Obesity and mortality after locoregional breast cancer diagnosis.

PURPOSE: Higher mortality after a breast cancer diagnosis has been observed among women who are obese. We investigated the relationships between body mass index (BMI) and all-cause or breast cancer-specific mortality after a diagnosis of locoregional breast cancer. METHODS: Women diagnosed in 2004 with AJCC Stage I, II, or III breast cancer (n = 5394) were identified from a population-based National Program of Cancer Registries (NPCR) patterns of care study (POC-BP) drawing from registries in seven U.S. states. Differences in overall and breast cancer-specific mortality were investigated using Cox proportional hazards regression models adjusting for demographic and clinical covariates, including age- and stage-based subgroup analyses. RESULTS: In women 70 or older, higher BMI was associated with lower overall mortality (HR for a 5 kg/m2 difference in BMI = 0.85, 95% CI 0.75-0.95). There was no significant association between BMI and overall mortality for women under 70. BMI was not associated with breast cancer death in the full sample, but among women with Stage I disease; those in the highest BMI category had significantly higher breast cancer mortality (HR for BMI ≥ 35 kg/m2 vs. 18.5-24.9 kg/m2 = 4.74, 95% CI 1.78-12.59). CONCLUSIONS: Contrary to our hypothesis, greater BMI was not associated with higher overall mortality. Among older women, BMI was inversely related to overall mortality, with a null association among younger women. Higher BMI was associated with breast cancer mortality among women with Stage I disease, but not among women with more advanced disease.

Risk of cancer death by comorbidity severity and use of adjuvant chemotherapy among women with locoregional breast cancer.

OBJECTIVES: To examine the associations of comorbidity and chemotherapy with breast cancer- and non-breast cancer-related death. MATERIALS AND METHODS: Included were women with invasive locoregional breast cancer diagnosed in 2004 from seven population-based cancer registries. Data were abstracted from medical records and verified with treating physicians when there were inconsistencies and missing information on cancer treatment. Comorbidity severity was quantified using the Adult Comorbidity Evaluation 27. Treatment guideline concordance was determined by comparing treatment received with the National Comprehensive Cancer Network guidelines. Kaplan-Meier method and multivariable Cox proportional hazards regressions were employed for statistical analyses. RESULTS: Of 5852 patients, 76% were under 70years old and 69% received guideline concordant adjuvant chemotherapy. Comorbidity was more prevalent in women age 70 and older (79% vs. 51%; p<0.001). After adjusting for tumor characteristics and treatment, severe comorbidity burden was associated with significantly higher cancer-related mortality in older patients (Hazard Ratio [HR]=2.38, 95% CI 1.08-5.24), but not in younger patients (HR=1.78, 95% CI 0.87-3.64). Among patients receiving guideline adjuvant chemotherapy, cancer-related mortality was significantly higher in older patients (HR=2.35, 95% CI 1.52-3.62), and those with severe comorbidity (HR=3.79, 95% CI 1.72-8.33). CONCLUSIONS: Findings suggest that, compared to women with no comorbidity, patients with breast cancer age 70 and older with severe comorbidity are at increased risk of dying from breast cancer, even after adjustment for adjuvant chemotherapy and other tumor and treatment differences. This information adds to risk-benefit discussions and emphasizes the need for further study of the role for adjuvant chemotherapy in these patient groups.

Racial and Socioeconomic Disparities Are More Pronounced in Inflammatory Breast Cancer Than Other Breast Cancers.

Inflammatory breast cancer (IBC) is a rare yet aggressive form of breast cancer. We examined differences in patient demographics and outcomes in IBC compared to locally advanced breast cancer (LABC) and all other breast cancer patients from the Breast and Prostate Cancer Data Quality and Patterns of Care Study (POC-BP), containing information from cancer registries in seven states. Out of 7,624 cases of invasive carcinoma, IBC and LABC accounted for 2.2% (N = 170) and 4.9% (N = 375), respectively. IBC patients were more likely to have a higher number (P = 0.03) and severity (P = 0.01) of comorbidities than other breast cancer patients. Among IBC patients, a higher percentage of patients with metastatic disease versus nonmetastatic disease were black, on Medicaid, and from areas of higher poverty and more urban areas. Black and Hispanic IBC patients had worse overall and breast cancer-specific survival than white patients; moreover, IBC patients with Medicaid, patients from urban areas, and patients from areas of higher poverty and lower education had worse outcomes. These data highlight the effects of disparities in race and socioeconomic status on the incidence of IBC as well as IBC outcomes. Further work is needed to reveal the causes behind these disparities and methods to improve IBC outcomes.

What Predicts an Advanced-Stage Diagnosis of Breast Cancer? Sorting Out the Influence of Method of Detection, Access to Care, and Biologic Factors.

BACKGROUND: Multiple studies have yielded important findings regarding the determinants of an advanced-stage diagnosis of breast cancer. We seek to advance this line of inquiry through a broadened conceptual framework and accompanying statistical modeling strategy that recognize the dual importance of access-to-care and biologic factors on stage. METHODS: The Centers for Disease Control and Prevention-sponsored Breast and Prostate Cancer Data Quality and Patterns of Care Study yielded a seven-state, cancer registry-derived population-based sample of 9,142 women diagnosed with a first primary in situ or invasive breast cancer in 2004. The likelihood of advanced-stage cancer (American Joint Committee on Cancer IIIB, IIIC, or IV) was investigated through multivariable regression modeling, with base-case analyses using the method of instrumental variables (IV) to detect and correct for possible selection bias. The robustness of base-case findings was examined through extensive sensitivity analyses. RESULTS: Advanced-stage disease was negatively associated with detection by mammography (P < 0.001) and with age < 50 (P < 0.001), and positively related to black race (P = 0.07), not being privately insured [Medicaid (P = 0.01), Medicare (P = 0.04), uninsured (P = 0.07)], being single (P = 0.06), body mass index > 40 (P = 0.001), a HER2 type tumor (P < 0.001), and tumor grade not well differentiated (P < 0.001). This IV model detected and adjusted for significant selection effects associated with method of detection (P = 0.02). Sensitivity analyses generally supported these base-case results. CONCLUSIONS: Through our comprehensive modeling strategy and sensitivity analyses, we provide new estimates of the magnitude and robustness of the determinants of advanced-stage breast cancer. IMPACT: Statistical approaches frequently used to address observational data biases in treatment-outcome studies can be applied similarly in analyses of the determinants of stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 25(4); 613-23. ©2016 AACR.

Influence of patient, physician, and hospital characteristics on the receipt of guideline-concordant care for inflammatory breast cancer.

PURPOSE: Inflammatory breast cancer (IBC) is an aggressive subtype of breast cancer for which treatments vary, so we sought to identify factors that affect the receipt of guideline-concordant care. METHODS: Patients diagnosed with IBC in 2004 were identified from the Breast and Prostate Cancer Data Quality and Patterns of Care Study, containing information from cancer registries in seven states. Variation in guideline-concordant care for IBC, based on National Comprehensive Cancer Network (NCCN) guidelines, was assessed according to patient, physician, and hospital characteristics. RESULTS: Of the 107 IBC patients in the study without distant metastasis at the time of diagnosis, only 25.8% received treatment concordant with guidelines. Predictors of non-concordance included patient age (≥70 years), non-white race, normal body mass index (BMI 18.5-25 kg/m(2)), patients with physicians graduating from medical school >15 years prior, and smaller hospital size (<200 beds). IBC patients survived longer if they received guideline-concordant treatment based on either 2003 (p=0.06) or 2013 (p=0.06) NCCN guidelines. CONCLUSIONS: Targeting factors associated with receipt of care that is not guideline-concordant may reduce survival disparities in IBC patients. Prompt referral for neoadjuvant chemotherapy and post-operative radiation therapy is also crucial.

Clinical and Demographic Factors Associated With Receipt of Non Guideline-concordant Initial Therapy for Nonmetastatic Prostate Cancer.

OBJECTIVES: To determine the extent to which initial therapy for nonmetastatic prostate cancer was concordant with nationally recognized guidelines using supplemented cancer registry data and what factors were associated with receipt of nonguideline-concordant care. METHODS: Initial therapy for 8229 nonmetastatic prostate cancer cases diagnosed in 2004 from cancer registries in 7 states was abstracted as part of the Centers for Disease Control's Patterns of Care Breast and Prostate Cancer study conducted during 2007 to 2009. The National Comprehensive Cancer Network clinical practice guidelines version 1.2002 was used as the standard of care based on recurrence risk group and life expectancy (LE). A multivariable model was used to determine risk factors associated with receipt of nonguideline-concordant care. RESULTS: Nearly 80% with nonmetastatic prostate cancer received guideline-concordant care for initial therapy. Receipt of nonguideline-concordant care (including receiving either less aggressive therapy or more aggressive therapy than indicated) was related to older age, African American race/ethnicity, being unmarried, rural residence, and especially to being in the high recurrence risk group where receiving less aggressive therapy than indicated occurred more often than receiving more aggressive therapy (adjusted OR=4.2; 95% CL, 3.5-5.2 vs. low-risk group). Compared with life table estimates adjusted for comorbidity, physicians tended to underestimate LE. CONCLUSIONS: Receipt of less aggressive therapy than indicated among high-risk group men with >5-year LE based on life table estimates adjusted for comorbidity was a concern. Physicians may tend to underestimate 5-year survival among this group and should be alerted to the importance of recommending aggressive therapy when warranted. However, based on more recent guidelines, among those with low-risk disease, the proportion considered to be receiving less aggressive therapy than indicated may now be lower because active surveillance is now considered appropriate.

Patterns of Care for Metastatic Colorectal Cancer in Appalachia, and the Clinical, Sociodemographic, and Service Provider Determinants.

BACKGROUND: Appalachia has high colorectal cancer (CRC) incidence and mortality, at least in part due to screening disparities. This paper examines patterns and determinants of metastatic colorectal cancer care. METHODS: CRC patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009.) The final sample after exclusions included 855 stage IV and 590 stages I-III patients with metachronous or synchronous metastases. We estimate bivariate and multivariate analyses for several surgical and chemotherapeutic strategies of care using clinical, sociodemographic, and contextual determinants. RESULTS: Among 1,445 CRC patients, 84% had primary tumor resection and 44% received chemotherapy. Of the chemotherapy patients, 44% received newer systemic agents for at least 75% of the cycles. One year survivors with liver or lung metastases were more likely to have their primary tumor resected immediately (86.1% vs 69.5% for liver, and 78.2% vs 64.9% for lung) and have their metastases resected/ablated (15.7% vs 2.6% for liver and 15.0% vs 0.5% for lung). Patients with stages I-III primary tumors (versus IV) were much more likely to be resected, but they were less likely to receive chemotherapy. Patients with comorbidities (congestive heart failure, dementia, or respiratory disease) had lower odds of chemotherapy. Smaller hospital size and surgical volume had higher odds of immediate versus delayed surgery. The newer chemotherapeutic agents were more common with higher surgical volume. CONCLUSIONS: Metastatic colorectal cancer has clinical, sociodemographic, and service provider determinants.

Disparities in Colorectal Cancer Treatment Delay Within Appalachia--The Role of For-Profit Hospitals.

BACKGROUND: Appalachian residents have a higher overall cancer burden than the rest of the United States because of the unique features of the region. Treatment delays vary widely within Appalachia, with colorectal cancer patients undergoing median treatment delays of 5 days in Kentucky compared to 9 days for patients in Pennsylvania, Ohio, and North Carolina combined. OBJECTIVE: This study identified the source of this disparity in treatment delay using statistical decomposition techniques. METHODOLOGY: This study used linked 2006 to 2008 cancer registry and Medicare claims data for the Appalachian counties of Kentucky, Pennsylvania, Ohio, and North Carolina to estimate a 2-part model of treatment delay. An Oaxaca Decomposition of the 2-part model revealed the contribution of the individual determinants to the disparity in delay between Kentucky counties and the remaining 3 states. RESULTS: The Oaxaca Decomposition revealed that the higher percentage of patients treated at for-profit facilities in Kentucky proved the key contributor to the observed disparity. In Kentucky, 22.3% patients began their treatment at a for-profit facility compared to 1.4% in the remaining states. Patients initiating treatment at for-profit facilities explained 79% of the observed difference in immediate treatment (<2 days after diagnosis) and 72% of Kentucky's advantage in log days to treatment. CONCLUSIONS: The unique role of for-profit facilities led to reduced treatment delay for colorectal cancer patients in Kentucky. However, it remains unknown whether for-profit hospitals' more rapid treatment converts to better health outcomes for colorectal cancer patients.

Diabetes management before and after cancer diagnosis: missed opportunity.

BACKGROUND: Few studies have examined the management of comorbidities in cancer patients. This study used population-based data to estimate the guideline concordance rates for diabetes management before and after cancer diagnosis and examined if diabetes management services among cancer patients was associated with characteristics of the hospital where the patient was treated. METHODS: We linked 2005-2009 Medicare claims data to information on 2,707 breast and colorectal cancers patients in state cancer registry files. Multivariate logistic regression models examined hospital characteristics associated with receipt of diabetes management care after cancer diagnosis. RESULTS: The rates of HbAlc testing, LDL-C testing, and retinal eye exam decreased from 72.7%, 79.6%, and 57.9% before cancer diagnosis to 58.3%, 69.5%, and 55.8% after diagnosis. The pre- and post-diagnosis diabetes management care was not significantly different by hospital characteristics in the bivariate analysis except for that the distance between residence and hospital was negatively related to retinal eye exam after diagnosis (P<0.05). The multivariate analysis did not identify any significant differences in diabetes management care after cancer diagnosis by hospital characteristics. CONCLUSIONS: Cancer patients received fewer diabetes management care after diagnosis than prior to diagnosis, even for those who were treated in large comprehensive centers. This may reflect a missed opportunity to connect diabetic cancer patients to diabetes care. This study provides benchmarks to measure improvements in comorbidity management among cancer patients.

Patterns of locoregional treatment for nonmetastatic breast cancer by patient and health system factors.

BACKGROUND: The purpose of this study was to examine local definitive therapy for nonmetastatic breast cancer with the Patterns of Care Breast and Prostate Cancer (POCBP) study of the National Program of Cancer Registries (Centers for Disease Control and Prevention). METHODS: POCBP medical record data were re-abstracted in 7 state/regional registry systems (Georgia, North Carolina, Kentucky, Louisiana, Wisconsin, Minnesota, and California) to verify data quality and assess treatment patterns in the population. National Comprehensive Cancer Network clinical practice treatment guidelines were aligned with American Joint Committee on Cancer staging at diagnosis to appraise care. RESULTS: Six thousand five hundred five of 9142 patients with registry-confirmed breast cancer were coded as having primary disease with stage 0 to IIIA tumors and were included in the study. Approximately 88% received guideline-concordant locoregional treatment. However, this outcome varied by age group: 92% of women < age 50 versus 80% of women ≥ age 70 years old received guideline care (P < 0.01). Characteristics that best discriminated receipt (no/yes) of guideline-concordant care in receiver operating curve analyses were the receipt of breast-conserving surgery (BCS) versus mastectomy (C = 0.70), patient age (C = 0.62), a greater tumor stage (C = 0.60), public insurance (C = 0.58), and the presence of at least mild comorbidity (C = 0.55). Radiation therapy (RT) after BCS was the most omitted treatment component causing nonconcordance in the study population. In multivariate regression, the effects of the treatment facility, ductal carcinoma in situ, race, and comorbidity on nonconcordant care differed by age group. CONCLUSIONS: Patterns of underuse of standard therapies for breast cancer vary by age group and BCS use, with which there is a risk of omission of RT.

Patient and provider perspectives on the relationship between multiple morbidity management and disease prevention.

Despite competing demands of multiple morbidity (MM) management and disease prevention, our recent survey of 1,153 Appalachian residents aged 50 to 76 documented that individuals with MM were more likely to obtain colorectal cancer screening (CRCS) than those without MM. Nearly two thirds of respondents obtained CRCS, and the more MM, the greater the likelihood of screening. To gain insight into this relationship, we conducted nine focus groups, six with providers and three with patients. Three main explanations emerged: (a) patients' MM increases providers' vigilance for other health vulnerabilities; (b) having MM increases patients' own vigilance; and (c) patients' vigilance may stem from experiencing more symptoms, having a family history of cancer, and having successfully obtained health care. More frequent contact with health care providers appears to encourage preventive referral, especially in low-income populations that otherwise may not receive such counselling. We highlight participant recommendations to improve MM management and prevention.

The influence of diabetes severity on receipt of guideline-concordant treatment for breast cancer.

Diabetes severity may influence breast cancer treatment choices. We examined whether receipt of guideline-concordant breast cancer treatment varied with diabetes severity. Cancer registry data from seven states regarding 6,912 stage I-III breast cancers were supplemented by medical record abstraction and physician verification. We used logistic regression models to examine associations of diabetes severity with guideline-concordant locoregional treatment, adjuvant chemotherapy, and hormonal therapy adjusted for sociodemographics, comorbidity, and tumor characteristics. We defined guideline concordance using National Comprehensive Cancer Network guidelines, and diabetes and comorbidities using the Adult Comorbidity Evaluation-27 index. After adjustment, there was significant interaction of diabetes severity with age for locoregional treatment (p = 0.001), with many diabetic women under age 70 less frequently receiving guideline-concordant treatment than non-diabetic women. Among similarly aged women, guideline concordance was lower for women with mild diabetes in their late fifties through mid-sixties, and with moderate/severe diabetes in their late forties to early sixties. Among women in their mid-seventies to early eighties, moderate/severe diabetes was associated with increased guideline concordance. For adjuvant chemotherapy, moderate/severe diabetes was less frequently associated with guideline concordance than no diabetes [OR 0.58 (95 % CI 0.36-0.94)]. Diabetes was not associated with guideline-concordant hormonal treatment (p = 0.929). Some diabetic women were less likely to receive guideline-concordant treatment for stage I-III breast cancer than non-diabetic women. Diabetes severity was associated with lower guideline concordance for locoregional treatment among middle-aged women, and lower guideline concordance for adjuvant chemotherapy. Differences were not explained by comorbidity and may contribute to potentially worse breast cancer outcomes.

Comorbidity burden and guideline-concordant care for breast cancer.

OBJECTIVES: To explore the relationship between level and type of comorbidity and guideline-concordant care for early-stage breast cancer. DESIGN: Cross-sectional. SETTING: National Program of Cancer Registry (NPCR) Breast and Prostate Cancer Patterns of Care study, which re-abstracted medical records from 2004 in seven cancer registries. PARTICIPANTS: Individuals with stage 0-III breast cancer. MEASUREMENTS: Multicomponent guideline-concordant management was modeled based on tumor size, node status, and hormone receptor status, according to consensus guidelines. Comorbid conditions and severity were measured using the Adult Comorbidity Evaluation Index (ACE-27). Multivariate logistic regression models determined factors associated with guideline-concordant care and included overall ACE-27 scores and 26 separate ACE comorbidity categories, age, race, stage, and source of payment. RESULTS: The study sample included 6,439 women (mean age 58.7, range 20-99; 76% white; 44% with no comorbidity; 70% estrogen- or progesterone-receptor positive, or both; 31% human epidermal growth factor receptor 2 positive). Care was guideline concordant in 60%. Guideline concordance varied according to overall comorbidity burden (70% for none; 61% for minor; 58% for moderate, 43% for severe; P < .05). In multivariate analysis, the presence of hypertension (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.01-1.30) predicted guideline concordance, whereas dementia (OR = 0.45, 95% CI = 0.24-0.82) predicted lack of guideline concordance. Older age (≥ 50) and black race were associated with less guideline concordance, regardless of comorbidity level. CONCLUSION: When reporting survival outcomes in individuals with breast cancer with comorbidity, adherence to care guidelines should be among the covariates.

Clinical, sociodemographic, and service provider determinants of guideline concordant colorectal cancer care for Appalachian residents.

BACKGROUND: Colorectal cancer represents a significant cause of morbidity and mortality, particularly in Appalachia where high mortality from colorectal cancer is more prevalent. Adherence to treatment guidelines leads to improved survival. This paper examines determinants of guideline concordance for colorectal cancer. METHODS: Colorectal cancer patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009). Final sample size after exclusions was 2,932 stage I-III colon, and 184 stage III rectal cancer patients. The 3 measures of guideline concordance include adjuvant chemotherapy (stage III colon cancer, <80 years), ≥12 lymph nodes assessed (resected stage I-III colon cancer), and radiation therapy (stage III rectal cancer, <80 years). Bivariate and multivariate analyses with clinical, sociodemographic, and service provider covariates were estimated for each of the measures. RESULTS: Rates of chemotherapy, lymph node assessment, and radiation were 62.9%, 66.3%, and 56.0%, respectively. Older patients had lower rates of chemotherapy and radiation. Five comorbidities were significantly associated with lower concordance in the bivariate analyses: myocardial infarction, congestive heart failure, respiratory diseases, dementia with chemotherapy, and diabetes with adequate lymph node assessment. Patients treated by hospitals with no Commission on Cancer (COC) designation or lower surgical volumes had lower odds of adequate lymph node assessment. CONCLUSIONS: Clinical, sociodemographic, and service provider characteristics are significant determinants of the variation in guideline concordance rates of 3 colorectal cancer measures.

The relationship between perceived burden of chronic conditions and colorectal cancer screening among Appalachian residents.

PURPOSE: As the population living with several concurrent chronic conditions or multiple morbidity (MM) increases, understanding how to effectively fit prevention efforts into disease management becomes more important, particularly among rural, underserved populations. Compared to their urban counterparts, rural residents suffer higher rates of disease, receive fewer preventive services, and often live in environments limiting access to optimal medical care. This study describes rural residents' perceived burdens of disease management and explores the relationship between these burdens, as proxies of individuals' competing demands, and colorectal cancer screening (CRCS). METHODS: We conducted a cross-sectional study, based on telephone survey data from 1,012 Appalachian residents, ages 50-75, with 1 or more chronic conditions. Measures of perceived MM burdens were developed based on 85 pilot interviews previously undertaken with providers and patients with MM residing in Appalachian Kentucky. RESULTS: Many participants (81%) agreed with 1 or more statements indicating perceived burdens of disease management effects on receiving CRCS. A higher percentage of rural (vs nonrural) Appalachians perceived burdens related to physician's recommendation, preparation to colonoscopy, and time management and affordability of both current diseases and screening. These differences did not modify the overall association between perceiving MM as burdensome and forgoing CRCS. The negative effect on CRCS of perceived burdens related to interaction with physician and time management was lower for participants with multiple rather than single morbidity. CONCLUSION: Future research designed to address perceived burdens of MM and improved interaction with health care providers may enhance critical prevention efforts among vulnerable populations.

Impact of non-HIV related comorbidities on retention in HIV medical care: does retention improve over time?

The purpose of this study was to understand how the presence of comorbid conditions affects retention in HIV medical care over time. A retrospective cohort design employing a medical chart review was conducted. A generalized linear mixed model was used to determine the predictors that affect retention over time. The mean follow-up for the study population was 5.75 years, and only 48.6 % achieved optimal retention. During the study period, 882 non-HIV related comorbidities were diagnosed in 610 (44.9 %) patients of whom, approximately 31 % had ≥2 comorbidities diagnosed. In the mixed model, the number of comorbidities diagnosed during the study period was associated with improved retention over time (odds ratio = 2.28; 95 % confidence interval = 1.83-2.71). Having a non-HIV related comorbid condition was associated with improved retention, while those patients who were 'healthier' had worse retention. More research is needed to identify factors that improve retention and to quantify the impact of these factors.

Treatment patterns for prostate cancer: comparison of Medicare claims data to medical record review.

BACKGROUND: As evidence-based guidelines increasingly define standards of care, the accurate reporting of patterns of treatment becomes critical to determine if appropriate care has been provided. We explore the level of agreement between claims and record abstraction for treatment regimens for prostate cancer. METHODS: Medicare claims data were linked to medical records abstraction using data from the Centers for Disease Control and Prevention's National Program of Cancer Registry-funded Breast and Prostate Patterns of Care study. The first course of therapy included surgery, radiation therapy (RT), and hormonal therapy with luteinizing hormone-releasing hormone agonists. RESULTS: The linked sample included 2765 men most (84.7%) of whom had stage II prostate cancer. Agreement was excellent for surgery (κ=0.92) and RT (κ=0.92) and lower for hormonal therapy (κ=0.71); however, most of the discrepancies were due to greater number of patients reported who received hormonal therapy in the claims database than in the medical records database. For some standard multicomponent management strategies sensitivities were high, for example, hormonal therapy with either combination RT (86.9%) or cryosurgery (96.6%). CONCLUSIONS: Medicare claims are sensitive for determining patterns of multicomponent care for prostate cancer and for detecting use of hormonal therapy when not reported in the medical records abstracts.

Generic antiepileptic drug prescribing: a cross-sectional study.

The use of generic antiepileptic drugs (AEDs) in patients with epilepsy is controversial. The purpose of this study is to identify patient characteristics associated with increased odds of receiving a generic AED product. A large commercial database was used to identify patients with a primary diagnosis of epilepsy who were prescribed an AED during a three-month window. Data analysis found that those ≥65 years old had 15.7% greater odds of receiving a generic AED (OR = 1.157; 95% CI = 1.056-1.268). Patients with Medicaid were found to have 2.44 times the odds of having had a generic AED prescription (OR = 2.44; CI = 2.168-2.754). Patients residing in the Northeast had 12.6% decreased odds of receiving a generic AED (OR = 0.874; C I= 0.821-0.931). These patient characteristics could signify certain health care disparities and may represent potential confounders to future observational studies.

Regional, provider, and economic factors associated with the choice of active surveillance in the treatment of men with localized prostate cancer.

Data on initial treatment of 8232 cases of localized prostate cancer diagnosed in 2004 were obtained by medical record abstraction (including hospital and outpatient locations) from seven state cancer registries participating in the Centers for Disease Control and Prevention's Breast and Prostate Cancer Data Quality and Patterns of Care Study. Distinction was made between men receiving no therapy with no monitoring plan (no therapy/no plan [NT/NP]) and those receiving active surveillance (AS). Overall, 8.6% received NT/NP and 4.7% received AS. Older age at diagnosis, lower clinical risk group, and certain registry locations were significant predictors of use of both AS and NT/NP. AS was also related to having more severe comorbidities, whereas nonwhite race was predicted receiving NT/NP. Men receiving AS lived in areas with a higher number of urologists per 100 000 men than those receiving NT/NP. In summary, physician and clinical factors were stronger predictors of AS, whereas demographic and regional factors were related to receiving NT/NP. Physicians appear reluctant to recommend AS for younger patients with no comorbidities.