Developing an algorithm across integrated healthcare systems to identify a history of cancer using electronic medical records.

OBJECTIVE: Tumor registries in integrated healthcare systems (IHCS) have high precision for identifying incident cancer but often miss recently diagnosed cancers or those diagnosed outside of the IHCS. We developed an algorithm using the electronic medical record (EMR) to identify people with a history of cancer not captured in the tumor registry to identify adults, aged 40-65 years, with no history of cancer. MATERIALS AND METHODS: The algorithm was developed at Kaiser Permanente Colorado, and then applied to 7 other IHCS. We included tumor registry data, diagnosis and procedure codes, chemotherapy files, oncology encounters, and revenue data to develop the algorithm. Each IHCS adapted the algorithm to their EMR data and calculated sensitivity and specificity to evaluate the algorithm's performance after iterative chart review. RESULTS: We included data from over 1.26 million eligible people across 8 IHCS; 55 601 (4.4%) were in a tumor registry, and 44848 (3.5%) had a reported cancer not captured in a registry. The common attributes of the final algorithm at each site were diagnosis and procedure codes. The sensitivity of the algorithm at each IHCS was 90.65%-100%, and the specificity was 87.91%-100%. DISCUSSION: Relying only on tumor registry data would miss nearly half of the identified cancers. Our algorithm was robust and required only minor modifications to adapt to other EMR systems. CONCLUSION: This algorithm can identify cancer cases regardless of when the diagnosis occurred and may be useful for a variety of research applications or quality improvement projects around cancer care.

Prostate-specific antigen testing after the US Preventive Services Task Force recommendation: a population-based analysis of electronic health data.

PURPOSE: This study describes longitudinal trends in the use of prostate-specific antigen (PSA)-based testing in two geographically distinct healthcare systems following the 2011 US Preventive Services Task Force (USPSTF) recommendations against routine PSA screening. METHODS: We analyzed population-based health claims data from 253,139 men aged 40-80 who were enrolled at two US healthcare systems. We assessed trends in the percentage of eligible men receiving ≥ 1 PSA test per year by time period (2000-2008, 2009-2011, 2012-2014), age (40-54, 55-69, 70-80), and race (white, black, other, unknown), and conducted a joinpoint regression analysis. RESULTS: Men aged 55-69 and 70-80 years of all races had similar use of PSA testing between 2000 and 2011, ranging between 47 and 56% of eligible men by year, while only 22-26% of men aged 40-54 had a PSA test per year during this period. Overall, the percentage of men receiving at least one PSA test per year decreased by 26% between 2009-2011 and 2012-2014, with similar trends across race and age groups. PSA testing declined significantly after 2011 (annual percent change = - 11.28). CONCLUSIONS: Following the 2011 USPSTF recommendations against routine PSA screening, declines in PSA testing were observed among men of all races and across all age groups in two large US healthcare systems.

Epidemiology of Skin Diseases in a Diverse Patient Population.

BACKGROUND: Epidemiologic studies of patients who present to dermatology clinics are necessary to identify the needs of patients. OBJECTIVE: To quantify and compare diagnoses according to race, ethnicity, and socioeconomic status (SES) at 6 general dermatology clinics from January 2013 to December 2016. METHODS: A retrospective cohort of new patients was established using an electronic medical record database. Primary diagnoses and diagnostic codes were recorded. Geocoding was utilized to obtain SES. RESULTS: There were 65969 new patient visits. Racial and ethnic demographics were obtained with the overall top 3 conditions being eczema or dermatitis, benign skin neoplasm, and adnexal disease. In blacks, however, follicular disorders were the third most common condition seen. The most frequently encountered diagnoses at the clinics with the highest and lowest SES were benign skin neoplasm and eczema or dermatitis, respectively. LIMITATIONS: Only primary diagnoses were included in analysis. Determining one's race is increasingly difficult. CONCLUSION: Follicular disorders occurred with an increased frequency in blacks. When examining SES, eczema or dermatitis was the most frequently encountered primary diagnosis at the clinic with the lowest SES, with benign skin neoplasm seen with the highest frequency at the clinic with the highest SES. J Drugs Dermatol. 2018;17(10):1032-1036.

Squamous cell carcinoma originating from cutaneous cysts: The Henry Ford Experience and review of the literature.

PURPOSE: Malignant transformation to squamous cell carcinoma (SCC) arising within cutaneous epidermal cysts is a very rare phenomenon. We provide a series of new cases and an overview of the literature. We sought to define the prevalence of and characterize SCC arising within epidermal and pilar cysts. PATIENT AND METHODS: We searched Henry Ford Health System (HFHS) non-melanoma skin cancer (NMSC) registry from 2005 to 2009 to identify cases of SCC arising from epidermal cysts. RESULTS: We identified 1904 cases of epidermal cysts at our institution between 2005 and 2014. Of these, three cases of SCC arose from an epidermal cyst and one case of SCC developed from a pilar cyst. All lesions occurred below the waist with the exception of the pilar cyst on the scalp. CONCLUSIONS: Given the extremely low incidence, propensity of malignant lesions to become symptomatic and efficacy of treatment, we do not recommend routine excision of all epidermal cysts. Instead, we recommend excision and pathology for all symptomatic epidermal cysts, or those that rapidly grow, or do not respond to medical therapy.

Gene-environment interactions between JAZF1 and occupational and household lead exposure in prostate cancer among African American men.

PURPOSE: A single nucleotide polymorphism, rs10486567, in JAZF1 has consistently been associated with increased risk of prostate cancer. The physical interaction of zinc finger proteins, such as JAZF1, with heavy metals may play a role in carcinogenesis. This study assessed potential gene-environment statistical interactions (G×E) between rs10486567 and heavy metals in prostate cancer. METHODS: In a case-only study of 228 African American prostate cancer cases, G×E between rs10486567 and sources of cadmium and lead (Pb) were assessed. Unconditional logistic regression was used to estimate interaction odds ratios (IORs), and generalized estimating equations were used for models containing nested data. Case-control validation of IORs was performed, using 82 controls frequency matched to cases on age-race. RESULTS: Among cases, a potential G×E interaction was observed between rs10486567 CC genotype and living in a Census tract with a high proportion of housing built before 1950, a proxy for household Pb exposure, when compared to CT or TT carriers (OR 1.81; 95% CI 1.04-3.16; p = 0.036). A stronger G×E interaction was observed when both housing and occupational Pb exposure were taken into account (OR 2.62; 95% CI 1.03-6.68; p = 0.04). Case-control stratified analyses showed the odds of being a CC carrier were higher in cases compared to controls among men living in areas with older housing (OR 2.03; CI 0.99-4.19; p = 0.05) or having high occupational Pb exposure (OR 2.50; CI 1.01-6.18; p = 0.05). CONCLUSIONS: In African American men, the association between JAZF1 rs10486567 and prostate cancer may be modified by exposure to heavy metals such as Pb.

Is previous exposure to hepatitis B a risk factor for pancreatic cancer or hepatocellular carcinoma?

GOALS: We evaluated whether prior infection with the hepatitis B virus (HBV) influences the development of pancreatic cancer or hepatocellular carcinoma (HCC). BACKGROUND: Prior infection with HBV may predispose patients to developing pancreatic cancer or HCC. STUDY: We conducted a retrospective cohort study using administrative data from an integrated health care system. We identified all patients who had HBV testing over a 13-year period. These patients were divided into 1 of 3 cohorts based on HBV status: negative infection (n=28,719), previous exposure (n=5141), or active infection (n=404). Pancreatic cancer and HCC data were obtained from pathology reports in the health system's cancer registry. RESULTS: In a multivariable model, age [hazards ratio (HR), 1.08; confidence interval (CI), 1.06-1.09; P<0.001)] and presence of diabetes (HR, 1.88; CI, 1.27-2.80; P=0.002) were identified to have significant influence on pancreatic cancer development, whereas previous HBV exposure did not have a significant influence (HR, 1.41; CI, 0.88-2.27; P=0.16). In a separate multivariable model, male sex (HR, 2.05; CI, 1.35-3.11; P<0.001), age (HR, 1.08; CI, 1.06-1.09; P<0.001), being hepatitis C positive (HR, 5.40; CI, 3.51-8.33; P<0.001), and presence of cirrhosis (HR, 27.84; CI, 17.43-44.46, P<0.001) were all significant predictors of HCC. However, previous HBV exposure was not associated with HCC development (HR, 1.03; CI, 0.68-1.56; P=0.88). CONCLUSIONS: Data from this study indicate that previous HBV exposure is not a risk factor for the development of either pancreatic cancer or HCC.

Case-only gene-environment interaction between ALAD tagSNPs and occupational lead exposure in prostate cancer.

BACKGROUND: Black men have historically had higher blood lead levels than white men in the U.S. and have the highest incidence of prostate cancer in the world. Inorganic lead has been classified as a probable human carcinogen. Lead (Pb) inhibits delta-aminolevulinic acid dehydratase (ALAD), a gene recently implicated in other genitourinary cancers. The ALAD enzyme is involved in the second step of heme biosynthesis and is an endogenous inhibitor of the 26S proteasome, a master system for protein degradation and a current target of cancer therapy. METHODS: Using a case-only study design, we assessed potential gene-environment (G × E) interactions between lifetime occupational Pb exposure and 11 tagSNPs within ALAD in black (N = 260) and white (N = 343) prostate cancer cases. RESULTS: Two ALAD tagSNPs in high linkage disequilibrium showed significant interaction with high Pb exposure among black cases (rs818684 interaction odds ratio or IOR = 2.73, 95% CI 1.43-5.22, P = 0.002; rs818689 IOR = 2.20, 95% CI 1.15-4.21, P = 0.017) and an additional tagSNP, rs2761016, showed G × E interaction with low Pb exposure (IOR = 2.08, 95% CI 1.13-3.84, P = 0.019). Further, the variant allele of rs818684 was associated with a higher Gleason grade in those with high Pb exposure among both blacks (OR 3.96, 95% CI 1.01-15.46, P = 0.048) and whites (OR 2.95, 95% CI 1.18-7.39, P = 0.020). CONCLUSIONS: Genetic variation in ALAD may modify associations between Pb and prostate cancer. Additional studies of ALAD, Pb, and prostate cancer are warranted and should include black men. Prostate 74:637-646, 2014. © 2014 Wiley Periodicals, Inc.

The impact of income on clinical outcomes in FIGO stages I to II endometrioid adenocarcinoma of the uterus.

OBJECTIVE(S): To determine the influence of income on clinical outcomes in patients with surgical stages I to II endometrioid adenocarcinoma of the uterus. METHODS: We retrospectively analyzed the records of 660 women initially treated from 1985 to 2009. On the basis of income data obtained from the 2000 US census, patients were separated into various income groups (halves, tertiles, and quartiles) based on median household income, with most focus on the half income groups. RESULTS: Income groups were similar regarding treatments received and characteristics, with the exception of more African American (AA), unmarried patients, and a predilection for higher grade in the lower half income group (LHIG). Compared with the upper half income group (UHIG), the LHIG had lower disease-specific survival (DSS) (5 y: 93.9% vs. 97.0% and 10 y: 90.1% vs. 95.9%; P=0.023) and a trend toward lower overall survival (OS) (5 y: 83.4% vs. 86.5% and 10 y: 62.6% vs. 68.5%; P=0.067). In patients with higher-risk features, differences in outcomes between LHIG and UHIG were more pronounced; 10-year OS of 43.4% versus 60.2% (P=0.004) and 10-year DSS of 75.0% versus 93.0% (P=0.007), respectively. Regarding race, AA patients in the LHIG had lower OS than AA in the UHIG. On univariate analysis, income group and race were significant predictors for DSS, but on multivariate analysis, they were not statistically significant. CONCLUSIONS: Despite similar treatments and characteristics, a small decrease in DSS and a trend toward reduced OS was observed in LHIG patients, but income group was not statistically significant on multivariate analysis of outcome. These differences were more significant in patients with high-risk features.

Racial differences in the use of adjuvant chemotherapy for breast cancer in a large urban integrated health system.

Background. Racial differences in breast cancer survival may be in part due to variation in patterns of care. To better understand factors influencing survival disparities, we evaluated patterns of receipt of adjuvant chemotherapy among 2,234 women with invasive, nonmetastatic breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Methods. Sociodemographic and clinical information were obtained from linked datasets from the HFHS, Metropolitan Detroit Cancer Surveillance Systems, and U.S. Census. Comorbidity was measured using the Charlson comorbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index. Results. African American (AA) women were more likely than whites to have advanced tumors with more aggressive clinical features, to have more comorbidity and to be socioeconomically deprived. While in the unadjusted model, AAs were more likely to receive chemotherapy (odds ratio (OR) 1.22, 95% confidence interval (CI) 1.02-1.46) and to have a delay in receipt of chemotherapy beyond 60 days (OR 1.68, 95% CI, 1.26-1.48), after multivariable adjustment there were no racial differences in receipt (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.73-1.43), or timing of chemotherapy (OR 1.18, 95 CI, 0.8-1.74). Conclusions. Societal factors and not race appear to have an impact on treatment delay among African American women with early breast cancer.

Validation of claims data algorithms to identify nonmelanoma skin cancer.

Health maintenance organization (HMO) administrative databases have been used as sampling frames for ascertaining nonmelanoma skin cancer (NMSC). However, because of the lack of tumor registry information on these cancers, these ascertainment methods have not been previously validated. NMSC cases arising from patients served by a staff model medical group and diagnosed between 1 January 2007 and 31 December 2008 were identified from claims data using three ascertainment strategies. These claims data cases were then compared with NMSC identified using natural language processing (NLP) of electronic pathology reports (EPRs), and sensitivity, specificity, positive and negative predictive values were calculated. Comparison of claims data-ascertained cases with the NLP demonstrated sensitivities ranging from 48 to 65% and specificities from 85 to 98%, with ICD-9-CM ascertainment demonstrating the highest case sensitivity, although the lowest specificity. HMO health plan claims data had a higher specificity than all-payer claims data. A comparison of EPR and clinic log registry cases showed a sensitivity of 98% and a specificity of 99%. Validation of administrative data to ascertain NMSC demonstrates respectable sensitivity and specificity, although NLP ascertainment was superior. There is a substantial difference in cases identified by NLP compared with claims data, suggesting that formal surveillance efforts should be considered.

Vitamin D and nonmelanoma skin cancer in a health maintenance organization cohort.

OBJECTIVE: To examine the association of serum 25-hydroxyvitamin D (25-OHD) with the risk of nonmelanoma skin cancer (NMSC), defined as squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). DESIGN: Cohort study. SETTING: Health maintenance organization. PATIENTS: The study included 3223 white health maintenance organization patients who sought osteoporosis- or low-bone-density-related advice from 1997 to 2001. INTERVENTIONS: Vitamin D levels were ascertained at the time of the initial appointment, and a sufficient vitamin D level was defined as a baseline serum 25-OHD level greater than or equal to 30 ng/mL (to convert to nanomoles per liter, multiply by 2.496) and as a deficient vitamin D level less than 15 ng/mL. MAIN OUTCOME MEASURES: The NMSC cases diagnosed between 1997 and 2009 were ascertained using claims data, considering first occurrence of specified disease outcome and complete person-years of follow-up since baseline. Charts were abstracted for histologic subtype and anatomical location. RESULTS: More patients were vitamin D insufficient (n = 2257) than sufficient (n = 966). There were 240 patients with NMSC: 49 had an SCC, 163 had a BCC, and 28 had both. Vitamin D levels greater than 15 ng/mL ("not deficient level") were positively associated with NMSC (unadjusted odds ratio [OR], 1.7; 95% confidence interval [CI], 1.04-2.7), and this association was sustained after additional risk factors were adjusted for (adjusted OR, 1.8; 95% CI, 1.1-2.9). The 25-OHD levels were similarly positively associated, though statistically insignificant, with NMSC occurring on less UV-exposed anatomical locations (adjusted OR, 2.2; 95% CI, 0.7-7.0), whether for SCC (adjusted OR, 3.2; 95% CI, 0.4-24.0) or for BCC, although the risk estimate for BCC was lower (adjusted OR, 1.7; 95% CI, 0.5-5.8). CONCLUSIONS: An increased baseline serum 25-OHD level was significantly associated with an increased NMSC risk. This association was positive, though nonsignificant on less UV-exposed body sites, and UV exposure remains a likely confounder. The complex and confounded relationship of vitamin D, UV, and NMSC makes classic epidemiological investigation difficult in the absence of carefully measured history of cumulative UV exposure.

Secondhand smoke as a potential cause of chronic rhinosinusitis: a case-control study.

OBJECTIVE: To assess the role of secondhand smoke (SHS) in the etiology of chronic rhinosinusitis (CRS). DESIGN: Matched case-control study. Associations between SHS and CRS were evaluated by conditional logistic regression odds ratios. SETTING: Henry Ford Health System, Detroit, Michigan. PARTICIPANTS: A total of 306 nonsmoking patients diagnosed as having an incident case of CRS and 306 age-matched, sex-matched, and race/ethnicity-matched nonsmoking control patients. MAIN OUTCOME MEASURES: Exposure to SHS for the 5 years before diagnosis of CRS (case patients) and before study entry (controls) for 4 primary sources: home, work, public places, and private social functions outside the home, such as parties, dinners, and weddings. RESULTS: Of controls and case patients, respectively, 28 (9.1%) and 41 (13.4%) had SHS exposure at home, 21 (6.9%) and 57 (18.6%) at work, 258 (84.3%) and 276 (90.2%) in public places, and 85 (27.8%) and 157 (51.3%) at private social functions. Adjusted for potential confounders (socioeconomic status and exposures to air pollution and chemicals or respiratory irritants from hobbies, work, or elsewhere), the odds ratios for CRS were 1.69 (95% confidence interval, 0.92-3.10) for SHS exposure at home, 2.81 (1.42-5.57) for exposure at work, 1.48 (0.88-2.49) for exposure in public places, and 2.60 (1.74-3.89) for exposure at private functions. A strong, independent dose-response relationship existed between CRS and the number of venues where SHS exposure occurred (odds ratio per 1 of 4 levels, 2.03; 95% confidence interval, 1.55-2.66). Approximately 40.0% of CRS appeared to be attributable to SHS. CONCLUSIONS: Exposure to SHS is common and significantly independently associated with CRS. These findings have important clinical and public health implications.

Identification of patients with nonmelanoma skin cancer using health maintenance organization claims data.

Cancer registries usually exclude nonmelanoma skin cancers (NMSC), despite the large population affected. Health maintenance organization (HMO) and health system administrative databases could be used as sampling frames for ascertaining NMSC. NMSC patients diagnosed between January 1, 1988, and December 31, 2007, from such defined US populations were identified by using 3 algorithms: NMSC International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, NMSC treatment Current Procedural Terminology (CPT) codes, or both codes. A subset of charts was reviewed to verify NMSC diagnosis, including all records from HMO-enrollee members in 2007. Positive predictive values for NMSC ascertainment were calculated. Analyses of data from 1988-2007 ascertained 11,742 NMSC patients. A random sample of 965 cases was selected for chart review, and NMSCs were validated in 47.0% of ICD-9-CM-identified patients, 73.4% of CPT-identified patients, and 94.9% identified with both codes. All charts from HMO-health plan enrollees in 2007 were reviewed (n = 1,116). Cases of NMSC were confirmed in 96.5% of ICD-9-CM-identified patients, 98.3% of CPT-identified patients, and 98.7% identified with both codes. HMO administrative data can be used to ascertain NMSC with high positive predictive values with either ICD-9-CM or CPT code, but both codes may be necessary among non-HMO patient populations.

Incidence of nonmelanoma skin cancer in a cohort of patients with vitiligo.

BACKGROUND: Nonmelanoma skin cancer (NMSC) incidence in patients with vitiligo has not been studied. OBJECTIVE: We sought to quantify the incidence of NMSC in patients with vitiligo. METHODS: A cohort of 477 patients with vitiligo and no history of NMSC seen in an outpatient academic center between January 2001 and December 2006 was established. All charts for patients with vitiligo were reviewed for incident NMSC, and histopathology verified. Age-adjusted (2000 US Standard Million) incidence rates were calculated and compared to US rates. RESULTS: Six patients with NMSC were identified; all were Caucasian (>61 years). Age-adjusted incidence rates were: basal cell carcinoma, male 1382/100,000; basal cell carcinoma, female 0; squamous cell carcinoma, male 465/100,000; squamous cell carcinoma, female 156/100,000. Except for basal cell carcinoma in females, all rates were higher than US rates but not statistically significant. LIMITATIONS: Comparison incidence rates from the general patient population during the same time period were unavailable. CONCLUSION: Health care providers should be aware of the possible risk of NMSC in Caucasian patients with vitiligo.