Using the Community Readiness Model to Assess American Indian Communities Readiness to Address Cancer Prevention and Control Programs.

Cancer disparities continue among American Indian and Alaska Native (AI/AN) populations while they have decreased among other racial and ethnic groups. No studies were found that utilized the Community Readiness Model (CRM) to ascertain the readiness of Tribal and American Indian organizations to participate in cancer research and cancer prevention and control initiatives. The Partnership for Native American Cancer Prevention conducted an assessment of the status of American Indian communities' readiness to implement activities for prevention, early detection, and treatment to improve AI/AN cancer rates. The assessment was a component of the Community Outreach Core of the grant. Thirty-four key Informants participated in the interview process. The Community Readiness Assessment (CRA) provided a baseline assessment of community partners' readiness to participate in cancer research and programming. Despite years of cancer intervention programs, the communities were classified as being in the early stages of readiness [1-5] of the nine-stage model. Additionally, findings showed low levels of awareness of previous or ongoing cancer research. The findings in prevention and control efforts indicated a need for technical assistance and funding to support community projects in prevention and control. This supported the implementation of a community grants initiative. They also indicated that communities were not ready to conduct research, despite ongoing cancer related research in at least two communities. Communication tools and social media methods and messages were developed to increase awareness of cancer as a health concern and cancer research in the community. The CRM informed these and other engagement activities to meet the appropriate stage of readiness for each Tribe/community, and to build their capacity to participate in cancer research and programming activities.

Dual Diagnosis and Alcohol/Nicotine Use Disorders: Native American and White Hospital Patients in 3 States.

INTRODUCTION: Nationally, mental illness prevalence is comparable among Native Americans and Whites experiencing alcohol and nicotine use disorders. However, authors are concerned that mental illness in Native Americans with substance use disorders may be disparately underdiagnosed in medical settings. For 3 states with large Native American populations, this study compares the prevalence of mental illness diagnoses among Native Americans and Whites hospitalized with alcohol/nicotine use disorders. METHODS: In 2021, hospital discharge data were used to compare non-Hispanic Native Americans with non-Hispanic Whites in Arizona and New Mexico (2016-2018) and (regardless of Hispanic ethnicity) Native Americans with Whites in Oklahoma (2016-2017). Differences in any mental illness, mood, and anxiety diagnoses were assessed using multilevel regressions (adjusted for demographics, payor, comorbidities, facility). Adjusted predicted probabilities were constructed. RESULTS: Among alcohol-related discharges, probabilities of non-Hispanic Native Americans and non-Hispanic Whites receiving any mental illness diagnoses in Arizona were 18.0% (95% CI=16.1, 19.9) and 36.8% (95% CI=34.1, 39.5), respectively; in New Mexico, they were 24.5% (95% CI=20.7, 28.3) and 43.4% (95% CI=38.7, 48.1). Oklahoma's probabilities for Native Americans and Whites were 30.7% (95% CI=27.4, 34.0) and 36.8% (95% CI=33.5, 40.2), respectively. Among nicotine-related discharges, any mental illness diagnosis probabilities for non-Hispanic Native Americans and non-Hispanic Whites in Arizona were 21.2% (95% CI=18.9, 23.5) and 33.1% (95% CI=30.3, 35.9), respectively; in New Mexico, they were 25.9% (95% CI=22.7, 29.1) and 37.4% (95% CI=33.8, 40.9). Oklahoma's probabilities for Native Americans and Whites were 27.3% (95% CI=25.1, 29.6) and 30.2% (95% CI=28.0, 32.4), respectively. Mood and anxiety diagnoses were also significantly lower for non-Hispanic Native Americans in Arizona/New Mexico and Native Americans in Oklahoma. CONCLUSIONS: Findings suggest disparate underdiagnosis of mental illness among Native Americans hospitalized with alcohol/nicotine use disorders in the examined states.

With socioeconomic status controlled, cigarette use is lower among American Indians/Alaska Natives than whites.

BACKGROUND: Higher crude prevalence of cigarette use among American Indians/Alaska Natives (AI/AN) than non-Hispanic whites (NHW) has helped engender an assumption that race/ethnicity explains the difference. This study examines whether being AI/AN versus NHW predicts greater use when socioeconomic status and demographics are controlled. METHODS: Data came from the National Survey on Drug Use and Health (2013-2017). Using logistic regressions with socioeconomic (income, education) and demographic (gender, age, marital status) controls, differences between AI/AN (n = 4,305) and NHW (n = 166,348) regarding heavier cigarette use (past month daily use, past month use of 300+ cigarettes, and nicotine dependence) and current cigarette use (past month use plus 100+ cigarettes in lifetime) were assessed. Adjusted predicted probabilities were also constructed. RESULTS: NHW, compared to AI/AN, had greater odds of daily use: adjusted odds ratio (AOR) = 1.23 (95% CI: 1.03-1.49); predicted probabilities-15.3% and 13.0%, respectively. NHW had greater odds of using 300+ cigarettes: AOR = 1.47 (CI: 1.19-1.83); predicted probabilities-13.6% and 9.9%. NHW had greater odds of being nicotine dependent: AOR = 1.57 (CI: 1.31-1.89); predicted probabilities-10.3% and 7.1%. A difference in current use was not found. As controls, income and education were especially impactful. CONCLUSIONS: With controls, particularly for socioeconomic status, heavier cigarette use was lower among AI/AN than NHW, and a current cigarette use difference was not indicated. This contradicts the idea that being AI/AN versus NHW independently predicts greater cigarette use, and it underscores the importance of socioeconomic status for understanding cigarette use among AI/AN.

Cigarette Use Among American Indians and Alaska Natives in Metropolitan Areas, Rural Areas, and Tribal Lands.

CONTEXT: Cigarette use among the US general population is significantly lower in metropolitan areas than in rural areas. OBJECTIVE: To assess whether cigarette use among American Indians and Alaska Natives (AI/AN) is lower in metropolitan areas than in rural areas and tribal lands (which are predominantly rural). DESIGN: Data came from the National Survey on Drug Use and Health (2012-2016). Regressions with adjustments for demographics were performed to assess whether cigarette use differed in association with type of place. SETTINGS: The AI/AN in tribal lands (n = 1569), nontribal large metropolitan (1+ million people) areas (n = 582), nontribal small metropolitan (<1 million) areas (n = 1035), and nontribal rural areas (n = 1043). MAIN OUTCOME MEASURES: Cigarette abstinence, current smoking, daily use, number of cigarettes used, and days of use-all in the past month. Nicotine dependence was also examined. RESULTS: Metropolitan (large or small) areas versus rural areas: no statistically significant differences in cigarette use were found. Metropolitan (large or small) areas versus tribal lands: days of cigarette use and daily use were significantly lower in tribal lands. Tribal lands were also lower than small metropolitan areas regarding number of cigarettes used and nicotine dependence. Rural areas versus tribal lands: cigarette measures were consistently lower in tribal lands. For example, the prevalence of current smokers, daily users and nicotine dependence, respectively, was 37.9%, 25.9%, and 16.3% in rural areas and 27.4%, 13.6%, and 8.9% in tribal lands. CONCLUSIONS: Differences in cigarette use between AI/AN in nontribal rural and metropolitan areas were not indicated. Instead, the place differences found were lower cigarette use in tribal lands than in nontribal rural areas and, to some extent, metropolitan areas. These findings can help inform policy makers working to develop context-sensitive anticommercial tobacco efforts for AI/AN.

"Linearity assessment methods for sex steroid hormones and carrier proteins among men in the National Health and Nutrition Examination Survey (NHANES III)".

INTRODUCTION: It has been hypothesized that racial disparities among several diseases are explained by differences in testosterone (T), 17-ß estradiol (E), sex hormone binding globulin (SHBG) and albumin (A) levels, yet epidemiologic results have been mixed. Statistical advice regarding appropriate adjustment methods for carrier proteins of sex steroid hormones in the literature is scant. Therefore, we investigated different adjustment methods for carrier proteins. METHODS: Data for 1496 men, >17 years from the Third National Health and Nutrition Examination Survey (NHANES III) 1988-91 were used to analyze linearity between sex hormones and carrier proteins by examining correlation, plots, and regression models. The statistical importance of age, body mass index (BMI), and race/ethnicity were examined for changes in results by the adjustment method. RESULTS: T was weakly correlated with SHBG and A (r-squared, 0.25, 0.13, respectively) and E was weakly negatively correlated with A (p<0.0001), but not SHBG (p<0.1799). Based on the model residual plots and r-squared, the categorical model performed better than linear models. Regression coefficients for age, BMI, and race/ethnicity groups using quotient (e.g., T/A and E/A) models differed from continuous and categorical models. CONCLUSION: Choosing an appropriate adjustment for carrier proteins is important to prevent bias in analyses and inconsistency in findings across studies. Linearity between variables should not be assumed when adjusting models, and should be conducted and reported. An independent categorical carrier protein variable is recommended in analysis exploring factors predicting sex hormone levels, although statistical testing should always be employed.

A cross-sectional study of the association of age, race and ethnicity, and body mass index with sex steroid hormone marker profiles among men in the National Health and Nutrition Examination Survey (NHANES III).

OBJECTIVES: Since sex hormone markers are metabolically linked, examining sex steroid hormones singly may account for inconsistent findings by age, race/ethnicity and body mass index (BMI) across studies. First, these markers were statistically combined into profiles to account for the metabolic relationship between markers. Then, the relationships between sex steroid hormone profiles and age, race/ethnicity and BMI were explored in multinomial logistic regression models. DESIGN: Cross-sectional survey. SETTING: The US Third National Health and Nutrition Examination Survey (NHANES III). PARTICIPANTS: 1538 Men, >17 years. PRIMARY OUTCOME MEASURE: Sex hormone profiles. RESULTS: Cluster analysis was used to identify four statistically determined profiles with Blom-transformed T, E, sex hormone binding globulin (SHBG), and 3-α diol G. We used these four profiles with multinomial logistic regression models to examine differences by race/ethnicity, age and BMI. Mexican American men >50 years were associated with the profile that had lowest T, E and 3-α diol G levels compared to other profiles (p<0.05). Non-Hispanic Black, overweight (25-29.9 kg/m(2)) and obese (>30 kg/m(2)) men were most likely to be associated with the cluster with the lowest SHBG (p<0.05). CONCLUSION: The associations of sex steroid hormone profiles by race/ethnicity are novel, while the findings by age and BMI groups are largely consistent with observations from single hormone studies. Future studies should validate these hormone profile groups and investigate these profiles in relation to chronic diseases and certain cancers.

Assessment of the quality of medical care among patients with early stage prostate cancer undergoing expectant management in the United States.

PURPOSE: Given the increased attention to the quality and cost of medical care, the Institute of Medicine and Centers for Medicare and Medicaid Services have called for performance measurement and reporting. The clinical management of prostate cancer has been outlined, yet is not intended to describe quality prostate cancer care. Therefore, RAND researchers developed quality indicators for early stage prostate cancer. The ACoS (American College of Surgeons) used these indicators to perform the first national assessment to our knowledge of the quality of care among men with early stage prostate cancer undergoing expectant management. MATERIALS AND METHODS: Information from medical records was abstracted for evidence of compliance with the RAND indicators (structure and process). Weighted and stratified proportions were calculated to assess indicator compliance. Logistic regression models were fit and evaluated by hospital type and patient factors. RESULTS: A weighted and stratified total of 13,876 early stage prostate cancer cases on expectant management in 2000 to 2001 were investigated. Compliance with structural indicators was high (greater than 80%) and compliance with process indicators varied (19% to 87%). Differences in process indicators were observed from models by hospital type and comorbid conditions, but not for age, race or insurance status. CONCLUSIONS: Using the RAND quality indicators this study revealed several process areas for quality improvement among men with early stage prostate cancer on expectant management in the United States. Efforts to improve the quality of early stage prostate cancer care need to move beyond the paradigm of age, race and insurance status.

Prostate cancer incidence rates in Africa.

African American men have among the highest prostate cancer incidence rates in the world yet rates among their African counterparts are unclear. In this paper, we compared reported rates among black men of Sub-Saharan African descent using data from the International Agency for Research on Cancer (IARC) and the National Cancer Institute Surveillance, Epidemiology, and End Results Program for 1973-2007. Although population-based data in Africa are quite limited, the available data from IARC showed that rates among blacks were highest in the East (10.7-38.1 per 100,000 man-years, age-adjusted world standard) and lowest in the West (4.7-19.8). These rates were considerably lower than those of 80.0-195.3 observed among African Americans. Rates in Africa increased over time (1987-2002) and have been comparable to those for distant stage in African Americans. These patterns are likely due to differences between African and African American men in medical care access, screening, registry quality, genetic diversity, and Westernization. Incidence rates in Africa will likely continue to rise with improving economies and increasing Westernization, warranting the need for more high-quality population-based registration to monitor cancer incidence in Africa.

Surveillance of urothelial carcinoma: stage and grade migration, 1993-2005 and survival trends, 1993-2000.

BACKGROUND: Previous investigators have detected shifts to lower stages at diagnosis for renal cell carcinoma and prostate cancer. The authors investigated whether a similar pattern is seen for urothelial carcinomas of the bladder, ureter, and renal pelvis and sought to identify changes in cancer grade and survival trends from 1993 to 2005. METHODS: The National Cancer Data Base (NCDB) collects data on approximately 75% of all newly diagnosed cancer cases annually. The authors queried the database for cases of urothelial carcinomas diagnosed in 1993-2005 in patients aged 18 years and older. All cancer stage data were forward converted to the sixth edition of the American Joint Committee on Cancer staging definitions. RESULTS: A total of 334,480 bladder cancer cases, 15,105 renal pelvis cancer cases, and 10,128 ureteral carcinoma cases were identified. Stage data were available for 84% of bladder cases, 83% of renal pelvis cases, and 82% of ureter cases. With the classification of early stage tumors as stage 0a, 0is, and I and late stage tumors as II, III, and IV, the percentage of early stage renal pelvis and ureter tumors increased slightly from 1993 to 2005, whereas no stage migration was seen in bladder tumors. In looking specifically at early stage tumors, a significant increase in the proportion of stage 0a and a significant decrease in the proportion of stage I tumors for each cancer site was seen between 1993 and 2005. The proportion of high grade tumors in each disease site significantly increased from 1993 to 2005. For cases diagnosed in 1993-1996 and 1997-2000, a significant decrease in 5-year relative survival was observed for patients with stage I and stage II bladder cancer. The absolute change, however, was relatively small, and for bladder cases was not significantly different when adjusted for low or high grade tumors. CONCLUSIONS: When differentiating between early and late stage tumors, a slight stage migration was seen in renal pelvis and ureteral carcinomas, whereas no stage migration was seen in bladder tumors. Within early stage tumors of all sites, a stage shift was seen, most notably with the proportion of stage 0a tumors increasing and stage I tumors decreasing. The proportion of high grade tumors in all sites increased. No change in overall survival was observed, underscoring the need for new therapeutic advances.

Renal cell carcinoma: assessment of key pathologic prognostic parameters and patient characteristics in 47,909 cases using the National Cancer Data Base.

On the basis of the National Cancer Data Base (NCDB), we describe the disease characteristics and use of conventional prognostic parameters in a hospital-based cohort of pathologically confirmed renal cell carcinomas (RCCs). Between 1993 and 1998, the NCDB obtained 149 424 cases of kidney (and renal pelvis) cancers from registries all over the United States. This database was queried for 47 909 histologically specified RCCs. Survival outcome was analyzed based on conventional clinical and pathologic parameters reported to the database (up to 2003). Renal cell carcinoma was more common in men (male-female ratio = 1.6:1). The mean age was 62.6 years. Most (66.6%) were organ-confined (stage I/II) at the time of diagnosis. The mean tumor size was 6.49 cm. The 5-year observed survival of RCC was 62.9% for male and 68.1% for female and was 81.0% for younger than 40 years old and 64.2% for older than 40 years old. The 5-year observed survival of RCC patients by the fifth edition 1997 American Joint Committee on Cancer TNM staging were stages I, 77.8%; II, 72.8%; III, 55.0%; and IV, 16.9%, demonstrating a dramatic decline in patient survival at stage IV. By reported pathologic grade, significant stratification was achieved in the observed survival for RCC overall irrespective of histologic subtypes (grade 1, 77.8%; 2, 69.6%; 3, 48.8%; and 4, 35.3% 5-year observed survival). These large NCDB data in RCC confirm the importance of pathologic evaluation of traditional prognostic parameters of stage and grade in RCC and is a powerful resource in defining cancer patient characteristics and analysis of prognostic variables that helps influence future cancer care planning and resource allocation.

Variations in quality of care for men with early-stage prostate cancer.

PURPOSE: The commencement of quality-improvement initiatives such as Pay for Performance and the Physician Consortium for Performance Improvement has underscored calls to evaluate the quality of cancer care on a patient level for nationally representative samples. METHODS: We sampled early-stage prostate cancer cases diagnosed in 2000 through 2001 from the American College of Surgeons National Cancer Data Base and explicitly reviewed medical records from 2,775 men (weighted total = 55,160 cases) treated with radical prostatectomy or external-beam radiation therapy. We determined compliance with 29 quality-of-care disease-specific structure and process indicators developed by RAND, stratified by race, geographic region, and hospital type. RESULTS: Overall compliance exceeded 70% for structural and pretherapy disease assessment indicators but was lower for documentation of pretreatment functioning (46.4% to 78.4%), surgical pathology (37.1% to 86.3%), radiation technique (62.6% to 88.3%), and follow-up (55%). Geographic variations were observed as higher compliance in the South Atlantic division than the New England division for having at least one board-certified urologist (odds ratio [OR], 9.2; 95% CI, 1.9 to 45.0), at least one board-certified radiation oncologist (OR, 3.3; 95% CI, 1.2 to 9.0), use of Gleason grading (OR, 4.1; 95% CI, 1.2 to 13.8), and administering total radiation dose >or= 70 Gy (OR, 3.1; 95% CI, 1.6 to 6.1). Teaching/research hospitals and Comprehensive Cancer Centers had higher compliance than Community Cancer Centers, whereas racial differences were not observed for any indicator. CONCLUSION: The significant and unwarranted variations observed for these quality indicators by census division and hospital type illustrate the inconsistencies in prostate cancer care and represent potential targets for quality improvement. The lack of racial disparities suggests equity in care once a patient initiates treatment.

Renal cell cancer stage migration: analysis of the National Cancer Data Base.

BACKGROUND: Evidence exists to suggest a pattern of increasing early diagnosis of renal cell carcinoma (RCC). The aim of the study was to analyze patterns of disease presentation and outcome of RCC by AJCC stage using data from the National Cancer Data Base (NCDB) over a 12-year period. METHODS: The NCDB was queried for adults diagnosed between 1993 and 2004 presenting with ICD-O-2 of 3 renal cell tumors arising in the kidney. Cases were classified by demographics, 2002 AJCC stage (6th edition), and histology. The Cochran-Armitage Test for Trend was used to determine statistical significance of trends over time. Cox regression multivariate analysis was used to evaluate the impact of stage and histology on relative survival. SPSS 14.0 was used for analyses. RESULTS: Between 1993 and 2004 a total of 205,963 patients from the NCDB fit our case definition of RCC. Comparisons between 1993 and 2004 data show an increase in stage I disease and decrease in stage II, III, and IV disease (P < or = .001). The size of stage I tumors also decreased from a mean of 4.1 cm in 1993 to 3.6 cm in 2003. In multivariate analysis, stage, but not histology, predicted relative survival. A 3.3% increase in survival was found for patients diagnosed in 1998 compared with patients diagnosed in 1993. CONCLUSIONS: A greater proportion of newly diagnosed patients with RCC currently present with stage I disease compared with earlier years. Stage predicts relative survival for patients with kidney cancer. More recently diagnosed patients have improved relative survival.

Decreasing size at diagnosis of stage 1 renal cell carcinoma: analysis from the National Cancer Data Base, 1993 to 2004.

PURPOSE: The proportion of renal cell carcinoma cases diagnosed at stage I is known to be increasing significantly. We characterized stage I tumors further in terms of tumor size at diagnosis using a large national cancer registry. MATERIALS AND METHODS: The National Cancer Data Base captures approximately 75% of all newly diagnosed cancer cases in the United States. The database was queried for all adults who were diagnosed between 1993 and 2004 with stage I renal cell carcinoma. Trends were assessed in mean size with time as well as in the proportion of stage I tumors diagnosed at less than 2.0, less than 2.5 and less than 3.0 cm. RESULTS: There were 104,150 patients in the National Cancer Data Base diagnosed with stage I renal cell carcinoma during the study period. A total of 10,279 stage I tumors (9.9%) were less than 2.0 cm, 26,621 (25.6%) were 2.5 cm or less and 39,879 (38.3%) were 3.0 cm or less. Analysis of stage I renal cell carcinoma diagnoses with time demonstrated a statistically significant increase in the proportion of renal masses 3.0 cm or less between 1993 and 2004 (32.5% vs 43.4%). Of tumors 3.0 cm or less the proportion smaller than 2.0 cm increased significantly during the study period from 24.1% in 1993 to 29.4% in 2004. Mean tumor size decreased from 4.1 to 3.6 cm between 1993 and 2004 (p <0.001). CONCLUSIONS: Tumor size at diagnosis is decreasing with time in patients with stage I renal cell carcinoma. These data likely underestimate the proportion of all enhancing renal masses diagnosed at a small size. Patients with small masses may be appropriate candidates for nephron sparing surgery, energy based ablative therapy or active surveillance. Better technologies are needed to determine the diagnosis and prognosis of small enhancing renal masses.

Sex differences in renal cell cancer presentation and survival: an analysis of the National Cancer Database, 1993-2004.

PURPOSE: We analyzed patterns of disease presentation and outcome of renal cell carcinomas by gender using data from the National Cancer Database during a 10-year period. We hypothesized that women presented with lower stage disease and had increased survival than men due to increased imaging. MATERIALS AND METHODS: The National Cancer Database is a nationwide oncology data set that currently captures approximately 75% of all newly diagnosed cancer cases from more than 1,400 facility based cancer registries in the United States annually since 1985. The National Cancer Database was queried for adults with renal cell carcinoma diagnosed between 1993 and 2004. Cases were examined according to gender in relation to mean age, American Joint Committee on Cancer stage, histology, grade, tumor size, mortality and race. RESULTS: We identified a total of 236,930 patients with renal cell carcinoma diagnosed between 1993 and 2004 from the National Cancer Database. A total of 89,243 (37.7%) were female and 147,687 (62.3%) were male. Mean age was greater in females (64.3) than in males (62.9) (p <0.001). Women had a higher percentage of stage I tumors (54.1% vs 48.5%, p <0.001). Progressive stage migration was documented in men and women. A trend toward increased survival was noted in women relative to men that did not reach statistical significance. CONCLUSIONS: Results from this study show a ratio of 1.65 of renal cell carcinoma for males compared to females. Women are more likely than men to have stage I tumors. Both men and women have demonstrated stage migration, although women more so than men.

Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database.

BACKGROUND: With the development of stage-specific treatments for pancreatic cancer, controversies exist concerning optimal clinical and pathologic staging. The most recent edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual 6(th) Edition included some notable modifications. In anticipation of the 7(th) edition's publication, the authors evaluated the predictive ability of the current pancreatic adenocarcinoma staging system. METHODS: By using the National Cancer Data Base (1992-1998), 121,713 patients were identified with pancreatic adenocarcinoma. All patients were restaged by AJCC 6(th) edition guidelines. Stage-specific overall survival was estimated by using the Kaplan-Meier method and compared with log-rank tests. Concordance indices were calculated to evaluate the discriminatory power of the staging system. Cox modeling was used to determine the relative impact of T, N, and M classification on survival. RESULTS: For all patients, there was 5-year survival discrimination by stage (P < .0001). For patients who underwent pancreatectomy, stage predicted 5-year survival: stage IA, 31.4%; IB, 27.2%; IIA, 15.7%; IIB, 7.7%; III, 6.8%; IV, 2.8% (P < .0001). The concordance index for the staging system was 0.631 for all patients, 0.613 for those who underwent pancreatectomy, and 0.596 for patients who did not undergo resection. In patients who underwent pancreatectomy, tumor size, nodal status, and distant metastases were independent predictors of survival (P < .0001). CONCLUSIONS: This is the first large-scale validation of the pancreatic cancer staging system. AJCC 6(th) edition staging guidelines are accurate with respect to survival. Further investigation is needed to integrate new molecular and biochemical markers into the staging scheme.

Low incidence of perioperative chemotherapy for stage III bladder cancer 1998 to 2003: a report from the National Cancer Data Base.

PURPOSE: Studies of perioperative chemotherapy for muscle invasive bladder cancer have shown a survival benefit with combined modality therapy. We reviewed chemotherapy use in patients with stage III transitional cell carcinoma of the bladder from 1998 to 2003 to evaluate perioperative chemotherapy treatment patterns. MATERIALS AND METHODS: The National Cancer Data Base collected data on approximately 60% of all newly diagnosed bladder cancer cases in the United States from 1998 to 2003. We queried the National Cancer Data Base for all treatment of male and female patients 18 years old or older with bladder transitional cell carcinoma diagnosed between 1998 and 2003. A total of 224,060 bladder transitional cell carcinoma records were reviewed. Perioperative chemotherapy was defined as chemotherapy given within 4 months before and 4 months after surgery. Of 11,339 cases of stage III bladder cancer treatment, analysis was possible for 7,161. RESULTS: Treatment patterns were analyzed in 7,161 patients with stage III bladder transitional cell carcinoma. Perioperative chemotherapy was administered to 11.6% of patients with stage III bladder transitional cell carcinoma with 10.4% receiving adjuvant chemotherapy and 1.2% receiving neoadjuvant chemotherapy. When comparing perioperative chemotherapy use by diagnosis year in 1998 and 2003, a small statistically significant increase was observed using the Pearson's chi-square test with Bonferroni correction (p <0.05) at 11.3% of patients in 1998 vs 16.8% in 2003. CONCLUSIONS: Perioperative chemotherapy is underused in the management of surgically resectable stage III transitional cell carcinoma of the bladder. This finding may reflect a delay in implementing the results of recently reported randomized trials, a low incidence of referrals by urologists for chemotherapy and/or confidence in salvage chemotherapy as an equivalent alternative. Further followup will determine if this treatment pattern changes in the future.

The quality of surgical pathology care for men undergoing radical prostatectomy in the U.S.

BACKGROUND: The authors assessed adherence with the College of American Pathologists (CAP) radical prostatectomy (RP) practice protocol in a national sample of men who underwent RP for early-stage prostate cancer. METHODS: Using the National Cancer Data Base, the authors identified a nationally representative sample of 1240 men (unweighted) who underwent RP. For each patient, local cancer registrars performed an explicit medical record review to assess patient-level compliance with surgical pathology report documentation of 7 morphologic criteria (ie, quality indicators). Applying the CAP prognostic factor classification framework, composite measures and all-or-none measures of quality indicator compliance were calculated for the following analytic categories: 1) a strict subset of CAP category I prognostic factors (3 indicators), 2) a broad subset of CAP category I factors (6 indicators), and 3) the full set of 7 indicators. RESULTS: Among a weighted sample of 24,420 patients who underwent RP, compliance with documentation of the CAP category I factors varied from 54% (95% confidence interval [95% CI], 50-58%) for pathologic tumor, lymph node, metastases classification (according to the American Joint Committee on Cancer staging system) to 97% (95% CI, 96-99%) for Gleason score. In composite, RP pathology reports contained 83% (95% CI, 81-84%), 85% (95% CI, 84-87%), and 79% (95% CI, 78-80%) of the recommended data elements measured by the strict CAP category I subset, the broad CAP category I subset, and the full set of 7 indicators, respectively. In contrast to the generally higher composite scores, only 52% (95% CI, 48-56%) and 41% (95% CI, 37-45%) of men who underwent RP had complete documentation in their pathology reports for the strict and broad CAP category I subsets, respectively. CONCLUSIONS: RP surgical pathology reports contained most of the recommended data elements; however, the frequent absence of pathologic stage provides an opportunity for quality improvement.

Treatment choice and quality of care for men with localized prostate cancer.

BACKGROUND: Variations in patterns of care and treatment outcomes suggest differences in the quality of care for men treated for localized prostate cancer. OBJECTIVE: We sought to compare adherence with quality indicators for prostate cancer care among men treated with radical prostatectomy or external beam radiation therapy. RESEARCH DESIGN AND SUBJECTS: We sampled 5230 men diagnosed in 2000 or 2001 with early-stage prostate cancer from 984 facilities reporting to the National Cancer Data Base. Our analytic cohort includes 2604 men (from 770 facilities) treated with radical prostatectomy or external beam radiation. MAIN OUTCOME MEASURE: Subject-level compliance with the RAND quality indicators for localized prostate cancer care, stratified by treatment. We applied sampling weights to obtain national estimates of quality indicator adherence. RESULTS: The weighted samples represent 24,547 and 27,125 men treated with radical prostatectomy or external beam radiation therapy, respectively. Compliance with several quality indicators approached 100% in both treatment groups; however treatment-specific variations were noted. Men receiving radiation were less likely than those undergoing surgery to be treated in facilities with a board-certified urologist (odds ratio [OR] = 0.4, 95% confidence interval [95% CI] = 0.2-0.8). Adherence with process of care indicators was appreciably higher among radiation subjects, including documentation of clinical stage (OR = 7.5, 95% CI = 4.8-11.9), pretherapy assessment of urinary (OR = 2.8, 95% CI = 1.9-4.2) and sexual (OR = 1.6, 95% CI = 1.2-2.2) function, and discussion of treatment options (OR = 1.8, 95% CI = 1.1-2.9). CONCLUSIONS: Documented compliance with process of care quality indicators among men with localized prostate cancer appears superior for those treated with external beam radiation compared with those treated surgically.

Evidence-based gallbladder cancer staging: changing cancer staging by analysis of data from the National Cancer Database.

BACKGROUND: A recent revision of the American Joint Committee on Cancer (AJCC) staging for gallbladder cancer (6th Edition) involved some major changes. Most notably, T2N0M0 tumors were moved from stage II to stage IB; T3N1M0 disease was moved from stage III to stage IIB; and T4NxM0 (x = any) tumors were moved from stage IVA to stage III. METHODS: In order to determine if these changes were justified by data, an analysis of the 10,705 cases of gallbladder cancer collected between 1989 and 1996 in the NCDB was performed. All patients had >5 year follow-up. RESULTS: The staging according to the 6th Edition provided no discrimination between stage III and IV. Five-year survivals for stage IIA, IIB, III, and IV (6th Edition) were 7%, 9%, 3%, 2% respectively. The data from the National Cancer Database (NCDB) were used to derive a proposed new staging system that builds upon Edition 5 and had improved discrimination of stage groups over previous editions. CONCLUSIONS: Changes in staging systems should be justified by data. Multicenter databases, including the NCDB, represent important resources for verification of evidence-based staging systems.

Genetic variants of DNA repair genes and prostate cancer: a population-based study.

As part of a population-based case-control study in Shanghai, China, we investigated whether variants in several DNA repair genes, either alone or in conjunction with other risk factors, are associated with prostate cancer risk. Genomic DNA from 162 patients newly diagnosed with prostate cancer and 251 healthy men randomly selected from the population were typed for five nonsynonymous DNA repair markers. We found that the XRCC1-Arg399Gln AA and the MGMT-Leu84Phe CT+TT genotypes were associated with an increased risk of prostate cancer [odds ratio (OR), 2.18; 95% confidence interval (CI), 0.99-4.81 and OR, 1.99; 95% CI, 1.19-3.34, respectively]. In contrast, XRCC3-Thr241Met, XPD-Lys751Gln, and MGMT-Ile143Val markers showed no significant associations with risk, although due to the much lower frequency of their variant alleles in this population we cannot rule out small to modest effects. There was a significant interaction between the MGMT-84 marker and insulin resistance (P(interaction) = 0.046). Relative to men with the MGMT-84 CC genotype and a low insulin resistance (<0.097), those having the CT-TT genotype and a greater insulin resistance had a 5.4-fold risk (OR, 5.39; 95% CI, 2.46-11.82). In addition, for the XRCC3-241 marker, relative to men with the CC genotype and a low intake of preserved foods (<12.7 g/d), those harboring the CT+TT genotype and having a higher intake of preserved foods (>12.7 g/d), which contain nitrosamines and nitrosamine precursors, had a significantly increased risk of prostate cancer risk (OR, 2.62; 95% CI, 1.13-6.06). In contrast, men with the CT+TT genotype and a low intake of preserved foods had a 69% reduction in risk (OR, 0.31; 95% CI, 0.10-0.96; P(interaction) = 0.005). These results suggest that genetic variants in the DNA repair pathways may be involved in prostate cancer etiology and that other risk factors, including preserved foods and insulin resistance, may modulate prostate cancer risk in combination with genetic susceptibility in these repair pathways. Replication in larger studies is necessary to preclude chance findings, particularly those among subgroups, and clarify the mechanisms involved.