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De Veyra JMJ, Calma CS. Perceptions of Surgical and Other Medical Specialties about Medical Oncologists: A Survey among Physicians in a Filipino Tertiary Hospital. ASIAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.1055/s-0041-1729345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction There are unverified negative perceptions about medical oncologists. Identifying how they are perceived may provide guidance on how to strengthen the positive and correct the negative impressions.
Methods Questionnaires were distributed to 528 physicians. They were asked to answer a Likert scale of opposing descriptors.
Results Two hundred and fifty-nine of 528 physicians completed the questionnaire, yielding a 49% response rate. Medical oncologists were perceived to have a medical rather than social focus to their work, render holistic care, have a multifaceted role, communicate with many other professionals, work more effectively in a team, have deep relationships with patients, and care for their general well-being. They are considered to be the nonsporty, intellectual type, who do not consider themselves superior, but rather treat other physicians as colleagues. They are perceived to not only have the skills to deal with a psychiatric problem and a wide spectrum of patients, have a health education role, require a high level of intellectual skills, collaborate more with others, possess good interpersonal skills with an individual patient, but are also adept within a group. They are autonomous workers, but usually refer patients to other professionals as well. Lack of finances hinders referral to medical oncologists.
Conclusion Perceptions were generally positive in terms of breadth of professional outlook, degree of patient interaction, projected professional image, perception of own professional status, possession of skills for a wide professional scope of responsibility, level of rapport with patient and colleagues, and degree of professional interdependence. Mainly financial factors are the barriers to referral to medical oncologists.
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Affiliation(s)
- Jamila Marie J. De Veyra
- Department of Internal Medicine, Section of Medical Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, Manila, Philippines
| | - Clevelinda S. Calma
- Department of Internal Medicine, Section of Medical Oncology, Benavides Cancer Institute, University of Santo Tomas Hospital, Manila, Philippines
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Shelton RC, Brotzman LE, Crookes DM, Robles P, Neugut AII. Decision-making under clinical uncertainty: An in-depth examination of provider perspectives on adjuvant chemotherapy for stage II colon cancer. PATIENT EDUCATION AND COUNSELING 2019; 102:284-290. [PMID: 30262401 PMCID: PMC6377327 DOI: 10.1016/j.pec.2018.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/22/2018] [Accepted: 09/14/2018] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Decision-making about adjuvant chemotherapy (ACT) for stage II colon cancer is complex, particularly in light of clinical uncertainty regarding treatment benefits. Little is known about provider communication and factors influencing decision-making and recommendations in this setting. METHODS We recruited providers from six US cancer centers and hospitals who care for stage II colon cancer patients. Providers participated in a 30-45 minute interview. Transcripts of interviews were coded for qualitative analysis. RESULTS We interviewed 42 providers (Oncologists: 52%; surgeons: 24%; nurses: 14%). Though most providers were aware of stage II colon cancer treatment guidelines, their use and communication of recommended guidelines was limited. Most reported tailoring delivery and content of their communication, often based on perceived patient education level, but patient involvement in decision-making varied. Findings highlight the complexity of, ACT decision-making, including the central role of providers and family members. CONCLUSIONS Providers are not consistently following recommended guidelines for communicating about ACT among stage II colon cancer patients or eliciting patient preferences for involvement in treatment decisions. PRACTICE IMPLICATIONS Given clinical uncertainty surrounding use of ACT for stage II colon cancer, efforts are needed to enhance guideline implementation, provider education, and communication to facilitate decision-making.
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Affiliation(s)
- Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, USA.
| | - Laura E Brotzman
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, USA
| | - Danielle M Crookes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, USA
| | - Patrick Robles
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, USA
| | - AIfred I Neugut
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, USA
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Hsieh CI, Kuo RNC, Liang CC, Tsai HY, Chung KP. Differences in the outcomes of adjuvant chemotherapy for colon cancer prescribed by physicians in different disciplines: a population-based study in Taiwan. BMJ Open 2018; 8:e021341. [PMID: 30567819 PMCID: PMC6303636 DOI: 10.1136/bmjopen-2017-021341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 10/28/2018] [Accepted: 11/02/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES One feature unique to the Taiwanese healthcare system is the ability of physicians other than oncologists to prescribe systemic chemotherapy. This study investigated whether the care paths implemented by oncologists and non-oncologists differ with regard to patient outcomes. SETTING Data from the Taiwan Cancer Registry and National Health Insurance Database were linked to identify patients with colon cancer who underwent colectomy as first treatment within 3 months of diagnosis and adjuvant chemotherapy between 2005 and 2009. PARTICIPANTS AND METHODS Postoperative patients who underwent adjuvant chemotherapy were included in this study. The exclusion criteria included patients with stage IV disease, a positive surgical margin and early disease recurrence. Among the patients presenting with multiple primary cancers, we also excluded patients who were diagnosed with colon cancer but for whom this was not the first primary cancer. The variables included sex, age, comorbidities, disease stage, chemotherapy cycle and changes in treatment regimen as well as the specialty of treatment providers and their case volume. Cox regression models and Kaplan-Meier analysis were used to examine differences in outcomes in the matched cohorts. RESULTS We examined 3534 patients who were prescribed adjuvant chemotherapy by physicians from different disciplines. In terms of 5-year disease-free survival, no significant difference was observed between the groups of oncologists or surgeons among patients with stage II (90.02%vs88.99%) or stage III (77.64%vs79.99%) diseases. Patients who were subjected to changes in their chemotherapy regimens presented recurrence rates higher than those who were not. CONCLUSIONS The discipline of practitioners is seldom taken into account in most series. This is the first study to provide empirical evidence demonstrating that the outcomes of patients with colon cancer do not depend on the treatment path, as long as the selection criteria for adjuvant chemotherapy is appropriate. Further study will be required before making any further conclusions.
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Affiliation(s)
- Cheng-I Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Division of Hematology and Oncology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Raymond Nien-Chen Kuo
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
- Innovation and Policy Center for Population Health and Sustainable Environment, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chun-Chieh Liang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsin-Yun Tsai
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
- Innovation and Policy Center for Population Health and Sustainable Environment, College of Public Health, National Taiwan University, Taipei, Taiwan
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Yen TWF, Laud PW, Pezzin LE, McGinley EL, Wozniak E, Sparapani R, Nattinger AB. Prevalence and Consequences of Axillary Lymph Node Dissection in the Era of Sentinel Lymph Node Biopsy for Breast Cancer. Med Care 2018; 56:78-84. [PMID: 29087982 PMCID: PMC5725235 DOI: 10.1097/mlr.0000000000000832] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity. OBJECTIVE Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND. RESEARCH DESIGN/SUBJECTS Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009. MEASURES Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated. RESULTS Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases. CONCLUSIONS In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.
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Affiliation(s)
- Tina W F Yen
- Department of Surgery
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Purushottam W Laud
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics
| | - Liliana E Pezzin
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine
| | - Emily L McGinley
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Erica Wozniak
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Rodney Sparapani
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics
| | - Ann B Nattinger
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine
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Coping With Prediagnosis Symptoms of Colorectal Cancer: A Study of 244 Individuals With Recent Diagnosis. Cancer Nurs 2017; 40:145-151. [PMID: 27044057 DOI: 10.1097/ncc.0000000000000361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) symptoms are often vague and vary in severity, intensity, type, and timing. Receipt of medical care is dependent on symptom recognition and assessment, which may impede timely diagnosis. OBJECTIVE The aim of this study was to describe and categorize how CRC patients coped with symptoms prior to seeking medical care, examine sociodemographic differences in these coping strategies, and determine the strategies associated with time to seek medical care and overall time to diagnosis. METHODS Two hundred forty-four white and African American patients in Virginia and Ohio who received a diagnosis of CRC and who experienced symptoms prior to diagnosis were administered a semistructured interview and the Brief COPE questionnaire. RESULTS Eighty-three percent used more than 1 coping strategy. Common symptom-specific coping strategies were to "wait-and-see," self-treat, and rationalize symptoms. Males were more likely to wait and see (P < .001); African Americans and Medicaid recipients were more likely to self-treat via lifestyle changes (P's < .01). Younger individuals (<50 years old) had higher Brief COPE reframing, planning, and humor scores; those with lower education and income had higher denial scores (P's < .01). Using more symptom-specific coping strategies and engaging in avoidance/denial were associated with longer time to seek medical care and overall time to diagnosis (P's < .01). CONCLUSIONS Individuals experiencing CRC symptoms use multiple, diverse coping strategies that are influenced by sociodemographic characteristics. Denial is particularly relevant for delay in seeking care and timely diagnosis. IMPLICATIONS FOR PRACTICE Public health campaigns could focus on secondary prevention of CRC by targeting at-risk groups such as males, African Americans, or Medicaid recipients, who choose waiting or self-treatment in response to initial symptoms.
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Racial and Socioeconomic Disparities Are More Pronounced in Inflammatory Breast Cancer Than Other Breast Cancers. J Cancer Epidemiol 2017; 2017:7574946. [PMID: 28894467 PMCID: PMC5574219 DOI: 10.1155/2017/7574946] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/11/2017] [Indexed: 01/04/2023] Open
Abstract
Inflammatory breast cancer (IBC) is a rare yet aggressive form of breast cancer. We examined differences in patient demographics and outcomes in IBC compared to locally advanced breast cancer (LABC) and all other breast cancer patients from the Breast and Prostate Cancer Data Quality and Patterns of Care Study (POC-BP), containing information from cancer registries in seven states. Out of 7,624 cases of invasive carcinoma, IBC and LABC accounted for 2.2% (N = 170) and 4.9% (N = 375), respectively. IBC patients were more likely to have a higher number (P = 0.03) and severity (P = 0.01) of comorbidities than other breast cancer patients. Among IBC patients, a higher percentage of patients with metastatic disease versus nonmetastatic disease were black, on Medicaid, and from areas of higher poverty and more urban areas. Black and Hispanic IBC patients had worse overall and breast cancer-specific survival than white patients; moreover, IBC patients with Medicaid, patients from urban areas, and patients from areas of higher poverty and lower education had worse outcomes. These data highlight the effects of disparities in race and socioeconomic status on the incidence of IBC as well as IBC outcomes. Further work is needed to reveal the causes behind these disparities and methods to improve IBC outcomes.
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Mamounas E, Poulos C, Goertz HP, González JM, Pugh A, Antao V. Neoadjuvant Systemic Therapy for Breast Cancer: Factors Influencing Surgeons' Referrals. Ann Surg Oncol 2016; 23:3510-3517. [PMID: 27283292 PMCID: PMC5009159 DOI: 10.1245/s10434-016-5296-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Indexed: 11/18/2022]
Abstract
Background This study aimed to assess the influence of disease- and patient-related factors on surgeons’ decisions to refer patients with early-stage breast cancer (EBC) for neoadjuvant systemic therapy (NST). Methods An online survey of United States surgeons evaluated the influence of selected disease- and patient-related factors on surgeons’ decisions, rated their influence (individually and in combination), and provided a relative ranking of jointly considered factors using best–worst scaling. Results The participants in this study were 100 licensed surgeons. The surgeons referred approximately 25 % of EBC patients for NST to improve surgical management. Approximately 75 % of the surgeons agreed that NST is important for EBC, if only to improve surgical management. More than half were “very likely” to refer EBC patients for NST based on anatomicopathologic factors. Less than 50 % were “very likely” to do so when considering tumor phenotype factors. Tumor size and lymph node status were ranked highest in hypothetical patient scenarios. Regarding combinations of factors, the importance of any single factor varied according to the combinations presented. Less than half of the respondents were “very familiar,” and half were “somewhat familiar” with NST guidelines for breast cancer. More than half of the respondents were unaware that findings have shown achievement of pathologic complete response (pCR) after NST to be associated with improved survival. Conclusions Surgeons’ decision to refer for NST is strongly driven by surgical management goals. Anatomicopathologic factors are more influential than tumor phenotype. However, no single disease or patient factor consistently drives the decision to refer for NST. Surgeons’ awareness of the association between pCR achievement and longer survival could be improved. Electronic supplementary material The online version of this article (doi:10.1245/s10434-016-5296-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | - Amy Pugh
- RTI Health Solutions, Research Triangle Park, NC, USA
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Influence of patient, physician, and hospital characteristics on the receipt of guideline-concordant care for inflammatory breast cancer. Cancer Epidemiol 2015; 40:7-14. [PMID: 26605428 DOI: 10.1016/j.canep.2015.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/23/2015] [Accepted: 11/06/2015] [Indexed: 01/01/2023]
Abstract
PURPOSE Inflammatory breast cancer (IBC) is an aggressive subtype of breast cancer for which treatments vary, so we sought to identify factors that affect the receipt of guideline-concordant care. METHODS Patients diagnosed with IBC in 2004 were identified from the Breast and Prostate Cancer Data Quality and Patterns of Care Study, containing information from cancer registries in seven states. Variation in guideline-concordant care for IBC, based on National Comprehensive Cancer Network (NCCN) guidelines, was assessed according to patient, physician, and hospital characteristics. RESULTS Of the 107 IBC patients in the study without distant metastasis at the time of diagnosis, only 25.8% received treatment concordant with guidelines. Predictors of non-concordance included patient age (≥70 years), non-white race, normal body mass index (BMI 18.5-25 kg/m(2)), patients with physicians graduating from medical school >15 years prior, and smaller hospital size (<200 beds). IBC patients survived longer if they received guideline-concordant treatment based on either 2003 (p=0.06) or 2013 (p=0.06) NCCN guidelines. CONCLUSIONS Targeting factors associated with receipt of care that is not guideline-concordant may reduce survival disparities in IBC patients. Prompt referral for neoadjuvant chemotherapy and post-operative radiation therapy is also crucial.
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Yen TWF, Laud PW, Sparapani RA, Nattinger AB. Surgeon specialization and use of sentinel lymph node biopsy for breast cancer. JAMA Surg 2014; 149:185-92. [PMID: 24369337 DOI: 10.1001/jamasurg.2013.4350] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema. OBJECTIVE To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer. DESIGN, SETTING, AND POPULATION A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined. MAIN OUTCOME AND MEASURE Type of axillary surgery performed. RESULTS Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB. CONCLUSIONS AND RELEVANCE Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Purushuttom W Laud
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Rodney A Sparapani
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Ann B Nattinger
- Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
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Siminoff L, Thomson M, Dumenci L. Factors associated with delayed patient appraisal of colorectal cancer symptoms. Psychooncology 2014; 23:981-8. [PMID: 24615789 DOI: 10.1002/pon.3506] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 01/09/2014] [Accepted: 01/27/2014] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the relationship between symptoms, financial and cognitive barriers with patient delays in seeking evaluation of symptoms. METHODS Data were collected from 252 colorectal cancer patients from academic and community oncology practices in Virginia and Ohio. We used a cross-sectional, mixed methods design collected data through patient interviews and medical record reviews. Structural equation modeling (SEM) tested the hypothesized relationships between symptoms, financial and cognitive barriers and patient care seeking delays. RESULTS In bivariate analyses, patients who reported a financial barrier to accessing health care (t (246) = -2.6, p < 0.01) were more likely to have greater care-seeking delays. Model testing revealed that experiencing cognitive barriers was a significant, positive, direct predictor of appraisal delay (0.35; p < 0.01). Indirect pathways from symptoms (0.07; p < 0.05) and financial barriers (0.09; p < 0.05) to appraisal delay via cognitive barriers were significant. CONCLUSIONS Patient interpretations of symptoms were influenced by financial barriers. Conceptualizing financial barriers as a component of the symptom appraisal process is conceptually different from viewing it as only a structural barrier preventing healthcare access. Implications for practice These findings extend our understanding of why and how patients seemingly ignore serious symptoms, which hamper physician ability to provide curative therapy. In addition to uninsured patients, this may have important implications for the treatment and care of those who are underinsured.
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Affiliation(s)
- Laura Siminoff
- College Health Professions & Social Work, Jones Hall 302, Philadelphia, PA, USA
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Wu XC, Lund MJ, Kimmick GG, Richardson LC, Sabatino SA, Chen VW, Fleming ST, Morris CR, Huang B, Trentham-Dietz A, Lipscomb J. Influence of race, insurance, socioeconomic status, and hospital type on receipt of guideline-concordant adjuvant systemic therapy for locoregional breast cancers. J Clin Oncol 2011; 30:142-50. [PMID: 22147735 DOI: 10.1200/jco.2011.36.8399] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE For breast cancer, guidelines direct the delivery of adjuvant systemic therapy on the basis of lymph node status, histology, tumor size, grade, and hormonal receptor status. We explored how race/ethnicity, insurance, census tract-level poverty and education, and hospital Commission on Cancer (CoC) status were associated with the receipt of guideline-concordant adjuvant systemic therapy. METHODS Locoregional breast cancers diagnosed in 2004 (n = 6,734) were from the National Program of Cancer Registries-funded seven-state Patterns of Care study of the Centers for Disease Control and Prevention. Predictors of guideline-concordant (receiving/not receiving) adjuvant systemic therapy, according to National Comprehensive Cancer Network Guidelines, were explored by logistic regression. RESULTS Overall, 35% of women received nonguideline chemotherapy, 12% received nonguideline regimens, and 20% received nonguideline hormonal therapy. Significant predictors of nonguideline chemotherapy included Medicaid insurance (odds ratio [OR], 0.66; 95% CI, 0.50 to 0.86), high-poverty areas (OR, 0.77; 95% CI, 0.62 to 0.96), and treatment at non-CoC hospitals (OR, 0.69; 95% CI, 0.56 to 0.85), with adjustment for age, registry, and clinical variables. Predictors of nonguideline regimens among chemotherapy recipients included lack of insurance (OR, 0.47; 95% CI, 0.25 to 0.92), high-poverty areas (OR, 0.71; 95% CI, 0.51 to 0.97), and low-education areas (OR, 0.65; 95% CI, 0.48 to 0.89) after adjustment. Living in high-poverty areas (OR, 0.78; 95% CI, 0.64 to 0.96) and treatment at non-CoC hospitals (OR, 0.68; 95% CI, 0.55 to 0.83) predicted nonguideline hormonal therapy after adjustment. ORs for poverty, education, and insurance were attenuated in the full models. CONCLUSION Sociodemographic and hospital factors are associated with guideline-concordant use of systemic therapy for breast cancer. The identification of modifiable factors that lead to nonguideline treatment may reduce disparities in breast cancer survival.
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Affiliation(s)
- Xiao-Cheng Wu
- Louisiana State University Health Sciences Center, 1615 Poydras St, Suite 1400, New Orleans, LA 70112, USA.
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Kirkpatrick HM, Aitelli CL, Qin H, Becerra C, Lichliter WE, McCollum AD. Referral patterns and adjuvant chemotherapy use in patients with stage II colon cancer. Clin Colorectal Cancer 2010; 9:150-6. [PMID: 20643619 DOI: 10.3816/ccc.2010.n.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about the actual rate of use of adjuvant chemotherapy in stage II colon cancer and about referral patterns that give patients access to this treatment. PATIENTS AND METHODS We searched the tumor registry at Baylor University Medical Center at Dallas to identify patients with stage II colon cancer who underwent resection between 1995 and 2003. The rates of referral to medical oncology and adjuvant chemotherapy use were calculated and potential predictive variables were analyzed using univariate and multivariate techniques. RESULTS We identified 287 patients with stage II colon cancer. A total of 160 patients (56%) were referred to a medical oncologist. Eighty patients (28%) received adjuvant chemotherapy. Age < 50 years, private insurance status, lower comorbidity score, higher T stage, and poor tumor differentiation were significant predictors of adjuvant chemotherapy use (P <or= .05). CONCLUSION Variability and controversy exist over the use of adjuvant chemotherapy in patients with stage II colon cancer. Our study suggests many patients are not referred to a medical oncologist and may not be fully informed of all treatment options. Referral patterns become more important as a better understanding of recurrence risk is achieved and patient selection for adjuvant chemotherapy is optimized.
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Affiliation(s)
- Haskell M Kirkpatrick
- Texas Oncology, PA, Baylor Sammons Cancer Center and Department of Oncology, Baylor University Medical Center, Dallas, TX 75246, USA
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Puts MT, Monette J, Girre V, Costa-Lima B, Wolfson C, Batist G, Bergman H. Potential Medication Problems in Older Newly Diagnosed Cancer Patients in Canada during Cancer Treatment. Drugs Aging 2010; 27:559-72. [DOI: 10.2165/11537310-000000000-00000] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Tisnado DM, Malin JL, Tao ML, Ganz P, Rose-Ash D, Hu AF, Adams J, Kahn KL. The structural landscape of the health care system for breast cancer care: results from the Los Angeles Women's Health Study. Breast J 2008; 15:17-25. [PMID: 19120382 DOI: 10.1111/j.1524-4741.2008.00666.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The structure of health care has been rapidly evolving in response to financial pressures and demands to improve quality. Little work has documented the structure of care and its impact in the context of breast cancer care. We conducted a survey to characterize Los Angeles physicians caring for breast cancer patients and the structural landscape of the healthcare system in which they practice. Cross-sectional survey of physicians who treated a population-based cohort of breast cancer patients. We surveyed 477 physicians, targeting all Los Angeles County medical oncologists, radiation oncologists, and surgeons reported by patients participating in the Los Angeles Women's Health Study (77% response rate). Specialty-specific questionnaires were developed. Items were based on the structure and quality of care literature, cognitive interviews with cancer care specialists, and existing physician survey instruments. Breast cancer care providers in Los Angeles are diverse, with one-third non-white and 46% speaking a non-English language. Group practice is most common, (37% single specialty, 16% group-model HMO, 8% multi-specialty group). Minimal teaching involvement predominates. Mean new breast cancer patient volumes are relatively high (8 per month overall; six for surgeons), representing 46% of new cancer patients. Physicians reported high career satisfaction levels (83-92%). Physicians were least satisfied with the amount of time spent with patients (82%). Data from this study represent important building blocks for further analyses to determine the impact of structural characteristics on the quality of care that breast cancer patient's experience.
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Affiliation(s)
- Diana M Tisnado
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California, Los Angeles, California 90095-1736, USA.
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Erci B, Süreyya Özdemir. Psychometric properties of the Treatment Decision Evaluation Scale in patients with cancer in Turkey. Eur J Oncol Nurs 2008; 12:464-8. [DOI: 10.1016/j.ejon.2008.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Revised: 05/07/2008] [Accepted: 05/08/2008] [Indexed: 11/29/2022]
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Albritton KH, Wiggins CH, Nelson HE, Weeks JC. Site of Oncologic Specialty Care for Older Adolescents in Utah. J Clin Oncol 2007; 25:4616-21. [DOI: 10.1200/jco.2006.08.4103] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose Adolescents with cancer may access oncologic care from pediatric or adult medical centers, given overlapping age eligibility. However, some recent data suggest a benefit to adolescents with certain cancers when treated at pediatric centers or on pediatric protocols. We used a population-based registry to determine the site of care of children, adolescents, and young adults (age 0 to 24 years) with newly diagnosed cancer. Patients and Methods From the Utah Cancer Registry 1994 to 2000, new malignant cases in patients aged 0 to 24 years were chosen; data including diagnosis, home ZIP code and sites of oncologic care were abstracted. Distance between home ZIP code and Primary Children's Medical Center (PCMC; Salt Lake City, Utah), the state's sole site of pediatric oncology care, was determined. Results Sixty-six percent of Utah 15- to 19-year-olds with cancer were never seen by a PCMC oncologist. Even among this narrow age range, utilization of the pediatric center dropped with each additional year of age. Not unexpectedly, few of those with epithelial malignancies in this age group were seen at PCMC. But surprisingly, 47% of the older adolescents with leukemia, 66% with brain tumors, and 71% with lymphoma never saw a pediatric oncologist. After consideration of age and diagnosis, distance the patient lived from PCMC had a negligible effect on the likelihood of an adolescent being seen there. Conclusion The referral of adolescents with cancer to a pediatric oncology center diminishes greatly with age, and is moderately influenced by diagnosis and minimally by distance from center. Further study should investigate reasons for referral patterns, and impact on outcomes.
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Affiliation(s)
- Karen H. Albritton
- From the Dana-Farber Cancer Institute, Boston, MA; University of Utah, Salt Lake City, Utah; and the University of New Mexico, Albuquerque, NM
| | - Charles H. Wiggins
- From the Dana-Farber Cancer Institute, Boston, MA; University of Utah, Salt Lake City, Utah; and the University of New Mexico, Albuquerque, NM
| | - Harold E. Nelson
- From the Dana-Farber Cancer Institute, Boston, MA; University of Utah, Salt Lake City, Utah; and the University of New Mexico, Albuquerque, NM
| | - Jane C. Weeks
- From the Dana-Farber Cancer Institute, Boston, MA; University of Utah, Salt Lake City, Utah; and the University of New Mexico, Albuquerque, NM
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Luo R, Giordano SH, Freeman JL, Zhang D, Goodwin JS. Referral to medical oncology: a crucial step in the treatment of older patients with stage III colon cancer. Oncologist 2006; 11:1025-33. [PMID: 17030645 PMCID: PMC1913211 DOI: 10.1634/theoncologist.11-9-1025] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Adjuvant chemotherapy for stage III colon cancer produces a substantial survival benefit, but many older patients do not receive chemotherapy. This study examines factors associated with medical oncology consultation and evaluates the impact of such consultation on chemotherapy use. PATIENTS AND METHODS We used the Surveillance Epidemiology and End Results-Medicare linked database and identified 7,569 patients, aged 66-99, with stage III colon cancer diagnosed from 1992-1999. Modified Poisson regression was used to assess the relative risk for seeing a medical oncologist and for receiving chemotherapy as a function of individual characteristics. RESULTS 78.08% of patients saw a medical oncologist within 6 months of diagnosis. Patients who were female, white, married, had low comorbidity scores, were diagnosed in more recent years, or had four or more positive lymph nodes were more likely to see a medical oncologist. Patients seeing a medical oncologist were 10 times more likely to receive chemotherapy (odds ratio, 9.98; 95% confidence interval, 8.21-12.14), after controlling for demographic and tumor characteristics. Chemotherapy use increased over time, but was substantially lower among older, black, and unmarried patients. CONCLUSIONS Referral to medical oncology is one of the most important factors associated with receipt of chemotherapy among older patients with stage III colon cancer. Comorbidity decreases the likelihood of receiving chemotherapy, but its effect is the same for those who see a medical oncologist and all patients combined. Ensuring that high-risk patients are referred to medical oncology is a crucial step in quality care for patients with colon cancer.
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Affiliation(s)
- RuiLi Luo
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Sharon H. Giordano
- Department of Breast Medical Oncology, University of Texas M. D. Anderson Cancer Center, Galveston, Texas, USA
| | - Jean L. Freeman
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Dong Zhang
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - James S. Goodwin
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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Keating NL, Landrum MB, Guadagnoli E, Winer EP, Ayanian JZ. Factors related to underuse of surveillance mammography among breast cancer survivors. J Clin Oncol 2006; 24:85-94. [PMID: 16382117 DOI: 10.1200/jco.2005.02.4174] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Many older breast cancer survivors do not undergo annual mammography despite guideline recommendations. We identified factors associated with underuse of surveillance mammography and examined whether variation was explained by differences in follow-up care. PATIENTS AND METHODS We used Surveillance, Epidemiology, and End Results-Medicare data to identify a population-based sample of 44,511 women fee-for-service Medicare enrollees aged > or = 65 years who were diagnosed with stage I or II breast cancer in 1992 to 1999 who underwent primary surgical therapy. We assessed factors associated with mammography during months 7 to 18, 19 to 30, and 31 to 42 after breast cancer diagnosis using repeated-measures logistic regression; and we examined whether follow-up care with providers of various specialties explained variation in mammography use. RESULTS Only three quarters of women (77.6%) underwent mammography during months 7 to 18 after diagnosis, and only 56.7% had mammography yearly over 3 years. In multivariable analyses, women who were older, black, unmarried, and living in certain regions were less likely than other women to undergo surveillance mammography (all P < .05). Patients with more visits and patients who continued to see a medical oncologist, radiation oncologist, or surgeon were most likely to have mammograms (P < .001); however, adjusting for visits with providers did not explain the lower mammography rates based on age, race, marital status, and geographic region. CONCLUSION Many elderly breast cancer survivors do not undergo annual surveillance mammography, particularly women who are older, black, and unmarried, and this underuse was not explained by access to follow-up care. New strategies are needed to increase use of surveillance mammography and decrease variations based on nonclinical factors that are likely unrelated to appropriateness of medical care.
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Affiliation(s)
- Nancy L Keating
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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20
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Du XL, Key CR, Dickie L, Darling R, Geraci JM, Zhang D. External Validation of Medicare Claims for Breast Cancer Chemotherapy Compared With Medical Chart Reviews. Med Care 2006; 44:124-31. [PMID: 16434911 PMCID: PMC2567101 DOI: 10.1097/01.mlr.0000196978.34283.a6] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although Medicare claims data have been increasingly used to examine the patterns and outcomes of cancer chemotherapy, their external validity has not been well studied. OBJECTIVES We sought to validate Medicare claims for chemotherapy compared with medical chart reviews. PATIENTS AND METHODS We completed medical chart reviews for 1228 women who were diagnosed with breast cancer at age 65 and older between 1993 and 1999 in New Mexico that were linked with Medicare claims data, achieving an estimated sensitivity of more than 90% and a 0.05 level of precision. RESULTS Of the 150 subjects identified by Medicare claims as receiving chemotherapy within 6 months of diagnosis, 75% were confirmed by medical records as having received chemotherapy. Of the remaining 25% of cases without chart verification, (1) 33 cases had 7 or more claims for chemotherapy and also had specific chemotherapy drugs indicated in Medicare data, representing 22% (33/150) of all cases that received chemotherapy according to Medicare claims and (2) 4 cases had 1 to 6 claims for chemotherapy, representing 3% (4/150) of all cases with claims for chemotherapy. Of those 1078 subjects who did not receive chemotherapy according to Medicare claims, more than 99% were confirmed by chart reviews. Observed agreement on chemotherapy between Medicare claims and chart reviews was 94% and overall reliability (kappa) was 0.69 (95% confidence interval = 0.63-0.76). CONCLUSIONS Of cases identified as receiving chemotherapy by Medicare claims, 97% had strong evidence and only 3% had weak evidence for receiving this therapy.
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Affiliation(s)
- Xianglin L Du
- School of Public Health, Division of Epidemiology, University of Texas Health Science Center, Houston, Texas 77030, USA.
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Abstract
Increasing age remains the major risk factor for breast cancer and more than half of all breast cancers in North America and the European Union occur in women 65 years and older. Anticipated life expectancy, co-morbidity, and functional status must all be considered when offering systemic adjuvant treatment to older women. Tamoxifen significantly decreases the risk of recurrence and improves survival in all women with hormone receptor-positive invasive breast cancer, including women 70 years and older. More recently, aromatase inhibitors have been shown to be even more effective than tamoxifen in reducing breast cancer recurrence in postmenopausal women, and are an appropriate choice for initial endocrine therapy in older women. Adjuvant chemotherapy improves survival in postmenopausal women, but adds little to endocrine therapy in the majority of women with node-negative, hormone receptor-positive tumors. Chemotherapy should be considered for patients with high-risk node-negative, hormone receptor-negative tumors and those with node-positive tumors. Co-morbidity and its effect on survival should be factored into all chemotherapy decisions. Older women are frequently under-treated and are still under-represented in clinical trials; sometimes this represents good clinical judgment, but age bias alone can result in under-treatment and higher breast cancer-related mortality or state-of-the-art trials not being offered to older, but otherwise eligible, patients. Physician education and more clinical trials designed for older women are needed.
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Affiliation(s)
- S M Witherby
- Vermont Cancer Center, University of Vermont College of Medicine, Burlington, Vermont 05401, USA
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Abstract
Breast cancer is a disease of older women, and its incidence continues to rise with the growth and aging of the U.S. population. Elderly women have frequently been under-treated and have been poorly represented in clinical breast cancer trials. We reviewed the literature on early breast cancer in older women. We present current information on the tumor biology of elderly women and the role of surgical therapy and adjuvant treatment with hormonal therapy, chemotherapy, biologic agents, and radiation therapy in its management. Lastly, we discuss the importance of clinical trials in the elderly and future directions for therapy.
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Affiliation(s)
- S M Witherby
- Department of Medicine, University of Vermont College of Medicine, Vermont Cancer Center, Burlington, Vermont 05401, USA
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Du XL, Key CR, Dickie L, Darling R, Delclos GL, Waller K, Zhang D. Information on chemotherapy and hormone therapy from tumor registry had moderate agreement with chart reviews. J Clin Epidemiol 2005; 59:53-60. [PMID: 16360561 PMCID: PMC2567281 DOI: 10.1016/j.jclinepi.2005.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2004] [Revised: 05/06/2005] [Accepted: 06/12/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surveillance, Epidemiology, and End Results (SEER) cancer registries provide accurate information on cancer surgery and radiation, but the validity of registry data on chemotherapy and hormone therapy for breast cancer has not been well studied. We validated the registry data for chemotherapy and hormone therapy against an independent medical chart review. METHODS We identified 1,228 women diagnosed with breast cancer at age > or = 65 in 1993-1999 in the New Mexico SEER Tumor Registry and completed medical chart reviews. RESULTS Overall, there was moderate agreement between these two databases on chemotherapy that was received within 6 months of diagnosis. The observed agreement was 96.0%, with a kappa of 0.72 (95% confidence interval: 0.64-0.79). The sensitivity of the registry data for chemotherapy was 70.7% and the specificity was 98.2%. The positive predictive value of the registry data for chemotherapy was 77.8%. The sensitivity of the registry data for hormone therapy was 59.7%, and the specificity was 89.5%. The observed agreement for hormone therapy was 80.0%, with a kappa of 0.52 (0.46-0.57). CONCLUSION Agreement on chemotherapy and hormone therapy between the New Mexico SEER Tumor Registry and chart reviews was moderate. The preferred approach would be to combine data from different sources to obtain more complete information.
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Affiliation(s)
- Xianglin L Du
- School of Public Health, Department of Epidemiology, University of Texas Health Science Center, 1200 Herman Pressler Drive, RAS-E631, Houston, TX 77030, USA.
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Thwin SS, Fink AK, Lash TL, Silliman RA. Predictors and outcomes of surgeons' referral of older breast cancer patients to medical oncologists. Cancer 2005; 104:936-42. [PMID: 15986400 PMCID: PMC1266293 DOI: 10.1002/cncr.21256] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Older women are less likely than younger women to receive definitive care for a new diagnosis of breast cancer, but the reasons are not well understood. Although coordination of referral among specialists is an important component of quality of care, it has not been studied as a factor that contributes to observed age-related variations in breast cancer care. METHODS Treatment recommendations by 191 surgeons of 559 patients aged > or = 65 years with Stage I to IIIa breast cancer provided patient-specific assessments of comorbidity and medical oncologist referral. Demographic, tumor, and treatment characteristics from medical records and telephone interviews were evaluated by statistical regression methods to identify factors associated with referral to a medical oncologist and to evaluate whether a referral resulted in discussion and prescription of tamoxifen. RESULTS Estrogen receptor protein negativity and higher tumor stage increased the likelihood of referral (odds ratio [OR] = 5.6, 95% confidence interval [CI] = 1.9-16.7, and OR = 4.2, 95% CI = 1.7-10.3, respectively), whereas a moderate to severely ill health status decreased the likelihood of referral (OR = 0.4, 95% CI = 0.2-0.9). Those referred were twice as likely to report having a discussion about tamoxifen (OR = 2.0, 95% CI = 1.06-3.7) and to have been prescribed tamoxifen (OR = 2.1, 95% CI = 0.99-4.3). CONCLUSIONS Referral to medical oncologists is associated with receipt of adjuvant tamoxifen therapy. The current study findings suggest that more consistent referral of older women to medical oncologists may enhance quality of discussion and participation in decisions concerning treatment options.
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Affiliation(s)
- Soe Soe Thwin
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts 02118, USA.
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Maly RC, Umezawa Y, Leake B, Silliman RA. Determinants of participation in treatment decision-making by older breast cancer patients. Breast Cancer Res Treat 2004; 85:201-9. [PMID: 15111757 DOI: 10.1023/b:brea.0000025408.46234.66] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE To identify the impact of patient age and patient-physician communication on older breast cancer patients' participation in treatment decision-making. METHODS We conducted a cross-sectional survey of breast cancer patients aged 55 years or older (n = 222) in Los Angeles County. Patients received a breast cancer diagnosis between 1998 and 2000, and were interviewed on average 7.1 months (SD = 2.9) from diagnosis. All patient-physician communication variables were measured by patient self-report. Patient participation in treatment decision-making was defined by (1) questioning the surgeon about treatment, and (2) perception of self as the final decision-maker. RESULTS In multiple logistic regression analyses, surgeons' specific solicitation of patients' input about treatment preferences had positive relationships with both dimensions of patient participation in decision-making, that is, questioning the surgeon (adjusted odds ratio [OR] = 2.09, 95% confidence interval [CI] = 1.05-4.16) and perceiving oneself to be the final decision-maker (OR = 2.38, CI = 1.08-5.28), controlling for patients' sociodemographic and case-mix characteristics and social support. Greater emotional support from surgeons was negatively associated with patient perception of being the final decision-maker. Physicians' information-giving and patient age were not associated with the participation measures. However, greater patient-perceived self-efficacy in patient-physician interactions was related to participation. CONCLUSION In breast cancer patients aged 55 years and older, surgeons' solicitation of patients' treatment preferences was a powerful independent predictor of patient participation in treatment decision-making, as was patient's self-efficacy in interacting with physicians. Increasing both physicians' and patients' partnership-building skills might enhance the quality of treatment decision-making and treatment outcomes in this burgeoning patient population.
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Affiliation(s)
- Rose C Maly
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90024-2933, USA.
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Neuner JM, Gilligan MA, Sparapani R, Laud PW, Haggstrom D, Nattinger AB. Decentralization of breast cancer surgery in the United States. Cancer 2004; 101:1323-9. [PMID: 15368323 DOI: 10.1002/cncr.20490] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Physician volume of at least 15-30 annual breast cancer operations has been associated with higher 5-year survival rates. The authors sought to determine whether surgical volumes for breast cancer in the United States frequently reach this threshold. METHODS The authors conducted a retrospective cohort study of 987 surgeons who operated on 8105 Medicare patients with breast cancer during 1994-1995 in 6 areas in the Surveillance, Epidemiology and End Results tumor registry. The 2-year physician volume of breast cancer operations was estimated among Medicare patients (approximating the on-average annual volumes for patients of all ages) and its association was examined with physician characteristics and with 3 measures of surgical care. RESULTS The median 2-year Medicare volume for breast cancer surgeons was 6, and 79% of physicians performed < or = 12 operations. Approximately 50% of patients were cared for by physicians who performed < or = 12 operations over 2 years, and 10% of patients were cared for by physicians who performed > or = 30 operations. Surgeon characteristics of age, female gender, general surgery board certification, and academic affiliation were associated with modestly higher volumes of breast cancer surgery. Higher surgeon volumes were associated with higher patient receipt of breast-conserving surgery, testing for hormone receptors, and lymph node dissection during mastectomy. CONCLUSIONS Most physicians who perform breast cancer surgery perform few annual operations in Medicare patients, and lower volumes are associated with differences in surgical processes of care. Because patients in the Medicare age group comprise almost 50% of all incident breast cancer cases, surgical volumes for patients of all ages also are likely to be low. It is likely that only approximately 10% of patients in the United States are treated by surgeons who performing at least 30 annual operations.
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Affiliation(s)
- Joan M Neuner
- Department of Medicine, Medical College of Wisconsin, Milwaukee 53226, USA.
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Abstract
The major risk factor for breast cancer is increasing age and more than half of all breast cancers in affluent nations occur in women 65 years and older. Co-morbidity is a key consideration in offering systemic adjuvant treatment to older women since significant co-morbidity minimizes the potential value of any adjuvant therapy. Tamoxifen has clearly been shown to significantly decrease the risk of recurrence and improve survival in women of all ages who have estrogen (ER) or progesterone receptor (PR) positive invasive breast cancer, including those 70 years and older. Chemotherapy in older patients can improve survival but adds little to tamoxifen in women with node-negative, ER+ or PR+ tumors: it should be reserved for older women who have reasonable life-expectancy and larger node-negative tumors, or node-positive tumors. Ageism is still a barrier to clinical trials participation and clinical trials focusing on older women are needed.
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Affiliation(s)
- H B Muss
- University of Vermont College of Medicine, Vermont Cancer Center, Burlington, VT 05401, USA.
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Affiliation(s)
- Nina A Bickell
- Department of Health Policy, Mount Sinai School of Medicine, New York, NY, USA
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Earle CC, Neumann PJ, Gelber RD, Weinstein MC, Weeks JC. Impact of referral patterns on the use of chemotherapy for lung cancer. J Clin Oncol 2002; 20:1786-92. [PMID: 11919235 DOI: 10.1200/jco.2002.07.142] [Citation(s) in RCA: 142] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the extent to which unexplained variation in the use of chemotherapy for advanced lung cancer is due to access to oncologists' services as opposed to treatment decisions made after seeing an oncologist. METHODS We performed a retrospective cohort study of 12,015 patients over age 65 diagnosed with metastatic lung cancer between 1991 and 1996 while living in one of 11 regions monitored by a Survival, Epidemiology, and End Results (SEER) tumor registry. Assessment by an oncologist and subsequent treatment with chemotherapy were determined by examining linked Medicare claims. RESULTS Of patients who did not receive chemotherapy, 36% were never assessed by a physician who provides chemotherapy. Patients living in certain areas, those diagnosed in more recent years, and those who received care in a teaching hospital were all more likely to see a cancer specialist. These factors were unrelated to subsequent treatment decisions, however. Conversely, age and comorbidity did not have a significant effect on whether a patient was seen by an oncologist, but they were associated with the likelihood of subsequently receiving chemotherapy. Black race, probably acting as a proxy for lower socioeconomic status, was associated with both a diminished likelihood of seeing a cancer specialist and subsequently receiving chemotherapy. CONCLUSION Nonmedical factors are important determinants of whether a lung cancer patient is seen by a physician who provides chemotherapy. After seeing such a physician, treatment decisions seem to be mostly explained by appropriate medical factors. Racial and socioeconomic disparities still exist at both steps, however. As therapeutic options expand, referring physicians must ensure that biases and barriers to care do not deprive patients of the opportunity to consider all of their treatment options.
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Affiliation(s)
- Craig C Earle
- Center for Outcomes and Policy Research, Dana-Farber Cancer Center, Boston, MA 02115, USA.
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Affiliation(s)
- Alan Coates
- The Cancer Council Australia, Sydney, New South Wales.
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Abstract
OBJECTIVES To characterize the tests ordered for surveillance of breast cancer recurrence in the 4 years after breast cancer diagnosis by surgeons, medical oncologists, and radiation oncologists. RESEARCH DESIGN 303 stage I or II breast cancer patients age 55-years or older and diagnosed at 1 of 5 Boston hospitals. Patient interviews and medical record abstracts provided the data to characterize patient demographics, the breast cancer stage and its primary therapy, and the surveillance procedures ordered. RESULTS 279 of the 303 women had some surveillance testing. Among those who received some surveillance, a mean of 22.0 tests were ordered, most by their medical oncologists (mean = 14.4), followed by their surgeons (mean = 9.7) and their radiation oncologists (mean = 5.7). The most common test was a mammogram (mean = 3.9). Women ages 75 to 90 years old were at higher risk for failure to complete four consecutive years of surveillance and for receipt of less than guideline surveillance. Younger women, women treated at a breast cancer center with a unified patient chart, and women who worked full or part time were at lower risk for failure to complete 4 years of surveillance. CONCLUSION Most women in this cohort received some surveillance after completing primary therapy for breast cancer. Although no woman's surveillance corresponded exactly to existing guidelines, the oldest women were least likely to receive guideline surveillance. Surveillance after breast cancer therefore joins the list of aspects of breast cancer care-breast cancer screening, diagnosis, prognostic evaluation, and primary therapy-for which older women receive less than definitive care.
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Affiliation(s)
- T L Lash
- School of Public Health, Boston University Medical Center, Massachusetts 02118, USA.
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Nattinger AB. Care for breast cancer: the adoption of newer clinical paradigms. Med Care 2000; 38:693-5. [PMID: 10901352 DOI: 10.1097/00005650-200007000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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