Physician Nonprofessional Cancer Experience and Ovarian Cancer Screening Practices: Results from a National Survey of Primary Care Physicians.

OBJECTIVE: Routine ovarian cancer screening is ineffective; therefore, no professional organization recommends this screening in asymptomatic patients. However, many physicians have recommended screening, exposing patients to unnecessary risk. Little research exists on how nonprofessional experience with cancer influences physicians' screening practices. This study examines the association between physicians' nonprofessional experience with cancer and reported adherence to ovarian cancer screening guidelines. MATERIALS AND METHODS: A mail questionnaire with an annual examination vignette and questions about cancer screening recommendations was sent to a random sample of 3,200 U.S. family physicians, general internists, and obstetrician-gynecologists. This analysis included 497 physicians who received a vignette of a woman at average ovarian cancer risk and weighted results to represent these physician groups nationally. The outcome measure was adherence to ovarian cancer screening guidelines. Stepwise multivariate logistic regression estimated adjusted risk ratios for guideline adherence. RESULTS: In unadjusted analyses, 86.0% of physicians without nonprofessional cancer experience reported adherence to ovarian cancer screening guidelines compared with 69.2% of physicians with their own history of cancer, or a family member or close friend/coworker with cancer (p = 0.0045). In adjusted analyses, physicians with cancer themselves or in a family member or close friend/coworker were 0.82 times less likely (CI: 0.73-0.92) to report adhering to ovarian cancer screening recommendations than those without nonprofessional cancer experience. CONCLUSIONS: Despite recommendations to the contrary, many physicians reported recommending ovarian cancer screening in low-risk women. Physicians with nonprofessional cancer experience were more likely to report offering or ordering nonrecommended screening than physicians without this experience.

Thorough QT/QTc Evaluation of the Cardiac Safety of Secnidazole at Therapeutic and Supratherapeutic Doses in Healthy Individuals.

SYM-1219, a novel oral granule formulation of secnidazole, is under development as single-dose treatment for bacterial vaginosis. This 4-way, randomized, crossover study evaluated the effects of SYM-1219 on electrocardiographic (ECG) parameters in 52 healthy subjects. Subjects were administered single doses of SYM-1219, 2 g (proposed therapeutic dose), 6 g (supratherapeutic dose), placebo, and moxifloxacin (positive control). Serial digital 12-lead ECGs were recorded pre- and postdose; blood samples were taken to determine plasma secnidazole concentrations. A high-precision QT technique measured ECGs. The primary end point was change from baseline QTcF (∆QTcF); data were analyzed with the objective of excluding QT effects >10 milliseconds at postdosing time points and with exposure-response analysis. Safety and tolerability were assessed. Single doses of 2 g and 6 g SYM-1219 did not have a clinically relevant effect on the QTcF interval; an effect >10 milliseconds could be excluded at all postdosing time points. A shallow slope of the exposure-response relationship was seen (0.058 millisecond per µg/mL; 90%CI 0.042, 0.073); in this model, the effect on QTc can be predicted to be <10 milliseconds up to a secnidazole plasma concentration of ∼125 µg/mL, approximately 3.4-fold higher than anticipated peak therapeutic plasma levels. The moxifloxacin QT response demonstrated assay sensitivity. The most frequently reported treatment-emergent adverse events with SYM-1219 were headache, dizziness, and nausea. This thorough QT study demonstrated that SYM-1219 in doses and plasma concentrations up to 3-fold above therapeutically relevant levels does not have a clinically concerning effect on ECG parameters, including the QT interval.

Physicians' beliefs about effectiveness of cancer screening tests: a national survey of family physicians, general internists, and obstetrician-gynecologists.

OBJECTIVE: To study physicians' beliefs about the effectiveness of different tests for cancer screening. METHODS: Data were examined from the Women's Health Survey of 1574 Family Medicine, Internal Medicine, and Obstetrics-Gynecology physicians to questions about their level of agreement about the clinical effectiveness of different tests for breast, cervical, ovarian, and colorectal cancer screening among average risk women. Data were weighted to the U.S. physician population based on the American Medical Association Masterfile. Multivariable logistic regression identified physician and practice characteristics significantly associated with physicians' beliefs. RESULTS: There were 1574 respondents, representing a 62% response rate. The majority of physicians agreed with the effectiveness of mammography for women aged 50-69years, Pap tests for women aged 21-65years, and colonoscopy for individuals aged ≥50years. A substantial proportion of physicians believed that non-recommended tests were effective for screening (e.g., 34.4% for breast MRI and 69.1% for annual pelvic exam). Physicians typically listed their respective specialty organizations as a top influential organization for screening recommendations. CONCLUSIONS: There were several substantial inconsistencies between physician beliefs in the effectiveness of cancer screening tests and the actual evidence of these tests' effectiveness which can lead both to underuse and overuse of cancer screening tests.

Accuracy of ovarian and colon cancer risk assessments by U.S. physicians.

BACKGROUND: Studies have shown a mismatch between published cancer screening and genetic counseling referral recommendations and physician-reported screening and referral practices. Inaccurate cancer risk assessment is one potential cause of this mismatch. OBJECTIVE: To assess U.S. physicians' ability to accurately determine a woman's colon and ovarian cancer risk level. DESIGN, PARTICIPANTS: Cross-sectional survey of U.S. family physicians, general internists, and obstetrician-gynecologists. A twelve-page questionnaire with a vignette of a woman's annual examination included a question about the patient's level of colon and ovarian cancer risk. The final study sample included 1,555 physicians weighted to represent practicing U.S. physicians nationally. MAIN MEASURE: Accuracy of physicians' ovarian and colon cancer risk assessments. KEY RESULTS: Overall, most physicians accurately assessed women's risk of ovarian (57.0%, CI 54.3, 59.6) and colon cancer (62.0%, CI 59.4, 64.6). However, 27.1% (CI 23.0, 31.6) of physicians overestimated the ovarian cancer risk among women at the same risk as the general population, and 65.1% (CI 60.2, 69.7) underestimated ovarian cancer risk among women at much higher risk than the general population. Physicians overestimated colon more than ovarian cancer risk (38.0%, CI 35.4, 40.6 vs. 27.1%, CI 23.0, 31.6) for women at the same risk as the general population. CONCLUSIONS: Physicians' misestimation of patient ovarian and colon cancer risk may put average risk patients in jeopardy of unnecessary screening and higher risk patients in jeopardy of missed opportunities for prevention or early detection of cancers.

Vignette-based study of ovarian cancer screening: do U.S. physicians report adhering to evidence-based recommendations?

BACKGROUND: No professional society or group recommends routine ovarian cancer screening, yet physicians' enthusiasm for several cancer screening tests before benefit has been proven suggests that some women may be exposed to potential harms. OBJECTIVE: To provide nationally representative estimates of physicians' reported nonadherence to recommendations against ovarian cancer screening. DESIGN: Cross-sectional survey of physicians offering women's primary care. The 12-page questionnaire contained a woman's annual examination vignette and questions about offers or orders for transvaginal ultrasonography (TVU) and cancer antigen 125 (CA-125). SETTING: United States. PARTICIPANTS: 3200 physicians randomly sampled equally from the 2008 American Medical Association Physician Masterfile lists of family physicians, general internists, and obstetrician-gynecologists; 61.7% responded. After exclusions, 1088 respondents were included; their responses were weighted to represent the specialty distribution of practicing U.S. physicians nationally. MEASUREMENTS: Reported nonadherence to screening recommendations (defined as sometimes or almost always ordering screening TVU or CA-125 or both). RESULTS: Twenty-eight percent (95% CI, 24.5% to 32.9%) of physicians reported nonadherence to screening recommendations for women at low risk for ovarian cancer; 65.4% (CI, 61.1% to 69.4%) did so for women at medium risk for ovarian cancer. Six percent (CI, 4.4% to 8.9%) reported routinely ordering or offering ovarian cancer screening for low-risk women, as did 24.0% (CI, 20.5% to 28.0%) for medium-risk women (P ≤ 0.001). Thirty-three percent believed TVU or CA-125 was an effective screening test. In adjusted analysis, actual and physician-perceived patient risk, patient request for ovarian cancer screening, and physician belief that TVU or CA-125 was an effective screening test were the strongest predictors of physician-reported nonadherence to published recommendations. LIMITATION: The results are limited by their reliance on survey methods; there may be respondent-nonrespondent bias. CONCLUSION: One in 3 physicians believed that ovarian cancer screening was effective, despite evidence to the contrary. Substantial proportions of physicians reported routinely offering or ordering ovarian cancer screening, thereby exposing women to the documented risks of these tests. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention and the National Cancer Institute.

Involvement of gynecologic oncologists in the treatment of patients with a suspicious ovarian mass.

OBJECTIVE: To identify the factors associated with inclusion of a gynecologic oncologist in managing the care of a woman with suspected ovarian cancer. METHODS: A vignette-based survey was mailed to 3,200 physicians aged 64 and younger who were randomly sampled from family physician, general internist, and obstetrician-gynecologist (ob-gyn) lists from the American Medical Association Physician Masterfile. The vignette described a 57-year-old woman with pain, bloating, and a suspicious right adnexal mass with ascites. Using multivariable analysis we evaluated patient, physician, and practice characteristics associated with a self-reported referral or inclusion of a gynecologic oncologist in the patient's care. RESULTS: The response rate was 61.7%. After exclusions we included 569 ob-gyns, 591 family physicians, and 414 general internists. Gynecologic oncologist referral and consultation was self reported by 39.3% of family physicians and 51.0% of general internists (P=.01). Among ob-gyns, 33.7% indicated they would perform surgery and 66.3% recommended consultation or referral. Factors associated with not referring and consulting included patients having Medicaid insurance (family physicians), providers' weekly average number of patients being more than 91 (family physicians and general internists), male sex (family physicians), a rural practice location (general internists), and solo practice (general internists). Factors associated with primary surgical management for ob-gyns were small and remote rural practice locations and Census division. CONCLUSION: When presented with a patient with a suspicious ovarian mass, the majority of primary care physicians do not self-report direct referral to a gynecologic oncologist. This may contribute to the high rates of noncomprehensive surgery for ovarian cancer patients in the United States. LEVEL OF EVIDENCE: II.

Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians: a vignette-based study.

BACKGROUND: Genetic counseling and testing is recommended for women at high but not average risk of ovarian cancer. National estimates of physician adherence to genetic counseling and testing recommendations are lacking. METHODS: Using a vignette-based study, we surveyed 3200 United States family physicians, general internists, and obstetrician/gynecologists and received 1878 (62%) responses. The questionnaire included an annual examination vignette asking about genetic counseling and testing. The vignette varied patient age, race, insurance status, and ovarian cancer risk. Estimates of physician adherence to genetic counseling and testing recommendations were weighted to the United States primary care physician population. Multivariable logistic regression identified independent patient and physician predictors of adherence. RESULTS: For average-risk women, 71% of physicians self-reported adhering to recommendations against genetic counseling or testing. In multivariable modeling, predictors of adherence against referral/testing included black versus white race (relative risk [RR], 1.16; 95% confidence interval [CI], 1.03-1.31), Medicaid versus private insurance (RR, 1.15; 95% CI, 1.02-1.29), and rural versus urban location. Among high-risk women, 41% of physicians self-reported adhering to recommendations to refer for genetic counseling or testing. Predictors of adherence for referral/testing were younger patient age [35 vs 51 years [RR, 1.78; 95% CI, 1.41-2.24]), physician sex (female vs male [RR, 1.30; 95% CI, 1.07-1.64]), and obstetrician/gynecologist versus family medicine specialty (RR, 1.64; 95% CI, 1.31-2.05). For both average-risk and high-risk women, physician-estimated ovarian cancer risk was the most powerful predictor of recommendation adherence. CONCLUSION: Physicians reported that they would refer many average-risk women and would not refer many high-risk women for genetic counseling/testing. Intervention efforts, including promotion of accurate risk assessment, are needed.

How are symptoms of ovarian cancer managed? A study of primary care physicians.

BACKGROUND: A study was undertaken to identify the diagnostic approaches that primary care physicians and gynecologists undertake in women with symptoms associated with ovarian cancer. METHODS: A vignette-based survey was mailed to 3200 primary care physicians from the American Medical Association Physician Masterfile. The vignette described a 55-year-old woman with symptoms associated with ovarian cancer, although ovarian cancer was never mentioned. The authors evaluated patient, physician, and practice characteristics associated with a workup that could detect ovarian cancer. RESULTS: The survey response rate was 61.7%. After exclusions, 1532 physicians were included. Overall, 89.5% of physicians reported that they would recommend testing that can detect ovarian cancer (71.2% ultrasound; 25.4% pelvic computed tomography; 26.5% CA125). In adjusted analysis, the only patient factor associated with ovarian cancer testing was symptom type, genitourinary versus gastrointestinal (risk ratio, 1.07; 95% confidence interval, 1.03-1.11). Physician and practice characteristics associated with recommending of ovarian cancer testing included specialty (gynecologists > family physicians and internists); type of practice (group > solo); clinical teaching (yes > no); and within Census division, location of practice, with all Central (East, West, North, and South) and Atlantic (Middle and South) areas having a lower likelihood than New England. CONCLUSIONS: On the basis of a vignette in which a woman reported symptoms associated with ovarian cancer, the majority of primary care physicians and gynecologists would not recommend CA125, but would recommend imaging of the pelvis. Gynecologists, physicians involved with clinical teaching, and those in group practices were significantly more likely to recommend testing that could lead to an ovarian cancer diagnosis.

Access to cancer services for rural colorectal cancer patients.

CONTEXT: Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. PURPOSE: To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services--surgery, medical oncology consultation, and radiation oncology consultation. METHODS: Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996. FINDINGS: Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles. CONCLUSIONS: Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

Residual treatment disparities after oncology referral for rectal cancer.

BACKGROUND: Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists. METHODS: We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided. RESULTS: There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy. CONCLUSION: Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Does surgeon case volume influence nonfatal adverse outcomes after rectal cancer resection?

BACKGROUND: The aim of this study was to assess the relationship between surgeon and hospital volume and major postoperative complications after rectal cancer surgery, and to define other surgeon and hospital characteristics that may explain observed volume-complication relationships. STUDY DESIGN: This was a retrospective cohort design using data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry program for individuals with stage I to III rectal cancer diagnosed between 1992 and 1999 and treated with resection. The patients' Surveillance, Epidemiology, and End Results data were linked with Medicare claims data from 1991 to 2000. The primary outcomes were 30-day postoperative procedural interventions (PPI) to treat surgical complications, such as reoperation. The association between surgeon volume and PPI was examined using logistic regression modeling with adjustment for covariates. RESULTS: The odds of a rectal cancer patient requiring a PPI is notably less if the operation is performed by one of a small subset of very high volume surgeons (unadjusted odds ratio 0.53; 95% CI 0.31 to 0.92). Board certification in colorectal surgery did not alter the relationship between surgeon volume and PPI, although surgeon age did, with mid-career surgeons having the lowest rates of PPI, regardless of practice volume. When adjusted for surgeon age, surgeon volume is no longer a marked predictor of complications (adjusted odds ratio 0.57; 95% CI 0.30 to 1.09). CONCLUSIONS: Overall, rectal cancer operations are safe, with a low frequency of severe complications. A subset of very high volume rectal surgeons performs these operations with fewer complications that require procedural intervention or reoperation. Surgeon age, as an indicator of experience, also contributes modestly to outcomes. These data do not justify regionalizing rectal cancer care based on safety concerns.

Survival benefits and trends in use of adjuvant therapy among elderly stage II and III rectal cancer patients in the general population.

BACKGROUND: This study examined elderly stage II and III rectal cancer patients' adjuvant chemoradiation therapy adherence, trends in adherence over time, and the relation of levels of adherence to mortality. METHODS: The authors studied 2886 stage II and III rectal cancer patients who had surgical resection and who appeared in 1992-1999 linked SEER-Medicare claims data. The authors compared measures of adjuvant radiation and chemotherapy receipt and completion between stage II and III patients. Adjusted risk of cancer-related 5-year mortality was calculated by multivariate logistic regression for different levels of chemoradiation adherence among stage II and III patients. RESULTS: Of the 2886 patients, 45.4% received both adjuvant radiation and chemotherapy. Stage III patients were more likely to receive chemoradiation than stage II patients. The receipt of chemoradiation by stage II patients increased significantly from 1992 to 1999. Stage III patients were more likely to complete radiation therapy (96.6%), chemotherapy (68.2%), and both modalities (67.5%) than stage II patients (91.5%, 49.8%, 47.6%, respectively). Only a complete course of both radiation and chemotherapy for both stage II (relative risk [RR] 0.74; 95% CI, 0.54, 0.97) and III (RR 0.80; 95% CI, 0.65, 0.96) decreased the adjusted 5-year cancer mortality risk compared with counterparts with no adjuvant therapy. CONCLUSIONS: Even though stage II rectal cancer patients were less likely than stage III patients to receive and complete adjuvant chemoradiation, both patient groups in the general population had lower cancer-related mortality if they completed chemoradiation. These patients deserve support and encouragement to complete treatment.

Predictors of comprehensive surgical treatment in patients with ovarian cancer.

BACKGROUND: Providing appropriate surgical treatment for women with ovarian cancer is one of the most effective ways to improve ovarian cancer outcomes. In this study, the authors identified factors that were associated with a measure of comprehensive surgery, so that interventions may be targeted appropriately to improve surgical care. METHODS: Using Healthcare Cost and Utilization Project hospital discharge data from 1999 to 2002 for 9 states, the authors identified 10,432 admissions of women who had an International Classification of Disease, 9th Revision (ICD-9) primary diagnosis of ovarian cancer and who had undergone oophorectomy. Based on National Institutes of Health Consensus Panel recommendations, surgeries were categorized as comprehensive by using ICD-9 diagnosis and procedure codes. Logistic regression analysis using data from 5 states with a full set of variables (n = 6854 patients)was used to identify factors that were associated with the receipt of comprehensive surgical care. RESULTS: Overall, 66.9% of admissions (range, 46.3-80.8% of admissions) received comprehensive surgery. Factors that were associated independently with comprehensive surgical care included age (ages 21-50 years vs ages 71-80 years or > or = 81 years), race (Caucasian vs African American or Hispanic), payer (private insurance vs Medicaid), cancer stage (advanced vs early), annual surgeon volume (low/medium [2-9 surgeries per year] or high [>10 surgeries per year] vs very low [1 surgery per year]), and surgeon specialty (gynecologic oncologists vs obstetrician gynecologists or general surgeons). Among nonteaching hospitals, medium-volume hospitals (10-19 ovarian cancer surgeries per year) and high-volume hospitals (> or = 20 surgeries per year) had significantly higher comprehensive surgery rates than low-volume facilities (1-9 surgeries per year). Volume did not influence comprehensive surgery rates in teaching hospitals. CONCLUSIONS: Many women with ovarian cancer, especially those in poor, elderly, or minority groups, are not receiving recommended comprehensive surgery. Efforts should be made to ensure that all women with ovarian cancer, especially those in vulnerable populations, have the opportunity to receive care from centers or surgeons with higher comprehensive surgery rates.

Surgeon and hospital characteristics as predictors of major adverse outcomes following colon cancer surgery: understanding the volume-outcome relationship.

HYPOTHESIS: Although numerous studies have demonstrated an association between surgical volume and improved outcome in cancer surgery, the specific structures and mechanisms of care that are associated with volume and lead to improved outcomes remain poorly defined. We hypothesize that there are modifiable surgeon and hospital characteristics that explain observed volume-outcome relationships. DESIGN: Retrospective cohort study. SETTING: Surveillance, Epidemiology, and End Results cancer registry areas. PATIENTS: Patients aged 66 years and older, diagnosed and surgically treated for stage I, II, or III colon cancer between 1992 and 1996 (n = 22 672). MAIN OUTCOME MEASURES: Thirty-day postoperative mortality and 30-day postoperative procedural interventions, including reoperation and image-guided percutaneous procedures. RESULTS: Surgeon volume, but not hospital volume, is a significant predictor of postoperative procedural intervention (adjusted odds ratio for very high-volume surgeons vs low-volume surgeons, 0.79; 95% confidence interval, 0.64-0.98). In the unadjusted analyses, high hospital volume (odds ratio, 0.67; 95% confidence interval, 0.56-0.81) and very high hospital volume (odds ratio, 0.65; 95% confidence interval, 0.54-0.79) is associated with lower postoperative mortality. Postoperative procedural intervention is not a significant mediator of the relationship between hospital volume and mortality. A single variable-the presence of sophisticated clinical services-was the most important explanatory variable underlying the relationship between hospital volume and mortality. CONCLUSIONS: Very high surgeon volume is associated with a reduction in surgical complications. However, the association between increasing hospital volume and postoperative mortality appears to derive mainly from a full spectrum of clinical services that may facilitate the prompt recognition and treatment of complications.

Reoperation as a quality indicator in colorectal surgery: a population-based analysis.

OBJECTIVE: To describe unplanned procedures following colorectal cancer surgery that might be used as intermediate outcome measures, and to determine their association with mortality and length of stay. SUMMARY BACKGROUND: Variation in the quality of surgical care, especially for common illnesses like colorectal cancer, has received increasing attention. Nonfatal complications resulting in procedural interventions are likely to play a role in poor outcomes but have not been well explored. METHODS: Cohort analysis of 26,638 stage I to III colorectal cancer patients in the 1992 to 1996 SEER-Medicare database. INDEPENDENT VARIABLES: sociodemographics, tumor characteristics, comorbidity, and acuity. PRIMARY OUTCOME: postoperative procedural intervention. ANALYSIS: Logistic regression identified patient characteristics predicting postoperative procedures and the adjusted risk of 30-day mortality and prolonged hospitalization among patients with postoperative procedures. RESULTS: A total of 5.8% of patients required postoperative intervention. Patient characteristics had little impact on the frequency of postoperative procedures, except for acute medical conditions, including bowel perforation (relative risk [RR] = 3.0, 95% confidence interval [CI] = 2.5-3.6), obstruction (RR = 1.6; 95% CI = 1.4-1.8), and emergent admission (RR = 1.3; 95% CI = 1.1-1.4). After a postoperative procedure, patients were more likely to experience early mortality (RR = 2.4; 95% CI = 2.1-2.9) and prolonged hospitalization (RR = 2.2; 95% CI = 2.1-2.4). The most common interventions were performed for abdominal infection (31.7%; RR mortality = 2.9; 95% CI = 2.3-3.7), wound complications (21.1%; RR mortality = 0.7; 95% CI = 0.4-1.3), and organ injury (18.7%; RR mortality = 1.6; 95% CI = 1.1-2.3). CONCLUSIONS: Postoperative complications requiring additional procedures among colorectal cancer patients correlate with established measures of surgical quality. Prospective tracking of postoperative procedures as complication markers may facilitate outcome studies and quality improvement programs.

Ovarian cancer: patterns of surgical care across the United States.

OBJECTIVE: To describe the primary surgical procedures and procedures for intraoperative and postoperative complications, and factors associated with these procedures, in women with ovarian cancer. METHODS: Using hospital discharge data from nine states, obtained from the Heath Care Cost and Utilization Project from 1999 to 2002, we evaluated 10,432 women with a primary diagnosis of ovarian cancer who underwent at least an oophorectomy for additional procedural ICD-9 codes during their initial hospitalization. RESULTS: Surgical procedures performed in addition to oophorectomy included: omentectomy/debulking 81.9%, hysterectomy 73.4%, lymph node dissection 41.4%, appendectomy 23.8%, bowel procedures 19.8%, laparoscopy 5.6%, diaphragmatic procedures 4.9%, colostomy 3.5%, and splenectomy 1.2%. Transfusions were given to 15.5% of patients. Intraoperative and postoperative procedures for complications were coded in 7.4% of patients, including repair of surgical injury 3.5%, procedures for cardiopulmonary complications 2.8%, reoperation 1.1%, and infection treatment 0.3%. In early stage disease 21.4% of women received no additional staging procedures and 46.8% did not have nodal sampling. In bivariate analysis of crude rates, factors associated with lymph node dissection were patient age, race, payer, teaching hospital status, hospital and surgeon volume, and surgeon specialty, p<.01. for all observations. Colostomies were performed by general surgeons in 23.1% of cases, by gynecologic oncologists in 2.7% of cases, and by obstetrician/gynecologists in no cases, p<.001. Complications were associated with age, payer, median household income, and stage, p<.001 for all observations. Complication rates were similar for low- and high-volume hospitals and surgeons. However, in higher volume settings, significantly more patients received debulking procedures, lymph node dissections, and additional surgical procedures, p<.001 for all observations. CONCLUSIONS: A significant percentage of women with ovarian cancer did not receive recommended surgical procedures. Almost 50% of women with early stage disease were not adequately staged and in women with advanced disease, the percentage who had additional surgical procedures such as bowel resections was much lower than in institutions that report high optimal cytoreduction rates.

Completion of therapy by Medicare patients with stage III colon cancer.

BACKGROUND: Certain factors, such as race or age, are known to be associated with variation in initiation of adjuvant chemotherapy for stage III colon cancer, but little is known about what factors are associated with completion of adjuvant therapy. To determine whether predictors of initiation also predict completion, we analyzed Surveillance, Epidemiology, and End Results (SEER) program data linked to Medicare claims. We investigated mortality as a means to testing the validity of the completion measure that we created. METHODS: We studied 3193 stage III colon cancer patients whose diagnosis was recorded in 1992-1996 SEER program data linked to 1991-1998 Medicare claims and who initiated adjuvant chemotherapy after colon cancer resection. We defined a measure of adjuvant chemotherapy completion as one chemotherapy administration claim in a month. We tested the validity of the created measure and its relation to 3-year cancer mortality adjusted for demographic, clinical, and environmental variables. We explored the association of patient characteristics and treating physician characteristics with chemotherapy completion by use of multivariable logistic regression modeling. RESULTS: Of the 3193 patients, 2497 (78.2%) completed the course. Risk of cancer-related mortality was statistically significantly lower among those completing chemotherapy (relative risk = 0.79, 95% confidence interval = 0.69 to 0.89) than those with no adjuvant therapy. Patients who were female, widowed, increasingly elderly, rehospitalized, and living in certain regions were less likely to complete adjuvant chemotherapy than other patients. Race and other clinical, environmental, and physician characteristics were not associated with completion of therapy. CONCLUSIONS: Factors associated with incomplete adjuvant chemotherapy may represent physical frailty, treatment complications, and lack of social and psychological support. Interventions to mitigate these influences are a logical next step toward increasing chemotherapy completion rates.

Autologous stem-cell transplantation can be performed safely without the use of blood-product support.

PURPOSE: Autologous stem-cell transplantation has been shown to be a curative procedure for a variety of leukemias and lymphomas. Most transplants require RBC and platelet support. We report the ability to perform autologous transplantation without blood-product support. SUBJECTS AND METHODS: In this study, we treated 26 patients with religious objection to blood products with autologous stem-cell support without the use of any blood products. Patients received a combination of granulocyte colony-stimulating factor (G-CSF), erythropoietin, and interleukin-11 or G-CSF alone to mobilize stem cells. Post-transplant patients received intravenous iron, erythropoietin, G-CSF, and epsilon aminocaproic acid. RESULTS: There were two major bleeding complications (8%), with two treatment-related deaths (8%). There were three minor bleeding complications (12%). The median fall in hemoglobin level was 4.7 g/dL; the median hemoglobin level 30 days after transplantation was 9.2 g/dL. The median total number of days with platelet count less than 10 x 10(9)/L was 4 days; the median days to platelet recovery greater than 20 x 10(9)/L was 12 days. CONCLUSION: Autologous stem-cell transplantation can be performed safely without the use of any blood products.