Impact of patient and provider characteristics on the treatment and outcomes of colorectal cancer

Adjuvant Chemotherapy Benefit in Elderly Stage II/III Colon Cancer Patients

Background

Studies providing more evidence to guide adjuvant chemotherapy decisions in elderly colon cancer patients are expected.

Methods

We obtained data from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2012. Kaplan-Meier survival curves were constructed to calculate the cancer-specific survival (CSS) rate, and comparisons of survival difference between different subgroups were performed using the log-rank test. Multivariate Cox proportional hazards regression models were carried out to estimate hazard ratio (HR) and 95% confidence intervals (CIs) of different clinicopathological characteristics.

Results

In stage II colon cancer patients aged 70 years or older, the Kaplan-Meier survival analysis showed that the 5-year CSS rates of no chemotherapy and chemotherapy groups were 82.0% and 72.4%, respectively (P < 0.001). In stage III colon cancer patients aged 70 years or older, the Kaplan-Meier survival analysis showed that the 5-year CSS rates of no chemotherapy and chemotherapy groups were 50.7% and 61.3%, respectively (P < 0.001). Patients with chemotherapy receipt were independently associated with a 35.8% lower cancer-specific mortality rate (HR = 0.642, 95% CI: 0.620-0.665, P < 0.001) compared with those who did not receive chemotherapy.

Conclusions

Adjuvant chemotherapy should be considered during the treatment of stage III colon cancer patients aged 70 years or older, but the chemotherapy benefit in elderly stage II colon cancer is suboptimal.

Racial disparities in treatments and mortality among a large population-based cohort of older men and women with colorectal cancer

Background:

There were racial disparities in treatment and mortality among patients with colorectal cancer, but few studies incorporated information on hypertension and diabetes and their treatment status.

Patients and methods:

The study identified 101,250 patients from Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in the United States who were diagnosed with colorectal cancer at age ≥65 years between 2007 and 2015 with follow-up to December 2016.

Results:

There were substantial racial and ethnic disparities in the prevalence of hypertension and diabetes in patients with colorectal cancer, in receiving chemotherapy and radiation therapy, and in receiving antihypertensive and antidiabetic treatment. Racial disparities in receiving these therapies remained significant in this large cohort of Medicare beneficiaries after stratifications by private health insurance status at the time of cancer diagnosis and by tumor stage. Non-Hispanic black patients had a significantly higher risk of all-cause mortality (hazard ratio: 1.07, 95% CI: 1.04–1.10), which remained significantly higher (1.05, 1.02–1.08) after adjusting for patient sociodemographics, tumor factors, comorbidity and treatments as compared to non-Hispanic white patients. The adjusted risk of colorectal cancer-specific mortality was also significantly higher (1.08, 1.04–1.12) between black and white patients.

Conclusions:

There were substantial racial disparities in prevalence of hypertension and diabetes in men and women diagnosed with colorectal cancer and in receipt of chemotherapy, radiation therapy, antihypertensive and antidiabetic treatment. Black patients with colorectal cancer had a significantly higher risk of all-cause mortality and colorectal cancer-specific mortality than whites, even after adjusting for sociodemographic characteristics, tumor factors, comorbidity scores, and treatments.

The Utility of Pathology Reports to Identify Persons With Cancer Recurrence

BACKGROUND

Cancer recurrence is an important measure of the impact of cancer treatment. However, no population-based data on recurrence are available. Pathology reports could potentially identify cancer recurrences. Their utility to capture recurrences is unknown.

OBJECTIVE

This analysis assesses the sensitivity of pathology reports to identify patients with cancer recurrence and the stage at recurrence.

SUBJECTS

The study includes patients with recurrent breast (n=214) or colorectal (n=203) cancers.

RESEARCH DESIGN

This retrospective analysis included patients from a population-based cancer registry who were part of the Patient-Centered Outcomes Research (PCOR) Study, a project that followed cancer patients in-depth for 5 years after diagnosis to identify recurrences.

MEASURES

Information abstracted from pathology reports for patients with recurrence was compared with their PCOR data (gold standard) to determine what percent had a pathology report at the time of recurrence, the sensitivity of text in the report to identify recurrence, and if the stage at recurrence could be determined from the pathology report.

RESULTS

One half of cancer patients had a pathology report near the time of recurrence. For patients with a pathology report, the report's sensitivity to identify recurrence was 98.1% for breast cancer cases and 95.7% for colorectal cancer cases. The specific stage at recurrence from the pathology report had a moderate agreement with gold-standard data.

CONCLUSIONS

Pathology reports alone cannot measure population-based recurrence of solid cancers but can identify specific cohorts of recurrent cancer patients. As electronic submission of pathology reports increases, these reports may identify specific recurrent patients in near real-time.

Race, Income, and Survival in Stage III Colon Cancer: CALGB 89803 (Alliance)

Background

Disparities in colon cancer outcomes have been reported across race and socioeconomic status, which may reflect, in part, access to care. We sought to assess the influences of race and median household income (MHI) on outcomes among colon cancer patients with similar access to care.

Methods

We conducted a prospective, observational study of 1206 stage III colon cancer patients enrolled in the CALGB 89803 randomized adjuvant chemotherapy trial. Race was self-reported by 1116 White and 90 Black patients at study enrollment; MHI was determined by matching 973 patients’ home zip codes with publicly available US Census 2000 data. Multivariate analyses were adjusted for baseline sociodemographic, clinical, dietary, and lifestyle factors. All statistical tests were 2-sided.

Results

Over a median follow-up of 7.7 years, the adjusted hazard ratios for Blacks (compared with Whites) were 0.94 (95% confidence interval [CI] = 0.66 to 1.35, P = .75) for disease-free survival, 0.91 (95% CI = 0.62 to 1.35, P = .65) for recurrence-free survival, and 1.07 (95% CI = 0.73 to 1.57, P = .73) for overall survival. Relative to patients in the highest MHI quartile, the adjusted hazard ratios for patients in the lowest quartile were 0.90 (95% CI = 0.67 to 1.19, P_trend = .18) for disease-free survival, 0.89 (95% CI = 0.66 to 1.22, P_trend = .14) for recurrence-free survival, and 0.87 (95% CI = 0.63 to 1.19, P_trend = .23) for overall survival.

Conclusions

In this study of patients with similar health-care access, no statistically significant differences in outcomes were found by race or MHI. The substantial gaps in outcomes previously observed by race and MHI may not be rooted in differences in tumor biology but rather in access to quality care.

Factors contributing to time to diagnosis in symptomatic colorectal cancer: A scoping review

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer worldwide (Ferlay et al., 2015, International Journal of Cancer, 136, E359), and delayed diagnosis is associated with mortality (Tørring et al., 2011, British Journal of Cancer, 104, 934; Tørring et al., 2012, Journal of Clinical Epidemiology, 65, 669). The purpose of this review was to determine the factors associated with time to diagnosis in symptomatic CRC using scoping review methods.

METHODS

We performed database and citation searches to identify studies which examine the length of any interval from symptom presentation to diagnosis. Study selection was conducted by two independent reviewers. Factors contributing to time to diagnosis were extracted from selected articles and mapped onto a conceptual framework consisting of four levels: patient and disease factors, provider factors, organisation/setting factors and sectors of influence.

RESULTS

From the 31 studies included in this review, we identified 138 unique factors, 17 of which were investigated by at least three studies and 11 of which had consistent results. Patient and disease factors were most commonly studied. Patient perception that their symptoms were benign, a non-urgent referral, female sex and rectal tumour location were each associated with a longer time to diagnosis.

CONCLUSION

Thus far, the literature has focused on patient or disease-related factors, while other levels of influence have been relatively understudied.

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

BACKGROUND

Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important.

OBJECTIVES

The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups.

METHODS

In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections.

RESULTS

We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included.

CONCLUSIONS

Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.

Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review

BACKGROUND

Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes.

METHODS

Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics.

RESULTS

There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (β = - 0.16, p < 0.001) and for each specialty (GS: β = - 0.18, p < 0.001; CRS β = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.

Margins in Sinonasal Squamous Cell Carcinoma: Predictors, Outcomes, and the Endoscopic Approach

OBJECTIVES

To identify factors associated with positive margins following surgical management of sinonasal squamous cell carcinoma (SNSCC), especially with regard to endoscopic treatment.

METHODS

In a retrospective analysis of adult patients with clinically staged tumor (T)1 to T4a SNSCC within the National Cancer Database (NCDB) from 2004 to 2014, factors were associated with positive margins using multivariable binary logistic regression. Cases from 2010 to 2014 had surgical approach (open vs. endoscopic) available and were analyzed in a subgroup to assess the association of surgical approach with margin status. The association of margin status with overall survival (OS) and additional therapy administration was also assessed.

RESULTS

We identified 2,968 cases, of which 807 (27.2%) had positive margins. On multivariable analysis, factors associated with positive margins included higher T stage (T4a vs. T1: odds ratio [OR] 2.768 [95% CI 2.143-3.577]), less differentiated tumors (poorly differentiated vs. well differentiated: OR 1.403 [95% CI 1.060-1.856]), and tumors in the ethmoid sinus (vs. nasal cavity; OR 1.889 [95% CI 1.305-2.734]). Cases treated at higher volume facilities (HVFs) were associated with a lower likelihood of positive margins (OR 0.716 [95% CI 0.582-0.881]). Positive margins were associated with decreased OS (hazard ratio 1.672 [95% CI 1.464-1.908]) and an increased rate of additional therapy (OR 1.966 [95% confidence interval 1.597-2.421]). An endoscopic approach was not associated with an increased likelihood of obtaining positive margins (vs. open; OR 1.151 [0.903-1.651]).

CONCLUSION

Positive margins were less likely when performed at HVFs and more likely in the ethmoid sinus than other subsites. Importantly, there was no association between positive margins and surgical approach. Endoscopic surgery may offer a safe, less invasive alternative to open surgery for select patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:E388-E396, 2020.

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

OBJECTIVE

To identify prognostic case volume thresholds of facilities that manage HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer-accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

EXPOSURES

Treatment of HNSCC at facilities with varying case volumes.

MAIN OUTCOMES AND MEASURES

Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

RESULTS

Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

CONCLUSIONS AND RELEVANCE

Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.

Impact of age on the use of adjuvant treatments in patients undergoing surgery for colorectal cancer: patients with stage III colon or stage II/III rectal cancer

Background

Many older patients don’t receive appropriate oncological treatment. Our aim was to analyse whether there are age differences in the use of adjuvant chemotherapy and preoperative radiotherapy in patients with colorectal cancer.

Methods

A prospective cohort study was conducted in 22 hospitals including 1157 patients with stage III colon or stage II/III rectal cancer who underwent surgery. Primary outcomes were the use of adjuvant chemotherapy for stage III colon cancer and preoperative radiotherapy for stage II/III rectal cancer. Generalised estimating equations were used to adjust for education, living arrangements, area deprivation, comorbidity and clinical tumour characteristics.

Results

In colon cancer 92% of patients aged under 65 years, 77% of those aged 65 to 80 years and 27% of those aged over 80 years received adjuvant chemotherapy (χ²_trends < 0.001). In rectal cancer preoperative radiotherapy was used in 68% of patients aged under 65 years, 60% of those aged 65 to 80 years, and 42% of those aged over 80 years (χ²_trends < 0.001). Adjusting by comorbidity level, tumour characteristics and socioeconomic level, the odds ratio of use of chemotherapy compared with those under age 65, was 0.3 (0.1–0.6) and 0.04 (0.02–0.09) for those aged 65 to 80 and those aged over 80, respectively; similarly, the odds ratio of use of preoperative radiotherapy was 0.9 (0.6–1.4) and 0.5 (0.3–0.8) compared with those under 65 years of age.

Conclusions

The probability of older patients with colorectal cancer receiving adjuvant chemotherapy and preoperative radiotherapy is lower than that of younger patients; many of them are not receiving the treatments recommended by clinical practice guidelines. Differences in comorbidity, tumour characteristics, curative resection, and socioeconomic factors do not explain this lower probability of treatment. Research is needed to identify the role of physical and cognitive functional status, doctors’ attitudes, and preferences of patients and their relatives, in the use of adjuvant therapies.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5910-z) contains supplementary material, which is available to authorized users.

Adjuvant Systemic Therapies in Patients with Colorectal Cancer: An Audit on Clinical Practice in Italy

Aims and Background

Rarely are conclusions from clinical trials summarized in international consensus conferences and promptly transferred to patient care. The adjuvant therapy for colorectal cancer used in daily clinical practice in Italy is described and compared with the recommendations of the 1990 NIH Consensus Conference.

Patients and Methods

We audited prescriptions of adjuvant systemic therapies for Italian colorectal cancer patients in 82 centers during a fixed one-week period.

Results

Among 434 patients receiving adjuvant chemotherapy there were 139 (42.5%) colon cancer patients with N- and 169 (51.7%) with N+ regional nodal involvement. Treatment at academic centers, a young age, T4 and a low total number of lymph nodes removed at surgery were the factors potentially justifying the decision for adjuvant chemotherapy in stage II colon cancer patients. The most common chemotherapy used was a bolus of 5-fluorouracil/folinic acid for 6 months (75.8%). Adjuvant radiotherapy was not administered to 37 (38.5%) of 96 patients with stage II and III rectal cancer.

Conclusions

The study shows that a substantial proportion of patients on adjuvant treatment at a certain time point in a large enough sample of Italian centers are stage II (potential over-treatment) and that an under-treatment of stage II and III rectal cancer patients (lack of radiotherapy) occurs too often in daily clinical practice in this country.

Association of the prognostic nutritional index and overall survival in patients with colorectal cancer: A STROBE compliant retrospective cohort study

BACKGROUND

The TNM classification does not completely reflect the prognosis of patients with colorectal cancer (CRC). Several clinical factors have been used to increase its prognostic value, but factors pertaining to the patient's immunonutritional status have not usually been addressed. The aim of this study is to evaluate the role of Prognostic nutritional index (PNI) and other well-known prognostic factors by multivariate analysis in a cohort of patients with CRC.

METHODS

This is a retrospective cohort study of consecutive patients with CRC managed in a cancer center between January 1992 and December 2016. Cox's model was used to define the association of the PNI and other factors with Overall survival (OS).

RESULTS

A total of 3301 patients were included: 47.7% were female and 52.3% were male, with a mean age of 58.7 years. By bivariate analysis, PNI was strongly associated with OS (Risk ratio [RR] 0.968, 95% Confidence interval [CI] 0.962-0.974; P < 0.001). On multivariate analysis, PNI was an independent explanatory variable (as continuous variable and as categorized variable; RR 0.732, 95% CI 0.611-0.878; RR 0.656, 95% CI 0.529-0.813 and RR 0.646, 95% CI 0.521-0.802, for quintiles 2, 3, and 4-5, respectively); a biological gradient effect was demonstrated. The final prognostic model included PNI, location of the neoplasia in the colorectum, basal hemoglobin, lymphocyte count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, TNM stage, differentiation degree, R classification, and postoperative complications.

CONCLUSIONS

PNI is a significant and independent prognostic factor in patients with CRC. Its prognostic value adds precision to the TNM staging system including specific subgroups of patients with CRC; it should be evaluated in prospective clinical studies.

Geographic variations in stage at diagnosis and survival for colorectal cancer in Australia: A systematic review

INTRODUCTION

Australia has one of the highest incidence rates of colorectal cancer (CRC) in the world. Residents in rural areas of Australia experience disadvantage in health care and outcomes. This review investigates whether patients with CRC in rural areas demonstrate poorer survival and more advanced stages of disease at diagnosis.

METHODS

Systematic review of peer-reviewed articles and grey literature. Studies were included if they provided data on survival or stage of disease at diagnosis across multiple geographical locations; focused on CRC patients; and were conducted in Australia.

RESULTS

Twenty-six articles met inclusion criteria. Twenty-three studies examined survival, while five studies investigated stage at diagnosis. The evidence suggests that non-metropolitan patients are less likely to survive CRC for five years compared to patients living in metropolitan areas, yet there was limited evidence to suggest geographical disparity in stage of diagnosis.

CONCLUSIONS

While five-year survival disparities are apparent, these patterns appear to vary as a function of specific region and health jurisdiction, cancer type and year/s of data collection. Future research should examine current data using consistent and robust methods of reporting survival and classifying geographical location. The impact of population-level screening programmes on survival and stage at diagnosis also needs to be thoroughly explored.

Effect of an Integrated Payment System on the Direct Economic Burden and Readmission of Rural Cerebral Infarction Inpatients: Evidence from Anhui, China

Rural China is piloting an integrated payment system, which prepays a budget to a medical alliance rather than a single hospital. This study aims to evaluate the effect of this reform on the direct economic burden and readmission rates of cerebral infarction inpatients. The settlement records of 78,494 cerebral infarction inpatients were obtained from the New Rural Cooperative Medical Scheme (NRCMS) database in Dingyuan and Funan Counties in the Anhui Province. The direct economic burden was estimated by total costs, out-of-pocket expenditures, the out-of-pocket ratio, and the compensation ratio of the NRCMS. Generalized additive models and multivariable linear/logistic regression were applied to measure the changes of the dependent variables along with the year. Within the county, the total costs positively correlated to the year (β = 313.10 in 2015; 163.06 in 2016). The out-of-pocket expenditures, out-of-pocket ratios, and the length-of-stay positively correlated to the year in 2015 (β = 105.10, 0.01, and 0.18 respectively), and negatively correlated to the year in 2016 (β = −58.40, −0.03, and −0.30, respectively). The odds ratios of the readmission rates were less than one within the county (0.70 in 2015; 0.53 in 2016). The integrated payment system in the Anhui Province has considerably reduced the direct economic burden for the rural cerebral infarction inpatients, and the readmission rate has decreased within the county. Inpatients’ health outcomes should be given further attention, and the long-term effect of this reform model awaits further evaluation.

Analysis of Physician Variation in Provision of Low-Value Services

IMPORTANCE

Facing new financial incentives to reduce unnecessary spending, health care organizations may attempt to reduce wasteful care by influencing physician practices or selecting more cost-effective physicians. However, physicians' role in determining the use of low-value services has not been well described.

OBJECTIVES

To quantify variation in provision of low-value health care services among primary care physicians and to estimate the proportion of variation attributable to physician characteristics that may be used to predict performance.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective analysis included national Medicare fee-for-service claims of 3 159 834 beneficiaries served by 41 773 generalist physicians from January 1, 2008, through December 31, 2013 (data were analyzed in 2016 through 2018). Multilevel modeling was used to estimate the extent of variation in service use across physicians within their region and provider organization, adjusted for patient clinical and sociodemographic characteristics and sampling variation. The proportion of variation attributable to physician characteristics that may be used to predict performance (age, sex, academic degree, professorship, publication record, trial investigation, grant receipt, pharmaceutical or device manufacturer payment, and panel size) was estimated via additional regression analysis.

MAIN OUTCOMES AND MEASURES

Annual count per beneficiary of 17 primary care-associated services that provide minimal clinical benefit.

RESULTS

Among the 3 159 834 beneficiaries (58.3% women; mean [SD] age, 73.2 [11.0] years) served by 41 773 physicians (74.9% men; mean [SD] age, 48.0 [10.1] years), the mean annual rate of low-value services was 33.1 services per 100 beneficiaries. Considerable variation across physicians within the same region was found (SD, 8.8 [95% CI, 8.7-8.9]; 90th:10th percentile ratio, 2.03 [95% CI, 2.01-2.06]) and across physicians within the same organization (SD, 6.1 [95% CI, 6.0-6.2]; 90th:10th percentile ratio, 1.61 [95% CI, 1.60-1.63]). The corresponding rates at the 10th percentile of physicians within region and within organization respectively were 21.8 and 25.3 services per 100 beneficiaries. Observable physician characteristics accounted for only 4.4% of physician variation within region and 1.4% of physician variation within organization.

CONCLUSIONS AND RELEVANCE

Physician practices may substantially contribute to low-value service use, which is prevalent even among the least wasteful physicians. Because little variation is predicted by measured physician characteristics, direct measures of low-value care provision may aid organizational efforts to encourage high-value practices.

Racial Differences in Hospital Stays among Patients Undergoing Craniotomy for Tumour Resection at a Single Academic Hospital

Background

Racial differences in American patients undergoing brain tumour surgery remain poorly characterized within urban medical centres. Our objective was to assess racial differences in operative brain tumour patients at a single academic hospital in Los Angeles, California.

Methods

We reviewed medical records of adult patients undergoing craniotomy for tumour resection from March 2013 to January 2017 at UCLA Medical Centre. Patients were categorized as Asian, Hispanic, Black, or White. Racial cohorts were matched on demographic variables for comparisons. Our primary outcome was post-operative length of stay (LOS). Secondary outcomes included hospital mortality and discharge disposition.

Results

In this study, 462 patients identified as Asian (15.1%), Hispanic (8.7%), Black (3.9%), or White (72.3%). After cohort matching, non-White patients had elevated risk of prolonged LOS [odds ratio (OR)=2.62 (1.44, 4.76)]. No differences were observed in hospital mortality or non-routine discharge. Longer LOS was positively correlated with non-routine discharge [r_pb (458)=0.41, p<0.001]. Black patients with government insurance had average LOS 2.84 days shorter than Black patients with private insurance (p=0.04). Among Hispanics, government insurance was associated with non-routine discharge [OR=4.93 (1.03, 24.00)].

Conclusion

Racial differences manifested as extended LOS for non-White patients, with comparable rates of hospital mortality and non-routine discharge across races. Prolonged LOS loosely reflected complicated clinical course with greater risk of adverse discharge disposition. Private insurance coverage predicted markedly lower risk of non-routine discharge for Hispanic patients, and LOS of three additional days among Black patients. Further research is needed to elucidate the basis of these differences.

Age-related inequalities in colon cancer treatment persist over time: a population-based analysis

Background

Older people experience poorer outcomes from colon cancer. We examined if treatment for colon cancer was related to age and if inequalities changed over time.

Methods

Data from the UK population-based Northern and Yorkshire Cancer Registry on 31 910 incident colon cancers (ICD10 C18) diagnosed between 1999–2010 were obtained. Likelihood of receipt of: (1) cancer-directed surgery, (2) chemotherapy in surgical patients, (3) chemotherapy in non-surgical patients by age, adjusting for sex, area deprivation, cancer stage, comorbidity and period of diagnosis, was examined.

Results

Age-related inequalities in treatment exist after adjustment for confounding factors. Patients aged 60– 69, 70–79 and 80+ years were significantly less likely to receive surgery than those aged <60 years (multivariable ORs (95% CI) 0.84(0.74 to 0.95), 0.54(0.48 to 0.61) and 0.19(0.17 to 0.21), respectively). Age-related differences in receipt of surgery and adjuvant chemotherapy (but not chemotherapy in non-surgical patients) narrowed over time for the ’younger old’ (aged <80 years) but did not diminish for the oldest patients.

Conclusions

Age inequality in treatment of colon cancer remains after adjustment for confounders, suggesting age remains a major factor in treatment decisions. Research is needed to better understand the cancer treatment decision-making process, and how to influence this, for older patients.

Survival trends among non-small-cell lung cancer patients over a decade: impact of initial therapy at academic centers

Background

Treatment of non‐small‐cell lung cancer (NSCLC) has been rapidly advancing over the last decade. Academic centers are considered equipped with better expertise. NSCLC outcome trends in novel therapeutic era and impact of initial treatment at academic centers have not been reported.

Methods

The National Cancer Database (NCDB) was used to identify NSCLC incident cases from 2004 to 2013. Overall survival (OS) was plotted by year of diagnosis and type of initial treatment center, accounting for several factors available in NCDB.

Results

A total of 1 150 722 NSCLC patients were included and separated by initial treatment center type (academic: 31.5%; nonacademic: 68.5%). Median follow‐up and OS for all patients were 11.8 months (range: 0‐133.6 months) and 13.1 months (95% CI: 13.08‐13.17), respectively. Median OS improved significantly for those diagnosed in 2010‐2013 (14.8 months [95% CI: 14.7‐14.9]) as compared to 2004‐2009 (12.4 months [95% CI: 12.3‐12.5]) (P < 0.001). Treatment at academic centers was associated with improved OS (multivariate HR for OS = 0.929 [95% CI: 0.92‐0.94], P < 0.0010). Four‐year OS for academic and nonacademic cohorts was 28.5%% and 22.1%, respectively (P < 0.001), and the difference was more pronounced in stage I to III NSCLC.

Conclusion

In this largest analysis, thus far, NSCLC survival has improved over time, and type of initial treatment center significantly influences survival. Identifying and removing barriers to obtaining initial treatment of NSCLC at academic medical centers could improve OS.

Establishment of three novel cell lines derived from African American patients with colorectal carcinoma: A unique tool for assessing racial health disparity

The incidence and mortality rates of colorectal carcinoma (CRC) are higher among African Americans (AAs) compared with Caucasian Americans (CAs). To assess the molecular properties associated with racial health disparity, three cell lines derived from colorectal tumors of three AA subjects were established. Cellular and molecular characterization of the cell lines designated CHTN06, SB501 and SB521 was performed using standard technologies, including immunofluorescence, electron microscopy, karyotyping, reverse transcription-polymerase chain reaction, ELISA and immunoblot analysis. The histology and morphology of CHTN06 xenografts were examined by hematoxylin and eosin staining. A total of three AA CRC cell lines derived from primary tumors were established and characterized. These cell lines were successfully cultured without immortalization and were found to be tumorigenic as mouse xenografts. In the present study, immunoblotting and immunofluorescence confirmed the expression of proteins known to be dysregulated in CRC, such as p53, DNA mismatch repair proteins and villin-1. Oncogenic miRNAs (i.e., miR-17, miR-21, miR-182, miR-210 and miR-222) were overexpressed in the AA CRC lines compared with the CA CRC lines (HT-29, HCT116 and SW480). Additionally, the AA CRC cell lines exhibited a differential inflammatory profile compared with HT-29 (CA CRC cell line); specifically noted was IL-8 secretion in response to inflammatory stimuli. In conclusion, three novel cell lines derived from AA CRC tissues were generated. These cell lines were characterized as epithelial in nature and exhibited differential expression of several miRNAs and inflammatory responses compared with commercially available cell lines of CA origin. The CRC cell lines CHTN06, SB501 and SB521 represent novel tools that may be used to provide diverse in vitro and in vivo models for studying CRC and racial health disparity.

Impact of Comorbidities on Survival in Gastric, Colorectal, and Lung Cancer Patients

BACKGROUND

The presence of comorbidities in cancer patients may influence treatment decisions and prognoses. This study aimed to examine the impact of comorbidities on overall survival in Japanese patients diagnosed with major solid tumors.

METHODS

To obtain patient-level information on clinical conditions and vital status, we performed a record linkage of population-based cancer registry data from Osaka Prefecture, Japan and administrative data produced under the Diagnosis Procedure Combination (DPC) system. The study population comprised patients who received a primary diagnosis of gastric, colorectal, or lung cancer between 2010 and 2012 at any of five cancer centers. We employed the Charlson Comorbidity Index (CCI) score to quantify the impact of comorbidities on survival. The association between CCI score and survival for each cancer site was analyzed using Cox proportional hazards regression models for all-cause mortality, after adjusting for patient sex, age at cancer diagnosis, and cancer stage.

RESULTS

A total of 2,609 patients with a median follow-up duration of 1,372 days were analyzed. The most frequent CCI score among the patients was 0 (77.7%), followed by 2 (14.3%). After adjusting for the covariates, we detected a significant association between CCI score and all-cause mortality. The hazard ratios per one-point increase in CCI score were 1.12 (95% confidence interval [CI], 1.02-1.23), 1.20 (95% CI, 1.08-1.34), and 1.14 (95% CI, 1.04-1.24) for gastric, colorectal, and lung cancer, respectively.

CONCLUSIONS

Comorbidities have a negative prognostic impact on overall survival in cancer patients, and should be assessed as risk factors for mortality when reporting outcomes.

A decade of improved access to screening is associated with fewer colorectal cancer deaths in African Americans: a single-center retrospective study

Background

Controversy exists as to whether disparities in colorectal cancer (CRC) outcomes in African Americans (AAs) are best resolved by screening at age 45 or by proper use of existing guidelines. In 2004, an aggressive colonoscopy-based CRC screening program was implemented throughout New York City. Our goal was to determine the effect of that program on CRC outcomes in our mostly AA population.

Methods

CRC cases entered into Harlem Hospital’s tumor registry from January 1992 to December 2011 were divided into two cohorts: 1992-2003, the pre-intensive screening era (PSE), and 2004-2011, the intensive screening era (ISE). Each cohort was reviewed for demographics, indication for colonoscopy, tumor location, tumor stage, and mortality. Multivariate analysis was applied to the pooled cohorts to determine factors associated with survival.

Results

Inclusion criteria were met by 379 patients: 207 PSE and 172 ISE. Racial distribution, gender, age at presentation, and tumor location were not different during the two eras. Over 75% of patients were AA. During the ISE, 84% were insured compared to 34% in the PSE (P<0.0001). Fewer patients died during the ISE (21%) than during the PSE (67%) (P<0.0001). The ISE patients were diagnosed with earlier stages of CRC compared to the PSE. Increased survival was associated with being insured (hazard ratio [HR] 1.91, 95% confidence interval [CI] 1.30-2.81), distal tumors (HR 1.43, 95%CI 1.05-1.95), and being female (HR 1.36, 95%CI 1.01-1.850).

Conclusions

A multifaceted program reduced CRC outcome disparities in a poor AA community. Aggressive implementation of current colonoscopy screening guidelines still has unrealized potential to reduce CRC mortality disparities in AAs.

Baseline serum albumin and other common clinical markers are prognostic factors in colorectal carcinoma: A retrospective cohort study

The aim of the present study was to define the prognostic role of baseline serum albumin (BSA) in colorectal cancer (CRC) across tumor-node-metastasis (TNM) stages and other well defined prognostic factors. Many prognostic models in medicine employ BSA to define or refine treatments in very specific settings; in CRC, BSA has been found to be a prognostic factor as well. A retrospective cohort study of consecutive patients with CRC demonstrated by biopsy, who attended a cancer center during a 7-year period. Multivariate analysis was utilized to define prognostic factors associated with overall survival (OS) employing the Cox model. In this retrospective cohort study, 1465 patients were included; 46.6% were females and 53.4% males (mean age, 59.1 years). Mean BSA was inversely correlated with TNM stages. By multivariate analysis, it was an independent explanatory variable. TNM stages, "R" classification, age, lymphocyte count, neutrophil/platelet ratio, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, postoperative morbidity, and BSA were independently associated with OS. Morbidities, surgery type, chemotherapy, and radiotherapy were considered confounders after adjusting by TNM stages. BSA is a significant and independent prognostic factor in patients with CRC, and its effect is maintained across TNM strata and other well known clinical prognostic factors. It can be easily used in prognostic models and should be employed to stratify prognosis in therapeutic randomized clinical trials.

Effects of Hospital Type and Distance on Lymph Node Assessment for Colon Cancer Among Metropolitan and Nonmetropolitan Patients in Appalachia

We studied differences in access to large or accredited cancer programs as a possible explanation for geographic disparities in adherence to the national guideline on lymph node assessment for Stages I to III colon cancer. State cancer registries were linked with Medicare claims of patients diagnosed from 2006 to 2008 from Appalachian counties of four states. Metropolitan and nonmetropolitan patients differed on adherence, proximity to high-volume or accredited hospitals, and hospital type. We modeled effects of hospital type on adherence with ordinary least squares and instrumental variables (instrumenting for hospital type with relative distance). The evidence was strongest for improved adherence in high-volume hospitals for nonmetropolitan patients. We estimate that roughly 100 deaths might be prevented over 5 years among each year's incident cases if the nonmetropolitan disparity in hospital volume were eliminated nationally. We conclude that regionalization or targeting smaller hospitals would improve adherence in nonmetropolitan areas, but also argue for improving adherence generally.

Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample

Background

The purpose of this study was to examine racial and socio-economic differences in the receipt of laparoscopic or open surgery among patients with colorectal cancer, and to determine if racial and socio-economic differences exist in post-surgical complications, in-hospital mortality and hospital length of stay among patients who received surgery.

Methods

We conducted a cross-sectional analysis of hospitalized patients with a primary diagnosis of colorectal cancer between 2007 and 2011 using data from Nationwide Inpatient Sample. ICD-9 codes were used to capture primary diagnosis, surgical procedures, and health outcomes during hospitalization. We used logistic regression analysis to determine racial and socio-economic predictors of surgery type, post-surgical complications and mortality, and linear regression analysis to assess hospital length of stay.

Results

A total of 122,631 patients were admitted with a primary diagnosis of malignant colorectal cancer between 2007 and 2011. Of these, 17,327 (14.13 %) had laparoscopic surgery, 70,328 (57.35 %) received open surgery, while 34976 (28.52 %) did not receive any surgery. Black (36 %) and Hispanic (34 %) patients were more likely to receive no surgery compared with Whites (27 %) patients. However, among patients that received any surgery, there were no racial differences in which surgery was received (laparoscopic versus open, p = 0.2122), although socio-economic differences remained, with patients from lower residential income areas significantly less likely to receive laparoscopic surgery compared with patients from higher residential income areas (OR: 0.74, 95 % CI: 0.70-0.78). Among patients who received any surgery, Black patients (OR = 1.07, 95 % CI: 1.01-1.13), and patients with Medicare (OR = 1.16, 95 % CI: 1.11-1.22) and Medicaid (OR = 1.15, 95 % CI: 1.07-1.25) insurance experienced significantly higher post-surgical complications, in-hospital mortality (Black OR = 1.18, 95 % CI: 1.00-1.39), and longer hospital stay (Black β = 1.33, 95 % CI: 1.16-1.50) compared with White patients or patients with private insurance.

Conclusion

Racial and socio-economic differences were observed in the receipt of surgery and surgical outcomes among hospitalized patients with malignant colorectal cancer in the US.

Colorectal cancer outcomes in patients aged over 85 years

INTRODUCTION

The prevalence of colorectal cancer is increasing in the elderly. We examined the treatment and outcomes in our institution of patients aged over 85 years with proven colorectal adenocarcinoma.

METHODS

One hundred and five patients were identified and stratified by treatment received: curative surgery (CS), other treatments (OT) or best supportive care (BSC). Data on demographics, staging, treatment and survival was collected and analysed.

RESULTS

Forty two patients received CS, 36 OT and 27 BSC. While the treated groups (CS and OT) were similar in terms of age (p=0.35) and staging (p=0.16), BSC patients were significantly older and had higher stage disease (p<0.01). Survival was significantly poorer among BSC patients, at a mean of 9.7 months (95% confidence interval [CI] 4.7-14.7) versus 41.6 months (95% CI 32.5-50.7) and OT 27.3 months (95% CI 20.4-34.1) for the CS and OT groups (p<0.001). There was no significant survival difference between CS and OT groups within 2 years of treatment (p=0.12). Thereafter, OT patients had a very similar 5-year survival to that of the BSC group, at 13% versus 43% in CS patients (p<0.001).

CONCLUSIONS

These data suggest that, up to 2 years following treatment, the risks of resectional surgery for colorectal cancer may neutralise any benefit. However, those that survive beyond this period show improvements. The challenge of improving patient selection is most acute in the growing ageing population, and highlights the current focus on presenting all treatment options to 'a reasonable patient'.

Impact of a diagnosis-related group payment system on cesarean section in Korea

Cesarean sections (CSs) are the most expensive method of delivery, which may affect the physician's choice of treatment when providing health services to patients. We investigated the effects of the diagnosis-related group (DRG)-based payment system on CSs in Korea. We used National Health Insurance claim data from 2011 to 2014, which included 1,289,989 delivery cases at 674 hospitals. We used a generalized estimating equation model to evaluate the association between the likelihood of cesarean delivery and the length of the DRG adoption period. A total of 477,309 (37.0%) delivery cases were performed by CSs. We found that a longer DRG adoption period was associated with a lower odds ratio of CSs (odds ratio [OR]: 0.997, 95% CI: 0.996-0.998). In addition, a longer DRG adoption period was associated with a lower odds ratio for CSs in hospitals that had voluntarily adopted the DRG system. Similar results were also observed for urban hospitals, primiparas, and those under 28 years old and over 33 years old. Our results suggest that the change in the reimbursement system was associated with a low likelihood of CSs. The impact of DRG adoption on cesarean delivery can also be expected to increase with time, as our finding provides evidence that the reimbursement system is associated with the health provider's decision to provide health services for patients.

Aberrant DNA Methylation: Implications in Racial Health Disparity

Background

Incidence and mortality rates of colorectal carcinoma (CRC) are higher in African Americans (AAs) than in Caucasian Americans (CAs). Deficient micronutrient intake due to dietary restrictions in racial/ethnic populations can alter genetic and molecular profiles leading to dysregulated methylation patterns and the inheritance of somatic to germline mutations.

Materials and Methods

Total DNA and RNA samples of paired tumor and adjacent normal colon tissues were prepared from AA and CA CRC specimens. Reduced Representation Bisulfite Sequencing (RRBS) and RNA sequencing were employed to evaluate total genome methylation of 5’-regulatory regions and dysregulation of gene expression, respectively. Robust analysis was conducted using a trimming-and-retrieving scheme for RRBS library mapping in conjunction with the BStool toolkit.

Results

DNA from the tumor of AA CRC patients, compared to adjacent normal tissues, contained 1,588 hypermethylated and 100 hypomethylated differentially methylated regions (DMRs). Whereas, 109 hypermethylated and 4 hypomethylated DMRs were observed in DNA from the tumor of CA CRC patients; representing a 14.6-fold and 25-fold change, respectively. Specifically; CHL1, 4 anti-inflammatory genes (i.e., NELL1, GDF1, ARHGEF4, and ITGA4), and 7 miRNAs (of which miR-9-3p and miR-124-3p have been implicated in CRC) were hypermethylated in DNA samples from AA patients with CRC. From the same sample set, RNAseq analysis revealed 108 downregulated genes (including 14 ribosomal proteins) and 34 upregulated genes (including POLR2B and CYP1B1 [targets of miR-124-3p]) in AA patients with CRC versus CA patients.

Conclusion

DNA methylation profile and/or products of its downstream targets could serve as biomarker(s) addressing racial health disparity.

How Does Outcomes Research Help Advance Our Knowledge of Patient Outcomes in Hepatopancreaticobiliary Surgery?

Randomized controlled trials have historically been regarded as the gold standard of modern clinical research tools, allowing us to elucidate the efficacy of novel therapeutics in an unparalleled manner. However, when attempting to generalize trial results to broader populations, it becomes apparent that the unexplained outcome variability exists among treatment recipients, suggesting that randomized controlled trials harbor inherent limitations. Herein, we explore the benefits of health services (outcomes) research utilization in addressing variation in patient outcomes following surgical intervention in the non-randomized setting, with a specific focus on hepatopancreaticobiliary surgery outcomes. To achieve this, we have constructed a framework that outlines the complex interactions existing between therapeutic, patient, and provider factors that subsequently lead to variation in outcomes. By exploring examples in the current literature, we have highlighted the areas where the knowledge is currently lacking and can be further strengthened through the application of outcomes research. Furthermore, we have attempted to demonstrate the utility of alternative study designs in the investigation of novel clinical questions currently unanswered in the field of hepatopancreaticobiliary surgery.

Lgr5 expression is a valuable prognostic factor for colorectal cancer: evidence from a meta-analysis

Background

Lgr5 has recently been identified as a reliable biomarker of cancer stem cells (CSCs) in colorectal cancer (CRC); however, its prognostic value is still controversial.

Methods

We searched PubMed, Web of Science, and Wanfang databases with identical strategies to retrieve articles. We evaluated the impact of Lgr5 expression on survival of CRC patients through meta-analysis.

Results

A total of 12 studies comprising 2600 patients revealed that Lgr5 overexpression was negatively associated with overall survival (OS) (HR = 1.73, 95 % CI: 1.28–2.33; P = 0.00) and disease free survival (DFS) (HR = 2.89, 95 % CI: 1.89–4.44; P = 0.000) in CRC patients. Subgroup analysis suggested that Lgr5 overexpression was significantly associated with worse OS in subgroups with IHC as the method of Lgr5 assessment (HR = 2.01, 95 % CI: 1.39–2.89; P = 0.001), patients from Asia (HR = 1.81, 95 % CI: 1.27–2.58; P = 0.000), and NOS scores greater than 6 (HR = 2.12, 95 % CI: 1.41–3.19; P = 0.000). Furthermore, sensitivity analysis showed that the estimated HR ranged from 1.6 to 1.86 upon excluding one study sequentially from each analysis. In addition, Lgr5 overexpression was significantly associated with deep invasion of CRC (OR = 0.39, 95 % CI: 0.17–0.87; P = 0.002), lymphnode metastasis (OR = 0.45, 95 % CI: 0.26–0.76; P = 0.003), distant metastasis (OR = 0.37, 95 % CI: 0.22–0.62; P = 0.000), and AJCC stage (OR = 0.35, 95 % CI: 0.15–0.78; P = 0.01). However, Lgr5 overexpression was not correlated with tumor grade (OR = 0.75 95 % CI: 0.37–1.54; P = 0.433).

Conclusions

This study shows that Lgr5 can be a valuable and reliable prognostic factor of colorectal cancer progression.

Lgr5 expression is a valuable prognostic factor for colorectal cancer: evidence from a meta-analysis

Background

Lgr5 has recently been identified as a reliable biomarker of cancer stem cells (CSCs) in colorectal cancer (CRC); however, its prognostic value is still controversial.

Methods

We searched PubMed, Web of Science, and Wanfang databases with identical strategies to retrieve articles. We evaluated the impact of Lgr5 expression on survival of CRC patients through meta-analysis.

Results

A total of 12 studies comprising 2600 patients revealed that Lgr5 overexpression was negatively associated with overall survival (OS) (HR = 1.73, 95 % CI: 1.28–2.33; P = 0.00) and disease free survival (DFS) (HR = 2.89, 95 % CI: 1.89–4.44; P = 0.000) in CRC patients. Subgroup analysis suggested that Lgr5 overexpression was significantly associated with worse OS in subgroups with IHC as the method of Lgr5 assessment (HR = 2.01, 95 % CI: 1.39–2.89; P = 0.001), patients from Asia (HR = 1.81, 95 % CI: 1.27–2.58; P = 0.000), and NOS scores greater than 6 (HR = 2.12, 95 % CI: 1.41–3.19; P = 0.000). Furthermore, sensitivity analysis showed that the estimated HR ranged from 1.6 to 1.86 upon excluding one study sequentially from each analysis. In addition, Lgr5 overexpression was significantly associated with deep invasion of CRC (OR = 0.39, 95 % CI: 0.17–0.87; P = 0.002), lymphnode metastasis (OR = 0.45, 95 % CI: 0.26–0.76; P = 0.003), distant metastasis (OR = 0.37, 95 % CI: 0.22–0.62; P = 0.000), and AJCC stage (OR = 0.35, 95 % CI: 0.15–0.78; P = 0.01). However, Lgr5 overexpression was not correlated with tumor grade (OR = 0.75 95 % CI: 0.37–1.54; P = 0.433).

Conclusions

This study shows that Lgr5 can be a valuable and reliable prognostic factor of colorectal cancer progression.

Racial disparities in operative outcomes after major cancer surgery in the United States

BACKGROUND

Numerous studies have recorded racial disparities in access to care for major cancers. We investigate contemporary national disparities in the quality of perioperative surgical oncological care using a nationally representative sample of American patients and hypothesize that disparities in the quality of surgical oncological care also exists.

METHODS

A retrospective, serial, and cross-sectional analysis of a nationally representative cohort of 3,024,927 patients, undergoing major surgical oncological procedures (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, pneumonectomy, pancreatectomy, and prostatectomy), between 1999 and 2009.

RESULTS

After controlling for multiple factors (including socioeconomic status), Black patients undergoing major surgical oncological procedures were more likely to experience postoperative complications (OR: 1.24; p < 0.001), in-hospital mortality (OR: 1.24; p < 0.001), homologous blood transfusions (OR: 1.52; p < 0.001), and prolonged hospital stay (OR: 1.53; p < 0.001). Specifically, Black patients have higher rates of vascular (OR: 1.24; p < 0.001), wound (OR: 1.10; p = 0.004), gastrointestinal (OR: 1.38; p < 0.001), and infectious complications (OR: 1.29; p < 0.001). Disparities in operative outcomes were particularly remarkable for Black patients undergoing colectomy, prostatectomy, and hysterectomy. Importantly, substantial attenuation of racial disparities was noted for radical cystectomy, lung resection, and pancreatectomy relative to earlier reports. Finally, Hispanic patients experienced no disparities relative to White patients in terms of in-hospital mortality or overall postoperative complications for any of the eight procedures studied.

CONCLUSIONS

Considerable racial disparities in operative outcomes exist in the United States for Black patients undergoing major surgical oncological procedures. These findings should direct future health policy efforts in the allocation of resources for the amelioration of persistent disparities in specific procedures.

Patterns of Care for Metastatic Colorectal Cancer in Appalachia, and the Clinical, Sociodemographic, and Service Provider Determinants

BACKGROUND

Appalachia has high colorectal cancer (CRC) incidence and mortality, at least in part due to screening disparities. This paper examines patterns and determinants of metastatic colorectal cancer care.

METHODS

CRC patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009.) The final sample after exclusions included 855 stage IV and 590 stages I-III patients with metachronous or synchronous metastases. We estimate bivariate and multivariate analyses for several surgical and chemotherapeutic strategies of care using clinical, sociodemographic, and contextual determinants.

RESULTS

Among 1,445 CRC patients, 84% had primary tumor resection and 44% received chemotherapy. Of the chemotherapy patients, 44% received newer systemic agents for at least 75% of the cycles. One year survivors with liver or lung metastases were more likely to have their primary tumor resected immediately (86.1% vs 69.5% for liver, and 78.2% vs 64.9% for lung) and have their metastases resected/ablated (15.7% vs 2.6% for liver and 15.0% vs 0.5% for lung). Patients with stages I-III primary tumors (versus IV) were much more likely to be resected, but they were less likely to receive chemotherapy. Patients with comorbidities (congestive heart failure, dementia, or respiratory disease) had lower odds of chemotherapy. Smaller hospital size and surgical volume had higher odds of immediate versus delayed surgery. The newer chemotherapeutic agents were more common with higher surgical volume.

CONCLUSIONS

Metastatic colorectal cancer has clinical, sociodemographic, and service provider determinants.

A moral dilemma argument against clinical trials of incentives for kidney donation

Commercial transplant tourism results in significant harm to both kidney donors and recipients. However, proponents of incentives for kidney donation assert that proper oversight of the process prevents these harms and also that transplant numbers can be safely increased so that the moral burden of poor end-stage kidney disease outcomes can be alleviated. In a moral dilemma analysis, the principle of preventing donor harm can be dissociated from the principles of providing benefits to the recipient and to society. It is plausible that an incentivized donor is fundamentally different from an uncompensated donor. Incentivized donors can experience harms unrelated to lack of regulation because their characteristics are determined by the incentive superimposed upon a poverty circumstance. Moreover, creating a system of incentivized donation without established national registries for capturing all long-term donor outcomes would be morally inconsistent, since without prior demonstration that donor outcomes are not income or wealth-dependent, a population of incentivized donors cannot be morally created in a clinical trial. Socioeconomic factors adversely affect outcome in other surgical populations, and interventions on income or wealth in these populations have not been studied. Coercion will be increased in families not affected by kidney disease, where knowledge of a new income source and not of a potential recipient is the incentive. In the case of elective surgery such as kidney donation, donor non-maleficence trumps donor autonomy, recipient beneficence, and beneficence to society when there is a conflict among these principles. Yet, we are still faced with the total moral burden of end-stage kidney disease, which belongs to the society that cannot provide enough donor kidneys. Acting according to one arm of the dilemma to prevent donor harm does not erase obligations towards the other, to provide recipient benefit. To resolve the moral burden, as moral agents, we must rearrange our institutions by increasing available donor organs from other sources. The shortage of donor kidneys creates a moral burden for society, but incentives for donation will only increase the total moral burden of end-stage kidney disease.

A Decade of Research on the Quality of Systemic Cancer Therapy in Routine Care: What Aspects of Quality Are We Measuring?

Most studies evaluating quality of systemic cancer therapy have focused on access to cytotoxic chemotherapy in early-stage disease. Studies on other aspects of quality and in different clinical settings are needed.

Differential expression of miRNAs in colon cancer between African and Caucasian Americans: implications for cancer racial health disparities

Colorectal cancer (CRC) incidence and mortality are higher in African Americans (AAs) than in Caucasian Americans (CAs) and microRNAs (miRNAs) have been found to be dysregulated in colonic and other neoplasias. The aim of this exploratory study was to identify candidate miRNAs that could contribute to potential biological differences between AA and CA colon cancers. Total RNA was isolated from tumor and paired adjacent normal colon tissue from 30 AA and 31 CA colon cancer patients archived at Stony Brook University (SBU) and Washington University (WU)‑St. Louis Medical Center. miRNA profiles were determined by probing human genome-wide miRNA arrays with RNA isolated from each sample. Using repeated measures analysis of variance (RANOVA), miRNAs were selected that exhibited significant (p<0.05) interactions between race and tumor or significant (fold change >1.5, p<0.05) main effects of race and/or tumor. Quantitative polymerase chain reaction (q-PCR) was used to confirm miRNAs identified by microarray analysis. Candidate miRNA targets were analyzed using immunohistochemistry. RANOVA results indicated that miR-182, miR152, miR-204, miR-222 and miR-202 exhibited significant race and tumor main effects. Of these miRNAs, q-PCR analysis confirmed that miR-182 was upregulated in AA vs. CA tumors and exhibited significant race:tumor interaction. Immunohistochemical analysis revealed that the levels of FOXO1 and FOXO3A, two potential miR-182 targets, are reduced in AA tumors. miRNAs may play a role in the differences between AA and CA colon cancer. Specifically, differences in miRNA expression levels of miR-182 may contribute to decreased survival in AA colon cancer patients.

Hospital and geographic variability in two colorectal cancer surgery outcomes: complications and mortality after complications

BACKGROUND

The purpose of this study was to describe hospital and geographic variation in 30-day risk of surgical complications and death among colorectal cancer (CRC) patients and the extent to which patient-, hospital-, and census-tract-level characteristics increased risk of these outcomes.

METHODS

We included patients at least 66 years old with first primary stage I-III CRC from the 2000-2005 National Cancer Institute's Surveillance, Epidemiology, and End Results data linked with 1999-2005 Medicare claims. A multilevel, cross-classified logistic model was used to account for nesting of patients within hospitals and within residential census tracts. Outcomes were risk of complications and death after a complication within 30 days of surgery.

RESULTS

Data were analyzed for 35,946 patients undergoing surgery at 1,222 hospitals and residing in 12,187 census tracts; 27.2 % of patients developed complications, and of these 13.4 % died. Risk-adjusted variability in complications across hospitals and census tracts was similar. Variability in mortality was larger than variability in complications, across hospitals and across census tracts. Specific characteristics increased risk of complications (e.g., census-tract-poverty rate, emergency surgery, and being African-American). No hospital characteristics increased complication risk. Specific characteristics increased risk of death (e.g. census-tract-poverty rate, being diagnosed with colon (versus rectal) cancer, and emergency surgery), while hospitals with at least 500 beds showed reduced death risk.

CONCLUSIONS

Large, unexplained variations exist in mortality after surgical complications in CRC across hospitals and geographic areas. The potential exists for quality improvement efforts targeted at the hospital and/or census-tract levels to prevent complications and augment hospitals' ability to reduce mortality risk.

Hospital and geographic variability in thirty-day all-cause mortality following colorectal cancer surgery

OBJECTIVE

To assess hospital and geographic variability in 30-day mortality after surgery for CRC and examine the extent to which sociodemographic, area-level, clinical, tumor, treatment, and hospital characteristics were associated with increased likelihood of 30-day mortality in a population-based sample of older CRC patients.

DATA SOURCES/STUDY SETTING

Linked Surveillance Epidemiology End Results (SEER) and Medicare data from 47,459 CRC patients aged 66 years or older who underwent surgical resection between 2000 and 2005, resided in 13,182 census tracts, and were treated in 1,447 hospitals.

STUDY DESIGN

An observational study using multilevel logistic regression to identify hospital- and patient-level predictors of and variability in 30-day mortality.

DATA COLLECTION/EXTRACTION METHODS

We extracted sociodemographic, clinical, tumor, treatment, hospital, and geographic characteristics from Medicare claims, SEER, and census data.

PRINCIPAL FINDINGS

Of 47,459 CRC patients, 6.6 percent died within 30 days following surgery. Adjusted variability in 30-day mortality existed across residential census tracts (predicted mortality range: 2.7-12.3 percent) and hospitals (predicted mortality range: 2.5-10.5 percent). Higher risk of death within 30 days was observed for CRC patients age 85+ (12.7 percent), census-tract poverty rate >20 percent (8.0 percent), two or more comorbid conditions (8.8 percent), stage IV at diagnosis (15.1 percent), undifferentiated tumors (11.6 percent), and emergency surgery (12.8 percent).

CONCLUSIONS

Substantial, but similar variability was observed across census tracts and hospitals in 30-day mortality following surgery for CRC in patients 66 years and older. Risk of 30-day mortality is driven not only by patient and hospital characteristics but also by larger social and economic factors that characterize geographic areas.

Disparities in survival improvement for metastatic colorectal cancer by race/ethnicity and age in the United States

PURPOSE

Previous studies documented significant increase in overall survival for metastatic colorectal cancer (CRC) since the late 1990s coinciding with the introduction and dissemination of new treatments. We examined whether this survival increase differed across major racial/ethnic populations and age groups.

METHODS

We identified patients diagnosed with primary metastatic colorectal cancer during 1992-2009 from 13 population-based cancer registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, which cover about 14 % of the US population. The 5-year cause-specific survival rates were calculated using SEER*Stat software.

RESULTS

From 1992-1997 to 2004-2009, 5-year cause-specific survival rates increased significantly from 9.8 % (95 % CI 9.2-10.4) to 15.7 % (95 % CI 14.7-16.6) in non-Hispanic whites and from 11.4 % (95 % CI 9.4-13.6) to 17.7 % (95 % CI 15.1-20.5) in non-Hispanic Asians, but not in non-Hispanic blacks [from 8.6 % (95 % CI 7.2-10.1) to 9.8 % (95 % CI 8.1-11.8)] or Hispanics [from 14.0 % (95 % CI 11.8-16.3) to 16.4 % (95 % CI 14.0-19.0)]. By age group, survival rates increased significantly for the 20-64-year age group and 65 years or older age group in non-Hispanic whites, although the improvement in the older non-Hispanic whites was substantially smaller. Rates also increased in non-Hispanic Asians for the 20-64-year age group although marginally nonsignificant. In contrast, survival rates did not show significant increases in both younger and older age groups in non-Hispanic blacks and Hispanics.

CONCLUSION

Non-Hispanic blacks, Hispanics, and older patients diagnosed with metastatic CRC have not equally benefitted from the introduction and dissemination of new treatments.

Referral patterns and treatment choices for patients with hepatocellular carcinoma: a United States population-based study

BACKGROUND

Patterns of care of physician specialists may differ for patients with hepatocellular carcinoma (HCC). Reasons underlying variations are poorly understood. One source of variation may be disparate referral rates to specialists, leading to differences in cancer-directed treatments.

STUDY DESIGN

Surveillance, Epidemiology, and End Results (SEER)-linked Medicare database was queried for patients with HCC, diagnosed between 1998 and 2007, who consulted 1 or more physicians after diagnosis. Visit and procedure records were abstracted from Medicare billing records. Factors associated with specialist consult and subsequent treatment were examined.

RESULTS

There were 6,752 patients with HCC identified; 1,379 (20%) patients had early-stage disease. Median age was 73 years; the majority were male (66%), white (60%), and from the West region (56%). After diagnosis, referral to a specialist varied considerably (hepatology/gastroenterology, 60%; medical oncology, 62%; surgery, 56%; interventional radiology [IR], 33%; radiation oncology, 9%). Twenty-two percent of patients saw 1 specialist; 39% saw 3 or more specialists. Time between diagnosis and visitation with a specialist varied (surgery, 37 days vs IR, 55 days; p = 0.04). Factors associated with referral to a specialist included younger age (odds ratio [OR] 2.16), Asian race (OR 1.49), geographic region (Northeast OR 2.10), and presence of early-stage disease (OR 2.21) (all p < 0.05). Among patients with early-stage disease, 77% saw a surgeon, while 50% had a consultation with medical oncologist. Receipt of therapy among patients with early-stage disease varied (no therapy, 30%; surgery, 39%; IR, 9%; chemotherapy, 23%). Factors associated with receipt of therapy included younger age (OR 2.48) and early-stage disease (OR 2.20).

CONCLUSIONS

After HCC diagnosis, referral to a specialist varied considerably. Both clinical and nonclinical factors were associated with consultation. Disparities in referral to a specialist and subsequent therapy need to be better understood to ensure all HCC patients receive appropriate care.

Do diagnostic and treatment delays for colorectal cancer increase risk of death?

BACKGROUND

Using 1998-2005 SEER-Medicare data, we examined the effect of diagnostic and treatment delays on all-cause and colorectal cancer (CRC)-specific death among US adults aged ≥ 66 years with invasive colon or rectal cancer. We hypothesized that longer delays would be associated with a greater risk of death.

METHODS

We defined diagnostic and treatment delays, respectively, as days between (1) initial medical consult for CRC symptoms and pathologically confirmed diagnosis (maximum: 365 days) and (2) pathologically confirmed diagnosis and treatment (maximum: 120 days). Cases (CRC deaths) and controls (deaths due to other causes or censored) were matched on survival time. Logistic regression analyses adjusted for sociodemographic, tumor, and treatment factors.

RESULTS

Median diagnostic delays were 60 (colon) and 40 (rectal) days and treatment delays were 13 (colon) and 16 (rectal) days in 10,663 patients. Colon cancer patients with the longest diagnostic delays (8-12 months vs. 14-59 days) had higher odds of all-cause (aOR: 1.31 CI: 1.08-1.58), but not CRC-specific death. Colon cancer patients with the shortest treatment delays (<1 vs. 1-2 weeks) had higher odds of all-cause (aOR: 1.23 CI: 1.01-1.49), but not CRC-specific death. Among rectal cancer patients, delays were not associated with risk of all-cause or CRC-specific death.

CONCLUSIONS

Longer delays of up to 1 year after symptom onset and 120 days for treatment did not increase odds of CRC-specific death. There may be little clinical benefit in detecting and treating existing symptomatic disease earlier. Screening prior to symptom onset must remain the primary goal to reduce CRC incidence, morbidity, and mortality.

The modifying effect of patient location on stage-specific survival following colorectal cancer using geosurvival models

Colorectal cancer (CRC) is the third leading cause of cancer death in the US, and stage at diagnosis is the primary prognostic factor. To date, the interplay between geographic place and individual characteristics such as cancer stage with CRC survival is unexplored. We used a Bayesian geosurvival statistical model to evaluate whether the spatial patterns of CRC survival at the census tract level varies by stage at diagnosis (in situ/local, regional, distant), controlling for patient characteristics, surveillance test use, and treatment using linked 1991-2005 SEER-Medicare data of patients ≥ 66 years old in two US metropolitan areas. The spatial pattern of survival varied by stage at diagnosis for both cancer sites and registries. Significant spatial effects were identified in all census tracts for colon cancer and the majority of census tracts for rectal cancer. Geographic disparities appeared to be highest for distant-stage rectal cancer. Compared to those with in situ/local stage in the same census tracts, patients with distant-stage cancer were at most 7.73 times and 4.69 times more likely to die of colon and rectal cancer, respectively. Moreover, frailty areas for CRC at in situ/local stage more likely have a higher relative risk at regional stage, but not at distant stage. We identified geographic areas with excessive risk of CRC death and demonstrated that spatial patterns varied by both cancer type and cancer stage. More research is needed to understand the moderating pathways between geographic and individual-level factors on CRC survival.

Assessing short- and long-term outcomes among black vs white Medicare patients undergoing resection of colorectal cancer

BACKGROUND

We sought to identify differences among black and white Medicare-insured patients with colorectal cancer who underwent resection.

METHODS

Surveillance, Epidemiology and End Results-Medicare (SEER-Medicare) linked inpatient data from 1986 to 2005 were examined. Differences in short- and long-term outcomes among black vs white patients were investigated.

RESULTS

There were 125,676 (92.4%) white and 9,891 (7.6%) black patients who met the criteria. Black patients were younger (75.5 vs 77.2 years; P < .001) but had more comorbidities than did white patients (mean Charlson comorbidity index score 3.99 vs 3.87; P < .001). Black patients demonstrated greater odds of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.30 to 1.56) and readmission within 30 days (OR, 1.26; 95% CI, 1.18 to 1.34). Comparing 1986 to 1990 vs 2001 to 2005, black patients had greater odds of 30-day readmission (OR, 1.12 vs 1.31) but reduced odds of index in-hospital mortality (OR, 1.84 vs 1.28). Black patients had worse long-term survival after colorectal surgery (hazard ratio [HR], 1.21; 95% CI, 1.17 to 1.25; P < .001).

CONCLUSIONS

Black patients with colorectal cancer demonstrated increased risk of mortality and readmission after controlling for age, sex, and comorbidities. Although black vs white differences in perioperative mortality decreased over time, disparities in readmission and long-term survival persisted.

Hospital volume of percutaneous radiofrequency ablation is closely associated with treatment outcomes for patients with hepatocellular carcinoma

BACKGROUND

Hospital volume for several major operations is associated with treatment outcomes. In this study, the authors explored the influence of hospital radiofrequency ablation (RFA) volume on the prognosis of patients who received RFA for hepatocellular carcinoma (HCC).

METHODS

The authors searched for all patients who were diagnosed with stage I or stage II HCC from 2004 to 2006 and who received RFA as first-line therapy in a population-based cohort. Overall survival (OS) and liver cancer-specific survival (CSS) were compared according to hospital volume. A Cox proportional hazards model was used for multivariate analysis.

RESULTS

In total, 661 patients received first-line RFA for stage I and II HCC in 28 hospitals. Among these, there were 480 patients (72.6%) in the high-volume group (those who received RFA at hospitals that treated >10 first-line patients per year), and there were 181 patients (27.4%) in the low-volume group (those who received RFA at hospitals that treated ≤ 10 first-line patients per year). The sex, age, stage, tumor size, and year of diagnosis for patients in the 2 groups did not differ significantly. Patients in the high-volume group demonstrated significantly longer OS and CSS than those in the low-volume group (5-year OS rate, 58.7% vs 47.2%; P = .001; 5-year CSS rate, 67.1% vs 57.1%; P = .009). After adjusting for covariates, high-volume hospitals remained an independent predictor of longer OS (hazard ratio, 0.57; P < .001) and CSS (hazard ratio, 0.57; P = .003).

CONCLUSIONS

Patients who received first-line RFA for HCC in high-volume hospitals demonstrated better survival outcomes.

Elderly patients with colon cancer have unique tumor characteristics and poor survival

BACKGROUND

The incidence of colon cancer increases with age, and colon cancer predominantly affects individuals >65 years old. However, there are limited data regarding clinical and pathologic factors, treatment characteristics, and survival of older patients with colon cancer. The objective of this study was to determine the effects of increasing age on colon cancer.

METHODS

Patients diagnosed with colon cancer between 1988 and 2006 were identified through the Los Angeles County Cancer Surveillance Program, in Southern California. Patients were stratified into 4 age groups: 18-49, 50-64, 65-79, and ≥80 years. Clinical and pathologic characteristics and disease-specific and overall survival were compared between patients from different age groups.

RESULTS

A total of 32,819 patients were assessed. Patients aged 18 to 49 and 65 to 79 years represented the smallest and largest groups, respectively. A near equal number of males and females were diagnosed with colon cancer in the 3 youngest age groups, whereas patients who were ≥80 years old were more commonly white and female. Tumor location was different between groups, and the frequency of larger tumors (>5 cm) was greatest in youngest patients (18-49 years). The oldest patients (≥80 years) were administered chemotherapy at the lowest frequency, and disease-specific and overall survival rates decreased with increasing age.

CONCLUSIONS

This investigation demonstrates that older age is associated with alterations in clinical and pathologic characteristics and decreased survival. This suggests that the phenotype of colon cancer and the efficacy of colon cancer therapies may be dependent on the age of patients.

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study

BACKGROUND

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.

METHODS

Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.

RESULTS

Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.

CONCLUSIONS

The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

Health-related quality of life differences between African Americans and non-Hispanic whites with head and neck cancer

BACKGROUND

Cancers of the head and neck are associated with detriments in health-related quality of life (HRQOL); however, little is known about different experiences between African Americans and non-Hispanic whites.

METHODS

HRQOL was measured by the Functional Assessment of Cancer Therapy - Head and Neck (FACT-H&N) approximately 5 months postdiagnosis among 222 patients with cancer from North Carolina. Higher scores represent better HRQOL. Regression models included sociodemographic characteristics and clinical factors.

RESULTS

African Americans reported higher physical well-being than whites (adjusted means, 23.1 vs 20.9). African Americans with incomes <$20,000 reported higher emotional well-being (21.4) and fewer head and neck symptoms (22.0). Non-Hispanic whites making <$20,000 reported the poorest emotional well-being (17.3), whereas African Americans making >$20,000 reported the most head and neck symptoms (18.7).

CONCLUSIONS

Further investigation is needed to explore variation in HRQOL experiences among different race and socioeconomic groups that may inform resource allocation to improve cancer care.