Cancer stages and mortality risk of breast cancer between women with and without disabilities: A national population-based cohort study in Taiwan.

BACKGROUND: The second-most common cause of cancer-related death for women worldwide is breast cancer. However, there is little information about breast cancer among women with disabilities in Taiwan. OBJECTIVES: This study investigated differences between women with and without disabilities regarding breast cancer stages and evaluated the probability of developing an advanced stage and the mortality risk of breast cancer. METHODS: This study conducted a nationwide retrospective cohort study using the National Health Insurance Research Database and other nationwide databases. Our participants were newly diagnosed breast cancer patients, including women with and without disabilities, between 2004 and 2010. We matched both of them with propensity score matching methods (1:5), and all were followed up until the end of 2016. RESULTS: This study included 50,683 participants with breast cancer. After matching, women with disabilities who did not receive breast cancer screening had a more significant proportion of advanced-stage breast cancer (19.95 %) than those without disabilities who did not receive breast cancer screening (16.87 %). After adjusting for related variables, women with disabilities were 1.27 times more likely to have advanced-stage breast cancer than those without disabilities. Additionally, after suffering from breast cancer, individuals with disabilities had a 1.23 times greater mortality risk compared to those without disabilities. CONCLUSIONS: Although cancer stages were controlled, women with disabilities still had a higher mortality risk of breast cancer. Hence, policymakers should pay more attention to women with disabilities to treat them at an early stage, which can reduce the mortality risk attributable to advanced stages.

Effects of the Time of Hospice and Palliative Care Enrollment before Death on Morphine, Length of Stay, and Healthcare Expense in Patients with Cancer in Taiwan.

We aimed to investigate the effects of the time from hospice and palliative care enrollment to death on the quality of care and the effectiveness and trend of healthcare utilization in patients with terminal cancer. Data on the cancer-related mortality rates between 2005 and 2018 reported in the National Health Insurance Research Database in Taiwan were obtained. The effect of hospice and palliative care enrollment at different timepoints before death on healthcare utilization was explored. This retrospective cohort study included 605,126 patients diagnosed with terminal cancer between 2005 and 2018; the percentage of patients receiving hospice and palliative care before death increased annually. Terminal cancer patients who enrolled in hospice and palliative care at different timepoints before death received higher total morphine doses; the difference in the total morphine doses between the two groups decreased as the time to death shortened. The difference in the total morphine doses between the groups gradually decreased from 2005 to 2018. The enrolled patients had longer hospital stays; the length of hospital stays for both groups increased as the time to death lengthened, but the difference was not significant. The enrolled patients incurred lower total medical expenses, but the difference between the two groups increased as the time to death shortened.

Effectiveness of Palliative Care before Death in Reducing Emergency Care Utilization for Patients with Terminal Cancer and Trends in the Utilization of Palliative Care from 2005-2018.

This retrospective cohort study aimed to examine the effect of palliative care for patients with terminal cancer on healthcare utilization. The National Health Insurance (NHI) Research Database and death certificates were utilized to identify patients who died of cancer between 2005 and 2018. The number of terminal cancer patients between 2005 and 2018 was 605,126. Propensity score matching and conditional logistic regression were performed. The odds ratios (ORs) for "emergency care utilization", "CPR", "endotracheal intubation", and "ICU admission" were significantly lower for enrolled patients regardless of enrollment time compared to unenrolled patients. Compared to unenrolled patients, the OR for "emergency care utilization" increased from 0.34 to 0.68, the OR for "CPR use" increased from 0.13 to 0.26, the OR for "intubation" increased from 0.15 to 0.26, and the OR for "ICU admission" increased from 0.27 to 0.40 in enrolled patients. Between 2005 and 2010, CPR utilization, intubation, and ICU admission in patients enrolled in palliative care declined each year. Since the inclusion of palliative care in NHI (from 2010 onward), its utilization has increased slightly each year. Patients with terminal cancer enrolled in palliative care consume fewer medical resources before death than unenrolled patients; however, the difference decreases with longer times before death.

Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system.

BACKGROUND: Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system. OBJECTIVE: To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan. METHODS: This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program. RESULTS: T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one. CONCLUSIONS: Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.

Comparison of Cervical Cancer Screening Used between Individuals with Disabilities and Individuals without Disabilities.

OBJECTIVE: Cervical cancer is the fourth most prevalent cancer in women worldwide. It is vital to achieve a high cervical cancer screening rate among women. We compared the Pap smear test (PST) used between individuals with disabilities and those without disabilities in Taiwan. METHODS: Individuals registered in the Taiwan Disability Registration File and the National Health Insurance Research Database (NHIRD) were screened for this nationally representative retrospective cohort study. Women aged 30 and above in 2016 and who were still alive in 2016 were matched in a 1:1 ratio via propensity score matching (PSM); 186,717 individuals with disabilities and 186,717 individuals without disabilities were included. Controlling for relevant variables, the odds of receiving PST were compared using conditional logistic regression analysis. RESULTS: A lower percentage of individuals with disabilities (16.93%) received PST than those without disabilities (21.82%). The odds of individuals with disabilities receiving PST were 0.74 times that of individuals without disabilities (OR = 0.74, 95% CI = 0.73-0.76). Compared to individuals without disabilities, individuals with intellectual and developmental disabilities had the lower odds of receiving PST (OR = 0.38, 95% CI = 0.36-0.40), followed by individuals with dementia (OR = 0.40, 95% CI = 0.33-0.48) or multiple disabilities (OR = 0.52, 95% CI = 0.49-0.54). CONCLUSIONS: We highly recommend that healthcare practitioners recognize the unique needs of individuals with different types of disabilities, especially those with cognitive impairments.

Disparities in the first-ever diagnosed liver cancers between the emergency department and outpatient department in Taiwan: a population-based study.

BACKGROUND: Liver cancer is ranked fifth in incidence and second in mortality among cancers in Taiwan. Nevertheless, the Taiwan government does not screen for liver cancer in its free cancer screening and preventive health examination service. This study compared the differences in cancer stage and survival between patients who received an initial liver cancer diagnosis in outpatient departments (OPDs) and those who received such a diagnosis in emergency departments (EDs). METHODS: This retrospective cohort study used the 2000-2016 National Health Insurance Database to obtain a sample from 2 million Taiwanese residents. To evaluate the effect of the utilization of the adult health examination offered to people aged ≥ 40 years, patients aged ≥ 40 years who received an initial liver cancer diagnosis between 2003 and 2015 were followed up until December 31, 2016. RESULTS: In total, 2,881 patients were included in this study. A greater proportion of cancer cases in the OPD group were non-advanced than those in the ED group (75.26% vs. 54.23%). Having stage C or D cancer, having a low monthly salary, and a Charlson comorbidity index score ≥ 8, not having hepatitis B, being divorced, and attending a non-public hospital as the primary care institution were risk factors for initial ED diagnosis. The risk of liver cancer-specific death among the ED group patients was 1.38 times that among the OPD group patients (adjusted hazard ratio = 1.38, 95% confidence interval [CI] = 1.14-1.68, P < 0.001). However, the use of health examination did not exert a significant effect on the likelihood of liver cancer diagnosis in an ED (adjusted odds ratio = 0.86, 95% CI = 0.61-1.21, P = 0.381). CONCLUSION: Government-subsidized health examinations are insufficient to prevent first-ever diagnosed liver cancers in EDs. Patients with liver cancers diagnosed in EDs had a higher risk of advanced stage and mortality. For early detection and treatment, the government may consider implementing liver cancer screening for high-risk and low-socioeconomic people.

Comparison of Quality of Life Between Breast Cancer Patients Treated With and Without Adjunctive Traditional Chinese Medicine in Taiwan.

In Taiwan, breast cancer has the highest incidence among all cancers. Although adjunctive traditional Chinese medicine treatment (TCM) have been used to ameliorate the side effects or discomfort caused by cancer treatments, no study has focused on the assessment of the quality of life of patients undergoing adjunctive TCM treatments. This study compared the quality of life between breast cancer patients treated with and without adjunctive TCM. Questionnaires were collected from 7 hospitals with a Chinese medicine clinic in 2018 to 2019. Breast cancer patients who had cancer stages I, II, or III and also underwent resection surgery were included in the study. They were divided into 2 groups: patients receiving cancer treatments with adjunctive traditional Chinese medicine (TCM group) and those receiving cancer treatments without adjunctive traditional Chinese medicine (non-TCM group). A 1:1 matching was used to obtain the study participants. The EQ-5D questionnaire was used to assess the quality of life. Statistical analysis was performed using the t-test and ANOVA to compare the differences between variables. The conditional multiple regression model was applied to explore the factors associated with quality of life in breast cancer patients. A total of 543 participants were surveyed, and 450 participants were included in the study. The EQ-5D score of the TCM group (81.60 ± 11.67) was significantly higher than that of the non-TCM group (78.80 ± 13.10; P < .05). The results of a conditional multiple regression model showed that the TCM group had a higher (3.45 points) quality of life than non-TCM group (P = .002) after adjusting for other related factors. After stratifying by cancer stage, patients with cancer stages II and III scored 5.58 and 4.35 points higher in the TCM group than did those in the non-TCM group (P < .05). Breast cancer patients undergoing cancer treatment with adjunctive traditional Chinese medicine have a higher quality of life than those treated without adjunctive traditional Chinese medicine.

Effect of multidisciplinary team care on patient survival in chronic hepatitis B or C hepatocellular carcinoma.

Introduction: Multidisciplinary team care coordinates with medical teams to improve the quality of cancer care. This study explored multidisciplinary team care in hepatitis B or hepatitis C virus-related hepatocellular carcinoma patients from the time of diagnosis to the first-time treatment interval and investigated treatment outcomes and prognosis. Methods: This retrospective cohort study included data from a nationwide population from 2007 to 2016. Data were collected from the Taiwan Cancer Registry Database, linked to the Taiwan National Health Insurance Research Database. Propensity score matching was applied at a ratio of 1:2 to reduce the selection bias. A multiple regression model with generalized estimating equations was used to analyze whether multidisciplinary team care affected the diagnosis-to-treatment interval. The stratified Cox proportional hazards model examined whether involvement in multidisciplinary team care influenced survival status. Results: A total of 10,928 and 21,856 patients with hepatocellular carcinoma received multidisciplinary and non-multidisciplinary care, respectively. Participants with multidisciplinary care had a longer diagnosis-to-treatment interval but a lower risk of cumulative cancer death (HR=0.88, 95% CI:0.84-0.92). In patients with intermediate- to advanced-stage hepatocellular carcinoma, multidisciplinary team care has obvious benefits for improving survival. Conclusion: Patients with hepatocellular carcinoma who participated in multidisciplinary team care had a longer diagnosis-to-treatment interval but a lower risk of cancer death. Patients with intermediate- to advanced-stage hepatocellular carcinoma who received multidisciplinary team care significantly benefited from this outcome. Hospitals should provide HCC patients with multidisciplinary team care to improve cancer care.

Association of treatment delay and stage with mortality in breast cancer: a nationwide cohort study in Taiwan.

Breast cancer is the fifth leading cause of cancer death globally. In this retrospective study, we investigated the effects of the diagnosis-to-first-treatment interval (DFTI) and other related factors on cancer-specific survival in patients with breast cancer. We included 49,426 patients newly diagnosed as having breast cancer during 2011-2017. The Cox proportional hazards model was used to analyze the hazard ratio (HR) for mortality with various DFTIs; the HRs of the 31-60-, 61-90-, and ≥ 91-day DFTI groups did not differ significantly compared with the reference group (DFTI ≤ 30 days). After stratifying the patients according to initial tumor stage and age, we found that patients aged 55-64 and ≥ 65 years with stage II breast cancer treated ≥ 91 days after diagnosis had a 3.34- and 2.93-fold higher mortality risk (95% confidence intervals [CIs] 1.29-8.69 and 1.06-8.10, respectively). Patients aged ≥ 65 years with stage IV breast cancer treated within 61-90 or ≥ 91 days after diagnosis had a 7.14- and 34.78-fold higher mortality risk (95% CIs 1.28-39.82 and 3.08-393.32, respectively). In conclusion, DFTI is associated with mortality in patients with stage II and IV breast cancer, especially at an older age.

Inequality in the Utilization of Breast Cancer Screening between Women with and without Disabilities in Taiwan: A Propensity-Score-Matched Nationwide Cohort Study.

Because of the difficulties in accessing medical care, the likelihood of receiving breast cancer screening may be low for women with disabilities. We aimed to investigate differences in the utilization of breast cancer screening among women with and without disabilities. Participants included women with and without disabilities from 2004 to 2010, and it was observed whether the participants had received a breast cancer screening during 2011 and 2012. Propensity-score matching was employed to match disabled women with non-disabled women (1:1). Data sources included the National Health Insurance Research Database, the Cancer Screening Database, and the Disability Registration File. Conditional logistic regression was performed to examine the odds ratios (ORs) that both groups would undergo breast cancer screening. The proportion of women with disabilities who received breast cancer screening was 18.33%, which was significantly lower than that of women without disabilities (25.52%) (p < 0.001). Women with dementia had the lowest probability of receiving a mammography examination (OR = 0.34; 95% CI: 0.28−0.43), followed by those with multiple disabilities (OR = 0.43; 95% CI: 0.40−0.47) and intellectual disabilities (OR = 0.45; 95% CI: 0.41−0.50). In conclusion, compared to women without disabilities, those with disabilities were less likely to undergo breast cancer screening.

Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study.

PURPOSE: Taiwan has implemented an integrated prospective payment program (IPP) for prolonged mechanical ventilation (PMV) patients that consists of four stages of care: intensive care unit (ICU), respiratory care center (RCC), respiratory care ward (RCW), and respiratory home care (RHC). We aimed to investigate the life impact on family caregivers of PMV patients opting for a payment program and compared different care units. METHOD: A total of 610 questionnaires were recalled. Statistical analyses were conducted by using the chi-square test and multivariate logistic regression model. RESULTS: The results indicated no associations between caregivers' stress levels and opting for a payment program. Participants in the non-IPP group spent less time with friends and family owing to caregiver responsibilities. The results of the family domain show that the RHC group (OR = 2.54) had worsened family relationships compared with the ICU group; however, there was less psychological stress in the RCC (OR = 0.54) and RCW (OR = 0.16) groups than in the ICU group. In the social domain, RHC interviewees experienced reduced friend and family interactivity (OR = 2.18) and community or religious activities (OR = 2.06) than the ICU group. The RCW group felt that leisure and work time had less effect (OR = 0.37 and 0.41) than the ICU group. Furthermore, RCW interviewees (OR = 0.43) were less influenced by the reduced family income than the ICU group in the economic domain. CONCLUSIONS: RHC family caregivers had the highest level of stress, whereas family caregivers in the RCW group had the lowest level of stress.

Statin Therapy for Hyperlipidemic Patients With Chronic Kidney Disease and End-Stage Renal Disease: A Retrospective Cohort Study Based on 925,418 Adults in Taiwan.

Background: For non-dialysis patients with hyperlipidemia, statins may provide clinical benefits in reducing mortality risk; however, the optimal treatment for dialysis patients with hyperlipidemia remains debatable. We evaluated the mortality risks for hyperlipidemic patients with renal disorders associated with statin therapy (ST), using the insurance claims data of Taiwan. Methods: From hyperlipidemic patients diagnosed in 2000-2011, we identified 555,153 patients receiving statin treatment for at least 90 days continuously and 1,141,901 non-statin users, and then randomly selected, from both groups, the propensity score-matched subcohorts of statin users and nonusers in a 1:1 pair by renal function: 415,453 pairs with normal renal function , 43,632 pairs with chronic kidney disease (CKD), and 3,624 pairs with end-stage renal disease (ESRD). We compared the mortalities, by the end of 2016, from all causes, cancer, heart disease, and septicemia between statin users and non-users and between hydrophilic-statin users and lipophilic-statin users. The Cox method estimated ST users to non-user hazard ratios. The time-dependent model was also conducted as sensitivity analysis. Results: The mean ages were 58.7 ± 10.7, 64.2 ± 10.7, and 62.2 ± 10.8 years in normal renal function, CKD, and ESRD groups, respectively. Compared with non-users, statin users had reduced mortality risks from all causes for 32%-38%, from cancer for 37%-46%, from heart disease for 6%-24%, and from septicemia for 17%-21% in all three renal groups. The hydrophilic statin therapy was superior than the lipophilic statin therapy, particularly for reducing deaths from all-causes and cancer. The results under the time-dependent model were similar. Conclusion: Statin therapy is associated with reduced all-causes and non-cardiovascular mortality in ESRD patients.

Statins Reduce Hepatocellular Carcinoma Risk in Patients with Chronic Kidney Disease and End-Stage Renal Disease: A 17-Year Longitudinal Study.

Hepatocellular carcinoma (HCC) is the most common cancer in end-stage renal disease (ESRD) patients in Taiwan. Whether statin therapy associated with the HCC risk in hyperlipidemic patients with chronic kidney disease (CKD) and ESRD is unclear. Using population-based insurance claim data from Taiwan, we identified from hyperlipidemic patients taking statins or not (677,364 versus 867,707) in 1999-2015. Among them, three pairs of propensity score matched statin and non-statin cohorts were established by renal function: 413,867 pairs with normal renal function (NRF), 46,851 pairs with CKD and 6372 pairs with ESRD. Incidence rates of HCC were compared, by the end of 2016, between statin and non-statin cohorts, between hydrophilic statins (HS) and lipophilic statins (LS) users, and between statin-ezetimibe combination therapy (SECT) and statin monotherapy (SM) users. The HCC incidence increased progressively from NRF to CKD and ESRD groups, was lower in the statin cohort than in the non-statin cohort, with the differences of incidence per 10,000 person-years increased from (7.77 vs. 21.4) in NRF group to (15.8 vs. 37.1) in CKD group to (19.1 vs. 47.8) in ESRD group. The incidence increased with age, but the Cox method estimated hazard ratios showed a greater statin effectiveness in older patients. Among statin users, the HCC incidence was lower in HS users than in LS users, and lower in SECT users than in SM users, but the difference was significant only in the NRF group. Hyperlipidemic patients with CKD and ESRD receiving statins are at reduced HCC risks; the treatment effectiveness is superior for HS users than for LS users, and for SECT users than for SM users, but not significant.

Impact of Socioeconomic Status on Cancer Incidence Risk, Cancer Staging, and Survival of Patients with Colorectal Cancer under Universal Health Insurance Coverage in Taiwan.

This study examined the impact of socioeconomic status on colorectal cancer risk, staging, and survival under the National Health Insurance (NHI) system in Taiwan. Monthly salary and education level were used as measures of socioeconomic status to observe the risk of colorectal cancer among individuals aged 40 years or above in 2006-2015 and survival outcomes of patients with colorectal cancer until the end of 2016. Data from 286,792 individuals were used in this study. Individuals with a monthly salary ≤Q1 were at a significantly lower incidence risk of colorectal cancer than those with a monthly salary >Q3 (HR = 0.80, 95% CI = 0.74-0.85), while those with elementary or lower education were at a significantly higher risk than those with junior college, university, or higher education (HR = 1.18, 95% CI = 1.06-1.31). The results show that socioeconomic status had no significant impact on colorectal cancer stage at diagnosis. Although salary was not associated with their risk of mortality, patients with colorectal cancer who had elementary or lower education incurred a significantly higher risk of mortality than those who had junior college, university, or higher education (HR = 1.39, 95% CI = 1.07-1.77). Education level is a significant determinant of the incidence risk and survival in patients with colorectal cancer, but only income significantly impacts incidence risk.

Comparison of colorectal cancer screening between people with and without disability: a nationwide matched cohort study.

BACKGROUND: The World Health Organization has recognized that people with disability are among the most marginalized in the world. This study's objective was to investigate the differences in the probability of colorectal cancer (CRC) screening with faecal immunochemical testing (FIT) between people with disability and without disability in Taiwan. METHODS: The study participants included people with and without disability from the Disability Registration Database (2012) and the National Health Insurance Research Database (2009-2012). The study included 50- to 69-year-olds with and without disability who were screened from 2011 to 2012 and were alive in 2012. There were 16 categories of disability. After propensity score matching (PSM) between the two groups, conditional logistic regression analysis with control variables was used to investigate the odds ratio (OR) that people with or without disability would undergo CRC screening. RESULTS: The percentage of people with disability receiving CRC screening was 21.84%, and the highest rate of those receiving CRC screening (38.72%) was found in people with intractable epilepsy, whose OR was 1.47 times that of people with moving functional limitation (95% confidence interval (CI) = 1.17-1.85). The results showed that the probability of CRC screening in people with disability was lower than that in people without disability (OR = 0.88, 95%CI = 0.87-0.89). The probability of receiving CRC screening differed between people with different categories of disability. CONCLUSIONS: Although the probability of CRC screening in the four categories of disability was higher than that in the general population, overall, people with disability were less likely than people without disability to undergo CRC screening. Health inequalities still exist under National Health Insurance in Taiwan.

Effect of multidisciplinary team care on survival of oesophageal cancer patients: a retrospective nationwide cohort study.

Oesophageal cancer is the sixth leading cause of cancer death worldwide. This nationwide study analyses the survival results of oesophageal cancer under multidisciplinary team (MDT) care. We enrolled oesophageal cancer patients diagnosed between 2010 and 2015 with follow-up for at least 1 year. This study performed propensity score matching with a ratio of 1:1 between MDT participants and non-MDT participants. We performed conditional Cox proportional hazards model to research relative risk of survival and associated factors of survival. The adjusted survival curves were plotted. 8184 newly diagnosed oesophageal cancer patients were included. The favourable survival factors include participant status of MDT, gender, monthly salary, urbanization level, other catastrophic illness, stage of cancer, treatment methods, and service volume of physicians (P < 0.05). MDT participants showed lower risk of death (HR = 0.73; 95% CI 0.67-0.79). Further stratification analysis revealed that the incorporation of an MDT reduced the death risk of patients with stages 2, 3, and 4 cancer, with the greatest reduction observed in patients with stage 3 cancer (HR = 0.72; 95% CI 0.67-0.79). The risk of death was lower for oesophageal cancer patients who enrolled in MDT care.

The Cancer Risk among Physicians in Taiwan, a Population-Based Propensity Score Matched Cohort Study.

BACKGROUND: The field of physician health is gaining increasing attention; however, most research and interventions have concentrated on factors such as job stress, mental health, and substance abuse. The risks of major cancers in physicians remain unclear. We used a propensity score-matched analysis to investigate the risk of cancer in physicians relative to the general population who had no healthcare-related professional background. METHODS: Data were obtained from the National Health Insurance system in Taiwan. The physician cohort contained 29,713 physicians, and each physician was propensity score-matched with a person from the general population. RESULTS: The physicians demonstrated a 0.90-fold lower risk of all-cancers (95% confidence interval [CI] = 0.83 - 0.96) when compared with the general population. Female physicians had a higher risk of cancer than male physicians (adjusted hazard ratio [HR] = 1.59; 95% CI = 1.28 - 1.96). Physicians had higher risks of prostate (HR = 1.26; 95% CI = 1.00 - 1.59) and thyroid cancers (HR = 3.16; 95% CI = 1.69 - 5.90) when compared with the general population. CONCLUSION: Physicians have lower rates of overall cancer risk than the general population. Female physicians have higher cancer risks than male physicians. Male physicians have higher risks of thyroid and prostate cancer relative to the general population.

Cigarette smoke-induced LKB1/AMPK pathway deficiency reduces EGFR TKI sensitivity in NSCLC.

Smoker patients with non-small cell lung cancer (NSCLC) have poorer prognosis and survival than those without smoking history. However, the mechanisms underlying the low response rate of those patients to EGFR tyrosine kinase inhibitors (TKIs) are not well understood. Here we report that exposure to cigarette smoke extract enhances glycolysis and attenuates AMP-activated protein kinase (AMPK)-dependent inhibition of mTOR; this in turn reduces the sensitivity of NSCLC cells with wild-type EGFR (EGFRWT) to EGFR TKI by repressing expression of liver kinase B1 (LKB1), a master kinase of the AMPK subfamily, via CpG island methylation. In addition, LKB1 expression is correlated positively with sensitivity to TKI in patients with NSCLC. Moreover, combined treatment of EGFR TKI with AMPK activators synergistically increases EGFR TKI sensitivity. Collectively, the current study suggests that LKB1 may serve as a marker to predict EGFR TKI sensitivity in smokers with NSCLC carrying EGFRWT and that the combination of EGFR TKI and AMPK activator may be a potentially effective therapeutic strategy against NSCLC with EGFRWT.

Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study.

OBJECTIVES: Taiwan has implemented the Diagnosis Related Groups (DRGs) since 2010, and the quality of care under the DRG-Based Payment System is concerned. This study aimed to examine the characteristics, related factors, and time distribution of emergency department (ED) visits, readmission, and hospital transfers of inpatients under the DRG-Based Payment System for each Major Diagnostic Category (MDC). METHODS: We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) from 2012 to 2013 in Taiwan. Multilevel logistic regression analysis was used to examine the factors related to ED visits, readmissions, and hospital transfers of patients under the DRG-Based Payment System. RESULTS: In this study, 103,779 inpatients were under the DRG-Based Payment System. Among these inpatients, 4.66% visited the ED within 14 days after their discharge. The factors associated with the increased risk of ED visits within 14 days included age, lower monthly salary, urbanization of residence area, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, Diseases and Disorders of the Kidney and Urinary Tract (MDC11) conferred the highest risk of ED visits within 14 days (OR = 4.95, 95% CI: 2.69-9.10). Of the inpatients, 6.97% were readmitted within 30 days. The factors associated with the increased risk of readmission included gender, age, lower monthly salary, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, the inpatients with Pregnancy, Childbirth and the Puerperium (MDC14) had the highest risk of readmission within 30 days (OR = 20.43, 95% CI: 13.32-31.34). Among the inpatients readmitted within 30 days, 75.05% of them were readmitted within 14 days. Only 0.16% of the inpatients were transferred to other hospitals. CONCLUSION: The study shows a significant correlation between Major Diagnostic Categories in surgery and ED visits, readmission, and hospital transfers. The results suggested that the main reasons for the high risk may need further investigation for MDCs in ED visits, readmissions, and hospital transfers.

Recurrence, death risk, and related factors in patients with stage 0 colorectal cancer: A nationwide population-based study.

In this study, the National Health Insurance Research Database of Taiwan was used to examine the recurrence and death risk for stage 0 colorectal cancer patients. We examined stage 0 colorectal cancer patients to identify factors causing recurrence and death.This is a retrospective study, and stage 0 colorectal cancer patients that are registered in the Taiwan Cancer Registry of the Health Promotion Administration in 2007 to 2012 were included. The database was linked to the National Health Insurance Research Database, and subjects were followed up until the end of 2016. The mean follow-up period was 69 months. Bivariate analysis methods (log-rank test) and Cox proportional hazards model were used to evaluate the risk of recurrence and death and demographic characteristics, economic factors, environmental factors, health factors, treatment and hospitals, and absence/presence of postoperative tests were used to examine related risk factors.Our study showed that the 5-year recurrence rate and 5-year mortality rate for stage 0 colorectal cancer are 1.68% and 0.6%, respectively. For stage 0 colorectal cancer, age (61-74 years) is the only factor affecting recurrence in patients (hazard ratio (HR) = 2.44; 95% CI: 1.41-4.22), while age >75 years (HR = 4.35; 95% CI: 1.14-16.68) and Charlson Comorbidity Index >4 points (HR = 7.20, 95% CI: 2.60-19.94) can increase the risk of death. In contrast, patients who underwent one (HR = 0.27, 95% CI: 0.10-0.71) and two or more colonoscopies (HR = 0.26, 95% CI: 0.10-0.70) within 2 years after surgery can reduce the risk of death from stage 0 colorectal cancer. In addition, the risk of recurrence is higher in patients who underwent colonoscopic polypectomy (HR = 2.07, 95% CI: 0.98-4.33) and patients with rectal cancer (HR = 2.74, 95% CI: 0.96-7.83), but these differences are not statistically significant (P > .05).From this study, we can see that age and comorbidity index increase the risk of recurrence and death for stage 0 colorectal cancer, while postoperative colonoscopy can decrease the risk of death.