Neighborhood socioeconomic status influences the survival of elderly patients with myelodysplastic syndromes in the United States

Epidemiologic evaluation of clinical outcomes in ethnic minorities with myelodysplastic syndromes

Since race/ethnicity and socioeconomic status (SES), including economic and educational disadvantage (EED), may impact overall survival (OS) in primary myelodysplastic syndromes (MDS), we analyzed the impact of these characteristics on OS in Non-Hispanic White (NHW), Non-Hispanic Black (NHB) and Hispanic patients. In this retrospective review using the SEER US population and American Community Survey data between 2001 and 2016, factor analysis was used for 23 county-level SES indicators to identify groups of interrelated measures of EED. For the 52,739 patients identified, increased age at diagnosis, male sex, higher prognostic risk category and higher EED were all associated with reduced OS. The most prominent SES factor extracted by factor analysis was EED. NHB patients had the highest OS compared to NHW and Hispanics. For all patients, EED analysis showed lower OS for most compared to least disadvantaged, most notably in lower-risk disease and Hispanics. More NHB and Hispanics (51% and 49%) were in the most disadvantaged category compared with NHW (30%). No significant differences were noted for causes of death by race/ethnicity. In conclusion, these data indicate that in addition to standard clinical measures for analyzing OS, race/ethnicity, SES and EED are critical determinants for assessing clinical outcomes in MDS patients.

Income, education and their impact on treatments and survival in patients with myelodysplastic syndromes

OBJECTIVES

To assess whether socioeconomic indices such as income and educational level can explain part of the variation in survival among patients with myelodysplastic syndromes, and further to assess whether these factors influence care and treatment decisions.

METHODS

Population-based cohort study on 2945 Swedish patients diagnosed between 2009 and 2018 and included in the Swedish MDS Register. Relative mortality was assessed by Cox regression, whereas treatment differences were assessed by Poisson regression. Regarding mortality, patients were also compared to a matched comparison group from the general population.

RESULTS

Mortality was 50% higher among patients in the lowest income category compared to the highest and 40% higher in patients with mandatory school education only compared to those with college or university education. Treatment with hypomethylating agents and allogeneic stem cell transplantation, as well as investigation with cytogenetic diagnostics were also linked to income and education. The findings were not explained by differences in risk class or comorbidity at the time of diagnosis.

CONCLUSIONS

Income and education are linked to survival among patients with myelodysplastic syndromes. Socioeconomic status also seems to influence treatment intensity as patients with less income and education to a lesser degree receive hypomethylating agents and transplants.

Factors influencing the initiation of intensive care in elderly patients and their families: A retrospective cohort study

BACKGROUND

The number of elderly patients admitted to the intensive care unit is constantly growing. However, a decision regarding intensive care in these populations remains a challenge.

AIM

To identify factors that influences the decision of elderly patients and their families about whether to initiate intensive care in case of an acute event.

DESIGN/PARTICIPANTS

Medical records of patients (>80 years), who were admitted to general wards and referred for intensive care, were retrospectively reviewed. Patients who received intensive care were compared with those not agreeing to the initiation of intensive care.

RESULTS

Among the 125 patients, 45 agreed to receiving intensive care. Baseline characteristics at the time of intensive care unit referral were similar between the intensive care and non-intensive care groups. Only one patient had advance directives before the intensive care unit referral. Lower economic status (odds ratio = 0.27, 95% confidence interval = 0.08-0.94) and cognitive impairment (odds ratio = 0.20, 95% confidence interval = 0.07-0.56) were found associated with a lower likelihood of agreeing to intensive care, while a large number of participants involved in the decision-making process were associated with a higher likelihood of intensive care unit use (odds ratio = 1.82, 95% confidence interval = 1.08-3.09). Mean duration of hospital stay was longer for the intensive care group as compared with the non-intensive care group (28.8 days and 19.8 days, respectively, p = 0.03). However, there was no significant difference in the survival rate.

CONCLUSION

The initiation of intensive care in elderly patients was influenced not only by medical conditions but also by the patient's economic status and the number of family members involved in the decision-making process.

Myelodysplastic syndromes in South America: a multinational study of 1080 patients

There are previously reported data describing differences between Asian and European patients with Myelodysplastic Syndromes (MDS), few direct comparisons based on cancer registration characteristics or using cohorts to validate scoring systems. This is the first study from South-America, which attempts to describe demographic, clinical features, and outcome of MDS patients. We retrospectively analyzed 1,080 patients with de novo MDS from Argentina (635), Brazil (345), and Chile (100). Chilean patients were younger (P = 0.001) with female preponderance (P = 0.071). Brazilian series showed a higher predominance of RARS subtype regarding FAB and WHO classifications (P < 0.001). Hemoglobin levels were significantly lower in Brazilian and Chilean series (P < 0.001), and Chilean series also showed a lower platelet count (P = 0.028), with no differences concerning the neutrophil count, % BM blast, and the distribution of cytogenetic risk groups (P > 0.05). Chilean series depicted a lower overall survival (OS; 35 months vs. 56 months-Argentine; 55 months-Brazil, P = 0.030), which was consistent with a higher predominance of the high-risk group according both to the IPSS and IPSS-R (P = 0.046 and P < 0.001). The IPSS-R system and its variables showed a good reproducibility to predict clinical outcome for the whole South-American population. Epidemiological and clinical characteristics, distribution among prognostic subgroups, the OS, and the access to disease modifying therapies were more similar between Argentinean and Brazilian compared with Chilean MDS series. This will need further analysis in a larger group of patients. Descriptive and comparative studies are necessary to establish epidemiological features useful for public health attitudes to generate suitable therapeutic schemes.

Functional Principal Component Analysis of Spatio-Temporal Point Processes with Applications in Disease Surveillance

In disease surveillance applications, the disease events are modeled by spatio-temporal point processes. We propose a new class of semiparametric generalized linear mixed model for such data, where the event rate is related to some known risk factors and some unknown latent random effects. We model the latent spatio-temporal process as spatially correlated functional data, and propose Poisson maximum likelihood and composite likelihood methods based on spline approximations to estimate the mean and covariance functions of the latent process. By performing functional principal component analysis to the latent process, we can better understand the correlation structure in the point process. We also propose an empirical Bayes method to predict the latent spatial random effects, which can help highlight hot areas with unusually high event rates. Under an increasing domain and increasing knots asymptotic framework, we establish the asymptotic distribution for the parametric components in the model and the asymptotic convergence rates for the functional principal component estimators. We illustrate the methodology through a simulation study and an application to the Connecticut Tumor Registry data.

The impact of hypomethylating agents on the cost of care and survival of elderly patients with myelodysplastic syndromes

During 2004-2006, two hypomethylating agents (HMAs) were approved for the treatment of myelodysplastic syndromes (MDS) in the United States. We assessed the impact of HMAs on the cost of care and survival of MDS patients, by constructing a cohort of patients who were diagnosed during 2001-2007 (n=6556, age ≥66.5 years) and comparable non-cancer controls. We assessed MDS patients' and controls' Medicare expenditures to derive MDS-related cost. We evaluated the two-year survival of patients as a group and by major subtypes. Taking into account the survival probabilities of MDS, the expected MDS-related 5-year cost was $63,223 (95% confidence interval: $59,868-66,432 in 2009 dollars), higher than the reported comparable cost for any of the 18 most prevalent cancers in the United States. Compared with MDS patients diagnosed in the earlier period (January 2001-June 2004) who received no HMAs, patients diagnosed later (July 2004-December 2007) who received HMAs had a significantly higher 24-month cost ($97,977 vs. $42,628 in 2009 dollars) and an improved 24-month survival (especially among patients with refractory anemia or refractory anemia with excess blasts). The magnitude of the cost of care underscores a need for comparative cost-effectiveness studies to reduce the clinical and economic burden of MDS.

Epidemiology of myelodysplastic syndromes

Myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal hematopoietic stem cell malignancies with significant morbidity and high mortality. The incidence of MDS increases markedly with age, and the disease is most prevalent in individuals who are white and male. It is conservatively estimated that >10,000 new cases of MDS occur in the United States annually, and that ≥ 60,000 individuals with MDS currently reside in the country. With an aging population and an improving awareness of the disease, the documented disease burden is expected to escalate in the near future. Recent studies have identified new or inconsistent etiologic factors that warrant further research. Given the poor survival of individuals with MDS, it is important to identify prognostic factors to better risk-stratify patients for more effective treatment. The relevance of different comorbidities to MDS prognosis and the potential interaction between various comorbidities represents an interesting area of research.

Pattern of hypomethylating agents use among elderly patients with myelodysplastic syndromes

Little is known about how hypomethylating agents (HMAs) have been adopted into the treatment of myelodysplastic syndromes (MDS). We conducted a population-based study to assess the use of HMAs among 4416 MDS patients (age≥66 years) who were diagnosed during 2001-2005 and followed up through the end of 2007. Multivariate logistic regression models were utilized to evaluate the role of various patient characteristics. 475 (10.8%) patients had received HMAs by 2007, with the proportion increasing over time. Patients who were white (odds ratio (OR)=0.66, 95% confidence interval (CI): 0.46-0.95), male (OR=1.47, 95% CI: 1.19-1.82), young (Ptrend<0.01), more recently diagnosed (OR=1.90, 95% CI: 1.54-2.34), had fewer comorbidities (Ptrend<0.01), or had a history of other cancer (OR=1.28, 95% CI: 1.00-1.63) were more likely to receive HMAs. Compared with patients with refractory anemia, those diagnosed with refractory anemia with excess blasts or refractory cytopenia with multilineage dysplasia had a higher chance to be treated with HMAs (OR=3.52 and 2.32, respectively). Relatively few MDS patients were treated with HMAs during the introduction period of these agents, and multiple patient characteristics such as sex, comorbidities, and MDS subtype influence the likelihood a patient receives HMAs.

Cigarette smoking shortens the survival of patients with low-risk myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are a group of hematological malignancies with poor survival. Although previous studies have identified the prognostic role of multiple demographic and clinical characteristics, the potential role of lifestyle factors has not been evaluated. In this study, we conducted an extensive assessment of the predictors of MDS survival, with a special focus on lifestyle factors. A total of 616 patients (median survival = 4.1 years) were included in the analysis, and multivariate Cox proportional hazard models were utilized to estimate hazard ratios. Compared with non-smokers, MDS patients who smoked at the initial clinical encounter had a significantly increased risk of death [hazard ratio (HR) = 1.46, 95% confidence intervals (CI): 1.07-2.00]. The elevated risk was restricted to men (HR = 1.76, 95% CI: 1.21-2.56) and not observed among women (HR = 0.98, 95% CI: 0.51-1.85). When patients were stratified by the IPSS categorization, a near three fold increased risk of death was associated with smoking among patients with low-risk MDS (HR = 2.83, 95% CI: 1.48-5.39), whereas smoking did not appear to influence the survival of patients with intermediate- or high-risk MDS. This study was the first to identify smoking as a significant and independent predictor of MDS survival, particularly among low-risk patients.