Risk Factors for Adverse Events in Patients With Breast, Colorectal, and Lung Cancer

OBJECTIVE

The aim of the study was to identify risk factors associated with medical errors and iatrogenic injuries during an initial course of cancer-directed treatment.

METHODS

In this retrospective cohort study of 400 patients 18 years or older undergoing an initial course of treatment for breast, colorectal, or lung cancer at a comprehensive cancer center, we abstracted patient, disease, and treatment-related variables from the electronic medical record. We examined adverse events (AEs) and preventable AEs by risk factor using the χ2 or Fisher exact tests. We estimated the association between risk factors and the relative risk of an additional AE or preventable AE in multivariable negative binomial regression models with backwards selection (P < 0.1).

RESULTS

There were 304 AEs affecting 136 patients (34%) and 97 preventable AEs affecting 53 patients (13%). In multivariable analyses, AEs were overrepresented in those with lung cancer compared with patients with breast cancer (incident rate ratio = 1.9, 95% confidence interval = 1.1-3.2). Nonwhite race (1.6, 1.0-2.6), Hispanic or Latino ethnicity (2.0, 0.9-4.1), advanced disease (1.7, 1.1-2.6), use of each additional class of high-risk nonchemotherapy medication (1.6, 1.3-1.9), and chemotherapy (2.1, 1.3-3.3) were all associated with risk of an additional AE. Preventable AEs were associated with lung cancer (7.4, 2.4-23.2), Hispanic or Latino ethnicity (5.5, 1.7-17.9), and high-risk nonchemotherapy medications (1.5, 1.2-2.0).

CONCLUSIONS

Risk factors for AEs among patients with cancer reflected patients' underlying disease, cancer-directed therapy, and high-risk noncancer medications. The association of AEs with ethnicity merits further research. Risk factor models could be used prospectively to identify patients with cancer at increased risk of harm.

Practice Patterns for Older Adult Patients With Advanced Cancer: Physician Office Versus Hospital Outpatient Setting

PURPOSE

A shift in outpatient oncology care from the physician's office to hospital outpatient settings has generated interest in the effect of practice setting on outcomes. Our objective was to examine whether medical oncologists' prescribing of drugs and services for older adult patients with advanced cancer is used more in physicians' offices compared with hospital outpatient departments.

METHODS

This was a retrospective comparative study. SEER-Medicare data (2004 to 2011) were used to identify Medicare beneficiaries diagnosed with advanced breast, colon, esophagus, non-small-cell lung, pancreatic, or stomach cancer. Between physicians' offices and hospital outpatient departments, we compared use of selected likely low-value supportive drugs, low-value therapeutic drugs, chemotherapy-related hospitalizations, and hospice. We used hierarchical modeling to assess differences between settings to account for correlation within physicians.

RESULTS

Compared with patients treated in a hospital outpatient department, those treated in a physician's office setting were more likely to receive erythropoiesis-stimulating agents (odds ratio, 1.72; 95% CI, 1.53 to 1.94) and granulocyte colony-stimulating factors (odds ratio, 1.28; 95% CI, 1.18 to 1.38). For combination chemotherapy and nanoparticle albumin-bound-paclitaxel in patients with breast cancer, there was a trend toward higher use in physicians' offices, although this was not statistically significant. Chemotherapy-related hospitalizations and hospice did not vary by setting.

CONCLUSION

We found somewhat higher use of several drugs for patients with advanced cancer in physicians' office settings compared with hospital outpatient departments. Findings support research to dissect the mechanisms through which setting might influence physicians' behavior.

Long-term quality of life in older patients with HPV-related oropharyngeal cancer

BACKGROUND

We explored if age affects quality of life (QOL) in survivors of locally advanced human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCC).

METHODS

In a cross-sectional survey of 185 patients, at least 12 months from radiation, we evaluated generic (EuroQOL-5D questionnaire [EQ-5D]) and head and neck specific (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35-questions [EORTC-QLQ-H&N35]) QOL questionnaires and compared differences between younger (<65) and older (≥65) patients.

RESULTS

The median age was 57.0 years (range 25-77 years), and 31 patients (16.8%) were ≥65 years old. There was no significant difference in EQ-5D global QOL scores by age (P = .53). Patients ≥65 years reported more immobility (P < .01), problems with social eating (P < .0001), and coughing (P < .01). Patients ≥65 years were not more likely to ever require a gastrostomy (P = .24) but were more likely to remain gastrostomy-dependent at the time of the survey (P = .02).

CONCLUSION

Despite similar generic QOL, older survivors may have more mobility problems and issues with social eating compared with younger survivors deserving of further evaluation.

Percutaneous Ablation Versus Partial and Radical Nephrectomy for T1a Renal Cancer: A Population-Based Analysis

Background

Stage T1a renal cell carcinoma (RCC) (tumors <4 cm) is usually curable. Nephron-sparing partial nephrectomy (PN) has replaced radical nephrectomy (RN) as the standard of care for these tumors. Radical nephrectomy remains the first alternative treatment option, whereas percutaneous ablation (PA), a newer, nonsurgical treatment, is recommended less strongly because of the relative paucity of comparative PA data.

Objective

To compare PA, PN, and RN outcomes.

Design

Observational cohort analysis using inverse probability of treatment-weighted propensity scores.

Setting

Population-based SEER (Surveillance, Epidemiology, and End Results) cancer registry data linked to Medicare claims.

Patients

Persons aged 66 years or older who received treatment for T1a RCC between 2006 and 2011.

Interventions

PA versus PN and RN.

Measurements

RCC-specific and overall survival, 30- and 365-day postintervention complications.

Results

4310 patients were followed for a median of 52 months for overall survival and 42 months for RCC-specific survival. After PA versus PN, the 5-year RCC-specific survival rate was 95% (95% CI, 93% to 98%) versus 98% (CI, 96% to 99%); after PA versus RN, 96% (CI, 94% to 98%) versus 95% (CI, 93% to 96%). After PA versus PN, the 5-year overall survival rate was 77% (CI, 74% to 81%) versus 86% (CI, 84% to 88%); after PA versus RN, 74% (CI, 71% to 78%) versus 75% (CI, 73% to 77%). Cumulative rates of renal insufficiency 31 to 365 days after PA, PN, and RN were 11% (CI, 8% to 14%), 9% (CI, 8% to 10%), and 18% (CI, 17% to 20%), respectively. Rates of nonurologic complications within 30 days after PA, PN, and RN were 6% (CI, 4% to 9%), 29% (CI, 27% to 30%), and 30% (CI, 28% to 32%), respectively. Ten percent of patients in the PN group had intraoperative conversion to RN. Seven percent of patients in the PA group received additional PA within 1 year of treatment.

Limitations

Analysis of observational data may have been affected by residual confounding by provider or from selection bias toward younger, healthier patients in the PN group. Findings from this older study population are probably less applicable to younger patients. Use of SEER-Medicare linked files prevented analysis of patients who received treatment after 2011, possibly reducing generalizability to the newest PA, PN, and RN techniques.

Conclusion

For well-selected older adults with T1a RCC, PA may result in oncologic outcomes similar to those of RN, but with less long-term renal insufficiency and markedly fewer periprocedural complications. Compared with PN, PA may be associated with slightly shorter RCC-specific survival but fewer periprocedural complications.

Primary Funding Source

Association of University Radiologists GE Radiology Research Academic Fellowship and Society of Interventional Radiology Foundation.

Delays in the Publication of Important Clinical Trial Findings in Oncology

Importance

The complete and timely dissemination of clinical trial data is essential to all fields of medicine, with delayed or incomplete data release having potentially deleterious effects on both patient care and scientific inquiry. While prior analyses have noted a substantial lag in the reporting of final clinical study results, we sought to refine these observations through use of a novel starting point for the measurement of dissemination delays: the date of a corporate press release regarding a phase 3 study's results.

Objective

To measure the length of time elapsed between when a sponsor had results of study findings they deemed important to announce, and when the medical community had access to them.

Design and Setting

Covering the years 2011 through 2016, we measured the delay from when 8 large pharmaceutical companies issued a press release announcing completed analyses of phase 3 clinical trials in oncology, and the public sharing of those results either on ClinicalTrials.gov or in a peer-reviewed biomedical journal as found via PubMed or Google Scholar. Press releases announcing regulatory steps and presentation schedules for conferences were excluded, as were those announcing results from preclinical trials, follow-up analyses, and studies of supportive care therapies or various modes of infusion for the same therapy.

Main Outcomes and Measures

Time to public dissemination of clinical trial data.

Results

Of the 100 press releases in our sample, 70 (70%) reported positive results, but only 31 (31%) included the magnitude of study findings. Through the end of follow-up, 99 (99%) of press releases had an associated peer-reviewed publication, complete data posting to ClinicalTrials.gov, or both, with a median time to reporting of 300 days (95% CI, 263-348 days). Positive findings were reported more quickly than negative ones (median of 272; 95% CI, 211-318 days vs 407; 95% CI, 298-705 days; log-rank P < .001).

Conclusions and Relevance

Even for the most pressing study findings, median publication delays approach 1 year. As publication delays hinder research progress and advancements in clinical care, policies that enable early preprint release or public posting of completed data analysis should be pursued.

Preventable and mitigable adverse events in cancer care: Measuring risk and harm across the continuum

BACKGROUND

Patient safety is a critical concern in clinical oncology, but the ability to measure adverse events (AEs) across cancer care is limited by a narrow focus on treatment-related toxicities. The objective of this study was to assess the nature and extent of AEs among cancer patients across inpatient and outpatient settings.

METHODS

This was a retrospective cohort study of 400 adult patients selected by stratified random sampling who had breast (n = 128), colorectal (n = 136), or lung cancer (n = 136) treated at a comprehensive cancer center in 2012. Candidate AEs, or injuries due to medical care, were identified by trained nurse reviewers over the course of 1 year from medical records and safety-reporting databases. Physicians determined the AE harm severity and the likelihood of preventability and harm mitigation.

RESULTS

The 400-patient sample represented 133,358 days of follow-up. Three hundred four AEs were identified for an overall rate of 2.3 events per 1000 patient days (91.2 per 1000 inpatient days and 0.9 per 1000 outpatient days). Thirty-four percent of the patients had 1 or more AEs (95% confidence interval, 29%-39%), and 16% of the patients had 1 or more preventable or mitigable AEs (95% confidence interval, 13%-20%). The AE rate for patients with breast cancer was lower than the rate for patients with colorectal or lung cancer (P ≤ .001). The preventable or mitigable AE rate was 0.9 per 1000 patient days. Six percent of AEs and 4% of preventable AEs resulted in serious harm. Examples included lymphedema, abscess, and renal failure.

CONCLUSIONS

A heavy burden of AEs, including preventable or mitigable events, has been identified. Future research should examine risk factors and improvement strategies for reducing their burden. Cancer 2017;123:4728-4736. © 2017 American Cancer Society.

Facilitating informed decisions about breast cancer screening: development and evaluation of a web-based decision aid for women in their 40s

Background

Expert groups and national guidelines recommend individualized decision making about screening mammography for women in their 40s at low-to-average risk of breast cancer. We created Breast Screening Decisions (BSD), a personalized, web-based decision aid, to help women decide when to start and how often to have routine screening mammograms. We evaluated BSD in a large, prospective pilot trial of women and their clinicians.

Methods

Women ages 40–49 were invited to use BSD before a scheduled preventive care visit. One month post-visit, users were asked about decisional conflict, knowledge, perceptions and worry about breast cancer and screening. They were also asked whether they had a screening mammogram since their visit, scheduled an appointment for a screening mammogram, or if they were planning to schedule an appointment within the next six months. Women who responded “no” to each of these successive questions were considered to have no plan for a screening mammogram within the next 6 months, unless they explicitly stated that they were unsure about screening mammography. Clinicians were surveyed regarding mammography discussions and perceived patient knowledge and anxiety.

Results

Of 1,100 women invited to use BSD, 253 accessed the website, and 168 were eligible to participate in the pilot study. One-fifth had a family history of breast cancer, and at least 76% had any prior mammogram. At follow-up, 88% of BSD users reported discussing mammography at their visit, and 77% said they had a screening mammogram since the visit or that they made or were planning to make a screening mammogram appointment. The average decisional conflict score was 22.5, within the threshold for implementing decisions. Decisional conflict scores were lowest in women who said that they had or planned to have a mammogram (mean 21.4, 95% CI 18.3-24.6), higher in those who did not (mean 24.8, 95% CI 19.2-30.5), and highest in those who were unsure (mean 31.5, 95% CI 13.9-49.1). Most BSD users expressed accurate perceptions of their breast cancer risk and the benefits and limitations of screening.

Conclusions

A web-based decision aid may support informed, individualized decisions about screening mammography and facilitate discussions about screening between women in their 40s and their clinicians.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0423-7) contains supplementary material, which is available to authorized users.

Performance of a Trigger Tool for Identifying Adverse Events in Oncology

PURPOSE

Although patient safety is a priority in oncology, few tools measure adverse events (AEs) beyond treatment-related toxicities. The study objective was to assemble a set of clinical triggers in the medical record and assess the extent to which triggered events identified AEs.

METHODS

We performed a retrospective cohort study to assess the performance of an oncology medical record screening tool at a comprehensive cancer center. The study cohort included 400 patients age 18 years or older diagnosed with breast (n = 128), colorectal (n = 136), or lung cancer (n = 136), observed as in- and outpatients for up to 1 year.

RESULTS

We identified 790 triggers, or 1.98 triggers per patient (range, zero to 18 triggers). Three hundred four unique AEs were identified from medical record reviews and existing AE databases. The overall positive predictive value (PPV) of the original tool was 0.40 for total AEs and 0.15 for preventable or mitigable AEs. Examples of high-performing triggers included return to the operating room or interventional radiology within 30 days of surgery (PPV, 0.88 and 0.38 for total and preventable or mitigable AEs, respectively) and elevated blood glucose (> 250 mg/dL; PPV, 0.47 and 0.40 for total and preventable or mitigable AEs, respectively). The final modified tool included 49 triggers, with an overall PPV of 0.48 for total AEs and 0.18 for preventable or mitigable AEs.

CONCLUSION

A valid medical record screening tool for AEs in oncology could offer a powerful new method for measuring and improving cancer care quality. Future improvements could optimize the tool's efficiency and create automated electronic triggers for use in real-time AE detection and mitigation algorithms.

ReCAP: Detection of Potentially Avoidable Harm in Oncology From Patient Medical Records

PURPOSE

Widespread consensus exists about the importance of addressing patient safety issues in oncology, yet our understanding of the frequency, spectrum, and preventability of adverse events (AEs) across cancer care is limited.

METHODS

We developed a screening tool to detect AEs across cancer care settings through medical record review. Members of the study team reviewed the scientific literature and obtained structured input from an external multidisciplinary panel of clinicians by using a modified Delphi process.

RESULTS

The screening tool comprises 76 triggers-readily identifiable findings to screen for possible AEs that occur during cancer care. Categories of triggers are general care, vital signs, medication related, laboratory tests, other orders, and consultations.

CONCLUSION

Although additional testing is required to assess its performance characteristics, this tool may offer an efficient mechanism for identifying possibly preventable AEs in oncology and serve as an instrument for quality improvement.

ReCAP: Hospitalizations in Older Adults With Advanced Cancer: The Role of Chemotherapy

PURPOSE

Hospital readmissions are often cited as a marker of poor quality of care. Limited data suggest some readmissions may be preventable depending upon definitions and available outpatient support.

METHODS

General criteria to define preventable and not preventable admissions were developed before data collection began. The records of sequential nonsurgical oncology readmissions were reviewed independently by two reviewers. When the reviewers disagreed about assigning admissions as preventable or not preventable, a third reviewer was the tie breaker. The reasons for assigning admissions as preventable or not preventable were analyzed.

RESULTS

Seventy-two readmissions occurring among 69 patients were analyzed. The first two reviewers agreed that 18 (25%) of 72 were preventable and that 29 (40%) of 72 were not. A third reviewer found four of the split 25 cases to be preventable; therefore, the consensus preventability rate was 22 (31%) of 72. The most common causes of preventability were overwhelming symptoms in patients who qualified for hospice but were not participating in hospice and insufficient communication between patients and the care team about symptom burden. The most common reason for assignment of a not preventable admission was a high symptom burden among patients without strong indications for hospice or for whom aggressive outpatient management was inadequate. The median survival after readmission was 72 days.

CONCLUSION

A substantial proportion of oncology readmissions could be prevented with better anticipation of symptoms in high-risk ambulatory patients and enhanced communication about symptom burden between patients and physicians before an escalation that leads to an emergency department visit. Managing symptoms in patients who are appropriate for hospice is challenging. Readmission is a marker of poor prognosis.

Surgeon Adoption of Minimally Invasive Radical Prostatectomy

INTRODUCTION

Minimally invasive radical prostatectomy has become the most common surgical treatment for prostate cancer. In this study we describe patterns of minimally invasive radical prostatectomy adoption among surgeons who performed open radical prostatectomy before their first minimally invasive radical prostatectomy and those who did not.

METHODS

We performed a retrospective cohort study using the population based SEER (Surveillance, Epidemiology, and End Results)-Medicare data set. We identified all surgeons who performed minimally invasive radical prostatectomy in 2003 to 2010 in men with prostate cancer 66 years old or older. Surgeons were classified as "converters" if they performed open radical prostatectomy before their first minimally invasive radical prostatectomy or "de novos" if they had not. We estimated annual minimally invasive radical prostatectomy volume and the proportion of prostatectomies performed minimally invasively. We used logistic regression to identify predictors of minimally invasive radical prostatectomy discontinuation.

RESULTS

A total of 11,511 minimally invasive radical prostatectomies were performed by 738 minimally invasive radical prostatectomy surgeons (converters 337 and de novos 401). Converters performed 55% of all minimally invasive radical prostatectomies and had higher median annual minimally invasive radical prostatectomy volume than de novos (4 vs 2). About 34% of converters and 54% of de novos discontinued minimally invasive radical prostatectomy after their first year. Second year discontinuation of minimally invasive radical prostatectomy was more likely among de novo surgeons (OR 1.9, 95% CI 1.3-2.7) and less likely among surgeons with higher minimally invasive radical prostatectomy volume in their first year (OR 0.5, 95% CI 0.5-0.6).

CONCLUSIONS

During the years of the greatest growth in minimally invasive radical prostatectomy, surgeon adoption of this technique varied by surgeon type and volume. Many surgeons discontinued, and possibly abandoned, minimally invasive radical prostatectomy. Based on these observations, experienced and higher volume surgeons will be most successful adopting new surgical technology.

Physician-Driven Variation in Nonrecommended Services Among Older Adults Diagnosed With Cancer

IMPORTANCE

Interventions to address overuse of health care services may help reduce costs and improve care. Understanding physician-level variation and behavior patterns can inform such interventions.

OBJECTIVE

To assess patterns of physician ordering of services that tend to be overused in the treatment of patients with cancer. We hypothesized that physicians exhibit consistent behavior.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of patients 66 years and older diagnosed with cancer between 2004 and 2011, using population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess physician-level variation in 5 nonrecommended services. Services included imaging for staging and surveillance in low-risk disease, intensity-modulated radiation therapy (IMRT) after breast-conserving surgery, and extended fractionation schemes for palliation of bone metastases.

MAIN OUTCOME AND MEASURES

To assess variation in service use between physicians, we used a random effects model and a logistic regression model with a lag variable to assess whether a physician's use of a service for a prior patient predicts subsequent service use.

RESULTS

Cohorts ranged from 3464 to 89 006 patients. The total proportion of patients receiving each service varied from 14% for imaging in staging early breast cancer to 41% in early prostate cancer. From the random effects analysis, we found significant unexplained variation in service use between physicians (P < .001 for each service; ICC, 0.04-0.59). Controlling for case mix, whether a physician ordered a service for the prior patient was highly predictive of service use, with adjusted odds ratios (aORs) ranging from 1.12 (95% CI, 1.07-1.18) for surveillance imaging for patients with breast cancer (28% service use if prior patient had imaging vs 25% if not), to 24.91 (95% CI, 22.86-27.15) for IMRT for whole breast radiotherapy (69% vs 7%, respectively).

CONCLUSIONS AND RELEVANCE

Physicians' utilization of nonrecommended services that tend to be overused exhibit patterns that suggest consistent behavior more than personalized patient care decisions. Reducing overuse may require understanding cognitive drivers of repetitive inappropriate decisions.

Employment and return to work following chemoradiation in patient with HPV-related oropharyngeal cancer

Background

Human papillomavirus (HPV)-positive oropharyngeal cancer primarily affects working-age adults. Chemotherapy and radiation (CTRT) used to treat this disease may adversely impact a survivors' ability to work after treatment.

Methods

We surveyed participants with HPV-positive oropharyngeal cancer who completed CTRT regarding employment. We examined the associations between 1) sociodemographic and clinical factors and employment outcomes, and 2) health-related quality of life and satisfaction with ability to work.

Results

102 participants were employed full-time at diagnosis for pay and surveyed at a median of 23 months post-CTRT (range 12-57 months). The median age at diagnosis was 57 years (range 25-76 years). During CTRT, 8 % stopped working permanently, 89 % took time off or reduced responsibility but later returned, and 3 % reported no change. For those who took time off but returned, median time to return to work was 14.5 weeks. In multivariable analysis, younger age predicted for needing more than the median time off. At time of survey, 85 % participants were working, 7 % had retired, and 8 % were not working for other reasons. Seventeen percent of participants were not satisfied with their current ability to work, which was associated with poorer health-related quality of life and persistent treatment toxicities (p < 0.001).

Conclusions

CTRT interrupts employment in the majority of working patients with HPV-positive oropharyngeal cancer but most return. However, treatment-related toxicities might lead to dissatisfaction with ability to work.

Patterns of surveillance imaging after nephrectomy in the Medicare population

OBJECTIVES

To characterize patterns of imaging surveillance after nephrectomy in a population-based cohort of older patients with kidney cancer.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified patients aged ≥ 66 years who underwent partial or radical nephrectomy for localized kidney cancer diagnosed between 2000 and 2009. Primary outcomes were chest imaging (X-ray or computed tomography [CT]) and abdominal imaging (CT, MRI or ultrasonography) in Medicare claims from 4 to 36 months after surgery. We estimated the frequency of imaging in three time periods (postoperative months 4-12, 13-24, 25-36), stratified by tumour stage. Repeated-measures logistic regression was used to identify the patient and disease characteristics associated with imaging.

RESULTS

Rates of chest imaging were 65-80%, with chest X-ray surpassing CT in each time period. Rates of abdominal imaging were 58-76%, and cross-sectional imaging was more common than ultrasonography in each time period. Use of cross-sectional chest and abdominal imaging increased over time, while the use of chest X-ray decreased (P < 0.01). Ultrasonography use remained stable for patients with T1 and T2 disease, but the rate of use decreased in patients with T3 disease (P < 0.05). Rates of chest and abdominal imaging increased with tumour stage (P < 0.001).

CONCLUSIONS

Patterns of imaging suggest possible overuse in patients at low risk of recurrence and underuse in those at greater risk. New surveillance imaging guidelines may reduce unwarranted variability and promote risk-based, cost-effective management after nephrectomy.

Trends in chemoradiation use in elderly patients with head and neck cancer: Changing treatment patterns with cetuximab

BACKGROUND

Cetuximab was approved for use in chemoradiation therapy (CRT) for locally advanced head and neck squamous cell carcinoma (HNSCC) in 2006.

METHODS

Among 3705 patients with locally advanced HNSCC identified in the linked Surveillance Epidemiology and End Results (SEER) Medicare database, we assessed treatment trends, including surgery, radiation therapy (RT), CRT, and specific agents used in CRT. We examined the influence of demographic and clinical characteristics on the likelihood of receiving CRT before and after 2006.

RESULTS

Chemoradiation use increased from 29% of patients diagnosed in 2001 to 61% in 2009 (p < .0001). Compared to before 2006, neither age nor comorbidity score was associated with receipt of CRT after 2006. Platinum combinations were the most commonly used concurrent chemotherapies before 2006, but, since then, cetuximab has become the most commonly used agent.

CONCLUSION

The use of CRT has increased substantially and cetuximab may have increased CRT use, especially in older and sicker patients. © 2015 Wiley Periodicals, Inc. Head Neck 38: E165-E171, 2016.

Treatment-related toxicities in older adults with head and neck cancer: A population-based analysis

BACKGROUND

Despite advantages in terms of cancer control and organ preservation, the benefits of chemotherapy and radiation therapy (CTRT) may be offset by potentially severe treatment-related toxicities, particularly in older patients. The objectives of this study were to assess the types and frequencies of toxicities in older adults with locally or regionally advanced head and neck squamous cell carcinoma (HNSCC) who were receiving either primary CTRT or radiation therapy (RT) alone.

METHODS

With Surveillance, Epidemiology, and End Results cancer registry data linked with Medicare claims, patients who were 66 years old or older with locally advanced HNSCC, were diagnosed from 2001 to 2009, and received CTRT or RT alone were identified. Differences in the frequency of toxicity-related hospital admissions and emergency room visits as well as feeding tube use were examined, and controlling for demographic and disease characteristics, this study estimated the impact of chemotherapy on the likelihood of toxicity.

RESULTS

Among patients who received CTRT (n = 1502), 62% had a treatment-related toxicity, whereas 46% of patients who received RT alone (n = 775) did. When the study controlled for demographic and disease characteristics, CTRT patients were twice as likely to experience an acute toxicity in comparison with their RT-only peers. Fifty-five percent of CTRT patients had a feeding tube placed during or after treatment, whereas 28% of the RT-only group did.

CONCLUSIONS

In this population-based cohort of older adults with HNSCC, the rates of acute toxicities and feeding tube use in patients receiving CTRT were considerable. It is possible that for certain older patients, the potential benefit of adding chemotherapy to RT does not outweigh the harms of this combined-modality therapy.

Impact of observation status on hospital use for patients with cancer

PURPOSE

For patients with cancer, the impact of observation status on hospital and patient outcomes is not well understood. Our objective was to assess the impact that an observation unit had on hospital use for patients with cancer who presented to the Urgent Care Center at a comprehensive cancer center.

METHODS

We assessed the proportion of Urgent Care Center visits that resulted in an admission to the hospital at a comprehensive cancer center, before (July 9, 2012-December 31, 2012) versus after (July 9, 2013-December 31, 2013) implementation of the observation unit. We also assessed differences in length of stay and stratified the data by presenting complaint.

RESULTS

During each 6-month study interval, there were more than 10,000 patient visits to the Urgent Care Center, representing approximately 6,000 unique patients. Fewer visits resulted in an inpatient admission postimplementation (47%) compared with preimplementation (50%). The duration of hospital stay for admitted patients was higher in the post period (median 108 hours) than in the pre period (median 96 hours). Alternatively, the proportion of hospital admissions with a length of stay less than 24 hours was lower in the post period (pre: 7%; post: 5%). Lower admission rates postimplementation were observed for patients who presented with fluid and electrolyte disorders, nausea and vomiting, syncope, and chest pain.

CONCLUSION

We observed reductions in hospital use for patients with cancer related to an observation unit in a comprehensive cancer center. Adoption of this approach for this patient population has the potential to reduce hospital use, which is of interest to hospitals, payers, and patients.

Hospital Volume, Complications, and Cost of Cancer Surgery in the Elderly

Purpose

Hospital surgical volume has been shown to correlate with short-term outcomes after cancer surgery, but the relationship between volume and cost of care is unclear. We sought to characterize variation in payments for cancer surgery and assess the relationship between hospital volume and payments.

Methods

Using 2000 to 2007 Surveillance, Epidemiology, and End Results–Medicare data, we assessed risk-adjusted 30-day episode Medicare payments for elderly patients undergoing one of six procedures for resection of cancer. Payments for the index hospitalization, readmissions, physician services, emergency room visits, and postdischarge ancillary care were analyzed, as were data on 30-day mortality and complications.

Results

The analysis included 31,191 colectomies, 2,670 cystectomies, 1,514 pancreatectomies, 2,607 proctectomies, 12,228 prostatectomies, and 10,151 pulmonary lobectomies. There was substantial variation in cost; differences between the first and third terciles of cost varied from 27% for cystectomy to 40% for colectomy. The majority of variation (66% to 82%) was attributable to payments for the index admission rather than readmissions or physician services. There were no meaningful associations between total risk-adjusted payments and hospital volume. Surgical mortality was low, but complication rates ranged from 10% (prostatectomy) to 56% (lobectomy). Complication rates were not correlated with hospital volume, but occurrence of complications was associated with 47% to 70% higher costs.

Conclusion

We found substantial variation in Medicare payments for these six cancer procedures. Cost was strongly associated with postoperative complications and primarily driven by differences in the cost of the index hospitalization. Efforts to prevent and cost-effectively manage complications are more likely to reduce costs than volume-based referral of cancer surgery alone.

Treatment complications and survival in advanced laryngeal cancer: a population-based analysis

OBJECTIVES/HYPOTHESIS

Primary curative treatment of advanced laryngeal cancer may include surgery or chemoradiation, although recommendations vary and both are associated with complications. We evaluated predictors and trends in the use of these modalities and compared rates of complications and overall survival in a population-based cohort of older adults.

STUDY DESIGN

Retrospective population-based cohort study.

METHODS

Using Surveillance Epidemiology and End Results (SEER) cancer registry data linked with Medicare claims, we identified patients over 65 with advanced laryngeal cancer diagnosed 1999 to 2007 who had total laryngectomy (TL) or chemoradiation (CTRT) within 6 months following diagnosis. We identified complications and estimated the impact of treatment on overall survival, using propensity score methods.

RESULTS

The proportion of patients receiving TL declined from 74% in 1999 to 26% in 2007 (P < 0.0001). Almost 20% of the CTRT patients had a tracheostomy following treatment, and 57% had a feeding tube. TL was associated with an 18% lower risk of death, adjusting for patient and disease characteristics. The benefit of TL was greatest in patients with the highest propensity to receive surgery.

CONCLUSION

TL remains an important treatment option in well selected older patients. However, treatment selection is complex; and factors such as functional status, patient preference, surgeon expertise, and post-treatment support services should play a role in treatment decisions.

LEVEL OF EVIDENCE

2b. Laryngoscope, 124:2707-2713, 2014.

Development of a medical record-based trigger tool for identifying adverse events during cancer care

152

Background: Adverse events for patients with cancer can be harmful and costly. Our understanding of these events and their associated harm for this patient population is limited. The objective of this study was to develop a medical record based trigger tool that can be used to help detect adverse events during cancer care. Methods: The trigger tool was developed using input from a multidisciplinary group of clinicians and researchers. First, clinicians from the study team, with input from specialists, compiled lists of adverse events that may occur during the receipt of cancer-directed treatment. Then, they created symptom-based or treatment-based ‘triggers’ that might indicate that the adverse event had occurred. From this list, the study team narrowed the triggers based on feasibility, frequency, severity of the associated adverse events, and overall expected usefulness. Additional feedback was obtained from an expert panel of nine clinicians outside the study team using a modified Delphi approach. The expert panel included representatives from medical oncology, radiation oncology, surgery, nursing, anesthesiology, general medicine, and emergency medicine. Feedback was summarized and the study team narrowed the list of triggers to create the final tool. Results: The final trigger tool for use in detecting adverse events during cancer care consisted of 76 triggers representing adverse events across organ systems. For ease of use, the tool was organized by general care, vital signs, medication related, labs, orders, and consults. Conclusions: From this study, we created a trigger tool to be used to detect key adverse events in cancer care, with an emphasis on those that may be preventable or for which the harm may be able to be mitigated. This information can be used to prioritize quality improvement activities, help to develop quality measures, and set relevant benchmarks for these events for cancer patients in order to improve the safety of cancer care.

Risk of fracture after radical cystectomy and urinary diversion for bladder cancer

PURPOSE

Radical cystectomy and urinary diversion may cause chronic metabolic acidosis, leading to long-term bone loss in patients with bladder cancer. However, the risk of fractures after radical cystectomy has not been defined. We assessed whether radical cystectomy and intestinal urinary diversion are associated with increased risk of fracture.

PATIENTS AND METHODS

Population-based study using SEER-Medicare-linked data from 2000 through 2007 for patients with stage 0-III bladder cancer. We evaluated the association between radical cystectomy and risk of fracture at any site, controlling for patient and disease characteristics.

RESULTS

The cohort included 50,520 patients, of whom 4,878 had cystectomy and urinary diversion. The incidence of fracture in the cystectomy group was 6.55 fractures per 100 person-years, compared with 6.39 fractures per 100 person-years in those without cystectomy. Cystectomy was associated with a 21% greater risk of fracture (adjusted hazard ratio, 1.21; 95% CI, 1.10 to 1.32) compared with no cystectomy, controlling for patient and disease characteristics. There was no evidence of an interaction between radical cystectomy and age, sex, comorbidity score, or cancer stage.

CONCLUSION

Patients with bladder cancer who have radical cystectomy and urinary diversion are at increased risk of fracture.

Long-term central venous catheter use and risk of infection in older adults with cancer

PURPOSE

Long-term central venous catheters (CVCs) are often used in patients with cancer to facilitate venous access to administer intravenous fluids and chemotherapy. CVCs can also be a source of bloodstream infections, although this risk is not well understood. We examined the impact of long-term CVC use on infection risk, independent of other risk factors such as chemotherapy, in a population-based cohort of patients with cancer.

PATIENTS AND METHODS

We conducted a retrospective analysis using SEER-Medicare data for patients age > 65 years diagnosed from 2005 to 2007 with invasive colorectal, head and neck, lung, or pancreatic cancer, non-Hodgkin lymphoma, or invasive or noninvasive breast cancer. Cox proportional hazards regression was used to examine the relationship between CVC use and infections, with CVC exposure as a time-dependent predictor. We used multivariable analysis and propensity score methods to control for patient characteristics.

RESULTS

CVC exposure was associated with a significantly elevated infection risk, adjusting for demographic and disease characteristics. For patients with pancreatic cancer, risk of infections during the exposure period was three-fold greater (adjusted hazard ratio [AHR], 2.93; 95% CI, 2.58 to 3.33); for those with breast cancer, it was six-fold greater (AHR, 6.19; 95% CI, 5.42 to 7.07). Findings were similar when we accounted for propensity to receive a CVC and limited the cohort to individuals at high risk of infections.

CONCLUSION

Long-term CVC use was associated with an increased risk of infections for older adults with cancer. Careful assessment of the need for long-term CVCs and targeted strategies for reducing infections are critical to improving cancer care quality.

Adherence to surveillance guidelines after radical cystectomy: a population-based analysis

OBJECTIVES

Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database.

METHODS AND MATERIALS

The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics.

RESULTS

Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60-0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68-0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70-2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27-1.82). We also observed significant geographic variability in adherence.

CONCLUSION

Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.

Gender disparities in hematuria evaluation and bladder cancer diagnosis: a population based analysis

PURPOSE

Men are diagnosed with bladder cancer at 3 times the rate of women. However, women present with advanced disease and have poorer survival, suggesting delays in bladder cancer diagnosis. Hematuria is the presenting symptom in most cases. We assessed gender differences in hematuria evaluation in older adults with bladder cancer.

MATERIALS AND METHODS

Using the SEER (Surveillance, Epidemiology and End Results) cancer registry linked with Medicare claims we identified Medicare beneficiaries 66 years old or older diagnosed with bladder cancer between 2000 and 2007 with a claim for hematuria in the year before diagnosis. We examined the impact of gender, and demographic and clinical factors on time from initial hematuria claim to urology visit and on time from initial hematuria claim to hematuria evaluation, including cystoscopy, upper urinary tract imaging and urine cytology.

RESULTS

Of 35,646 patients with a hematuria claim in the year preceding bladder cancer diagnosis 97% had a urology visit claim. Mean time to urology visit was 27 days (range 0 to 377). Time to urology visit was longer for women than for men (adjusted HR 0.9, 95% CI 0.87-0.92). Women were more likely to undergo delayed (after greater than 30 days) hematuria evaluation (adjusted OR 1.13, 95% CI 1.07-1.21).

CONCLUSIONS

We observed longer time to a urology visit for women than for men presenting with hematuria. These findings may explain stage differences in bladder cancer diagnosis and inform efforts to decrease gender disparities in bladder cancer stage and outcomes.

Changes in the availability of screening mammography, 2000-2010

BACKGROUND

Rates of screening mammography have plateaued, and the number of mammography facilities has declined in the past decade. The objective of this study was to assess changes over time and geographic disparities in the availability of mammography services.

METHODS

Using information from the US Food and Drug Administration and the US Census, county-level mammography capacity was defined as the number of mammography machines per 10,000 women aged ≥ 40 years. Cross-sectional variation and longitudinal changes in capacity were examined in relation to county characteristics.

RESULTS

Between 2000 and 2010, the number of mammography facilities declined 10% from 9434 to 8469, the number of mammography machines declined 10% from 13,100 to 11,762, and the median county mammography capacity decreased nearly 20% from 1.77 to 1.42 machines per 10,000 women aged ≥ 40 years. In cross-sectional analysis, counties with greater percentages of uninsured residents, less educated residents, greater population density, and higher managed care penetration had lower mammography capacity. Conversely, counties with more hospital beds per 100,000 population had higher capacity. High initial mammography capacity, growth in both the percentage of the population aged ≥ 65 years and the percentage living in poverty, and increased managed care penetration were all associated with a decrease in mammography capacity between 2000 and 2010. Only the percentage of rural residents was associated with an increase in capacity.

CONCLUSIONS

Geographic variation in mammography capacity and declines in capacity over time are associated with demographic, socioeconomic, and health care market characteristics. Maldistribution of mammography resources may explain geographic disparities in breast cancer screening rates.

Impact of cetuximab on chemoradiation use in older patients with locally advanced head and neck cancer

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Background: The benefit of chemoradiation (CTRT) in the treatment of locally advanced head and neck cancer (LAHNC) declines in older and sicker patients. In 2006, the FDA approved cetuximab in LAHNC. Cetuximab with radiation has a perceived lower side effect profile compared to standard chemotherapies used in CTRT. Our objective was to examine the impact of cetuximab on the use of CTRT in elderly patients with LAHNC. Methods: We identified adults aged 66 and older diagnosed with LAHNC between 1999 and 2007 in the Surveillance Epidemiology and End Results (SEER)-Medicare linked database. Treatment was categorized as CTRT or other based on Medicare claims within 6 months of diagnosis. We excluded patients who did not receive definitive treatment. In patients who had CTRT, we identified use of cetuximab based on drug-specific billing codes. We assessed trends in the use of CTRT over the entire study period and in the use of cetuximab since 2006. We examined the influence of age and comorbidity on the likelihood of receiving CTRT before and after 2006 adjusting for clinical and demographic factors. Results: We identified 4,809 patients with LAHNC. One-fourth were ≥80 years and almost a fifth had a Charlson comorbidity score (CCS) of ≥2. Overall more than 20% of patients received CTRT. The use of CTRT more than tripled over time, from 10% of patients diagnosed in 1999 to 38% in 2007 (p<0.0001 for trend). Of the 336 patients who had CTRT since 2006, 45% received cetuximab. Prior to 2006, patients ≥80 years or those with a CCS of ≥2 were significantly less likely to be treated with CTRT compared to younger patients or those with a CCS of 0. In patients diagnosed in 2006 or later, age and comorbidity no longer predicted the likelihood of receiving CTRT. Conclusions: In this population-based cohort of older adults, the use of CTRT increased substantially over time. The availability of cetuximab, with a perceived gentler side effect profile, may have increased the use of CTRT, especially in older and sicker patients. [Table: see text]

Risk of incisional hernia after minimally invasive and open radical prostatectomy

PURPOSE

The number of radical prostatectomies has increased. Many urologists have shifted from the open surgical approach to minimally invasive techniques. It is not clear whether the risk of post-prostatectomy incisional hernia varies by surgical approach.

MATERIALS AND METHODS

In the linked Surveillance, Epidemiology and End Results (SEER)-Medicare data set we identified men 66 years old or older who were treated with minimally invasive or open radical prostatectomy for prostate cancer diagnosed from 2003 to 2007. The main study outcome was incisional hernia repair, as identified in Medicare claims after prostatectomy. We also examined the frequency of umbilical, inguinal and other hernia repairs.

RESULTS

We identified 3,199 and 6,795 patients who underwent minimally invasive and open radical prostatectomy, respectively. The frequency of incisional hernia repair was 5.3% at a median 3.1-year followup in the minimally invasive group and 1.9% at a 4.4-year median followup in the open group, corresponding to an incidence rate of 16.1 and 4.5/1,000 person-years, respectively. Compared to the open technique, the minimally invasive procedure was associated with more than a threefold increased risk of incisional hernia repair when controlling for patient and disease characteristics (adjusted HR 3.39, 95% CI 2.63-4.38, p<0.0001). Minimally invasive radical prostatectomy was associated with an attenuated but increased risk of any hernia repair compared with open radical prostatectomy (adjusted HR 1.48, 95% CI 1.29-1.70, p<0.0001).

CONCLUSIONS

Minimally invasive radical prostatectomy was associated with a significantly increased risk of incisional hernia compared with open radical prostatectomy. This is a potentially remediable complication of prostate cancer surgery that warrants increased vigilance with respect to surgical technique.

Changes in access to screening mammography, 2008-2011

Screening mammography is a cornerstone of preventive health care for adult women in the United States. As rates of screening mammography have declined and plateaued in the past decade, access to services remains a concern. In 2011, we repeated a survey of mammography facilities initially surveyed in 2008 in six states. The availability of digital mammography increased and appointment wait times generally improved between the two survey periods, but more facilities required payment upfront. Provisions of the federal healthcare reform law that eliminate cost sharing for selected preventive health services may improve access to screening mammography and prevent further declines in the rate of breast cancer screening.

Costs and trends in pancreatic cancer treatment

BACKGROUND

Pancreatic cancer poses a substantial morbidity and mortality burden in the United States, and predominantly affects older adults. The objective of this study was to estimate the direct medical costs of pancreatic cancer treatment in a population-based cohort of Medicare beneficiaries, and the contribution of different treatment modalities and health care services to the total cost of care and trends in costs over time.

METHODS

In the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, pancreatic cancer patients were identified who were aged 66 years or older and who were diagnosed from 2000 to 2007. Total direct medical costs were estimated from Medicare payments overall and within categories of care. Costs attributable to pancreatic cancer were estimated by subtracting the costs of medical care in a matched cohort of cancer-free beneficiaries.

RESULTS

A total of 15,037 patients were identified, of whom 97% were observed from diagnosis until death. Mean total direct medical costs were $65,500. Mean total costs were greater for patients with resectable locoregional disease ($134,700) than for those with unresectable locoregional or distant disease ($65,300 and $49,000, respectively). Hospitalizations and cancer-directed procedures collectively accounted for the largest fraction of health care costs. The total cost of care appeared to increase slightly over the study period (P = .05). The mean costs attributable to pancreatic cancer were $61,700.

CONCLUSIONS

Despite poor prognosis and short survival, the economic burden of pancreatic cancer in the elderly is substantial. Demographic trends, greater use of targeted therapies, and possible implementation of screening strategies are likely to impact treatment patterns and costs in the future.

Mammography capacity and appointment wait times: barriers to breast cancer screening

OBJECTIVE

To assess the impact of mammography capacity on appointment wait times.

METHODS

We surveyed by telephone all mammography facilities federally certified in 2008 in California, Connecticut, Georgia, Iowa, New Mexico, and New York using a simulated patient format. County-level mammography capacity, defined as the number of mammography machines per 10,000 women aged 40 and older, was estimated from FDA facility certification records and US Census data.

RESULTS

1,614 (86%) of 1,882 mammography facilities completed the survey. Time until next available screening mammogram appointment was <1 week at 55% of facilities, 1-4 weeks at 34% of facilities, and >1 month at 11% of facilities. Facilities in counties with lower capacity had longer wait times, and a one-unit increase in county capacity was associated with 21% lower odds of a facility reporting a wait time >1 month (p < 0.01). There was no association between wait time and the availability of evening or weekend appointments or digital mammography.

CONCLUSION

Lower mammography capacity is associated with longer wait times for screening mammograms.

IMPACT

Enhancement of mammography resources in areas with limited capacity may reduce wait times for screening mammogram appointments, thereby increasing access to services and rates of breast cancer screening.

Locally advanced prostate cancer: a population-based study of treatment patterns

Study Type--Therapy (practice patterns). Level of Evidence 2b. What's known on the subject? And what does the study add? The treatment of locally advanced prostate cancer varies widely even though there is level one evidence supporting the use of multimodality therapy as compared with monotherapy. This study defines treatment patterns of locally advanced prostate cancer within the United States and identifies predicators of who receives multimodality therapy rather than monotherapy.

OBJECTIVE

• To identify treatment patterns and predictors of receiving multimodality therapy in patients with locally advanced prostate cancer (LAPC).

PATIENTS AND METHODS

• The cohort comprised patients ≥66 years with clinical stage T3 or T4 non-metastatic prostate cancer diagnosed between 1998 and 2005 identified from the Surveillance, Epidemiology and End Results (SEER) cancer registry records linked with Medicare claims. • Treatments were classified as radical prostatectomy (RP), radiation therapy (RT) and androgen deprivation therapy (ADT) received within 6 and 24 months of diagnosis. • We assessed trends over time and used multivariable logistic regression to identify predictors of multimodality treatment.

RESULTS

• Within the first 6 months of diagnosis, 1060 of 3095 patients (34%) were treated with a combination of RT and ADT, 1486 (48%) received monotherapy (RT alone, ADT alone or RP alone), and 461 (15%) received no active treatment. • The proportion of patients who received RP increased, exceeding 10% in 2005. • Use of combined RT and ADT and use of ADT alone fluctuated throughout the study period. • In all 6% of patients received RT alone in 2005. • Multimodality therapy was less common in patients who were older, African American, unmarried, who lived in the south, and who had co-morbidities or stage T4 disease.

CONCLUSIONS

• Treatment of LAPC varies widely, and treatment patterns shifted during the study period. • The slightly increased use of multimodality therapy since 2003 is encouraging, but further work is needed to increase combination therapy in appropriate patients and to define the role of RP.

Androgen deprivation and thromboembolic events in men with prostate cancer

BACKGROUND

Androgen deprivation therapy (ADT) improves prostate cancer outcomes in specific clinical settings, but is associated with adverse effects, including cardiac complications and possibly thromboembolic complications. The objective of this study was to estimate the impact of ADT on thromboembolic events (TEs) in a population-based cohort.

METHODS

In the linked Surveillance, Epidemiology and End Results-Medicare database, we identified men older than 65 who were diagnosed with nonmetastatic prostate cancer between 1999 and 2005. Medical or surgical ADT was identified by Medicare claims for gonadotropin-releasing hormone agonists or bilateral orchiectomy at any time following diagnosis. TEs included deep venous thrombosis, pulmonary embolism, and arterial embolism. The impact of ADT on the risk of any TE and on total number of events was estimated, controlling for patient and tumor characteristics.

RESULTS

Of 154,611 patients with prostate cancer, 58,466 (38%) received ADT. During a median follow-up of 52 months, 15,950 men had at least 1 TE, including 8829 (55%) who had ADT and 7121 (45%) with no ADT. ADT was associated with increased risk of a TE (adjusted hazard ratio = 1.56; 95% confidence interval, 1.50-1.61; P < .0001), and duration of ADT was associated with the total number of events (P < .0001).

CONCLUSIONS

In this population-based cohort, ADT was associated with increased risk of a TE, and longer durations of ADT were associated with more TEs. Men with intermediate- and low-risk prostate cancer should be assessed for TE risk factors before starting ADT and counseled regarding the risks and benefits of this therapy.

Staging laparoscopy in the management of gastric cancer: a population-based analysis

BACKGROUND

Staging laparoscopy can detect radiographically occult peritoneal metastases and prevent futile laparotomy in patients with gastric adenocarcinoma. We sought to assess the use of staging laparoscopy for gastric adenocarcinoma in a cohort of older patients and to compare outcomes after laparoscopy alone with nontherapeutic laparotomy.

STUDY DESIGN

Using Surveillance, Epidemiology and End Results (SEER) population-based cancer registry data linked with Medicare claims, we identified patients aged 65 or older diagnosed with gastric adenocarcinoma between 1998 and 2005. We defined staging laparoscopy as a laparoscopic procedure from 1 month before the date of diagnosis until death and futile laparotomy as a laparotomy in the absence of a therapeutic intervention. We examined trends in the use of staging laparoscopy and compared outcomes between patients who underwent staging laparoscopy alone and those who had a futile laparotomy.

RESULTS

Of 11,759 patients with gastric adenocarcinoma, 6,388 (54.3%) had at least 1 surgical procedure. Staging laparoscopy was performed in 506 (7.9%) patients who had any surgery, and 151 (29.8%) of these patients did not have a subsequent therapeutic intervention. Patients who underwent staging laparoscopy alone had a significantly lower rate of in-hospital mortality (5.3% vs 13.1%, p < 0.001) and shorter length of hospitalization (2 vs 10 days, p < 0.001) than patients who had futile laparotomy.

CONCLUSIONS

Our findings in this large, population-based cohort suggest that staging laparoscopy is used infrequently in the management of older patients with gastric adenocarcinoma. Increased use of staging laparoscopy could reduce the substantial morbidity and mortality associated with nontherapeutic laparotomy.

Abstract 1927: Race, health conditions, and endometrial cancer survival

Background: Endometrial cancer shows the largest disparity in outcomes between black and white cases of any cancer in the US. Black women have higher prevalence of diabetes and hypertension, conditions that might be associated with poorer survival. Our objectives were to determine whether the presence of diabetes or hypertension was related to disease-specific survival and to investigate whether accounting for these conditions influenced the survival difference for the two racial groups. Methods: Using Surveillance, Epidemiology and End Results cancer registry data linked with Medicare claims, we identified women with diabetes (as defined by Hebert et al, Univ of Minn Rural Health Research Center Working Paper 22, March 1998) and hypertension (defined as 2 claims at least 30 days apart for ICD9 codes 401-404) and investigated the influence of these conditions on survival in black and white women age &gt;=66 diagnosed with endometrial cancer between 2000 and 2005. We used Cox proportional hazards models, adjusted for demographics, tumor characteristics, and treatment, to evaluate whether presence of diabetes or hypertension influenced disease-specific survival and whether adjustment for these factors influenced the difference in outcome between blacks and whites. Results: 22% of whites and 41% of blacks with endometrial cancer met the criteria for diabetes and 52% and 73%, respectively, met the criteria for hypertension. Having diabetes was associated with poorer endometrial cancer specific survival in whites (HR=1.19, 95% CI 1.06-1.35) but not in blacks (HR=0.97, 95% CI 0.73-1.30), after adjustment for variables related to demographics, tumor characteristics, and treatment. Presence of hypertension did not significantly influence survival in either group. As expected, both overall survival and endometrial cancer specific survival were poorer in black women compared to whites, with adjusted hazard ratios for blacks of 1.19 (95% CI 1.08-1.31) for overall survival and 1.30 (95% CI 1.11-1.52) for disease-specific survival. Very little influence was found for diabetes or hypertension for either overall or disease specific survival: after adjustment for these variables the hazard ratios were 1.16 (95% CI 1.05-1.28) for overall survival and 1.27 (95% CI 1.08-1.49) for disease-specific survival. Conclusions: Diabetes influences disease-specific survival only in white women, while hypertension is not associated with disease-specific survival. The racial disparity in survival after a diagnosis of endometrial cancer is not explained by the presence of diabetes or hypertension.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1927. doi:10.1158/1538-7445.AM2011-1927