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DuMontier C, Loh KP, Bain PA, Silliman RA, Hshieh T, Abel GA, Djulbegovic B, Driver JA, Dale W. Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review. J Clin Oncol 2020; 38:2558-2569. [PMID: 32250717 PMCID: PMC7392742 DOI: 10.1200/jco.19.02809] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms. METHODS We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability. RESULTS Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%). CONCLUSION Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.
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Affiliation(s)
- Clark DuMontier
- Brigham and Women’s Hospital, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | | | | | - Tammy Hshieh
- Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Jane A. Driver
- Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Veterans Affairs Boston Healthcare System, New England Geriatric Research Education and Clinical Center, Boston, MA
| | - William Dale
- City of Hope Comprehensive Cancer Center, Duarte, CA
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Ahern TP, Collin LJ, Baurley JW, Kjærsgaard A, Nash R, Maliniak ML, Damkier P, Zwick ME, Isett RB, Christiansen PM, Ejlertsen B, Lauridsen KL, Christensen KB, Silliman RA, Sørensen HT, Tramm T, Hamilton-Dutoit S, Lash TL, Cronin-Fenton D. Metabolic Pathway Analysis and Effectiveness of Tamoxifen in Danish Breast Cancer Patients. Cancer Epidemiol Biomarkers Prev 2020; 29:582-590. [PMID: 31932415 PMCID: PMC7060091 DOI: 10.1158/1055-9965.epi-19-0833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 07/15/2019] [Revised: 11/15/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Tamoxifen and its metabolites compete with estrogen to occupy the estrogen receptor. The conventional dose of adjuvant tamoxifen overwhelms estrogen in this competition, reducing breast cancer recurrence risk by nearly half. Phase I metabolism generates active tamoxifen metabolites, and phase II metabolism deactivates them. No earlier pharmacogenetic study has comprehensively evaluated the metabolism and transport pathways, and no earlier study has included a large population of premenopausal women. METHODS We completed a cohort study of 5,959 Danish nonmetastatic premenopausal breast cancer patients, in whom 938 recurrences occurred, and a case-control study of 541 recurrent cases in a cohort of Danish predominantly postmenopausal breast cancer patients, all followed for 10 years. We collected formalin-fixed paraffin-embedded tumor blocks and genotyped 32 variants in 15 genes involved in tamoxifen metabolism or transport. We estimated conventional associations for each variant and used prior information about the tamoxifen metabolic path to evaluate the importance of metabolic and transporter pathways. RESULTS No individual variant was notably associated with risk of recurrence in either study population. Both studies showed weak evidence of the importance of phase I metabolism in the clinical response to adjuvant tamoxifen therapy. CONCLUSIONS Consistent with prior knowledge, our results support the role of phase I metabolic capacity in clinical response to tamoxifen. Nonetheless, no individual variant substantially explained the modest phase I effect on tamoxifen response. IMPACT These results are consistent with guidelines recommending against genotype-guided prescribing of tamoxifen, and for the first time provide evidence supporting these guidelines in premenopausal women.
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Affiliation(s)
- Thomas P Ahern
- Department of Surgery, Larner College of Medicine at The University of Vermont, Burlington, Vermont
| | - Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maret L Maliniak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael E Zwick
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
- Emory Integrated Genomics Core, Emory University, Atlanta, Georgia
| | - R Benjamin Isett
- Emory Integrated Genomics Core, Emory University, Atlanta, Georgia
| | - Peer M Christiansen
- Breast Unit, Aarhus University Hospital/Randers Regional Hospital, Aarhus, Denmark
- Danish Breast Cancer Group, Copenhagen University Hospital, Copenhagen, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Group, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Rebecca A Silliman
- Boston University School of Medicine, Boston University, Boston, Massachusetts
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Winship Cancer Institute, Emory University, Atlanta, Georgia
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DuMontier C, Loh KP, Bain PA, Silliman RA, Abel GA, Djulbegovic B, Driver JA, Dale W. Defining undertreatment and overtreatment in older patients with cancer: A scoping review of the literature. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e23020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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
e23020 Background: The terms “undertreatment” and “overtreatment” are often used to describe the management of older adults with cancer. The aim of this scoping review was to explore the explicit and implicit definitions associated with the use of these terms. Methods: We searched PubMed (NCBI), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms "undertreatment" or "overtreatment" (overtreat OR undertreat OR over treat OR under treat) of older adults with cancer. We included all types of articles, cancers, and treatments. We excluded studies that only included patients younger than 60 years old or studies without a defined focus on older adults. CD and KL independently reviewed a subset of included articles to assess for inter-reviewer reliability. Results: We identified 224 primary and secondary research articles that used the terms “undertreatment” (192), “overtreatment” (72), or both (45) regarding the management of older adults with cancer. Only 14 (6.3%) articles provided an explicit definition; for the remaining articles, we derived the implicit definitions from the terms’ surrounding context. There was substantial agreement between CD and KL in their interpretation of definitions of these terms (kappa 0.81). “Undertreatment” was commonly used to imply less than “standard” therapy (130 articles, 67.7%), or less than “standard” therapy that contributed to worse outcomes (62, 32.3%). Many articles did not account for the underrepresentation of older adults in trials leading to “standard” therapy, and 24 primary studies performed no or limited adjustment for geriatric domains (e.g., function) in their analyses that suggested worse survival in older adults treated with substandard therapy. “Overtreatment” was commonly used to imply cancer treatment in an older adult whose cancer would not have caused symptoms in his/her remaining lifetime (31, 43.1%), or aggressive treatment in whom the harms of treatment outweigh its benefits (41, 56.9%). Conclusions: Nearly all articles used the terms “undertreatment” and/or “overtreatment” without an explicit definition, and we identified variability and limitations in the meanings implied by these terms.
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Affiliation(s)
- Clark DuMontier
- Beth Israel Deaconess Medical Center, VA Boston Healthcare System, and Harvard Medical School, Boston, MA
| | - Kah Poh Loh
- University of Rochester Medical Center, Rochester, NY
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, MA
| | | | | | | | - Jane A. Driver
- VA Boston Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - William Dale
- City of Hope National Medical Center, Duarte, CA
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Collin LJ, Cronin-Fenton DP, Ahern TP, Christiansen PM, Damkier P, Ejlertsen B, Hamilton-Dutoit S, Kjærsgaard A, Silliman RA, Sørensen HT, Lash TL. Cohort Profile: the Predictors of Breast Cancer Recurrence (ProBe CaRE) Premenopausal Breast Cancer Cohort Study in Denmark. BMJ Open 2018; 8:e021805. [PMID: 30068618 PMCID: PMC6074634 DOI: 10.1136/bmjopen-2018-021805] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The Predictors of Breast Cancer Recurrence (ProBe CaRe) study was established to evaluate modification of tamoxifen (TAM) effectiveness in premenopausal women through reduced activity of TAM-metabolising enzymes. It comprehensively evaluates the effects of pharmacogenetic variants, use of concomitant medications and biomarkers involved in oestrogen metabolism on breast cancer recurrence risk. PARTICIPANTS The ProBe CaRe study was established using resources from the Danish Breast Cancer Group (DBCG), including 5959 premenopausal women diagnosed with stage I-III primary breast cancer between 2002 and 2010 in Denmark. Eligible participants were divided into two groups based on oestrogen receptor alpha (ERα) expression and receipt of TAM therapy, 4600 are classified as ERα+/TAM+ and 1359 are classified as ERα-/TAM-. The ProBe CaRe study is a population-based cohort study nested in a nearly complete source population, clinical, tumour and demographic data were abstracted from DBCG registry data. Linkage to Danish registries allows for abstraction of information regarding comorbid conditions, comedication use and mortality. Formalin-fixed paraffin-embedded tissue samples have been prepared for DNA extraction and immunohistochemical assay. FINDINGS TO DATE To mitigate incorrect classification of patients into specific categories, we conducted a validation substudy. We compared data acquired from registry and from medical record review to calculate positive predictive values (PPVs) and negative predictive values. We observed PPVs near 100% for tumour size, lymph node involvement, receptor status, surgery type, receipt of radiotherapy, receipt of chemotherapy and TAM treatment. We found that the PPVs were 96% (95% CI 83% to 100%) for change in endocrine therapy and 61% (95% CI 42% to 77%) for menopausal transition. FUTURE PLANS The ProBeCaRe cohort study is well positioned to comprehensively examine pharmacogenetic variants. We will use a Bayesian pathway analysis to evaluate the complete TAM metabolic path to allow for gene-gene interactions, incorporating information of other important patient characteristics.
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Affiliation(s)
- Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Thomas P Ahern
- Department of Surgery, The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, Vermont, USA
| | - Peer M Christiansen
- Breast Unit, Surgical Department, Randers Regional Hospital, Randers, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Danish Breast Cancer Group, Copenhagen, Denmark
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Group, Copenhagen, Denmark
- Rigshospitalet, Copenhagen, Denmark
| | | | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecca A Silliman
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Boston University School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, California, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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DuMontier C, Clough-Gorr KM, Silliman RA, Stuck AE, Moser A. Health-Related Quality of Life in a Predictive Model for Mortality in Older Breast Cancer Survivors. J Am Geriatr Soc 2018. [PMID: 29533469 DOI: 10.1111/jgs.15340] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To develop a predictive model and risk score for 10-year mortality using health-related quality of life (HRQOL) in a cohort of older women with early-stage breast cancer. DESIGN Prospective cohort. SETTING Community. PARTICIPANTS U.S. women aged 65 and older diagnosed with Stage I to IIIA primary breast cancer (N=660). MEASUREMENTS We used medical variables (age, comorbidity), HRQOL measures (10-item Physical Function Index and 5-item Mental Health Index from the Medical Outcomes Study (MOS) 36-item Short-Form Survey; 8-item Modified MOS Social Support Survey), and breast cancer variables (stage, surgery, chemotherapy, endocrine therapy) to develop a 10-year mortality risk score using penalized logistic regression models. We assessed model discriminative performance using the area under the receiver operating characteristic curve (AUC), calibration performance using the Hosmer-Lemeshow test, and overall model performance using Nagelkerke R2 (NR). RESULTS Compared to a model including only age, comorbidity, and cancer stage and treatment variables, adding HRQOL variables improved discrimination (AUC 0.742 from 0.715) and overall performance (NR 0.221 from 0.190) with good calibration (p=0.96 from HL test). CONCLUSION In a cohort of older women with early-stage breast cancer, HRQOL measures predict 10-year mortality independently of traditional breast cancer prognostic variables. These findings suggest that interventions aimed at improving physical function, mental health, and social support might improve both HRQOL and survival.
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Affiliation(s)
- Clark DuMontier
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kerri M Clough-Gorr
- National Cancer Registry Ireland, Cork, Ireland.,University College Cork, Cork, Ireland.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Rebecca A Silliman
- Section of Geriatrics, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts
| | - Andreas E Stuck
- Department of Geriatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - André Moser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Department of Geriatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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6
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Gunn CM, Bokhour B, Battaglia TA, Silliman RA, Hanchate A. False-positive mammography and its association with health service use. Am J Manag Care 2018; 24:131-138. [PMID: 29553275] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES A false-positive mammogram can result in anxiety, distress, and increased perceptions of breast cancer risk, potentially changing how women utilize healthcare. This study examined whether having an abnormal mammogram, considered a proxy for elevated risk perception, was associated with greater future health service use (outpatient visits and referrals). STUDY DESIGN A retrospective cohort study using electronic health record data, spanning 2008 to 2012, from Boston Medical Center, a safety-net hospital. METHODS We grouped 3920 women aged 40 to 75 years receiving primary care and who had a mammogram between 2010 and 2011 into 3 categories: false-positive mammogram at index date; previous false positive, but normal index mammogram; and no history of false-positive mammograms. We contrasted the longitudinal changes in outpatient visits and provider referrals, before versus after the index mammogram, between women with false-positive mammogram and those without using Poisson regression models with a difference-in-differences specification. Clinical, visit, and demographic data were obtained from the institutional clinical data warehouse. RESULTS Adjusting for baseline differences in sociodemographic characteristics across risk groups and for secular changes between pre- and postindex periods, a current false-positive mammogram was associated with an 18% increase in overall outpatient visits (incidence rate ratio [IRR], 1.18; 95% CI, 1.07-1.51), but no corresponding increase in provider referrals (IRR, 1.15; 95% CI, 0.99‑1.34), relative to never having a false positive. A previous false-positive mammogram had no associated change in outpatient utilization (IRR, 0.99; 95% CI, 0.91-1.07). CONCLUSIONS Providers should discuss the implications of mammography findings at the time of screening to help mitigate potential detrimental effects and promote appropriate engagement in health services.
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Affiliation(s)
- Christine M Gunn
- Women's Health Unit, Boston Medical Center, 801 Massachusetts Ave, 1st Fl, Boston, MA 02118.
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7
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Kapoor A, Matheos T, Walz M, McDonough C, Maheswaran A, Ruppell E, Mohamud D, Shaffer N, Zhou Y, Kaur S, Heard S, Crawford S, Cabral H, White DK, Santry H, Jette A, Fielding R, Silliman RA, Gurwitz J. Self-Reported Function More Informative than Frailty Phenotype in Predicting Adverse Postoperative Course in Older Adults. J Am Geriatr Soc 2017; 65:2522-2528. [PMID: 28926087 DOI: 10.1111/jgs.15108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND/OBJECTIVE Current preoperative assessment tools such as the American College of Surgeons Surgical Risk Calculator (ACS Calculator) are suboptimal for evaluating older adults. The objective was to evaluate and compare the performance of the ACS Calculator for predicting risk of serious postoperative complications with the addition of self-reported physical function versus a frailty score. DESIGN Prospective cohort. SETTING Two tertiary care academic medical centers in Massachusetts. PARTICIPANTS Individuals aged 65 and older undergoing any surgery with a risk of serious complication of 5% or greater (N = 403). MEASUREMENTS We measured self-reported physical function using the Late-Life Function and Disability Instrument (LLFDI FUNCTION) and frailty phenotype (FP), which has a score ranging from 0 to 5 based on slow gait speed, weak handgrip, exhaustion, weight loss, or low activity. Using c-statistic and net classification improvement (NRI), we then analyzed capability of LLFDI-FUNCTION versus FP to improve the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery). Increase in c-statistic and net reclassification improvement (NRI) for LLFDI-FUNCTION versus FP in addition to the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery) RESULTS: Over 30 days, 26% of participants developed an adverse postoperative course. The increase in c-statistic for the ACS Calculator (baseline value 0.645) was slightly greater with LLFDI-FUNCTION (0.076) than with FP (0.058), with a bootstrapped difference in c-statistic of 0.005 (95% confidence interval = 0.002-0.007). NRI was also better with LLFDI-FUNCTION. CONCLUSION The LLFDI-FUNCTION predicted postoperative complications slightly better than the FP. Further studies are needed to confirm these findings and validate the use of the LLFDI-FUNCTION with the ACS Calculator for preoperative assessments of older adults.
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Affiliation(s)
- Alok Kapoor
- Division of Hospital Medicine, Department of Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts.,Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts.,Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Theofilos Matheos
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Matthias Walz
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Christine McDonough
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Abiramy Maheswaran
- Department of Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Evan Ruppell
- Department of Radiology, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Deeqo Mohamud
- Department of Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Nicholas Shaffer
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Yanhua Zhou
- Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Shubjeet Kaur
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Stephen Heard
- Department of Anesthesiology & Perioperative Medicine, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Sybil Crawford
- Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Howard Cabral
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Daniel K White
- Department of Physical Therapy, University of Delaware, Newark, Delaware
| | - Heena Santry
- Department of Surgery & Quantitative Health Sciences, School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Alan Jette
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Roger Fielding
- Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Tufts University, Boston, Massachusetts
| | - Rebecca A Silliman
- Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Jerry Gurwitz
- Department of Medicine and Meyers Primary Care Institute, School of Medicine, University of Massachusetts, Worcester, Massachusetts
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Cronin-Fenton DP, Kjærsgaard A, Ahern TP, Mele M, Ewertz M, Hamilton-Dutoit S, Christiansen PM, Ejlertsen B, Sørensen HT, Lash TL, Silliman RA. Validity of Danish Breast Cancer Group (DBCG) registry data used in the predictors of breast cancer recurrence (ProBeCaRe) premenopausal breast cancer cohort study. Acta Oncol 2017; 56:1155-1160. [PMID: 28585885 DOI: 10.1080/0284186x.2017.1327720] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Validation studies of the Danish Breast Cancer Group (DBCG) registry show good agreement with medical records for adjuvant treatment data, but inconsistent recurrence information. No studies have validated changes in menopausal status or endocrine therapy during follow-up. In a longitudinal study, we validated DBCG data using medical records as the gold standard. MATERIAL AND METHODS From a cohort of 5959 premenopausal women diagnosed during 2002-2010 with stage I-III breast cancer, we selected 151 patients - 77 estrogen-receptor-positive and 74 estrogen-receptor-negative - from three hospitals. We assessed the validity of DBCG registry data on patient, tumor, and treatment factors, and follow-up information on menopausal transition, changes in endocrine therapy, and recurrence. We computed positive predictive values (PPVs) with 95% confidence intervals (95%CI). RESULTS Agreement was near perfect for tumor size, lymph node involvement, receptor status, surgery type, and receipt of radiotherapy, chemotherapy, or tamoxifen treatment. The PPV for a change in endocrine therapy in the DBCG was 96% (95%CI = 83, 100). The PPV for menopausal transition was 61% (95%CI = 42, 77). The PPV for DBCG-recorded recurrence was 100%. However, of 19 patients who had a recurrence documented in their medical record, 13 had the recurrence registered in DBCG. CONCLUSIONS DBCG data are valid for most epidemiological studies of breast cancer treatment. Data on menopausal transition may be less valid, though this interpretation depends on the suitability of medical records for making this assessment. Although recurrence is missing for some, this would not bias most ratio measures of association.
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Affiliation(s)
| | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas P. Ahern
- The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, VT, USA
| | - Marco Mele
- Breast Unit, Surgical Department, Randers Regional Hospital, Randers, Denmark
| | - Marianne Ewertz
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Peer M. Christiansen
- Breast Unit, Surgical Department, Randers Regional Hospital, Randers, Denmark
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
- Rigshospitalet, Copenhagen, Denmark
| | - Henrik T. Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, CA, USA
| | - Timothy L. Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rebecca A. Silliman
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Boston University School of Medicine, Boston University, Boston, MA, USA
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9
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DuMontier C, Clough-Gorr K, Silliman RA, Stuck A, Moser A. Using health-related quality of life and treatment measures to predict 10-year mortality in older survivors of early stage breast cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e21548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
e21548 Background: Older women make up the growing majority of breast cancer (BC) survivors. Guideline BC treatments are known contributors to long-term survival, and health-related quality of life (HRQOL) is emerging as not only an important outcome in survivorship care but also as a factor thought to influence mortality. However, prognostic models that include HRQOL alongside BC treatment measures are lacking. We aimed to develop a 10-year mortality risk score based on a priori chosen treatment and HRQOL variables. Methods: We studied 660 women ≥65-years old diagnosed with stage I-IIIA primary breast cancer in years 1997-1999. Data from medical and psychosocial domains were collected over 10 years from interviews, medical records, and death indexes. BC treatment variables included receipt of definitive locoregional surgery +/- radiation, chemotherapy, and tamoxifen. HRQOL variables included physical function [10-item Physical Function Index (PFI-10) from the Medical Outcomes Study Short Form-36 (MOS SF-36)]; mental health [5-item Mental Health Index (MHI-5) from the MOS SF-36]; and social support [8-item modified MOS Social Support Scale (mMOS-SSS)]. We used penalized logistic regression models to develop a 10-year mortality risk score, and investigated its discrimination (c-statistic) and calibration (observed versus predicted mortality using the Hosmer-Lemeshow (HL) test). Results: Mortality though 10-years of follow-up was 34.8% (230 of 660 women). The c-statistic of a risk score using only age, number of comorbidities, stage of BC, and BC treatment was 0.71. The c-statistic increased to 0.74 with the addition of HRQOL measures and showed good calibration (p = 0.72 from HL test). Physical function and mental health had strong independent associations with mortality (women with high PFI-10: OR 0.63, 95% CI 0.43, 0.92; women with high MHI-5: OR 0.57, 95% CI 0.39, 0.85). Conclusions: In older early stage breast cancer survivors, our risk score combining HRQOL with treatment measures showed good discrimination and calibration. HRQOL is independently associated with 10-year mortality and adds predictive ability to age, comorbidity, stage of BC, and BC treatment.
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Affiliation(s)
| | | | | | - Andreas Stuck
- Bern University Hospital and University of Bern, Bern, Switzerland
| | - André Moser
- Institut für Sozial- und Präventivmedizin, Bern, Switzerland
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VanderWalde N, Jagsi R, Dotan E, Baumgartner J, Browner IS, Burhenn P, Cohen HJ, Edil BH, Edwards B, Extermann M, Ganti AKP, Gross C, Hubbard J, Keating NL, Korc-Grodzicki B, McKoy JM, Medeiros BC, Mrozek E, O'Connor T, Rugo HS, Rupper RW, Shepard D, Silliman RA, Stirewalt DL, Tew WP, Walter LC, Wildes T, Bergman MA, Sundar H, Hurria A. NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016. J Natl Compr Canc Netw 2016; 14:1357-1370. [DOI: 10.6004/jnccn.2016.0146] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kapoor A, Shaffer NS, McDonough CM, White DK, Wang N, Rosenkranz P, Glantz A, McAneny D, Doherty GM, Cabral HJ, Gurwitz JH, Fielding RA, Jette AM, Silliman RA. Examining New Preoperative Assessment Tools. J Am Geriatr Soc 2016; 64:e102-e104. [PMID: 27590632 DOI: 10.1111/jgs.14349] [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] [Indexed: 11/30/2022]
Affiliation(s)
- Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Meyers Primary Care Institute, Worcester, Massachusetts.,Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Nicholas S Shaffer
- Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Christine M McDonough
- Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Daniel K White
- Department of Physical Therapy, University of Delaware, Newark, Delaware
| | - Na Wang
- Data Coordinating Center, School of Public Health, Boston University, Boston, Massachusetts
| | - Pamela Rosenkranz
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - Andrew Glantz
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - David McAneny
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - Howard J Cabral
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Jerry H Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Meyers Primary Care Institute, Worcester, Massachusetts
| | - Roger A Fielding
- Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Tufts University, Boston, Massachusetts
| | - Alan M Jette
- Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Rebecca A Silliman
- Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
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Abstract
We studied the family caregivers of elderly stroke patients, focusing on perceptions of the positive and negative aspects of caregiving and the resources used by caregivers to meet its demands. Most caregivers were women and either spouses of daughters. The majority were satisfied with their roles as caregivers and would do it again if faced with that decision. They relied on family and friends for help with caregiving, but not on formal services. Greater understanding of the determinants of caregivers' heterogeneous responses to the demands of caregiving is needed.
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DuMontier C, Clough-Gorr K, Silliman RA, Moser A. Motivation and mortality in geriatric patients with early stage breast cancer. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.28_suppl.105] [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: 11/20/2022] Open
Abstract
105 Background: Evidence suggests that an older patient’s motivation and life outlook are associated with health outcomes. A measure of motivation called the Getting Out of Bed Scale (GOB) was previously validated in a cohort of geriatric patients with early stage breast cancer. The aim of our project was to assess the association between GOB and mortality, both all-cause and breast-cancer specific, using the same dataset. Methods: We evaluated 660 women ≥ 65-years old diagnosed with stage I-IIIA primary breast cancer in four geographic regions in the US. Data were collected over ten-years of follow-up from consenting women’s medical records, telephone interviews, National Death Index, and Social Security Death Index. To address attrition bias, a multiple imputation approach using two-fold fully conditional specification was used to generate a complete dataset and allow for sufficient power in our statistical testing. Results: Using this dataset, a cox regression survival analysis found no significant association between GOB and mortality, both all-cause [5 years HR (95% CI): 0.76 (0.50,1.15), 10 years: 0.77 (0.59, 1.01)] and breast-cancer-specific [5 years: 0.92 (0.48, 1.73), 10 years: 0.84 (0.53, 1.33)]. This observation held true even after adjustment for other validated health-related quality of life measures of mental health, physical functioning, and socioeconomic status. Notably, patients with high mental health scores as measured by the Mental Health Index Short Form had significantly lower mortality, both all-cause [5 years: 0.42 (0.27, 0.65), 10 years: 0.59 (0.44, 0.79)] and breast-cancer specific [5 years: 0.42 (0.20, 0.90), 10 years: 0.52 (0.31, 0.89)]. Conclusions: These results suggest that GOB does not predict mortality in geriatric patients with early stage breast cancer; however, more research is needed to assess hope and outcomes in geriatric cancer patients. This study would not have been possible without the multiple imputations approach, which allows for greater power in researching longitudinal datasets that would otherwise suffer from loss to follow up.
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Affiliation(s)
| | - Kerri Clough-Gorr
- National Institute for Cancer Epidemiology and Registration, Zürich, Switzerland
| | | | - André Moser
- Institut für Sozial- und Präventivmedizin, Bern, Switzerland
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14
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Eng JA, Clough-Gorr K, Cabral HJ, Silliman RA. Predicting 5- and 10-year survival in older women with early-stage breast cancer: self-rated health and walking ability. J Am Geriatr Soc 2015; 63:757-62. [PMID: 25900489 DOI: 10.1111/jgs.13340] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To determine life expectancy for older women with breast cancer. DESIGN Prospective longitudinal study with 10 years of follow-up data. SETTING Hospitals or collaborating tumor registries in four geographic regions (Los Angeles, California; Minnesota; North Carolina; Rhode Island). PARTICIPANTS Women aged 65 and older at time of breast cancer diagnosis with Stage I to IIIA disease with measures of self-rated health (SRH) and walking ability at baseline (N = 615; 17% aged ≥80, 52% Stage I, 58% with ≥2 comorbidities). MEASUREMENTS Baseline SRH, baseline self-reported walking ability, all-cause and breast cancer-specific estimated probability of 5- and 10-year survival. RESULTS At the time of breast cancer diagnosis, 39% of women reported poor SRH, and 28% reported limited ability to walk several blocks. The all-cause survival curves appear to separate after approximately 3 years, and the difference in survival probability between those with low SRH and limited walking ability and those with high SRH and no walking ability limitation was significant (0.708 vs 0.855 at 5 years, P ≤ .001; 0.300 vs 0.648 at 10 years, P < .001). There were no differences between the groups in breast cancer-specific survival at 5 and 10 years (P = .66 at 5 years, P = .16 at 10 years). CONCLUSION The combination of low SRH and limited ability to walk several blocks at diagnosis is an important predictor of worse all-cause survival at 5 and 10 years. These self-report measures easily assessed in clinical practice may be an effective strategy to improve treatment decision-making in older adults with cancer.
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Affiliation(s)
- Jessica A Eng
- Division of Geriatrics, University of California at San Francisco, San Francisco, California; San Francisco Veterans Affairs Medical Center, San Francisco, California
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15
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Perkins RB, Lin M, Silliman RA, Clark JA, Hanchate A. Why are U.S. girls getting meningococcal but not human papilloma virus vaccines? Comparison of factors associated with human papilloma virus and meningococcal vaccination among adolescent girls 2008 to 2012. Womens Health Issues 2015; 25:97-104. [PMID: 25747517 DOI: 10.1016/j.whi.2014.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 12/17/2014] [Accepted: 12/19/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Human papilloma virus (HPV) vaccination rates in the United States remain low, compared with other recommended adolescent vaccines. We compared factors associated with intention to receive and receipt of HPV and meningococcal vaccines and completion of the HPV vaccine series among U.S. adolescent girls. METHODS Secondary analysis of data from the National Immunization Survey-Teen for 2008 through 2012 was performed. Multivariable logistic modeling was used to determine factors associated with intent to receive and receipt of HPV and meningococcal vaccination, completion of the HPV vaccine series among girls who started the series, and receipt of HPV vaccination among girls who received meningococcal vaccination. FINDINGS Provider recommendation increased the odds of receipt and intention to receive both HPV and meningococcal vaccines. Provider recommendation was also associated with a three-fold increase in HPV vaccination among girls who received meningococcal vaccination (p<.001), indicating a relationship between provider recommendation and missed vaccine opportunities. However, White girls were 10% more likely to report provider recommendation than Black or Hispanic girls (p<.01), yet did not have higher vaccination rates, implying a role for parental refusal. No factors predicted consistently the completion of the HPV vaccine series among those who started. CONCLUSION Improving provider recommendation for co-administration of HPV and meningococcal vaccines would reduce missed opportunities for initiating the HPV vaccine series. However, different interventions may be necessary to improve series completion.
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Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
| | - Mengyun Lin
- Department of Medicine, Division of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Rebecca A Silliman
- Department of Medicine, Division of Geriatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Jack A Clark
- Boston University School of Public Health, Edith Nourse Rogers Veterans Hospital, Boston, Massachusetts
| | - Amresh Hanchate
- Veterans Affairs Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
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Schonberg MA, Silliman RA, Ngo LH, Birdwell RL, Fein-Zachary V, Donato J, Marcantonio ER. Older women's experience with a benign breast biopsy—a mixed methods study. J Gen Intern Med 2014; 29:1631-40. [PMID: 25138983 PMCID: PMC4242866 DOI: 10.1007/s11606-014-2981-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [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: 03/26/2014] [Revised: 06/30/2014] [Accepted: 07/15/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about older women's experience with a benign breast biopsy. OBJECTIVES To examine the psychological impact and experience of women ≥ 65 years of age with a benign breast biopsy. DESIGN Prospective cohort study using quantitative and qualitative methods. SETTING Three Boston-based breast imaging centers. PARTICIPANTS Ninety-four English-speaking women ≥ 65 years without dementia referred for breast biopsy as a result of an abnormal mammogram, not aware of their biopsy results at baseline, and with a subsequent negative biopsy. MEASUREMENTS We interviewed women at the time of breast biopsy (before women knew their results) and 6 months post-biopsy. At both interviews, participants completed the validated negative psychological consequences of screening mammography questionnaire (PCQ, scores range from 0 to 36 [high distress], PCQ ≥ 1 suggests a psychological consequence, PCQs <1 are reported at time of screening) and women responded to open-ended questions about their experience. At follow-up, participants described the quality of information received after their benign breast biopsy. We used a linear mixed effects model to examine if PCQs declined over time. We also reviewed participants' open-ended comments for themes. RESULTS Overall, 88% (83/94) of participants were non-Hispanic white and 33% (31/94) had a high-school degree or less. At biopsy, 76% (71/94) reported negative psychological consequences from their biopsy compared to 39% (37/94) at follow-up (p < 0.01). In open-ended comments, participants noted the anxiety (29%, 27/94) and discomfort (28%, 26/94) experienced at biopsy (especially from positioning on the biopsy table). Participants requested more information to prepare for a biopsy and to interpret their negative results. Forty-four percent (39/89) reported at least a little anxiety about future mammograms. CONCLUSIONS The high psychological burden of a benign breast biopsy among older women significantly diminishes with time but does not completely resolve. To reduce this burden, older women need more information about undergoing a breast biopsy.
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Affiliation(s)
- Mara A. Schonberg
- />Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Rebecca A. Silliman
- />Geriatrics Section, Boston University Schools of Medicine and Public Health, Boston University Medical Center, Boston, MA USA
| | - Long H. Ngo
- />Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Robyn L. Birdwell
- />Breast Imaging, Department of Radiology, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA USA
| | - Valerie Fein-Zachary
- />Department of Radiology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Jessica Donato
- />Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Edward R. Marcantonio
- />Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA USA
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Misra D, Felson DT, Silliman RA, Nevitt M, Lewis CE, Torner J, Neogi T. Knee osteoarthritis and frailty: findings from the Multicenter Osteoarthritis Study and Osteoarthritis Initiative. J Gerontol A Biol Sci Med Sci 2014; 70:339-44. [PMID: 25063080 DOI: 10.1093/gerona/glu102] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) and frailty are two conditions that are associated with functional limitation and disability in elders, yet their relation to one another is not known. METHODS We included participants from two large, multicenter studies enriched with community dwelling older adults with knee OA (Multicenter Osteoarthritis Study and Osteoarthritis Initiative). Knee OA was defined radiographically (ROA) and symptomatically (SOA). Frailty was defined using the Study of Osteoporotic Fracture index as the presence of ≥2 of the following: (i) weight loss >5% between two consecutive visits; (ii) inability to arise from chair five times without support; (iii) poor energy. Cross-sectional and longitudinal associations of knee OA with prevalent and incident frailty, respectively, were examined using binomial regression with robust variance estimation, adjusting for potential confounders. RESULTS In the cross-sectional analyses, frailty was more prevalent among participants with ROA (4.39% vs 2.77%; PR 1.60 [1.07, 2.39]) and SOA (5.88% vs 2.79%; PR 1.92 [1. 35, 2.74]) compared with those without ROA or SOA, respectively. In the longitudinal analyses, risk of developing frailty was greater among those with ROA (4.73% vs 2.50%; RR 1.45 [0.91, 2.30]) and SOA (6.30% vs 2.83%; RR 1.66 [1.11, 2.48]) than those without ROA or SOA, respectively. CONCLUSIONS Knee OA is associated with greater prevalence and risk of developing frailty. Understanding the mechanisms linking these two common conditions of older adults would aid in identifying novel targets for treatment or prevention of frailty.
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Affiliation(s)
- Devyani Misra
- Department of Medicine, Boston University School of Medicine, Massachusetts.
| | - David T Felson
- Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Rebecca A Silliman
- Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Michael Nevitt
- Department of Epidemiology and Biostatistics, University of California at San Francisco
| | - Cora E Lewis
- Department of Medicine, University of Alabama School of Medicine, Birmingham
| | | | - Tuhina Neogi
- Department of Medicine, Boston University School of Medicine, Massachusetts
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Mandelblatt JS, Stern RA, Luta G, McGuckin M, Clapp JD, Hurria A, Jacobsen PB, Faul LA, Isaacs C, Denduluri N, Gavett B, Traina TA, Johnson P, Silliman RA, Turner RS, Howard D, Van Meter JW, Saykin A, Ahles T. Cognitive impairment in older patients with breast cancer before systemic therapy: is there an interaction between cancer and comorbidity? J Clin Oncol 2014; 32:1909-18. [PMID: 24841981 PMCID: PMC4050204 DOI: 10.1200/jco.2013.54.2050] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To determine if older patients with breast cancer have cognitive impairment before systemic therapy. PATIENTS AND METHODS Participants were patients with newly diagnosed nonmetastatic breast cancer and matched friend or community controls age > 60 years without prior systemic treatment, dementia, or neurologic disease. Participants completed surveys and a 55-minute battery of 17 neuropsychological tests. Biospecimens were obtained for APOE genotyping, and clinical data were abstracted. Neuropsychological test scores were standardized using control means and standard deviations (SDs) and grouped into five domain z scores. Cognitive impairment was defined as any domain z score two SDs below or ≥ two z scores 1.5 SDs below the control mean. Multivariable analyses evaluated pretreatment differences considering age, race, education, and site; comparisons between patient cases also controlled for surgery. RESULTS The 164 patient cases and 182 controls had similar neuropsychological domain scores. However, among patient cases, those with stage II to III cancers had lower executive function compared with those with stage 0 to I disease, after adjustment (P = .05). The odds of impairment were significantly higher among older, nonwhite, less educated women and those with greater comorbidity, after adjustment. Patient case or control status, anxiety, depression, fatigue, and surgery were not associated with impairment. However, there was an interaction between comorbidity and patient case or control status; comorbidity was strongly associated with impairment among patient cases (adjusted odds ratio, 8.77; 95% CI, 2.06 to 37.4; P = .003) but not among controls (P = .97). Only diabetes and cardiovascular disease were associated with impairment among patient cases. CONCLUSION There were no overall differences between patients with breast cancer and controls before systemic treatment, but there may be pretreatment cognitive impairment within subgroups of patient cases with greater tumor or comorbidity burden.
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Affiliation(s)
- Jeanne S Mandelblatt
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN.
| | - Robert A Stern
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Gheorghe Luta
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Meghan McGuckin
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Jonathan D Clapp
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Arti Hurria
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Paul B Jacobsen
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Leigh Anne Faul
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Claudine Isaacs
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Neelima Denduluri
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Brandon Gavett
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Tiffany A Traina
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Patricia Johnson
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Rebecca A Silliman
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - R Scott Turner
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Darlene Howard
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - John W Van Meter
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Andrew Saykin
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
| | - Tim Ahles
- Jeanne S. Mandelblatt, Gheorghe Luta, Meghan McGuckin, Jonathan D. Clapp, Leigh Anne Faul, Claudine Isaacs, Neelima Denduluri, R. Scott Turner, Darlene Howard, and John W. Van Meter, Georgetown University, Washington, DC; Robert A. Stern, Brandon Gavett, Patricia Johnson, and Rebecca A. Silliman, Boston University School of Medicine, Boston, MA; Arti Hurria, City of Hope Comprehensive Cancer Center, Duarte, CA; Paul B. Jacobsen, Moffitt Cancer Center; Patricia Johnson, University of South Florida, Tampa, FL; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Tiffany A. Traina and Tim Ahles, Memorial Sloan-Kettering Cancer Center; Tiffany A. Traina, Weill Medical College of Cornell University, New York, NY; and Andrew Saykin, Indiana University School of Medicine, Indianapolis, IN
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Kaufman LB, Setiono TK, Doros G, Andersen S, Silliman RA, Friedman PK, Perls TT. An oral health study of centenarians and children of centenarians. J Am Geriatr Soc 2014; 62:1168-73. [PMID: 24889721 DOI: 10.1111/jgs.12842] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine whether oral health is better in centenarians than in a published birth cohort-matched sample and to compare oral health in centenarian offspring with a case-controlled reference sample. DESIGN Observational cross-sectional study. SETTING New England Centenarian Study (NECS). PARTICIPANTS Seventy-three centenarians, 467 offspring, and 251 offspring generation-reference cohort subjects from the NECS. MEASUREMENTS A self-report questionnaire was administered to measure oral health in all three groups, with edentulous rate as the primary outcome measure. The NECS made information on sociodemographic characteristics and medical history available. Centenarian results were compared with published birth cohort-matched results. Data from offspring and reference cohorts were analyzed to determine differences in oral health and associations between oral health measures and specific medical conditions. RESULTS The edentulous rate of centenarians (36.5%) was lower than that of their birth cohort (46%) when they were aged 65 to 74 in 1971 to 1974 (according to National Center of Health Statistics). Adjusting for confounding factors, the reference cohort was more likely to be edentulous (adjusted odds ratio (AOR) = 2.78, 95% confidence interval CI = 1.17-6.56), less likely to have all or more than half of their own teeth (AOR = 0.48, 95% CI = 0.3-0.76), and less likely to report excellent or very good oral health (AOR = 0.65, 95% CI = 0.45-0.94) than the centenarian offspring. CONCLUSION Centenarians and their offspring have better oral health than their respective birth cohorts. Oral health may prove to be a helpful marker for systemic health and healthy aging.
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Affiliation(s)
- Laura B Kaufman
- Section of Geriatrics, Department of Medicine, Boston Medical Center, Boston, Massachusetts; Department of General Dentistry, Boston University, Henry M. Goldman School of Dental Medicine, Boston, Massachusetts
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Schonberg MA, Birdwell RL, Bychkovsky BL, Hintz L, Fein-Zachary V, Wertheimer MD, Silliman RA. Older women's experience with breast cancer treatment decisions. Breast Cancer Res Treat 2014; 145:211-23. [PMID: 24682710 PMCID: PMC8370713 DOI: 10.1007/s10549-014-2921-y] [Citation(s) in RCA: 17] [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] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 03/15/2014] [Indexed: 10/25/2022]
Abstract
The purpose of this study was to better understand older women's experience with breast cancer treatment decisions. We conducted a longitudinal study of non-demented, English-speaking women ≥ 65 years recruited from three Boston-based breast imaging centers. We interviewed women at the time of breast biopsy (before they knew their results) and 6 months later. At baseline, we assessed intention to accept different breast cancer treatments, sociodemographic, and health characteristics. At follow-up, we asked women about their involvement in treatment decisions, to describe how they chose a treatment, and influencing factors. We assessed tumor characteristics through chart abstraction. We used quantitative and qualitative analyses. Seventy women (43 ≥ 75 years) completed both interviews and were diagnosed with breast cancer; 91 % were non-Hispanic white. At baseline, women 75+ were less likely than women 65-74 to report that they would accept surgery and/or take a medication for ≥ 5 years if recommended for breast disease. Women 75+ were ultimately less likely to receive hormonal therapy for estrogen receptor positive tumors than women 65-74. Women 75+ asked their surgeons fewer questions about their treatment options and were less likely to seek information from other sources. A surgeon's recommendation was the most influential factor affecting older women's treatment decisions. In open-ended comments, 17 women reported having no perceived choice about treatment and 42 stated they simply followed their physician's recommendation for at least one treatment choice. In conclusion, to improve care of older women with breast cancer, interventions are needed to increase their engagement in treatment decision-making.
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Affiliation(s)
- Mara A Schonberg
- Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 1309 Beacon, Office 219, Brookline, Boston, MA, 02446, USA,
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21
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Goldenheim A, Oates D, Parker V, Russell M, Winter M, Silliman RA. Rehospitalization of older adults discharged to home hospice care. J Palliat Med 2014; 17:841-4. [PMID: 24708490 DOI: 10.1089/jpm.2013.0224] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Acute hospital readmission of older adults receiving hospice care is not aligned with hospice goals. OBJECTIVE To identify factors associated with 30-day readmission among older adults newly discharged to hospice. DESIGN/SUBJECTS Medical record review of 59 patients, 19 readmitted within 30 days and 40 randomly selected controls not readmitted, from 206 patients newly discharged to home hospice care between February 1, 2005 and January 31, 2010. Measures/Analysis: Information was collected about hospital course, end-of-life planning, and posthospitalization follow-up. We calculated bivariate associations and developed a Cox Proportional Hazards model examining the relation between index admission characteristics and readmission. RESULTS Patients' mean age was 79.7±8.4; 74.6% were female; 52.5% were black. Among those readmitted, 25% had received a palliative care consultation, compared to 47.1% of those not readmitted (p=0.06). Patients without a participating decision-maker involved in their hospice decision had 3.5 times the risk of readmission within 30 days, compared to those with (hazard ratio [HR] 3.53, confidence interval [CI] 0.97, 12.82). Patients who had one or more telephone contacts with their primary care physician (PCP) during week 1 after discharge had 2.4 times the readmission risk within 30 days, compared to patients with no such contacts during this period (HR 2.35, CI 0.9, 6.1). CONCLUSIONS Readmission within 30 days of initial discharge to hospice is associated with several measures of care and care planning. Further study of these measures may identify opportunities for interventions to improve the hospital-to-hospice transition and to decrease hospital readmissions.
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Affiliation(s)
- Anna Goldenheim
- 1 Boston University School of Medicine , Boston, Massachusetts
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22
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Lash TL, Thwin SS, Yood MU, Geiger AM, Bosco J, Quinn VP, Field TS, Pawloski PA, Silliman RA. Comprehensive evaluation of the incidence of late effects in 5-year survivors of breast cancer. Breast Cancer Res Treat 2014; 144:643-63. [PMID: 24584822 DOI: 10.1007/s10549-014-2885-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/23/2022]
Abstract
Late effects of breast cancer affect the quality of survivorship. Using administrative data, we compared the occurrence of almost all ICD9 codes among older breast cancer survivors to that among a matched comparison cohort to generate new hypotheses. Breast cancer patients 65 years or older diagnosed 1990-1994 in 6 integrated care settings and who survived at least 5 years were matched with a cohort of women without a history of breast cancer on care setting, age, and calendar time. We collected data on the occurrence of incident ICD9 codes beginning 6 years after the breast cancer diagnosis date and continuing to year 15, and comparable data for the matched woman. We calculated hazard ratios (HRs) and 95 % confidence intervals associating breast cancer survivorship with incidence of each ICD9 code. We used semi-Bayes methods to address multiple comparisons. Older breast cancer survivors had about the same occurrence of diseases and conditions 6-15 years after breast cancer diagnosis as comparable women. The median of 564 adjusted HRs equaled 1.06, with interquartile range 0.92-1.3. The distribution of HRs pertaining to cancer-related ICD codes was shifted toward positive associations, and the distribution pertaining to cardiovascular-related ICD codes was shifted toward negative associations. In this hypothesis-scanning study, we observed little difference in the occurrence of non-breast cancer-related diseases and conditions among older, long-term breast cancer survivors, and comparable women without a history of breast cancer.
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Affiliation(s)
- Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA,
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23
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Hurria A, Wildes T, Blair SL, Browner IS, Cohen HJ, deShazo M, Dotan E, Edil BH, Extermann M, Ganti AKP, Holmes HM, Jagsi R, Karlekar MB, Keating NL, Korc-Grodzicki B, McKoy JM, Medeiros BC, Mrozek E, O’Connor T, Rugo HS, Rupper RW, Silliman RA, Stirewalt DL, Tew WP, Walter LC, Weir AB, Bergman MA, Sundar H. Senior Adult Oncology, Version 2.2014. J Natl Compr Canc Netw 2014; 12:82-126. [DOI: 10.6004/jnccn.2014.0009] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Haque R, Prout M, Geiger AM, Kamineni A, Thwin SS, Avila C, Silliman RA, Quinn V, Yood MU. Comorbidities and cardiovascular disease risk in older breast cancer survivors. Am J Manag Care 2014; 20:86-92. [PMID: 24512167 PMCID: PMC4072034] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate cardiovascular disease (CVD) risk factors in older breast cancer survivors compared with a group of women without breast cancer. STUDY DESIGN The retrospective study included (1) women aged 65 or more years who were initially diagnosed with stage I or II breast cancer from 1990 to 1994 in 6 US health plans and who survived at least 5 years post-diagnosis (cases) and (2) a matched comparison group. They were followed for a maximum of 15 years. METHODS Data sources included medical charts and electronic health records. Cases (n = 1361) were matched on age, health plan site, and enrollment year to women in the comparison group (n = 1361). Subjects were followed to the first CVD outcome, health plan disenrollment, death, or study end. We compared rates of CVD in these 2 groups and used Cox proportional hazard models to estimate the hazard ratio (HR), considering body mass index, smoking history, diabetes, and hypertension. RESULTS The strongest predictors of CVD were smoking history (HR = 1.29; 95% confidence interval [CI], 1.15-1.46), diabetes (HR = 1.72; 95% CI, 1.48-1.99), and hypertension (HR = 1.48; 95% CI, 1.31-1.67) rather than breast cancer case-comparison status (HR = 0.97; 95% CI, 0.87-1.09). CONCLUSION Results suggest that long-term prognosis in breast cancer patients is affected by management of preexisting conditions. Assessment of comorbid conditions and effective management of diabetes and hypertension in older breast cancer survivors may lead to longer overall survival.
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Affiliation(s)
- Reina Haque
- Kaiser Permanente Southern California, Department of Research and Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA 91101. E-mail:
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25
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Bickmore TW, Silliman RA, Nelson K, Cheng DM, Winter M, Henault L, Paasche-Orlow MK. A randomized controlled trial of an automated exercise coach for older adults. J Am Geriatr Soc 2013. [PMID: 24001030 DOI: 10.1111/jgs.12449.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the efficacy of a computer-based physical activity program (Embodied Conversational Agent-ECA) with that of a pedometer control condition in sedentary older adults. DESIGN Single-blind block-randomized controlled trial stratified according to clinic site and health literacy status. SETTING Three urban ambulatory care practices at Boston Medical Center between April 2009 and September 2011. PARTICIPANTS Older adults (N = 263; mean age 71.3; 61% female; 63% African American; 51% high school diploma or less). INTERVENTION ECA participants were provided with portable tablet computers with touch screens to use for 2 months and were directed to connect their pedometers to the computer using a data cable and interact with a computer-animated virtual exercise coach daily to discuss walking and to set walking goals. Intervention participants were then given the opportunity to interact with the ECA in a kiosk in their clinic waiting room for the following 10 months. Control participants were given a control pedometer intervention that only tracked step counts for an equivalent period of time. Intervention participants were also provided with pedometers. MEASUREMENTS The primary outcome was average daily step count for the 30 days before the 12-month interview. Secondary outcomes were average daily step count for the 30 days before the 2-month interview. Outcomes were also stratified according to health literacy level. RESULTS ECA participants walked significantly more steps than control participants at 2 months (adjusted mean 4,041 vs 3,499 steps/day, P = .01), but this effect waned by 12 months (3,861 vs 3,383, P = .09). For participants with adequate health literacy, those in the ECA group walked significantly more than controls at both 2 months (P = .03) and 12 months (P = .02), while those with inadequate health literacy failed to show significant differences between treatment groups at either time point. Intervention participants were highly satisfied with the program. CONCLUSION An automated exercise promotion system deployed from outpatient clinics increased walking among older adults over the short-term. Effective methods for long-term maintenance of behavior change are needed.
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Affiliation(s)
- Timothy W Bickmore
- College of Computer and Information Science, Northeastern University, Boston, Massachusetts
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26
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Bickmore TW, Silliman RA, Nelson K, Cheng DM, Winter M, Henault L, Paasche-Orlow MK. A randomized controlled trial of an automated exercise coach for older adults. J Am Geriatr Soc 2013; 61:1676-83. [PMID: 24001030 DOI: 10.1111/jgs.12449] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the efficacy of a computer-based physical activity program (Embodied Conversational Agent-ECA) with that of a pedometer control condition in sedentary older adults. DESIGN Single-blind block-randomized controlled trial stratified according to clinic site and health literacy status. SETTING Three urban ambulatory care practices at Boston Medical Center between April 2009 and September 2011. PARTICIPANTS Older adults (N = 263; mean age 71.3; 61% female; 63% African American; 51% high school diploma or less). INTERVENTION ECA participants were provided with portable tablet computers with touch screens to use for 2 months and were directed to connect their pedometers to the computer using a data cable and interact with a computer-animated virtual exercise coach daily to discuss walking and to set walking goals. Intervention participants were then given the opportunity to interact with the ECA in a kiosk in their clinic waiting room for the following 10 months. Control participants were given a control pedometer intervention that only tracked step counts for an equivalent period of time. Intervention participants were also provided with pedometers. MEASUREMENTS The primary outcome was average daily step count for the 30 days before the 12-month interview. Secondary outcomes were average daily step count for the 30 days before the 2-month interview. Outcomes were also stratified according to health literacy level. RESULTS ECA participants walked significantly more steps than control participants at 2 months (adjusted mean 4,041 vs 3,499 steps/day, P = .01), but this effect waned by 12 months (3,861 vs 3,383, P = .09). For participants with adequate health literacy, those in the ECA group walked significantly more than controls at both 2 months (P = .03) and 12 months (P = .02), while those with inadequate health literacy failed to show significant differences between treatment groups at either time point. Intervention participants were highly satisfied with the program. CONCLUSION An automated exercise promotion system deployed from outpatient clinics increased walking among older adults over the short-term. Effective methods for long-term maintenance of behavior change are needed.
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Affiliation(s)
- Timothy W Bickmore
- College of Computer and Information Science, Northeastern University, Boston, Massachusetts
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27
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Abstract
Life expectancy for US women lags behind that for women in other countries. Factors contributing to inequitable health for women are complex and include policy, community, healthcare access, and the interaction between the patient and her healthcare provider working within the healthcare system. We propose a societal pyramid of health accounting for the effects of these different factors and their impact on prevention, screening, diagnosis, and management of disease using the examples of smoking and obesity, two of the most important yet modifiable risk factors for chronic disease and death among US women.
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Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Massachusetts, United States
| | - Bonnie J Sherman
- Women's Health Unit/Department of General Internal Medicine, Boston University School of Medicine, Massachusetts, United States
| | - Rebecca A Silliman
- Department of Geriatrics, Boston University School of Medicine, Massachusetts, United States
| | - Tracy A Battaglia
- Women's Health Unit/Department of General Internal Medicine, Boston University School of Medicine, Massachusetts, United States
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Pawloski PA, Geiger AM, Haque R, Kamineni A, Fouayzi H, Ogarek J, Petersen HV, Bosco JLF, Thwin SS, Silliman RA, Field TS. Fracture risk in older, long-term survivors of early-stage breast cancer. J Am Geriatr Soc 2013; 61:888-895. [PMID: 23647433 DOI: 10.1111/jgs.12269] [Citation(s) in RCA: 13] [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] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To examine the effect of breast cancer and its treatment on fracture risk in older breast cancer survivors. DESIGN A 10-year prospective cohort study beginning 5 years after a diagnosis of breast cancer for survivors and match date for comparison women. SETTING Six integrated healthcare systems. PARTICIPANTS Women aged 65 and older (1,286 survivors, 1,286 comparison women, mean age 77.7 in both groups, white, non-Hispanic: survivors, 81.6%; comparison women, 85.2%) who were alive and recurrence free 5 years after a diagnosis of early-stage breast cancer and matched on age, study site, and enrollment year to a comparison cohort without breast cancer. MEASUREMENTS Cox proportional hazards models were used to estimate the association between fracture risk and survivor-comparison status, adjusting for drugs and risk factors associated with bone health. A subanalysis was used to evaluate the association between tamoxifen exposure and fracture risk. RESULTS No difference was observed in fracture rates between groups (hazard ratio (HR) = 1.1, 95% confidence interval (CI) = 0.9-1.3). The protective effect of tamoxifen was not statistically significant (HR = 0.9, 95% CI = 0.6-1.2). CONCLUSION Long-term survivors of early-stage breast cancer diagnosed at age 65 and older are not at greater risk of osteoporotic fractures than age-matched women without breast cancer. There appears to be no long-term protection from fractures with tamoxifen use.
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Affiliation(s)
- Pamala A Pawloski
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota 55425, USA.
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Kapoor A, Chew P, Silliman RA, Hylek EM, Katz JN, Cabral H, Berlowitz D. Venous thromboembolism after joint replacement in older male veterans with comorbidity. J Am Geriatr Soc 2013; 61:590-601. [PMID: 23581913 DOI: 10.1111/jgs.12161] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To identify older adults with comorbidities or poor functional status at high risk of postoperative venous thromboembolism (VTE). DESIGN Retrospective cohort study. SETTING Veterans Affairs Medical Center (VAMC). PARTICIPANTS Older adults who underwent total hip and knee replacement (THR and TKR) from 2002 to 2009. MEASUREMENTS Using multivariate logistic regression, the independent effect of cardiopulmonary comorbidities and diabetes on VTE was analyzed. Functional status expressed in a summary physical component score (PCS) was also analyzed in a subset of individuals in whom information on it was available. RESULTS There were 23,326 THR and TKR surgeries performed at the VAMC during the study period. Individuals with chronic obstructive pulmonary disease (COPD) had a 25% greater risk of VTE (odds ratio (OR) = 1.25, 95% confidence interval (CI) = 1.06-1.48), whereas those with coronary artery disease, congestive heart failure, and cerebrovascular disease did not have a greater risk of VTE. Individuals with diabetes mellitus had a lower risk of VTE (OR = 0.77, 95% CI = 0.64-0.92). Individuals with low PCS, which were available for 3,169 patients, had a 62% greater risk, although the effect did not reach statistical significance (lowest vs highest quartile OR = 1.62, 95% CI = 0.93-2.80). CONCLUSION Individuals with COPD had slightly greater risk of VTE, whereas low functional status had a larger effect that did not reach statistical significance. The constraints of administrative data analysis and sample size available for PCS limit conclusions about the role of these comorbidities and functional status.
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Affiliation(s)
- Alok Kapoor
- Hospital Medicine Unit, School of Medicine, Boston University, Boston, MA 02118, USA.
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Sequeira SS, Eggermont LHP, Silliman RA, Bickmore TW, Henault LE, Winter MR, Nelson K, Paasche-Orlow MK. Limited health literacy and decline in executive function in older adults. J Health Commun 2013; 18 Suppl 1:143-157. [PMID: 24093352 PMCID: PMC3807941 DOI: 10.1080/10810730.2013.825673] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Limited health literacy is associated with worse executive function, but the association between limited health literacy and decline in executive function has not been established because of a lack of longitudinal studies. The authors aimed to examine this association by studying a prospective cohort in the setting of a randomized controlled trial to promote walking in older adults. Participants were community-dwelling older adults (65 years of age or older) who scored 2 or more on the Mini-Cog, without depression (score of less than 15 on the 9-item Patient Health Questionnaire), and who completed baseline and 12-month evaluations (n = 226). Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Executive function measured at baseline and 12 months using the Trail Making Test (TMT), Controlled Oral Word Association Test, and Category Fluency. The associations between health literacy and 12-month decline in each test of executive function were modeled using multivariate linear regression. Health literacy was found to be limited in 37% of participants. Limited health literacy was associated with reduced performance on all 3 executive function tests. In fully adjusted models, limited health literacy was associated with greater 12-month decline in performance on the TMT than higher health literacy (p = .01). In conclusion, older adults with limited health literacy are at risk for more rapid decline in scores on the TMT, a measure of executive function.
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Affiliation(s)
| | | | | | | | - Lori E. Henault
- Boston University Medical Center, Boston, Massachusetts, USA
| | | | - Kerrie Nelson
- Boston University Medical Center, Boston, Massachusetts, USA
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Clough-Gorr KM, Thwin SS, Bosco JLF, Silliman RA, Buist DSM, Pawloski PA, Quinn VP, Prout MN. Incident malignancies among older long-term breast cancer survivors and an age-matched and site-matched nonbreast cancer comparison group over 10 years of follow-up. Cancer 2012; 119:1478-85. [PMID: 23280284 DOI: 10.1002/cncr.27914] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 10/24/2012] [Accepted: 10/29/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Of the approximately 2.4 million American women with a history of breast cancer, 43% are aged ≥ 65 years and are at risk for developing subsequent malignancies. METHODS Women from 6 geographically diverse sites included 5-year breast cancer survivors (N = 1361) who were diagnosed between 1990 and 1994 at age ≥ 65 years with stage I or II disease and a comparison group of women without breast cancer (N = 1361). Women in the comparison group were age-matched and site-matched to breast cancer survivors on the date of breast cancer diagnosis. Follow-up began 5 years after the index date (survivor diagnosis date or comparison enrollment date) until death, disenrollment, or through 15 years after the index date. Data were collected from medical records and electronic sources (cancer registry, administrative, clinical, National Death Index). Analyses included descriptive statistics, crude incidence rates, and Cox proportional hazards regression models for estimating the risk of incident malignancy and were adjusted for death as a competing risk. RESULTS Survivors and women in the comparison group were similar: >82% were white, 55% had a Charlson Comorbidity Index of 0, and ≥ 73% had a body mass index ≤ 30 kg/m(2) . Of all 306 women (N = 160 in the survivor group, N = 146 in the comparison group) who developed a first incident malignancy during follow-up, the mean time to malignancy was similar (4.37 ± 2.81 years vs 4.03 ± 2.76 years, respectively; P = .28), whereas unadjusted incidence rates were slightly higher in survivors (1882 vs 1620 per 100,000 person years). The adjusted hazard of developing a first incident malignancy was slightly elevated in survivors in relation to women in the comparison group, but it was not statistically significant (hazard ratio, 1.17; 95% confidence interval, 0.94-1.47). CONCLUSIONS Older women who survived 5 years after an early stage breast cancer diagnosis were not at an elevated risk for developing subsequent incident malignancies up to 15 years after their breast cancer diagnosis.
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Affiliation(s)
- Kerri M Clough-Gorr
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
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Moser A, Stuck AE, Silliman RA, Ganz PA, Clough-Gorr KM. The eight-item modified Medical Outcomes Study Social Support Survey: psychometric evaluation showed excellent performance. J Clin Epidemiol 2012; 65:1107-16. [PMID: 22818947 DOI: 10.1016/j.jclinepi.2012.04.007] [Citation(s) in RCA: 251] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 03/28/2012] [Accepted: 04/09/2012] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Evaluation and validation of the psychometric properties of the eight-item modified Medical Outcomes Study Social Support Survey (mMOS-SS). STUDY DESIGN AND SETTING Secondary analyses of data from three populations: Boston breast cancer study (N=660), Los Angeles breast cancer study (N=864), and Medical Outcomes Study (N=1,717). The psychometric evaluation of the eight-item mMOS-SS compared performance across populations and with the original 19-item Medical Outcomes Study Social Support Survey (MOS-SS). Internal reliability, factor structure, construct validity, and discriminant validity were evaluated using Cronbach's alpha, principal factor analysis (PFA), and confirmatory factor analysis (CFA), Spearman and Pearson correlation, t-test and Wilcoxon rank sum tests. RESULTS mMOS-SS internal reliability was excellent in all three populations. PFA factor loadings were similar across populations; one factor >0.6, well-discriminated two factor (instrumental/emotional social support four items each) >0.5. CFA with a priori two-factor structure yielded consistently adequate model fit (root mean squared errors of approximation 0.054-0.074). mMOS-SS construct and discriminant validity were similar across populations and comparable to MOS-SS. Psychometric properties held when restricted to women aged ≥ 65 years. CONCLUSION The psychometric properties of the eight-item mMOS-SS were excellent and similar to those of the original 19-item instrument. Results support the use of briefer mMOS-SS instrument; better suited to multidimensional geriatric assessments and specifically in older women with breast cancer.
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Affiliation(s)
- André Moser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, CH 3012 Bern, Switzerland
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Oates DJ, Kornetsky D, Winter MR, Silliman RA, Caruso LB, Sharbaugh ME, Hardt EJ, Parker VA. Minimizing geriatric rehospitalizations: a successful model. Am J Med Qual 2012; 28:8-15. [PMID: 22684011 DOI: 10.1177/1062860612445181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rehospitalizations may indicate care quality problems. The authors conducted a retrospective cohort study of adults aged 65 years and older, comparing 30-day rehospitalization rates. Rates were compared for comprehensive geriatrics practice patients and for patients receiving usual general medical care. The unadjusted 30-day rehospitalization rate was 18% overall, 21% for geriatrics patients cared for on the geriatrics inpatient service, 22% for geriatrics practice patients on general medical services (GMSs), and 17% for older patients on GMS. Compared with older adults discharged from a GMS, geriatrics patients on the geriatrics service had an adjusted odds ratio for readmission of 1.00 (95% confidence interval = 0.88-1.13). Despite greater frailty, patients cared for in an interdisciplinary geriatrics practice were no more likely to be rehospitalized than adults receiving "usual care," when adjusted for age and disease burden. Incomplete adjustment may account for this finding, which did not confirm the hypothesis that comprehensive geriatrics care would yield fewer rehospitalizations.
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Affiliation(s)
- Daniel J Oates
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA.
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Sehl ME, Lu X, Silliman RA, Ganz PA. Decline in physical functioning in first 2 years after breast cancer diagnosis to predict survival in older women. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.e11003] [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: 11/20/2022] Open
Abstract
e11003 Background: Breast cancer patients often experience a decline in physical functioning following cancer diagnosis. Although most patients recover after treatment, some patients do not. These changes may be magnified in older women with comorbid conditions and could impact survival outcomes. Methods: We used longitudinal data from a prospective cohort study of women 65+ years of age, recruited shortly after diagnosis of early stage breast cancer, to examine changes in self-reported physical functioning measured with the Physical Function Index (PF-10) of the Medical Outcomes Study Short Form-36 (SF-36). Outcomes were constructed for small (0.2 SD), medium (0.5 SD), and large (0.8 SD) decline in the PF-10 measurement over two intervals 1) 3 to 15 months following cancer diagnosis, encompassing treatment and early recovery, and 2) 3 to 27 months following cancer diagnosis, in order to detect sustained recovery versus persistent decline. Cox-proportional hazards regression was used to examine association between survival and decline in PF-10 scores. Results: A large (> 0.8 SD) decline in PF-10 scores from 3 to 27 months predicted shorter 10 year survival (HR=1.37, 95% CI 1.07-1.74). Persistent decline at 27 months was associated with less education, higher baseline PF-10, increased comorbidity, and lack of exercise at baseline. Conclusions: Older women with breast cancer who experience a large and persistent decline in PF-10 are at increased mortality risk. Future research should examine the value of clinical assessment of physical function as a marker for mortality and test interventions to prevent decline in physical function to improve post-treatment survival outcomes.
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Affiliation(s)
| | - Xiang Lu
- UCLA Department of Biostatistics, Los Angeles, CA
| | | | - Patricia A. Ganz
- Division of Cancer Prevention and Control Research, Jonsson Comprehensive Cancer Center at UCLA, Los Angeles, CA
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Hurria A, Browner IS, Cohen HJ, Denlinger CS, deShazo M, Extermann M, Ganti AKP, Holland JC, Holmes HM, Karlekar MB, Keating NL, McKoy J, Medeiros BC, Mrozek E, O'Connor T, Petersdorf SH, Rugo HS, Silliman RA, Tew WP, Walter LC, Weir AB, Wildes T. Senior adult oncology. J Natl Compr Canc Netw 2012; 10:162-209. [PMID: 22308515 PMCID: PMC3656650 DOI: 10.6004/jnccn.2012.0019] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Cronin-Fenton DP, Hellberg Y, Lauridsen KL, Ahern TP, Garne JP, Rosenberg C, Silliman RA, Sørensen HT, Lash TL, Hamilton-Dutoit S. Factors associated with concordant estrogen receptor expression at diagnosis and centralized re-assay in a Danish population-based breast cancer study. Acta Oncol 2012; 51:254-61. [PMID: 22129357 DOI: 10.3109/0284186x.2011.633556] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Estrogen receptor (ER) expression predicts tamoxifen response, which halves the risk of breast cancer recurrence. We examined clinical factors associated with concordance between ER expression at diagnosis and centralized re-assay, and the association of concordance with breast cancer recurrence. MATERIAL AND METHODS We used immunohistochemistry to assess ER expression on archived fixed, paraffin-embedded breast carcinoma tissue excised from women aged 35-69 years, diagnosed 1985-2001 in Jutland, Denmark. We calculated the percentage agreement, positive predictive value (PPV) and negative predictive value (NPV) of ER status at diagnosis and re-assay. We used logistic regression to investigate factors associated with concordance, and its association with recurrence (odds ratios (OR) and associated 95% confidence intervals (95%CI)). RESULTS ER was re-assayed in 91% of patients (n = 1530). Concordance was better in ER + than ER- tumors (PPV = 94% vs. NPV = 75%). Factors associated with concordance included menopausal status, tumor size, surgical procedure, diagnostic period, lymph node status and time to recurrence. ER + women at diagnosis who re-assayed ER + were less likely to have recurrent disease (OR = 0.49, 95% CI = 0.28, 0.86) than those who re-assayed ER-. In originally ER- women, concordance was not associated with recurrence (OR = 0.97, 95% CI = 0.66, 1.42). CONCLUSIONS Several clinical factors were associated with ER assay concordance. Some women were ineffectively treated with tamoxifen, or required but did not receive tamoxifen. We observed almost exactly the protective effect of endocrine therapy among tamoxifen-treated ER + women whose tumors expressed the ER on re-assay, compared with those ER- on re-assay. Diagnostic pathology results for ER + tumors appear a valid and useful resource for research studies. However, those for ER- tumors have lower validity. Study-specific considerations regarding the aims, diagnostic period, and consequences of including ER- patients with truly ER + disease ought to be examined when using diagnostic pathology results for ER- tumors in research studies.
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Abstract
OBJECTIVES To identify factors that influence the breast cancer treatment decisions of women aged 80 and older. DESIGN Medical record review. SETTING One academic primary care clinic and two community health centers in Boston. PARTICIPANTS Sixty-five women aged 80 and older diagnosed with breast cancer between 1994 and 2004 and followed through June 30, 2010. MEASUREMENTS Data were abstracted on breast cancer characteristics, comorbidities, treatments received, and outcomes. Notes from primary care physicians, oncologists, and breast surgeons were reviewed to determine factors involved in treatment decision-making. RESULTS Median age at diagnosis was 84.0 (interquartile range 82.0-86.3), 55 (84.6%) were non-Hispanic white, and 40 (61.5%) had at least one comorbidity. Nine women were diagnosed with ductal carcinoma in situ, 42 with a new primary invasive breast cancer, eight with a second primary, and six with a breast cancer recurrence. Sixty-three (96.9%) received some type of treatment. Fifty-six (86.2%) had at least one detailed physician note on treatment decision-making in their charts. The main categories found to influence participant, family, and physician treatment decision-making were tumor characteristics, ratio of treatment benefits to risks, logistics (e.g., transportation, finances), and participant age, health (including a concurrent diagnosis), and psychosocial characteristics. Family was involved in treatment discussions for 46 (70.8%) participants. CONCLUSION The quality of physician documentation about decision-making in these women was high. A great amount of thoughtful and complex decision-making involving patients, family, and physicians occurs after a woman aged 80 and older is diagnosed with breast cancer.
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Affiliation(s)
- Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Division of General Medicine and Primary Care, Harvard Medical School, Boston, Massachusetts, USA.
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Schonberg MA, Marcantonio ER, Ngo L, Silliman RA, McCarthy EP. Does Life Expectancy Affect Treatment of Women Aged 80 and Older with Early Stage Breast Cancers? J Geriatr Oncol 2012; 3:8-16. [PMID: 22368726 DOI: 10.1016/j.jgo.2011.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND: Data are needed on how life expectancy affects treatment decisions among women ≥80 years with early stage breast cancer. METHODS: We used the linked Surveillance Epidemiology and End Results-Medicare claims dataset from 1992-2005 to identify women aged ≥80 newly diagnosed with lymph node negative, estrogen receptor positive tumors, ≤5 centimeters. To estimate life expectancy, we matched these women to women of similar age, region, and insurance, not diagnosed with breast cancer. We examined 5-year mortality of matched controls by illness burden (measured with the Charlson Comorbidity Index [CCI]) using Kaplan-Meier statistics. We examined treatments received by estimated life expectancy within CCI levels. We further examined factors associated with receipt of radiotherapy after breast conserving surgery (BCS). RESULTS: Of 9,932 women, 39.6% underwent mastectomy, 30.4% received BCS plus radiotherapy, and 30.0% received BCS alone. Estimated 5-year mortality was 72% for women with CCIs of 3+, yet 38.0% of these women underwent mastectomy and 22.9% received radiotherapy after BCS. Conversely, estimated 5-year mortality was 36% for women with CCIs of 0 and 26.6% received BCS alone. Age 80-84, urban residence, higher grade, recent diagnosis, mammography use, and low comorbidity, were factors associated with receiving radiotherapy after BCS. Among women with CCIs of 3+ treated with BCS, 36.9% underwent radiotherapy. CONCLUSIONS: Many women aged ≥80 with limited life expectancies receive radiotherapy after BCS for treatment of early stage breast cancers while many in excellent health do not. More consideration needs to be given to patient life expectancy when considering breast cancer treatments. KEY WORDS: Breast cancer, older women, treatment, life expectancy, radiation.
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Affiliation(s)
- Mara A Schonberg
- Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
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Huybrechts KF, Brookhart MA, Rothman KJ, Silliman RA, Gerhard T, Crystal S, Schneeweiss S. Comparison of different approaches to confounding adjustment in a study on the association of antipsychotic medication with mortality in older nursing home patients. Am J Epidemiol 2011; 174:1089-99. [PMID: 21934095 DOI: 10.1093/aje/kwr213] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Selective prescribing of conventional antipsychotic medication (APM) to frailer patients is thought to have led to overestimation of the association with mortality in pharmacoepidemiologic studies relying on claims data. The authors assessed the validity of different analytic techniques to address such confounding. The cohort included 82,012 persons initiating APM use after admission to a nursing home in 45 states with 2001-2005 Medicaid/Medicare data, linked to clinical data (Minimum Data Set) and institutional characteristics. The authors compared the association between APM class and 180-day mortality with multivariate outcome modeling, propensity score (PS) adjustment, and instrumental variables. The unadjusted risk difference (per 100 patients) of 10.6 (95% confidence interval (CI): 9.4, 11.7) comparing use of conventional medication with atypical APM was reduced to 7.8 (95% CI: 6.6, 9.0) and 7.0 (95% CI: 5.8, 8.2) after PS adjustment and high-dimensional PS (hdPS) adjustment, respectively. Results were similar in analyses limited to claims-based Medicaid /Medicare variables (risk difference = 8.2 for PS, 7.1 for hdPS). Instrumental-variable estimates were imprecise (risk difference = 8.8, 95% CI: -1.3, 19.0) because of the weak instrument. These results suggest that residual confounding has a relatively small impact on the effect estimate and that hdPS methods based on claims alone provide estimates at least as good as those from conventional analyses using claims enriched with clinical information.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA.
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Field TS, Bosco JLF, Prout MN, Gold HT, Cutrona S, Pawloski PA, Ulcickas Yood M, Quinn VP, Thwin SS, Silliman RA. Age, comorbidity, and breast cancer severity: impact on receipt of definitive local therapy and rate of recurrence among older women with early-stage breast cancer. J Am Coll Surg 2011; 213:757-65. [PMID: 22014658 DOI: 10.1016/j.jamcollsurg.2011.09.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 09/14/2011] [Accepted: 09/14/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND The definitive local therapy options for early-stage breast cancer are mastectomy and breast-conserving surgery followed by radiation therapy. Older women and those with comorbidities frequently receive breast-conserving surgery alone. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of definitive therapy have not been well-studied. STUDY DESIGN In a cohort of 1,837 women aged 65 years and older receiving treatment for early-stage breast cancer in 6 integrated health care delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving nondefinitive local therapy and assessed the impact on breast cancer recurrence within levels of severity, defined as level of risk for recurrence. RESULTS Age and comorbidity were associated with receipt of nondefinitive therapy. Compared with those at low risk, women at the highest risk were less likely to receive nondefinitive therapy (odds ratio = 0.32; 95% CI, 0.22-0.47), and women at moderate risk were about half as likely (odds ratio = 0.54; 95% CI, 0.35-0.84). Nondefinitive local therapy was associated with higher rates of recurrence among women at moderate (hazard ratio = 5.1; 95% CI, 1.9-13.5) and low risk (hazard ratio = 3.2; 95% CI, 1.1-8.9). The association among women at high risk was weak (hazard ratio = 1.3; 95% CI, 0.75-2.1). CONCLUSIONS Among these older women with early-stage breast cancer, decisions about therapy partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk, omitting definitive local therapy was associated with increased recurrence.
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Affiliation(s)
- Terry S Field
- Meyers Primary Care Institute, Worcester, MA 01605, USA.
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Haque R, Yood MU, Geiger AM, Kamineni A, Avila CC, Shi J, Silliman RA, Quinn VP. Long-term safety of radiotherapy and breast cancer laterality in older survivors. Cancer Epidemiol Biomarkers Prev 2011; 20:2120-6. [PMID: 21878589 DOI: 10.1158/1055-9965.epi-11-0348] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although adjuvant radiotherapy (RT) following surgery for breast cancer improves overall survival, controversy exists about its long-term adverse impact on cardiovascular health in older survivors. AIM To determine whether incident cardiovascular disease (CVD) is associated with RT and whether tumor laterality modifies this association. METHODS Women aged 65+ years diagnosed with stage I and II breast cancer between 1990 and 1994 were identified from three health plans. Women were followed through CVD outcomes, health plan disenrollment, death, or study end (December 31, 2004). The main independent variable was RT use. Adjusted HRs and 95% CIs were estimated using Cox proportional hazards models with time-dependent tamoxifen and RT use status. We adjusted for age, race, stage, estrogen receptor/progesterone receptor, hypertension, and diabetes. RESULTS In the full cohort (N = 806), RT was not associated with greater risk of CVD (maximum follow-up was 14 years). However, within the RT-exposed group (N = 340), women treated for left-side breast cancer had a significant increased risk of CVD outcomes (HR = 1.53, 95% CI: 1.06-2.21) compared with women with right-sided tumors. CONCLUSION Laterality is critical to understanding the effect of RT on CVD. Studies of more contemporary cohorts of women treated with RT should incorporate this variable to determine whether the risk persists with refinements in the dosing and delivery of RT. IMPACT As some irradiation to the heart is unavoidable even with refined modern RT techniques, continued effort is required to minimize such exposures, especially in older women with left-sided tumors.
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Affiliation(s)
- Reina Haque
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA 91101, USA.
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Ahern TP, Pedersen L, Tarp M, Cronin-Fenton DP, Garne JP, Silliman RA, Sørensen HT, Lash TL. Statin prescriptions and breast cancer recurrence risk: a Danish nationwide prospective cohort study. J Natl Cancer Inst 2011; 103:1461-8. [PMID: 21813413 DOI: 10.1093/jnci/djr291] [Citation(s) in RCA: 272] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Accumulating evidence suggests that statins affect diseases other than cardiovascular disease, including cancer, and that these effects may depend on the lipid solubility of specific statins. Though many studies have reported an association between statin use and breast cancer incidence, the relationship between statin use and breast cancer recurrence has not been well studied. METHODS We conducted a nationwide, population-based prospective cohort study of all female residents in Denmark diagnosed with stage I-III invasive breast carcinoma who were reported to the Danish Breast Cancer Cooperative Group registry between 1996 and 2003 (n = 18,769). Women were followed for a median of 6.8 years after diagnosis. Prescriptions for lipophilic and hydrophilic statins were ascertained from the national electronic pharmacy database. Associations between statin prescriptions and breast cancer recurrence were estimated with generalized linear models and Cox proportional hazards regression with adjustment for age and menopausal status at diagnosis; histological grade; estrogen receptor status; receipt of adjuvant therapy; type of primary surgery received; pre-diagnosis hormone replacement therapy; and co-prescriptions of aspirin, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, or anticoagulants. All statistical tests were two-sided. RESULTS Most prescriptions for lipophilic statins in the study population were for simvastatin. Exclusive simvastatin users experienced approximately 10 fewer breast cancer recurrences per 100 women after 10 years of follow-up (adjusted 10-year risk difference = -0.10, 95% confidence interval = -0.11 to -0.08), compared with women who were not prescribed a statin. Exclusive hydrophilic statin users had approximately the same risk of breast cancer recurrence as women not prescribed a statin over follow-up (adjusted 10-year risk difference = 0.05, 95% confidence interval = -0.01 to 0.11). CONCLUSIONS Simvastatin, a highly lipophilic statin, was associated with a reduced risk of breast cancer recurrence among Danish women diagnosed with stage I-III breast carcinoma, whereas no association between hydrophilic statin use and breast cancer recurrence was observed.
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Affiliation(s)
- Thomas P Ahern
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Ave, Rm 355, Boston, MA 02115, USA.
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Ahern TP, Christensen M, Cronin-Fenton DP, Lunetta KL, Søiland H, Gjerde J, Garne JP, Rosenberg CL, Silliman RA, Sørensen HT, Lash TL, Hamilton-Dutoit S. Functional polymorphisms in UDP-glucuronosyl transferases and recurrence in tamoxifen-treated breast cancer survivors. Cancer Epidemiol Biomarkers Prev 2011; 20:1937-43. [PMID: 21750172 DOI: 10.1158/1055-9965.epi-11-0419] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [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] Open
Abstract
BACKGROUND Tamoxifen is oxidized by cytochrome-P450 enzymes (e.g., CYP2D6) to two active metabolites, which are eliminated via glucuronidation by UDP-glucuronosyl transferases (UGT). We measured the association between functional polymorphisms in key UGTs (UGT2B15*2, UGT2B7*2, and UGT1A8*3) and the recurrence rate among breast cancer survivors. METHODS We used the Danish Breast Cancer Cooperative Group registry to identify 541 cases of recurrent breast cancer among women with estrogen receptor-positive tumors treated with tamoxifen for at least 1 year (ER(+)/TAM(+)), and 300 cases of recurrent breast cancer among women with estrogen receptor-negative tumors who were not treated with tamoxifen (ER(-)/TAM(-)). We matched one control to each case on ER status, menopausal status, stage, calendar period, and county. UGT polymorphisms were genotyped from archived primary tumors. We estimated the recurrence OR for the UGT polymorphisms by using logistic regression models, with and without stratification on CYP2D6*4 genotype. RESULTS No UGT polymorphism was associated with breast cancer recurrence in either the ER(+)/TAM(+) or ER(-)/TAM(-) groups [in the ER(+)/TAM(+) group, compared with two normal alleles: adjusted OR for two UGT2B15*2 variant alleles = 1.0 (95% CI, 0.70-1.5); adjusted OR for two UGT2B7*2 variant alleles = 0.96 (95% CI, 0.65-1.4); adjusted OR for one or two UGT1A8*3 variant alleles = 0.95 (0.49-1.9)]. Associations were similar within strata of CYP2D6*4 genotype. CONCLUSIONS Functional polymorphisms in key tamoxifen-metabolizing enzymes were not associated with breast cancer recurrence risk. IMPACT Our results do not support the genotyping of key metabolic enzyme polymorphisms to predict response to tamoxifen therapy.
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Affiliation(s)
- Thomas P Ahern
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Clough-Gorr KM, Thwin SS, Stuck AE, Silliman RA. Examining five- and ten-year survival in older women with breast cancer using cancer-specific geriatric assessment. Eur J Cancer 2011; 48:805-12. [PMID: 21741826 DOI: 10.1016/j.ejca.2011.06.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 06/07/2011] [Accepted: 06/07/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To examine five- and ten-year survival based on cancer-specific geriatric assessment (C-SGA) in older women with early stage breast cancer. METHODS We evaluated 660 women ≥65-years old diagnosed with stage I-IIIA primary breast cancer and attending physician permission to contact in four geographic regions in the United States of America (USA). Data were collected over ten-years of follow-up from consenting women's medical records, telephone interviews, National Death Index and Social Security Death Index. C-SGA was described by four domains using six measures: socio-demographic (financial resources); clinical (comorbidity, obesity); function (physical function limitations); and psychosocial (general mental health, social support). Survival from all-cause and breast-cancer-specific mortality and receipt of guideline-recommended therapy was assessed for different groups of subjects with C-SGA domain deficits (cut-off ≥3 deficits). RESULTS The proportion of women with ≥3 C-SGA deficits surviving ten-years was consistently statistically significantly lower (all-cause 26% versus 46% and breast-cancer-specific 76% versus 89%, p≤0.04). The proportion significantly decreased as number of C-SGA deficits increased (linear trend p<0.0001). Receipt of guideline-recommended therapy decreased with age but not consistently by number of C-SGA deficits. The all-cause and breast-cancer-specific death rate at five- and ten-years was consistently approximately two times higher in women with ≥3 C-SGA deficits even when fully adjusted for confounding factors (HR(5-yrAllCauseFullyAdjusted)=1.87 [1.36-2.57], HR(10-yrAllCauseFullyAdjusted)=1.74 [1.35-2.15], HR(5-yrBreastCancerFullyAdjusted)=1.95 [1.18-3.20], HR(10-yrBreastCancerFullyAdjusted)=1.99 [1.21-3.28]). CONCLUSION Regardless of age and stage of disease, C-SGA predicts five- and ten-year all-cause and breast-cancer-specific survival in older women. Hence, C-SGA may provide an effective strategy to guide treatment decision-making and to identify risk factors for intervention.
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Affiliation(s)
- Kerri M Clough-Gorr
- Section of Geriatrics, Boston University Medical Center, 88 East Newton Street, Robinson Building, Boston, MA 02118, USA.
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Ahern TP, Pedersen L, Cronin-Fenton DP, Tarp M, Silliman RA, Sørensen HT, Lash TL. Abstract 4678: Post-diagnosis use of lipophilic statins and breast cancer recurrence: A Danish nationwide cohort study. Cancer Res 2011. [DOI: 10.1158/1538-7445.am2011-4678] [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
Statins may affect non-cardiovascular endpoints, including cancer incidence and survival. These effects may depend on the solubility of the specific medicine. Our objective was to measure the association between post-diagnosis lipophilic and hydrophilic statin use and recurrence among non-metastatic breast cancer patients.
We ascertained incident cases of stage I-III invasive breast cancer diagnosed in Denmark between 1996 and 2006 from the Danish Breast Cancer Cooperative Group registry, and linked these records to the Register of Medicinal Products (RMP), which automatically logs pharmacy transactions in Denmark. We determined statin prescriptions filled by cohort members by searching the RMP for appropriate ATC codes. Statins were classified by solubility (Table 1) and exposure status was updated yearly. Follow-up began upon completion of primary therapy and continued until the first of breast cancer recurrence, death from any cause, emigration from Denmark, or the end of 2006. Associations were estimated with time-dependent crude and multivariate Cox regression models.
We enrolled 18,769 breast cancer patients, with a median follow-up of 6.2 years. Of the 3,282 women ever prescribed a statin after diagnosis, 2,518 were exclusively prescribed lipophilic statins and 210 were exclusively prescribed hydrophilic statins.
Crude and multivariate models yielded similar estimates. Lipophilic (but not hydrophilic) statin use was associated with a reduced rate of breast cancer recurrence (compared with no statin use: multivariate HR for lipophilic statin use = 0.65, 95% CI: 0.55, 0.76; multivariate HR for hydrophilic statin use = 0.89, 95% CI: 0.61, 1.3). Associations were similar when estimated in the subset of women with no pre-diagnosis statin exposure.
In this population-based prospective cohort study with complete information on prognostic and treatment variables, breast cancer patients who took lipophilic statins had a reduced rate of breast cancer recurrence.
(a) Hazard ratios adjusted for age, menopausal status, tumor stage, ER status, adjuvant hormonal therapy, type of surgery, comorbidity, and co-prescription of aspirin. Estimates were similar in models further adjusted for chemotherapy, type of surgery, receipt of radiotherapy, and co-prescription of hormone replacement therapy, NSAIDs, anticoagulants and ACE inhibitors.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4678. doi:10.1158/1538-7445.AM2011-4678
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Affiliation(s)
- Thomas P. Ahern
- 1Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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- 2Aarhus University Hospital, Aarhus, Denmark
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Huybrechts KF, Rothman KJ, Silliman RA, Brookhart MA, Schneeweiss S. Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes. CMAJ 2011; 183:E411-9. [PMID: 21444611 DOI: 10.1503/cmaj.101406] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite safety-related concerns, psychotropic medications are frequently prescribed to manage behavioural symptoms in older adults, particularly those with dementia. We assessed the comparative safety of different classes of psychotropic medications used in nursing home residents. METHODS We identified a cohort of patients who were aged 65 years or older and had initiated treatment with psychotropics after admission to a nursing home in British Columbia between 1996 and 2006. We used proportional hazards models to compare rates of death and rates of hospital admissions for medical events within 180 days after treatment initiation. We used propensity-score adjustments to control for confounders. RESULTS Of 10,900 patients admitted to nursing homes, atypical antipsychotics were initiated by 1942, conventional antipsychotics by 1902, antidepressants by 2169 and benzodiazepines by 4887. Compared with users of atypical antipsychotics, users of conventional antipsychotics and antidepressants had an increased risk of death (rate ratio [RR] 1.47, 95% confidence interval [CI] 1.14-1.91 for conventional antipsychotics and RR 1.20, 95% CI 0.96-1.50 for antidepressants), and an increased risk of femur fracture (RR 1.61, 95% CI 1.03-2.51 for conventional antipsychotics and RR 1.29, 95% CI 0.86-1.94 for antidepressants). Users of benzodiazepines had a higher risk of death (RR 1.28, 95% CI 1.04-1.58) compared with users of atypical antipsychotics. The RR for heart failure was 1.54 (95% CI 0.89-2.67), and for pneumonia it was 0.85 (95% CI 0.56-1.31). INTERPRETATION Among older patients admitted to nursing homes, the risks of death and femur fracture associated with conventional antipsychotics, antidepressants and benzodiazepines are comparable to or greater than the risks associated with atypical antipsychotics. Clinicians should weigh these risks against the potential benefits when making prescribing decisions.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass., USA.
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Schonberg MA, Marcantonio ER, Ngo L, Li D, Silliman RA, McCarthy EP. Causes of death and relative survival of older women after a breast cancer diagnosis. J Clin Oncol 2011; 29:1570-7. [PMID: 21402602 DOI: 10.1200/jco.2010.33.0472] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [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 To understand the impact of breast cancer on older women's survival, we compared survival of older women diagnosed with breast cancer with matched controls. METHODS Using the linked 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER) -Medicare data set, we identified women age 67 years or older who were newly diagnosed with ductal carcinoma in situ (DCIS) or breast cancer. We identified women not diagnosed with breast cancer from the 5% random sample of Medicare beneficiaries residing in SEER areas.We matched patient cases to controls by birth year and registry (99% or 66,039 [corrected] patient cases matched successfully). We assigned the start of follow-up for controls as the patient cases' date of diagnosis. Mortality data were available through 2006. We compared survival of women with breast cancer by stage with survival of controls using multivariable proportional hazards models adjusting for age at diagnosis, comorbidity, prior mammography use, and sociodemographics. We repeated these analyses stratifying by age. RESULTS Median follow-up time was 7.7 years. Differences between patient cases and controls in sociodemographics and comorbidities were small (< 4%). Women diagnosed with DCIS (adjusted hazard ratio [aHR], 0.7; 95% CI, 0.7 to 0.7) or stage I disease (aHR, 0.8; 95% CI, 0.8 to 0.8) had slightly lower mortality than controls.Women diagnosed with stage II disease or higher had greater mortality than controls (stage II disease:aHR, 1.2; 95% CI, 1.2 to 1.2). The association of a breast cancer diagnosis with mortality declined with age among women with advanced disease [corrected]. CONCLUSION Compared with matched controls, a diagnosis of DCIS or stage I breast cancer in older women is associated with better [corrected] survival, whereas a diagnosis of stage II or higher breast cancer is associated with worse survival.
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Affiliation(s)
- Mara A Schonberg
- Beth Israel Deaconess Medical Center, 1309 Beacon St, Office 202, Brookline, MA 02446, USA.
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Lash TL, Cronin-Fenton D, Ahern TP, Rosenberg CL, Lunetta KL, Silliman RA, Garne JP, Sørensen HT, Hellberg Y, Christensen M, Pedersen L, Hamilton-Dutoit S. CYP2D6 inhibition and breast cancer recurrence in a population-based study in Denmark. J Natl Cancer Inst 2011; 103:489-500. [PMID: 21325141 DOI: 10.1093/jnci/djr010] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cytochrome P450 2D6 (CYP2D6) inhibition reduces the concentration of 4-hydroxylated tamoxifen metabolites, but the clinical relevance remains uncertain. METHODS We conducted a large case-control study nested in the population of 11 251 women aged 35-69 years at diagnosis of stage I-III breast cancer between 1985 and 2001 on Denmark's Jutland Peninsula and registered with the Danish Breast Cancer Cooperative Group. We identified 541 recurrent or contralateral breast cancers among women with estrogen receptor-positive (ER+) disease treated with tamoxifen for at least 1 year and 300 cancers in women with ER-negative (ER-) disease never treated with tamoxifen. We matched one control subject per case patient on ER status, menopausal status, stage, calendar time, and county, genotyped the CYP2D6*4 allele to assess genetic inhibition, and ascertained prescription history to assess drug-drug inhibition. We estimated the odds ratio (OR), associating CYP2D6 inhibition with breast cancer recurrence and adjusted for potential confounding with logistic regression. To address bias from incomplete information on CYP2D6 function, we used Monte Carlo simulation to complete a record-level probabilistic bias analysis. All statistical tests were two-sided. RESULTS The frequency of the CYP2D6*4 minor allele was 24% in case patients with ER+ tumors, 23% in case patients with ER- tumors, and 22% each in control subjects with ER+ and ER- tumors. In women with ER+ tumors, the associations of one functional allele with recurrence (OR = 0.99; 95% confidence interval = 0.76 to 1.3) and no functional allele with recurrence (OR = 1.4; 95% confidence interval = 0.84 to 2.3) were near null, as were those for women with ER- tumors. The near-null associations persisted when evaluated by intake of medications, by combining genotype with medication history, in the probabilistic bias analysis, or by restricting the analysis to women with ER expression confirmed by re-assay. CONCLUSION The association between CYP2D6 inhibition and recurrence in tamoxifen-treated patients is likely null or small.
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Affiliation(s)
- Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.
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Hanchate AD, Clough-Gorr KM, Ash AS, Thwin SS, Silliman RA. Longitudinal patterns in survival, comorbidity, healthcare utilization and quality of care among older women following breast cancer diagnosis. J Gen Intern Med 2010; 25:1045-50. [PMID: 20532657 PMCID: PMC2955471 DOI: 10.1007/s11606-010-1407-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [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: 09/30/2009] [Revised: 03/31/2010] [Accepted: 05/12/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare longitudinal patterns of health care utilization and quality of care for other health conditions between breast cancer-surviving older women and a matched cohort without breast cancer. DESIGN Prospective five-year longitudinal comparison of cases and matched controls. SUBJECTS Newly identified breast cancer patients recruited during 1997-1999 from four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island; N = 422) were matched by age, race, baseline comorbidity and zip code location with up to four non-breast-cancer controls (N = 1,656). OUTCOMES Survival; numbers of hospitalized days and physician visits; total inpatient and outpatient Medicare payments; guideline monitoring for patients with cardiovascular disease and diabetes, and bone density testing and colorectal cancer screening. RESULTS Five-year survival was similar for cases and controls (80% and 82%, respectively; p = 0.18). In the first follow-up year, comorbidity burden and health care utilization were higher for cases (p < 0.01), with most differences diminishing over time. However, the number of physician visits was higher for cases (p < 0.01) in every year, driven partly by more cancer and surgical specialist visits. Cases and controls adhered similarly to recommended bone density testing, and monitoring of cardiovascular disease and diabetes; adherence to recommended colorectal cancer screening was better among cases. CONCLUSION Breast cancer survivors' health care utilization and disease burden return to pre-diagnosis levels after one year, yet their greater use of outpatient care persists at least five years. Quality of care for other chronic health problems is similar for cases and controls.
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Affiliation(s)
- Amresh D Hanchate
- Center for Organization, Leadership and Management Research (COLMR), VA Boston Healthcare System, Boston, MA, USA.
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Kapoor A, Labonte AJ, Winter MR, Segal JB, Silliman RA, Katz JN, Losina E, Berlowitz D. Risk of venous thromboembolism after total hip and knee replacement in older adults with comorbidity and co-occurring comorbidities in the Nationwide Inpatient Sample (2003-2006). BMC Geriatr 2010; 10:63. [PMID: 20846450 PMCID: PMC2949673 DOI: 10.1186/1471-2318-10-63] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Accepted: 09/17/2010] [Indexed: 11/17/2022] Open
Abstract
Background Venous thromboembolism is a common, fatal, and costly injury which complicates major surgery in older adults. The American College of Chest Physicians recommends high potency prophylaxis regimens for individuals undergoing total hip or knee replacement (THR or TKR), but surgeons are reluctant to prescribe them due to fear of excess bleeding. Identifying a high risk cohort such as older adults with comorbidities and co-occurring comorbidities who might benefit most from high potency prophylaxis would improve how we currently perform preoperative assessment. Methods Using the Nationwide Inpatient Sample, we identified older adults who underwent THR or TKR in the U.S. between 2003 and 2006. Our outcome was VTE, including any pulmonary embolus or deep venous thrombosis. We performed multivariate logistic regression analyses to assess the effects of comorbidities on VTE occurrence. Comorbidities under consideration included coronary artery disease, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and cerebrovascular disease. We also examined the impact of co-occurring comorbidities on VTE rates. Results CHF increased odds of VTE in both the THR cohort (OR = 3.08 95% CI 2.05-4.65) and TKR cohort (OR = 2.47 95% CI 1.95-3.14). COPD led to a 50% increase in odds in the TKR cohort (OR = 1.49 95% CI 1.31-1.70). The data did not support synergistic effect of co-occurring comorbidities with respect to VTE occurrence. Conclusions Older adults with CHF undergoing THR or TKR and with COPD undergoing TKR are at increased risk of VTE. If confirmed in other datasets, these older adults may benefit from higher potency prophylaxis.
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Affiliation(s)
- Alok Kapoor
- Hospital Medicine Unit, Boston University School of Medicine, 715 Albany Street, Boston, MA 02118, USA.
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