Investigating potential disparities in clinical trial eligibility and enrollment at an NCI-designated comprehensive cancer center.

BACKGROUND: Although barriers to trial accrual are well-reported, few studies have explored trial eligibility and trial offers as potential drivers of disparities in cancer clinical trial enrollment. METHODS: We identified patients with gastrointestinal (GI) or head/neck (HN) malignancies who were seen as new patients at the University of Michigan Health Rogel Cancer Center in 2016. By exhaustive review of the electronic medical record, we assessed the primary outcomes: (1) eligibility for, (2) documented offer of, and (3) enrollment in a clinical trial. All 41 of the clinical trials available to these patients were considered. Independent variables included clinical and non-clinical patient-related factors. We assessed associations between these variables and the primary outcomes using multivariable regression. RESULTS: Of 1446 patients, 43% were female, 15% were over age 75, 6% were Black. 305 (21%) patients were eligible for a clinical trial. Among eligible patients, 154 (50%) had documentation of a trial offer and 90 (30%) enrolled. Among the GI cohort, bivariate analyses demonstrated that older age was associated with decreased trial eligibility. Bivariate analyses also demonstrated that Black race was associated with increased trial offer. After adjustment, patients 75 or older were less likely to be eligible for a clinical trial in the GI cohort; however, we found no significant associations between race and any of the outcomes after adjustment. Among eligible GI patients, we found no significant associations between non-clinical factors and enrollment. Among the HN cohort, bivariate analyses demonstrated that female sex, older age, Black race, and unpartnered marital status were associated with decreased likelihood of trial offer; however, we found no significant associations between race, age, and marital status and any of the outcomes after adjustment. We found no significant associations between non-clinical factors and eligibility after adjustment; however, women were less likely to be offered and to enroll in a clinical trial in the HN cohort. CONCLUSION: Factors associated with eligibility, documented offer, and enrollment differed between disease site cohorts at our institution. Future work is needed to ensure the equitable inclusion of women and elderly patients in clinical trials.

Employment outcomes in family supporters of patients with early stage breast cancer and their association with patients' health-related quality of life and financial burden.

BACKGROUND: Little is known about how cancer impacts the employment status of patients' family supporters, or about associations between patients' health-related quality of life, perceived financial burden, and supporters' employment trajectory. METHODS: We surveyed patients with early stage breast cancer reported to the Georgia and Los Angeles SEER registries in 2014-15, and their spouse/partner or other family supporters. Patients and supporters were asked about employment impacts of the patient's cancer, and descriptive analyses of supporters' employment trajectories were generated. We measured patients' health-related quality of life (HRQoL) using the PROMIS scale for global health. We measured patients' perceived financial burden attributed to cancer by asking them two questions regarding (i) their financial status since their breast cancer diagnosis and (ii) how much it was impacted by their breast cancer and treatment. Associations between patients' HRQoL, perceived financial burden, and supporters' employment status were assessed using linear mixed model regression analyses. RESULTS: In total, 2502 patients (68% response rate) and 1203 supporters (70% response rate) responded; 1057 paired patient-supporter dyads were included. Similar proportions of spouse/partner and other family supporters reported missed work and lost employment due to patients' cancer. After adjustment, lower HRQoL and an increased odds of perceived financial burden among patients were associated with changes in other family supporters' employment (both p < 0.05), but not with changes in spouses'/partners' employment. Lower HRQoL was also associated with changes in patients' own employment among patients with both types of supporters (both p < 0.001). An increased odds of perceived financial burden among patients was associated with changes in patients' employment only in those supported by other family members (p < 0.001). CONCLUSIONS: Both spouse/partner and other family supporters faced adverse employment outcomes due to patients' cancer. This contributes to worse HRQoL and greater perception of financial burden among patients, especially those whose supporter is not a spouse/partner.

Primary Care Physician Perspectives on Low Risk Prostate Cancer Management: Results of a National Survey.

Introduction: Primary care providers can collaborate with urologists to ensure men with low risk prostate cancer on active surveillance receive followup testing and adhere to the management strategy, yet primary care provider attitudes about active surveillance and their roles remain unknown. Methods: We surveyed 1,000 primary care providers (347/741 eligible primary care providers responded). We assessed primary care provider support for and beliefs about active surveillance, and attitudes about and preferences for their role in various aspects of low risk prostate cancer management. We then examined associations between 1) primary care provider support for and primary care provider beliefs about active surveillance; and 2) primary care provider attitudes and preferences for their role. Results: Nearly 50% of primary care providers strongly supported active surveillance for all low risk men, and 81% strongly agreed that active surveillance allows men to avoid side effects, while 57% strongly agreed it caused worry. Primary care providers who strongly supported active surveillance were less likely to strongly agree that active surveillance contributes to worry (50.3% vs 63.7% respectively, p=0.01). Half of the primary care providers strongly agreed that primary care providers can provide cancer-related care (50.5%), and the majority preferred a shared care model to ordering prostate specific antigen tests (60.1%). Primary care providers who strongly agreed that primary care providers can provide cancer-related care were more likely to prefer a primary care provider-led (79.3% vs 20.7%) or shared care (53.9% vs 46.1%) model vs urologist-led for ordering prostate specific antigen tests (p <0.01). Conclusions: While many primary care providers supported active surveillance for low risk prostate cancer, primary care providers still had concerns with it as the primary management strategy. Understanding primary care providers perspectives on low risk prostate cancer management can inform strategies to improve high quality active surveillance care.

Primary Care Providers' Perceptions About Participating in Low-Risk Prostate Cancer Treatment Decisions.

BACKGROUND: Primary care provider's (PCP) role in cancer care is expanding and may include supporting patients in their treatment decisions. However, the degree to which PCPs engage in this role for low-risk prostate cancer is unknown. OBJECTIVE: Characterize PCP perceptions regarding their role in low-risk prostate cancer treatment decision-making. DESIGN: Cross-sectional, national survey. MAIN MEASURES: For men with low-risk prostate cancer, PCP reports of (1) confidence in treatment decision-making (high vs. low); (2) intended participation in key aspects of active surveillance treatment decision-making (more vs. less). KEY RESULTS: A total of 347 from 741 eligible PCPs responded (adjusted response rate 56%). Half of respondent PCPs (50.3%) reported high confidence about engaging in low-risk prostate cancer treatment decision-making. The odds of PCPs reporting high confidence were greater among those in solo practice (vs working with > 1 PCP) (OR 2.18; 95% CI 1.14-4.17) and with higher volume of prostate cancer patients (> 15 vs. 6-10 in past year) (OR 2.16; 95% CI 1.02-4.61). PCP report of their intended participation in key aspects of active surveillance treatment decision-making varied: discussing worry (62.4%), reviewing benefits (48.5%) and risks (41.8%), and reviewing all treatment options (34.2%). PCPs who reported high confidence had increased odds of more participation in all aspects of active surveillance decision-making: reviewing all treatment options (OR 3.11; 95% CI 1.82-5.32), discussing worry (OR 2.12; 95% CI 1.28-3.51), and reviewing benefits (OR 3.13; 95% CI 1.89-5.16) and risks (OR 3.20; 95% CI 1.91-5.36). CONCLUSIONS: The majority of PCPs were confident about engaging with patients in low-risk prostate cancer treatment decision-making, though their intended participation varied widely across four key aspects of active surveillance care. With active surveillance being considered for other low-risk cancers (such as breast and thyroid), understanding factors influencing PCP involvement will be instrumental to supporting team-based cancer care.

A population-based study of invitation to and participation in clinical trials among women with early-stage breast cancer.

PURPOSE: Although many studies clearly demonstrate disparities in cancer clinical trial enrollment, there is a lack of consensus on potential causes. Furthermore, virtually nothing is known about associations between patients' decision-making style and their participation in clinical trials. METHODS: Women with newly diagnosed, stage 0-II breast cancer reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries in 2013-2014 were surveyed approximately seven months after diagnosis. We investigated two primary outcome variables: (1) invitation to participate in a clinical trial, (2) participation in a clinical trial. We evaluated bivariate associations using Chi-squared tests and used multivariable logistic regression models to investigate associations between patient variables, including decision-making style, and the primary outcomes. RESULTS: 2578 patients responded (71% response rate); 30% were > age 65, 18% were black, 18% were Latina, 29% had ≤ high school education. 10% of patients reported invitation to participate in a clinical trial; 5% reported participation in a clinical trial. After adjustment younger age, receipt of chemotherapy or radiation, disease stage, and a more rational (versus more intuitive) decision-making style were associated with a higher odds of invitation to participate. Being married was associated with a higher odds of participation; having an annual family income ≥ $40,000 was associated with a lower odds of participation. CONCLUSIONS: 10% of patients reported invitation to participate in a clinical trial, and half of these reported participation. Invitation to participate varied by age and decision-making style, and participation varied by marital status and income.

Long-term Functional Decline After High-Risk Elective Colorectal Surgery in Older Adults.

BACKGROUND: Although most surgical outcomes research focuses on clinical end points and complications, older adult patients may value functional outcomes more. However, little is known about the risk of long-term functional disability after colorectal procedures. OBJECTIVE: The purpose of this research was to understand the incidence and likelihood of functional decline after high-risk (ie, ≥1% inpatient mortality) colorectal operations both without and with complications. DESIGN: This was a retrospective matched cohort study. SETTINGS: The Health and Retirement Study, a nationally representative, longitudinal survey of adults >50 years of age, collects data on functional status, cognition, and demographics, among other topics. The survey was linked with Medicare claims and National Death Index data from 1992 to 2012. PATIENTS: Patients ≥65 years of age who underwent elective high-risk colorectal surgery with functional status measured before and after surgery were included. These patients were matched 1:3 to survey respondents who did not undergo major surgery, based on propensity scores. MAIN OUTCOME MEASURES: Functional decline, the primary outcome, was defined as an increase in the number of activities of daily living and instrumental activities of daily living requiring assistance before and after surgery. Using logistic regression, we examined whether surgery without or with complications was associated with functional decline. RESULTS: We identified 289 patients who underwent high-risk colorectal surgery and 867 matched control subjects. Of the surgery patients, 90 (31%) experienced a complication. Compared with the control subjects, surgery patients experienced greater likelihood of functional decline (without complications: OR = 1.82 (95% CI, 1.22-2.71), and with complications: OR = 2.96 (95% CI, 1.70-5.14)). Increasing age also predicted greater odds of functional decline (OR = 2.09, per decade (95% CI, 1.57-2.80)). LIMITATIONS: The functional measures were self-reported by survey participants. CONCLUSIONS: High-risk colorectal surgery, without or with complications, is associated with increased likelihood of functional decline in older adults. Patient-centered decision-making should include discussion of expected functional outcomes and long-term disability. See Video Abstract at http://links.lww.com/DCR/B78. PÉRDIDA DE LA FUNCIONALIDAD A LARGO PLAZO LUEGO DE CIRUGÍA ELECTIVA COLORRECTAL DE ALTO RIESGO EN EL PACIENTE AÑOSO: Aunque en la mayoría de las investigaciones los resultados quirúrgicos se centran en los puntos finales clínicos y las complicaciones, actualmente se pueden valorar los resultados funcionales en el paciente añoso. Sin embargo, se sabe poco sobre el riesgo de la discapacidad funcional a largo plazo después de un procedimiento colorrectal.Comprender la incidencia y la probabilidad del deterioro funcional después de operaciones colorrectales de alto riesgo (es decir, ≥1% de mortalidad hospitalaria) con y sin complicaciones.Estudio de cohorte emparejado retrospectivo.El seguimiento longitudinal representativo a nivel nacional en adultos de >50 años y que recopila datos sobre su estado funcional, su estado cognitivo y su demografía, entre otros temas es el llamado "Estudio de Salud en jubilados." La encuesta se vinculó con los reclamos de Medicare y los datos del Índice Nacional de Defunciones entre 1992 y 2012.Aquellos de ≥65 años que se sometieron a cirugía colorrectal electiva de alto riesgo con un estado funcional medido antes y después de la cirugía. Estos pacientes se compararon 1: 3 con los encuestados que no se sometieron a cirugía mayor, según puntajes de propensión.La disminución functional como resultado primario, se definió como un aumento en el número de actividades de la vida diaria y actividades instrumentales de la vida diaria que requieren asistencia antes y después de la cirugía. Mediante la regresión logística, evaluamos si la cirugía sin complicaciones y/o con complicaciones se asoció con un deterioro funcional.Identificamos 289 pacientes que se sometieron a cirugía colorrectal de alto riesgo y 867 controles pareados. De los pacientes de cirugía, 90 (31%) experimentaron algun tipo de complicación. En comparación con los controles, los pacientes de cirugía experimentaron una mayor probabilidad de deterioro funcional (sin complicaciones: OR 1.82, IC 95% 1.22-2.71, y con complicaciones: OR 2.96, IC 95% 1.70-5.14). El aumento de la edad también predijo mayores probabilidades en el deterioro funcional (OR 2.09, por década, IC 95% 1.57-2.80).Las medidas funcionales fueron autoinformadas por los participantes de la encuesta.La cirugía colorrectal de alto riesgo, con o sin complicaciones, se asocia con una mayor probabilidad de deterioro funcional en adultos mayores. La toma de decisiones centradas en el paciente deben incluir la discusión de los resultados funcionales esperados y la discapacidad a largo plazo. Vea el resumen del video en http://links.lww.com/DCR/B78.

Understanding the engagement of key decision support persons in patient decision making around breast cancer treatment.

BACKGROUND: Patients with breast cancer involve multiple decision support persons (DSPs) in treatment decision making, yet little is known about DSP engagement in decision making and its association with patient appraisal of the decision process. METHODS: Patients newly diagnosed with breast cancer reported to Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries in 2014-2015 were surveyed 7 months after their diagnosis. The individual most involved in each respondent's decision making (the key DSP) was surveyed. DSP engagement was measured across 3 domains: 1) informed about decisions, 2) involved in decisions, and 3) aware of patient preferences. Patient decision appraisal included subjective decision quality (SDQ) and deliberation. This study evaluated bivariate associations with chi-square tests between domains of DSP engagement and independent DSP variables. Analysis of variance and multivariable logistic regression were used to compare domains of DSP engagement with patient decision appraisal. RESULTS: In all, 2502 patients (68% response rate) and 1203 eligible DSPs (70% response rate) responded. Most DSPs were husbands/partners or daughters, were white, and were college graduates. Husbands/partners were more likely to be more informed, involved, and aware (all P values < .01). English- and Spanish-speaking Latinos had a higher extent of (P = .02) but lower satisfaction with involvement (P < .01). A highly informed DSP was associated with higher odds of patient-reported SDQ (odds ratio, 1.46; 95% confidence interval, 1.03-2.08; P = .03). A highly aware DSP was associated with higher odds of patient-reported deliberation (odds ratio, 1.83; 95% confidence interval, 1.36-2.47; P < .01). CONCLUSIONS: In this population-based study, informal DSPs were engaged with and positively contributed to patients' treatment decision making. To improve decision quality, future interventions should incorporate DSPs.

Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer.

BACKGROUND: Little is known regarding whether growing awareness of the financial toxicity of a cancer diagnosis and its treatment has increased clinician engagement or changed the needs of current patients. METHODS: The authors surveyed patients with early-stage breast cancer who were identified through population-based sampling from 2 Surveillance, Epidemiology, and End Results (SEER) regions and their physicians. The authors described responses from approximately 73% of surgeons (370 surgeons), 61% of medical oncologists (306 medical oncologists), 67% of radiation oncologists (169 radiation oncologists), and 68% of patients (2502 patients). RESULTS: Approximately one-half (50.9%) of responding medical oncologists reported that someone in their practice often or always discusses financial burden with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists. Patients indicated that financial toxicity remains common: 21.5% of white patients and 22.5% of Asian patients had to cut down spending on food, as did 45.2% of black and 35.8% of Latina patients. Many patients desired to talk to providers about the financial impact of cancer (15.2% of whites, 31.1% of blacks, 30.3% of Latinas, and 25.4% of Asians). Unmet patient needs for engagement with physicians about financial concerns were common. Of 945 women who worried about finances, 679 (72.8%) indicated that physicians and their staff did not help. Of 523 women who desired to talk to providers regarding the impact of breast cancer on employment or finances, 283 (55.4%) reported no relevant discussion. CONCLUSIONS: Many patients report inadequate clinician engagement in the management of financial toxicity, even though many providers believe that they make services available. Clinician assessment and communication regarding financial toxicity must improve; cure at the cost of financial ruin is unacceptable. Cancer 2018;000:000-000. © 2018 American Cancer Society.

The Effect of Peer Support on Colorectal Cancer Patients' Adherence to Guideline-Concordant Multidisciplinary Care.

BACKGROUND: Multidisciplinary care is critical for the successful treatment of stage III colorectal cancer, yet receipt of adjuvant chemotherapy remains unacceptably low. Peer support, or exposure to others treated for colorectal cancer, has been proposed as a means to improve patient acceptance of cancer care. OBJECTIVE: The purpose of our study was to evaluate the effect of peer support on the attitudes of patients with colorectal cancer toward chemotherapy and their adherence to it. DESIGN: We conducted a population-based survey of patients with sage III colorectal cancer and compared demographics and adjuvant chemotherapy adherence after patient-reported exposure to peer support. SETTINGS: Patients were identified by using Surveillance, Epidemiology, and End Results Program cancer registries and were recruited 3 to 12 months after cancer resection. PATIENTS: All patients with stage III colorectal cancer who underwent colorectal resection between 2011 and 2013 and were located in the Detroit and Georgia regions were included. MAIN OUTCOME MEASURES: The main outcome measure was adjuvant chemotherapy adherence. Exposure to peer support was an intermediate outcome. RESULTS: Among 1301 patient respondents (68% response rate), 48% reported exposure to peer support. Exposure to peer support was associated with younger age, higher income, and having a spouse or domestic partner. Exposure to peer support was significantly associated with receipt of adjuvant chemotherapy (OR, 2.94; 95% CI, 1.89-4.55). Those exposed to peer support reported positive effects on attitudes toward chemotherapy. LIMITATIONS: This study has limitations inherent to survey research including the potential lack of generalizability and responses that are subject to recall bias. Additionally, the survey results do not allow for determination of the temporal relationship between peer support exposure and receipt of chemotherapy. CONCLUSION: Our study demonstrates that exposure to peer support is associated with higher adjuvant chemotherapy adherence. These data suggest that facilitated peer support programs could positively influence patient expectations and coping with diagnosis and treatment, thereby affecting the uptake of postoperative chemotherapy. See Video Abstract at http://links.lww.com/DCR/A587.

Treatment decisions and employment of breast cancer patients: Results of a population-based survey.

BACKGROUND: Many patients with breast cancer work for pay at the time of their diagnosis, and the treatment plan may threaten their livelihood. Understanding work experiences in a contemporary population-based sample is necessary to inform initiatives to reduce the burden of cancer care. METHODS: Women who were 20 to 79 years old and had been diagnosed with stage 0 to II breast cancer, as reported to the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries in 2014-2015, were surveyed. Of the 3672 eligible women, 2502 responded (68%); 1006 who reported working before their diagnosis were analyzed. Multivariate models evaluated correlates of missing work for >1 month and stopping work altogether versus missing work for ≤1 month. RESULTS: In this diverse sample, most patients (62%) underwent lumpectomy; 16% underwent unilateral mastectomy (8% with reconstruction); and 23% underwent bilateral mastectomy (19% with reconstruction). One-third (33%) received chemotherapy. Most (84%) worked full-time before their diagnosis; however, only 50% had paid sick leave, 39% had disability benefits, and 38% had flexible work schedules. Surgical treatment was strongly correlated with missing >1 month of work (odds ratio [OR] for bilateral mastectomy with reconstruction vs lumpectomy, 7.8) and with stopping work altogether (OR for bilateral mastectomy with reconstruction vs lumpectomy, 3.1). Chemotherapy receipt (OR for missing >1 month, 1.3; OR for stopping work altogether, 3.9) and race (OR for missing >1 month for blacks vs whites, 2.0; OR for stopping work altogether for blacks vs whites, 1.7) also correlated. Those with paid sick leave were less likely to stop working (OR, 0.5), as were those with flexible schedules (OR, 0.3). CONCLUSIONS: Working patients who received more aggressive treatments were more likely to experience substantial employment disruptions. Cancer 2017;123:4791-9. © 2017 American Cancer Society.

Treatment experiences of Latinas after diagnosis of breast cancer.

BACKGROUND: The authors examined racial/ethnic differences in patient perspectives regarding their breast cancer treatment experiences. METHODS: A weighted random sample of women newly diagnosed with breast cancer between 2013 and 2015 in Los Angeles County and Georgia were sent surveys 2 months after undergoing surgery (5080 women; 70% response rate). The analytic sample was limited to patients residing in Los Angeles County (2397 women). RESULTS: The pattern of visits with different specialists before surgery was found to be similar across racial/ethnic groups. Low acculturated Latinas (Latinas-LA) were less likely to report high clinician communication quality for both surgeons and medical oncologists (<69% vs >72% for all other groups; P<.05). The percentage of patients who reported high satisfaction regarding how physicians worked together was similar across racial/ethnic groups. Latinas-LA were more likely to have a low autonomy decision style (48% vs 24%-50% for all other groups; P<.001) and were more likely to report receiving too much information versus other ethnic groups (20% vs <16% for other groups; P<.001). Patients who reported a low autonomy decision style were more likely to rate the amount of information they received for the surgery decision as "too much" (16% vs 9%; P<.001). CONCLUSIONS: There appears to be moderate disparity in breast cancer treatment communication and decision-making experiences reported by Latinas-LA versus other groups. The approach to treatment decision making by Latinas-LA represents an important challenge to health care providers. Initiatives are needed to improve patient engagement in decision making and increase clinician awareness of these challenges in this patient population. Cancer 2017;123:3022-30. © 2017 American Cancer Society.

Discordance between original and central laboratories in ER and HER2 results in a diverse, population-based sample.

PURPOSE: To investigate the discordance between original and central laboratories in estrogen receptor (ER) status, in tumors originally deemed to be ER-negative, and in HER2 status in a diverse population-based sample. METHODS: In a follow-up study of 1785 women with Stage I-III breast cancer diagnosed between 2005 and 2007 in the Detroit and Los Angeles County SEER registry catchment areas, participants were asked to consent to reassessment of ER (in tumors originally deemed to be ER-negative) and HER2 status on archival tumor samples approximately four years after diagnosis. Blocks were centrally prepared and analyzed for ER and HER2 using standardized methods and the guidelines of the American Society of Clinical Oncology and the College of American Pathologists. Analyses determined the discordance between original and central laboratories. RESULTS: 132 (31%) of those eligible for ER reassessment and 367 (21%) eligible for HER2 reassessment had archival blocks reassessed centrally. ER discordance was only 6%. HER2 discordance by immunohistochemistry (IHC) was 26%, but final HER2 results-employing FISH in tumors that were IHC 2+ at the central laboratory-were discordant in only 6%. Half of the original laboratories did not perform their own assays. CONCLUSIONS: Discordance between original and central laboratories in two large metropolitan areas was low in this population-based sample compared to previously reported patient samples. Centralization of testing for key pathology variables appears to be occurring in many hospitals. In addition, quality improvement efforts may have preceded the publication and dissemination of specialty society guidelines.

Adjuvant endocrine therapy initiation and persistence in a diverse sample of patients with breast cancer.

Adjuvant endocrine therapy for breast cancer reduces recurrence and improves survival rates. Many patients never start treatment or discontinue prematurely. A better understanding of factors associated with endocrine therapy initiation and persistence could inform practitioners how to support patients. We analyzed data from a longitudinal study of 2,268 women diagnosed with breast cancer and reported to the Metropolitan Detroit and Los Angeles SEER cancer registries in 2005-2007. Patients were surveyed approximately both 9 months and 4 years after diagnosis. At the 4-year mark, patients were asked if they had initiated endocrine therapy, terminated therapy, or were currently taking therapy (defined as persistence). Multivariable logistic regression models examined factors associated with initiation and persistence. Of the 743 patients eligible for endocrine therapy, 80 (10.8 %) never initiated therapy, 112 (15.1 %) started therapy but discontinued prematurely, and 551 (74.2 %) continued use at the second time point. Compared with whites, Latinas (OR 2.80, 95 % CI 1.08-7.23) and black women (OR 3.63, 95 % CI 1.22-10.78) were more likely to initiate therapy. Other factors associated with initiation included worry about recurrence (OR 3.54, 95 % CI 1.31-9.56) and inadequate information about side effects (OR 0.24, 95 % CI 0.10-0.55). Factors associated with persistence included two or more medications taken weekly (OR 4.19, 95 % CI 2.28-7.68) and increased age (OR 0.98, 95 % CI 0.95-0.99). Enhanced patient education about potential side effects and the effectiveness of adjuvant endocrine therapy in improving outcomes may improve initiation and persistence rates and optimize breast cancer survival.

Factors associated with receipt of breast cancer adjuvant chemotherapy in a diverse population-based sample.

PURPOSE: Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample. PATIENTS AND METHODS: Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt. RESULTS: The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt. CONCLUSION: In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

Use of palliative radiotherapy among patients with metastatic non-small-cell lung cancer.

PURPOSE: Radiotherapy (RT) is known to effectively palliate many symptoms of patients with metastatic non-small-cell lung cancer (NSCLC). Anecdotally, RT is believed to be commonly used in this setting, but limited population-based data are available. The objective of this study was to examine the utilization patterns of palliative RT among elderly patients with Stage IV NSCLC and, in particular, to identify factors associated with its use. METHODS AND MATERIALS: A retrospective population-based cohort study was performed using linked Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify 11,084 Medicare beneficiaries aged > or =65 years who presented with Stage IV NSCLC in the 11 SEER regions between 1991 and 1996. The primary outcome was receipt of RT. Logistic regression analysis was used to identify factors associated with receipt of RT. RESULTS: A total of 58% of these patients received RT, with its use decreasing over time (p = 0.01). Increasing age was negatively associated with receipt of treatment (p <0.001), as was increasing comorbidities (p <0.001). Factors positively associated with the receipt of RT included income (p = 0.001), hospitalization (p <0.001), and treatment with chemotherapy (p <0.001). Although the use varied across the SEER regions (p = 0.001), gender, race/ethnicity, and distance to the nearest RT facility were not associated with treatment. CONCLUSIONS: Elderly patients with metastatic NSCLC frequently receive palliative RT, but its use varies, especially with age and receipt of chemotherapy. Additional research is needed to determine whether this variability reflects good quality care.

Colorectal cancer screening behavior in women attending screening mammography: longitudinal trends and predictors.

PURPOSE: Nationally representative surveys demonstrate that the adherence to screening mammography guidelines are associated with increased prevalence of colorectal cancer (CRC) screening; however, the incidence of CRC screening in the screening mammography population is unknown. Our purpose was to describe non-fecal occult blood test (FOBT) CRC screening utilization by women prior to and subsequent to screening mammography at a large academic medical center. MATERIALS AND METHODS: Using the institutional administrative data base, 17,790 women aged 50 and older who underwent screening mammography between 1998 and 2002 were retrospectively identified. We determined that women were current with non-FOBT CRC screening at the time of mammography if they had undergone flexible sigmoidoscopy or double-contrast barium enema in the 5 years or colonoscopy since 1995, the earliest for which data are available. We excluded FOBT as a form of CRC screening because the administrative data base did not adequately capture episodes of FOBT. Women who were not current were considered eligible for non-FOBT CRC screening. We then assessed the number of women who underwent flexible sigmoidoscopy, barium enema, or colonoscopy within 12 months following mammography. Age, insurance status, Breast Imaging Reporting and Data System classification, recommendations after screening mammography and year of mammography were examined as potential predictors of non-FOBT CRC screening completion. RESULTS: At the time of mammography, 13.3% women were current with non-FOBT CRC screening. Of women eligible for non-FOBT CRC screening at the time of mammography, 1.1% completed non-FOBT CRC screening within 12 months after mammography. The rate of non-FOBT CRC screening completion increased over time. After multivariate analysis, being insured by a commercial managed care organization or by Medicaid remained significant predictors of non-FOBT CRC screening. CONCLUSION: The prevalence of non-FOBT CRC screening is low in the population of women undergoing screening mammography, with an incidence of 1.0%. Future studies should examine whether delivering CRC screening interventions at a screening mammography visit increase adherence to non-FOBT CRC screening.

Completion of colorectal cancer screening in women attending screening mammography.

RATIONALE AND OBJECTIVES: The American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF) recommend colorectal cancer (CRC) screening to begin at age 50 in individuals at average risk for CRC. To estimate rate at which women eligible for CRC screening at the time of screening mammography attendance later completed in CRC screening, we retrospectively evaluated CRC screening utilization in women who underwent screening mammography at our institution. MATERIALS AND METHODS: We retrospectively identified 3357 women between the ages of 50 to 75 who received screening mammography in 1998 at a single academic medical center using the institution's Radiology Information System (RIS). Additional information collected from the institution's Health System Data Warehouse and the Radiology department's mammography quality assurance data included mammography results, Breast Imaging Reporting and Database System (BI-RADS) classification of mammography findings, recommendation for screening mammography follow-up, insurance status, and CRC screening utilization after screening mammography. After excluding women who were current with CRC screening at the time of mammography, we determined the proportion of eligible women who completed CRC screening after mammography. Age, insurance type, BI-RADS code, and recommendation code were evaluated as potential predictors of CRC screening completion in eligible women. RESULTS: Of the 3357 women between the ages of 50 and 75 who received screening mammography in 1998, only 414 (12.3%) were current with CRC screening at the time of screening mammography. Of the remaining 2943 women who were eligible for CRC screening at the time of screening mammography, 142 (4.8%) subsequently completed CRC screening. Average time to completion of CRC screening after screening mammography is 35.4 months (range, 0.27-64.9). Managed care insurance was the only significant predictor of CRC screening completion after screening mammography in eligible women after adjusting for other variables (adjusted OR 1.73, 95% CI 1.21-2.47, P < .0001). Neither BI-RADS classification nor postmammography recommendations were significantly associated with CRC screening completion. CONCLUSIONS: Prevalence studies have demonstrated that women who were compliant with screening mammography were more compliant with CRC screening. Our data suggest that despite this increased compliance, overall incidence of CRC screening is low in the screening mammography population.

Incorporating patient-centered outcomes in the analysis of cost-effectiveness: imaging strategies for renovascular hypertension.

OBJECTIVE: Our aim was to assess the contribution of patient-centered short-term disutilities and quality-of-life measures in the cost-effectiveness analysis of CT angiography, MR angiography, and conventional angiography in patients with medication-resistant hypertension. MATERIALS AND METHODS: A decision analytic model compared the life expectancy and incremental cost per life year using three initial diagnostic tests in a cohort of hypothetical individuals with medication-resistant hypertension over a range of renal artery stenosis probabilities: CT angiography (sensitivity, 96%; specificity, 96%; cost, $865); MR angiography (98%, 94%, $850); and conventional angiography (99%, 99%, $2,627). All imaging strategies were compared with a base case scenario mimicking the natural history of medication-resistant hypertension and with a scenario immediate enhanced medical therapy without prior imaging. Individuals without evidence of renal artery stenosis on initial testing underwent conventional angiography if enhanced medical therapy failed to control hypertension. Individuals diagnosed with renal artery stenosis on MR angiography required conventional angiography for definitive stent treatment ($11,1223). Blood pressure response to renal artery stenting or enhanced medical therapy varied according to blood pressure, as did the incidence of myocardial infarction and stroke resulting from hypertension. Patients who progressed to end-stage renal disease received dialysis ($60,000 per year). Quality-of-life adjustments were made for patients with hypertension, end-stage renal disease, myocardial infarction, and stroke. Short-term disutilities from undergoing an imaging test were included. The analysis accounted for direct costs derived from Medicare reimbursements and total costs derived from the literature. RESULTS: All imaging strategies were cost-effective compared with enhanced medical therapy alone or with natural history. When only direct costs were considered, MR angiography was the preferred strategy, with conventional angiography as a cost-effective alternative to MR angiography. When total costs were considered, conventional angiography dominated all other strategies. Adjusting for quality of life decreased the incremental cost-effectiveness ratios, making an already competitive strategy a more favorable alternative to the base case. Adjusting for test-related disutility did not significantly influence the cost-effectiveness of any of the imaging tests. Despite marked variation in the key clinical and cost variables, MR angiography remained the most cost-effective strategy. CONCLUSION: In the evaluation and treatment of medication-resistant hypertension, strategies that included preliminary imaging saved more lives than did the immediate institution of enhanced medical therapy at a lesser cost.

Percutaneous stenting of incidental unilateral renal artery stenosis: decision analysis of costs and benefits.

PURPOSE: To determine the incremental cost-effectiveness of prophylactic percutaneous transluminal angioplasty with stent placement (PTA-S) in patients with incidentally discovered, asymptomatic renal artery stenosis (RAS) compared to delaying PTA-S until patients develop refractory hypertension or renal insufficiency (therapeutic PTA-S). METHODS: The Markov decision analysis model was used to determine the incremental cost per quality adjusted life year (QALY) saved for prophylactic PTA-S as compared to therapeutic PTA-S in a hypothetical cohort of patients with 50% unilateral atherosclerotic RAS followed from age 61 to death. RESULTS: Prophylactic PTA-S compared to therapeutic PTA-S results in more QALYs/patient (10.9 versus 10.3) at higher lifetime costs ($23,664 versus $16,558). The incremental cost effectiveness of prophylactic PTA-S was estimated to be $12,466/QALY. Prophylactic stenting was not cost effective (>$50,000/QALY) if the modeled incidence of stent restenosis exceeded 15%/year and the incidence of progression in the contralateral renal artery was <2% of arteries/year. CONCLUSIONS: PTA-S of incidental, asymptomatic unilateral RAS may improve patients' quality of life at an acceptable incremental cost. However, this technology should be used hesitantly until a randomized comparison confirms its effectiveness.

Cost-effectiveness of pap smear screening for vaginal cancer after total hysterectomy for benign disease.

OBJECTIVE: To examine the cost effectiveness of Papanicolaou screening for cancer after total hysterectomy for benign disease. MATERIALS AND METHODS: Decision analysis including Markov modeling applied to women aged 40 or older with a history of total hysterectomy for benign disease. We derived expected discounted costs and life expectancy. RESULTS: Maximum gain in life expectancy between no screening and any screening strategy was approximately 3 weeks. Cost effectiveness in dollars per life-year gained was > or =$143,875 more than no screening for strategies starting at age 50, and over $12 million for aged 40 or more screening strategy. None of the sensitivity analyses caused the incremental cost effectiveness of any strategy to come to less than $100,000 per life year gained compared with no screening. CONCLUSIONS: Despite significant costs for any strategy, Pap smear screening after total hysterectomy for benign disease provides essentially no gain in life expectancy. In absence of risks for genital cancer, such screening is not cost effective.