Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

EMERGENCY DEPARTMENT USE FOR DENTAL PROBLEMS AMONG MEDICARE FEE-FOR-SERVICE OLDER ADULTS IN THE U.S. (2016 TO 2020)

Medicare Fee-for-Service (FFS) does not include dental coverage for older adults (65 years of age and older) but does cover emergency visits for dental problems. This study leverages Medicare Limited Data Sets to examine the use of emergency department (ED) for preventable, non-traumatic dental conditions (NTDCs) among Medicare FFS older adults from 2016 to 2020. Nationally, ~43.6 million beneficiaries sought care at the ED (average: ~8.7 million annually). Among these, ~550,000 ED visits (1.27%; ~110K annually) were for NTDCs as one of the diagnosis codes and ~200,000 ED visits (0.45%; ~40K annually) were for NTDCs as a primary diagnosis. Approximately, 5–6% of older adults with ED-NTDCs have multiple visits (94% with 1 ED-NTDC visit annually). Rates were similar in most years; however, ED use was lower in 2020 (COVID-19 pandemic). The most common diagnosis reasons include periapical abscess (tooth infection), sialadenitis, dental caries, jaw pain, and lesions of oral mucosa. Younger (65 to 74 years) and Black older adults were more likely to have primary ED-NTDC visits. Medicare paid ~$190 million for ED-NTDC visits (average: $38 million annually). Costs vary by inpatient (9%) and outpatient visits (91%). For ED-NTDCs as a primary diagnosis, the average Medicare payments for outpatient and inpatient visits were approximately $330 and $8,100, respectively. ED use for NTDCs indicates inappropriate use of valuable resources, because care provided in the EDs is incomplete (e.g., antibiotics, pain medication). Lack of follow-up with a dentist likely results in return ED visits, thus increasing costs to beneficiaries and public programs.

Longitudinal Comparison of Stability and Sensitivity in Quality of Life Scores Among Nursing Home Residents With and Without Diagnoses of Alzheimer's Disease and Related Dementias

BACKGROUND AND OBJECTIVES

Prevalence of nursing home residents with Alzheimer's disease and related dementias (ADRD) has increased along with a growing consensus that person-centered ADRD care in nursing homes should maximize quality of life (QoL). However, concerns about whether residents with ADRD can make appropriate QoL judgments persist. This study assesses the stability and sensitivity of a self-reported, multidomain well-being QoL measure for nursing home residents with and without ADRD.

RESEARCH DESIGN AND METHODS

This study linked the 2012-2015 Minnesota Nursing Home Resident QoL and Satisfaction with Care Survey, Minimum Data Set 3.0 (nursing home assessments), and Minnesota Department of Human Services Cost Reports. The QoL survey included cohort-resident pairs who participated for 2 consecutive years (N = 12 949; 8 803 unique residents from 2012-2013, 2013-2014, and 2014-2015 cohorts). Change in QoL between 2 years was conceptualized as stable when within 1.5 SD of the sample average. We used linear probability models to estimate associations of ADRD/Cognitive Function Scale status with the stability of QoL summary and domain scores (eg, social engagement) and the absolute change in QoL summary score, controlling for resident and facility characteristics.

RESULTS

Most (86.82%) residents had stable QoL summary scores. Residents with moderate to severe cognitive impairment, irrespective of ADRD, were less likely to have stable summary scores than cognitively capable residents without ADRD (p < .001), but associations varied by QoL domains. Among those with stable summary QoL scores, changes in health/functional status were associated with absolute changes in summary QoL score (p < .001), suggesting sensitivity of the QoL measure.

DISCUSSION AND IMPLICATIONS

QoL scores were similarly stable over time for most residents with and without ADRD diagnoses and were sensitive to changes in health/functional status. This self-reported QoL measure may be appropriate for nursing home residents, regardless of ADRD diagnosis, and can efficaciously be recommended to other states.

Are Quality-of-Life Scores Stable and Sensitive Over Time for Nursing Home Residents With and Without Dementia?

The proportion of older adults with Alzheimer’s Disease and Related Dementias (ADRD) in nursing homes (NHs) has been increasing over time and creates a mandate to meaningfully examine their care. There is also a growing recognition that person-centered measures are important for dementia care, and consensus about the need to maximize residents’ quality of life (QoL). Yet, because QoL is fundamentally subjective, and residents with ADRD experience declines in cognitive function, their ability to make complex judgements about QoL has been questioned. This presentation will longitudinally assess whether QoL scores for residents with ADRD are stable and sensitive over time compared to those without ADRD. We use 2012-2015 Minnesota Resident Quality of Life and Satisfaction with Care Survey data, which contain in-person resident responses from a random sample of residents of all Medicare/Medicaid certified NHs in the state, about 40% of whom have AD/ADRD. These data were linked to the Minimum Data Set (MDS) 3.0. and facility characteristics data. The final sample contained 12,949 cohort-resident pairs, 8,803 unique residents, and 3,120 residents participated in more than two surveys. QoL scores of residents with and without ADRD were similarly stable over time and sensitive to health status change. We also found that stability of QoL scores may be driven by cognitive impairment as opposed to ADRD diagnoses. Thus, self-report QoL scores can also represent the QoL status for nursing home residents with ADRD diagnoses, and residents with ADRD diagnoses shouldn’t be excluded from quality of life surveys based on ADRD diagnoses.

Racial Disparities at Mixed-Race and Minority Hospitals : Treatment of African American Males With High-Grade Splenic Injuries

INTRODUCTION

Racial and socioeconomic disparities in health access and outcomes for many conditions is well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American ([AA] vs White) males with high-grade splenic injuries.

METHODS

Data from the National Trauma Data Bank were utilized from 2007 to 2015; 24 855 AA or White males with high-grade splenic injuries were included. Multilevel mixed-effects regression analysis was used to evaluate disparities in outcomes and resource allocation.

RESULTS

Mortality was significantly higher for AA males at mixed-race (OR 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI, 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2, P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08).

DISCUSSION

While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.

Risk of Genitourinary Malignancy in the Renal Transplant Patient

OBJECTIVE

To better understand the risk of genitourinary malignancies in the renal transplant patient. Currently, no consensus exists regarding screening and intervention, with much of the clinical decision-making based on historical practices established before recent progress in immunosuppression protocols and in genitourinary cancer diagnosis and management.

METHODS

A database of all solid organ transplants performed at the University of Minnesota from 1984 to 2019 was queried for renal transplant recipients in whom development of subsequent urologic malignancies (prostate, bladder, renal, penile, and testicular cancer) was found.

RESULTS

Among 6172 renal transplant recipients examined, cumulative incidence of all cancers of genitourinary etiology are presented over an average follow-up time of 10 years. Kidney cancer (combined graft and native), prostate cancer, and bladder cancer each demonstrated respective 30-year incidence of 4.6%, 8.7%, and 1.5% from the time of transplant. By comparison, age-matched data from the Surveillance, Epidemiology, and End Results database demonstrated 30-year cumulative incidence of 1.1%, 11.1%, and 1.7% for kidney cancer, prostate cancer, and bladder cancer respectively. The predominant genitourinary cancer was renal cell cancer, both of the native and of the transplanted kidney (native, n = 64; transplanted, n =11), followed by prostate cancer (n = 63), and bladder cancer (n = 37).

CONCLUSION

In this closely followed cohort of renal transplant recipients, renal cancer occurs at a higher incidence rate than in the non-transplanted population, while a lower rate of prostate cancer was found, with bladder cancer demonstrating a comparable cumulative incidence between transplant patients and the national age-matched population.

Racial Disparities at Mixed-Race and Minority Hospitals: Treatment of African American Males With High-Grade Splenic Injuries

INTRODUCTION

Racial and socioeconomic disparities in health access and outcomes for many conditions are well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American (AA) versus white males with high-grade splenic injuries.

METHODS

Data from the National Trauma Data Bank was utilized from 2007 to 2015. A total of 24 855 AA or white males with high-grade splenic injuries were included. Multilevel mixed effects regression analysis was used to evaluate disparities in outcomes and resource allocation.

RESULTS

Mortality was significantly higher for AA males at mixed-race (odds ratio [OR] 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2; P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08).

DISCUSSION

While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.

RACIAL-ETHNIC DIFFERENCES IN NURSING HOME QUALITY OF LIFE FOR ALZHEIMER’S DISEASE AND DEMENTIA RESIDENTS

Nursing homes (NHs) are often racially segregated, and minority residents admitted to NHs usually have more advanced stages of dementia at the time of admission than their white counterparts, with different care needs. Previous work has shown that racial disparities in NH quality of life (QoL) were partially due to different case mix of white and minority residents; it is unclear if disparities persist when comparing residents with similar ADRD diagnoses. The 2011-2015 Minnesota Resident Quality of Life and Satisfaction with Care Survey data contain in-person resident responses from a random sample of residents of all Medicare/Medicaid certified NHs in the state, about 40% of whom have AD/ADRD. These data were linked to the Minimum Data Set (MDS) and facility characteristics data. The population consists of 25,039 White, 580 Black, 94 Hispanic, 229 Native Americans, and 99 Asian/Pacific Islander NH residents with ADRD residing in 376 NHs. Racial/ethnic minority residents reported significantly lower QoL scores compared to their white counterparts, with the largest disparities in the food and relationships domains. We adjusted for resident (age, marital status, education, sex, length of stay, anxiety/mood disorder, activities of daily living scores) and facility characteristics (proportion of minority residents, ownership, urban vs rural, size, and occupancy ratio) using a multivariate random intercept model. After adjustment, significant differences remained in total QoL score and several QoL domains for Black, Asian and Hispanic residents (no significant differences for Native American residents). Practice guidelines should consider different care needs of racial/ethnic minority NH residents with ADRD.

Racial and Geographic Disparities in Hepatocellular Carcinoma Outcomes

INTRODUCTION

Hepatocellular carcinoma disproportionately affects minorities. Southern states have high proportions of black populations and prevalence of known risk factors. Further research is needed to understand the role of southern geography in hepatocellular carcinoma disparities. This paper examined racial disparities in hepatocellular carcinoma incidence, demographics, tumor characteristics, receipt of treatment, and all-cause mortality in southern and non-southern cancer registries.

METHODS

Surveillance Epidemiology and End Results data were probed in 2015 to identify 43,868 patients diagnosed with hepatocellular carcinoma from 2000 to 2012 (5,455 in southern registries [Atlanta, Louisiana, and Rural and Greater Georgia]).

RESULTS

Southern registries showed steeper increases of age-adjusted hepatocellular carcinoma incidence (from 2.89 to 5.29cases/100,000 people) versus non-southern areas (from 3.58 to 5.54cases/100,000 people). Blacks were over-concentrated in southern registries (32% vs 10%). Compared with whites, blacks were significantly younger at diagnosis, more likely diagnosed with metastasis, and less likely to receive surgical therapies in both registry groups. After adjustment, blacks had a significantly higher risk of all-cause mortality compared with whites in southern (hazard ratio=1.10, p=0.007) and non-southern areas (hazard ratio=1.08, p<0.001). For overall populations, southern registries had higher risk of all-cause mortality versus non-southern registries (hazard ratio=1.13, p<0.001).

CONCLUSIONS

Age-adjusted incidence rates of hepatocellular carcinoma are plateauing overall, but are still rising in southern areas. Race and geography had independent associations with all-cause mortality excess risk among patients with hepatocellular carcinoma. Further studies are needed to understand the root causes of potential mortality risk excess among overall populations with hepatocellular carcinoma living in the South.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Penetrating Colon Trauma Outcomes in Black and White Males

INTRODUCTION

Racial disparities have been both published and disputed in trauma patient mortality, outcomes, and rehabilitation. In this study, the objective was to assess racial disparities in patients with penetrating colon trauma.

METHODS

The National Trauma Data Bank was searched for males aged ≥14years from 2010 through 2014 who underwent operative intervention for penetrating colon trauma. The primary outcomes for this study were stoma formation and transfer to rehabilitation; secondary outcomes were postoperative morbidity and mortality. Analyses were performed in 2016-2018.

RESULTS

There were 7,324 patients identified (4,916 black, 2,408 white). Black and white patients underwent fecal diversion with stoma formation at a similar rate (19.6% vs 18.5%, p=0.28). Black patients were more likely than white patients to be uninsured (self-pay; 37.1% vs 29.9%) and more likely to be injured by firearms (88.3% vs 70.2%, p<0.001), but had a lower overall postoperative morbidity rate (52.6% vs 55.3%, p=0.04). The odds of stoma formation (OR=0.92, 95% CI=0.78, 1.09, p=0.35) and the odds of transfer to rehabilitation (OR=1.03, 95% CI=0.82, 1.30, p=0.78) were similar for black versus white patients.

CONCLUSIONS

Black patients experienced similar rates of stoma formation and transfer to rehabilitation as white patients with penetrating colon trauma. Multivariate analysis confirmed expected findings that trauma severity increased the odds of receiving an ostomy and rehabilitation placement. The protocol-based management approach to emergency trauma care potentially decreases the risk for the racial biases that could lead to healthcare disparities.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

A Simplified Frailty Index to Predict Outcomes After Radical Cystectomy

BACKGROUND

Traditional surgical risk indices are notoriously inaccurate, especially for the elderly, so there has been a trend to evaluate frailty instead.

OBJECTIVE

To describe a simplified five-item frailty index for evaluating radical cystectomy outcomes and compare its predictive ability with other risk assessment tools for a total patient cohort and a subgroup of patients aged ≥65yr.

DESIGN, SETTING, AND PARTICIPANTS

The National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2015 was queried for radical cystectomy cases for bladder cancer. A simplified five-item frailty index (sFI) was created based on previously described measures of frailty.

OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS

Correlation of the sFI with postoperative outcomes was investigated using multivariate logistic regression analyses. The predictive ability of the sFI was compared to the extended 11-item frailty index, NSQIP risk calculator, and the American Society of Anesthesiologists (ASA) score by comparing the area under the receiver operating characteristic curve. Subgroup analysis was performed for those aged ≥65 yr to evaluate the accuracy of the index in the older age group, for which traditional risk indices are notoriously inaccurate.

RESULTS AND LIMITATIONS

Of 5516 cases identified, 10.7% experienced a Clavien grade ≥3 complication within 30 d of surgery. Individuals with an sFI of 3+ had a greater likelihood of experiencing a major complication (odds ratio 3.22, 95% confidence interval 2.01-5.17). The sFI outperformed the ASA score in predicting major complications and had a similar predictive ability to the more complex 11-item index and NSQIP risk calculator. There was also a significant correlation between the sFI and discharge destination. These relationships were consistent in the subgroup of patients aged ≥65yr. The study is limited by the database, which only records 30-d outcomes and does not allow evaluation of long-term sequelae.

CONCLUSIONS

There is a strong correlation between frailty assessed via the sFI and radical cystectomy outcomes, including in the elderly. This tool can be used in the clinical setting to counsel patients and aid decision-making.

PATIENT SUMMARY

This study demonstrated that a simple five-item frailty index can be used to assess preoperative risk in patients undergoing radical cystectomy.

Decreased Use of Sphincter-Preserving Procedures Among African Americans with Rectal Cancer

BACKGROUND

Improved multimodality rectal cancer treatment has increased the use of sphincter-preserving surgery. This study sought to determine whether African American (AA) patients with rectal cancer receive sphincter-preserving surgery at the same rate as non-AA patients.

METHODS

The study used the Nationwide Inpatient Sample for years 1998-2012 to compare AA and non-AA patients with rectal cancer undergoing low anterior resection or abdominoperineal resection. The logistic regression model was used to adjust for age, gender, admission type, Elixhauser comorbidity index, and hospital factors such as size, location (urban vs.rural), teaching status, and procedure volume.

RESULTS

The search identified 22,697 patients, 1600 of whom were identified as AA. After adjustment for age and gender, the analysis showed that AA patients were less likely to undergo sphincter-preserving surgery than non-AA patients [odds ratio (OR) 0.70; 95% confidence interval (CI) 0.63-0.78; p < 0.0001). After further adjustment for the Elixhauser comorbidity index, admission type, hospital-specific factors, and insurance status, the analysis showed that AA patients still were less likely to undergo sphincter-preserving surgery (OR 0.78; 95% CI 0.70-0.87; p < 0.0001). Although the proportion of non-AA patients undergoing sphincter-preserving surgery increased during the study period (p = 0.0003), this trend was not significant for the AA patients (p = 0.13).

CONCLUSION

In this data analysis, the AA patients with rectal cancer had lower rates of sphincter-preserving surgery than the non-AA patients, even after adjustment for patient- and hospital-specific factors. Further work is required to elucidate why. Eliminating racial disparities in rectal cancer treatment should continue to be a priority for the surgical community.

Urethral Rest with Suprapubic Cystostomy for Obliterative or Nearly Obliterative Urethral Strictures: Urethrographic Changes and Implications for Management

PURPOSE

Precise preoperative characterization of urethral stricture is important for surgical planning. A period of urethral rest by a suprapubic cystostomy tube may aid in stricture characterization and affect the surgical approach. In this study fellowship trained reconstructive urologists compared the radiographic characterization of anterior urethral strictures before and after a period of urethral rest. We then determined how this changed the planned operative approach.

MATERIALS AND METHODS

We queried our prospectively maintained urethroplasty database at our institution for men with an anterior urethral stricture who underwent retrograde urethrogram and voiding cystourethrogram before and after preoperative suprapubic cystostomy tube placement. A total of 29 men were identified for analysis. To minimize responder fatigue 20 pairs of radiographs were selected at random. All images before and after suprapubic tube placement were interpreted in random order by 11 fellowship trained reconstructive urologists. Interpretation included stricture length, diameter, location and surgeon operative plan. Preplacement and post-placement results were compared. Post-placement stricture length was also compared to intraoperative length. ICC was used to evaluate homogeneity among the urologists. Linear regression analysis was performed to determine the association of post-radiographic length after tube placement with intraoperative stricture length.

RESULTS

Imaging agreement among interpreting urologists was satisfactory (ICC 0.72). There was no statistically significant difference in stricture length before vs after suprapubic tube placement. Of the images 23% were considered obliterative before tube placement while 58% were obliterative after placement (p = 0.0005). Mean ± SD post-placement radiographic and intraoperative stricture length was 3.0 ± 2.6 and 3.8 ± 3.3 cm, respectively (p <0.0001). Deviation between the radiographic and intraoperative lengths increased with stricture length (slope 0.26, p = 0.0023). The surgeon operative plan changed 47% of the time, including to an excision approach in 37% of cases.

CONCLUSIONS

Despite optimal urethral imaging with a suprapubic tube in men with high grade stricture reconstructive urologists underestimated length by an average of almost 1 cm. This underestimation was less for shorter strictures and it increased with stricture length. In addition, a period of urethral rest resulted in more frequent stricture obliteration, which was associated with a change in the planned operative approach about half of the time. If urologists do not place a suprapubic cystostomy tube prior to urethroplasty for high grade stricture, the operative plan should account for the stricture being tighter than it may appear.

The burden of chronic ureteral stenting in cervical cancer survivors

PURPOSE

Ureteral obstruction in cervical cancer occurs in up to 11% of patients, many of whom undergo ureteral stenting. Our aim was to describe the patient burden of chronic ureteral stenting in a population-based cohort by detailing two objectives: (1) the frequency of repeat procedures for ureteral obstruction; and, (2) the frequency of urinary adverse effects (UAEs) (e.g., lower urinary tract symptoms, flank pain).

MATERIALS AND METHODS

From SEER-Medicare, we identified 202 women who underwent ureteral stent placement prior to or following cervical cancer treatment. The frequency of repeat procedures and rate ratios were compared between treatment modalities. The rates and rate ratios of UAEs were compared between our primary cohort (stent + cervical cancer) and the following groups: no stent + cervical cancer, stent + no cancer, and no stent + no cancer. The "no cancer" group was drawn from the 5% Medicare sample.

RESULTS

117/202 women (58%) underwent >1 stent procedure. The frequency of additional procedures was significantly higher in patients who received radiation as part of their treatment. UAEs were very common in women with stent + cancer. The rate of UTI was 190 (per 100 person-years), 67 for LUTS, 42 for stones, and 6 for flank pain. These rates were 3-10 fold higher than in the no stent + no cancer control group; rates were also higher than in the no stent + cancer and the stent + no cancer women.

CONCLUSIONS

The burden of disease associated with ureteral stents is higher than expected and urologists should be actively involved in stent management, screening for associated symptoms and offering definitive reconstruction when appropriate.

Inverse probability of treatment-weighted competing risks analysis: an application on long-term risk of urinary adverse events after prostate cancer treatments

BACKGROUND

To illustrate the 10-year risks of urinary adverse events (UAEs) among men diagnosed with prostate cancer and treated with different types of therapy, accounting for the competing risk of death.

METHODS

Prostate cancer is the second most common malignancy among adult males in the United States. Few studies have reported the long-term post-treatment risk of UAEs and those that have, have not appropriately accounted for competing deaths. This paper conducts an inverse probability of treatment (IPT) weighted competing risks analysis to estimate the effects of different prostate cancer treatments on the risk of UAE, using a matched-cohort of prostate cancer/non-cancer control patients from the Surveillance, Epidemiology and End Results (SEER) Medicare database.

RESULTS

Study dataset included men age 66 years or older that are 83% white and had a median follow-up time of 4.14 years. Patients that underwent combination radical prostatectomy and external beam radiotherapy experienced the highest risk of UAE (IPT-weighted competing risks: HR 3.65 with 95% CI (3.28, 4.07); 10-yr. cumulative incidence = 36.5%).

CONCLUSIONS

Findings suggest that IPT-weighted competing risks analysis provides an accurate estimator of the cumulative incidence of UAE taking into account the competing deaths as well as measured confounding bias.

Time Course and Accumulated Risk of Severe Urinary Adverse Events After High- Versus Low-Dose-Rate Prostate Brachytherapy With or Without External Beam Radiation Therapy

PURPOSE

Severe urinary adverse events (UAEs) include surgical treatment of urethral stricture, urinary incontinence, and radiation cystitis. We compared the incidence of grade 3 UAEs, according to the Common Terminology Criteria for Adverse Events, after low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy, as well as after LDR plus external beam radiation therapy (EBRT) and HDR plus EBRT.

METHODS AND MATERIALS

Men aged >65 years with nonmetastatic prostate cancer were identified from the Surveillance, Epidemiology, and End Results-Medicare database who were treated with LDR (n=12,801), HDR (n=685), LDR plus EBRT (n=8518), or HDR plus EBRT (n=2392). The populations were balanced by propensity weighting, and the Kaplan-Meier incidence of severe UAEs was compared. Propensity-weighted Cox proportional hazards models were used to compare the adjusted hazard of UAEs. These UAEs were compared with those in a cohort of men not treated for prostate cancer.

RESULTS

Median follow-up was 4.3 years. At 8 years, the propensity-weighted cumulative UAE incidence was highest after HDR plus EBRT (26.6% [95% confidence interval, 23.8%-29.7%]) and lowest after LDR (15.7% [95% confidence interval, 14.8%-16.6%]). The absolute excess risk over nontreated controls at 8 years was 1.9%, 3.8%, 8.4%, and 12.9% for LDR, HDR, LDR plus EBRT, and HDR plus EBRT, respectively. These represent numbers needed to harm of 53, 26, 12, and 8 persons, respectively. The additional risk of development of a UAE related to treatment for LDR, LDR plus EBRT, and HDR plus EBRT was greatest within the 2 years after treatment and then continued to decline over time. Beyond 4 years, the risk of development of a new severe UAE matched the baseline risk of the control population for all treatments.

CONCLUSIONS

Toxicity differences were observed between LDR and HDR, but the differences did not meet statistical significance. However, combination radiation therapy (either HDR plus EBRT or LDR plus EBRT) increases the risk of severe UAEs compared with HDR alone or LDR alone. The highest increased risk of urinary toxicity occurs within the 2 years after therapy and then declines to an approximately 1% increase in incidence per year.

Long-term comparative toxicity of LDR versus HDR prostate brachytherapy ± EBRT and evaluation of risk hazard over time: A SEER-Medicare analysis

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Background: Severe urinary adverse events (UAEs) include surgical treatment of urethral stricture, urinary incontinence and radiation cystitis. Our objective is to compare the incidence of late UAEs after low dose rate BT (LDR) and high dose rate BT (HDR) as well as LDR+EBRT and HDR+EBRT. Methods: We identified men treated with LDR (n=12,801), HDR (n=685), LDR+EBRT (8,518) and HDR+EBRT (n=2,392) from the SEER-Medicare Database. The populations were balanced by propensity weighting and the Kaplan-Meier incidence of severe UAEs was compared. Propensity-weighted Cox proportional hazards models were used to compare the adjusted hazard of UAEs. These UAEs were compared to a cohort of men not treated for prostate cancer. Results: Median follow-up was 4.3 years. At 8 years, the propensity weighted cumulative UAE incidence was highest after HDR+EBRT (28%) and lowest after LDR (17%; see Figure). The absolute excess risk over non-treated controls of a UAE at 8 years was 1.9%, 3.8%, 8.4% and 12.9% for the LDR, HDR, LDR + EBRT, and HDR + EBRT respectively. This translates into a number needed to harm of 53, 26, 12, and 8 persons. There is no statistical difference in severe UAE risk between HDR vs. LDR or between HDR+EBRT vs. LDR+EBRT. The additional risk for developing a UAE related to treatment for LDR, LDR+EBRT, and HDR+EBRT, was greatest within the 2 years following treatment, and continued to decline over time. For HDR monotherapy, the risk was greatest within the first 4 years, and then declined. The risk of developing a severe UAE matched the baseline risk of the control population for all treatments at 4 years following therapy. Conclusions: LDR and HDR brachytherapy are statistically indistinguishable for late severe urinary adverse events. However, combination radiotherapy (either HDR+EBRT or LDR+EBRT) increases the risk of severe UAEs compared to HDR alone or LDR alone. In the 8 years following brachytherapy treatment, the increased risk of urinary toxicity occurs almost exclusively within the 2 years following therapy, and then declines to a baseline hazard. The hypothesis that late urinary radiation toxicity accelerates over time is not supported by this study.

The Patient Burden of Bladder Outlet Obstruction after Prostate Cancer Treatment

PURPOSE

Bladder outlet obstruction after prostate cancer therapy imposes a significant burden on health and quality of life in men. Our objective was to describe the burden of bladder outlet obstruction after prostate cancer therapy by detailing the type of procedures performed and how often those procedures were repeated in men with recurrent bladder outlet obstruction.

MATERIALS AND METHODS

Using SEER (Surveillance, Epidemiology and End Results)-Medicare linked data from 1992 to 2007 with followup through 2009 we identified 12,676 men who underwent at least 1 bladder outlet obstruction procedure after prostate cancer therapy, including external beam radiotherapy in 3,994, brachytherapy in 1,485, brachytherapy plus external beam radiotherapy in 1,847, radical prostatectomy in 4,736, radical prostatectomy plus external beam radiotherapy in 369 and cryotherapy in 245. Histogram, incidence rates and Cox proportional hazards models with repeat events analysis were done to describe the burden of repeat bladder outlet obstruction treatments stratified by prostate cancer therapy type. We describe the type of bladder outlet obstruction surgery grouped by level of invasiveness.

RESULTS

At a median followup of 8.8 years 44.6% of men underwent 2 or more bladder outlet obstruction procedures. Compared to men who underwent radical prostatectomy those treated with brachytherapy and brachytherapy plus external beam radiotherapy were at increased adjusted risk for repeat bladder outlet obstruction treatment (HR 1.2 and 1.32, respectively, each p <0.05). After stricture incision the men treated with radical prostatectomy or radical prostatectomy plus external beam radiotherapy were most likely to undergo dilation at a rate of 34.7% to 35.0%. Stricture resection/ablation was more common after brachytherapy, external beam radiotherapy or brachytherapy plus external beam radiotherapy at a rate of 28.9% to 41.2%.

CONCLUSIONS

Almost half of the men with bladder outlet obstruction after prostate cancer therapy undergo more than 1 procedure. Furthermore men with bladder outlet obstruction after radiotherapy undergo more invasive endoscopic therapies and are at higher risk for multiple treatments than men with bladder outlet obstruction after radical prostatectomy.

Propensity-Weighted Comparison of Long-Term Risk of Urinary Adverse Events in Elderly Women Treated For Cervical Cancer

PURPOSE

Cervical cancer treatment is associated with a risk of urinary adverse events (UAEs) such as ureteral stricture and vesicovaginal fistula. We sought to measure the long-term UAE risk after surgery and radiation therapy (RT), with confounding controlled through propensity-weighted models.

METHODS AND MATERIALS

From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified women ≥66 years old with nonmetastatic cervical cancer treated with simple surgery (SS), radical hysterectomy (RH), external beam RT plus brachytherapy (EBRT+BT), or RT+surgery. We matched them to noncancer controls 1:3. Differences in demographic and cancer characteristics were balanced by propensity weighting. Grade 3 to 4 UAEs were identified by diagnosis codes plus treatment codes. Cumulative incidence was measured using Kaplan-Meier methods. The hazard associated with different cancer treatments was compared using Cox models.

RESULTS

UAEs occurred in 272 of 1808 cases (17%) and 222 of 5424 (4%) controls; most (62%) were ureteral strictures. The raw cumulative incidence of UAEs was highest in advanced cancers. UAEs occurred in 31% of patients after EBRT+BT, 25% of patients after RT+surgery, and 15% of patients after RH; however, after propensity weighting, the incidence was similar. In adjusted Cox models (reference = controls), the UAE risk was highest after RT+surgery (hazard ratio [HR], 5.07; 95% confidence interval [CI], 2.32-11.07), followed by EBRT+BT (HR, 3.33; 95% CI, 1.45-7.65), RH (HR, 3.65; 95% CI, 1.41-9.46) and SS (HR, 0.99; 95% CI, 0.32-3.01). The higher risk after RT+surgery versus EBRT+BT was statistically significant, whereas, EBRT+BT and RH were not significantly different from each other.

CONCLUSIONS

UAEs are common after cervical cancer treatment, particularly in patients with advanced cancers. UAEs are more common after RT, but these women tend to have the advanced cancers. After propensity weighting, the risk after RT was similar to that after surgery.

Omission of radiation therapy after breast-conserving surgery in the United States: a population-based analysis of clinicopathologic factors

BACKGROUND

Radiation therapy (RT) after breast-conserving surgery (BCS) is associated with a significant reduction in ipsilateral breast tumor recurrence and breast cancer mortality rates in patients with early stage breast cancer. The authors of this report sought to determine which patients with breast cancer do not receive RT after BCS in the United States.

METHODS

The Surveillance, Epidemiology, and End Results registry was used to determine the rates of RT after BCS for women with stage I through III breast cancer in the United States from 1992 through 2007. A multivariate analysis was performed to identify independent predictors of omission of RT.

RESULTS

In total, 294,254 patients with invasive, nonmetastatic breast cancer were identified who underwent surgery from 1992 through 2007. Most patients (57%) underwent BCS; among those, 21.1% did not receive RT after BCS. The omission of RT increased significantly from 1992 (15.5%) to 2007 (25%). The receipt of RT also decreased significantly for patients with increased cancer stage, age <55 years, high-grade tumors, large tumors, positive or untested lymph node status, African American or Hispanic race, and negative or unknown estrogen receptor status. Significant geographic variation was observed in the rates of RT after BCS.

CONCLUSIONS

The omission of RT after BCS was more common in recent years, especially among women who had an increased risk of breast cancer recurrence. This trend represents a serious health care concern because of the potential increased risk of local recurrence and breast cancer mortality.

Lymph node evaluation is associated with improved survival after surgery for early stage gallbladder cancer

BACKGROUND

Guidelines for the current National Comprehensive Cancer Network recommend radical cholecystectomy, including hepatic resection and portal lymph node (LN) dissection, for patients with early stage gallbladder (GB) cancer. We sought to determine the survival benefit conferred by adequate LN evaluation.

METHODS

We used the surveillance, epidemiology and end results (SEER) neoplasm registry to identify patients who had an operation for GB cancer between 1988 and 2004. Patients were classified by stage of disease, operative procedure performed (cholecystectomy alone or radical resection), number of LNs evaluated (0, 1, >1), and receipt of radiation (RT). We included patients with T1B, T2, and T3 neoplasms who were LN positive or negative. Patients with T4 neoplasms and those with metastatic disease were excluded. Multivariate analysis included adjustment for age, race, sex, neoplasm grade, stage, operation performed, receipt of RT, and neoplasm registry.

RESULTS

We identified 4,614 patients who underwent operative treatment for stage 1-2B GB (including T1B-T3 and LN positive or negative) cancer between 1988 and 2004. Of 4,614 patients, 9.6% (442) had radical resection, whereas 90.4% (4,172) had cholecystectomy alone. Among patients undergoing radical resection, 56% had LNs evaluated as compared with 28% of patients after cholecystectomy. For patients with T1B and T2 neoplasms who underwent radical resection, pathologic evaluation of at least 1 LN was associated with a significant improvement in median overall survival (OS) compared with those who had no LN evaluated (123 months vs 22 months; P < .0001). Radical resection with no LN evaluation provided similar OS compared with cholecystectomy alone (22 months vs 23 months; P = NS). For patients with T3 neoplasms, radical resection, including pathologic evaluation of at least 1 LN, was also associated with improved OS compared with radical resection with no LN evaluation (12 months vs 7 months; P = .0014). Again, individuals who had radical resection without LN evaluation had similar OS compared with those who had cholecystectomy alone (7 months vs 6 months; P = NS). Individuals who had radical resection with LN evaluation were more likely to receive RT than those who had radical resection without LN evaluation (33.1% vs 19.1%; P = .002). In multivariate analysis (including adjustment for RT), however, LN evaluation was still associated with a decrease in mortality compared with no LN evaluated (HR = 0.611; 95% CI = 0.484, 0.770). The pathologic evaluation of additional LN (>1) did not provide any additional benefit compared with the evaluation of a single node (HR = 0.795; 95% CI = 0.571, 1.107). Radical resection alone (without LN evaluation) did not provide any benefit over cholecystectomy alone (HR = 1.098; 95% CI = 0.971, 1.241).

CONCLUSION

LN evaluation is a critical component of radical resection for GB cancer. In the absence of LN evaluation, radical resection provides no benefit over cholecystectomy alone.

Increasing rates of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ

PURPOSE

Some women with unilateral ductal carcinoma in situ (DCIS) undergo contralateral prophylactic mastectomy (CPM) to prevent cancer in the opposite breast. The use and trends of CPM for DCIS in the United States have not previously been reported.

METHODS

We used the Surveillance, Epidemiology, and End Results database to analyze the initial treatment (within 6 months) of patients with unilateral DCIS diagnosed from 1998 through 2005. We determined the CPM rate as a proportion of all surgically treated patients and as a proportion of all patients who underwent mastectomy. We compared demographic and tumor variables in women with unilateral DCIS who underwent surgical treatment.

RESULTS

We identified 51,030 patients with DCIS; 2,072 patients chose CPM. The CPM rate was 4.1% for all surgically treated patients and 13.5% for patients undergoing mastectomy. Among all surgically treated patients (including breast-conserving surgery), the CPM rate increased by 148% from 1998 (2.1%) to 2005 (5.2%). Among patients who underwent mastectomy to treat DCIS (excluding patients undergoing breast-conserving surgery), the CPM rate increased by 188% from 1998 (6.4%) to 2005 (18.4%). Young patient age, white race, recent year of diagnosis, and the presence of lobular carcinoma in situ were significantly associated with higher CPM rates among all surgically treated patients and all patients undergoing mastectomy. Large tumor size and higher grade were significantly associated with increased CPM rates among all surgically treated patients but lower CPM rates among patients undergoing mastectomy.

CONCLUSION

The use of CPM for DCIS in the United States markedly increased from 1998 through 2005.