1
|
Eule CJ, Warren A, Molina Kuna E, Callihan EB, Kim SP, Flaig TW. Neoadjuvant Cisplatin-based Chemotherapy in Nonmetastatic Muscle-invasive Bladder Cancer: A Systematic Review and Pooled Meta-analysis to Determine the Preferred Regimen. Urology 2024:S0090-4295(24)00306-6. [PMID: 38685388 DOI: 10.1016/j.urology.2024.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/01/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE To determine whether neoadjuvant gemcitabine and cisplatin (GC) vs dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC) before radical cystectomy improves overall survival (OS), progression-free survival (PFS), and pathologic complete response (pCR) for patients with muscle-invasive bladder cancer with secondary analyses of pathological downstaging and toxicity. MATERIALS AND METHODS This systematic review and meta-analysis identified studies of patients with muscle-invasive bladder cancer treated with neoadjuvant GC compared to ddMVAC from PubMed, Web of Science, and EMBASE. Random-effect models for pooled log-transformed hazard ratios (HR) for OS and PFS and pooled odds ratios for pCR and downstaging were developed using the generic inverse variance method and Mantel-Haenszel method, respectively. RESULTS Ten studies were identified (4 OS, 2 PFS, and 6 pCR clinical endpoints). Neoadjuvant ddMVAC improved OS (HR 0.71 [95% confidence intervals 0.56; 0.90]), PFS (HR 0.76 [95% confidence intervals 0.60; 0.97]), and pathological downstaging (odds ratio 1.34 [95% confidence interval 1.01; 1.78]) as compared to GC. There was no significant difference between regimens for pCR rates (odds ratio 1.38 [95% confidence interval 0.90; 2.12]). Treatment toxicity was greater with ddMVAC. Limitations result from differences in number of ddMVAC cycles and patient selection between studies. CONCLUSION Neoadjuvant ddMVAC is associated with improved OS and PFS vs gemcitabine/cisplatin for patients with muscle-invasive bladder cancer before radical cystectomy. Although rates of pathological complete response were not significantly different, pathological downstaging correlated with OS. ddMVAC should be preferred over gemcitabine/cisplatin for patients with muscle-invasive bladder cancer who can tolerate its greater toxicity.
Collapse
Affiliation(s)
- Corbin J Eule
- University of Colorado Cancer Center, Division of Medical Oncology, Department of Medicine, Aurora, CO.
| | - Adam Warren
- University of Colorado Cancer Center, Population Health Shared Resource, Aurora, CO.
| | - Elizabeth Molina Kuna
- University of Colorado Cancer Center, Population Health Shared Resource, Aurora, CO.
| | - Eryn B Callihan
- University of Colorado Cancer Center, Division of Medical Oncology, Department of Medicine, Aurora, CO.
| | - Simon P Kim
- University of Colorado Cancer Center, Division of Urology, Department of Surgery, Aurora, CO.
| | - Thomas W Flaig
- University of Colorado Cancer Center, Division of Medical Oncology, Department of Medicine, Aurora, CO.
| |
Collapse
|
2
|
Hannemann A, Pessoa RR, Flaig T, Kuna EM, Warren A, Robin T, Kim SP, Ballon-Landa E. Cost of upper tract imaging obtained during hematuria evaluation: Analysis of a national claims database. Urol Oncol 2024:S1078-1439(24)00364-8. [PMID: 38679529 DOI: 10.1016/j.urolonc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/14/2023] [Accepted: 03/10/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION To investigate the actual cost of hematuria evaluation using nationally representative claims data, given that the workup for hematuria burdens the healthcare system with significant associated costs. We hypothesized that evaluation with contrast-enhanced computed tomography (CT) confers more cost to hematuria evaluation than renal ultrasound (US). METHODS Using a national, privately insured database (MarketScan), we identified all individuals with an incident diagnosis of hematuria. We included patients who underwent cystoscopy and upper tract imaging within 3 months of diagnosis. We tabulated the costs of the imaging study as well as the total healthcare cost per patient. A multivariable model was developed to evaluate patient factors associated with total healthcare costs. RESULTS We identified 318,680 patients with hematuria who underwent evaluation. Median costs associated with upper tract imaging were $362 overall, $504 for CT with contrast, $163 for US, $680 for magnetic resonance imaging (MRI), $283 for CT without contrast, and $294 for retrograde pyelogram. Median cystoscopy cost was $283. Total healthcare costs per patient were highest when utilizing MRI and CT imaging. When adjusted for comorbidities, the use of any imaging other than ultrasound was associated with higher costs. CONCLUSIONS In this nationally representative analysis, hematuria evaluation confers a significant cost burden, while the primary factor associated with higher costs of screening was imaging type. Based upon reduced cost of US-based strategies, further investigation should delineate its cost-effectiveness in the diagnosis of urological disease.
Collapse
Affiliation(s)
| | | | | | - Elizabeth Molina Kuna
- CU Anschutz School of Medicine, Aurora, CO; University of Colorado Cancer Center, Population Health Shared Resource, Aurora, CO
| | - Adam Warren
- University of Colorado Cancer Center, Population Health Shared Resource, Aurora, CO
| | | | | | - Eric Ballon-Landa
- CU Anschutz School of Medicine, Aurora, CO; Rocky Mountain Regional VA Medical Center, Aurora, CO.
| |
Collapse
|
3
|
Collins A, Molina Kuna E, Anderson-Mellies A, Cost C, Green AL. Investigating the Impact of Tumor Biology and Social Determinants on Time to Diagnosis and Stage at Presentation of Wilms Tumor. J Pediatr Hematol Oncol 2024; 46:147-153. [PMID: 38447110 PMCID: PMC10956656 DOI: 10.1097/mph.0000000000002846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 02/04/2024] [Indexed: 03/08/2024]
Abstract
Delays in diagnosis and time to diagnosis generally are used interchangeably in cancer disparity research, but these terms may have important differences. Although these terms are related, we hypothesize that time to diagnosis is determined by the aggressiveness of the tumor based on intrinsic factors such as tumor biology, whereas delays in diagnosis are caused by extrinsic factors such as socioeconomic status, leading to presentation at higher stage of disease due to barriers of care. We conducted a retrospective study of 306 patients diagnosed with Wilms tumor at Children's Hospital Colorado between 1971 and 2016 identifying patient barriers as extrinsic markers and using unfavorable histology and loss of heterozygosity as markers of aggressive tumor biology. Multivariable logistic regression was performed. Patients with Medicaid were more likely to present greater than 4 days after initial symptoms compared to those with private insurance, and those with housing concerns were more likely to be diagnosed greater than 9 days from initial symptoms. Tumor biology was noted to be associated with higher stage at diagnosis, but patient barriers were not. These findings suggest the interplay between tumor biology, patient barriers, diagnostic timing, and stage at diagnosis is more complex, multifactorial, and in need of further study.
Collapse
Affiliation(s)
| | - Elizabeth Molina Kuna
- University of Colorado School of Medicine
- Department of Medicine
- Division of Medical Oncology
- University of Colorado Cancer Center
- Population Health Shared Resource
| | - Amy Anderson-Mellies
- University of Colorado School of Medicine
- Department of Medicine
- Division of Medical Oncology
- University of Colorado Cancer Center
- Population Health Shared Resource
| | - Carrye Cost
- University of Colorado School of Medicine
- University of Colorado Cancer Center
- Children’s Hospital Colorado
| | - Adam L. Green
- University of Colorado School of Medicine
- University of Colorado Cancer Center
- Children’s Hospital Colorado
| |
Collapse
|
4
|
Pool A, Kuna EM, Anderson-Mellies A, Kreis A, Marable M, Fraley C, Pacheco D, Green AL. Medical Record Level-Evaluation of Impact of Demographic and Socioeconomic Factors on Pediatric Neuro-Oncology Outcomes at Children's Hospital Colorado. Res Sq 2024:rs.3.rs-3849043. [PMID: 38260550 PMCID: PMC10802725 DOI: 10.21203/rs.3.rs-3849043/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Purpose A medical record-level cohort study to investigate demographic and socioeconomic factors influencing treatment, timing of care, and survival outcomes in pediatric patients diagnosed with central nervous system (CNS) tumors. Methods Using electronic health records of patients at Children's Hospital Colorado from 1986-2020, we identified 898 patients treated for CNS tumors. The primary outcomes of interest were 5-year survival, timing of diagnosis, and treatment. Multivariable logistic regression and Cox regression were used to identify covariates associated with our outcomes of interest. Results We found that age, race, tumor type, diagnosis year, and social concerns influenced receipt and timing of treatment. Age, race, patient rural vs. urban residence, and tumor impacted survival outcomes. Time to presentation and treatment were significantly different between White and minority patients. American Indian/Alaska Native and Black patients were less likely to receive chemo compared to White patients (OR 0.28, 0.93 p = 0.037, < 0.001). Patients with 3 + social concerns were more likely to survive after 5 years than children with no or unknown social concerns (OR 1.84, p = 0.011). However, with an adjusted hazards ratio, children with 2 social concerns were less likely to survive to 5 years than children with no or unknown concerns (OR 0.58, p = 0.066). Conclusions Demographic and socioeconomic factors influence timing of care and survival outcomes in pediatric patients with CNS tumors. Minority status, age, social factors, rural, and urban patients experience differences in care. This emphasizes the importance of considering these factors and addressing disparities to achieve equitable care.
Collapse
|
5
|
Roy S, Lakritz S, Schreiber AR, Kuna EM, Bradley CJ, Kondapalli L, Diamond JR. Major cardiovascular adverse events in older adults with early-stage triple-negative breast cancer treated with adjuvant taxane + anthracycline versus taxane-based chemotherapy regimens: A SEER-medicare study. Eur J Cancer 2024; 196:113426. [PMID: 38000217 DOI: 10.1016/j.ejca.2023.113426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Triple-negative breast cancer (TNBC) is more aggressive as compared to other subtypes of breast cancer with characteristic metastatic patterns and a poor prognosis. The standard of care for early-stage TNBC is historically anthracycline and taxane-based chemotherapy (ATAX). Despite the effectiveness of this regimen, anthracyclines carry a small but important risk of cardiotoxicity, which is specifically a concern in the older population. This study evaluates major adverse cardiovascular events (MACE) in older women with TNBC treated with ATAX compared to taxane-based chemotherapy (TAX). METHODS Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified women aged 66 and older with TNBC diagnosed between 2010 and 2015 (N = 2215). We compared patient and clinical characteristics according to adjuvant chemotherapy regimen (chemotherapy versus no chemotherapy and ATAX versus TAX). Logistic regression was performed to estimate the odds ratios (OR) and 95% confidence intervals (CIs), Kaplan-Meier survival curves were generated to estimate three-year overall survival (OS) and cancer specific survival (CSS). Cox proportional hazards models were used to analyze OS and CSS while controlling for patient and tumor characteristics. MACE was defined as acute myocardial infarction, heart failure, potentially fatal arrhythmia, and cerebral vascular incidence. Few patients experienced a cardiac death and therefore this was excluded in the analysis. RESULTS Of the 2215 patients in our cohort, most patients (n = 1334; 60.26%) received TAX compared to ATAX (n = 881; 39.78%). Patients who received ATAX were not statistically significantly more likely than those who received TAX to experience acute myocardial infarction, cerebral vascular accident (CVA), or potentially fatal arrhythmia when controlling for traditional risk factors. Among patients who experienced MACE, there was no difference in OS or CSS in patients who received TAX vs ATAX. Patients who received ATAX were less likely to develop heart failure than those who received TAX (OR 0.63, 95% CI [0.45-0.88], p < 0.01). Patients who developed MACE and who were > 76 years old had worse OS compared to those who experienced MACE and were age 66-75 years old (HR 1.67, 95% CI [1.07-2.62], p = 0.02). CONCLUSION Among older women with TNBC, receipt of adjuvant chemotherapy with ATAX was not associated with increased risk of major adverse cardiac events. For those who experienced a cardiac event, there was no difference in survival amongst those who received TAX vs ATAX. Other factors including additional chemotherapy toxicities should be investigated as a potential etiology for the inferior OS previously observed with ATAX vs TAX in older women with node negative or 1-3 positive lymph nodes.
Collapse
Affiliation(s)
- Savannah Roy
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Stephanie Lakritz
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anna R Schreiber
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Molina Kuna
- Population Health Shared Resource, University of Colorado Cancer Center, Aurora, CO, USA
| | - Cathy J Bradley
- Department of Health Systems, Management, and Policy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lavanya Kondapalli
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer R Diamond
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
6
|
Callaway C, Kuna EM, Overholser L. Development of a novel cancer survivorship database to describe health care utilization patterns for Coloradans who have completed primary cancer treatment. J Cancer Surviv 2023:10.1007/s11764-023-01506-x. [PMID: 38135830 DOI: 10.1007/s11764-023-01506-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE Electronic health records (EHR) and data warehouses contain large amounts of data that hold promise for understanding and improving population health management. Utilizing the Health Data Compass (HDC) warehouse, a comprehensive and novel database of adult Coloradans who have completed curative-intent cancer treatment within a health care system was created. By analyzing patient demographics and health care utilization among this group, gaps in and barriers to coordinated care post-active cancer treatment may be identified and better understood. METHODS A survivorship database (HDC-SD) was built from the Health Data Compass (HDC) warehouse by identifying individuals with histories of cancer who received treatment summary care plans (TSCPs) through the University of Colorado Cancer Center (UCCC) between January 1, 2020, and December 31, 2021. Patient sociodemographic characteristics, disease characteristics, and health maintenance were described and compared between urban and rural settings using chi-square tests. RESULTS The HDC-SD includes 1933 records representing 13 categories of cancers. The majority live in an urban setting (89.8%). Patients in HDC-SD living in urban areas had higher rates of completing recommended colorectal screening, mammography, Prostate-Specific Antigen (PSA) tests, flu shots, and COVID-19 vaccination. Additionally, emergency department visits occurred at a statistically significant higher level for those living in urban areas. CONCLUSIONS Creating and analyzing a comprehensive database of individuals who have completed active cancer treatment may highlight gaps in care within complex health care systems. Engaging different stakeholders to address these issues may help improve and enhance systematic population management for cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS Completed treatment summary care plans may be used to increase the completion of individual health maintenance recommendations and potentially population health maintenance recommendations.
Collapse
Affiliation(s)
- Carlin Callaway
- Division of Medical Oncology, University of Colorado Department of Medicine, 1665 Aurora Court, Aurora, CO, 80045, USA.
| | - Elizabeth Molina Kuna
- Population Health Shared Resource, University of Colorado Cancer Center, 13001 East 17th Place, Aurora, CO, 80045, USA
| | - Linda Overholser
- Division of Internal Medicine, University of Colorado Department of Medicine, 12631 East 17th Avenue, Aurora, CO, 80045, USA
| |
Collapse
|