Racial differences in the treatment of early-stage lung cancer

Racial disparities in VA service connection for posttraumatic stress disorder disability

BACKGROUND

"Service connected" veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access.

OBJECTIVES

To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status.

RESEARCH DESIGN

Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample.

SETTING AND SUBJECTS

The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998.

RESULTS

A total of 3337 veterans returned usable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of 20,000 US dollars or less. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003).

CONCLUSION

Black persons' rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.

Culturally competent healthcare systems. A systematic review

Culturally competent healthcare systems-those that provide culturally and linguistically appropriate services-have the potential to reduce racial and ethnic health disparities. When clients do not understand what their healthcare providers are telling them, and providers either do not speak the client's language or are insensitive to cultural differences, the quality of health care can be compromised. We reviewed five interventions to improve cultural competence in healthcare systems-programs to recruit and retain staff members who reflect the cultural diversity of the community served, use of interpreter services or bilingual providers for clients with limited English proficiency, cultural competency training for healthcare providers, use of linguistically and culturally appropriate health education materials, and culturally specific healthcare settings. We could not determine the effectiveness of any of these interventions, because there were either too few comparative studies, or studies did not examine the outcome measures evaluated in this review: client satisfaction with care, improvements in health status, and inappropriate racial or ethnic differences in use of health services or in received and recommended treatment.

[Duration of the diagnostic process for lung cancer versus other solid tumors at the National Oncology Institute of Ecuador]

OBJECTIVE

To determine the duration of the outpatient diagnostic process for lung cancer in comparison to that of other solid organ tumors/all tumors at the National Oncology Institute-Society to Fight Cancer (ION-SOLCA) of Ecuador.

PATIENTS AND METHODS

All patients with non-small cell lung cancer (NSCLC) seen between January 1 and December 31, 1995 at the ION-SOLCA, a specialized tertiary care hospital in Guayaquil, Ecuador, were studied. The duration of the patients' diagnostic process was compared to that of other patients with solid organ tumors (1 control per NSCLC patient).

DESIGN

Retrospective study of health care services to measure the duration of each stage of the diagnostic process for cancer patients at the ION-SOLCA.

MEASURES

The main variable was the duration of the diagnostic process. The duration of each phase of the process was also recorded.

RESULTS

Results are given as means ( standard deviations, with standard errors between parentheses). The overall duration of the diagnostic process for all solid organ tumors (lung and others) at the ION-SOLCA was 54.5 days 62.3 (7.6). No differences were detected between the duration of diagnosis for lung and other tumors. The durations of the different phases of diagnosis were as follows: from the first pre-admission contact with the hospital until a visit with a specialist, 12.5 days 11.4 (1.4); from the visit with a specialist until a diagnostic procedure, 33.3 days 57 (7); and from the diagnostic procedure until the pathological diagnosis, 8.7 days 6.9 (0.8).

CONCLUSIONS

Outpatient evaluation is an inefficient, slow and potentially dangerous process in cases in which the probability of a cancer diagnosis is high. A more interventionist process involving hospital admission may accelerate diagnosis in such cases.

Surgical decisions for early stage, non-small cell lung cancer: which racially sensitive perceptions of cancer are likely to explain racial variation in surgery?

OBJECTIVES

Twenty-three percent of white and 36% of African American patients who suffer from early stage non-small cell lung cancer do not undergo potentially curative surgery A simple decision model is presented to probe for elements of surgical decision making that could explain decisions against lung cancer surgery and racial variation in these decisions.

METHODS

A survey of 181 diverse individuals to measure health utility scores for conditions relevant to lung cancer surgery was performed. These scores were inserted into a simple model that calculates quality-adjusted survival related to decisions for and against cancer surgery

RESULTS

The health utility score (HUS) for progressive lung cancer, as determined by a survey using the standard gamble approach, is nearly twice as high in African Americans as whites (0.32 v. 0.18). However, in a model incorporating African American utility data, lung cancer surgery remains heavily favored compared to the no-surgery decision (2.32 v. 0.48 quality-adjusted life years). Sensitivity analysis shows that factors that lead to a belief of cancer "cure" in the absence of surgical intervention are much more important than variations of HUS in directing model results away from surgery.

CONCLUSION

This analysis illustrates that racial differences in quality-of-life ratings of progressive lung cancer as measured by HUS exist but may not explain decisions against surgery as much as other elements of patient care.

Outcomes research in oncology: improving patients' experiences with cancer treatment

Outcomes research in oncology is a relatively young field, but its potential for expanding our understanding of patients' experiences with cancer gives it increasing relevance to clinical oncology research. We provide a brief overview of the growing prevalence of oncology outcomes research, and we discuss some of the key areas of inquiry currently engaging outcomes researchers. In doing so, we introduce the articles in this supplemental section, which address some of the unique concerns of outcomes researchers and outline the most important challenges confronting this research community.

Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication?

African Americans and Latinos use services that require a doctor's order at lower rates than do whites. Racial bias and patient preferences contribute to disparities, but their effects appear small. Communication during the medical interaction plays a central role in decision making about subsequent interventions and health behaviors. Research has shown that doctors have poorer communication with minority patients than with others, but problems in doctor-patient communication have received little attention as a potential cause, a remediable one, of health disparities. We evaluate the evidence that poor communication is a cause of disparities and propose some remedies drawn from the communication sciences.

Differences in mortality of black and white patients enrolled in the program of all-inclusive care for the elderly

OBJECTIVES

To examine the relationship between race and mortality in frail community-dwelling older people with access to a program providing comprehensive access and coordination of services.

DESIGN

A longitudinal cohort study.

SETTING

Twelve nationwide demonstration sites of the Program of All-Inclusive Care for the Elderly (PACE) from 1990 to 1996. PACE provides comprehensive medical and long-term care services for nursing home-eligible older people who live in the community.

PARTICIPANTS

Two thousand two white patients and 859 black patients.

MEASUREMENTS

Patients were followed after enrollment until death or the end of the follow-up period. Time from enrollment to death was measured with adjustment of the Cox proportional hazards model for comorbid conditions, functional status, site, and other demographic characteristics.

RESULTS

Black patients were younger than white patients (mean age 77 vs 80, P <.001) but had worse functional status (mean activity of daily living (ADL) score 6.5 vs 7.2, P <.001) on enrollment. Survival for black and white patients was 88% and 86% at 1 year, 67% and 61% at 3 years, and 51% and 42% at 5 years, respectively (unadjusted hazard ratio (HR) for black patients = 0.77; 95% confidence interval (CI) = 0.67-0.89). After adjustment for baseline comorbid conditions, functional status, site, and demographic characteristics, black patients still had a lower mortality rate (HR = 0.77; 95% CI =.65-0.93). The survival advantage for black patients did not emerge until about 1 year after PACE enrollment (HR for first year after enrollment = 0.97; 95% CI = 0.72-1.31; HR after first year = 0.67; 95% CI = 0.54-0.85, P-value for time interaction <.001). During the first year of enrollment, black patients were more likely to improve and less likely to decline in ADL function than white patients (P <.001).

CONCLUSION

In PACE, a system providing access to and coordination of comprehensive medical and long-term care services for frail older people, black patients have a lower mortality rate than white patients. This survival advantage, which emerges approximately 1 year after PACE enrollment, may be related to the comprehensive access and coordination of services provided by the PACE program.

Ethnicity and prognosis in acute myeloid leukemia

Ethnicity has been described as a prognostic factor in breast cancer and in childhood acute lymphocytic leukemia but not in adult acute myeloid leukemia (AML). We reviewed the records of 225 consecutive AML patients who were diagnosed and treated between 1983 and 1995. Data were collected concerning demographic factors, presenting clinical features, and treatment protocols. We categorized ethnicity as follows: European Jews, non-European Jews, and Arabs. We assessed the role of ethnicity controlling for other known prognostic factors on treatment outcome and survival in this population. Older age, high leukocyte count at diagnosis, and high-risk chromosomal aberrations were significantly associated with overall survival in univariate analysis. In multivariate analysis high leukocyte count and high-risk chromosomal aberrations exerted an independent negative effect on survival. European origin was associated with longer event-free survival in univariate analysis (P = 0.024) and longer overall (P < 0.01) and event-free (P < 0.01) survival but not with a higher remission rate in multivariate analysis. For AML patients who achieved remission after induction chemotherapy and survived its complications, European origin is an independent favorable prognostic factor for long-term remission and survival in Israel. These findings may reflect better socioeconomic status, social support, increased compliance with treatment protocols, or better psychological coping mechanisms with malignancy.

Prognosis after rectal cancer in blacks and whites participating in adjuvant therapy randomized trials

PURPOSE

National health statistics indicate that blacks have lower survival rates from colorectal cancer than do whites. This disparity has been attributed to differences in stage at diagnosis and other disease features, extent and quality of treatment, and socioeconomic factors. We evaluated outcomes for blacks and whites with rectal cancer who participated in randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP). The randomized trial setting enhances uniformity in disease stage and treatment plan among all participants.

PATIENTS AND METHODS

The study included black (N = 104) or white (N = 1,070) patients from two serially conducted NSABP randomized trials for operable rectal cancer. Recurrence-free survival and survival were compared using statistical modeling to account for differences in patient and disease characteristics between the groups.

RESULTS

Blacks and whites had largely similar disease features at diagnosis. After adjustment for patient and tumor prognostic covariates, the black/white recurrence hazard ratio (HR) was 1.25 (95% confidence interval [CI], 0.94 to 1.66). The mortality HR was somewhat larger at 1.45 (95% CI = 1.09 to 1.93). Outcomes were improved for both groups in the more recent trial, which employed systemic adjuvant chemotherapy in all treatment arms.

CONCLUSION

Recurrence-free survival was modestly less favorable for blacks, whereas overall survival was more disparate. Outcomes between groups were more comparable than those noted in national health statistics surveys and other studies. Adequate treatment access and the identification of new prognostic factors that can identify patients at high risk of recurrence are needed to ensure optimal outcomes for rectal cancer patients of all racial/ethnic backgrounds.

Racial differences in the outcome of patients with colorectal carcinoma

BACKGROUND

African-American (AA) patients with colorectal carcinoma have a worse prognosis compared with Caucasians. To analyze the causes of this disparity in survival, a retrospective study of patients with colorectal carcinoma was undertaken. The impact of treatments received and the role of socioeconomic factors such as income, education, and poverty levels were studied.

METHODS

A retrospective analysis of patients with colorectal carcinoma at a single institution was conducted. The overall survival of AA and Caucasians, stage at presentation, treatment received, and socioeconomic factors were analyzed using the institutional tumor registry and 1990 census data.

RESULTS

The overall survival of AA patients was worse compared with Caucasians, both due to all causes (P < 0.001) and cancer-related deaths (P < 0.001). The relative risk of death due to all causes was 1.4 (95% confidence interval [CI] 1.2-1.8) for AA, 4.3 for patients with Stage IV disease (95% CI 3.2-5.7), and 2.3 for patients not undergoing surgery (95% CI 1.7-3.1). After multivariate adjustment for gender, site, socioeconomic factors, and therapeutic modalities, the relative risks for death were 1.5 (95% CI 1.2) for AA, 1.4 (95% CI 1.1-1.7) for patients 60 years of age or older, and 4.2 (95% CI 3.4-5.2) for Stage IV disease. The survival difference between AA and Caucasians was not influenced by income, poverty level, and education. African Americans were treated less frequently with chemotherapy and radiation therapy compared with their Caucasian counterparts.

CONCLUSIONS

African American patients with colorectal carcinoma have a poorer prognosis compared with Caucasians. This discrepancy may be due to decreased utilization of chemotherapy and radiation therapy. Socioeconomic factors and lack of access to health care do not entirely explain the worse prognosis of AA. These factors should be identified and dealt with to improve the health care of AA patients with various malignant disorders.

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care

OBJECTIVES

Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care.

METHODS

The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers.

RESULTS

Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care.

CONCLUSIONS

Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

Symptom severity in advanced cancer, assessed in two ethnic groups by interviews with bereaved family members and friends

Little research has been reported on the experience of cancer among minority ethnic communities in the UK. As part of a wider survey in inner London we interviewed bereaved family members or close friends of 34 first-generation black Caribbeans and of 35 UK-born white patients about symptoms and symptom control in the year before death with cancer. They were drawn from population samples in which the response rates were equal at about 46%. Symptoms in the two ethnic groups were similar. However, multivariate logistic regression indicated greater symptom-related distress in black Caribbeans for appetite loss, pain, dry mouth, vomiting and nausea, and mental confusion. Respondents were also more likely to say, in relation to black Caribbean patients, that general practitioners (though not hospital doctors) could have tried harder to manage symptoms. The findings suggest a need for better assessment and management of cancer symptoms in first-generation Caribbean Londoners, guided by a deeper understanding of cultural influences on their responses to advanced illness.

Symptom severity in advanced cancer, assessed in two ethnic groups by interviews with bereaved family members and friends

Little research has been reported on the experience of cancer among minority ethnic communities in the UK. As part of a wider survey in inner London we interviewed bereaved family members or close friends of 34 first-generation black Caribbeans and of 35 UK-born white patients about symptoms and symptom control in the year before death with cancer. They were drawn from population samples in which the response rates were equal at about 46%. Symptoms in the two ethnic groups were similar. However, multivariate logistic regression indicated greater symptom-related distress in black Caribbeans for appetite loss, pain, dry mouth, vomiting and nausea, and mental confusion. Respondents were also more likely to say, in relation to black Caribbean patients, that general practitioners (though not hospital doctors) could have tried harder to manage symptoms. The findings suggest a need for better assessment and management of cancer symptoms in first-generation Caribbean Londoners, guided by a deeper understanding of cultural influences on their responses to advanced illness.

Increasing the pool of academically oriented African-American medical and surgical oncologists

BACKGROUND

In the United States, breast cancer mortality rates are significantly higher among African-American women than among women of other ethnic backgrounds. Research efforts to evaluate the socioeconomic, environmental, biologic, and genetic mechanisms explaining this disparity are needed.

METHODS

Data regarding patterns in the ethnic distribution of physicians and oncologists were accumulated from a review of the literature and by contacting cancer-oriented professional societies. This information was evaluated by participants in a national meeting, "Summit Meeting Evaluating Research on Breast Cancer in African American Women." Results of the data collection and the conference discussion are summarized.

RESULTS

Ethnic minority specialists are underrepresented in academic medicine in general, and in the field of oncology in particular. This fact is unfortunate because ethnic minority students are more likely to express a commitment to providing care to medically underserved communities and, thus, they need to be better represented in these professions. Correcting these patterns of underrepresentation may favorably influence the design and implementation of culturally and ethnically sensitive research.

CONCLUSIONS

Efforts to improve the ethnic diversity of oncology specialists should begin at the level of recruiting an ethnically diverse premed and medical student population. These recruitment efforts should place an emphasis on the value of mentoring.

Screening for lung cancer: a review of the current literature

STUDY OBJECTIVES

To review the available data on the early detection of lung cancer, with a focus on three technologies: chest x-ray (CXR), sputum cytology, and low-dose CT (LDCT) scanning.

DESIGN, SETTING, PARTICIPANTS

Review of published clinical studies of early detection technologies. The best available evidence on each topic was selected for analysis. Randomized trials were used to evaluate CXR and sputum cytology. Cohort studies, as well as studies providing evidence regarding rates of overdiagnosis and efficacy of initial treatment, were considered in evaluation of LDCT. Study design and results were summarized in evidence tables. Statistical analyses of combined data were not performed.

MEASUREMENT AND RESULTS

Five randomized trials of CXR with or without sputum cytology have been conducted, each which reports disease-specific mortality as well as other end points. None of these studies provide support for the use of either CXR or sputum cytology for the early detection of lung cancer in asymptomatic individuals. Eight completed and ongoing trials of LDCT were identified. All of these studies report the frequency and stage distribution of lung cancers found during initial ("prevalence") screening, and several studies also report rates of detection at the time of annual follow-up. No outcome data on survival or treatment are available. A number of studies support the hypothesis of "overdiagnosis"--that some lung cancers detected by LDCT may behave in an indolent manner.

CONCLUSIONS

The use of either CXR or sputum cytology for the early detection of lung cancer is not supported by the published evidence. The evidence for LDCT appears promising, in that the technology typically identifies lung cancer at an early stage, although corollary studies suggest that these findings in isolation may be misleading. Further high-quality research is needed to better define the role of LDCT in the evaluation of asymptomatic high-risk individuals.

Cohort study of surgical bypass to the gallbladder or bile duct for the palliation of jaundice due to pancreatic cancer

OBJECTIVE

To compare patterns in mortality and the use of subsequent biliary drainage interventions (surgical, endoscopic, and percutaneous) associated with the different types of biliary bypass.

SUMMARY BACKGROUND DATA

Surgical palliation of obstructive jaundice due to pancreatic cancer is often accomplished with an intestinal bypass to either the gallbladder or the bile duct. It is not known whether a gallbladder bypass, which is a simpler operation and more amenable to laparoscopic surgery, performs as well as a bypass to the bile duct.

METHODS

The authors conducted a retrospective cohort study of 1,919 patients 65 years of age or older who had a surgical biliary bypass for pancreatic cancer diagnosed between 1991 and 1996 using Medicare claims data and the Surveillance, Epidemiology and End Results (SEER) database.

RESULTS

At 1, 2, and 5 years, 7.5%, 17.4%, and 26.0% of 945 patients initially treated with a gallbladder bypass had additional biliary interventions, as compared with 2.9%, 11.0%, and 13.3% of 974 patients initially treated with a bile duct bypass. Patients who initially had a gallbladder bypass were 4.4 times as likely to have additional biliary surgery and 2.9 times as likely to have any subsequent biliary intervention as were patients who initially had a bile duct bypass. Median survival was longer following bile duct bypass. The adjusted hazard ratio for death associated with gallbladder bypass was 1.2.

CONCLUSIONS

Compared to patients whose initial biliary bypass was to the bile duct, the risk of having one or more additional surgical, endoscopic, or percutaneous biliary drainage procedures is substantially greater in patients whose initial bypass was to the gallbladder.

Participants' ratings of male physicians who vary in race and communication style

Research has shown minorities receive lower quality health care than White persons even with socioeconomic conditions controlled. This difference may partially be related to racially biased attitudes and impaired communication in interracial relationships between physicians and patients. This study investigated the effect of physicians' race and nonverbal communication style on participants' evaluations. Patients at a local health clinic were participants (N = 116: 84% Black, 16% White). Each participant viewed one of four videotapes showing varied race of a physician (Black or White) and the physician's nonverbal behavior (expressing concern or distance), and then completed a questionnaire evaluating the depicted physician. Overall, participants did not give significantly different preferences for physicians of the same race. However, participants' evaluations were significantly associated with physicians' nonverbal style. Nonverbal concern was associated with highest satisfaction, trust, self-disclosure, recall of information, likelihood of recommending the physician, and intent to comply with the physician's recommendations. When male and female participants were compared, preference for a physician of the same race was found only among male participants who viewed verbally distant physicians. Results suggest that social skills are more important than race in shaping patients' perceptions of physicians.

Racism as a source of health disparity in families with children with attention deficit hyperactivity disorder

Although poverty and health are inextricably linked, one cannot assume that simple poverty and low socioeconomic status are the primary causes of health disparity among racial groups. Examining the roles of racism and discrimination in access to health care and in the health experiences of people of color is fundamental to the goal of eliminating health disparities by 2010. Data from ethnic minority groups on how race influences health and health care services are absent from much of the nursing research literature. This article explores racism as a source of health disparity and discusses methodological implications for research, using attention deficit hyperactivity disorder (ADHD) research as an example.

Advanced presentation of lung cancer in Asian immigrants: a case-control study

STUDY OBJECTIVES

To determine if Asian immigrants to the United States present with more advanced lung cancer compared to non-Asians.

DESIGN

A 5-year retrospective case-control study (January 1, 1992, to December 31, 1996) of patients with lung cancer identified using the New England Medical Center cancer center database. A 2-year follow up was obtained in all subjects.

SETTING

A tertiary level care hospital providing all levels of medical care to the local Asian population in the Boston area.

PATIENTS

Forty-two Asian immigrants with lung cancer diagnosed over the study period were matched for age and sex with 42 non-Asian control subjects.

RESULTS

Asians presented more frequently with advanced stage (stage III or IV) and less frequently with early stage (stage I or II) lung cancer compared with the non-Asian control group (p < 0.05). Asians were more likely to present with hemoptysis or constitutional symptoms (p < 0.01) and had a longer duration of symptoms prior to presentation (p < 0.01) compared with non-Asians. There was no difference in the length of time elapsed between diagnosis and start of treatment (approximation of workup time) between the two groups. The utilization of tests and procedures for clinical disease staging was not significantly different between the two groups. The incidence of large cell carcinoma (p < 0.05) was higher in Asians compared with non-Asians. Asians were more likely to receive radiotherapy and less likely to receive combination therapy compared with non-Asians (p < 0.05). The treatment of stage I and II lung cancer did not differ between the two groups. The median 2-year survival was significantly reduced in Asians compared with non-Asians: Asians, 7 months (95% confidence interval [CI], 3.1 to 10.9); non-Asians, 15 months (95% CI, 12.0 to 17.5) [p < 0.001].

CONCLUSIONS

Asian immigrants with lung cancer appear to present with more advanced stage of disease, have more prolonged symptomatology, and have reduced survival compared with non-Asians. These data suggest that ethnicity may play a role in the presentation and outcome of lung cancer in the Asian immigrant population.

Carotid endarterectomy and race: do clinical indications and patient preferences account for differences?

BACKGROUND AND PURPOSE

Carotid endarterectomy (CE) has been proved to reduce the risk of stroke for certain patients, but black patients are less likely than whites to receive CE. The purpose of this work was to determine the importance of clinical indications and patient preferences in predicting the use of carotid angiography and CE in a racially stratified sample of patients.

METHODS

Between 1997 and 1999, 708 patients with at least 1 carotid artery containing a >/=50% stenosis were enrolled (617 whites, 91 blacks) from 5 Veteran Affairs Medical Centers. Patient interviews were conducted at the time of the index carotid ultrasound, and each patient was followed up for 6 months to determine clinical events and receipt of carotid angiography or CE.

RESULTS

Black and white patients were similar in terms of age, sex, education level, and social support. More black than white patients received ultrasound for a completed stroke (36% versus 13%), and fewer black patients were classified as asymptomatic (56% versus 70%) or as having had a TIA (8% versus 17%; P<0.001). Health-related quality of life scores, trust in physician, and medical comorbidity scores were similar for black and white patients. Black patients expressed higher aversion to CE than white patients (31% versus 15% in the highest aversion quartile for blacks and whites, respectively; P=0.01). During follow-up, 20% of white patients and 14% of black patients received CE (P=0.19). In adjusted analyses, only patient clinical status as it relates to the indication for CE and site were associated with receipt of CE.

CONCLUSIONS

Contrary to prior research, patient's race was not associated with receipt of invasive carotid imaging or CE for older male veterans. These findings persist after controlling for patient preferences, comorbid illness, and quality of life. For patients enrolled in an equal-access health care system, clinical status was the primary determinant of the receipt of CE.

Adjuvant chemotherapy use for Medicare beneficiaries with stage II colon cancer

PURPOSE

Clinical trials have not demonstrated that adjuvant chemotherapy improves survival for patients with resected stage II colon cancer. Nevertheless, patients may receive this treatment despite its uncertain benefit. The objective of this study was to determine the extent to which adjuvant chemotherapy is used for patients with stage II colon cancer.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 3,151 patients aged 65 to 75 with resected stage II colon cancer and no adverse prognostic features. The primary outcome was chemotherapy use within 3 months of surgery ascertained from claims submitted to Medicare. Relationships between patient characteristics and adjuvant chemotherapy use were measured and their significance was assessed using multivariable logistic regression. Survival for treated and untreated patients was compared using a Cox model.

RESULTS

Twenty-seven percent of patients received chemotherapy during the 3 postoperative months. Younger age at diagnosis, white race, unfavorable tumor grade, and low comorbidity were each associated with a greater likelihood of receiving treatment. Sex, the number of examined lymph nodes in the tumor specimen, the urgency of the surgical admission, and median income was each unrelated to treatment. Five-year survival was 75% for untreated patients and 78% for treated patients. After adjusting for known between-group differences, the hazard ratio for survival associated with adjuvant treatment was 0.91 (95% confidence interval, 0.77 to 1.09).

CONCLUSION

A substantial percentage of Medicare beneficiaries with resected stage II colon cancer receive adjuvant chemotherapy despite its uncertain benefit.

Ethnic variation in the impact of negative affect and emotion inhibition on the health of older adults

The relations between patterns of emotional experience, emotion inhibition, and physical health have been little studied in older adults or ethnically diverse samples. Testing hypotheses derived from work on younger adults, the authors examined the relations between negative affect and emotion inhibition and that of illness (hypertension, respiratory disease, arthritis, and sleep disorder) in a sample (N = 1,118) of community-dwelling older adults from four ethnic groups: U.S.-born African Americans, African Caribbeans, U.S.-born European Americans, and Eastern European immigrants. Participants completed measures of stress, lifestyle risk factors, health, social support, trait negative emotion, and emotion inhibition. As expected, the interaction of ethnicity with emotion inhibition, and, to a lesser extent, negative affect, was significantly related to illness, even when other known risk factors were controlled for. However, the relations among these variables were complex, and the patterns did not hold for all types of illness or operate in the same direction across ethnic groups. Implications for emotion-health relationships in ethnically diverse samples are discussed.

Patient demographic and socioeconomic characteristics in the SEER-Medicare database applications and limitations

Users of the linked SEER-Medicare database commonly perform analyses that focus on the complex interactions among patient characteristics, cancer treatments, and outcomes. The authors review the source and scope of the patient-specific data elements, with a focus on three domains--demographic characteristics, socioeconomic characteristics, and survival status. They offer some concrete recommendations regarding the use of these data elements. In particular, they describe analyses that provide an estimate of the accuracy of the sex and age variables, and raise some cautionary notes about race and ethnicity variables. The authors describe the available measures of socioeconomic status, and recommend, with some caveats, the use of median income measures as a proxy for socioeconomic status. Finally, they describe the available data on date of death, and explain why confidence in these measures is justified.

Assessing comorbidity using claims data: an overview

Comorbidity, additional disease beyond the condition under study that increases a patient's total burden of illness, is one dimension of health status. For investigators working with observational data obtained from administrative databases, comorbidity assessment may be a useful and important means of accounting for differences in patients' underlying health status. There are multiple ways of measuring comorbidity. This paper provides an overview of current approaches to and issues in assessing comorbidity using claims data, with a particular focus on established indices and the SEER-Medicare database. In addition, efforts to improve measurement of comorbidity using claims data are described, including augmentation of claims data with medical record, patient self-report, or health services utilization data; incorporation of claims data from sources other than inpatient claims; and exploration of alternative conditions, indices, or ways of grouping conditions. Finally, caveats about claims data and areas for future research in claims-based comorbidity assessment are discussed. Although the use of claims databases such as SEER-Medicare for health services and outcomes research has become increasingly common, investigators must be cognizant of the limitations of comorbidity measures derived from these data sources in capturing and controlling for differences in patient health status. The assessment of comorbidity using claims data is a complex and evolving area of investigation.

Socioeconomic and demographic disparities in treatment for carcinomas of the colon and rectum

BACKGROUND

The current study examined the relationship between socioeconomic and demographic factors and type of treatment for carcinomas of the colon and rectum. The National Institutes of Health and the National Cancer Institute recommend surgery followed by adjuvant chemo- and/or radiotherapy for Stage III colon and Stages II and III rectal carcinomas.

METHODS

The authors linked Washington State's cancer registry and hospital discharge records and U.S. census data to assess socioeconomic and demographic factors related to treatment, controlling for clinical factors.

RESULTS

Compared to colon carcinoma patients under age 65 years, patients aged 75-84 years and 85 years or older were at higher risk for a treatment plan of surgery without adjuvant therapy (adjusted odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.3-4.7; OR = 14.1, CI = 6.3-31.4, respectively). Risk of no adjuvant therapy was more than doubled for patients in zip codes in the lowest quartile of per capita income compared to the top three quartiles (OR = 2.3, CI = 1.5-3.4) and for those with Medicare compared to private insurance (OR = 2.2, CI = 1.3-3.8). Older patients with rectal carcinoma were also at higher risk of a treatment plan that did not include adjuvant therapy.

CONCLUSIONS

The current findings suggest disparities in the provision of recommended medical procedures related to socioeconomic and demographic factors.

Disparities in surgical resection of early-stage non-small cell lung cancer

OBJECTIVES

The aim of our study was to identify the factors that determined whether a patient underwent surgery and its impact on patient outcome.

METHODS

A retrospective evaluation of the records of all patients diagnosed with resectable stages I and II non-small cell lung cancer between 1990 and 1998 at the University of Arkansas and Veterans Administration Hospitals were included in the study. Demographic, clinical, pathologic, and outcome data were captured. Analysis was conducted to identify prognostic factors as well as factors leading to surgical treatment disparities.

RESULTS

A total of 551 patients were included; 490 (89%) were men, 480 (87%) were white, and 315 (57%) were aged >65 years. Median follow-up of these patients was 24 months (1-109 months). Surgery was performed on 455 patients (82.6%); 26 patients received nonsurgical treatment including chemotherapy, radiation therapy, or both, and 70 patients did not receive any type of treatment. A univariate analysis revealed that age, race, sex, and forced expiratory volume in the first second were significantly different between the surgery and no surgery groups. However, a multivariate analysis showed that age, forced expiratory volume in 1 second, and hemoglobin were significantly different between both groups. The median overall survival was 45.5 months (1-109 months) for the surgically treated patients compared with 12.0 months (1-86 months) for those who did not undergo surgery (P <.0001).

CONCLUSION

Elderly patients with early-stage non-small cell lung cancer are less likely to undergo a potentially curative surgical resection. Racial and sex disparities may be due to other comorbidities.

African-American ethnicity, socioeconomic status, and breast cancer survival: a meta-analysis of 14 studies involving over 10,000 African-American and 40,000 White American patients with carcinoma of the breast

BACKGROUND

African-American women are at increased risk for breast cancer mortality compared with white American women, and the extent to which socioeconomic factors account for this outcome disparity is unclear.

METHODS

A MEDLINE search was conducted to identify published studies that used a Cox proportional hazards regression model to evaluate the outcome of African-American women and white American women with breast carcinoma after adjusting for socioeconomic status. A meta-analysis was performed using specialized statistical software; the random-effects method of statistical evaluation was used because of the a priori impression that the studies reviewed would be at least moderately heterogeneous in study design and patient populations.

RESULTS

The initial literature search yielded 3962 studies. Fourteen studies met all criteria for inclusion in the meta-analysis, resulting in a sample size of 10,001 African-American patients and 42,473 white American patients with breast carcinoma. There was substantial variation in the method used for defining socioeconomic status. Summary statistics revealed a significant odds ratio of 1.22 (95% confidence interval, 1.13-1.30) for the adverse effect of African-American ethnicity on breast cancer mortality. Subset meta-analyses yielded similar results, supporting the robustness of this finding.

CONCLUSIONS

This meta-analysis revealed that African-American ethnicity is an independent predictor of a worse breast cancer outcome. The pooled analysis has added strength because of the aggregate sample size and indicates that the true biologic and/or therapeutic determinants of disparities in breast cancer outcome for different ethnic groups and for different socioeconomic strata are incompletely understood.

Use of adjuvant chemotherapy and radiation therapy for rectal cancer among the elderly: a population-based study

PURPOSE

Combined adjuvant fluorouracil (5-FU)-based chemotherapy with radiation is now the standard of care for locally advanced rectal cancer in the United States. We investigated the use of these treatments for stages II and III rectal cancer among the elderly and the effectiveness of these treatments on a population-based scale.

PATIENTS AND METHODS

The linked Surveillance, Epidemiology, and End-Results-Medicare database was used to identify 1,807 Medicare beneficiaries > or = 65 years of age with stage II or III rectal cancer who underwent surgical resection between 1992 and 1996. We excluded members of a health maintenance organization in the 12 months before or 4 months after their diagnosis and those who died within 4 months of diagnosis. We used multivariate analysis to identify factors associated with combined 5-FU and radiation therapy, and propensity score methodology to determine survival benefit for those treated.

RESULTS

We found that 37% of patients received both adjuvant 5-FU and radiation therapy, 11% 5-FU alone, and 14% radiation alone. Decreasing age, increasing lymph node positivity, comorbid conditions, and nonblack race were associated with increased probability of treatment with 5-FU and radiation. Combined chemotherapy/radiation therapy was associated with improved survival for stage III (relative risk, 0.71; 95% confidence interval, 0.56 to 0.90), but not for stage II rectal cancer (relative risk, 0.89; 95% confidence interval, 0.70 to 1.14).

CONCLUSION

The association of combined treatment with improved survival in node-positive disease was similar to that observed in other studies. In the absence of data from well-designed randomized controlled trials, our observational data support efforts on the part of clinicians to make appropriate referrals and provide combined treatment for elderly patients with stage III rectal cancer.

Impact of referral patterns on the use of chemotherapy for lung cancer

PURPOSE

To determine the extent to which unexplained variation in the use of chemotherapy for advanced lung cancer is due to access to oncologists' services as opposed to treatment decisions made after seeing an oncologist.

METHODS

We performed a retrospective cohort study of 12,015 patients over age 65 diagnosed with metastatic lung cancer between 1991 and 1996 while living in one of 11 regions monitored by a Survival, Epidemiology, and End Results (SEER) tumor registry. Assessment by an oncologist and subsequent treatment with chemotherapy were determined by examining linked Medicare claims.

RESULTS

Of patients who did not receive chemotherapy, 36% were never assessed by a physician who provides chemotherapy. Patients living in certain areas, those diagnosed in more recent years, and those who received care in a teaching hospital were all more likely to see a cancer specialist. These factors were unrelated to subsequent treatment decisions, however. Conversely, age and comorbidity did not have a significant effect on whether a patient was seen by an oncologist, but they were associated with the likelihood of subsequently receiving chemotherapy. Black race, probably acting as a proxy for lower socioeconomic status, was associated with both a diminished likelihood of seeing a cancer specialist and subsequently receiving chemotherapy.

CONCLUSION

Nonmedical factors are important determinants of whether a lung cancer patient is seen by a physician who provides chemotherapy. After seeing such a physician, treatment decisions seem to be mostly explained by appropriate medical factors. Racial and socioeconomic disparities still exist at both steps, however. As therapeutic options expand, referring physicians must ensure that biases and barriers to care do not deprive patients of the opportunity to consider all of their treatment options.

Race, epithelial ovarian cancer survival, and membership in a large health maintenance organization

BACKGROUND

African-American ovarian cancer patients present with more advanced disease and have poorer survival than do white patients.

METHODS

To determine whether these differences occur among African-American and white patients who have equal access to medical care, we analyzed ovarian cancer patient characteristics separately for 1,587 members of the Kaiser Permanente Medical Plan of Northern California and 5,757 non-members.

RESULTS

The distributions of disease stage at diagnosis were similar among African-American and white patients, both in the Kaiser plan and elsewhere. However, ovarian cancer death rates, adjusted for disease stage and age at diagnosis and for histology, were higher for African-American patients compared with white patients, regardless of Kaiser membership status. The death rate ratios for African-Americans compared with whites were 1.32 (95% CI = 1.02-1.70) for Kaiser members and 1.20 (95% CI = 1.04-1.40) for Kaiser non-members.

CONCLUSION

Further research within an equal-access care system is needed to evaluate other important factors such as specialty of surgeon, extent of residual tumor after surgery, chemotherapy treatment, and postoperative management to determine whether these factors are contributing to the differences in survival between African-American and white ovarian cancer patients.

Therapy for stage I and stage II non-small cell lung cancer

Despite complete resection of what seems to be all evident tumor, one third to three quarters of patients with stages I and II NSCLC ultimately succumb to this neoplasm. Patients who are cured of an original NSCLC or small cell cancer remain at risk for a new primary lung cancer. Although the importance of lifelong surveillance is clear, the extent and timing of optimal follow-up remain undefined. Although clinicians refer to the development after treatment of clinically discernible sites of tumor as "recurrence," it is probably more accurate to consider these foci as "persistence"--that is, the locoregional site was not sterilized by surgery, and the distant implants were present from the outset but undetected. Although data are sparse, induction and improved adjuvant therapy for early NSCLC may be helpful. Much further experience is needed. Further study and application of biologic indicators in addition to TNM staging likely will help identify patients at high risk for surgical failure who may benefit by combination treatment.

Epidemiology, etiology, and prevention of lung cancer

Over the past century, lung cancer has gone from an obscure disease to the leading cause of cancer death worldwide. Initially an epidemic disease among men in industrialized nations, lung cancer now has become the leading cancer killer in both sexes in the United States and an increasingly common disease of both sexes in developing countries. Lung cancer incidence largely mirrors smoking prevalence, with a latency period of several decades. Other important risk factors for the development of lung cancer include environmental exposure to tobacco smoke, radon, occupational carcinogens, and pre-existing nonmalignant lung disease. Studies in molecular biology have elucidated the role that genetic factors play in modifying an individual's risk for lung cancer. Although chemopreventive agents may be developed to prevent lung cancer, prevention of smoking initiation and promotion of smoking cessation are currently the best weapons to fight lung cancer. No other malignancy has been shown to have such a strong epidemiologic relation between a preventable behavior and incidence of disease. Despite this knowledge, more than 20% of all Americans smoke, and tobacco use is exploding in developing countries. Based on current and projected smoking patterns, it is anticipated that lung cancer will remain the leading cause of cancer death in the world for decades to come.

When is risk stratification by race or ethnicity justified in medical care?

Issues of race and ethnicity have been controversial in both clinical care and medical education. In daily practice, many physicians struggle to be culturally competent and avoid racial stereotyping. One educational development that makes this goal more complex is the rise of clinical epidemiology and Bayesian thinking. These population-based, probabilistic approaches to medicine help guide the diagnostic and therapeutic pathways for patients, and are foundations of the evidence-based medicine movement. Can Bayesian thinking be applied effectively to issues of race and ethnicity in medical care, or are the dangers of prejudicial stereotyping too great? The authors draw upon lessons from recent cases of racial profiling, and develop a conceptual framework for thinking about ethnicity as a clinical tool. In their typology of ethnicity as a proxy, they argue that the costs of using ethnicity as a proxy for socioeconomic status and behavior are too high, but that ethnicity may appropriately be used as an initial proxy for history, language, culture, and health beliefs. They discuss their approach within the context of new curricula in cultural competence, and argue that viewing the patient within a wider cultural setting can help guide the initial clinical approach, but individualized care is mandatory. Also, physicians must remain sensitive to the changing nature of cultural norms; thus lifelong learning and flexibility are necessary.

Ethnic differences in survival among Pacific Island patients diagnosed with cervical cancer

BACKGROUND

It was the purpose of this study to investigate whether Pacific Island (PI) ethnicity, Micronesian and Polynesian, is an independent prognostic factor in the survival of cervical cancer in a health care system with minimal racial bias and few barriers to access to care.

METHODS

Records from 1988 to 1999 were reviewed for the U.S. Military Health Care System. The medical records of women with the diagnosis of invasive cervical cancer were abstracted and clinical data recorded. A cohort analysis based on Pacific Island ethnicity was also performed on all patients treated at Tripler Army Medical Center (TAMC) during this time period. Significant differences in distribution of clinical factors were determined by Wilcoxon rank-sum test and survival analyses were performed using Kaplan-Meier actuarial statistics.

RESULTS

A total of 153 patients were identified who were treated at TAMC; 74 were of PI ethnicity. An additional 1400 patients were identified throughout the military health care system during this time. Forty-eight percent of non-PI TAMC patients were Caucasian, 14% Filipino, and 13% Korean. The mean age of PI was 45 versus 40 years for their non-PI counterparts. There was no difference in the distribution of the grade of tumors among cohorts analyzed. Seventy-five percent of non-PI patients presented at an early stage while 74% of PI women presented at an advanced stage. Twenty-three percent of PI patients had positive lymph nodes, versus 7% of non-PI patients. There was no difference in the radiation dosages among patients treated with primary radiation therapy. PI patients had a significantly decreased 5-year survival, 32% versus 71%, compared to their cervical cancer patient counterparts, P < 0.001. Multivariate analysis revealed PI ethnicity to be a significant independent predictor of decreased survival, P < 0.001.

CONCLUSION

PI women diagnosed with cervical cancer tend to present at an advanced age and stage with metastatic disease. They have a decreased survival that remains present after adjusting for age, stage, and grade. The poor prognosis is likely due to lack of uniform screening among this population; however, molecular etiologies and human papillomavirus could also contribute to decreased survival.

Variations in the use of chemotherapy for elderly patients with advanced ovarian cancer: a population-based study

PURPOSE

Since 1986, the recommended therapy for patients with ovarian cancer has included surgery and chemotherapy with a platinum compound (cisplatin or carboplatin). The purpose of this study is to assess the use of chemotherapy in elderly patients with advanced ovarian cancer.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare database represents approximately 14% of the United States population and provides clinical and demographic information on cancer patients covered by Medicare, along with health care-utilization data from Medicare claims files. We analyzed the association of demographic and clinical factors with treatment among patients diagnosed from 1992 to 1996 with stage III or IV ovarian cancer, who survived > or = 120 days beyond diagnosis, and were > or = 65 years of age (N = 1,775).

RESULTS

Approximately 83% of elderly patients received some form of chemotherapy within 4 months of diagnosis. In a multiple logistic regression model with patients aged 65 to 69 years as the reference, the odds ratios of receiving chemotherapy were 0.96 (95% confidence interval [CI], 0.63 to 1.46) for ages 70 to 74, 0.65 (95% CI, 0.43 to 1.00) for 75 to 79, 0.24 (95% CI, 0.15 to 0.37) for 80 to 84, and 0.12 (95% CI, 0.07 to 0.19) for 85+. Hispanic patients were less likely to receive chemotherapy than non-Hispanic white patients. Since 1992, paclitaxel has gradually replaced cyclophosphamide as the drug most commonly used with platinum.

CONCLUSION

Despite its proven efficacy in treating ovarian cancer, chemotherapy seems to be used less among patients over age 65, especially those who are nonwhite and/or in the oldest age groups. Further research is needed to elucidate to what degree this represents appropriate clinical judgment and to what degree other factors, such as patient choice, play a role.

Overview of themes identified from African American discourse on quality of care

The article reports on an exploratory descriptive study conducted to establish quality-of-care dimensions from African Americans' perspective, using a combined focus group interview and modified Delphi process. Descriptors of quality, which were identified using participants' vocabulary and thinking patterns, were used to establish quality-of-care dimensions; they were then examined in terms of an adapted quality-of-care framework. Themes and issues related to quality of care also were identified. The article analyzes the qualitative themes abstracted from that discourse and relates focus group interview guide questions to the emerging quality-of-care issues. An interpersonal processes-of-care framework is used to examine the quality-of-care themes, and the quality-of-care issues are discussed using a systems theoretical perspective.

Barriers to optimum end-of-life care for minority patients

Although major efforts are underway to improve end-of-life care, there is growing evidence that improvements are not being experienced by those at particularly high risk for inadequate care: minority patients. Ethnic disparities in access to end-of-life care have been found that reflect disparities in access to many other kinds of care. Additional barriers to optimum end-of-life care for minority patients include insensitivity to cultural differences in attitudes toward death and end-of-life care and understandable mistrust of the healthcare system due to the history of racism in medicine. These barriers can be categorized as institutional, cultural, and individual. Efforts to better understand and remove each type of barrier are needed. Such efforts should include quality assurance programs to better assess inequalities in access to end-of-life care, political action to address inadequate health insurance and access to medical school for minorities, and undergraduate and continuing medical education in cultural sensitivity.

Identifying and caring for underserved populations: experience of the National Centers of Excellence in Women's Health

From 1996 through 1998, 18 National Centers of Excellence in Women's Health (CoEs) were designated by the Office on Women's Health (OWH) of the U.S. Department of Health and Human Services (DHHS). These CoEs were charged with developing standards for comprehensive, multidisciplinary, and culturally competent approaches to women's health. One specific mandate to the CoEs was to address the needs of underserved women. This paper presents the efforts of the CoE Racial and Ethnic Minority and Underserved Women Working Group to describe the work done within the CoEs to meet this mandate. One method of defining underserved populations is the seven-point definition used in the current "Index for Primary Care Shortage," which categorizes underserved populations based on characteristics including race, ethnicity, geography, and health outcomes. The definition allows the local identification of underserved communities based on this group of variables. The analysis included in this paper focuses specifically on the CoEs' efforts to operationalize this definition in order to meet the clinical care needs of women who are of low socioeconomic status (SES), racial or ethnic minorities, or non-English speaking. A brief review of the literature linking these characteristics to being underserved is provided, followed by examples of ongoing activities at the 15 currently funded CoEs, to understand the needs of diverse women, to improve the quality of care provided to women, and to address healthcare needs of underserved women who meet this definition. Efforts to serve three additional underserved populations defined by age, sexual orientation, and disability status are also presented.

Statistical discrimination in health care

This paper considers the role of statistical discrimination as a potential explanation for racial and ethnic disparities in health care. The underlying problem is that a physician may have a harder time understanding a symptom report from minority patients. If so, even if there are no objective differences between Whites and minorities, and even if the physician has no discriminatory motives, minority patients will benefit less from treatment, and may rationally demand less care. After comparing these and other predictions to the published literature, we conclude that statistical discrimination is a potential source of racial/ethnic disparities, and worthy of research.

Administrative data for public health surveillance and planning

Electronically available administrative data are increasingly used by public health researchers and planners. The validity of the data source has been established, and its strengths and weaknesses relative to data abstracted from medical records and obtained via survey are documented. Administrative data are available from a variety of state, federal, and private sources and can, in many cases, be combined. As a tool for planning and surveillance, administrative data show great promise: They contain consistent elements, are available in a timely manner, and provide information about large numbers of individuals. Because they are available in an electronic format, they are relatively inexpensive to obtain and use. In the United States, however, there is no administrative data set covering the entire population. Although Medicare provides health care for an estimated 96% of the elderly, age 65 years and older, there is no comparable source for those under 65.

Impact of race in lung cancer: analysis of temporal trends from a surveillance, epidemiology, and end results database

STUDY OBJECTIVES

We analyzed data from a community-based cancer database over a 26-year period in order to characterize clinicopathologic differences between black and white patients with lung cancer, and to identify relevant temporal trends in incidence and survival.

DESIGN, SETTING, AND PATIENTS

Data on demographics, stage, histology, and survival were obtained on all black and white patients with primary bronchogenic carcinoma registered in the community-based metropolitan Detroit Surveillance, Epidemiology, and End Results database from 1973 to 1998.

RESULTS

Of 48,318 eligible patients, 23% were black. Lung cancer incidence rates decreased for men of both races from 1985 to 1998, with a greater decline occurring in black men (p < 0.0001). Although incidence rates declined over time for men of both races < 50 years of age, this decrease was greater in white men, resulting in an increase in the racial differential in younger men. Temporal trends in incidence rates were similar for women of both races. The incidence of distant-stage disease was higher among blacks throughout the study period. The incidence of local-stage disease decreased for both races, though this decline was greater in blacks. A significant racial difference in 2-year and 5-year survival rates developed during the study period, due to a distinct lack of improvement in black patients. In a multivariate model, the relative risks of death for black patients, relative to white patients, were 1.24 (p < 0.0001) for local stage, 1.14 (p < 0.0001) for regional stage, and 1.03 (p = 0.045) for distant stage.

CONCLUSION

Significant racial differences exist in the incidence and survival rates for lung cancer in metropolitan Detroit. Since 1973, several disturbing trends have developed, particularly with regard to the lack of improvement in overall survival in black patients. Further study is required to determine the factors responsible for these temporal trends.

The epidemiology of lung cancer

Lung cancer continues to be the leader in cancer deaths in the United States. The incidence of lung cancer in men has slowly decreased since the late 1980s, but has just now begun to plateau in women at the end of this decade. Despite modest advances in chemotherapy for treating lung cancer, it remains a deadly disease with overall 5-yr survival rates having not increased significantly over the last 25 years, remaining at approximately 14%. Tobacco smoking causes approximately 85-90% of bronchogenic carcinoma. Environmental tobacco exposure or a second-hand smoke also may cause lung cancer in life-long non-smokers. Certain occupational agents such as arsenic, asbestos, chromium, nickel and vinyl chloride increase the relative risk for lung cancer. Smoking has an additive or multiplicative effect with some of these agents. Familial predisposition for lung cancer is an area with advancing research. Developments in molecular biology have led to growing interest in investigation of biological markers, which may increase predisposition to smoking-related carcinogenesis. Hopefully, in the future we will be able to screen for lung cancer by using specific biomarkers. Finally, dietary factors have also been proposed as potential risk modulators, with vitamins A, C and E proposed as having a protective effect. Despite the slow decline of smoking in the United States, lung cancer will likely continue its devastation for years to come.

Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: the influence of ethnicity

BACKGROUND AND PURPOSE

We sought to measure the overall rate of usage of tissue-type plasminogen activator (tPA) for ischemic stroke at academic medical centers, and to determine whether ethnicity was associated with usage.

METHODS

Between June and December 1999, 42 academic medical centers in the United States each identified 30 consecutive ischemic stroke cases. Medical records were reviewed and information on demographics, medical history, and treatment were abstracted. Rates of tPA use were compared for African Americans and whites in univariate analysis and after adjustment for age, gender, stroke severity, and type of medical insurance with multivariable logistic regression.

RESULTS

Complete information was available for 1195 ischemic stroke patients; 788 were whites and 285 were African Americans: Overall, 49 patients (4.1%) received tPA. In the subgroup of 189 patients without a documented contraindication to therapy, 39 (20.6%) received tPA. Ten (20%) of those receiving tPA had documented contraindication. African Americans were one fifth as likely to receive tPA as whites (1.1% African Americans versus 5.3%; P=0.001), and the difference persisted after adjustment (OR 0.21, 95% CI 0.06 to 0.68; P=0.01). When comparison was restricted to those without a documented contraindication to tPA, the difference remained significant (OR 0.24, 95% CI 0.06 to 0.93; P=0.04). Medical insurance type was independently associated with tPA treatment. After adjustment for ethnicity and other demographic characteristics, those with Medicaid or no insurance were one ninth as likely to receive tPA as those with private medical insurance (OR 0.11, 95% CI 0.02 to 0.17; P=0.003).

CONCLUSIONS

tPA is used infrequently for ischemic stroke at US academic medical centers, even among qualifying candidates. African Americans are significantly less likely to receive tPA for ischemic stroke. Contraindications to treatment do not appear to account for the difference.