 3) in-person visits saved with TM. Safety was assessed by analyzing the number of patients in which an ED visit was required after TM visit and missed or delayed cases of malignancy. Estimates were then made of the number of patients that could safely be managed with TM alone.

Results

The most common diagnosis was voiding dysfunction (24%) followed by genitourinary pain (23%). Diagnoses were concordant in 90% of patients; compliance was high (radiology 91%, medications 89%); in-person visits were estimated to be saved in 80-94%. No men required peri-TM ED visits and no cases of malignancy were missed in the population that returned for an in-person visit. We estimated that over 50% of urologic complaints in this cohort could have been managed with TM alone.

Conclusions

TM was shown to be a safe and effective method to provide general urologic care that obviated the initial in-person visits in nearly 90% of patients. It is likely that TM could safely replace in-person visits for many urologic conditions, especially in younger men and those in which access to specialized care may be limited.

Prevalence and survival benefit of adjuvant chemotherapy in stage III colon cancer patients: Comparison of overall and age-stratified results by multivariable modeling and propensity score methodology in a population-based cohort

BACKGROUND

Few population-based studies have assessed the effectiveness of adjuvant chemotherapy (ACT) in stage III colon cancer patients according to age. We sought to quantify the prevalence of ACT use and the absolute and relative survival benefit of ACT overall and by age in a population-based cohort.

METHODS

Stage III patients with adenocarcinoma of the colon identified by the Georgia Comprehensive Cancer Registry for the years 2000-07 were eligible (final N=3057). We utilized Poisson regression to obtain adjusted mortality rates (MR) and Cox proportional hazards models to obtain adjusted hazard ratios (HRs) for 5-year overall survival. We evaluated control of confounding by comparing HRs obtained via multivariable modeling (MM), propensity score weighting (PSW), and propensity score matching (PSM).

RESULTS

Just over one-third of colon cancer patients did not receive ACT, and the proportion increased with age. Overall, receipt of ACT conferred an absolute (MR difference [No ACT rate-ACT rate] 25.4 deaths/1000 person-years [py], 95% confidence interval [CI]: 19.1-32.7 deaths/1000 py) and relative (MM HR=0.67, 95% CI: 0.59-0.76) survival benefit. The survival benefit was demonstrated across age groups. MM and propensity score methods yielded highly similar HRs.

CONCLUSION

Unless contraindicated, efforts to ensure receipt of ACT for stage III colon cancer patients up to 84 years of age are needed to improve the prognosis of patients with node-positive disease.

Is distance to chemotherapy an obstacle to adjuvant care among the N.C. Medicaid-enrolled colon cancer patients?

BACKGROUND

Adjuvant chemotherapy for colon cancer has been linked to patient and provider characteristics but little is known about whether distance to chemotherapy providers constitutes an obstacle to chemotherapy.

METHODS

A total of 1,184 Medicaid patients diagnosed with colon cancer in North Carolina in 1999-2002 comprised the sample. Data from the N.C. Central Cancer Registry, N.C. Medicaid Claims, American Hospital Directory and US Census were merged. Logistic regression models were used to estimate the association between chemotherapy receipt and the distance to nearest chemotherapy provider.

RESULTS

Compared to the referent group of SEER-staged II (local) cancer patients living less than 2 miles from the nearest chemotherapy provider, the odds of receiving chemotherapy fell as the distance to the nearest provider increased. The odds ratio (OR) for those living ≥5 to <15 miles away was 0.13 [95% confidence intervals (CI), 0.04-0.39], and OR for those living ≥15 miles away was 0.06 (95% CI, 0.01-0.52). Patients diagnosed with regional, SEER-staged III (regional) cancer were less likely to receive chemotherapy if they lived in rural areas more than 20 miles away from the nearest provider (OR =0.08; 95% CI, 0.01-0.72). However, we found no evidence of association between chemotherapy receipt and distance to the nearest provider for regional cancer patients living in urban areas and those living in rural areas within 20 miles from the nearest chemotherapy provider.

CONCLUSIONS

Distance to provider may be an obstacle to chemotherapy for some groups of low-income colon cancer patients. Relieving travel burdens of rural patients living far from providers may help Medicaid increase guideline-consistent adjuvant care for regional cancer patients.

Inequalities in premature death from colorectal cancer by state

PURPOSE

Although disparities in colorectal cancer (CRC) with regard to race, socioeconomic status, and geography are well documented, the extent to which these factors contribute to premature death resulting from CRC nationwide and by state is unknown.

PATIENTS AND METHODS

We calculated age-standardized CRC death rates for three broad educational categories as a marker of socioeconomic status by race/ethnicity and state among individuals age 25 to 64 years from 2008 through 2010. We also calculated the proportion of premature death resulting from CRC that could potentially be averted in each state by applying the average death rate for the five states with the lowest rates among the most educated whites (Connecticut, North Dakota, Utah, Vermont, and Wisconsin) to all populations.

RESULTS

Compared with those with the most education, those with the least education had significantly higher CRC death rates in virtually all states for each racial/ethnic group. For example, rate ratios ranged from 1.15 (95% CI, 0.66 to 2.01) in Delaware to 3.18 (95% CI, 2.01 to 5.05) in New Mexico among whites. Overall, half the premature deaths resulting from CRC that occurred nationwide from 2008 through 2010, or 7,690 deaths annually, would have been avoided if everyone had experienced the lowest death rates of the most educated whites. More premature deaths could be averted in southern states (60% to 70%) than in northern and western states (30% to 40%). Restricting the analyses to persons age 50 to 64 years, for whom CRC screening is recommended, resulted in similar findings.

CONCLUSION

The majority of premature deaths from CRC in southern states and half these deaths nationwide are due to racial/ethnic, socioeconomic, and geographic inequalities.

Physical and mental health among cancer survivors: considerations for long-term care and quality of life

The physical and mental health of cancer patients needs to be addressed not only during active treatment but also throughout the continuum of survivorship care. This commentary provides an overview of issues pertinent to cancer survivors, with an emphasis on mental health issues and recommendations for annual clinical screening and monitoring using recently published guidelines from the American Society of Clinical Oncology.

Disparities in survival improvement for metastatic colorectal cancer by race/ethnicity and age in the United States

PURPOSE

Previous studies documented significant increase in overall survival for metastatic colorectal cancer (CRC) since the late 1990s coinciding with the introduction and dissemination of new treatments. We examined whether this survival increase differed across major racial/ethnic populations and age groups.

METHODS

We identified patients diagnosed with primary metastatic colorectal cancer during 1992-2009 from 13 population-based cancer registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, which cover about 14 % of the US population. The 5-year cause-specific survival rates were calculated using SEER*Stat software.

RESULTS

From 1992-1997 to 2004-2009, 5-year cause-specific survival rates increased significantly from 9.8 % (95 % CI 9.2-10.4) to 15.7 % (95 % CI 14.7-16.6) in non-Hispanic whites and from 11.4 % (95 % CI 9.4-13.6) to 17.7 % (95 % CI 15.1-20.5) in non-Hispanic Asians, but not in non-Hispanic blacks [from 8.6 % (95 % CI 7.2-10.1) to 9.8 % (95 % CI 8.1-11.8)] or Hispanics [from 14.0 % (95 % CI 11.8-16.3) to 16.4 % (95 % CI 14.0-19.0)]. By age group, survival rates increased significantly for the 20-64-year age group and 65 years or older age group in non-Hispanic whites, although the improvement in the older non-Hispanic whites was substantially smaller. Rates also increased in non-Hispanic Asians for the 20-64-year age group although marginally nonsignificant. In contrast, survival rates did not show significant increases in both younger and older age groups in non-Hispanic blacks and Hispanics.

CONCLUSION

Non-Hispanic blacks, Hispanics, and older patients diagnosed with metastatic CRC have not equally benefitted from the introduction and dissemination of new treatments.

Identification of underserved areas for urologic cancer care

BACKGROUND

The delivery of urologic oncology care is susceptible to regional variation. In the current study, the authors sought to define patterns of care for patients undergoing genitourinary cancer surgery to identify underserved areas for urologic cancer care in Washington State.

METHODS

The authors accessed the Washington State Comprehensive Hospital Abstract Reporting System from 2003 through 2007. They identified patients undergoing radical prostatectomy, radical cystectomy (RC), partial nephrectomy (PN), radical nephrectomy, and transurethral resection of the prostate (TURP). TURP was included for comparison as a reference procedure indicative of access to urologic care. Hospital service areas (HSAs) are where the majority of local patients are hospitalized; hospital referral regions (HRR) are where most patients receive tertiary care. The authors created multivariate hierarchical logistic regression models to examine patient and HSA characteristics associated with the receipt of urologic oncology care out of the HRR for each procedure.

RESULTS

Greater than one-half of patients went out of their HRR in 7 HSAs (11%) for radical prostatectomy, 3 HSAs (5%) for radical nephrectomy, 10 HSAs (15%) for PN, and 14 HSAs (22%) for RC. No HSAs had high export rates for TURP. Few patient factors were found to be associated with surgical care out of the HRR. High-export HSAs for PN and RC exhibited lower socioeconomic characteristics than low-export HSAs, adjusting for HSA population, race, and HSA procedure rates for PN and RC.

CONCLUSIONS

Patients living in areas with lower socioeconomic status have a greater need to travel for complex urologic surgery. Consideration of geographic delineation in the delivery of urologic oncology care may aid in regional quality improvement initiatives.

Rural-urban disparities in health status among US cancer survivors

BACKGROUND

Although rural residents are more likely to be diagnosed with more advanced cancers and to die of cancer, little is known about rural-urban disparities in self-reported health among survivors.

METHODS

The authors identified adults who had a self-reported history of cancer from the National Health Interview Survey (2006-2010). Rural-urban residence was defined using US Census definitions. Logistic regression with weighting to account for complex sampling was used to assess rural-urban differences in health status after accounting for differences in demographic characteristics.

RESULTS

Of the 7804 identified cancer survivors, 20.8% were rural residents. This translated to a population of 2.8 million rural cancer survivors in the United States. Rural survivors were more likely than urban survivors to be non-Hispanic white (P < .001), to have less education (P < .001), and to lack health insurance (P < .001). Rural survivors reported worse health in all domains. After adjustment for sex, race/ethnicity, age, marital status, education, insurance, time since diagnosis, and number of cancers, rural survivors were more likely to report fair/poor health (odds ratio, 1.39; 95% confidence interval, 1.20-1.62), psychological distress (odds ratio, 1.23; 95% confidence interval, 1.00-1.50), ≥2 noncancer comorbidities (odds ratio, 1.15; 95% confidence interval, 1.01-1.32), and health-related unemployment (odds ratio, 1.66; 95% confidence interval, 1.35-2.03).

CONCLUSIONS

The current results provide the first estimates of the proportion and number of US adult cancer survivors who reside in rural areas. Rural cancer survivors are at greater risk for a variety of poor health outcomes, even many years after their cancer diagnosis, and should be a target for interventions to improve their health and well being.

State disparities in colorectal cancer mortality patterns in the United States

BACKGROUND

Colorectal cancer (CRC) mortality rates have been decreasing for many decades in the United States, with the decrease accelerating in the most recent time period. The extent to which this decrease varies across states and its influence on the geographic patterns of rates is unknown.

METHODS

We analyzed the temporal trend in age-standardized CRC death rates for each state from 1990 to 2007 using joinpoint regression. We also examined the change in death rates between 1990-1994 and 2003-2007 using rate ratios with 95% confidence intervals and illustrated the change in pattern using maps. The relationship between the change in mortality rates and CRC screening rates for 2004 by state was examined using Pearson's correlation.

RESULTS

CRC mortality rates significantly decreased in all states except Mississippi between 1990 and 2007 based on the joinpoint model. The decrease in death rates between 1990-1994 and 2003-2007 ranged from 9% in Alabama to greater than 33% in Massachusetts, Rhode Island, New York, and Alaska; Mississippi and Wyoming showed no significant decrease. Generally, the northeastern states showed the largest decreases, whereas southern states showed the smallest decreases. The highest CRC mortality rates shifted from the northeastern states during 1990 to 1994 to the southern states along the Appalachian corridor during 2003 to 2007. The decrease in CRC mortality rates by state correlated strongly with uptake of screening (r = -0.65, P < 0.0001).

CONCLUSIONS

Progress in reducing CRC mortality varies across states, with the Northeast showing the most progress and the South showing the least progress.

IMPACT

These findings highlight the need for wider dissemination of CRC screening.

Influence of place of residence in access to specialized cancer care for African Americans

CONTEXT

Disparities in cancer care for rural residents and for African Americans have been documented, but the interaction of these factors is not well understood.

PURPOSE

The authors examined the simultaneous influence of race and place of residence on access to and utilization of specialized cancer care in the United States.

METHODS

Access to specialized cancer care was measured using: (1) travel time to National Cancer Institute (NCI) Cancer Centers, academic medical centers, and any oncologist for the entire continental US population, and (2) per capita availability of oncologists for the entire United States. Utilization was measured as attendance at NCI Cancer Centers, specialized hospitals, and other hospitals in the Surveillance, Epidemiology, and End Results (SEER) program Medicare population from 1998-2004.

FINDINGS

In urban settings, travel times were shorter for African Americans compared with Caucasians for all three cancer care settings, but they were longer for rural African Americans traveling to NCI Cancer Centers. Per capita oncologist availability was not significantly different by race or place of residence. Urban African American patients were almost 70% more likely to attend an NCI Cancer Center than urban Caucasian patients (OR = 1.66; 95% CI 1.51-1.83), whereas rural African American patients were 58% less likely to attend an NCI Cancer Center than rural Caucasian patients (OR = 0.42; 95% CI 0.26-0.66).

CONCLUSIONS

Urban African Americans have similar or better access to specialized cancer care than urban Caucasians, but rural African Americans have relatively poor access and lower utilization compared with all other groups.

Use of adjuvant 5-fluorouracil and radiation therapy after gastric cancer resection among the elderly and impact on survival

PURPOSE

In randomized trials patients with resected nonmetastatic gastric cancer who received adjuvant chemotherapy and radiotherapy (chemoRT) had better survival than those who did not. We investigated the effectiveness of adjuvant chemoRT after gastric cancer resection in an elderly general population and its effects by stage.

METHODS AND MATERIALS

We identified individuals in the Surveillance, Epidemiology, and End Results-Medicare database aged 65 years or older with Stage IB through Stage IV (M0) gastric cancer, from 1991 to 2002, who underwent gastric resection, using multivariate modeling to analyze predictors of chemoRT use and survival.

RESULTS

Among 1,993 patients who received combined chemoRT or no adjuvant therapy after resection, having a later year of diagnosis, having a more advanced stage, being younger, being white, being married, and having fewer comorbidities were associated with combined treatment. Among 1,476 patients aged less than 85 years who survived more than 4 months, the 313 who received combined treatment had a lower mortality rate (hazard ratio, 0.83; 95% confidence interval, 0.71-0.98) than the 1,163 who received surgery alone. Adjuvant therapy significantly reduced the mortality rate for Stages III and IV (M0), trended toward improved survival for Stage II, and showed no benefit for Stage IB. We observed trends toward improved survival in all age categories except 80 to 85 years.

CONCLUSIONS

The association of combined adjuvant chemoRT with improved survival in an overall analysis of Stage IB through Stage IV (M0) resected gastric cancer is consistent with clinical trial results and suggests that, in an elderly population, adjuvant chemoradiotherapy is effective. However, our observational data suggest that adjuvant treatment may not be effective for Stage IB cancer, is possibly appropriate for Stage II, and shows significant survival benefits for Stages III and IV (M0) for those aged less than 80 years.

Doxorubicin, cardiac risk factors, and cardiac toxicity in elderly patients with diffuse B-cell non-Hodgkin's lymphoma

PURPOSE

Anthracycline-based chemotherapy, which improves survival for patients with non-Hodgkin's lymphoma, is often withheld from elderly patients because of its cardiotoxicity. We studied the cardiac effects of doxorubicin in a population-based sample of older patients with diffuse large B-cell lymphoma (DLBCL).

PATIENTS AND METHODS

Among patients age > or = 65 years diagnosed with DLBCL from 1991 to 2002 in the Surveillance, Epidemiology, and End Results-Medicare database, we developed logistic regression models of the associations of doxorubicin with demographic, clinical, and cardiac variables. We then developed Cox proportional hazards models of the association between doxorubicin and subsequent congestive heart failure (CHF), taking predictors of CHF into account.

RESULTS

Of 9,438 patients with DLBCL, 3,164 (42%) received doxorubicin-based chemotherapy. Any doxorubicin use was associated with a 29% increase in risk of CHF (95% CI, 1.02 to 1.62); CHF risk increased with number of doxorubicin claims, increasing age, prior heart disease, comorbidities, diabetes, and hypertension; hypertension intensified the effect of doxorubicin on risk of CHF (hazard ratio = 1.8; P < .01). In the 8 years after diagnosis, the adjusted CHF-free survival rate was 74% in doxorubicin-treated patients versus 79% in patients not treated with doxorubicin.

CONCLUSION

Among patients receiving chemotherapy for DLBCL, those with prior heart disease were less likely than others to be treated with doxorubicin, and those who received doxorubicin were more likely than others to develop CHF. Various cardiac risk factors increased CHF risk, but only hypertension was synergistic with doxorubicin. Doxorubicin has dramatically improved survival of DLBCL patients; nonetheless, some subgroups may benefit from efforts to reduce doxorubicin-related CHF risk.

African-American and Caucasian disparities in colorectal cancer mortality and survival by data source: an epidemiologic review

Over the past four decades in the United States, there has been a divergent trend in mortality rates between African-Americans and Caucasians with colorectal cancer (CRC). Rates among Caucasians have been steadily declining, whereas rates among African-Americans have only started a gradual decline in recent years. We reviewed epidemiologic studies of CRC racial disparities between African-Americans and Caucasians, including studies from SEER and population-based cancer registries, Veterans Affairs (VA) databases, healthcare coverage databases, and university and other medical center data sources. Elevated overall and stage-specific risks of CRC mortality and shorter survival for African-Americans compared with Caucasians were reported across all data sources. The magnitude of racial disparities varied across study groups, with the strongest associations observed in university and non-VA hospital-based medical center studies, while an attenuated discrepancy was found in VA database studies. An advanced stage of disease at the time of diagnosis among African-Americans is a major contributing factor to the racial disparity in survival. Several studies, however, have shown that an increased risk of CRC death among African-Americans remains even after controlling for tumor stage at diagnosis, socioeconomic factors, and co-morbidity. Despite advances in treatment, improvements in the standard of care, and increased screening options, racial differences persist in CRC mortality and survival. Therefore, continued research efforts are necessary to disentangle the clinical, social, biological, and environmental factors that constitute the racial disparity. In addition, results across data sources should be considered when evaluating racial differences in cancer outcomes.

Assessing the quality of colorectal cancer care: do we have appropriate quality measures? (A systematic review of literature)

RATIONALE, AIMS AND OBJECTIVES

The burden of illness from colorectal cancer (CRC) can be reduced by improving the quality of care. Identifying appropriate quality measures is the first step in this direction. We identified process measures currently available to assess the quality of diagnosis and management of CRC. We also evaluated the extent to which these measures are ready to be implemented in clinical practice, and identified areas for future research.

METHODS

We searched MEDLINE, Cochrane Database of Systematic Reviews, and relevant grey literature. We identified 3771 abstracts and reviewed 74 articles that included quality measures for diagnosis or management of CRC. Measures from traditional quality improvement literature, and from epidemiological and other studies that included quality measures as part of their research agenda, were considered. In addition, we devised a summary rating scale (IST) to appraise the extent of a measure's importance and usability, scientific acceptability and extent of testing.

RESULTS

The coverage of general process measures in CRC is extensive. Most measures are important, but need to be developed and field-tested. The best available measures relate to pathology and chemotherapy. No measures are available for assessing quality of management of stage IV rectal cancer and hepatic metastasis; chemotherapy for stage II colon cancer; and procedure notes.

CONCLUSIONS

There is an urgent need to refine existing measures and to develop scientifically accurate quality measures for a comprehensive assessment of the quality of CRC care. The role of the federal government and professional societies is critical in pursuing this goal.

Colorectal cancer model of health disparities: understanding mortality differences in minority populations

African Americans are more likely to be diagnosed with and die as a result of colorectal cancer than white patients. This review briefly documents these differences and explores the factors that may contribute to advanced stage at diagnosis and reduced survival once African Americans are diagnosed with colorectal cancer. Attention is focused on what is known about the role of socioeconomic status, cancer screening, comorbidities and lifestyle factors, tumor biology and genetics, and the differences in the receipt of and benefit of appropriate therapy. Finally, areas of ongoing and future research and policy initiatives aimed at reducing disparities are discussed.

Completion of therapy by Medicare patients with stage III colon cancer

BACKGROUND

Certain factors, such as race or age, are known to be associated with variation in initiation of adjuvant chemotherapy for stage III colon cancer, but little is known about what factors are associated with completion of adjuvant therapy. To determine whether predictors of initiation also predict completion, we analyzed Surveillance, Epidemiology, and End Results (SEER) program data linked to Medicare claims. We investigated mortality as a means to testing the validity of the completion measure that we created.

METHODS

We studied 3193 stage III colon cancer patients whose diagnosis was recorded in 1992-1996 SEER program data linked to 1991-1998 Medicare claims and who initiated adjuvant chemotherapy after colon cancer resection. We defined a measure of adjuvant chemotherapy completion as one chemotherapy administration claim in a month. We tested the validity of the created measure and its relation to 3-year cancer mortality adjusted for demographic, clinical, and environmental variables. We explored the association of patient characteristics and treating physician characteristics with chemotherapy completion by use of multivariable logistic regression modeling.

RESULTS

Of the 3193 patients, 2497 (78.2%) completed the course. Risk of cancer-related mortality was statistically significantly lower among those completing chemotherapy (relative risk = 0.79, 95% confidence interval = 0.69 to 0.89) than those with no adjuvant therapy. Patients who were female, widowed, increasingly elderly, rehospitalized, and living in certain regions were less likely to complete adjuvant chemotherapy than other patients. Race and other clinical, environmental, and physician characteristics were not associated with completion of therapy.

CONCLUSIONS

Factors associated with incomplete adjuvant chemotherapy may represent physical frailty, treatment complications, and lack of social and psychological support. Interventions to mitigate these influences are a logical next step toward increasing chemotherapy completion rates.

Quality measures for the use of adjuvant chemotherapy and radiation therapy in patients with colorectal cancer

BACKGROUND

Chemotherapy (CT) and radiation therapy (RT) are essential components of adjuvant (preoperative or postoperative) therapy for many patients with colorectal cancer (CRC); however, quality measures (QMs) of these critical aspects of CRC treatment have not been characterized well. Therefore, the authors conducted a systematic review of the literature to determine the available QMs for adjuvant CT and RT in patients with CRC and rated their usefulness for assessing the delivery of quality care.

METHODS

The MEDLINE and Cochrane data bases were searched for all publications that contained potential/actual QMs pertaining to adjuvant therapy for CRC. Identified QMs were rated by using criteria developed by the National Quality Forum.

RESULTS

Thirty-two articles met the established inclusion/exclusion criteria. Those 32 articles contained 12 potential or actual QMs, 6 of which had major flaws that limited their applicability. The most useful QMs identified were 1) the percentage of patients with AJCC Stage III colon cancer who received postoperative CT and 2) the percentage of patients with Stage II or III rectal cancer who received chemoradiotherapy.

CONCLUSIONS

To the authors' knowledge, very few QMs pertaining to adjuvant CT or RT for CRC have been published to date, and only half of those measures were rated as useful, acceptable, and valid in the current literature review. Future research should focus on refining existing QMs and on developing new QMs that target important leverage points with respect to the provision of adjuvant therapy for patients with CRC.

Differences in colorectal carcinoma stage and survival by race and ethnicity

BACKGROUND

In the United States, blacks with colorectal carcinoma (CRC) presented with more advanced-stage disease and had higher mortality rates compared with non-Hispanic whites. Data regarding other races/ethnicities were limited, especially for Asian/Pacific Islander and Hispanic white subgroups.

METHODS

Using data from 11 population-based cancer registries that participate in the Surveillance, Epidemiology and End Results program, the authors evaluated the relation among 18 different races/ethnicities and disease stage and mortality rates among 154,103 subjects diagnosed with CRC from 1988 to 2000.

RESULTS

Compared with non-Hispanic whites, blacks, American Indians, Chinese, Filipinos, Koreans, Hawaiians, Mexicans, South/Central Americans, and Puerto Ricans were 10-60% more likely to be diagnosed with Stage III or IV CRC. Alternatively, Japanese had a 20% lower risk of advanced-stage CRC. With respect to mortality rates, blacks, American Indians, Hawaiians, and Mexicans had a 20-30% greater risk of mortality, whereas Chinese, Japanese, and Indians/Pakistanis had a 10-40 % lower risk.

CONCLUSIONS

The authors observed numerous racial/ethnic disparities in the risks of advanced-stage cancer and mortality among patients with CRC, and there was considerable variation in these risks across Asian/Pacific Islander and Hispanic white subgroups. Although the etiology of these disparities was multifactorial, developing screening and treatment programs that target racial/ethnic populations with elevated risks of poor CRC outcomes may be an important means of reducing these disparities.

Colorectal cancer and race: understanding the differences in outcomes between African Americans and whites

Understanding the differences in the incidence and mortality rate between African Americans and whites with CRC remains a perplexing problem. There is clearly not any one factor that explains the observed differences. Clinicians are just beginning to understand the importance of tumor biology, genetics, and lifestyle risk factors in explaining differences in how CRCs present and how they behave. This holds true regardless of a patient's race, sex, or age. Whether these factors will add disproportionately to the understanding of racial differences in presentation and outcome remains to be seen. Certainly, issues surrounding screening for CRC remain important in understanding the advanced stage of presentation for African Americans. In particular, a better understanding is needed of who is being screened and who is not and why. For example, are higher-risk African Americans being screened and if not what are the reasons for this? Importantly, even if one were able to eliminate the differences in stage at presentation between African Americans and whites, a survival disadvantage, albeit a much smaller one, would likely persist. Clearly, there is a need to understand better why African Americans are not receiving recommended therapy at the same rate as whites. This becomes even more important as the life-prolonging options for treating both localized and metastatic colon cancer continue to multiply. Finally, the apparent greater disparity in outcome for African Americans who have stage II disease should be explored in more detail, because this could have an immediate impact on treatment recommendations. For example, a 23-gene signature was recently found to be predictive of recurrence among patients with Dukes B colon cancer [66]. If this model is validated in further studies, one could look at whether African-American patients are more likely to have this predictive signature. The problem has been clearly defined: a higher incidence of and a higher mortality from CRC for African Americans than whites. The task now becomes to continue to understand the reasons for the disparities and ultimately to come up with workable solutions so that the amazing progress in CRC treatment benefits all groups in this country.

Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries

BACKGROUND

African Americans are diagnosed more frequently with colorectal carcinoma at a later stage compared with Caucasians. One potential reason for the disparity is a lower rate of screening examinations.

METHODS

Using Outpatient and Physician-Supplier claims for all Medicare beneficiaries age > or = 65 years in 1999, indications for fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and barium enema were divided into diagnostic, surveillance, or screening categories. Annualized rates were calculated based on the number of eligible fee-for-service months.

RESULTS

Rates of FOBT (18.24% vs. 11.86%; P < 0.001) and sigmoidoscopy (3.07% vs. 2.17%; P < 0.001) were higher in Caucasians compared with African Americans, whereas rates of barium enema were higher in African Americans (2.26% vs. 1.88%; P < 0.001). Colonoscopy use was more frequent among men only in Caucasians compared with African-Americans (8.00% vs. 6.97%; P < 0.001). For FOBT, sigmoidoscopy, and colonoscopy, the racial differences in procedures performed for diagnostic purposes were of smaller magnitude than for screening; and, for colonoscopy, the use of diagnostic procedures actually was higher for African Americans.

CONCLUSIONS

Racial disparities exist not only in the use of colorectal procedures but also in the indications for such testing, with African Americans less likely to undergo screening tests. The differences are consistent with delay in diagnosis until symptoms or signs develop and may contribute to disparities in cancer mortality.

Effectiveness of adjuvant fluorouracil in clinical practice: a population-based cohort study of elderly patients with stage III colon cancer

PURPOSE

Although randomized controlled trials (RCTs) consistently show that adjuvant fluorouracil (5-FU) extends the survival of patients with stage III colon cancer, it is not yet known whether this benefit exists in populations underrepresented on clinical trials, particularly the elderly with medical comorbidity treated in the community. In this study, we ask the following: (1) What is the hazard of death associated with adjuvant 5-FU in the general population of elderly stage III colon cancer patients? (2) Does the hazard vary with patient age?

PATIENTS AND METHODS

In this prospective, nonrandomized, population-based cohort study of 3,357 elderly Medicare beneficiaries who had undergone resection of stage III colon cancer according to the Surveillance, Epidemiology, and End-Results registries, we use propensity score matching to compare the all-cause mortality of patients who received 5-FU to matched untreated patients.

RESULTS

5-FU reduces the hazard of death by 27% (hazard ratio, 0.73; 95% confidence interval [CI], 0.65 to 0.82) across the 6 years of our data in a Cox model. At 5 years, 52.7% (95% CI, 49.6% to 55.6%) of the treated and 40.7% (95% CI, 38.1% to 43.4%) of the matched untreated are still alive. We find that these effects do not diminish with advancing patient age.

CONCLUSION

The survival benefit of adjuvant 5-FU that has been demonstrated in participants of RCTs is also evident in a population sample of elderly Medicare beneficiaries with stage III colon cancer treated in the community. Furthermore, this survival benefit does not appear to diminish with patient age. These findings support the continued use of adjuvant 5-FU in the general population of elderly patients with stage III colon cancer and suggest that oncologists in the community are practicing at a high level of effectiveness.

Use of adjuvant chemotherapy and radiation therapy for rectal cancer among the elderly: a population-based study

PURPOSE

Combined adjuvant fluorouracil (5-FU)-based chemotherapy with radiation is now the standard of care for locally advanced rectal cancer in the United States. We investigated the use of these treatments for stages II and III rectal cancer among the elderly and the effectiveness of these treatments on a population-based scale.

PATIENTS AND METHODS

The linked Surveillance, Epidemiology, and End-Results-Medicare database was used to identify 1,807 Medicare beneficiaries > or = 65 years of age with stage II or III rectal cancer who underwent surgical resection between 1992 and 1996. We excluded members of a health maintenance organization in the 12 months before or 4 months after their diagnosis and those who died within 4 months of diagnosis. We used multivariate analysis to identify factors associated with combined 5-FU and radiation therapy, and propensity score methodology to determine survival benefit for those treated.

RESULTS

We found that 37% of patients received both adjuvant 5-FU and radiation therapy, 11% 5-FU alone, and 14% radiation alone. Decreasing age, increasing lymph node positivity, comorbid conditions, and nonblack race were associated with increased probability of treatment with 5-FU and radiation. Combined chemotherapy/radiation therapy was associated with improved survival for stage III (relative risk, 0.71; 95% confidence interval, 0.56 to 0.90), but not for stage II rectal cancer (relative risk, 0.89; 95% confidence interval, 0.70 to 1.14).

CONCLUSION

The association of combined treatment with improved survival in node-positive disease was similar to that observed in other studies. In the absence of data from well-designed randomized controlled trials, our observational data support efforts on the part of clinicians to make appropriate referrals and provide combined treatment for elderly patients with stage III rectal cancer.

Efficacy and toxicity of adjuvant chemotherapy in elderly patients with colon carcinoma: a 10-year experience of the Geisinger Medical Center

BACKGROUND

Although the benefit from adjuvant chemotherapy has been established clearly in patients with Stage III colon carcinoma, the degree to which elderly patients with colon carcinoma can tolerate such therapy generally has remained unknown.

METHODS

The authors reviewed all patients in their Tumor Registry with Stage II and Stage III adenocarcinoma of the colon who underwent potentially curative resection for their disease at the Geisinger Medical Center between January 1990 and September 2000. One hundred twenty patients underwent complete resection of their colon carcinoma and received 5-fluorouracil-based (5-FU) adjuvant chemotherapy.

RESULTS

The 5-year disease free survival rate for patients age > or =65 years (Group A) was 70% compared with 56% for patients age < 65 years (Group B) (P = 0.085). The 5-year overall survival rate for patients in Group B was 77% compared with 62% for the patients in Group A (P = 0.143). In a Cox regression model, age was not a predictor of disease free survival (P = 0.633) or overall survival (P = 0.900) when it was analyzed as a continuous variable. Only 19 patients were age > 75 years, and the disease free and overall survival rates for this group were similar but were underpowered compared with the rates for the patients ages between 65-75 years. When gender and disease stage were included in the model, age remained a nonsignificant variable (P = 0.400 for disease free survival; P = 0.615 for overall survival). Nine of 56 patients in Group A (16%) experienced Grade 3-4 toxicity compared with 14 of 64 patients in Group B (22%) (P = 0.420). The lack of a correlation between toxicity and age was maintained after controlling for disease stage and patient gender (P = 0.343). There were no correlations between preoperative carcinoembryonic antigen level, tumor grade, or lymph node involvement and patient age (P = 0.258, P = 0.256, and P = 0.519, respectively).

CONCLUSIONS

Elderly patients with Stage II and Stage III colon carcinoma benefit from 5-FU-based adjuvant therapy without a significant increase in toxicity compared with their younger counterparts. Adjuvant chemotherapy should be presented to elderly patients with high-risk, resected colon carcinoma. The data regarding age cannot be generalized to patients age > 75 years.

Construct validity of medicare chemotherapy claims: the case of 5FU

BACKGROUND

The elderly are under represented in clinical trials of cancer therapy and the elderly who are enrolled may be unrepresentative.

OBJECTIVE

To assess whether Medicare claims data might be used to understand the benefits and tolerance of chemotherapy in the general elderly population, the construct validity of Medicare 5FU claims for elderly colon cancer patients within the SEER-Medicare data set was determined.

METHODS

In this validation study of Medicare chemotherapy claims from the linked the SEER-Medicare data set, the patterns of 5FU chemotherapy claims were evaluated for an incident cohort of elderly colon cancer patients (n = 15,039) during the 13 months following their diagnosis. Patterns of Medicare National Claims History (NCH) 5FU claims were evaluated with respect to prespecified patient-level disease and demographic factors from the data set.

RESULTS

Twenty-two percent of patients had at least one detectable 5FU claim during the observation period. Among those patients, the median dose of 5FU was 1000 mg, the median interval between 5FU claims was 7 days, and the median number of claims during this period was 24. Multivariate regression revealed expected associations between demographic and disease factors and the likelihood of having a Medicare NCH 5FU claim. With increasing cancer stage, patients' likelihood of having a 5FU claim increased. Younger patients, married patients, white patients, patients with low comorbidity, and patients living in urban and less impoverished regions were each more likely to have 5FU claims.

CONCLUSION

Because their pattern is consistent with the standard of medical care and with previously described associations with disease and demographic factors, it was concluded that Medicare NCH claims for 5FU administration in the SEER-Medicare data set exhibit construct validity. Criterion validation studies with an external gold standard should be pursued to determine the sensitivity and specificity of chemotherapy codes in the Medicare NCH files.

Age, sex, and racial differences in the use of standard adjuvant therapy for colorectal cancer

PURPOSE

Dissemination of efficacious adjuvant therapies for resectable colorectal cancer has not been comprehensively described. Trends, patterns, and outcomes of adjuvant therapy for colorectal cancer, focusing on age, sex, and racial/ethnic differences, are reported.

MATERIALS AND METHODS

Population-based random samples of patients diagnosed with colorectal cancer diagnosed in nine geographic areas were collected annually between 1987 and 1991 and in 1995 (n = 4,706). Data were obtained from medical record reviews. Multiple logistic regression was used to assess the use of standard adjuvant chemotherapy for colon and rectal cancers. The Cox proportional hazards model was used to assess 9-year mortality.

RESULTS

From 1987 until 1995, the use of adjuvant therapy increased in all age groups. There was an increase starting in 1989 for colon and in 1988 for rectal cancer. Use of standard therapy was 78% for those younger than 55 years and 24% for those older than 80 years. White patients received standard therapy more frequently than African-Americans (odds ratio, 1.75; 95% confidence interval [CI], 1.09 to 2.83). All-cause and cancer-specific mortality exceeding 9 years were lower in those who received standard therapy (all-cause risk ratio [RR], 0.73; 95% CI, 0.61 to 0.88; cancer-specific RR, 0.87; 95% CI, 0.70 to 1.09).

CONCLUSION

Standard adjuvant therapies for colorectal cancer disseminated into community practices during the 1990s. However, evidence exists of differential use of therapies by older patients and by African-Americans. The use of standard therapies in the general population is associated with lower mortality. Improved dissemination of standard adjuvant therapies to all segments of the population could help reduce mortality.

Impact of patient and provider characteristics on the treatment and outcomes of colorectal cancer

While the management and prognosis of colorectal cancer are largely dependent on clinical features such as tumor stage, there is considerable variation in treatment and outcome not explained by traditional prognostic factors. To guide efforts by researchers and health-care providers to improve quality of care, we review studies of variation in treatment and outcome by patient and provider characteristics. Surgeon expertise and case volume are associated with improved tumor control, although surgeon and hospital factors are not associated consistently with perioperative mortality or long-term survival. Some studies indicate that patients are less likely to undergo permanent colostomy if they are treated by high-volume surgeons and hospitals. Differences in treatment and outcome of patients managed by health maintenance organizations or fee-for-service providers have not generally been found. Older patients are less likely to receive adjuvant therapy after surgery, even after adjustment for comorbid illness. In the United States, black patients with colorectal cancer receive less aggressive therapy and are more likely to die of this disease than white patients, but cancer-specific survival differences are reduced or eliminated when black patients receive comparable treatment. Patients of low socioeconomic status (SES) have worse survival than those of higher SES, although the reasons for this discrepancy are not well understood. Variations in treatment may arise from inadequate physician knowledge of practice guidelines, treatment decisions based on unmeasured clinical factors, or patient preferences. To improve quality of care for colorectal cancer, a better understanding of mechanisms underlying associations between patient and provider characteristics and outcomes is required.