Influence of primary care on breast cancer outcomes among Medicare beneficiaries

PURPOSE

We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes.

METHODS

Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations.

RESULTS

Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis.

CONCLUSIONS

Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

A cluster randomized trial of sun protection at elementary schools. Results from year 2

BACKGROUND

Elementary schools are one potential venue for sun protection interventions that reduce childhood sun exposure.

PURPOSE

To assess Year-2 results from a cluster randomized trial promoting hat use at schools.

DESIGN

Block randomization was used to assign intervention/control status to participating schools. Data were collected from 2006 to 2008 and analyzed in 2007-2010.

SETTING/PARTICIPANTS

Of the 24 schools in the School District of Hillsborough County, Florida enrolled, 4th-graders were targeted in the first year and followed through their 5th-grade year.

INTERVENTION

Classroom sessions were conducted to improve sun protection knowledge, foster more positive attitudes about hat use, and change the subjective norm of wearing hats when at school.

MAIN OUTCOME MEASURES

Year-2 outcomes assessed included hat use at school (measured by direct observation), hat use outside of school (measured by self-report) and skin pigmentation and nevi counts (measured for a subgroup of 439 students).

RESULTS

The percentage of students observed wearing hats at control schools remained unchanged during the 2-year period (range 0%-2%) but increased significantly at intervention schools (2% at baseline, 41% at end of Year 1, 19% at end of Year 2; p<0.001 for intervention effect). Measures of skin pigmentation, nevi counts, and self-reported use of hats outside of school did not change during the study period.

CONCLUSIONS

This intervention increased use of hats at school through Year 2 but had no measurable effect on skin pigmentation or nevi. Whether school-based interventions can ultimately prevent skin cancer is uncertain.

Abstract B68: The influence of primary care on breast cancer outcomes among Medicare beneficiaries

Introduction: Primary care physicians (PCP) are integral in the early detection of cancer. Patients who are referred to a PCP, or who are assigned a PCP, are more likely to undergo most forms of cancer screening including mammograms and clinical breast examinations. PCPs may also ensure more timely diagnosis after screening abnormalities and prevent diagnostic delay. The Medicare-SEER database was used to explore the possibility of an association between primary care visits and breast cancer outcomes. With the usage of Medicare-SEER data, age, gender, and racial disparities exist.

Methods: A retrospective cohort study design was used to evaluate 109,188 women that were Medicare beneficiaries and diagnosed with breast cancer in SEER registries during the years of 1994–2005. This data was used to analyze the association between primary care encounters and breast cancer outcomes. Health services related to cancer prevention and screening have been shown to occur in the ambulatory setting. The total number of ambulatory physician encounters and the percentage of such encounters with a primary care physician (PCP) were examined over a 24 month period before cancer diagnosis. Women with invasive cancers odds of late American Joint Commission on Cancer (AJCC) stage at diagnosis (stages III and IV vs. stages I and II) and survival (breast cancer specific and all cause) were examined using logistic regression and proportional hazards models respectively. Whether including non-invasive cancers (such as ductal carcinoma in situ, DCIS) would alter results and whether prior mammography was a potential mediator of associations was also explored.

Results: Increasing numbers of ambulatory physician encounters were associated with improved breast cancer outcomes. In addition, subjects having between 40 and 60 percent of all encounters with PCPs were most likely to have had prior mammograms, least likely diagnosed at late stage, and to have lower breast cancer and all-cause mortality. Prior mammography mediated these associations in part but not completely. Results were unchanged when women with DCIS were included in the analysis. The average age of women involved in this study was 77 years old and 86 percent of the sample were non-minority.

Conclusions: Although there is the existence of age, racial, and gender disparities because of the use of the Medicare-SEER data, using this information helps to identify better care tactics for aging women. Medicare beneficiaries with breast cancer had better outcomes if they had greater use of ambulatory care and care that was balanced between primary and specialty providers. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B68.

Abstract A3: P20 Center of Excellence – The Research Conglomerate: Using a business marketing approach in cancer health disparities research

Introduction: As the types of grant funded research mechanisms are becoming more elaborate, business acumen in research is becoming necessary. One mechanism in particular that essentially can almost be mirrored as a small corporation is the P20 – Centers of Excellence (COE). The composition of a Center of Excellence is similar to that of a corporation and because of this uncanny likeness, business insight can be used to help guide the leadership of a COE. Even though marketing is usually thought of primarily as a business idiom, using social marketing is very common in public health research. But for a COE, a better way to succeed in the planning, directing, and executing of this particular research project would be to cross-pollinate business and social marketing. To aid in the planning, directing, and execution of the USF/Moffitt Center of Excellence – Center for Equal Health (CEH) – an approach combining business marketing with research was used. CEH is a joint partnership between the University of South Florida and the H. Lee Moffitt Cancer Center and Research Institute that conducts studies and promotes activities to reduce cancer health disparities among minority and underserved communities in the state of Florida.

To ensure that the vision, mission, and purpose of CEH are aligned with the actual work that has been done and to stay on track for what is intended to be done for the remainder of the funding allotment, a comprehensive marketing plan is being created using business and social marketing concepts in tandem. From the vantage point of the CEH administration, a business approach for the marketing plan is ideal for the overall COE, while a social marketing approach would also be used to focus on the behavioral changes that are needed within CEH. The processes associated with business and social marketing are the same, but a few of the concepts are very different. Using the business approach, the plan will identify and analyze other Centers with a focus of health disparities, or other competitors in the running for P20 funds. The marketing plan also explores the 4 P's of marketing (product, placement, price, promotion) which is a concept used in business and social marketing.

Summary: The initial stages of the marketing plan formulation were the most helpful for the CEH administration. During the initial stages, situation analysis and formative research was done to identify information gaps to be addressed that could help CEH pursue continual success. Using a mixed methods approach gave the administration the opportunity to qualitatively examine CEH as well as gain quantitative information about CEH from the other members. And while it is very important to obtain quantitative information about CEH, the administration found that the exploration of qualitative information assisted with the identification of the gaps that needed to be addressed within CEH.

Conclusions: Although a bit uncanny to think of using business to do health disparities research, using a business approach is seen to be an effective way gather information regarding the monstrous P20 COE mechanism. A lot of times research projects do not factor in the need for strategic planning at the time of grant submission, but it is essentially a very important process that is needed to keep administration and staff on track with the aims and goals that are set at the time of submission. Ultimately, because the P20 can be thought of as a research conglomerate, the use business marketing in health disparities research is very beneficial.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A3.