Racial differences in the treatment and outcomes for prostate cancer in Massachusetts.

BACKGROUND: Massachusetts is a northeastern state with universally mandated health insurance since 2006. Although Black men have generally worse prostate cancer outcomes, emerging data suggest that they may experience equivalent outcomes within a fully insured system. In this setting, the authors analyzed treatments and outcomes of non-Hispanic White and Black men in Massachusetts. METHODS: White and Black men who were 20 years old or older and had been diagnosed with localized intermediate- or high-risk nonmetastatic prostate cancer in 2004-2015 were identified in the Massachusetts Cancer Registry. Adjusted logistic regression models were used to assess predictors of definitive therapy. Adjusted and unadjusted survival models compared cancer-specific mortality. Interaction terms were then used to assess whether the effect of race varied between counties. RESULTS: A total of 20,856 men were identified. Of these, 19,287 (92.5%) were White. There were significant county-level differences in the odds of receiving definitive therapy and survival. Survival was worse for those with high-risk cancer (adjusted hazard ratio [HR], 1.50; 95% CI, 1.4-1.60) and those with public insurance (adjusted HR for Medicaid, 1.69; 95% CI, 1.38-2.07; adjusted HR for Medicare, 1.2; 95% CI, 1.14-1.35). Black men were less likely to receive definitive therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.83) but had a 17% lower cancer-specific mortality (adjusted HR, 0.83; 95% CI, 0.7-0.99). CONCLUSIONS: Despite lower odds of definitive treatment, Black men experience decreased cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population. LAY SUMMARY: There is a growing body of evidence showing that the excess risk of death among Black men with prostate cancer may be caused by disparities in access to care, with few or no disparities seen in universally insured health systems such as the Veterans Affairs and US Military Health System. Therefore, the authors sought to assess racial disparities in prostate cancer in Massachusetts, which was the earliest US state to mandate universal insurance coverage (in 2006). Despite lower odds of definitive treatment, Black men with prostate cancer experience reduced cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population.

Evaluating the Effectiveness of Human Papillomavirus Educational Intervention among Oral Health Professionals.

This study aims to evaluate the effectiveness of an educational intervention that was designed to increase human papillomavirus (HPV) awareness and knowledge among oral health providers (OHPs). HPV educational lectures and a dental information toolkit on HPV were offered to OHPs in New England in 2016-2017. OHPs included dentists and dental hygienists. Post intervention surveys were distributed 1 month later. A total of 230 participants attended the educational lectures and received the toolkit. Descriptive statistics were used to compare the difference in knowledge and preparedness about HPV before and after the intervention. Eighty-nine OHPs completed the surveys. The response rate was 38.7%; however, for each question, the number of responses varied. Fifty-four (54%) (n = 26) of survey respondents were between 55 and 75 years of age with 73.5% (n = 36) being female and 55% (n = 45) working in private practice. Post intervention, 67.5% (n = 27) of the respondents felt more prepared, 82.6% (n = 38) reported clarity of their roles in educating their patients about HPV, and 91.6% (n = 44) reported an increase in knowledge about HPV. The HPV educational intervention was well received and successful at improving self-reported knowledge, comfort level, and preparedness of OHPs in discussing HPV with their patients. OHPs have the great opportunity to educate their patients about HPV and HPV vaccination. Further continuing education efforts may improve OHPs' participation in HPV prevention.

The use of cancer treatment summaries and care plans among Massachusetts physicians.

PURPOSE: Cancer survivorship presents many challenges for affected individuals and their health care providers. Reports from The Institute of Medicine document these challenges and recommend the use of survivorship treatment summaries and care plans to improve communication and coordination of care for cancer survivors. The purpose of our study was to assess current use of treatment summaries and care plans in Massachusetts and identify obstacles to greater use. METHODS: A survey was mailed to cancer specialist physicians (CSPs) and primary care physicians (PCPs) in Massachusetts. The survey asked CSPs about their preparation of treatment summaries and care plans for their cancer survivor patients and perceived barriers to the provision of these documents. PCPs were asked about receipt and utility of treatment summaries and care plans and information they would like to see in these reports. RESULTS: One hundred eight CSPs and 400 PCPs answered the survey. Fifty-six percent of CSPs reported that they, or their staff, prepared treatment summaries for their cancer survivor patients; however, only 14% reported preparing care plans. Fifty-four percent of PCPs reported ever receiving a treatment summary, but only 16% ever received a care plan. CSPs cited lack of training, reimbursement, and templates as barriers to preparing care plans. CONCLUSIONS: Interventions are needed to make treatment summaries and care plans a part of standard care for all cancer survivors. Increasing the use of treatment summaries and care plans will require specific training and reimbursement and may be facilitated by templates that capture automated data.

Lifestyle behaviors in Massachusetts adult cancer survivors.

INTRODUCTION: Adoption of healthy lifestyles in cancer survivors has potential to reduce subsequent adverse health. We sought to determine the prevalence of tobacco use, alcohol use, and physical inactivity among cancer survivors overall and site-specific survivors. METHODS: We performed a cross-sectional analysis of the Massachusetts Behavioral Risk Factor Surveillance System, 2006-2008, and identified 1,670 survivors and 18,197 controls. Specific cancer sites included prostate, colorectal, female breast, and gynecologic (cervical, ovarian, uterine). Covariates included age, gender, race/ethnicity, education, income, marital status, health insurance, and physical and mental health. Gender stratified logistic regression models associated survivorship with each health behavior. RESULTS: 4.9% of men and 7.7% of women reported a cancer history. In adjusted regression models, male survivors were similar to gender matched controls, while female survivors had comparable tobacco and alcohol use but had more physical inactivity than controls (OR 1.5; 95% CI, 1.2-1.8). By site, breast cancer survivors were more likely to be physically inactive (OR 1.5; 95% CI, 1.1-2.0) and gynecologic cancer survivors were more likely to report current tobacco use (OR 1.8; 95% CI, 1.2-2.8). CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Specific subgroups of cancer survivors are more likely to engage in unhealthy behaviors. Accurate assessment of who may derive the most benefit will aid public health programs to effectively target limited resources.

Cost estimation of cardiovascular disease events in the US.

BACKGROUND: In this study, we developed cost prediction equations that facilitate estimation of the costs of various cardiovascular events for patients of specific demographic and clinical characteristics over varying time horizons. METHODS: We used administrative claims data and generalized linear models to develop cost prediction equations for selected cardiovascular events, including myocardial infarction (MI), angina, strokes and revascularization procedures. Separate equations were estimated for patients with events and for their propensity score-matched controls. Attributable costs were estimated on a monthly basis for the first 36 months after each event and annually thereafter, with differences in survival between cases and controls factored into the longitudinal cost calculations. The regression models were used to estimate event costs ($US, year 2007 values) for the 'average' patient in each event group, over various time periods ranging from 1 month to lifetime. RESULTS: When the equations are run for the average patient in each event group, attributable costs of each event in the acute phase (i.e. first 3 years) are substantial (e.g. MI $US 73 300; hospitalization for angina $US 36 000; non-fatal haemorrhagic stroke $US 71 600). Furthermore, for most events, cumulative costs remain substantially higher among cases than among controls over the remaining lifetime of the patients. CONCLUSIONS: This study provides updated estimates of medical care costs of cardiovascular events among a managed care population over various time horizons. Results suggest that the economic burden of cardiovascular disease is substantial, both in the acute phase as well as over the longer term.

Does Type of Tumor Histology Impact Survival among Patients with Stage IIIB/IV Non-Small Cell Lung Cancer Treated with First-Line Doublet Chemotherapy?

Chemotherapy regimens may have differential efficacy by histology in nonsmall cell lung cancer (NSCLC). We examined the impact of histology on survival of patients (N = 2,644) with stage IIIB/IV NSCLC who received first-line cisplatin/carboplatin plus gemcitabine (C/C+G) and cisplatin/carboplatin plus a taxane (C/C+T) identified retrospectively in the SEER cancer registry (1997-2002). Patients with squamous and nonsquamous cell carcinoma survived 8.5 months and 8.1 months, respectively (P = .018). No statistically significant difference was observed in survival between C/C+G and C/C+T in both histologies. Adjusting for clinical and demographic characteristics, the effect of treatment regimen on survival did not differ by histology (P for interaction = .257). There was no statistically significant difference in hazard of death by histology in both groups. These results contrast the predictive role of histology and improved survival outcomes observed for cisplatin-pemetrexed regimens in advanced nonsquamous NSCLC.

High intra/interindividual variance ratios for energy and nutrient intakes of pregnant women in rural Malawi show that many days are required to estimate usual intake.

Conventional wisdom suggests that because there is less variety in food intake, fewer days may be needed to capture "usual intake" of individuals in developing countries, but it is also known that intakes may vary considerably across seasons. Because few studies have examined the sources of variation in nutrient intake in subsistence communities, where food availability also may limit day-to-day food choices, our objective was to examine intraindividual and interindividual variability in energy and nutrient intakes in pregnant subsistence farmers in Africa. From 1988 through 1991, we collected a total of 1061 diet days (mean = 6; range; 2-12 d/woman), using the direct food weighing method, from 184 pregnant women in a farming community west of Lilongwe City, Malawi. Two or four consecutive days were collected for each of several visits during the 2nd and 3rd trimesters. Variance ratios were calculated as the error variance/variance across individuals. We found major seasonal differences in energy and nutrient intakes with greater intakes in the harvest than in the preharvest seasons. Adjustment for season and stage of pregnancy did not reduce variance ratios. To estimate true individual intakes within an error range of +/- 20% required 8-23 d for energy, protein, carbohydrates and fiber; and 95-213 d for micronutrients. Thus, despite limited dietary diversity, large within-person variation in nutrient intake demonstrated that more, rather than fewer days of dietary intake were required to correctly identify usual intake in subsistence farmers compared with previous reports for urbanized or Western populations.