Patterns of opioid use in older people diagnosed with cancer in New South Wales, Australia.

PURPOSE: Opioids provide effective analgesia for most cancer patients, but little is known about individual-level opioid use after cancer diagnosis. We examined the patterns of and factors associated with opioid use in older people diagnosed with cancer. METHODS: We used the Department of Veterans' Affairs (DVA) client data linked with the New South Wales (NSW) Cancer Registry and the Repatriation Pharmaceutical Benefits Scheme data. We included people aged ≥65 years diagnosed with cancer in NSW, Australia in 2005 to 2015. We examined patterns of opioid use in the 12 months after cancer diagnosis and used cause-specific hazards models to examine factors associated with opioid use. RESULTS: Of 13 527 people diagnosed with cancer, 51% were dispensed opioids after their diagnosis. We observed the highest proportions of use in people diagnosed with pancreas, liver, or lung cancers. Opioid use was associated with female sex, younger age, more advanced degree of cancer spread, opioid use before cancer diagnosis, and multimorbidity. Forty-four percentages of all people dispensed opioids had a history of opioid use in the 12 months before their cancer diagnosis; these people had higher median number of different opioids and opioid dispensings, and a shorter time to first opioid dispensing than opioid-naive people. CONCLUSION: Our study suggests that many older cancer patients were dispensed opioids before their cancer diagnosis. Previously opioid-treated people had more intense opioid use patterns after diagnosis than opioid-naïve people. Acknowledging the history of opioid use is important as it may complicate pain treatment in clinical practice.

Risk of emergency hospitalisation and survival outcomes following adjuvant chemotherapy for early breast cancer in New South Wales, Australia.

OBJECTIVE: To examine risk of emergency hospital admission and survival following adjuvant chemotherapy for early breast cancer. METHODS: Linked data from New South Wales population-based and clinical cancer registries (2008-2012), hospital admissions, official death records and pharmaceutical benefit claims. Women aged ≥18 years receiving adjuvant chemotherapy for early-stage operable breast cancer in NSW public hospitals were included. Odds ratios (OR) for emergency hospitalisation within 6 months following chemotherapy initiation were estimated using logistic regression and survival using Kaplan-Meier and Cox proportional hazards methods. RESULTS: A total of 3,950 women were included and 30.6% were hospitalised. The most common principal diagnosis at admission was neutropenia (30.8%). Women receiving docetaxel/carboplatin/trastuzumab (TCH) and docetaxel/cyclophosphamide (TC) were the most frequently hospitalised. After adjustment for demographic and clinical factors, the increased risk of hospitalisation for TCH and TC remained compared with doxorubicin/cyclophosphamide 3-weekly (OR 1.71, 95% confidence interval [CI] 1.24-2.37 and OR 1.47, 95% CI 1.17-1.85 respectively). Five-year overall survival was similar for women who were (92.2%, 95% CI 90.7-93.8) and were not hospitalised (93.1%, 95% CI 92.1-94.1). CONCLUSION: Emergency hospitalisations following chemotherapy for early breast cancer were relatively common, especially following docetaxel-containing protocols. Further examination of reasons for admission is needed to inform actions to improve patient safety.

Differences in cancer incidence by age at diagnosis between Aboriginal and non-Aboriginal people for cancer types included in Australian national screening programs.

BACKGROUND: This study examined age distributions and age-specific incidence of screened cancers by Aboriginal status in New South Wales (NSW) to consider the appropriateness of screening target age ranges. METHODS: The NSW Cancer Registry identified invasive (female) breast, cervical and bowel cancers in people diagnosed in 2001-2014. RESULTS: Aboriginal people were younger at diagnosis with higher proportions of breast and bowel cancers diagnosed before the screening target age range (<50 years) compared with non-Aboriginal people (30.6% vs. 22.8%, and 17.3% vs. 7.3%, respectively). Age-specific incidence rate ratios (IRRs) were lower/similar for breast and bowel cancers in younger and higher in older Aboriginal than non-Aboriginal people. All age-specific cervical cancer IRRs were higher for Aboriginal compared with non-Aboriginal people. CONCLUSION: Although higher proportions of breast and colorectal cancers were diagnosed before screening commencement age in Aboriginal people, this does not necessarily indicate a need for earlier screening commencement. Other aspects needing consideration include benefits, harms and cost-effectiveness.

Patterns of endocrine therapy in a national cohort of early stage HER2-positive breast cancer patients.

PURPOSE: Guidelines recommend ≥5 years of endocrine therapy for hormone receptor-positive breast cancer patients, but nonadherence and treatment discontinuation are common. We examined adherence trajectories and early discontinuation of endocrine therapy over 5 years from treatment initiation. METHODS: Our retrospective cohort study used a national sample of Australian women dispensed publicly subsidised trastuzumab for early HER2-positive breast cancer. We included women initiating endocrine therapy between April 2007 and June 2011, followed until June 2016 (n = 2656). We used group-based trajectory modelling and Kaplan-Meier analysis to examine patterns of adherence and time to discontinuation and restarting. RESULTS: We identified five adherence trajectories: quick decline (10.4%), moderate decline (8.6%), quick decline then stable (10.3%), stable with late decline (23.6%), and high and stable (47.2%). Women in the high and stable trajectory group were older and more likely to initiate therapy with anastrozole than women in other groups. Time periods after first 6 months, 1.5, and 4 years from initiation seemed critical in terms of remaining adherent on endocrine therapy; 45.8% of the cohort discontinued endocrine therapy with a median time to discontinuation of 2.6 years (interquartile range 1.0-4.4), and 45.8% of the women discontinuing restarted treatment (median time 182.0, interquartile range 133.0-279.0 days). CONCLUSIONS: Our study highlights evidence-practice gaps in the use of endocrine therapy, with half of our sample experiencing suboptimal adherence or persistence. Trajectory modelling provided detailed information about patterns of nonadherence and critical time periods for adherence to endocrine therapy. This information is important for developing targeted interventions to improve adherence.

Using data linkage to enhance the reporting of cancer outcomes of Aboriginal and Torres Strait Islander people in NSW, Australia.

BACKGROUND: Aboriginal people are known to be under-recorded in routinely collected datasets in Australia. This study examined methods for enhancing the reporting of cancer incidence among Aboriginal people using linked data methodologies. METHODS: Invasive cancers diagnosed in New South Wales (NSW), Australia, in 2010-2014 were identified from the NSW Cancer Registry (NSWCR). The NSWCR data were linked to the NSW Admitted Patient Data Collection, the NSW Emergency Department Data Collection and the Australian Coordinating Register Cause of Death Unit Record File. The following methods for enhancing the identification of Aboriginal people were used: 'ever-reported', 'reported on most recent record', 'weight of evidence' and 'multi-stage median'. The impact of these methods on the number of cancer cases and age-standardised cancer incidence rates (ASR) among Aboriginal people was explored. RESULTS: Of the 204,948 cases of invasive cancer, 2703 (1.3%) were recorded as Aboriginal on the NSWCR. This increased with enhancement methods to 4184 (2.0%, 'ever'), 3257 (1.6%, 'most recent'), 3580 (1.7%, 'weight of evidence') and 3583 (1.7%, 'multi-stage median'). Enhancement was generally greater in relative terms for males, people aged 25-34 years, people with cancers of localised or unknown degree of spread, people living in urban areas and areas with less socio-economic disadvantage. All enhancement methods increased ASRs for Aboriginal people. The weight of evidence method increased the overall ASR by 42% for males (894.1 per 100,000, 95% CI 844.5-945.4) and 27% for females (642.7 per 100,000, 95% CI 607.9-678.7). Greatest relative increases were observed for melanoma and prostate cancer incidence (126 and 63%, respectively). ASRs for prostate and breast cancer increased from below to above the ASRs of non-Aboriginal people with enhancement of Aboriginal status. CONCLUSIONS: All data linkage methods increased the number of cancer cases and ASRs for Aboriginal people. Enhancement varied by demographic and cancer characteristics. We considered the weight of evidence method to be most suitable for population-level reporting of cancer incidence among Aboriginal people. The impact of enhancement on disparities in cancer outcomes between Aboriginal and non-Aboriginal people should be further examined.

Cancer survival disparities worsening by socio-economic disadvantage over the last 3 decades in new South Wales, Australia.

BACKGROUND: Public concerns are commonly expressed about widening health gaps. This cohort study examines variations and trends in cancer survival by socio-economic disadvantage, geographical remoteness and country of birth in an Australian population over a 30-year period. METHODS: Data for cases diagnosed in New South Wales (NSW) in 1980-2008 (n = 651,245) were extracted from the population-based NSW Cancer Registry. Competing risk regression models, using the Fine & Gray method, were used for comparative analyses to estimate sub-hazard ratios (SHR) with 95% confidence intervals (CI) among people diagnosed with cancer. RESULTS: Increased risk of cancer death was associated with living in the most socio-economically disadvantaged areas compared with the least disadvantaged areas (SHR 1.15, 95% CI 1.13-1.17), and in outer regional/remote areas compared with major cities (SHR 1.05, 95% CI 1.03-1.06). People born outside Australia had a similar or lower risk of cancer death than Australian-born (SHR 0.99, 95% CI 0.98-1.01 and SHR 0.91, 95% CI 0.90-0.92 for people born in other English and non-English speaking countries, respectively). An increasing comparative risk of cancer death was observed over time when comparing the most with the least socio-economically disadvantaged areas (SHR 1.07, 95% CI 1.04-1.10 for 1980-1989; SHR 1.14, 95% CI 1.12-1.17 for 1990-1999; and SHR 1.24, 95% CI 1.21-1.27 for 2000-2008; p < 0.001 for interaction between disadvantage quintile and year of diagnosis). CONCLUSIONS: There is a widening gap in comparative risk of cancer death by level of socio-economic disadvantage that warrants a policy response and further examination of reasons behind these disparities.

After accounting for competing causes of death and more advanced stage, do Aboriginal and Torres Strait Islander peoples with cancer still have worse survival? A population-based cohort study in New South Wales.

BACKGROUND: Aboriginal and Torres Strait Islander peoples in Australia have been found to have poorer cancer survival than non-Aboriginal people. However, use of conventional relative survival analyses is limited due to a lack of life tables. This cohort study examined whether poorer survival persist after accounting for competing risks of death from other causes and disparities in cancer stage at diagnosis, for all cancers collectively and by cancer site. METHODS: People diagnosed in 2000-2008 were extracted from the population-based New South Wales Cancer Registry. Aboriginal status was multiply imputed for people with missing information (12.9%). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for 'advanced stage' at diagnosis (separately for distant and distant/regional stage). Survival was examined using competing risk regression to compute subhazard ratios (SHRs) with 95%CIs. RESULTS: Of the 301,356 cases, 2517 (0.84%) identified as Aboriginal (0.94% after imputation). After adjusting for age, sex, year of diagnosis, socio-economic status, remoteness, and cancer site Aboriginal peoples were more likely to be diagnosed with distant (OR 1.30, 95%CI 1.17-1.44) or distant/regional stage (OR 1.29, 95%CI 1.18-1.40) for all cancers collectively. This applied to cancers of the female breast, uterus, prostate, kidney, others (those not included in other categories) and cervix (when analyses were restricted to cases with known stages/known Aboriginal status). Aboriginal peoples had a higher hazard of death than non-Aboriginal people after accounting for competing risks from other causes of death, socio-demographic factors, stage and cancer site (SHR 1.40, 95%CI 1.31-1.50 for all cancers collectively). Consistent results applied to colorectal, lung, breast, prostate and other cancers. CONCLUSIONS: Aboriginal peoples with cancer have an elevated hazard of cancer death compared with non-Aboriginal people, after accounting for more advanced stage and competing causes of death. Further research is needed to determine reasons, including any contribution of co-morbidity, lifestyle factors and differentials in service access to help explain disparities.

Characteristics of first-time varenicline users - A cross-sectional study in Finnish quitters.

BACKGROUND: Varenicline is an efficacious medicine for smoking cessation (SC) but little is known about the characteristics of varenicline users. This study examined the characteristics of first-time (naïve) varenicline users in Finland and compared those who had previously used SC pharmacotherapy to those who were trying SC pharmacotherapy for the first time. METHODS: A cross-sectional survey was conducted in Finnish community pharmacies between February 2014 and January 2015. Pharmacy customers purchasing a varenicline starter package for the first time ever were asked to complete a questionnaire or to participate in a structured interview conducted by the pharmacist (identical questions). The questionnaire included questions about demographic characteristics, smoking habits, previous cessation attempts and factors associated with varenicline use. RESULTS: Altogether 98 people completed the survey. The majority were daily smokers (96%, n = 94), with a history of over 10 years of regular smoking (94%, n = 92), and a strong/very strong nicotine dependence (67%, n = 66). Half of the participants (54%, n = 53) were trying a SC pharmacotherapy for the first time. Demographic characteristics and smoking habits were similar between first-time and previous users of SC medications (p > 0.05). Health centers (42%, n = 41) and occupational health care clinics (37%, n = 36) were the most common sources of varenicline prescriptions. The majority of participants received the prescription for varenicline after mentioning their desire for quitting to a physician (70%, n = 69). CONCLUSIONS: Considering the relatively large proportion of SC naïve medicine users among new users of varenicline, smokers who have previously been reluctant to quit smoking, to use other pharmacological SC interventions, or perhaps unaware of these options may be interested in attempting cessation with varenicline. Most participants made the initiative to discuss their smoking with the physician, which led to varenicline prescribing. This suggests that physicians may not satisfactorily recognize their patients' nicotine dependence and desire to quit, and they should more actively support patients' smoking cessation.

Does exclusion of cancers registered only from death-certificate information diminish socio-demographic disparities in recorded survival?

BACKGROUND: Death Certificate Only (DCO) cancer cases are commonly excluded from survival analyses due to unknown survival time. This study examines whether socio-demographic factors are associated with DCO diagnosis, and the potential effects of excluding DCO cases on socio-demographic cancer survival disparities in NSW, Australia. METHODS: NSW Cancer Registry data for cases diagnosed in 2000-2008 were used in this study. Logistic regression was used to estimate the odds of DCO registration by socio-demographic sub-group (socio-economic disadvantage, residential remoteness, country of birth, age at diagnosis). Cox proportional hazard regression was used to estimate the probability of death from cancer by socio-demographic subgroup when DCO cases were included and excluded from analyses. RESULTS: DCO cases consisted of 1.5% (n=4336) of all cases (n=299,651). DCO diagnosis was associated with living in socio-economically disadvantaged areas (most disadvantaged compared with least disadvantaged quintile: odds ratio OR 1.25, 95%CI 1.12-1.40), living in inner regional (OR 1.16, 95%CI 1.08-1.25) or remote areas (OR 1.48, 95%CI 1.01-2.19), having an unknown country of birth (OR 1.63, 95%CI 1.47-1.81) and older age. Including or excluding DCO cases had no significant impact on hazard ratios for cancer death by socio-economic disadvantage quintile or remoteness category, and only a minor impact on hazard ratios by age. CONCLUSION: Socio-demographic factors were associated with DCO diagnosis in NSW. However, socio-demographic cancer survival disparities remained unchanged or varied only slightly irrespective of including/excluding DCO cases. Further research could examine the upper limits of DCO proportions that significantly alter estimated cancer survival differentials if DCOs are excluded.

Factors associated with use of falls risk-increasing drugs among patients of a geriatric oncology outpatient clinic in Australia: a cross-sectional study.

Older people with cancer are at increased risk of falling. Falls risk-increasing drugs (FRIDs), comprising psychotropics and medications that cause orthostatic hypotension, are a potentially modifiable risk factor for falls. The objective of this study was to determine the prevalence and factors associated with use of FRIDs in older people with cancer. Patients aged ≥70 years who presented to a hospital outpatient clinic between January 2009 and July 2010 were included in the study. Information on current medication use, falls in previous 6 months, and frailty criteria was collected. Multinomial logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CIs) for factors associated with levels of FRID use. Overall, 76.1% (n = 293) of 383 patients used FRIDs. This comprised psychotropics (31.2%, n = 120) and medications causing orthostatic hypotension (69.9%, n = 269). In total, 24.0% (n = 92) patients reported falling in the previous 6 months. Risk factors for falling were associated with use of psychotropics but not orthostatic hypotension drugs. Patients with a history of falls had increased odds of using psychotropics (≥3 psychotropics; OR 13.50; 95%CI, 2.64-68.94). Likewise, frail patients had increased odds of using psychotropics (≥3 psychotropics; OR 27.78; 95%CI, 6.06-127.42). Risk factors for falling were associated with the use of psychotropics. This suggests that clinicians either do not recognize or underestimate the contribution of medications to falls in this high-risk patient group. Further efforts are needed to rationalize medication regimens at the time of patients' first presentation to outpatient oncology services.

The impact of geographic unit of analysis on socioeconomic inequalities in cancer survival and distant summary stage - a population-based study.

OBJECTIVE: When using area-level disadvantage measures, size of geographic unit can have major effects on recorded socioeconomic cancer disparities. This study examined the extent of changes in recorded socioeconomic inequalities in cancer survival and distant stage when the measure of socioeconomic disadvantage was based on smaller Census Collection Districts (CDs) instead of Statistical Local Areas (SLAs). METHODS: Population-based New South Wales Cancer Registry data were used to identify cases diagnosed with primary invasive cancer in 2000-2008 (n=264,236). Logistic regression and competing risk regression modelling were performed to examine socioeconomic differences in odds of distant stage and hazard of cancer death for all sites combined and separately for breast, prostate, colorectal and lung cancers. RESULTS: For all sites collectively, associations between socioeconomic disadvantage and cancer survival and distant stage were stronger when the CD-based socioeconomic disadvantage measure was used compared with the SLA-based measure. The CD-based measure showed a more consistent socioeconomic gradient with a linear upward trend of risk of cancer death/distant stage with increasing socioeconomic disadvantage. Site-specific analyses provided similar findings for the risk of death but less consistent results for the likelihood of distant stage. CONCLUSIONS: The use of socioeconomic disadvantage measure based on the smallest available spatial unit should be encouraged in the future. Implications for public health: Disadvantage measures based on small spatial units can more accurately identify socioeconomic cancer disparities to inform priority settings in service planning.

Differences in impact of Aboriginal and Torres Strait Islander status on cancer stage and survival by level of socio-economic disadvantage and remoteness of residence-A population-based cohort study in Australia.

BACKGROUND: Aboriginal and Torres Strait Islander people (referred to in this paper as "Aboriginal people") generally have lower cancer survivals and more advanced stages at diagnosis than non-Aboriginal people. There is conflicting evidence on whether these disparities vary by socio-economic disadvantage and geographic remoteness. This study examines variations in these disparities in New South Wales (NSW), Australia. METHODS: Data for cancers diagnosed in 2000-2008 were extracted from the NSW Cancer Registry (n=264,219). Missing Aboriginal status (13.3%) was multiply imputed. Logistic regression and competing risk regression models were used to examine likelihood of advanced summary stage and risk of cancer death among Aboriginal compared with non-Aboriginal people by socio-economic disadvantage (categorised into quintiles 1: least disadvantaged-5: most disadvantaged) and remoteness. RESULTS: Aboriginal people showed a general pattern of more advanced stage at diagnosis compared with non-Aboriginal people across socio-economic disadvantage and remoteness categories. After adjusting for demographic factors, year of diagnosis, summary stage and cancer site, Aboriginal people living outside the least disadvantaged areas had an increased risk of cancer death compared with non-Aboriginal people living in similar areas (sub-hazard ratio SHR 1.41, 95% confidence interval CI 1.09-1.81; SHR 1.59, 95%CI 1.31-1.93; SHR 1.42, 95%CI 1.22-1.64 and SHR 1.34, 95%CI 1.22-1.48 for quintiles 2-5, respectively). Compared with non-Aboriginal people, Aboriginal people had an elevation in the risk of cancer death irrespective of the remoteness, with the most pronounced elevations detected in remote/very remote areas (SHR 1.56, 95%CI 1.10-2.21). CONCLUSION: Compared with non-Aboriginal people, Aboriginal people had a higher risk of cancer death and higher likelihood of more advanced stage across socio-economic disadvantage and remoteness categories. All areas appear to require attention in endeavours to improve cancer survival outcomes for Aboriginal people.

Socio-demographic disadvantage and distant summary stage of cancer at diagnosis--A population-based study in New South Wales.

BACKGROUND: Past studies generally indicate that socio-demographic disadvantage is associated with lower cancer survival but evidence of an association with stage of cancer at diagnosis has been less consistent. This study examines the associations between distant summary stage and remoteness, socio-economic status and country of birth in New South Wales for invasive cancers overall and by cancer site. METHODS: The population-based New South Wales Central Cancer Registry was used to obtain data on all cases diagnosed in 1980-2009 (n=699,382). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for odds of distant summary stage at diagnosis. RESULTS: A higher likelihood of being diagnosed with distant cancer was detected for those living in the most socio-economically disadvantaged areas compared with the least disadvantaged areas (OR 1.27, 95% CI 1.24-1.30) and for those born in other English and non-English speaking countries compared with Australian-born (OR 1.10, 95% CI 1.07-1.12 and OR 1.12, 95% CI 1.10-1.14, respectively) after adjusting for age, sex, diagnostic period, remoteness, socio-economic status and country of birth. Cases living in inner (OR 0.90, 95% CI 0.88-0.91) and outer regional (OR 0.92, 95% CI 0.89-0.94) areas were less likely to be diagnosed with distant stage than cases living in major cities. Odds of distant stage increased over time for those living in socio-economically disadvantaged areas. In cancer site-specific analyses, living in socio-economically disadvantaged areas was generally a stronger predictor of distant stage than remoteness or country of birth. CONCLUSION: Our results highlight the importance of lower socio-economic status as a predictor of distant stage at diagnosis. Socio-demographic disadvantage patterns varied for specific cancers, but in general, policy actions are recommended that emphasize earlier detection of cancers in people from lower socio-economic areas.