Examining colorectal cancer survivors' surveillance patterns and experiences of care: a SEER-CAHPS study.

PURPOSE: We examined associations between experiences of care and adherence to surveillance guidelines among Medicare Fee-For-Service beneficiaries with colorectal cancer (CRC). METHODS: Using linked data from the National Cancer Institute's Surveillance, Epidemiology, and End results (SEER) cancer registry program and the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient experience surveys (SEER-CAHPS), we identified local/regional CRC survivors diagnosed in 1999-2009 aged 65+, who underwent surgical resection and completed a CAHPS survey <36 months of diagnosis. Adherence for a 3-year observation period was defined as receiving a colonoscopy; ≥2 carcinoembryonic antigen (CEA) tests; and each year had ≥2 office visits and ≥1 computerized tomography test. RESULTS: Many of the 314 participants reported ratings of a 9 or 10 out of 10 for overall care (55.4%), personal doctor (58.6%), health plan (59.6%), and specialist doctor (47.0%). Adherence to post-resection surveillance was 76.1% for office visits, 36.9% for CEA testing, 48.1% for colonoscopy, and 10.3% for CT Imaging. Overall, 37.9% of the sample were categorized as non-adherent (adhering to ≤1 surveillance guideline). In multivariable models, ratings of personal doctor and specialist doctor were positively associated with adherence to office visits, and ratings of personal doctor were associated with adherence overall. CONCLUSIONS: Findings point to the potentially important role of patient-provider relationships in adherence to office visits for CRC surveillance. As adherence may increase survival among CRC survivors, further investigation is needed to identify specific components of this relationship that impact office visit adherence, and other potentially modifiable drivers of surveillance guidelines.

Unveiling SEER-CAHPS®: a new data resource for quality of care research.

BACKGROUND: Since 1990, the National Cancer Institute (NCI) and Centers for Medicare and Medicaid Services (CMS) have collaborated to create linked data resources to improve our understanding of patterns of care, health care costs, and trends in utilization. However, existing data linkages have not included measures of patient experiences with care. OBJECTIVE: To describe a new resource for quality of care research based on a linkage between the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient surveys and the NCI's Surveillance, Epidemiology and End Results (SEER) data. DESIGN: This is an observational study of CAHPS respondents and includes both fee-for-service and Medicare Advantage beneficiaries with and without cancer. The data linkage includes: CAHPS survey data collected between 1998 and 2010 to assess patient reports on multiple aspects of their care, such as access to needed and timely care, doctor communication, as well as patients' global ratings of their personal doctor, specialists, overall health care, and their health plan; SEER registry data (1973-2007) on cancer site, stage, treatment, death information, and patient demographics; and longitudinal Medicare claims data (2002-2011) for fee-for-service beneficiaries on utilization and costs of care. PARTICIPANTS: In total, 150,750 respondents were in the cancer cohort and 571,318 were in the non-cancer cohort. MAIN MEASURES: The data linkage includes SEER data on cancer site, stage, treatment, death information, and patient demographics, in addition to longitudinal data from Medicare claims and information on patient experiences from CAHPS surveys. KEY RESULTS: Sizable proportions of cases from common cancers (e.g., breast, colorectal, prostate) and short-term survival cancers (e.g., pancreas) by time since diagnosis enable comparisons across the cancer care trajectory by MA vs. FFS coverage. CONCLUSIONS: SEER-CAHPS is a valuable resource for information about Medicare beneficiaries' experiences of care across different diagnoses and treatment modalities, and enables comparisons by type of insurance.

31-Gene Expression Profile Testing in Cutaneous Melanoma and Survival Outcomes in a Population-Based Analysis: A SEER Collaboration.

PURPOSE: The DecisionDx-Melanoma 31-gene expression profile (31-GEP) test is validated to classify cutaneous malignant melanoma (CM) patient risk of recurrence, metastasis, or death as low (class 1A), intermediate (class 1B/2A), or high (class 2B). This study aimed to examine the effect of 31-GEP testing on survival outcomes and confirm the prognostic ability of the 31-GEP at the population level. METHODS: Patients with stage I-III CM with a clinical 31-GEP result between 2016 and 2018 were linked to data from 17 SEER registries (n = 4,687) following registries' operation procedures for linkages. Melanoma-specific survival (MSS) and overall survival (OS) differences by 31-GEP risk category were examined using Kaplan-Meier analysis and the log-rank test. Crude and adjusted hazard ratios (HRs) were calculated using Cox regression model to evaluate variables associated with survival. 31-GEP tested patients were propensity score-matched to a cohort of non-31-GEP tested patients from the SEER database. Robustness of the effect of 31-GEP testing was assessed using resampling. RESULTS: Patients with a 31-GEP class 1A result had higher 3-year MSS and OS than patients with a class 1B/2A or class 2B result (MSS: 99.7% v 97.1% v 89.6%, P < .001; OS: 96.6% v 90.2% v 79.4%, P < .001). A class 2B result was an independent predictor of MSS (HR, 7.00; 95% CI, 2.70 to 18.00) and OS (HR, 2.39; 95% CI, 1.54 to 3.70). 31-GEP testing was associated with a 29% lower MSS mortality (HR, 0.71; 95% CI, 0.53 to 0.94) and 17% lower overall mortality (HR, 0.83; 95% CI, 0.70 to 0.99) relative to untested patients. CONCLUSION: In a population-based, clinically tested melanoma cohort, the 31-GEP stratified patients by their risk of dying from melanoma.

Use of the Decipher genomic classifier among men with prostate cancer in the United States.

BACKGROUND: Management of localized or recurrent prostate cancer since the 1990s has been based on risk stratification using clinicopathological variables, including Gleason score, T stage (based on digital rectal exam), and prostate-specific antigen (PSA). In this study a novel prognostic test, the Decipher Prostate Genomic Classifier (GC), was used to stratify risk of prostate cancer progression in a US national database of men with prostate cancer. METHODS: Records of prostate cancer cases from participating SEER (Surveillance, Epidemiology, and End Results) program registries, diagnosed during the period from 2010 through 2018, were linked to records of testing with the GC prognostic test. Multivariable analysis was used to quantify the association between GC scores or risk groups and use of definitive local therapy after diagnosis in the GC biopsy-tested cohort and postoperative radiotherapy in the GC-tested cohort as well as adverse pathological findings after prostatectomy. RESULTS: A total of 572 545 patients were included in the analysis, of whom 8927 patients underwent GC testing. GC biopsy-tested patients were more likely to undergo active active surveillance or watchful waiting than untested patients (odds ratio [OR] =2.21, 95% confidence interval [CI] = 2.04 to 2.38, P < .001). The highest use of active surveillance or watchful waiting was for patients with a low-risk GC classification (41%) compared with those with an intermediate- (27%) or high-risk (11%) GC classification (P < .001). Among National Comprehensive Cancer Network patients with low and favorable-intermediate risk, higher GC risk class was associated with greater use of local therapy (OR = 4.79, 95% CI = 3.51 to 6.55, P < .001). Within this subset of patients who were subsequently treated with prostatectomy, high GC risk was associated with harboring adverse pathological findings (OR = 2.94, 95% CI = 1.38 to 6.27, P = .005). Use of radiation after prostatectomy was statistically significantly associated with higher GC risk groups (OR = 2.69, 95% CI = 1.89 to 3.84). CONCLUSIONS: There is a strong association between use of the biopsy GC test and likelihood of conservative management. Higher genomic classifier scores are associated with higher rates of adverse pathology at time of surgery and greater use of postoperative radiotherapy.In this study the Decipher Prostate Genomic Classifier (GC) was used to analyze a US national database of men with prostate cancer. Use of the GC was associated with conservative management (ie, active surveillance). Among men who had high-risk GC scores and then had surgery, there was a 3-fold higher chance of having worrisome findings in surgical specimens.

Erratum: Author Correction: Breast-cancer-specific mortality in patients treated based on the 21-gene assay: a SEER population-based study.

[This corrects the article DOI: 10.1038/npjbcancer.2016.17.].

Medical Record-Documented TNM Categories and Stage Group: Feasibility of Use for Cancer Surveillance.

BACKGROUND AND OBJECTIVES: In 2016, with the discontinuation of the Collaborative Staging system, the cancer surveillance community planned to rely on physician-assigned TNM stage documented in the medical record. The objectives of this study were to describe how often physician-assigned staging components were documented in the medical records accessible to the registrar and to assess the agreement of these physician-assigned components with registrar-assigned values. METHODS: Medical record documents for 282 routine cases from 5 cancer sites were selected from the Surveillance, Epidemiology, and End Results registries. First, the documents were evaluated to determine how often they contained the TNM staging components. Next, the available components were compared with values assigned by a panel of experienced cancer registrars. The agreement for each type of source document was estimated among 100 cases. RESULTS: Overall, the physician-assigned TNM components and stage groups were not often found in the medical record. Pathologic T and N were found most frequently (65% and 64%, respectively). Agreement between physician-assigned and registrar-assigned TNM components varied (cT = 57%, cN = 72%, pT = 83%, pN = 89%). For stage group, agreement was better when the stage group was documented more than once (clinical, 71%; pathologic, 67%). Path reports included valid pT and pN in 79% and 89% of cases, respectively. Oncology consultation notes provided valid cT for 83% of cases. Validity was lower for other document sources. CONCLUSIONS: The physician-assigned TNM components will rarely be documented in the medical record and available to the registrar. Collection of accurate stage information for cancer surveillance requires cancer registrars to review the full medical record and assign the TNM components required for stage.

Breast-cancer-specific mortality in patients treated based on the 21-gene assay: a SEER population-based study.

The 21-gene Recurrence Score assay is validated to predict recurrence risk and chemotherapy benefit in hormone-receptor-positive (HR+) invasive breast cancer. To determine prospective breast-cancer-specific mortality (BCSM) outcomes by baseline Recurrence Score results and clinical covariates, the National Cancer Institute collaborated with Genomic Health and 14 population-based registries in the the Surveillance, Epidemiology, and End Results (SEER) Program to electronically supplement cancer surveillance data with Recurrence Score results. The prespecified primary analysis cohort was 40-84 years of age, and had node-negative, HR+, HER2-negative, nonmetastatic disease diagnosed between January 2004 and December 2011 in the entire SEER population, and Recurrence Score results (N=38,568). Unadjusted 5-year BCSM were 0.4% (n=21,023; 95% confidence interval (CI), 0.3-0.6%), 1.4% (n=14,494; 95% CI, 1.1-1.7%), and 4.4% (n=3,051; 95% CI, 3.4-5.6%) for Recurrence Score <18, 18-30, and ⩾31 groups, respectively (P<0.001). In multivariable analysis adjusted for age, tumor size, grade, and race, the Recurrence Score result predicted BCSM (P<0.001). Among patients with node-positive disease (micrometastases and up to three positive nodes; N=4,691), 5-year BCSM (unadjusted) was 1.0% (n=2,694; 95% CI, 0.5-2.0%), 2.3% (n=1,669; 95% CI, 1.3-4.1%), and 14.3% (n=328; 95% CI, 8.4-23.8%) for Recurrence Score <18, 18-30, ⩾31 groups, respectively (P<0.001). Five-year BCSM by Recurrence Score group are reported for important patient subgroups, including age, race, tumor size, grade, and socioeconomic status. This SEER study represents the largest report of prospective BCSM outcomes based on Recurrence Score results for patients with HR+, HER2-negative, node-negative, or node-positive breast cancer, including subgroups often under-represented in clinical trials.

Costs of treatment for elderly women with early-stage breast cancer in fee-for-service settings.

PURPOSE: This study provides population-based estimates of the treatment costs for elderly women with early-stage breast cancer, with emphasis on costs of modified radical mastectomy (MRM) compared with breast-conserving surgery (BCS) and radiation therapy (RT). PATIENTS AND METHODS: Women with breast cancer from the Surveillance, Epidemiology, and End Results cancer registries were linked with their Medicare claims, 1990 through 1998. Each claim was assigned to an initial, continuing, or terminal care phase after a cancer diagnosis. Mean monthly phase-specific costs were determined for all health care and for treatment related only to cancer. Cumulative long-term costs of care that accrue during a women's remaining lifetime were calculated by treatment group. RESULTS: Initial care costs for the 6 months after diagnosis for women who underwent BCS with RT were approximately $450 per month higher than for women with MRM. During the continuing-care phase, costs for women undergoing BCS with RT were significantly less expensive than for MRM cases. The two groups had similar costs in the terminal-care phase. Assuming the same survival distributions, long-term costs for women undergoing BCS with RT were not statistically different than for women undergoing MRM. CONCLUSION: Although mastectomy was less costly in the initial phase, the lifetime costs of BCS with RT and mastectomy were equivalent. Thus, women's preferences, resources to cover out-of-pocket costs, and life situations should be the major factors addressed in shared decision making about treatment options.

Availability of TNM Staging Data Elements in the Medical Record and Training Needs Assessment: Results from the 2014 SEER Training Needs Assessment for TNM Study.

BACKGROUND: In 2016, the cancer registry community will directly assign T, N and M components of stage. The Surveillance, Epidemiology, and End Results program implemented a field study to determine how often T, N and M were not available in the medical record, requiring the registrar to directly assign clinical or pathologic TNM stage components. The field study also identified specific training needs. METHODS: T, N and M status were collected from multiple sources within medical records for a total of 280 cases, 56 each from breast, prostate, colon, lung, and ovarian cancer. TNM data elements were also directly assigned by a series of reviewers and by study participants using the medical records with TNM information redacted. Availability of physician-assigned TNM was estimated from the medical record. Also, participant responses were compared to preferred answers. RESULTS: Pathologic T, N and M were available more often in the medical records than were clinical values and varied by site. Pathologic T and N were available for about two-thirds of the cases, but the clinical elements were available for only about 20% of cases. The agreement between participant responses and review panel assignments varied by data element and cancer site. Agreement was modest for most data elements and cancer sites, ranging from 54% for clinical T to 92% for clinical M for all cancer sites combined. CONCLUSIONS: The data elements for TNM staging and stage group were often missing from the medical records, so registrars in the field will need to assign TNM frequently. Furthermore, the results of this study strongly suggest that more training is required, even among those who currently assign TNM.

Patient demographic and socioeconomic characteristics in the SEER-Medicare database applications and limitations.

Users of the linked SEER-Medicare database commonly perform analyses that focus on the complex interactions among patient characteristics, cancer treatments, and outcomes. The authors review the source and scope of the patient-specific data elements, with a focus on three domains--demographic characteristics, socioeconomic characteristics, and survival status. They offer some concrete recommendations regarding the use of these data elements. In particular, they describe analyses that provide an estimate of the accuracy of the sex and age variables, and raise some cautionary notes about race and ethnicity variables. The authors describe the available measures of socioeconomic status, and recommend, with some caveats, the use of median income measures as a proxy for socioeconomic status. Finally, they describe the available data on date of death, and explain why confidence in these measures is justified.

Measuring breast, colorectal, and prostate cancer screening with medicare claims data.

BACKGROUND: Evaluating the use and effectiveness of cancer screening is an important component of cancer control programs. Medicare claims may be a useful source of data when screening older populations, but they are limited in terms of completeness and the ability to distinguish screening tests from those provided for diagnosis or surveillance. RESEARCH DESIGN: A review of the major screening modalities for breast, colorectal, and prostate cancer, Medicare's policies for covering these tests, and the procedure codes used to identify them in Medicare claims. RESULTS: Although Medicare's coverage has been extended to include screening mammography, colonoscopy, sigmoidoscopy, fecal occult blood tests, double-contrast barium enema, and prostate-specific antigen tests, providers have been slow to adopt the corresponding screening codes. CONCLUSION: Challenges persist in measuring screening use, and innovative approaches are required to distinguish screening tests from diagnostic and follow-up evaluations.

Use of SEER-Medicare data for measuring cancer surgery.

BACKGROUND: The accuracy and completeness of the SEER-Medicare data for measuring cancer-related therapy have not been extensively evaluated. OBJECTIVES: To investigate the best method for measuring cancer-related surgery among patients in the SEER-Medicare database. SUBJECTS: A total of 149,970 incident cases of breast, colorectal, endometrial, lung, pancreatic, and prostate cancer diagnosed between 1991 and 1993.MEASURES The most invasive surgical procedure identified through Medicare's inpatient, physician, and hospital outpatient claims was compared with corresponding data from the SEER files. RESULTS: Agreement between the SEER and Medicare files was generally highest for resection and radical surgery (eg, kappa 0.70-0.90). While there was less agreement regarding no surgical therapy and biopsy individually, the concordance of the two sources in excluding cancer-directed surgery was high. Compared with inpatient data alone, using the combined inpatient, physician, and outpatient data increased concordance between SEER and Medicare for less invasive procedures. CONCLUSIONS: The agreement of SEER and Medicare data appears to be good for major surgical procedures and for excluding persons who did not undergo cancer-directed surgery. Both the SEER and the Medicare data captured a small number of surgeries not reported in the other file. Therefore, where possible, using both data sources will enhance identification of surgeries. Because the analysis was performed with linked data, the accuracy of surgical claims in Medicare data alone cannot be assessed.

Studying radiation therapy using SEER-Medicare-linked data.

BACKGROUND: Numerous studies have used the SEER or Medicare data to assess the use of radiation therapy. However, the completeness of these data has not been evaluated. METHODS: Using linked SEER-Medicare data, a cohort was created that included incident cases of breast, endometrial, lung, prostate, or rectal cancer from 1991 to 1996 in persons 65 years and older. For each of these cases, use of radiation therapy as an initial course of treatment reported from the SEER data was compared with use of radiation therapy in the months following diagnosis, as determined from the Medicare claims. RESULTS: Overall, there was a high agreement between SEER and Medicare sources for use of radiation therapy. Agreement was 88% for lung cancer, 93% for prostate cancer, 94% for rectal and breast cancers, and 95% for endometrial cancer. Within the Medicare files, radiation claims were found in MedPAR Physician Supplier Part B and Outpatient files. CONCLUSIONS: There is a high level of agreement between SEER and Medicare reporting of radiation treatments after a cancer diagnosis, suggesting that either source can be used to assess radiation-related treatment patterns. However, for the most complete ascertainment of radiation use, both SEER and Medicare sources should be used.