Factors Associated With Guideline-recommended KRAS Testing in Colorectal Cancer Patients: A Population-based Study

OBJECTIVES

Response to epidermal growth factor receptor inhibitors is poorer among stage IV colorectal cancer (CRC) patients with KRAS mutations; thus KRAS testing is recommended before treatment. KRAS testing was collected by Surveillance, Epidemiology, and End Results (SEER) registries for 2010 CRC cases, and our goal was to provide the first population-based estimates of testing in the United States.

METHODS

SEER CRC cases diagnosed in 2010 were evaluated (n=30,351). χ tests and logistic regression were conducted to determine patient characteristics associated with KRAS testing, stratified by stages I-III versus stage IV. Log-rank tests were used to examine survival by testing status.

RESULTS

KRAS testing among stage IV cases ranged from 39% in New Mexico to 15% in Louisiana. In the model, younger age, being married, living in a metropolitan area, and having primary site surgery were associated with greater odds of receiving KRAS testing. Those who received testing had significantly better survival than those who did not (P<0.0001). Among those who received testing, there was no significant difference in survival by mutated versus wild-type KRAS. Five percent of stage I-III cases received testing.

CONCLUSIONS

Wide variation in documented KRAS testing for stage IV CRC patients exists among SEER registries. Age remained highly significant in multivariate models, suggesting that it plays an independent role in the patient and/or provider decision to be tested. Further research is needed to determine drivers of variation in testing, as well as reasons for testing in stage I-III cases where it is not recommended.

Treatment selection in oropharyngeal cancer: a surveillance, epidemiology, and end results (SEER) patterns of care analysis

PURPOSE

Treatment for oropharyngeal cancer (OPC) has changed over the past two decades under multiple influences. We provide a population-based description of the application of radiotherapy, surgery, and chemotherapy to OPC in 1997, 2004, and 2009.

METHODS

The National Cancer Institute's Patterns of Care study for OPC included multiple variables not available in the public-use dataset. We identified factors correlating with selection of primary surgery versus radiotherapy with or without chemotherapy (RTC) and analyzed predictors of all-cause mortality. We estimated the frequency of human papillomavirus (HPV) testing.

RESULTS

RTC was more common in 2009 than in 1997, and was more commonly applied to Stage IV cases. However, RTC was not an independent risk factor for mortality compared with surgery. HPV status was known in 14% of patients in 2009.

CONCLUSIONS

RTC is the most common treatment for OPC, but it may not provide the best outcomes. HPV testing was uncommon in 2009.

Predictors of Long-Term Quality of Life for Survivors of Stage II/III Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium

PURPOSE

Many patients do not receive guideline-recommended neoadjuvant chemoradiotherapy for resectable rectal cancer. Little is known regarding long-term quality of life (QOL) associated with various treatment approaches. Our objective was to determine patient characteristics and subsequent QOL associated with treatment approach.

METHODS

Our study was a geographically diverse population- and health system-based cohort study that included adults age 21 years or older with newly diagnosed stage II/III rectal cancer who were recruited from 2003 to 2005. Eligible patients were contacted 1 to 4 months after diagnosis and asked to participate in a telephone survey and to consent to medical record review, with separate follow-up QOL surveys conducted 1 and 7 years after diagnosis.

RESULTS

Two hundred thirty-nine patients with stage II/III rectal cancer were included in this analysis. Younger age (< 65 v ≥ 65 years: odds ratio, 2.49; 95% CI, 1.33 to 4.65) was significantly associated with increased odds of receiving neoadjuvant or adjuvant chemoradiotherapy. The adjuvant chemoradiotherapy group had significantly worse mean EuroQol-5D (range, 0 to 1) and Short Form-12 physical health component scores (standardized mean, 50) at 1-year follow-up than the neoadjuvant chemoradiotherapy group (0.75 v 0.85; P = .002; 37.2 v 43.3; P = .01, respectively) and the group that received only one or neither form of treatment (0.75 v 0.85; P = .02; 37.2 v 45.1; P = .008, respectively).

CONCLUSION

Neoadjuvant treatment may result in better QOL and functional status 1 year after diagnosis. Further evaluation of patient and provider reasons for not pursuing neoadjuvant therapy is necessary to determine how and where to target process improvement and/or education efforts to ensure that patients have access to recommended treatment options.

Increasing colorectal cancer screening in an overdue population: participation and cost impacts of adding telephone calls to a FIT mailing program

Many people who live in rural areas face distance barriers to colonoscopy. Our previous study demonstrated the utility of mailing fecal immunochemical tests (FIT) to average risk patients overdue for colorectal cancer (CRC screening). The aims of this study were to determine if introductory and reminder telephone calls would increase the proportion of returned FITs as well as to compare costs. Average risk patients overdue for CRC screening received a high intensity intervention (HII), which included an introductory telephone call to see if they were interested in taking a FIT prior to mailing the test out and reminder phone calls if the FIT was not returned. This HII group was compared to our previous low intensity intervention (LII) where a FIT was mailed to a similar group of veterans with no telephone contact. While a higher proportion of eligible respondents returned FITs in the LII (92 vs. 45 %), there was a much higher proportion of FITs returned out of those mailed in the HII (85 vs. 14 %). The fewer wasted FITs in the HII led to it having lower cost per FIT returned ($27.43 vs. $44.86). Given that either intervention is a feasible approach for patients overdue for CRC screening, health care providers should consider offering FITs using a home-based mailing program along with other evidence-based CRC screening options to average risk patients. Factors such as location, patient population, FIT cost and reimbursement, and personnel costs need to be considered when deciding the most effective way to implement FIT screening.

What increased registry outreach may mean for cutaneous melanoma surveillance: impact of changes in Iowa

BACKGROUND

Cutaneous melanoma (CM) is underreported to cancer registries, in part due to insufficient reporting in the nonhospital setting. The objective of this study was to better understand the impact of dermatologist and private pathology laboratory reporting on CM rates.

METHODS

We examined the impact of targeted casefinding in private pathology laboratories and dermatology offices by the State Health Registry of Iowa (SHRI) on CM incidence, as well as the characteristics of nonhospital reported cases.

RESULTS

Over the 39-year period (1973-2011), 22,541 cases of CM were captured by the SHRI; 16,183 (72%) were invasive melanoma cases and 6,358 (28%) were in situ cases. The incidence of invasive melanoma increased 3.6 fold between the time periods of 1973-1975 and 2009-2011 (6.6 vs. 24 per 100,000 person-years, respectively). If case reporting from private pathology laboratories and dermatology offices was not conducted, the 2009-2011 invasive CM rate would have decreased to 19.1. The ratio of invasive to in situ cases declined from 8:1 from 1973-1987 to less 2:1 from 2007-2011. Age at diagnosis also significantly increased across time periods, while the proportion of females declined. From 2007-2011, the majority (55%) of nonhospital cases were in situ, and 90% of the invasive cases were localized. A higher percentage of urban residents were attributed to nonhospital-based reporting sources compared to hospital-based sources (57% vs 45%, P < .0001) CONCLUSIONS: Electronic health records and incentivized Meaningful Use for reporting may provide an efficient method for nonhospital based providers to easily and accurately report CM cases to registries.

Inflammatory and non-inflammatory breast cancer survival by socioeconomic position in the Surveillance, Epidemiology, and End Results database, 1990-2008

Although it has been previously reported that patients with inflammatory breast cancer (IBC) experience worse survival than patients with other breast cancer (BC) types, the socioeconomic and ethnic factors leading to this survival difference are not fully understood. The association between county-level percent of persons below the poverty level and BC-specific (BCS) survival for cases diagnosed from 1990 to 2008 in the Surveillance, Epidemiology, and End Results (SEER) database linked to census derived county attributes was examined. A sub-analysis of cases from 2000 to 2008 also examined BCS survival by an index combining percent below poverty and less than high school graduates as well as metropolitan versus non-metropolitan county of residence. The Kaplan-Meier estimator was used to construct survival curves by stage, inflammatory status, and county-level socioeconomic position (SEP). Stage and inflammatory status stratified proportional hazards models, adjusted for age, race/ethnicity, tumor and treatment characteristics were used to determine the hazard of BCS death by county-level SEP. Kaplan-Meier survival curves indicated IBC has worse survival than stage matched non-IBC, (stage III IBC median survival = 4.75 years vs. non-IBC = 13.4 years, p < 0.0001). Residing in a lower SEP, non-metro county significantly worsens BCS survival for non-IBC in multivariate proportional hazards models. African American cases appear to have worse survival than non-Hispanic Whites regardless of inflammatory status, stage, county-level SEP, tumor, or treatment characteristics. This is the first study to examine IBC survival by SEP in a nation-wide population-based tumor registry. As this analysis found generally poorer survival for IBC, regardless of SEP or race/ethnicity, it is important that interventions that help educate women on IBC symptoms target women in various SEP and race/ethnicity groups.

Association of inflammatory and noninflammatory breast cancer with socioeconomic characteristics in the Surveillance, Epidemiology, and End Results database, 2000-2007

BACKGROUND

Inflammatory breast cancer (IBC) is a rare and highly aggressive form of primary breast cancer. Little is known about the risk factors for IBC, specifically the association with socioeconomic position (SEP).

METHODS

The association between breast cancer type (IBC vs. non-IBC) with county-level SEP in the Surveillance, Epidemiology, and End Results database for cases diagnosed from 2000 to 2007 was examined. County-level SEP characteristics included metropolitan versus non-metropolitan residence, percentage below the poverty level, percentage less than high-school graduate, and an index combining the poverty and high-school variables. IBC and non-IBC age-adjusted incidence rates were calculated, stratified on SEP and race/ethnicity. The odds of IBC versus non-IBC given a particular SEP characteristic, adjusting for age and race/ethnicity, was examined through fitting of hierarchical logistic regression models (HLM).

RESULTS

Incidence rates for IBC generally increased as SEP decreased, whereas the opposite was found for non-IBC. HLM results showed that low SEP is associated with higher odds of IBC: highest (≥ 20%) versus lowest (<10%) persons below the poverty level [OR (95% confidence interval, CI) = 1.25 (1.09-1.43)]; highest (>28.76%) versus lowest (≤ 15.99%) persons less than high-school graduate [OR (95% CI) = 1.25 (1.10-1.42)]; and low SEP as measured by poverty-high school index versus high SEP [OR (95% CI)= 1.26 (1.11-1.44)].

CONCLUSION

Overall breast cancer has been found to be positively associated with SEP, whereas in this analysis, IBC was associated with decreasing SEP.

IMPACT

Studies focused on understanding the disparity in IBC incidence, as well as interventions to eliminate these differences are needed.

Insurance status and quality of diabetes care in community health centers

OBJECTIVES

We sought to compare quality of diabetes care by insurance type in federally funded community health centers. Method. We categorized 2018 diabetes patients, randomly selected from 27 community health centers in 17 states in 2002, into 6 mutually exclusive insurance groups. We used multivariate logistic regression analyses to compare quality of diabetes care according to 6 National Committee for Quality Assurance Health Plan Employer Data and Information Set diabetes processes of care and outcome measures.

RESULTS

Thirty-three percent of patients had no health insurance, 24% had Medicare only, 15% had Medicaid only, 7% had both Medicare and Medicaid, 14% had private insurance, and 7% had another insurance type. Those without insurance were the least likely to meet the quality-of-care measures; those with Medicaid had a quality of care similar to those with no insurance.

CONCLUSIONS

Research is needed to identify the major mediators of differences in quality of care by insurance status among safety-net providers such as community health centers. Such research is needed for policy interventions at Medicaid benefit design and as an incentive to improve quality of care.

Provider perceptions of limited health literacy in community health centers

OBJECTIVE

To examine techniques used by community health center (HC) providers to care for patients with limited health literacy (LHL).

METHODS

Survey mailed to 803 HC providers in 10 Midwestern states. Response rate was 47.5%. Associations between variables were examined using generalized estimating equations (GEE) models to account for clustering of respondents within HCs.

RESULTS

The average provider estimates of LHL prevalence among English- and Spanish-speaking patients were 41+/-24% (mean+/-S.D.) and 48+/-30%, respectively. Those with training in health literacy were more likely to have patients repeat instructions back to check understanding (OR=2.05 and p=0.04) and were more likely to give out health education materials designed for patients with LHL (OR=2.80 and p=0.0002). Providers differed by type in encouraging patients to bring friends or family members to appointments (p=0.02).

CONCLUSION

Providers estimate LHL to be highly prevalent in their HCs, and use various techniques to assist patients.

PRACTICE IMPLICATIONS

Training in health literacy is associated with increased usage of evidence-based techniques to assist patients with LHL. Providers at all levels would likely benefit from LHL training. Most providers believe providing health education materials designed specifically for patients with LHL would be very helpful.