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Sabik LM, Eom KY, Dahman B, Li J, van Londen GJ, Bradley CJ. Breast Cancer Treatment Following Health Reform: Evidence From Massachusetts. Med Care Res Rev 2021; 79:371-381. [PMID: 34467806 DOI: 10.1177/10775587211042532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are well-documented differences in breast cancer treatment by insurance status. Insurance expansions provide a context to assess the relationship between insurance and patterns of breast cancer care. We examine the association of Massachusetts health reform with use of breast conserving surgery, reconstruction, and adjuvant radiation using data from the Massachusetts Cancer Registry and Surveillance Epidemiology and End Results registries for 2001-2013 and a difference-in-differences approach. We observe statistically significant increases in breast conserving surgery among nonelderly women in Massachusetts relative to trends in states and age groups not affected by health reform. We also observe relative increases in reconstruction and adjuvant radiation, though trends in these outcomes were not the same across states prior to reform, limiting our ability to draw conclusions about the relationship between reform and these outcomes. Our results suggest that health reform was associated with some improvements in breast cancer treatment.
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Affiliation(s)
| | | | | | - Jie Li
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Cathy J Bradley
- University of Colorado Comprehensive Cancer Center, Aurora, CO, USA
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Unger JM, Blanke CD, LeBlanc M, Barlow WE, Vaidya R, Ramsey SD, Hershman DL. Association of Patient Demographic Characteristics and Insurance Status With Survival in Cancer Randomized Clinical Trials With Positive Findings. JAMA Netw Open 2020; 3:e203842. [PMID: 32352530 PMCID: PMC7193331 DOI: 10.1001/jamanetworkopen.2020.3842] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Few new treatments tested in phase 3 cancer randomized clinical trials show an overall survival benefit. Although understanding whether the benefits are consistent among all patient groups is critical for informing guideline care, individual trials are designed to assess the benefits of experimental treatments among all patients and are too small to reliably determine whether treatment benefits apply to demographic or insurance subgroups. OBJECTIVE To systematically examine whether positive treatment effects in cancer randomized clinical trials apply to specific demographic or insurance subgroups. DESIGN, SETTING, AND PARTICIPANTS Cohort study of pooled patient-level data from 10 804 patients in SWOG Cancer Research Network clinical treatment trials reported from 1985 onward with superior overall survival for those receiving experimental treatment. Patients were enrolled from 1984 to 2012. Maximum follow-up was 5 years. MAIN OUTCOMES AND MEASURES Interaction tests were used to assess whether hazard ratios (HRs) for death comparing standard group vs experimental group treatments were associated with age (≥65 vs <65 years), race/ethnicity (minority vs nonminority populations), sex, or insurance status among patients younger than 65 years (Medicaid or no insurance vs private insurance) in multivariable Cox regression frailty models. Progression- or relapse-free survival was also examined. Data analyses were conducted from August 2019 to February 2020. RESULTS In total, 19 trials including 10 804 patients were identified that reported superior overall survival for patients randomized to experimental treatment. Patients were predominantly younger than 65 years (67.3%) and female (66.3%); 11.4% were black patients, and 5.7% were Hispanic patients. There was evidence of added survival benefits associated with receipt of experimental therapy for all groups except for patients with Medicaid or no insurance (HR, 1.23; 95% CI, 0.97-1.56; P = .09) compared with those with private insurance (HR, 1.66; 95% CI, 1.44-1.92; P < .001; P = .03 for interaction). Receipt of experimental treatment was associated with reduced added overall survival benefits in patients 65 years or older (HR, 1.21; 95% CI, 1.11-1.32; P < .001) compared with patients younger than 65 years (HR, 1.41; 95% CI, 1.30-1.53; P < .001; P = .01 for interaction), although both older and younger patients appeared to strongly benefit from receipt of experimental treatment. The progression- or relapse-free survival HRs did not differ by age, sex, or race/ethnicity but differed between patients with Medicaid or no insurance (HR, 1.32; 95% CI, 1.06-1.64; P = .01) vs private insurance (HR, 1.74; 95% CI, 1.54-1.97; P < .001; P = .03 for interaction). CONCLUSIONS AND RELEVANCE Patients with Medicaid or no insurance may have smaller added benefits from experimental therapies compared with standard treatments in clinical trials. A better understanding of the quality of survivorship care that patients with suboptimal insurance receive, including supportive care and posttreatment care, could help establish how external factors may affect outcomes for these patients.
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Affiliation(s)
- Joseph M. Unger
- SWOG Cancer Research Network Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Charles D. Blanke
- SWOG Cancer Research Network Group Chair’s Office, Knight Cancer Institute, Oregon Health & Science University, Portland
| | - Michael LeBlanc
- SWOG Cancer Research Network Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - William E. Barlow
- SWOG Cancer Research Network Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Riha Vaidya
- SWOG Cancer Research Network Statistics and Data Management Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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Guidolin K, Lock M, Vogt K, McClure JA, Winick-Ng J, Vinden C, Brackstone M. Appropriate treatment receipt after breast-conserving surgery. ACTA ACUST UNITED AC 2019; 25:e545-e552. [PMID: 30607122 DOI: 10.3747/co.25.4117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Breast-conserving surgery (bcs) and radiation therapy (rt) are the standard of care for early breast cancer, although some women receive ipsilateral mastectomy or adjuvant tamoxifen, both of which can be appropriate alternatives to rt. Objectives of the present study were to determine the proportion of women who are treated appropriately after bcs and to identify factors associated with non-receipt of rt. Methods This retrospective cohort study used Ontario data linked at the Institute for Clinical and Evaluative Sciences to examine 33,718 patients who received bcs during 2004-2010. Primary outcome was rt receipt. The ipsilateral mastectomy rate and patient, surgeon, and setting variables were measured. Results Of the study patients, 86.1% received either rt or completion mastectomy; in the cohort less than 70 years of age, 90.8% received rt or completion mastectomy. Among patients less than 70 years of age, 3 risk factors for non-receipt of rt were identified: age less than 46 years, treatment in a non-academic institution, and earlier year of initial bcs. Additionally, in the overall cohort, rt non-receipt was associated with high comorbidity, more than 40 km to the cancer centre, income quintile, and breast care specialization. Conclusions In Ontario, 90.8% of patients less than 70 years of age are appropriately treated for early breast cancer; approximately 1 in 10 do not receive rt or completion mastectomy. Based on those findings, women less than 46 years of age might be at increased risk of recurrence and death because of incomplete treatment. It also appears that academic centres more effectively treat breast cancer; however, breast cancer care appears to be improving over time in Ontario.
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Affiliation(s)
- K Guidolin
- Department of Surgery, University of Toronto, Toronto
| | - M Lock
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London
| | - K Vogt
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London
| | - J A McClure
- Institute for Clinical Evaluative Sciences, London, ON
| | - J Winick-Ng
- Institute for Clinical Evaluative Sciences, London, ON
| | - C Vinden
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London.,Institute for Clinical Evaluative Sciences, London, ON
| | - M Brackstone
- Schulich School of Medicine and Dentistry, Western University, London.,London Health Sciences Centre, London
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Guidolin K, Lock M, Richard L, Boldt G, Brackstone M. Predicting which patients actually receive radiation following breast conserving therapy in Canadian populations. Can J Surg 2017; 59:358-60. [PMID: 27438052 DOI: 10.1503/cjs.000516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
SUMMARY Canadian women with breast cancer may choose breast conserving therapy as their course of treatment, requiring both breast conserving surgery and adjuvant radiation therapy. However, more than 15% of Canadian women fail to receive the appropriate radiation therapy, putting them at increased risk for recurrence. Age, distance from their radiation therapy centre and stage of disease affect patients' likelihood of receiving prescribed radiation therapy. We propose a nomogram that allows physicians to predict which patients will and will not receive radiation. This nomogram, once validated, could be used to guide decision making when choosing between breast conserving therapy and mastectomy as the treatment course and thereby change the practice of breast cancer management.
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Affiliation(s)
- Keegan Guidolin
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (Guidolin, Lock, Brackstone); and the London Health Sciences Centre, London, Ont. (Lock, Richard, Boldt, Brackstone)
| | - Michael Lock
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (Guidolin, Lock, Brackstone); and the London Health Sciences Centre, London, Ont. (Lock, Richard, Boldt, Brackstone)
| | - Lucie Richard
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (Guidolin, Lock, Brackstone); and the London Health Sciences Centre, London, Ont. (Lock, Richard, Boldt, Brackstone)
| | - Gabriel Boldt
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (Guidolin, Lock, Brackstone); and the London Health Sciences Centre, London, Ont. (Lock, Richard, Boldt, Brackstone)
| | - Muriel Brackstone
- From the Schulich School of Medicine & Dentistry, Western University, London, Ont. (Guidolin, Lock, Brackstone); and the London Health Sciences Centre, London, Ont. (Lock, Richard, Boldt, Brackstone)
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Meyer AM, Olshan AF, Green L, Meyer A, Wheeler SB, Basch E, Carpenter WR. Big data for population-based cancer research: the integrated cancer information and surveillance system. N C Med J 2014; 75:265-9. [PMID: 25046092 DOI: 10.18043/ncm.75.4.265] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Integrated Cancer Information and Surveillance System (ICISS) facilitates population-based cancer research by developing extensive information technology systems that can link and manage large data sets. Taking an interdisciplinary 'team science' approach, ICISS has developed data, systems, and methods that allow researchers to better leverage the power of big data to improve population health.
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Affiliation(s)
- Anne-Marie Meyer
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill; Integrated Cancer Information and Surveillance System (ICISS), Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Andrew F Olshan
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura Green
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adrian Meyer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ethan Basch
- Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William R Carpenter
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill; Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Meyer AM, Reeder-Hayes KE, Liu H, Wheeler SB, Penn D, Weiner BJ, Carpenter WR. Differential receipt of sentinel lymph node biopsy within practice-based research networks. Med Care 2013; 51:812-8. [PMID: 23942221 PMCID: PMC4080805 DOI: 10.1097/mlr.0b013e31829c8ca4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Practice-based research networks (PBRNs) are promising for accelerating not only research, but also dissemination of research-based evidence into broader community practice. Sentinel lymph node biopsy (SLNB) is an innovation in breast cancer care associated with equivalent survival and lower morbidity, as compared with standard axillary lymph node dissection. We examined the diffusion of SLNB into practice and whether affiliation with the Community Clinical Oncology Program (CCOP), a cancer-focused PBRN, was associated with more rapid uptake of SLNB. RESEARCH DESIGN Surveillance Epidemiology and End Results-Medicare data were used to study women diagnosed with stage I or II breast cancer in the years 2000-2005 and undergoing breast-conserving surgery with axillary staging (n=6226). The primary outcome was undergoing SLNB. CCOP affiliation of the surgical physician was ascertained from NCI records. Multivariable generalized linear modeling with generalized estimating equations was used to measure association between CCOP exposure and undergoing SLNB, controlling for potential confounders. RESULTS Women treated by a CCOP physician had significantly higher odds of receiving SLNB compared with women treated by a non-CCOP physician (OR 2.68; 95% CI, 1.35-5.34). The magnitude of this association was larger than that observed among patients treated by physicians operating in medical school-affiliated hospitals (OR 1.76; 95% CI, 1.30-2.39). CONCLUSIONS Women treated by CCOP-affiliated physicians were more likely to undergo SLNB irrespective of the hospital's medical school affiliation, suggesting that the CCOP PBRN may play a role in the rapid adoption of research-based innovation in community practice.
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Affiliation(s)
- Anne-Marie Meyer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599-7293, USA.
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Is medical home enrollment associated with receipt of guideline-concordant follow-up care among low-income breast cancer survivors? Med Care 2013; 51:494-502. [PMID: 23673393 DOI: 10.1097/mlr.0b013e31828d4d0c] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Community Care of North Carolina (CCNC) initiated an innovative medical home program in the 1990 s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes but has not been evaluated in the context of cancer care. We explored whether CCNC enrollment was associated with guideline-concordant follow-up care among breast cancer survivors. METHODS Using state cancer registry records matched to Medicaid claims, we identified women 18 to 64 years old who were diagnosed with stage 0, I, II, or unstaged breast cancer from 2003 to 2007 and tracked their monthly CCNC enrollment. Using published American Society for Clinical Oncology guidelines to define our outcomes, we employed multivariate logistic regressions to examine, as a function of CCNC enrollment, receipt of mammogram and at least 2 physical examinations/history-taking visits within observational windows consistent with the guidelines. RESULTS Of the 840 women, approximately half were enrolled into the CCNC for some time during the study period. Between 40% and 85% received follow-up mammogram in accordance with guidelines, with significant variation by CCNC status, and 95% of women received at least 2 physical examinations/history-taking visits. In multivariate models, increasing months of CCNC enrollment was significantly positively associated with receipt of follow-up mammogram but not with physical examinations/history-taking visits. CONCLUSIONS Results suggest that CCNC enrollment is associated with guideline-concordant follow-up care for Medicaid-insured survivors. Given the growing population of cancer survivors and increased emphasis on primary care medical homes, future studies should explore what factors are associated with medical home participation and whether similar findings are observed with extended follow-up.
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Krotneva S, Reidel K, Nassif M, Trabulsi N, Mayo N, Tamblyn R, Meguerditchian AN. Rates and predictors of consideration for adjuvant radiotherapy among high-risk breast cancer patients: a cohort study. Breast Cancer Res Treat 2013; 140:397-405. [PMID: 23881523 PMCID: PMC3732766 DOI: 10.1007/s10549-013-2636-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/08/2013] [Indexed: 11/28/2022]
Abstract
Radiotherapy (RT) after breast conserving surgery (BCS) represents the standard for local control of breast cancer (BC). However, variations in practice persist. We aimed to characterize the rate of RT consideration (or referral) after BCS and identify predictors in Quebec, Canada, where universal health insurance is in place. A historical prospective cohort study using the provincial hospital discharge and medical services databases was conducted. All women with incident, non-metastatic BC (stages I–III) undergoing BCS (1998–2005) were identified. Odds ratios (ORs) and 95 % confidence intervals (CIs) for RT consideration were estimated with a generalized estimating equations regression model, adjusting for clustering of patients within physicians. Of the 27,483 women selected, 90 % were considered for RT and 84 % subsequently received it. Relative to women 50–69 years old, younger and older women were less likely to be considered: ORs of 0.82 (95 % CI 0.73–0.93) and 0.10 (0.09–0.12), respectively. Emergency room visits and hospitalizations unrelated to BC were associated with decreased odds of RT consideration: 0.85 (0.76–0.94) and 0.83 (0.71–0.97). Women with regional BC considered for chemotherapy were more likely to be considered for RT: 3.41 (2.83–4.11). RT consideration odds increased by 7 % (OR of 1.07, 95 % CI 1.03–1.10) for every ten additional BCSs performed by the surgeon in the prior year. Social isolation, comorbidities, and greater distance to a referral center lowered the odds. Demographic and clinical patient-related risk factors, health service use, gaps in other aspects of BC management, and surgeon’s experience predicted RT consideration.
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Affiliation(s)
- Stanimira Krotneva
- Clinical and Health Informatics Research Group, McGill University, 1140 Pine Avenue West, Montreal, QC, H3A 1A3, Canada.
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Krotneva SP, Reidel KE, Verma A, Mayo N, Tamblyn R, Meguerditchian AN. Factors influencing the quality of local management of ductal carcinoma in situ: a cohort study. Curr Oncol 2013; 20:e212-22. [PMID: 23737691 DOI: 10.3747/co.20.1293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Guidelines recommend radiotherapy (rt) after breast-conserving surgery (bcs) for optimal control of ductal carcinoma in situ (dcis). The aim of the present study was to characterize the rates of rt consideration and administration, and to identify factors influencing those rates in a cohort of women diagnosed between 1998 and 2005 in Quebec. METHODS Quebec's medical service claims and discharge abstract database were used. Using consultation for rt as an indicator for rt consideration, odds ratios (ors) and 95% confidence intervals (cis) were estimated using a generalized estimating equations regression model. RESULTS Of 4139 women analyzed (mean age: 58 years), 3435 (83%) received a consultation for rt, and 3057 of them (89%) proceeded with treatment. The rate of rt consideration increased by 7.1% over the study period, with notable differences in the various age groups. Relative to women 50-69 years of age, the ors for being considered for rt were, respectively, 0.89 (95% ci: 0.71 to 1.12), 0.71 (95% ci: 0.55 to 0.92), and 0.20 (95% ci: 0.14 to 0.31) for women younger than 50, 70-79, and 80 years of age and older. Distance to a designated breast care centre lowered the probability of rt consideration, but the presence of comorbidities did not. A surgeon's volume of bcss increased the probability of being considered for rt by 7% for every 10 such procedures performed (or: 1.07; 95% ci: 1.04 to 1.11). CONCLUSIONS Consideration for rt has increased over time. However, older women (despite being in good health) and those living far from a designated breast care centre or having a low-case-volume surgeon were less likely to be considered for rt.
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Affiliation(s)
- S P Krotneva
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC
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Smith JL, Pollack LA, Rodriguez JL, Hawkins NA, Smith T, Rechis R, Miller A, Willis A, Miller H, Hall IJ, Fairley TL, Stone-Wiggins B. Assessment of the status of a National Action Plan for Cancer Survivorship in the USA. J Cancer Surviv 2013; 7:425-38. [PMID: 23609522 DOI: 10.1007/s11764-013-0276-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 03/01/2013] [Indexed: 01/23/2023]
Abstract
PURPOSE There are currently more than 12 million cancer survivors in the USA. Survivors face many issues related to cancer and treatment that are outside the purview of the clinical care system. Therefore, understanding and providing for the evolving needs of cancer survivors offers challenges and opportunities for the public health system. In 2004, the Centers for Disease Control and Prevention and the Lance Armstrong Foundation, now the Livestrong Foundation, partnered with national cancer survivorship organizations to develop the National Action Plan for Cancer Survivorship (NAPCS). This plan outlines public health strategies to address the needs of cancer survivors. To date, no assessment of NAPCS strategies and their alignment with domestic cancer survivorship activities has been conducted. METHODS The activities of five national organizations with organized public health agendas about cancer survivorship were assessed qualitatively during 2003-2007. Using the NAPCS as an organizing framework, interviews were conducted with key informants from all participating organizations. Interview responses were supplemented with relevant materials from informants and reviews of the organizations' websites. RESULTS Strategies associated with surveillance and applied research; communication, education, and training; and programs, policy, and infrastructure represent a large amount of the organizational efforts. However, there are gaps in research on preventive interventions, evaluation of implemented activities, and translation. CONCLUSIONS Numerous NAPCS strategies have been implemented. Future efforts of national cancer survivorship organizations should include rigorous evaluation of implemented activities, increased translation of research to practice, and assessment of dissemination efforts. IMPLICATIONS FOR CANCER SURVIVORS The results of this descriptive assessment provide cancer survivors, cancer survivorship organizations, researchers, providers, and policy makers with initial information about cancer survivorship public health efforts in the USA. Additionally, results suggest areas in need of further attention and next steps in advancing the national cancer survivorship public health agenda.
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Affiliation(s)
- Judith Lee Smith
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341, USA.
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