Determinants of progression to AIDS or death after HIV diagnosis, United States, 1996 to 2001.

PURPOSE: The aim of the study is to determine factors associated with disease progression after human immunodeficiency virus (HIV) infection diagnosis. METHODS: We applied generalized linear models with Poisson errors to obtain adjusted relative excess risk for death for persons diagnosed with acquired immunodeficiency syndrome (AIDS) or HIV infection (with or without concurrent AIDS) during 1996 to 2001. We examined differences in time between HIV diagnosis and AIDS by using standardized Kaplan-Meier survival methods. RESULTS: Relative excess risk for death within 3 years after AIDS diagnosis was significantly greater for non-Hispanic blacks (1.15; 95% confidence interval [CI], 1.12-1.18), American Indians (1.33; 95% CI, 1.16-1.52), and Hispanics (1.16; 95% CI, 1.13-1.20) compared with whites. Risk for death also was greater among injection drug users (men, 1.50; 95% CI, 1.46-1.54; women, 1.57; 95% CI, 1.51-1.62) compared with men who have sex with men and among those diagnosed at older ages compared with younger persons. Similar disparities between groups in risk for death were observed from HIV diagnosis. Risk for progression from HIV to AIDS was greater for nonwhites, men, and older persons compared with whites, women, and younger persons, respectively. CONCLUSIONS: Interventions should target those at excess risk for death or morbidity to ensure access to quality care and adherence to treatment to slow disease progression.

Racial and ethnic disparities in HIV diagnoses for women in the United States.

BACKGROUND: An estimated 361,000 persons in the United States are currently living with HIV (not AIDS), and approximately 29% are women. METHODS: Data on all HIV cases diagnosed from 1999 through 2004 for adult and adolescent women at least 13 years old and reported to the Centers for Disease Control and Prevention from 33 states with confidential name-based reporting systems were used. HIV diagnoses and rates per 100,000 women (95% confidence intervals) were analyzed by age group, race and/or ethnicity, transmission category, diagnosis year, and geographic region. RESULTS: The annual estimated rate of HIV diagnosis for black women decreased significantly, from 82.7 in 2001 to 67.0 in 2004, but remained 21 times that of white women. Rates also decreased significantly for women in all age groups except those aged 50 years and older. In 2004, rates were highest in the Mid Atlantic (23.2 per 100,000) and South Atlantic (20.8 per 100,000) regions, where rates also significantly decreased. CONCLUSIONS: Rates of HIV diagnoses remain disproportionately high for Hispanic women and especially for black women.

HIV/AIDS risk factor ascertainment: A critical challenge.

Ascertainment of risk factors for HIV transmission is critical to monitoring the HIV epidemic. Since 1993, there has been an increase in the proportion of HIV/AIDS cases that are reported to the Centers for Disease Control and Prevention (CDC) without an identified risk factor for HIV. About this time many areas implemented laboratory reporting, which generates an initial report with little to no HIV risk factor information. In 2001, the CDC convened a group of experts who recommended changes to the presentation of HIV risk factor data. The CDC subsequently funded two projects to improve the collection of HIV risk factors by surveillance staff. Since 2004, the CDC and state surveillance coordinators revised surveillance guidance to recommend prioritization of follow-up and provider training, and to monitor key variables while providing feedback to reporters. The CDC also began an evaluation of provider-targeted educational materials. The CDC has also been working with professional associations to incorporate methods for documenting HIV risk factors into existing training modules. CDC and state surveillance coordinators will need to continue efforts to educate, train, and identify barriers for providers in order to improve the completeness of HIV risk factor documentation and reporting.

Comorbidities and the risk of late-stage prostate cancer.

The degree to which comorbidities affect the diagnosis of prostate cancer is not clear. The purpose of this study was to determine how comorbidities affect the stage at which prostate cancer is diagnosed in elderly white and black men. We obtained data from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute merged with Medicare claims data. For each patient, we estimated associations between stage of disease at diagnosis and each of the 27 comorbidities. The sample included 2,489 black and 2,587 white men with staged prostate cancer. Coronary artery disease, benign hypertension, and dyslipidemia reduced the odds of late-stage prostate cancer. A prior diagnosis of peripheral vascular disease, severe renal disease, or substance abuse increased the odds of being diagnosed with late-stage disease. The study shows some effect modification by race, particularly among white men with substance abuse, cardiac conduction disorders, and other neurologic conditions. The strongest predictors of late-stage prostate cancer diagnosis for both white and black men were age at diagnosis of at least 80 years and lack of PSA screening. Comorbidities do affect stage at diagnosis, although in different ways. Four hypotheses are discussed to explain these findings.

Prostate cancer incidence and mortality rates and trends in the United States and Canada.

OBJECTIVE: The purpose of this study was to compare prostate cancer incidence and mortality trends between the United States and Canada over a period of approximately 30 years. METHODS: Prostate cancer incident cases were chosen from the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) Program to estimate rates for the United States white males and from the Canadian Cancer Registry for Canadian men. National vital statistics data were used for prostate cancer mortality rates for both countries, and age-adjusted and age-specific incidence and mortality rates were calculated. Joinpoint analysis was used to identify significant changes in trends over time. RESULTS: Canada and the U.S. experienced 3.0% and 2.5% growth in age-adjusted incidence from 1969-90 and 1973-85, respectively. U.S. rates accelerated in the mid- to late 1980s. Similar patterns occurred in Canada with a one-year lag. Annual age-adjusted mortality rates in Canada were increasing 1.4% per year from 1977-93 then fell 2.7% per year from 1993-99. In the U.S., annual age-adjusted mortality rates for white males increased 0.7% from 1969-1987 and 3.0% from 1987-91, then decreased 1.2% and 4.5% during the 1991-94 and 1994-99 periods, respectively. CONCLUSIONS: Recent incidence patterns observed between the U.S. and Canada suggest a strong relationship to prostate-specific antigen (PSA) test use. Clinical trials are required to determine any effects of PSA test use on prostate cancer and overall mortality.

Rationale and design of the National Program of Cancer Registries' Breast, Colon, and Prostate Cancer Patterns of Care Study.

BACKGROUND: Investigators from the Centers for Disease Control and Prevention (CDC), National Program of Cancer Registries (NPCR), are collaborating with public health professionals from seven states and the District of Columbia to conduct the Patterns of Care study to assess the quality of cancer data and to determine whether stage-specific treatments are being carried out. METHODS: To assess the quality and completeness of cancer care data in the United States, trained staff from the Patterns of Care study are abstracting medical records to obtain detailed clinical data on treatment, tumor characteristics, stage at diagnosis, and demographics of representative samples of patients diagnosed with breast, colon, and prostate cancer. Altogether staff from each of the eight participating cancer registries will abstract 500 cases of breast, prostate, and colon/rectum/anus cancer for the CONCORD study and an additional 150 cases of localized breast cancer, 100 cases of stage III colon cancer, and 100 cases of localized prostate cancer for the Patterns of Care study. Chi-square tests will be used to compare routine registry data with re-abstracted data. The investigators will use logistic regression techniques to describe the characteristics of patients with localized breast and prostate cancer and stage III colon cancer. Age, race, sex, type of insurance, and comorbidity will be examined as predictors of the use of those treatments that are consistent with consensus guidelines. The investigators plan to use data from the CONCORD study to determine whether treatment factors are the reason for the reported differences between relative survival rates in the United States and Europe. CONCLUSIONS: Results from the methodology used in the Patterns of Care study will provide, for the first time, detailed information about the quality and completeness of stage and treatment data that are routinely collected by states participating in the NPCR. It will add significantly to our understanding of factors that determine receipt of treatment in compliance with established guidelines. As part of the CONCORD study, it will also examine differences in survival among cancer patients with breast, prostate, and colon/rectum/anus cancers in the United States and Europe.

The development and validation of a comorbidity index for prostate cancer among Black men.

BACKGROUND AND OBJECTIVES: The purpose of this study was to develop a comorbidity index specific to Black Men with prostate cancer, because certain comorbidities and prostate cancer are particularly prevalent among this racial group. METHODS: This research used the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database to develop an index of comorbidity burden based on survival, and the presence/absence of comorbid illness in 2,931 Black males diagnosed with prostate cancer. Comorbidity burden was recognized using inpatient, outpatient, and physician claims for a 2-year period prior to the diagnosis of prostate cancer. We compared five different statistical models, each with two-way, three-way, and/or four-way interactions among the comorbidities, and selected the model with only two-way interactions as the optimal choice. We demonstrated the utility of refining the simplest model, with 27 comorbidity categories only, by adjusting for the number of different diagnoses within statistically significant categories.

Cancer survival in Kentucky and health insurance coverage.

BACKGROUND: Access to health insurance influences the amount and quality of health care received, which in turn is likely to be related to survival. Few studies have systematically examined cancer survival by individual level health insurance data from a state population-based cancer registry for 4 anatomic sites. METHODS: Men and women aged 18 to 99 years who were registered from 1995 to 1998 with the Kentucky Cancer Registry, Lexington, with colorectal, lung, breast, or prostate cancer were followed up through 1999. Three-year crude and relative survival proportion by 7 health insurance categories and by sex for all 4 sites were calculated. Poisson regression was used to model the risk of death (controlling for age group at diagnosis, sex, race, stage at diagnosis, and treatment) relative to expected deaths in the general population from all 4 cancers by health insurance category. RESULTS: Among patients with prostate cancer, 3-year relative survival proportion was 98% for the privately insured and 83% for the uninsured; comparable figures were 91% and 78% for patients with breast cancer; 71% and 53% for patients with colorectal cancer; and 23% and 13% for patients with lung cancer. For all 4 cancers the uninsured ranked fifth or sixth on survival, above patients with unknown insurance type or Medicaid/welfare. CONCLUSION: These findings confirm purported disparities in cancer care and point toward the need to make quality care accessible to all segments of the population.