Sociodemographic differences in the receipt of colorectal cancer surveillance care following treatment with curative intent

Disparities in post-operative surveillance testing for metastatic recurrence among colorectal cancer survivors

PURPOSE

Among colorectal cancer (CRC) survivors, treatment for metastatic recurrence is most effective when malignancies are detected early through surveillance with carcinoembryonic antigen (CEA) level test and computer tomography (CT) imaging. However, utilization of these tests is low, and many survivors fail to meet the recommended guidelines. This population-based study assesses individual- and neighborhood-level factors associated with receipt of CEA and CT surveillance testing.

METHODS

We used the Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify Medicare beneficiaries diagnosed with CRC stages II-III between 2010 and 2013. We conducted multivariate logistic regression to estimate the effect of individual and neighborhood factors on receipt of CEA and CT tests within 18 months post-surgery.

RESULTS

Overall, 78% and 58% of CRC survivors received CEA and CT testing, respectively. We found significant within racial/ethnic differences in receipt of these surveillance tests. Medicare-Medicaid dual coverage was associated with 39% lower odds of receipt of CEA tests among non-Hispanic Whites, and Blacks with dual coverage had almost two times the odds of receiving CEA tests compared to Blacks without dual coverage.

CONCLUSIONS

Although this study did not find significant differences in receipt of initial CEA and CT surveillance testing across racial/ethnic groups, the assessment of the factors that measure access to care suggests differences in access to these procedures within racial/ethnic groups.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings have implications for developing targeted interventions focused on promoting surveillance for the early detection of metastatic recurrence among colorectal cancer survivors and improve their health outcomes.

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.

Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample

Background

The purpose of this study was to examine racial and socio-economic differences in the receipt of laparoscopic or open surgery among patients with colorectal cancer, and to determine if racial and socio-economic differences exist in post-surgical complications, in-hospital mortality and hospital length of stay among patients who received surgery.

Methods

We conducted a cross-sectional analysis of hospitalized patients with a primary diagnosis of colorectal cancer between 2007 and 2011 using data from Nationwide Inpatient Sample. ICD-9 codes were used to capture primary diagnosis, surgical procedures, and health outcomes during hospitalization. We used logistic regression analysis to determine racial and socio-economic predictors of surgery type, post-surgical complications and mortality, and linear regression analysis to assess hospital length of stay.

Results

A total of 122,631 patients were admitted with a primary diagnosis of malignant colorectal cancer between 2007 and 2011. Of these, 17,327 (14.13 %) had laparoscopic surgery, 70,328 (57.35 %) received open surgery, while 34976 (28.52 %) did not receive any surgery. Black (36 %) and Hispanic (34 %) patients were more likely to receive no surgery compared with Whites (27 %) patients. However, among patients that received any surgery, there were no racial differences in which surgery was received (laparoscopic versus open, p = 0.2122), although socio-economic differences remained, with patients from lower residential income areas significantly less likely to receive laparoscopic surgery compared with patients from higher residential income areas (OR: 0.74, 95 % CI: 0.70-0.78). Among patients who received any surgery, Black patients (OR = 1.07, 95 % CI: 1.01-1.13), and patients with Medicare (OR = 1.16, 95 % CI: 1.11-1.22) and Medicaid (OR = 1.15, 95 % CI: 1.07-1.25) insurance experienced significantly higher post-surgical complications, in-hospital mortality (Black OR = 1.18, 95 % CI: 1.00-1.39), and longer hospital stay (Black β = 1.33, 95 % CI: 1.16-1.50) compared with White patients or patients with private insurance.

Conclusion

Racial and socio-economic differences were observed in the receipt of surgery and surgical outcomes among hospitalized patients with malignant colorectal cancer in the US.

The Life History Interview Method: Applications to Intervention Development

There is an urgent need to develop and test health promotion strategies that both address health disparities and elucidate the full impact of social, cultural, economic, institutional, and political elements on people's lives. Qualitative research methods, such as life history interviewing, are well suited to exploring these factors. Qualitative methods are also helpful for preparing field staff to implement a social contextual approach to health pro-motion. This article reports results and application of findings of life history interviews conducted as part of intervention planning for the Harvard Cancer Prevention Program Project, “Cancer Prevention in Working-Class, Multi-Ethnic Populations.” The salient themes that emerged from interviews with a multi-ethnic, purposive sample are centered on six construct domains: immigration and social status, social support, stress, food, physical activity, and occupational health. Insights gained from thematic analysis of the interviews were integrated throughout intervention and materials development processes.

Surveillance patterns after curative-intent colorectal cancer surgery in Ontario

BACKGROUND

Postoperative surveillance following curative-intent resection of colorectal cancer (CRC) is variably performed due to existing guideline differences and to the limited data supporting different strategies.

OBJECTIVES

To examine population-based rates of surveillance imaging and endoscopy in patients in Ontario following curative-intent resection of CRC with no evidence of recurrence, as well as patient or disease factors that may predispose certain groups to more frequent versus less frequent surveillance; to provide insight to the care patients receive in the presence of conflicting guidelines, in efforts to help improve care of CRC survivors by identifying any potential underuse or overuse of particular surveillance modalities, or inequalities in access to surveillance.

METHOD

A retrospective cohort study was conducted using data from the Ontario Cancer Registry and several linked databases. Ontario patients undergoing curative-intent CRC resection from 2003 to 2007 were identified, excluding patients with probable disease relapse. In the five-year period following surgery, the number of imaging and endoscopic examinations was determined.

RESULTS

There were 4960 patients included in the study. Over the five-year postoperative period, the highest proportion of patients who underwent postoperative surveillance received the following number of tests for each modality examined: one to three abdominopelvic computed tomography (CT) scans (n=2073 [41.8%]); one to three abdominal ultrasounds (n=2443 [49.3%]); no chest CTs, one to three chest x-rays (n=2385 [48.1%]); and two endoscopies (n=1845 [37.2%]). Odds of not receiving any abdominopelvic imaging (CT or abdominal ultrasound) were higher in those who did not receive adjuvant chemotherapy (OR 6.99 [95% CI 5.26 to 9.35]) or those living in certain geographical areas, but were independent of age, sex and income. Nearly all patients (n=4473 [90.2%]) underwent ≥1 endoscopy at some point during the follow-up period.

CONCLUSION

In contrast to findings from similar studies in other jurisdictions, most Ontario CRC survivors receive postoperative surveillance with imaging and endoscopy, and care is equitable across sociodemographic groups, although unexplained geographical variation in practice exists and warrants further investigation.

The role of social support in posttreatment surveillance among African American survivors of colorectal cancer

African Americans are less likely than other groups to receive appropriate surveillance after colorectal cancer (CRC) treatment. The objective of this study is to qualitatively explore the role of social support in post-CRC treatment surveillance and ultimately, inform interventions to promote surveillance in African American survivors of CRC. Interviews were conducted with 60 African American survivors of CRC recruited from the Cancer Care Outcomes Research and Surveillance (CanCORS) study and the Alabama Statewide Cancer Registry. Interviews were recorded and transcribed. Transcripts were reviewed and coded independently by the authors. The NVivo software package was used to facilitate coding and data management. Survivors were from 4 to 6 years post diagnosis, 57% female, 60% older than age 65 years, 57% from rural Alabama, 30% with stage 1, 32% with stage 2, and 38% with stage 3 disease. Material and emotional social support from family and one's faith community were cited as playing an important role in coping with the disease and posttreatment surveillance. Survivors who reported being adherent with posttreatment surveillance recommendations (according to stage of disease based on self-report of colonoscopy, computed tomography scans, and blood work) reported more religious material and non-material social support, and support from other survivors of CRC. In these African American survivors of CRC, support from family, other survivors of cancer, and the faith community was perceived as being important for adherence to posttreatment surveillance. Interventions to increase posttreatment surveillance in this population may be enhanced by including components that emphasize familial, other cancer survivor, and religious support.

Colorectal cancer survivors' needs and preferences for survivorship information

PURPOSE

Before developing a survivorship care plan (SCP) that colorectal cancer (CRC) survivors will value, understanding the informational needs of CRC survivors is critical.

METHODS

We surveyed survivors treated for nonmetastatic CRC at two hospitals in New York about their needs and preferences for survivorship information. Participants completed treatment 6 to 24 months before the interview and had not received an SCP. We evaluated whether survivors knew their treatment history (10 topics), whether they understood ongoing risks (four topics), and their preferences for receiving 16 topics of survivorship information.

RESULTS

One hundred seventy-five survivors completed the survey. Most survivors remembered information about past treatment (98% to 99% for each treatment). Fewer survivors knew their risks of local recurrence, distant recurrence, or developing a new CRC (69%, 77%, and 40%, respectively). Most participants reported receiving information about their cancer history and ongoing oncology visits (77% to 86% across topics). Across all topics, 93% to 99% of those who reported receiving information found the information useful. A minority of survivors reported they received information about symptoms to report to doctors, returning to work, or financial or legal issues (5% to 48% across topics), but those who did found the information useful (89% to 100% across topics).

CONCLUSIONS

In the absence of an SCP, CRC survivors still generally understood their cancer history. However, many lacked knowledge of ongoing risks and prevention. Most survivors stated that they found the survivorship information they received useful. SCPs for CRC survivors should focus less on past care and more on helping survivors understand their risks and plan for the future.

Predictors of colonoscopy use one year after colonoscopy: prospective study of surveillance behavior for colorectal cancer

We hypothesized that perceived risk of colorectal cancer (CRC) and CRC worry would be the main predictors of surveillance behavior in patients undergoing colonoscopy. We therefore assessed factors predicting colonoscopy use for re-examination one year after colonoscopy. Patients who had undergone colonoscopy and were scheduled for re-examination one year later were recruited. Patients were administered questionnaires after baseline colonoscopy assessing demographic factors, perceived risk, CRC worry, cancer preventability, knowledge of CRC and results of colonoscopy. We confirmed whether participants underwent colonoscopy re-examinations one year later (follow-up). Finally, 56 participants completed the research and were used in the final analysis (response rate = 65.1%). We found that 37.5% of the participants who underwent baseline colonoscopy underwent follow-up colonoscopy one year later. Follow-up colonoscopy was not significantly associated with any psychological variables, but was significantly associated with educational status (postsecondary) (odds ratio [OR] = 7.10, 95% confidence interval [CI] = 1.83-27.56) and the results of baseline colonoscopy in patients who did not undergo polypectomy but had remaining polyps (OR = 4.26, 95% CI = 1.02-17.84). Additionally, significant differences in cancer threat-related variables were observed among groups of patients who, during baseline colonoscopy, underwent polypectomy but had no remaining polyps, had polyps removed with some polyps remaining, or did not undergo polypectomy but had remaining polyps (p < .05), with the latter group having a significant relationship with repeat colonoscopy. Cancer threat-related variables were not predictive of repeat colonoscopy after one year. In contrast, patient educational status and the colonoscopy results were predictors. We also found a non-linear relationship between high CRC threat and inhibition of the screening behavior in that the CRC threat functions as motivation for the surveillance behavior of colonoscopy.

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.

Health disparities and the cancer survivor

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

Surveillance instructions and knowledge among African American colorectal cancer survivors

INTRODUCTION

African Americans are less likely than other racial/ethnic groups to receive appropriate surveillance, an important component of care to achieve better long-term outcomes and well-being after colorectal cancer (CRC) treatment. This study explored survivors' understanding of surveillance instructions and purpose.

PATIENTS AND METHODS

Interviews with 60 African American CRC survivors were recorded and transcribed. Compliance with surveillance guidelines was defined by disease stage and self-reported tests. Four coders (blind to compliance status) independently reviewed transcripts. Frequency of themes was reported by compliance status.

RESULTS

Survivors (4 to 6 years postdiagnosis; women, 57%; age ≥ 65 years, 60%; rural location, 57%; early-stage disease, 62%) were 48% noncompliant. Most survivors reported receiving surveillance instructions from providers (compliant, 80%; noncompliant, 76%). There was variation in recommended frequency of procedures (eg, every 3 or 12 months) and in importance of surveillance stressed by physicians. Most survivors understood the need for follow-up (compliant, 87%; noncompliant, 79%). Lack of knowledge of/interest in surveillance was more common among noncompliant individuals (compliant, 32%; noncompliant, 52%).

CONCLUSION

Patients' limited understanding about the importance of CRC surveillance and procedures may negatively affect compliance with recommendations in African American CRC survivors. Clear and enhanced communications about post-treatment recommendations in this population are warranted.

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.

Association of race and socioeconomic status and outcomes of patients with rectal cancer

BACKGROUND

Few studies have evaluated disparities of race and socioeconomic status (SES) with outcomes in patients with rectal cancer. We hypothesize that disparities exist in the treatment and outcomes among patients with rectal cancer.

METHODS

Medical records of all patients with rectal cancer treated from 2000 to 2009 at an NCI cancer center (Fox Chase Cancer Center) and an urban academic center (Temple University Hospital) were retrospectively reviewed from a prospectively maintained tumor registry database. SES was estimated using census data. Quartiles of income and education based on zip codes were calculated. Lowest vs other quartiles were compared. Clinicopathologic variables included: initial stage, chemotherapy refusal, sphincter preservation, and overall survival (OS).

RESULTS

A total of 748 patients were included in the analysis (581 white, 135 black, 6 other, 26 unknown). No difference in race, SES, or insurance status was seen with regard to stage at presentation. Chemotherapy and radiation refusal was rare. After excluding stage IV patients; sphincter preservation was more common among those with higher income. Median OS for all stages was worse for nonwhite patients (31 vs 50 months, p < .001), and those with low income and education. OS disparities were most pronounced among nonwhite patients with advanced disease. Insurance was not associated with a survival difference. Age, stage, and race were independent predictors of survival.

CONCLUSIONS

Disparity exists in outcomes of patients with rectal cancer. Nonwhite race is associated with worse OS, and lower SES is associated with lower OS and sphincter preservation among patients with rectal cancer.

Are cancer registries a viable tool for cancer survivor outreach? A feasibility study

PURPOSE

Little is known about cancer survivors' receptivity to being contacted through cancer registries for research and health promotion efforts. We sought to (1) determine breast and colorectal cancer (CRC) survivors' responsiveness to a mailed survey using an academic medical center's cancer registry, (2) assess whether responsiveness varied according to sociodemographic characteristics and medical history, and (3) examine the prevalence and correlates of respondents' awareness and willingness to be contacted through the state cancer registry for future research studies.

METHODS

Stage 0-III breast and CRC survivors diagnosed between January 2004 and December 2009 were identified from an academic medical center cancer registry. Survivors were mailed an invitation letter with an opt-out option, along with a survey assessing sociodemographic characteristics, medical history, and follow-up cancer care access and utilization.

RESULTS

A total of 452 (31.4 %) breast and 53 (22.2 %) CRC survivors responded. Willingness to be contacted through the state cancer registry was high among both breast (74 %) and CRC (64 %) respondents even though few were aware of the registry and even fewer knew that their information was in the registry. In multivariable analyses, tumor stage I and not having a family history of cancer were associated with willingness among breast and CRC survivors, respectively.

CONCLUSIONS

Our findings support the use of state cancer registries to contact survivors for participation in research studies.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors would benefit from partnerships between researchers and cancer registries that are focused on health promotion interventions.

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.

Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996-2011

Background

We examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California.

Methods

We analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none.

Results

Evidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men.

Conclusions

Health insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.

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.

Screening colonoscopy among colorectal cancer survivors insured by Medicaid

OBJECTIVES

The objectives of this research study are to describe the proportion of Medicaid-insured colorectal cancer survivors who had a colonoscopy between 3 and 18 months after surgery of the colon or rectum and to determine if patient, health services, and community characteristics are associated with colonoscopy follow-up after treatment.

METHODS

A retrospective cohort study among 1044 Medicaid-insured individuals diagnosed with local or regional colorectal cancer was conducted. Multivariable logistic regression analyses assessed patient, hospital, and community characteristics associated with colonoscopy.

RESULTS

About 42% of the study population had a colonoscopy 3 to 18 months after surgery. Factors associated with receipt of colonoscopy in the multivariable model include having colon (vs rectal) cancer, having local (vs regional) cancer, and having received chemotherapy as part of first course of therapy. Being 75 or older (vs <65), having first course of therapy at a hospital with the highest surgical volume (vs lowest surgical volume), and living in an urban (vs rural) environment were associated with a decreased likelihood of colonoscopy. Colonoscopy utilization patterns diverge after 65 years of age when persons become dually insured by Medicare. By age 80 years, there seems to be an almost 3-fold difference in receipt of colonoscopy-those with comorbidity are more likely to be screened than those without comorbidity.

CONCLUSIONS

Less than half of Medicaid-insured colorectal cancer survivors received a colonoscopy in 3 to 18 months after colorectal resection. Improvements in screening in this high-risk population should be the target of future interventions to reduce the probability of recurrence.

Adherence to surveillance care guidelines after breast and colorectal cancer treatment with curative intent

BACKGROUND

Evidence-based guidelines recommend routine surveillance, including office visits and testing, to detect new and recurrent disease among survivors of breast and colorectal cancer. The extent to which surveillance practice is consistent with guideline recommendations or may vary by age is not known.

METHODS

Cohorts of adult patients diagnosed with breast (n = 6205) and colorectal (n = 2297) cancer between 2000 and 2008 and treated with curative intent in 4 geographically diverse managed care environments were identified via tumor registries. Kaplan-Meier estimates were used to describe time to initial and subsequent receipt of surveillance services. Cox proportional hazards models evaluated the relation between patient characteristics and receipt of metastatic screening.

RESULTS

Within 18 months of treatment, 87.2% of breast cancer survivors received recommended mammograms, with significantly higher rates noted for patients aged 50 years to 65 years. Among survivors of colorectal cancer, only 55.0% received recommended colon examinations, with significantly lower rates for those aged ≥ 75 years. The majority of breast (64.7%) and colorectal (73.3%) cancer survivors received nonrecommended metastatic disease testing. In patients with breast cancer, factors associated with metastatic disease testing include white race (hazards ratio [HR], 1.13), comorbidities (HR, 1.17), and younger age (HR, 1.13; 1.15; 1.13 for age groups: <50, 50-64, and 65-74 respectively). In those with colorectal cancer, these factors included younger age (HR, 1.31; 1.25 for age groups: <50 and 50-64 respectively) and comorbidities (HR, 1.10).

CONCLUSIONS

Among an insured population, wide variation regarding the use of surveillance care was found by age and relative to guideline recommendations. Breast cancer survivors were found to have high rates of both guideline-recommended recurrence testing and non-guideline-recommended metastatic testing. Only approximately 50% of colorectal cancer survivors received recommended tests but greater than 67% received metastatic testing.

Disparities in survival after Hodgkin lymphoma: a population-based study

Survival after Hodgkin lymphoma (HL) is generally favorable, but may vary by patient demographic characteristics. The authors examined HL survival according to race/ethnicity and neighborhood socioeconomic status (SES), determined from residential census-block group at diagnosis. For 12,492 classical HL patients ≥ 15 years diagnosed in California during 1988-2006 and followed through 2007, we determined risk of overall and HL-specific death using Cox proportional hazards regression; analyses were stratified by age and Ann Arbor stage. Irrespective of disease stage, patients with lower neighborhood SES had worse overall and HL-specific survival than patients with higher SES. Patients with the lowest quintile of neighborhood SES had a 64% (patients aged 15-44 years) and 36% (≥ 45 years) increased risk of HL-death compared to patients with the highest quintile of SES; SES results were similar for overall survival. Even after adjustment for neighborhood SES, blacks and Hispanics had increased risks of HL-death 74% and 43% (15-44 years) and 40% and 17% (≥ 45 years), respectively, higher than white patients. The racial/ethnic differences in survival were evident for all stages of disease. These data provide evidence for substantial, and probably remediable, racial/ethnic and neighborhood SES disparities in HL outcomes.

A simulation model approach to analysis of the business case for eliminating health care disparities

BACKGROUND

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.

METHODS

To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma.

RESULTS

The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%.

CONCLUSIONS

For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

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.

Health disparities: a primer for public health social workers

In 2001, the U.S. Department of Health and Human Services published Healthy People 2010, which identified objectives to guide health promotion and to eliminate health disparities. Since 2001, much research has been published documenting racial and ethnic disparities in healthcare. Although progress has been made in eliminating the disparities, ongoing work by public health social workers, researchers, and policy analysts is needed. This paper focuses on racial and ethnic health disparities, why they exist, where they can be found, and some of the key health/medical conditions identified by the U.S. Department of Health and Human Services to receive attention. Finally, there is a discussion of what policy, professional and community education, and research can to do to eliminate racial and ethnic disparities in healthcare.

A black-white comparison of the quality of stage-specific colon cancer treatment

BACKGROUND

Several studies have attributed racial disparities in cancer incidence and mortality to variances in socioeconomic status and health insurance coverage. However, an Institute of Medicine report found that blacks received lower quality care than whites after controlling for health insurance, income, and disease severity.

METHODS

To examine the effects of race on colorectal cancer outcomes within a single setting, the authors performed a retrospective cohort study that analyzed the cancer registry, billing, and medical records of 365 university hospital patients (175 blacks and 190 whites) diagnosed with stage II-IV colon cancer between 2000 and 2005. Racial differences in the quality (effectiveness and timeliness) of stage-specific colon cancer treatment (colectomy and chemotherapy) were examined after adjusting for socioeconomic status, health insurance coverage, sex, age, and marital status.

RESULTS

Blacks and whites had similar sociodemographic characteristics, tumor stage and site, quality of care, and health outcomes. Age and diagnostic stage were predictors of quality of care and mortality. Although few patients (5.8%) were uninsured, they were more likely to present at advanced stages (61.9% at stage IV) and die (76.2%) than privately insured and publicly insured patients (p = .002).

CONCLUSIONS

In a population without racial differences in socioeconomic status or insurance coverage, patients receive the same quality of care, regardless of racial distinction, and have similar health outcomes. Age, diagnostic stage, and health insurance coverage remained independently associated with mortality. Future studies of disparities in colon cancer treatment should examine sociocultural barriers to accessing appropriate care in various healthcare settings.

Screening for colorectal cancer in a safety-net health care system: access to care is critical and has implications for screening policy

BACKGROUND

Data on the number of individuals eligible for screening, and rates of screening, are necessary to assess national colorectal cancer screening efforts. Such data are sparse for safety-net health systems.

METHODS

A retrospective cohort study of individuals ages 50 to 75 served by a safety-net health system in Tarrant County, TX was conducted to determine (a) the size of the potential screen-eligible population ages 50 to 75, (b) the rate of screening over 5 years among individuals ages 54 to 75, and (c) the potential predictors of screening, including sex, race/ethnicity, insurance status, frequency of outpatient visits, and socioeconomic status.

RESULTS

Of 28,708 potential screen-eligible individuals, 20,416 were ages 54 to 75 and analyzed for screening; 22.0% were screened within the preceding 5 years. Female gender, Hispanic ethnicity, ages 65 to 75, insurance status, and two or more outpatient visits were independently associated with screening. Access to care was an important factor: adjusted odds ratio, 2.57 (95% confidence interval, 2.23-2.98) for any insurance; adjusted odds ratio, 3.53 (95% confidence interval, 3.15-3.97) for two or more outpatient visits.

CONCLUSIONS

The screen-eligible population served by our safety-net health system was large, and the projected deficit in screen rates was substantial. Access to care was the dominant predictor of screening participation. If our results are replicable in similar health systems, the data suggest that screening guidelines and policy efforts must take into account the feasibility of proposed interventions. Strong advocacy for more resources for colorectal cancer screening interventions (including research into the best manner to provide screening for large populations) is needed.

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.

Examining racial disparities in colorectal cancer care

African Americans are disproportionately burdened with colorectal cancer. Although incidence and mortality rates have declined in the past two decades, the disparity in health outcomes has progressively increased. This comprehensive review examines the existing literature regarding racial disparities in colorectal cancer screening, stage at diagnosis, and treatment to determine if differences exist in the quality of care delivered to African Americans. A comprehensive review of relevant literature was performed. Two databases (EBSCOHOST Academic Search Premier and Scopus) were searched from 2000 to 2007. Articles that assessed racial disparities in colorectal cancer screening, stage of disease at diagnosis, and treatment were selected. The majority of studies identified examined colorectal cancer screening outcomes. Although racial disparities in screening have diminished in recent years, African American men and women continue to have higher colorectal cancer incidence and mortality rates and are diagnosed at more advanced stages. Several studies regarding stage of disease at diagnosis identified socioeconomic status (SES) and health insurance status as major determinants of disparity. However, some studies found significant racial disparities even after controlling for these factors. Racial disparities in treatment were also found at various diagnostic stages. Many factors affecting disparities between African Americans and Whites in colorectal cancer incidence and mortality remain unexplained. Although the importance of tumor biology, genetics, and lifestyle risk factors have been established, prime sociodemographic factors need further examination to understand variances in the care of African Americans diagnosed with colorectal 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.

Influence of year of diagnosis, patient age, and sociodemographic status on recommending adjuvant radiation treatment for stage I testicular seminoma

PURPOSE

Adjuvant radiation therapy (ART) for stage I seminoma can cause adverse late effects and alternative postorchiectomy management strategies have been developed. This study evaluated ART trends in the United States and the impact of clinical and sociodemographic factors on ART recommendations.

METHODS

Of men diagnosed with stage I seminoma from 1990 through 2004, 3,125 were identified using the Surveillance, Epidemiology, and End Results cancer registry. A multivariable logistic regression analysis was performed to assess whether there was a significant association between diagnosis year, diagnosis age, race, county education level, region, tumor size, tumor category, and the recommendation for ART.

RESULTS

There was a significant association (P < .001) between later year of diagnosis and a decrease in ART recommendation. Compared with men diagnosed in 1990 to 1994, men diagnosed in 1995 to 1999, and 2000 to 2004 were less likely to have ART (adjusted odds ratio [OR], 0.63; 95% CI, 0.48 to 0.84; and OR, 0.49; 95% CI, 0.37 to 0.63, respectively). There also was a significant association (P < .001) between county education level and ART recommendation. Men residing in counties with the highest education level were more likely to receive ART than men residing in counties with the lowest education level (OR, 2.12; 95% CI, 1.59 to 2.82). Also, men older than 30 years were more likely to receive ART than men age 30 or younger (OR, 1.26; 95% CI, 1.03 to 1.55).

CONCLUSION

ART recommendations for stage I seminoma are declining. Men in less educated regions and the youngest men were less likely to receive a recommendation for ART.

Association of demographic and treatment variables in long-term colon cancer survival

The purpose of this study is to examine demographic and treatment variables because they relate to 5-year survival in colon cancer. The study design is analysis of 174 471 patients with colon and rectosigmoid cancer as reported to the American College of Surgeons National Cancer Data Base. Factors associated with a reduced risk of mortality included female gender (hazard ratio = 0.89; 95% confidence interval, 0.87-0.90), education status (hazard ratio = 0.87; 95% confidence interval, 0.85-0.89), increased number of lymph nodes resected (compared with <8, 8-12: hazard ratio = 0.90; 95% confidence interval, 0.89-0.92; >12: hazard ratio = 0.79; 95% confidence interval, 0.77-0.80), and addition of chemotherapy (hazard ratio = 0.69; 95% CI, 0.68-0.71). African American race (hazard ratio = 1.14; 95% confidence interval, 1.11-1.18) and increasing age correlated with an increased hazard risk (61-75 years: hazard ratio = 1.26; 95% confidence interval, 1.23-1.29; >or=76 years: hazard ratio = 2.15; 95% confidence interval, 2.09-2.21, compared with age <60 years). Survival in colon cancer is significantly impacted by patient's age, race, gender, and education status but not by income or area of residence.

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.

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.

The promise and limits of racial/ethnic concordance in physician-patient interaction

Although some scholars suggest that racial/ethnic concordance between physicians and patients will do much to eliminate disparities in medical care, the evidence for concordance effects is mixed. Using nationally representative data with an oversample of blacks and Latinos, this study examines a variety of topics, including beliefs about and preferences for concordance, the effects of concordance on patient experiences, and interactions between expectations and experiences. The results point to the limited effects of concordance in general but illuminate for whom concordance matters most. The results encourage more nuanced and contingent theories. They suggest that racial/ethnic concordance holds little salience in the minds of most black and Latino patients and that discordance has little effect. Nevertheless, there is some evidence that concordance has a positive effect among those who prefer concordance-thus the apparent effects of concordance might reflect the effects of patient choice more than concordance per se. The conclusion sketches policy implications, including the merits of promoting concordance among targeted groups of patients, even in the absence of overall effects on disparities.

Origins of socio-economic inequalities in cancer survival: a review

BACKGROUND

Cancer survival is known to vary by socio-economic group. A review of studies published by 1995 showed this association to be universal and resilient to the many different ways in which socio-economic status was determined. Differences were most commonly attributed to differences in stage of disease at diagnosis.

MATERIALS AND METHODS

A review of research published since 1995 examining the association of cancer survival with socio-economic variables.

RESULTS

An association between socio-economic status and cancer survival has continued to be demonstrated in the last decade of research. Stage at diagnosis and differences in treatment have been cited as the most important explanatory factors. Some research has evaluated the psychosocial elements of this association.

CONCLUSIONS

Socio-economic differences in cancer survival are now well documented. The explanatory power of stage at diagnosis, although great, should not detract from the evidence of differential treatment between social groups. Neither factor can completely explain the observed socio-economic differences in survival, however, and the importance of differences in tumour and patient factors should now be quantified.

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.

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.

Population-Based Assessment of Surgical Treatment Trends for Patients With Melanoma in the Era of Sentinel Lymph Node Biopsy

Purpose

The surgical staging of melanoma dramatically changed with the introduction of sentinel lymph node (SLN) biopsy. In this study, Surveillance, Epidemiology, and End Results (SEER) data were examined to determine how surgical treatment is being carried out and whether SLN biopsy is being performed in melanoma patients in conformance with National Comprehensive Cancer Network (NCCN) guidelines.

Patients and Methods

The SEER database (1998 to 2001) was searched for all patients with invasive melanoma. NCCN guidelines were used to define optimal stage-specific surgical treatment. Treatment trends in patients with stages I to III disease were summarized, and multivariate analyses were performed to identify factors associated with nonadherence with treatment guidelines.

Results

A total of 21,867 melanoma patients were identified; 18,499 of these patients met the inclusion criteria. The number of patients diagnosed with stage III melanoma increased by 55.7% over the study period, and this corresponded to a 53% increase in the number of SLN biopsies performed annually. The odds ratios for nonadherence were 2.32, 2.27, and 1.54 for stages IB, II, and III disease, respectively, compared with stage IA melanoma. Multivariate analyses revealed that age more than 65 years, marital status, minority populations, and primary tumor location were associated with nonadherence with guidelines. Treatment patterns among tumor registries also varied significantly.

Conclusion

Stage migration is evident in the SEER registries in consort with increasing use of SLN biopsy. Although treatment trends are improving, SLN biopsy continues to be underused, particularly in the elderly and minority populations, in patients with truncal and head/neck melanomas, and also in some geographic regions of the United States.

Routine Surveillance Care After Cancer Treatment With Curative Intent

BACKGROUND

Many consensus guidelines recommend routine surveillance to detect recurrent disease among cancer survivors. We compare surveillance care receipt to guideline recommendations.

METHODS

Cohorts of patients aged 30 years or older diagnosed with breast, colorectal, endometrial, lung, or prostate cancer between 1990 and 1995 and treated with curative intent were identified (n = 100 per site). Receipt and indications for examinations and procedures were abstracted from medical records for as long as 5 years after treatment. Kaplan-Meier product estimates were used to estimate time to initial and subsequent service receipt.

RESULTS

Most cancer patients received the recommended minimum number of physical examinations after treatment. In fact, a sizable number of cancer survivors received physical examinations at a frequency in excess of what is currently recommended. Similarly, most of these cancer survivors received recommended testing for local recurrence. Yet, less than two thirds of colorectal cancer patients received recommended colon examinations in the initial year after treatment. Among colorectal, lung, and prostate cancer patients who received recommended initial local recurrence testing, repeat testing tended to occur more frequently than what is currently recommended. The use of testing for metastatic disease that is not recommended in guidelines is also commonplace among these cancer survivors.

CONCLUSIONS

Among cohorts of cancer patients, we found wide variation in the use of surveillance care, including patterns of care receipt reflective of both underuse and overuse relative to guideline recommendations. Clinical reasons for these variations and the cost and health implications deserve further study.

Untreated cervical cancer in the United States

OBJECTIVE

To evaluate treatment patterns, including lack of treatment, among women diagnosed with cervical cancer in the United States.

METHODS

Using the National Cancer Institute's (NCI's) Surveillance, Epidemiology, and End Results (SEER) program, we identified 13,715 women diagnosed with invasive cervical cancer between 1992 and 1999 and eligible for inclusion in the study.

RESULTS

Nearly 9% of women diagnosed with invasive cervical cancer received no therapy for their disease. Lack of therapy was associated with a later stage of disease at diagnosis, older age, and unmarried status. More than 16% of women aged 65 and older with stage IIB/IV cervical cancer received no therapy for their disease.

CONCLUSION

We must educate women diagnosed with cervical cancer and their families about the importance of treatment for potential cure and control of symptoms. We must identify and overcome obstacles that may prevent adherence to treatment recommendations. These may include comorbidity, access to cancer treatment, inability to pay for treatment, and inadequate social support.

Prospective evaluation of screening colonoscopy: who is being screened?

BACKGROUND

Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by colonoscopy differed among socioeconomic classes and to assess adherence to screening guidelines.

METHODS

Consecutive patients scheduled to undergo colonoscopy at a single center between August 2000 and August 2002 completed a questionnaire that determined patient characteristics and indications for the procedure. The patients were divided into two groups: screening patients, defined as individuals who indicated they were undergoing colonoscopy for screening purposes and were asymptomatic, and a control group, which comprised patients undergoing colonoscopy because of symptoms. Statistical analysis was performed to determine if patients in the screening group had different characteristics with respect to socioeconomic class, compared with the control group.

RESULTS

A total of 1088 patients completed the questionnaire: 707 (65%) had colonoscopy because of symptoms, compared with 381 (35%) who underwent a screening examination. Mean age and marital status were similar in both groups. Of all colonoscopy procedures, there was a significantly greater proportion of men undergoing colonoscopy for screening purposes: 199 (52.2%) vs. 294 (41.6%) in the symptomatic group ( p = 0.001). Based on the Cochran-Armitage test, patients in the screening group had significantly higher education levels ( p = 0.004) and household incomes ( p = 0.001).

CONCLUSIONS

Income and education level, two indices of socioeconomic status, are statistically significantly higher in patients undergoing screening colonoscopy compared with those having colonoscopy for any other reason.

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.