A History of Health Economics and Healthcare Delivery Research at the National Cancer Institute

With increased attention to the financing and structure of healthcare, dramatic increases in the cost of diagnosing and treating cancer, and corresponding disparities in access, the study of healthcare economics and delivery has become increasingly important. The Healthcare Delivery Research Program (HDRP) in the Division of Cancer Control and Population Sciences at the National Cancer Institute (NCI) was formed in 2015 to provide a hub for cancer-related healthcare delivery and economics research. However, the roots of this program trace back much farther, at least to the formation of the NCI Division of Cancer Prevention and Control in 1983. The creation of a division focused on understanding and explaining trends in cancer morbidity and mortality was instrumental in setting the direction of cancer-related healthcare delivery and health economics research over the subsequent decades. In this commentary, we provide a brief history of health economics and healthcare delivery research at NCI, describing the organizational structure and highlighting key initiatives developed by the division, and also briefly discuss future directions. HDRP and its predecessors have supported the growth and evolution of these fields through the funding of grants and contracts; the development of data, tools, and other research resources; and thought leadership including stimulation of research on previously understudied topics. As the availability of new data, methods, and computing capacity to evaluate cancer-related healthcare delivery and economics expand, HDRP aims to continue to support this growth and evolution.

Comparative analysis of the ileal bacterial composition of post-weaned pigs fed different high-quality protein sources

To further understand the contribution of feedstuff ingredients to gut health in swine, gut histology and intestinal bacterial profiles associated with the use of two high-quality protein sources, microbially enhanced soybean meal (MSBM) and Menhaden fishmeal (FM) were assessed. Weaned pigs were fed one of three experimental diets: (1) basic diet containing corn and soybean meal (Negative Control (NEG)), (2) basic diet + fishmeal (FM; Positive Control (POS)) and (3) basic diet + MSBM (MSBM). Phase I POS and MSBM diets (d 0 to d 7 post-wean) included FM or MSBM at 7.5%, while Phase II POS and MSBM diets (d 8 to d 21) included FM or MSBM at 5.0%. Gastrointestinal tissue and ileal digesta were collected from euthanised pigs at d 21 (eight pigs/diet) to assess gut histology and intestinal bacterial profiles, respectively. Data were analysed using Proc Mixed in SAS, with pig as the experimental unit and pig (treatment) as the random effect. Histological and immunohistochemical analyses of stomach and small intestinal tissue using haematoxylin-eosin, Periodic Acid Schiff/Alcian blue and inflammatory cell staining did not reveal detectable differences in host response to dietary treatment. Ileal bacterial composition profiles were obtained from next-generation sequencing of PCR generated amplicons targeting the V1 to V3 regions of the 16S rRNA gene. Lactobacillus-affiliated sequences were found to be the most highly represented across treatments, with an average relative abundance of 64.0%, 59.9% and 41.80% in samples from pigs fed the NEG, POS and MSBM diets, respectively. Accordingly, the three most abundant Operational Taxonomic Units (OTUs) were affiliated to Lactobacillus, showing a distinct abundance pattern relative to dietary treatment. One OTU (SD_Ssd_00001), most closely related to Lactobacillus amylovorus, was found to be more abundant in NEG and POS samples compared to MSBM (23.5% and 35.0% v. 9.2%). Another OTU (SD_Ssd_00002), closely related to Lactobacillus johnsonii, was more highly represented in POS and MSBM samples compared to NEG (14.0% and 15.8% v. 0.1%). Finally, OTU Sd_Ssd-00011, highest sequence identity to Lactobacillus delbrueckii, was found in highest abundance in ileal samples from MSBM-fed pigs (1.9% and 3.3% v. 11.3, in POS, NEG and MSBM, respectively). There was no effect of protein source on bacterial taxa to the genus level or diversity based on principal component analysis. Dietary protein source may provide opportunity to enhance presence of specific members of Lactobacillus genus that are associated with immune-modulating properties without altering overall intestinal bacterial diversity.

Collaborating on Data, Science, and Infrastructure: The 20-Year Journey of the Cancer Research Network

The Cancer Research Network (CRN) is a consortium of 12 research groups, each affiliated with a nonprofit integrated health care delivery system, that was first funded in 1998. The overall goal of the CRN is to support and facilitate collaborative cancer research within its component delivery systems. This paper describes the CRN's 20-year experience and evolution. The network combined its members' scientific capabilities and data resources to create an infrastructure that has ultimately supported over 275 projects. Insights about the strengths and limitations of electronic health data for research, approaches to optimizing multidisciplinary collaboration, and the role of a health services research infrastructure to complement traditional clinical trials and large observational datasets are described, along with recommendations for other research consortia.

Evaluation of microbially enhanced soybean meal as an alternative to fishmeal in weaned pig diets

An experimental, microbially enhanced soybean product (MEPRO) was evaluated as a replacement for fishmeal (FM). Assessment of feedstuffs should include estimation of digestibility as well as pig performance and in combination with dietary additives. Digestibility values determined in growing pigs may not apply to nursery pigs; thus, standardized ileal digestibility (SID) of amino acids (AA) in MEPRO and FM were determined using 30±1.6 kg BW ileal-cannulated barrows (n=6) and 9.8±1.2 kg BW barrows (n=37; serial slaughter). Experimental diets included MEPRO, FM and nitrogen free where FM and MEPRO were included as the sole protein source. The SID of AAs was 3% to 5% lower in MEPRO than FM when fed to 30 kg pigs. The SID of arginine and methionine was greater (P<0.05) in MEPRO than FM when fed to 10 kg pigs. The SID of AAs was 12% to 20% lower in FM when fed to 10 v. 30 kg pigs but only 3% to 9% lower in MEPRO. A total of 336 barrows and gilts were weaned at 21 days of age (initial BW=6.1±0.8 kg) and used in a performance trial. Pens of pigs were assigned to one of the six experimental diets (8 pens/diet in two blocks). Treatment diets were fed in Phase I (7 days) and Phase II (14 days) with all pigs fed a common Phase III diet (14 days). Experimental diets included (1) negative control (NEG) containing corn, soybean meal and whey, (2) NEG+acidifier, (3) NEG+FM (POS), (4) POS+acidifier (POS A+), (5) NEG+MEPRO (MEPRO) and (6) MEPRO+acidifier. The FM and MEPRO were included at 7.5% and 5.0% in Phase I and II diets, respectively. Diets were formulated to meet the standard nutrient requirements for weaned pigs. Pig BW and feed disappearance was measured weekly and fecal scores were measured daily for the first 14 days post-weaning as an indicator of post-weaning diarrhea syndrome (PWDS). Performance (BW, daily gain, feed intake and gain : feed) was not significantly different among treatments. Treatment for PWDS occurred on different days in each block. Analysis of fecal score was completed separately by block. Pigs fed the NEG diets had higher (P=0.02) fecal scores than pigs fed the POS diets on days 2 and 3 (block 1) and higher (P<0.05) than pigs fed MEPRO or POS diets and diets with dietary acidifier on days 6 and 3 (block 2). The MEPRO holds promise as an alternative to FM in nursery pig diets.

Harms of cervical cancer screening in the United States and the Netherlands

We studied harms related to cervical cancer screening and management of screen-positive women in the United States (US) and the Netherlands. We utilized data from four US integrated health care systems (SEARCH), the US National Health Interview Survey, New Mexico state, the Netherlands national histopathology registry, and included studies on adverse health effects of cervical screening. We compared the number of Papanicolaou (Pap) smear tests, abnormal test results, punch biopsies, treatments, health problems (anxiety, pain, bleeding and discharge) and preterm births associated with excisional treatments. Results were age-standardized to the 2007 US population. Based on SEARCH, an estimated 36 million Pap tests were performed in 2007 for 91 million US women aged 21-65 years, leading to 2.3 million abnormal Pap tests, 1.5 million punch biopsies, 0.3 million treatments for precancerous lesions, 5 thousand preterm births and over 8 million health problems. Under the Netherlands screening practice, fewer Pap tests (58%), abnormal test results (64%), punch biopsies (75%), treatment procedures (40%), preterm births (60%) and health problems (63%) would have occurred. The SEARCH data did not differ much from other US data for 2007 or from more recent data up to 2013. Thus compared to the less intensive screening practice in the Netherlands, US practice of cervical cancer screening may have resulted in two- to threefold higher harms, while the effects on cervical cancer incidence and mortality are similar. The results are also of high relevance in making recommendations for HPV screening. Systematic collection of harms data is needed for monitoring and for better incorporation of harms in making screening recommendations.

Physician Recommendations for Follow-Up of Positive Fecal Occult Blood Tests

Following a positive fecal occult blood test (FOBT), physician recommendation of complete diagnostic evaluation (CDE) is an important first step to ensure identification and treatment of preinvasive or invasive colorectal cancer. Physicians may not recommend CDE, however, potentially compromising the effectiveness of colorectal cancer screening programs and the quality of care for individual patients. The authors used a theoretical model of health behavior and two national physician samples to explore factors associated with recommendations for CDE. Overall, 63 percent of the sample of physicians providing primary care and 76 percent of the gastroenterologist and general surgeon sample reported recommending CDE. Variables representing the theoretical model constructs of physician background, experience, and practice patterns; practice environment; physician psychosocial representations; and patient characteristics were significantly associated with recommendations of CDE. Development of interventions to improve recommendations of CDE is an important area for future research.

Challenges in meeting Healthy People 2020 objectives for cancer-related preventive services, National Health Interview Survey, 2008 and 2010

Introduction

Healthy People (HP) is the US program that formulates and tracks national health objectives for the nation. The National Health Interview Survey (NHIS) is a designated data source for setting and evaluating several HP targets in cancer. We used data from the 2008 and 2010 NHIS to provide a benchmark for national performance toward meeting HP 2020 cancer-related objectives.

Methods

HP 2020 cancer screening, provider counseling, and health care access objectives were selected. For each objective, NHIS measures for the overall population and several sociodemographic subgroups were calculated; the findings were compared with established HP 2020 targets.

Results

From 2008 to 2010, rates of breast and cervical cancer screening declined slightly while colorectal cancer screening rates increased by 7 percentage points. Rates of cancer screening and provider counseling were below HP targets. Meeting HP targets seems less likely for subgroups characterized by low income, no health insurance, or no usual source of care. Meeting HP targets for access to health services will require an increase of 18 percentage points in the proportion of persons under age 65 with health insurance coverage and an increase of 10 percentage points in the proportion aged 18 to 64 with a usual source of care.

Conclusion

Whether HP objectives for cancer screening and health care access are met may depend on implementation of health care reform measures that improve access to and coordination of care. Better integration of clinical health care and community-based efforts for delivering high-quality screening and treatment services and elimination of health disparities are also needed.

Cervical cancer screening in the United States and the Netherlands: a tale of two countries

CONTEXT

This article compares cervical cancer screening intensity and cervical cancer mortality trends in the United States and the Netherlands to illustrate the potential of cross-national comparative studies. We discuss the lessons that can be learned from the comparison as well as the challenges in each country to effective and efficient screening.

METHODS

We used nationally representative data sources in the United States and the Netherlands to estimate the number of Pap smears and the cervical cancer mortality rate since 1950. The following questions are addressed: How do differences in intensity of Pap smear use between the countries translate into differences in mortality trends? Can population coverage rates (the proportion of eligible women who had a Pap smear within a specified period) explain the mortality trends better than the total intensity of Pap smear use?

FINDINGS

Even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries' mortality trends were quite similar. The five-year coverage rates for women aged thirty to sixty-four were quite comparable at 80 to 90 percent. Because screening in the Netherlands was limited to ages thirty to sixty, screening rates for women under thirty and over sixty were much higher in the United States. These differences had consequences for age-specific mortality trends. The relatively good coverage rate in the Netherlands can be traced back to a nationwide invitation system based on municipal population registries. While both countries followed a "policy cycle" involving evidence review, surveillance of screening practices and outcomes, clinical guidelines, and reimbursement policies, the components of this cycle were more systematically linked and implemented nationwide in the Netherlands than in the United States. To a large extent, this was facilitated by a public health model of screening in the Netherlands, rather than a medical services model.

CONCLUSIONS

Cross-country studies like ours are natural experiments that can produce insights not easily obtained from other types of study. The cervical cancer screening system in the Netherlands seems to have been as effective as the U.S. system but used much less screening. Adequate coverage of the female population at risk seems to be of central importance.

Phenotypic variation and associated predation risk of juvenile common carp Cyprinus carpio

Juvenile common carp Cyprinus carpio were collected from 10 lakes with variable predator abundance over 4 months to evaluate if morphological defences increased with increasing predation risk. Cyprinus carpio dorsal and pectoral spines were longer and body depth was deeper when predators were more abundant, with differences becoming more pronounced from July to October. To determine if morphological plasticity successfully reduced predation risk, prey selection of largemouth bass Micropterus salmoides foraging on deep- and shallow-bodied C. carpio was evaluated in open and vegetated environments. Predators typically selected deep- over shallow-bodied phenotypes in open habitats and neutrally selected both phenotypes in vegetated habitats. When exposed to predators, shallow-bodied C. carpio phenotypes shoaled in open habitat, whereas deep-bodied phenotypes occupied vegetation. Although deep-bodied phenotypes required additional handling time, shallow-bodied phenotypes were more difficult to capture. These results suggest that juvenile C. carpio gradually develop deeper bodies and larger spines as predation risk increases. Morphological defences made it more difficult for predators to consume these prey but resulted in higher vulnerability to predation in some instances.

Polygamain, a new microtubule depolymerizing agent that occupies a unique pharmacophore in the colchicine site

Bioassay-guided fractionation was used to isolate the lignan polygamain as the microtubule-active constituent in the crude extract of the Mountain torchwood, Amyris madrensis. Similar to the effects of the crude plant extract, polygamain caused dose-dependent loss of cellular microtubules and the formation of aberrant mitotic spindles that led to G(2)/M arrest. Polygamain has potent antiproliferative activities against a wide range of cancer cell lines, with an average IC(50) of 52.7 nM. Clonogenic studies indicate that polygamain effectively inhibits PC-3 colony formation and has excellent cellular persistence after washout. In addition, polygamain is able to circumvent two clinically relevant mechanisms of drug resistance, the expression of P-glycoprotein and the βIII isotype of tubulin. Studies with purified tubulin show that polygamain inhibits the rate and extent of purified tubulin assembly and displaces colchicine, indicating a direct interaction of polygamain within the colchicine binding site on tubulin. Polygamain has structural similarities to podophyllotoxin, and molecular modeling simulations were conducted to identify the potential orientations of these compounds within the colchicine binding site. These studies suggest that the benzodioxole group of polygamain occupies space similar to the trimethoxyphenyl group of podophyllotoxin but with distinct interactions within the hydrophobic pocket. Our results identify polygamain as a new microtubule destabilizer that seems to occupy a unique pharmacophore within the colchicine site of tubulin. This new pharmacophore will be used to design new colchicine site compounds that might provide advantages over the current agents.

Productivity savings from colorectal cancer prevention and control strategies

BACKGROUND

Lost productivity represents a considerable portion of the total economic burden of colorectal cancer (CRC), but cost-effectiveness studies of CRC prevention and control have not included these costs and therefore underestimate potential savings from CRC prevention and control.

PURPOSE

To use microsimulation modeling study to estimate and project productivity costs of CRC and to model the savings from four approaches to reducing CRC incidence and mortality: risk factor reduction, improved screening, improved treatment, and a simultaneous approach where all three strategies are implemented.

METHODS

A model was developed to project productivity losses from CRC using the U.S. population with CRC incidence and mortality projected through the year 2020. Outcome measures were CRC mortality, morbidity, and productivity savings.

RESULTS

With 2005 levels in risk factors, screening, and treatment, 48,748 CRC deaths occurred in 2010, amounting to $21 billion of lost productivity. Using prevention and treatment strategies simultaneously, 3586 deaths could have been avoided in 2010, leading to a savings of $1.4 billion. Cumulatively, by 2020, simultaneous strategies that reduce risk factors and increase screening and treatment could result in 101,353 deaths avoided and $33.9 billion in savings in reduced productivity loss. Improved screening rates alone led to nearly $14.7 billion in savings between 2005 and 2020, followed by risk factor reduction ($12.4 billion) and improved treatment ($8.4 billion).

CONCLUSIONS

The savings in productivity loss from strategies to reduce CRC incidence and mortality are substantial, providing evidence that CRC prevention and control strategies are likely to be cost-saving.

Treatment of primary nocturnal enuresis in children: a review

Primary nocturnal enuresis is a common childhood disorder. Treatment approaches bridge the psychological and medical fields. A substantial body of literature addresses the various ways of treating enuresis, from pharmaceuticals to behavioural interventions. The medical and psychological literatures have proceeded relatively independently from one another and there has been little interconnection between the US and international literatures, resulting in a lack of discourse and integration among researchers investigating treatment outcomes for enuresis. This review examined the evidence base for treatments of primary nocturnal enuresis in children. Psychological, pharmaceutical and multi-component interventions are discussed. This review sought to provide an integrated interdisciplinary and international perspective on treatment efficacy for nocturnal enuresis by expressly gathering publications from psychological and medical fields, as well as US and international sources. The literature supported the urine alarm as the most effective intervention for nocturnal enuresis and demonstrated the benefit of combining the urine alarm with other components, both behavioural and pharmaceutical. In particular, recent literature showed that the urine alarm, when used in conjunction with antidiuretic medication (i.e. desmopressin), leads to more dry nights earlier in the conditioning process. Disparities between the different literatures were discussed.

Are physicians' recommendations for colorectal cancer screening guideline-consistent?

BACKGROUND

Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.

METHODS

We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.

RESULTS

Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).

CONCLUSIONS

Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice.

Projections of the cost of cancer care in the United States: 2010-2020

BACKGROUND

Current estimates of the costs of cancer care in the United States are based on data from 2003 and earlier. However, incidence, survival, and practice patterns have been changing for the majority of cancers.

METHODS

Cancer prevalence was estimated and projected by phase of care (initial year following diagnosis, continuing, and last year of life) and tumor site for 13 cancers in men and 16 cancers in women through 2020. Cancer prevalence was calculated from cancer incidence and survival models estimated from Surveillance, Epidemiology, and End Results (SEER) Program data. Annualized net costs were estimated from recent SEER-Medicare linkage data, which included claims through 2006 among beneficiaries aged 65 years and older with a cancer diagnosis. Control subjects without cancer were identified from a 5% random sample of all Medicare beneficiaries residing in the SEER areas to adjust for expenditures not related to cancer. All cost estimates were adjusted to 2010 dollars. Different scenarios for assumptions about future trends in incidence, survival, and cost were assessed with sensitivity analysis.

RESULTS

Assuming constant incidence, survival, and cost, we projected 13.8 and 18.1 million cancer survivors in 2010 and 2020, respectively, with associated costs of cancer care of 124.57 and 157.77 billion 2010 US dollars. This 27% increase in medical costs reflects US population changes only. The largest increases were in the continuing phase of care for prostate cancer (42%) and female breast cancer (32%). Projections of current trends in incidence (declining) and survival (increasing) had small effects on 2020 estimates. However, if costs of care increase annually by 2% in the initial and last year of life phases of care, the total cost in 2020 is projected to be $173 billion, which represents a 39% increase from 2010.

CONCLUSIONS

The national cost of cancer care is substantial and expected to increase because of population changes alone. Our findings have implications for policy makers in planning and allocation of resources.

Cell Density and Growth Phase as Factors in the Resistance of a Biofilm of Pseudomonas aeruginosa (ATCC 27853) to Iodine

Previous studies have shown that biofilms exhibit enhanced resistance to iodine. Investigations were conducted to determine the relative importance of growth phase versus cell density on biofilm resistance of Pseudomonas aeruginosa (ATCC 27853) to iodine. Cell density is a contributing factor to resistance, whereas growth to the stationary phase is not sufficient to achieve resistance.

Trends in colorectal cancer test use in the medicare population, 1998-2005

BACKGROUND

Colorectal cancer (CRC) screening has been covered under the Medicare program since 1998. No prior study has addressed the question of the completeness of CRC screening in the entire Medicare cohort.

METHODS

In 2008, CRC test-use rates were analyzed for the national fee-for-service Medicare population using Medicare enrollment and claims data from 1998 through 2005. Annual test-use rates were calculated for fecal occult blood testing, sigmoidoscopy, barium enema, and colonoscopy for each year by the demographic characteristics of enrollees. A current-in-Medicare rate was calculated to assess the percentage of enrollees with CRC testing according to recommended intervals.

RESULTS

Colonoscopy rates have increased every year since the introduction of CRC screening coverage. Test-use rates for all other test modalities have steadily decreased. The percentage of Medicare enrollees receiving appropriate tests has slowly increased. In 2005, 47% of enrollees aged >or=65 years and 33% of enrollees aged 50-64 years had claims indicating that they had been tested according to recommended intervals.

CONCLUSIONS

CRC test-use rates in the Medicare population are low. Disparities are apparent by age, race/ethnicity, gender, disability, income, and geographic residence. Much work remains to be done to increase testing to acceptable levels.

Adverse events after outpatient colonoscopy in the Medicare population

BACKGROUND

Although use of colonoscopy has increased substantially among elderly Medicare beneficiaries, no one has described colonoscopy-related adverse events in a representative sample of Medicare patients.

OBJECTIVE

To determine risk for adverse events after outpatient colonoscopy in elderly patients.

DESIGN

Population-based, matched cohort study.

SETTING

Surveillance, Epidemiology, and End Results cancer registry areas.

PATIENTS

Random 5% sample of Medicare beneficiaries, age 66 to 95 years, who underwent outpatient colonoscopy between 1 July 2001 and 31 October 2005 (n = 53 220), matched with beneficiaries who did not have colonoscopy.

MEASUREMENTS

Medicare claims were used to measure the rate of serious gastrointestinal events (bleeding and perforation), other gastrointestinal events, and cardiovascular events resulting in a hospitalization or emergency department visit within 30 days after colonoscopy compared with matched beneficiaries who did not have colonoscopy. Logistic regression was used to estimate adjusted predictive risks for adverse events and to assess whether these events varied by age, comorbid conditions, or type of colonoscopy.

RESULTS

Persons undergoing colonoscopy had a higher risk for adverse gastrointestinal events than their matched group. Rates of adverse events after colonoscopy increased with age. Patients having polypectomy had higher risk for all adverse events compared with their matched group and with the screening and diagnostic colonoscopy groups. Comorbid conditions increased the risk for adverse events. Patients with a history of stroke, chronic obstructive pulmonary disease, atrial fibrillation, or congestive heart failure had significantly higher risk for serious gastrointestinal events.

LIMITATION

The analysis relied on the diagnosis and procedure codes recorded on the Medicare claims.

CONCLUSION

Risks for adverse events after outpatient colonoscopy among elderly Medicare beneficiaries were low; however, they increased with age with specific comorbid conditions and depending on whether polypectomy was done. These data may inform decisions on whether to perform colonoscopy in persons of advanced age or those with comorbid conditions.

Parity violation constraints using cosmic microwave background polarization spectra from 2006 and 2007 observations by the QUaD polarimeter

We constrain parity-violating interactions to the surface of last scattering using spectra from the QUaD experiment's second and third seasons of observations by searching for a possible systematic rotation of the polarization directions of cosmic microwave background photons. We measure the rotation angle due to such a possible "cosmological birefringence" to be 0.55 degrees +/-0.82 degrees (random) +/-0.5 degrees (systematic) using QUaD's 100 and 150 GHz temperature-curl and gradient-curl spectra over the spectra over the multipole range 200<l<2000, consistent with null, and constrain Lorentz-violating interactions to <2 x 10;{-43} GeV (68% confidence limit). This is the best constraint to date on electrodynamic parity violation on cosmological scales.

A health services research agenda for cellular, molecular and genomic technologies in cancer care

BACKGROUND

In recent decades, extensive resources have been invested to develop cellular, molecular and genomic technologies with clinical applications that span the continuum of cancer care.

METHODS

In December 2006, the National Cancer Institute sponsored the first workshop to uniquely examine the state of health services research on cancer-related cellular, molecular and genomic technologies and identify challenges and priorities for expanding the evidence base on their effectiveness in routine care.

RESULTS

This article summarizes the workshop outcomes, which included development of a comprehensive research agenda that incorporates health and safety endpoints, utilization patterns, patient and provider preferences, quality of care and access, disparities, economics and decision modeling, trends in cancer outcomes, and health-related quality of life among target populations.

CONCLUSIONS

Ultimately, the successful adoption of useful technologies will depend on understanding and influencing the patient, provider, health care system and societal factors that contribute to their uptake and effectiveness in 'real-world' settings.

Estimates and projections of value of life lost from cancer deaths in the United States

BACKGROUND

Value-of-life methods are increasingly used in policy analyses of the economic burden of disease. The purpose of this study was to estimate and project the value of life lost from cancer deaths in the United States.

METHODS

We estimated and projected US age-specific mortality rates for all cancers and for 16 types of cancer in men and 18 cancers in women in the years 2000-2020 and applied them to US population projections to estimate the number of deaths in each year. Cohort life tables were used to calculate the remaining life expectancy in the absence of cancer deaths-the person-years of life lost (PYLL). We used a willingness-to-pay approach in which the value of life lost due to cancer death was calculated by multiplying PYLL by an estimate of the value of 1 year of life ($150,000). We performed sensitivity analyses for female breast, colorectal, lung, and prostate cancers using varying assumptions about future cancer mortality rates through the year 2020.

RESULTS

The value of life lost from all cancer deaths in the year 2000 was $960.6 billion; lung cancer alone represented more than 25% of this value. Projections for the year 2020 with current cancer mortality rates showed a 53% increase in the total value of life lost ($1472.5 billion). Projected annual decreases of cancer mortality rates of 2% reduced the expected value of life lost in the year 2020 from $121.0 billion to $80.7 billion for breast cancer, $140.1 billion to $93.5 billion for colorectal cancer, from $433.4 billion to $289.4 billion for lung cancer, and from $58.4 billion to $39.0 billion for prostate cancer.

CONCLUSIONS

Estimated value of life lost due to cancer deaths in the United States is substantial and expected to increase dramatically, even if mortality rates remain constant, because of expected population changes. These estimates and projections may help target investments in cancer control strategies to tumor sites that are likely to result in the greatest burden of disease and to interventions that are the most cost-effective.

Productivity costs of cancer mortality in the United States: 2000-2020

BACKGROUND

A model that predicts the economic benefit of reduced cancer mortality provides critical information for allocating scarce resources to the interventions with the greatest benefits.

METHODS

We developed models using the human capital approach, which relies on earnings as a measure of productivity, to estimate the value of productivity lost as a result of cancer mortality. The base model aggregated age- and sex-specific data from four primary sources: 1) the US Bureau of the Census, 2) US death certificate data for 1999-2003, 3) cohort life tables from the Berkeley Mortality Database for 1900-2000, and 4) the Bureau of Labor Statistics Current Population Survey. In a model that included costs of caregiving and household work, data from the National Human Activity Pattern Survey and the Caregiving in the U.S. study were used. Sensitivity analyses were performed using six types of cancer assuming a 1% decline in cancer mortality rates. The values of forgone earnings for employed individuals and imputed forgone earnings for informal caregiving were then estimated for the years 2000-2020.

RESULTS

The annual productivity cost from cancer mortality in the base model was approximately $115.8 billion in 2000; the projected value was $147.6 billion for 2020. Death from lung cancer accounted for more than 27% of productivity costs. A 1% annual reduction in lung, colorectal, breast, leukemia, pancreatic, and brain cancer mortality lowered productivity costs by $814 million per year. Including imputed earnings lost due to caregiving and household activity increased the base model total productivity cost to $232.4 billion in 2000 and to $308 billion in 2020.

CONCLUSIONS

Investments in programs that target the cancers with high incidence and/or cancers that occur in younger, working-age individuals are likely to yield the greatest reductions in productivity losses to society.

Breast cancer screening policies in developing countries: a cost-effectiveness analysis for India

BACKGROUND

India, the largest developing country, has a steadily rising incidence of breast cancer. Estimates and comparisons of the cost-effectiveness of feasible breast cancer screening policies in developing countries and identification of the determinants of cost and efficacy are needed.

METHODS

A Microsimulation Screening Analysis model of breast cancer was calibrated to available data on breast cancer incidence, stage distribution, and mortality in India. The model was used to estimate the costs of screening for breast cancer in India, its effects on mortality, and its cost-effectiveness (ie, costs of screening per life-year gained or life saved). Screening using clinical breast examination (CBE) or mammography among different age groups and at various frequencies was analyzed. Costs were expressed in international dollars (Int.$), the currency used by the World Health Organization, which has the same purchasing power in India as the US dollar has in the United States. To determine which factors influenced cost-effectiveness, sensitivity analyses were performed.

RESULTS

The estimated mortality reduction was the greatest for programs targeting women between age 40 and 60 years. Using a 3% discount rate, a single CBE at age 50 had an estimated cost-effectiveness ratio of Int.$793 per life year gained and a breast cancer mortality reduction of 2%. The cost-effectiveness ratio increased to Int.$1135 per life year gained for every-5-year CBE (age 40-60 years) and to Int.$1341 for biennial CBE (age 40-60 years); the corresponding reductions in breast cancer mortality were 8.2% and 16.3%, respectively. CBE performed annually from ages 40 to 60 was predicted to be nearly as efficacious as biennial mammography screening for reducing breast cancer mortality while incurring only half the net costs. The main factors affecting cost-effectiveness were breast cancer incidence, stage distribution, and cost savings on prevented palliative care.

CONCLUSION

The estimated cost-effectiveness of CBE screening for breast cancer in India compares favorably with that of mammography in developed countries. However, in view of competing priorities and economic conditions, the introduction of screening in India represents a greater challenge than it has been in more developed countries.

Current and future utilization of services from medical oncologists

PURPOSE

There is limited information on the current use of oncologists and projections of future need. This analysis assesses current utilization patterns and projects the number of people with cancer and their use of oncologists' services through 2020.

METHODS

Data from the Surveillance, Epidemiology, and End Results cancer registries and Medicare physician claims were used to estimate oncologists' services from 1998 to 2003. We estimated the portion of patients with cancer who saw an oncologist, the mean number of visits, and the clinical setting where care was provided. Care was divided into initial, continuing, and last-year-of-life phases. Projections for future number of patients with cancer and visits were calculated by applying incidence and prevalence rates derived from Surveillance, Epidemiology, and End Results data to census population projections through 2020.

RESULTS

The percentage of patients who saw an oncologist was 47% during the initial-care phase, 36% during the continuing-care phase, and 70% in the last year of life. The number of visits varied by age, sex, cancer site, and phase. The total number of cancer patients in the United States is projected to increase 55%, from 11.8 million in 2005 to 18.2 million in 2020. Total oncology visits are projected to increase from 38 million in 2005 to 57 million in 2020.

CONCLUSION

Utilization of oncologists' services will increase appreciably between 2005 and 2020; this will be driven predominantly by an increase in survivors of cancer and by the aging of the population. The United States may face an acute shortage of medical oncologists if efforts are not taken to meet this growing need.

Projections of the costs associated with colorectal cancer care in the United States, 2000-2020

Because of aging trends in the US, the number of prevalent colorectal cancer patients is expected to increase. We projected economic burden to the Medicare program and its beneficiaries through the year 2020. Burden was estimated for the initial phase of care, the period following diagnosis, the last year of life, and the continuing phase. Projected burden was evaluated with varying assumptions about incidence, survival, and costs of care. Estimated costs of care in 2000 in the initial, continuing, and last year of life phases of care were approximately $3.18 billion, $1.68 billion, and $2.63 billion, respectively. By the year 2020 under the 'fixed' current incidence, survival, and cost scenario, projected costs for the initial, continuing, and last year of life phases were $4.75 billion, $2.63 billion, and $4.05 billion. Under the current trends scenario (decreasing incidence, improving survival, and increasing costs), costs were $5.19 billion, $3.57 billion, and $5.27 billion. By the year 2020, estimated costs of colorectal cancer care among individuals aged 65 and older increased by 53% in the fixed scenario and by 89% in the current trends scenario. The future economic burden of colorectal cancer to the Medicare program and its beneficiaries in the US will be substantial.

Evaluation of trends in the cost of initial cancer treatment

BACKGROUND

Despite reports of increases in the cost of cancer treatment, little is known about how costs of cancer treatment have changed over time and what services have contributed to the increases.

METHODS

We used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database for 306,709 persons aged 65 and older and diagnosed with breast, lung, colorectal, or prostate cancer between 1991 and 2002 to assess the number of patients assigned to initial cancer care, from 2 months before diagnosis to 12 months after diagnosis, and mean annual Medicare payments for this care according to cancer type and type of treatment. Mutually exclusive treatment categories were cancer-related surgery, chemotherapy, radiation therapy, and other hospitalizations during the period of initial cancer care. Linear regression models were used to assess temporal trends in the percentage of patients receiving treatment and costs for those treated. We extrapolated our results based on the SEER data to the US Medicare population to estimate national Medicare payments by cancer site and treatment category. All statistical tests were two-sided.

RESULTS

For patients diagnosed in 2002, Medicare paid an average of $39,891 for initial care for each lung cancer patient, $41 134 for each colorectal cancer patient, and $20,964 for each breast cancer patient, corresponding to inflation-adjusted increases from 1991 of $7139, $5345, and $4189, respectively. During the same interval, the mean Medicare payment for initial care for prostate cancer declined by $196 to $18261 in 2002. Costs for any hospitalization accounted for the largest portion of payments for all cancers. Chemotherapy use increased markedly for all cancers between 1991 and 2002, as did radiation therapy use (except for colorectal cancers). Total 2002 Medicare payments for initial care for these four cancers exceeded $6.7 billion, with colorectal and lung cancers being the most costly overall.

CONCLUSIONS

The statistically significant increase in costs of initial cancer treatment reflects more patients receiving surgery and adjuvant therapy and rising prices for these treatments. These trends are likely to continue in the near future, although more efficient targeting of costly therapies could mitigate the overall economic impact of this trend.

Disentangling effects of nuclear structure in heavy element formation

Forming the same heavy compound nucleus with different isotopes of the projectile and target elements allows nuclear structure effects in the entrance channel (resulting in static deformation) and in the dinuclear system to be disentangled. Using three isotopes of Ti and W, forming 232Cm, with measurement spanning the capture barrier energies, alignment of the heavy prolate deformed nucleus is shown to be the main reason for the broadening of the mass distribution of the quasifission fragments as the beam energy is reduced. The complex, consistently evolving mass-angle correlations that are observed carry more information than the integrated mass or angular distributions, and should severely test models of quasifission.

Cost of care for elderly cancer patients in the United States

BACKGROUND

Timely estimates of the costs of care for cancer patients are an important element in the formulation of national cancer programs and policies. We estimated net costs of care for elderly cancer patients in the United States for the 18 most prevalent cancers and for all other tumor sites combined.

METHODS

We used Surveillance, Epidemiology, and End Results-Medicare files to identify 718,907 cancer patients and 1,623,651 noncancer control subjects. Within each tumor site, noncancer control subjects were matched to patients by sex, age group, geographic location, and phase of care (ie, initial, continuing, and last year of life). Costs of care were estimated for each phase by use of Medicare claims data from January 1, 1999, through December 31, 2003. Per-patient net costs of care were applied to the 5-year survival of cancer patients by phase of care to estimate 5-year costs of care and extrapolated to the elderly US Medicare population diagnosed with cancer in 2004.

RESULTS

Across tumor sites, mean net costs of care were highest in the initial and last year of life phases of care and lowest in the continuing phase. Mean 5-year net costs varied widely, from less than $20,000 for patients with breast cancer or melanoma of the skin to more than $40,000 for patients with brain or other nervous system, esophageal, gastric, or ovarian cancers or lymphoma. For elderly cancer patients diagnosed in 2004, aggregate 5-year net costs of care to Medicare were estimated to be approximately $21.1 billion. Costs to Medicare were highest for lung, colorectal, and prostate cancers, reflecting underlying incidence, stage distribution at diagnosis, survival, and phase-specific costs for these tumor sites.

CONCLUSIONS

The costs of cancer care to Medicare are substantial and vary by tumor site, phase of care, stage at diagnosis, and survival.

Costs of cancer care in the USA: a descriptive review

Although many studies assessing the cost of cancer care have been conducted in the US, to date, these studies and the underlying methods used to estimate costs have not been reviewed systematically. We conducted a descriptive review of the published literature on the cost of cancer care in the US, and identified 60 papers published between 1995 and 2006 pertinent to our study. We found heterogeneity across the studies in terms of the settings, populations studied, measurement of costs, and study methods. We also identified limitations in the generalizability of findings, the misclassification of patient groups and costs, and concerns with study methods. Among studies that reported costs of cancer care in multiple phases of care and for multiple tumor sites, costs were generally highest in the initial year following diagnosis and the last year of life, and lower in the continuing phase (i.e. the period between the initial and last year of life phases), following a 'u-shaped' curve. Within phase of care, costs for lung and colorectal cancer care were generally higher than those for breast and prostate cancer care, however, the long-term or lifetime costs for each type of cancer were more similar, reflecting the differences in survival and costs in each phase between the different disease types.

Association of regional variation in primary care physicians' colorectal cancer screening recommendations with individual use of colorectal cancer screening

INTRODUCTION

Studies show that the recommendations of a primary care physician for colorectal cancer screening may be one important influence on an individual's use of screening. However, another possible influence, the effect of regional differences in physicians' beliefs and recommendations on screening use, has not been assessed.

METHODS

We linked data from the National Health Interview Survey on the use of colorectal cancer screening by respondents aged 50 years or older, by hospital-referral region, with data from the Survey of Colorectal Cancer Screening Practices on the colorectal cancer screening recommendations of primary care physicians, by region. Our principal independent variables were the proportion of physicians in a region who recommended screening at age 50 and continuing screening at the recommended frequency.

RESULTS

On average, 53.3% of physicians in a region correctly recommended initiating colorectal cancer screening, and 64.8% advised screening at the recommended frequency. Of adults who lived in regions where less than 30% of physicians correctly recommended initiating screening, 47.3% had been screened, in contrast to 54.8% in areas where 70% or more of physicians made correct recommendations. Seventy-one percent of respondents living in regions where less than 30% of physicians advised screening at the recommended frequency were current on screening, in contrast to 79.9% of respondents living in regions where 70% or more of physicians made this recommendation. These differences were statistically significant after adjustment for individual characteristics.

CONCLUSION

Strategies to improve colorectal cancer screening recommendations of primary care physicians may improve the use of screening for millions of Americans.

Trends in abnormal cancer screening results in the United States of America

BACKGROUND

Although recent trends in the use of recommended breast and cervical cancer screening have been well documented in the USA, little is known about trends in the prevalence of abnormal screening results.

METHODS

Trends in abnormal screening results for mammography and Papanicolaou (Pap) smear were assessed descriptively using data from the 1987 and 2000 National Health Interview Surveys. Estimates were stratified by sociodemographic characteristics of the populations who reported ever receiving screening. All comparisons were evaluated with two-sided tests of statistical significance.

RESULTS

The age-standardized prevalence of abnormal Pap smears increased from 12.9% (95% confidence interval [CI] 12.1-13.8%) of women ever screened in 1987 to 20.3% (95% CI 19.5-21.0%) in 2000, and the age-standardized prevalence of abnormal mammogram results increased from 18.8% (95% CI 17.0-20.7%) to 21.6% (95% CI 20.5-22.7%) of women ever screened over the same period. Among women aged 40 years and older who reported ever receiving both a Pap smear and a mammogram, 29.6% (95% CI: 27.3-32.2%) in 1987 and 35% (95% CI: 33.8-36.2%) in 2000 reported either an abnormal Pap smear or an abnormal mammogram. In 2000, abnormal screening results were positively associated with reported frequency of recent screening (P<0.001).

CONCLUSIONS

A substantial portion of women in the USA reporting cancer screening also report having had abnormal results, although the magnitude of trends between 1987 and 2000 vary by screening test. Additional research is needed to assess the relative contributions of changes in classification of test results, test characteristics and changes in underlying screening histories to increases in abnormal screening results.

Health limitations and quality of life associated with cancer and other chronic diseases by phase of care

OBJECTIVE

To estimate health limitations and health-related quality of life (HRQL) associated with cancer and other chronic conditions in a nationally representative sample within a phase-of-care framework.

STUDY DESIGN AND SETTING

We used a nested case-control design to assess health limitations and HRQL in individuals reporting a breast, colorectal, prostate, or lung cancer diagnosis, or a diagnosis of arthritis, diabetes, heart disease, or hypertension compared with similar controls without these conditions. All subjects were selected from the 1986-1994 National Health Interview Surveys linked to mortality files in 1995, and classified into the initial, continuing, or last year of life phase of care. Health limitations and HRQL were compared for cases and controls for each condition with 2-sided statistical tests.

RESULTS

Across all conditions, individuals in the last year of life phase of care reported greater health limitations and lower HRQL, as measured by the Health Activities and Limitations Index (HALex), than did individuals in the initial and continuing phases of care. Compared with their matched controls, individuals with cancer or other chronic conditions were more likely to report health limitations and lower mean HALex values in the initial, continuing, and last year of life phases of care (P < 0.05).

CONCLUSIONS

We observed greater health limitations and lower HRQL associated with cancer and other chronic diseases compared with similar individuals without these conditions. The phase-of-care framework used in this study seems to be applicable to the assessment of HRQL for cancer and other chronic diseases.

Surveillance endoscopy does not improve survival for patients with local and regional stage colorectal cancer

BACKGROUND

Endoscopic surveillance is recommended and widely practiced after definitive treatment for colorectal cancer, yet to the authors' knowledge there is little evidence supporting its benefit. The purpose of the current study was to estimate the impact of endoscopic surveillance on colorectal cancer-specific survival for persons with localized or regional colorectal cancer. The population included Medicare patients (age >or=65 years) who were diagnosed with local or regional stage colorectal cancer between 1986 and 1996.

METHODS

The current study was a retrospective case-control study. Cases were defined as those individuals who died of colorectal cancer and controls were defined as those with colorectal cancer who did not die of colorectal cancer; controls were frequency matched to cases. Surveillance was defined as the use of colonoscopy, flexible sigmoidoscopy, or barium enema >or=6 months after diagnosis. Logistic regression was used to control for endoscopic procedure, race, comorbidity index at the time of diagnosis, and types of initial treatments after surgery.

RESULTS

The analysis group contained 8130 cases (29%) and 20,079 controls (71%). The average time to first bowel surveillance for those with at least 1 surveillance examination was 15.9 months after the diagnosis (median, 13 months). In the regression analysis, surveillance endoscopy was not found to be associated with improved colorectal cancer-specific survival (odds ratio of 1.01; 95% confidence interval, 0.95-1.06 [P=0.85]). Setting the surveillance interval to 12 months and 15 months rather than 6 months after diagnosis did not appear to influence the results.

CONCLUSIONS

Surveillance endoscopy does not appear to influence colorectal cancer-specific mortality in patients age >65 years who are diagnosed with localized or regional stage colorectal cancer.

Patient time costs associated with cancer care

BACKGROUND

Although costs of medical care for cancer have been investigated extensively, patient time costs associated with cancer care have rarely been estimated systematically. In this study, we estimated patient time costs associated with cancer care in patients aged 65 years and older in the United States.

METHODS

We identified 763,527 patients with breast, colorectal, corpus uteri, gastric, head and neck, lung, melanoma of the skin, ovary, prostate, renal, and urinary bladder cancers from linked Surveillance, Epidemiology, and End Results-Medicare files and 1,145,159 noncancer control subjects among Medicare enrollees who were matched by sex, age-group, and geographic location. Frequency of service use was calculated by category for patients and control subjects using Medicare claims data from 1995 to 2001. For each service category, time estimates were combined with service frequency and an hourly value of patient time. Net patient time costs were summed in the initial, continuing, and last-year-of-life phases of care for each tumor site. Net time cost estimates for the initial phase of care were applied to national estimates of numbers of new cancers in 2005 to obtain national time costs for the initial phase of care.

RESULTS

Net patient time costs during the initial phase of care ranged from 271 dollars (95% confidence interval [CI] = 213 dollars to 329 dollars) and 842 dollars (95% CI = 806 dollars to 878 dollars) for melanoma of the skin and prostate cancer, respectively, to 5348 dollars (95% CI = 4978 dollars to 5718 dollars) and 5605 dollars (95% CI = 5273 dollars to 5937 dollars) for gastric and ovarian cancers, respectively. Net patient time costs for care during the last year of life ranged from 1509 dollars (95% CI = 1343 dollars to 1675 dollars) for melanoma of the skin to 7799 dollars (95% CI = 7433 dollars to 8165 dollars), 7435 dollars (95% CI = 7207 dollars to 7663 dollars), and 7388 dollars (95% CI = 7018 dollars to 7758 dollars) for gastric, lung, and ovarian cancers, respectively. In 2005, patient time costs for the initial phase of care were 2.3 billion dollars.

CONCLUSIONS

Patient time costs for cancer care in the United States are substantial and vary by tumor site and phase of care, likely reflecting differences in stage at diagnosis and availability and intensity of treatment.

Insurance status and the use of guideline therapy in the treatment of selected cancers

PURPOSE

This study estimates the impact of type of insurance coverage on the receipt of guideline therapy in a population-based sample of cancer patients treated in the community.

PATIENTS AND METHODS

Patients (n = 7,134) from the National Cancer Institute's Patterns of Care studies who were newly diagnosed with 11 different types of cancer were analyzed. The definition of guideline therapy was based on the National Comprehensive Cancer Network treatment recommendations. Insurance status was categorized as a mutually exclusive hierarchical variable (no insurance, any private insurance, any Medicaid, Medicare only, and all other). Multivariate analyses were used to examine the association between insurance and receipt of guideline therapy.

RESULTS

Adjusting for clinical and nonclinical variables, insurance status was a modest, although statistically significant, determinant of receipt of guideline therapy, with 65% of the privately insured patients receiving recommended therapy compared with 60% of patients with Medicaid. Seventy percent of the uninsured patients received guideline therapy, which was nonsignificantly different compared with private insurance. When stratified by race, insurance was a statistically significant predictor of the receipt of guideline therapy only for non-Hispanic blacks.

CONCLUSION

Overall, levels of guideline treatment were lower than expected and particularly low for patients with Medicaid or Medicare only. The use of guideline therapy for ovarian and cervical cancer patients and for patients with rectal cancers was unrelated to type of insurance. Of particular concern is the significantly lower use of guideline therapy for non-Hispanic black patients with Medicaid. After adjusting for other factors, only half of these patients received guideline therapy.

Effect of perioperative antioxidant therapy on suboptimal islet transplantation in rats

Islet transplantation success is limited by the posttransplant inflammatory response, and we are investigating the ability of antioxidants to neutralize this islet damage. We have shown that pyruvate can enhance the engraftment and functionality of a suboptimal islet mass in rats. The present study further investigated the effects of pyruvate, as well as the antioxidants vitamin E and vitamin C. In study A, 350 syngeneic islets were transplanted into the liver of chemically diabetic rats. Antioxidant treatment, or vehicle, was administered during the perioperative period and an intraperitoneal glucose tolerance test (IPGTT) was performed 2 months posttransplant. In study B, 500 syngeneic islets were transplanted under the kidney capsule of chemically diabetic rats. Antioxidant treatment was administered during the perioperative period. Islet-bearing kidney grafts were harvested 24, 48, and 96 hours posttransplant for histological study. Results revealed that pyruvate was the only significantly effective treatment in enhancing the engraftment and functionality of a suboptimal islet mass. Respectively, 56% and 80% of pyruvate-treated rats became normoglycemic after islet transplantation in study A and study B and had a normal insulin response to IPGTT. Histology results from the islet-bearing kidneys were inconclusive as to whether or not pyruvate has an antiapoptotic effect. We conclude that pyruvate, but not vitamin E or vitamin C, aids in the engraftment and functionality of a suboptimal islet mass with as much effectiveness as a full mass in this study. Further investigation into the mechanism of pyruvate protection is still warranted.

Annual report to the nation on the status of cancer, 1975-2002, featuring population-based trends in cancer treatment

BACKGROUND

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide information on cancer rates and trends in the United States. This year's report updates statistics on the 15 most common cancers in the five major racial/ethnic populations in the United States for 1992-2002 and features population-based trends in cancer treatment.

METHODS

The NCI, the CDC, and the NAACCR provided information on cancer cases, and the CDC provided information on cancer deaths. Reported incidence and death rates were age-adjusted to the 2000 U.S. standard population, annual percent change in rates for fixed intervals was estimated by linear regression, and annual percent change in trends was estimated with joinpoint regression analysis. Population-based treatment data were derived from the Surveillance, Epidemiology, and End Results (SEER) Program registries, SEER-Medicare linked databases, and NCI Patterns of Care/Quality of Care studies.

RESULTS

Among men, the incidence rates for all cancer sites combined were stable from 1995 through 2002. Among women, the incidence rates increased by 0.3% annually from 1987 through 2002. Death rates in men and women combined decreased by 1.1% annually from 1993 through 2002 for all cancer sites combined and also for many of the 15 most common cancers. Among women, lung cancer death rates increased from 1995 through 2002, but lung cancer incidence rates stabilized from 1998 through 2002. Although results of cancer treatment studies suggest that much of contemporary cancer treatment for selected cancers is consistent with evidence-based guidelines, they also point to geographic, racial, economic, and age-related disparities in cancer treatment.

CONCLUSIONS

Cancer death rates for all cancer sites combined and for many common cancers have declined at the same time as the dissemination of guideline-based treatment into the community has increased, although this progress is not shared equally across all racial and ethnic populations. Data from population-based cancer registries, supplemented by linkage with administrative databases, are an important resource for monitoring the quality of cancer treatment. Use of this cancer surveillance system, along with new developments in medical informatics and electronic medical records, may facilitate monitoring of the translation of basic science and clinical advances to cancer prevention, detection, and uniformly high quality of care in all areas and populations of the United States.

Barriers to colorectal cancer screening: a comparison of reports from primary care physicians and average-risk adults

BACKGROUND

Barriers to colorectal cancer (CRC) screening are not well understood.

OBJECTIVES

We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening.

RESEARCH DESIGN

This was a comparative study using data from the 1999-2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS).

SUBJECTS

We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS.

MEASURES

We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening.

RESULTS

Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation.

CONCLUSIONS

A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.

Estimating patient time costs associated with colorectal cancer care

BACKGROUND

Nonmedical costs of care, such as patient time associated with travel to, waiting for, and seeking medical care, are rarely measured systematically with population-based data.

OBJECTIVES

The purpose of this study was to estimate patient time costs associated with colorectal cancer care.

METHODS

We identified categories of key medical services for colorectal cancer care and then estimated patient time associated with each service category using data from national surveys. To estimate average service frequencies for each service category, we used a nested case control design and SEER-Medicare data. Estimates were calculated by phase of care for cases and controls, using data from 1995 to 1998. Average service frequencies were then combined with estimates of patient time for each category of service, and the value of patient time assigned. Net patient time costs were calculated for each service category, summarized by phase of care, and compared with previously reported net direct costs of colorectal cancer care.

RESULTS

Net patient time costs for the 3 phases of colorectal cancer care averaged dollar 4592 (95% confidence interval [CI] dollar 4427-4757) over the 12 months of the initial phase, dollar 2788 (95% CI dollar 2614-2963) over the 12 months of the terminal phase, and dollar 25 (95% CI: dollar 23-26) per month in the continuing phase of care. Hospitalizations accounted for more than two thirds of these estimates. Patient time costs were 19.3% of direct medical costs in the initial phase, 15.8% in the continuing phase, and 36.8% in the terminal phase of care.

CONCLUSIONS

Patient time costs are an important component of the costs of colorectal cancer care. Application of this method to other tumor sites and inclusion of other components of the costs of medical care will be important in delineating the economic burden of cancer in the United States.

A national framework for cancer surveillance in the United States

Enhancements to cancer surveillance systems are needed for meeting increased demands for data and for developing effective program planning, evaluation, and research on cancer prevention and control. Representatives from the American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, National Cancer Registrars Association, and North American Association of Central Cancer Registries have worked together on the National Coordinating Council for Cancer Surveillance to develop a national framework for cancer surveillance in the United States. The framework addresses a continuum of disease progression from a healthy state to the end of life and includes primary prevention (factors that increase or decrease cancer occurrence in healthy populations), secondary prevention (screening and diagnosis), and tertiary prevention (factors that affect treatment, survival, quality of life, and palliative care). The framework also addresses cross-cutting information needs, including better data to monitor disparities by measures of socioeconomic status, to assess economic costs and benefits of specific interventions for individuals and for society, and to study the relationship between disease and individual biologic factors, social policies, and the environment. Implementation of the framework will require long-term, extensive coordination and cooperation among these major cancer surveillance organizations.

Burden of illness in cancer survivors: findings from a population-based national sample

BACKGROUND

Population trends in aging and improved cancer survival are likely to result in increased cancer prevalence in the United States, but few estimates of the burden of illness among cancer survivors are currently available. The purpose of this study was to estimate the burden of illness in cancer survivors in a national, population-based sample.

METHODS

A total of 1823 cancer survivors and 5469 age-, sex-, and educational attainment-matched control subjects were identified from the 2000 National Health Interview Survey. Multiple measures of burden, including utility, a summary measure of health, and days lost from work, were compared using two-sided tests of statistical significance for the two groups overall and for subgroups stratified by tumor site and time since diagnosis.

RESULTS

Compared with matched control subjects, cancer survivors had poorer outcomes across all burden measures (P<.01). Cancer survivors had lower utility values (0.74 versus 0.80; P<.001) and higher levels of lost productivity and were more likely to report their health as fair or poor (31.0% versus 17.9%; P<.001) than matched control subjects. Cancer survivors reported statistically significantly higher burden than did control subjects across tumor sites and across time since diagnosis (i.e., within the past year, 2-5 years, 6-10 years, and > or =11 years for the majority of measures.

CONCLUSIONS

Cancer survivors have poorer health outcomes than do similar individuals without cancer across multiple burden measures. These decrements are consistent across tumor sites and are found in patients many years following reported diagnosis. Improved measurement of long-term burden of illness will be important for future prospective research.

Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy

BACKGROUND

Increasing use of colonoscopy for colorectal cancer screening and surveillance of colorectal adenomas after polypectomy has given rise to concerns about the availability of endoscopic resources in the United States. Guidelines recommend surveillance after polypectomy at 3 to 5 years for a small adenoma, and follow-up is not advised for hyperplastic polyps. The intensity of physicians' surveillance is largely unstudied.

OBJECTIVE

To survey practicing gastroenterologists and general surgeons about their perceived need for the frequency of surveillance after polypectomy, to compare survey responses to practice guidelines, and to identify factors influencing their recommendations for surveillance.

DESIGN

Survey study conducted by the National Cancer Institute.

SETTING

A nationally representative study of physicians in the United States.

PARTICIPANTS

349 gastroenterologists and 316 general surgeons.

MEASUREMENTS

Questionnaires mailed in 1999 and 2000 assessed physicians' recommendations for surveillance after polypectomy in asymptomatic, average-risk patients.

RESULTS

Response rates were 83%. Among gastroenterologists (317 of 349) and surgeons (125 of 316) who perform screening colonoscopy, 24% (95% CI, 19.3% to 28.7%) of gastroenterologists and 54% (CI, 44.9% to 62.5%) of surgeons recommend surveillance for a hyperplastic polyp. For a small adenoma, most physicians recommended surveillance colonoscopy and more than 50% recommended examinations every 3 years or more often. Physicians indicated that published evidence was very influential in their practice (83% [CI, 78.8% to 87.2%] of gastroenterologists and 78% [CI, 72.5% to 86.8%] of surgeons). By contrast, only half of respondents reported that guidelines were very influential.

LIMITATIONS

The study was based on physicians' self-reported practice patterns. Results may overestimate or underestimate the performance of surveillance colonoscopy.

CONCLUSIONS

Some surveillance colonoscopy seems to be inappropriately performed and in excess of guidelines, particularly for hyperplastic polyps and low-risk lesions such as a small adenoma. These results suggest unnecessary demand for endoscopic resources.

Health plan policies and programs for colorectal cancer screening: a national profile

BACKGROUND

A consensus has emerged that average-risk adults 50 years of age or older should be screened for colorectal cancer (CRC).

OBJECTIVES

To describe health plans' coverage policies, guidelines, and organized programs to promote CRC screening.

STUDY DESIGN AND METHODS

Review of data from the National Cancer Institute Survey of Colorectal Cancer Screening Practices, administered to a national sample of health plans in 1999-2000. The survey inquired about coverage policies for fecal occult blood testing, sigmoidoscopy, colonoscopy, and double-contrast barium enema; the nature of any guidelines the plan had issued to its providers on CRC screening; and systems for recruiting patients into screening and for tracking and reporting the results of screening and follow-up procedures.

RESULTS

Of 346 eligible health plans, 180 (52%) responded. Nearly all health plans covered at least 1 CRC screening modality. Plans were most likely to cover fecal occult blood testing (97%) and least likely to cover colonoscopy (57%). Sixty-five percent had issued guidelines on CRC screening to providers. One quarter had a mechanism to remind patients that they are due for CRC screening, but fewer had systems for prompting providers, contacting noncompliant patients, or tracking completion of screening.

CONCLUSIONS

Health plans have the ability to provide organizational infrastructure for a broad range of preventive services to well-defined populations. However, few health plans had all 3 essential CRC screening delivery components--coverage, guidelines, and tracking systems--in place in 1999-2000.

Racial differences in the receipt of bowel surveillance following potentially curative colorectal cancer surgery

OBJECTIVE

To investigate racial differences in posttreatment bowel surveillance after colorectal cancer surgery in a large population of Medicare patients.

DATA SOURCES

We used a large population-based dataset: Surveillance, Epidemiology, and End Results (SEER) linked to Medicare data.

STUDY DESIGN

This is a retrospective cohort study. We analyzed data from 44,768 non-Hispanic white, 2,921 black, and 4,416 patients from other racial/ethnic groups, aged 65 and older at diagnosis, who had a diagnosis of local or regional colorectal cancer between 1986 and 1996, and were followed through December 31, 1998. Cox Proportional Hazards models were used to investigate the relation of race and receipt of posttreatment bowel surveillance.

DATA COLLECTION

Sociodemographic, hospital, and clinical characteristics were collected at the time of diagnosis for all members of the cohort. Surgery and bowel surveillance with colonoscopy, sigmoidoscopy, and barium enema were obtained from Medicare claims using ICD-9-CM and CPT-4 codes.

PRINCIPAL FINDINGS

The chance of surveillance within 18 months of surgery was 57 percent, 48 percent, and 45 percent for non-Hispanic whites, blacks, and others, respectively. After adjusting for sociodemographic, hospital, and clinical characteristics, blacks were 25 percent less likely than whites to receive surveillance if diagnosed between 1991 and 1996 (RR = 0.75, 95 percent CI = 0.70-0.81).

CONCLUSIONS

Elderly blacks were less likely than non-Hispanic whites to receive posttreatment bowel surveillance and this result was not explained by measured racial differences in sociodemographic, hospital, and clinical characteristics. More research is needed to explore the influences of patient- and provider-level factors on racial differences in posttreatment bowel surveillance.