Erroneous Reporting of Deaths Attributed to Pneumonia and Influenza at 2 New York City Teaching Hospitals, 2013-2014

OBJECTIVES

Cause-of-death information, reported by frontline clinicians after a patient's death, is an irreplaceable source of public health data. However, systematic bias in cause-of-death reporting can lead to over- or underestimation of deaths attributable to different causes. New York City consistently reports higher rates of deaths attributable to pneumonia and influenza than many other US cities and the country. We investigated systematic erroneous reporting as a possible explanation for this phenomenon.

METHODS

We reviewed all deaths from 2 New York City hospitals during 2013-2014 in which pneumonia or influenza was reported as the underlying cause of death (n = 188), and we examined the association between erroneous reporting and multiple extrinsic factors that may influence cause-of-death reporting (patient demographic characteristics and medical comorbidities, time and hospital location of death, type of medical provider reporting the death, and availability of certain diagnostic information).

RESULTS

Pneumonia was erroneously reported as the underlying cause of death in 163 (86.7%) reports. We identified heart disease and dementia as the more likely underlying cause of death in 21% and 17% of erroneously reported deaths attributable to pneumonia, respectively. We found no significant association between erroneous reporting and the multiple extrinsic factors examined.

CONCLUSIONS

Our results underscore how erroneous reporting of 1 condition can lead to underreporting of other causes of death. Misapplication or misunderstanding of procedures by medical providers, rather than extrinsic factors influencing the reporting process, are key drivers of erroneous cause-of-death reporting.

Examination of Cause-of-Death Data Quality Among New York City Deaths Due to Cancer, Pneumonia, or Diabetes From 2010 to 2014

The cause-of-death (COD) statement on the standard US death certificate is a valuable tool for public health practice, but its utility is impaired by reporting inaccuracies. To assess the quality of CODs reported in New York City, we developed and applied a quality measure to 3 leading CODs: cancer, pneumonia, and diabetes. The COD quality measure characterized 5 common issues with COD completion: nonspecific conditions as the underlying COD (UCOD); UCOD discrepancies; the presence of only 1 informative cause on the entire certificate; competing causes listed together on 1 line; and clinically improbable sequences. COD statements with more than 1 quality issue were defined as statements of "limited" quality. Of 82,116 deaths with cancer, diabetes, or pneumonia assigned as the UCOD in New York City from 2010 to 2014, 66.8% of pneumonia certificates were classified as "limited" quality as compared with 45.6% of cancer certificates and 32.3% of diabetes certificates. Forty percent of cancer certificates listed only 1 informative condition on the death certificate. Almost half of pneumonia certificates (45.9%) contained only enough information to assign International Classification of Diseases, Tenth Revision, code J18.9 ("unspecified pneumonia") as the UCOD, whereas most diabetes certificates contained UCOD discrepancies (25.2%). These limitations affect the quality of mortality data but may be reduced through quality improvement efforts.

Association Between Complementary and Alternative Medicine Use and Breast Cancer Chemotherapy Initiation: The Breast Cancer Quality of Care (BQUAL) Study

IMPORTANCE

Not all women initiate clinically indicated breast cancer adjuvant treatment. It is important for clinicians to identify women at risk for noninitiation.

OBJECTIVE

To determine whether complementary and alternative medicine (CAM) use is associated with decreased breast cancer chemotherapy initiation.

DESIGN, SETTING, AND PARTICIPANTS

In this multisite prospective cohort study (the Breast Cancer Quality of Care [BQUAL] study) designed to examine predictors of breast cancer treatment initiation and adherence, 685 women younger than 70 years with nonmetastatic invasive breast cancer were recruited from Columbia University Medical Center, Kaiser Permanente Northern California, and Henry Ford Health System and enrolled between May 2006 and July 31, 2010. Overall, 306 patients (45%) were clinically indicated to receive chemotherapy per National Comprehensive Cancer Network guidelines. Participants were followed for up to 12 months.

EXPOSURES

Baseline interviews assessed current use of 5 CAM modalities (vitamins and/or minerals, herbs and/or botanicals, other natural products, mind-body self-practice, mind-body practitioner-based practice). CAM use definitions included any use, dietary supplement use, mind-body use, and a CAM index summing the 5 modalities.

MAIN OUTCOMES AND MEASURES

Chemotherapy initiation was assessed via self-report up to 12 months after baseline. Multivariable logistic regression models examined a priori hypotheses testing whether CAM use was associated with chemotherapy initiation, adjusting for demographic and clinical covariates, and delineating groups by age and chemotherapy indication.

RESULTS

A cohort of 685 women younger than 70 years (mean age, 59 years; median age, 59 years) with nonmetastatic invasive breast cancer were recruited and followed for up to 12 months to examine predictors of breast cancer treatment initiation. Baseline CAM use was reported by 598 women (87%). Chemotherapy was initiated by 272 women (89%) for whom chemotherapy was indicated, compared with 135 women (36%) for whom chemotherapy was discretionary. Among women for whom chemotherapy was indicated, dietary supplement users and women with high CAM index scores were less likely than nonusers to initiate chemotherapy (odds ratio [OR], 0.16; 95% CI, 0.03-0.51; and OR per unit, 0.64; 95% CI, 0.46-0.87, respectively). Use of mind-body practices was not related to chemotherapy initiation (OR, 1.45; 95% CI, 0.57-3.59). There was no association between CAM use and chemotherapy initiation among women for whom chemotherapy was discretionary.

CONCLUSIONS AND RELEVANCE

CAM use was high among patients with early-stage breast cancer enrolled in a multisite prospective cohort study. Current dietary supplement use and higher number of CAM modalities used but not mind-body practices were associated with decreased initiation of clinically indicated chemotherapy. Oncologists should consider discussing CAM with their patients during the chemotherapy decision-making process.

Multiple Chronic Conditions and Use of Complementary and Alternative Medicine Among US Adults: Results From the 2012 National Health Interview Survey

Introduction

More than 25% of American adults report having 2 or more chronic conditions. People with chronic conditions often use complementary and alternative medicine (CAM) for self-care and disease management, despite a limited evidence base.

Methods

Data from the 2012 National Health Interview Survey (NHIS) (n = 33,557) were analyzed to assess associations between presence of multiple chronic conditions (n = 13) and CAM use, using multivariable relative risk and linear regressions weighted for complex NHIS sampling. CAM use was defined as self-reported use of one or more of 16 therapies in the previous 12 months.

Results

Chronic conditions were common. US adults reported one (22.3%) or 2 or more (33.8%) conditions. Many used at least one form of CAM. Multivitamins, multiminerals, or both (52.7%); vitamins (34.8%); and minerals (28.4%) were the most common. Compared with adults with no conditions, adults with 2 or more conditions were more likely to use multivitamins or multiminerals or both, vitamins, minerals, nonvitamins or herbs, mind–body therapies, chiropractic or osteopathic manipulation, massage, movement therapies, special diets, acupuncture, naturopathy, or some combination of these therapies (P <.003).

Conclusion

People with multiple chronic conditions have a high prevalence of CAM use. Longitudinal studies are needed to understand the association between CAM use and chronic disease prevention and treatment.

High use of complementary and alternative medicine among a large cohort of women with a family history of breast cancer: the Sister Study

Use of complementary and alternative medicine (CAM) is high among U.S. women, yet information is limited on use among women at increased breast cancer risk. We analyzed CAM use among women with a family history of breast cancer. CAM use was analyzed among women enrolled 2003-2009 in the Sister Study cohort. Eligible women were aged 35-74, U.S. or Puerto Rican residents, no personal history of breast cancer, and had ≥1 sister with breast cancer. Baseline data on CAM use in the past year were available for 49,734 women. Logistic regression models examined the association between CAM use and Gail Model breast cancer risk score. Results were compared to female participants in the 2007 National Health Interview Survey (n = 7965). Among Sister Study participants, there was high use of vitamin/mineral supplements (79 %), mind-body practices (41 %), manipulative/body-based practices (32 %), and botanicals (23 %). Overall use was higher than the U.S. female population. No association was observed between familial breast cancer risk and CAM use. Black women were more likely to use spirituality/meditation-based CAM modalities, while non-Hispanic white and Asian women were high users of dietary supplements. In a cohort of women with increased breast cancer risk due to family history, CAM use is higher than women in the general U.S. population and is associated with race/ethnicity. Use was not associated with breast cancer risk. Given the high prevalence of CAM use among women at risk for breast caner, research on the effectiveness of CAM use for disease prevention is needed.

Complementary and alternative medicine use among US cancer survivors

PURPOSE

US cancer survivors commonly use vitamins/minerals and complementary and alternative medicine (CAM). We compare use of vitamins/minerals and CAM between adult cancer survivors and cancer-free adults and estimate annual out-of-pocket expenses.

METHODS

Data on self-reported vitamin/mineral and CAM use in the past 12 months from the cross-sectional 2012 US National Health Interview Survey were used to estimate prevalence of use and out-of-pocket expenditures. The cohort included adults with (n = 2977) and without (n = 30,551) a self-reported cancer diagnosis.

RESULTS

Approximately 79 % of cancer survivors and 68 % of cancer-free adults reported using ≥1 vitamins/minerals and/or CAM modality in the past year. Compared to cancer-free adults, cancer survivors were more likely to report use of vitamin/minerals (75 vs. 61 %, P < 0.001), non-vitamin/mineral natural products (24 vs. 19 %, P < 0.001), manipulative and body-based therapies (19 vs. 17 %, P = 0.03), and alternative medical systems (5 vs. 4 %, P = 0.04). Adult cancer survivors and cancer-free adults spent an annual estimated $6.7 billion and $52 billion out-of-pocket, respectively, on vitamins/minerals and CAM. Survivors spent 60 % of the total on vitamins/minerals ($4 billion), 18 % ($1.2 billion) on non-vitamin/mineral natural products, and 7 % ($0.5 billion) on massage.

CONCLUSIONS

Compared with cancer-free adults, a higher proportion of cancer survivors report vitamin/mineral and CAM use. Cancer survivors, who accounted for 6.9 % of the total population, accrued more than 11.4 % of the annual out-of-pocket costs on vitamins/minerals and CAM spent by US adults.

IMPLICATIONS FOR CANCER SURVIVORS

Given the high use of vitamins/minerals and CAM in cancer survivors, studies are needed to analyze health outcomes and the cost/benefit ratio of such use.

Abstract PD4-05: Complementary and alternative medicine use and breast cancer chemotherapy initiation: The BQUAL study

PURPOSE: Adjuvant therapy is associated with improved survival for women with breast cancer, but not all women who could benefit initiate treatment. Women's belief systems are related to treatment initiation. It has been hypothesized that complementary and alternative (CAM) use is associated with decreased initiation of standard oncology treatments because patients may be exploring alternative treatment approaches. However, there are limited data on the association between CAM use and cancer treatment initiation. We examined the association between CAM use and initiation of adjuvant breast cancer chemotherapy in a prospective cohort of early stage breast cancer patients.

PATIENTS AND METHODS: Subjects participated in a multi-center prospective cohort study of women with early stage invasive breast cancer (n=1,156). National Comprehensive Cancer Network guidelines were used to define groups based on whether chemotherapy was indicated. Three subgroups were created: chemotherapy indicated for subjects &lt;70 years, chemotherapy discretionary for subjects &lt;70 years, and chemotherapy discretionary for subjects ≥70 years. CAM use was assessed based upon self-reported use of 5 CAM modalities, including vitamin/mineral supplements, herbal supplements, other over-the-counter natural products, mind-body based approaches, and body/energy-based treatments. Psychosocial factors potentially related to chemotherapy initiation were assessed. Multivariable logistic regression models evaluated the associations between CAM use and chemotherapy initiation, adjusted for demographic, clinical and psychosocial factors.

RESULTS: Current CAM use was reported by 87% of women and 38% reporting current use of ≥3 modalities. The most commonly used CAM modalities were mind body therapies (63%) and other natural products (41%). In bivariate analyses, among women &lt;70 years where chemotherapy was indicated, women who reported current use of vitamins/minerals or current use of all 5 CAM modalities were less likely to initiate chemotherapy compared to non-users (P&lt;.0001), but this was not observed among women for whom chemotherapy was discretionary. Psychosocial factors were also associated with high levels of current CAM use in this group, including higher expectations of adverse effects from chemotherapy, more concerns about the physical effects of chemotherapy, lower beliefs in the benefits of chemotherapy, and lower positive decision balance while making chemotherapy decisions (all P&lt;.05). Among women age &lt;70 years for whom chemotherapy was indicated, 89% initiated treatment, and current use of all 5 CAM modalities was inversely associated with initiation in multivariable analyses adjusted for demographic and clinical factors (OR=0.08, CI: 0.02-0.32). The association remained after separately adjusting for psychosocial factors (all P&lt;.05), except for positive decision balance, which was no longer statistically significant.

CONCLUSIONS: High use of CAM was associated with decreased chemotherapy initiation among women with breast cancer for whom chemotherapy was indicated. It is important for oncologists to discuss CAM use with their patients, especially since high CAM use is associated with negative expectations and beliefs about chemotherapy.

Citation Format: Greenlee H, Neugut AI, Falci L, Hillyer GC, Buono D, Roh JM, Ergas IJ, Kwan ML, Lee M, Tsai WY, Shi Z, Lamerato L, Mandelblatt JS, Kushi LH, Hershman DL. Complementary and alternative medicine use and breast cancer chemotherapy initiation: The BQUAL study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-05.

Dietary modifications, weight loss, and changes in metabolic markers affect global DNA methylation in Hispanic, African American, and Afro-Caribbean breast cancer survivors

BACKGROUND

Lower levels of global DNA methylation in tissue and blood have been associated with increased cancer risk. Conversely, cross-sectional analyses of healthier lifestyle patterns have been associated with higher levels of global DNA methylation.

OBJECTIVE

In this trial, we explored the associations between changes in lifestyle modifications (diet, weight loss), metabolic markers, and global epigenetic biomarkers in white blood cells.

METHODS

Study participants were Hispanic, African American, and Afro-Caribbean overweight and sedentary female breast cancer survivors (n = 24) who participated in a larger randomized, crossover, pilot study of a 6-mo weight loss intervention and who had available blood specimens. Anthropometric measures, a food-frequency questionnaire, and peripheral blood were collected at baseline, 6 mo, and 12 mo. Plasma samples were analyzed for metabolic markers (insulin, glucose). We measured DNA methylation of long interspersed nucleotide element 1 (LINE-1) and satellite 2 by pyrosequencing and MethyLight, respectively, and global DNA methylation by the luminometric methylation assay (LUMA).

RESULTS

DNA methylation of LINE-1 was statistically significantly elevated at 6 mo [75.5% vs. 78.5% (P < 0.0001)] and 12 mo [75.5% vs. 77.7% (P < 0.0001)], compared to baseline. Over a 12-mo period, changes in percentage body fat and plasma glucose concentrations were positively associated with LINE-1 DNA methylation (β = 0.19, P = 0.001) and LUMA DNA methylation levels (β = 0.24, P = 0.02), respectively. Similarly, 12-mo changes in dietary measures such as vegetable (β = 0.009, P = 0.048), protein (β = 0.04, P = 0.001), and total caloric (β = 0.05, P = 0.01) intake were positively associated with changes in LUMA DNA methylation, as was intake of fruit positively associated with changes in LINE-1 DNA methylation (β = 0.004, P = 0.02).

CONCLUSIONS

Our hypothesis-generating results suggest that lifestyle modifications may be associated with changes in global DNA methylation detectable at 6 and 12 mo. These biomarkers may be useful intermediate biomarkers to use in future intervention trials. This trial was registered at clinicaltrials.gov as NCT00811824.

Are the unusual morphological and physiological features of the leatherback turtle (Dermochelys coriacea) paralleled at the molecular level? A study on A4 (muscle-type) isozyme of its lactate dehydrogenase

A4 (muscle-type) Lactate Dehydrogenase was purified to homogeneity from Dermochelys coriacea. The steady-state kinetic features of the enzyme show remarkable similarities with those displayed by many other heterothermal LDH's from cold-blooded vertebrates.