Racial differences in the treatment of early-stage lung cancer

Referral patterns, treatment choices, and outcomes in locoregional esophageal cancer: a population-based analysis of elderly patients

PURPOSE To determine the impact of demographics and comorbidity on access to specialists' services, treatment, and outcome for patients with locoregional esophageal cancer. PATIENTS AND METHODS We performed a retrospective cohort study of 3,538 patients older than age 65 years who were diagnosed with locoregional esophageal cancer between 1991 and 1999 in one of 11 regions monitored by the Surveillance, Epidemiology, and End Results tumor program. We examined linked Medicare claims for assessment by a surgeon, radiation oncologist, or medical oncologist and subsequent treatment with surgery, radiation, or chemotherapy. Logistic regression analyses were performed for seeing a specialist and for undergoing treatment according to age, sex, race, socioeconomic status, geographic region, and presence of comorbidities. Cox proportional hazards analyses were performed to estimate hazard ratios (HRs) for survival with and without adjustment for treatment received. Results Seeing a cancer specialist depended especially on age and region of diagnosis. These same factors were also related to subsequent treatment decisions, but associations were reversed in some regions, such that treatment depended less on region. Older patients had poorer survival (HR = 2.0 for 85+ v 65 to 69 years), which was partly explained by treatment received (HR decreased to 1.5 when adjusted for treatment). CONCLUSION Older patients have less intensive treatment of esophageal cancer, which is explained by both a lower rate of seeing a cancer specialist and by less intensive treatment once seen. Referring physicians and treating specialists must ensure that elderly patients are not deprived of the opportunity to consider all of their treatment options.

Ethnic/Racial Disparities in Hospital Procedure Volume for Lung Resection for Lung Cancer

BACKGROUND

Ethnic/racial minorities experience poorer outcomes from lung cancer than non-Hispanic whites. Higher hospital procedure volume is associated with better survival from lung resection for lung cancer.

OBJECTIVES

We examined whether (1) ethnic/racial minorities are more likely to obtain lung resections at lower volume hospitals, (2) ethnicity/race is associated with inpatient mortality, (3) hospital volume mediates this association, and (4) hospital selection is mediated by racial/ethnic segregation, differences in insurance coverage, or limited hospital choice.

METHODS

Six years of data from the Nationwide Inpatient Sample (NIS 1998-2003, unweighted n = 50,245, weighted n = 129,506) were used in multivariate models controlling for sociodemographic factors, case complexity, and hospital characteristics. Additional analyses were conducted using the Area Resource File, which provided data on ethnic density and number of surgical hospitals in the hospital region.

RESULTS

Blacks/African Americans (odds ratio [OR] = 0.45; 0.34-0.58) and Latinos (OR = 0.44; 0.32-0.63) had lower odds of obtaining lung resection at a high-volume hospital than non-Hispanic whites. Blacks/African Americans (OR = 1.30; 1.01-1.67), Latinos (OR = 1.41; 1.02-1.94), and other racial/ethnic minorities (OR = 1.46; 1.04-2.06) also had higher odds of dying in hospital, but this association was statistically nonsignificant after controlling for hospital volume. Hospital location was not associated with lung resection procedure volume, nor did location mediate the association between ethnicity/race and hospital volume.

CONCLUSIONS

Ethnic/racial minorities are obtaining lung resection in lower volume hospitals and are more likely to die in hospital. Hospital volume is associated with higher mortality, but health insurance, segregation, and number of surgical hospitals within a county do not account for observed disparities.

Insurance status, but not race, predicts perforation in adult patients with acute appendicitis

BACKGROUND

Delay in treatment is a strong risk factor for perforation during acute appendicitis. In addition, lower socioeconomic status has been linked to impaired access to surgical care. We sought to examine the relationships among race, insurance status, and perforation in a recent, adult population with acute appendicitis.

STUDY DESIGN

Data on adult patients with acute appendicitis were abstracted from the New York State Statewide Planning and Cooperative Systems Database for the years 2003 and 2004. A multiple logistic regression model, which adjusted for patient, community, and hospital factors, was used to examine the independent effects of both race and insurance status on likelihood of perforation.

RESULTS

A total of 29,637 patients had acute appendicitis; 7,969 (26.9%) of these were perforated. Although Caucasian patients were more likely to perforate compared with minority patients, by univariate analysis, adjustment for age alone eliminated this disparity. In addition, by multivariable analysis, no difference existed in odds of perforation for Caucasian patients compared with African-American (odds ratio [OR]=1.03, 95% CI [0.93, 1.15], p=0.52), Hispanic (OR=0.99, 95% CI [0.90, 1.08], p=0.82), or Asian patients (OR=0.85, 95% CI [0.73, 1.00], p=0.05). But compared with privately insured patients, uninsured patients (OR 1.18, 95% CI [1.07 to 1.30], p=0.0005), Medicaid patients (OR=1.22, 95% CI [1.12 to 1.33], p < 0.0001), and Medicare patients (OR=1.14, 95% CI [1.03, 1.25], p=0.01) were significantly more likely to have perforation.

CONCLUSIONS

Race does not appear to be an important variable in predicting perforation in adult patients with acute appendicitis, but the likelihood of perforation varies significantly according to insurance status. Future research is necessary to both understand and have an impact on this socioeconomic disparity.

Hidden barriers between knowledge and behavior: the North Carolina prostate cancer screening and treatment experience

BACKGROUND

Prostate cancer (PC) mortality is much greater for African American than for Caucasian men. To identify patient factors that might account for some of this disparity, men within 6 months of diagnosis were surveyed about health attitudes and behavior.

METHODS

Using Rapid Identification in the North Carolina Cancer Registry, 207 African American and 348 Caucasian recently diagnosed PC patients were identified and surveyed.

RESULTS

African American men were younger and less often currently married, and had lesser education, job status, and income than Caucasian men (all P < .001). African American men were at no greater distance to medical care, but had less access: poorer medical insurance coverage, more use of public clinics and emergency wards, less continuity with a primary physician, and more often omitted physician visits they felt they needed. They also expressed less trust in physicians. African American men acknowledged their greater risk of PC, accepted greater responsibility for their health, and reported more personal failures that delayed diagnosis. African American men more often requested the tests that diagnosed their cancers, which resulted more often from routinely ordered screening tests for Caucasian men. African American men expressed less interest in nontraditional treatments.

CONCLUSIONS

Despite lesser education, African American men in North Carolina are aware of their increased risk of cancer, the importance of treatment, and their responsibility for their health. Obstacles to timely diagnosis and appropriate care, including greater physician distrust, appear more likely to arise from reduced access and continuity of medical care arising from their worse socioeconomic position.

Predictors of comprehensive surgical treatment in patients with ovarian cancer

BACKGROUND

Providing appropriate surgical treatment for women with ovarian cancer is one of the most effective ways to improve ovarian cancer outcomes. In this study, the authors identified factors that were associated with a measure of comprehensive surgery, so that interventions may be targeted appropriately to improve surgical care.

METHODS

Using Healthcare Cost and Utilization Project hospital discharge data from 1999 to 2002 for 9 states, the authors identified 10,432 admissions of women who had an International Classification of Disease, 9th Revision (ICD-9) primary diagnosis of ovarian cancer and who had undergone oophorectomy. Based on National Institutes of Health Consensus Panel recommendations, surgeries were categorized as comprehensive by using ICD-9 diagnosis and procedure codes. Logistic regression analysis using data from 5 states with a full set of variables (n = 6854 patients)was used to identify factors that were associated with the receipt of comprehensive surgical care.

RESULTS

Overall, 66.9% of admissions (range, 46.3-80.8% of admissions) received comprehensive surgery. Factors that were associated independently with comprehensive surgical care included age (ages 21-50 years vs ages 71-80 years or > or = 81 years), race (Caucasian vs African American or Hispanic), payer (private insurance vs Medicaid), cancer stage (advanced vs early), annual surgeon volume (low/medium [2-9 surgeries per year] or high [>10 surgeries per year] vs very low [1 surgery per year]), and surgeon specialty (gynecologic oncologists vs obstetrician gynecologists or general surgeons). Among nonteaching hospitals, medium-volume hospitals (10-19 ovarian cancer surgeries per year) and high-volume hospitals (> or = 20 surgeries per year) had significantly higher comprehensive surgery rates than low-volume facilities (1-9 surgeries per year). Volume did not influence comprehensive surgery rates in teaching hospitals.

CONCLUSIONS

Many women with ovarian cancer, especially those in poor, elderly, or minority groups, are not receiving recommended comprehensive surgery. Efforts should be made to ensure that all women with ovarian cancer, especially those in vulnerable populations, have the opportunity to receive care from centers or surgeons with higher comprehensive surgery rates.

Differences in severity-adjusted pediatric hospitalization rates are associated with race/ethnicity

OBJECTIVE

Racial/ethnic disparities in health care delivery have been well described, but little is known about such disparities for children who seek emergency care. The objective of this study was to test the hypothesis that severity-adjusted emergency department pediatric admission rates are associated with race/ethnicity.

METHODS

Secondary analyses were conducted of an established database of 16 emergency departments that participated in a national study to validate the Pediatric Risk of Admission II score, which is used to measure severity of illness. Patients were randomly selected by the coordinating center from daily emergency department visit logs. Crude and severity-adjusted admission rates were compared among the 3 most common races/ethnicities: white, black, and Hispanic. Adjusted admission rates were calculated by using the standardized admission ratio, which was calculated by dividing the observed admissions by the predicted admissions, when predicted was calculated from the Pediatric Risk of Admission II score.

RESULTS

After exclusion of 3 sites that recorded race/ethnicity in <10% of patients, there were 13 sites with 8952 patients in the 3 major race/ethnicity groups. Black and Hispanic patients were similar to each other and different from white patients; therefore, these 2 groups were combined for analyses. Both crude (8.2% vs 5.3%) and severity-adjusted (standardized admission ratio: 1.71 vs 1.1) admission rates were higher in white than in nonwhite patients. Standardized admission ratios were close to 1.0 in both race/ethnicity groups in the higher quintiles of illness severity. In contrast, white patients were admitted at 1.5 to 2 times the expected rate in the lowest 2 quintiles of severity.

CONCLUSIONS

There are differences in both crude and adjusted admission rates between white and black/Hispanic patients. The results are more consistent with high rates of discretionary admissions for white patients with low illness severity than with underadmitting severely ill black or Hispanic patients.

Cancer stage at diagnosis and survival among persons with Social Security Disability Insurance on Medicare

OBJECTIVE

To examine stage at diagnosis and survival for disabled Medicare beneficiaries diagnosed with cancer under age 65 and compare their experiences with those of other persons diagnosed under age 65.

DATA SOURCES

Surveillance, Epidemiology, and End Results (SEER) Program data and SEER-Medicare linked data for 1988-1999. SEER-11 Program includes 11 population-based tumor registries collecting information on all incident cancers in catchment areas. Tumor registry and Medicare data are linked for persons enrolled in Medicare.

STUDY DESIGN

307,595 incident cases of non-small cell lung (51,963), colorectal (52,092), breast (142,281), and prostate (61,259) cancer diagnosed in persons under age 65 from 1988 to 1999. Persons who qualified for Social Security Disability Insurance and had Medicare (SSDI/Medicare) were identified from Medicare enrollment files. Ordinal polychotomous logistic regression and Cox proportional hazards regression were used to estimate adjusted associations between disability status and later-stage diagnoses and mortality (all-cause and cancer-specific).

PRINCIPAL FINDINGS

Persons with SSDI/Medicare had lower rates of Stages III/IV diagnoses than others for lung (63.3 versus 69.5 percent) and prostate (25.5 versus 30.8 percent) cancers, but not for breast or colorectal cancers. After adjustment, they remained less likely to be diagnosed at later stages for lung and prostate cancers. Nevertheless, persons with SSDI/Medicare experienced higher all-cause mortality for each cancer. Cancer-specific mortality was higher among persons with SSDI/Medicare for breast and colorectal cancer patients.

CONCLUSIONS

Disabled Medicare beneficiaries are diagnosed with cancer at similar or earlier stages than others. However, they experience higher rates of cancer-related mortality when diagnosed at the same stage of breast and colorectal cancer.

Ablative treatments for lung tumors: radiofrequency ablation, stereotactic radiosurgery, and microwave ablation

RFA and SRS have been demonstrated to be safe with reasonable efficacy in the treatment of small lung tumors. It is unclear which option is the most effective in the treatment of NSCLC, with both RFA and SRS demonstrating similar early response and progression rates. RFA can be performed in one treatment session, whereas it now seems that SRS is more effective if larger doses of radiation over two to three fractions are performed. RFA is not recommended for centrally based tumors. There are also some tumors (eg, small apical tumors, posteriorly positioned tumors close to the diaphragm, and tumors close to the scapula) where it may be difficult percutaneously to position an active electrode. Such patients are more optimally treated with SRS. In certain circumstances, a combined approach may be beneficial (RFA and SRS). At this point in time, MWA is the least well developed modality. Although treatment times and heat-sink effect may be less compared with RFA, larger trials are needed to understand better the impact of this factor on effectiveness and safety. The heat-sink effect may be protective, minimizing the necrosis of large blood vessels and the risk of subsequent fatal hemoptysis. Future studies need to address long-term outcomes using standardized assessments of treatment response between centers. Comparisons between different RFA systems and ablation modalities need to be undertaken to delineate the optimal use of these strategies in the treatment of early stage lung cancer. Until long-term data with these ablative techniques become available, surgical resection should be performed when clinically possible.

Why African-American women are at greater risk for pregnancy-related death

PURPOSE

Our study aim was to identify factors that may contribute to the racial disparity in pregnancy-related mortality.

METHODS

We examined differences in severity of disease, comorbidities, and receipt of care among 608 (304 African-American and 304 white) consecutive patients of non-Hispanic ethnicity with one of three pregnancy-related morbidities (pregnancy-related hypertension, puerperal infection, and hemorrhage) from hospitals selected at random from a statewide region.

RESULTS

African-American women had more severe hypertension, lower hemoglobin concentrations preceding hemorrhage, more antepartum hospital admissions, and a higher rate of obesity. The rate of surgical intervention for hemorrhage was lower among African-Americans, although the severity of hemorrhage did not differ between the two racial groups. More African-American women received eclampsia prophylaxis. After stratifying by severity of hypertension, we found that more African-Americans received antihypertensive therapy. The rate of enrollment for prenatal care was lower in the African-American group. Among women receiving prenatal care, African-American women enrolled significantly later in their pregnancies.

CONCLUSIONS

We have identified racial differences in severity of disease, comorbidities, and care status among women with pregnancy-related complications that would place African-Americans at disadvantage to survive pregnancy. These differences are potentially modifiable.

Racial disparities in treatment and survival of male breast cancer

PURPOSE

Black women with breast cancer have poorer survival than do white women, but little is known about racial disparities in male breast cancer. We analyzed race and other predictors of treatment and survival among men with stage I-III breast cancer.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) Medicare database to identify men 65 years of age or older diagnosed with stage I-III breast cancer from 1991 to 2002. Multivariate regression was used to compare those treated with those not treated with either chemotherapy or radiation therapy, adjusting for known clinical and demographic factors. Cox proportional hazards regression models were used to analyze survival.

RESULTS

Of 510 male breast cancer cases (456 white, 34 black), 94% underwent mastectomy, 28% received adjuvant chemotherapy, and 29% received radiation therapy. Among those with known hormone receptors, 95% had hormone-sensitive tumors. In a multivariate analysis, chemotherapy was associated with younger age, advanced stage, and hormone receptor-negative tumors. Radiation therapy was associated with younger age and advanced stage. Black men were approximately 50% less likely to undergo consultation with an oncologist and subsequently receive chemotherapy; however, the results did not reach statistical significance. The breast cancer-specific mortality hazard ratio was more than tripled for black versus white men (hazard ratio = 3.29; 95% CI, 1.10 to 9.86).

CONCLUSION

After adjustment for known clinical, demographic, and treatment factors, there was an association of black race with increased male breast cancer-specific mortality. Although male breast cancer is rare, the reasons for these disparities need to be better understood.

Hypofractionated high-dose proton beam therapy for stage I non-small-cell lung cancer: preliminary results of a phase I/II clinical study

PURPOSE

To present treatment outcomes of hypofractionated high-dose proton beam therapy for Stage I non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Twenty-one patients with Stage I NSCLC (11 with Stage IA and 10 with Stage IB) underwent hypofractionated high-dose proton beam therapy. At the time of irradiation, patient age ranged from 51 to 85 years (median, 74 years). Nine patients were medically inoperable because of comorbidities, and 12 patients refused surgical resection. Histology was squamous cell carcinoma in 6 patients, adenocarcinoma in 14, and large cell carcinoma in 1. Tumor size ranged from 10 to 42 mm (median, 25 mm) in maximum diameter. Three and 18 patients received proton beam irradiation with total doses of 50 Gy and 60 Gy in 10 fractions, respectively, to primary tumor sites.

RESULTS

Of 21 patients, 2 died of cancer and 2 died of pneumonia at a median follow-up period of 25 months. The 2-year overall and cause-specific survival rates were 74% and 86%, respectively. All but one of the irradiated tumors were controlled during the follow-up period. Five patients showed recurrences 6-29 months after treatment, including local progression and new lung lesions outside of the irradiated volume in 1 and 4 patients, respectively. The local progression-free and disease-free rates were 95% and 79% at 2 years, respectively. No therapy-related toxicity of Grade > or =3 was observed.

CONCLUSIONS

Hypofractionated high-dose proton beam therapy seems feasible and effective for Stage I NSCLC. Proton beams may contribute to enhanced efficacy and lower toxicity in the treatment of patients with Stage I NSCLC.

Lung carcinoma in African Americans

Lung carcinoma is the most commonly diagnosed cancer and the leading cause of cancer deaths in the US. It accounts for 12% of all cancers diagnosed worldwide, making it the most common malignancy, other than nonmelanoma skin cancer. A new focus has emerged involving the role of race and ethnicity in lung carcinoma. Current health statistics data demonstrate striking disparities, which are most evident between African American patients and their white counterparts. This disparity is greatest among male patients, where statistically significant differences are seen not only in lung cancer incidence and risk, but also in survival and treatment outcomes. Several hypotheses that attempt to explain this disparity include genetic, cultural and socioeconomic differences, in addition to differences in tobacco use and exposure. Current evidence does not clearly identify the reasons for this observed disparity, or the role the aforementioned factors play in the development and overall outcomes of people with lung cancer in these populations. This disease continues to pose a considerable public health burden and more research is needed to improve understanding of the disparity of lung carcinoma statistics among African Americans. This review summarizes the existing body of knowledge regarding lung carcinoma in African Americans and attempts to identify promising areas for future investigation and intervention.

Influence of race on inpatient treatment intensity at the end of life

OBJECTIVE

To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.

DESIGN

Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.

SETTING

United States, 1989-1999.

PARTICIPANTS

Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.

MEASUREMENTS AND MAIN RESULTS

Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than non-blacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99-1.03], p = .36; terminal hospitalization AOR 1.03 [1.0-1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08-1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20-1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91-0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70-0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital's black census was a strong predictor of inpatient end-of-life treatment intensity.

CONCLUSIONS

Black decedents were treated more intensively during hospitalization than non-black decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital's black census. The causes and consequences of these hospital-level differences in intensity deserve further study.

Cost of cancer care: issues and implications

Medical technology is increasingly costly in most fields of clinical medicine. Oncology has not been spared from issues related to cost, in part resulting from the tremendous scientific progress that has lead to new tools for diagnosis, treatment, and follow-up of our patients. The increasing cost of health care in general (and cancer care in particular) raises complex questions related to its effects on our economy and the citizens of our society. This article reviews the macroeconomic principles and individual behaviors that govern medical spending, and examines how cost disproportionately affects various populations. Our overall goal is to frame debate about health policy concerns that influence the clinical practice of oncology.

Racial variation in end-of-life intensive care use: a race or hospital effect?

OBJECTIVE

To determine if racial and ethnic variations exist in intensive care (ICU) use during terminal hospitalizations, and, if variations do exist, to determine whether they can be explained by systematic differences in hospital utilization by race/ethnicity.

DATA SOURCE

1999 hospital discharge data from all nonfederal hospitals in Florida, Massachusetts, New Jersey, New York, and Virginia.

DESIGN

We identified all terminal admissions (N = 192,705) among adults. We calculated crude rates of ICU use among non-Hispanic whites, blacks, Hispanics, and those with "other" race/ethnicity. We performed multivariable logistic regression on ICU use, with and without adjustment for clustering of patients within hospitals, to calculate adjusted differences in ICU use and by race/ethnicity. We explored both a random-effects (RE) and fixed-effect (FE) specification to adjust for hospital-level clustering.

DATA COLLECTION

The data were collected by each state.

PRINCIPAL FINDINGS

ICU use during the terminal hospitalization was highest among nonwhites, varying from 64.4 percent among Hispanics to 57.5 percent among whites. Compared to white women, the risk-adjusted odds of ICU use was higher for white men and for nonwhites of both sexes (odds ratios [ORs] and 95 percent confidence intervals: white men = 1.16 (1.14-1.19), black men = 1.35 (1.17-1.56), Hispanic men = 1.52 (1.27-1.82), black women = 1.31 (1.25-1.37), Hispanic women =1.53 (1.43-1.63)). Additional adjustment for within-hospital clustering of patients using the RE model did not change the estimate for white men, but markedly attenuated observed differences for blacks (OR for men =1.12 (0.96-1.31), women = 1.10 (1.03-1.17)) and Hispanics (OR for men =1.19 (1.00-1.42), women = 1.18 (1.09-1.27)). Results from the FE model were similar to the RE model (OR for black men = 1.10 (0.95-1.28), black women = 1.07 (1.02-1.13) Hispanic men = 1.17 (0.96-1.42), and Hispanic women = 1.14 (1.06-1.24))

CONCLUSIONS

The majority of observed differences in terminal ICU use among blacks and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital.

Physician perspectives on end-of-life care: factors of race, specialty, and geography

OBJECTIVES

To describe physicians' end-of-life practices, perceptions regarding end-of-life care and characterize differences based upon physician specialty and demographic characteristics. To illuminate physicians' perceptions about differences among their African-American and Caucasian patients' preferences for end-of-life care.

DESIGN AND METHODS

Twenty-four African-American and 16 Caucasian physicians (N=40) participated in an in-person interview including 23 primary care physicians, 7 cardiologists, and 10 oncologists. Twenty-four practices were in urban areas and 16 were in rural counties.

RESULTS

Physicians perceived racial differences in preferences for end-of-life care between their Caucasian and African-American patients. Whereas oncologists and primary care physicians overwhelmingly reported having working relationships with hospice, only 57% of cardiologists reported having those contacts. African-American physicians were more likely than Caucasian physicians to perceive racial differences in their patients preferences for pain medication.

SIGNIFICANCE OF RESULTS

Demographic factors such as race of physician and patient may impact the provider's perspective on end-of-life care including processes of care and communication with patients.

Communication patterns in medical encounters for the treatment of child psychosocial problems: does pediatrician-parent concordance matter?

This study examined how pediatrician-parent social status concordance related to communication patterns in medical encounters during which children received treatment for psychosocial problems indicating attention deficit disorder or attention deficit hyperactivity disorder. Using data from 28 pediatric medical encounters occurring in a large southeastern metropolitan city during 2003, we focused on concordance according to race, gender, and education, and its relation to laughter, concern, self-disclosure, question asking, and information-giving utterances, and patient-centeredness. Results indicated that race-concordant pediatricians and parents frequently laughed, whereas parents asked many biomedical questions in gender-concordant encounters. Education-concordant pediatricians and parents expressed concern repeatedly, exchanged biomedical information freely, and shared communication control. Pediatricians also self-disclosed when interacting with college-educated parents.

Pain in aging community-dwelling adults in the United States: non-Hispanic whites, non-Hispanic blacks, and Hispanics

Racial and ethnic disparities in healthcare persist in the U.S. Although pain is one of the most prevalent and disabling symptoms of disease, only a few studies have assessed disparities in pain in large racially and ethnically diverse, middle- to late aged community samples, thus limiting the generalizability of study findings in broader populations. With data from the 2000 Health and Retirement Study, we assessed the prevalence and impact of pain in a community sample of aging (> or =51 years old) non-Hispanic whites (n = 11,021), non-Hispanic blacks (n = 1,804), and Hispanics (n = 952) in the U.S. Pain, pain severity, activity limitation as a result of pain, comorbid conditions, and sociodemographic variables were assessed. Results showed that pain prevalence was 28%, and 17% of the sample reported activity limitation as a result of pain. Non-Hispanic blacks (odds ratio [OR], 1.78; 99% confidence interval [CI], 1.33-2.37) and Hispanics (OR, 1.80; 99% CI, 1.26-2.56) had higher risk for severe pain compared with non-Hispanic whites. Analyses of respondents with pain (n = 3,811) showed that having chronic diseases (2 comorbid conditions, OR, 1.5; 99% CI, 1.09-2.17), psychological distress (OR, 1.99; 99% CI, 1.54-2.43), being a Medicaid recipient (OR, 1.63; 99% CI, 1.17-2.25), and lower educational level (OR, 1.45; 99% CI, 1.14-1.85) were significant predictors for severe pain and helped to explain racial/ethnic differences in pain severity.

PERSPECTIVE

This study, which used a large racially and ethnically diverse community sample, provided empirical evidence that racial/ethnic difference in pain severity in aging community adults in the U.S. can be accounted for by differential vulnerability in terms of chronic disease, socioeconomic conditions, and access to care.

Complications of Thoracic Computed Tomography–Guided Fiducial Placement for the Purpose of Stereotactic Body Radiation Therapy

PURPOSE

This study examined the complication rates associated with percutaneous fiducial placement for the purpose of stereotactic body radiation therapy of primary and metastatic lung neoplasms.

PATIENTS AND METHODS

This is a retrospective review of computed tomography (CT) scans and follow-up chest radiographs of 48 consecutive patients who underwent CT-guided percutaneous fiducial placement. The effect of age, sex, number of fiducials placed, and performance of a concomitant biopsy on the complication rates were assessed.

RESULTS

Of 48 patients with a total of 221 fiducials placed, 16 (33%) had a procedure-related pneumothorax. There was no significant difference in pneumothorax rate based on age (P = 0.16), sex (P > 0.99), and number of fiducials placed (P = 0.21). Overall, 6 of 48 patients (12.5%) required a thoracostomy tube. Performance of a concomitant core needle biopsy at the time of fiducial placement was associated with pneumothorax rates of 64% compared with 26% without biopsies (P = 0.03). Postprocedural CT demonstrated hemorrhage in 9 patients (19%). Two patients had hemoptysis; one required admission. Patients' age, sex, number of fiducials placed, and performance of concomitant biopsy had no statistically significant implications on parenchymal hemorrhage incidence.

CONCLUSION

Approximately one third of the patients develop a pneumothorax during CT-guided fiducial placement. Most are asymptomatic and do not require a thoracostomy. A concurrent biopsy at the time of fiducial placement is associated with an increased risk of pneumothorax. Hemorrhage occurs but is usually clinically insignificant.

Timing of adjuvant chemotherapy initiation after surgery for stage III colon cancer

BACKGROUND

An important advance in medical oncology has been the use of adjuvant chemotherapy for lymph node-positive colon cancer. However, to the authors' knowledge, the effect of the interval between surgery and the initiation of chemotherapy on survival has not been investigated.

METHODS

The authors analyzed predictors and outcomes of time intervals to treatment after surgery among patients older than 65 years who were diagnosed with stage III colon cancer between 1992 and 1999 using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Linear and logistic regression analyses were used to model predictors of delay, and Cox proportional hazards models were used to analyze the impact of treatment timing on survival.

RESULTS

Among 4382 patients with colon cancer, 1122 patients (26%) began adjuvant chemotherapy within 1 month, 2391 patients (55%) began adjuvant chemotherapy in 1 to 2 months, 454 patients (10%) began adjuvant chemotherapy in 2 to 3 months, and 415 patients (9%) began adjuvant chemotherapy >/=3 months after surgery. Intervals of >/=3 months (delay) were associated with older age, increased comorbid conditions, well/moderately differentiated grade, and being unmarried. Colon cancer-specific mortality was associated with a delay in the initiation of chemotherapy (hazards ratio [HR], 1.48; 95% confidence interval [95% CI], 1.15-1.92), advanced age, increased comorbidity, poorly differentiated tumor grade, the presence of >/=4 positive lymph nodes, and undergoing surgery in a nonteaching hospital. All-cause mortality was associated with intervals >2 months between surgery and chemotherapy (2 to 3 months: HR, 1.41; 95% CI, 1.15-1.74; >/=3 months: HR, 1.62; 95% CI, 1.31-1.99) compared with <1 month.

CONCLUSIONS

In the older population that was studied, only 9% of patients initiated adjuvant chemotherapy >3 months after the date of curative surgery. However, delay in initiation was associated with both cancer-specific and all-cause mortality. Determining whether these results were because of chemotherapy timing or other associated factors will require further study.

Effect of patient socioeconomic status and body mass index on the quality of breast cancer adjuvant chemotherapy

PURPOSE

The purpose of this study was to investigate the relationship between socioeconomic status (SES) and the use of intentionally reduced doses of chemotherapy in the adjuvant treatment of breast cancer.

PATIENTS AND METHODS

Patients with breast cancer treated with a standard chemotherapy regimen (n = 764) were enrolled in a prospective registry after signing informed consent. Detailed information was collected on patient, disease, and treatment, including chemotherapy doses. Zip code level data on median household income, proportion of people living below the poverty level, and educational attainment were obtained from the US Census. Doses for the first cycle of chemotherapy lower than 85% of standard were considered to be reduced. Univariate analyses and multivariate logistic regression were performed to identify factors associated with the use of reduced first cycle doses.

RESULTS

In univariate analysis, individual education attainment, zip code SES measures, body mass index, and geographic region were all significantly associated with receipt of intentionally reduced doses of chemotherapy. In multivariate analysis, controlling for geography, factors independently associated with reduced doses were obesity (odds ratio [OR], 2.47; 95% CI, 1.36 to 4.51), severe obesity (OR, 4.04; 95% CI, 1.46 to 11.19), and education less than high school (OR, 3.07; 95% CI, 1.57 to 5.99).

CONCLUSION

Social disparities in breast cancer outcomes may be in part the result of lower quality chemotherapy doses in the adjuvant treatment of breast cancer. Efforts to address such prescribing patterns may help reduce SES disparities in breast cancer survival.

Racial disparities in late survival after rectal cancer surgery

BACKGROUND

African-American patients experience higher mortality than Caucasian patients after surgery for most common cancer types. Whether longterm survival after rectal cancer surgery varies by race is less clear.

STUDY DESIGN

Using 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we examined race and longterm survival among African-American and Caucasian rectal cancer patients undergoing resection. We identified racial differences in patient characteristics, structure, and processes of care. We then assessed mortality using a Cox proportional hazards model, sequentially adding variables to explore the extent to which they attenuated the association between race and mortality.

RESULTS

African-American patients had a substantially poorer overall survival rate than Caucasian patients did. Five-year survival rates were 41% and 50%, respectively (p < 0.0001). African Americans were younger (p=0.006), more likely to reside in low income areas (p < 0.0001), and had more baseline comorbid disease (p < 0.0001). They were also more likely to be diagnosed emergently (p < 0.001) and with more advanced cancer (p < 0.001). Accounting for demographic and clinical characteristics reduced the mortality difference, although it remained pronounced (hazard ratio=1.13, CI=1.01 to 1.26). African Americans were more likely to be treated by low volume surgeons and less likely to receive adjuvant therapy (48.6% versus 60.9%, p < 0.0001). After adjusting for provider variables, the hazard ratio for mortality by race was additionally attenuated and became statistically nonsignificant (hazard ratio=1.05, CI=0.92 to 1.20).

CONCLUSIONS

Poorer longterm survival after rectal cancer surgery among African Americans is explained by measurable differences in processes of care and patient characteristics. These data suggest that outcomes disparities could be reduced by strategies targeting earlier diagnosis and increasing adjuvant therapy use among African-American patients.

Dissimilarity in gene expression profiles of lung adenocarcinoma in Japanese men and women

BACKGROUND

Although clinical differences in lung cancer between men and women have been noted, few studies have examined the sex dissimilarity using gene expression analysis.

OBJECTIVE

The purpose of this study was to determine the different molecular carcinogenic mechanisms involved in lung cancers in Japanese men and women.

METHODS

Patients who received surgery for stage I lung adenocarcinoma were included. RNA was extracted from cancerous and normal tissue, and gene expression was then examined with oligonucleotide microarray analysis. A quantitative polymerase chain reaction assay was performed.

RESULTS

In a microarray analysis of tissue from 13 men and 6 women, 12 genes were under-expressed and 24 genes were overexpressed in lung adenocarcinoma in women compared with men. Genes related to cell cycle were present in underexpressed genes, and genes related to apoptosis, ubiquitination, and metabolism were observed in overexpressed genes. Of interest among the selected genes were WAP four-disulfide core domain 2 (WFDC2) and major histocompatibility complex, class II, DM alpha (HLA-DMA); these genes were classified into 2 groups by hierarchical clustering analysis. Expression of WFDC2 in nonsmokers was significantly higher than that in smokers (P=0.023). However, there was no significant difference in HLA-DMA expression between smokers and nonsmokers.

CONCLUSION

Thirty-six genes that characterize lung adenocarcinoma by sex were selected. This information may contribute to the development of novel diagnostic techniques and treatment modalities that consider sex differences in lung adenocarcinoma.

Trends in Lung Surgery

BACKGROUND

Reports on the temporal evolution in lung resection are limited. To elucidate temporal changes in the demographics of lung resections, we analyzed nationally representative data that were collected for the National Hospital Discharge Survey from 1988 to 2002.

METHODS

Data collected between 1988 and 2002 were analyzed. Patients with International Classification of Diseases, ninth revision, clinical modification, procedure codes for lung resection were included in the sample. Three 5-year time periods were created (1988 to 1992, 1993 to 1997, and 1998 to 2002) to simplify the temporal analysis. Changes in the prevalence of procedures, age, gender, race, length of care, mortality, disposition status, and distribution by hospital size were evaluated. Trends in procedure-related complications were analyzed.

RESULTS

Between 1988 and 2002, a total of 512,758 lung resections were performed. Comparing the earliest to the most recent time period, we found increases in the average age (61.1 years [range, 1 to 89 years] vs 63.2 years [range, 1 to 91 years], respectively), in the proportion of patients who were female (40.1% vs 49.6%, respectively), and in the proportion of Medicare/Medicaid patients (43.8% vs 49%/4.7% vs 6.7%, respectively). Decreases in the average length of stay (12.9 days [range, 1 to 358 days] vs 9.1 days [range, 1 to 175 days], respectively) and in the proportion of patients discharged to their primary residence (86% vs 79.5%, respectively) were seen. The proportion of patients who had undergone lobectomies compared to other types of lung resection increased. Mortality rates were 5% vs 5.4%, respectively, while the frequency of complications decreased.

CONCLUSION

We identified temporal changes in lung resection surgery that may help in the construction of health-care policies to address the changing needs of and financial burdens on the health-care system.

Racial and Ethnic Disparities in the Emergency Department: A Public Health Perspective

This article discusses racial and ethnic disparities from a public health perspective, specifically why they threaten to impede the efforts to improve the nation's health. The authors (1) provide background information, including a review of the Institute of Medicine report on health care disparities; (2) describe the racial and ethnic compositions of the individuals in the emergency department setting from the perspective of both the patient and health care provider; (3) discuss the most prevalent disease presentations to the emergency department that are likely to have racial and ethnic disparities; and (4) give conclusions and general recommendations on how to address disparities in emergency health care.

Advancing health disparities research within the health care system: a conceptual framework

We provide a framework for health services-related researchers, practitioners, and policy makers to guide future health disparities research in areas ranging from detecting differences in health and health care to understanding the determinants that underlie disparities to ultimately designing interventions that reduce and eliminate these disparities. To do this, we identified potential selection biases and definitions of vulnerable groups when detecting disparities. The key factors to understanding disparities were multilevel determinants of health disparities, including individual beliefs and preferences, effective patient-provider communication; and the organizational culture of the health care system. We encourage interventions that yield generalizable data on their effectiveness and that promote further engagement of communities, providers, and policymakers to ultimately enhance the application and the impact of health disparities research.

Racial differences in doctors' information-giving and patients' participation

BACKGROUND

Whether doctor-patient communication differs by race was investigated in patients with pulmonary nodules or lung cancer.

METHODS

Eligible patients (n = 137) had pulmonary nodules or lung cancer and were seen in thoracic surgery or oncology clinics for initial treatment recommendations at a large southern Veterans Affairs Medical Center from 2001-2004. Doctor-patient consultations were audiotaped. Audiotapes were transcribed, unitized into utterances, and utterances were coded as doctors' information-giving or patients' and companions' active participation (asking questions, expressing concerns, and making assertions). Data were compared by patient race and doctor-patient racial concordance using t-tests or chi-square tests as appropriate. Mixed linear regression was used to determine the independent predictors of doctor's information-giving after controlling for clustering of patients by doctor.

RESULTS

Patient age, gender, marital status, clinical site, and health status were similar by race (P > .20), but black patients were somewhat less likely to have education beyond high school and to bring a companion to the visit (P = .06) than white patients. Black patients and their companions received significantly less information from doctors (49.3 vs. 87.3 mean utterances; P < .001) and produced significantly fewer active participation utterances (21.4 vs. 37.2; P < .001) than white patients. In mixed regression analyses, after adjusting for patients' and companions' participation, clustering by doctor, and other factors, race no longer predicted information-giving (P = .54). Patients in racially discordant interactions received significantly less information and were significantly less active participants (P < .001) when compared with patients in racially concordant interactions, and after controlling for patients' participation and other factors using mixed regression, racial discordance did not predict information-giving.

CONCLUSIONS

The results indicate a pattern of communication that may perpetuate patient passivity and limited information exchange where black patients and patients in discordant interactions do less to prompt doctors for information and doctors in turn provide less information to these patients.

The role of socio-economic status in the decision making on diagnosis and treatment of oesophageal cancer in The Netherlands

In the United States (USA), a correlation has been demonstrated between socio-economic status (SES) of patients on the one hand, and tumour histology, stage of the disease and treatment modality of various cancer types on the other hand. It is unknown whether such correlations are also involved in patients with oesophageal cancer in The Netherlands. Between 1994 and 2003, 888 oesophageal cancer patients were included in a prospective database with findings on the diagnostic work-up and treatment of oesophageal cancer. Socio-economic status of patients was defined as the average net yearly income. Linear-by-linear association testing revealed that oesophageal adenocarcinoma was more frequently observed in patients with higher SES and squamous cell carcinoma in patients with lower SES (P=0.02). Multivariable logistic regression analysis showed no correlation between SES and staging procedures and preoperative TNM stage. The adjusted odds ratio (OR) for stent placement was 0.82 (95% CI 0.71–0.95), indicating that with an increase in SES by 1200 €, the likelihood that a stent was placed declined by 18%. Patients with a higher SES more frequently underwent resection or were treated with chemotherapy (OR: 1.15; 95% CI 1.01–1.32 and OR: 1.16; 95% CI 1.02–1.32, respectively). Socio-economic factors are involved in oesophageal cancer in The Netherlands, as patients with a higher SES are more likely to have an adenocarcinoma and patients with a lower SES a squamous cell carcinoma. Moreover, the correlations between SES and different treatment modalities suggest that both patient and doctor determinants contribute to the decision on the most optimal treatment modality in patients with oesophageal cancer.

Lung cancer disparities in African Americans: health versus health care

African Americans with lung cancer have disproportionately worse outcomes than other ethnic groups. The incidence of lung cancer in blacks has remained well above the rates seen for the general population and the 5-year and overall survival rates for blacks with lung cancer are among the lowest of all racial groups. Many studies have focused on socioeconomic status of African Americans as the sole cause of these disparities. Other stu-dies, however, have identified additional factors related to risks for poor outcomes in blacks with lung cancer. This article reviews data on these risks and their relationships to the health and health care of African Americans with lung cancer.

COPD: racial disparities in susceptibility, treatment, and outcomes

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and mortality continues to increase particularly among African Americans. Although this increase may be caused by changing smoking habits, some studies suggest that African Americans may be more susceptible to tobacco smoke than whites. Unlike other respiratory diseases for which there are significant published data on racial and ethnic disparities in disease outcomes, such information is notably lacking in the COPD literature. This article examines the available data concerning racial disparities in COPD susceptibility and care.

A prescription for cultural competence in medical education

Cultural competence programs have proliferated in U.S. medical schools in response to increasing national diversity, as well as mandates from accrediting bodies. Although such training programs share common goals of improving physician-patient communication and reducing health disparities, they often differ in their content, emphasis, setting, and duration. Moreover, training in cross-cultural medicine may be absent from students' clinical rotations, when it might be most relevant and memorable. In this article, the authors recommend a number of elements to strengthen cultural competency education in medical schools. This "prescription for cultural competence" is intended to promote an active and integrated approach to multicultural issues throughout medical school training.

Patient characteristics and hospital quality for colorectal cancer surgery

OBJECTIVE

To assess associations of patient characteristics with quality-related characteristics of the hospitals where they were treated for colorectal cancer and the role of these associations in disparities in treatment quality affecting vulnerable patient groups or variations across health plans.

SETTING

Population-based cancer registry in California.

PARTICIPANTS

A total of 38 237 patients diagnosed with stage I-III (non-metastatic) colorectal cancer in California between 1994 and 1998.

METHODS

Registry data were linked with hospital discharge abstracts, US census data, and Medicare enrollment data. The associations of patients' sociodemographic, clinical, and geographic covariates with treatment at high-volume institutions were assessed with logistic regression. The associations of patients' covariates with the risk-adjusted 30-day mortality rates of the hospitals where they received surgery were tested with linear regression.

RESULTS

Patients with more advanced tumor stage or more extensive comorbidity, those of Hispanic or Asian race/ethnicity, and those from less affluent communities were less likely to undergo surgery at high-volume institutions and were treated at hospitals with higher risk-adjusted 30-day postoperative mortality rates than those who were less severely ill, white, or more affluent, respectively (all P < 0.05). Black patients also received surgery at hospitals with above-average mortality. Among patients 65 years and older, Medicare managed-care enrollees underwent surgery in higher-volume hospitals than Medicare fee-for-service enrollees, and there was substantial variation in hospital volume and adjusted hospital mortality among Medicare managed-care plans.

CONCLUSION

Improving access of sicker, poorer, and minority patients to high-quality hospitals for cancer surgery may improve their outcomes. Further study of processes affecting hospital referral is warranted.

Eliminating racial and ethnic disparities in health care: what is the role of academic medicine?

Research has shown that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, and cancer. In addition to racial and ethnic disparities in health, there is also evidence of racial and ethnic disparities in health care. The Institute of Medicine Report Unequal Treatment remains the preeminent study of the issue of racial and ethnic disparities in health care in the United States. Unequal Treatment provided a series of general and specific recommendations to address such disparities in health care, focusing on a broad set of stakeholders including academic medicine. Academic medicine has several important roles in society, including providing primary and specialty medical services, caring for the poor and uninsured, engaging in research, and educating health professionals. Academic medicine should also provide national leadership by identifying innovations and creating solutions to the challenges our health care system faces in its attempt to deliver high-quality care to all patients. Several of the recommendations of Unequal Treatment speak directly to the mission and roles of academic medicine. For instance, patient care can be improved by collecting and reporting data on patients' race/ethnicity; education can minimize disparities by integrating cross-cultural education into health professions training; and research can help improve health outcomes by better identifying sources of disparities and promising interventions. These recommendations have clear and direct implications for academic medicine. Academic medicine must make the elimination of health care disparities a critical part of its mission, and provide national leadership by identifying quality improvement innovations and creating disparities solutions.

Delayed Diagnosis and Elevated Mortality in an Urban Population With HIV and Lung Cancer

OBJECTIVE

Lung cancer is more common in HIV-infected patients than in the general population. We examined how effectively lung cancer was being diagnosed in our HIV-infected patients.

METHODS

Retrospective study assessing clinical diagnosis of lung cancer in HIV-infected patients at Johns Hopkins Hospital between 1986 and 2004.

RESULTS

Ninety-two patients were identified. Compared to HIV-indeterminate patients (n=4973), HIV-infected individuals were younger with more advanced cancer. CD4 counts and HIV-1 RNA levels indicated preserved immune function. Mortality was higher in HIV-infected patients, with 92% dying of lung cancer (hazard ratio, 1.57; 95% confidence interval, 1.25-1.96), compared to HIV-uninfected patients. Advanced stage and black race were associated with worse survival. After adjustment for these factors, HIV infection was not associated with increased mortality (hazard ratio, 1.04; 95% confidence interval, 0.83-1.32). Of 32 patients followed in our HIV clinic, 60% of chest radiographs had no evidence of neoplasm within 1 year of diagnosis compared to only 1 (4%) of 28 chest computed tomography scans. Nonspecific infiltrates were observed in 9 patients in the same area that cancer was subsequently diagnosed.

CONCLUSIONS

HIV-infected lung cancer patients have shortened survival mainly due to advanced stage. Low clinical suspicion and overreliance on chest radiographs hindered earlier detection. Aggressive follow-up of nonspecific pulmonary infiltrates in these patients is warranted.

Impact of Cultural Competence on Medical Care: Where are we Today?

The Institute of Medicine's 2002 Report on Unequal Treatment calls attention to disparities in health care and proposes corrective steps. Proposed actions included improvement in cross-cultural skills among providers. This article highlights evidence for unequal treatment, and delineates current medical educational efforts aimed at improving cultural competence. Improvement is needed in the uniform adoption of cultural competence curricula and focus needs to be placed on its impact through outcomes research.

Rates and predictors of hepatitis C virus treatment in HCV-HIV-coinfected subjects

BACKGROUND

True treatment rates and the impact of comorbidities on treatment rates for hepatitis C virus in the HCV-HIV-coinfected subjects are unknown.

AIM

To quantify the rates of treatment prescription and the effect of comorbidities on hepatitis C virus treatment rates in HCV-HIV-coinfected veterans.

METHODS

The Veterans Affairs National Patient Care Database was used to identify all hepatitis C virus-infected subjects between 1999 and 2003 using ICD-9 codes. Demographics, comorbidities and pharmacy data were retrieved. We used logistic regression to compare the predictors of hepatitis C virus treatment in hepatitis C virus-monoinfected and HCV-HIV-coinfected subjects.

FINDINGS

We identified 120 507 hepatitis C virus-infected subjects, of which 6502 were HIV coinfected. 12% of the hepatitis C virus-monoinfected and 7% of the -coinfected subjects were prescribed hepatitis C virus treatment (P < 0.0001). Those not prescribed treatment were older (48.6 years vs. 47.7 years, P = 0.007) and more likely to be black (52% vs. 32%, P < 0.0001). HIV coinfected was less likely to be prescribed hepatitis C virus treatment (OR 0.74, 95% CI: 0.67-0.82). Among the coinfected subjects, the following were associated with non-treatment (OR, 95% CI): black race (0.45, 0.35-0.57); Hispanic race (0.56, 0.38-0.82); drug use (0.68, 0.53-0.88); anaemia (0.17, 0.11-0.26); bipolar disorder (0.63, 0.40-0.99); major depression (0.72, 0.53-0.99); mild depression (0.47, 0.35-0.62).

CONCLUSIONS

A small number of HCV-HIV-coinfected veterans are prescribed treatment for hepatitis C virus. Non-treatment is associated with increasing age, minority race, drug use and psychiatric illness. Further studies are needed to determine the eligibility for treatment and reasons for non-treatment for hepatitis C virus.

Outcomes of sublobar resection versus lobectomy for stage I non-small cell lung cancer: a 13-year analysis

BACKGROUND

The appropriate use of sublobar resection versus lobectomy for stage I non-small cell lung cancer continues to be debated. A long-term analysis of the outcomes of these resections for stage I non-small cell lung cancer in a high-volume tertiary referral university hospital center was performed.

METHODS

The outcomes of all stage I non-small cell lung cancer patients (n = 784) undergoing resection were analyzed from our lung cancer registry from 1990 to 2003. Lobectomy was the standard of care for patients with adequate cardiopulmonary reserve. Sublobar resection was reserved for patients with cardiopulmonary impairment prohibiting lobectomy. Predictors of overall survival and disease-free survival were evaluated. Statistical analyses included Kaplan-Meier estimates of survival, log-rank tests of survival differences, and multivariate Cox proportional hazards models.

RESULTS

Lobectomy was used for 577 patients and sublobar resection for 207 patients. The median age was 70 years (range, 31 to 107 years). The median follow-up of patients remaining alive was 31 months. Compared with lobectomy, sublobar resection had no significant impact on disease-free survival, with a hazard ratio of 1.20 (95% confidence interval, 0.90 to 1.61; p = 0.24). Sublobar resection had a statistically significant association with overall survival when compared with lobectomy, with an increased hazard ratio of 1.39 (95% confidence interval, 1.11 to 1.75; p = 0.004). Twenty-eight percent of lobectomy patients experienced disease recurrence in that time compared with 29% of the sublobar patients. Seventy-two percent of the recurrences in the lobectomy cohort were distant metastasis versus 52% of the sublobar group recurrences (p = 0.0204).

CONCLUSIONS

Although sublobar resection is thought to be associated with increased incidence of local recurrence when compared with lobectomy, we found no difference in disease-free survival between the two types of resection for stage IA patients but slightly worse disease-free survival for stage IB.

Reaching African American Men: A Qualitative Analysis

African American men are disproportionately affected by most illnesses and associated complications. These men are also less likely to participate in primary and secondary prevention interventions. Little is known about reaching them. The purpose of this study(1) was to explore factors associated with effectively reaching African American men. Ethnographic methods were used. Key and general informants from an urban Northeastern community were recruited for this study. The data revealed 3 major themes as essential to reaching African American men: a trusted and respected community member providing the outreach, a perceived safe and caring environment during outreach, and a perceived benefit from participating in the outreach. The findings from this study provided a foundation for designing community interventions that will increase participation among African American men. Future research efforts should focus on operationalizing these findings in the community.

Can reproductive pattern explain better survival of women with lung cancer?

We examined whether women's survival from lung cancer is influenced by hormonal factors associated with reproductive events. In all 4235 women and 4797 men born on 1 January 1935 or later with lung cancer diagnosed in 1978-1999 were identified in the Danish Cancer Registry and followed up to 31 December 2002 by linkage to the Central Population Registry. Cox regression analysis was used to estimate hazard rate ratios (HRs), and survival probabilities were calculated. Both nulliparous women and men without children had worse prognoses than those with children (women: HR 1.14; CI 1.03-1.26; men: HR 1.24; CI 1.15-1.34). The 5-year survival rate of nulliparous women with adenocarcinoma was 20.3%, while that for parous women was 20.5%; the corresponding rates for men were 13.0% and 16.6%. The number of children affected the risk for death in both sexes, indicating that the finding is not due to hormonal factors but to unmeasured elements such as socio-economic status or lifestyle factors related to parenthood.

Prostate cancer screening behavior in men from seven ethnic groups: the fear factor

Rates of prostate cancer screening are known to vary among the major ethnic groups. However, likely variations in screening behavior among ethnic subpopulations and the likely role of psychological characteristics remain understudied. We examined differences in prostate cancer screening among samples of 44 men from each of seven ethnic groups (N = 308; U.S.-born European Americans, U.S.-born African Americans, men from the English-speaking Caribbean, Haitians, Dominicans, Puerto Ricans, and Eastern Europeans) and the associations among trait fear, emotion regulatory characteristics, and screening. As expected, there were differences in the frequency of both digital rectal exam (DRE) and prostate-specific antigen (PSA) tests among the groups, even when demographic factors and access were controlled. Haitian men reported fewer DRE and PSA tests than either U.S.-born European American or Dominican men, and immigrant Eastern European men reported fewer tests than U.S.-born European Americans; consistent with prior research, U.S.-born African Americans differed from U.S.-born European Americans for DRE but not PSA frequency. Second, the addition of trait fear significantly improved model fit, as did the inclusion of a quadratic, inverted U, trait fear term, even where demographics, access, and ethnicity were controlled. Trait fear did not interact with ethnicity, suggesting its effect may operate equally across groups, and adding patterns of information processing and emotion regulation to the model did not improve model fit. Overall, our data suggest that fear is among the key psychological determinants of male screening behavior and would be usefully considered in models designed to increase male screening frequency.

Factors Influencing the Use of Antitumoral Chemotherapy in the South East of England

Influences on the use of chemotherapy for the treatment of cancer within the South East region of England for patients diagnosed with colorectal, lung, breast and prostate cancer were investigated. The variables investigated as possibly influencing the selection of chemotherapy were the sex of the patients, their age, the year of diagnosis, the cancer site, the cancer stage, the index of multiple deprivation (IMD) and the cancer network of residence. Logistic regression used to adjust the proportion receiving chemotherapy in relation to other variables considered showed significant differences in the proportion of patients receiving chemotherapy between different cancer sites and different networks. There was also a highly significant trend seen in use of chemotherapy over time; the adjusted proportion of patients receiving chemotherapy increasing from 10.6% in 1993 to 24.3% in 2002. Age, stage and cancer site seemed to have the most influence on the use of chemotherapy.

Early experiences with e-health services (1999-2002): promise, reality, and implications

BACKGROUND

E-health services may improve the quality and efficiency of care; however, there is little quantitative data on e-health use.

OBJECTIVE

The objective of this study was to examine trends in e-health use and user characteristics.

RESEARCH DESIGN

This was a longitudinal study of e-health use (1999-2002) within an integrated delivery system (IDS). We classified 4 e-health services into transactional (drug refills and appointment scheduling) and care-related (medical and medication advice) services.

SUBJECTS

Approximately 3.3 million members of a large, prepaid IDS.

MEASUREMENTS

Amount and frequency of e-health use over time and characteristics of users.

RESULTS

The number of members registered for access to e-health increased from 20,617 (0.7% of all members) in Q1 1999 to 270,987 (8.6%) in Q3 2002. Between Q1 and Q3 2002, 42,845 members (1.3%) used the drug refill service and 55,901 (1.7%) used the appointment scheduling service compared with 10,756 members (0.3%) who used the medical advice service and 3069 (0.1%) who used the medication advice service. Over the same period, transactional service users averaged 3.5 uses/user versus 1.6 uses/user among care-related service users. Members most likely to use e-health services had a high level of clinical need, a regular primary care provider, were 30 to 64 years old, female, white, and lived in a nonlow socioeconomic status neighborhood. These findings were consistent across e-health service types.

CONCLUSIONS

Although use of all e-health services grew rapidly, use of care-related services lagged significantly behind use of transactional services. Subjects with greater clinical need and better ties to the health system were more likely to use both types of e-health services.

Promoting advance directives among African Americans: a faith-based model

BACKGROUND

Studies show that African Americans are less likely than other ethnic groups to complete advance directives. However, what influences African Americans' decisions to complete or not complete advance directives is unclear.

METHODS

Using a faith-based promotion model, 102 African Americans aged 55 years or older were recruited from local churches and community-based agencies to participate in a pilot study to promote advance care planning. Focus groups were used to collect data on participants' preferences for care, desire to make personal choices, values and attitudes, beliefs about death and dying, and advance directives. A standardized interview was used in the focus groups, and the data were organized and analyzed using NUDIST 4 software (QRS Software, Victoria, Australia).

RESULTS

Three fourths of the participants refused to complete advance directives. The following factors influenced the participants' decisions about end-of-life care and completion of an advance directive: spirituality; view of suffering, death, and dying; social support networks; barriers to utilization; and mistrust of the health care system.

CONCLUSION

The dissemination of information apprises individuals of their right to self-determine about their care, but educational efforts may not produce a significant change in behavior toward completion of advance care planning. Thus, ongoing efforts are needed to improve the trust that African Americans have in medical and health care providers.

Improving the lung cancer resection rate in the US Department of Veterans Affairs Health System

BACKGROUND

The optimal treatment for non-small-cell lung cancer (NSCLC) is surgical resection; however, most patients are ineligible because of advanced disease. Although resection rates of 25% have been reported nationally, rates in the Veterans Affairs (VA) system appear lower, perhaps because of limited access to specialized care. We hypothesized that, since the introduction of a specialized Lung Mass Clinic in 1999, the resection rate at the Birmingham VA Medical Center would be comparable with US benchmarks. We also sought to identify the medical and nonmedical factors that influenced the use of surgery.

PATIENTS AND METHODS

We reviewed the electronic medical records of all veterans seen in the Lung Mass Clinic from 1999 to 2003 and identified patients with NSCLC. Demographics, comorbidities, diagnostic methods, times to diagnosis/resection, and postoperative survival were recorded. Reasons for non-resection were documented and tabulated, and differences between the resected and nonresected subgroups were examined.

RESULTS

One hundred fifty-six patients with NSCLC were identified, and 31 (20%) underwent resection. There were no differences in age, ethnicity, or sex between those undergoing resection and those denied surgery. Patients who underwent resection were less likely to have chronic obstructive pulmonary disease and had better pulmonary function. Eighty-four percent of those who did not undergo resection had advanced disease, poor pulmonary function, or had refused therapy. Although the median time to resection was longer than expected (104 days), overall survival was comparable with other reports (65% at 3 years).

CONCLUSION

Since the inception of the Lung Mass Clinic, the resection rate at Birmingham VA Medical Center has improved. The primary limitation to resection was late presentation and not preoperative delays.

Delay of adjuvant chemotherapy initiation following breast cancer surgery among elderly women

BACKGROUND

Delay in the diagnosis of breast cancer is associated with worse stage distribution at diagnosis and decreased survival. However, the occurrence of delay in the delivery of adjuvant therapy and its impact on prognosis is not well understood.

METHODS

To investigate the timeliness of initiation of adjuvant chemotherapy following surgery for breast cancer, we used data from the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database. Among women > or = 65 years diagnosed between 1992 and 1999 with stages I-II breast cancer, we used linear regression and Cox proportional hazards models to investigate the time intervals between surgery and initiation of adjuvant chemotherapy, factors associated with delay, and the effect of delay on survival.

RESULTS

Our sample consisted of 5003 women who received adjuvant chemotherapy. Of these, 47% initiated chemotherapy within 1 month, 37% between 1 and 2 months, 6% between 2 and 3 months and 10% >3 months (delay) following surgery. Delay was associated with increasing age, residing in a rural location, being unmarried, earlier tumor stage, hormone receptor positivity, mastectomy, and non-receipt of radiation therapy. Survival did not differ among patients who initiated chemotherapy within 1, 2, or 3 months after surgery. Delay beyond 3 months was, however, associated with increased disease-specific mortality (HR 1.69; 95% CI 1.31-2.19) and overall mortality (HR 1.46; 95% CI 1.21-1.75).

CONCLUSIONS

Among older patients, moderate delays in the receipt of adjuvant chemotherapy occur frequently, but long delays (>3 months) are uncommon. While early initiation of therapy is no benefit, significant delays are associated with increased mortality. Whether this reflects the medical impact of the delay of chemotherapy or factors associated with delay is unclear, but until this is clarified, patients should be encouraged to initiate treatment without significant delay.