Treatment and survival differences in older Medicare patients with lung cancer as compared with those who are dually eligible for Medicare and Medicaid

Nanomaterial-assisted oncolytic bacteria in solid tumor diagnosis and therapeutics

Cancer presents a formidable challenge in modern medicine due to the intratumoral heterogeneity and the dynamic microenvironmental niche. Natural or genetically engineered oncolytic bacteria have always been hailed by scientists for their intrinsic tumor-targeting and oncolytic capacities. However, the immunogenicity and low toxicity inevitably constrain their application in clinical practice. When nanomaterials, characterized by distinctive physicochemical properties, are integrated with oncolytic bacteria, they achieve mutually complementary advantages and construct efficient and safe nanobiohybrids. In this review, we initially analyze the merits and drawbacks of conventional tumor therapeutic approaches, followed by a detailed examination of the precise oncolysis mechanisms employed by oncolytic bacteria. Subsequently, we focus on harnessing nanomaterial-assisted oncolytic bacteria (NAOB) to augment the effectiveness of tumor therapy and utilizing them as nanotheranostic agents for imaging-guided tumor treatment. Finally, by summarizing and analyzing the current deficiencies of NAOB, this review provides some innovative directions for developing nanobiohybrids, intending to infuse novel research concepts into the realm of solid tumor therapy.

Racial disparities in staging, treatment, and mortality in non-small cell lung cancer

Background

Black race is associated with advanced stage at diagnosis and increased mortality in non-small cell lung cancer (NSCLC). Most studies focus on race alone, without accounting for social determinants of health (SDOH). We explored the hypothesis that racial disparities in stage at diagnosis and outcomes are associated with SDOH and influence treatment decisions by patients and providers.

Methods

Patients with NSCLC newly diagnosed at Indiana University Simon Comprehensive Cancer Center (IUSCCC) from January 1, 2000 to May 31, 2015 were studied. Multivariable regression analyses were conducted to examine the impact of SDOH (race, gender, insurance status, and marital status) on diagnosis stage, time to treatment, receipt of and reasons for not receiving guideline concordant treatment, and 5-year overall survival (OS) based on Kaplan-Meier curves.

Results

A total of 3,349 subjects were included in the study, 12.2% of Black race. Those diagnosed with advanced-stage NSCLC had a significantly higher odds of being male, uninsured, and Black. Five-year OS was lower in those of Black race, male, single, uninsured, Medicare/Medicaid insurance, and advanced stage. Adjusted for multiple variables, individuals with Medicare, Medicare/Medicaid, uninsured, widowed, and advanced stage at diagnosis, were associated with significantly lower OS time. Black, single, widowed, and uninsured individuals were less likely to receive stage appropriate treatment for advanced disease. Those uninsured [odds ratio (OR): 3.876, P<0.001], Medicaid insurance (OR: 3.039, P=0.0017), and of Black race (OR: 1.779, P=0.0377) were less likely to receive curative-intent surgery for early-stage NSCLC because it was not a recommended treatment.

Conclusions

We found racial, gender, and socioeconomic disparities in NSCLC diagnosis stage, receipt of stage-appropriate treatment, and reasons for guideline discordance in receipt of curative intent surgery for early-stage NSCLC. While insurance type and marital status were associated with worse OS, race alone was not. This suggests racial differences in outcomes may not be associated with race alone, but rather worse SDOH disproportionately affecting Black individuals. Efforts to understand advanced diagnosis and reasons for failure to receive stage-appropriate treatment by vulnerable populations is needed to ensure equitable NSCLC care.

Survival among lung cancer patients: comparison of the U.S. military health system and the surveillance, epidemiology, and end results (SEER) program by health insurance status

PURPOSE

The U.S. military health system (MHS) provides beneficiaries with universal health care while health care access varies in the U.S. general population by insurance status/type. We divided the patients from the U.S. general population by insurance status/type and compared them to the MHS patients in survival.

METHODS

The MHS patients were identified from the Department of Defense's Automated Central Tumor Registry (ACTUR). Patients from the U.S. general population were identified from the Surveillance, Epidemiology, and End Results (SEER) program. Multivariable Cox regression analysis was conducted to compare different insurance status/type in SEER to ACTUR in overall survival.

RESULTS

Compared to ACTUR patients with non-small cell lung cancer (NSCLC), SEER patients showed significant worse survival. The adjusted hazard ratios (HRs) were 1.08 [95% Confidence Interval (CI) = 1.03-1.13], 1.22 (95% CI = 1.16-1.28), 1.40 (95% CI = 1.33-1.47), 1.50 (95% CI = 1.41-1.59), for insured, insured/no specifics, Medicaid, and uninsured patients, respectively. The pattern was consistently observed in subgroup analysis by race, gender, age, or tumor stage. Results were similar for small cell lung cancer (SCLC), although they were only borderline significant in some subgroups.

CONCLUSION

The survival advantage of patients receiving care from a universal health care system over the patients from the general population was not restricted to uninsured or Medicaid as expected, but was present cross all insurance types, including patients with private insurance. Our findings highlight the survival benefits of universal health care system to lung cancer patients.

The "Medicare effect" on head and neck cancer diagnosis and survival

BACKGROUND

Uninsured individuals age 55-64 experience disproportionately poor outcomes compared to their insured counterparts. Adequate coverage may prevent these delays. This study investigates a "Medicare-effect" on head and neck squamous cell carcinoma (HNSCC) diagnosis and treatment.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for persons ages 60-70 years in the United States from 2000 to 2016 with HNSCC. A "Medicare effect" was defined as an increase in incidence, reduction in advanced stage presentation, and/or decrease in cancer-specific mortality (CSM).

RESULTS

Compared to their Medicaid or uninsured counterparts, patients age 65 have an increased incidence of HNSCC diagnosis, reduction in advanced stage presentation, decrease in cancer-specific mortality, and higher likelihood of receiving cancer-specific surgery.

CONCLUSIONS

Patients age 65 with Medicare have decreased incidence of HNSCC, less hazard of late-stage diagnosis, and lower cancer-specific mortality than their Medicaid or uninsured counterparts, supporting the idea of a "Medicare effect" in HNSCC.

A Medicare Claims Analysis of Racial and Ethnic Disparities in the Access to Radiation Therapy Services

PURPOSE

Reduced access and utilization of radiation therapy (RT) is a well-documented healthcare disparity observed among racial and ethnic minority groups in the USA and a contributor to the inferior health outcomes observed among Black, Hispanic, and Native American patient groups. What is less understood are the points during the process of care following RT consultation at which patients either fail to complete their prescribed treatment or encounter delays. Identification of those points where significant differences exist among different patient groups may help identify opportunities to close gaps in the access of clinically indicated RT.

METHODS AND MATERIALS

This analysis examines 261,559 RT episodes abstracted from Medicare claims and beneficiary data between 2016 and 2018 to determine rates of treatment initiation following planning and timeliness of treatment completion for different racial groups.

RESULTS

Failure to initiate treatment was observed to be 29.3% relatively greater for Black, Hispanic, and Native American patients than for White and Asian patients. Among episodes for which treatment was initiated, Black and Hispanic patients were observed to require a significantly greater number of calendar days (when adjusted for fraction number) for completion than for White, Asian, and Native American patients.

CONCLUSIONS

There appears to be a patient cohort for which RT disparities may be more marginal in their effects-allowing for access to consultation and treatment prescription but not for treatment initiation or timely completion of treatment-and may therefore permit effective solutions to help address current differences in cancer outcomes.

Disparities in localized malignant lung cancer surgical treatment: A population‐based cancer registry analysis

BACKGROUND

Lung cancer (LC) continues to be the leading cause of cancer deaths in the United States. Surgical treatment has proven to offer a favorable prognosis and a better 5-year relative survival for patients with early or localized tumors. This novel study investigates the factors associated with the odds of receiving surgical treatment for localized malignant LC in Tennessee.

METHODS

Population-based data of 9679 localized malignant LC patients from the Tennessee Cancer Registry (2005-2015) were utilized to examine the factors associated with receiving surgical treatment for localized malignant LC. Bivariate and multivariate logistic regression analyses, cross-tabulation, and Chi-Square ( χ ² ) tests were conducted to assess these factors.

RESULTS

Patients with localized malignant LC who initiated treatment after 2.7 weeks were 46% less likely to receive surgery (adjusted odds ratio [AOR] = 0.54; 95% confidence interval [CI] = 0.50-0.59; p < 0.0001). Females had a greater likelihood (AOR = 1.14; CI = 1.03-1.24) of receiving surgical treatment compared to men. Blacks had lower odds (AOR = 0.76; CI = 0.65-0.98) of receiving surgical treatment compared to Whites. All marital groups had higher odds of receiving surgical treatment compared to those who were single/never married. Patients living in Appalachian county had lower odds of receiving surgical treatment (AOR = 0.65; CI = 0.59-0.71) compared with those in the non-Appalachian county. Patients with private (AOR = 2.09; CI = 1.55-2.820) or public (AOR = 1.42; CI = 1.06-1.91) insurance coverage were more likely to receive surgical treatment compared to self-pay/uninsured patients. Overall, the likelihood of patients receiving surgical treatment for localized malignant LC decreases with age.

CONCLUSION

Disparities exist in the receipt of surgical treatment among patients with localized malignant LC in Tennessee. Health policies should target reducing these disparities to improve the survival of these patients.

Intensity of end-of-life care for dual-eligible beneficiaries with cancer and the impact of delivery system affiliation

BACKGROUND

Dual-eligible beneficiaries, who qualify for Medicare and Medicaid, are a vulnerable population with much to gain from efforts to improve quality. Integrated delivery networks and cancer centers, with their emphasis on care coordination and communication, may improve quality of care for dual-eligible patients with cancer at the end of life.

METHODS

This study used Surveillance, Epidemiology, and End Results registry data linked with Medicare claims to evaluate quality for beneficiaries who died of cancer and were diagnosed from 2009 to 2014. High-intensity care was evaluated with 7 end-of-life quality measures according to dual-eligible status with multivariable logistic regression models. Regression-based techniques were used to assess the effect of delivery system affiliation (ie, cancer center or integrated delivery network vs no affiliation).

RESULTS

Among 100,549 beneficiaries who died during the study interval, 22% were dually eligible. Inferior outcomes were identified for dual-eligible beneficiaries in comparison with nondual beneficiaries across nearly every quality measure assessed, including >1 hospitalization in the last 30 days (12.6% vs 11.3%; P < .001) and a greater proportion of deaths occurring in a hospital setting (30.2% vs 26.2%; P < .001). Receipt of care in an affiliated delivery system was associated with reduced deaths in a hospital setting and increased hospice utilization for dual-eligible beneficiaries.

CONCLUSIONS

Dual-eligible status is associated with higher intensity care at the end of life. Delivery system affiliation has a modest impact on quality at the end of life, and this suggests that targeted efforts may be needed to optimize quality for this group of vulnerable patients.

Neighborhood and Individual Socioeconomic Disadvantage and Survival Among Patients With Nonmetastatic Common Cancers

IMPORTANCE

Disadvantaged neighborhood-level and individual-level socioeconomic status (SES) have each been associated with suboptimal cancer care and inferior outcomes. However, independent or synergistic associations between neighborhood and individual socioeconomic disadvantage have not been fully examined, and prior studies using simplistic neighborhood SES measures may not comprehensively assess multiple aspects of neighborhood SES.

OBJECTIVE

To investigate the associations of neighborhood SES (using a validated comprehensive composite measure) and individual SES with survival among patients with nonmetastatic common cancers.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, population-based cohort study was derived from the Surveillance, Epidemiology, and End Results-Medicare database from January 1, 2008, through December 31, 2011, with follow-up ending on December 31, 2017. Participants included older patients (≥65 years) with breast, prostate, lung, or colorectal cancer.

EXPOSURES

Neighborhood SES was measured using the area deprivation index (ADI; quintiles), a validated comprehensive composite measure of neighborhood SES. Individual SES was assessed by Medicare-Medicaid dual eligibility (yes vs no), a reliable indicator for patient-level low income.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall mortality, and the secondary outcome was cancer-specific mortality. Hazard ratios (HRs) for the associations of ADI and dual eligibility with overall and cancer-specific mortality were estimated via Cox proportional hazards regression. Statistical analyses were conducted from January 23 to April 15, 2021.

RESULTS

A total of 96 978 patients were analyzed, including 25 968 with breast, 35 150 with prostate, 16 684 with lung, and 19 176 with colorectal cancer. Median age at diagnosis was 76 years (IQR, 71-81 years) for breast cancer, 73 years (IQR, 70-77 years) for prostate cancer, 76 years (IQR, 71-81 years) for lung cancer, and 78 years (IQR, 72-84 years) for colorectal cancer. Among lung and colorectal cancer patients, 8412 (50.4%) and 10 486 (54.7%), respectively, were female. The proportion of non-Hispanic White individuals among breast cancer patients was 83.7% (n = 21 725); prostate cancer, 76.8% (n = 27 001); lung cancer, 83.5% (n = 13 926); and colorectal cancer, 81.1% (n = 15 557). Neighborhood-level and individual-level SES were independently associated with overall mortality, and no interactions were detected. Compared with the most affluent neighborhoods (ADI quintile 1), living in the most disadvantaged neighborhoods (ADI quintile 5) was associated with higher risk of overall mortality (breast: HR, 1.34; 95% CI, 1.26-1.43; prostate: HR, 1.51; 95% CI, 1.42-1.62; lung: HR, 1.21; 95% CI, 1.14-1.28; and colorectal: HR, 1.24; 95% CI, 1.17-1.32). Individual socioeconomic disadvantage (dual eligibility) was associated with higher risk of overall mortality (breast: HR, 1.22; 95% CI, 1.15-1.29; prostate: HR, 1.29; 95% CI, 1.21-1.38; lung: HR, 1.14; 95% CI, 1.09-1.20; and colorectal: HR, 1.23; 95% CI, 1.17-1.29). A similar pattern was observed for cancer-specific mortality.

CONCLUSIONS AND RELEVANCE

In this cohort study, neighborhood-level deprivation was associated with worse survival among patients with nonmetastatic breast, prostate, lung, and colorectal cancer, even after accounting for individual SES. These findings suggest that, in order to improve cancer outcomes and reduce health disparities, policies for ongoing investments in low-resource neighborhoods and low-income households are needed.

Comparative study of survival among small cell lung cancer patients in the U.S. military health system and those in the surveillance, epidemiology, and end results (SEER) program

PURPOSE

The U.S. military health system provides universal health care access to beneficiaries. However, whether the universal access has translated into improved patient outcome is unknown. We compared survival of small-cell lung cancer patients in the military health system with that in the U.S. general population. Stage and receipt of cancer treatment were also compared to see if they could contribute to survival difference.

METHODS

The data were obtained from The Department of Defense's Automated Central Tumor Registry (ACTUR) and the national Surveillance, Epidemiology, and End Results (SEER) program, respectively. ACTUR (N = 3040) and SEER patients (N = 12,160) were matched on age, sex, race and diagnosis year. Multivariable Cox regression model was used to compare all-cause mortality between ACTUR and SEER. Multivariable logistic regression was performed to compare cancer stage and treatment.

RESULTS

ACTUR patients exhibited significantly better survival than SEER counterparts (HR = 0.77, 95% CI= 0.71-0.83). ACTUR and SEER patients had similar stage, but ACTUR patients were more likely to receive radiation treatment (OR = 1.26, 95% CI = 1.12-1.42). The survival advantage of ACTUR patients remained across all tumor stages and radiation groups.

CONCLUSIONS

Survival of small-cell lung cancer patients with universal health care access had better survival than similar patients in the U.S. general population. Future studies are warranted to identify factors that may contribute to the improved survival.

Cancer diagnoses and survival rise as 65-year-olds become Medicare-eligible

BACKGROUND

A Medicare effect has been described to account for increased health care utilization occurring at the age of 65 years. The existence of such an effect in cancer care, where it would be most likely to reduce mortality, has been unclear.

METHODS

Patients aged 61 to 69 years who were diagnosed with lung, breast, colon, or prostate cancer from 2004 to 2016 were identified with the Surveillance, Epidemiology, and End Results database and were dichotomized on the basis of eligibility for Medicare (61-64 vs 65-69 years). With age-over-age (AoA) percent change calculations, trends in cancer diagnoses and staging were characterized. After matching, uninsured patients who were 61 to 64 years old (pre-Medicare group) were compared with insured patients who were 65 to 69 years old (post-Medicare group) with respect to cancer-specific mortality.

RESULTS

In all, 134,991 patients were identified with lung cancer, 175,558 were identified with breast cancer, 62,721 were identified with colon cancer, and 238,823 were identified with prostate cancer. The AoA growth in the number of cancer diagnoses was highest at the age of 65 years in comparison with all other ages within the decade for all 4 cancers (P < .01, P < .001, P < .01, and P < .001, respectively). In a comparison of diagnoses at the age of 65 years with those in the 61- to 64-year-old cohort, the greatest difference for all 4 cancers was seen in stage I. In matched analyses, the 5-year cancer-specific mortality was worse for lung (86.3% vs 78.5%; P < .001), breast (32.7% vs 11.0%; P < .001), colon (57.1% vs 35.6%; P < .001), and prostate cancer (16.9% vs 4.8%; P < .001) in the uninsured pre-Medicare group than the insured post-Medicare group.

CONCLUSIONS

The age threshold of 65 years for Medicare eligibility is associated with more cancer diagnoses (particularly stage I), and this results in lower long-term cancer-specific mortality for all cancers studied.

LAY SUMMARY

Contributing to the current debate regarding Medicare for all, this study shows that the expansion of Medicare would improve cancer outcomes for the near elderly.

Association of State Certificate of Need Regulation With Procedural Volume, Market Share, and Outcomes Among Medicare Beneficiaries

IMPORTANCE

Certificate of need laws provide state-level regulation of health system expenditure. These laws are intended to limit spending and control hospital expansion in order to prevent excess capacity and improve quality of care. Several states have recently introduced legislation to modify or repeal these regulations, as encouraged by executive order 13813, issued in October 2017 by the Trump administration.

OBJECTIVE

To evaluate the difference in markers of hospital activity and quality by state certificate of need status. These markers include hospital procedural volume, hospital market share, county-level procedures per 10 000 persons, and patient-level postoperative outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study involving Medicare beneficiaries aged 65 years or older who underwent 1 of the following 10 procedures from January 1, 2016, through November 30, 2018: total knee or hip arthroplasty, coronary artery bypass grafting, colectomy, ventral hernia repair, lower extremity vascular bypass, lung resection, pancreatic resection, cystectomy, or esophagectomy.

EXPOSURES

State certificate of need regulation status as determined by data from the National Conference of State Legislatures.

MAIN OUTCOMES AND MEASURES

Outcomes of interest included hospital procedural volume; hospital market share (range, 0-1; reflecting 0%-100% of market share); county-level procedures per 10 000 persons; and patient-level postoperative 30-day mortality, surgical site infection, and readmission.

RESULTS

A total of 1 545 952 patients (58.0% women; median age 72 years; interquartile range, 68-77 years) at 3631 hospitals underwent 1 of the 10 operations. Of these patients, 468 236 (30.3%) underwent procedures in the 15 states without certificate of need regulations and 1 077 716 (69.7%) in the 35 states with certificate of need regulations. The total number of procedures ranged between 729 855 total knee arthroplasties (47.21%) and 4558 esophagectomies (0.29%). When comparing states without vs with certificate of need regulations, there were no significant differences in overall hospital procedural volume (median hospital procedure volume, 241 vs 272 operations per hospital for 3 years; absolute difference, 31; 95% CI, -27.64 to 89.64; P = .30). There were no statistically significant differences between states without vs with certificate of need regulations for median hospital market share (median, 28% vs 52%; absolute difference, 24%; 95% CI, -5% to 55%; P = .11); procedure rates per 10 000 Medicare-eligible population (median, 239.23 vs 205.41 operations per Medicare-eligible population in 3 years; absolute difference, 33.82; 95% CI, -84.08 to 16.43; P = .19); or 30-day mortality (1.17% vs 1.33%, odds ratio [OR], 1.04; 95% CI, 0.93 to 1.16; P = .52), surgical site infection (1.24% vs 1.25%; OR, 0.93; 95% CI, 0.83 to 1.04; P = .21), or readmission rate (9.69% vs 8.40%; OR, 0.80; 95% CI, 0.57 to 1.12; P = .19).

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries who underwent a range of surgical procedures from 2016 through 2018, there were no significant differences in markers of hospital volume or quality between states without vs with certificate of need laws. Policy makers should consider reevaluating whether the current approach to certificate of need regulation is achieving the intended objectives and whether those objectives should be updated.

Socioeconomic disparity trends in diagnostic imaging, treatments, and survival for non-small cell lung cancer 2007-2016

Socioeconomic status (SES) has led to treatment and survival disparities; however, limited data exist for non‐small cell lung cancer (NSCLC). This study investigates the impact of SES on NSCLC diagnostic imaging, treatment, and overall survival (OS), and describes temporal disparity trends. The Ontario Cancer Registry was used to identify NSCLC patients diagnosed between 2007 and 2016. Through linkage to administrative datasets, patients’ demographics, imaging, treatment, and survival were obtained. Based on median household neighborhood income, the Ontario population was divided into five income quintiles (Q1‐Q5; Q1 = lowest income). Multivariable regressions assessed SES association with OS, imaging, treatment receipt, and treatment delay, and their interaction with year of diagnosis to understand temporal trends. Endpoints were adjusted for demographics, stage and comorbidities, along with treatments and imaging for OS. A total of 50 542 patients were identified. Higher SES patients (Q5 vs. Q1) showed improved 5‐year OS (hazard ratio, 0.89; 95% confidence interval [CI], 0.87‐0.92; P < .0001) and underwent greater magnetic resonance imaging head (stages IA‐IV; odds ratio [OR], 1.24; 95% CI, 1.16‐1.32; P < .0001), lung resection (IA‐IIIA; OR, 1.58; 95% CI, 1.43‐1.74; P < .0001), platinum‐based vinorelbine adjuvant chemotherapy (IB‐IIIA; OR, 1.63; 95% CI, 1.39‐1.92; P < .0001), palliative radiation (IV; OR, 1.14; 95% CI, 1.05‐1.25; P = .023), and intravenous chemotherapy (IV; OR, 1.45; 95% CI, 1.32‐1.60; P < .0001). Lower SES patients underwent greater thoracic radiation (IA‐IIIB; OR, 0.86; 95% CI, 0.79‐0.94; P = .0003). Across 2007‐2016, socioeconomic disparities remain largely unchanged (interaction P > .05) despite widening income inequality.

Health Insurance and Disparities in Mortality among Older Survivors of Critical Illness: A Population Study

OBJECTIVES

The 1.5 million Medicare beneficiaries who survive intensive care each year have a high post-hospitalization mortality rate. We aimed to determine whether mortality after critical illness is higher for Medicare beneficiaries with Medicaid compared with those with commercial insurance.

DESIGN

A retrospective cohort study from 2010 through 2014 with 1 year of follow-up using the New York Statewide Planning and Research Cooperative System database.

SETTING

A New York State population-based study of older (age ≥65 y) survivors of intensive care.

PARTICIPANTS

Adult Medicare beneficiaries age 65 years or older who were hospitalized with intensive care at a New York State hospital and survived to discharge.

INTERVENTION

None.

MEASUREMENT

Mortality in the first year after hospital discharge.

RESULTS

The study included 340 969 Medicare beneficiary survivors of intensive care with a mean (standard deviation) age of 77 (8) years; 20% died within 1 year. There were 152 869 (45%) with commercial insurance, 78 577 (23%) with Medicaid, and 109 523 (32%) with Medicare alone. Compared with those with commercial insurance, those with Medicare alone had a similar 1-year mortality rate (adjusted hazard ratio [aHR] = 1.01; 95% confidence interval [CI] = .99-1.04), and those with Medicaid had a 9% higher 1-year mortality rate (aHR = 1.09; 95% CI = 1.05-1.12). Among those discharged home, the 1-year mortality rate did not vary by insurance coverage, but among those discharged to skilled-care facilities (SCFs), the 1-year mortality rate was 16% higher for Medicaid recipients (aHR = 1.16; 95% CI = 1.12-1.21; P for interaction <.001).

CONCLUSIONS

Older adults with Medicaid insurance have a higher 1-year post-hospitalization mortality compared with those with commercial insurance, especially among those discharged to SCFs. Future studies should investigate care disparities at SCFs that may mediate these higher mortality rates. J Am Geriatr Soc 67:2497-2504, 2019.

Care experiences among dually enrolled older adults with cancer: SEER-CAHPS, 2005-2013

PURPOSE

Given the associations between poverty and poorer outcomes among older adults with cancer, we sought to understand the effects of dual enrollment in Medicare and Medicaid-as a marker of poverty-on self-reported care experiences among seniors diagnosed with cancer.

METHODS

Retrospective, observational study using cancer registry, Medicare claims, and care experience survey data (Surveillance, Epidemiology, and End Results [SEER]-Consumer Assessment of Healthcare Providers and Systems [CAHPS®]) for a national sample of fee-for-service (FFS) and Medicare Advantage (MA) enrollees aged 65 or older. We included people with one incident primary, malignant cancer diagnosed between 2005 and 2011, surveyed within 2 years after diagnosis (n = 9,800; 995 dual enrollees). Medicare CAHPS measures included 5 global ratings and 3 composite scores.

RESULTS

After adjustment for potential confounders, people with cancer histories who were dually enrolled were significantly more likely to report better experiences than non-duals on 2 measures (Medicare/their health plan: adjusted odds ratio [aOR]: 0.68, 95% confidence interval [CI] 0.53-0.87; prescription drug plan [PDP]: aOR: 0.54, 95% CI 0.40-0.73).

CONCLUSIONS

Dual enrollees with cancer reported better experiences than Medicare-only enrollees in terms of their health plan (Medicare FFS or Medicare Advantage) and their PDP. Better ratings among dually enrolled beneficiaries suggest possible divergence between health outcomes and care experiences, warranting additional investigation.

Disparities in Systemic Treatment Use in Advanced-stage Non-Small Cell Lung Cancer by Source of Health Insurance

BACKGROUND

Management of advanced-stage non-small cell lung cancer (NSCLC) has changed significantly over the past two decades with the development of numerous systemic treatments, including targeted therapies. However, a high proportion of advanced-stage patients are untreated. The role that health insurance plays in receipt of systemic treatments is unclear.

METHODS

Using California Cancer Registry data (2012-2014), we developed multivariable Poisson regression models to assess the independent effect of health insurance type on systemic treatment utilization among patients with stage IV NSCLC. Systemic treatment information was manually abstracted from treatment text fields.

RESULTS

A total of 17,310 patients were evaluated. Patients with Medicaid/other public insurance were significantly less likely to receive any systemic treatments [risk ratio (RR), 0.78; 95% confidence interval (CI), 0.75-0.82], bevacizumab combinations (RR, 0.57; 95% CI, 0.45-0.71), or tyrosine kinase inhibitors (RR, 0.70; 95% CI, 0.60-0.82) compared with the privately insured. Patients with Medicare or dual Medicare-Medicaid insurance were not significantly different from the privately insured in their likelihood of receiving systemic treatments.

CONCLUSIONS

Substantial disparities in the use of systemic treatments for stage IV NSCLC exist by source of health insurance in California. Patients with Medicaid/other public insurance were significantly less likely to receive systemic treatments compared with their privately insured counterparts.

IMPACT

Source of health insurance influences care received. Further research is warranted to better understand barriers to treatment that patients with Medicaid face.

A review of cancer outcomes among persons dually enrolled in Medicare and Medicaid

The fragmentation and lack of coordination of health care may result in less efficient and more costly care and lead to poorer outcomes. There has been increasing interest in examining cancer outcomes among persons who are dually enrolled in Medicare and Medicaid. Previous studies have identified disparities in the quality of cancer treatment according to race, ethnicity, socioeconomic status, and source of health insurance. This article, which is based upon bibliographic searches in PubMed, reviews the literature on dual enrollment in Medicare and Medicaid and cancer survival and quality of cancer treatment. A total of 65 articles were identified. Of the 65 articles that were screened using the full texts or abstracts, 13 studies met the eligibility criteria, one cross-sectional study and 12 cohort studies. The results of this systematic review indicate that there is only limited evidence that dual enrollment in Medicare and Medicaid is associated with poorer survival or quality of cancer care. The number of studies that have looked for associations between dual Medicare-Medicaid status and survival and quality of cancer treatment is still small. Outcomes and cancer site(s) varied among the studies. Additional studies are needed to determine the replicability of findings reported to date. Of particular interest are studies of major forms of cancer (breast, prostate, lung, colorectal) that include adequate numbers of patients described by insurance status, race, comorbidity, stage, receipt of appropriate cancer therapy, and survival.

Making the Evidentiary Case for Universal Multidisciplinary Thoracic Oncologic Care

The goal of this article is to provide an overview of the state of the evidence for, and challenges to, sustainable implementation of multidisciplinary thoracic oncology programs. Multidisciplinary care is much advocated by professional groups and makers of clinical guidelines, but little practiced. The gap between universal recommendation and scant evidence of practice suggests the existence of major barriers to program implementation. We examine 2 articles published in this issue of Clinical Lung Cancer to illustrate problems with the evidence base for multidisciplinary care. The inherent complexity of care delivery for the lung cancer patient drives near-universal advocacy for multidisciplinary care as a means of overcoming the heterogeneous quality and outcomes of patient care. However, the evidence to support this model of care delivery is poor. Challenges include the absence of a clear definition of "multidisciplinary care" in the literature, a consequent hodge-podge of poorly-defined examples of tested models, methodologically flawed studies, exemplified by the near-total absence of prospective studies examining this model of care delivery, and absence of scientifically sound dissemination and implementation studies, as well as cost-effectiveness studies. Against this background, we examined the results of a recent large single-institutional retrospective study suggesting the survival benefit of care within a colocated multidisciplinary lung cancer clinic, and an ambitious systematic review of existing literature on multidisciplinary cancer clinics. Better-quality evidence is still needed to establish the value of the multidisciplinary care concept. Such studies need to be prospective, use standardized definitions of multidisciplinary care, and provide clear information about program structure.

Survival among Lung Cancer Patients in the U.S. Military Health System: A Comparison with the SEER Population

Background: The U.S. military health system (MHS) provides universal health care access to its beneficiaries. However, whether the universal access has translated into improved patient outcome is unknown. This study compared survival of non-small cell lung cancer (NSCLC) patients in the MHS with that in the U.S. general population.Methods: The MHS data were obtained from The Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR), and the U.S. population data were drawn from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. The study subjects were NSCLC patients diagnosed between January 1, 1987, and December 31, 2012, in ACTUR and a sample of SEER patients who were matched to the ACTUR patients on age group, sex, race, and year of diagnosis group with a matching ratio of 1:4. Patients were followed through December 31, 2013.Results: A total of 16,257 NSCLC patients were identified from ACTUR and 65,028 matched patients from SEER. Compared with SEER patients, ACTUR patients had significantly better overall survival (log-rank P < 0.001). The better overall survival among the ACTUR patients remained after adjustment for potential confounders (HR = 0.78, 95% confidence interval, 0.76-0.81). The survival advantage of the ACTUR patients was present regardless of cancer stage, grade, age group, sex, or race.Conclusions: The MHS's universal care and lung cancer care programs may have translated into improved survival among NSCLC patients.Impact: This study supports improved survival outcome among NSCLC patients with universal care access. Cancer Epidemiol Biomarkers Prev; 27(6); 673-9. ©2018 AACR.

Regional variation in racial disparities among patients with peripheral artery disease

OBJECTIVE

Prior studies identified significant racial disparities as well as regional variation in outcomes of patients with peripheral artery disease (PAD). We aimed to determine whether regional variation contributes to these racial disparities.

METHODS

We identified all white or black patients who underwent infrainguinal revascularization or amputation in 15 deidentified regions of the Vascular Quality Initiative between 2003 and 2017. We excluded three regions with <100 procedures. We used multivariable linear regression, allowing clustering at the hospital level to calculate the marginal effects of race and region on adjusted 30-day mortality, major adverse limb events (MALEs), and amputation. We compared long-term outcomes between black and white patients within each region and within patients of each race treated in different regions using multivariable Cox regression.

RESULTS

We identified 90,418 patients, 15,527 (17%) of whom were black. Patients underwent 31,263 bypasses, 52,462 endovascular interventions, and 6693 amputations. Black patients were younger and less likely to smoke, to have coronary artery disease, or to have chronic obstructive pulmonary disease, but they were more likely to have diabetes, limb-threatening ischemia, dialysis dependence, and hypertension and to be self-insured or on Medicaid (all P < .05). Adjusted 30-day mortality ranged from 1.2% to 2.1% across regions for white patients and 0% to 3.0% for black patients; adjusted 30-day MALE varied from 4.0% to 8.3% for white patients and 2.4% to 8.1% for black patients; and adjusted 30-day amputation rates varied from 0.3% to 1.2% for white patients and 0% to 2.1% for black patients. Black patients experienced significantly different (both higher and lower) adjusted rates of 30-day mortality and amputation than white patients did in several regions (P < .05) but not MALEs. In addition, within each racial group, we found significant variation in the adjusted rates of all outcomes between regions (all P < .01). In adjusted analyses, compared with white patients, black patients experienced consistently lower long-term mortality (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73-0.88; P < .001) and higher rates of MALEs (HR, 1.15; 95% CI, 1.06-1.25; P < .001) and amputation (HR, 1.33; 95% CI, 1.18-1.51; P < .001), with no statistically significant variation across the regions. However, rates of all long-term outcomes varied within both racial groups across regions.

CONCLUSIONS

Significant racial disparities exist in outcomes after lower extremity procedures in patients with PAD, with regional variation contributing to perioperative but not long-term outcome disparities. Underperforming regions should use these data to generate quality improvement projects, as understanding the etiology of these disparities is critical to improving the care of all patients with PAD.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States, part 1: African-American patients

Introduction

African Americans experience the highest burden of cancer incidence and mortality in the United States and have been persistently less likely to receive interventional care, even when such care has been proven superior to conservative management by randomized controlled trials. The presence of disparities in access to radiation therapy (RT) for African American cancer patients has rarely been examined in an expansive fashion.

Methods and materials

An extensive literature search was performed using the PubMed database to examine studies investigating disparities in RT access for African Americans.

Results

A total of 55 studies were found, spanning 11 organ systems. Disparities in access to RT for African Americans were most prominently study in cancers of the breast (23 studies), prostate (7 studies), gynecologic system (5 studies), and hematologic system (5 studies). Disparities in RT access for African Americans were prevalent regardless of organ system studied and often occurred independently of socioeconomic status. Fifty of 55 studies (91%) involved analysis of a population-based database such as Surveillance, Epidemiology and End Result (SEER; 26 studies), SEER-Medicare (5 studies), National Cancer Database (3 studies), or a state tumor registry (13 studies).

Conclusions

African Americans in the United States have diminished access to RT compared with Caucasian patients, independent of but often in concert with low socioeconomic status. These findings underscore the importance of finding systemic and systematic solutions to address these inequalities to reduce the barriers that patient race provides in receipt of optimal cancer care.

Real-world treatment patterns for patients receiving second-line and third-line treatment for advanced non-small cell lung cancer: A systematic review of recently published studies

Most patients with advanced non-small cell lung cancer (NSCLC) have a poor prognosis and receive limited benefit from conventional treatments, especially in later lines of therapy. In recent years, several novel therapies have been approved for second- and third-line treatment of advanced NSCLC. In light of these approvals, it is valuable to understand the uptake of these new treatments in routine clinical practice and their impact on patient care. A systematic literature search was conducted in multiple scientific databases to identify observational cohort studies published between January 2010 and March 2017 that described second- or third-line treatment patterns and clinical outcomes in patients with advanced NSCLC. A qualitative data synthesis was performed because a meta-analysis was not possible due to the heterogeneity of the study populations. A total of 12 different study cohorts in 15 articles were identified. In these cohorts, single-agent chemotherapy was the most commonly administered treatment in both the second- and third-line settings. In the 5 studies that described survival from the time of second-line treatment initiation, median overall survival ranged from 4.6 months (95% CI, 3.8–5.7) to 12.8 months (95% CI, 10.7–14.5). There was limited information on the use of biomarker-directed therapy in these patient populations. This systematic literature review offers insights into the adoption of novel therapies into routine clinical practice for second- and third-line treatment of patients with advanced NSCLC. This information provides a valuable real-world context for the impact of recently approved treatments for advanced NSCLC.

Variation in Intensity and Costs of Care by Payer and Race for Patients Dying of Cancer in Texas: An Analysis of Registry-linked Medicaid, Medicare, and Dually Eligible Claims Data

PURPOSE

To investigate end-of-life care for Medicaid, Medicare, and dually eligible beneficiaries dying of cancer in Texas.

METHODS

We analyzed the Texas Cancer Registry (TCR)-Medicaid and TCR-Medicare linked databases' claims data for 69,572 patients dying of cancer in Texas from 2000 to 2008. We conducted regression models in adjusted analyses of cancer-directed and acute care and total costs of care (in 2014 dollars) in the last 30 days of life.

RESULTS

Medicaid patients were more likely to receive chemotherapy and radiation therapy. Medicaid patients were more likely to have >1 emergency room (ER) [odds ratio (OR)=5.27; 95% confidence interval (CI), 4.76-5.84], and were less likely to enroll in hospice (OR=0.59; 95% CI, 0.55-0.63) than Medicare patients. Dual eligibles were more likely to have >1 ER visit than Medicare-only beneficiaries (OR=1.19; 95% CI, 1.07-1.33). Black and Hispanic patients were more likely to experience >1 ER visit and >1 hospitalization than whites. Costs were higher for nonwhite Medicare, Medicaid, and dually eligible patients compared with white Medicare enrollees.

CONCLUSIONS

Variation in acute care utilization and costs by race and payer suggest efforts are needed to address palliative care coordination at the end of life for Medicaid and dually eligible beneficiaries and minority patients dying of cancer.

Non-small cell lung cancer treatment receipt and survival among African-Americans and whites in a rural area

Data on racial disparities among lung cancer patients in rural areas are scarce. We examined differences in treatment receipt and survival among African-American (AA) and Non-Hispanic White (NHW) non-small cell lung cancer (NSCLC) patients residing in Southwest Georgia (SWGA)-a primarily rural 33-county area; population 700,000. Medical records for 934 SWGA NSCLC patients diagnosed in 2001-2003 were used to extract information on age, race, marital status, insurance coverage, comorbidities, and treatment. Information pertaining to socioeconomic status, urban/rural residence, and survival was obtained from the cancer registry. Multivariable logistic regression analyses examined the relation of various patient and disease characteristics to receipt of tumor-directed therapy. Cox regression models were used to assess determinants of survival. Treatment receipt was associated with age, marital status, comorbidities, and disease stage in most analyses. No associations were observed between race and either surgery [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.49-1.39] or radiation (OR 0.72; 95% CI 0.52-1.00). NHW patients were more likely to receive no treatment at all (OR 1.50, 95% CI 1.01-2.23). There was no racial difference in survival (hazard ratio = 1.07, 95% CI 0.90-1.26). Effects of insurance and treatment on survival were most pronounced within 6 months post-diagnosis, but were attenuated over time. We found no evidence of racial disparities in survival and, in some analyses, a decreased likelihood of treatment receipt among NHW NSCLC patients compared to AA. The results from SWGA stand in contrast to studies that applied different methodologies and were conducted elsewhere.

Guideline-concordant lung cancer care and associated health outcomes among elderly patients in the United States

OBJECTIVES

In the United States (US), the elderly carry a disproportionate burden of lung cancer. Although evidence-based guidelines for lung cancer care have been published, lack of high quality care still remains a concern among the elderly. This study comprehensively evaluates the variations in guideline-concordant lung cancer care among elderly in the US.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2002-2007), we identified elderly patients (aged ≥65 years) with lung cancer (n = 42,323) and categorized them by receipt of guideline-concordant care, using evidence-based guidelines from the American College of Chest Physicians. A hierarchical generalized logistic model was constructed to identify variables associated with receipt of guideline-concordant care. Kaplan-Meier analysis and Log Rank test were used for estimation and comparison of the three-year survival. Multivariate Cox proportional hazards model was constructed to estimate lung cancer mortality risk associated with receipt of guideline-discordant care.

RESULTS

Only less than half of all patients (44.7%) received guideline-concordant care in the study population. The likelihood of receiving guideline-concordant care significantly decreased with increasing age, non-white race, higher comorbidity score, and lower income. Three-year median survival time significantly increased (exceeded 487 days) in patients receiving guideline-concordant care. Adjusted lung cancer mortality risk significantly increased by 91% (HR = 1.91, 95% CI: 1.82-2.00) among patients receiving guideline-discordant care.

CONCLUSION

This study highlights the critical need to address disparities in receipt of guideline-concordant lung cancer care among elderly. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern.

A Multi-institutional Analysis of Insurance Status as a Predictor of Morbidity Following Breast Reconstruction

Background:

Although recent literature suggests that patients with Medicaid and Medicare are more likely than those with private insurance to experience complications following a variety of procedures, there has been limited evaluation of insurance-based disparities in reconstructive surgery outcomes. Using a large, multi-institutional database, we sought to evaluate the potential impact of insurance status on complications following breast reconstruction.

Methods:

We identified all breast reconstructive cases in the 2008 to 2011 Tracking Operations and Outcomes for Plastic Surgeons clinical registry. Propensity scores were calculated for each case, and insurance cohorts were matched with regard to demographic and clinical characteristics. Outcomes of interest included 15 medical and 13 surgical complications.

Results:

Propensity-score matching yielded 493 matched patients for evaluation of Medicaid and 670 matched patients for evaluation of Medicare. Overall complication rates did not significantly differ between patients with Medicaid or Medicare and those with private insurance (P = 0.167 and P = 0.861, respectively). Risk-adjusted multivariate regressions corroborated this finding, demonstrating that Medicaid and Medicare insurance status does not independently predict surgical site infection, seroma, hematoma, explantation, or wound dehiscence (all P > 0.05). Medicaid insurance status significantly predicted flap failure (odds ratio = 3.315, P = 0.027).

Conclusions:

This study is the first to investigate the differential effects of payer status on outcomes following breast reconstruction. Our results suggest that Medicaid and Medicare insurance status does not independently predict increased overall complication rates following breast reconstruction. This finding underscores the commitment of the plastic surgery community to providing consistent care for patients, irrespective of insurance status.

Patient preference and contraindications in measuring quality of care: what do administrative data miss?

PURPOSE

Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy.

PATIENTS AND METHODS

Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment.

RESULTS

Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments.

CONCLUSION

Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.

Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation

BACKGROUND

To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans.

METHODS

Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR.

RESULTS

In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P < .01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73).

CONCLUSIONS

After the enactment of policy designed to improve access to IBR, Medicaid and Medicare patients experienced the greatest relative increase in rates of IBR. Although policy changes had the most impact on traditionally underserved populations, disparities still exist. Future studies should endeavor to understand why such disparities have persisted.

Effect of insurance status on the surgical treatment of early-stage non-small cell lung cancer

BACKGROUND

Social disparities permeate non-small cell lung cancer (NSCLC) treatment, yet little is known about the effect of insurance status on the delivery of guideline surgical treatment for early-stage (I or II) NSCLC.

METHODS

We used the California Cancer Registry (1996 through 2008) to identify patients 50 to 94 years old with early-stage NSCLC. We used logistic regression models to assess whether or not insurance status (private insurance, Medicare, Medicaid, no insurance, and unknown) had an effect on whether or not a lobectomy (or bilobectomy) is performed.

RESULTS

A total of 10,854 patients met our inclusion criteria. Compared with patients with private insurance, we found that patients with Medicare (adjusted odds ratio [aOR] 0.87; 95% confidence interval [CI]: 0.79 to 0.95), Medicaid (aOR 0.45; 95% CI: 0.36 to 0.57), or no insurance (aOR 0.45; 95% CI: 0.29 to 0.70) were significantly less likely to undergo lobectomy, even after adjusting for patient factors (age, race, and gender) and tumor characteristics (histology and tumor size). Increasing age, African American race, squamous cell carcinoma, and increasing tumor size were significant independent negative predictors of whether or not a lobectomy was performed.

CONCLUSIONS

Patients without private insurance were significantly less likely than patients with private insurance to undergo a lobectomy for early-stage NSCLC. The variables(s) contributing to this disparity have yet to be elucidated.

Cancer Treatment for Dual Eligibles: What Are the Costs and Who Pays?

This study quantifies treatment costs for melanoma and breast, cervical, colorectal, lung, and prostate cancer among patients with dual Medicare and Medicaid eligibility. The analyses use merged Medicare and Medicaid Analytic eXtract enrollment and claims data for dually eligible beneficiaries age>18 in Georgia, Illinois, Louisiana, and Maine in 2003 (n=892,001). We applied ordinary least squares regression analysis to estimate annual expenditures attributable to each cancer after controlling for beneficiaries' age, race/ethnicity, sex, and comorbid conditions, and state fixed effects. Cancers and comorbid conditions were identified on the basis of diagnosis codes on insurance claims. The most prevalent cancers were prostate (38.4 per 1,000 men) and breast (30.7 per 1,000 women). Dual eligibles with the study cancers had higher rates of other chronic conditions such as hypertension and arthritis than other beneficiaries. Total Medicare and Medicaid expenditures for dual eligibles with the study cancers ranged from $30,328 for those with lung cancer to $17,011 for those with breast cancer, compared with $10,664 for beneficiaries without the cancers. However, only 9% to 30% of medical expenditures for dual eligibles with the study cancers were attributable to the cancer itself. In 2003, combined Medicare/Medicaid spending for dual eligibles attributable to the six cancers in the four study states exceeded $256 million ($314 million in 2012 dollars). Dual eligibles with these cancers also had high rates of other medical conditions. These comorbidities should be recognized, both in documenting cancer treatment costs and in developing programs and policies that promote timely cancer diagnosis and treatment.

Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis

BACKGROUND

Intervention-generated inequalities are unintended variations in outcome that result from the organisation and delivery of health interventions. Socioeconomic inequalities in treatment may occur for some common cancers. Although the incidence and outcome of lung cancer varies with socioeconomic position (SEP), it is not known whether socioeconomic inequalities in treatment occur and how these might affect mortality. We conducted a systematic review and meta-analysis of existing research on socioeconomic inequalities in receipt of treatment for lung cancer.

METHODS AND FINDINGS

MEDLINE, EMBASE, and Scopus were searched up to September 2012 for cohort studies of participants with a primary diagnosis of lung cancer (ICD10 C33 or C34), where the outcome was receipt of treatment (rates or odds of receiving treatment) and where the outcome was reported by a measure of SEP. Forty-six papers met the inclusion criteria, and 23 of these papers were included in meta-analysis. Socioeconomic inequalities in receipt of lung cancer treatment were observed. Lower SEP was associated with a reduced likelihood of receiving any treatment (odds ratio [OR] = 0.79 [95% CI 0.73 to 0.86], p<0.001), surgery (OR = 0.68 [CI 0.63 to 0.75], p<0.001) and chemotherapy (OR = 0.82 [95% CI 0.72 to 0.93], p = 0.003), but not radiotherapy (OR = 0.99 [95% CI 0.86 to 1.14], p = 0.89), for lung cancer. The association remained when stage was taken into account for receipt of surgery, and was found in both universal and non-universal health care systems.

CONCLUSIONS

Patients with lung cancer living in more socioeconomically deprived circumstances are less likely to receive any type of treatment, surgery, and chemotherapy. These inequalities cannot be accounted for by socioeconomic differences in stage at presentation or by differences in health care system. Further investigation is required to determine the patient, tumour, clinician, and system factors that may contribute to socioeconomic inequalities in receipt of lung cancer treatment.

Cancer outcomes in low-income elders: is there an advantage to being on Medicaid?

BACKGROUND

Because of reduced financial barriers, dual Medicare-Medicaid enrollment of low-income Medicare beneficiaries may be associated with receipt of definitive cancer treatment and favorable survival outcomes.

METHODS

We used a database developed by linking records from the Ohio Cancer Incidence Surveillance System with Medicare and Medicaid files, death certificates, and U.S. Census data. The study population included community-dwelling Medicare fee-for-service beneficiaries, age 66 years or older, with low incomes, residing in Ohio, and diagnosed with incident loco-regional breast (n=838), colorectal (n=784), or prostate cancer (n=946) in years 1997-2001. We identified as "duals" Medicare beneficiaries who were enrolled in Medicaid at least three months prior to cancer diagnosis. Multivariable logistic regression and survival models were developed to analyze the association between dual status and (1) receipt of definitive treatment; and (2) overall and disease-specific survival, after adjusting for tumor stage and patient covariates.

RESULTS

DUAL STATUS WAS ASSOCIATED WITH A SIGNIFICANTLY LOWER LIKELIHOOD TO RECEIVE DEFINITIVE TREATMENT AMONG COLORECTAL CANCER PATIENTS (ADJUSTED ODDS RATIO: 0.60, 95% Confidence Interval, or CI, [0.38, 0.95]), but not among breast or prostate cancer patients. Furthermore, dual status was associated with decreased overall survival among prostate cancer patients (Adjusted Hazard Ratio, or AHR, 1.45, 95% CI [1.05, 2.02]), and decreased disease-specific survival among colorectal cancer patients (AHR: 1.52 [1.05, 2.19]).

CONCLUSION

Enrollment of low-income Medicare beneficiaries in Medicaid is not associated with favorable treatment patterns or survival outcomes. Differences in health and functional status between community-dwelling duals and non-duals might help explain the observed disparities.

Analysis of Florida and New York state hospital discharges suggests that carotid stenting in symptomatic women is associated with significant increase in mortality and perioperative morbidity compared with carotid endarterectomy

BACKGROUND

Although large randomized studies have established the efficacy and safety of carotid endarterectomy (CEA) and, recently, carotid artery stenting (CAS), the under-representation of women in these trials leaves the comparison of risks to benefits of performing these procedures on women an open question. To address this issue, we reviewed the hospital outcomes and delineated patient characteristics predicting outcome in women undergoing carotid interventions using New York and Florida statewide hospital discharge databases.

METHODS

We analyzed in-hospital mortality, postoperative stroke, cardiac postoperative complications, and combined postoperative stoke and mortality in 20,613 CEA or CAS hospitalizations for the years 2007 to 2009. Univariate and multiple logistic regression analyses of variables were performed.

RESULTS

CEA was performed in 16,576 asymptomatic and 1744 symptomatic women and CAS in 1943 asymptomatic and 350 symptomatic women. Compared with CAS, CEA rates, in asymptomatic vs symptomatic, were significantly lower for in-hospital mortality (0.3% vs 0.8% and 0.4% vs 3.4%), stroke (1.5% vs 2.6% and 3.5% vs 9.4%), and combined stroke/mortality (1.7% vs 3.1% and 3.8% vs 10.9%). In cohorts matched by propensity scores, the same trend favoring CEA remained significant in symptomatic women. There was no difference in cardiac complication rates among asymptomatic women, but among symptomatic woman cardiac complications were more frequent after CAS (10.6% vs 6.5%; P = .0077). Among symptomatic women, the presence of renal disease, coronary artery disease, or age ≥80 years increased the risk of CAS over CEA threefold for the composite end point of stroke or death. For asymptomatic women only in those with coronary artery disease or diabetes, there was a statistical difference in the composite mortality/stroke rates favoring CEA (1.9% vs 3.3% and 1.7% vs 3.4%, respectively). After adjusting for relevant clinical and demographic risk factors and hospital annual volume, for CAS vs CEA, the risk of the composite end point of stroke or mortality was 1.7-fold higher in symptomatic and 3.4-fold higher in asymptomatic patients. Medicaid insurance, symptomatic patient, history of cancer, and presence of heart failure on admission were among other strong predictors of composite stroke/mortality outcome.

CONCLUSIONS

Databases reflecting real-world practice performance and management of carotid disease in women suggest that CEA compared with CAS has overall better perioperative outcomes in women. Importantly, CAS is associated with significantly higher morbidity in certain clinical settings and this should be taken into account when choosing a revascularization procedure.

An official American Thoracic Society systematic review: insurance status and disparities in lung cancer practices and outcomes

RATIONALE

Insurance coverage is an important determinant of access to care and is one potential cause of disparities in lung cancer care outcomes.

OBJECTIVES

We performed a systematic review of the available literature to examine the association between insurance status and lung cancer practices and outcomes.

METHODS

We searched multiple electronic databases through November 6, 2008 for studies that examined the association between lung cancer outcomes and insurance status. Two reviewers independently selected studies. One investigator evaluated their quality according to predetermined criteria, and abstracted data about study design, patients' demographic and clinical characteristics, and outcome measures.

MEASUREMENTS AND MAIN RESULTS

Of 3,798 potentially relevant studies, 23 met eligibility criteria and were included. Studies reported heterogeneous outcomes among heterogeneous samples of patients that precluded a quantitative synthesis. In general, compared with patients with private or Medicare insurance, patients with Medicaid or no insurance had poorer lung cancer outcomes, including higher incidence rates, later stage at diagnosis, and poorer survival. Overall, patients with Medicaid or no insurance were less likely to undergo curative procedures, but patients without insurance were more likely to receive guideline-concordant care.

CONCLUSIONS

Patients with Medicaid or no insurance consistently had worse outcomes than other patients with lung cancer. Some of the disparities may be secondary to residual confounding from smoking and other health behaviors, but available data suggest that patients with lung cancer without insurance do poorly because access to care is limited and/or they present with more advanced disease that is less amenable to treatment.

Using claims-based measures to predict performance status score in patients with lung cancer

BACKGROUND

Performance status (PS) is a good prognostic factor in lung cancer and is used to assess chemotherapy appropriateness. Researchers studying chemotherapy use are often hindered by the unavailability of PS in automated data sources. To the authors' knowledge, no attempts have been made to estimate PS using claims-based measures. The current study explored the ability to estimate PS using routinely available measures.

METHODS

A cohort of insured patients aged ≥50 years who were diagnosed with American Joint Committee on Cancer stage II through IV lung cancer between 2000 and 2007 was identified via a tumor registry (n = 552). PS was abstracted from medical records. Automated medical and pharmaceutical claims from the year preceding diagnosis were linked to tumor registry data. A logistic regression model was fit to estimate good versus poor PS in a random half of the sample. C statistics, sensitivity, specificity, and R2 were used to compare the predictive ability of models that included demographic factors, comorbidity measures, and claims-based utilization variables. Model fit was evaluated in the other half of the sample.

RESULTS

PS was available in 80% of medical records. The multivariable regression model predicted good PS with high sensitivity (0.88 or 0.94 depending on how good PS was defined), but moderate specificity (0.45 or 0.32) with a 0.50 prediction cutoff, and good sensitivity (0.64 or 0.83) and specificity (0.69 or 0.55) when the cutoff was 0.70. The goodness-of-fit c statistic was 0.76 or 0.78.

CONCLUSIONS

PS can be estimated, with some accuracy, using claims-based measures. Emphasis should be placed on documenting PS in medical records and tumor registries.

Looking beyond surveillance, epidemiology, and end results: patterns of chemotherapy administration for advanced non-small cell lung cancer in a contemporary, diverse population

INTRODUCTION

Chemotherapy prolongs survival without substantially impairing quality of life for medically fit patients with advanced non-small cell lung cancer (NSCLC), but population-based studies have shown that only 20 to 30% of these patients receive chemotherapy. These earlier studies have relied on Medicare-linked Surveillance, Epidemiology, and End Results (SEER) data, thus excluding the 30 to 35% of lung cancer patients younger than 65 years. Therefore, we determined the use of chemotherapy in a contemporary, diverse NSCLC population encompassing all patient ages.

METHODS

We performed a retrospective analysis of patients diagnosed with stage IV NSCLC from 2000 to 2007 at the University of Texas Southwestern Medical Center. Demographic, treatment, and outcome data were obtained from hospital tumor registries. The association between these variables was assessed using univariate analysis and multivariate logistic regression.

RESULTS

In all, 718 patients met criteria for analysis. Mean age was 60 years, 58% were men, and 45% were white. Three hundred fifty-three patients (49%) received chemotherapy. In univariate analysis, receipt of chemotherapy was associated with age (53% of patients younger than 65 years versus 41% of patients aged 65 years and older; p = 0.003) and insurance type (p < 0.001). In a multivariate model, age and insurance type remained associated with receipt of chemotherapy. For individuals receiving chemotherapy, median survival was 9.2 months, compared with 2.3 months for untreated patients (p < 0.001).

CONCLUSIONS

In a contemporary population representing the full age range of patients with advanced NSCLC, chemotherapy was administered to approximately half of all patients-more than twice the rate reported in some earlier studies. Patient age and insurance type are associated with receipt of chemotherapy.

Treatment disparities following the diagnosis of an astrocytoma

Post-operative radiation and chemotherapy following diagnosis of astrocytoma are standard care. No research has examined racial or insurance-based disparities in treatment receipt. The purpose of this study was to evaluate whether African Americans and patients with dual eligibility in Medicare and Medicaid (DE), compared to Caucasians and patients with Medicare alone, experienced differences in (1) seeing a radiation oncologist, (2) receiving radiation or chemotherapy, and (3) overall survival. Using a retrospective descriptive design, statewide Medicaid and Medicare data were merged with the Michigan Tumor Registry to extract a sample of patients (n = 604) ≥ 65 years old with a first primary astrocytoma diagnosis in Michigan between 1996 and 2000. There were no racial or insurance-based differences in reporting a claim for a radiation oncologist. Controlling for age, income, surgical intervention, residence population, comorbidities, gender, and stage, African Americans were less likely to report radiation claims than Caucasians (OR = 0.20; 95% CI = 0.07-0.54). DE patients were less likely to report radiation claims (OR = 0.50; 95% CI = 0.26-0.94) than those with Medicare only. These differences were not seen with chemotherapy. When only those with a glioblastoma multiforme were examined, DE patients (OR = 0.47; 95% CI = 0.24-0.92) and African Americans (OR = 0.13; 95% CI = 0.04-0.44) were much less likely to report radiation claims. Race and insurance status did not significantly affect survival, although income did. Data suggest disparities in race and insurance status may exist in receiving standard of care for astrocytomas. Further research is warranted to replicate the data and determine potential sources for these disparities.

Racial differences in the perception of lung cancer: the 2005 Health Information National Trends Survey

BACKGROUND

Racial disparities in lung cancer have been described well in the literature; however, little is known about perceptions of lung cancer in the general population and whether these perceptions differ by race.

METHODS

Data were obtained from the 2005 Health Information National Trends Survey (HINTS) survey. The authors used a sample design of random digit dialing of listed telephone exchanges in the United States. Complete interviews were conducted with 5491 adults, including 1872 respondents who were assigned to receive questions pertaining to lung cancer. All analyses were conducted on this subset of respondents. A statistical software program was used to calculate chi-square tests and to perform logistic regression analyses that would model racial differences in perceptions of lung cancer. All estimates were weighted to be nationally representative of the US population; a jack-knife weighting method was used for parameter estimation.

RESULTS

Black patients and white patients shared many of the same beliefs about lung cancer mortality, and etiology. African Americans were more likely than whites 1) to agree that it is hard to follow recommendations about preventing lung cancer (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.19-3.53), 2) to avoid an evaluation for lung cancer for fear that they have the disease (OR, 3.32; 95% CI, 1.84-5.98), and 3) to believe that patients with lung cancer would have pain or other symptoms before diagnosis (OR, 2.20; 95% CI, 1.27-3.79).

CONCLUSIONS

African Americans were more likely to hold beliefs about lung cancer that could interfere with prevention and treatment.

Inadequate access to surgeons: reason for disparate cancer care?

OBJECTIVE

To compare the likelihood of seeing a surgeon between elderly dually eligible non-small-cell lung cancer (NSCLC) and colon cancer patients and their Medicare counterparts. Surgery rates between dually eligible and Medicare patients who were evaluated by a surgeon were also assessed.

METHODS

We used statewide Medicaid and Medicare data merged with the Michigan Tumor Registry to extract a sample of patients with a first primary NSCLC (n = 1100) or colon cancer (n = 2086). The study period was from January 1, 1997 to December 31, 2000. We assessed the likelihood of a surgical evaluation using logistic models that included patient characteristics, tumor stage, and census tracts. Among patients evaluated by a surgeon, we used logistic regression to predict if a resection was performed.

RESULTS

Dually eligible patients were nearly half as likely to be evaluated by a surgeon as Medicare patients (odds ratio [OR] = 0.49; 95% confidence interval = 0.32, 0.77 and odds ratio = 0.59; 95% confidence interval = 0.41, 0.86 for NSCLC and colon cancer patients, respectively). Among patients who were evaluated by a surgeon, the likelihood of resection was not statistically significantly different between dually eligible and Medicare patients.

CONCLUSIONS

This study suggests that dually eligible patients, in spite of having Medicaid insurance, are less likely to be evaluated by a surgeon relative to their Medicare counterparts. Policies and interventions aimed toward increasing access to specialists and complete diagnostic work-ups (eg, colonoscopy, bronchoscopy) are needed.