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Gutierrez RD, Smith EJT, Matthay ZA, Gasper WJ, Hiramoto JS, Conte MS, Finlayson E, Walter LC, Iannuzzi JC. Risk factors and associated outcomes of postoperative delirium after open abdominal aortic aneurysm repair. J Vasc Surg 2024; 79:793-800. [PMID: 38042511 DOI: 10.1016/j.jvs.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Open abdominal aortic aneurysm repair (OAR) is a major vascular procedure that incurs a large physiologic demand, increasing the risk for complications such as postoperative delirium (POD). We sought to characterize POD incidence, identify delirium risk factors, and evaluate the effect of delirium on postoperative outcomes. We hypothesized that POD following OAR would be associated with increased postoperative complications and resource utilization. METHODS This was a retrospective study of all OAR cases from 2012 to 2020 at a single tertiary care center. POD was identified via a validated chart review method based on key words and Confusion Assessment Method assessments. The primary outcome was POD, and secondary outcomes included length of stay, non-home discharge, 90-day mortality, and 1-year survival. Bivariate analysis as appropriate to the data was used to assess the association of delirium with postoperative outcomes. Multivariable binary logistic regression was used to identify risk factors for POD and Cox regression for variables associated with worse 1-year survival. RESULTS Overall, 198 OAR cases were included, and POD developed in 34% (n = 67). Factors associated with POD included older age (74 vs 69 years; P < .01), frailty (50% vs 28%; P < .01), preoperative dementia (100% vs 32%; P < .01), symptomatic presentation (47% vs 27%; P < .01), preoperative coronary artery disease (44% vs 28%; P = .02), end-stage renal disease (89% vs 32%; P < .01) and Charlson Comorbidity Index score >4 (42% vs 26%; P = .01). POD was associated with 90-day mortality (19% vs 5%; P < .01), non-home discharge (61% vs 30%; P < .01), longer median hospital length of stay (14 vs 8 days; P < .01), longer median intensive care unit length of stay (6 vs 3 days; P < .01), postoperative myocardial infarction (7% vs 2%; P = .045), and postoperative pneumonia (19% vs 8%; P = .01). On multivariable analysis, risk factors for POD included older age, history of end-stage renal disease, lack of epidural, frailty, and symptomatic presentation. A Cox proportional hazards model revealed that POD was associated with worse survival at 1 year (hazard ratio, 3.8; 95% confidence interval, 1.6-9.0; P = .003). CONCLUSIONS POD is associated with worse postoperative outcomes and increased resource utilization. Future studies should examine the role of improved screening, implementation of delirium prevention bundles, and multidisciplinary care for the most vulnerable patients undergoing OAR.
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Affiliation(s)
- Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Eric J T Smith
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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2
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Wolf AMD, Oeffinger KC, Shih TYC, Walter LC, Church TR, Fontham ETH, Elkin EB, Etzioni RD, Guerra CE, Perkins RB, Kondo KK, Kratzer TB, Manassaram-Baptiste D, Dahut WL, Smith RA. Screening for lung cancer: 2023 guideline update from the American Cancer Society. CA Cancer J Clin 2024; 74:50-81. [PMID: 37909877 DOI: 10.3322/caac.21811] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 11/03/2023] Open
Abstract
Lung cancer is the leading cause of mortality and person-years of life lost from cancer among US men and women. Early detection has been shown to be associated with reduced lung cancer mortality. Our objective was to update the American Cancer Society (ACS) 2013 lung cancer screening (LCS) guideline for adults at high risk for lung cancer. The guideline is intended to provide guidance for screening to health care providers and their patients who are at high risk for lung cancer due to a history of smoking. The ACS Guideline Development Group (GDG) utilized a systematic review of the LCS literature commissioned for the US Preventive Services Task Force 2021 LCS recommendation update; a second systematic review of lung cancer risk associated with years since quitting smoking (YSQ); literature published since 2021; two Cancer Intervention and Surveillance Modeling Network-validated lung cancer models to assess the benefits and harms of screening; an epidemiologic and modeling analysis examining the effect of YSQ and aging on lung cancer risk; and an updated analysis of benefit-to-radiation-risk ratios from LCS and follow-up examinations. The GDG also examined disease burden data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. The GDG judged that the overall evidence was moderate and sufficient to support a strong recommendation for screening individuals who meet the eligibility criteria. LCS in men and women aged 50-80 years is associated with a reduction in lung cancer deaths across a range of study designs, and inferential evidence supports LCS for men and women older than 80 years who are in good health. The ACS recommends annual LCS with low-dose computed tomography for asymptomatic individuals aged 50-80 years who currently smoke or formerly smoked and have a ≥20 pack-year smoking history (strong recommendation, moderate quality of evidence). Before the decision is made to initiate LCS, individuals should engage in a shared decision-making discussion with a qualified health professional. For individuals who formerly smoked, the number of YSQ is not an eligibility criterion to begin or to stop screening. Individuals who currently smoke should receive counseling to quit and be connected to cessation resources. Individuals with comorbid conditions that substantially limit life expectancy should not be screened. These recommendations should be considered by health care providers and adults at high risk for lung cancer in discussions about LCS. If fully implemented, these recommendations have a high likelihood of significantly reducing death and suffering from lung cancer in the United States.
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Affiliation(s)
- Andrew M D Wolf
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine and Duke Cancer Institute Center for Onco-Primary Care, Durham, North Carolina, USA
| | - Tina Ya-Chen Shih
- David Geffen School of Medicine and Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, California, USA
| | - Louise C Walter
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Timothy R Church
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth T H Fontham
- Health Sciences Center, School of Public Health, Louisiana State University, New Orleans, Louisiana, USA
| | - Elena B Elkin
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Ruth D Etzioni
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Carmen E Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca B Perkins
- Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Karli K Kondo
- Early Cancer Detection Science, American Cancer Society, Atlanta, Georgia, USA
| | - Tyler B Kratzer
- Cancer Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia, USA
| | | | | | - Robert A Smith
- Early Cancer Detection Science, American Cancer Society, Atlanta, Georgia, USA
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3
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Shaw NM, Breyer BN, Walter LC, Sudore RL, Suskind AM, Baussan C, Quanstrom K, Allen IE, Cooperberg MR, Dohan D, Hampson LA. How older men live with stress urinary incontinence: Patient experience and navigation to treatment. Neurourol Urodyn 2024; 43:11-21. [PMID: 38014566 PMCID: PMC10866353 DOI: 10.1002/nau.25325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/29/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES To explore the context in which older men navigate treatment for stress urinary incontinence (SUI) following prostate surgery by characterizing lived experience of men with symptomatic SUI. SUBJECTS/PATIENTS AND METHODS Mixed method study using surveys and semistructured interviews to examine a cohort of men who underwent evaluation for treatment of postprostatectomy SUI. RESULTS Thirty-six men were interviewed after consultation for SUI and 31 had complete quantitative clinical data. Twenty-six underwent surgery and 10 chose no surgical intervention. In qualitative interviews, respondents experienced substantial decline in quality of life due to incontinence citing concerns associated with use of pads and worrying about incontinence. Most patients reported "workarounds"-efforts to mitigate or manage incontinence including Kegels, physical therapy, and garments. Participants also reported lifestyle changes including less strenuous physical activity, less sexual activity, and/or fewer social gatherings. Patients then described a "breaking point" where incontinence workarounds were no longer sufficient. After seeking evaluation, men described challenges in exploring treatment for SUI, including access to care and provider knowledge of treatment options. CONCLUSION In a novel study of patients living with SUI a predictable lived experience was observed that culminated in a desire for change or "breaking point." In all men, this led to treatment-seeking behaviors and for many it led to SUI intervention. Despite effective treatments, patients continue to meet barriers gaining access to SUI evaluation and treatment.
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Affiliation(s)
- Nathan M Shaw
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Urology, MedStar Georgetown, Washington, District of Columbia, USA
| | - Benjamin N Breyer
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Louise C Walter
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Rebecca L Sudore
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Anne M Suskind
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Caitlin Baussan
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kathryn Quanstrom
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Isabel E Allen
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Cooperberg
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Dan Dohan
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Lindsay A Hampson
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Neumann AV, Gonzalez A, Walter LC, Rivera J. Improving older adults' telehealth through a novel community-academic partnership: Preliminary data. J Am Geriatr Soc 2023; 71:3886-3895. [PMID: 37607098 DOI: 10.1111/jgs.18556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND The COVID-19 pandemic increased the use of telehealth, which posed unique challenges for the provision of care to older adults who face numerous barriers to accessing and using technology. To improve older adults' online health-related abilities, the UCSF Geriatrics Workforce Enhancement Program (UCSF-GWEP) partnered with Little Brothers Friends of the Elderly-San Francisco (LBFE-SF) to develop a model telehealth training intervention. METHODS LBFE-SF recruited older adults from their members with wi-fi and paired each one with a new device and volunteer trainer to cover seven lessons and four key tasks (emailing providers, video visits, accessing health information, and using patient portals). Older adults completed surveys to self-assess their skill level after training, and their confidence before, immediately after, and 3 months post training. A subset of trainees were also interviewed about their program goals and experiences. UCSF-GWEP conducted statistical analyses of survey data, and coded interview transcripts to identify aspects of the model supportive to learning and success. RESULTS Of 43 participants, 31 completed training. Their median age was 75; 48% were non-white; 45% had no more than a high school education; and 63% reported yearly income below U.S. $20,000. Three months after completing the program, more than 50% of trainees reported that they needed little or no help performing all four key tasks, and confidence with video visits, online searches, and patient portals showed significant improvement. Additionally, in interviews participants reported improved health, social benefits, and explained that learning was facilitated by self-pacing, repetition, and longitudinal support from volunteer trainers. CONCLUSIONS Older adults with various barriers to learning technology showed online independence and increased confidence with some telehealth tasks after a novel training intervention. Key characteristics of the model included a tablet device, one-on-one longitudinal support from volunteers, comprehensive learning materials, and community-academic partnership.
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Affiliation(s)
- Alicia V Neumann
- School of Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
| | - Andrea Gonzalez
- School of Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
| | - Louise C Walter
- School of Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- San Francisco VA Medical Center, San Francisco, California, USA
| | - Josette Rivera
- School of Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
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5
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Schifferdecker KE, Ramesh NP, Walter LC, Calderwood AH. Multi-level Factors Influencing Decisions About Stopping Surveillance Colonoscopy in Older Adults: a Qualitative Study. J Gen Intern Med 2023; 38:2761-2767. [PMID: 37225959 PMCID: PMC10506966 DOI: 10.1007/s11606-023-08225-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/28/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Little is known about patient or provider experience and perceptions of stopping surveillance among older adults with a history of colon polyps. While guidelines recommend ceasing routine colorectal cancer screening in adults > 75 years and those with limited life expectancy, guidance for ceasing surveillance colonoscopy in those with prior colon polyps suggests individualizing recommendations. OBJECTIVE Identify processes, experiences, and gaps around individualizing decisions to stop or continue surveillance colonoscopy for older adults and areas for improvement. DESIGN Phenomenological qualitative study design using recorded semi-structured interviews from May 2020 through March 2021. PARTICIPANTS 15 patients aged ≥ 65 in polyp surveillance, 12 primary care providers (PCPs), and 13 gastroenterologists (GIs). APPROACH Data were analyzed using a mixed deductive (directed content analysis) and inductive (grounded theory) approach to identify themes related to stopping or continuing surveillance colonoscopies. KEY RESULTS Analysis resulted in 24 themes and were clustered into three main categories: health and clinical considerations; communication and roles; and system-level processes or structures. Overall, the study found support for discussions around age 75-80 on stopping surveillance colonoscopy with considerations for health and life expectancy and that PCPs should take a primary role. However, systems and processes for scheduling surveillance colonoscopies largely bypass PCPs which reduces opportunities to both individualize recommendations and facilitate patients' decision-making. CONCLUSIONS This study identified gaps in processes to implement current guidelines for individualizing surveillance colonoscopy as adults grow older, including opportunities to discuss stopping. Increasing the role of PCPs in polyp surveillance as patients grow older provides more opportunities for individualized recommendations, so patients can consider their own preferences, ask questions, and make a more informed choice for themselves. Changing existing systems and processes and creating supportive tools for shared decision-making specific to older adults with polyps would improve how surveillance colonoscopy is individualized in this population.
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Affiliation(s)
- Karen E Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Lebanon, NH, USA.
- Center for Program Design and Evaluation at Dartmouth, NH, Lebanon, USA.
| | - Nithya Puttige Ramesh
- Center for Program Design and Evaluation at Dartmouth, NH, Lebanon, USA
- School of Public Health, Brown University, Providence, RI, USA
| | - Louise C Walter
- Division of Geriatrics, University of California San Francisco and San Francisco VA Health Care System, San Francisco, CA, USA
| | - Audrey H Calderwood
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Lebanon, NH, USA
- Section of Gastroenterology, Dartmouth-Hitchcock Medical Cancer, Lebanon, NH, USA
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6
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Hampson LA, Shaw NM, Breyer BN, Walter LC, Sudore RL, Cooperberg MR, Baussan C, Quanstrom K, Elaine Allen I, Dohan D. Patient-identified Treatment Attributes Among Older Men With Stress Urinary Incontinence: A Qualitative Look at What Matters to Patients Making Treatment Decisions. Urology 2023; 177:189-196. [PMID: 37076021 PMCID: PMC10524507 DOI: 10.1016/j.urology.2022.12.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/19/2022] [Accepted: 12/27/2022] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To investigate which treatment attributes matter to patients with stress urinary incontinence (SUI), why and how they matter, and the context in which patients consider treatment attributes. Nearly a quarter of older men have decisional regret following SUI treatment. Knowledge of what matters to patients when making SUI treatment decisions is necessary to improve goal-concordant care. METHODS We conducted semi-structured interviews with 36 men ≥65 years of age with SUI. Semi-structured interviews were conducted by telephone and transcribed. Four researchers (L.H., N.S., E.A., C.B.) coded the transcripts using both deductive and inductive codes to identify and describe treatment attributes. RESULTS We identified 5 patient-derived treatment attributes of interest among older men with SUI who have faced treatment decisions: (1) dryness, (2) simplicity, (3) potential need for future intervention, (4) treatment regret/satisfaction, and (5) surgical avoidance. These themes reliably emerged in our patient-centered interviews from within various contexts, including prior negative healthcare experiences, the impact of incontinence on daily and quality of life, and the mental health burden of incontinence, among others. CONCLUSION Men with SUI weigh a variety of treatment attributes in addition to dryness, a traditional clinical endpoint, and do so within the context of their individual experience. These additional attributes, such as simplicity, may run counter to the goal of dryness. This suggests that traditional clinical endpoints alone are not adequate for counseling patients. Contextualized patient-identified treatment attributes should be used to create decision-support materials to promote goal-concordant SUI treatment.
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Affiliation(s)
- Lindsay A Hampson
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; the; Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA; the.
| | - Nathan M Shaw
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; the
| | - Benjamin N Breyer
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; the; Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA; the
| | - Louise C Walter
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; the; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA; the
| | - Rebecca L Sudore
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; the; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA; the
| | - Matthew R Cooperberg
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; the; Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA; the
| | - Caitlin Baussan
- University of Pittsburg School of Health and Rehabilitation Sciences, Pittsburg, PA; the
| | - Kathryn Quanstrom
- Department of Internal Medicine, Trinity Health Livonia Hospital, Livonia
| | - I Elaine Allen
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA; the
| | - Dan Dohan
- ; and the Institute for Health Policy Studies, Department of Medicine, University of California San Francisco, San Francisco, CA
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7
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Shaw NM, Nik-Ahd F, Jones C, Breyer BN, Walter LC, Sudore R, Cooperberg MR, Baussan C, Quanstrom K, Allen IE, Hampson LA. Patient decision-making for surgical treatment of post-prostatectomy stress urinary incontinence: a mixed-methods exploratory pilot study. Transl Androl Urol 2023; 12:849-858. [PMID: 37305624 PMCID: PMC10251091 DOI: 10.21037/tau-22-618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 03/15/2023] [Indexed: 11/08/2023] Open
Abstract
Background Male stress urinary incontinence (SUI) is a known complication following surgical intervention on the prostate, particularly following surgery for prostate cancer. Effective surgical treatments for SUI include artificial urinary sphincter (AUS) and male urethral sling. Prior data suggest that men may forego available treatment despite bothersome symptoms. The objective was to explore how men who underwent surgical correction for post-prostatectomy SUI navigated SUI treatment decisions. Methods Mixed method study was employed. Semi-structured interviews, participant surveys and objective clinical assessment of SUI were performed among a group of men living with incontinence after prostate cancer surgery who underwent surgery for SUI at the University of California in 2017. Results Eleven men were interviewed after consultation for SUI and all had complete quantitative clinical data. Surgery for SUI included AUS (n=8) and sling (n=3). There was a decrease in pads per day from 3.2 to 0.9 and no major complications. Most patients found that the impact on activities and their treating urologist were of great importance. Sexual and relationships played a variable role with some participants ranking these as "great deal of influence" and others "little or no influence". Participants who underwent AUS were more likely to cite a higher importance on "being very dry" in choosing that surgery while sling patients had more variable ranking of important factors. Participants found a variety of inputs helpful in hearing information about SUI treatment options. Conclusions Among a group of 11 men who underwent surgical correction for post-prostatectomy SUI, there were identifiable themes on how men make decisions, evaluate quality of life (QoL) changes and approach treatment options. Men value more than being dry with measures of individual success that can include sexual and relationship health. Furthermore the role of the Urologist remains crucial as patients relied heavily on input and discussion with their Urologist to assist in treatment decisions. These findings can be used to inform future studies of the experience of men with SUI.
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Affiliation(s)
- Nathan M. Shaw
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Farnoosh Nik-Ahd
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Charles Jones
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Benjamin N. Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Louise C. Walter
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Rebecca Sudore
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Matthew R. Cooperberg
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
- Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Caitlin Baussan
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Kathryn Quanstrom
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - I. Elaine Allen
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lindsay A. Hampson
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
- Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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8
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Jones CP, Shaw NM, Mena J, Breyer BN, Walter LC, Baussan C, Quanstrom K, Allen IE, Dohan D, Hampson LA. The relationship between frailty, incontinence severity, and treatment decisions for men with post-prostatectomy stress urinary incontinence: a mixed methods analysis. Transl Androl Urol 2023; 12:840-848. [PMID: 37305619 PMCID: PMC10251103 DOI: 10.21037/tau-22-839] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/28/2023] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Frailty is common among urology patients in general as well as among men seeking evaluation for stress urinary incontinence (SUI), with 6.1% of men undergoing artificial urinary sphincter placement considered frail. It is unclear if and how patient views on frailty and incontinence severity impact decision-making with regards to SUI treatment. METHODS We undertook a mixed methods analysis to evaluate the intersection of frailty, incontinence severity, and treatment decision-making is presented. To do so, we utilized a previously published cohort of men undergoing evaluation for SUI at the University of California, San Francisco between 2015 and 2020, selecting those who had evaluation with timed up and go test (TUGT), objective measures of incontinence, and patient-reported outcome measures (PROMs). A subset of these participants had additionally undergone semi-structured interviews, and these interviews were re-examined to thematically code them with a focus on the impact of frailty and incontinence severity on SUI treatment decision-making. RESULTS Among the original cohort of 130 patients, 72 had an objective measure of frailty and were included in our analysis; 18 of these individuals had corresponding qualitative interviews. Common themes identified included (I) impact of incontinence severity on decision-making; (II) the interaction between frailty and incontinence; (III) the impact of comorbidity on treatment decision-making; and (IV) age as a construct of frailty and impact on surgical choice and/or recovery. Direct quotations regarding each theme provides insight into patients' views and drivers of SUI treatment decision-making. CONCLUSIONS The impact of frailty on treatment decision-making for patients with SUI is complex. This mixed methods study highlights the variety of patient views on frailty with regards to surgical intervention for male SUI. Urologists should make a concerted effort to personalize patient counseling for SUI management and take time to understand each patient's perspective in order to individualize SUI treatment decision-making. More research is needed to help identify factors that influence decision-making for frail male patients with SUI.
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Affiliation(s)
- Charles P. Jones
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nathan M. Shaw
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jorge Mena
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Benjamin N. Breyer
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Louise C. Walter
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Caitlin Baussan
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kathryn Quanstrom
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - I. Elaine Allen
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Daniel Dohan
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lindsay A. Hampson
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
- Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Calderwood AH, Tosteson TD, Wang Q, Onega T, Walter LC. Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults. JAMA Intern Med 2023; 183:426-434. [PMID: 36912828 PMCID: PMC10012041 DOI: 10.1001/jamainternmed.2023.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/11/2023] [Indexed: 03/14/2023]
Abstract
Importance Surveillance after prior colon polyps is the most frequent indication for colonoscopy in older adults. However, to our knowledge, the current use of surveillance colonoscopy, clinical outcomes, and follow-up recommendations in association with life expectancy, factoring in both age and comorbidities, have not been studied. Objective To evaluate the association of estimated life expectancy with surveillance colonoscopy findings and follow-up recommendations among older adults. Design, Setting, and Participants This registry-based cohort study used data from the New Hampshire Colonoscopy Registry (NHCR) linked with Medicare claims data and included adults in the NHCR who were older than 65 years, underwent colonoscopy for surveillance after prior polyps between April 1, 2009, and December 31, 2018, and had full Medicare Parts A and B coverage and no Medicare managed care plan enrollment in the year prior to colonoscopy. Data were analyzed from December 2019 to March 2021. Exposures Life expectancy (<5 years, 5 to <10 years, or ≥10 years), estimated using a validated prediction model. Main Outcomes and Measures The main outcomes were clinical findings of colon polyps or colorectal cancer (CRC) and recommendations for future colonoscopy. Results Among 9831 adults included in the study, the mean (SD) age was 73.2 (5.0) years and 5285 (53.8%) were male. A total of 5649 patients (57.5%) had an estimated life expectancy of 10 or more years, 3443 (35.0%) of 5 to less than 10 years, and 739 (7.5%) of less than 5 years. Overall, 791 patients (8.0%) had advanced polyps (768 [7.8%]) or CRC (23 [0.2%]). Among the 5281 patients with available recommendations (53.7%), 4588 (86.9%) were recommended to return for future colonoscopy. Those with longer life expectancy or more advanced clinical findings were more likely to be told to return. For example, among patients with no polyps or only small hyperplastic polyps, 132 of 227 (58.1%) with life expectancy of less than 5 years were told to return for future surveillance colonoscopy vs 940 of 1257 (74.8%) with life expectancy of 5 to less than 10 years and 2163 of 2272 (95.2%) with life expectancy of 10 years or more (P < .001). Conclusions and Relevance In this cohort study, the likelihood of finding advanced polyps and CRC on surveillance colonoscopy was low regardless of life expectancy. Despite this observation, 58.1% of older adults with less than 5 years' life expectancy were recommended to return for future surveillance colonoscopy. These data may help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.
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Affiliation(s)
- Audrey H. Calderwood
- Department of Medicine, Dartmouth-Hitchcock Medical Cancer, Lebanon, New Hampshire
- The Dartmouth Institute at Geisel School of Medicine, Lebanon, New Hampshire
| | - Tor D. Tosteson
- The Dartmouth Institute at Geisel School of Medicine, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
- Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute at Geisel School of Medicine, Lebanon, New Hampshire
| | - Tracy Onega
- Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Louise C. Walter
- Division of Geriatrics, University of California, San Francisco
- VA Health Care System, San Francisco, California
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Huang AJ, Walter LC, Yaffe K, Vittinghoff E, Kornblith E, Schembri M, Chang A, Subak LL. TReating Incontinence for Underlying Mental and Physical Health (TRIUMPH): a study protocol for a multicenter, double-blinded, randomized, 3-arm trial to evaluate the multisystem effects of pharmacologic treatment strategies for urgency-predominant urinary incontinence in ambulatory older women. Trials 2023; 24:287. [PMID: 37085880 PMCID: PMC10122333 DOI: 10.1186/s13063-023-07279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/27/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Urgency-type urinary incontinence affects one in four older community-dwelling women and overlaps with other common aging-associated health syndromes such as cognitive impairment, physical mobility impairment, and depression. Observational studies have raised concern about potentially higher rates of delirium and dementia in older adults taking anticholinergic bladder medications, but few prospective data are available to evaluate the effects of these and other pharmacologic treatments for urgency incontinence on cognition and other multisystem functional domains important to older women. METHODS The TRIUMPH study is a randomized, double-blinded, 3-arm, parallel-group trial comparing the multisystem effects of anticholinergic versus beta-3-adrenergic agonist bladder therapy and versus no active bladder anti-spasmodic pharmacotherapy in older women with urgency incontinence. Women aged 60 years and older (target N = 270) who have chronic urgency-predominant urinary incontinence and either normal or mildly impaired cognition at baseline are recruited from the community by investigators based in northern California, USA. Participants are randomized in equal ratios to take identically encapsulated oral anticholinergic bladder therapy (in the form of tolterodine 2 mg extended release [ER]), oral beta-3 adrenergic agonist bladder therapy (mirabegron 25 mg ER), or placebo daily for 24 weeks, with the option of participant-directed dose titration (to tolterodine 4 mg ER, mirabegron 50 mg ER, or matching placebo daily). Participants also receive patient-oriented information and instructions about practicing first-line behavioral management strategies for incontinence. The primary outcome is change in composite cognitive function over 24 weeks assessed by a comprehensive battery of cognitive tests, with a secondary exploration of the persistence of change at 36 weeks. Secondary outcomes include changes over 24 and 36 weeks in domain-specific cognitive function; frequency, severity, and impact of urgency-associated urinary symptoms; physical function and balance; sleep quality and daytime sleepiness; psychological function; and bowel function. DISCUSSION The TRIUMPH trial addresses the need for rigorous evidence to guide counseling and decision-making for older women who are weighing the potential multisystem benefits and risks of pharmacologic treatments for urgency incontinence in order to preserve their day-to-day functioning, quality of life, and independence in older age. TRIAL REGISTRATION ClinicalTrials.gov NCT05362292. Registered on May 5, 2022.
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Affiliation(s)
- Alison J Huang
- University of California San Francisco, San Francisco, USA.
| | | | - Kristine Yaffe
- University of California San Francisco, San Francisco, USA
| | | | - Erica Kornblith
- University of California San Francisco, San Francisco, USA
- San Francisco Veterans Affairs, San Francisco, USA
| | | | - Ann Chang
- University of California San Francisco, San Francisco, USA
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Smith EJT, Gasper WJ, Schneider PA, Finlayson E, Walter LC, Covinsky KE, Conte MS, Iannuzzi JC. Cognitive Impairment is Common in a Veterans Affairs Population with Peripheral Arterial Disease. Ann Vasc Surg 2023; 91:210-217. [PMID: 36581154 DOI: 10.1016/j.avsg.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there are little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized. METHODS Cognitive impairment screening was prospectively performed for veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of <26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment. RESULTS Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, P = 0.03), Black versus White race (94% vs. 54%, P < 0.01), hypertension (66% vs. 31%, P = 0.01), prior stroke/TIA (79% vs. 58%, P = 0.03), diabetes treated with insulin (79% vs. 58%, P = 0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, P = 0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥70 years, diabetes treated with insulin, PTSD, and Black race. CONCLUSIONS Many veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.
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Affiliation(s)
- Eric J T Smith
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Peter A Schneider
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | - Ken E Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | | | - James C Iannuzzi
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Singhal S, Walter LC, Smith AK, Loh KP, Cohen HJ, Zeng S, Shi Y, Boscardin WJ, Presley CJ, Williams GR, Magnuson A, Mohile SG, Wong ML. Change in four measures of physical function among older adults during lung cancer treatment: A mixed methods cohort study. J Geriatr Oncol 2023; 14:101366. [PMID: 36058839 PMCID: PMC9974579 DOI: 10.1016/j.jgo.2022.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Functional outcomes during non-small cell lung cancer (NSCLC) treatment are critically important to older adults. Yet, data on physical function and which measures best capture functional change remain limited. MATERIALS AND METHODS This multisite, mixed methods cohort study recruited adults ≥65 years with advanced NSCLC starting systemic treatment (i.e., chemotherapy, immunotherapy, and/or targeted therapy) with non-curative intent. Participants underwent serial geriatric assessments prior to starting treatment and at one, two, four, and six months, which included the Karnofsky Performance Scale (KPS, range: 0-100%), instrumental activities of daily living (IADL, range: 0-14), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Physical Functioning subscale (EORTC QLQ-C30 PF, range: 0-100), and Life-Space Assessment (LSA, range: 0-120). For all measures, higher scores represent better functioning. In a qualitative substudy, 20 patients completed semi-structured interviews prior to starting treatment and at two and six months to explore how treatment affected their daily functioning. We created joint displays for each interview participant that integrated their longitudinal KPS, IADL, EORTC QLQ-C30 PF, and LSA scores with patient quotes describing their function. RESULTS Among 87 patients, median age was 73 years (range 65-96). Mean pretreatment KPS score was 79% (standard deviation [SD] 13), EORTC QLQ-C30 PF was 69 (SD 23), and LSA was 67 (SD 28); median IADL was 13 (interquartile range [IQR] 10-14). At two months after treatment initiation, 70% of patients experienced functional decline on at least one measure, with only 13% of these patients recovering at six months. At two and six months, decline in LSA was the most common (48% and 35%, respectively). Joint displays revealed heterogeneity in how well each quantitative measure of physical function captured the qualitative patient experience. DISCUSSION Functional decline during NSCLC treatment is common among older adults. LSA is a useful measure to detect subtle functional decline that may be missed by other measures. Given heterogeneity in how well each quantitative measure captures changes in physical function, there is value to including more than one functional measure in geriatric oncology research studies.
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Affiliation(s)
- Surbhi Singhal
- Division of Medical Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Louise C Walter
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Alexander K Smith
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging & Human Development and Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Sandra Zeng
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Carolyn J Presley
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Grant R Williams
- Divisions of Hematology/Oncology and Gerontology, Geriatrics, and Palliative Care, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Allison Magnuson
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Melisa L Wong
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA; Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.
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Tsang M, Gan S, Boscardin J, Wong ML, Walter LC, Smith AK. The epidemiology of preexisting geriatric and palliative conditions in older adults with poor prognosis cancers. J Am Geriatr Soc 2022; 70:3402-3412. [PMID: 36259424 PMCID: PMC9772051 DOI: 10.1111/jgs.18039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/19/2022] [Accepted: 08/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Older patients with poor prognosis cancers have complex needs that can benefit from geriatrics and palliative care principles. Because they are not routinely assessed, the prevalence of preexisting geriatric and palliative conditions in this population is unknown. METHODS We used the nationally representative Health and Retirement Study (HRS) linked with Medicare claims (1998-2016) to identify adults aged ≥65 years diagnosed with poor prognosis cancers (cancers with a median survival ≤1 year). Using the HRS interview before the first Medicare cancer claim, we used survey-weighted descriptive statistics and modified Poisson regression analysis to examine the prevalence of the following clinically significant conditions: functional impairment, difficulty with mobility, falls and injurious falls, social support, cognition, advance care planning, use of pain or sleep medications, and presence of pain or breathlessness. RESULTS Of 2105 participants (mean age 76, 53% women, 34% lung cancer, 21% gastrointestinal cancer), the median survival was 9.6 months. Approximately 65% had difficulty climbing stairs (95% CI 63%-67%), 49% had no advance directive (95% CI 45%-54%), 35% lived alone (95% CI 33%-37%), 36% fell in the last 2 years (95% CI 34%-38%), and 32% rated their memory as poor (95% CI 29%-34%). After adjusting for gender, cancer type, and HRS survey time before the first Medicare claim for a poor prognosis cancer, functional impairment and falls were highest among adults aged 85+. Adults aged 65-74 years were less likely to have an advance directive. After adjusting for age, cancer type, and HRS survey time, women had a higher rate of pain and physical impairment. In exploratory analyses, race and socioeconomic status predicted difficulty with mobility and instrumental activities of daily living, living alone, and advance directive completion. CONCLUSIONS Due to a high prevalence across multiple domains, all older adults with poor prognosis cancers should be assessed for geriatric and palliative care conditions.
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Affiliation(s)
- Mazie Tsang
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA
| | - Siqi Gan
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Melisa L. Wong
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA
| | - Louise C. Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Calderwood AH, Tosteson TD, Walter LC, Hua P, Onega T. Colonoscopy utilization and outcomes in older adults: Data from the New Hampshire Colonoscopy Registry. J Am Geriatr Soc 2022; 70:801-811. [PMID: 34859887 PMCID: PMC8904292 DOI: 10.1111/jgs.17560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/09/2021] [Accepted: 10/19/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Colonoscopy is frequently performed in older adults, yet data on current use, and clinical outcomes of and follow-up recommendations after colonoscopy in older adults are lacking. METHODS This was an observational study using the New Hampshire Colonoscopy Registry of adults age ≥65 years undergoing colonoscopy for screening, surveillance of prior polyps, or evaluation of symptoms. The main outcomes were clinical findings of polyps and colorectal cancer and recommendations for future colonoscopy by age. RESULTS Between 2009 and 2019, there were 42,611 colonoscopies, of which 17,527 (41%) were screening, 19,025 (45%) surveillance, and 6059 (14%) for the evaluation of symptoms. Mean age was 71.1 years (SD 5.0), and 49.3% were male. The finding of colorectal cancer was rare (0.71%), with the highest incidence among diagnostic examinations (2.4%). The incidence of advanced polyps increased with patient age from 65-69 to ≥85 years for screening (7.1% to 13.6%; p = 0.05) and surveillance (9.4% to 12.0%; p < 0.001). Recommendations for future colonoscopy decreased with age and varied by findings at current colonoscopy. In patients without any significant findings, 85% aged 70-74 years, 61.9% aged 75-79 years, 39.1% aged 80-84 years, and 27.4% aged ≥85 years (p < 0.001) were told to continue colonoscopy. Among patients with advanced polyps, 97.2% aged 70-74 years, 89.6% aged 75-79 years, 78.4% aged 80-84 years, and 66.7% aged ≥85 years were told to continue colonoscopy (p < 0.001). CONCLUSIONS Within this comprehensive statewide registry, clinical findings during colonoscopy varied by indication and increased with age. Overall rates of finding advanced polyps and colorectal cancer are low. Older adults are frequently recommended to continue colonoscopy despite advanced age and insignificant clinical findings on current examination. These data inform the potential benefits of ongoing colonoscopy, which must be weighed with the low but known potential immediate and long-term harms of colonoscopy, including cost, psychological distress, and long lag time to benefit exceeding life expectancy.
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Affiliation(s)
- Audrey H. Calderwood
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Department of Health Policy and Clinical Practice, Dartmouth’s Geisel School of Medicine, Hanover, NH, USA,Department of Medicine, Dartmouth’s Geisel School of Medicine, Hanover, NH, USA
| | - Tor D. Tosteson
- Department of Health Policy and Clinical Practice, Dartmouth’s Geisel School of Medicine, Hanover, NH, USA,Department of Biomedical Data Science and Community and Family Medicine, Dartmouth’s Geisel School of Medicine, Hanover, NH, USA
| | - Louise C. Walter
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA, USA,Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Peiying Hua
- Department of Biomedical Data Science and Community and Family Medicine, Dartmouth’s Geisel School of Medicine, Hanover, NH, USA
| | - Tracy Onega
- Department of Population Health Sciences, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT, USA
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Advani S, Abraham L, Buist DS, Kerlikowske K, Miglioretti DL, Sprague BL, Henderson LM, Onega T, Schousboe JT, Demb J, Zhang D, Walter LC, Lee CI, Braithwaite D, O’Meara ES. Breast biopsy patterns and findings among older women undergoing screening mammography: The role of age and comorbidity. J Geriatr Oncol 2022; 13:161-169. [PMID: 34896059 PMCID: PMC9450010 DOI: 10.1016/j.jgo.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/06/2021] [Accepted: 11/29/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Limited evidence exists on the impact of age and comorbidity on biopsy rates and findings among older women. MATERIALS AND METHODS We used data from 170,657 women ages 66-94 enrolled in the United States Breast Cancer Surveillance Consortium (BCSC). We estimated one-year rates of biopsy by type (any, fine-needle aspiration (FNA), core or surgical) and yield of the most invasive biopsy finding (benign, ductal carcinoma in situ (DCIS) and invasive breast cancer) by age and comorbidity. Statistical significance was assessed using Wald statistics comparing coefficients estimated from logistic regression models adjusted for age, comorbidity, BCSC registry, and interaction between age and comorbidity. RESULTS Of 524,860 screening mammograms, 9830 biopsies were performed following 7930 exams (1.5%) within one year, specifically 5589 core biopsies (1.1%), 3422 (0.7%) surgical biopsies and 819 FNAs (0.2%). Biopsy rates per 1000 screens decreased with age (66-74:15.7, 95%CI:14.8-16.8), 75-84:14.5(13.5-15.6), 85-94:13.2(11.3,15.4), ptrend < 0.001) and increased with Charlson Comorbidity Score (CCS = 0:14.4 (13.5-15.3), CCS = 1:16.6 (15.2-18.1), CCS ≥2:19.0 (16.9-21.5), ptrend < 0.001).Biopsy rates increased with CCS at ages 66-74 and 75-84 but not 85-94. Core and surgical biopsy rates increased with CCS at ages 66-74 only. For each biopsy type, the yield of invasive breast cancer increased with age irrespective of comorbidity. DISCUSSION Women aged 66-84 with significant comorbidity in a breast cancer screening population had higher breast biopsy rates and similar rates of invasive breast cancer diagnosis than their counterparts with lower comorbidity. A considerable proportion of these diagnoses may represent overdiagnoses, given the high competing risk of death from non-breast-cancer causes among older women.
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Affiliation(s)
- Shailesh Advani
- Department of Oncology, Georgetown University, Washington, DC
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Diana S.M. Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Karla Kerlikowske
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA,Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Diana L. Miglioretti
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA
| | - Brian L. Sprague
- Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT
| | | | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Joshua Demb
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, University of California, San Diego, La Jolla, CA
| | - Dongyu Zhang
- Department of Epidemiology, University of Florida, Gainesville, FL
| | - Louise C. Walter
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Christoph I. Lee
- Department of Radiology, University of Washington School of Medicine; Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Dejana Braithwaite
- Department of Epidemiology, University of Florida, Gainesville, FL, United States of America; University of Florida Health Cancer Center, Gainesville, FL, United States of America; Department of Aging and Geriatric Research, University of Florida, Gainesville, FL, United States of America.
| | - Ellen S. O’Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
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Smith EJ, Gasper WJ, Schneider P, Finlayson E, Walter LC, Covinsky KE, Conte MS, Iannuzzi JC. Unrecognized Cognitive Impairment Is Common In A VA Population With Peripheral Arterial Disease. Ann Vasc Surg 2022. [DOI: 10.1016/j.avsg.2021.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Zhang D, Abraham L, Sprague BL, Onega T, Advani S, Demb J, Miglioretti DL, Henderson LM, Wernli KJ, Walter LC, Kerlikowske K, Schousboe JT, Chrischilles E, Braithwaite D, O'Meara ES. Mammography adherence in relation to function-related indicators in older women. Prev Med 2022; 154:106869. [PMID: 34762965 PMCID: PMC8724400 DOI: 10.1016/j.ypmed.2021.106869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/08/2021] [Accepted: 11/04/2021] [Indexed: 01/03/2023]
Abstract
Prior studies of screening mammography patterns by functional status in older women show inconsistent results. We used Breast Cancer Surveillance Consortium-Medicare linked data (1999-2014) to investigate the association of functional limitations with adherence to screening mammography in 145,478 women aged 66-74 years. Functional limitation was represented by a claims-based function-related indicator (FRI) score which incorporated 16 items reflecting functional status. Baseline adherence was defined as mammography utilization 9-30 months after the index screening mammography. Longitudinal adherence was examined among women adherent at baseline and defined as time from the index mammography to end of the first 30-month gap in mammography. Multivariable logistic regression and Cox proportional hazards models were used to investigate baseline and longitudinal adherence, respectively. Subgroup analyses were conducted by age (66-70 vs. 71-74 years). Overall, 69.6% of participants had no substantial functional limitation (FRI score 0), 23.5% had some substantial limitations (FRI score 1), and 6.8% had serious limitations (FRI score ≥ 2). Mean age at baseline was 68.5 years (SD = 2.6), 85.3% of participants were white, and 77.1% were adherent to screening mammography at baseline. Women with a higher FRI score were more likely to be non-adherent at baseline (FRI ≥ 2 vs. 0: aOR = 1.13, 95% CI = 1.06, 1.20, p-trend < 0.01). Similarly, a higher FRI score was associated with longitudinal non-adherence (FRI ≥ 2 vs. 0: aHR = 1.16, 95% CI = 1.11, 1.22, p-trend < 0.01). Effect measures of FRI did not differ substantially by age categories. Older women with a higher burden of functional limitations are less likely to be adherent to screening mammography recommendations.
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Affiliation(s)
- Dongyu Zhang
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, United States of America; University of Florida Health Cancer Center, Gainesville, FL, United States of America
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Brian L Sprague
- Department of Surgery, University of Vermont College of Medicine, Burlington, VT, United States of America
| | - Tracy Onega
- Department of Population Health Sciences and the Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States of America
| | - Shailesh Advani
- Department of Oncology, Georgetown University School of Medicine, Washington DC, United States of America
| | - Joshua Demb
- Division of Gastroenterology, Department of Internal Medicine, University of California, San Diego, La Jolla, CA, United States of America
| | - Diana L Miglioretti
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America; Department of Public Health Sciences, University of California, Davis, CA, United States of America
| | - Louise M Henderson
- Department of Radiology, University of North Carolina at Chapel Hill, NC, United States of America
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Karla Kerlikowske
- Department of Medicine, University of California, San Francisco, CA, United States of America; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States of America
| | - John T Schousboe
- Park Nicollet Clinic and HealthPartners Institute, HealthPartners Inc, Bloomington, MN, United States of America; Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, United States of America
| | - Elizabeth Chrischilles
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, United States of America
| | - Dejana Braithwaite
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, United States of America; University of Florida Health Cancer Center, Gainesville, FL, United States of America; Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, Florida.
| | - Ellen S O'Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America. Ellen.S.O'
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Wong ML, Shi Y, Smith AK, Miaskowski C, Boscardin WJ, Cohen HJ, Lam V, Mazor M, Metzger L, Presley CJ, Williams GR, Loh KP, Ursem CJ, Friedlander TW, Blakely CM, Gubens MA, Allen G, Shumay D, Walter LC. Changes in older adults' life space during lung cancer treatment: A mixed methods cohort study. J Am Geriatr Soc 2022; 70:136-149. [PMID: 34611887 PMCID: PMC8742783 DOI: 10.1111/jgs.17474] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Maintenance of function during cancer treatment is important to older adults. Characteristics associated with pretreatment life-space mobility and changes during non-small cell lung cancer (NSCLC) treatment remain unknown. METHODS This mixed methods cohort study recruited adults age ≥65 with advanced NSCLC starting palliative chemotherapy, immunotherapy, and/or targeted therapy from a Comprehensive Cancer Center, Veterans Affairs, and safety-net clinic. Patients completed geriatric assessments including Life-Space Assessment (LSA) pretreatment and at 1, 2, 4, and 6 months after treatment initiation. LSA scores range from 0 to 120 (greater mobility); LSA <60 is considered restricted. We used mixed-effects models to examine pretreatment LSA, change from 0 to 1 month, and change from 1 to 6 months. A subgroup participated in semistructured interviews pretreatment and at 2 and 6 months to understand the patient experience of life-space change. For each interview participant, we created joint displays of longitudinal LSA scores juxtaposed with illustrative quotes. RESULTS Among 93 patients, median age was 73 (range 65-94). Mean pretreatment LSA score was 67.1. On average, LSA declined 10.1 points from pretreatment to 1 month and remained stable at 6 months. Pretreatment LSA score was associated with several demographic, clinical, geriatric assessment, and symptom characteristics. LSA decline at 1 month was greater among patients with high anxiety (slope = -12.6 vs. -2.3, p = 0.048). Pretreatment body mass index <21 kg/m2 was associated with LSA improvement from 1 to 6 months (slope = 4.1 vs. -0.04, p = 0.003). Joint displays illustrated the impact of different life-space trajectories on patients' lives in their words. CONCLUSION Older adults with NSCLC have low pretreatment life space with many developing restricted life space during treatment. Incorporating life-space assessments into clinical cancer care may help older adults concretely visualize how treatment might impact their daily function to allow for informed decision making and identify early changes in mobility to implement supportive interventions.
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Affiliation(s)
- Melisa L. Wong
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Christine Miaskowski
- Departments of Physiological Nursing and Anesthesiology and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging & Human Development and Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Vivian Lam
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Melissa Mazor
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center. Columbus, OH, USA
| | - Grant R. Williams
- Divisions of Hematology/Oncology & Gerontology, Geriatrics, and Palliative Care, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kah Poh Loh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Carling J. Ursem
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
- Division of Hematology-Oncology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Terence W. Friedlander
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
- Division of Hematology-Oncology, Zuckerberg San Francisco General, San Francisco, CA, USA
| | - Collin M. Blakely
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew A. Gubens
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Gregory Allen
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Dianne Shumay
- Department of Psychiatry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Louise C. Walter
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Bauer S, Ensrud K, Walter LC, Suskind AM, Ricke WA, Liu TT, McVary KT, Covinsky K. Association of Frailty Index with Clinical BPH Progression and Serious Adverse Events: the MTOPS Trial. Innov Aging 2021. [PMCID: PMC8681221 DOI: 10.1093/geroni/igab046.2992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Lower urinary tract symptoms due to suspected benign prostatic hyperplasia (BPH) are increasingly treated with medications targeting obstruction among older men, but frailty may represent a novel risk factor for this condition. Our objective was to assess the associations between frailty and clinical BPH progression or serious adverse events (SAE) among 3047 men, age 50-89 years, enrolled in the Medical Therapy of Prostatic Symptoms Study, a placebo-controlled RCT of doxazosin, finasteride, or combination therapy on clinical BPH progression. We created a frailty index using 69 items collected at baseline and categorized men as fit (0-0.1), less fit (0.1-<0.25), or frail (0.25-1.0). The primary outcomes were time to 1) first composite event of clinical BPH progression, and 2) SAE requiring hospitalization. Cox proportional hazards models were adjusted for demographics, intervention, BPH surrogates, and comorbidities. At baseline, 28% men were fit, 58% were less fit, and 14% were frail. During follow-up (mean 4.5 years), the incidence rate of clinical BPH progression was 2.2/100p-y among fit, 3.0/100p-y among less fit (HR =1.28, 95% CI 0.98, 1.67), and 4.1/100p-y among frail men (HR=1.60, 95% CI 1.13, 2.26). Among men randomized to combination therapy, the SAE incidence rate was 3.4/100p-y for fit men versus 12.7/100p-y for frail men (HR=5.98, 95% CI 3.76, 9.52). In conclusion, frailty is independently associated with greater risk of both clinical BPH progression and SAE. The decision to initiate medical therapy for BPH among frail men should therefore include a discussion of both benefits and risks via shared decision making.
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Affiliation(s)
- Scott Bauer
- UCSF and San Francisco VA, San Francisco, California, United States
| | - Kristine Ensrud
- University of Minnesota, Minneapolis, Minnesota, United States
| | - Louise C Walter
- University of California, San Francisco, San Francisco, California, United States
| | - Anne M Suskind
- University of California, San Francisco, San Francisco, California, United States
| | - William A Ricke
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Teresa T Liu
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Kevin T McVary
- Stritch School of Medicine and Loyola University Medical Center, Maywood, Illinois, United States
| | - Kenneth Covinsky
- University of California, San Francisco, San Francisco, California, United States
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Bauer SR, Walter LC, Ensrud KE, Suskind AM, Newman JC, Ricke WA, Liu TT, McVary KT, Covinsky K. Assessment of Frailty and Association With Progression of Benign Prostatic Hyperplasia Symptoms and Serious Adverse Events Among Men Using Drug Therapy. JAMA Netw Open 2021; 4:e2134427. [PMID: 34817584 PMCID: PMC8613596 DOI: 10.1001/jamanetworkopen.2021.34427] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE Benign prostatic hyperplasia (BPH) in older men can cause lower urinary tract symptoms (LUTS), which are increasingly managed with medications. Frailty may contribute to both symptom progression and serious adverse events (SAEs), shifting the balance of benefits and harms of drug therapy. OBJECTIVE To assess the association between a deficit accumulation frailty index and clinical BPH progression or SAE. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Medical Therapy of Prostatic Symptoms trial, which compared placebo, doxazosin, finasteride, and combination therapy in men with moderate-to-severe LUTS, reduced urinary flow rate, and no prior BPH interventions, hypotension, or elevated prostate-specific antigen. Enrollment was from 1995 to 1998, and follow-up was through 2001. Data were assessed in February 2021. EXPOSURES A frailty index (score range, 0-1) using 68 potential deficits collected at baseline was used to categorized men as robust (score ≤0.1), prefrail (score 0.1 to <0.25), or frail (score ≥0.25). MAIN OUTCOMES AND MEASURES Primary outcomes were time to clinical BPH progression and time to SAE, as defined in the parent trial. Adjusted hazard ratios (AHRs) were estimated using Cox proportional hazards regressions adjusted for demographic variables, treatment group, measures of obstruction, and comorbidities. RESULTS Among 3047 men (mean [SD] age, 62.6 [7.3] years; range, 50-89 years) in this analysis, 745 (24%) were robust, 1824 (60%) were prefrail, and 478 (16%) were frail at baseline. Compared with robust men, frail men were older (age ≥75 years, 12 men [2%] vs 62 men [13%]), less likely to be White (646 men [87%] vs 344 men [72%]), less likely to be married (599 men [80%] vs 342 men [72%]), and less likely to have 16 years or more of education (471 men [63%] vs 150 men [31%]). During mean (SD) follow-up of 4.0 (1.5) years, the incidence rate of clinical BPH progression was 2.2 events per 100 person-years among robust men, 2.9 events per 100 person-years among prefrail men (AHR, 1.36; 95% CI, 1.02-1.83), and 4.0 events per 100 person-years among frail men (AHR, 1.82; 95% CI, 1.24-2.67; linear P = .005). Larger point estimates were seen among men who received doxazosin or combination therapy, although the test for interaction between frailty index and treatment group did not reach statistical significance (P for interaction = .06). Risk of SAE was higher among prefrail and frail men (prefrail vs robust AHR, 1.81; 95% CI, 1.48-2.23; frail vs robust AHR, 2.86; 95% CI, 2.21-3.69; linear P < .001); this association was similar across treatment groups (P for interaction = .76). CONCLUSIONS AND RELEVANCE These findings suggest that frailty is independently associated with greater risk of both clinical BPH progression and SAEs. Older frail men with BPH considering initiation of drug therapy should be counseled regarding their higher risk of progression despite combination therapy and their likelihood of experiencing SAEs regardless of treatment choice.
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Affiliation(s)
- Scott R. Bauer
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco
- Department of Urology, University of California, San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Louise C. Walter
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Kristine E. Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
- Center for Care Delivery and Outcomes Research, Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Anne M. Suskind
- Department of Urology, University of California, San Francisco
| | - John C. Newman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Buck Institute for Research on Aging, Novato, California
| | - William A. Ricke
- George M. O’Brien Center of Research Excellence, Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Teresa T. Liu
- George M. O’Brien Center of Research Excellence, Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Kevin T. McVary
- Department of Urology and Center for Male Health, Stritch School of Medicine and Loyola University Medical Center, Maywood, Illinois
| | - Kenneth Covinsky
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
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Chang A, Schwartz BS, Harleman E, Johnson M, Walter LC, Fernandez A. Guiding Academic Clinician Educators at Research-Intensive Institutions: a Framework for Chairs, Chiefs, and Mentors. J Gen Intern Med 2021; 36:3113-3121. [PMID: 33846943 PMCID: PMC8481436 DOI: 10.1007/s11606-021-06713-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/09/2021] [Indexed: 11/21/2022]
Abstract
Department chairs and division chiefs at research-intensive academic medical centers often find mentoring clinician educators challenging. These faculty constitute the majority of academic physicians. Supporting excellent clinician educators is key to ensuring high-quality patient care and developing tomorrow's physicians. Little has been written for leaders on strategies to advance academic clinician educators' career success. We present a framework to guide chairs, chiefs, and mentors seeking to address clinician educator retention and satisfaction in academic medical centers.
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Affiliation(s)
- Anna Chang
- Division of Geriatrics, Department of Medicine, University of California San Francisco School of Medicine (UCSF), San Francisco, CA, USA.
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, USA.
| | - Brian S Schwartz
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco School of Medicine (UCSF), San Francisco, CA, USA
| | - Elizabeth Harleman
- Division of Hospital Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco School of Medicine (UCSF), San Francisco, CA, USA
| | - Meshell Johnson
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, USA
- Division of Pulmonary Medicine, Department of Medicine, University of California San Francisco School of Medicine (UCSF), San Francisco, CA, USA
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California San Francisco School of Medicine (UCSF), San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System (SFVAHCS), San Francisco, CA, USA
| | - Alicia Fernandez
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco School of Medicine (UCSF), San Francisco, CA, USA
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22
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Dotan E, Walter LC, Browner IS, Clifton K, Cohen HJ, Extermann M, Gross C, Gupta S, Hollis G, Hubbard J, Jagsi R, Keating NL, Kessler E, Koll T, Korc-Grodzicki B, McKoy JM, Misra S, Moon D, O'Connor T, Owusu C, Rosko A, Russell M, Sedrak M, Siddiqui F, Stella A, Stirewalt DL, Subbiah IM, Tew WP, Williams GR, Hollinger L, George GV, Sundar H. NCCN Guidelines® Insights: Older Adult Oncology, Version 1.2021. J Natl Compr Canc Netw 2021; 19:1006-1019. [PMID: 34551388 DOI: 10.6004/jnccn.2021.0043] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults, including screening and comprehensive geriatric assessment (CGA), assessing the risks and benefits of treatment, preventing or decreasing complications from therapy, and managing patients deemed to be at high risk for treatment-related toxicity. CGA is a multidisciplinary, in-depth evaluation that assesses the objective health of the older adult while evaluating multiple domains, which may affect cancer prognosis and treatment choices. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines providing specific practical framework for the use of CGA when evaluating older adults with cancer.
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Affiliation(s)
| | | | - Ilene S Browner
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Katherine Clifton
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Cary Gross
- Yale Cancer Center/Smilow Cancer Hospital
| | - Sumati Gupta
- Huntsman Cancer Institute at the University of Utah
| | | | | | | | | | | | | | | | - June M McKoy
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Dominic Moon
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | - Cynthia Owusu
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Ashley Rosko
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | - Amy Stella
- University of Wisconsin Carbone Cancer Center
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23
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Wray CM, Vali M, Walter LC, Christensen L, Chapman W, Austin PC, Byers AL, Keyhani S. Examining the association of social risk with heart failure readmission in the Veterans Health Administration. BMC Health Serv Res 2021; 21:874. [PMID: 34445974 PMCID: PMC8393433 DOI: 10.1186/s12913-021-06888-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/10/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Previous research has found that social risk factors are associated with an increased risk of 30-day readmission. We aimed to assess the association of 5 social risk factors (living alone, lack of social support, marginal housing, substance abuse, and low income) with 30-day Heart Failure (HF) hospital readmissions within the Veterans Health Affairs (VA) and the impact of their inclusion on hospital readmission model performance. METHODS We performed a retrospective cohort study using chart review and VA and Centers for Medicare and Medicaid Services (CMS) administrative data from a random sample of 1,500 elderly (≥ 65 years) Veterans hospitalized for HF in 2012. Using logistic regression, we examined whether any of the social risk factors were associated with 30-day readmission after adjusting for age alone and clinical variables used by CMS in its 30-day risk stratified readmission model. The impact of these five social risk factors on readmission model performance was assessed by comparing c-statistics, likelihood ratio tests, and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS The prevalence varied among the 5 risk factors; low income (47 % vs. 47 %), lives alone (18 % vs. 19 %), substance abuse (14 % vs. 16 %), lacks social support (2 % vs. <1 %), and marginal housing (< 1 % vs. 3 %) among readmitted and non-readmitted patients, respectively. Controlling for clinical factors contained in CMS readmission models, a lack of social support was found to be associated with an increased risk of 30-day readmission (OR 4.8, 95 %CI 1.35-17.88), while marginal housing was noted to decrease readmission risk (OR 0.21, 95 %CI 0.03-0.87). Living alone (OR: 0.9, 95 %CI 0.64-1.26), substance abuse (OR 0.91, 95 %CI 0.67-1.22), and having low income (OR 1.01, 95 %CI 0.77-1.31) had no association with HF readmissions. Adding the five social risk factors to a CMS-based model (age and comorbid conditions; c-statistic 0.62) did not improve model performance (c-statistic: 0.62). CONCLUSIONS While a lack of social support was associated with 30-day readmission in the VA, its prevalence was low. Moreover, the inclusion of some social risk factors did not improve readmission model performance. In an integrated healthcare system like the VA, social risk factors may have a limited effect on 30-day readmission outcomes.
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Affiliation(s)
- Charlie M Wray
- Department of Medicine, University of California, San Francisco, USA.
- Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, University of California San Francisco, 4150 Clement Street, San Francisco, CA, 94121, USA.
| | - Marzieh Vali
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, USA
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - Lee Christensen
- Department of Biomedical Informatics, University of Utah, Salt Lake City, USA
| | - Wendy Chapman
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Amy L Byers
- Department of Psychiatry, University of California, San Francisco, USA
- Mental Health Services, San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - Salomeh Keyhani
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, USA
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24
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Advani SM, Zhu W, Demb J, Sprague BL, Onega T, Henderson LM, Buist DSM, Zhang D, Schousboe JT, Walter LC, Kerlikowske K, Miglioretti DL, Braithwaite D. Association of Breast Density With Breast Cancer Risk Among Women Aged 65 Years or Older by Age Group and Body Mass Index. JAMA Netw Open 2021; 4:e2122810. [PMID: 34436608 PMCID: PMC8391100 DOI: 10.1001/jamanetworkopen.2021.22810] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE Breast density is associated with breast cancer risk in women aged 40 to 65 years, but there is limited evidence of its association with risk of breast cancer among women aged 65 years or older. OBJECTIVE To compare the association between breast density and risk of invasive breast cancer among women aged 65 to 74 years vs women aged 75 years or older and to evaluate whether the association is modified by body mass index (BMI). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used data from the Breast Cancer Surveillance Consortium from January 1, 1996, to December 31, 2012, for US women aged 65 years or older who underwent screening mammography. Data were analyzed from January 1, 2018, to December 31, 2020. EXPOSURES Breast Imaging Reporting and Data System breast density category, age, and BMI. MAIN OUTCOMES AND MEASURES The 5-year cumulative incidence of invasive breast cancer by level of breast density (almost entirely fat, scattered fibroglandular densities, or heterogeneous or extreme density) and age (65-74 vs ≥75 years) was calculated using weighted means. Cox proportional hazards models were fit to estimate the association of breast density with invasive breast cancer risk. The likelihood ratio test was used to test the interaction between BMI and breast density. RESULTS A total of 221 714 screening mammograms from 193 787 women were included in the study; a total of 38% of the study population was aged 75 years or older. Of the mammograms, most were from women aged 65 to 74 years (64.6%) and non-Hispanic White individuals (81.4%). The 5-year cumulative incidence of invasive breast cancer increased in association with increasing breast density among women aged 65 to 74 years (almost entirely fatty breasts: 11.3 per 1000 women [95% CI, 10.4-12.5 per 1000 women]; scattered fibroglandular densities: 17.2 per 1000 women [95% CI, 16.1-17.9 per 1000 women]; extremely or heterogeneously dense breasts: 23.7 per 1000 women [95% CI, 22.4-25.3 per 1000 women]) and among those aged 75 years or older (fatty breasts: 13.5 per 1000 women [95% CI, 11.6-15.5]; scattered fibroglandular densities: 18.4 per 1000 women [95% CI, 17.0-19.5 per 1000 women]; extremely or heterogeneously dense breasts: 22.5 per 1000 women [95% CI, 20.2-24.2 per 1000 women]). Extreme or heterogeneous breast density was associated with increased risk of breast cancer compared with scattered fibroglandular breast density in both age categories (65-74 years: hazard ratio [HR], 1.39 [95% CI, 1.28-1.50]; ≥75 years: HR, 1.23 [95% CI, 1.10-1.37]). Women with almost entirely fatty breasts had a decrease of approximately 30% (range, 27%-34%) in the risk of invasive breast cancer compared with women with scattered fibroglandular breast density (65-74 years: HR, 0.66 [95% CI, 0.58-0.75]; ≥75 years: HR, 0.73; 95% CI, 0.62-0.86). Associations between breast density and breast cancer risk were not significantly modified by BMI (for age 65-74 years: likelihood ratio test, 2.67; df, 2; P = .26; for age ≥75 years, 2.06; df, 2; P = .36). CONCLUSIONS AND RELEVANCE The findings suggest that breast density is associated with increased risk of invasive breast cancer among women aged 65 years or older. Breast density and life expectancy should be considered together when discussing the potential benefits vs harms of continued screening mammography in this population.
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Affiliation(s)
- Shailesh M. Advani
- Department of Oncology, Georgetown University, Washington, DC
- Terasaki Institute of Biomedical Innovation, Los Angeles, California
| | - Weiwei Zhu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joshua Demb
- Department of Medicine, University of California, San Diego
| | - Brian L. Sprague
- Department of Surgery, Larner College of Medicine, University of Vermont, Burlington
| | - Tracy Onega
- Department of Population Sciences, University of Utah, Salt Lake City
| | | | - Diana S. M. Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Dongyu Zhang
- Department of Epidemiology, University of Florida, Gainesville
| | - John T. Schousboe
- Division of Research, Health Partners Institute, Bloomington, Minnesota
| | | | - Karla Kerlikowske
- Department of Medicine, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Public Health Sciences, School of Medicine, University of California, Davis
| | - Dejana Braithwaite
- Terasaki Institute of Biomedical Innovation, Los Angeles, California
- Cancer Control and Population Sciences Program, University of Florida Health Cancer Center, Gainesville
- Department of Epidemiology, University of Florida, Gainesville
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Zhang D, Abraham L, Demb J, Miglioretti DL, Advani S, Sprague BL, Henderson LM, Onega T, Wernli K, Walter LC, Kerlikowske K, Schousboe JT, O'Meara ES, Braithwaite D. Abstract 2531: Function-related indicator and outcomes of screening mammography in older women from the BCSC-Medicare Cohort. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-2531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Although there is evidence pointing to the role of comorbidity and age in screening mammography outcomes among older women, the impact of functional decline on mortality in this population is unknown.
Methods: We used data from 238,849 women in the Breast Cancer Surveillance Consortium-Medicare (BCSC) linked database from 1999-2015 who had at least one screening mammogram at ages 66-94 years. We estimated the 10-year cumulative incidence of breast cancer, breast cancer death, and non-breast cancer death by function-related indicator (FRI) which incorporated 16 claims-based items reflecting functional or health status in older people. In the analysis, FRI score was categorized as an ordinal variable (0, 1, and 2+) and a higher score indicated a higher burden of functional limitations. Fine and Gray proportional sub-distribution hazards models were applied with incident breast cancer and death treated as competing events. Risk estimates by FRI scores (0, 1, and 2+) were adjusted by age and NCI comorbidity index separately and stratified by these factors.
Results: During a median follow-up of 101 months, 9,252 women were diagnosed with breast cancer. During follow-up, 406 women died of breast cancer and 41,640 died from non-breast cancer causes. The 10-year age-adjusted cumulative incidence of invasive breast cancer slightly decreased with increasing FRI score (FRI=0: 4.0%, 95% CI=3.8%-4.1%; FRI=1: 3.9%, 95% CI=3.7%-4.2%; FRI=2+: 3.5%, 95% CI=3.1%-3.9%). Risk of death from non-breast cancer causes increased with FRI score (FRI=0: 18.8%, 95% CI=18.5%-19.1%; FRI=1: 24.4%, 95% CI=23.9%-25.0%; FRI=2+: 39.8%, 95% CI=38.8%-40.9%). Risk of breast cancer death was low with minimal risk differences across FRI scores (FRI=0: 0.24%, 95%CI=0.20%-0.28%; FRI=1: 0.20%, 95%CI=0.14%-0.26%; FRI=2+: 0.30%, 95% CI=0.18%-0.42%). Risk estimates in NCI comorbidity index-adjusted models were largely similar to outcomes in age-adjusted models. Stratified analyses suggested similar patterns of risk estimates by FRI.
Conclusion: Cumulative risk of death from non-breast cancer causes substantially increases with FRI score, suggesting that the potential of screening mammography to benefit older women is low among those with a high burden of functional limitation.
Citation Format: Dongyu Zhang, Linn Abraham, Joshua Demb, Diana L. Miglioretti, Shailesh Advani, Brian L. Sprague, Louise M. Henderson, Tracy Onega, Karen Wernli, Louise C. Walter, Karla Kerlikowske, John T. Schousboe, Ellen S. O'Meara, Dejana Braithwaite. Function-related indicator and outcomes of screening mammography in older women from the BCSC-Medicare Cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2531.
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Affiliation(s)
| | - Linn Abraham
- 2Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Joshua Demb
- 3University of California, San Diego, La Jolla, CA
| | | | | | | | | | | | - Karen Wernli
- 2Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Louise C. Walter
- 9University of California, San Francisco, San Francisco, San Francisco, CA
| | - Karla Kerlikowske
- 9University of California, San Francisco, San Francisco, San Francisco, CA
| | | | - Ellen S. O'Meara
- 2Kaiser Permanente Washington Health Research Institute, Seattle, WA
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26
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Zhang D, Abraham L, Demb J, Miglioretti DL, Advani S, Sprague BL, Henderson LM, Onega T, Wernli KJ, Walter LC, Kerlikowske K, Schousboe JT, O'Meara ES, Braithwaite D. Function-related Indicators and Outcomes of Screening Mammography in Older Women: Evidence from the Breast Cancer Surveillance Consortium Cohort. Cancer Epidemiol Biomarkers Prev 2021; 30:1582-1590. [PMID: 34078641 DOI: 10.1158/1055-9965.epi-21-0152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/02/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Previous reports suggested risk of death and breast cancer varied by comorbidity and age in older women undergoing mammography. However, impacts of functional limitations remain unclear. METHODS We used data from 238,849 women in the Breast Cancer Surveillance Consortium-Medicare linked database (1999-2015) who had screening mammogram at ages 66-94 years. We estimated risk of breast cancer, breast cancer death, and non-breast cancer death by function-related indicator (FRI) which incorporated 16 claims-based items and was categorized as an ordinal variable (0, 1, and 2+). Fine and Gray proportional sub-distribution hazards models were applied with breast cancer and death treated as competing events. Risk estimates by FRI scores were adjusted by age and NCI comorbidity index separately and stratified by these factors. RESULTS Overall, 9,252 women were diagnosed with breast cancer, 406 died of breast cancer, and 41,640 died from non-breast cancer causes. The 10-year age-adjusted invasive breast cancer risk slightly decreased with FRI score [FRI = 0: 4.0%, 95% confidence interval (CI) = 3.8-4.1; FRI = 1: 3.9%, 95% CI = 3.7-4.2; FRI ≥ 2: 3.5%, 95% CI = 3.1-3.9). Risk of non-breast cancer death increased with FRI score (FRI = 0: 18.8%, 95% CI = 18.5-19.1; FRI = 1: 24.4%, 95% CI = 23.9-25.0; FRI ≥ 2: 39.8%, 95% CI = 38.8-40.9]. Risk of breast cancer death was low with minimal differences across FRI scores. NCI comorbidity index-adjusted models and stratified analyses yielded similar patterns. CONCLUSIONS Risk of non-breast cancer death substantially increases with FRI score, whereas risk of breast cancer death is low regardless of functional status. IMPACT Older women with functional limitations should be informed that they may not benefit from screening mammography.
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Affiliation(s)
- Dongyu Zhang
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, Florida.,University of Florida Health Cancer Center, Gainesville, Florida
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joshua Demb
- Division of Gastroenterology, Department of Internal Medicine, University of California, San Diego, La Jolla, California
| | - Diana L Miglioretti
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington.,Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, California
| | - Shailesh Advani
- Transplant Education Research Center, Terasaki Institute of Biomedical Innovation, Los Angeles, California
| | - Brian L Sprague
- Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont
| | - Louise M Henderson
- Department of Radiology, University of North Carolina at Chapel Hill, North Carolina
| | - Tracy Onega
- Department of Population Health Sciences, University of Utah, and Huntsman Cancer Institute, Salt Lake City, Utah
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Karla Kerlikowske
- Department of Medicine, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - John T Schousboe
- Park Nicollet Clinic and HealthPartners Institute, HealthPartners Inc, Bloomington, Minnesota.,Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota
| | - Ellen S O'Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Hampson LA, Suskind AM, Breyer BN, Lai L, Cooperberg MR, Sudore RL, Keyhani S, Allen IE, Walter LC. Understanding the Health Characteristics and Treatment Choices of Older Men with Stress Urinary Incontinence. Urology 2021; 154:281-287. [PMID: 34004214 DOI: 10.1016/j.urology.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To describe the health characteristics and current treatment choices of male stress urinary incontinence (mSUI) patients to inform patient-centered decision-making. METHODS We identified a cohort of mSUI patients aged ≥65 at UCSF and San Francisco VA. Using retrospective chart review and telephone interviews, we ascertained demographics, incontinence characteristics, Charlson Comorbidity Index (score ≥ 4 indicates significant morbidity), frailty with Timed Up and Go (TUG) test, functional dependence with activities of daily living (ADL), calculated life expectancy, and assessed mental health and quality of life (QOL). Bivariate analysis evaluated associations between subject characteristics and ultimate treatment type (conservative vs surgery; sling vs sphincter). Logistic multivariable models evaluating treatment choice were also constructed. RESULTS The 130 participants had a mean age of 75 and a mean incontinence score of 14.2 representing moderately bothersome incontinence. Nearly 80% had significant morbidity, three-quarters had >50% 10-year mortality risk, 10% needed help with 1 + ADL and 22% had a TUG >10 seconds indicating frailty. The mean physical and mental QOL scores were similar to the general population. Anxiety and depression were reported by 3.9% and 10%. In univariate and multivariable analysis, only incontinence characteristics were associated with conservative vs surgical treatment choice (P < .01). CONCLUSION Multi-morbidity, functional dependence, frailty, and limited life expectancy are common among older men with mSUI, yet current treatment choices appear to be driven by incontinence characteristics. As such, mSUI surgery should be considered among men across the spectrum of health and life expectancy.
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Affiliation(s)
- Lindsay A Hampson
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA.
| | - Anne M Suskind
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Benjamin N Breyer
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Lillian Lai
- Department of Urology, University of Michigan Medical School, Ann Arbor, MICH
| | - Matthew R Cooperberg
- Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Rebecca L Sudore
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Salomeh Keyhani
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - I Elaine Allen
- Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Louise C Walter
- Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
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Loh KP, Lam V, Webber K, Padam S, Sedrak MS, Musinipally V, Grogan M, Presley CJ, Grandi J, Sanapala C, Castillo DA, DiGiovanni G, Mohile SG, Walter LC, Wong ML. Characteristics Associated With Functional Changes During Systemic Cancer Treatments: A Systematic Review Focused on Older Adults. J Natl Compr Canc Netw 2021; 19:1055-1062. [PMID: 33857918 DOI: 10.6004/jnccn.2020.7684] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Maintaining functional status is important to older adults with cancer, but data are limited on how systemic treatments affect functional status. We systematically reviewed changes in functional status during systemic cancer treatments and identified characteristics associated with functional decline and improvement. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Register of Controlled Trials for articles examining characteristics associated with functional changes in older adults during systemic cancer treatment published in English between database inception and January 11, 2019 (PROSPERO CRD42019123125). Findings were summarized with descriptive statistics. Study characteristics between older adult-specific and non-older adult-specific studies were compared using the Fisher exact test. RESULTS We screened 15,244 titles/abstracts and 519 full texts. The final analysis included 44 studies, which enrolled >8,400 patients; 39% of studies focused on older adults (1 study enrolled adults aged ≥60 years, 10 enrolled adults aged ≥65 years, and 6 enrolled adults aged ≥70 years). Almost all studies (98%) used patient-reported outcomes to measure functional status; only 20% used physical performance tests. Reporting of functional change was heterogeneous, with 48% reporting change scores. Older adult-specific studies were more likely to analyze functional change dichotomously (29% vs 4%; P=.008). Functional decline ranged widely, from 6% to 90%. The most common patient characteristics associated with functional decline were older age (n=7 studies), worse performance status (n=4), progressive disease status (n=4), pain (n=4), anemia (n=4), and worse nutritional status (n=4). Twelve studies examined functional improvement and identified 11 unique associated characteristics. CONCLUSIONS Functional decline is increasingly recognized as an important outcome in older adults with cancer, but definitions and analyses are heterogeneous, leading to a wide range of prevalence. To identify patients at highest risk of functional decline during systemic cancer treatments, trials need to routinely analyze functional outcomes and measure characteristics associated with decline (eg, nutrition).
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Affiliation(s)
- Kah Poh Loh
- 1Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Vivian Lam
- 2Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Katey Webber
- 3School of Public Health, University of California, Berkeley, Berkeley, California
| | - Simran Padam
- 4Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, California
| | - Mina S Sedrak
- 4Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, California
| | - Vivek Musinipally
- 5Department of Adult and Family Medicine, Kaiser Permanente, San Francisco, California
| | - Madison Grogan
- 6Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Carolyn J Presley
- 6Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Janice Grandi
- 2Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Chandrika Sanapala
- 1Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Daniel A Castillo
- 7Edward G. Miner Library, University of Rochester School of Medicine and Dentistry, Rochester, New York; and
| | - Grace DiGiovanni
- 1Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Supriya G Mohile
- 1Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Louise C Walter
- 8Division of Geriatrics, University of California, San Francisco, and.,9San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Melisa L Wong
- 2Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California.,8Division of Geriatrics, University of California, San Francisco, and.,9San Francisco Veterans Affairs Medical Center, San Francisco, California
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Freedman RA, Minami CA, Winer EP, Morrow M, Smith AK, Walter LC, Sedrak MS, Gagnon H, Perilla-Glen A, Wildiers H, Wildes TM, Lichtman SM, Loh KP, Brain EGC, Ganschow PS, Hunt KK, Mayer DK, Ruddy KJ, Jagsi R, Lin NU, Canin B, LeStage BK, Revette AC, Schonberg MA, Keating NL. Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer: Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement. JAMA Oncol 2021; 7:609-615. [PMID: 33507222 DOI: 10.1001/jamaoncol.2020.7582] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance There is currently no guidance on how to approach surveillance mammography for older breast cancer survivors, particularly when life expectancy is limited. Objective To develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography for breast cancer survivors 75 years or older. Evidence After a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the harms and benefits associated with mammography, a multidisciplinary expert panel was convened to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older. Using an iterative consensus-based approach, input from clinician focus groups, and critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized. Findings The literature review established a low risk for ipsilateral and contralateral breast cancer events in most older breast cancer survivors and summarized the benefits and harms associated with mammography. Draft mammography guidelines were iteratively evaluated by the expert panel and clinician focus groups, emphasizing a patient's risk for in-breast cancer events, age, life expectancy, and personal preferences. The final consensus guidelines recommend discontinuation of routine mammography for all breast cancer survivors when life expectancy is less than 5 years, including those with a history of high-risk cancers; consideration to discontinue mammography when life expectancy is 5 to 10 years; and continuation of mammography when life expectancy is more than 10 years. Individualized, shared decision-making is encouraged to optimally tailor recommendations after weighing the benefits and harms associated with surveillance mammography and patient preferences. The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue. Conclusions and Relevance It is anticipated that these expert guidelines will enhance clinical practice by providing a framework for individualized discussions, facilitating shared decision-making regarding surveillance mammography for breast cancer survivors 75 years or older.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Adriana Perilla-Glen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hans Wildiers
- Department of General Medical Oncology and Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Tanya M Wildes
- Division of Medical Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Pamela S Ganschow
- Department of Medicine, Rush University Medical College and Cook County Health, Chicago, Illinois
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Reshma Jagsi
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor.,Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Barbara K LeStage
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Alliance for Clinical Trials in Oncology, Boston, Massachusetts
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mara A Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Wong ML, Gao J, Thanarajasingam G, Sloan JA, Dueck AC, Novotny PJ, Jatoi A, Hurria A, Walter LC, Miaskowski C, Cohen HJ, Wood WA, Feliciano JL, Stinchcombe TE, Wang X. Expanding Beyond Maximum Grade: Chemotherapy Toxicity over Time by Age and Performance Status in Advanced Non-Small Cell Lung Cancer in CALGB 9730 (Alliance A151729). Oncologist 2021; 26:e435-e444. [PMID: 32951293 PMCID: PMC7930405 DOI: 10.1002/onco.13527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Prior comparisons of chemotherapy adverse events (AEs) by age and performance status (PS) are limited by the traditional maximum grade approach, which ignores low-grade AEs and longitudinal changes. MATERIALS AND METHODS To compare fatigue and neuropathy longitudinally by age (<65, ≥65 years) and PS (0-1, 2), we analyzed data from a large phase III trial of carboplatin and paclitaxel versus paclitaxel for advanced non-small cell lung cancer (CALGB 9730, n = 529). We performed multivariable (a) linear mixed models to estimate mean AE grade over time, (b) linear regression to estimate area under the curve (AUC), and (c) proportional hazards models to estimate the hazard ratio of developing grade ≥2 AE, as well as traditional maximum grade analyses. RESULTS Older patients had on average a 0.17-point (95% confidence interval [CI], 0.00-0.34; p = .049) higher mean fatigue grade longitudinally compared with younger patients. PS 2 was associated with earlier development of grade ≥2 fatigue (hazard ratio [HR], 1.56; 95% CI, 1.07-2.27; p = .02). For neuropathy, older age was associated with earlier development of grade ≥2 neuropathy (HR, 1.41; 95% CI, 1.00-1.97; p = .049). Patients with PS 2 had a 1.30 point lower neuropathy AUC (95% CI, -2.36 to -0.25; p = .02) compared with PS 0-1. In contrast, maximum grade analyses only detected a higher percentage of older adults with grade ≥3 fatigue and neuropathy at some point during treatment. CONCLUSION Our comparison of complementary but distinct aspects of chemotherapy toxicity identified important longitudinal differences in fatigue and neuropathy by age and PS that are missed by the traditional maximum grade approach. Clinical trial identification number: NCT00003117 (CALGB 9730) IMPLICATIONS FOR PRACTICE: The traditional maximum grade approach ignores persistent low-grade adverse events (AEs) and changes over time. This toxicity over time analysis of fatigue and neuropathy during chemotherapy for advanced non-small cell lung cancer demonstrates how to use longitudinal methods to comprehensively characterize AEs over time by age and performance status (PS). We identified important longitudinal differences in fatigue and neuropathy that are missed by the maximum grade approach. This new information about how older adults and patients with PS 2 experience these toxicities longitudinally may be used clinically to improve discussions about treatment options and what to expect to inform shared decision making and symptom management.
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Affiliation(s)
- Melisa L. Wong
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San FranciscoSan FranciscoCaliforniaUSA,Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical CenterSan FranciscoCaliforniaUSA
| | - Junheng Gao
- Alliance Statistics and Data Center, Duke UniversityDurhamNorth CarolinaUSA
| | | | - Jeff A. Sloan
- Alliance Statistics and Data Center, Mayo ClinicRochesterMinnesotaUSA
| | - Amylou C. Dueck
- Alliance Statistics and Data Center, Mayo ClinicScottsdaleArizonaUSA
| | | | - Aminah Jatoi
- Division of Medical Oncology, Mayo ClinicRochesterMinnesotaUSA
| | - Arti Hurria
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer CenterDuarteCaliforniaUSA
| | - Louise C. Walter
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical CenterSan FranciscoCaliforniaUSA
| | - Christine Miaskowski
- Department of Physiological Nursing, University of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Harvey J. Cohen
- Center for the Study of Aging and Human Development, Duke UniversityDurhamNorth CarolinaUSA
| | - William A. Wood
- Lineberger Comprehensive Cancer Center, Division of Hematology/Oncology, University of North Carolina, Chapel HillChapel HillNorth CarolinaUSA
| | - Josephine L. Feliciano
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical CenterBaltimoreMarylandUSA
| | | | - Xiaofei Wang
- Alliance Statistics and Data Center, Duke UniversityDurhamNorth CarolinaUSA
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Wray CM, Vali M, Walter LC, Christensen L, Abdelrahman S, Chapman W, Keyhani S. Examining the Interfacility Variation of Social Determinants of Health in the Veterans Health Administration. Fed Pract 2021; 38:15-19. [PMID: 33574644 DOI: 10.12788/fp.0080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction Recently, numerous studies have linked social determinants of health (SDoH) with clinical outcomes. While this association is well known, the interfacility variability of these risk favors within the Veterans Health Administration (VHA) is not known. Such information could be useful to the VHA for resource and funding allocation. The aim of this study is to explore the interfacility variability of 5 SDoH within the VHA. Methods In a cohort of patients (aged ≥ 65 years) hospitalized at VHA acute care facilities with either acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2012, we assessed (1) the proportion of patients with any of the following five documented SDoH: lives alone, marginal housing, alcohol use disorder, substance use disorder, and use of substance use services, using administrative diagnosis codes and clinic stop codes; and (2) the documented facility-level variability of these SDoH. To examine whether variability was due to regional coding differences, we assessed the variation of living alone using a validated natural language processing (NLP) algorithm. Results The proportion of veterans admitted for AMI, HF, and pneumonia with SDoH was low. Across all 3 conditions, lives alone was the most common SDoH (2.2% [interquartile range (IQR), 0.7-4.7]), followed by substance use disorder (1.3% [IQR, 0.5-2.1]), and use of substance use services (1.2% [IQR, 0.6-1.8]). Using NLP, the proportion of hospitalized veterans with lives alone was higher for HF (14.4% vs 2.0%, P < .01), pneumonia (11% vs 1.9%, P < .01), and AMI (10.2% vs 1.4%, P < .01) compared with International Classification of Diseases, Ninth Edition codes. Interfacility variability was noted with both administrative and NLP extraction methods. Conclusions The presence of SDoH in administrative data among patients hospitalized for common medical issues is low and variable across VHA facilities. Significant facility-level variation of 5 SDoH was present regardless of extraction method.
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Affiliation(s)
- Charlie M Wray
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Marzieh Vali
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Louise C Walter
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Lee Christensen
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Samir Abdelrahman
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Wendy Chapman
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Salomeh Keyhani
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
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Demb J, Abraham L, Miglioretti DL, Sprague BL, O'Meara ES, Advani S, Henderson LM, Onega T, Buist DSM, Schousboe JT, Walter LC, Kerlikowske K, Braithwaite D. Screening Mammography Outcomes: Risk of Breast Cancer and Mortality by Comorbidity Score and Age. J Natl Cancer Inst 2021; 112:599-606. [PMID: 31593591 DOI: 10.1093/jnci/djz172] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/22/2019] [Accepted: 08/23/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Potential benefits of screening mammography among women ages 75 years and older remain unclear. METHODS We evaluated 10-year cumulative incidence of breast cancer and death from breast cancer and other causes by Charlson Comorbidity Index (CCI) and age in the Medicare-linked Breast Cancer Surveillance Consortium (1999-2010) cohort of 222 088 women with no less than 1 screening mammogram between ages 66 and 94 years. RESULTS During median follow-up of 107 months, 7583 were diagnosed with invasive breast cancer and 1742 with ductal carcinoma in situ; 471 died from breast cancer and 42 229 from other causes. The 10-year cumulative incidence of invasive breast cancer did not change with increasing CCI but decreased slightly with age: ages 66-74 years (CCI0 = 4.0% [95% CI = 3.9% to 4.2%] vs CCI ≥ 2 = 3.9% [95% CI = 3.5% to 4.3%]); ages 75-84 years (CCI0 = 3.7% [95% CI = 3.5% to 3.9%] vs CCI ≥ 2 = 3.4% [95% CI = 2.9% to 3.9%]); and ages 85-94 years (CCI0 = 2.7% [95% CI = 2.3% to 3.1%] vs CCI ≥ 2 = 2.1% [95% CI = 1.3% to 3.0%]). The 10-year cumulative incidence of other-cause death increased with increasing CCI and age: ages 66-74 years (CCI0 = 10.4% [95% CI = 10.3 to 10.7%] vs CCI ≥ 2 = 43.4% [95% CI = 42.2% to 44.4%]), ages 75-84 years (CCI0 = 29.8% [95% CI = 29.3% to 30.2%] vs CCI ≥ 2 = 61.7% [95% CI = 60.2% to 63.3%]), and ages 85 to 94 years (CCI0 = 60.3% [95% CI = 59.1% to 61.5%] vs CCI ≥ 2 = 84.8% [95% CI = 82.5% to 86.9%]). The 10-year cumulative incidence of breast cancer death was small and did not vary by age: ages 66-74 years = 0.2% (95% CI = 0.2% to 0.3%), ages 75-84 years = 0.29% (95% CI = 0.25% to 0.34%), and ages 85 to 94 years = 0.3% (95% CI = 0.2% to 0.4%). CONCLUSIONS Cumulative incidence of other-cause death was many times higher than breast cancer incidence and death, depending on comorbidity and age. Hence, older women with increased comorbidity may experience diminished benefit from continued screening.
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Affiliation(s)
- Joshua Demb
- Department of Epidemiology and Biostatistics.,University of California, San Francisco, San Francisco.,Department of Oncology, Georgetown University, Washington, DC
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Diana L Miglioretti
- Kaiser Permanente Washington Health Research Institute, Seattle.,Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA
| | - Brian L Sprague
- Department of Surgery, University of Vermont College of Medicine, Burlington, VT
| | - Ellen S O'Meara
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Shailesh Advani
- University of California, San Francisco, San Francisco.,Department of Oncology, Georgetown University, Washington, DC
| | - Louise M Henderson
- Department of Radiology, University of North Carolina at Chapel Hill, NC
| | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - John T Schousboe
- Park Nicollet Clinic & Health Partners Institute, Bloomington, MN
| | | | - Karla Kerlikowske
- Department of Epidemiology and Biostatistics.,Department of Medicine
| | - Dejana Braithwaite
- University of California, San Francisco, San Francisco.,Department of Oncology, Georgetown University, Washington, DC
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Abstract
Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered more effective, easy to understand, and acceptable by older adults and clinicians.
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Affiliation(s)
- Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers CR, Herzig A, Guerra CE, Oeffinger KC, Shih YCT, Walter LC, Kim JJ, Andrews KS, DeSantis CE, Fedewa SA, Manassaram-Baptiste D, Saslow D, Wender RC, Smith RA. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin 2020; 70:321-346. [PMID: 32729638 DOI: 10.3322/caac.21628] [Citation(s) in RCA: 376] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/09/2020] [Indexed: 12/22/2022] Open
Abstract
The American Cancer Society (ACS) recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation). The ACS recommends that individuals aged >65 years who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, and who have documented adequate negative prior screening in the prior 10 years, discontinue all cervical cancer screening (qualified recommendation). These new screening recommendations differ in 4 important respects compared with the 2012 recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers. Evidence related to other relevant issues was reviewed, and no changes were made to recommendations for screening intervals, age or criteria for screening cessation, screening based on vaccination status, or screening after hysterectomy. Follow-up for individuals who screen positive for HPV and/or cytology should be in accordance with the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.
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Affiliation(s)
| | - Andrew M D Wolf
- Division of General Medicine, Geriatrics, and Palliative Care, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Timothy R Church
- Division of Environmental Health Sciences, University of Minnesota School of Public Health and Masonic Cancer Center, Minneapolis, Minneapolis
| | - Ruth Etzioni
- Public Health Sciences Division, the Fred Hutchinson Cancer Research Center, Seattle, Washington
- Biostatistics, University of Washington Seattle, Seattle, Washington
| | - Christopher R Flowers
- Department of Lymphoma/Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Abbe Herzig
- University of Albany School of Public Health, Albany, New York
| | - Carmen E Guerra
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Kevin C Oeffinger
- Duke Cancer Institute Center for Onco-Primary Care, Durham, North Carolina
| | - Ya-Chen Tina Shih
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Louise C Walter
- Division of Geriatrics, University of California-San Francisco, San Francisco, California
- Division of Geriatrics, San Francisco VA Health Care System, San Francisco, California
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kimberly S Andrews
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia
| | - Carol E DeSantis
- Surveillance Research, American Cancer Society, Atlanta, Georgia
| | - Stacey A Fedewa
- Surveillance Research, American Cancer Society, Atlanta, Georgia
| | | | - Debbie Saslow
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia
| | - Richard C Wender
- Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert A Smith
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia
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Zhang D, Advani S, Zhu Z, Dang L, Walter LC, Braithwaite D. Mammography use in relation to comorbidities and functional limitations among older breast cancer survivors. J Cancer Surviv 2020; 15:119-126. [PMID: 32720225 DOI: 10.1007/s11764-020-00917-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE We sought to examine associations of mammography utilization with comorbidities and functional limitations in older breast cancer survivors. METHODS Female breast cancer survivors (N = 1064) identified in the 2016 and 2018 Behavioral Risk Factor Surveillance System (BRFSS) who were aged ≥ 65 years were included for this study. Mammography use, major comorbidities (diabetes mellitus, myocardial infarction, coronary heart disease, stroke, chronic obstructive pulmonary disease, arthritis, chronic kidney disease, depression, and malignancy other than breast cancer), functional limitations (impairment of vision, audition, cognition, and mobility), and other covariates were measured by self-report. We used multivariable logistic regression models to calculate adjusted odds ratios (aOR) of comorbidities and functional limitations. Subgroup analyses were conducted by age (65-74 vs. ≥ 75 years) and survival time (< 10 vs. ≥ 10 years), and interactions were examined by Wald tests. RESULTS Of the 1064 respondents, 841 (79.0%) had comorbidities, 418 (39.3%) had functional limitations, and 744 (69.9%) underwent mammography last year. Overall, the mean age was 73.8 years (SD = 5.1 years) and 91.4% were white. The multivariable model identified inverse associations with mammography use for functional limitations (≥ 2 vs. 0: aOR = 0.61, 95% CI = 0.39-0.95, p-trend = 0.09) but not comorbidities (≥ 2 vs. 0: aOR = 0.91, 95% CI = 0.61-1.35, p-trend = 0.62). The Wald test did not find any significant interaction. CONCLUSIONS A higher burden of functional limitations, not comorbidities, is associated with a lower rate of mammography use among older breast cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS Interventions are needed to individualize surveillance mammography among older breast cancer survivors based on their health status.
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Affiliation(s)
- Dongyu Zhang
- Department of Oncology, Georgetown University School of Medicine, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Shailesh Advani
- Department of Oncology, Georgetown University School of Medicine, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.,Social Behavioral Research Branch, National Institute of Health, National Human Genome Research Institute, Bethesda, MD, USA
| | - Zhikai Zhu
- Department of Oncology, Georgetown University School of Medicine, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.,Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) & Peking Union Medical College (PUMC), Beijing, China
| | - Le Dang
- Department of Oncology, Georgetown University School of Medicine, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.,National Cancer Center/National Clinical Research Center for Cancer /Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) & Peking Union Medical College (PUMC), Beijing, China
| | - Louise C Walter
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, CA, USA.,Department of Medicine, Division of Geriatrics, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Dejana Braithwaite
- Department of Oncology, Georgetown University School of Medicine, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.
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Junn A, Shukla NR, Morrison L, Halley M, Chren MM, Walter LC, Frosch DL, Matlock D, Torres JS, Linos E. Development of a patient decision aid for the management of superficial basal cell carcinoma (BCC) in adults with a limited life expectancy. BMC Med Inform Decis Mak 2020; 20:81. [PMID: 32349762 PMCID: PMC7191775 DOI: 10.1186/s12911-020-1081-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 03/29/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Basal cell carcinoma (BCC) is a slow-growing, rarely lethal skin cancer that affects people 65 years or older. A range of treatment options exist for BCC, but there is little evidence available to guide patients and providers in selecting the best treatment options. OBJECTIVES This study outlines the development of a patient decision aid (PDA) for low-risk BCC that can be used by patients and providers to assist in shared decision-making. METHODS In accordance with the International Patient Decision Aids Standards (IPDAS) Collaboration framework, feedback from focus groups and semi-structured interviews with patients and providers, an initial prototype of the PDA was developed. This was tested using cognitive interviews and iteratively updated. RESULTS We created eighteen different iterations using feedback from 24 patients and 34 providers. The key issues identified included: 1) Addressing fear of cancer; 2) Communicating risk and uncertainty; 3) Values clarification; and 4) Time lag to benefit. LIMITATIONS The PDA does not include all possible treatment options and is currently paper based. CONCLUSIONS Our PDA has been specifically adapted and designed to support patients with a limited life expectancy in making decisions about their low risk BCC together with their doctors.
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Affiliation(s)
- Alexandra Junn
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, USA
| | - Neha R Shukla
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, USA
| | - Lily Morrison
- Department of Dermatology, Stanford University, CCSR Building Room 4235, 269 Campus Drive, Stanford, USA
| | - Meghan Halley
- Department of Dermatology, Stanford University, CCSR Building Room 4235, 269 Campus Drive, Stanford, USA
- Palo Alto Medical Foundation Research Institute, Palo Alto, USA
| | - Mary-Margaret Chren
- Department of Dermatology, Vanderbilt University Medical Centre, Tennessee, Nashville, USA
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
- San Francisco and San Francisco VA Medical Center, San Francisco, USA
| | - Dominick L Frosch
- Palo Alto Medical Foundation Research Institute, Palo Alto, USA
- Department of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Dan Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Centre, Denver, USA
| | - Jeanette S Torres
- Program for Clinical Research, Department of Dermatology, University of California San Francisco, San Francisco, USA
| | - Eleni Linos
- Department of Dermatology, Stanford University, CCSR Building Room 4235, 269 Campus Drive, Stanford, USA.
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Sedrak MS, Li D, Walter LC, Mustian K, High KP, Canin B, Mohile SG, Dale W, Sun CL. Cores for geriatric oncology infrastructure in the Cancer and Aging Research Group: Biostatistics, epidemiology, and research design (the analytics core). J Geriatr Oncol 2020; 11:355-358. [PMID: 31326391 PMCID: PMC6980442 DOI: 10.1016/j.jgo.2019.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, United States of America.
| | - Daneng Li
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, United States of America
| | - Louise C Walter
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, United States of America; San Francisco VA Medical Center, San Francisco, CA, United States of America
| | - Karen Mustian
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Kevin P High
- Wake Forest Baptist Medical Center, Winston-Salem, NC, United States of America
| | - Beverly Canin
- SCOREboard Advisory Group, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Supriya G Mohile
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States of America
| | - William Dale
- Department of Supportive Care Medicine, City of Hope, Duarte, CA, United States of America
| | - Can-Lan Sun
- Department of Supportive Care Medicine, City of Hope, Duarte, CA, United States of America
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Tang V, Zhao S, Boscardin J, Sudore R, Covinsky K, Walter LC, Esserman L, Mukhtar R, Finlayson E. Functional Status and Survival After Breast Cancer Surgery in Nursing Home Residents. JAMA Surg 2019; 153:1090-1096. [PMID: 30167636 DOI: 10.1001/jamasurg.2018.2736] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Breast cancer surgery, the most common cancer operation performed in nursing home residents, is viewed as a low-risk surgical intervention. However, outcomes in patients with high functional dependence and limited life expectancy are poorly understood. Objective To assess the overall survival and functional status changes after breast cancer surgery in female nursing home residents stratified by surgery type. Design, Setting, and Participants This study used Medicare claims from 2003 to 2013 to identify 5969 US nursing home residents who underwent inpatient breast cancer surgery. Using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, this study examined preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs) of mortality. Fine-Gray competing risks regression was used to estimate unadjusted and adjusted subhazard ratios (sHRs) of functional decline. Statistical analysis was performed from January 2016 to January 2018. Main Outcomes and Measures Functional status and death. Results From 2003 to 2013, a total of 5969 female nursing home residents (mean [SD] age, 82 [7] years; 4960 [83.1%] white) underwent breast cancer surgery: 666 (11.2%) underwent lumpectomy, 1642 (27.5%) underwent mastectomy, and 3661 (61.3%) underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND). The 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND. The 1-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND. Among 1-year survivors, the functional decline rate was 56% to 60%. The mean MDS-ADL score increased (signifying greater dependency) by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND. In multivariate analysis, poor baseline MDS-ADL score (range, 20-28) was associated with a higher 1-year mortality risk (lumpectomy: HR, 1.92 [95% CI, 1.23-3.00], P = .004; mastectomy: HR, 1.80 [95% CI, 1.35-2.39], P < .001; and ALND: HR, 1.77 [95% CI, 1.46-2.15], P < .001). After multivariate adjustment, preoperative decline in MDS-ADL score (lumpectomy: sHR, 1.59 [95% CI, 1.25-2.03], P < .001; mastectomy: sHR, 1.79; [95% CI, 1.52-2.09], P < .001; and ALND: sHR, 1.72 [95% CI, 1.56-1.91], P < .001) and cognitive impairment (lumpectomy: sHR, 1.27 [95% CI, 1.03-1.56], P = .02; mastectomy: sHR, 1.26 [95% CI, 1.09-1.45], P = .002; and ALND: sHR, 1.14 [95% CI, 1.04-1.24], P = .003) were significantly associated with 1-year functional decline across all breast cancer surgery groups. Conclusions and Relevance For female nursing home residents who underwent breast cancer surgery, 30-day mortality and survival as well as 1-year mortality and functional decline were high. The 1-year survivors had significant functional decline. This study's findings suggest that this information should be incorporated into collaborative surgical decision-making processes.
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Affiliation(s)
- Victoria Tang
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Shoujun Zhao
- Department of Surgery, University of California, San Francisco
| | - John Boscardin
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Rebecca Sudore
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kenneth Covinsky
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Louise C Walter
- Division of Geriatrics, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco.,Department of Radiology, University of California, San Francisco.,Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Rita Mukhtar
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco.,Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco
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Carpenter CR, Mody L, Lundebjerg NE, Walter LC, Schmader KE, High K. Do what you love. Love what you do. Dr. Arti Hurria's trailblazing transdisciplinary legacy. J Geriatr Oncol 2019; 11:158-159. [PMID: 31378641 DOI: 10.1016/j.jgo.2019.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/25/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher R Carpenter
- Washington University in St. Louis School of Medicine, 660 S Euclid Avenue, Campus Box 8072, Saint Louis, MO 63110, USA.
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Geriatrics Research Education and Clinical Center, VA Ann Arbor Healthcare System, 300 North Ingalls Building, Rm 905, Ann Arbor, MI 48109, USA.
| | - Nancy E Lundebjerg
- American Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038, USA.
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco VA Medical Center, 4150 Clement Street, 181-G, San Francisco, CA 94121, USA.
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center Durham, NC, USA; Durham VA Health Care System, 182 GRECC, 508 Fulton St., Durham, NC 27705, USA.
| | - Kevin High
- Health System, Wake Forest Baptist Health, USA; Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA; Sections on Infectious Diseases, Wake Forest School of Medicine, Winston Salem, NC, USA; Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest School of Medicine, Winston Salem, NC, USA.
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Kotwal AA, Walter LC, Lee SJ, Dale W. Are We Choosing Wisely? Older Adults' Cancer Screening Intentions and Recalled Discussions with Physicians About Stopping. J Gen Intern Med 2019; 34:1538-1545. [PMID: 31147981 PMCID: PMC6667516 DOI: 10.1007/s11606-019-05064-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 01/11/2019] [Accepted: 04/11/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND National guidelines recommend against cancer screening for older individuals with less than a 10-year life expectancy, but it is unknown if this population desires ongoing screening. OBJECTIVE To determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening. DESIGN National Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey. PARTICIPANTS Community-dwelling adults 55-97 years old (n = 3816). MAIN MEASURES Self-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates. KEY RESULTS Among women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001). CONCLUSION Over 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.
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Affiliation(s)
- Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA
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Wray CM, Vali M, Abraham A, Zhang A, Walter LC, Keyhani S. Validation of Administrative Measures of Social and Behavioral Risk in Veterans Affairs Medical Records. J Gen Intern Med 2019; 34:796-798. [PMID: 30604115 PMCID: PMC6544671 DOI: 10.1007/s11606-018-4792-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Charlie M Wray
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA. .,Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, Clement Street, San Francisco, CA, USA.
| | - Marzieh Vali
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Ann Abraham
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Alysandra Zhang
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Louise C Walter
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Wray CM, Vali M, Walter LC, Lopez L, Austin PC, Byers A, Keyhani S. Examining the Utility of 30-day Readmission Rates and Hospital Profiling in the Veterans Health Administration. J Hosp Med 2019; 14:266-271. [PMID: 30794141 DOI: 10.12788/jhm.3155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 12/20/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) reports hospital-specific 30-day risk-standardized readmission rates (RSRRs) using CMS-derived models. OBJECTIVE The aim of this study was to examine and describe the interfacility variability of 30-day RSRRs for acute myocardial infarction (AMI), heart failure (HF), and pneumonia as a means to assess its utility for VA quality improvement and hospital comparison. RESEARCH DESIGN A retrospective analysis of VA and Medicare claims data using one-year (2012) and three-year (2010-2012) data given their use for quality improvement or for hospital comparison, respectively. SUBJECTS This study included 3,571 patients hospitalized for AMI at 56 hospitals, 10,609 patients hospitalized for HF at 102 hospitals, and 10,191 patients hospitalized for pneumonia at 106 hospitals. MEASURES Hospital-specific 30-day RSRRs for AMI, HF, and pneumonia hospitalizations were calculated using hierarchical generalized linear models. RESULTS Of 164 qualifying VA hospitals, 56 (34%), 102 (62%), and 106 (64%) qualified for analysis based on CMS criteria for AMI, HF, and pneumonia cohorts, respectively. Using 2012 data, we found that two hospitals (2%) had CHF RSRRs worse than the national average (+95% CI), whereas no hospital demonstrated worse-than-average risk-stratified readmission Rate (RSRR; +95% CI) for AMI or pneumonia. After increasing the number of facility admissions by combining three years of data, we found that four (range: 3.5%-5.3%) hospitals had RSRRs worse than the national average (+95% CI) for all three conditions. CONCLUSIONS The Centers for Medicare and Medicaid Services-derived 30-day readmission measure may not be a useful measure to distinguish VA interfacility performance or drive quality improvement given the low facility-level volume of such readmissions.
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Affiliation(s)
- Charlie M Wray
- Department of Medicine, University of California, San Francisco, California
- Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Marzieh Vali
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, California
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Lenny Lopez
- Department of Medicine, University of California, San Francisco, California
- Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Amy Byers
- Department of Medicine, University of California, San Francisco, California
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, California
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
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Conway M, Keyhani S, Christensen L, South BR, Vali M, Walter LC, Mowery DL, Abdelrahman S, Chapman WW. Moonstone: a novel natural language processing system for inferring social risk from clinical narratives. J Biomed Semantics 2019; 10:6. [PMID: 30975223 PMCID: PMC6458709 DOI: 10.1186/s13326-019-0198-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background Social risk factors are important dimensions of health and are linked to access to care, quality of life, health outcomes and life expectancy. However, in the Electronic Health Record, data related to many social risk factors are primarily recorded in free-text clinical notes, rather than as more readily computable structured data, and hence cannot currently be easily incorporated into automated assessments of health. In this paper, we present Moonstone, a new, highly configurable rule-based clinical natural language processing system designed to automatically extract information that requires inferencing from clinical notes. Our initial use case for the tool is focused on the automatic extraction of social risk factor information — in this case, housing situation, living alone, and social support — from clinical notes. Nursing notes, social work notes, emergency room physician notes, primary care notes, hospital admission notes, and discharge summaries, all derived from the Veterans Health Administration, were used for algorithm development and evaluation. Results An evaluation of Moonstone demonstrated that the system is highly accurate in extracting and classifying the three variables of interest (housing situation, living alone, and social support). The system achieved positive predictive value (i.e. precision) scores ranging from 0.66 (homeless/marginally housed) to 0.98 (lives at home/not homeless), accuracy scores ranging from 0.63 (lives in facility) to 0.95 (lives alone), and sensitivity (i.e. recall) scores ranging from 0.75 (lives in facility) to 0.97 (lives alone). Conclusions The Moonstone system is — to the best of our knowledge — the first freely available, open source natural language processing system designed to extract social risk factors from clinical text with good (lives in facility) to excellent (lives alone) performance. Although developed with the social risk factor identification task in mind, Moonstone provides a powerful tool to address a range of clinical natural language processing tasks, especially those tasks that require nuanced linguistic processing in conjunction with inference capabilities.
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Affiliation(s)
- Mike Conway
- Department of Biomedical Informatics, 421 Wakara Way, University of Utah, alt Lake City, 84108, UT, USA.
| | - Salomeh Keyhani
- San Francisco VA Medical Center, 4150 Clement Street, San Francisco, 94121, CA, USA.,Department of Medicine, University of California San Francisco, 505 Parnassus Ave, San Francisco, 94143, CA, USA
| | - Lee Christensen
- Department of Biomedical Informatics, 421 Wakara Way, University of Utah, alt Lake City, 84108, UT, USA
| | - Brett R South
- Department of Biomedical Informatics, 421 Wakara Way, University of Utah, alt Lake City, 84108, UT, USA.,Salt Lake City VA Health Care System, 500 Foothill Drive, Salt Lake City, 84148, UT, USA
| | - Marzieh Vali
- San Francisco VA Medical Center, 4150 Clement Street, San Francisco, 94121, CA, USA
| | - Louise C Walter
- San Francisco VA Medical Center, 4150 Clement Street, San Francisco, 94121, CA, USA.,Department of Medicine, University of California San Francisco, 505 Parnassus Ave, San Francisco, 94143, CA, USA
| | - Danielle L Mowery
- Department of Biomedical Informatics, 421 Wakara Way, University of Utah, alt Lake City, 84108, UT, USA.,Salt Lake City VA Health Care System, 500 Foothill Drive, Salt Lake City, 84148, UT, USA
| | - Samir Abdelrahman
- Department of Biomedical Informatics, 421 Wakara Way, University of Utah, alt Lake City, 84108, UT, USA
| | - Wendy W Chapman
- Department of Biomedical Informatics, 421 Wakara Way, University of Utah, alt Lake City, 84108, UT, USA.,Salt Lake City VA Health Care System, 500 Foothill Drive, Salt Lake City, 84148, UT, USA
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Carpenter CR, Hurria A, Lundebjerg NE, Walter LC, Mody L. Leadership Lessons: Developing Mentoring Infrastructure for GEMSSTAR Scholars. J Am Geriatr Soc 2019; 67:650-656. [PMID: 30693945 PMCID: PMC6458079 DOI: 10.1111/jgs.15787] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/22/2018] [Indexed: 11/28/2022]
Abstract
Through the National Institute on Aging's (NIA's) "Grants for Early Medical/Surgical Specialists" Transition to Aging Research (GEMSSTAR) U13 grant, the NIA and the American Geriatrics Society (AGS) developed three transdisciplinary research conferences with a focus on mentoring and leadership skills development. The NIA's GEMSSTAR program evolved from two earlier programs, the AGS' Dennis W. Jahnigen and the Association of Specialty Professors' T. Franklin Williams Career Development Scholars Awards. It supports the continued cultivation of the next generation of medical and surgical specialty researchers with an interest in aging research. The award requires both geriatrics and specialty mentoring and currently provides up to $150,000 a year in direct support to scholars. Additionally, the award requires that scholars have a professional development plan that is complementary to the GEMSSTAR award. The U13 conferences, focused on frailty, models of aging, and cognition, brought together GEMSSTAR scholars, former scholars, innovators, mentors, and leaders in aging research, the specialties, and geriatric medicine. This article describes the themes of each of the GEMSSTAR U13 conferences and highlights the lessons learned on mentoring, team science, aging research networks, and work-life balance. We plan to use these lessons to guide the support we provide to the growing group of emerging leaders who are poised to lead the transdisciplinary research network of the future. J Am Geriatr Soc 67:650-656, 2019.
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Affiliation(s)
| | - Arti Hurria
- City of Hope National Medical Center, Duarte, CA
| | | | - Louise C. Walter
- University of California, San Francisco School of Medicine, San Francisco, CA
| | - Lona Mody
- University of Michigan, Ann Arbor, MI
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Washington SL, Porten SP, Quanstrom K, Jin C, Bridge M, Finlayson E, Walter LC, Suskind AM. The Association Between Race and Frailty in Older Adults Presenting to a Nononcologic Urology Practice. Urology 2019; 127:19-23. [PMID: 30822479 DOI: 10.1016/j.urology.2019.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/08/2019] [Accepted: 02/21/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To explore whether there is an association between nonwhite race and frailty among older adults presenting to an academic nononcologic urology practice. MATERIALS AND METHODS This is a prospective study of individuals ages ≥65years presenting to a nononcologic urology practice between December 2015 and November 2016. All individuals had a Timed Up and Go Test (TUGT, where a slower TUGT time of ≥15 seconds is suggestive of frailty. TUGT times, race (white vs nonwhite), and other clinical data were extracted from the electronic medical record using direct queries. Multivariable logistic regression was used to identify the association between race and slower TUGT times while adjusting for age, gender, number of medications, body mass index, and number of urologic diagnoses. RESULTS Among the 1715 individuals in our cohort, 33.9% were of nonwhite race and 15.3% had TUGT ≥15 seconds. A higher percentage of nonwhite individuals had TUGT times ≥15 seconds compared to white individuals (23.6% vs 11.1%, P <.01). TUGT times ≥15 seconds were significantly associated with nonwhite race after adjusting for clinical factors (adjusted odds ratio 2.5, 95% confidence interval 1.8-3.3). CONCLUSION Among older adults presenting to an academic nononcologic urology practice, nonwhite race was associated with increased odds of frailty. A greater understanding of the relationship between race and frailty is needed to better address the needs of this vulnerable population.
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Affiliation(s)
| | - Sima P Porten
- Department of Urology, University of California, San Francisco, CA
| | | | - Chengshi Jin
- Department of Urology, University of California, San Francisco, CA
| | - Mark Bridge
- Department of Urology, University of California, San Francisco, CA
| | - Emily Finlayson
- Department of General Surgery, University of California, San Francisco, CA
| | - Louise C Walter
- Division of Geriatrics, University of California, San Francisco, CA; San Francisco VA Medical Center, San Francisco, CA
| | - Anne M Suskind
- Department of Urology, University of California, San Francisco, CA
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Wong ML, Paul SM, Mastick J, Ritchie C, Steinman MA, Walter LC, Miaskowski C. Characteristics Associated With Physical Function Trajectories in Older Adults With Cancer During Chemotherapy. J Pain Symptom Manage 2018; 56:678-688.e1. [PMID: 30144536 PMCID: PMC6195841 DOI: 10.1016/j.jpainsymman.2018.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/07/2018] [Accepted: 08/13/2018] [Indexed: 12/27/2022]
Abstract
CONTEXT Studies on physical function trajectories in older adults during chemotherapy remain limited. OBJECTIVES The objective of this study was to determine demographic, clinical, and symptom characteristics associated with initial levels as well as trajectories of physical function over two cycles of chemotherapy in adults aged ≥65 years with breast, gastrointestinal, gynecological, or lung cancer. METHODS Older adults with cancer (n = 363) who had received chemotherapy within the preceding four weeks were assessed six times over two cycles of chemotherapy using the Short Form-12 Physical Component Summary (PCS) score. Hierarchical linear modeling was used to evaluate for interindividual variability in initial levels and trajectories of PCS scores. RESULTS Mean age was 71.4 years (SD 5.5). Mean PCS score at enrollment was 40.5 (SD .45). On average, PCS scores decreased slightly (i.e., 0.21 points) at each subsequent assessment. Lower PCS scores at enrollment were associated with older age, greater comorbidity, being unemployed, lack of regular exercise, higher morning fatigue, lower evening energy, occurrence of pain, lower trait anxiety, and lower attentional function. Only higher morning fatigue and lower enrollment PCS scores were associated with decrements in physical function over time. CONCLUSION While several symptoms were associated with decrements in PCS scores at enrollment in older adults with cancer receiving chemotherapy, morning fatigue was the only symptom associated with decreases in physical function over time. Regular assessments of symptoms and implementation of evidence-based interventions should be considered to maintain physical function in older adults during chemotherapy.
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Affiliation(s)
- Melisa L Wong
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA.
| | - Steven M Paul
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California, USA
| | - Judy Mastick
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California, USA
| | - Christine Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Christine Miaskowski
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California, USA
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Wong ML, McMurry TL, Schumacher JR, Hu CY, Stukenborg GJ, Francescatti AB, Greenberg CC, Chang GJ, McKellar DP, Walter LC, Kozower BD. Comorbidity Assessment in the National Cancer Database for Patients With Surgically Resected Breast, Colorectal, or Lung Cancer (AFT-01, -02, -03). J Oncol Pract 2018; 14:e631-e643. [PMID: 30207852 DOI: 10.1200/jop.18.00175] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Accurate comorbidity measurement is critical for cancer research. We evaluated comorbidity assessment in the National Cancer Database (NCDB), which uses a code-based Charlson-Deyo Comorbidity Index (CCI), and compared its prognostic performance with a chart-based CCI and individual comorbidities in a national sample of patients with breast, colorectal, or lung cancer. PATIENTS AND METHODS Through an NCDB Special Study, cancer registrars re-abstracted perioperative comorbidities for 11,243 patients with stage II to III breast cancer, 10,880 with stage I to III colorectal cancer, and 9,640 with stage I to III lung cancer treated with definitive surgical resection in 2006-2007. For each cancer type, we compared the prognostic performance of the NCDB code-based CCI (categorical: 0 or missing data, 1, 2+), Special Study chart-based CCI (continuous), and 18 individual comorbidities in three separate Cox proportional hazards models for postoperative 5-year overall survival. RESULTS Comorbidity was highest among patients with lung cancer (13.2% NCDB CCI 2+) and lowest among patients with breast cancer (2.8% NCDB CCI 2+). Agreement between the NCDB and Special Study CCI was highest for breast cancer (rank correlation, 0.50) and lowest for lung cancer (rank correlation, 0.40). The NCDB CCI underestimated comorbidity for 19.1%, 29.3%, and 36.2% of patients with breast, colorectal, and lung cancer, respectively. Within each cancer type, the prognostic performance of the NCDB CCI, Special Study CCI, and individual comorbidities to predict postoperative 5-year overall survival was similar. CONCLUSION The NCDB underestimated comorbidity in patients with surgically resected breast, colorectal, or lung cancer, partly because the NCDB codes missing data as CCI 0. However, despite underestimation of comorbidity, the NCDB CCI was similar to the more complete measures of comorbidity in the Special Study in predicting overall survival.
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Affiliation(s)
- Melisa L Wong
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Timothy L McMurry
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Jessica R Schumacher
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Chung-Yuan Hu
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - George J Stukenborg
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Amanda B Francescatti
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Caprice C Greenberg
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - George J Chang
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Daniel P McKellar
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Louise C Walter
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Benjamin D Kozower
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
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Wong ML, Shi Y, Fung KZ, Ngo S, Elicker BM, Brown JK, Hiatt RA, Tang VL, Walter LC. Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans. PLoS One 2018; 13:e0200496. [PMID: 30044854 PMCID: PMC6059441 DOI: 10.1371/journal.pone.0200496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 06/27/2018] [Indexed: 12/20/2022] Open
Abstract
Background Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy. Objectives To characterize comorbidity and life expectancy in older veterans with incidental, symptom-detected, or screen-detected nodules in 2008–09 compared to 2013–14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008–09 subgroup. Design Retrospective cohort study. Setting Urban Veterans Affairs Medical Center. Participants 243 veterans age ≥65 with newly diagnosed pulmonary nodules in 2008–09 (followed for four years through 2012 or 2013) and 446 older veterans diagnosed in 2013–14. Measurements The primary outcome was receipt of any follow-up nodule imaging and/or biopsy within four years after nodule diagnosis. Primary predictor variables included age, Charlson-Deyo Comorbidity Index (CCI), and life expectancy. Favorable life expectancy was defined as age 65–74 with CCI 0 while limited life expectancy was defined as age ≥85 with CCI ≥1 or age ≥65 with CCI ≥4. Interaction by nodule size was also examined. Results From 2008–09 to 2013–14, the number of older veterans diagnosed with new pulmonary nodules almost doubled, including among those with severe comorbidity and limited life expectancy. Overall among the 2008–09 subgroup, receipt of nodule follow-up decreased with increasing comorbidity (CCI ≥4 versus 0: adjusted RR 0.61, 95% CI 0.39–0.95) with a trend towards decreased follow-up among those with limited life expectancy (adjusted RR 0.69, 95% CI 0.48–1.01). However, we detected an interaction effect with nodule size such that comorbidity and life expectancy were associated with decreased follow-up only among those with nodules ≤6 mm. Conclusions We found some individualization of pulmonary nodule follow-up according to comorbidity and life expectancy in older veterans with smaller nodules only. As increased imaging detects nodules in sicker patients, guidelines need to be more explicit about how to best incorporate comorbidity and life expectancy to maximize benefits and minimize harms for patients with nodules of all sizes.
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Affiliation(s)
- Melisa L. Wong
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, United States of America
- * E-mail:
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Kathy Z. Fung
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Sarah Ngo
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Brett M. Elicker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - James K. Brown
- Pulmonary, Critical Care, and Sleep Medicine Section, San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Robert A. Hiatt
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Victoria L. Tang
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
| | - Louise C. Walter
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States of America
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Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Etzioni R, McKenna MT, Oeffinger KC, Shih YCT, Walter LC, Andrews KS, Brawley OW, Brooks D, Fedewa SA, Manassaram-Baptiste D, Siegel RL, Wender RC, Smith RA. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018; 68:250-281. [PMID: 29846947 DOI: 10.3322/caac.21457] [Citation(s) in RCA: 1092] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.
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Affiliation(s)
- Andrew M D Wolf
- Associate Professor and Attending Physician, University of Virginia School of Medicine, Charlottesville, VA
| | - Elizabeth T H Fontham
- Emeritus Professor, Louisiana State University School of Public Health, New Orleans, LA
| | - Timothy R Church
- Professor, University of Minnesota and Masonic Cancer Center, Minneapolis, MN
| | - Christopher R Flowers
- Professor and Attending Physician, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA
| | - Carmen E Guerra
- Associate Professor of Medicine of the Perelman School of Medicine and Attending Physician, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Samuel J LaMonte
- Independent retired physician and patient advocate, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ruth Etzioni
- Biostatistician, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Matthew T McKenna
- Professor and Director, Division of Preventive Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kevin C Oeffinger
- Professor and Director of the Duke Center for Onco-Primary Care, Durham, NC
| | - Ya-Chen Tina Shih
- Professor, Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Louise C Walter
- Professor and Attending Physician, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA
| | - Kimberly S Andrews
- Director, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Otis W Brawley
- Chief Medical and Scientific Officer and Executive Vice President-Research, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Vice President, Cancer Control Interventions, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Strategic Director for Risk Factor Screening and Surveillance, American Cancer Society, Atlanta, GA
| | | | - Rebecca L Siegel
- Strategic Director, Surveillance Information Services, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
| | - Robert A Smith
- Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA
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