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Maganty A, Kaufman SR, Oerline MK, Lai LY, Caram MEV, Shahinian VB, Hollenbeck BK. National Trends in Management of Newly Diagnosed Prostate Cancer. Clin Genitourin Cancer 2024; 22:10-17. [PMID: 37468340 DOI: 10.1016/j.clgc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Deciding whether to treat or conservatively manage patients with prostate cancer is challenging. Recent changes in guidelines, advances in treatment technologies, and policy can influence decision making surrounding management, particularly for those for whom the decision to treat is discretionary. Contemporary trends in management of newly diagnosed prostate cancer are unclear. METHODS Using national Medicare data, men with newly diagnosed prostate cancer were identified between 2014 and 2019. Patients were classified by 5- and 10-year noncancer mortality risk. Multinomial logistic regression models were fit to assess adjusted trends in management over time. The primary outcome was management of prostate cancer: local treatment (inclusive of surgery, radiation, brachytherapy, or cryotherapy), hormone therapy, or observation. RESULTS Local treatment was the most common form of management and stable across years (68%). Use of observation increased (21%-23%, P < .001) and use of hormone therapy decreased (11%-8%, P < 0.001). After stratifying by 10-year non-cancer mortality risk, observation increased among men with low (22.3%-26.1%, P < .001) and moderate (19.9%-23.5%, P < .001) mortality risk. Conversely, use of treatment increased among those with high (62.8%-68.0%, P = .004) and very high (45.5%-54.1%, P < .001) risk of noncancer mortality. These trends were similar across groups when stratified by 5-year noncancer mortality risk. CONCLUSION Nationally, use of local treatment remains common and was stable throughout the study period. However, while local treatment declined among men with a lower risk of noncancer mortality, it increased among men with a higher risk of non-cancer mortality.
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Affiliation(s)
- Avinash Maganty
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary K Oerline
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lillian Y Lai
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Megan E V Caram
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Brent K Hollenbeck
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Maganty A, Kaufman SR, Oerline MK, Faraj KS, Caram MEV, Shahinian VB, Hollenbeck BK. Value-based payment models and management of newly diagnosed prostate cancer. Cancer Med 2023; 13:e6810. [PMID: 38146905 PMCID: PMC10807592 DOI: 10.1002/cam4.6810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer. METHODS Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis. RESULTS Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]). CONCLUSIONS How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.
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Affiliation(s)
- Avinash Maganty
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Samuel R. Kaufman
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Mary K. Oerline
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Kassem S. Faraj
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
| | - Megan E. V. Caram
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- VA Health Services Research & Development, Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Vahakn B. Shahinian
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
- Division of Nephrology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Brent K. Hollenbeck
- Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMichiganUSA
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Faraj KS, Kaufman SR, Herrel LA, Oerline MK, Maganty A, Shahinian VB, Hollenbeck BK. Association between urology practice use of multiparametric MRI and genomic testing and treatment of men with newly diagnosed prostate cancer. Urol Oncol 2023; 41:430.e17-430.e23. [PMID: 37580226 PMCID: PMC10836888 DOI: 10.1016/j.urolonc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/12/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Biomarkers for prostate cancer, such as multiparametric MRI (mpMRI) and tissue-based genomics, are increasingly used for treatment decision-making. Using biomarkers indiscriminately and thus ignoring competing risks of mortality may lead to treatment in some men who derive little clinical benefit. We assessed the relationship between urology practice use of biomarkers and subsequent treatment in men with newly diagnosed prostate cancer. METHODS We used a 20% random sample of national Medicare data to perform a retrospective cohort study of men with newly diagnosed prostate cancer diagnosed from 2015 through 2019. Urology practice-level use of biomarkers was characterized based on urology practice propensity to use either biomarker after diagnosis (never, below median, above the median). Noncancer mortality risk within 10 years of diagnosis was calculated for all men. Multilevel models were used to assess the relationship between practice-level biomarker use and treatment by noncancer mortality risk. RESULTS Between 2015 and 2019, 1,764 (65%) urology practices used mpMRI and 897 (33%) used genomic testing for prostate cancer. Compared with urology practices never using each biomarker, those using mpMRI above the median (56% vs. 47%, P = 0.003) and tissue-based genomics below the median (56% vs. 50%, P = 0.03) were more likely to treat men with >75% risk of noncancer mortality. Additionally, compared with urology practices never using either biomarker, use of mpMRI (72% vs. 69%, P = 0.07) or tissue-based genomics (71% vs. 70%, P = 0.65) did not impact treatment in the healthiest group (i.e., those with <25% risk of noncancer mortality). CONCLUSIONS Compared to practices that do not use each biomarker in men with newly diagnosed prostate cancer, urology practices using mpMRI, and tissue-based genomics to a lesser extent, are more likely to treat men at very high risk of dying from competing risks of mortality within 10 years of prostate cancer diagnosis.
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Affiliation(s)
- Kassem S Faraj
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary K Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Maganty A, Hollenbeck BK, Kaufman SR, Oerline MK, Lai LY, Caram MEV, Shahinian VB. Practice Competition and Treatment of Newly Diagnosed Prostate Cancer. Urology 2023; 177:95-102. [PMID: 37146728 PMCID: PMC10524390 DOI: 10.1016/j.urology.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To examine the effect of urology practice market competition on use of treatment in men with newly diagnosed prostate cancer. METHODS We performed a retrospective national cohort study of 48,067 Medicare beneficiaries with newly diagnosed prostate cancer between 2014 and 2018. The primary exposure was urology practice-level market competition. Markets were established by the flow of patients to a practice using a variable radius approach. Practice level competition was measured annually using the Herfindahl-Hirschman Index. The primary outcome was use of treatment for prostate cancer (ie, surgery, radiation, or cryotherapy) stratified by 10-year risk of noncancer mortality. RESULTS Between 2014 and 2018, there was a decrease in the total percent of urologists practicing in small single-specialty groups (49%-41%) with an increase in multispecialty practices (38%-47%). After adjusting for demographic and clinical characteristics, a lower percentage of men underwent treatment in practices with low competition relative to those managed in practices with high competition (70% vs 67.0%, P < .001). Among men with the highest risk of noncancer mortality, those managed in practices in the least competitive markets were less likely to receive treatment relative to men managed by practices in the most competitive markets (48% vs 60%, P-value<.001). CONCLUSION Reduction in competition between urology practices is not associated with greater use of treatment in men with newly diagnosed prostate cancer, particularly in those with a high risk of noncancer mortality.
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Affiliation(s)
- Avinash Maganty
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel R Kaufman
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mary K Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lillian Y Lai
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Megan E V Caram
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Vahakn B Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Johns AC, Yang M, Wei L, Grogan M, Patel SH, Li M, Husain M, Kendra KL, Otterson GA, Burkart JT, Spakowicz D, Hoyd R, Owen DH, Presley CJ. Association of medical comorbidities and cardiovascular disease with toxicity and survival among patients receiving checkpoint inhibitor immunotherapy. Cancer Immunol Immunother 2023; 72:2005-2013. [PMID: 36738310 PMCID: PMC10992740 DOI: 10.1007/s00262-023-03371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Medical comorbidities (MC) are highly prevalent among patients with cancer and predict worse outcomes for traditional therapies. This association is poorly understood for checkpoint inhibitor immunotherapy (IO). We aimed to explore the relationship between common MC including cardiovascular disease (CVD), immune-related adverse events (irAEs), and overall survival (OS) among patients receiving IO for advanced cancer. METHODS This is a retrospective cohort study of 671 patients with any cancer who received IO at our institution from 2011 to 2018. Clinical data were abstracted via chart review and query of ICD-10 codes and used to calculate modified Charlson comorbidity index (mCCI) scores. The primary outcomes were the association of individual MC with irAEs and OS using bivariate and multivariable analyses. Secondary outcomes included association of mCCI score with irAEs and OS. RESULTS Among 671 patients, 62.1% had a mCCI score ≥ 1. No individual MC were associated with irAEs or OS. Increased CCI score was associated with decreased OS (p < 0.01) but not with irAEs. Grade ≥ 3 irAEs were associated with increased OS among patients without CVD (HR 0.37 [95% CI: 0.25, 0.55], p < 0.01), but not among patients with CVD. CONCLUSIONS No specific MC predicted risk of irAEs or OS for patients receiving IO. Increased CCI score did not predict risk of irAEs but was associated with shorter OS. This suggests IO is safe for patients with MC, but MC may limit survival benefits of IO. CVD may predict shorter OS in patients with irAEs and should be evaluated among patients receiving IO.
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Affiliation(s)
- Andrew C Johns
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mike Yang
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Lai Wei
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Madison Grogan
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sandipkumar H Patel
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mingjia Li
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Marium Husain
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kari L Kendra
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory A Otterson
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jarred T Burkart
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel Spakowicz
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rebecca Hoyd
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Dwight H Owen
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carolyn J Presley
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- The James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, 1335 Lincoln Tower, 1800 Cannon Dr, Columbus, OH, 43210, USA.
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Shi J, Li Y, Song W, Wang M, Zhang L, Lian H, He Z, Wei N, Zheng Z, Wen J. Risk of colon cancer-related death in people who had cancer in the past. Int J Colorectal Dis 2022; 37:1785-1797. [PMID: 35796872 DOI: 10.1007/s00384-022-04202-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The rate of second primary malignancies (SPM) is gradually increasing. Yet, the risk of death from primary cancer vs. SPM is still not well understood. In this study, we investigated the survival of patients with colorectal cancer (as SPM) who had cancer in the past (prior cancer) and the risk factors of SPM death in this population. MATERIALS AND METHODS Based on the Surveillance, Epidemiology, and End Results (SEER) database, we identified 1866 colon cancer patients with prior cancer in our main cohort and 43,959 colon cancer patients, including 37,440 patients with colon cancer as only malignancy and 6519 patients with colon cancer as subsequent colon cancer (SCC), in a second cohort and 3429 colon cancer patients, including 2371 patients with prior colon cancer (PCC) and 1058 patients with colon cancer as SPM, in a third cohort. After propensity score matching, 6519 pairs of subjects were identified in second cohort. RESULTS Patients with prior prostate and breast cancer had a higher risk of developing colon cancer compared to those with gastrointestinal cancer. Also, colon cancer patients with different prior cancer had different survival rates. Furthermore, except for prior lung cancer (52.78 vs. 25.93%), most subjects died due to colon cancer complications. The ratio of colon cancer deaths to prior cancer deaths in patients with a low stage and high stage was 1.51 and 6.64, respectively. In addition, colon cancer-specific survival (CSS) and OS rates were significantly lower in subjects with colon cancer as the SPM than in those with PCC. Also, compared with PCC, SPM was associated with OS and CSS with HR 1.59 (95 CI 1.43-1.78) and HR 2.00 (95% CI 1.70-2.36). Furthermore, compared with only colon cancer, SCC was associated with OS and CSS with HR 1.23 (95 CI 1.17-1.29) and HR 1.13 (95% CI 1.06-1.21). CONCLUSIONS Prior cancer was found to have an adverse impact on OS in patients with colon cancer (secondary cancer), most of whom died due to colon cancer as secondary cancer itself rather than prior cancer. Early detection and treatment strategies should be investigated in this population.
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Affiliation(s)
- Jing Shi
- Mega Data Application Center of Department of Information Management, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China
| | - Yingmei Li
- Department of Pharmacy, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China
| | - Wei Song
- Mega Data Application Center of Department of Information Management, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China
| | - Mingxue Wang
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Linyu Zhang
- Mega Data Application Center of Department of Information Management, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China
| | - Haobin Lian
- Mega Data Application Center of Department of Information Management, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China
| | - Zhi He
- Mega Data Application Center of Department of Information Management, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China
| | - Nijun Wei
- Mega Data Application Center of Department of Information Management, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China
| | - Zilong Zheng
- Mega Data Application Center of Department of Information Management, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China.
| | - Juan Wen
- Department of Dermatovenereology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, Guangdong, People's Republic of China.
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Chen LJ, Nguyen TNM, Chang-Claude J, Hoffmeister M, Brenner H, Schöttker B. Incorporation of functional status, frailty, comorbidities, and co-medication in prediction models for colorectal cancer survival. Int J Cancer 2022; 151:539-552. [PMID: 35435251 DOI: 10.1002/ijc.34036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/08/2022]
Abstract
Limitations in functional status, frailty, multiple comorbidities, and co-medications are common among older colorectal cancer (CRC) patients. We investigated whether adding these factors could improve the predictive value of a reference model containing age, sex, tumor stage and location for prediction of 5-year overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), recurrence-free survival (RFS), and non-disease-specific survival (nDSS) for all CRC patients as well as for younger (<65 years) and older patients (≥65 years). Overall, 3,410 CRC patients from the DACHS study were analyzed and area under receiver operating characteristic curves (AUC) and net reclassification improvements (NRI) were assessed. In prediction of OS, the reference model plus functional status was identified as the best model among all CRC patients (AUC: 0.762) and younger CRC patients (AUC: 0.820). In older CRC patients, comorbidity should additionally be added (AUC: 0.747). For nDSS, the reference model plus comorbidity and frailty had the best predictive performance in all CRC patients (AUC: 0.776). For the outcomes DFS (AUC: 0. 727), DSS (AUC: 0. 838), and RFS (AUC: 0. 784), the reference model was already the best model in all CRC patients because no significant NRIs were observed. The pattern "The less CRC-specific the survival outcome and the older the CRC patients, the more relevant the inclusion of functional status, comorbidity, and frailty in CRC prognostic scores is" was observed. Thus, different nomograms for younger and older CRC patients for 1-, 3-, and 5-year OS prognosis estimation are being suggested.
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Affiliation(s)
- Li-Ju Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Thi Ngoc Mai Nguyen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Jenny Chang-Claude
- Unit of Genetic Epidemiology, Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Cancer Epidemiology Group, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany
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Mady LJ, Baddour K, Hodges JC, Magaña LC, Schwarzbach HL, Borrebach JD, Nilsen ML, Johnson JT, Hall DE. The impact of frailty on mortality in non-surgical head and neck cancer treatment: Shifting the clinical paradigm. Oral Oncol 2022; 126:105766. [PMID: 35168191 PMCID: PMC9642850 DOI: 10.1016/j.oraloncology.2022.105766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/11/2022] [Accepted: 02/06/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Compare survival of head and neck cancer (HNC) patients treated with surgical or non-surgical management according to frailty, quantify frailty with the Risk Analysis Index (RAI), a validated 14-item instrument. MATERIALS AND METHODS Prospective cohort study of newly diagnosed HNC patients (≥18 years) who had frailty assessment from April 13, 2016 to September 30, 2016. Primary outcome was overall survival at 1- and 3-years. Cox proportional hazard models were utilized to examine mortality with predictor variables. Adjusted and unadjusted (Kaplan-Meier) survival curves stratified by either RAI scores or treatment modality were plotted. Kruskal-Wallis and likelihood ratio chi-square tests were used for comparing clinicodemographic variables. RESULTS Of 165 patients, 54 (32.7%) were managed non-surgically, 49 (29.7%) were treated with definitive surgery only, and 62 (37.6%) were treated with multimodality (surgery + adjuvant) therapy. Among the full cohort and subgroup analysis of the frail/very frail (RAI ≥ 37), non-surgical patients had worse or similar 3-year survival than those treated with surgery +/- adjuvant therapy. Multivariable Cox proportional hazard models demonstrate that frail patients treated non-surgically experienced worse survival than their counterparts treated with surgery (HR = 2.50, p = 0.015, 95% CI: 1.19, 5.23) or multimodality therapy (HR = 3.91, p < 0.001, 95% CI: 1.94-7.89). CONCLUSION Across all levels of frailty, long term survival of HNC patients treated without surgery is either worse than or like those treated with surgery. These findings (1) challenge current practices of steering patients "too frail for surgery" towards non-surgical, "non-invasive" therapy, and (2) suggest equipoise warranting randomized trials to clarify treatment of frail patients.
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Affiliation(s)
- Leila J. Mady
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Linda C. Magaña
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hannah L. Schwarzbach
- Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Marci L. Nilsen
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jonas T. Johnson
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel E. Hall
- Wolff Center at UPMC, Pittsburgh, PA, USA,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Shavelle RM, Saur RC, Kwak JH, Brooks JC, Hameed B. Life Expectancy After Liver Transplantation for Alcoholic Cirrhosis. Prog Transplant 2021; 31:345-356. [PMID: 34779671 DOI: 10.1177/15269248211046004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Alcohol-associated liver disease is the leading cause of liver transplantation in the western world. For these patients we calculated life expectancies both at time of transplant and several years later, stratified by key risk factors, and determined if survival has improved in recent years. METHODS Data on 14 962 patients with alcohol-associated liver disease who underwent liver transplantation in the MELD era (2002-2018) from the United States Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods. RESULTS Demographic and past medical history factors related to survival were patient age, presence of diabetes or severe hepatic encephalopathy, and length of hospital stay. Survival improved over the study period, at roughly 3% per calendar year during the first 5 years posttransplant and 1% per year thereafter. CONCLUSIONS Life expectancy in transplanted patients with alcohol-associated liver disease was much reduced from normal, and varied according to age, medical risk factors, and functional status. Survival improved modestly over the study period. Information on patient longevity can be helpful in making treatment decisions.
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Affiliation(s)
| | - Rachel C Saur
- Life Expectancy Project, San Francisco, California, USA
| | - Ji Hun Kwak
- Life Expectancy Project, San Francisco, California, USA
| | | | - Bilal Hameed
- Division of Gastroenterology, University of California, San Francisco, USA
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Alem A, Edae CK, Kelta Wabalo E, Abera Tareke A, Ayalew Bedanie A, Reta W, Bariso M, Bekele G, Zawdie B. Factors influencing the occurrence of electrolyte disorders in cancer patients. SAGE Open Med 2021; 9:20503121211052861. [PMID: 34691474 PMCID: PMC8532243 DOI: 10.1177/20503121211052861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/25/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: The objective of this study was to determine the magnitude of electrolyte disorders and influencing factors among cancer patients in Southwest Ethiopia. Methods: Facility-based cross-sectional study was conducted in Jimma Medical Center (JMC). Eighty-four cancer patients admitted to JMC were recruited for this study. A structured questionnaire and serum electrolyte measurements were used for data collection. Bivariate and multiple logistic regression was employed to determine the association between electrolyte disorders and associated factors among admitted cancer patients. P value ⩽ 0.05 was used as a cut point to declare statistical significance. Result: The overall prevalence of electrolyte disorders was 60.7%. The presence or absence of comorbid diseases, age, body mass index (BMI), nutritional status, and current prescribed medication use were associated with electrolyte disorders. Younger patients had lower odds for electrolyte disorders (odds ratio (OR) = 0.128 (P value = 0.05) and OR = 0.08 (P value = 0.033)) for the first and the second quartile, respectively. Underweight patients had a threefold likelihood to develop electrolyte disorders (OR = 3.13 (P value = 0.043)) than having normal BMI. Compared with those in need of nutritional intervention, patients not in need of nutritional intervention had lower odds for the disorders (OR = 0.109 (P value = 0.006)). Medication had increased the likelihood of electrolyte disorders by 5.5 times than with no medication (P value = 0.023). Those who had comorbid disease had 10 times likely to develop electrolyte disorders than those who did not have comorbid diseases (P value = 0.004). Conclusion: Electrolyte disorders were prevalent in cancer patients. Age, BMI, nutritional condition, comorbid disease, and prescribed drugs were the predictors of electrolyte disorders in cancer patients. Authors recommend routine screening of electrolyte disorders in cancer patients and special emphasis on controlling and managing risk factors.
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Affiliation(s)
- Addis Alem
- Biochemistry Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Chala Kenenisa Edae
- Biochemistry Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Endriyas Kelta Wabalo
- Biochemistry Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Amare Abera Tareke
- Physiology Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Almaz Ayalew Bedanie
- Physiology Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Wondu Reta
- Physiology Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Moyeta Bariso
- Physiology Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Gadisa Bekele
- Department of Nursing, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Belay Zawdie
- Biochemistry Unit, Department of Biomedical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
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Marrie RA, Maxwell C, Mahar A, Ekuma O, McClintock C, Seitz D, Groome P. Colorectal Cancer Survival in Multiple Sclerosis: A Matched Cohort Study. Neurology 2021; 97:e1447-e1456. [PMID: 34526374 PMCID: PMC8520388 DOI: 10.1212/wnl.0000000000012634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/16/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES We tested the hypothesis that overall and cancer-specific survival after a colorectal cancer diagnosis is lower in persons with multiple sclerosis (MS) than in those without MS using a retrospective matched cohort design. METHODS Using population-based administrative data in Manitoba and Ontario, we identified persons with MS from a validated case definition and linked these cohorts to cancer registries to identify those with colorectal cancer. We selected persons with colorectal cancer and without MS, matching 4:1 on birth year, sex, cancer diagnosis year, and region. We used Cox proportional hazards regression to compare all-cause survival between cohorts, adjusting for age at cancer diagnosis, cancer diagnosis year, income, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a cause-specific hazards model. We pooled findings across provinces using random-effects meta-analysis. Complementary analyses using a subcohort from Ontario, adjusted for cancer stage and disability status, as measured from the use of home care or long-term care services. RESULTS We included 338 MS cases and 1,352 controls with colorectal cancer. The mean (SD) age at cancer diagnosis was 64.7 (11.1) years. After adjustment, MS was associated with an increased hazard for all-cause death that was highest 6 months after diagnosis (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.19-1.76) and then declined over time (HR [95% CI] at 1 year 1.34 [1.09-1.63], 2 years 1.24 [0.99-1.56], 5 years 1.10 [0.80-1.50]). MS was associated with increased cancer-specific death at 6 months after diagnosis only (HR 1.29, 95% CI 1.04-1.61). After adjustment for cancer stage, MS was associated with an increased hazard of death due to any cause (1.60, 95% CI 1.16-2.21) and with cancer-specific death (HR 1.47, 95% CI 1.02-2.12). The association of MS and all-cause death was partially attenuated after adjustment for disability status (HR 1.37, 95% CI 0.97-1.92), as was the association with cancer-specific death (HR 1.34, 95% CI 0.91-1.97). DISCUSSION Overall and cancer-specific survival was lower in persons with than without MS in the early period after colorectal cancer diagnosis. Further study is warranted to determine what factors underlie these worse outcomes.
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Affiliation(s)
- Ruth Ann Marrie
- From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health and Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.G.) and Division of Cancer Care and Epidemiology (P.G.), Cancer Research Institute, Queen's University, Kingston, Ontario; and Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary, Alberta, Canada.
| | - Colleen Maxwell
- From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health and Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.G.) and Division of Cancer Care and Epidemiology (P.G.), Cancer Research Institute, Queen's University, Kingston, Ontario; and Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Alyson Mahar
- From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health and Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.G.) and Division of Cancer Care and Epidemiology (P.G.), Cancer Research Institute, Queen's University, Kingston, Ontario; and Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Okechukwu Ekuma
- From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health and Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.G.) and Division of Cancer Care and Epidemiology (P.G.), Cancer Research Institute, Queen's University, Kingston, Ontario; and Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Chad McClintock
- From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health and Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.G.) and Division of Cancer Care and Epidemiology (P.G.), Cancer Research Institute, Queen's University, Kingston, Ontario; and Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Dallasl Seitz
- From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health and Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.G.) and Division of Cancer Care and Epidemiology (P.G.), Cancer Research Institute, Queen's University, Kingston, Ontario; and Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Patti Groome
- From the Department of Internal Medicine (R.A.M.), Department of Community Health Sciences (R.A.M., A.M.), and Manitoba Centre for Health Policy (A.M., O.E.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg; ICES (C. Maxwell), Toronto; Schools of Pharmacy and Public Health and Health Systems (C. Maxwell), University of Waterloo; ICES Queen's (A.M., C. McClintock, D.S., P.G.) and Division of Cancer Care and Epidemiology (P.G.), Cancer Research Institute, Queen's University, Kingston, Ontario; and Departments of Psychiatry and Community Health Sciences (D.S.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older? ACTA ACUST UNITED AC 2021; 28:2540-2547. [PMID: 34287279 PMCID: PMC8293045 DOI: 10.3390/curroncol28040231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022]
Abstract
The current recommendation to stop colorectal cancer screening for older adults is based on a lack of evidence due to systematic exclusion of this population from trials. Older adults are a heterogenous population with many available strategies for patient-centered assessment and decision-making. Evolutions in management strategies for colorectal cancer have made safe and effective options available to older adults, and the rationale to screen for treatable disease more reasonably, especially given the aging Canadian population. In this commentary, we review the current screening guidelines and the evidence upon which they were built, the unique considerations for screening older adults, new treatment options, the risks and benefits of increased screening and potential considerations for the new guidelines.
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Niedersüß-Beke D, Orlinger M, Falch D, Heiler C, Piringer G, Thaler J, Hilbe W, Petzer A, Rumpold H. Clinical Effectiveness of Oncological Treatment in Metastatic Colorectal Cancer Is Independent of Comorbidities and Age. Cancers (Basel) 2021; 13:cancers13092091. [PMID: 33925931 PMCID: PMC8123394 DOI: 10.3390/cancers13092091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Colorectal cancer (CRC) is the third most common cancer worldwide. As with many other cancers, the risk for CRC increases with age. This is also true for comorbidities, which may hamper sufficient treatment of the cancer. Due to restrictive inclusion criteria, older patients and patients with comorbidities are underrepresented in clinical trials. Comprehensive knowledge about modern effectiveness of oncological treatments in older and/or comorbid patients is sparse. Due to the lack of clinical trials, this issue is investigated in real-life settings predominantly. In our retrospective study we show that patients benefit from oncological treatments irrespective of comorbidities, measured by the age-adjusted Charlson Comorbity (aaCCI) index, and age. Differences found in treatment outcomes are marginal and are likely due to less intense treatment of comorbid or elderly patients. Balancing risk and benefit for treatment decisions should take potential under-treatment of comorbid and older patients into account. Abstract We aimed to investigate the effectiveness of oncological treatments in metastatic CRC related to comorbidities and age. This retrospective study included 1105 patients from three oncological centers. aaCCI and CCI was available from 577 patients. An aaCCI > 3 was of the highest predictive value compared to other aaCCI-levels, CCI or age (p < 0.001 for all). Treatment (best supportive care (BSC), systemic treatment only (STO) and resection of metastases (ROM)) significantly prolonged survival in patients with aaCCI > 3 (STO: HR 0.39, CI 0.29–0.51; ROM: HR 0.16, CI 0.10–0.24) and patients older than 70 years (STO: HR 0.56, CI 0.47–0.66; ROM: HR 0.23, 0.18–0.30). Median overall survival was shorter in patients with aaCCI or age > 70 years and interaction for treatment type not significant for aaCCI, but significant for age older or younger than 70 years (STO: p = 0.01; ROM p = 0.02). BSC is more often considered as optimal care for patients with an aaCCI > 3 (37.6% vs. 12.4%; p < 0.001) or age > 70 years (35.7% vs. 11.2%; p < 0.001). Older patients or patients with comorbidities benefit from cancer-specific therapy independently of their age and comorbidities.
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Affiliation(s)
- Dora Niedersüß-Beke
- Department of Internal Medicine I, Wilhelminenspital, 1160 Vienna, Austria; (D.N.-B.); (D.F.); (C.H.); (W.H.)
| | - Manuel Orlinger
- Department of Hematology and Medical Oncology, Ordensklinikum Linz, 4010 Linz, Austria; (M.O.); (A.P.)
| | - David Falch
- Department of Internal Medicine I, Wilhelminenspital, 1160 Vienna, Austria; (D.N.-B.); (D.F.); (C.H.); (W.H.)
| | - Cordula Heiler
- Department of Internal Medicine I, Wilhelminenspital, 1160 Vienna, Austria; (D.N.-B.); (D.F.); (C.H.); (W.H.)
| | - Gudrun Piringer
- Department of Internal Medicine IV, Hospital Wels-Grieskirchen, 4600 Wels, Austria; (G.P.); (J.T.)
- Medical Faculty, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Josef Thaler
- Department of Internal Medicine IV, Hospital Wels-Grieskirchen, 4600 Wels, Austria; (G.P.); (J.T.)
| | - Wolfgang Hilbe
- Department of Internal Medicine I, Wilhelminenspital, 1160 Vienna, Austria; (D.N.-B.); (D.F.); (C.H.); (W.H.)
| | - Andreas Petzer
- Department of Hematology and Medical Oncology, Ordensklinikum Linz, 4010 Linz, Austria; (M.O.); (A.P.)
| | - Holger Rumpold
- Medical Faculty, Johannes Kepler University Linz, 4020 Linz, Austria
- Gastrointestinal Cancer Center, Ordensklinikum Linz, 4010 Linz, Austria
- Correspondence:
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14
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Kwak JH, Shavelle R, Brooks J. Life Expectancy After Liver Transplantation for Hepatocellular Carcinoma With Cirrhosis. Prog Transplant 2021; 31:62-71. [PMID: 33686888 DOI: 10.1177/1526924820978603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatocelluar carcinoma, the most common primary liver cancer, has a historically dire prognosis. For hepatic cancer patients with cirrhosis who underwent liver transplantation, we sought to calculate life expectancies both at time of transplant and several years later, stratified by some key variables, and to determine if survival has improved in recent years. METHODS Data on 13,797 hepatic cancer patients with cirrhosis who underwent liver transplantation in the MELD era (2002-2018) from the US Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods. RESULTS The major factors related to survival were age, donor age, transplant year, diabetes, functional status, and the presence of severe hepatic encephalopathy. Survival was significantly worse with increasing age and decreasing functional status level. There was no significant difference in survival between males and females. Survival improved over the study period, at 5% per calendar year during the first 5 years post transplant, and 1% per year thereafter. CONCLUSIONS Life expectancies were markedly reduced from normal, even among 5-year survivors with the most favorable characteristics. Survival improved modestly over the years 2002-2018.
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Affiliation(s)
- Ji Hun Kwak
- Life Expectancy Project, San Francisco, CA, USA
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15
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Papamichael D, Hernandez P, Mistry R, Xenophontos E, Kakani C. Adjuvant chemotherapy in patients with colorectal cancer. Is there a role in the older adult? Eur J Surg Oncol 2020; 46:363-368. [PMID: 31973924 DOI: 10.1016/j.ejso.2020.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/06/2019] [Accepted: 01/02/2020] [Indexed: 01/13/2023] Open
Abstract
As global life expectancy has increased in most countries, there is a rising percentage of patients over 65 years old being diagnosed with colorectal cancer. Despite an increase in the incidence and prevalence of colorectal cancer in older adults, this cohort receives adjuvant therapy at a decreased rate due to anticipated intolerance. The presumed limitations seem to be based on chronologic age, competing life limiting diagnoses, and the paucity of data studying this population in major clinical trials. This review explores the data regarding disparities in the treatment of older patients with colorectal cancer, safety and efficacy of adjuvant therapy, and newer tools to make decisions based on the biologic age, rather than chronologic age, of the patient.
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Affiliation(s)
| | - Paul Hernandez
- Division of Colorectal Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ronak Mistry
- Department of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Xenophontos
- Division of Medical Oncology, Bank Of Cyprus Oncology Centre, Nicosia, Cyprus
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16
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Wang SY, Abujarad F, Chen T, Evans SB, Killelea BK, Mougalian SS, Fraenkel L, Gross CP. "Radiotherapy for older women (ROW)": A risk calculator for women with early-stage breast cancer. J Geriatr Oncol 2019; 11:850-859. [PMID: 31899199 DOI: 10.1016/j.jgo.2019.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/30/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Among older adult women with early-stage breast cancer who undergo lumpectomy, the benefits of radiotherapy vary according to tumor characteristics and life expectancy. We aimed to develop a risk calculator to predict individualized probability of long-term survival and local recurrence, accounting for these factors. METHODS We developed a simulation model to estimate an individual patient's risk of local recurrence and all-cause mortality according to age, comorbidities, functional status, tumor characteristics, and radiotherapy status. We integrated two existing prediction models, the Early Breast Cancer Trialist's Collaborative Group prediction model for breast cancer specific outcomes and ePrognosis for life expectancy. An online risk calculator "Radiotherapy for Older Women (ROW)" was developed through an iterative multi-stage process, that included individual consultation and group meetings with an advisory committee (AC) comprised of patients, advocates, clinicians, and researchers. RESULTS We developed the tool over 40 months and had 15 group meetings. The risk calculator developed as a simulation model with 16 factors (5 tumor-related, 3 demographic, 4 comorbidities, and 4 functional statuses). Across 56,700 simulated scenarios, the benefit of RT in terms of absolute 10-year local recurrence reduction, ranged from 0% to 34%, depending on individual characteristics. Based on feedback from the AC, overall survival and local recurrence were chosen as the output for ROW, with these outcomes displayed numerically (percentages and natural frequencies) and graphically (pictographs). CONCLUSIONS This tool "ROW" could facilitate shared decision making regarding receipt of radiotherapy for older women with early breast cancer. Additional studies to examine usability testing are underway.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, United States of America; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, United States of America.
| | - Fuad Abujarad
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Tiange Chen
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, United States of America
| | - Suzanne B Evans
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, United States of America; Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Brigid K Killelea
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, United States of America; Department of Surgery, Yale University School of Medicine, New Haven, CT, United States of America
| | - Sarah S Mougalian
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, United States of America; Section of Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Liana Fraenkel
- Section of Rheumatology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, United States of America; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
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Shavelle RM, Brooks JC, Strauss DJ, Turner-Stokes L. Life Expectancy after Stroke Based On Age, Sex, and Rankin Grade of Disability: A Synthesis. J Stroke Cerebrovasc Dis 2019; 28:104450. [PMID: 31676160 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104450] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/16/2019] [Accepted: 09/25/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Stroke is a leading cause of death and disability in the developed world. The major factor affecting long term survival (other than age) is known to be the severity of disability. Yet to our knowledge there are no studies reporting life expectancies stratified by both age and severity. Remaining life expectancy is a key measure of health. METHODS We identified 11 long-term follow-up studies of stroke patients that reported the multivariate effects of age, sex, the modified Rankin Scale (mRS) grade of disability, and other factors. From these we computed the composite effects of these factors on survival, then used these to calculate age-, sex-, and mRS-specific mortality rates. Finally we used the rates to construct life tables, and hence obtain life expectancies. RESULTS Life expectancy varies by age, sex, and mRS. The life expectancies of males age 70, for example, were 13, 13, 11, 8, 6, and 5 years for Rankin Grades 0-5, respectively, representing reductions of 1, 1, 3, 6, 8, and 9 years from the corresponding general population figure. CONCLUSIONS These figures demonstrate the importance of rehabilitation following stroke, and can be used in discussion of public policy and benchmarking of future results.
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Affiliation(s)
| | | | | | - Lynne Turner-Stokes
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Northwick Park Hospital, Harrow, Middlesex, UK
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18
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Yu L, Wang L, Tan Y, Hu H, Shen L, Zheng S, Ding K, Zhang S, Yuan Y. Accuracy of Magnetic Resonance Imaging in Staging Rectal Cancer with Multidisciplinary Team: A Single-Center Experience. J Cancer 2019; 10:6594-6598. [PMID: 31777588 PMCID: PMC6856893 DOI: 10.7150/jca.32685] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 08/06/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose: To investigate the accuracy of magnetic resonance imaging (MRI) in preoperative staging diagnosis for rectal cancer with multidisciplinary team (MDT) discussion. Methods: The retrospective study included 377 patients of rectal cancer with preoperative MRI staging from February 2015 to April 2018, in which 137 patients (36 received MDT discussion) received neoadjuvant therapy, 240 did not (97 received MDT discussion) and direct surgery was given. With postoperative pathological stage as the standard, the accuracy of MRI in preoperative staging for rectal cancer with MDT discussion was compared with non-MDT. Results: For direct surgery group, 21 out 97 (21.6%) patients changed their therapy strategy due to the change of the stage assessment after MDT. The accuracy of MRI for the diagnosis of preoperative N stage with MDT was significantly higher than those without MDT (56.2% vs. 42.1%, P=0.021). And for those without lymph node metastasis, the accuracy of MRI was higher after MDT (61.2% vs. 37.8%, P=0.009). For neoadjuvant therapy group, 7 out of 36 (19.4%) patients altered their therapy after MDT because of the changed stage. MDT improved the accuracy of restaging N stage with MRI (70.0% vs. 33.3%, P=0.003). The accuracy of MRI in staging T stage seemed not improved after MDT in both groups. Conclusions: In conclusion, MDT discussion increased the accuracy of MRI in preoperative staging diagnosis for rectal cancer. This mode could give a more accurate clinical stage of patients, which was in favor of choosing a preferable therapy strategy.
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Affiliation(s)
- Linzhen Yu
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Liuhong Wang
- Department of Radiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yinuo Tan
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Hanguang Hu
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Li Shen
- Department of Radiation Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Shu Zheng
- Department of Colorectal Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Kefeng Ding
- Department of Colorectal Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Suzhan Zhang
- Department of Colorectal Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ying Yuan
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
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Cudennec T, Benyahia S. [Cancer surgery and risk assessment in the elderly]. SOINS. GÉRONTOLOGIE 2019; 24:22-24. [PMID: 30765082 DOI: 10.1016/j.sger.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The assessment of the risks involved in the surgical treatment of cancer in an elderly patient is necessary. It makes it possible to identify and sometimes anticipate the occurrence of complications observed in the perioperative period. It also enables patients to be given sound information regarding treatment methods, their medical situation and the expectations and risks of the surgical procedure envisaged.
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Affiliation(s)
- Tristan Cudennec
- Service de médecine gériatrique du Pr Laurent Teillet, équipe mobile d'oncogériatrie, Hôpitaux universitaires Paris-Île-de-France-Ouest, site Ambroise-Paré, 9 avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France.
| | - Stéphanie Benyahia
- Service de médecine gériatrique du Pr Laurent Teillet, équipe mobile d'oncogériatrie, Hôpitaux universitaires Paris-Île-de-France-Ouest, site Ambroise-Paré, 9 avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
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20
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Abstract
GOALS We aimed to assess use of colorectal cancer screening (CRCS) as per United States Preventive Task Force guidelines among people with mobility disability using a nationally representative data set. BACKGROUND Individuals with mobility disability have decreased access to health care services, but the impact of mobility disability on CRCS has not been investigated. STUDY Data from the 2013 National Health Interview Survey were used to estimate sociodemographic characteristics of adults with mobility disability, prevalence of CRCS, and odds of CRCS given mobility disability among Americans aged 50 to 75. RESULTS In total, 56.8% of the entire sample (n=81,953,585) were up-to-date with CRCS. Mobility disability was not associated with CRCS status on univariable analysis but was significantly associated after adjustment for covariates including age and comorbidities, with an inverse relationship between the degree of mobility disability and odds of CRCS. Odds ratio for CRCS given progressively severe disability were 0.78 (0.66 to 0.93), 0.71 (0.53 to 0.94), 0.65 (0.31 to 1.19). CONCLUSIONS The present study indicates reduced CRCS among people with mobility disability and highlights the need for CRCS to be especially targeted toward this group. Future research should identify the specific systemic, social, and/or physical barriers to CRCS for this subgroup so that they can be addressed.
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McWilliams L, Farrell C, Grande G, Keady J, Swarbrick C, Yorke J. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health 2018; 22:1254-1271. [PMID: 28718298 DOI: 10.1080/13607863.2017.1348476] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care. METHOD Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively. RESULTS Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use. CONCLUSIONS There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.
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Affiliation(s)
- L McWilliams
- a Christie Patient Centred Research (CPCR), School of Oncology , The Christie NHS Foundation Trust , Manchester , UK
| | - C Farrell
- a Christie Patient Centred Research (CPCR), School of Oncology , The Christie NHS Foundation Trust , Manchester , UK.,b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - G Grande
- b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - J Keady
- b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - C Swarbrick
- b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - J Yorke
- a Christie Patient Centred Research (CPCR), School of Oncology , The Christie NHS Foundation Trust , Manchester , UK.,b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
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22
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Impact of Accountable Care Organizations on Diagnostic Testing for Prostate Cancer. Urology 2018; 116:68-75. [PMID: 29630957 DOI: 10.1016/j.urology.2018.01.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 12/30/2017] [Accepted: 01/16/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if Accountable Care Organizations (ACOs) have the potential to accelerate the impact of prostate cancer screening recommendations. METHODS We performed a retrospective cohort study using Medicare data evaluating the rates of PSA testing and prostate biopsy among men without prostate cancer between 2011 and 2014. We assessed PSA testing and biopsy rates before and after policy implementation among patients of ACO and non-ACO-aligned physicians. To control for secular trends, difference-in-differences methods were used to determine the effects of ACO implementation. RESULTS We identified 1.1 million eligible men without prostate cancer. From 2011 to 2014, the rates of PSA testing and biopsy declined by 22.3% and 7.0%, respectively. PSA testing declined similarly regardless of ACO participation-from 618 to 530 tests per 1000 beneficiaries among ACO-aligned physicians and from 607 to 516 tests per 1000 beneficiaries among non-ACO-aligned physicians (difference-in-differences P = .11). Whereas rates of prostate biopsy remained constant for patients of non-ACO-aligned physicians at 12 biopsies per 1000 beneficiaries, these rates increased from 11.6 to 12.5 biopsies per 1000 beneficiaries of patients of ACO-aligned physicians (difference-in-differences P = .03). CONCLUSION PSA testing and prostate biopsy rates decreased significantly between 2011 and 2014. The rate of PSA testing was not differentially affected by ACO participation. Conversely, there was an increase in the rate of prostate biopsy among patients of ACO-aligned physicians. ACOs did not accelerate deimplementation of PSA testing for eligible Medicare beneficiaries without prostate cancer.
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Soriano LC, Soriano-Gabarró M, García Rodríguez LA. Trends in the contemporary incidence of colorectal cancer and patient characteristics in the United Kingdom: a population-based cohort study using The Health Improvement Network. BMC Cancer 2018; 18:402. [PMID: 29636012 PMCID: PMC5894203 DOI: 10.1186/s12885-018-4265-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/20/2018] [Indexed: 12/03/2022] Open
Abstract
Background Cancer registry data show that survival of colorectal cancer (CRC) in the United Kingdom is poor compared with other European countries and the United States, yet these data sources lack information on patient comorbidities and medication use, which could help explain these differences. Methods Among individuals aged 40–89 years in The Health Improvement Network (2000–2014), we identified first ever cases of CRC and calculated incidence rates with 95% confidence intervals (CIs). For CRC cases and non-cases in two separate calendar years (2002 and 2014), we evaluated patient demographics, lifestyle factors, comorbidities and medication use and bowel screening. Results The incidence of CRC remained relatively constant across the study period; incidence rates per 10,000 person-years (95% CIs) were 9.27 (8.59–1.01) in 2000, 10.65 (10.15–11.18) in 2007 and 8.37 (7.93–8.83) in 2014. Incidence rates per 10,000 person-years were higher in men than women at 11.44 (95% CI: 10.35-12.66) vs. 7.40 (95% CI: 6.59–8.32) in 2000, and 9.39 (95% CI: 8.74–10.10) vs. 7.38 (95% CI: 6.81–8.00) in 2014. An increase was seen in the proportion of CRC cases diagnosed at age < 60 years. In 2002, 3.5% of CRC cases were diagnosed at age 40–49 compared with 5.1% in 2014 (p = 0.064). Similarly, in 2002, 12.5% were diagnosed at age 50–59 years compared with 16.2% in 2014 (p = 0.002). Between 2002 and 2014, previous bowel screening increased in both CRC cases (+ 10.6%) and non-cases (+ 9.7%)(p < 0.001 for both groups). Greater rises in the following were seen among CRC cases compared with non-cases: diabetes (+ 9.3% vs. + 3.3%; p < 0.001 for both), obesity (+ 14.5% vs. + 10.1%; p < 0.001 for both), hypertension (+ 8.3% vs. + 3.6%; p < 0.001 for both), atrial fibrillation (+ 2.6% [p < 0.01] vs. + 0.3% [p < 0.001]), and use of proton pump inhibitors (+ 11.5% vs. + 9.0%), anti-hypertensives (+ 9.9% vs. + 1.4%) and warfarin (+ 3.2% vs. + 0.4%); p < 0.001 for CRC cases and non-cases with respect to each medication. Conclusions CRC incidence has remained relatively stable in the UK over the last decade. The increased prevalence of some comorbidities and medications among CRC cases should be considered when evaluating patterns in CRC survival. Electronic supplementary material The online version of this article (10.1186/s12885-018-4265-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28, 28004, Madrid, Spain.,Department of Public Health and Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | | | - Luis A García Rodríguez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28, 28004, Madrid, Spain
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Baretti M, Rimassa L, Personeni N, Giordano L, Tronconi MC, Pressiani T, Bozzarelli S, Santoro A. Effect of Comorbidities in Stage II/III Colorectal Cancer Patients Treated With Surgery and Neoadjuvant/Adjuvant Chemotherapy: A Single-Center, Observational Study. Clin Colorectal Cancer 2018; 17:e489-e498. [PMID: 29650416 DOI: 10.1016/j.clcc.2018.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 03/09/2018] [Accepted: 03/14/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Comorbidity has a detrimental effect on cancer survival, however, it is difficult to disentangle its direct effect from its influence on treatment choice. In this study we assessed the effect of comorbidity on survival in patients who received standard treatment for resected stage II and III colorectal cancer (CRC). PATIENTS AND METHODS In total, 230 CRC patients, 68 rectal (29.6%) and 162 colon cancer (70.4%) treated with surgical resection and neoadjuvant/adjuvant chemotherapy from December 2002 to December 2009 at Humanitas Cancer Center were retrospectively reviewed. The key independent variable was the Charlson Comorbidity Index (CCI) score, measured as a continuous variable. The differences between groups for categorical data were tested using the χ2 test. Actuarial survival curves were generated using the Kaplan-Meier method. RESULTS Median follow-up was 113 (range, 8.2-145.0) months. Median age was 63 (range, 37-78) years. In univariate analysis CCI score was significantly associated with poorer disease-free survival (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.52-1.80; P < .001), and overall survival (OS; HR, 1.55; 95% CI, 1.41-1.71; P < .001). Factors associated with poorer outcome also included (stage III vs. stage II, P < .029) and age (age >70 vs. ≤70 years, P < .001). After adjusting for these factors, a significant negative prognostic role of CCI score was still observed (adjusted HR for OS, 1.59; 95% CI, 1.43-1.76; P < .001). CONCLUSION Among CRC patients who underwent surgical resection and chemotherapy, a higher CCI score was associated with poorer outcome and might predict long-term survival.
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Affiliation(s)
- Marina Baretti
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Lorenza Rimassa
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Nicola Personeni
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Laura Giordano
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Maria Chiara Tronconi
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Tiziana Pressiani
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Silvia Bozzarelli
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Armando Santoro
- Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
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Boakye D, Rillmann B, Walter V, Jansen L, Hoffmeister M, Brenner H. Impact of comorbidity and frailty on prognosis in colorectal cancer patients: A systematic review and meta-analysis. Cancer Treat Rev 2018; 64:30-39. [DOI: 10.1016/j.ctrv.2018.02.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/07/2018] [Indexed: 12/18/2022]
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Huang XZ, Gao P, Song YX, Sun JX, Chen XW, Zhao JH, Ma B, Wang J, Wang ZN. Impact of age on efficacy of postoperative oxaliplatin-based chemotherapy in patients with rectal cancer after neoadjuvant chemoradiotherapy. Oncotarget 2017; 7:19643-53. [PMID: 26910371 PMCID: PMC4991408 DOI: 10.18632/oncotarget.7544] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/31/2016] [Indexed: 12/18/2022] Open
Abstract
Background Clinical practice guidelines focusing on age-related adjuvant chemotherapy for rectal cancer are currently limited. The present study aimed to explore the impact of age on the efficacy of adjuvant oxaliplatin-based chemotherapy in patients with rectal cancer after neoadjuvant chemoradiotherapy. Methods We performed a retrospective cohort analysis using data from the Surveillance, Epidemiology, and End Results-Medicare-linked database from 1992–2009. We enrolled patients with yp stages I–III rectal cancer who received neoadjuvant chemoradiotherapy and underwent curative resection. The age-related survival benefit of adding oxaliplatin to adjuvant 5-fluorouracil (5-FU) chemotherapy was evaluated using Kaplan–Meier survival analysis with propensity score-matching and Cox proportional hazards models. Results Comparing the oxaliplatin group with the 5-FU group, there were significant interactions between age and chemotherapy efficacy in terms of overall survival (OS) (p for interaction = 0.017) among patients with positive lymph nodes (ypN+). Adding oxaliplatin to 5-FU could prolong survival in patients aged < 73 years and ypN+ category, and but did not translate into survival benefits in patients aged ≥ 73 years and ypN+ category. No significant interactions were observed among ypN− patients, and oxaliplatin did not significantly improve OS, regardless of age. Conclusions In patients with rectal cancer who have already received neoadjuvant chemoradiotherapy and undergone curative resection, adding oxaliplatin to 5-FU could prolong OS in patients aged < 73 years and ypN+ category. However, adding oxaliplatin did not translate into survival benefits in patients age ≥ 73 years and ypN+ category, or in ypN− patients.
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Affiliation(s)
- Xuan-Zhang Huang
- Department of Chemotherapy and Radiotherapy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Lucheng District, Wenzhou City 325027, P.R. China.,Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Yong-Xi Song
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Jing-Xu Sun
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Xiao-Wan Chen
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Jun-Hua Zhao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Bin Ma
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Jun Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
| | - Zhen-Ning Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Heping District, Shenyang City 110001, P.R. China
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Maida M, Macaluso FS, Ianiro G, Mangiola F, Sinagra E, Hold G, Maida C, Cammarota G, Gasbarrini A, Scarpulla G. Screening of colorectal cancer: present and future. Expert Rev Anticancer Ther 2017; 17:1131-1146. [PMID: 29022408 DOI: 10.1080/14737140.2017.1392243] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) is the third most common cancer in males and second in females, and the fourth most common cause of cancer death worldwide. Currently, about 60-70% of diagnosed cases in symptomatic patients are detected at an advanced stage of disease. Earlier stage detection through the use of screening strategies would allow for better outcomes in terms of reducing the disease burden. Areas covered: The aim of this paper is to review the current published evidence from literature which assesses the performance and effectiveness of different screening tests for the early detection of CRC. Expert commentary: Adequate screening strategies can reduce CRC incidence and mortality. In the last few decades, several tests have been proposed for CRC screening. To date, there is still insufficient evidence to identify which approach is definitively superior, and no screening strategy for CRC can therefore be defined as universally ideal. The best strategy would be the one that can be economically viable and to which the patient can adhere best to over time. The latest guidelines suggest colonoscopy every 10 years or annual fecal immuno-chemical test (FIT) for people with normal risk, while for individuals with high risk or hereditary syndromes specific recommendations are provided.
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Affiliation(s)
- Marcello Maida
- a Section of Gastroenterology , S.Elia - Raimondi Hospital , Caltanissetta , Italy
| | | | - Gianluca Ianiro
- c Internal Medicine, Gastroenterology & Liver Unit , Università Cattolica Sacro Cuore , Rome , Italy
| | - Francesca Mangiola
- c Internal Medicine, Gastroenterology & Liver Unit , Università Cattolica Sacro Cuore , Rome , Italy
| | - Emanuele Sinagra
- d Gastroenterology and Endoscopy Unit , Fondazione Istituto San Raffaele Giglio , Cefalù , Italy
| | - Georgina Hold
- e School of Medicine, Medical Sciences and Nutrition , University of Aberdeen , Aberdeen , UK
| | - Carlo Maida
- f Section of Internal Medicine , DIBIMIS, University of Palermo , Palermo , Italy
| | - Giovanni Cammarota
- c Internal Medicine, Gastroenterology & Liver Unit , Università Cattolica Sacro Cuore , Rome , Italy
| | - Antonio Gasbarrini
- c Internal Medicine, Gastroenterology & Liver Unit , Università Cattolica Sacro Cuore , Rome , Italy
| | - Giuseppe Scarpulla
- a Section of Gastroenterology , S.Elia - Raimondi Hospital , Caltanissetta , Italy
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Borza T, Kaufman SR, Yan P, Herrel LA, Luckenbaugh AN, Miller DC, Skolarus TA, Jacobs BL, Hollingsworth JM, Norton EC, Shahinian VB, Hollenbeck BK. Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care. Cancer 2017; 124:563-570. [PMID: 29053177 DOI: 10.1002/cncr.31081] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low-value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care. METHODS Using a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer from 2010 through 2013. Rates of treatment, potential overtreatment (ie, treatment in men with a ≥75% chance of 10-year mortality from competing risks), and Medicare payments were measured using regression models. The impact of ACO participation was assessed using difference-in-differences analyses. RESULTS Before implementation of ACOs, the treatment rate was 71.8% (95% confidence interval [95% CI], 70.2%-73.3%) for ACO-aligned beneficiaries and 72.3% (95% CI, 71.7%-73.0% [P = .51]) for non-ACO-aligned beneficiaries. After implementation, this rate declined to 68.4% (95% CI, 66.1%-70.7% [P = .017]) for ACO-aligned beneficiaries and 69.3% (95% CI, 68.5%-70.1% [P<.001]) for non-ACO-aligned beneficiaries. There was no differential effect noted for ACO participation. The rate of potential overtreatment decreased from 48.2% (95% CI, 43.1%-53.3%) to 40.2% (95% CI, 32.4%-48.0% [P = .087]) for ACO-aligned beneficiaries and increased from 44.3% (95% CI, 42.1%-46.5%) to 47.0% (95% CI, 44.5%-49.5% [P = .11]) for non-ACO-aligned beneficiaries. These changes resulted in a significant relative decrease in overtreatment of 17% for ACO-aligned beneficiaries (difference-in-differences, 10.8%; P = .031). Payments were not found to be differentially affected by ACO alignment. CONCLUSIONS The treatment of prostate cancer and annual payments decreased significantly between 2010 and 2013, but ACO participation did not appear to impact these trends. Among men least likely to benefit, Medicare Shared Savings Program ACO alignment was associated with a significant decline in prostate cancer treatment. Cancer 2018;124:563-70. © 2017 American Cancer Society.
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Affiliation(s)
- Tudor Borza
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Phyllis Yan
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Lindsey A Herrel
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Amy N Luckenbaugh
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John M Hollingsworth
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan.,Department of Economics, University of Michigan, Ann Arbor, Michigan.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Vahakn B Shahinian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
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Urologist Practice Affiliation and Intensity-modulated Radiation Therapy for Prostate Cancer in the Elderly. Eur Urol 2017; 73:491-498. [PMID: 28823605 DOI: 10.1016/j.eururo.2017.08.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 08/01/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prostate cancer treatment is a significant source of morbidity and spending. Some men with prostate cancer, particularly those with significant health problems, are unlikely to benefit from treatment. OBJECTIVE To assess relationships between financial incentives associated with urologist ownership of radiation facilities and treatment for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort of Medicare beneficiaries with prostate cancer diagnosed between 2010 and 2012. Patients were further classified by their risk of dying from noncancer causes in the 10 yr following their cancer diagnosis by using a mortality model derived from comparable patients known to be cancer-free. INTERVENTION Urologists were categorized by their practice affiliation (single-specialty groups by size, multispecialty group) and ownership of a radiation facility. OUTCOME MEASUREMENTS AND ANALYSIS Use of intensity-modulated radiation therapy (IMRT) and use of any treatment within 1 yr of diagnosis. Generalized estimating equations were used to adjust for patient differences. RESULTS Among men with newly diagnosed prostate cancer, use of IMRT ranged from 24% in multispecialty groups to 37% in large urology groups (p<0.001). Patients managed in groups with IMRT ownership (n=5133) were more likely to receive IMRT than those managed by single-specialty groups without ownership (43% vs 30%, p<0.001), regardless of group size. Among patients with a very high risk (> 75%) of noncancer mortality within 10 yr of diagnosis, both IMRT use (42% vs 26%, p<0.001) and overall treatment (53% vs 44%, p<0.001) were more likely in groups with ownership than in those without, respectively. CONCLUSIONS Urologists practicing in single-specialty groups with an ownership interest in radiation therapy are more likely to treat men with prostate cancer, including those with a high risk of noncancer mortality. PATIENT SUMMARY We assessed treatment for prostate cancer among urologists with varying levels of financial incentives favoring intervention. Those with stronger incentives, as determined by ownership interest in a radiation facility, were more likely to treat prostate cancer, even when treatment was unlikely to provide a survival benefit to the patient.
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Hall DE, Arya S, Schmid KK, Carlson MA, Lavedan P, Bailey TL, Purviance G, Bockman T, Lynch TG, Johanning JM. Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and 365 Days. JAMA Surg 2017; 152:233-240. [PMID: 27902826 DOI: 10.1001/jamasurg.2016.4219] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance As the US population ages, the number of operations performed on elderly patients will likely increase. Frailty predicts postoperative mortality and morbidity more than age alone, thus presenting opportunities to identify the highest-risk surgical patients and improve their outcomes. Objective To examine the effect of the Frailty Screening Initiative (FSI) on mortality and complications by comparing the surgical outcomes of a cohort of surgical patients treated before and after implementation of the FSI. Design, Setting, and Participants This single-site, facility-wide, prospective cohort quality improvement project studied all 9153 patients from a level 1b Veterans Affairs medical center who presented for major, elective, noncardiac surgery from October 1, 2007, to July 1, 2014. Interventions Assessment of preoperative frailty in all patients scheduled for elective surgery began in July 2011. Frailty was assessed with the Risk Analysis Index (RAI), and the records of all frail patients (RAI score, ≥21) were flagged for administrative review by the chief of surgery (or designee) before the scheduled operation. On the basis of this review, clinicians from surgery, anesthesia, critical care, and palliative care were notified of the patient's frailty and associated surgical risks; if indicated, perioperative plans were modified based on team input. Main Outcomes and Measures Postoperative mortality at 30, 180, and 365 days. Results From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16). Conclusions and Relevance Implementation of the FSI was associated with reduced mortality, suggesting the feasibility of widespread screening of patients preoperatively to identify frailty and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Additional investigation is required to establish a causal connection.
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Affiliation(s)
- Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania2Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shipra Arya
- Surgical Service Line, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia4Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia
| | - Kendra K Schmid
- Department of Biostatistics, University of Nebraska Medical Center, Omaha
| | - Mark A Carlson
- Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha7Department of Surgery, University of Nebraska Medical Center, Omaha8Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Pierre Lavedan
- Department of Extended Care and Rehabilitation, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Travis L Bailey
- Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha10Department of Orthopaedic Surgery, University of Utah School of Medicine, Salt Lake City
| | - Georgia Purviance
- Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Tammy Bockman
- Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Thomas G Lynch
- Office of Health Operations and Management, Department of Veterans Affairs, Veterans Health Administration, Washington, DC12Department of Surgery, George Washington University School of Medicine, Washington, DC
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha8Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
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Hall DE, Arya S, Schmid KK, Carlson MA, Lavedan P, Bailey TL, Purviance G, Bockman T, Lynch TG, Johanning JM. Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and 365 Days. JAMA Surg 2017. [PMID: 27902826 DOI: 10.1001/jamasurg.2016.4219.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance As the US population ages, the number of operations performed on elderly patients will likely increase. Frailty predicts postoperative mortality and morbidity more than age alone, thus presenting opportunities to identify the highest-risk surgical patients and improve their outcomes. Objective To examine the effect of the Frailty Screening Initiative (FSI) on mortality and complications by comparing the surgical outcomes of a cohort of surgical patients treated before and after implementation of the FSI. Design, Setting, and Participants This single-site, facility-wide, prospective cohort quality improvement project studied all 9153 patients from a level 1b Veterans Affairs medical center who presented for major, elective, noncardiac surgery from October 1, 2007, to July 1, 2014. Interventions Assessment of preoperative frailty in all patients scheduled for elective surgery began in July 2011. Frailty was assessed with the Risk Analysis Index (RAI), and the records of all frail patients (RAI score, ≥21) were flagged for administrative review by the chief of surgery (or designee) before the scheduled operation. On the basis of this review, clinicians from surgery, anesthesia, critical care, and palliative care were notified of the patient's frailty and associated surgical risks; if indicated, perioperative plans were modified based on team input. Main Outcomes and Measures Postoperative mortality at 30, 180, and 365 days. Results From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16). Conclusions and Relevance Implementation of the FSI was associated with reduced mortality, suggesting the feasibility of widespread screening of patients preoperatively to identify frailty and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Additional investigation is required to establish a causal connection.
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Affiliation(s)
- Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania2Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shipra Arya
- Surgical Service Line, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia4Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia
| | - Kendra K Schmid
- Department of Biostatistics, University of Nebraska Medical Center, Omaha
| | - Mark A Carlson
- Department of Genetics, Cell Biology, and Anatomy, University of Nebraska Medical Center, Omaha7Department of Surgery, University of Nebraska Medical Center, Omaha8Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Pierre Lavedan
- Department of Extended Care and Rehabilitation, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Travis L Bailey
- Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha10Department of Orthopaedic Surgery, University of Utah School of Medicine, Salt Lake City
| | - Georgia Purviance
- Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Tammy Bockman
- Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
| | - Thomas G Lynch
- Office of Health Operations and Management, Department of Veterans Affairs, Veterans Health Administration, Washington, DC12Department of Surgery, George Washington University School of Medicine, Washington, DC
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha8Department of Surgery, VA Nebraska-Western Iowa Health Care System, Omaha
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Borza T, Kaufman SR, Shahinian VB, Yan P, Miller DC, Skolarus TA, Hollenbeck BK. Sharp Decline In Prostate Cancer Treatment Among Men In The General Population, But Not Among Diagnosed Men. Health Aff (Millwood) 2017; 36:108-115. [DOI: 10.1377/hlthaff.2016.0739] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Tudor Borza
- Tudor Borza ( ) is a research fellow in the Dow Health Services Research Division, Department of Urology, Institute for Healthcare Policy and Innovation, at the University of Michigan Health System, in Ann Arbor
| | - Samuel R. Kaufman
- Samuel R. Kaufman is a research analyst in the Dow Health Services Research Division, Department of Urology, University of Michigan Health System
| | - Vahakn B. Shahinian
- Vahakn B. Shahinian is a research investigator in the Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan Health System
| | - Phyllis Yan
- Phyllis Yan is a research analyst in the Dow Health Services Research Division, Department of Urology, University of Michigan Health System
| | - David C. Miller
- David C. Miller is a research investigator in the Dow Health Services Research Division, Department of Urology, Institute for Healthcare Policy and Innovation, University of Michigan Health System
| | - Ted A. Skolarus
- Ted A. Skolarus is a research investigator in the Dow Health Services Research Division, Department of Urology, University of Michigan Health System, and VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | - Brent K. Hollenbeck
- Brent K. Hollenbeck is a research investigator in the Dow Health Services Research Division, Department of Urology, Institute for Healthcare Policy and Innovation, University of Michigan Health System
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Presley CJ, Soulos PR, Tinetti M, Montori VM, Yu JB, Gross CP. Treatment Burden of Medicare Beneficiaries With Stage I Non-Small-Cell Lung Cancer. J Oncol Pract 2016; 13:e98-e107. [PMID: 27997301 DOI: 10.1200/jop.2016.014100] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To quantify the burden and complexity associated with treatment of Medicare beneficiaries with stage I non-small-cell lung cancer (NSCLC). METHODS Using the SEER-Medicare database, we conducted a retrospective cohort study of Medicare beneficiaries who were diagnosed with stage I NSCLC from 2007 to 2011 and who were treated with surgery, stereotactic body radiation therapy, or external beam radiation therapy. Main outcome measures were the number of days a patient was in contact with the health care system (encounter days), the number of physicians involved in a patient's care, and the number of medications prescribed. Logistic regression modeled the association between patient characteristics, treatment type, and high treatment burden (defined as ≥ 66 encounter days). RESULTS On average, 7,955 patients spent 1 in 3 days interacting with the health care system during the initial 60 days of treatment. Patients experienced a median of 44 encounter days with high variability (interquartile range [IQR], 29 to 66) in the 12 months after treatment initiation. The median number of physicians involved was 20 (IQR, 14 to 28), and the median number of medications prescribed was 12 (IQR, 8 to 17). Patients who were treated with surgery had high treatment burden (predicted probability, 21.6%; 95% CI, 20.2 to 23.1) compared with patients who were treated with stereotactic body radiation therapy (predicted probability, 16.1%; 95% CI, 12.9 to 19.3), whereas patients who were treated with external beam radiation therapy had the highest burden (predicted probability, 46.8%; 95% CI, 43.3 to 50.2). CONCLUSION The treatment burden imposed on patients with early-stage NSCLC was substantial in terms of the number of encounters, physicians involved, and medications prescribed. Because treatment burden varied markedly across patients and treatment types, future work should identify opportunities to understand and ameliorate this burden.
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Affiliation(s)
- Carolyn J Presley
- Yale University School of Medicine, New Haven, CT; and Mayo Clinic, Rochester, MN
| | - Pamela R Soulos
- Yale University School of Medicine, New Haven, CT; and Mayo Clinic, Rochester, MN
| | - Mary Tinetti
- Yale University School of Medicine, New Haven, CT; and Mayo Clinic, Rochester, MN
| | - Victor M Montori
- Yale University School of Medicine, New Haven, CT; and Mayo Clinic, Rochester, MN
| | - James B Yu
- Yale University School of Medicine, New Haven, CT; and Mayo Clinic, Rochester, MN
| | - Cary P Gross
- Yale University School of Medicine, New Haven, CT; and Mayo Clinic, Rochester, MN
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Moth EB, Vardy J, Blinman P. Decision-making in geriatric oncology: systemic treatment considerations for older adults with colon cancer. Expert Rev Gastroenterol Hepatol 2016; 10:1321-1340. [PMID: 27718755 DOI: 10.1080/17474124.2016.1244003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Colon cancer is common and can be considered a disease of older adults with more than half of cases diagnosed in patients aged over 70 years. Decision-making about treatment with chemotherapy for older adults may be complicated by age-related physiological changes, impaired functional status, limited social supports, concerns regarding the occurrence of and ability to tolerate treatment toxicity, and the presence of comorbidities. This is compounded by a lack of high quality evidence guiding cancer treatment decisions for older adults. Areas covered: This narrative review evaluates the evidence for adjuvant and palliative systemic therapy in older adults with colon cancer. The value of an adequate assessment prior to making a treatment decision is addressed, with emphasis on the geriatric assessment. Guidance in making a treatment decision is provided. Expert commentary: Treatment decisions should consider goals of care, a patient's treatment preferences, and weigh up relative benefits and harms.
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Affiliation(s)
- Erin B Moth
- a Concord Cancer Centre , Concord Repatriation General Hospital , Sydney , Australia.,b Sydney Medical School , University of Sydney , Sydney , Australia
| | - Janette Vardy
- a Concord Cancer Centre , Concord Repatriation General Hospital , Sydney , Australia.,b Sydney Medical School , University of Sydney , Sydney , Australia
| | - Prunella Blinman
- a Concord Cancer Centre , Concord Repatriation General Hospital , Sydney , Australia.,b Sydney Medical School , University of Sydney , Sydney , Australia
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Abstract
BACKGROUND Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening. OBJECTIVE To determine the association between receipt of screening mammography or PSA and overall survival. DESIGN Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001-2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening. PARTICIPANTS A 5 % sample of Medicare beneficiaries aged 69-90 years as of 1/1/2003 (n = 906,723). INTERVENTIONS Receipt of screening mammography in 2001-2002 for women, or a screening PSA test in 2002 for men. MAIN MEASURES Survival from 1/1/2003 through 12/31/2012. KEY RESULTS Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1 years for women and 0.9 to 1.1 years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR = 1.52; 95 % CI = 1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR = 1.23; 1.22, 1.25). CONCLUSIONS Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.
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Affiliation(s)
- James S Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.
- Sealy Center on Aging, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555-0177, USA.
- Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX, USA.
| | - Kristin Sheffield
- Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, 46285, USA
| | - Shuang Li
- Sealy Center on Aging, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555-0177, USA
| | - Alai Tan
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
- Sealy Center on Aging, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555-0177, USA
- Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX, USA
- Ohio State University School of Nursing, 1582 Neil Ave, Columbus, OH, 43210, USA
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Aparicio T, Pamoukdjian F, Quero L, Manfredi S, Wind P, Paillaud E. Colorectal cancer care in elderly patients: Unsolved issues. Dig Liver Dis 2016; 48:1112-8. [PMID: 27260332 DOI: 10.1016/j.dld.2016.05.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/24/2016] [Accepted: 05/12/2016] [Indexed: 12/11/2022]
Abstract
Colorectal cancers are common in elderly patients. However, cancer screening is poorly used after 75. Elderly patients form a heterogeneous population with specific characteristics. Standards of care cannot therefore be transposed from young to elderly patients. Tumour resection is frequently performed but adjuvant chemotherapy is rarely prescribed as there are no clearly established standards of care. In a metastatic setting, recent phase III studies have demonstrated that doublet front-line chemotherapy provided no survival benefit. Moreover, several studies have established the benefit of bevacizumab in association with chemotherapy. There is a lack of evidence for the efficacy of anti-epidermal growth factor antibodies in elderly patients. Geriatric assessments could help to select the adequate treatment strategy for individual patients. Geriatric oncology is now the challenge we have to face, and more specific trials are needed.
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Affiliation(s)
- Thomas Aparicio
- Gastroenterology and Digestive Oncology Department, CHU Avicenne, APHP, Bobigny, France.
| | | | - Laurent Quero
- Radiotherapy Department, CHU Saint Louis, APHP, Paris, France
| | - Sylvain Manfredi
- Hepato-Gastroenterology and Oncology Department, INSERM U866, CHU Dijon, Dijon, France
| | - Philippe Wind
- Surgery Department, CHU Avicenne, APHP, Bobigny, France
| | - Elena Paillaud
- Geriatric Department, CHU Henri Mondor, APHP, Créteil, France
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Abstract
Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.
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Affiliation(s)
- Diana Sarfati
- Director, Cancer Control and Screening Research Group, University of Otago, Wellington, New Zealand
| | - Bogda Koczwara
- Senior Staff Specialist, Flinders Center for Innovation in Cancer, Flinders University, Adelaide, South Australia, Australia
| | - Christopher Jackson
- Senior Lecturer in Medicine, Department of Medicine, Dunedin School of Medicine, University of Otago, Wellington, New Zealand
- Consultant Medical Oncologist, Southern District Health Board, Dunedin, New Zealand
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Breslau ES, Gorin SS, Edwards HM, Schonberg MA, Saiontz N, Walter LC. An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework. J Gen Intern Med 2016; 31:539-47. [PMID: 26941042 PMCID: PMC4835387 DOI: 10.1007/s11606-016-3629-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 02/05/2016] [Accepted: 02/05/2016] [Indexed: 11/29/2022]
Abstract
Guidelines for optimal cancer screening in older adults remain unclear, particularly for adults over the age of 75. While cancer screening in older adults may benefit some in good health, it may cause unnecessary burdens in others with limited life expectancy. Thus, a systematic approach to enable individualized cancer screening decisions in older adults is needed. We suggest a framework that guides such decisions through evidence-based approaches from multiple interactions, and that involves the patient, clinician, and healthcare system. An individualized approach considers differences in disease risk rather than the chronological age of the patient. This paper presents a comprehensive framework that depicts the independent and converging levels of influences on individualized cancer screening decisions in older adults. This Individualized Decisions for Screening (IDS) framework recognizes the reality of these interrelationships, including the tensions that arise when behaviors and outcomes are valued differently at the patient, clinician, and healthcare organization levels. Person-centered approaches are essential to advancing multilevel research of individualized cancer screening decisions among older adults.
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Affiliation(s)
- Erica S Breslau
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850-9761, USA.
| | - Sherri Sheinfeld Gorin
- Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, MD, 21702, USA
- New York Physicians Against Cancer, Herbert Irving Comprehensive Cancer Center, New York, 10032, NY, USA
| | - Heather M Edwards
- Patient-Centered Outcomes Research Institute, Washington, 20036, DC, USA
| | - Mara A Schonberg
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, 02215, MA, USA
| | - Nicole Saiontz
- Office of the Director, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, 20850-9761, MD, USA
| | - Louise C Walter
- Department of Medicine, Division of Geriatrics, University of California San Francisco and the San Francisco VA Medical Center, San Francisco, 94121, CA, USA
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Hsieh MC, Thompson T, Wu XC, Styles T, O'Flarity MB, Morris CR, Chen VW. The effect of comorbidity on the use of adjuvant chemotherapy and type of regimen for curatively resected stage III colon cancer patients. Cancer Med 2016; 5:871-80. [PMID: 26773804 PMCID: PMC4864816 DOI: 10.1002/cam4.632] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/02/2015] [Accepted: 12/04/2015] [Indexed: 12/26/2022] Open
Abstract
Postsurgical chemotherapy is guideline-recommended therapy for stage III colon cancer patients. Factors associated with patients not receiving adjuvant chemotherapy were identified in numerous studies; comorbidity was recognized as an important factor besides patient's age. We assessed the association between comorbidity and the use of adjuvant chemotherapy and type of chemotherapy regimen. Stage III colon cancer patients who underwent surgical resection were obtained from ten Centers for Disease Control and Prevention (CDC)-NPCR Specialized Registries which participated in the Comparative Effectiveness Research (CER) project. Comorbidity was classified into no comorbidity recorded, Charlson, non-Charlson comorbidities, number, and severity of Charlson comorbidity. Pearson chi-square test and multivariable logistic regression were employed. Of 3180 resected stage III colon cancer patients, 64% received adjuvant chemotherapy. After adjusting for patient's demographic and tumor characteristics, there were no significant differences in receipt of chemotherapy between Charlson and non-Charlson comorbidity. However, patients who had two or more Charlson comorbidities or had moderate to severe disease were significantly less likely to have chemotherapy (ORs 0.69 [95% CI, 0.51-0.92] and 0.62 [95% CI, 0.42-0.91], respectively) when compared with those with non-Charlson comorbidity. In addition, those with moderate or severe comorbidities were more likely to receive single chemotherapy agent (P < 0.0001). Capecitabine and FOLFOX were the most common single- and multi-agent regimens regardless of type of comorbidity grouping. Both the number and severity of comorbidity were significantly associated with receipt of guideline-recommended chemotherapy and type of agent in stage III resected colon cancer patients. Better personalized care based on individual patient's condition ought to be recognized.
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Affiliation(s)
- Mei-Chin Hsieh
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Trevor Thompson
- Cancer Surveillance Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Timothy Styles
- Cancer Surveillance Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary B O'Flarity
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Cyllene R Morris
- Public Health Institute, California Cancer Registry, Sacramento, California
| | - Vivien W Chen
- Louisiana Tumor Registry and Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Berger BM, Schroy PC, Dinh TA. Screening for Colorectal Cancer Using a Multitarget Stool DNA Test: Modeling the Effect of the Intertest Interval on Clinical Effectiveness. Clin Colorectal Cancer 2015; 15:e65-74. [PMID: 26792032 DOI: 10.1016/j.clcc.2015.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/01/2015] [Accepted: 12/09/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND A multitarget stool DNA (mt-sDNA) test was recently approved for colorectal cancer (CRC) screening for men and women, aged ≥ 50 years, at average risk of CRC. The guidelines currently recommend a 3-year interval for mt-sDNA testing in the absence of empirical data. We used clinical effectiveness modeling to project decreases in CRC incidence and related mortality associated with mt-sDNA screening to help inform interval setting. MATERIALS AND METHODS The Archimedes model (Archimedes Inc., San Francisco, CA) was used to conduct a 5-arm, virtual, clinical screening study of a population of 200,000 virtual individuals to compare the clinical effectiveness of mt-sDNA screening at 1-, 3-, and 5-year intervals compared with colonoscopy at 10-year intervals and no screening for a 30-year period. The study endpoints were the decrease in CRC incidence and related mortality of each strategy versus no screening. Cost-effectiveness ratios (US dollars per quality-adjusted life year [QALY]) of mt-sDNA intervals were calculated versus no screening. RESULTS Compared with 10-year colonoscopy, annual mt-sDNA testing produced similar reductions in CRC incidence (65% vs. 63%) and related mortality (73% vs. 72%). mt-sDNA testing at 3-year intervals reduced the CRC incidence by 57% and CRC mortality by 67%, and mt-sDNA testing at 5-year intervals reduced the CRC incidence by 52% and CRC mortality by 62%. At an average price of $600 per test, the annual, 3-year, and 5-year mt-sDNA screening costs would be $20,178, $11,313, and $7388 per QALY, respectively, compared with no screening. CONCLUSION These data suggest that screening every 3 years using a multitarget mt-sDNA test provides reasonable performance at acceptable cost.
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Affiliation(s)
| | - Paul C Schroy
- Department of Gastroenterology, Boston University School of Medicine, Boston, MA
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Abstract
Deciding when to stop cancer screening in older adults is a complex challenge that involves multiple factors: individual health status and life expectancy; risks and benefits of screening, which vary with age and comorbidity; and individual preferences and values. This article examines current cancer screening practices and reviews the risks and benefits of cancer screening for colorectal, breast, lung, prostate, and cervical cancer, particularly in older individuals and those with multiple comorbidities. Tools for estimating life expectancy are reviewed, and a practical framework is presented to guide discussions on when the harms of screening likely outweigh the benefits.
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Affiliation(s)
- Michael C Soung
- General Internal Medicine, Internal Medicine Residency Core Faculty, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101, USA.
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Hung MC, Lai WW, Chen HHW, Su WC, Wang JD. Comparison of expected health impacts for major cancers: integration of incidence rate and loss of quality-adjusted life expectancy. Cancer Epidemiol 2014; 39:126-32. [PMID: 25553846 DOI: 10.1016/j.canep.2014.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 11/14/2014] [Accepted: 12/08/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE The study aims to quantify the expected impacts of different cancers through multiplying the incidence rate by loss-of-QALE (quality-adjusted life expectancy), with QALY (quality-adjusted life year) as the common unit, to aid prevention policy decisions. METHODS 464,722 patients with pathologically verified cancer registered in the Taiwan Cancer Registry during 1998-2009 were used to estimate lifetime survival through Kaplan-Meier estimation combined with a semi-parametric method. A convenience sample for measuring the utility value with EQ-5D was conducted with 11,453 cancer patients, with the results then multiplied by the survival functions to estimate QALE. The loss-of-QALE was calculated by subtracting the QALE of each cancer cohort from the life expectancy of the corresponding age- and gender-matched reference population. The cumulative incidence rates from age 20 to 79 (CIR₂₀₋₇₉) were calculated to estimate the lifetime risk of cancer for each organ-system. RESULTS Liver and lung cancer were found the highest expected lifetime health impacts in males and females, or expected lifetime losses of 0.97 and 0.41 QALYs that could be averted, respectively. While the priority changes for prevention based on expected health impacts were slightly different for females based on standardized mortality rates, those of males involve a broader spectrum, including oral, colorectal, esophageal and stomach cancer. CONCLUSION The integration of incidence rate with loss-of-QALE could be used to represent the expected losses that could be averted by prevention, which may be useful in prioritizing strategies for cancer control.
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Affiliation(s)
- Mei-Chuan Hung
- Department of Public Health, National Cheng Kung University College of Medicine, Tainan 704, Taiwan
| | - Wu-Wei Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Helen H W Chen
- Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Wu-Chou Su
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Jung-Der Wang
- Department of Public Health, National Cheng Kung University College of Medicine, Tainan 704, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan 704, Taiwan.
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Decision-making and cancer screening: a qualitative study of older adults with multiple chronic conditions. J Geriatr Oncol 2014; 6:93-100. [PMID: 25544380 DOI: 10.1016/j.jgo.2014.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/29/2014] [Accepted: 12/01/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To understand how older persons with multiple chronic conditions (MCC) approach decisions about cancer screening. MATERIALS AND METHODS We conducted interviews with adults >65 years old with at least two chronic conditions who were taking ≥five medications daily. Patients were first asked how age and multimorbidity influence their cancer screening decisions. After showing them an educational prompt that explained the relationship between life expectancy and the benefits of cancer screening, respondents were then asked about screening in the context of specific health scenarios. Using grounded theory, three independent readers coded responses for salient themes. Sample size was determined by thematic saturation. RESULTS Most respondents (26 of 28) initially indicated that their overall health or medical conditions do not influence their cancer screening decisions. After viewing the educational prompt, respondents described two broad approaches to cancer screening in the setting of increasing age or multi-morbidity. The first was a "benefits versus harms" approach in which participants weighed direct health benefits (e.g. reducing cancer incidence or mortality) and harms (e.g. complications or inconvenience). The second was a heuristic approach. Some heuristics favored screening, such as a persistent belief in unspecified benefits from screening, value of knowledge about cancer status, and not wanting to "give up", whereas other heuristics discouraged screening, such as fatalism or a reluctance to learn about their cancer status. CONCLUSIONS When considering cancer screening, some older persons with MCC employ heuristics which circumvent the traditional quantitative comparison of risks and benefits, providing an important challenge to informed decision making.
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Kleber G. [Colorectal cancer: prevention and curative treatment in the elderly: An appraisal from the viewpoint of geriatric gastroenterology]. Chirurg 2014; 86:861-5. [PMID: 25488000 DOI: 10.1007/s00104-014-2898-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND More than half of colorectal cancers occur in patients older than 75 years. This group is not homogeneous but variably vulnerable to disease, diagnostics, treatment procedures and complications. OBJECTIVES This review highlights the age-specific aspects of diagnostics and screening, curative and adjuvant treatment and the prognostic and predictive value of a geriatric assessment. METHODS A survey was carried out based on a selection of the relevant literature. RESULTS The number of publications is currently rapidly increasing and even now it becomes apparent that a geriatric assessment carried out by the primary physician, can better predict therapy-linked adverse events and allow for a more individualized assessment of indications for diagnostics and screening of surgical and medicinal treatment. In particular this applies to total mesorectal resection and to the adjuvant use of oxaliplatin. CONCLUSION Even in the older age group screening colonoscopy and surgical and medicinal adjuvant treatment can be reasonably used when aligned to the results of a carefully performed geriatric assessment. A severely reduced life-expectancy (generally with more than 2 comorbidities) should lead to more conservative approaches.
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Affiliation(s)
- G Kleber
- Med. Klinik I, Ostalb-Klinikum Aalen, Akad. Lehrkrankenhaus der Universität Ulm, Kälblesrain 1, 73430, Aalen, Deutschland,
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McCleary NJ, Dotan E, Browner I. Refining the Chemotherapy Approach for Older Patients With Colon Cancer. J Clin Oncol 2014; 32:2570-80. [DOI: 10.1200/jco.2014.55.1960] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Population studies support an increased incidence of most cancers among older adults. Colorectal cancer has high prevalence in the aging population, with a median age of 69 years at diagnosis and 74 years at death. The vast majority of patients with colon cancer (CC) will require chemotherapy treatments during their disease course, challenging oncologists with the task of tailoring therapy for older patients with CC in the face of limited evidence-based data to guide them. Factors such as comorbidity, performance status, cognitive function, and social support may affect decision making and complicate tolerance of any recommended therapy. In recent years, attention to the specific needs of the aging population with cancer has given rise to the field of geriatric oncology in general, and has generated an increasing fund of knowledge on which to base chemotherapy delivery for this specific population of patients with CC. This article will review the available data specifically for chemotherapy management of older patients with CC in the postoperative and metastatic settings.
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Affiliation(s)
- Nadine J. McCleary
- Nadine J. McCleary, Dana-Farber Cancer Institute, Boston MA; Efrat Dotan, Fox Chase Cancer Center, Philadelphia, PA; and Ilene Browner, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, MD
| | - Efrat Dotan
- Nadine J. McCleary, Dana-Farber Cancer Institute, Boston MA; Efrat Dotan, Fox Chase Cancer Center, Philadelphia, PA; and Ilene Browner, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, MD
| | - Ilene Browner
- Nadine J. McCleary, Dana-Farber Cancer Institute, Boston MA; Efrat Dotan, Fox Chase Cancer Center, Philadelphia, PA; and Ilene Browner, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, MD
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Kim CAK, Spratlin JL, Armstrong DE, Ghosh S, Mulder KE. Efficacy and safety of single agent or combination adjuvant chemotherapy in elderly patients with colon cancer: a Canadian cancer institute experience. Clin Colorectal Cancer 2014; 13:199-206. [PMID: 25088184 DOI: 10.1016/j.clcc.2014.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 06/16/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND The pattern of adjuvant chemotherapy (AC) use, toxicity profile, and survival benefit in elderly patients with colon cancer (CC) is unclear. We sought to (1) determine whether patients ≥ 65 years with stage III CC were offered single-agent or combination AC, (2) evaluate the reason for selecting single-agent versus combination AC, (3) evaluate the toxicity profile of single-agent and combination AC in the elderly, and (4) determine whether a survival benefit exists for elderly patients receiving combination AC. PATIENTS AND METHODS A retrospective analysis of records of patients ≥ 65 years diagnosed with stage III CC from 2004 to 2010 was performed to identify baseline characteristics, AC protocols, toxicity, dose intensity, and survival. RESULTS Two hundred sixty-eight patients ≥ 65 years were diagnosed and treated with AC from 2004 to 2010. Of these patients, 178 were treated with single-agent AC and 90 were treated with combination AC. The most common reasons for choosing single-agent AC were patient preference, comorbidities, and lack of drug coverage. For each year over 65 years, the odds of receiving combination over single-agent AC decreased by 22%. There were more dose delays, dose reductions, and early chemotherapy discontinuation in the combination AC group because of hematologic toxicity. The 5-year overall survival (OS) was 73% in patients who received single-agent AC compared with 84% in those who received combination AC. There was no difference in cancer-related deaths between the groups. CONCLUSION In elderly patients treated with AC for stage III CC, single-agent AC is used more frequently than combination AC, based on age, comorbidities, and patient choice. Toxicity with combination AC in elderly patients is high. No survival benefit was seen with combination AC over single-agent AC.
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Affiliation(s)
| | | | | | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
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Zhang D, Wang C, Zhou Z. Meta-Analysis of ABCB1 3435C>T Polymorphism and Colorectal Cancer. Pak J Med Sci 2014; 29:1269-74. [PMID: 24353734 PMCID: PMC3858949 DOI: 10.12669/pjms.295.3758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 07/05/2013] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Many studies have focused on the association between the ABCB1 3435C>T polymorphism and colorectal cancer (CRC) risk. However, the results were conflicting. The aim of this meta-analysis is to evaluate the precise association between this polymorphism and CRC risk. METHODS We formally reviewed the literature at Pubmed, EMBASE and the Cochrane Library with the key words as follows: ABCB1/MDR1/P-glycoprotein, polymorphism, colorectal and cancer/neoplasm/tumor. This meta-analysis was assessed by Review manager 5.0. The fixed-effects model was used to pool the odds ratios (OR) with 95% confidence intervals (CI) for CRC risk. RESULTS There were 8 studies identified. The pooled OR with 95% CI of CC+CT versus TT genotype of the ABCB1 3435C>T polymorphism for CRC risk was 1.01 [0.90-1.13]. The sensitivity analysis further confirmed the result. Heterogeneity and publication bias were not observed in this meta-analysis. CONCLUSIONS In summary, there was no significant association between the ABCB1 3435C>T polymorphism and CRC risk. Abbreviations used: the ATP-binding cassette, subfamily B, member 1 (ABCB1); multidrug resistance gene 1 (MDR1); P-glycoprotein (P-gp); colorectal cancer (CRC); single nucleotide polymorphisms (SNPs); odds ratio (OR); confidence interval (CI); Hardy-Weinberg equilibrium (HWE).
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Affiliation(s)
- Dan Zhang
- Dan Zhang, Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 on Guoxue Xiang, Chengdu, Sichuan Province, China
| | - Cun Wang
- Cun Wang, Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 on Guoxue Xiang, Chengdu, Sichuan Province, China
| | - Zongguang Zhou
- Zongguang Zhou Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 on Guoxue Xiang, Chengdu, Sichuan Province, China
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Does patient age still affect receipt of adjuvant therapy for colorectal cancer in New South Wales, Australia? J Geriatr Oncol 2014; 5:323-30. [PMID: 24656735 DOI: 10.1016/j.jgo.2014.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 01/14/2014] [Accepted: 02/26/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To investigate the effect of patient age on receipt of stage-appropriate adjuvant therapy for colorectal cancer in New South Wales, Australia. MATERIALS AND METHODS A linked population-based dataset was used to examine the records of 580 people with lymph node-positive colon cancer and 498 people with high-risk rectal cancer who underwent surgery following diagnosis in 2007/2008. Multilevel logistic regression models were used to determine whether age remained an independent predictor of adjuvant therapy utilisation after accounting for significant patient, surgeon and hospital characteristics. RESULTS Overall, 65-73% of eligible patients received chemotherapy and 42-53% received radiotherapy. Increasing age was strongly associated with decreasing likelihood of receiving chemotherapy for lymph node-positive colon cancer (p<0.001) and radiotherapy for high-risk rectal cancer (p=0.003), even after adjusting for confounders such as Charlson comorbidity score and ASA health status. People aged over 70years for chemotherapy and over 75years for radiotherapy were significantly less likely to receive treatment than those aged less than 65. Emergency resection, intensive care admission, and not having a current partner also independently predicted chemotherapy nonreceipt. Other predictors of radiotherapy nonreceipt included being female, not being discussed at multidisciplinary meeting, and lower T stage. Adjuvant therapy rates varied widely between hospitals where surgery was performed. CONCLUSION There are continuing age disparities in adjuvant therapy utilisation in NSW that are not explained by patients' comorbidities or health status. Further exploration of these complex treatment decisions is needed. Variation by hospital and patient characteristics indicates opportunities to improve patient care and outcomes.
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Mittal S, Lin YL, Tan A, Kuo YF, El-Serag HB, Goodwin JS. Limited life expectancy among a subgroup of medicare beneficiaries receiving screening colonoscopies. Clin Gastroenterol Hepatol 2014; 12:443-450.e1. [PMID: 23973925 PMCID: PMC3944371 DOI: 10.1016/j.cgh.2013.08.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/08/2013] [Accepted: 08/13/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND & AIMS Life expectancy is an important consideration when assessing appropriateness of preventive programs for older individuals. Most studies on this subject have used age cutoffs as a proxy for life expectancy. We analyzed patterns of utilization of screening colonoscopy in Medicare enrollees by using estimated life expectancy. METHODS We used a 5% random national sample of Medicare claims data to identify average-risk patients who underwent screening colonoscopies from 2008 to 2010. Colonoscopies were considered to be screening colonoscopies in the absence of diagnoses for nonscreening indications, which were based on either colonoscopies or any claims in the preceding 3 months. We estimated life expectancies by using a model that combined age, sex, and comorbidity. Among patients who underwent screening colonoscopies, we calculated the percentage of those with life expectancies <10 years. RESULTS Among the 57,597 Medicare beneficiaries 66 years old or older who received at least 1 screening colonoscopy, 24.8% had an estimated life expectancy of <10 years. There was a significant positive association between total Medicare per capita costs in hospital referral regions and the proportion of patients with limited life expectancies (<10 years) at the time of screening colonoscopy (R = 0.25; P < .001, Pearson correlation test). In a multivariable analysis, men were substantially more likely than women to have limited life expectancy at the time of screening colonoscopy (odds ratio, 2.25; 95% confidence interval, 2.16-2.34). CONCLUSIONS Nearly 25% of Medicare beneficiaries, especially men, had life expectancies <10 years at the time of screening colonoscopies. Life expectancy should therefore be incorporated in decision-making for preventive services.
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Affiliation(s)
- Sahil Mittal
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
| | - Yu-Li Lin
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
| | - Alai Tan
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - James S Goodwin
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
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50
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Guillerme F, Clavier JB, Nehme-Schuster H, Leroy V, Heitz D, Schumacher C, Abdelghani MB, Brigand C, Kurtz JE, Noël G. Age impacts the pattern of care for elderly patients with rectal cancer. Int J Colorectal Dis 2014; 29:157-63. [PMID: 24127011 DOI: 10.1007/s00384-013-1778-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE This study analyzed the current approaches for rectal cancer treatment in elderly patients. METHODS We retrospectively studied 240 rectal cancer patients who had undergone radiotherapy from 2000 to 2008. The ages of the patients ranged from 65 and 75 years (group A, n = 127) and older than 75 years (group B, n = 113). The distribution of the Charlson comorbidity index was similar between the two groups, but the ECOG performance status (PS) differed between the groups (66 % of the patients of group A were PS 0, and 40 % were PS 0 in group B (p < 0.0001)). The tumor stages were comparable between groups. RESULTS The median age of the patients was 74.3 years (range 65-90.6). Treatment was discussed during a multidisciplinary cancer team meeting before treatment for 55 % of the cases in group A and 73 % of the cases in group B (p < 0.001), and treatment proposals were in accordance with guidelines in 96 % of the cases in group A and 76 % of the cases in group B (p < 0.001). Group B patients received slightly less concurrent chemotherapy (35 vs. 30 % for group A; p = 0.54), more hypofractionated radiotherapy (41 vs. 54 % for group A; p = 0.064), less surgery (92 vs. 80 % for group A; p = 0.014), and less adjuvant chemotherapy (34 vs. 10 % for group A; p < 0.001). Finally, 80 % of the patients in group A and 60 % of the patients in group B received treatment in accordance with guidelines (p = 0.007) and in the logistic regression model. Non-metastatic patients who were aged below 75 years were predicted for conformal management (HR = 0.323; 95 % CI = 0.152-0.684) irrespective of their performance status, comorbidity, or disease stage. CONCLUSIONS Treatment proposals and administered therapy differed according to age.
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Affiliation(s)
- Florence Guillerme
- Center de lutte contre le cancer Paul Strauss, 3, rue de la porte de l'hôpital, 67065, Strasbourg cedex, France
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