Progress in Cancer Control in Maryland: 1985-2015.

PURPOSE: Maryland historically had a high cancer burden, which prompted the implementation of aggressive cancer control strategies. We examined the status of cancer in Maryland and work under the current and previous editions of the MD Comprehensive Cancer Control Plan. METHODS: We examined the prevalence of cancer mortality, cancer incidence, and cancer-related behaviors in Maryland and the United States from 1985 to 2015 using publicly available data in the US Cancer Control PLANET, CDC WONDER, and Behavioral Risk Factor Surveillance System portals. We estimated the average annual cancer deaths avoided by triangulation. RESULTS: In 1983-1987, Maryland had the highest age-adjusted cancer mortality rate of all 50 states, second only to Washington, District of Columbia. Today (2011-2015), Maryland's age-adjusted cancer mortality rate ranks 31st. Overall cancer mortality rates have declined 1.9% annually from 1990 to 2015, avoiding nearly 60 000 deaths over 3 decades. While the prevalence of healthy cancer-related behaviors in Maryland was qualitatively similar or higher than that of the United States in 2015, Maryland's 5-year (2011-2015) cancer incidence rate was significantly greater than that of the United States. CONCLUSIONS: Maryland's 30-year cancer mortality declines have outpaced other states. However, a reduction in mortality while incidence rates remain high indicates a need for enhanced focus on primary prevention.

Leveraging the electronic health record to eliminate hepatitis C: Screening in a large integrated healthcare system.

Highly efficacious and tolerable treatments that cure hepatitis C viral (HCV) infection exist today, increasing the feasibility of disease elimination. However, large healthcare systems may not be fully prepared for supporting recommended actions due to knowledge gaps, inadequate infrastructure and uninformed policy direction. Additionally, the HCV cascade of care is complex, with many embedded barriers, and a significant number of patients do not progress through the cascade and are thus not cured. The aim of this retrospective cohort study was to evaluate a large healthcare system's HCV screening rates, linkage to care efficiency, and provider testing preferences. Patients born during 1945-1965, not previously HCV positive or tested from within the Electronic Health Record (EHR), were identified given that three-quarters of HCV-infected persons in the United States are from this Birth Cohort (BC). In building this HCV testing EHR prompt, non-Birth Cohort patients were excluded as HCV-specific risk factors identifying this population were not usually captured in searchable, structured data fields. Once completed, the BC prompt was released to primary care locations. From July 2015 through December 2016, 11.5% of eligible patients (n = 9,304/80,556) were HCV antibody tested (anti-HCV), 3.8% (353/9,304) anti-HCV positive, 98.1% (n = 311/317) HCV RNA tested, 59.8% (n = 186/311) HCV RNA positive, 86.6% (161/186) referred and 76.4% (n = 123/161) seen by a specialist, and 34.1% (n = 42/123) cured of their HCV. Results from the middle stages of the cascade in this large healthcare system are encouraging; however, entry into the cascade-HCV testing-was performed for only 11% of the birth cohort, and the endpoint-HCV cure-accounted for only 22% of all infected. Action is needed to align current practice with recommendations for HCV testing and treatment given that these are significant barriers toward elimination.

Impact of intraoperative high-volume autologous blood collection on allogeneic transfusion during and after cardiac surgery: a propensity score matched analysis.

BACKGROUND: Perioperative use of allogeneic blood products is associated with higher morbidity, mortality, and hospital costs after cardiac surgery. Blood conservation techniques such as acute normovolemic hemodilution (ANH) report variable success. We hypothesized that large-volume ANH with limited hemodilution would reduce allogeneic blood transfusion compared to the standard practice. STUDY DESIGN AND METHODS: Retrospective observational study of cardiac surgery patients at the University of Maryland Medical Center between January 2014 and September 2017. Using the institutional Society of Thoracic Surgeons database 91 autologous and 981 control patients who underwent coronary artery bypass grafting, aortic valve replacement, or both were identified. After propensity matching of 13 preoperative characteristics, 84 autologous and 84 control patients were evaluated. Our primary endpoint was avoidance of blood transfusion during index hospitalization, and secondary endpoints were postoperative bleeding and major adverse outcomes. RESULTS: The median harvest volumes in the ANH and control groups were 1100 mL and 400 mL, respectively. Of the ANH group, 25% received any transfusion versus 45.2% of the control group after propensity score matching (p < 0.006). When controlling for preoperative platelet count, the transfusion rate ratios for ANH were 0.58 (95% confidence interval, 0.39-0.88) for RBCs and 0.63 (0.44-0.89) for non-RBC components, which were both found to be statistically significant. There was no difference found in major adverse events. CONCLUSION: These results suggest that large-volume ANH is beneficial in reducing both RBC and non-RBC component usage in cardiac surgery. A further prospective validation is warranted.

Quality Metrics and Health Care Utilization for Adult Patients with Sickle Cell Disease.

BACKGROUND: To date, there are no standardized, well-accepted, quality metrics that guide care for adults with sickle cell disease (SCD). The primary objective of this study was to evaluate the quality metrics that are in use at the Adult Sickle Cell Disease Program at Johns Hopkins Hospital (JHH) and the applicability of the metrics to Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated healthcare system with a developing adult sickle cell disease program. METHODS: We performed a retrospective cross-sectional study of 146 KPMAS and 308 JHH patients from January 1, 2014-December 31, 2015. Demographics, genotype and data on several key quality metrics (yearly screening labs, documented vaccinations and appropriate hydroxyurea prescriptions) were collected from electronic health records (EPIC Systems). We defined hydroxyurea adherence as having had at least 6 months of refills prescribed during the two years of study by either EHR or patient report. RESULTS: Patients at KPMAS were older than those at JHH (median age 44 and 33 respectively) and less likely to have hemoglobin SS disease (29% and 66% respectively). Among KPMAS patients, 85% had documentation of any pneumococcal vaccination compared to 87% at JHH. 21 of 54 eligible patients at KPMAS and 95 of 165 eligible patients at JHH were prescribed hydroxyurea. At both institutions, 62% of patients were adherent to hydroxyurea. There were limitations to diagnosis coding and availability of vaccination and refill documentation. CONCLUSIONS: Interventions to improve preventative care adherence are needed to improve outcomes in both academic medical centers and integrated health systems.

Increasing prevalence of human papillomavirus-positive oropharyngeal cancers among older adults.

BACKGROUND: The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is increasing among older adults. It is unknown whether these trends can be explained by human papillomavirus (HPV) and whether HPV-related tumors remain associated with an improved prognosis among older patients. METHODS: In a retrospective study of OPSCCs diagnosed from 1995 to 2013 at 2 National Comprehensive Cancer Network-designated cancer centers, p16 immunohistochemistry and in situ hybridization (ISH) for HPV-16, high-risk DNA, and/or E6/E7 RNA were performed. The median age at diagnosis was compared by p16 and ISH tumor status. Trends in age were analyzed with nonparametric trends. Survival was analyzed with the Kaplan-Meier method and Cox proportional hazards models. RESULTS: Among 239 patients, 144 (60%) were p16-positive. During 1998-2013, the median age increased among p16-positive patients (Ptrend = .01) but not among p16-negative patients (Ptrend = .71). The median age of p16-positive patients increased from 53 years (interquartile range [IQR] in 1995-2000, 45-65 years) to 58 years (IQR for 2001-2013, 53-64 years). Among patients ≥ 65 years old, the proportion of OPSCCs that were p16-positive increased from 41% during 1995-2000 to 75% during 2007-2013 (Ptrend = .04). Among all age groups, including older patients, a p16-positive tumor status conferred improved overall survival in comparison with a p16-negative status. CONCLUSIONS: The median age at diagnosis for HPV-related OPSCC is increasing as the proportion of OPSCCs caused by HPV rises among older adults. The favorable survival conferred by an HPV-positive tumor status persists in older adults. Cancer 2018;124:2993-9. © 2018 American Cancer Society.

Association Between Preconception Counseling and Folic Acid Supplementation Before Pregnancy and Reasons for Non-Use.

To examine the relationship between folic acid preconception counseling (PCC) and folic acid use and reasons for non-use among women with a recent live birth. We analyzed Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) survey responses from 2009 to 2011 (n = 4,426, response rate = 67%). Multivariable weighted logistic regression models were used to explore associations between folic acid PCC receipt and folic acid use and reasons for non-use. Approximately 30% of women reported daily folic acid use the month before pregnancy, with lower rates among those who were <30, non-white, or unmarried; received WIC during pregnancy; had suffered a stressful event prepregnancy; smoked prepregnancy; had a previous live birth; or had an unintended pregnancy (all p < 0.05). The most common reasons for folic acid non-use were "not planning pregnancy" (61%) and "didn't think needed to take" (41%). Folic acid PCC receipt was reported by 27% of women and was associated with three times the odds of folic acid use (adjusted odds ratio [aOR] 3.15, 95% CI 2.47-4.03) and half the odds of reporting "didn't think needed to take" (aOR 0.47, 95% CI 0.28-0.78) as a reason for non-use. Less than one-third of recent Maryland mothers reported using folic acid daily before pregnancy and only 27% reported receiving folic acid PCC. However, folic acid PCC was associated with increased folic acid use and decreased reporting that women did not think they needed to take folic acid. Our data support initiatives to promote provision of folic acid PCC to all women of childbearing age.

Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Mesothelioma: Experience of a Peritoneal Surface Malignancy Center.

Diffuse malignant peritoneal mesothelioma (DMPM) is an uncommon malignancy, which can be difficult to treat. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have evolved as the treatment of choice when complete cytoreduction is to be achieved. This study reports the outcomes of CRS/HIPEC for peritoneal mesothelioma performed in a center for peritoneal surface malignancy. A retrospective analysis of a prospective database of 389 CRS/HIPEC procedures identified 23 patients who underwent CRS/HIPEC for DMPM from 1999 to 2014. Gender, age at diagnosis, age at surgery, previous surgeries, follow-up time, peritoneal cancer index (PCI) score, completeness of cytoreduction (CC), pathology, and overall survival (OS) were analyzed. The univariate analysis was used to determine the prognostic value of age, gender, neoadjuvant chemotherapy, histopathology of the tumor, PCI, CC, and lymph node status on survival. Mean follow-up time from surgery was 31 months (range = 0.5-124). The median PCI score was 28, and 77 per cent had PCI ≥20. CC 0-1 was achieved in 65 per cent of cases. One- and 5-year actuarial OS rates from diagnosis were 86 per cent and 60 per cent, respectively. One- and 5-year actuarial OS from HIPEC was 70 per cent and 64 per cent, respectively. The univariate analysis showed that the CC was the only significant prognostic factor. Patients with DMPM may achieve long-term survival when treated with CRS/HIPEC. The CC is the most significant prognostic factor for long-term survival.

Serological investigation of transplacental infection with Neospora hughesi and Sarcocystis neurona in broodmares.

The aim of the present study was to investigate the likelihood of transplacental transmission of Neospora hughesi and Sarcocystis neurona in foals, born from seropositive mares. Three broodmares with persistent N. hughesi infection gave birth to eight healthy foals over a period of 7 years. These foals were seropositive to N. hughesi prior to colostrum ingestion, with titers ranging between 640 and 20,480, measured by indirect fluorescence antibody test (IFAT). Of 174 foals born at another farm to mares with a high seroprevalence to S. neurona, only one (with a pre-colostrum antibody titer of 80) tested seropositive. Transplacental transmission of N. hughesi seems to occur from latently infected mares to their foals, while this route of transmission does not seem to occur commonly for S. neurona.

Using antibiograms to improve antibiotic prescribing in skilled nursing facilities.

BACKGROUND: Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. OBJECTIVE: To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. DESIGN AND SETTING: Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. METHODS: Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. RESULTS: We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). CONCLUSIONS: Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

Survival after community diagnosis of early-stage non-small cell lung cancer.

BACKGROUND: "Rush to surgery" among patients with worse symptoms, delays related to morbidity, and inclusion of patients with advanced disease in study populations have produced a mixed picture of importance of time to treatment to survival of non-small cell lung cancer. Our objective was to assess the contribution of diagnosis to first surgery interval to survival among patients diagnosed in the community with early-stage non-small cell lung cancer. METHODS: Patients with early-stage lung cancer (N = 174) at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins who were diagnosed and treated from 2003 to 2009 and followed through 2011 made up a prospective study of overall survival. Diagnosis to first surgery interval was examined overall, as 2 segments (referral interval and treatment interval), as short and longer intervals, and as a continuous variable. RESULTS: The majority of patients were female (55%) and aged more than 65 years (61%). The average mean referral and treatment delays were 61.2 and 5.9 days, respectively. Cox method hazard analysis revealed that older age (years) at diagnosis (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00-1.05), stage IIB (HR, 2.17; 95% CI, 1.12-4.21), large (>4 cm) (HR, 3.68; 95% CI, 1.05-12.93) or unknown tumor size (HR, 4.45; 95% CI, 1.21-16.38), and weeks from diagnosis to first surgery interval (HR, 1.04; 95% CI, 1.00-1.09) predicted worse overall survival. The threshold period of less than 42 days from diagnosis to surgery did not reach statistical significance. CONCLUSIONS: Patients seem to benefit from rapid reduction of tumor burden with surgery. Reasons for delay were not available. Nevertheless, referral delay experienced in the community is unduly long. In addition to patient choices, an unconscious patient or physician bias that lung cancer is untreatable or an inevitable consequence of smoking may be operating and needs further investigation.

Thyroxine and triiodothyronine content in commercially available thyroid health supplements.

BACKGROUND: As defined by the Dietary Supplement Health and Education Act 1997, such substances as herbs and dietary supplements fall under general Food and Drug Administration supervision but have not been closely regulated to date. We examined the thyroid hormone content in readily available dietary health supplements marketed for "thyroid support." METHODS: Ten commercially available thyroid dietary supplements were purchased. Thyroid supplements were dissolved in 10 mL of acetonitrile and water with 0.1% trifloroacetic acid and analyzed using high-performance liquid chromatography for the presence of both thyroxine (T4) and triiodothyronine (T3) using levothyroxine and liothyronine as a positive controls and standards. RESULTS: The amount of T4 and T3 was measured separately for each supplement sample. Nine out of 10 supplements revealed a detectable amount of T3 (1.3-25.4 µg/tablet) and 5 of 10 contained T4 (5.77-22.9 µg/tablet). Taken at the recommended dose, 5 supplements delivered T3 quantities of greater than 10 µg/day, and 4 delivered T4 quantities ranging from 8.57 to 91.6 µg/day. CONCLUSIONS: The majority of dietary thyroid supplements studied contained clinically relevant amounts of T4 and T3, some of which exceeded common treatment doses for hypothyroidism. These amounts of thyroid hormone, found in easily accessible dietary supplements, potentially expose patients to the risk of alterations in thyroid levels even to the point of developing iatrogenic thyrotoxicosis. The current study results emphasize the importance of patient and provider education regarding the use of dietary supplements and highlight the need for greater regulation of these products, which hold potential danger to public health.

Contemporary evaluation of the National Comprehensive Cancer Network prostate cancer risk classification system.

OBJECTIVE: To analyze the National Comprehensive Cancer Network prostate cancer guidelines pretreatment risk groups in a contemporary series of patients treated with radical prostatectomy. METHODS: We analyzed our institutional radical prostatectomy database, including all patients with clinically localized disease treated from 2000 to 2010. Using the National Comprehensive Cancer Network guidelines, the patients were classified into low-, intermediate-, or high-risk groups. The pathologic outcomes were assessed, and the biochemical recurrence (BCR)-free survival rates were calculated and compared using the log-rank test and Cox proportional hazards analysis. RESULTS: A total of 12 821 men met the inclusion criteria. The pathologic and 10-year BCR-free survival rates differed significantly by risk group (low risk, 92.1%; intermediate risk, 71.0%; and high risk, 38.8%; P < .01). Among the intermediate-risk men, the 10-year BCR-free survival was significantly greater for men assigned to the intermediate-risk group by clinical stage (88.8%) than for those deemed intermediate risk by the Gleason score (73.6%) or prostate-specific antigen (PSA) level (79.5%; P = .01). Likewise, in the high-risk men, a trend was seen toward improved 5-year BCR-free survival for patients with clinical stage T3a tumors (77.8%) compared with those considered high risk because of the Gleason score (53.7%) or PSA level (41.0%; P = .13). On multivariate analysis, clinical stage, Gleason score, and PSA level were all significantly associated with BCR. CONCLUSION: We observed heterogeneous outcomes among patients within the National Comprehensive Cancer Network intermediate- and high-risk groups. The BCR-free survival rates were superior for men with an advanced clinical stage compared with those with an advanced Gleason score or elevated PSA level. This within-group heterogeneity must be considered when choosing the treatment modality and predicting an individual patient's prognosis.

The impact of fish and shellfish consumption on age-related macular degeneration.

PURPOSE: To determine the relationship between fish and shellfish consumption and age-related macular degeneration (AMD) status in the Salisbury Eye Evaluation (SEE) Study participants. DESIGN: A cross-sectional study of dietary and ophthalmologic data. PARTICIPANTS: A random sample of 2520 Salisbury, Maryland, residents aged 65 to 84 years. METHODS: A food frequency questionnaire was used to estimate weekly fish/shellfish consumption for each participant. Age-related macular degeneration status was determined from fundus photographs obtained at baseline and graded by 2 masked readers for drusen size, retinal pigment epithelium abnormalities, geographic atrophy (GA), and choroidal neovascularization (CNV). The association between weekly fish/shellfish intake and risk of AMD was investigated using logistic regression while adjusting for risk factors and correlation between eyes. MAIN OUTCOME MEASURES: Status of AMD. RESULTS: The distribution of weekly fish/shellfish consumption was not different between specific AMD categories compared with controls (P = 0.6, 0.7, and 0.7 for large drusen, pigment abnormalities, and advanced AMD compared with controls, respectively). Those with advanced AMD (CNV or GA) were significantly less likely to consume fish/shellfish high in omega-3 fatty acids (odds ratio 0.4; confidence interval, 0.2-0.8). There was no relationship of AMD with intake of crab and oysters combined, each of which has high levels of zinc. CONCLUSIONS: These data support a protective effect of fish/shellfish intake against advanced AMD.

The impact of different dog-related stimuli on engagement of persons with dementia.

OBJECTIVE: To provide further empirical evaluation of the effectiveness of animal-assisted therapy in nursing home residents with dementia. METHODS: Participants were 56 residents of 2 suburban Maryland nursing homes and had a diagnosis. Activities of daily living performance was assessed via the minimum data set and cognitive functioning assessed using the Mini-Mental State Examination. Engagement with dog-related stimuli was systematically assessed via the observational measurement of engagement. RESULTS: Mean engagement duration was significantly lower for the small dog. Highest mean engagement duration was found for the puppy video, followed by the real dog and lowest was for the dog-coloring activity. Positive attitudes were found toward the real dogs, robotic dog, the puppy video, and the plush dog. No significant differences were found in engagement duration among our dog-related stimuli. CONCLUSIONS: Nursing homes should consider animal-assisted therapy and dog-related stimuli, as they successfully engage residents with dementia.

Toothache pain: behavioral impact and self-care strategies.

A computer-assisted telephone interview in Maryland of adults who had low income and were Hispanic, Black, and White and who had experienced a toothache during the previous 12 months was conducted. Respondents reported a high prevalence of toothaches, with 44.3% having experienced more than five toothaches during the preceding 10 years. Pain intensity associated with the most recent toothache was high with 45.1% of the respondents reporting the highest pain possible. Pain interfered with many aspects of normal functioning. Self-care strategies generally took precedence over professional health services. Pain sufferers used a combination of self-care and formal care strategies. Initial strategies most often focused on nonprescription medicines(home remedies and prayer. The majority of respondents ultimately sought pain relief from a dentist. We identified a number of significant differences in the strategies used across racial/ethnic groups.

Partnering with education and job and training programs for sustainable tobacco control among Baltimore african american young adults.

BACKGROUND: Young adults are generally overlooked in tobacco control initiatives, even though they are critical to sustained success. African American young adults who are not in higher education or working are particularly vulnerable to harmful tobacco use, given high smoking rates and limited access to cessation services. OBJECTIVES: Guided by community-based participatory research (CBPR) principles, we sought to identify program and community-level strategies to reduce tobacco use among African American young adults in Baltimore. We describe the challenges and opportunities for integrating effective tobacco control into community-based education and job training programs for unemployed young adults. METHODS: As part of a longstanding community-research partnership in Baltimore, we conducted fourteen semistructured key informant interviews with leaders from city government and education and job training programs for young adults. The research design, data collection, analysis, and dissemination all included dialogue between and active contribution by both research and community partners. RESULTS: Interview data were structured into opportunities (mindset for change and desire for bonds with a trusted adult), challenges (culture of fatalism, tobacco as a stress reliever, and culture of tobacco use among young adults), and possible tobacco control solutions (tobacco education designed with and for program staff and participants and integration of tobacco issues into holistic program goals and policies). CONCLUSIONS: The emergent themes enhance our understanding of how tobacco is situated in the lives of unemployed young adults and the potential for building sustainable, community-based public health solutions.

Invited commentary: Preventing neural tube defects and more via food fortification?

Many neural tube defects can be prevented if women take folic acid around the time of conception. However, the majority of women do not take folic acid at the critical time, so the US government required that food be fortified with folic acid effective January 1, 1998. Whether the amount being added was sufficient to prevent all folate-related neural tube defects has been hotly debated. Mosley et al. (Am J Epidemiol. 2008;169(1):9-17) found no evidence that folic acid supplement use or dietary folate intake was related to neural tube defects, indicating that fortified food is probably providing sufficient folic acid to prevent folate-related defects. Because data on the effectiveness of fortification in the United States are scarce, this is an important contribution. There is great interest in the other effects of fortification. Folic acid reduces homocysteine levels, and homocysteine has been linked to cardiovascular disease and cancer. On the basis of current evidence, however, it seems unlikely that fortification will reduce cardiovascular disease rates. Its effect on cancer remains unclear. Folic acid may be useful in primary prevention but may also stimulate the growth of existing malignancies or premalignant lesions. Although these issues remain unresolved, Mosley et al. have provided important data to address the primary question: Does fortification prevent folate-related neural tube defects?

Colorectal cancer test use--Maryland, 2002-2006.

During 2000-2004, Maryland had the thirteenth highest mortality rate for colorectal cancer (CRC) among the 50 states and the District of Columbia. The American Cancer Society (ACS), the U.S. Preventive Services Task Force, and other organizations recommend that adults begin CRC screening at age 50 years if they are at average risk for CRC and before age 50 years if they are at increased risk. For those at average risk, ACS recommends screening with 1) a fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year, 2) flexible sigmoidoscopy every 5 years, 3) an annual FOBT or FIT combined with flexible sigmoidoscopy every 5 years, 4) double-contrast barium enema (DCBE) every 5 years, or 5) colonoscopy every 10 years. In 2002, the Maryland Department of Health and Mental Hygiene initiated the Maryland Cancer Survey (MCS) to assess testing prevalence and risk behaviors for seven types of cancer, including CRC. Reducing CRC mortality and disparities in CRC incidence and mortality are goals described in Maryland's Comprehensive Cancer Control Plan (MCCCP). As milestones toward these goals, Maryland set the following targets for 2008 for persons aged > or =50 years: 1) decrease the percentage of Maryland residents who have never been screened for CRC to < or =15% (from a 2002 baseline of 25.9%); 2) increase the percentage of residents who are up to date with CRC screening (per ACS guidelines) to > or =73% (from a 2002 baseline of 63.8%); and 3) increase the percentage of residents who have been screened with either colonoscopy in the past 10 years, or FOBT in the past year plus flexible sigmoidoscopy in the past 5 years, to > or =57% (from a baseline of 46.5% in 2002). This report describes trends in CRC test use based on results from MCS surveys completed in 2002, 2004, and 2006. The results indicated a significant decline (6.1 percentage points) in the percentage of Maryland residents aged > or =50 years who had never been tested for CRC, a 5.4 percentage-point increase in prevalence of up-to-date testing by any method, and a 13.9 percentage-point increase in prevalence of either colonoscopy in the past 10 years or FOBT in the past year plus flexible sigmoidoscopy in the past 5 years. However, Maryland residents who were neither white nor black (i.e., persons of other races) had a significantly lower prevalence of ever having a CRC test, as did persons without health insurance or those without a recent checkup. Although overall increases in CRC testing reflect substantial progress in Maryland, additional measures are needed to increase CRC testing among racial minority groups and the medically underserved.

Adjuvant concurrent chemoradiation for node-positive adenocarcinoma of the duodenum.

HYPOTHESIS: Adjuvant chemoradiation improves local control and survival in patients with node-positive duodenal adenocarcinoma treated with pancreaticoduodenectomy. DESIGN: A retrospective review of outcomes, with a planned comparison with historical controls. SETTING: A single, high-volume academic referral center. PATIENTS: All patients with periampullary carcinoma treated with pancreaticoduodenectomy and adjuvant chemoradiotherapy at The Johns Hopkins Hospital between 1994 and 2003. Fourteen cases of node-positive duodenal adenocarcinoma were identified. Median radiation dose was 5000 cGy (range, 4000-5760 cGy). Concurrent fluorouracil-based chemotherapy was given with radiation therapy, followed by maintenance chemotherapy. RESULTS: The median follow-up was 12 months for patients who died and 42 months for those who lived. Death occurred in 7 of 14 patients (50%) during the follow-up period. Median survival for all patients was 41 months, and the 5-year survival rate was 44%. Of the 7 patients who experienced disease recurrence, 6 experienced distant metastasis as first recurrence. One of these 7 patients experienced both local recurrence and distant metastasis. Local control for all patients in the study was 93%, which compares favorably with local control reported in a series of patients treated with surgery alone (67%). Compared with historical controls treated with surgery alone, patients who received adjuvant chemoradiation therapy had an improved median survival (21 months vs 41 months, respectively). Overall 5-year survival, however, was not improved (44% vs 43%, respectively). CONCLUSION: Adjuvant chemoradiation therapy after pancreaticoduodenectomy for node-positive duodenal adenocarcinoma may improve local control and median survival but does not impact 5-year overall survival.