CIPHR Research Publications

Frailty Index Developed From a Cancer-Specific Geriatric Assessment and the Association With Mortality Among Older Adults With Cancer
Author(s):
Guerard EJ, Deal AM, Chang Y, Williams GR, Nyrop KA, Pergolotti M, Muss HB, Sanoff HK, Lund JL
Source:
Journal of the National Comprehensive Cancer Network, July 2017, Pages 894-902
Tumor Sites:
all

Abstract

Background:
An objective measure is needed to identify frail older adults with cancer who are at increased risk for poor health outcomes. The primary objective of this study was to develop a frailty index from a cancer-specific geriatric assessment (GA) and evaluate its ability to predict all-cause mortality among older adults with cancer.

Patients and Methods:
Using a unique and novel data set that brings together GA data with cancer-specific and long-term mortality data, we developed the Carolina Frailty Index (CFI) from a cancer-specific GA based on the principles of deficit accumulation. CFI scores (range, 0-1) were categorized as robust (0-0.2), pre-frail (0.2-0.35), and frail (>0.35). The primary outcome for evaluating predictive validity was all-cause mortality. The Kaplan-Meier method and log-rank tests were used to compare survival between frailty groups, and Cox proportional hazards regression models were used to evaluate associations.

Results:
In our sample of 546 older adults with cancer, the median age was 72 years, 72% were women, 85% were white, and 47% had a breast cancer diagnosis. Overall, 58% of patients were robust, 24% were pre-frail, and 18% were frail. The estimated 5-year survival rate was 72% in robust patients, 58% in pre-frail patients, and 34% in frail patients (log-rank test, P<.0001). Frail patients had more than a 2-fold increased risk of all-cause mortality compared with robust patients (adjusted hazard ratio, 2.36; 95% CI, 1.51-3.68).

Conclusions:
The CFI was predictive of all-cause mortality in older adults with cancer, a finding that was independent of age, sex, cancer type and stage, and number of medical comorbidities. The CFI has the potential to become a tool that oncologists can use to objectively identify frailty in older adults with cancer.
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Medical costs of treating breast cancer among younger medicaid beneficiaries by stage at diagnosis
Author(s):
Trogdon JG, Ekwueme DU, Poehler D, Thomas CC, Reeder-Hayes K, Allaire BT
Source:
Breast Cancer Research and Treatment, July 2017, Pages epub
Tumor Sites:
breast

Abstract

BACKGROUND:
Younger women (aged 18-44 years) diagnosed with breast cancer often face more aggressive tumors, higher treatment intensity, and lower survival rates than older women. In this study, we estimated incident breast cancer costs by stage at diagnosis and by race for younger women enrolled in Medicaid.

METHODS:
We analyzed cancer registry data linked to Medicaid claims in North Carolina from 2003 to 2008. We used Surveillance, Epidemiology, and End Results (SEER) Summary 2000 definitions for cancer stage. We split breast cancer patients into two cohorts: a younger and older group aged 18-44 and 45-64 years, respectively. We conducted a many-to-one match between patients with and without breast cancer using age, county, race, and Charlson Comorbidity Index. We calculated mean excess total cost of care between breast cancer and non-breast cancer patients.

RESULTS:
At diagnosis, younger women had a higher proportion of regional cancers than older women (49 vs. 42%) and lower proportions of localized cancers (44 vs. 50%) and distant cancers (7 vs. 9%). The excess costs of breast cancer (all stages) for younger and older women at 6 months after diagnosis were $37,114 [95% confidence interval (CI) = $35,769-38,459] and $28,026 (95% CI = $27,223-28,829), respectively. In the 6 months after diagnosis, the estimated excess cost was significantly higher to treat localized and regional cancer among younger women than among older women. There were no statistically significant differences in excess costs of breast cancer by race, but differences in treatment modality were present among younger Medicaid beneficiaries.

CONCLUSIONS:
Younger breast cancer patients not only had a higher prevalence of late-stage cancer than older women, but also had higher within-stage excess costs.
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Breast cancer treatment costs in younger, privately insured women
Author(s):
Allaire BT, Ekwueme DU, Poehler D, Thomas CC, Guy GP Jr, Subramanian S, Trogdon JG
Source:
Breast Cancer Research and Treatment, July 2017, Pages 429-436
Tumor Sites:
breast

Abstract

PURPOSE:
Younger women (under age 45 years) diagnosed with breast cancer often face more aggressive tumors, higher treatment intensity, lower survival rates, and greater financial hardship. The purpose of this study was to estimate breast cancer costs by stage at diagnosis during the first 18 months of treatment for privately insured younger women.

METHODS:
We analyzed North Carolina cancer registry data linked to claims data from private insurers from 2003 to 2010. Breast cancer patients were split into two cohorts: a younger and older group aged 21-44 and 45-64 years, respectively. We conducted a cohort study and matched women with and without breast cancer using age, ZIP, and Charlson Comorbidity Index. We calculated mean excess costs between breast cancer and non-breast cancer patients at 6, 12, and 18 months.

RESULTS:
For younger women, AJCC 6th edition stage II cancer was the most common at diagnosis (40%), followed by stage I (34%). On the other hand, older women had more stage I (46%) cancer followed by stage II (34%). The excess costs for younger and older women at 12 months were $97,486 (95% confidence interval [CI] $93,631-101,341) and $75,737 (95% CI $73,962-77,512), respectively. Younger breast cancer patients had both a higher prevalence of later-stage disease and higher within-stage costs.

CONCLUSIONS:
The study reports high costs of treatment for both younger and older women than a non-cancer comparison group; however, the estimated excess cost was significantly higher for younger women. The financial implications of breast cancer treatment costs for younger women need to be explored in future studies.
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Data Linkage to Improve Geriatric Oncology Research: A Feasibility Study
Author(s):
Lund JL, Meyer AM, Deal AM, Choi BJ, Chang Y, Williams GR, Pergolotti M, Guerard EJ, Muss HB, Sanoff HK
Source:
The Oncologist, April 2017, Pages epub
Tumor Sites:
all

Abstract

Older adults (aged 65 years and older) diagnosed with cancer account for most cancer-related morbidity and mortality in the United States but are often underrepresented on clinical trials. Recent attention from a variety of professional, research, regulatory, and patient advocacy groups has centered on data linkage and data sharing as a means to capture patient information and outcomes outside of clinical trials to accelerate progress in the fight against cancer. The development of a more robust observational research data infrastructure would help to address gaps in the evidence base regarding optimal approaches to treating cancer among the growing and complex population of older adults. To demonstrate the feasibility of building such a resource, we linked information from a sample of older adults with cancer in North Carolina using three distinct, but complementary, data sources: (a) the Carolina Senior Registry, (b) the North Carolina Central Cancer Registry, and (c) North Carolina fee-for-service Medicare claims data. A description of the linkage process, metrics, and characteristics of the final cohort is reported. This study highlights the potential for data linkage to improve the characterization of health status among older adults with cancer and the possibility to conduct passive follow-up for outcomes of interest over time. Extensions of these linkage efforts in partnership with other institutions will enhance our ability to generate evidence that can inform the management of older adults with cancer.
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Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer
Author(s):
Chen RC, Basak R, Meyer AM, Kuo TM, Carpenter WR, Agans RP, Broughman JR, Reeve BB, Nielsen ME, Usinger DS, Spearman KC, Walden S, Kaleel D, Anderson M, Stürmer T, Godley PA
Source:
Journal of the American Medical Association, March 2017, Pages 1141-1150
Tumor Sites:
prostate

Abstract

Importance:
Patients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects.

Objective:
To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance.

Design, Setting, and Participants:
Population-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015.

Exposures:
Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance.

Main Outcomes and Measures:
Quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains-sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems-each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point.

Results:
Of 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI, 27.8-39.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI, 8.7-14.8]) and brachytherapy (20.5 [95% CI, 15.1-25.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains.

Conclusions and Relevance:
In this cohort of men with localized prostate cancer, each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.
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Hospice Utilization and Its Effect on Acute Care Needs at the End of Life in Medicare Beneficiaries With Hepatocellular Carcinoma
Author(s):
Sanoff HK, Chang Y, Reimers M, Lund JL
Source:
Journal of Oncology Practice, March 2017, Pages e197-e206
Tumor Sites:
hepatocellular carcinoma

Abstract

INTRODUCTION:
Hepatocellular carcinoma (HCC) is a poor-prognosis cancer with a high symptom burden. Multidisciplinary HCC care is complex and unique in cancer medicine. We sought to determine whether the distinct process affects hospice use and how hospice affects end-of-life acute care utilization.

PATIENTS AND METHODS:
Patients dying after HCC diagnosed from 2004 to 2011 were identified within SEER-Medicare. Hospice use and associated factors were described using logistic regression. Coarse exact and propensity score matching created groups of hospice and nonhospice comparators balanced on clinical characteristics. Health care use from first hospice claim to death and the matched duration in the nonhospice group were compared.

RESULTS:
Of 7,992 decedent patients with HCC, 63% used hospice before death, with a median duration of 18 days (interquartile range, 5-51 days). Initial treatment with surgery and ablation (odds ratio [OR], 0.63; 95% CI, 0.53 to 0.74) or chemoembolization/radioembolization (OR, 0.71; 95% CI, 0.62 to 0.80) was associated with decreased odds of subsequent hospice use compared with untreated patients. Hospice use was more likely in those consulting hematology/oncology (OR, 1.33; 95% CI, 1.13 to 1.56) but not in those consulting gastroenterology (OR, 0.79; 95% CI, 0.65 to 0.95). Hospice patients had lower rates of hospitalization (7.9% v 47.8%; risk ratio [RR], 0.16; 95% CI, 0.14 to 0.19), intensive care unit stay (2.8% v 25.3%; RR, 0.11; 95% CI, 0.09 to 0.14), and in-hospital death (3.5% v 58.4%; RR, 0.06; 95% CI, 0.05 to 0.07).

CONCLUSION:
Processes of care influence which patients with HCC are referred to hospice. Hospice use has a marked effect on acute care use at the end of life in patients with HCC. Efforts to incorporate cancer-focused palliative care might improve the quality of end-of-life care in HCC.
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Cost-Effectiveness Analysis of Four Simulated Colorectal Cancer Screening Interventions, North Carolina
Author(s):
Hassmiller Lich K, Cornejo DA, Mayorga ME, Pignone M, Tangka FK, Richardson LC, Kuo TM, Meyer AM, Hall IJ, Smith JL, Durham TA, Chall SA, Crutchfield TM, Wheeler SB
Source:
Preventing Chronic Disease, Feb 2017, Pages
Tumor Sites:
colorectal

Abstract

INTRODUCTION:
Colorectal cancer (CRC) screening rates are suboptimal, particularly among the uninsured and the under-insured and among rural and African American populations. Little guidance is available for state-level decision makers to use to prioritize investment in evidence-based interventions to improve their population's health. The objective of this study was to demonstrate use of a simulation model that incorporates synthetic census data and claims-based statistical models to project screening behavior in North Carolina.

METHODS:
We used individual-based modeling to simulate and compare intervention costs and results under 4 evidence-based and stakeholder-informed intervention scenarios for a 10-year intervention window, from January 1, 2014, through December 31, 2023. We compared the proportion of people living in North Carolina who were aged 50 to 75 years at some point during the window (that is, age-eligible for screening) who were up to date with CRC screening recommendations across intervention scenarios, both overall and among groups with documented disparities in receipt of screening.

RESULTS:
We estimated that the costs of the 4 intervention scenarios considered would range from $1.6 million to $3.75 million. Our model showed that mailed reminders for Medicaid enrollees, mass media campaigns targeting African Americans, and colonoscopy vouchers for the uninsured reduced disparities in receipt of screening by 2023, but produced only small increases in overall screening rates (0.2-0.5 percentage-point increases in the percentage of age-eligible adults who were up to date with CRC screening recommendations). Increased screenings ranged from 41,709 additional life-years up to date with screening for the voucher intervention to 145,821 for the mass media intervention. Reminders mailed to Medicaid enrollees and the mass media campaign for African Americans were the most cost-effective interventions, with costs per additional life-year up to date with screening of $25 or less. The intervention expanding the number of endoscopy facilities cost more than the other 3 interventions and was less effective in increasing CRC screening.

CONCLUSION:
Cost-effective CRC screening interventions targeting observed disparities are available, but substantial investment (more than $3.75 million) and additional approaches beyond those considered here are required to realize greater increases population-wide.
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Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50
Author(s):
Wheeler SB, Kuo TM, Meyer AM, Martens CE, Hassmiller Lich KM, Tangka FK, Richardson LC, Hall IJ, Smith JL, Mayorga ME, Brown P, Crutchfield TM, Pignone MP
Source:
Preventive Medicine Reports, Dec 2016, Pages 9-16
Tumor Sites:
colorectal

Abstract

Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p < 0.05). Of 56,151 privately-insured persons turning 50 years old who received CRC testing, 42% received colonoscopy, whereas 58% received FOBT/FIT, with significant regional variation. In multivariable models, females with private insurance had lower odds of colonoscopy than males (OR = 0.43; p < 0.05). People living 10-15 miles away from endoscopy facilities also had lower odds of colonoscopy than those living within 5 miles (OR = 0.91; p < 0.05). Both colonoscopy and FOBT/FIT are widely used in North Carolina among insured persons newly age-eligible for screening. The high level of FOBT/FIT use among privately insured persons and women suggests that renewed emphasis on FOBT/FIT as a viable screening alternative to colonoscopy may be important.
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Statewide geographic variation in outcomes for adults with acute myeloid leukemia in North Carolina
Author(s):
Freeman AT, Meyer AM, Smitherman AB, Zhou L, Basch EM, Shea TC, Wood WA
Source:
Cancer, Oct 2016, Pages 3041-50
Tumor Sites:
AML

Abstract

BACKGROUND:
Population-based studies have demonstrated survival disparities related to socioeconomic factors for patients with acute myeloid leukemia (AML). The objective of the current study was to determine whether the local health care infrastructure, represented by Area Health Education Centers (AHEC) region, or treating center experience, represented by National Cancer Institute Comprehensive Cancer Center (NCICCC) designation, were associated with outcomes among patients with AML in North Carolina.

METHODS:
Patients who were diagnosed with AML from 2003 to 2009 were identified using the University of North Carolina Lineberger Integrated Cancer Information and Surveillance System, a database linking insurance claims to the North Carolina Cancer Registry. A Cox proportional-hazards model was used to explore survival based on AHEC region. A subset of patients who received inpatient chemotherapy was examined to evaluate the impact of treatment at an NCICCC.

RESULTS:
Nine hundred patients were identified in the study period, 553 of whom received inpatient chemotherapy therapy within 30 days of diagnosis. Almost one-half of these patients (n = 294) received chemotherapy at a non-NCICCC. Among the patients who received intensive inpatient therapy, residence in 3 of 9 AHEC regions was associated with a higher risk of mortality (hazard ratio: range, 1.97-4.03; P < .01) at 1 year in multivariate analysis. Treatment at a non-NCICCC was not associated with an increased risk of mortality at 1 year (hazard ratio, 1.25; 95% confidence interval, 0.95-1.65).

CONCLUSIONS:
Survival among patients with AML in North Carolina varies according to geographic region. Further examination of local practice and referral patterns may inform strategies to improve AML outcomes across the state.
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Referral patterns between high- and low-volume centers and associations with uterine cancer treatment and survival: a population-based study of Medicare, Medicaid, and privately insured women
Author(s):
Doll KM, Meng K, Gehrig PA, Brewster WR, Meyer AM
Source:
American Journal of Obstetrics and Gynecology, Oct 2016, Pages 447
Tumor Sites:
uterine

Abstract

BACKGROUND:
High-volume center surgery and gynecologic oncology care are associated with improved outcomes for women with uterine cancer. Referral patterns, from biopsy through to chemotherapy, may have patients interacting with high-volume centers for all, a portion, or none of their care. The relative frequency, the underlying factors that contribute to referral, and the potential impact of these referral patterns on treatment outcomes are unknown.

OBJECTIVE:
We sought to analyze the referral patterns and subsequent impact of care sites on treatment for women with high- and low-risk uterine cancer.

STUDY DESIGN:
This is a population-based retrospective cohort study of uterine cancer cases from 2004 through 2009 in North Carolina. Using state cancer registry files linked to Medicare, Medicaid, and private payer insurance claims, we analyzed referral and treatment patterns by annual surgical volume (high ≥12/y). We examined clinical and demographic factors associated with referral and used modified Poisson regression to evaluate risk of referral, lymphadenectomy, and chemotherapy. Stratified Kaplan-Meier plots and Cox proportional hazard models were used to examine survival.

RESULTS:
A total of 2053 women were analyzed, including 34% (n = 677) with grade 3 histology. Of 1630 (80%) women with preoperative biopsies, referral patterns (biopsy to surgery) were: low volume to high volume (n = 652, 40%), followed by high volume to high volume (n = 605, 37%), then low volume to low volume (n = 318, 20%), and the rare high volume to low volume (n = 50, 3%). Women retained in low-volume centers after biopsy were older, were less likely to have private insurance, and had more comorbidities. High-risk histology (aRR, 1.14; 95% confidence interval, 1.04-1.25) was positively associated with referral, while Medicaid insurance was negatively associated with referral (aRR, 0.64; 95% confidence interval, 0.42-0.96). Most women (74%, n = 1557) had surgery at high-volume centers. Lymphadenectomy was less likely at low-volume centers (aRR, 0.71; 95% confidence interval, 0.64-0.77). Similarly, for high-risk patients, the relationship between low-volume center surgery and subsequent chemotherapy was aRR, 0.71 (95% confidence interval, 0.48-1.02). Of 290 women who received chemotherapy, the referral patterns (surgery to chemotherapy) were: high volume-all (high volume to high volume), high volume-hybrid (high volume to low volume, or low volume to high volume), and high volume-none (low volume to low volume). In all, 36% (n = 104/290) received chemotherapy at a low-volume center, the majority (68%, n = 71/104) of whom were referred from high-volume centers after surgery. Crude, unadjusted mortality risk of chemotherapy recipients differed by referral pattern (surgery to chemotherapy): high volume-all patients (hazard ratio, 1.0; referent), followed by high volume-hybrid (hazard ratio, 1.33; 95% confidence interval, 0.93-1.91) then high volume-none patients (RR, 1.95; 95% confidence interval, 1.24-3.08).

CONCLUSION:
Most women with uterine cancer treated at high-volume centers arrive through referral, which is affected by age and type of insurance, in addition to histology. For high-risk women who require chemotherapy, survival may be related to the extent of treatment received at high-volume centers.
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Sorafenib Effectiveness in Advanced Hepatocellular Carcinoma
Author(s):
Sanoff HK, Chang Y, Lund JL, O'Neil BH, Dusetzina SB
Source:
The Oncologist, Sept 2016, Pages 1113-20
Tumor Sites:
hepatocellular carcinoma

Abstract

BACKGROUND:
Phase III trials show sorafenib improves survival in advanced hepatocellular carcinoma (HCC). Because of narrow trial eligibility, results may not be generalizable to a broader HCC population. We sought to evaluate the effectiveness of initial sorafenib versus no treatment among Medicare beneficiaries with advanced HCC.

MATERIALS AND METHODS:
Patients with advanced HCC diagnosed from 2008 to 2011 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Eligible patients received initial sorafenib or no therapy and were covered by Medicare parts A, B, and D. Sorafenib use and outcomes were described in this population. Using a propensity score (PS)-matched sample, we compared the effectiveness of sorafenib versus no treatment by Cox proportional hazards and binomial regression, using a landmark requiring all patients to survive ≥60 days after diagnosis.

RESULTS:
Of 1,532 patients, 27% received initial sorafenib. Median duration of sorafenib use was 60 days (interquartile range [IQR], 30-107 days), and median survival from first prescription was 3 months (IQR, 1-8 months). In the PS-matched cohort, median survival was 3 months from the 60-day landmark in sorafenib-treated (n = 223) and 2 months in untreated (n = 223) patients (adjusted hazard ratio, 0.95 [95% confidence interval (CI), 0.78-1.16]). Sorafenib was associated with a nonsignificant reduction in mortality at 3 months (44% versus 51%; adjusted risk ratio, 0.88 [95% CI, 0.72-1.07]), but no reduction thereafter.

CONCLUSION:
Survival after sorafenib initiation in newly diagnosed Medicare beneficiaries with HCC is exceptionally short, suggesting trial results are not generalizable to all HCC patients. The downsides of sorafenib use-high drug-related symptom burden and high drug cost-must be considered in light of this minimal benefit.

IMPLICATIONS FOR PRACTICE:
The findings of a median survival of only 3 months in Medicare beneficiaries with HCC prescribed sorafenib as first-line therapy highlight the questionable value of sorafenib in this population. Patients should be cautioned that outside of the narrow confines of randomized trials, their life expectancy may be very short, and any benefit of sorafenib is likely to be quite small. Given that sorafenib causes considerable adverse effects and offers no symptom palliation, supportive care should be discussed as a reasonable alternative to sorafenib, particularly for patients who have a poor performance status or advanced cirrhosis.
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Impact of Location of Readmission on Outcomes After Major Cancer Surgery
Author(s):
Stitzenberg KB, Chang Y, Smith AB, Meyers MO, Nielsen ME
Source:
Annals of Surgical Oncology, Sept 2016, Pages epub ahead of print
Tumor Sites:
multiple

Abstract

BACKGROUND:
The burden of readmissions after major cancer surgery is high. Prior work suggests that one-third of readmitted patients are readmitted to a different hospital than where the surgery was performed. The impact of this location of readmission needs to be more thoroughly understood.

METHODS:
This retrospective cohort study was performed on Surveillance, Epidemiology, and End Results (SEER)-Medicare patients with bladder, esophagus, lung, or pancreas cancer diagnosed from 2001 to 2007 who underwent extirpative surgery and were readmitted within 90 days. Readmission location was classified as 'index' if readmission was at the hospital where surgery was performed, or 'different' if readmission was elsewhere. Outcomes including complications, reoperations, in-hospital mortality, 90-day mortality, and 90-day total costs were compared based on the location of readmission using a propensity score inverse probability treatment weight analysis.

RESULTS:
Overall, 7903 (28 %) patients were readmitted within 90 days of index hospitalization. Thirty-three percent were readmitted to a different hospital (bladder 30 %, esophagus 34 %, lung 34 %, pancreas 34 %). Ninety-day mortality and total costs of care were not significantly different between the readmission location groups (all p > 0.05); however, substantial differences in the types of patients, and timing of and reasons for readmission were observed between the two groups.

CONCLUSIONS:
Patients readmitted to different hospitals after major cancer surgery are a different group of patients than those readmitted to the index hospital. Accounting for this, we did not find significant differences in short-term clinical outcomes or costs of care based on readmission location; however, differences in long-term outcomes were observed that should be further explored in future studies.
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Framework for Deploying a Virtualized Computing Environment for Collaborative and Secure Data Analytics
Author(s):
Meyer A, Green L, Faulk C, Galla S, Meyer AM
Source:
eGEMs, Aug 2016, Pages 1224
Tumor Sites:
none

Abstract

Introduction: Large amounts of health data generated by a wide range of health care applications across a variety of systems have the potential to offer valuable insight into populations and health care systems, but robust and secure computing and analytic systems are required to leverage this information.

Framework: We discuss our experiences deploying a Secure Data Analysis Platform (SeDAP), and provide a framework to plan, build and deploy a virtual desktop infrastructure (VDI) to enable innovation, collaboration and operate within academic funding structures. It outlines 6 core components: Security, Ease of Access, Performance, Cost, Tools, and Training.

Conclusion: A platform like SeDAP is not simply successful through technical excellence and performance. Its adoption is dependent on a collaborative environment where researchers and users plan and evaluate the requirements of all aspects.
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Distance to a Plastic Surgeon and Type of Insurance Plan Are Independently Predictive of Postmastectomy Breast Reconstruction
Author(s):
Roughton MC, DiEgidio P, Zhou L, Stitzenberg K, Meyer AM
Source:
Plastic and Reconstructive Surgery, Aug 2016, Pages 203e-211e
Tumor Sites:
breast

Abstract

BACKGROUND:
The psychosocial benefits of postmastectomy breast reconstruction are well established; however, health care barriers persist. The authors evaluated statewide patient population to further identify obstacles to reconstruction.

METHODS:
A linked data set combining the North Carolina Central Cancer Registry with administrative claims from Medicare, Medicaid, and private insurance plans identified women diagnosed with breast cancer from 2003 to 2006. For inclusion in the study, women must have had a mastectomy within 6 months of diagnosis and had continuous insurance enrollment at least 2 years postoperatively (n = 5381). Multivariable logistic regression was used to model odds of reconstruction.

RESULTS:
Approximately 20 percent underwent reconstruction (n = 1130). Distance to a plastic surgeon-10 to 20 miles (OR, 0.78) and greater than 20 miles (OR, 0.73; p < 0.05)-was significantly predictive of no reconstruction, independent of other well-known disparities, including age, race, rural location, and lower household income. Women with government-funded health care, such as Medicare (OR, 0.58) and Medicaid (OR, 0.24; p < 0.001), were also significantly less likely to undergo reconstruction. Consistent with previous study, advanced cancer stage and receipt of radiation therapy decreased the likelihood of reconstruction. Furthermore, when the authors compared immediate to delayed reconstruction, rural location, chemotherapy, and radiation therapy were significantly predictive of delay.

CONCLUSIONS:
This is the first population-based study to demonstrate distance to care and insurance plan as significant predictors of receipt of reconstruction. Additional research is needed to understand health care barriers and to determine whether distance to a plastic surgeon can be ameliorated by outreach programs.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Risk, III.
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Clinical Benefits Associated With Medicaid Coverage Before Diagnosis of Gynecologic Cancers
Author(s):
Doll KM, Basch EM, Meng K, Barber EL, Gehrig PA, Brewster WR, Meyer AM
Source:
Journal of Oncology Practice, June 2016, Pages 724-33
Tumor Sites:
gynecological

Abstract

PURPOSE:
Many low-income patients enroll in Medicaid at the time of cancer diagnosis, which improves survival outcomes. Medicaid enrollment before cancer diagnosis may confer additional benefits. Our objective was to compare stage at diagnosis and overall mortality between women with and without Medicaid enrollment before gynecologic cancer diagnosis.

METHODS AND MATERIALS:
Women younger than 65 years with a gynecologic cancer (2003 to 2008) were identified through the North Carolina Central Cancer Registry and linked to state Medicaid enrollment files. Those with and without Medicaid enrollment within 6 months before diagnosis were identified. Propensity matching was used to balance the exposure groups. Stage at diagnosis was evaluated by using logistic regression, and all-cause mortality was assessed with Cox proportional hazard models.

RESULTS:
Of 564 women, one half (n = 282) had prediagnosis Medicaid enrollment. Disease sites included the cervix (44%), uterus (25%), ovary (26%), and vulva/vagina (5%). More than one half (51%) of cancers were advanced stage. Women without prediagnosis Medicaid had an increased odds of advanced-stage disease (hazard ratio, 1.46; 95% CI, 1.03 to 2.05). Crude survival outcomes differed significantly between the groups; however, when adjusted for stage at diagnosis, lack of prediagnosis Medicaid coverage had a hazard ratio of 1.19 (95% CI, 0.92 to 1.53).

CONCLUSION:
Medicaid enrollment before gynecologic cancer diagnosis is associated with an earlier stage at presentation. Given the existence of a cervical cancer screening program in North Carolina and lack of Medicaid expansion, these data suggest that screening programs alone are not sufficient to counteract the delay in diagnosis that is common for uninsured individuals.
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Disparities in Use of Human Epidermal Growth Hormone Receptor 2-Targeted Therapy for Early-Stage Breast Cancer
Author(s):
Reeder-Hayes K, Peacock Hinton S, Meng K, Carey LA, Dusetzina SB
Source:
Journal of Clinical Oncology, Apr 2016, Pages epub ahead of print
Tumor Sites:
breast

Abstract

PURPOSE:
Trastuzumab is a key component of adjuvant therapy for stage I to III human epidermal growth factor receptor 2 (HER2)-positive breast cancer. The rates and patterns of trastuzumab use have never been described in a population-based sample. The recent addition of HER2 information to the SEER-Medicare database offers an opportunity to examine patterns of trastuzumab use and to evaluate possible disparities in receipt of trastuzumab.

METHODS:
We examined a national cohort of Medicare beneficiaries with incident stage I to III HER2-positive breast cancer diagnosed in 2010 and 2011 (n = 1,362). We used insurance claims data to track any use of trastuzumab in the 12 months after diagnosis as well as to identify chemotherapy drugs used in partnership with trastuzumab. We used modified Poisson regression analysis to evaluate the independent effect of race on likelihood of receiving trastuzumab by controlling for clinical need, comorbidity, and community-level socioeconomic status.

RESULTS:
Overall, 50% of white women and 40% of black women received some trastuzumab therapy. Among women with stage III disease, 74% of whites and 56% of blacks received trastuzumab. After adjustment for tumor characteristics, poverty, and comorbidity, black women were 25% less likely to receive trastuzumab within 1 year of diagnosis than white women (risk ratio, 0.745; 95% CI, 0.60 to 0.93).

CONCLUSION:
Approxemately one half of patients 65 years of age and older with stage I to III breast cancer do not receive trastuzumab-based therapy, which includes many with locally advanced disease. Significant racial disparities exist in the receipt of this highly effective therapy. Further research that identifies barriers to use and increases uptake of trastuzumab could potentially improve recurrence and survival outcomes in this population, particularly among minority women.
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Are Small Reimbursement Changes Enough to Change Cancer Care? Reimbursement Variation in Prostate Cancer Treatment
Author(s):
Ellis SD, Chen RC, Dusetzina SB, Wheeler SB, Jackson GL, Nielsen ME, Carpenter WR, Weinberger M
Source:
Journal of Oncology Practice, Apr 2016, Pages e423-e436
Tumor Sites:
prostate

Abstract

PURPOSE:
The Centers for Medicare and Medicaid Services recently initiated small reimbursement adjustments to improve the value of care delivered under fee-for-service. To estimate the degree to which reimbursement influences physician decision making, we examined utilization of gonadotropin-releasing hormone (GnRH) agonists among urologists as Part B drug reimbursement varied in a fee-for-service environment.

METHODS:
We analyzed treatment patterns of urologists treating 15,128 men included in SEER-linked Medicare claims who were diagnosed with localized prostate cancer between January 1, 2000, and December 31, 2003. We calculated a reimbursement generosity index to measure differences in GnRH agonist reimbursement among regional Medicare carriers and over time. We used multilevel analysis to control for patient and provider characteristics.

RESULTS:
Among urologists treating early-stage and lower grade prostate cancer, variation in reimbursement was not associated with overuse of GnRH agonists from 2000 to 2003, a period of guideline stability (odds ratio, 1.00; 95% CI, 0.99 to 1.00).

CONCLUSION:
Small differences in androgen-deprivation therapy reimbursement generosity were not associated with differential use. Fee-for-service reimbursement changes currently being implemented to improve quality in fee-for-service Medicare may not affect patterns of cancer care.
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Adaptive Contextualization: Combating Bias During High-Dimensional Visualization and Data Selection
Author(s):
Gotz D, Sun S, Cao N
Source:
Proceedings of the 21st International Conference on Intelligent User Interfaces, March 2016, Pages 85-95
Tumor Sites:
n/a

Abstract

Large and high-dimensional real-world datasets are being gathered across a wide range of application disciplines to enable data-driven decision making. Interactive data visualization can play a critical role in allowing domain experts to select and analyze data from these large collections. However, there is a critical mismatch between the very large number of dimensions in complex real-world datasets and the much smaller number of dimensions that can be concurrently visualized using modern techniques. This gap in dimensionality can result in high levels of selection bias that go unnoticed by users. The bias can in turn threaten the very validity of any subsequent insights. In this paper, we present Adaptive Contextualization (AC), a novel approach to interactive visual data selection that is specifically designed to combat the invisible introduction of selection bias. Our approach (1) monitors and models a user's visual data selection activity, (2) computes metrics over that model to quantify the amount of selection bias after each step, (3) visualizes the metric results, and (4) provides interactive tools that help users assess and avoid bias-related problems. We also share results from a user study which demonstrate the effectiveness of our technique.
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Enrollment and Racial Disparities in Cancer Treatment Clinical Trials in North Carolina
Author(s):
Zullig LL, Fortune-Britt AG, Rao S, Tyree SD, Godley PA, Carpenter WR
Source:
North Carolina Medical Journal, Jan 2016, Pages 52-8
Tumor Sites:
all

Abstract

BACKGROUND:
Clinical trials provide access to innovative, high-quality cancer treatment. Simultaneously, broad access helps to ensure that trials include heterogeneous patient populations, which improves the generalizability of findings and the development of interventions that are effective for diverse populations. We provide updated data describing enrollment into cancer treatment trials in North Carolina.

METHODS:
For the period 1996-2009, person-level data regarding cancer clinical trial enrollment and cancer incidence were obtained from the North Carolina Central Cancer Registry and the National Cancer Institute (NCI). Enrollment rates were estimated as the ratio of trial enrollment to cancer incidence for race, sex, and year for each county, Area Health Education Center region, and the state overall. Enrollment rates for common cancers are presented.

RESULTS:
From 1996 to 2009, North Carolina NCI treatment trial enrollment rates were 2.4% and 2.2% for white patients and minority patients, respectively. From 2007 to 2009, rates were 3.8% for white women, 3.5% for minority women, 1.3% for white men, and 1.0% for minority men; there was greater enrollment among more urban populations (2.4%) than among the most rural populations (1.5%).

LIMITATIONS:
This study is limited to NCI-sponsored treatment trials in North Carolina. Policies governing collection of original data necessitate a delay in data availability.

CONCLUSIONS:
Effort is needed to ensure trial access and enrollment among all North Carolina populations. Specifically, we identified racial and sex disparities, particularly for certain cancers (eg, breast cancer). Programs in North Carolina and across the nation can use the methods we employed to assess their success in broadening clinical trial enrollment to include diverse populations.
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Association between medical home enrollment and health care utilization and costs among breast cancer patients in a state Medicaid program
Author(s):
Kohler RE, Goyal RK, Lich KH, Domino ME, Wheeler SB
Source:
Cancer, Nov 2015, Pages 3975-3981
Tumor Sites:
breast

Abstract

BACKGROUND:
The patient-centered medical home (PCMH) is increasingly being implemented in an effort to improve and coordinate primary care, but its effect on health care utilization among breast cancer patients remains unclear. The objective of this study was to examine health care utilization and expenditures as a function of PCMH enrollment among breast cancer patients in North Carolina's Medicaid program.

METHODS:
North Carolina Medicaid claims linked to North Carolina Central Cancer Registry records (2003-2007) were used to examine monthly patterns of health care use and expenditures. Controlling for a selection bias for time-invariant characteristics, fixed effects regression models analyzed associations between PCMH enrollment and utilization of outpatient, inpatient, and emergency department (ED) services and Medicaid expenditures during the 15 months after the diagnosis of breast cancer.

RESULTS:
Among 758 breast cancer patients, 381 (50%) were enrolled in a PCMH at some time in the 15 months after diagnosis. After controlling for individual fixed effects, PCMH enrollment was significantly associated with greater outpatient service use, but there was no difference in the probability of inpatient hospitalizations or ED visits. Enrollment in a PCMH was associated with increased average expenditures of $429 per month during the first 15 months.

CONCLUSIONS:
Greater outpatient care utilization and increased average expenditures among breast cancer patients enrolled in a PCMH may suggest that these women have improved access to primary and specialty care. Expanding PCMHs may change patterns of service utilization for Medicaid breast cancer patients but may not be associated with lower costs.
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Comparative Effectiveness of Oxaliplatin Versus 5-flourouricil in Older Adults: An Instrumental Variable Analysis
Author(s):
Mack CD, Brookhart MA, Glynn RJ, Meyer AM, Carpenter WR, Sandler RS, Stürmer T
Source:
Epidemiology, Sept 2015, Pages 690-9
Tumor Sites:
colon

Abstract

BACKGROUND:
Oxaliplatin was rapidly adopted for treatment of stage III colon cancer after FDA approval in November 2004, thus providing an opportunity to use calendar time as an instrumental variable in nonexperimental comparative effectiveness research. Assuming instrument validity, instrumental variable analyses account for unmeasured confounding and are particularly valuable in sub-populations of unresolved effectiveness, such as older individuals.

METHODS:
We examined stage III colon cancer patients ages 65+ years initiating chemotherapy between 2003 and 2008 using US population-based cancer registry data linked with Medicare claims (N = 3,660). Risk differences for all-cause mortality were derived from Kaplan-Meier survival curves. We examined instrumental variable strength and compared risk differences with propensity score estimates.

RESULTS:
Calendar time greatly affected oxaliplatin receipt. The calendar time instrument compared patients treated from January 2003 through September 2004 (N = 1,449) with those treated from March 2005 through May 2007 (N = 1,432), resulting in 54% compliance. The 1-, 2-, and 3-year local average treatment effect of the risk differences per 100 patients in the "compliers" (95% confidence intervals) were -4.6 (-8.2, -0.44), -6.3 (-12, -0.16), and -9.2 (-15, -2.5), respectively. Corresponding propensity score-matched results were -1.9 (-4.0, 0.2), -3.4 (-6.2, -0.05), and -4.3 (-7.5, -0.96).

CONCLUSIONS:
Instrumental variable and propensity score analyses both indicate better survival among patients treated with oxaliplatin. As these results are based on different populations and assumptions, the instrumental variable analysis adds to evidence of oxaliplatin's effectiveness in older adults, who bear the greatest burden of colon cancer yet were underrepresented in clinical trials. In nonexperimental comparative effectiveness research of rapidly emerging therapies, the potential to use calendar time as an instrumental variable is worth consideration.
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Effectiveness of Initial Transarterial Chemoembolization for Hepatocellular Carcinoma Among Medicare Beneficiaries
Author(s):
Sanoff HK, Chang Y, Stavas JM, Stürmer T, Lund J
Source:
Journal of the National Comprehensive Cancer Network, Sept 2015, Pages 1102-10
Tumor Sites:
HCC

Abstract

BACKGROUND:
Optimal administration of transarterial chemoembolization (TACE), the standard approach for intermediate-stage hepatocellular carcinoma (HCC), requires clinical and technical expertise. We sought to evaluate whether TACE retains its effectiveness when administered across a broad range of health care settings. Furthermore, as the use of yttrium(90) (Y(90)) radioembolization has been increasing, we explored the comparative effectiveness of Y(90) as an alternative to TACE.

METHODS:
Patients with HCC diagnosed from 2004 through 2009 treated initially with TACE or Y(90) were identified from the SEER-Medicare linkage. Key covariates included prediagnosis α-fetoprotein (AFP) screening, complications of cirrhosis, and tumor extent. Effect of treatment, patient, and health care system factors on overall survival (OS) was evaluated using multivariable Cox proportional hazards. Stratified OS estimates are provided. Propensity score (PS) weighting was used to compare effectiveness of Y(90) with TACE.

RESULTS:
Of 1528 patients who underwent intra-arterial embolization, 577 received concurrent chemotherapy (eg, TACE). Median OS was 21 months (95% CI, 18-23) following TACE and 9 months (95% CI, 1-41) following Y(90). Refined survival estimates stratified by stage, AFP screening, and liver comorbidity are presented. The 90-day mortality rate after TACE was 21% to 25% in patients with extrahepatic spread or vascular invasion. In the PS-weighted analysis, Y(90) was associated with inferior survival, with an adjusted hazard ratio of 1.39 (95% CI, 1.02-1.90).

CONCLUSIONS:
The effectiveness of TACE is generalizable to Medicare patients receiving care in a variety of treatment settings. However, early posttreatment mortality is high in patients with advanced disease. We found no evidence of improved outcomes with Y(90) compared with TACE. Survival estimates from this large cohort can be used to provide prognostic information to patients considering palliative TACE.
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Gynecologic cancer outcomes in the elderly poor: A population-based study
Author(s):
Doll KM, Meng K, Basch EM, Gehrig PA, Brewster WR, Meyer AM
Source:
Cancer, July 2015, Pages 3591-9
Tumor Sites:
ovarian, uterine, cervical

Abstract

BACKGROUND
Adults aged ≥65 years who are dually enrolled in Medicare and Medicaid are an at-risk group in health care. However, to the best of the authors' knowledge, the outcomes of women with gynecologic cancers in this population are unknown.

METHODS
The current study was a population-based cohort study of North Carolina state cancer registry cases of uterine, ovarian, cervical, and vulvar/vaginal cancers (2003-2009), with linked enrollment in Medicare and state Medicaid. Outcomes of all-cause mortality and stage of disease at the time of diagnosis were analyzed as a function of enrollment status using multivariate analysis and survival curves.

RESULTS
Of 4522 women aged ≥65 years (3702 of whom were enrolled in Medicare [82%] and 820 of whom were dually enrolled [18%]), there were 2286 cases of uterine (51%), 1587 cases of ovarian (35%), 302 cases of cervical (7%), and 347 cases of vulvar/vaginal (8%) cancers. Dual enrollees had increased all-cause mortality overall (adjusted hazard ratio [aHR], 1.34; 95% confidence interval [95% CI], 1.19-1.49), and within each cancer site (uterine: aHR, 1.22 [95% CI, 1.02-1.47]; ovarian: aHR, 1.25 [95% CI, 1.05-1.49]; cervical: aHR, 1.34 [95% CI, 0.96-1.87]; and vulvar/vaginal: aHR, 1.93 [95% CI, 1.36-2.72]). Increased odds of advanced-stage disease at the time of diagnosis among dual enrollees was only present in patients with uterine cancer (adjusted odds ratio, 1.38; 95% CI, 1.06-1.79). Stratified survival curves demonstrated the strongest disparities among women with early-stage uterine and early-stage vulvar/vaginal cancers.

CONCLUSIONS
Women aged ≥65 years who were dually enrolled in Medicare and Medicaid were found to have an overall 34% increase in all-cause mortality after diagnosis with a gynecologic cancer compared with the non-dually enrolled Medicare population. Women with early-stage uterine and vulvar/vaginal cancers appeared to have the most disparate outcomes. Because these malignancies are generally curable, they have the most potential for benefit from targeted interventions.
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Gonadotropin-releasing hormone agonist overuse: urologists' response to reimbursement and characteristics associated with persistent overuse
Author(s):
Ellis SD, Nielsen ME, Carpenter WR, Jackson GL, Wheeler SB, Liu H, Weinberger M
Source:
Prostate Cancer and Prostatic Disease, June 2015, Pages 173-181
Tumor Sites:
prostate

Abstract

BACKGROUND: Medicare reimbursement cuts have been associated with declining gonadotropin-releasing hormone (GnRH) agonist overuse in localized prostate cancer. Medical school affiliation and foreign training have been associated with persistent overuse. However, physician-level prescribing changes and the practice type of persistent overusers have not been examined. We sought to describe physician-level changes in GnRH agonist overuse and test the association of time in practice and solo practice type with GnRH agonist overuse.

METHODS: We matched American Medical Association physician data for 2138 urologists to Surveillance, Epidemiology and End Result-Medicare data for 12,943 men diagnosed with early-stage and lower-grade adenocarcinoma of the prostate between 2000 and 2007. We conducted a population-based, retrospective study using multilevel modeling to control for patient and provider characteristics.

RESULTS: Three distinct patterns of GnRH agonist overuse were observed. Urologists' time in practice was not associated with GnRH agonist overuse (odds ratio (OR) 0.89; 95% confidence interval (CI): 0.75-1.05). However, solo practice type (OR 1.65; 95% CI: 1.34-2.02), medical school affiliation (OR 0.65; 95% CI: 0.55-0.77) and patient race were. Compared with non-Hispanic whites, non-Hispanic blacks (OR 1.76; 95% CI: 1.37-2.27), Hispanics (OR 1.41; 95% CI: 1.12-1.79) and men of 'other' race (OR 1.44; 95% CI: 1.04-1.99) had greater odds of receiving unnecessary GnRH agonists.

CONCLUSIONS: GnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach. These urologists treat more vulnerable populations, which may contribute to health disparities in prostate cancer treatment quality. Nonetheless, these findings provide guidance to develop interventions to address overuse in prostate cancer.
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Big data infrastructure for cancer outcomes research: implications for the practicing oncologist
Author(s):
Meyer AM, Basch E
Source:
Journal of Oncology Practice, May 2015, Pages 207-8
Tumor Sites:

Abstract

Big data on real-world patients and practices are essential for answering questions regarding treatment effectiveness and long-term outcomes.
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Building the evidence for decision-making: the relationship between local public health capacity and community mortality
Author(s):
Schenck AP, Meyer AM, Kuo TM, Cilenti D
Source:
American Journal of Public Health, April 2015, Pages S211-6
Tumor Sites:

Abstract

Objectives
We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina.

Methods
We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality.

Results
Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05).

Conclusions
Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.
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A new privacy debate
Author(s):
Meyer AM, Gotz D
Source:
Science, April 2015, Pages 194
Tumor Sites:
n/a

Abstract

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Provider-based research networks and diffusion of surgical technologies among patients with early-stage kidney cancer
Author(s):
Tan HJ, Meyer AM, Kuo TM, Smith AB, Wheeler SB, Carpenter WR, Nielsen ME
Source:
Cancer, March 2015, Pages 836-43
Tumor Sites:
kidney

Abstract

BACKGROUND:
Provider-based research networks such as the National Cancer Institute's Community Clinical Oncology Program (CCOP) have been shown to facilitate the translation of evidence-based cancer care into clinical practice. This study compared the utilization of laparoscopy and partial nephrectomy among patients with early-stage kidney cancer according to their exposure to CCOP-affiliated providers.

METHODS:
With linked Surveillance, Epidemiology, and End Results-Medicare data, patients with T1aN0M0 kidney cancer who had been treated with nephrectomy from 2000 to 2007 were identified. For each patient, the receipt of care from a CCOP physician or hospital and treatment with laparoscopy or partial nephrectomy were determined. Adjusted for patient characteristics (eg, age, sex, and marital status) and other organizational features (eg, community hospital and National Cancer Institute-designated cancer center), multivariate logistic regression was used to estimate the association between each surgical innovation and CCOP affiliation.

RESULTS:
During the study interval, 1578 patients (26.8%) were treated by a provider with a CCOP affiliation. Trends in the utilization of laparoscopy and partial nephrectomy remained similar between affiliated and nonaffiliated providers (P ≥ .05). With adjustments for patient characteristics, organizational features, and clustering, no association was noted between CCOP affiliation and the use of laparoscopy (odds ratio [OR], 1.11; 95% confidence interval [CI], 0.81-1.53) or partial nephrectomy (OR, 1.04; 95% CI, 0.82-1.32) despite the more frequent receipt of these treatments in academic settings (P < .05).

CONCLUSIONS:
At a population level, patients treated by providers affiliated with CCOP were no more likely to receive at least 1 of 2 surgical innovations for treatment of their kidney cancer, indicating perhaps a more limited scope to provider-based research networks as they pertain to translational efforts in cancer care. Cancer 2014. © 2014 American Cancer Society.
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Exploring the burden of inpatient readmissions after major cancer surgery
Author(s):
Stitzenberg KB, Chang Y, Smith AB, Nielsen ME
Source:
Journal of Clinical Oncology, Feb 2015, Pages 455-64
Tumor Sites:
bladder, lung, pancreas, esophagus

Abstract

PURPOSE:
Travel distances to care have increased substantially with centralization of complex cancer procedures at high-volume centers. We hypothesize that longer travel distances are associated with higher rates of postoperative readmission and poorer outcomes.

METHODS:
SEER-Medicare patients with bladder, lung, pancreas, or esophagus cancer who were diagnosed in 2001 to 2007 and underwent extirpative surgery were included. Readmission rates and survival were calculated using Kaplan-Meier functions. Multivariable negative binomial models were used to examine factors associated with readmission.

RESULTS:
Four thousand nine hundred forty cystectomies, 1,573 esophagectomies, 20,362 lung resections, and 2,844 pancreatectomies were included. Thirty- and 90-day readmission rates ranged from 13% to 29% and 23% to 43%, respectively, based on tumor type. Predictors of readmission were discharge to somewhere other than home, longer length of stay, comorbidities, higher stage at diagnosis, and longer travel distance (P < .001 for each). Patients who lived farther from the index hospital also had increased emergency room visits and were more likely to be readmitted to a hospital other than the index hospital (P < .001). Of readmitted patients, 31.9% were readmitted more than once. Long-term survival was worse and costs of care higher for patients who were readmitted (P < .001 for all).

CONCLUSION:
The burden of readmissions after major cancer surgery is high, resulting in substantially poorer patient outcomes and higher costs. Risk of readmission was most strongly associated with length of stay and discharge destination. Travel distance also has an impact on patterns of readmission. Interventions targeted at higher risk individuals could potentially decrease the population burden of readmissions after major cancer surgery.
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Racial Differences in Diffusion of Intensity-Modulated Radiation Therapy for Localized Prostate Cancer
Author(s):
Cobran EK, Chen RC, Overman R, Meyer AM, Kuo TM, O'Brien J, Sturmer T, Sheets NC, Goldin GH, Penn DC, Godley PA, Carpenter WR
Source:
American Journal of Men's Health, Feb 2015, Pages Epub ahead of print
Tumor Sites:
prostate

Abstract

Intensity-modulated radiation therapy (IMRT), an innovative treatment option for prostate cancer, has rapidly diffused over the past decade. To inform our understanding of racial disparities in prostate cancer treatment and outcomes, this study compared diffusion of IMRT in African American (AA) and Caucasian American (CA) prostate cancer patients during the early years of IMRT diffusion using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database. A retrospective cohort of 947 AA and 10,028 CA patients diagnosed with localized prostate cancer from 2002 through 2006, who were treated with either IMRT or non-IMRT as primary treatment within 1 year of diagnoses was constructed. Logistic regression was used to examine potential differences in diffusion of IMRT in AA and CA patients, while adjusting for socioeconomic and clinical covariates. A significantly smaller proportion of AA compared with CA patients received IMRT for localized prostate cancer (45% vs. 53%, p < .0001). Racial differences were apparent in multivariable analysis though did not achieve statistical significance, as time and factors associated with race (socioeconomic, geographic, and tumor related factors) explained the preponderance of variance in use of IMRT. Further research examining improved access to innovative cancer treatment and technologies is essential to reducing racial disparities in cancer care.
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Preoperatively Misclassified, Surgically Removed Benign Renal Masses: A Systematic Review of Surgical Series and United States Population-Level Burden Estimate
Author(s):
Johnson DC, Vukina J, Smith AB, Meyer AM, Wheeler SB, Kuo TM, Tan HJ, Woods ME, Raynor MC, Wallen EM, Pruthi RS, Nielsen ME
Source:
Journal of Urology, January 2015, Pages 30-5
Tumor Sites:
renal

Abstract

Purpose
A significant proportion of renal masses removed for suspected malignancy are histologically benign, with probabilities inversely proportional to lesion size. The number of preoperatively misclassified benign renal masses (BRM) undergoing nephrectomy is currently unknown. Given the increasing incidence and decreasing average size of renal cell carcinoma (RCC), this burden is likely increasing. The purpose of this study is to estimate the population-level burden of surgically removed, preoperatively misclassified BRM in the US.

Materials and Methods
A systematic review of the literature was conducted for studies reporting pathology of renal masses removed for suspected RCC based on pre-operative imaging through July 1, 2014. We excluded studies not reporting benign pathology, not stratified by size, and in which pathology was based on biopsy. SEER data were queried for incidence of surgically removed RCC in 2000-2009.

Results
19 studies reporting tumor pathology based on size met criteria for review. The pooled estimates of the proportion of benign histology in our primary analysis (US studies only, 1 cm increments) were 40.4%, 20.9%, 19.6%, 17.2%, 9.2%, and 6.4% for <1, 1-2, 2-3, 3-4, 4-7, and > 7 cm tumors, respectively. The estimated number of surgically resected BRM in the US from 2000 to 2009 increased by 82%, from 3098 to 5624.

Conclusions
These estimates suggest that the population-level burden of preoperatively misclassified BRM is substantial and increasing rapidly, paralleling increases in surgically resected small RCCs. This study illustrates an important and previously unstudied dimension of overtreatment, not directly quantified in contemporary surveillance data.
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Provider-based research networks may improve early access to innovative colon cancer treatment for African Americans treated in the community
Author(s):
Penn DC, Chang Y, Meyer AM, DeFilippo Mack C, Sanoff HK, Stitzenberg KB, Carpenter WR
Source:
Cancer, Jan 2015, Pages 93-101
Tumor Sites:
colon

Abstract

BACKGROUND:
African American (AA) patients with colon cancer (CC) experience worse outcomes than whites partly due to differential treatment. The National Cancer Institute's Community Clinical Oncology Program (CCOP), a provider-based research network, adopts and diffuses innovative CC treatments quickly. The authors hypothesized that CCOP participation would lessen racial differences in the receipt of oxaliplatin, an innovative treatment for CC, among patients with stage III CC in the community.

METHODS:
Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors performed a population-based retrospective cohort study of AA and white individuals aged ≥66 years who were diagnosed with AJCC stage III CC from 2003 through 2005. Generalized estimating equations were used to calculate the odds of receiving an oxaliplatin-containing regimen. Predicted probabilities of oxaliplatin receipt for race-CCOP combinations were calculated. The absolute difference in oxaliplatin receipt between races was estimated using the interaction contrast ratio.

RESULTS:
Of 2971 included individuals, 36% received oxaliplatin, 29.5% were CCOP-affiliated, and 7.6% were AA. On multivariate analysis, early diffusion of oxaliplatin was not found to be associated with race or CCOP participation. The probability of receiving oxaliplatin for AAs participating in a CCOP (0.46) was nearly double that of AAs who were not participating in a CCOP (0.25; P <.05). For white individuals, the probabilities of receiving oxaliplatin did not differ by CCOP participation. For oxaliplatin receipt, the joint effects assessment suggested a greater benefit of CCOP participation among AAs (interaction contrast ratio, 1.7).

CONCLUSIONS:
Among older patients with stage III CC, there is a differential impact of race on oxaliplatin receipt depending on CCOP participation. AAs treated by CCOPs were more likely to receive oxaliplatin than AAs treated elsewhere. Provider-based research networks may facilitate early access to innovative treatment for AAs with stage III CC. Cancer 2015;121:93-101. © 2014 American Cancer Society.
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Endocrine therapy initiation among Medicaid-insured breast cancer survivors with hormone receptor-positive tumors
Author(s):
Wheeler SB, Kohler RE, Reeder-Hayes KE, Goyal RK, Lich KH, Moore A, Smith TW, Melvin CL, Muss HB
Source:
Journal of Cancer Survivorship, Dec 2014, Pages 603-10
Tumor Sites:
breast

Abstract

PURPOSE:
Hormone receptor-positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR + breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40 %. Observational studies in Medicare- and privately-insured survivors suggest underutilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina.

METHODS:
Medicaid claims data were matched to state cancer registry records for survivors aging 18-64 diagnosed with stage 0-II HR + breast cancer from 2003 to 2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15 months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, comorbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year.

RESULTS:
Of 222 women meeting the inclusion criteria, only 50 % filled a prescription for ET. Involvement in the BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (adjusted odds ratio [AOR] for the BCCCP 3.76, 95 % confidence interval [CI] 1.67-8.48; AOR for 2004 relative to 2007 2.80, 95 % CI 1.03-7.62; AOR for 2005 relative to 2007 2.11, 95 % CI 0.92-4.85).

CONCLUSIONS:
Results suggest substantial underutilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET.

IMPLICATIONS FOR CANCER SURVIVORS:
Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.
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Using Procedure Codes to Define Radiation Toxicity in Administrative Data: The Devil is in the Details
Author(s):
Meyer AM, Kuo TM, Chang Y, Carpenter WR, Chen RC, Sturmer T
Source:
Medical Care, Dec 2014, Pages Epub ahead of print
Tumor Sites:

Abstract

BACKGROUND:
Systematic coding systems are used to define clinically meaningful outcomes when leveraging administrative claims data for research. How and when these codes are applied within a research study can have implications for the study validity and their specificity can vary significantly depending on treatment received.

SUBJECTS:
Data are from the Surveillance, Epidemiology, and End Results-Medicare linked dataset.

STUDY DESIGN:
We use propensity score methods in a retrospective cohort of prostate cancer patients first examined in a recently published radiation oncology comparative effectiveness study.

RESULTS:
With the narrowly defined outcome definition, the toxicity event outcome rate ratio was 0.88 per 100 person-years (95% confidence interval, 0.71-1.08). With the broadly defined outcome, the rate ratio was comparable, with 0.89 per 100 person-years (95% confidence interval, 0.76-1.04), although individual event rates were doubled. Some evidence of surveillance bias was suggested by a higher rate of endoscopic procedures the first year of follow-up in patients who received proton therapy compared with those receiving intensity-modulated radiation treatment (11.15 vs. 8.90, respectively).

CONCLUSIONS:
This study demonstrates the risk of introducing bias through subjective application of procedure codes. Careful consideration is required when using procedure codes to define outcomes in administrative data.
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Linking Data for Health Services Research: A Framework and Instructional Guide
Author(s):
Dusetzina SB, Tyree S, Meyer AM, Meyer A, Green L, Carpenter WR
Source:
AHRQ Research Report, September 2014, Pages AHRQ Publication No. 14-EHC033-EF
Tumor Sites:
n/a

Abstract

Health registries greatly enhance health services research, especially when linked with other data sources such as administrative claims. Recently, concerns about patient privacy and data security have produced policies such as the
Health Insurance Portability and Accountability Act (HIPAA) that reduce the availability of sensitive identifying information. In this context, the development of effective record linkage approaches for varying scenarios of data availability is critical. This report presents a conceptual framework and instructional information that scientifically describe the strengths and limitations of different approaches to record linkage of registries to other data sources.

(Prepared by the University
of North Carolina at Chapel Hill under Contract No. 290-2010-000141.) AHRQ Publication No.
14-EHC033-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014.
www.effectivehealthcare.ahrq.gov/reports/final.cfm
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Occupational therapy use by older adults with cancer
Author(s):
Pergolotti M, Cutchin MP, Weinberger M, Meyer AM
Source:
American Journal of Occupational Therapy, September 2014, Pages 597-607
Tumor Sites:

Abstract

Occupational therapy may significantly improve cancer survivors' ability to participate in activities, thereby improving quality of life. Little is known, however, about the use of occupational therapy services by adults with cancer. The objective of this study was to understand what shapes patterns of occupational therapy use to help improve service delivery. We examined older (age >65 yr) adults diagnosed with breast, prostate, lung, or melanoma (skin) cancer between 2004 and 2007 (N = 27,131) using North Carolina Central Cancer Registry data linked to Medicare billing claims. Survivors who used occupational therapy within 1 yr before their cancer diagnosis were more likely to use occupational therapy after diagnosis but also experienced the highest levels of comorbidities. Survivors with Stage 4 cancers or lung cancer were less likely to use occupational therapy. These findings suggest possible disparities in utilization of occupational therapy by older adults with cancer.
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Effects of distance to care and rural or urban residence on receipt of radiation therapy among North Carolina Medicare enrollees with breast cancer
Author(s):
Wheeler SB, Kuo TM, Durham D, Frizzelle B, Reeder-Hayes KE, Meyer AM
Source:
North Carolina Medical Journal, July 2014, Pages 239-246
Tumor Sites:
breast

Abstract

BACKGROUND:
Distance to oncology service providers and rurality may affect receipt of guideline-recommended radiation therapy (RT), but the extent to which these factors affect the care of Medicare-insured patients is unknown.

METHODS:
Using cancer registry data linked to Medicare claims from the Integrated Cancer Information and Surveillance System (ICISS), we identified all women aged 65 years or older who were diagnosed with stage I, II, or III breast cancer from 2003 through 2005, who had Medicare claims through 2006, and who were clinically eligible for RT. We geocoded the address of each RT service provider's practice location and calculated the travel distance from each patient's residential address to the nearest RT provider. We used ZIP codes to classify each patient's residence as rural or urban according to rural- urban commuting area codes. We used generalized estimating equations models with county-level clustering and interaction terms between distance categories and rural-urban status to estimate the effect of distance to care and rural-urban status on receipt of RT.

RESULTS:
In urban areas, increasing distance to the nearest RT provider was associated with a lower likelihood of receiving RT (odds ratio [OR] = 0.54; 95% confidence interval [CI], 0.30-0.97) for those living more than 20 miles from the nearest RT provider compared with those living less than 10 miles away. In rural areas, those living within 10-20 miles of the nearest RT provider were more likely to receive RT than those living less than 10 miles away (OR = 1.73; 95% CI, 1.08-2.76).

LIMITATIONS:
Results may not be generalizable to areas outside North Carolina or to non-Medicare populations.

CONCLUSION:
Coordinated outreach programs targeted differently to rural and urban patients may be necessary to improve the quality of oncology care.
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Health care utilization from chemotherapy-related adverse events among low-income breast cancer patients: effect of enrollment in a medical home program
Author(s):
Goyal RK, Wheeler SB, Kohler RE, Lich KH, Lin CC, Reeder-Hayes K, Meyer AM, Mayer DK
Source:
North Carolina Medical Journal, July 2014, Pages 231-238
Tumor Sites:
breast

Abstract

BACKGROUND:

Chemotherapy-related health care utilization by breast cancer patients can be expensive for payers and patients. This study evaluated the patient-centered medical home program Community Care of North Carolina (CCNC) in terms of its potential to reduce health care utilization associated with chemotherapy-related adverse events (AEs).

METHODS:
Early-stage breast cancer cases diagnosed during the 5-year period 2003-2007 were identified in the North Carolina Central Cancer Registry; these cases were then linked to North Carolina Medicaid claims data. We measured health care utilization associated with chemotherapy-related AEs by setting (inpatient, outpatient, or emergency department) during a 15-month postdiagnosis follow-up period. Descriptive and multivariate analyses were performed to examine associations between CCNC enrollment and health care utilization associated with chemotherapy-related AEs.

RESULTS:
A large proportion of breast cancer patients had at least 1 health care visit associated with a chemotherapy-related AE (n = 412 [72.3%]). The mean numbers of AE-related visits occurring in inpatient, outpatient, and emergency department settings were 0.30 (standard deviation [SD] = 0.83), 6.92 (SD = 10.94), and 0.46 (SD = 1.26), respectively. CCNC enrollment was associated with significantly fewer inpatient admissions (marginal effect, -0.1421; 95% confidence interval, -0.280 to -0.004).

LIMITATIONS:
In this observational study, we were unable to draw conclusions about the causality of these associations.

CONCLUSIONS:
Patients enrolled in CCNC had fewer inpatient health care visits associated with chemotherapy-related AEs. Future research should continue to explore the extent to which patient-centered medical homes can monitor and help manage the effects of cancer treatments.
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Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population
Author(s):
Wheeler SB, Kuo TM, Goyal RK, Meyer AM, Hassmiller Lich K, Gillen EM, Tyree S, Lewis CL, Crutchfield TM, Martens CE, Tangka F, Richardson LC, Pignone MP
Source:
Health and Place, July 2014, Pages 114-123
Tumor Sites:
colorectal

Abstract

Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003-2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.
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Big data for population-based cancer research: the Integrated Cancer Information and Surveillance System
Author(s):
Meyer AM, Olshan AF, Green L, Meyer A, Wheeler SB, Basch E, Carpenter WR
Source:
North Carolina Medical Journal, July 2014, Pages 265-269
Tumor Sites:

Abstract

The Integrated Cancer Information and Surveillance System (ICISS) facilitates population-based cancer research by developing extensive information technology systems that can link and manage large data sets. Taking an interdisciplinary 'team science' approach, ICISS has developed data, systems, and methods that allow researchers to better leverage the power of big data to improve population health.
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Racial disparities in initiation of adjuvant endocrine therapy of early breast cancer
Author(s):
Reeder-Hayes KE, Meyer AM, B Dusetzina S, Liu H, Wheeler SB
Source:
Breast Cancer Research and Treatment, June 2014, Pages 743-751
Tumor Sites:
breast

Abstract

Endocrine therapy (ET) is the cornerstone of adjuvant therapy for hormone-receptor positive (HR+) breast cancer. The survival gap between African-American (AA) and white women with breast cancer is most pronounced in HR+ subtypes, and could be related to differences in ET use. The relationship between race and initiation of ET is not well defined. We investigated patterns of ET initiation by race in a diverse cohort of women covered by commercial health insurance. We identified 2,640 women with incident HR+ breast cancer in the North Carolina Central Cancer Registry whose records linked to commercial insurance claims using the Integrated Cancer Information and Surveillance System (ICISS) database. The sample included women age <65 years diagnosed with stage I-III HR+ cancers between 2004 and 2009. We used multivariate Poisson regression to examine the effect of race on likelihood of initiating ET. 14 % of women did not initiate ET within 12 months of diagnosis. AA women were 17 % less likely to initiate ET than whites (aRR 0.83, 95 % CI 0.74-0.93). When analyzed by subset, racial disparities persisted among women who received chemotherapy (aHR 0.67, 95 % CI 0.56-0.80) but not among women who did not receive chemotherapy (aHR 0.96, 95 % CI 0.76-1.21). AA women in our sample were less likely to initiate ET than whites, and this disparity was concentrated among chemotherapy-treated women. ET under-utilization may contribute to the racial survival gap in HR+ breast cancer, and represents an opportunity for intervention to reduce breast cancer disparities.
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Effectiveness of chemoradiation for head and neck cancer in an older patient population
Author(s):
Vanderwalde NA, Meyer AM, Deal AM, Layton JB, Liu H, Carpenter WR, Weissler MC, Hayes DN, Fleming ME, Chera BS
Source:
International Journal of Radiation Oncology, Biology, and Physics, May 2014, Pages 30-37
Tumor Sites:

Abstract

PURPOSE:
The purpose of this study was to compare chemoradiation therapy (CRT) with radiation therapy (RT) only in an older patient population with head and neck squamous cell carcinoma (HNSCC).

METHODS AND MATERIALS:
Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database (1992-2007), we identified a retrospective cohort of nonmetastatic HNSCC patients and divided them into treatment groups. Comparisons were made between CRT and RT cohorts. Propensity scores for CRT were estimated from covariates associated with receipt of treatment using multivariable logistic regression. Standardized mortality ratio weights (SMRW) were created from the propensity scores and used to balance groups on measured confounders. Multivariable and SMR-weighted Cox proportional hazard models were used to estimate the hazard ratio (HR) of death for receipt of CRT versus RT among the whole group and for separate patient and tumor categories.

RESULTS:
The final cohort of 10,599 patients was 68% male and 89% white. Median age was 74 years. Seventy-four percent were treated with RT, 26% were treated with CRT. Median follow-up points for CRT and RT survivors were 4.6 and 6.3 years, respectively. On multivariable analysis, HR for death with CRT was 1.13 (95% confidence interval [CI]: 1.07-1.20; P<.01). Using the SMRW model, the HR for death with CRT was 1.08 (95% CI: 1.02-1.15; P=.01).

CONCLUSIONS:
Although the addition of chemotherapy to radiation has proven efficacious in many randomized controlled trials, it may be less effective in an older patient population treated outside of a controlled trial setting.
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Improving Our Understanding of the Surgical Oncology Workforce
Author(s):
Stitzenberg KB, Chang Y, Louie R, Groves JS, Durham D, Fraher EF
Source:
Annals of Surgery, March 2014, Pages 556-562
Tumor Sites:

Abstract

OBJECTIVE:
This study characterizes the surgical oncology workforce as a baseline for future workforce projections.

BACKGROUND:
Measuring the capacity of the surgical oncology workforce is difficult due to the wide variety of surgeons who contribute to surgical cancer care. We hypothesize that the bulk of surgical oncology care is provided by general surgeons.

METHODS:
Using Medicare claims data linked to the North Carolina Central Cancer Registry, all patients 65 years or older who had a diagnosis of incident cancer of the bladder, breast, colon/rectum, esophagus, gallbladder, kidney, liver, lung, skin (melanoma-only), ovary, pancreas, prostate, small bowel, stomach, or uterus in 2005 and who underwent an extirpative procedure for cancer were identified. The proportion of procedures performed by different types of providers was examined.

RESULTS:
A total of 7759 patients underwent 16,734 extirpative surgical procedures. Excluding procedures for gynecologic/urologic malignancies, the proportion of procedures performed by general surgeons and surgical oncologists was 48% and 12%, respectively. Patients treated by general surgeons were more likely to be older, female, minority, and from areas of high poverty. For each tumor type, travel distances were shorter for patients treated by general surgeons than those treated by specialists.

CONCLUSIONS:
Workforce projections must account for the significant overlap in the scope of services delivered by providers of different specialties and for the large contribution of general surgeons to cancer care. Efforts to improve the quality of cancer care need to move beyond centralization and focus on educating the surgeons who are providing the bulk of oncology care.
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Trends in stage-specific incidence rates for urothelial carcinoma of the bladder in the United States: 1988 to 2006
Author(s):
Nielsen ME, Smith AB, Meyer AM, Kuo TM, Tyree SD, Kim WY, Milowsky MI, Pruthi RS, Millikan RC
Source:
Cancer, January 2014, Pages 86-95
Tumor Sites:
Bladder

Abstract

BACKGROUND
Bladder cancer is notable for a striking heterogeneity of disease-specific risks. Among the approximately 75% of incident cases found to be superficial to the muscularis propria at the time of presentation (non–muscle-invasive bladder cancer), the risk of progression to the lethal phenotype of muscle-invasive disease is strongly associated with stage and grade of disease. Given the suggestion of an increasing percentage of low-risk cases in hospital-based registry data in recent years, the authors hypothesized that population-based data may reveal changes in the stage distribution of early-stage cases.

METHODS
Surveillance, Epidemiology, and End Results (SEER) data were used to examine trends for the stage-specific incidence of bladder cancer between 1988 and 2006, adjusted for age, race, and sex, using Joinpoint and nonparametric tests.

RESULTS
The adjusted incidence rate of papillary noninvasive (Ta) predominantly low grade (77%) disease was found to increase from 5.52 to 9.09 per 100,000 population (P < .0001), with an average annual percentage change of +3.3. Over the same period, concomitant, albeit smaller, decreases were observed for flat in situ (Tis) and lamina propria-invasive (T1) disease (2.57 to 1.19 and 6.65 to 4.61 per 100,000 population [both P < .0001]; average annual percent change of −5.0 and −1.6, respectively). The trend was most dramatic among patients in the oldest age strata, suggesting a previously unappreciated cohort phenomenon.

CONCLUSIONS
The findings of the current study should motivate further epidemiological investigations of differential associations of genetic and environmental factors with different bladder cancer phenotypes as well as further scrutiny of clinical practice guideline recommendations for the growing subgroup of predominantly older patients with lower-risk disease.
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An overview of methods for comparative effectiveness research
Author(s):
Meyer AM, Wheeler SB, Weinberger M, Chen RC, Carpenter WR
Source:
Seminars in Radiation Oncology, January 2014, Pages 5-13
Tumor Sites:

Abstract

Comparative effectiveness research (CER) is a broad category of outcomes research encompassing many different methods employed by researchers and clinicians from numerous disciplines. The goal of cancer-focused CER is to generate new knowledge to assist cancer stakeholders in making informed decisions that will improve health care and outcomes of both individuals and populations. There are numerous CER methods that may be used to examine specific questions, including randomized controlled trials, observational studies, systematic literature reviews, and decision sciences modeling. Each has its strengths and weaknesses. To both inform and serve as a reference for readers of this issue of Seminars in Radiation Oncology as well as the broader oncology community, we describe CER and several of the more commonly used approaches and analytical methods.
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Preoperative breast MRI and surgical outcomes in elderly women with invasive ductal and lobular carcinoma: a population-based study
Author(s):
Fortune-Greeley AK, Wheeler SB, Meyer AM, Reeder-Hayes KE, Biddle AK, Muss HB, Carpenter WR
Source:
Breast Cancer Research and Treatment, January 2014, Pages 202-213
Tumor Sites:

Abstract

Existing evidence suggests that preoperative breast magnetic resonance imaging (MRI) might not improve surgical outcomes in the general breast cancer population. To determine if patients differentially benefit from breast MRI, we examined surgical outcomes-initial mastectomy, reoperation, and final mastectomy rates-among patients grouped by histologic type. We identified women diagnosed with early-stage breast cancer from 2004 to 2007 in the SEER-Medicare dataset. We classified patients as having invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), mixed ductal/lobular carcinoma (IDLC) or other histologic type. Medicare claims were used to identify breast MRI and definitive surgeries during the initial surgical treatment episode. We used propensity score methods to account for the differential likelihood of exposure to MRI. Of the 20,332 patients who met our inclusion criteria for this study, 12.2 % had a preoperative breast MRI. Patients with ILC as compared to other histologic groups were most likely to receive MRI [OR 2.32; 95 % CI (2.02-2.67)]. In the propensity score-adjusted analyses, breast MRI was associated with an increased likelihood of an initial mastectomy for all patients and among all histologic subgroups. Among patients with ILC, having a breast MRI was associated with lower odds of a reoperation [OR 0.59; 95 % CI (0.40-0.86)], and an equal likelihood of a final mastectomy compared to similar patients without a breast MRI. Overall and among patients with IDC and IDLC, breast MRI was not significantly associated with a likelihood of a reoperation but was associated with greater odds of a final mastectomy. Our study provides evidence in support of the targeted use of preoperative breast MRI among patients with ILC to improve surgical planning; it does not provide evidence for the routine use of breast MRI among all newly diagnosed breast cancer patients or among patients with IDC.
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Use of prostate-specific antigen testing as a disease surveillance tool following radical prostatectomy
Author(s):
Trantham LC, Nielsen ME, Mobley LR, Wheeler SB, Carpenter WR, Biddle AK
Source:
Cancer, October 2013, Pages 3523-30
Tumor Sites:
Prostate

Abstract

BACKGROUND:
Prostate-specific antigen (PSA) testing is recommended every 6 to 12 months for the first 5 years following radical prostatectomy as a means to detect potential disease recurrence. Despite substantial research on factors affecting treatment decisions, recurrence, and mortality, little is known about whether men receive guideline-concordant surveillance testing or whether receipt varies by year of diagnosis, time since treatment, or other individual characteristics.

METHODS:
Surveillance testing following radical prostatectomy among elderly men was examined using Surveillance, Epidemiology, and End Results cancer registry data linked to Medicare claims. Multivariate logistic regression was used to examine the effect of demographic, tumor, and county-level characteristics on the odds of receiving surveillance testing within a given 1-year period following treatment.

RESULTS:
Overall, receipt of surveillance testing was high, with 96% of men receiving at least one test the first year after treatment and approximately 80% receiving at least one test in the fifth year after treatment. Odds of not receiving a test declined with time since treatment. Nonmarried men, men with less-advanced disease, and non-Hispanic blacks and Hispanics had higher odds of not receiving a surveillance test. Year of diagnosis did not affect the receipt of surveillance tests.

CONCLUSIONS:
Most men receive guideline-concordant surveillance PSA testing after prostatectomy, although evidence of a racial disparity between non-Hispanic whites and some minority groups exists. The decline in surveillance over time suggests the need for well-designed long-term surveillance plans following radical prostatectomy. Cancer 2013. © 2013 American Cancer Society.
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Racial difference in histologic subtype of renal cell carcinoma
Author(s):
Olshan AF, Kuo T, Meyer AM, Nielsen ME, Purdue MP, Rathmell WK
Source:
Cancer Medicine, October 2013, Pages 744-749
Tumor Sites:
renal

Abstract

In the United States, renal cell carcinoma (RCC) has rapidly increased in incidence for over two decades. The most common histologic subtypes of RCC, clear cell, papillary, and chromophobe have distinct genetic and clinical characteristics; however, epidemiologic features of these subtypes have not been well characterized, particularly regarding any associations between race, disease subtypes, and recent incidence trends. Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, we examined differences in the age-adjusted incidence rates and trends of RCC subtypes, including analysis focusing on racial differences. Incidence rates increased over time (2001–2009) for all three subtypes. However, the proportion of white cases with clear cell histology was higher than among blacks (50% vs. 31%, respectively), whereas black cases were more likely than white cases to have papillary RCC (23% vs. 9%, respectively). Moreover, papillary RCC incidence increased more rapidly for blacks than whites (P < 0.01) over this period. We also observed that increased incidence of papillary histology among blacks is not limited to the smallest size strata. We observed racial differences in proportionate incidence of RCC subtypes, which appear to be increasing over time; this novel finding motivates further etiologic, clinical, molecular, and genetic studies.
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Differential Receipt of Sentinel Lymph Node Biopsy Within Practice-based Research Networks
Author(s):
Meyer AM, Reeder-Hayes KE, Liu H, Wheeler SB, Penn D, Weiner BJ, Carpenter WR
Source:
Medical Care, September 2013, Pages 812-818
Tumor Sites:
Breast

Abstract

Background: Practice-based research networks (PBRNs) are promising for accelerating not only research, but also dissemination of research-based evidence into broader community practice. Sentinel lymph node biopsy (SLNB) is an innovation in breast cancer care associated with equivalent survival and lower morbidity, as compared with standard axillary lymph node dissection. We examined the diffusion of SLNB into practice and whether affiliation with the Community Clinical Oncology Program (CCOP), a cancer-focused PBRN, was associated with more rapid uptake of SLNB.

Research Design: Surveillance Epidemiology and End Results-Medicare data were used to study women diagnosed with stage I or II breast cancer in the years 2000–2005 and undergoing breast-conserving surgery with axillary staging (n=6226). The primary outcome was undergoing SLNB. CCOP affiliation of the surgical physician was ascertained from NCI records. Multivariable generalized linear modeling with generalized estimating equations was used to measure association between CCOP exposure and undergoing SLNB, controlling for potential confounders.

Results: Women treated by a CCOP physician had significantly higher odds of receiving SLNB compared with women treated by a non-CCOP physician (OR 2.68; 95% CI, 1.35–5.34). The magnitude of this association was larger than that observed among patients treated by physicians operating in medical school–affiliated hospitals (OR 1.76; 95% CI, 1.30–2.39).

Conclusions: Women treated by CCOP-affiliated physicians were more likely to undergo SLNB irrespective of the hospital’s medical school affiliation, suggesting that the CCOP PBRN may play a role in the rapid adoption of research-based innovation in community practice.
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Calendar time-specific propensity scores and comparative effectiveness research for stage III colon cancer chemotherapy
Author(s):
Mack CD, Glynn RJ, Brookhart MA, Carpenter WR, Meyer AM, Sandler RS, Stürmer T
Source:
Pharmacoepidemiology and Drug Safety, August 2013, Pages 810-818
Tumor Sites:
Colon

Abstract

PURPOSE:
Nonexperimental studies of treatment effectiveness provide an important complement to randomized trials by including heterogeneous populations. Propensity scores (PSs) are common in these studies but may not adequately capture changes in channeling experienced by innovative treatments. We use calendar time-specific (CTS) PSs to examine the effect of oxaliplatin during dissemination from off-label to widespread use.

METHODS:
Stage III colon cancer patients aged 65+ years initiating chemotherapy between 2003 and 2006 were examined using cancer registry data linked with Medicare claims. Two PS approaches for receipt of oxaliplatin versus 5-flourouricil were constructed using logistic models with key components of age, sex, substage, grade, census-level income, and comorbidities: (i) a conventional, year-adjusted PS and (ii) a CTS PS constructed and matched separately within 1-year intervals, then combined. We compared PS-matched hazard ratios (HRs) for mortality using Cox models.

RESULTS:
Oxaliplatin use increased significantly; 8% (n = 86) of patients received it in the first time period versus 52% (n = 386) in the last. Channeling by comorbidities, income, and age appeared to change over time. The CTS PS improved covariate balance within calendar time strata and yielded an attenuated estimated benefit of oxaliplatin (HR = 0.75) compared with the conventional PS (HR = 0.69).

CONCLUSION:
In settings where prescribing patterns have changed and calendar time acts as a confounder, a CTS PS can characterize changes in treatment choices and estimating separate PSs within specific calendar time periods may result in enhanced confounding control. To increase validity of comparative effectiveness research, researchers should carefully consider drug lifecycles and effects of innovative treatment dissemination over time. Copyright © 2013 John Wiley & Sons, Ltd.
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Patterns of care in older patients with squamous cell carcinoma of the head and neck: A Surveillance, Epidemiology, and End Results-Medicare analysis
Author(s):
VanderWalde NA, Meyer AM, Liu H, Tyree SD, Zullig LL, Carpenter WR, Shores CD, Weissler MC, Hayes DN, Fleming M, Chera BS
Source:
Journal of Geriatric Oncology, July 2013, Pages 262-270
Tumor Sites:
Head and neck

Abstract

There is growing evidence in the literature that older patients may not benefit from more intensive therapy for head and neck squamous cell carcinoma (HNSCC). A growing number of patients with HNSCC are age 65years or older; however, much of the evidence base informing treatment decisions is based on substantially younger and healthier clinical trial populations. The purpose of this study was to assess the patterns of care of older HNSCC patients to better understand how age is associated with treatment decisions.
Methods

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (1992–2007), we identified patients with non-metastatic HNSCC (n=10,867) and categorized them by treatment: surgery vs. non-surgery and chemoradiotherapy (CRT) vs. radiotherapy (RT). Multivariate logistic regression models were used to identify variables associated with the receipt of surgery and CRT.
Results

Increasing age w\as associated with decreased odds of receiving CRT (OR=0.94; 95% CI 0.93–0.94) but not surgery (OR 1.00; 95% CI 0.99–1.00). Co-morbidity and race were not associated with receipt of either surgery or CRT. Utilization of CRT increased while surgery decreased between 1992 and 2007.
Conclusion

Age may influence the receipt of CRT for older HNSCC patients. There has been an increasing trend in the receipt of CRT and a decrease in primary surgery.
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Effectiveness of etoposide chemomobilization in lymphoma patients undergoing auto-SCT
Author(s):
Wood WA, Whitley J, Goyal R, Brown PM, Sharf A, Irons R, Rao KV, Essenmacher A, Serody JS, Coghill JM, Armistead PM, Sarantopoulos S, Gabriel DA, Shea TC
Source:
Bone Marrow Transplant, June 2013, Pages 771-776
Tumor Sites:

Abstract

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 μg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.Bone Marrow Transplantation advance online publication, 19 November 2012; doi:10.1038/bmt.2012.216.
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Comparative effectiveness of intensity modulated radiation therapy and conventional conformal radiation therapy in the treatment of prostate cancer after radical prostatectomy
Author(s):
Goldin GH, Sheets NC, Meyer AM, Kuo TM, Wu Y, Stürmer T, Godley PA, Carpenter WR, Chen RC
Source:
JAMA Internal Medicine, June 2013, Pages 1136-1143
Tumor Sites:
prostate

Abstract

IMPORTANCE Comparative effectiveness research of prostate cancer therapies is needed because of the development and rapid clinical adoption of newer and costlier treatments without proven clinical benefit. Radiotherapy is indicated after prostatectomy in select patients who have adverse pathologic features and in those with recurrent disease.

OBJECTIVES To examine the patterns of use of intensity-modulated radiotherapy (IMRT), a newer, more expensive technology that may reduce radiation dose to adjacent organs compared with the older conformal radiotherapy (CRT) in the postprostatectomy setting, and to compare disease control and morbidity outcomes of these treatments.

DESIGN AND SETTING Data from the Surveillance, Epidemiology, and End Results-Medicare-linked database were used to identify patients with a diagnosis of prostate cancer who had received radiotherapy within 3 years after prostatectomy.

PARTICIPANTS Patients who received IMRT or CRT.

MAIN OUTCOMES AND MEASURES The outcomes of 457 IMRT and 557 CRT patients who received radiotherapy between 2002 and 2007 were compared using their claims through 2009. We used propensity score methods to balance baseline characteristics and estimate adjusted incidence rate ratios (RRs) and their 95% CIs for measured outcomes.

RESULTS Use of IMRT increased from zero in 2000 to 82.1% in 2009. Men who received IMRT vs CRT showed no significant difference in rates of long-term gastrointestinal morbidity (RR, 0.95; 95% CI, 0.66-1.37), urinary nonincontinent morbidity (0.93; 0.66-1.33), urinary incontinence (0.98; 0.71-1.35), or erectile dysfunction (0.85; 0.61-1.19). There was no significant difference in subsequent treatment for recurrent disease (RR, 1.31; 95% CI, 0.90-1.92).

CONCLUSIONS AND RELEVANCE Postprostatectomy IMRT and CRT achieved similar morbidity and cancer control outcomes. The potential clinical benefit of IMRT in this setting is unclear. Given that IMRT is more expensive, its use for postprostatectomy radiotherapy may not be cost-effective compared with CRT, although formal analysis is needed.
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Is medical home enrollment associated with receipt of guideline-concordant follow-up care among low-income breast cancer survivors?
Author(s):
Wheeler SB, Kohler RE, Goyal RK, Lich KH, Lin C, Moore A, Smith TW, Melvin CL, Reeder-Hayes K, Domino ME
Source:
Medical Care, March 2013, Pages 494-502
Tumor Sites:

Abstract

Background: Community Care of North Carolina (CCNC) initiated an innovative medical home program in the 1990s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes but has not been evaluated in the context of cancer care. We explored whether CCNC enrollment was associated with guideline-concordant follow-up care among breast cancer survivors.

Methods: Using state cancer registry records matched to Medicaid claims, we identified women aged from 18 to 64 who were diagnosed with stage 0, I, II, or unstaged breast cancer from 2003 to 2007 and tracked their monthly CCNC enrollment. Using published American Society for Clinical Oncology guidelines to define our outcomes, we employed multivariate logistic regressions to examine the correlation of receipt of mammogram and at least 2 physical examinations/history-taking visits within observational windows consistent with the guidelines.

Results: Of the 840 women, approximately half were enrolled into the CCNC for some time during the study period. Between 40% and 85% received follow-up mammogram in accordance with guidelines, with significant variation by CCNC status, and 95% of women received at least 2 physical examinations/history-taking visits. In multivariate models, increasing months of CCNC enrollment was significantly positively associated with receipt of follow-up mammogram but not with physical examinations/history-taking visits.

Conclusions: Results suggest that CCNC enrollment is associated with guideline-concordant follow-up care for Medicaid-insured survivors. Given the growing population of cancer survivors and increased emphasis on primary care medical homes, future studies should explore what factors are associated with medical home participation and whether similar findings are observed with extended follow-up.
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A framework for understanding cancer comparative effectiveness research data needs
Author(s):
Carpenter WR, Meyer AM, Abernethy AP, Stürmer T, Kosorok MR
Source:
Journal of Clinical Epidemiology, November 2012, Pages 1150-1158
Tumor Sites:
All

Abstract

OBJECTIVES:
Randomized controlled trials remain the gold standard for evaluating cancer intervention efficacy. Randomized trials are not always feasible, practical, or timely and often don't adequately reflect patient heterogeneity and real-world clinical practice. Comparative effectiveness research can leverage secondary data to help fill knowledge gaps randomized trials leave unaddressed; however, comparative effectiveness research also faces shortcomings. The goal of this project was to develop a new model and inform an evolving framework articulating cancer comparative effectiveness research data needs.

STUDY DESIGN AND SETTING:
We examined prevalent models and conducted semi-structured discussions with 76 clinicians and comparative effectiveness research researchers affiliated with the Agency for Healthcare Research and Quality's cancer comparative effectiveness research programs.

RESULTS:
A new model was iteratively developed and presents cancer comparative effectiveness research and important measures in a patient-centered, longitudinal chronic care model better reflecting contemporary cancer care in the context of the cancer care continuum, rather than a single-episode, acute-care perspective.

CONCLUSION:
Immediately relevant for federally funded comparative effectiveness research programs, the model informs an evolving framework articulating cancer comparative effectiveness research data needs, including evolutionary enhancements to registries and epidemiologic research data systems. We discuss elements of contemporary clinical practice, methodology improvements, and related needs affecting comparative effectiveness research's ability to yield findings clinicians, policy makers, and stakeholders can confidently act on.
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Reply to Journal of the American Medical Association letters to the editor
Author(s):
Meyer AM, Godley P, Chen RC
Source:
Journal of the American Medical Association, August 2012, Pages
Tumor Sites:
Prostate

Abstract

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A surveillance system for monitoring, public reporting, and improving minority access to cancer clinical trials
Author(s):
Carpenter WR, Tyree S, Wu Y, Meyer AM, Dimartino L, Zullig L, Godley PA
Source:
Clinical Trials, August 2012, Pages 426-435
Tumor Sites:
All

Abstract

BACKGROUND:
The Institute of Medicine (IOM) has recommended that each person with cancer should have access to clinical trials, which have been associated with improving care quality and disparities. With no effective enrollment monitoring system, patterns of trial enrollment remain unclear.

PURPOSE:
We developed a population-based, statewide system designed to facilitate monitoring of cancer trial enrollment and targeting of future interventions to improve it.

METHODS:
Person-level cancer incidence data from the North Carolina Central Cancer Registry (NCCCR), person-level treatment trial accrual data from the National Cancer Institute (NCI), and county-level Area Resource Files (ARF) measures for 12 years, 1996-2007, were studied. Deidentified person-level data necessitated county-level analysis. Enrollment rates were estimated as the ratio of trial enrollment to cancer incidence for each race, gender, year, and county combination. Multivariable analysis examined factors associated with trial accrual. Sensitivity analyses examined spurious fluctuations and temporal discordance of incidence and enrollment.

RESULTS:
The NCI treatment trial enrollment rate was 2.39% for whites and 2.20% for minorities from 1996 to 2007, and 2.88% and 2.47%, respectively, from 2005 to 2007. Numerous counties had no minority enrollment. The 2005-2007 enrollment rates for white and minority females was 4.04% and 3.59%, respectively, and for white and minority males was 1.74% and 1.36%, respectively. Counties with a medical school or NCI Community Clinical Oncology Program (CCOP)-affiliated practice had higher trial enrollment.

LIMITATIONS:
We examined NCI trial accrual only - industry-sponsored and investigator-initiated trials were excluded; however, studies comprise the majority of all clinical trial participants. Delays in data availability may hinder the immediacy of population-based analyses.

CONCLUSIONS:
Model stability and consistency suggest that this system is effective for population-based enrollment surveillance. For North Carolina, it suggests a worsening disparity in minority trial enrollment, though our analyses elucidate targets for intervention. Regional enrollment variation suggests the importance of access to clinical research networks and infrastructure. Substantial gender differences merit further examination.
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Cost analysis of robot-assisted laparoscopic versus hand-assisted laparoscopic partial nephrectomy
Author(s):
Ferguson JE 3rd, Goyal RK, Raynor MC, Nielsen ME, Pruthi RS, Brown PM, Wallen EM.
Source:
Journal of Endourology, August 2012, Pages 1030-1037
Tumor Sites:
Kidney

Abstract

PURPOSE:
To perform a cost comparison of three approaches to partial nephrectomy (PN): Open (OPN), hand-assisted laparoscopic (HALPN), and robot-assisted (RAPN).

PATIENTS AND METHODS:
We retrospectively evaluated cost and clinical data from patients undergoing OPN, HALPN, and RAPN from 2007 to 2010 (n=89). Baseline demographic data, patient comorbidities, R.E.N.A.L. nephrometry score, and perioperative outcomes were assessed. Costs and subcosts from the operating room (OR) and hospital were evaluated using nonparametric statistical analyses.

RESULTS:
Patient demographics and tumor characteristics were similar between HALPN and RAPN, while OPN patients had more comorbidities and more difficult-to-resect tumors. Thus, HALPN and RAPN were directly compared, while OPNs were excluded from the analysis. No difference was found in overall costs between HALPN and RAPN ($13,560 vs $13,439, P=0.29). OR costs were higher for RAPN ($7276 vs $5708, P=0.0001) because of the higher robotic capital and reusable equipment costs that outweighed higher disposable costs in the HALPN group. OR time-related costs were similar between groups. RAPN patients had a shorter length of stay (LOS), which decreased postoperative hospital costs ($4371 vs $5984, P=0.002).

CONCLUSIONS:
No difference in overall cost was found between RAPN and HALPN. Robot allocation, OR equipment use, and LOS are important determinants of total cost. Further study regarding recovery and quality of life may reveal added benefits to minimally invasive approaches and increase use of nephron-sparing surgery.
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Translating research into practice: the role of provider based research networks in the diffusion of an evidence-based colon cancer treatment innovation
Author(s):
Carpenter WR, Meyer AM, Wu Y, Qaqish B, Sanoff HK, Goldberg RM, Weiner BJ.
Source:
Medical Care, August 2012, Pages 737-748
Tumor Sites:
Colon

Abstract

BACKGROUND:
Provider-based research networks (PBRNs)--collaborative research partnerships between academic centers and community-based practitioners--are a promising model for accelerating the translation of research into practice; however, empirical evidence of accelerated translation is limited. Oxaliplatin in adjuvant combination chemotherapy is an innovation with clinical trial-proven survival benefit compared with prior therapies. The goal of this study is to examine the diffusion of oxaliplatin into community practice, and whether affiliation with the National Cancer Institute's (NCI's) Community Clinical Oncology Program (CCOP)--a nationwide cancer-focused PBRN--is associated with accelerated innovation adoption.

DESIGN, SETTING, AND PARTICIPANTS:
This retrospective observational study used linked Surveillance, Epidemiology, and End Results-Medicare and NCI CCOP data to examine Medicare participants with stage III colon cancer initiating treatment in 2003 through 2006, the years surrounding oxaliplatin's Food and Drug Administration approval. A fixed-effects analysis examined chemotherapy use among patients treated outside academic centers at CCOP-affiliated practices compared with non-CCOP practices. Two-group modeling controlled for multiple levels of clustering, year of chemotherapy initiation, tumor characteristics, patient age, race, comorbidity, Medicaid dual-eligibility status, and education.

RESULTS:
Of 4055 community patients, 35% received 5-fluoruracil, 20% received oxaliplatin, 7% received another chemotherapy, and 38% received no chemotherapy. Twenty-five percent of CCOP patients received oxaliplatin, compared with 19% of non-CCOP patients. In multivariable analysis, CCOP exposure was associated with higher odds of receiving guideline-concordant treatment in general, and oxaliplatin specifically.

CONCLUSIONS:
These findings contribute to a growing set of evidence linking PBRNs with a greater probability of receiving treatment innovations and high-quality cancer care, with implications for clinical and research policy.
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Racial disparities in receipt and comparative effectiveness of oxaliplatin for stage III colon cancer in older adults
Author(s):
Mack CD, Carpenter W, Meyer AM, Sanoff H, Stürmer T
Source:
Cancer, June 2012, Pages 2925-2934
Tumor Sites:
Colon

Abstract

BACKGROUND:
African Americans in the United States have higher rates of colon cancer mortality than other races. This study examines the use of oxaliplatin, a novel chemotherapeutic agent approved in 2004, among African American and Caucasian American patients with stage III colon cancer to determine whether differential receipt or differential effectiveness of the drug may explain the racial disparity in colon cancer mortality.

METHODS:
The authors conducted a population-based retrospective cohort study of stage III colon cancer patients aged 65 years and older treated from 2004 through 2006 who initiated chemotherapy within 90 days of surgical resection (N = 1162) using Surveillance, Epidemiology and End Results-Medicare data. Patients receiving oxaliplatin (n = 477) were compared with those receiving 5-fluorouracil without oxaliplatin (n = 685). The authors estimated prevalence ratios and hazard ratios (HRs) using multivariate binomial regression and Cox models to evaluate racial differences in oxaliplatin receipt and survival.

RESULTS:
African Americans were as likely as Caucasian Americans to receive oxaliplatin (40.5 vs 41.1%; prevalence ratio, 0.90; 95% confidence interval [CI], 0.71-1.13). Oxaliplatin was associated with lower mortality compared with 5-fluorouracil (HR, 0.76; 95% CI, 0.58-1.00). This benefit appeared stronger among African Americans (HR, 0.31; 95% CI, 0.09-1.05) than Caucasian Americans (HR, 0.80; 95% CI, 0.60-1.06).

CONCLUSIONS:
In Medicare-insured patients receiving chemotherapy, the authors observed no meaningful racial disparities in receipt of oxaliplatin and, among those receiving it, potentially better survival among African Americans. Differential receipt and effectiveness of oxaliplatin-containing regimens does not appear to contribute to the previously documented racial disparities in colon cancer survival. Understanding reasons for potentially enhanced effectiveness among African Americans may inform efforts to resolve racial disparities in colon cancer outcomes.
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Use and timeliness of radiation therapy after breast-conserving surgery in low-income women with early-stage breast cancer
Author(s):
Wheeler SB, Wu Y, Meyer AM, Carpenter WR, Richardson LC, Smith JL, Lewis MA, Weiner BJ
Source:
Cancer Investigation, May 2012, Pages 258-267
Tumor Sites:
Breast

Abstract

PURPOSE:
To characterize overall receipt and timeliness of radiation therapy (RT) following breast-conserving surgery among Medicaid-insured patients.

METHOD:
State cancer registry data linked with Medicaid claims from 2003 to 2009 were analyzed. Multivariate logistic and Cox proportional hazards regressions were employed.

RESULTS:
Overall, 81% of patients received guideline-recommended RT. Significant variation in timing of RT initiation was documented. Having fewer comorbitidies and receiving chemotherapy were correlated with higher odds of RT initiation within 1 year.

CONCLUSION:
Although RT use in Medicaid-insured women appears to have improved since earlier studies, documented delays in RT are troublesome and warrant further investigation.
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Data for cancer comparative effectiveness research: Past, present, and future potential
Author(s):
Meyer AM, Carpenter WR, Abernethy AP, Stürmer T, Kosorok MR
Source:
Cancer, April 2012, Pages 5186-5197
Tumor Sites:
All

Abstract

Comparative effectiveness research (CER) can efficiently and rapidly generate new scientific evidence and address knowledge gaps, reduce clinical uncertainty, and guide health care choices. Much of the potential in CER is driven by the application of novel methods to analyze existing data. Despite its potential, several challenges must be identified and overcome so that CER may be improved, accelerated, and expeditiously implemented into the broad spectrum of cancer care and clinical practice. To identify and characterize the challenges to cancer CER, the authors reviewed the literature and conducted semistructured interviews with 41 cancer CER researchers at the Agency for Healthcare Research and Quality's Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Cancer CER Consortium. Several data sets for cancer CER were identified and differentiated into an ontology of 8 categories and were characterized in terms of strengths, weaknesses, and utility. Several themes emerged during the development of this ontology and discussions with CER researchers. Dominant among them was accelerating cancer CER and promoting the acceptance of findings, which will necessitate transcending disciplinary silos to incorporate diverse perspectives and expertise. Multidisciplinary collaboration is required, including those with expertise in nonexperimental data, statistics, outcomes research, clinical trials, epidemiology, generalist and specialty medicine, survivorship, informatics, data, and methods, among others. Recommendations highlight the systematic, collaborative identification of critical measures; application of more rigorous study design and sampling methods; policy-level resolution of issues in data ownership, governance, access, and cost; and development and application of consistent standards for data security, privacy, and confidentiality.
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Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer
Author(s):
Sheets NC, Goldin GH, Meyer AM, Wu Y, Chang Y, Stürmer T, Holmes JA, Reeve BB, Godley PA, Carpenter WR, Chen RC
Source:
Journal of the American Medical Association, April 2012, Pages 1611-1620
Tumor Sites:
Prostate

Abstract

CONTEXT:
There has been rapid adoption of newer radiation treatments such as intensity-modulated radiation therapy (IMRT) and proton therapy despite greater cost and limited demonstrated benefit compared with previous technologies.

OBJECTIVE:
To determine the comparative morbidity and disease control of IMRT, proton therapy, and conformal radiation therapy for primary prostate cancer treatment.

DESIGN, SETTING, AND PATIENTS:
Population-based study using Surveillance, Epidemiology, and End Results-Medicare-linked data from 2000 through 2009 for patients with nonmetastatic prostate cancer.

MAIN OUTCOME MEASURES:
Rates of gastrointestinal and urinary morbidity, erectile dysfunction, hip fractures, and additional cancer therapy.

RESULTS:
Use of IMRT vs conformal radiation therapy increased from 0.15% in 2000 to 95.9% in 2008. In propensity score-adjusted analyses (N = 12,976), men who received IMRT vs conformal radiation therapy were less likely to receive a diagnosis of gastrointestinal morbidities (absolute risk, 13.4 vs 14.7 per 100 person-years; relative risk [RR], 0.91; 95% CI, 0.86-0.96) and hip fractures (absolute risk, 0.8 vs 1.0 per 100 person-years; RR, 0.78; 95% CI, 0.65-0.93) but more likely to receive a diagnosis of erectile dysfunction (absolute risk, 5.9 vs 5.3 per 100 person-years; RR, 1.12; 95% CI, 1.03-1.20). Intensity-modulated radiation therapy patients were less likely to receive additional cancer therapy (absolute risk, 2.5 vs 3.1 per 100 person-years; RR, 0.81; 95% CI, 0.73-0.89). In a propensity score-matched comparison between IMRT and proton therapy (n = 1368), IMRT patients had a lower rate of gastrointestinal morbidity (absolute risk, 12.2 vs 17.8 per 100 person-years; RR, 0.66; 95% CI, 0.55-0.79). There were no significant differences in rates of other morbidities or additional therapies between IMRT and proton therapy.

CONCLUSIONS:
Among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction; IMRT compared with proton therapy was associated with less gastrointestinal morbidity.
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Impact of distance to a urologist on early diagnosis of prostate cancer among black and white patients
Author(s):
Holmes JA, Carpenter WR, Wu Y, Hendrix LH, Peacock S, Massing M, Schenck AP, Meyer AM, Diao K, Wheeler SB, Godley PA, Stitzenberg KB, Chen RC
Source:
Journal of Urology, March 2012, Pages 883-888
Tumor Sites:
Prostate

Abstract

PURPOSE:
We examined whether an increased distance to a urologist is associated with a delayed diagnosis of prostate cancer among black and white patients, as manifested by higher risk disease at diagnosis.

MATERIALS AND METHODS:
North Carolina Central Cancer Registry data were linked to Medicare claims for patients with incident prostate cancer diagnosed in 2004 to 2005. Straight-line distances were calculated from the patient home to the nearest urologist. Race stratified multivariate ordinal logistic regression was used to examine the association between distance to a urologist and prostate cancer risk group (low, intermediate, high or very high/metastasis) at diagnosis for black and white patients while accounting for age, comorbidity, marital status and diagnosis year. An overall model was then used to examine the distance × race interaction effect.

RESULTS:
Included in analysis were 1,720 white and 531 black men. In the overall cohort the high risk cancer rate increased monotonically with distance to a urologist, including 40% for 0 to 10, 45% for 11 to 20 and 57% for greater than 20 miles. Correspondingly the low risk cancer rate decreased with longer distance. On race stratified multivariate analysis longer distance was associated with higher risk prostate cancer for white and black patients (p = 0.04 and <0.01, respectively) but the effect was larger in the latter group. The distance × race interaction term was significant in the overall model (p = 0.03).

CONCLUSIONS:
Longer distance to a urologist may disproportionally impact black patients. Decreasing modifiable barriers to health care access, such as distance to care, may decrease racial disparities in prostate cancer.
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A balancing act for breast cancer? Everolimus for hormone receptor positive patients.
Author(s):
Wheeler SB, Reeder-Hayes K, Meyer AM
Source:
Translational Cancer Research, March 2012, Pages 109-112
Tumor Sites:
Breast

Abstract

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Race and age disparities in receipt of sentinel lymph node biopsy for early-stage breast cancer
Author(s):
Reeder-Hayes KE, Bainbridge J, Meyer AM, Amos KD, Weiner BJ, Godley PA, Carpenter WR
Source:
Breast Cancer Research and Treatment, August 2011, Pages 863-871
Tumor Sites:
Breast

Abstract

To evaluate differences in use of sentinel lymph node biopsy (SLNB) by age and race in Medicare recipients with early-stage breast cancer, we examined Surveillance, Epidemiology and End Results—Medicare linked data for women undergoing breast conserving surgery for stage I or II breast cancer, including axillary staging, between January 2000 and December 2002. Multivariable generalized linear modeling with generalized estimating equations was used to identify predictors of receiving SLNB versus standard axillary lymph node dissection as the primary axillary staging modality. Women were significantly less likely to receive SLNB as their primary staging procedure if they were African American (OR 0.65), greater than 80 years of age (OR 0.71 vs. age <70), or dually eligible for Medicare and Medicaid (OR 0.61). Tumor characteristics, including well-differentiated histology and stage I disease, were associated with increased likelihood of SLNB, but estrogen receptor status was not a significant predictor. Women treated at an institution affiliated with an NCI cooperative research group had significantly greater likelihood of receiving SLNB (OR 2.31). Likelihood of receiving SLNB increased for women diagnosed in 2001 and 2002 compared with 2000. Significant disparities exist in receipt of SLNB in the Medicare population, with African Americans, the elderly, and economically disadvantaged patients being less likely to receive this innovative and morbidity-sparing procedure. These findings continue a previously observed pattern of reduced access to state of the art breast cancer care among underserved populations.
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The role of organizational affiliations and research networks in the diffusion of breast cancer treatment innovation
Author(s):
Carpenter WR, Reeder-Hayes K, Bainbridge J, Meyer AM, Amos KD, Weiner BJ, Godley PA
Source:
Medical Care, February 2011, Pages 172-9
Tumor Sites:
Breast

Abstract

INTRODUCTION:
The National Institutes of Health (NIH) sees provider-based research networks and other organizational linkages between academic researchers and community practitioners as promising vehicles for accelerating the translation of research into practice. This study examines whether organizational research affiliations and teaching affiliations are associated with accelerated diffusion of sentinel lymph node biopsy (SLNB), an innovation in the treatment of early-stage breast cancer.

METHODS:
Surveillance Epidemiology and End Results-Medicare data were used to examine the diffusion of SLNB for treatment of early-stage breast cancer among women aged 65 years and older diagnosed between 2000 and 2002, shortly after Medicare approved and began reimbursing for the procedure.

RESULTS:
In this population, patients treated at an organization affiliated with a research network--the American College of Surgeons Oncology Group (ACOSOG) or other National Cancer Institute (NCI) cooperative groups--were more likely to receive the innovative treatment (SLNB) than patients treated at unaffiliated organizations (odds ratio: 2.70, 95% confidence interval: 1.77-4.12; odds ratio: 1.84, 95% confidence interval: 1.26-2.69, respectively). Neither hospital teaching status nor surgical volume was significantly associated with differences in SLNB use.

DISCUSSION:
Patients who receive cancer treatment at organizations affiliated with cancer research networks have an enhanced probability of receiving SLNB, an innovative procedure that offers the promise of improved patient outcomes. Study findings support the NIH Roadmap and programs such as the NCI's Community Clinical Oncology Program, as they seek to accelerate the translation of research into practice by simultaneously accelerating and broadening cancer research in the community.
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