Bowel surveillance patterns after a diagnosis of colorectal cancer in Medicare beneficiaries

Characteristics Associated With Nonreceipt of Surveillance Testing and the Relationship With Survival in Stage II and III Colon Cancer

We investigated characteristics of patients with colon cancer that predicted nonreceipt of posttreatment surveillance testing and the subsequent associations between surveillance status and survival outcomes. This was a retrospective cohort study of the Surveillance, Epidemiology, and End Results database combined with Medicare claims. Patients diagnosed between 2002 and 2009 with disease stages II and III and who were between 66 and 84 years of age were eligible. A minimum of 3 years' follow-up was required, and patients were categorized as having received any surveillance testing (any testing) versus none (no testing). Poisson regression was used to obtain risk ratios with 95% confidence intervals for the relative likelihood of No Testing. Cox models were used to obtain subdistribution hazard ratios with 95% confidence intervals for 5- and 10-year cancer-specific and noncancer deaths. There were 16,009 colon cancer cases analyzed. Patient characteristics that predicted No Testing included older age, Black race, stage III disease, and chemotherapy. Patients in the No Testing group had an increased rate of 10-year cancer death that was greater for patients with stage III disease (subdistribution hazard ratio = 1.79, 95% confidence interval: 1.48, 2.17) than those with stage II disease (subdistribution hazard ratio = 1.41, 95% confidence interval: 1.19, 1.66). Greater efforts are needed to ensure all patients receive the highest quality medical care after diagnosis of colon cancer.

A comparison of the effects of epidural analgesia versus traditional pain management on outcomes after gastric cancer resection: a population-based study

BACKGROUND AND OBJECTIVES

Epidural analgesia may increase survival after cancer surgery by reducing recurrence. This population-based study compared survival and treated recurrence after gastric cancer resection between patients receiving epidurals and those who did not.

METHODS

We used the linked federal Surveillance, Epidemiology, and End Results Program/Medicare database to identify patients aged 66 years or older with nonmetastatic gastric carcinoma diagnosed 1996 to 2005 who underwent resection. Exclusions included diagnosis at autopsy, no Medicare Part B, familial cancer syndrome, emergency surgery, and laparoscopic procedures. Epidurals were identified by Current Procedural Terminology codes. Treated recurrence was defined as chemotherapy greater than or equal to 16 months and/or radiation greater than or equal to 12 months after surgery. Recurrence was compared by conditional logistic regression. Survival was compared via marginal Cox proportional hazards regression model.

RESULTS

We identified 2745 patients, 766 of whom had epidural codes. Patients receiving epidurals were more likely to have regional disease, be white, and live in areas with relatively high socioeconomic status. Overall treated recurrence was 25.6% (27.5% epidural and 24.9% nonepidural). In the adjusted logistic regression, there was no difference in recurrence (odds ratio, 1.40; 95% confidence interval [CI], 0.96-2.05). Median survival did not differ: 28.1 months (95% CI, 24.8-32.3) in the epidural versus 27.4 months (95% CI, 24.8-30.0) in the nonepidural groups. The marginal Cox models showed no association between epidural use and mortality (adjusted hazard ratio, 0.93; 95% CI, 0.84-1.03).

CONCLUSIONS

There was no difference between groups regarding treated recurrence or survival. Whether this is true or simply a result of insufficient power is unclear. Prospective studies are needed to provide stronger evidence.

Patterns of colorectal cancer care in the United States and Canada: a systematic review

Colorectal cancer is the third most common cancer in the United States and Canada. Given the high incidence and increased survival of colorectal cancer patients, prevalence is increasing over time in both countries. Using MEDLINE, we conducted a systematic review of the literature published between 2000 and 2010 to describe patterns of colorectal cancer care. Specifically we examined data sources used to obtain treatment information and compared patterns of cancer-directed initial care, post-diagnostic surveillance care, and end-of-life care among colorectal cancer patients diagnosed in the United States and Canada. Receipt of initial treatment for colorectal cancer was associated with the anatomical position of the tumor and extent of disease at diagnosis, in accordance with consensus-based guidelines. Overall, care trends were similar between the United States and Canada; however, we observed differences with respect to data sources used to measure treatment receipt. Differences were also present between study populations within country, further limiting direct comparisons. Findings from this review will allow researchers, clinicians, and policy makers to evaluate treatment receipt by patient, clinical, or system characteristics and identify emerging trends over time. Furthermore, comparisons between health-care systems in the United States and Canada can identify disparities in care, allow the evaluation of different models of care, and highlight issues regarding the utility of existing data sources to estimate national patterns of care.

Receipt of recommended surveillance among colorectal cancer survivors: a systematic review

PURPOSE

Regular surveillance decreases the risk of recurrent cancer in colorectal cancer (CRC) survivors. However, studies suggest that receipt of follow-up tests is not consistent with guidelines. This systematic review aimed to: (1) examine receipt of recommended post-treatment surveillance tests and procedures among CRC survivors, including adherence to established guidelines, and (2) identify correlates of CRC surveillance.

METHODS

Systematic searches of Medline, PubMed, PsycINFO, CINAHL Plus, and Scopus databases were conducted using terms adapted for each database's keywords and subject headings. Studies were screened for inclusion using a three-step process: (1) lead author reviewed abstracts of all eligible studies; (2) coauthors reviewed random 5 % samples of abstracts; and (3) two sets of coauthors reviewed all "maybe" abstracts. Discrepancies were adjudicated through discussion.

RESULTS

Thirty-four studies are included in the review. Overall adherence ranged from 12 to 87 %. Within the initial 12 to 18 months post-treatment, adherence to recommended office visits was 93 %. Adherence ranged from 78 to 98 % for physical exams, 18-61 % for colonoscopy, and 17-71 % for carcinoembryonic antigen (CEA) testing. By 2 to 3 years post-treatment, cumulative adherence ranged from 70 to 88 % for office visits, 89-93 % for physical exams, 49-94 % for colonoscopy, and 7-79 % for CEA testing. Between 18 and 28 % of CRC survivors received greater than recommended overall surveillance; overuse of physical exams (42 %), colonoscopy (24-76 %), and metastatic disease testing (1-29 %) was also prevalent. Studies of correlates of CRC surveillance focused on sociodemographic and disease/treatment characteristics, and patterns of association were inconsistent across studies.

CONCLUSIONS

Deviation from surveillance recommendations includes both under- and overuse. Examination of modifiable determinants is needed to inform interventions targeting appropriate and timely receipt of recommended surveillance.

IMPLICATIONS FOR CANCER SURVIVORS

Among CRC survivors, it remains unclear what modifiable psychosocial factors are associated with the observed under- and overuse of surveillance. Understanding and intervening with these psychosocial factors is critical to improving adherence to guideline-recommended surveillance and thereby reducing mortality among this group of survivors.

Postresection surveillance for pancreatic cancer performance status, imaging, and serum markers

Approximately 15% of patients with a diagnosis of pancreatic adenocarcinoma are candidates for potentially curative surgery. However, most patients who undergo such surgery will die from recurrent disease, most within the first few years, whereas nearly all succumb by 5 to 7 years from diagnosis. Currently, there is a lack of high-level evidence to guide consensus recommendations as to the optimal surveillance strategy after resection. There is considerable variability in clinical practice, ranging from frequent clinical follow-up, with serial Ca 19-9 measurement and routine computed tomographic imaging on a 3- to 6-monthly basis, to a practice of no routine serum or imaging follow-up after surgery. In most part, this divergence in practice reflects a lack of data to define optimal practice. The argument in favor of limited surveillance presumably stems from the relatively uniform poor outcomes after recurrence and the absence of evidence indicating that early detection of local, regional, or metastatic recurrence improves outcomes. However, recent advancements in the treatment of metastatic disease offer hope that earlier detection and initiation of treatment for recurrent disease may positively impact clinical outcomes and at least urges review of the topic. One advantage to the development of defined guidelines would be greater consistency in the setting of both routine clinical follow-up and follow-up after adjuvant therapy on trial.

Ethnic disparities in colonoscopy use among colorectal cancer survivors: a systematic review

PURPOSE

After curative treatment for colorectal cancer (CRC), routine colonoscopies are recommended. We aimed to identify all studies of ethnic disparities in CRC surveillance and examine any association between race/ethnicity and colonoscopy use.

METHODS

We conducted a systematic literature review to address the association between race/ethnicity and colonoscopy use among CRC survivors. We searched Medline for relevant articles. Two authors reviewed titles, abstracts, and articles based on pre-determined inclusion/exclusion criteria.

RESULTS

Of the 1,544 titles reviewed, eight studies published since 2001 investigated racial/ethnic disparities in colonoscopy use. Four articles showed a small significant ethnic disparity in the receipt of timely colonoscopy, and the remaining four articles showed a nonsignificant trend in the same direction. The effect did not vary by time of diagnosis or proportion of minorities in each study, though studies with larger samples showed somewhat greater racial/ethnic disparities in colonoscopy use.

CONCLUSIONS

We found at least a small disparity in the use of colonoscopy among CRC survivors, suggesting that ethnic disparities continue beyond prevention, detection, and treatment of CRC. It is important to identify areas of unequal care in CRC survivorship and to promote timely surveillance among CRC survivors who belong to racial/ethnic minorities to decrease disparities in mortality.

IMPLICATIONS FOR CANCER SURVIVORS

CRC survivors who belong to racial/ethnic minorities may be less likely to receive follow-up colonoscopies on time, which could contribue to higher rates of death from CRC among minorities.

Surveillance after resection for colorectal cancer

BACKGROUND

Professional societies recommend posttreatment surveillance for colorectal cancer (CRC) survivors. This study describes the use of surveillance over time, with a particular focus on racial/ethnic disparities, and also examines the role of area characteristics, such as capacity for CRC screening, on surveillance.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify individuals aged 66 to 85 years who were diagnosed with CRC from 1993 to 2005 and treated with surgery. The study examined factors associated with subsequent receipt of a colonoscopy, carcinoembryonic antigen (CEA) testing, primary care (PC) visits, and a composite measure of overall surveillance.

RESULTS

Of eligible subjects, 61.0% had a colonoscopy, 68.0% had CEA testing, 77.1% had PC visits, and 43.0% received overall surveillance. After adjustment, blacks were less likely than whites to undergo colonoscopy (odds ratio [OR] 0.76, 95% confidence interval [CI] = 0.69-0.83) and to receive CEA testing and overall surveillance, whereas white/Hispanic rates did not differ. Rates for all outcomes increased from 1993 to 2005, but black/white disparities remained. Individuals in areas with greatest capacity for CRC screening were more likely (OR = 1.09, 95% CI = 1.02-1.18) to receive colonoscopy, and those in areas with the greatest percentage of blacks were less likely (OR = 0.89, 95% CI = 0.83-0.95) to receive colonoscopy. Those living in areas with shortage of PC were less likely to receive PC visits (OR = 0.55, 95% CI = 0.48-0.64) and overall surveillance (OR = 0.83, 95% CI = 0.71-0.98).

CONCLUSIONS

Many CRC survivors do not get recommended surveillance, and black/white disparities in rates of surveillance have not improved. Characteristics of the area where an individual lives contribute to the use of surveillance.

Predictors of initial 18F-fluorodeoxyglucose-positron emission tomography indication among patients with colorectal cancer

OBJECTIVES

To evaluate the determinants of initial F-fluorodeoxyglucose (F-FDG)-PET indication following primary colorectal cancer diagnosis among patients who underwent surgery between January 2000 and December 2007 and who were observed at a single institution for at least 2 years after diagnosis.

METHODS

Of the 530 patients who underwent colorectal cancer resection, 113 patients received at least one F-FDG-PET following diagnosis. Outcome variables included indication and time of the first F-FDG-PET following diagnosis. Potential predictors included disease-level and patient-level characteristics. Univariate and multivariate regression analyses were performed.

RESULTS

Patients diagnosed later in the study period and patients with higher-stage disease were more likely to receive their first F-FDG-PET for initial staging (P<0.001 and P=0.016, respectively). Patients with lower-stage disease were more likely to receive their initial F-FDG-PET for suspected recurrence on conventional imaging. When performed more than 2 years after diagnosis, F-FDG-PET was more likely to be ordered for suspected recurrence either on the basis of conventional imaging or on the basis of patient symptoms/tumor markers (P=0.003 and 0.031, respectively). F-FDG-PET demonstrated disease progression in at least 50% of patients referred for each indication (P=0.037).

CONCLUSION

Higher utilization of F-FDG-PET may be appropriate among patients referred for a number of indications including: initial staging, particularly among those with higher-stage disease; suspected recurrence on conventional imaging among patients with lower-stage disease; and suspected recurrence more than 2 years after diagnosis. Further research is needed to verify these findings.

An international review of the patterns and determinants of health service utilisation by adult cancer survivors

Background

There is a need to review factors related to health service utilisation by the increasing number of cancer survivors in order to inform care planning and the organisation and delivery of services.

Methods

Studies were identified via systematic searches of Medline, PsycINFO, CINAHL, Social Science Citation Index and the SEER-MEDICARE library. Methodological quality was assessed using STROBE; and the Andersen Behavioural Model was used as a framework to structure, organise and analyse the results of the review.

Results

Younger, white cancer survivors were most likely to receive follow-up screening, preventive care, visit their physician, utilise professional mental health services and least likely to be hospitalised. Utilisation rates of other health professionals such as physiotherapists were low. Only studies of health service use conducted in the USA investigated the role of type of health insurance and ethnicity. There appeared to be disparate service use among US samples in terms of ethnicity and socio-demographic status, regardless of type of health insurance provision s- this may be explained by underlying differences in health-seeking behaviours. Overall, use of follow-up care appeared to be lower than expected and barriers existed for particular groups of cancer survivors.

Conclusions

Studies focussed on the use of a specific type of service rather than adopting a whole-system approach and future health services research should address this shortcoming. Overall, there is a need to improve access to care for all cancer survivors. Studies were predominantly US-based focussing mainly on breast or colorectal cancer. Thus, the generalisability of findings to other health-care systems and cancer sites is unclear. The Andersen Behavioural Model provided an appropriate framework for studying and understanding health service use among cancer survivors. The active involvement of physicians and use of personalised care plans are required in order to ensure that post-treatment needs and recommendations for care are met.

Patient-clinician information engagement improves adherence to colorectal cancer surveillance after curative treatment: results from a longitudinal study

Introduction. Follow-up surveillance after curative treatment for colorectal cancer (CRC) patients is recommended to detect early cancer recurrences and improve survival outcomes. However, a substantial proportion of CRC patients do not undergo cancer surveillance. Several demographic and disease-related factors have been associated with cancer surveillance adherence. Thus far, patient-centered communication has not been studied as a determinant for undergoing cancer surveillance. The purpose of this study is to determine whether patient-clinician information engagement (PCIE) influences patients' self-reported adherence to recommended CRC surveillance procedures. Methods. The study was a longitudinal survey among Pennsylvanian patients diagnosed with CRC in 2005. CRC patients who were eligible for surveillance and participated in both the baseline and 1-year follow-up surveys were included in this analysis (n = 305). The main outcome measure was self-reported adherence to physical examination, carcinoembryonic antigen testing, and colonoscopy according to recommended guidelines. Results. Controlling for potential confounders, higher PCIE at baseline predicted a higher odds for CRC patients reporting adherence to recommended surveillance 1 year later by 2.8 times. Other significant predictors of adhering to recommended surveillance were a higher education level and having received systemic therapy. Discussion. In this longitudinal study among CRC patients who received curative treatment, greater patient engagement with clinicians about cancer-related information was found to improve patients' subsequent adherence to recommended surveillance. This finding provides support for encouraging greater patient-physician communication among CRC patients.

Awareness of postpolypectomy surveillance guidelines: a nationwide survey of colonoscopists in Canada

INTRODUCTION

Due to the increasing demand for colonoscopy, adherence to postpolypectomy surveillance guidelines is important. Suboptimal compliance can lead to unnecessary risks and ineffective use of resources.

OBJECTIVE

To determine the awareness of and adherence to postpolypectomy surveillance guidelines among members of the Canadian Association of Gastroenterology (CAG).

METHODS

A survey describing 14 clinical cases was mailed to all physician members (n=411) of the CAG. Respondents were required to recommend a surveillance interval and a reason for his or her choice.

RESULTS

A total of 150 colonoscopists (37%) completed the survey. Adherence to the guidelines varied from 23% to 96% per clinical scenario (median 63%). Recommended surveillance intervals were too short in 0% to 60% of the different cases (median 8%). The recommended interval was most often (60%) too short for a patient with one tubular adenoma with high-grade dysplasia. Surveillance intervals were too long in 4% to 75% of the cases (median 9%). The recommended interval was most often too long in a patient with a villous adenoma 15 mm in size and removed piecemeal (75%). Most often, recommendations were reported to be based on guidelines (median 74%; range 31% to 94%). However, in nine of 14 cases, more than 10% (median 18%; range 12% to 38%) of the respondents stated that their recommendation was based on guidelines, but did not provide the appropriate surveillance interval.

CONCLUSIONS

Compliance to colonoscopy surveillance guidelines is suboptimal and reflects both overuse and underuse. The results show that awareness about the content of guidelines needs to be raised and strategies implemented to increase adherence.

Surveillance of pancreatic cancer patients after surgical resection

BACKGROUND

There are no clear recommendations to guide posttreatment surveillance in patients with pancreatic cancer. Our goal was to describe the posttreatment surveillance patterns in patients undergoing curative-intent resection for pancreatic cancer.

METHODS

We used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2005) to identify CT scans and physician visits in patients with pancreatic cancer who underwent curative resection (n = 2393). Surveillance began 90 days after surgery, and patients were followed for 2 years at 6-month intervals. Patients were censored if they died, experienced recurrence of disease, or entered hospice.

RESULTS

A total of 2045 patients survived uncensored to the beginning of the surveillance period. CT scan use decreased from 20.9% of patients in month 4 to 6.4% in month 27. There was no temporal pattern in CT use to suggest regular surveillance. Twenty-three percent of patients did not receive a CT scan in the year after surgery, increasing to 42% the second year. Patients who underwent adjuvant therapy and patients diagnosed in later years had higher CT scan use over the surveillance periods. Most patients visited both a primary care physician and a cancer specialist in each 6-month surveillance period. Patients who visited cancer specialists were more likely to have any CT scan and to be scanned more frequently.

CONCLUSIONS

Current surveillance patterns after resection for pancreatic cancer reflect the lack of established guidelines, implying a need for evaluation and standardization of surveillance protocols. The lack of a temporal pattern in CT testing suggests that most were obtained to evaluate symptoms rather than for routine surveillance.

Routine preventive care and cancer surveillance in long-term survivors of colorectal cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol LTS-01

PURPOSE

National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol LTS-01 examines routine preventive care and cancer surveillance in long-term colorectal cancer (CRC) survivors previously treated in NSABP adjuvant trials.

PATIENTS AND METHODS

Long-term CRC survivors (≥5 years) from five completed NSABP trials (Protocols C-05, C-06, C-07, R-02, and R-03) at 60 study sites were recruited and surveyed using preventive health care items from the National Health Interview Survey (NHIS). A 3:1 comparison cohort case-matched by age, sex, race, and education was created from the 2005 NHIS. Contingency tables and multivariate models were used to compare cohorts and determine predictors of preventive care and cancer surveillance.

RESULTS

A total of 708 patients in protocol LTS-01 (681 patients with colon cancer, 27 patients with rectal cancer) completed the interview: 57.1% male, mean age 66.2 years (standard deviation=10.6), median survival 8 years. Patients in the LTS-01 protocol were more likely to have a usual source of health care (97.7% v 93.8%, P<.0001), have received a flu shot in the past 12 months (67.5% v 44.3%, P<.0001), and have undergone cancer screening by Pap smear (67.3% v 54.8%, P<.0001), mammogram (80.4% v 70.7%, P<.0001), and prostate-specific antigen test (84.5% v 74.5%, P<.0001) than patients in the NHIS cohort. For CRC surveillance, 96.5% of patients in protocol LTS-01 had a colonoscopy, 88.2% had a carcinoembryonic antigen test, and 66.4% had a computed tomography scan in the previous 5 years. Health insurance was the best predictor of cancer screening for all three methods (odds ratio=2.6 to 4.5). No factor was uniformly associated with CRC surveillance.

CONCLUSION

This select population of long-term CRC survivors who participated in clinical trials achieved better routine preventive care and cancer screening than the general population and high rates of cancer surveillance.

Endoscopic surveillance after curative surgery for sporadic colorectal cancer: patient-tailored, tumor-targeted or biology-driven?

OBJECTIVE

Endoscopy has been endorsed and introduced in most surveillance programs following curative surgery for colorectal cancer (CRC), yet little data are available to support its use in terms of patient selection, efficacy and frequency of surveillance.

MATERIAL AND METHODS

A literature search in the English language using the PubMed/Medline database for the MeSH terms "colorectal cancer", "surveillance", and "endoscopy", with focus on sporadic CRC, excluding CRC developed on a hereditary or inflammatory bowel disease background. Focus on results from the past 5 years was applied.

RESULTS

Recent systematic reviews, meta-analyses, randomized trials and prospective studies made the backbone of the article, supported by population-based findings and recent reports on tumor biology. Hard evidence to support a survival benefit from endoscopy alone is lacking. Definitions of "synchronous", "interval", and "metachronous" cancers are not uniform and hampers comparison of studies. The number of metachronous cancers (usually 2-4%) that develop after curative CRC surgery is small, and better patient-tailored surveillance could improve the diagnostic yield. Compliance with endoscopy is low compared to other modalities. Age and socio-demographic factors influence on the surveillance coverage and need to be addressed in any given program. The majority of local recurrences occur within the first 3 years after surgery independent of stage, and microsatellite instable (MSI) tumors appear to be at higher risk.

CONCLUSIONS

Endoscopy in surveillance after curative surgery for CRC is a resource demanding procedure. A tailored approach according to factors associated with an increased risk for metachronous cancer/local recurrence would increase efficiency.

Variation in use of surveillance colonoscopy among colorectal cancer survivors in the United States

BACKGROUND

Clinical practice guidelines recommend colonoscopies at regular intervals for colorectal cancer (CRC) survivors. Using data from a large, multi-regional, population-based cohort, we describe the rate of surveillance colonoscopy and its association with geographic, sociodemographic, clinical, and health services characteristics.

METHODS

We studied CRC survivors enrolled in the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Eligible survivors were diagnosed between 2003 and 2005, had curative surgery for CRC, and were alive without recurrences 14 months after surgery with curative intent. Data came from patient interviews and medical record abstraction. We used a multivariate logit model to identify predictors of colonoscopy use.

RESULTS

Despite guidelines recommending surveillance, only 49% of the 1423 eligible survivors received a colonoscopy within 14 months after surgery. We observed large regional differences (38% to 57%) across regions. Survivors who received screening colonoscopy were more likely to: have colon cancer than rectal cancer (OR = 1.41, 95% CI: 1.05-1.90); have visited a primary care physician (OR = 1.44, 95% CI: 1.14-1.82); and received adjuvant chemotherapy (OR = 1.75, 95% CI: 1.27-2.41). Compared to survivors with no comorbidities, survivors with moderate or severe comorbidities were less likely to receive surveillance colonoscopy (OR = 0.69, 95% CI: 0.49-0.98 and OR = 0.44, 95% CI: 0.29-0.66, respectively).

CONCLUSIONS

Despite guidelines, more than half of CRC survivors did not receive surveillance colonoscopy within 14 months of surgery, with substantial variation by site of care. The association of primary care visits and adjuvant chemotherapy use suggests that access to care following surgery affects cancer surveillance.

Analytical strategies for characterizing chemotherapy diffusion with patient-level population-based data

To inform assessments of the quality of cancer care, we describe analytical approaches to characterizing trends in diffusion of chemotherapy drugs subsequent to their US FDA approval. The economics and medical literature provide two distinct sets of empirical methods for investigating diffusion of innovations: aggregate models, which use the level of market penetration as an estimator of diffusion; and disaggregate models, which evaluate diffusion based on the time required for different individual units to adopt innovations. When patient-level population-based data are available, disaggregate methods make the best use of the available information. We propose a method that employs time-to-event techniques to describe the probability of utilization of a drug within a specified timeframe subsequent to the diagnosis of cancer. By mapping the relationship between this probability and calendar time of a patient's diagnosis, we can assess trends in diffusion. Our approach accounts for the dependent censoring for death, as well as for the clustering of patients within physicians. The method proposed is illustrated using Surveillance, Epidemiology, and End Results (SEER)-Medicare data applied to two case studies: gemcitabine, approved for stage III/IV pancreatic cancer; and irinotecan, approved as a second-line therapy for stage IV colorectal cancer.

Association of health beliefs and colonoscopy use among survivors of colorectal cancer

OBJECTIVES

Clinical practice guidelines recommend ongoing testing (surveillance) for colorectal cancer survivors because they remain at risk for both local recurrences and second primary tumors. However, survivors often do not receive colorectal cancer surveillance. We used the Health Belief Model (HBM) to identify health beliefs that predict intentions to obtain routine colonoscopies among colorectal cancer survivors.

METHODS

We completed telephone interviews with 277 colorectal cancer survivors who were diagnosed 4 years earlier, between 2003 and 2005, in North Carolina. The interview measured health beliefs, past preventive behaviors, and intentions to have a routine colonoscopy in the next 5 years.

RESULTS

In bivariate analyses, most HBM constructs were associated with intentions. In multivariable analyses, greater perceived likelihood of colorectal cancer (OR = 2.00, 95% CI = 1.16-3.44) was associated with greater intention to have a colonoscopy. Survivors who already had a colonoscopy since diagnosis also had greater intentions of having a colonoscopy in the future (OR = 9.47, 95% CI = 2.08-43.16).

CONCLUSIONS

Perceived likelihood of colorectal cancer is an important target for further study and intervention to increase colorectal cancer surveillance among survivors. Other health beliefs were unrelated to intentions, suggesting that the health beliefs of colorectal cancer survivors and asymptomatic adults may differ due to the experience of cancer.

Receipt of guideline-recommended follow-up in older colorectal cancer survivors : a population-based analysis

BACKGROUND

After curative resection for colorectal cancer, routine follow-up with office visits, carcinoembryonic antigen (CEA), and colonoscopy is recommended. The actual adherence to these guidelines as well as the potential overuse of testing in routine practice has not been well studied.

METHODS

The authors identified 9426 eligible patients aged > or = 66 years in a linked tumor registry-claims database who were diagnosed with adenocarcinoma of the colon or rectum from 2000 to 2001. Patients were observed to 3 years after diagnosis. Receipt of > or = 2 office visits per year, > or = 2 CEA tests per year (years 1 and 2), and > or = 1 colonoscopy within 3 years constituted guideline fulfillment.

RESULTS

Guidelines for office visits, colonoscopy, and CEA testing were met in 92.3%, 73.6%, and 46.7% of patients, respectively. In addition, receipt of 2 nonrecommended procedures, abdominal/pelvic computed tomography scans and positron emission tomography scans, was documented in 47.7% and 6.8%, respectively. Overall, 60.2% received testing below recommended levels, 17.1% at recommended frequency, and 22.7% above guideline recommendations. In a multivariate analysis, factors associated with meeting guidelines included younger age group, white race, regional stage cancers, and poorly differentiated tumors. Considerable geographic variation in meeting guidelines was also observed.

CONCLUSIONS

Many older colorectal cancer survivors in this population-based cohort underwent testing below a minimum frequency specified by clinical practice guidelines, especially with regard to CEA. Further studies should ascertain the reasons for poor compliance and the effect on patient outcome.

Surveillance endoscopy does not improve survival for patients with local and regional stage colorectal cancer

BACKGROUND

Endoscopic surveillance is recommended and widely practiced after definitive treatment for colorectal cancer, yet to the authors' knowledge there is little evidence supporting its benefit. The purpose of the current study was to estimate the impact of endoscopic surveillance on colorectal cancer-specific survival for persons with localized or regional colorectal cancer. The population included Medicare patients (age >or=65 years) who were diagnosed with local or regional stage colorectal cancer between 1986 and 1996.

METHODS

The current study was a retrospective case-control study. Cases were defined as those individuals who died of colorectal cancer and controls were defined as those with colorectal cancer who did not die of colorectal cancer; controls were frequency matched to cases. Surveillance was defined as the use of colonoscopy, flexible sigmoidoscopy, or barium enema >or=6 months after diagnosis. Logistic regression was used to control for endoscopic procedure, race, comorbidity index at the time of diagnosis, and types of initial treatments after surgery.

RESULTS

The analysis group contained 8130 cases (29%) and 20,079 controls (71%). The average time to first bowel surveillance for those with at least 1 surveillance examination was 15.9 months after the diagnosis (median, 13 months). In the regression analysis, surveillance endoscopy was not found to be associated with improved colorectal cancer-specific survival (odds ratio of 1.01; 95% confidence interval, 0.95-1.06 [P=0.85]). Setting the surveillance interval to 12 months and 15 months rather than 6 months after diagnosis did not appear to influence the results.

CONCLUSIONS

Surveillance endoscopy does not appear to influence colorectal cancer-specific mortality in patients age >65 years who are diagnosed with localized or regional stage colorectal cancer.

Attendance at surveillance endoscopy of patients with adenoma or colorectal cancer

OBJECTIVE

Surveillance of patients treated for adenoma or colorectal cancer (CRC) is intended to reduce the incidence of CRC. Responsibility for the adherence to surveillance advice is often left to the patients and family physician. It is not known whether this type of passive policy affects the efficacy of surveillance. The aim of this study was to determine the yield of surveillance without active invitation to follow-up endoscopy.

MATERIAL AND METHODS

The study comprised a cohort follow-up of patients under 75 years of age with adenomas or CRC at index endoscopy in the period 1997-99. Adherence and intervals of follow-up endoscopy were determined up to December 2004.

RESULTS

During the inclusion period 2946 patients underwent lower endoscopy. In total, 393 patients were newly diagnosed with colorectal polyps (n=280) or CRC (n=113). Polyps were classified as adenomas in 167/280 (61%) patients. Forty-five (27%) of the adenoma patients underwent surveillance endoscopy within the guideline interval, 63 (38%) underwent delayed endoscopy, and 59 (35%) did not have any follow-up at all. CRC was diagnosed in 113 patients. Thirty-six patients who died during the first year or were diagnosed with metastases were excluded from the analysis. Twenty-three (30%) of the remaining 77 patients underwent endoscopic surveillance according to the guidelines, 40 (52%) had delayed surveillance endoscopy, and 14/77 (18%) did not undergo surveillance endoscopy at all.

CONCLUSIONS

In surveillance for colorectal neoplasia, active follow-up invitation is important. Given the low follow-up rate in our series, passive follow-up policies may lead to under-performance of surveillance programs. An active and controlled follow-up is advisable.

The Utility of Administrative Data for Measuring Adherence to Cancer Surveillance Care Guidelines

BACKGROUND

Adherence to professional society guidelines for follow-up or surveillance care in cancer survivors usually is measured with medical record review. Administrative data represent an alternative approach that may encompass larger numbers of patients with relatively low incremental costs.

OBJECTIVES

We sought to determine the feasibility of using claims data to measure guideline adherence.

METHODS

By reviewing paper and electronic medical records and claims data of 429 patients with 1 of 5 common cancers who received treatment with curative intent, we compared specific procedure receipt as well as guideline adherence classification as derived from claims and medical record data. Concordance was measured via kappa statistics.

MEASURES

Care in the initial 18-month follow-up period was characterized as less than recommended, recommended, or greater than recommended per practice guidelines in both medical record and administrative data.

RESULTS

Matching rates for individual procedures varied and were generally highest for certain laboratory tests and lowest for physical examinations. There were generally good-to-excellent levels of agreement (kappa=0.34-0.96) between a patient's classification in claims data and medical record data. No consistent differences in agreement were observed according to insurance type.

CONCLUSIONS

In general, claims data capturing procedures and visit use for characterizing guideline adherence was comparable with what was documented in the medical record and suggests that if validated in other settings, administrative data could be used to describe patterns of follow up care.

Temporal trends in colorectal procedure use after colorectal cancer resection

BACKGROUND

After curative cancer resection, routine colon surveillance is recommended. It is not known whether trends over time in cancer survivors parallel that of the general population.

OBJECTIVE

Our purpose was to describe temporal changes in the use of posttreatment procedures.

DESIGN

Retrospective cohort study.

SETTING

Linked tumor registry and Medicare claims data.

PATIENTS

Medicare beneficiaries >65 years old who were diagnosed with local or regional stage colorectal cancer from 1992-2002 and who underwent surgical resection.

MAIN OUTCOME MEASUREMENTS

Use of colonoscopy, sigmoidoscopy, or barium enema within 1 year, 18 months, or 3 years of diagnosis.

RESULTS

A total of 62,882 patients were followed up for 1 year and 35,784 for 3 years. Colonoscopy within 1 year was performed in 25.9%, within 18 months in 53.8%, and within 3 years in 70.3%. Corresponding rates for sigmoidoscopy were 7.4%, 10.2%, and 14.9%, respectively, and were 3.4%, 5.1%, and 7.9%, respectively, for barium enema. There was a decrease over time in the receipt of colonoscopy within 1 year of diagnosis (31.3% in 1992 to 20.6% in 2002), no change in 18-month rates, and a smaller increase in colonoscopy use within 3 years (66.5% to 72.3%). The use of sigmoidoscopy and barium enema declined over time. Overall procedure use within 1 year and 18 months also decreased and 3-year rates were essentially unchanged. These differences were maintained in multivariate analyses.

LIMITATIONS

Accuracy of procedure coding and indications for tests could not be measured.

CONCLUSIONS

Temporal trends in procedure use in cancer survivors were consistent with the general population. Importantly, despite guideline recommendations and Medicare reimbursement, 25% of patients who undergo curative treatment do not receive surveillance examinations and this was unchanged over time.

Temporal trend in relative risk of second primary colorectal cancer

BACKGROUND

Patients with colorectal cancer (CRC) are at a higher risk for developing a second primary. Factors (such as survival rate, rate of receipt of surveillance procedures, and the overall incidence of CRC) with potential impact on the risk for second primary CRC have changed over the last three decades. Thus, it is likely that the risk for second primary CRC also has changed over the years.

OBJECTIVES

We used the Surveillance, Epidemiology, and End Results public-use database to assess whether the relative risk of second primary CRC has changed in patients with initial primary CRC.

METHODS

The temporal trend in the standardized incidence ratio (SIR) for a second primary CRC was estimated. Also, the clinical features of the second primary CRC were compared in two subgroups based on the year of diagnosis of the first primary CRC: Group A (1973-1977) and Group B (1988-1992).

RESULTS

During the period of 1973 to 2002, 216,751 patients developed a primary CRC and over a follow-up period of 1,250,687 person-years, 5,595 of these patients developed a second primary CRC, with an SIR of 1.36 (95% CI 1.32-1.39). In a Cox regression model, the period of diagnosis of the first primary CRC was an independent risk factor for a subsequent primary CRC, with a relative hazard of second colon cancer in Group B compared with Group A being 1.18 (95% CI 1.06-1.31), after controlling for age at diagnosis, site, stage of first primary, gender, and race.

CONCLUSION

The relative risk of the second primary CRC has increased since early 1990s. These subsequent cancers are being diagnosed at an earlier stage. Increased surveillance may be one of the factors contributing to this temporal difference.

Improving compliance with postpolypectomy surveillance guidelines: an interventional study using a continuous quality improvement initiative

BACKGROUND

Despite guidelines, physicians tend to perform postpolypectomy surveillance colonoscopies too frequently.

OBJECTIVE

The objective of the study was to determine the baseline compliance rate with postpolypectomy guidelines in our unit and to determine the influence of a continuous quality improvement (CQI) intervention on improving the compliance rate and on decreasing the potential additional costs because of the scheduling of postpolypectomy surveillance colonoscopies earlier than indicated.

DESIGN

This was a single-arm, pretest-posttest design.

SETTING

This study took place at a tertiary care, academic medical center.

PATIENTS

The medical records of all patients who underwent colonoscopy with polypectomy in our unit retrospectively during 6 months preceding (baseline period) and prospectively for 6 months after an intervention (postintervention period) were reviewed for patient demographics, colonoscopy findings, and scheduling of repeat colonoscopies.

INTERVENTION

We used 3 components: (1) distribution of a wallet-size card with a summary of postpolypectomy guidelines to all endoscopists, (2) placement of guideline charts near computers used for typing endoscopy reports, and (3) distribution and reinforcement of the guidelines in a monthly continuous quality improvement meeting.

MAIN OUTCOME MEASURES

The main outcome measures were compliance rates, mean times to repeat colonoscopy, and additional costs from surveillance colonoscopies being scheduled earlier than indicated were compared between the two periods.

RESULTS

There were 278 patients in the baseline period and 242 in the postintervention period, with similar patient and polyp characteristics. After the intervention, the compliance rate with guidelines improved from 57.2% to 81% (p < 0.001). The mean time to a repeat colonoscopy increased from 4.5 to 5.2 years (p = 0.003) (i.e., a 14% reduction in the number of postpolypectomy surveillance colonoscopies performed per year). This would result in a reduction of a total of 73 surveillance colonoscopies per year in our unit, with a projected cost savings of 171,331 dollars per year (cost of a colonoscopy assumed at 2347 dollars).

LIMITATIONS

The limitation of the study was possible enhanced performance secondary to being observed (Hawthorne effect). Because more than 1 intervention was used, we do not know which one is more effective.

CONCLUSIONS

Relatively simple and easy-to-implement quality improvement initiatives can significantly enhance compliance with postpolypectomy guidelines and result in cost savings because of a reduction in the number of postpolypectomy surveillance colonoscopies being scheduled earlier than recommended guidelines.

Computed tomography colonography: current issues

OBJECTIVE

Direct and indirect evidence supports the concept of screening for adenomas and early stage colorectal cancer in reducing the incidence and disease-specific mortality. Controversy remains as to the appropriateness of and preferred methods for screening an asymptomatic population.

METHODS

Review of computed tomography (CT) colonography based on the literature and personal experience.

RESULTS AND CONCLUSIONS

Current discrepancies in the data on accuracy and patient acceptance of CT colonography reflect differences in the performance and evaluation of this examination. Before CT colonography can be implemented in colorectal cancer screening, factors that cause this variability must be elucidated. Studies in which high-resolution scanning, three-dimensional review methods and an enhanced colonoscopic reference are used achieve an accuracy that is similar to colonoscopy. At the same time the evidence that ultra-low radiation dose CT colonography is feasible is mounting, a development that dramatically reduces one of the largest obstacles for large-scale application of this technique.

Annual report to the nation on the status of cancer, 1975-2002, featuring population-based trends in cancer treatment

BACKGROUND

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide information on cancer rates and trends in the United States. This year's report updates statistics on the 15 most common cancers in the five major racial/ethnic populations in the United States for 1992-2002 and features population-based trends in cancer treatment.

METHODS

The NCI, the CDC, and the NAACCR provided information on cancer cases, and the CDC provided information on cancer deaths. Reported incidence and death rates were age-adjusted to the 2000 U.S. standard population, annual percent change in rates for fixed intervals was estimated by linear regression, and annual percent change in trends was estimated with joinpoint regression analysis. Population-based treatment data were derived from the Surveillance, Epidemiology, and End Results (SEER) Program registries, SEER-Medicare linked databases, and NCI Patterns of Care/Quality of Care studies.

RESULTS

Among men, the incidence rates for all cancer sites combined were stable from 1995 through 2002. Among women, the incidence rates increased by 0.3% annually from 1987 through 2002. Death rates in men and women combined decreased by 1.1% annually from 1993 through 2002 for all cancer sites combined and also for many of the 15 most common cancers. Among women, lung cancer death rates increased from 1995 through 2002, but lung cancer incidence rates stabilized from 1998 through 2002. Although results of cancer treatment studies suggest that much of contemporary cancer treatment for selected cancers is consistent with evidence-based guidelines, they also point to geographic, racial, economic, and age-related disparities in cancer treatment.

CONCLUSIONS

Cancer death rates for all cancer sites combined and for many common cancers have declined at the same time as the dissemination of guideline-based treatment into the community has increased, although this progress is not shared equally across all racial and ethnic populations. Data from population-based cancer registries, supplemented by linkage with administrative databases, are an important resource for monitoring the quality of cancer treatment. Use of this cancer surveillance system, along with new developments in medical informatics and electronic medical records, may facilitate monitoring of the translation of basic science and clinical advances to cancer prevention, detection, and uniformly high quality of care in all areas and populations of the United States.

Patterns of surveillance practices after curative surgery for colorectal cancer in a French population

PURPOSE

Despite controversies, postoperative surveillance of colorectal cancer is generally recommended. This registry-based study was designed to assess the adherence of surveillance practices to French guidelines and identify three-year surveillance patterns and their demographic and clinical determinants.

METHODS

All patients (N = 409) diagnosed with first colorectal cancer in 1998 and alive without recurrence at least six months after curative surgery were identified from a population-based registry. Medical charts from multiple sources were reviewed to collect exhaustive information on follow-up procedures used during a three-year period. Multiple correspondence and cluster analyses were used to identify surveillance patterns.

RESULTS

The proportion of patients with a lower surveillance than that recommended was 35 percent for clinical examination, 65 percent for abdominal ultrasound, 52 percent for chest x-ray, and 20 percent for colonoscopy. Cluster analysis identified three patterns called minimal, moderate, and intensive surveillance patterns, which included 47, 24, and 29 percent of the patients respectively. The main independent predictors of both moderate and intensive surveillance patterns vs. minimal pattern were advanced tumor stage, chemotherapy, and radiation therapy. Younger age also was strongly associated with the intensive surveillance pattern, and the presence of symptoms with the moderate surveillance pattern.

CONCLUSIONS

Adherence of surveillance practices to French guidelines seems relatively poor. Surveillance patterns are mainly explained by patient age, tumor stage, and treatment modalities.

A retrospective study on the use of post-operative colonoscopy following potentially curative surgery for colorectal cancer in a Canadian province

Background

Surveillance colonoscopy is commonly recommended following potentially curative surgery for colorectal cancer. We determined factors associated with patients undergoing a least one colonoscopy within five years of surgery.

Methods

In this historical cohort study, data on 3918 patients age 30 years or older residing in Alberta, Canada, who had undergone a potentially curative surgical resection for local or regional stage colorectal cancer between 1983 and 1995 were obtained from the provincial cancer registry, ministry of health and cancer clinic charts. Kaplan-Meier estimates of the probability of undergoing a post-operative colonoscopy were calculated for patient, tumor and treatment-related variables of interest.

Results

A colonoscopy was performed within five years of surgery in 1979 patients. The probability of undergoing a colonoscopy for those diagnosed in the 1990s was greater than for those diagnosed earlier (0.65 vs 0.55, P < 0.0001). The majority of the difference was seen at one-year following surgery, consistent with changes in surveillance practices. Those most likely to undergo a colonoscopy were those under age 70 (0.74 vs 0.50 for those age 70 – 79, P < 0.0001), who underwent a pre-operative colonoscopy (0.69 vs 0.54, P < 0.0001), and who underwent a resection with reanastomosis (0.62 vs 0.47 for abdominoperineal resection, P < 0.0001) by a surgeon who performs colonoscopies (0.68 vs 0.54, P < 0.0001).

Conclusions

The majority of patients undergo colonoscopy following colorectal cancer surgery. However, there are important variations in surveillance practices across different patient and treatment characteristics.

Racial differences in the receipt of bowel surveillance following potentially curative colorectal cancer surgery

OBJECTIVE

To investigate racial differences in posttreatment bowel surveillance after colorectal cancer surgery in a large population of Medicare patients.

DATA SOURCES

We used a large population-based dataset: Surveillance, Epidemiology, and End Results (SEER) linked to Medicare data.

STUDY DESIGN

This is a retrospective cohort study. We analyzed data from 44,768 non-Hispanic white, 2,921 black, and 4,416 patients from other racial/ethnic groups, aged 65 and older at diagnosis, who had a diagnosis of local or regional colorectal cancer between 1986 and 1996, and were followed through December 31, 1998. Cox Proportional Hazards models were used to investigate the relation of race and receipt of posttreatment bowel surveillance.

DATA COLLECTION

Sociodemographic, hospital, and clinical characteristics were collected at the time of diagnosis for all members of the cohort. Surgery and bowel surveillance with colonoscopy, sigmoidoscopy, and barium enema were obtained from Medicare claims using ICD-9-CM and CPT-4 codes.

PRINCIPAL FINDINGS

The chance of surveillance within 18 months of surgery was 57 percent, 48 percent, and 45 percent for non-Hispanic whites, blacks, and others, respectively. After adjusting for sociodemographic, hospital, and clinical characteristics, blacks were 25 percent less likely than whites to receive surveillance if diagnosed between 1991 and 1996 (RR = 0.75, 95 percent CI = 0.70-0.81).

CONCLUSIONS

Elderly blacks were less likely than non-Hispanic whites to receive posttreatment bowel surveillance and this result was not explained by measured racial differences in sociodemographic, hospital, and clinical characteristics. More research is needed to explore the influences of patient- and provider-level factors on racial differences in posttreatment bowel surveillance.

Clinical and sociodemographic factors associated with colon surveillance among patients with a history of colorectal cancer

BACKGROUND

Substantial variability in the use of colon surveillance among colorectal cancer survivors has been reported. This study sought to examine trends in the use of colon surveillance among patients who have had colorectal cancer and to investigate factors associated with utilization.

METHODS

Health maintenance organization enrollees with a diagnosis of local or regional colon or rectal cancer between January 1993 and December 1999 were studied. Receipt of a colon examination by colonoscopy or by flexible sigmoidoscopy, together with barium contrast radiography of the colon was determined from automated clinical records, and rates of colon surveillance were estimated by using survival analysis.

RESULTS

A total of 1002 patients with a diagnosis of colorectal cancer met inclusion criteria for the study. Colon examinations were performed in 61% of patients within 18 months of diagnosis and in 80% of patients within 5 years of diagnosis. The median time from diagnosis to first colon surveillance examination (14 months) was unchanged over the study period, but the interval between first and second surveillance examinations increased by 17 months (p<0.001). Patients over 80 years of age (relative risk=0.32; 95% CI[0.22, 0.45]) and those with rectal cancer (relative risk=0.80; 95% CI[0.66, 0.97]) were less likely to undergo surveillance. Higher socioeconomic status (relative risk=1.29; 95% CI[1.03, 1.61]) and being married (relative risk=1.27; 95% CI[1.05, 1.53]) were associated with greater utilization. There was lower utilization among African American patients (relative risk=0.70; p=0.14) and increased utilization among other minorities (relative risk=1.47; p=0.06).

CONCLUSIONS

There is substantial variability in the use of colon examination for surveillance in patients with a history of colorectal cancer, and clinical and sociodemographic factors appear to influence the likelihood of surveillance.

Geographic and Patient Variation in Receipt of Surveillance Procedures After Local Excision of Cutaneous Melanoma11Tables 4, 6, and appendix can be found at http://www.blackwellpublishing.com/products/journals/suppmat/jid/jid22238/jid22238sm.htm

Little is known about variation in surveillance practices following the diagnosis of invasive melanoma. The objective of this study was to characterize geographic, patient, and tumor variation in the use of follow-up surveillance testing in patients with local or regional stage melanoma. A cohort of Medicare beneficiaries > or =65 y diagnosed with invasive melanoma during 1992 to 1996 living in a Surveillance, Epidemiology, and End Results registry area was studied. Outpatient and inpatient Medicare claims 3 mo following diagnosis were examined for up to 2 y for surveillance procedures of interest. Use of chest X-ray, chest computed tomography scan, abdominal and/or pelvic computed tomography scan, abdominal ultrasound, head computed tomography scan, head magnetic resonance imaging, laboratory testing, and skin examinations were compared between patient groups and geographic regions. A total of 3389 patients were identified for the analysis. Surveillance testing was relatively common, ranging from 13% for abdominal ultrasound to 80% for laboratory testing. Follow-up skin examinations were performed in 70% to 90% of patients. The use of most surveillance procedures was associated (p<0.01) with younger age, male gender, regional stage tumors, and geographical area, with up to 2-fold differences observed. In contrast, there was much less variability in the receipt of skin examinations. Further studies are needed to determine the etiology and impact of such disparities, and the influence of surveillance procedures on morbidity and mortality.

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.

The prevalence of patients with colorectal carcinoma under care in the U.S

BACKGROUND

Prevalence usually is defined as the proportion of individuals alive who previously had a diagnosis of the disease, regardless of whether the individuals still are receiving treatment or are cured. The objective of this study was to estimate the proportion of elderly patients with colorectal carcinoma (CRC) in the U.S. that actually were receiving care for their disease as a better quantification of the burden of CRC.

METHODS

The authors used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program linked to Medicare claims. Four phases of CRC care were defined: initial diagnosis and treatment, postdiagnostic monitoring, treatment for recurrent/metastatic disease, and terminal care. CRC care prevalence measures by phase were extrapolated to the U.S. population age 65 years and older.

RESULTS

For all patients with CRC who were diagnosed between 1975 and 1996, 62% received at least 1 service related to their CRC in 1996, and patients received an average of 2.1 months per person of CRC care. Among the U.S. population age 65 years and older, 1.81% had 1 diagnosis of CRC, and (1.81% x 0.62%) = 1.12% received at least 1 service related to their CRC. This translated to 380,783 individuals who received care and 1,210,121 person months of care during 1996.

CONCLUSIONS

To the authors' knowledge, this is the first report in which care prevalence has been estimated directly. The classification of CRC care by phases of care provides a very detailed picture of the amount of care delivered in the U.S. population. Person-month estimates can be used to estimate the cost of CRC.

Current capacity for endoscopic colorectal cancer screening in the United States: data from the National Cancer Institute Survey of Colorectal Cancer Screening Practices

PURPOSE

There is a national goal in the United States to increase the level of colorectal cancer screening, but there is currently little information on resources for the delivery of endoscopic screening and follow-up diagnostic and surveillance procedures. The purpose of this study was to provide nationally representative data on endoscopic resources at the provider level.

METHODS

A nationally representative survey of primary care physicians, general surgeons, and gastroenterologists that was conducted during 1999 to 2000 provided data from survey responses by 1235 primary care physicians, 349 gastroenterologists, and 316 general surgeons.

RESULTS

We estimated that 65% of all sigmoidoscopy procedures were performed by primary care physicians, 25% by gastroenterologists, and 10% by general surgeons. Only 30% of all primary care physicians performed any procedures, and average volume among those who did was relatively low (seven per month). Gastroenterologists performed two thirds of all colonoscopy procedures, with most of the remainder performed by general surgeons.

CONCLUSION

There is potential to increase the capacity to perform screening sigmoidoscopy procedures through primary care delivery. However, without careful consideration of organizational factors, this could result in increased cost and quality control problems. Increasing the capacity for screening colonoscopy is feasible, but will require attention to other problems, such as avoiding overfrequent (e.g., annual or biennial) procedures in low-risk patients.

Barriers to preventive intervention

A spectrum of colorectal cancer screening studies identified barriers to screening adherence, although definitive and comprehensive conclusions cannot be drawn. Barriers can be intrinsic (demographic, medical, psychological, and knowledge/attitudes/beliefs) or extrinsic (access to health care, health care provider knowledge and motivation, and lifestyle issues). Certain consistent patterns are emerging. Lower adherence is generally seen in persons who have less knowledge and lower perceived risk of colorectal cancer, as well as when health care providers do not recommend screening. Remedies that reduce intrinsic and extrinsic barriers to screening adherence are needed.

Methodological issues in the use of administrative claims data to study surveillance after cancer treatment

BACKGROUND

Administrative claims databases linked to tumor registry data provide an excellent opportunity for studying the follow-up care of cancer patients.

RESEARCH DESIGN

Methodological principles of study design are reviewed, using examples drawn from the recently published literature.

RESULTS

Most follow-up care is outpatient-based. Therefore, in studies using Medicare claims, the patient should be eligible for Medicare Part B and should not be enrolled in a Medicare HMO. In studies of surveillance testing, it may be appropriate to exclude subjects who are near death, in a hospice, or in whom a new or recurrent cancer develops. The definition of the period for measurements of surveillance testing requires consideration, as does periodicity in patterns of testing. Several analytic methods can be employed, from proportions undergoing testing to survival analysis methods. Measurement of 'surveillance tests' among control subjects (those without cancer) may be useful for comparison with cancer patients. To date, administrative claims data have been most useful in studies investigating the quality of, and disparities in, cancer care.

CONCLUSION

With appropriate attention to methodological issues, linked tumor registry and administrative databases can provide important insights into the quality of survivorship care for cancer.