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Immunotherapy: Tisagenlecleucel - the first approved CAR-T-cell therapy: implications for payers and policy makers. Nat Rev Clin Oncol 2017; 15:11-12. [PMID: 28975930 DOI: 10.1038/nrclinonc.2017.156] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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The automated patient discharge summary: improving communication at transfers of care after completion of radiotherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2017. [DOI: 10.1017/s1460396917000188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractAimTo develop an auto-generated patient discharge summary for all patients being treated in the Radiation Therapy Department.Materials and methodsA patient discharge summary was developed using auto-generated data for all patients being treated in the Radiation Therapy Department. This ensures information relevant to the care of the patient is communicated effectively during transitions of care following radiation treatment, and provides a record of the treatment site(s), dose delivered, start/completion dates and contact information for Radiation Oncologists. The eScribe feature in MosaiQTM is utilised to auto-generate the patient discharge summary in less than one minute, and then printed and given to patients on the last day of treatment. This was piloted with palliative radiotherapy patients (n=22), who also completed a telephone survey.ResultsResults revealed patients had passed this document onto other healthcare providers and appreciated having a record of their treatments. Feedback was obtained from radiation therapy staff and the Patient and Family Advisory Committee. Subsequently, the language of the patient discharge summary was simplified and a disclaimer was added, indicating the document is not a complete radiation therapy treatment record. This initiative was then rolled out to all radiotherapy patients.FindingsOverall, the patient discharge summary allows for a quick, automated and standardised approach for transfer of information during care transitions without significant impact to the Radiation Therapy Departmental workflow.
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Vetterlein MW, Löppenberg B, Karabon P, Dalela D, Jindal T, Sood A, Chun FKH, Trinh QD, Menon M, Abdollah F. Impact of travel distance to the treatment facility on overall mortality in US patients with prostate cancer. Cancer 2017; 123:3241-3252. [DOI: 10.1002/cncr.30744] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/09/2017] [Accepted: 03/29/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Malte W. Vetterlein
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
- Division of Urological Surgery and Center for Surgery and Public Health; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Björn Löppenberg
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
- Division of Urological Surgery and Center for Surgery and Public Health; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
- Department of Urology; Marien Hospital Herne, Ruhr-University Bochum; Herne Germany
| | - Patrick Karabon
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
- Department of Public Health Sciences; Henry Ford Health System; Detroit Michigan
| | - Deepansh Dalela
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
| | - Tarun Jindal
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
| | - Akshay Sood
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
| | - Felix K.-H. Chun
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Mani Menon
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
| | - Firas Abdollah
- Center for Outcomes Research; Analytics, and Evaluation, Vattikuti Urology Institute, Henry Ford Health System; Detroit Michigan
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The effect of socioeconomic status on gross total resection, radiation therapy and overall survival in patients with gliomas. J Neurooncol 2017; 132:447-453. [DOI: 10.1007/s11060-017-2391-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 02/23/2017] [Indexed: 01/27/2023]
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Referral Bias in Primary Total Knee Arthroplasty: Retrospective Analysis of 22,614 Surgeries in a Tertiary Referral Center. J Arthroplasty 2017; 32:390-394. [PMID: 27659395 DOI: 10.1016/j.arth.2016.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/14/2016] [Accepted: 08/08/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients who travel a significant distance to obtain surgical treatment typically experience better outcomes. This is called the referral bias and can limit the generalizability of studies performed at large tertiary care centers. We explored the influence of referral bias by comparing the clinical characteristics and outcomes of total knee arthroplasty (TKA) at a large tertiary care hospital in the United States. METHODS The study cohort included 22,614 primary TKA procedures performed between 1985 and 2010. Patients were stratified into 5 groups using home address zip codes and according to travel distance from the hospital. Clinical characteristics and the risk of TKA complications and surgical outcomes (instability, surgical-site infections, and thrombovascular complications within the first year, reoperations, revisions, and mortality) were compared across the 5 groups. RESULTS Compared with local patients, patients who traveled from other parts of the United States were significantly younger (mean age 67.8 vs 68.5 years; P < .05), were more likely to be male (47% vs 38%, P < .001), had lower body mass index (mean 30.4 vs 31.8 kg/m2; P < .001), were more likely to have inflammatory arthritis or neoplasms as surgical indications (P < .05), and were more likely to have a history of prior surgeries on the same knee (20% vs 14%; P < .001). Referral patients also had significantly higher American Society of Anesthesiologists scores and longer operative times (mean 173 vs 156 minutes P < .001). Despite these differences, the risk of instability, surgical-site infections, thrombovascular complications, reoperations, and revision surgeries were similar across the 5 groups. CONCLUSION Although referral patients differ from local patients, the groups seem to experience largely similar complication and revision rates after TKA.
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Kelly C, Hulme C, Farragher T, Clarke G. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open 2016; 6:e013059. [PMID: 27884848 PMCID: PMC5178808 DOI: 10.1136/bmjopen-2016-013059] [Citation(s) in RCA: 279] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this. DESIGN Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south. SETTINGS A wide range of settings within primary and secondary care (these were not restricted in the search). RESULTS 108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies. CONCLUSIONS The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.
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Affiliation(s)
- Charlotte Kelly
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Institute for Transport Studies, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Tracey Farragher
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Katsanos KH, Koutroumpakis E, Giagkou E, Malakos Z, Almpani E, Skamnelos A, Christodoulou DK. Fast-track drug approval in inflammatory bowel diseases. Ann Gastroenterol 2016; 29:439-444. [PMID: 27708508 PMCID: PMC5049549 DOI: 10.20524/aog.2016.0051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/26/2016] [Indexed: 12/22/2022] Open
Abstract
Fast-track drug designation of safe regimens represents an emerging method of development and approval of new medications targeting debilitating diseases including inflammatory bowel diseases (IBD). The goal of accelerated drug approval pathways is to shorten the time between application and approval of therapies that treat diseases with significant morbidity and mortality. Recently, fast-track drug approval approaches were supported by data deriving from central reading of images, a method of clinical data interpretation that has significantly benefited patients with gastrointestinal disorders. Biological agents and other emerging therapies in IBD represent "game-changing" or "treat-to-target" drugs and have satisfied quite successfully some of the patients' unmet needs. The development of biosimilars is an area where the Federal Drug Administration and the European Agency for Evaluation of Medicinal Products seem to have different approval processes. Biosimilars, including those for IBD, promise cost reductions and wide access to biologic therapies by patients, advantages similar to those already offered by generic drugs. Given the rapid development of IBD drugs and patients' needs, a consensus among the academic community, clinicians, researchers, sponsors, patients and regulatory authorities is required to standardize better the IBD trials and create a productive environment for fast-track approval of any "changing-game" IBD drug.
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Affiliation(s)
- Konstantinos H. Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University of Ioannina School of Medical Sciences, Ioannina, Greece (Konstantinos H. Katsanos, Eftychia Giagkou, Zikos Malakos, Eleni Almpani, Alexandros Skamnelos, Dimitrios K. Christodoulou)
| | - Efstratios Koutroumpakis
- Department of Internal Medicine, Albany Medical College, Albany, New York, USA (Efstratios Koutroumpakis)
| | - Eftychia Giagkou
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University of Ioannina School of Medical Sciences, Ioannina, Greece (Konstantinos H. Katsanos, Eftychia Giagkou, Zikos Malakos, Eleni Almpani, Alexandros Skamnelos, Dimitrios K. Christodoulou)
| | - Zikos Malakos
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University of Ioannina School of Medical Sciences, Ioannina, Greece (Konstantinos H. Katsanos, Eftychia Giagkou, Zikos Malakos, Eleni Almpani, Alexandros Skamnelos, Dimitrios K. Christodoulou)
| | - Eleni Almpani
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University of Ioannina School of Medical Sciences, Ioannina, Greece (Konstantinos H. Katsanos, Eftychia Giagkou, Zikos Malakos, Eleni Almpani, Alexandros Skamnelos, Dimitrios K. Christodoulou)
| | - Alexandros Skamnelos
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University of Ioannina School of Medical Sciences, Ioannina, Greece (Konstantinos H. Katsanos, Eftychia Giagkou, Zikos Malakos, Eleni Almpani, Alexandros Skamnelos, Dimitrios K. Christodoulou)
| | - Dimitrios K. Christodoulou
- Division of Gastroenterology, Department of Internal Medicine, Medical School, University of Ioannina School of Medical Sciences, Ioannina, Greece (Konstantinos H. Katsanos, Eftychia Giagkou, Zikos Malakos, Eleni Almpani, Alexandros Skamnelos, Dimitrios K. Christodoulou)
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Nicklett EJ, Omidpanah A, Whitener R, Howard BV, Manson SM. Access to Care and Diabetes Management Among Older American Indians With Type 2 Diabetes. J Aging Health 2016; 29:206-221. [PMID: 26944805 DOI: 10.1177/0898264316635562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine the relationship between health care access and diabetes management among a geographically diverse sample of American Indians (AIs) aged 50 and older with type 2 diabetes. METHOD We examined the relationship between access to care and diabetes management, as measured by HbA1c, using 1998-1999 data from the Strong Heart Family Study. A series of bivariate and multivariate linear models examined the relationships between nine access-related variables and HbA1c levels. RESULTS In bivariate analyses, out-of-pocket costs were associated with higher HbA1c levels. No other access-related characteristics were significantly associated with diabetes management in bivariate or in multivariate models. DISCUSSION Access-related barriers were not associated with worse diabetes management in multivariate analyses. The study concludes with implications for clinicians working with AI populations to enhance opportunities for diabetes management.
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Affiliation(s)
- Emily J Nicklett
- 1 University of Michigan School of Social Work, Ann Arbor, MI, USA
| | - Adam Omidpanah
- 2 Washington State University College of Nursing, Spokane, WA, USA
| | - Ron Whitener
- 3 University of Washington School of Law, Seattle, WA, USA
| | - Barbara V Howard
- 4 MedStar Health Research Institute; Hyattsville, MD, USA; Georgetown University School of Medicine, Washington, D.C., USA
| | - Spero M Manson
- 5 University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Khera N, Gooley T, Flowers MED, Sandmaier BM, Loberiza F, Lee SJ, Appelbaum F. Association of Distance from Transplantation Center and Place of Residence on Outcomes after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1319-1323. [PMID: 27013013 PMCID: PMC4905774 DOI: 10.1016/j.bbmt.2016.03.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/11/2016] [Indexed: 12/20/2022]
Abstract
Regionalization of specialized health services can deliver high-quality care but may have an adverse impact on access and outcomes because of distance from the regional centers. In the case of hematopoietic cell transplantation (HCT), the effect of increased distance between the transplantation center and the rural/urban residence is unclear because of conflicting results from the existing studies. We examined the association between distance from primary residence to the transplantation center and rural versus urban residence with clinical outcomes after allogeneic HCT in a large cohort of patients. Overall mortality (OM), nonrelapse mortality (NRM), and relapse in all patients and those who survived for 200 days after HCT were assessed in 2849 patients who received their first allogeneic HCT between 2000 and 2010 at Fred Hutchinson Cancer Research Center (FHCRC)/Seattle Cancer Care Alliance. Median distance from FHCRC was 263 miles (range, 0 to 2740 miles) and 83% of patients were urban residents. The association between distance and the hazard of OM varied according to conditioning intensity: myeloablative (MA) versus nonmyeloablative (NMA). Among MA patients, there was no evidence of an increased risk of mortality with increased distance, but for NMA patients, the results did show a suggestion of increased risk of mortality for some distances, although globally the difference was not statistically significant. In the subgroup of patients who survived 200 days, there was no evidence that the risks of OM, relapse, or NRM were increased with increasing distance. We did not find any association between longer distance from transplantation center and urban/rural residence and outcomes after MA HCT. In patients undergoing NMA transplantations, this relationship and how it is influenced by factors such as age, payers, and comorbidities needs to be further investigated.
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Affiliation(s)
- Nandita Khera
- Hematology/Oncology Division, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Ted Gooley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Fausto Loberiza
- Hematology/Oncology Division, University of Nebraska Medical Center, Omaha, Nebraska
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Frederick Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Oxnard GR, Wilcox KH, Gonen M, Polotsky M, Hirsch BR, Schwartz LH. Response Rate as a Regulatory End Point in Single-Arm Studies of Advanced Solid Tumors. JAMA Oncol 2016; 2:772-9. [PMID: 26914340 PMCID: PMC5574183 DOI: 10.1001/jamaoncol.2015.6315] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Objective response rate (ORR) is an increasingly important end point for accelerated development of highly active anticancer therapies, yet its relationship to regulatory approval is not well characterized. OBJECTIVE To identify circumstances in which a high ORR is associated with regulatory approval, and therefore might be an appropriate end point for definitive single-arm studies of anticancer therapies. DATA SOURCE A database of all oncology clinical trials registered at clinicaltrials.gov between October 1, 2007, and September 30, 2010. STUDY SELECTION Trials of palliative systemic therapies for 4 measurable solid tumor types, limited to those with trial arms of at least 20 patients reporting ORR per Response Evaluation Criteria in Solid Tumors (RECIST). DATA EXTRACTION AND SYNTHESIS A systematic search was used to identify the reported ORR for each eligible treatment arm that had been presented publicly. MAIN OUTCOMES AND MEASURES For each treatment regimen, defined as a single-agent or unique combination of agents for 1 cancer type, the mean ORR and the maximum ORR statistically exceeded were calculated, and their association with regulatory approval was studied. A regimen was considered approved for a specific cancer type if it had received regulatory approval in any country for treatment of advanced cancer of that type. RESULTS From 1800 trials, 874 eligible trial arms in 578 eligible trials were identified; 542 arms had ORR data available for 294 regimens. Maximum ORR and mean ORR were significantly associated with regulatory approval (τ = 0.27, P < .001; τ = 0.12, P = .01); this relationship was stronger for single-agent therapies (τ = 0.49; τ = 0.41) than for combination regimens (τ = 0.28; τ = 0.17). Evaluation of ORR thresholds between 20% and 60% as potential trial end points demonstrated that ORR statistically exceeding 30% with a single agent had 98% specificity and 89% positive predictive value for identifying regimens achieving regulatory approval. CONCLUSIONS AND RELEVANCE For single-agent regimens, high ORR was associated with regulatory approval; this relationship was less strong for combination regimens. Our data suggest that high ORR (eg, statistically exceeding an ORR of 30%) is an appropriate end point for single-arm trials aiming to demonstrate breakthrough activity of a single-agent anticancer therapy.
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Affiliation(s)
- Geoffrey R Oxnard
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katharine H Wilcox
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mithat Gonen
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York
| | - Mikhael Polotsky
- Department of Radiology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York
| | - Bradford R Hirsch
- Duke Cancer Care Research Program, Duke Cancer Institute, Dallas, Texas
| | - Lawrence H Schwartz
- Department of Radiology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York
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Wasif N, Chang YH, Pockaj BA, Gray RJ, Mathur A, Etzioni D. Association of Distance Traveled for Surgery with Short- and Long-Term Cancer Outcomes. Ann Surg Oncol 2016; 23:3444-3452. [PMID: 27126630 DOI: 10.1245/s10434-016-5242-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The influence of distance traveled for treatment on short- and long-term cancer outcomes is unclear. METHODS Patients with colon, esophageal, liver, and pancreas cancer from 2003 to 2006 were identified from the National Cancer Data Base (NCDB). Distance traveled for surgical treatment was estimated using zip code centroids. Propensity scores were generated for probability of traveling farther for treatment. Mixed effects logistic regression for 90-day mortality and Cox regression for 5-year mortality were compared between patients treated regionally and those traveling from farther away. RESULTS The mean distance traveled for all patients for surgical resection was 30.0 ± 227 miles, with a median distance of 7.5 (interquartile range 14.4) miles. Patients who were aged ≥80 years, on Medicaid, or African American were less likely to be in the fourth quartile of distance (Q4) traveled for surgery. Patients who were in Q4 had a lower risk-adjusted 90-day mortality compared to Q1 for colon [odds ratio (OR) 0.89, 95 % confidence interval (CI) 0.82-0.96], liver (OR 0.49, 95 % CI 0.3-0.78), and pancreatic (OR 0.74, 95 % CI 0.56-0.98) cancer. Similarly, patients in Q4 for all tumor types had a lower risk-adjusted 5-year mortality compared to patients in Q1; colon (hazard ratio (HR) 0.96, 95 % CI 0.93-0.99), esophagus (HR 0.84, 95 % CI 0.75-0.94), liver (HR 0.75, 95 % CI 0.62-0.89), and pancreas (HR 0.87, 95 % CI 0.80-0.95). CONCLUSIONS Greater travel distance for surgical resection of gastrointestinal cancers is associated with lower 90-day and 5-year mortality outcomes. This distance bias has implications for regionalization and reporting of cancer outcomes.
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Affiliation(s)
- Nabil Wasif
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA. .,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA.
| | - Yu-Hui Chang
- Department of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA.,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA
| | - Barbara A Pockaj
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA
| | - Richard J Gray
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA
| | - Amit Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA.,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA
| | - David Etzioni
- Division of Colorectal Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA.,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA
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Barker FG. Editorial: Randomized clinical trials and neurosurgery. J Neurosurg 2016; 124:552-6; discussion 556-7. [DOI: 10.3171/2015.2.jns142960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lorch JH, Hanna GJ, Posner MR, O'Neill A, Thotakura VL, Limaye SA, Rabinowits G, Sher DJ, Tishler RB, Haddad RI. Human papillomavirus and induction chemotherapy versus concurrent chemoradiotherapy in locally advanced oropharyngeal cancer: The Dana Farber Experience. Head Neck 2015; 38 Suppl 1:E1618-24. [DOI: 10.1002/hed.24289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jochen H. Lorch
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | - Glenn J. Hanna
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | - Marshall R. Posner
- Department of Medical Oncology; Mount Sinai School of Medicine; New York New York
| | - Anne O'Neill
- Department of Biostatistics and Computational Biology; Dana Farber Cancer Institute; Boston Massachusetts
| | - Vijaya L. Thotakura
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | - Sewanti A. Limaye
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | - Guilherme Rabinowits
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | - David J. Sher
- Department of Radiation Oncology; Rush Medical Center; Chicago Illinois
| | - Roy B. Tishler
- Department of Radiation Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | - Robert I. Haddad
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
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Zaidi RH, Casanova NF, Haydar B, Voepel-Lewis T, Wan JH. Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors. Paediatr Anaesth 2015. [PMID: 26201497 DOI: 10.1111/pan.12719] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Urethrocutaneous fistula is a well-known complication of hypospadias surgery. A recent prospective study by Kundra et al. (Pediatr Anesth 2012) has suggested that caudal anesthesia may increase the risk of fistula formation. We sought to evaluate this possible association and determine if any other novel factors may be associated with fistula formation. METHODS Children who underwent primary hypospadias repair between January 1, 1994 and March 31, 2013 at our tertiary care center were included in this study. Reviewed surgical data included repair type, duration of procedure, use of local anesthetic infiltration, and subcutaneous epinephrine. Analgesic factors included use of caudal and/or penile block, opioid usage, postoperative pain scores, and nausea/vomiting. Postoperative surgical complications and estimates of family household median income by zip code were also reviewed. RESULTS Fistula occurrence was not associated with caudal or penile block, severity of postoperative pain, or surgeon experience. A more proximal location of the urethral meatus, longer operating time, and use of subcutaneous epinephrine were significantly more common in patients who developed fistula. As assessed by home address zip code, distance of more than 100 miles and median household income in the bottom 25th percentile of our study population were not associated with fistula, as compared to closer distance or higher income. CONCLUSION In this series, we found no association between the use of caudal regional anesthesia and fistula formation. Location of the starting urethral meatus, prolonged surgical duration, and subcutaneous epinephrine use were associated with fistula formation. Our findings call into question the routine use of epinephrine in hypospadias repair.
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Affiliation(s)
- Raza H Zaidi
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Nina F Casanova
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Bishr Haydar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Julian H Wan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Patterns and Outcomes Associated with Patient Migration for Liver Transplantation in the United States. PLoS One 2015; 10:e0140295. [PMID: 26469071 PMCID: PMC4607372 DOI: 10.1371/journal.pone.0140295] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 09/23/2015] [Indexed: 11/19/2022] Open
Abstract
Background Traveling to seek specialized care such as liver transplantation (LT) is a reality in the United States. Patient migration has been attributed to organ availability. The aims of this study were to delineate patterns of patient migration and outcomes after LT. Study Design All deceased donor LT between 2008–2013 were extracted from UNOS data. Migrated patients were defined as those patients who underwent LT at a center in a different UNOS region from the region in which they resided and traveled a distance > 100 miles. Results Migrated patients comprised 8.2% of 28,700 LT performed. Efflux and influx of patients were observed in all 11 UNOS regions. Regions 1, 5, 6, and 9 had a net efflux, while regions 2, 3, 4, 7, 10, and 11 had a net influx of patients. After multivariate adjustment for donor and recipient factors, graft (p = 0.68) and patient survival (p = 0.52) were similar between migrated and non-migrated patients. Conclusion A significant number of patients migrated in patterns that could not be explained alone by regional variations in MELD score and wait time. Migration may be a complex interplay of factors including referral patterns, specialized services at centers of excellence and patient preference.
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Bhatt VR, Dhakal P, Dahal S, Giri S, Pathak R, Bociek RG, Silberstein PT, Armitage JO. Demographic and other characteristics of nodal non-Hodgkin's lymphoma managed in academic versus non-academic centers. Ther Adv Hematol 2015; 6:223-7. [PMID: 26425335 DOI: 10.1177/2040620715592568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cancer therapy and outcomes are known to be affected by various demographic features and hospital types. We aimed to identify the characteristics of non-Hodgkin's lymphoma (NHL) patients associated with receipt of care at academic centers. METHOD This is a retrospective study of all patients diagnosed with nodal NHL between 2000 and 2011 in the National Cancer Database (NCDB), who received the diagnosis, and all or part of their initial therapy in the reporting hospital (n = 243,436). Characteristics of patients receiving care in academic versus nonacademic centers were compared using the Chi-square test. RESULTS Approximately 27% received care in academic centers. Patients receiving care in nonacademic centers, compared with academic centers, were more likely to be ⩾60 years (69% versus 58%, p < .0001), White (89% versus 80%, p < .0001) and have lower educational attainment (>12% without high school diploma: 72% versus 69%, p < .0001) and economic status (household income <$49,000: 66% versus 61%, p < 0.0001). Patients receiving care in nonacademic centers were less likely to travel ⩾25 miles (21% versus 26%, p < 0.0001). White patients, compared with non-Whites, were more likely to be ⩾60 years (70% versus <50%, p < 0.0001), which probably explains less care in academic centers. CONCLUSIONS Patients ⩾60 years and those with poorer educational attainment and economic status were less likely to receive care in academic centers. Care in academic centers required a longer commute. Elderly patients frequently have inferior outcomes and may benefit from clinical trials with novel agents and expertise at academic centers.
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Affiliation(s)
- Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE 68198-7680, USA
| | - Prajwal Dhakal
- Department of Medicine, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal
| | - Sumit Dahal
- Department of Internal Medicine, Interfaith Medical Center, NY, USA
| | - Smith Giri
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ranjan Pathak
- Department of Medicine, Reading Health System, Reading, PA, USA
| | - R Gregory Bociek
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Peter T Silberstein
- Department of Internal Medicine, Division of Hematology-Oncology, Creighton University Medical Center, Omaha, NE, USA
| | - James O Armitage
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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Bruner DW, Pugh SL, Yeager KA, Bruner J, Curran W. Cartographic Mapping and Travel Burden to Assess and Develop Strategies to Improve Minority Access to National Cancer Clinical Trials. Int J Radiat Oncol Biol Phys 2015; 93:702-9. [PMID: 26281827 DOI: 10.1016/j.ijrobp.2015.06.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/22/2015] [Accepted: 06/28/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess how accrual to clinical trials is related to US minority population density relative to clinical trial site location and distance traveled to Radiation Therapy Oncology Group (RTOG) clinical trial sites. METHODS AND MATERIALS Data included member site address and ZIP codes, patient accrual, and patient race or ethnicity and ZIP code. Geographic Information System maps were developed for overall, Latino, and African American accrual to trials by population density. The Kruskal-Wallis test was used to assess differences in distance traveled by site, type of trial, and race or ethnicity. RESULTS From 2006 to 2009, 6168 patients enrolled on RTOG trials. The RTOG US site distribution is generally concordant with overall population density. Sites with highest accrual are located throughout the United States and parts of Canada and do not cluster, nor does highest minority accrual cluster in areas of highest US minority population density. Of the 4913 US patients with complete data, patients traveled a median of 11.6 miles to participate in clinical trials. Whites traveled statistically longer distances (12.9 miles; P<.0001) to participate, followed by Latinos (8.22 miles) and African Americans (5.85 miles). Patients were willing to drive longer distances to academic sites than community sites, and there was a trend toward significantly longer median travel for therapeutic versus cancer control or metastatic trials. CONCLUSIONS Location matters, but only to a degree, for minority compared with nonminority participation in clinical trials. Geographic Information System tools help identify gaps in geographic access and travel burden for clinical trials participation. Strategies that emerged using these tools are discussed.
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Affiliation(s)
| | - Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
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Tao L, Gomez SL, Keegan THM, Kurian AW, Clarke CA. Breast Cancer Mortality in African-American and Non-Hispanic White Women by Molecular Subtype and Stage at Diagnosis: A Population-Based Study. Cancer Epidemiol Biomarkers Prev 2015; 24:1039-45. [PMID: 25969506 PMCID: PMC4490947 DOI: 10.1158/1055-9965.epi-15-0243] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/05/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Higher breast cancer mortality rates for African-American than non-Hispanic White women are well documented; however, it remains uncertain if this disparity occurs in disease subgroups defined by tumor molecular markers and stage at diagnosis. We examined racial differences in outcome according to subtype and stage in a diverse, population-based series of 103,498 patients. METHODS We obtained data for all invasive breast cancers diagnosed between January 1, 2005, and December 31, 2012, and followed through December 31, 2012, among 93,760 non-Hispanic White and 9,738 African-American women in California. Molecular subtypes were categorized according to tumor expression of hormone receptor (HR, based on estrogen and progesterone receptors) and human epidermal growth factor receptor 2 (HER2). Cox proportional hazards models were used to calculate relative hazard (RH) and 95% confidence intervals (CI) for breast cancer-specific mortality. RESULTS After adjustment for patient, tumor, and treatment characteristics, outcomes were comparable by race for stage I or IV cancer regardless of subtype, and HR(+)/HER2(+) or HR(-)/HER2(+) cancer regardless of stage. We found substantially higher hazards of breast cancer death among African-American women with stage II/III HR(+)/HER2(-) (RH, 1.31; 95% CI, 1.03-1.65; and RH, 1.39; 95% CI, 1.10-1.75, respectively) and stage III triple-negative cancers relative to Whites. CONCLUSIONS There are substantial racial/ethnic disparities among patients with stages II/III HR(+)/HER2(-) and stage III triple-negative breast cancers but not for other subtype and stage. IMPACT These data provide insights to assess barriers to targeted treatment (e.g., trastuzumab or endocrine therapy) of particular subtypes of breast cancer among African-American patients.
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Affiliation(s)
- Li Tao
- Cancer Prevention Institute of California, Fremont, California
| | - Scarlett Lin Gomez
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Theresa H M Keegan
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Allison W Kurian
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California. Medicine, Stanford University School of Medicine, Stanford, California
| | - Christina A Clarke
- Cancer Prevention Institute of California, Fremont, California. Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.
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Nwachukwu BU, Dy CJ, Burket JC, Padgett DE, Lyman S. Risk for Complication after Total Joint Arthroplasty at a Center of Excellence: The Impact of Patient Travel Distance. J Arthroplasty 2015; 30:1058-61. [PMID: 25639857 DOI: 10.1016/j.arth.2015.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/02/2015] [Accepted: 01/11/2015] [Indexed: 02/01/2023] Open
Abstract
Healthcare reorganization and bundled payment schemes have resulted in increased patient travel distances in orthopedics. Travel distance has been previously associated with increased complication risk but has yet to be studied in orthopedics. We analyzed the impact of patient travel distance on short-term complications. We reviewed 38,887 TJAs performed between 2008 and 2011 and identified 1606 complications in 1110 procedures. There was no significant association between complication risk and patient travel distance. Complication risk was associated with age, ASA class, Medicare and Medicaid status (P<0.0001 for all). Regional centers of excellence appear to be a viable model in healthcare reorganization however continued attention should be paid to attenuating the individual patient factors associated with complication at these institutions.
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Wallis CJD, Herschorn S, Saskin R, Su J, Klotz LH, Chang M, Kulkarni GS, Lee Y, Kodama RT, Narod SA, Nam RK. Complications after radical prostatectomy or radiotherapy for prostate cancer: results of a population-based, propensity score-matched analysis. Urology 2015; 85:621-7. [PMID: 25733275 DOI: 10.1016/j.urology.2014.11.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 10/17/2014] [Accepted: 11/15/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess rates of treatment-related complications after radical prostatectomy or radiotherapy monotherapy, using propensity score matching to account for baseline differences between these patient populations. METHODS On the basis of a population-based study of men undergoing surgery or radiotherapy for prostate cancer in Ontario between 2002 and 2009, we undertook a propensity score-matched analysis including age, comorbidity, and year of treatment to assess treatment-related complication end points. These included hospital admission; urologic, rectal, or anal procedures; open surgeries; and secondary malignancies. RESULTS From the original cohort of 32,465 patients, 15,870 (48.9%) had surgery and 16,595 (51.1%) had radiation. Propensity score matching produced 8797 pairs (17,594 patients). Among these, when compared with patients treated with surgery, those treated with radiation experienced fewer admissions to hospital (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.78-0.92) and urologic procedures (HR, 0.50; 95% CI, 0.46-0.53) at year 1 but higher rates at year 3 (HR, 5.65; 95% CI, 4.61-6.91 and HR, 1.86; 95% CI, 1.62-2.13, respectively) and year 5. Although there was no significant difference in open surgeries at year 1, patients undergoing radiotherapy were at higher risk by year 3 (HR, 2.06; 95% CI, 1.23-3.47) and this rose by year 5. Over the study period, patients undergoing radiotherapy experienced more rectal-anal procedures (HR, 2.64; 95% CI, 2.37-2.95) and were diagnosed with more secondary malignancies (HR, 2.44; 95% CI, 1.16-5.14). Direct matching produced similar results. CONCLUSION From a propensity score-matched analysis, we found that patients undergoing radiation therapy for prostate cancer had higher rates of long-term complications in all 5 categories studied than patients undergoing surgery.
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Affiliation(s)
- Christopher J D Wallis
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Refik Saskin
- Institute of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Jiandong Su
- Institute of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Laurence H Klotz
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Chang
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Division of Urology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yuna Lee
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Narod
- Department of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.
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Smith AK, Shara NM, Zeymo A, Harris K, Estes R, Johnson LB, Al-Refaie WB. Travel patterns of cancer surgery patients in a regionalized system. J Surg Res 2015; 199:97-105. [PMID: 26076685 DOI: 10.1016/j.jss.2015.04.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/19/2015] [Accepted: 04/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Regionalization of complex surgeries has increased patient travel distances possibly leaving a substantial burden on those at risk for poorer surgical outcomes. To date, little is known about travel patterns of cancer surgery patients in regionalized settings. To inform this issue, we sought to assess travel patterns of those undergoing a major cancer surgery within a regionalized system. MATERIALS AND METHODS We identified 4733 patients who underwent lung, esophageal, gastric, liver, pancreatic, and colorectal resections from 2002-2014 within a multihospital system in the Mid-Atlantic region of the United States. Patient age, race and/or ethnicity, and insurance status were extracted from electronic health records. We used Geographical Information System capabilities in R software to estimate travel distance and map patient addresses based on cancer surgery type and these characteristics. We used visual inspection, analysis of variance, and interaction analyses to assess the distribution of travel distances between patient populations. RESULTS A total of 48.2% of patients were non-white, 49.9% were aged >65 y, and 54.9% had private insurance. Increased travel distance was associated with decreasing age and those undergoing pancreatic and esophageal resections. Also, black patients tend to travel shorter distances than other racial and/or ethnic groups. CONCLUSIONS These maps offer a preliminary understanding into variations of geospatial travel patterns among patients receiving major cancer surgery in a Mid-Atlantic regionalized setting. Future research should focus on the impact of regionalization on timely delivery of surgical care and other quality metrics.
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Affiliation(s)
- Andrew K Smith
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Nawar M Shara
- MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD; The Georgetown-Howard University Center for Clinical and Translational Science, Washington, DC
| | - Alexander Zeymo
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Katherine Harris
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Randy Estes
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Lynt B Johnson
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD; Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC
| | - Waddah B Al-Refaie
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD; Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC.
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Goldstein JA, Prasad V. Disease specific productivity of american cancer hospitals. PLoS One 2015; 10:e0121233. [PMID: 25781329 PMCID: PMC4364111 DOI: 10.1371/journal.pone.0121233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/28/2015] [Indexed: 11/18/2022] Open
Abstract
CONTEXT Research-oriented cancer hospitals in the United States treat and study patients with a range of diseases. Measures of disease specific research productivity, and comparison to overall productivity, are currently lacking. HYPOTHESIS Different institutions are specialized in research of particular diseases. OBJECTIVE To report disease specific productivity of American cancer hospitals, and propose a summary measure. METHOD We conducted a retrospective observational survey of the 50 highest ranked cancer hospitals in the 2013 US News and World Report rankings. We performed an automated search of PubMed and Clinicaltrials.gov for published reports and registrations of clinical trials (respectively) addressing specific cancers between 2008 and 2013. We calculated the summed impact factor for the publications. We generated a summary measure of productivity based on the number of Phase II clinical trials registered and the impact factor of Phase II clinical trials published for each institution and disease pair. We generated rankings based on this summary measure. RESULTS We identified 6076 registered trials and 6516 published trials with a combined impact factor of 44280.4, involving 32 different diseases over the 50 institutions. Using a summary measure based on registered and published clinical trails, we ranked institutions in specific diseases. As expected, different institutions were highly ranked in disease-specific productivity for different diseases. 43 institutions appeared in the top 10 ranks for at least 1 disease (vs 10 in the overall list), while 6 different institutions were ranked number 1 in at least 1 disease (vs 1 in the overall list). CONCLUSION Research productivity varies considerably among the sample. Overall cancer productivity conceals great variation between diseases. Disease specific rankings identify sites of high academic productivity, which may be of interest to physicians, patients and researchers.
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Affiliation(s)
- Jeffery A. Goldstein
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Vinay Prasad
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Austin MT, Nguyen H, Eberth JM, Chang Y, Heczey A, Hughes DP, Lally KP, Elting LS. Health disparities are important determinants of outcome for children with solid tumor malignancies. J Pediatr Surg 2015; 50:161-6. [PMID: 25598116 PMCID: PMC4408987 DOI: 10.1016/j.jpedsurg.2014.10.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to identify health disparities in children with non-CNS solid tumor malignancies and examine their impact on disease presentation and outcome. METHODS We examined the records of all children (age≤18years) diagnosed with a non-CNS solid tumor malignancy and enrolled in the Texas Cancer Registry between 1995 and 2009 (n=4603). The primary outcome measures were disease stage and overall survival (OS). Covariates included gender, age, race/ethnicity, year of diagnosis, socioeconomic status (SES), and driving distance to the nearest pediatric cancer treatment facility. Statistical analyses included life table methods, logistic, and Cox regression. Statistical significance was defined as p<0.05. RESULTS Children with advanced-stage disease were more likely to be male, <10years old, and Hispanic or non-Hispanic Blacks (all p<0.05). Distance to treatment and SES did not impact stage of disease at presentation. However, Hispanic and non-Hispanic Blacks and patients in the lowest SES quartile had the worst 1- and 5-year survival (all p<0.05). The adjusted OS differed by age, race, and stage, but not SES or distance to the nearest treatment facility. CONCLUSIONS Race/ethnicity plays an important role in survival for children with non-CNS solid tumor malignancies. Future work should better define these differences to establish mechanisms to decrease their impact.
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Affiliation(s)
- Mary T. Austin
- Department of Pediatrics, Children’s Cancer Hospital at the University of Texas M.D. Anderson Cancer Center, Houston, Texas
,Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
,Department of Pediatric Surgery, The University of Texas Medical School at Houston, Houston, Texas
,Corresponding author at: The University of Texas M. D. Anderson Cancer Center, 1400 Pressler, Unit 1406, Houston, TX 77030–1439. Tel.: +1 713 794 4408; fax: +1 713 794 5720. .
| | - Hoang Nguyen
- Department of Health Services Research, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jan M. Eberth
- Department of Epidemiology and Biostatistics, The University of South Carolina, Columbia, South Carolina
| | - Yuchia Chang
- Department of Health Services Research, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Andras Heczey
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Dennis P. Hughes
- Department of Pediatrics, Children’s Cancer Hospital at the University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Kevin P. Lally
- Department of Pediatric Surgery, The University of Texas Medical School at Houston, Houston, Texas
| | - Linda S. Elting
- Department of Health Services Research, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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Polinski JM, Brookhart MA, Ayanian JZ, Katz JN, Kim SC, Lii J, Tonner C, Yelin E, Solomon DH. Relationships between driving distance, rheumatoid arthritis diagnosis, and disease-modifying antirheumatic drug receipt. Arthritis Care Res (Hoboken) 2014; 66:1634-43. [PMID: 24664991 DOI: 10.1002/acr.22333] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 03/18/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Disease-modifying antirheumatic drugs (DMARDs) are recommended for all patients with rheumatoid arthritis (RA). Some estimate that approximately one-half of patients with RA do not receive DMARDs. We hypothesized that patients with RA living farther from rheumatologists would be less likely to receive RA diagnoses and to receive DMARDs. METHODS US-based Medicare patients ages >65 years were study eligible. We calculated driving distance from patients' homes to the nearest rheumatologist. Using multivariable logistic regression, we assessed relationships between driving distance and RA diagnosis and between driving distance and DMARD receipt. In one set of analyses, distance was divided into quartiles: 0-2, 2.1-5, 5.1-15.9, and ≥16 miles. In a second set of analyses, we used predefined categories: 0-15, 15.1-30, 30.1-60, and >60 miles. RESULTS Among 59,426 Medicare beneficiaries, 918 had diagnosed RA. Compared to the first quartile, increased distance was associated with decreased odds of RA diagnosis (odds ratio [OR] 0.96 [95% confidence interval (95% CI) 0.80-1.16] in second quartile, OR 0.88 [95% CI 0.72-1.07] in third quartile, and OR 0.72 [95% CI 0.56-0.93] in fourth quartile; P < 0.01 for trend). Similar results were observed using predefined categories. Among those with RA, increased distance was associated with increased odds of DMARD receipt across quartiles (OR 1.15 [95% CI 1.06-1.25] in second quartile, OR 1.41 [95% CI 1.29-1.54] in third quartile, and OR 1.32 [95% CI 1.18-1.46] in fourth quartile; P = 0.001 for trend). There was no relationship between predefined categories and DMARD receipt (P = 0.45 for trend). CONCLUSION Increased driving distance to rheumatologists was associated with decreased odds of RA diagnosis. Among those with diagnosed RA, the odds of DMARD receipt rose as distance increased from <2 to 16 miles, but not beyond. Urban residents living closer to rheumatologists may have barriers to DMARD use besides geographic access.
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Affiliation(s)
- Jennifer M Polinski
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Tomaszewski JJ, Smaldone MC, Uzzo RG, Kutikov A. Is radical nephrectomy a legitimate therapeutic option in patients with renal masses amenable to nephron-sparing surgery? BJU Int 2014; 115:357-63. [PMID: 25195528 DOI: 10.1111/bju.12696] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The decision to perform a radical nephrectomy (RN) or a partial nephrectomy (PN), not unlike most decisions in clinical practice, ultimately hinges on the balance of risk. Do the higher risks of a more complex surgery (PN) justify the theoretical benefits of kidney tissue preservation? Data suggest that for patients with an anatomically complex renal mass and a normal contralateral kidney, for whom additional surgical intensity may be risky, such as the elderly and comorbid, RN presents a robust treatment option. Nevertheless, PN, especially for small and anatomically simple renal masses in young patients without comorbidities should remain the surgical reference standard, as preservation of renal tissue can serve as an 'insurance policy' not only against future renal functional decline, but also against the possibility of tumour development in the contralateral kidney. In the present review, we outline the ongoing debate between the role of RN and PN in treatment of the enhancing renal mass.
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Affiliation(s)
- Jeffrey J Tomaszewski
- Division of Urologic Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA, USA
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Abstract
Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.
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Patterns of chemotherapy, toxicity, and short-term outcomes for older women receiving adjuvant trastuzumab-based therapy. Breast Cancer Res Treat 2014; 145:491-501. [PMID: 24756187 DOI: 10.1007/s10549-014-2968-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 04/12/2014] [Indexed: 10/25/2022]
Abstract
Limited data are available regarding patterns of chemotherapy receipt and treatment-related toxicities for older women receiving adjuvant trastuzumab-based therapy. We used surveillance, epidemiology and end results (SEER)-Medicare data to identify patients ≥66 years with stage I-III breast cancer treated during 2005-2009, who received trastuzumab-based therapy. We examined patterns of chemotherapy receipt, and using multivariable logistic regression, we examined associations of age and comorbidity with non-standard chemotherapy. In propensity-weighted cohorts of women receiving standard and non-standard trastuzumab-based therapy, we also examined rates of (1) hospital events during the first 6 months of chemotherapy and (2) short-term survival. Among 2,106 women, 29.7 % were aged ≥76 and 66 % had a comorbidity score = 0. Overall, 31.3 % of women received non-standard chemotherapy. Compared to patients aged 66-70, older patients more often received non-standard chemotherapy [adjusted odds ratio (OR) = 4.1, 95 % confidence interval (CI) = 3.40-4.92 (ages 76-80); OR = 15.3, 95 %CI = 9.92-23.67 (age ≥ 80)]. However, comorbidity was not associated with receipt of non-standard chemotherapy. After propensity score adjustment, hospitalizations were more frequent in the standard (vs. non-standard) group (adjusted OR = 1.7, 95 % CI = 1.29-2.24). With a median follow-up of 2.8 years, 276 deaths occurred; the adjusted hazard ratio (HR) for death was lower in standard versus non-standard treated women (HR = 0.69, 95 % CI = 0.52-0.91). Among a population-based cohort of older women receiving trastuzumab, nearly one-third received non-standard chemotherapy, with the highest rates among the oldest women. Non-standard chemotherapy was associated with fewer toxicity-related hospitalizations but worse survival. Further exploration of treatment toxicities and outcomes for older women with HER2-positive breast cancer is warranted.
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Perdue DG, Haverkamp D, Perkins C, Daley CM, Provost E. Geographic variation in colorectal cancer incidence and mortality, age of onset, and stage at diagnosis among American Indian and Alaska Native people, 1990-2009. Am J Public Health 2014; 104 Suppl 3:S404-14. [PMID: 24754657 DOI: 10.2105/ajph.2013.301654] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We characterized estimates of colorectal cancer (CRC) in American Indians/Alaska Natives (AI/ANs) compared with Whites using a linkage methodology to improve AI/AN classification in incidence and mortality data. METHODS We linked incidence and mortality data to Indian Health Service enrollment records. Our analyses were restricted to Contract Health Services Delivery Area counties. We analyzed death and incidence rates of CRC for AI/AN persons and Whites by 6 regions from 1999 to 2009. Trends were described using linear modeling. RESULTS The AI/AN colorectal cancer incidence was 21% higher and mortality 39% higher than in Whites. Although incidence and mortality significantly declined among Whites, AI/AN incidence did not change significantly, and mortality declined only in the Northern Plains. AI/AN persons had a higher incidence of CRC than Whites in all ages and were more often diagnosed with late stage CRC than Whites. CONCLUSIONS Compared with Whites, AI/AN individuals in many regions had a higher burden of CRC and stable or increasing CRC mortality. An understanding of the factors driving these regional disparities could offer critical insights for prevention and control programs.
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Affiliation(s)
- David G Perdue
- David G. Perdue is with the American Indian Cancer Foundation, and Minnesota Gastroenterology PA, Minneapolis. Donald Haverkamp is with the Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Carin Perkins is with the Minnesota Cancer Surveillance System, Minneapolis. Christine Makosky Daley is with the Center for American Indian Community Health, University of Kansas Medical Center, Kansas City. Ellen Provost is with the Alaska Native Tribal Health Consortium, Anchorage
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80
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Race and competing mortality in advanced head and neck cancer. Oral Oncol 2014; 50:40-4. [DOI: 10.1016/j.oraloncology.2013.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/16/2013] [Accepted: 09/23/2013] [Indexed: 11/18/2022]
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81
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Markman M. Provider Impact on Survival Outcomes in the Management of Malignant Disease. Curr Oncol Rep 2013; 15:193-6. [DOI: 10.1007/s11912-013-0304-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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82
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Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health 2013. [PMID: 23543372 DOI: 10.1007/s10900‐013‐9681‐1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.
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Affiliation(s)
- Samina T Syed
- Section of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, 1819 W. Polk Street, M/C 640, Chicago, IL 60612, USA.
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Unger JM, Hershman DL, Albain KS, Moinpour CM, Petersen JA, Burg K, Crowley JJ. Patient income level and cancer clinical trial participation. J Clin Oncol 2013. [PMID: 23295802 DOI: 10.1200/jco.2012.45.4553.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Studies have shown an association between socioeconomic status (SES) and quality of oncology care, but less is known about the impact of patient SES on clinical trial participation. PATIENTS AND METHODS We assessed clinical trial participation patterns according to important SES (income, education) and demographic factors in a large sample of patients surveyed via an Internet-based treatment decision tool. Logistic regression, conditioning on type of cancer, was used. Attitudes toward clinical trials were assessed using prespecified items about treatment, treatment tolerability, convenience, and cost. RESULTS From 2007 to 2011, 5,499 patients were successfully surveyed. Forty percent discussed clinical trials with their physician, 45% of discussions led to physician offers of clinical trial participation, and 51% of offers led to clinical trial participation. The overall clinical trial participation rate was 9%. In univariate models, older patients (P = .002) and patients with lower income (P = .001) and education (P = .02) were less likely to participate in clinical trials. In a multivariable model, income remained a statistically significant predictor of clinical trial participation (odds ratio, 0.73; 95% CI, 0.57 to 0.94; P = .01). Even in patients age ≥ 65 years, who have universal access to Medicare, lower income predicted lower trial participation. Cost concerns were much more evident among lower-income patients (P < .001). CONCLUSION Lower-income patients were less likely to participate in clinical trials, even when considering age group. A better understanding of why income is a barrier may help identify ways to make clinical trials better available to all patients and would increase the generalizability of clinical trial results across all income levels.
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Affiliation(s)
- Joseph M Unger
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, M3-C102, 1100 Fairview Ave, Seattle, WA 98109, USA.
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Unger JM, Hershman DL, Albain KS, Moinpour CM, Petersen JA, Burg K, Crowley JJ. Patient income level and cancer clinical trial participation. J Clin Oncol 2013; 31:536-42. [PMID: 23295802 DOI: 10.1200/jco.2012.45.4553] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Studies have shown an association between socioeconomic status (SES) and quality of oncology care, but less is known about the impact of patient SES on clinical trial participation. PATIENTS AND METHODS We assessed clinical trial participation patterns according to important SES (income, education) and demographic factors in a large sample of patients surveyed via an Internet-based treatment decision tool. Logistic regression, conditioning on type of cancer, was used. Attitudes toward clinical trials were assessed using prespecified items about treatment, treatment tolerability, convenience, and cost. RESULTS From 2007 to 2011, 5,499 patients were successfully surveyed. Forty percent discussed clinical trials with their physician, 45% of discussions led to physician offers of clinical trial participation, and 51% of offers led to clinical trial participation. The overall clinical trial participation rate was 9%. In univariate models, older patients (P = .002) and patients with lower income (P = .001) and education (P = .02) were less likely to participate in clinical trials. In a multivariable model, income remained a statistically significant predictor of clinical trial participation (odds ratio, 0.73; 95% CI, 0.57 to 0.94; P = .01). Even in patients age ≥ 65 years, who have universal access to Medicare, lower income predicted lower trial participation. Cost concerns were much more evident among lower-income patients (P < .001). CONCLUSION Lower-income patients were less likely to participate in clinical trials, even when considering age group. A better understanding of why income is a barrier may help identify ways to make clinical trials better available to all patients and would increase the generalizability of clinical trial results across all income levels.
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Affiliation(s)
- Joseph M Unger
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, M3-C102, 1100 Fairview Ave, Seattle, WA 98109, USA.
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85
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Korn EL, Freidlin B. Methodology for Comparative Effectiveness Research: Potential and Limitations. J Clin Oncol 2012; 30:4185-7. [DOI: 10.1200/jco.2012.44.8233] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Landrum MB, Keating NL, Lamont EB, Bozeman SR, Krasnow SH, Shulman L, Brown JR, Earle CC, Rabin M, McNeil BJ. Survival of older patients with cancer in the Veterans Health Administration versus fee-for-service Medicare. J Clin Oncol 2012; 30:1072-9. [PMID: 22393093 PMCID: PMC3341151 DOI: 10.1200/jco.2011.35.6758] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 12/20/2011] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. PATIENTS AND METHODS We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. RESULTS VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non-small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large-B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. CONCLUSION The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.
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87
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Reitzel LR, Nguyen N, Zafereo ME, Li G, Wei Q, Sturgis EM. Neighborhood deprivation and clinical outcomes among head and neck cancer patients. Health Place 2012; 18:861-8. [PMID: 22445028 DOI: 10.1016/j.healthplace.2012.03.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 02/03/2012] [Accepted: 03/04/2012] [Indexed: 11/17/2022]
Abstract
The unique effects of neighborhood-level economic deprivation on survival, recurrence, and second primary malignancy development were examined using adjusted Cox proportional hazards regression models among 1151 incident squamous cell carcinomas of the head and neck patients. Cancer site was examined as a potential moderator. Main analyses yielded null results; however, interaction analyses indicated poorer overall survival [HR=1.59 (1.00-2.53)] and greater second primary malignancy development [HR=2.99 (1.46-6.11)] among oropharyngeal cancer patients from highly deprived neighborhoods relative to less deprived neighborhoods. Results suggest a dual focus on individual and neighborhood risk factors could help improve clinical outcomes among oropharyngeal cancer patients.
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Affiliation(s)
- Lorraine R Reitzel
- Department of Health Disparities Research-Unit 1440, PO Box 301402, University of Texas MD Anderson Cancer Center, Houston, Texas 77230-1402, USA.
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Walker KO, Clarke R, Ryan G, Brown AF. Effect of closure of a local safety-net hospital on primary care physicians' perceptions of their role in patient care. Ann Fam Med 2011; 9:496-503. [PMID: 22084260 PMCID: PMC3252182 DOI: 10.1370/afm.1317] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We examined how the closure of a large safety-net hospital in Los Angeles County, California, affected local primary care physicians. METHODS We conducted semistructured interviews with 42 primary care physicians who practiced in both underserved and nonunderserved settings in Los Angeles County. Two investigators independently reviewed and coded transcripts. Three investigators used pile-sorting to sort the codes into themes. RESULTS Overall, 28 of 42 physicians (67%) described some effect of the hospital closure on their practices. Three major themes emerged regarding the impact of the closure on the affected physicians: (1) reduced local access to specialist consultations, direct hospital admissions, and timely emergency department evaluation; (2) more patient delays in care and worse health outcomes because of poor patient understanding of the health care system changes; and (3) loss of colleagues and opportunities to teach residents and medical students. CONCLUSIONS Physicians in close proximity to the closed hospital-even those practicing in nonunderserved settings-reported difficulty getting their patients needed care that extended beyond the anticipated loss of inpatient services. There is a need for greater recognition of and support for the role primary care physicians play in coordinating care; promoting continuity of care; and informing patients, clinic administrators and policy makers about system changes during such transitions.
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Affiliation(s)
- Kara Odom Walker
- Department of Family & Community Medicine, University of California-San Francisco, USA.
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89
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Michal SA, Adelstein DJ, Rybicki LA, Rodriguez CP, Saxton JP, Wood BG, Scharpf J, Ives DI. Multi-agent concurrent chemoradiotherapy for locally advanced head and neck squamous cell cancer in the elderly. Head Neck 2011; 34:1147-52. [DOI: 10.1002/hed.21891] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2011] [Indexed: 01/08/2023] Open
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Keating NL, Landrum MB, Brooks JM, Chrischilles EA, Winer EP, Wright K, Volya R. Outcomes following local therapy for early-stage breast cancer in non-trial populations. Breast Cancer Res Treat 2011; 125:803-13. [PMID: 20376555 PMCID: PMC2924956 DOI: 10.1007/s10549-010-0865-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Accepted: 03/19/2010] [Indexed: 12/26/2022]
Abstract
Recent studies suggest trends toward more mastectomies for primary breast cancer treatment. We assessed survival after mastectomy and breast-conserving surgery (BCS) with radiation for early-stage breast cancer among non-selected populations of women and among women similar to those in clinical trials. Using population-based data from Surveillance Epidemiology, and End Results cancer registries linked with Medicare administrative data from 1992 to 2005, we conducted propensity score analysis of survival following primary therapy for early-stage breast cancer, including BCS with radiation, BCS without radiation, mastectomy with radiation, and mastectomy without radiation. Adjusted survival was greatest among women who had BCS with radiation (median survival = 10.98 years). Compared with this group, mortality was higher among women who had mastectomy without radiation (median survival 10.04 years, adjusted hazard ratio (HR) = 1.19, 95% confidence interval (CI) = 1.14-1.23), mastectomy with radiation (median survival 10.02 years, HR = 1.20, 95% CI = 1.14-1.27), and BCS without radiation (median survival 7.63 years, HR = 1.81, 95% CI = 1.70-1.92). Among women representative of those eligible for clinical trials (age ≤70 years, Charlson comorbidity score = 0/1, and stage 1 tumors), there were no differences in survival for women who underwent BCS with radiation or mastectomy. In conclusion, after careful adjustment for differences in patient, physician, and hospital characteristics, we found better survival for BCS with radiation versus mastectomy among older early-stage breast cancer patients, with no difference in survival for BCS with radiation versus mastectomy among women representative of those in clinical trials. These findings are reassuring in light of recent trends towards more aggressive primary breast cancer therapy.
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Affiliation(s)
- Nancy L Keating
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Friese CR, Earle CC, Silber JH, Aiken LH. Hospital characteristics, clinical severity, and outcomes for surgical oncology patients. Surgery 2010; 147:602-9. [PMID: 20403513 DOI: 10.1016/j.surg.2009.03.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 03/02/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients and payers wish to identify hospitals with good surgical oncology outcomes. Our objective was to determine whether differences in outcomes explained by hospital structural characteristics are mitigated by differences in patient severity. METHODS Using hospital administrative and cancer registry records in Pennsylvania, we identified 24,618 adults hospitalized for cancer-related operations. Colorectal, prostate, endometrial, ovarian, head and neck, lung, esophageal, and pancreatic cancers were studied. Outcome measures were 30-day mortality and failure to rescue (FTR) (30-day mortality preceded by a complication). After severity of illness adjustment, we estimated logistic regression models to predict the likelihood of both outcomes. In addition to American Hospital Association survey data, we externally verified hospitals with National Cancer Institute (NCI) cancer center or Commission on Cancer (COC) cancer program status. RESULTS Patients in hospitals with NCI cancer centers were significantly younger and less acutely ill on admission (P < .001). Patients in high volume hospitals were younger, had lower admission acuity, yet had more advanced cancer (P < .001). Unadjusted 30-day mortality rates were lower in NCI-designated hospitals (3.76% vs 2.17%;P = .01). Risk-adjusted FTR rates were significantly lower in NCI-designated hospitals (4.86% vs 3.51%;P = .03). NCI center designation was a significant predictor of 30-day mortality when considering patient and hospital characteristics (OR, 0.68; 95% CI, 0.47-0.97;P = .04). We did not find significant outcomes effects based on COC cancer program approval. CONCLUSION Patient severity of illness varies significantly across hospitals, which may explain the outcome differences observed. Severity adjustment is crucial to understanding outcome differences. Outcomes were better than predicted for NCI-designated hospitals.
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Affiliation(s)
- Christopher R Friese
- Division of Nursing Business and Health Systems, School of Nursing, University of Michigan, Ann Arbor, MI 48109-5482, USA.
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Abstract
The increase in surgery for pancreatic cancer during the last 3 decades can be correlated with a gradual decline in operative mortality and postoperative complications. Although not all surgeons (nor all hospitals) can have equal outcomes, the definition and tabulation of these outcomes have been difficult. This article asks several pertinent questions: (1) what is the scientific rationale for pancreatic resection? (2) what are the best available results at this time? (3) who should be performing pancreatic resections? The article analyzes results of resection for adenocarcinoma of the exocrine pancreas, and excludes duodenal and ampullary cancers, pancreatic endocrine tumors, and tumors of less malignant potential.
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Su SC, Kanarek N, Fox MG, Guseynova A, Crow S, Piantadosi S. Spatial Analyses Identify the Geographic Source of Patients at a National Cancer Institute Comprehensive Cancer Center. Clin Cancer Res 2010; 16:1065-72. [DOI: 10.1158/1078-0432.ccr-09-1875] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mell LK, Dignam JJ, Salama JK, Cohen EE, Polite BN, Dandekar V, Bhate AD, Witt ME, Haraf DJ, Mittal BB, Vokes EE, Weichselbaum RR. Predictors of Competing Mortality in Advanced Head and Neck Cancer. J Clin Oncol 2010; 28:15-20. [DOI: 10.1200/jco.2008.20.9288] [Citation(s) in RCA: 201] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Death from noncancer causes (competing mortality) is an important event in head and neck cancer, but studies identifying predictors of this event are lacking. We sought to identify predictors of competing mortality and develop a risk stratification model for competing events. Patients and Methods Cohort study of 479 patients with stage III to IV carcinoma of the head and neck diagnosed between August 1993 and November 2004. Patients were treated on consecutive prospective clinical trials involving organ-preserving chemoradiotherapy and surgery. We used multivariable competing risks regression models to analyze factors associated with the cumulative incidence of competing mortality, locoregional and distant failure, and second malignancies as first events. Results Median follow-up was 52 months median for survivors. The 5-year cumulative incidence of competing mortality was 19.6% (95% CI, 15.8 to 23.4). On multivariable analysis, competing mortality was associated with female sex (hazard ratio [HR], 1.72; 95% CI, 1.13 to 2.63), increasing age (HR, 1.30; 95% CI, 1.04 to 1.62), increasing Charlson Comorbidity Index (HR, 1.24; 95% CI, 1.05 to 1.47), decreasing body mass index (HR, 0.33; 95% CI, 0.13 to 0.84), and decreasing distance traveled to the treating center (HR, 0.65; 95% CI, 0.44 to 0.98). Patients with zero, one, two, and ≥ three risk factors had 5-year competing mortality of 8.9% (95% CI, 3.0% to 14.8%), 12.4% (95% CI, 7.0% to 17.8%), 22.1% (95% CI, 14.5% to 29.7%), and 39.3% (95% CI, 28.6% to 50.1%), respectively. Conclusion Competing mortality in advanced head and neck cancer is associated with several demographic and health status characteristics. Analyses of risk factors for competing mortality may be useful in outcomes reporting and designing clinical trials.
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Affiliation(s)
- Loren K. Mell
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - James J. Dignam
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Joseph K. Salama
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ezra E.W. Cohen
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Blase N. Polite
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Virag Dandekar
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Amit D. Bhate
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Mary Ellyn Witt
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Daniel J. Haraf
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Bharat B. Mittal
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Everett E. Vokes
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ralph R. Weichselbaum
- From the Department of Radiation Oncology, University of California San Diego, La Jolla, CA; Departments of Health Studies and Radiation and Cellular Oncology, Section of Hematology/Oncology, Department of Medicine, University of Chicago; College of Medicine, University of Illinois at Chicago; and the Department of Radiation Oncology, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
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95
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Lamont EB, Landrum MB, Keating NL, Archer L, Lan L, Strauss GM, Lilenbaum R, Niell HB, Maurer LH, Kosty MP, Miller AA, Clamon GH, Elias AD, McClay EF, Vokes EE, McNeil BJ. Differences in clinical trial patient attributes and outcomes according to enrollment setting. J Clin Oncol 2009; 28:215-21. [PMID: 19933919 DOI: 10.1200/jco.2008.21.3652] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE During the last 25 years, National Cancer Institute (NCI) cooperative trial groups have extended trial networks from academic centers to include certain community and Veterans Health Administration (VHA) centers. We compared trial patients' attributes and outcomes by these enrollment settings. PATIENTS AND METHODS Studying 2,708 patients on one of 10 cooperative group, randomized lung trials at 272 institutions, we compared patient attributes by enrollment setting (ie, academic, community, and VHA affiliates). We used adjusted Cox regression to evaluate for survival differences by setting. RESULTS Main member institutions enrolled 44% of patients; community affiliates enrolled 44%; and VHAs enrolled 12%. Patient attributes (ie, case-mix) of age, ethnicity, sex, and performance status varied by enrollment setting. After analysis was adjusted for patient case-mix, no mortality differences by enrollment setting were noted. CONCLUSION Although trial patients with primarily advanced-stage lung cancer from nonacademic centers were older and had worse performance statuses than those from academic centers, survival did not differ by enrollment setting after analysis accounted for patient heterogeneity. An answer for whether long-term outcomes for patients at community and VHA centers affiliated with cooperative trial groups are equivalent to those at academic centers when care is delivered through NCI trials requires additional research among patients with longer survival horizons.
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Affiliation(s)
- Elizabeth B Lamont
- Dept of Health Care Policy, Harvard Medical School, 180A Longwood Ave, Boston, MA 02115, USA.
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96
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Amongst eligible patients, age and comorbidity do not predict for dose-limiting toxicity from phase I chemotherapy. Cancer Chemother Pharmacol 2009; 65:775-80. [PMID: 19649630 DOI: 10.1007/s00280-009-1084-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 07/14/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND There are no clear predictors clinicians can use to determine who is more likely to experience dose-limiting toxicity (DLT) in phase I chemotherapy clinical trials. Many providers are reluctant to refer older adults to phase I trials because of concerns about the development of toxicity. The goal of this study was to identify clinical and nonclinical factors which were associated with the development of DLT in phase I studies. METHODS Patients (pts) were included if they were treated at maximally tolerated dose (MTD) and above. Studies were included only if MTD was reached. Data collected included age, comorbidity (Cumulative Illness Rating Score-Geriatrics), labs at enrollment, height, weight, performance status, cancer type, duration of diagnosis, prior treatment, drug level, smoking status, marital status, mean income, percent of population high school educated as determined by ZIP code, and distance to the phase I trial hospital. Those who did and did not have DLT were compared by bivariate and then multivariate analysis. RESULTS A total of 242 charts were reviewed from 24 cytotoxic chemotherapy studies, and 27 different types of cancer were represented. On bivariate analysis, mean age, household income (higher), weight, body surface area, dose of drug, alkaline phosphatase, hemoglobin, and LDH were significantly associated with DLT (P < 0.05). CIRS-G score was not associated with DLT. In multivariate analysis, dose level (P = 0.004) and distance from the phase I trial hospital (P = 0.04) were still significant predictors of DLT. Age did not predict for severity of DLT. CONCLUSIONS Age and comorbidity did not predict for development of DLT in phase I chemotherapy trials. Many of these pts were very fit, with relatively low CIRS-G scores, so the impact of comorbidity may not have been fully evaluated. Several social and clinical factors may predict for development of DLT. A prospective study is being planned to confirm these results.
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97
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Kopetz S, Chang GJ, Overman MJ, Eng C, Sargent DJ, Larson DW, Grothey A, Vauthey JN, Nagorney DM, McWilliams RR. Improved survival in metastatic colorectal cancer is associated with adoption of hepatic resection and improved chemotherapy. J Clin Oncol 2009; 27:3677-83. [PMID: 19470929 DOI: 10.1200/jco.2008.20.5278] [Citation(s) in RCA: 986] [Impact Index Per Article: 65.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Fluorouracil/leucovorin as the sole therapy for metastatic colorectal cancer (CRC) provides an overall survival of 8 to 12 months. With an increase in surgical resections of metastatic disease and development of new chemotherapies, indirect evidence suggests that outcomes for patients are improving in the general population, although the incremental gain has not yet been quantified. METHODS We performed a retrospective review of patients newly diagnosed with metastatic CRC treated at two academic centers from 1990 through 2006. Landmark analysis evaluated the association of diagnosis year and liver resection with overall survival. Additional survival analysis of the Surveillance Epidemiology and End Results (SEER) database evaluated a similar population from 1990 through 2005. RESULTS Two thousand four hundred seventy patients with metastatic CRC at diagnosis received their primary treatment at the two institutions during this time period. Median overall survival for those patients diagnosed from 1990 to 1997 was 14.2 months, which increased to 18.0, 18.6, and 29.3 months for patients diagnosed in 1998 to 2000, 2001 to 2003, and 2004 to 2006, respectively. Likewise, 5-year overall survival increased from 9.1% in the earliest time period to 19.2% in 2001 to 2003. Improved outcomes from 1998 to 2004 were a result of an increase in hepatic resection, which was performed in 20% of the patients. Improvements from 2004 to 2006 were temporally associated with increased utilization of new chemotherapeutics. In the SEER registry, overall survival for the 49,459 identified patients also increased in the most recent time period. CONCLUSION Profound improvements in outcome in metastatic CRC seem to be associated with the sequential increase in the use of hepatic resection in selected patients (1998 to 2006) and advancements in medical therapy (2004 to 2006).
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Affiliation(s)
- Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA.
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98
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Comparison of community and referral intensive care unit patients in a tertiary medical center: evidence for referral bias in the critically ill. Crit Care Med 2008; 36:2779-86. [PMID: 18828201 DOI: 10.1097/ccm.0b013e318186ab1b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the existence of referral bias in the critically ill by comparing the clinical and epidemiologic characteristics of community (Olmsted County, MN residents) and referral (non-Olmsted County residents) patients admitted to the intensive care unit. DESIGN Retrospective, cohort study. SETTING Academic tertiary care medical center. PATIENTS Patients admitted to the medical and surgical intensive care units at Mayo Medical Center from 1995 to 2004. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Residency status, demographics, Acute Physiology and Chronic Health Evaluation III score, intensive care unit admission diagnosis and treatment status, intensive care unit and hospital mortality, length of stay, and travel distances to Mayo Clinic. Referral patients with a medical intensive care unit admission were more severely ill, had greater mortality rates and length of stay and were more likely to receive an active intensive care unit intervention compared with community patients (p < 0.0001). Referral and community patients who had a surgical intensive care unit admission had similar severity of illness, length of stay, and intensive care unit mortality rate. Hospital mortality rate was lower in the referral surgical patients compared with community surgical patients (p = 0.0001). When adjusted for severity of illness, intensity of treatment, and admission source, community and referral medical intensive care unit patients had a similar risk of hospital death, whereas referral surgical patients had a lower risk of hospital death compared with community patients. Referral patients who had a medical intensive care unit admission and traveled greater distances to Mayo Clinic had greater mortality rates and length of stay; those who had a surgical intensive care unit admission and traveled greater distances had lower mortalities and length of stay. CONCLUSIONS Patients who resided outside of our local community and who had medical admissions to the intensive care unit were more severely ill, had greater mortality rates, and had longer length of stay compared with community patients. Our findings support the existence of referral bias in critically ill medical patients at our tertiary medical center.
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Machens A, Hauptmann S, Dralle H. Referral bias in thyroid cancer surgery: Direction and magnitude. Eur J Surg Oncol 2008; 34:556-62. [PMID: 17716850 DOI: 10.1016/j.ejso.2007.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Accepted: 07/02/2007] [Indexed: 11/15/2022] Open
Abstract
AIM This study was conducted to clarify the impact of referral bias in thyroid cancer surgery. METHODS Analysis of 1419 consecutive patients with papillary (n=653), follicular (n=248), and medullary thyroid cancer (n=518) referred to a specialist center for initial surgery or reoperation. RESULTS With increasing travel distance (successive postal code areas), mean age decreased among patients referred for initial surgery (from 53 to 35 years for papillary cancer, 65 to 49 years for sporadic medullary cancer, and 40 to 23 years for hereditary medullary cancer, all p< or =0.001; and from 65 to 54 years for follicular cancer, p=0.26). The significant decline in mean age continued among patients reoperated on for papillary cancer (from 53 to 43 years, p<0.001), but was lost among patients reoperated on for medullary cancers. For patients with differentiated, but not medullary cancers, greater travel distance was associated with higher frequencies of extrathyroidal extension at initial surgery (from 17% to 63% for follicular cancer, p=0.003) and reoperation (from 18% to 47% for papillary, and 5% to 44% for follicular cancer, all p<0.001), and higher frequencies of lymph node metastasis at initial surgery (from 23% to 58% for papillary, and 17% to 50% for follicular cancer, p< or =0.008) and reoperation (from 27% to 77% for papillary, and 0% to 35% for follicular cancer, all p<0.001). CONCLUSION Referral bias in thyroid cancer surgery can include two components working in opposite directions: age and extent of disease. Controlling for these components should reduce the impact of referral bias on thyroid cancer research.
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Affiliation(s)
- A Machens
- Department of General, Visceral and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06097 Halle (Saale), Germany.
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100
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Chan JK, Ueda SM, Sugiyama VE, Stave CD, Shin JY, Monk BJ, Sikic BI, Osann K, Kapp DS. Analysis of Phase II Studies on Targeted Agents and Subsequent Phase III Trials: What Are the Predictors for Success? J Clin Oncol 2008; 26:1511-8. [PMID: 18285603 DOI: 10.1200/jco.2007.14.8874] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To identify the characteristics of phase II studies that predict for subsequent “positive” phase III trials (those that reached the proposed primary end points of study or those wherein the study drug was superior to the standard regimen investigating targeted agents in advanced tumors. Methods We identified all phase III clinical trials of targeted therapies against advanced cancers published from 1985 to 2005. Characteristics of the preceding phase II studies were reviewed to identify predictive factors for success of the subsequent phase III trial. Data were analyzed using the χ2 test and logistic regression models. Results Of 351 phase II studies, 167 (47.6%) subsequent phase III trials were positive and 184 (52.4%) negative. Phase II studies from multiple rather than single institutions were more likely to precede a successful trial (60.4% v 39.4%; P < .001). Positive phase II results were more likely to lead to a successful phase III trial (50.8% v 22.5%; P = .003). The percentage of successful trials from pharmaceutical companies was significantly higher compared with academic, cooperative groups, and research institutes (89.5% v 44.2%, 45.2%, and 46.3%, respectively; P = .002). On multivariate analysis, these factors and shorter time interval between publication of phase II results and III study publication were independent predictive factors for a positive phase III trial. Conclusion In phase II studies of targeted agents, multiple- versus single-institution participation, positive phase II trial, pharmaceutical company-based trials, and shorter time period between publication of phase II to phase III trial were independent predictive factors of success in a phase III trial. Investigators should be cognizant of these factors in phase II studies before designing phase III trials.
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Affiliation(s)
- John K. Chan
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Stefanie M. Ueda
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Valerie E. Sugiyama
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Christopher D. Stave
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Jacob Y. Shin
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Bradley J. Monk
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Branimir I. Sikic
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Kathryn Osann
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
| | - Daniel S. Kapp
- From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, San Francisco, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco; Department of Radiation Therapy, Division of Medical Oncology; Lane Medical Library & Knowledge Management Center, Stanford Cancer Center, Stanford University School of Medicine, Stanford; and the Chao Family Comprehensive Cancer Center, University of California, Irvine, Medical Center, Orange, CA
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