Geographic variations in breast cancer survival among older women: implications for quality of breast cancer care

Increase in mortality rate of liver transplant candidates residing in specific geographic areas: analysis of UNOS data

We sought to evaluate survival of liver transplant candidates living in geographic areas with limited access to specialized transplant centers (TxC). We analyzed survival outcome among candidates listed for liver transplant in United Network of Organ Sharing (UNOS) Region 4 from 2004 to 2010. Candidates were stratified into three groups according to the distance from the patient's residence to the closest hospital with a liver transplant program: Group 1 (Gr 1) <30 miles (m), Group 2 (Gr 2) 30-60 m and Group 3 (Gr 3) >60 m. Of the 5673 patients included in the study, 49% resided >30 m from a TxC. Eight percent of the cohort experienced death or dropped out of the list due to medical condition deterioration, with worse outcomes for Gr 2 and Gr 3 (8.5% and 9.9%, respectively, vs. 6.5% for Gr 1 [p < 0.001]). Among patients with a MELD score <20, mortality was higher in Gr 2 and Gr 3 compared to Gr 1 (p < 0.001). We conclude that for Region 4, the mortality risk in patients living >30 m from a TxC is higher. We suggest that the variable "distance from a TxC" should be used to improve the estimate of the mortality risk for patients on the waiting list.

Variations in process and outcome in inpatient palliative care services in Korea

PURPOSES

Hospice programs in Korea have been largely based on volunteer activity, religious services, or social services. Recent government policy of designating medically based inpatient palliative care services and per diem payment system made it necessary to monitor the quality of these services. We examined the variation in the process and outcomes of palliative care services, using 2009 data obtained from the Korean Terminal Cancer Patient Information System.

METHODS

Data were collected from 3,867 patients with terminal cancer who were registered in 34 inpatient palliative care centers designated by the Ministry of Health and Welfare. We used the mean length of stay and the subsequent place of care as process indicators, and change in average pain score as an outcome indicator. The data were analyzed using descriptive statistics, and analysis of covariance for the case-mix adjustment.

RESULTS

There were considerable variations among services with regards to the mean length of stay (i.e., 10.5 to 32.6 days for each admission) and subsequent place of care (i.e., 39.8% to 92.6% ended in death at the first admission), even after stratification by service level. The mean change in average pain score varied from -1.48 to 2.16, and remained significant after case-mix adjustment.

CONCLUSION

We found considerable variations among palliative care services with regard to the mean length of stay, subsequent place of care, and change in average pain score. Continued assessment of the variations in process and outcomes will assist in developing the national benchmarking system and the evaluation of the government policy.

Geographic disparities in colorectal cancer survival

BACKGROUND

Examining geographic variation in cancer patient survival can help identify important prognostic factors that are linked by geography and generate hypotheses about the underlying causes of survival disparities. In this study, we apply a recently developed spatial scan statistic method, designed for time-to-event data, to determine whether colorectal cancer (CRC) patient survival varies by place of residence after adjusting survival times for several prognostic factors.

METHODS

Using data from a population-based, statewide cancer registry, we examined a cohort of 25,040 men and women from New Jersey who were newly diagnosed with local or regional stage colorectal cancer from 1996 through 2003 and followed to the end of 2006. Survival times were adjusted for significant prognostic factors (sex, age, stage at diagnosis, race/ethnicity and census tract socioeconomic deprivation) and evaluated using a spatial scan statistic to identify places where CRC survival was significantly longer or shorter than the statewide experience.

RESULTS

Age, sex and stage adjusted survival times revealed several areas in the northern part of the state where CRC survival was significantly different than expected. The shortest and longest survival areas had an adjusted 5-year survival rate of 73.1% (95% CI 71.5, 74.9) and 88.3% (95% CI 85.4, 91.3) respectively, compared with the state average of 80.0% (95% CI 79.4, 80.5). Analysis of survival times adjusted for age, sex and stage as well as race/ethnicity and area socioeconomic deprivation attenuated the risk of death from CRC in several areas, but survival disparities persisted.

CONCLUSION

The results suggest that in areas where additional adjustments for race/ethnicity and area socioeconomic deprivation changed the geographic survival patterns and reduced the risk of death from CRC, the adjustment factors may be contributing causes of the disparities. Further studies should focus on specific and modifiable individual and neighborhood factors in the high risk areas that may affect a person's chance of surviving cancer.

Area-level poverty is associated with greater risk of ambulatory-care-sensitive hospitalizations in older breast cancer survivors

OBJECTIVES

To estimate the frequency of ambulatory care-sensitive hospitalizations (ACSHs) and to compare the risk of ACSH in breast cancer survivors living in high-poverty with that of those in low-poverty areas.

DESIGN

Prospective, multilevel study.

SETTING

National, population-based 1991 to 1999 National Cancer Institute Surveillance, Epidemiology, and End Results Program data linked with Medicare claims data throughout the United States.

PARTICIPANTS

Breast cancer survivors aged 66 and older.

MEASUREMENTS

ACSH was classified according to diagnosis at hospitalization. The percentage of the population living below the U.S. federal poverty line was calculated at the census-tract level. Potential confounders included demographic characteristics, comorbidity, tumor and treatment factors, and availability of medical care.

RESULTS

Of 47,643 women, 13.3% had at least one ACSH. Women who lived in high-poverty census tracts (>or=30% poverty rate) were 1.5 times (95% confidence interval (CI)=1.34-1.72) as likely to have at least one ACSH after diagnosis as women who lived in low-poverty census tracts (<10% poverty rate). After adjusting for most confounders, results remained unchanged. After adjustment for comorbidity, the hazard ratio (HR) was reduced to 1.34 (95% CI=1.18-1.52), but adjusting for all variables did not further reduce the risk of ACSH associated with poverty rate beyond adjustment for comorbidity (HR=1.37, 95% CI=1.19-1.58).

CONCLUSION

Elderly breast cancer survivors who lived in high-poverty census tracts may be at increased risk of reduced posttreatment follow-up care, preventive care, or symptom management as a result of not having adequate, timely, and high-quality ambulatory primary care as suggested by ACSH.

Increasing access to medical oncology consultation in older patients with stage II-IIIA non-small-cell lung cancer

BACKGROUND

Resectable non-small-cell lung cancer (NSCLC) was once considered a disease whose sole therapy was surgical resection. Therefore it was managed by surgeons. However, with growing evidence of the benefit of adjuvant chemotherapy, such patients should also be evaluated by a medical oncologist.

METHODS

Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, we identified 3,196 patients 66-85 years of age with stage II or IIIA NSCLC who underwent resection between 1992 and 2002 in the United States. We examined the trend in medical oncology consultation to identify predictors associated with oncology consultation and subsequent use of adjuvant chemotherapy, using modified Poisson regression.

RESULTS

From 1992 to 2002, 1,521 patients (47.6%) with resected stage II or IIIA NSCLC were seen by a medical oncologist within 4 months of diagnosis. Strong predictors for medical oncology referral included: being younger, married, having an advanced tumor, adenocarcinoma histology, receiving radiation, and certain SEER geographic regions. The proportion of patients seen by a medical oncologist more than doubled over the ten-year study period, from 28.4% in 1992 to 57.7% in 2002 (P < 0.001). The use of adjuvant chemotherapy rose similarly in this population. Chemotherapy use varied significantly by patient characteristics, including age, marital status, and geographic region. This variation decreased, however, when analysis was restricted to those seen by a medical oncologist within four months of diagnosis.

CONCLUSIONS

Our results demonstrate that the role of a medical oncologist as part of the multidisciplinary management of resected NSCLC increased over time, greatly reducing variation in NSCLC management.

Detection of spatial clusters: application to cancer survival as a continuous outcome

In this article, we develop the first detailed illustration of the use of a cluster detection method using a spatial scan statistic based on an exponential survival model. We use this approach to study the spatial patterns of survival of patients with stage III or stage IV colorectal cancer or with stage I/II, stage III, or stage IV lung cancer in the State of California and the County of Los Angeles (LA) diagnosed during 1988 through 2002. We present the location of the detected clusters of short survival or long survival and compute nonparametric estimates of survival inside and outside of those detected clusters confirming the survival pattern detected by the spatial scan statistic in both areas. In LA County, we investigate the possible relationship between the cluster locations and race, sex, and histology using nonparametric methods, and we compare socioeconomic factors such as education, employment, income, and health insurance inside and outside of the detected clusters. Finally, we evaluate the effect of related covariates on statistically significant long and short survival clusters detected in LA County using logistic regression models. This article illustrates a new way to understand survival patterns that may point to health disparities in terms of diagnosis and treatment patterns.

Chapter 7: The Wisconsin Breast Cancer Epidemiology Simulation Model

The Wisconsin Breast Cancer Epidemiology Simulation Model is a discrete-event, stochastic simulation model using a systems-science modeling approach to replicate breast cancer incidence and mortality in the U.S. population from 1975 to 2000. Four interacting processes are modeled over time: (1) natural history of breast cancer, (2) breast cancer detection, (3) breast cancer treatment, and (4) competing cause mortality. These components form a complex interacting system simulating the lives of 2.95 million women (approximately 1/50 the U.S. population) from 1950 to 2000 in 6-month cycles. After a "burn in" of 25 years to stabilize prevalent occult cancers, the model outputs age-specific incidence rates by stage and age-specific mortality rates from 1975 to 2000. The model simulates occult as well as detected disease at the individual level and can be used to address "What if?" questions about effectiveness of screening and treatment protocols, as well as to estimate benefits to women of specific ages and screening histories.

Regional and racial disparities in breast cancer-specific mortality

Where and how one lives is associated with cancer survival. This study was designed to assess geographical region of residence, race/ethnicity, and clinical and socioeconomic factors as predictors of survival in a population based cohort of women with breast cancer followed for up to 12 years. In a cohort of 218,879 breast cancer patients >20 years of age at diagnosis, registered in the database of the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program between 1990 and 2001, we analyzed the association of breast cancer-specific survival with SEER region; age; stage; histology; hormone receptor status; race/ethnicity; and census data on educational attainment, income, employment, and insurance coverage. We compared Kaplan-Meier survival curves by region and race/ethnicity. We used Cox proportional hazards regression models to assess the association of mortality with region, race/ethnicity, and the other variables. Women who lived in Detroit had significantly higher mortality than those living in most other SEER regions. In most regions, black women had the poorest survival. The association of mortality with race did not differ significantly across regions, but it was significantly stronger among women 50-64 years of age than among women 65 and older. The SEER data document the association of breast cancer mortality with region, race, and socioeconomic status. Black race was a strong predictor of mortality in each region even after controlling for socioeconomic factors. The diminishing effect of race with age, which may only partially be explained by insurance in those over 65, suggests a need for research on the role of other factors, such as comorbid conditions or access to care, in breast cancer mortality.

Trends in breast cancer mortality rates by region of the United States, 1950-1999

INTRODUCTION

Limited information is available on trends in breast cancer mortality by region of the country.

METHODS

Rates for broad age groups were calculated from 1950 to 1999 for whites and 1970-1999 for blacks for four census regions and 508 state economic areas of the United States.

RESULTS

For white women ages 50-64 years, the mortality relative risk [RR] for the Northeast compared to the South was 1.48 in 1950-1959 and 1.15 in 1990-1999. Rates increased in all regions from the 1950s to 1960s but more substantially in the South, increased slightly in the 1970s in all regions, declined slightly in the Northeast, Midwest and West but not in the South in the 1980s, and declined more in the Northeast, Midwest and West than in the South in the 1990s. Among similarly aged black women, the RRs for the Northeast compared to the South were 1.13 and 1.0 in 1970-1979 and 1990-1999, respectively. Among these women, rates increased in all regions in the 1980s; in the 1990s rates declined in the Northeast, Midwest and West but continued to increase in the South.

CONCLUSION

The historically lower breast cancer mortality rates in the South have been eroded because of relatively less favorable trends in the South.

Survival of patients with metastatic breast cancer: twenty-year data from two SEER registries

BACKGROUND

Many researchers are interested to know if there are any improvements in recent treatment results for metastatic breast cancer in the community, especially for 10- or 15-year survival.

METHODS

Between 1981 and 1985, 782 and 580 female patients with metastatic breast cancer were extracted respectively from the Connecticut and San Francisco-Oakland registries of the Surveillance, Epidemiology, and End Results (SEER) database. The lognormal statistical method to estimate survival was retrospectively validated since the 15-year cause-specific survival rates could be calculated using the standard life-table actuarial method. Estimated rates were compared to the actuarial data available in 2000. Between 1991 and 1995, further 752 and 632 female patients with metastatic breast cancer were extracted respectively from the Connecticut and San Francisco-Oakland registries. The data were analyzed to estimate the 15-year cause-specific survival rates before the year 2005.

RESULTS

The 5-year period (1981-1985) was chosen, and patients were followed as a cohort for an additional 3 years. The estimated 15-year cause-specific survival rates were 7.1% (95% confidence interval, CI, 1.8-12.4) and 9.1% (95% CI, 3.8-14.4) by the lognormal model for the two registries of Connecticut and San Francisco-Oakland respectively. Since the SEER database provides follow-up information to the end of the year 2000, actuarial calculation can be performed to confirm (validate) the estimation. The Kaplan-Meier calculation for the 15-year cause-specific survival rates were 8.3% (95% CI, 5.8-10.8) and 7.0% (95% CI, 4.3-9.7) respectively. Using the 1991-1995 5-year period cohort and followed for an additional 3 years, the 15-year cause-specific survival rates were estimated to be 9.1% (95% CI, 3.8-14.4) and 14.7% (95% CI, 9.8-19.6) for the two registries of Connecticut and San Francisco-Oakland respectively.

CONCLUSIONS

For the period 1981-1985, the 15-year cause-specific survival for the Connecticut and the San Francisco-Oakland registries were comparable. For the period 1991-1995, there was not much change in survival for the Connecticut registry patients, but there was an improvement in survival for the San Francisco-Oakland registry patients.

Residence, income and cancer hospitalizations in British Columbia during a decade of policy change

Background

Through the 1990s, governments across Canada shifted health care funding allocation and organizational foci toward a community-based population health model. Major concerns of reform based on this model include ensuring equitable access to health and health care, and enhancing preventive and community-based resources for care. Reforms may act differentially relative to specific conditions and services, including those geared to chronic versus acute conditions. The present study therefore focuses on health service utilization, specifically cancer hospitalizations, in British Columbia during a decade of health system reform.

Methods

Data were drawn from the British Columbia Linked Health Data resource; income measures were derived from Statistics Canada 1996 Census public use enumeration area income files. Records with a discharge (separation) date between 1 January 1991 and 31 December 1998 were selected. All hospitalizations with ICD-9 codes 140 through 208 (except skin cancer, code 173) as principal diagnosis were included. Specific cancers analyzed include lung; colorectal; female breast; and prostate. Hospitalizations were examined in total (all separations), and as divided into first and all other hospitalizations attributed to any given individual. Annual trends in age-sex adjusted rates were analyzed by joinpoint regression; longitudinal multivariate analyses assessing association of residence and income with hospitalizations utilized generalised estimating equations. Results are evaluated in relation to cancer incidence trends, health policy reform and access to care.

Results

Age-sex adjusted hospitalization rates for all separations for all cancers, and lung, breast and prostate cancers, decreased significantly over the study period; colorectal cancer separations did not change significantly. Rates for first and other hospitalizations remained stationary or gradually declined over the study period. Area of residence and income were not significantly associated with first hospitalizations; effects were less consistent for all and other hospitalizations. No interactions were observed for any category of separations.

Conclusions

No discontinuities were observed with respect to total hospitalizations that could be associated temporally with health policy reform; observed changes were primarily gradual. These results do not indicate whether equity was present prior to health care reform. However, findings concur with previous reports indicating no change in access to health care across income or residence consequent on health care reform.