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1.  Patient Preference and Contraindications in Measuring Quality of Care: What Do Administrative Data Miss? 
Journal of Clinical Oncology  2013;31(21):2716-2723.
Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy.
Patients and Methods
Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer–directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment.
Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments.
Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.
PMCID: PMC3709057  PMID: 23752110
2.  Medical Oncologists' Perceptions of Financial Incentives in Cancer Care 
Journal of Clinical Oncology  2012;31(5):530-535.
The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised about financial incentives associated with the chemotherapy concession in oncology practices and their impact on treatment recommendations.
The objective of this study was to measure the physician-reported effects of prescribing chemotherapy or growth factors or making referrals to other cancer specialists, hospice, or hospital admissions on medical oncologists' income. US medical oncologists involved in the care of a population-based cohort of patients with lung or colorectal cancer from the Cancer Care Outcomes Research and Surveillance (CanCORS) study were surveyed regarding their perceptions of the impact of prescribing practices or referrals on their income.
Although most oncologists reported that their incomes would be unaffected, compared with salaried oncologists, physicians in fee-for-service practice, and those paid a salary with productivity incentives were more likely to report that their income would increase from administering chemotherapy (odds ratios [ORs], 7.05 and 7.52, respectively; both P < .001) or administering growth factors (ORs, 5.60 and 6.03, respectively; both P < .001).
A substantial proportion of oncologists who are not paid a fixed salary report that their incomes increase when they administer chemotherapy and growth factors. Further research is needed to understand the impact of these financial incentives on both the quality and cost of care.
PMCID: PMC3565179  PMID: 23269996
3.  Is Race/Ethnicity Related to the Presence or Severity of Pain in Colorectal and Lung Cancer? 
Developing interventions to address racial/ethnic cancer pain disparities requires exploration of the role of socioeconomic status, health status, and pain severity from the time of diagnosis.
To examine patterns of disparities in cancer pain by evaluating differences by race/ethnicity in the odds of reporting pain and in pain severity, controlling for key patient-level covariates.
This study used data from a nationally representative cohort of colorectal and lung cancer patients. Multivariable logistic regression was conducted to examine the relationship between race/ethnicity and reporting pain. Multivariable linear regression was then conducted, among those who reported pain, to determine differences in pain severity by race/ethnicity.
The cohort included 5761 individuals (14% black, 7% Hispanic/Latino, 6% Asian or Pacific Islander, and 3% multiracial), among whom 48% reported pain. The adjusted odds of reporting differed only for multiracial patients, who were more likely to report pain than whites (odds ratio: 1.54; P = 0.036). However, among those with pain, severity was higher for black patients (β = 6.6; P ≤ 0.001) and multiracial patients (β = 4.5; P = 0.036) relative to white patients. Lower educational attainment, depressed affect, and lower levels of wealth also were associated with higher pain severity.
Although the odds of experiencing pain differed only for multiracial patients, among those reporting pain, both blacks and multiracial individuals reported higher pain severity than whites. Sociodemographic status, health status, and depression were associated with severity but did not explain the disparity. Interventions to address these disparities will need to focus on reported severity and patient-level factors.
PMCID: PMC4324611  PMID: 24747225
Cancer pain; health disparities; patient-reported outcomes; quality of life; colorectal cancer; lung cancer
4.  Prevalence, Predictors, and Patient Outcomes Associated with Physician Co-management: Findings from the Los Angeles Women's Health Study 
Health Services Research  2011;47(3 Pt 1):1091-1116.
Physician co-management, representing joint participation in the planning, decision-making, and delivery of care, is often cited in association with coordination of care. Yet little is known about how physicians manage tasks and how their management style impacts patient outcomes.
To describe physician practice style using breast cancer as a model. We characterize correlates and predictors of physician practice style for 10 clinical tasks, and then test for associations between physician practice style and patient ratings of care.
We queried 347 breast cancer physicians identified by a population-based cohort of women with incident breast cancer regarding care using a clinical vignette about a hypothetical 65-year-old diabetic woman with incident breast cancer. To test the association between physician practice style and patient outcomes, we linked medical oncologists’ responses to patient ratings of care (physician n = 111; patient n = 411).
After adjusting for physician and practice setting characteristics, physician practice style varied by physician specialty, practice setting, financial incentives, and barriers to referrals. Patients with medical oncologists who co-managed tasks had higher patient ratings of care.
Physician practice style for breast cancer is influenced by provider and practice setting characteristics, and it is an important predictor of patient ratings. We identify physician and practice setting factors associated with physician practice style and found associations between physician co-management and patient outcomes (e.g., patient ratings of care).
PMCID: PMC3423183  PMID: 22171977
Quality of care; physician practice style; physician co-management; patient ratings of care; breast cancer care; provider network restrictions
5.  Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study 
Journal of Clinical Oncology  2012;30(35):4387-4395.
National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death.
Patients and Methods
We studied 1,231 patients with stage IV lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium, a population- and health system–based prospective cohort study, who died during the 15-month study period but survived at least 1 month. Our main outcome measure was the aggressiveness of EOL care received.
Nearly half of patients received at least one marker of aggressive EOL care, including chemotherapy in the last 14 days of life (16%), intensive care unit care in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%). Patients who had EOL discussions with their physicians before the last 30 days of life were less likely to receive aggressive measures at EOL, including chemotherapy (P = .003), acute care (P < .001), or any aggressive care (P < .001). Such patients were also more likely to receive hospice care (P < .001) and to have hospice initiated earlier (P < .001).
Early EOL discussions are prospectively associated with less aggressive care and greater use of hospice at EOL.
PMCID: PMC3675701  PMID: 23150700
6.  Envisioning Watson As a Rapid-Learning System for Oncology 
Journal of Oncology Practice  2013;9(3):155-157.
The authors discuss what oncology might look like when supported by omniscient megacomputers like IBM Watson.
PMCID: PMC3651566  PMID: 23942497
7.  Uptake and Economic Impact of First-Cycle Colony-Stimulating Factor Use During Adjuvant Treatment of Breast Cancer  
Journal of Clinical Oncology  2012;30(8):806-812.
In 2002, pegfilgrastim was approved by the US Food and Drug Administration and the benefits of dose-dense breast cancer chemotherapy, especially for hormone receptor (HR) –negative tumors, were reported. We examined first-cycle colony-stimulating factor use (FC-CSF) before and after 2002 and estimated US expenditures for dose-dense chemotherapy.
We identified patients in Surveillance, Epidemiology, and End Results–Medicare greater than 65 years old with stages I to III breast cancer who had greater than one chemotherapy claim within 6 months of diagnosis(1998 to 2005) and classified patients with an average cycle length less than 21 days as having received dose-dense chemotherapy. The associations of patient, tumor, and physician-related factors with the receipt of any colony-stimulating factor (CSF) and FC-CSF use were analyzed by using generalized estimating equations. CSF costs were estimated for patients who were undergoing dose-dense chemotherapy.
Among the 10,773 patients identified, 5,266 patients (48.9%) had a CSF claim. CSF use was stable between 1998 and 2002 and increased from 36.8% to 73.7% between 2002 and 2005, FC-CSF use increased from 13.2% to 67.9%, and pegfilgrastim use increased from 4.1% to 83.6%. In a multivariable analysis, CSF use was associated with age and chemotherapy type and negatively associated with black/Hispanic race, rural residence, and shorter chemotherapy duration. FC-CSF use was associated with high socioeconomic status but not with age or race/ethnicity. The US annual CSF expenditure for women with HR-positive tumors treated with dose-dense chemotherapy is estimated to be $38.8 million.
A rapid increase in FC-CSF use occurred over a short period of time, which was likely a result of the reported benefits of dose-dense chemotherapy and the ease of pegfilgrastim administration. Because of the increasing evidence that elderly HR-positive patients do not benefit from dose-dense chemotherapy, limiting pegfilgrastim use would combat the increasing costs of cancer care.
PMCID: PMC3295569  PMID: 22312106
8.  Do Variations in Provider Discussions Explain Socioeconomic Disparities in Postmastectomy Breast Reconstruction? 
The utilization of post-mastectomy reconstruction varies with socioeconomic status, but the etiology of these variations is not understood. We investigate whether these differences reflect variations in the rate and/or qualitative aspects of the provider’s discussion of reconstruction as an option.
Data were collected via chart review and patient survey for Stage I - III breast cancer patients during the National Initiative on Cancer Care Quality. Multivariable logistic regression was used to identify predictors of reconstruction and discussion of reconstruction as an option. Predictors of not receiving reconstruction despite a documented discussion were also determined.
253 of 626 patients received reconstruction (40.4%). Younger, more educated, white women who were not overweight or receiving post-mastectomy radiation were more likely to receive reconstruction. Patients who were younger, more educated, and not receiving post-mastectomy radiation were more likely to have a discussion of reconstruction documented. If a discussion was documented, patients who were older, Hispanic, not born in the U.S., and women who received post-mastectomy radiation were less likely to receive reconstruction. The greatest predictor of reconstruction was medical record documentation of a discussion about reconstruction.
We observed disparities in the likelihood of reconstruction, which are at least partially explained by differences in the likelihood that reconstruction was discussed. However, there are also differences in the likelihood of reconstruction based on age, race, and radiation once discussions occurred. Efforts to increase and improve discussions regarding reconstruction may decrease disparities for this procedure.
PMCID: PMC4002201  PMID: 18387464
9.  The Value of Specialty Oncology Drugs 
Health Services Research  2010;45(1):115-132.
To estimate patients' elasticity of demand, willingness to pay, and consumer surplus for five high-cost specialty medications treating metastatic disease or hematologic malignancies.
Data Source/Study Setting
Claims data from 71 private health plans from 1997 to 2005.
Study Design
This is a revealed preference analysis of the demand for specialty drugs among cancer patients. We exploit differences in plan generosity to examine how utilization of specialty oncology drugs varies with patient out-of-pocket costs.
Data Collection/Extraction Methods
We extracted key variables from administrative health insurance claims records.
Principal Findings
A 25 percent reduction in out-of-pocket costs leads to a 5 percent increase in the probability that a patient initiates specialty cancer drug therapy. Among patients who initiate, a 25 percent reduction in out-of-pocket costs reduces the number of treatments (claims) by 1–3 percent, depending on the drug. On average, the value of these drugs to patients who use them is about four times the total cost paid by the patient and his or her insurer, although this ratio may be lower for oral specialty therapies.
The decision to initiate therapy with specialty oncology drugs is responsive to price, but not highly so. Among patients who initiate therapy, the amount of treatment is equally responsive. The drugs we examine are highly valued by patients in excess of their total costs, although oral agents warrant further scrutiny as copayments increase.
PMCID: PMC2813440  PMID: 19878344
Willingness to pay; economic analysis; cost–benefit analysis; oncology
10.  Use of Interpreters by Physicians Treating Limited English Proficient Women with Breast Cancer: Results from the Provider Survey of the Los Angeles Women's Health Study 
Health Services Research  2010;45(1):172-194.
Little is known about how cancer physicians communicate with limited English proficient (LEP) patients. We studied physician-reported use and availability of interpreters.
Data Sources
A 2004 survey was fielded among physicians identified by a population-based sample of breast cancer patients. Three hundred and forty-eight physicians completed mailed surveys (response rate: 77 percent) regarding the structure and organization of care.
Study Design and Settings
We used logistic regression to analyze use and availability of interpreters.
Principal Findings
Most physicians reported treating LEP patients. Among physicians using interpreters within the last 12 months, 42 percent reported using trained medical interpreters, 21 percent telephone interpreter services, and 75 percent reported using untrained interpreters to communicate with LEP patients. Only one-third of physicians reported good availability of trained medical interpreters or telephone interpreter services when needed. Compared with HMO physicians, physicians in solo practice and single-specialty medical groups were less likely to report using trained medical interpreters or telephone interpreter services, and they were less likely to report good availability of these services.
There were important practice setting differences predicting use and availability of trained medical interpreters and telephone interpretation services. These findings may have troubling implications for effective physician–patient communication critically needed during cancer treatment.
PMCID: PMC2813443  PMID: 19878346
Physician survey; limited English proficient patients; interpreters; breast cancer care
11.  Quality of Care for Breast Cancer for Uninsured Women in California Under the Breast and Cervical Cancer Prevention Treatment Act  
Journal of Clinical Oncology  2010;28(21):3479-3484.
The objective of this study was to evaluate the quality of care provided to uninsured women with breast cancer who received treatment through the Breast and Cervical Cancer Prevention Treatment Program (BCCTP).
Participants included women with stage I to III breast cancer (n = 658) from a consecutive sample of women 18 years or older who received coverage through the California BCCTP between February 2003 and September 2005 who consented to a survey and medical record review (61% response rate). Quality of breast cancer care was evaluated using 29 evidence-based quality measures developed for the National Initiative for Cancer Care Quality (NICCQ). NICCQ, a largely insured cohort of women diagnosed with stage I to III breast cancer in 1998, was used to benchmark the results.
Twenty-three percent of women presented with stage III disease compared with fewer than 10% nationally. Patients received 93% of recommended care (95% CI, 92% to 93%). Adherence to recommended care within domains ranged from 87% for post-treatment surveillance (95% CI, 84% to 90%) to 97% for diagnostic evaluation (95% CI, 96% to 97%). Compared to the NICCQ cohort, adherence to quality measures was as good or better for the BCCPT cohort in all domains except post-treatment surveillance.
The BCCTP has made important inroads in providing poor, uninsured women with access to high quality care when faced with the diagnosis of breast cancer; however, many present at an advanced stage, which is associated with worse outcomes.
PMCID: PMC2917212  PMID: 20530279
12.  Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study 
Cancer  2012;119(4):854-862.
Our objective was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.
Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained via medical record abstraction and patient surveys. Logistic regression was used to evaluate: patient characteristics associated with seeing medical oncology and receiving chemotherapy; and patient characteristics, beliefs and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.
Among 702 patients with mCRC, 91% saw a medical oncologist, and among those, 82% received chemotherapy. Patients 65-75 and ≥75 years were less likely to see an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses patients ≥75 years and with moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed chemotherapy would not extend their life (90%), chemotherapy would not likely help with cancer-related problems (89%), or preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.
The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with intensity or number of chemotherapy regimens.
PMCID: PMC3548062  PMID: 22972673
Colorectal cancer; decision making; patient preference; cohort studies; quality of healthcare
13.  Adherence to Adjuvant Hormone Therapy in Low-income Women with Breast Cancer: The Role of Provider-Patient Communication 
To assess the impact of patient-provider communication on adherence to tamoxifen (TAM) and aromatase inhibitors (AI) 36 months after breast cancer (BC) diagnosis in a low-income population of women.
California statewide surveys were conducted among 921 low-income women with BC at 6-, 18-, and 36-months after BC diagnosis. A subset of 303 women with stage I–III BC who initiated hormone treatment after diagnosis was identified. Bivariate and multivariate logistic regression analyses were performed, and adjusted adherence rates were calculated. The main outcome measure was self-reported hormone use at 36 months after BC diagnosis and the chief independent variables were patient-centered communication after diagnosis by patient report as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and patients’ self-efficacy in patient-physician interactions (PEPPI).
Overall adherence to TAM/AI was relatively high (88%). Adjusted rates of adherence were 59% and 94% for patients with the lowest vs. highest scores on the CAHPS communication scale (AOR=1.22, P=0.006) and 72% vs. 91% for patients with the lowest and highest rating of PEPPI (AOR=1.04, P=0.04). Having at least one comorbid condition also increased the odds of adherence to hormonal therapy (AOR=3.14, P=0.03). Having no health insurance and experiencing side-effects from hormone treatment were barriers for adherence (AOR=0.12, P=0.001; AOR=0.26, P=0.003, respectively).
Patient-centered communication and perceived self-efficacy in patient-physician interaction were significantly associated with patient adherence to ongoing TAM/AI therapy among low-income women with BC. Interventions on patient-provider communication may provide opportunities to improve patient outcomes in this vulnerable population.
PMCID: PMC3553239  PMID: 23263740
14.  Does Value Mean Quality? The Payer's Perspective 
Journal of Oncology Practice  2013;9(3):116-118.
The author concludes that quality cancer care needs to be high-value care, and it is up to the clinicians who are actually providing cancer care to determine how best to achieve the desired outcomes for individual patients.
PMCID: PMC3651553  PMID: 23942484
Cancer  2012;118(12):3153-3164.
Continued smoking after cancer diagnosis may adversely affect treatment effectiveness, subsequent cancer risk, and survival. The prevalence of continued smoking following cancer diagnosis is understudied.
In the multi-regional Cancer Care Outcomes Research and Surveillance cohort (lung cancer [N=2456], colorectal cancer [N=3063]), we examined smoking rates at diagnosis and 5 months following diagnosis and factors associated with continued smoking.
90.2% of lung and 54.8% of colorectal cancer patients reported ever smoking. At diagnosis, 38.7% of lung cancer and 13.7% of colorectal cancer patients were smoking; 14.2% of lung cancer and 9.0% of colorectal cancer patients were smoking 5 months post-diagnosis. Factors associated with continued smoking among non-metastatic lung cancer patients were: Medicare, other public/unspecified insurance, not having chemotherapy, not having surgery, prior cardiovascular disease, lower body mass index, lower emotional support, and higher ever daily smoking rates (all p<.05). Factors independently associated with continued smoking among non-metastatic colorectal cancer patients were male sex, high school education, being uninsured, not having surgery, and higher ever daily smoking rates (all p<.05).
Following diagnosis, a substantial minority of lung and colorectal cancer patients continue smoking. Lung cancer patients had higher rates of smoking at diagnosis and following diagnosis; colorectal cancer patients were less likely to quit smoking following diagnosis. Factors associated with continued smoking differed between the two groups. Future smoking cessation efforts should examine differences by cancer type, particularly when comparing cancers for which smoking is a well established risk factor versus cancers for which it is not.
PMCID: PMC3342424  PMID: 22271645
cigarette smoking; lung cancer; colorectal cancer; tobacco; risk factors
16.  End-of-life discussions among patients with advanced cancer: A cohort study 
Annals of internal medicine  2012;156(3):204-210.
National guidelines recommend that physicians discuss end-of-life (EOL) care planning with cancer patients whose life expectancy is less than one year.
To evaluate the incidence of EOL discussions for patients with stage IV lung or colorectal cancer, and where, when, and with whom discussions take place.
Prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005.
Subjects lived in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama, or received care in one of five large health maintenance organizations or one of fifteen Veteran’s Health Administration sites.
2155 patients with stage IV lung or colorectal cancer.
EOL discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis.
73% of patients had EOL discussions identified by at least one source. Among patients who died during follow-up (N=1470), 87% had EOL discussions, versus 41% of patients who were alive at the end of follow-up (N=685). Among first EOL discussions documented in records (N=1081), 55% occurred in the hospital. Oncologists documented EOL discussions with only 27% of their patients. Among patients with documented EOL discussions who died during follow-up (N=959), discussions took place a median of 33 days before death.
The depth and quality of EOL discussions was not evaluated. Much of the information about discussions came from surrogates of patients who died before baseline interviews could be obtained.
Although most patients with stage IV lung or colorectal cancer have discussions with physicians about EOL care planning before death, many discussions occur during acute hospital care, with non-oncology providers, and late in the course of illness.
PMCID: PMC3616320  PMID: 22312140
17.  Providing Cancer Care: Individual or Team Sport? 
PMCID: PMC3250546  PMID: 22086752
19.  Use of Colony-Stimulating Factors With Chemotherapy: Opportunities for Cost Savings and Improved Outcomes 
Myeloid colony-stimulating factors (CSFs) decrease the risk of febrile neutropenia (FN) from high-risk chemotherapy regimens administered to patients at 20% or greater risk of FN, but little is known about their use in clinical practice. We evaluated CSF use in a multiregional population-based cohort of lung and colorectal cancer patients (N = 1849). Only 17% (95% confidence interval [CI] = 8% to 26%) patients treated with high-risk chemotherapy regimens received CSFs, compared with 18% (95% CI = 16% to 20%) and 10% (95% CI = 8% to 12%) of patients treated with intermediate- (10%–20% risk of FN) and low-risk (<10% risk of FN) chemotherapy regimens, respectively. Using a generalized estimating equation model, we found that enrollment in a health maintenance organization (HMO) was strongly associated with a lower adjusted odds of discretionary CSF use, compared with non-HMO patients (odds ratio = 0.44, 95% CI = 0.32 to 0.60, P < .001). All statistical tests were two-sided. Overall, 96% (95% CI = 93% to 98%) of CSFs were administered in scenarios where CSF therapy is not recommended by evidence-based guidelines. This finding suggests that policies to decrease CSF use in patients at lower or intermediate risk of FN may yield substantial cost savings without compromising patient outcomes.
PMCID: PMC3119647  PMID: 21670423
20.  Documentation and Discussion of Preferences for Care Among Patients With Advanced Cancer 
Journal of Oncology Practice  2011;7(6):361-366.
Providers may need help identifying patients for appropriate palliative care services earlier in their trajectory.
We sought to describe the documentation, frequency, and timing of discussions about patient preferences for care and to examine patterns of palliative care and hospice use among patients with advanced cancer.
We prospectively abstracted the medical records of 118 patients receiving care at a Veterans Administration (VA) facility from diagnosis of stage IV disease to 12 months postdiagnosis or death. We used univariate statistics to describe the type and frequency of documentation of patient preferences and palliative care/hospice referral. We calculated the time from diagnosis to the first documentation of preferences and the time from first documentation to death. We compared documentation of patient preferences between decedents and nondecedents using χ2 tests.
The majority of patients (81%) had some documentation of their care preferences recorded, although decedents were significantly more likely to have had their preferences documented than nondecedents (96% v 60%; P < .000). Most (53%) patients did not have a formal advance directive documented in the medical record. The mean time from diagnosis to the first documentation of preferences was approximately 2 months. More than half of all patients (53%) and almost three-quarters of decedents (73%) had a palliative care consultation.
Despite high rates of preference documentation, there remains room for improvement. Providers may need to be helped to identify patients earlier in their trajectory for appropriate palliative care services, and future work should focus on developing useful alternatives to advance directives for adequately documenting patient preferences.
PMCID: PMC3219461  PMID: 22379417
21.  Cancer Patients' Roles in Treatment Decisions: Do Characteristics of the Decision Influence Roles? 
Journal of Clinical Oncology  2010;28(28):4364-4370.
Patients with more active roles in decisions are more satisfied and may have better health outcomes. Younger and better educated patients have more active roles in decisions, but whether patients' roles in decisions differ by characteristics of the decision itself is unknown.
Patients and Methods
We surveyed a large, population-based cohort of patients with recently diagnosed lung or colorectal cancer about their roles in decisions regarding surgery, radiation therapy, and/or chemotherapy. We used multinomial logistic regression to assess whether characteristics of the decision, including evidence about the treatment's benefit, whether the decision was likely preference-sensitive (palliative therapy for metastatic cancer), and treatment modality, influenced patients' roles in that decision.
Of 10,939 decisions made by 5,383 patients, 38.9% were patient controlled, 43.6% were shared, and 17.5% were physician controlled. When there was good evidence to support a treatment, shared control was greatest; when evidence was uncertain, patient control was greatest; and when there was no evidence for or evidence against a treatment, physician control was greatest (overall P < .001). Decisions about treatments for metastatic cancers tended to be more physician controlled than other decisions (P < .001).
Patients making decisions about treatments for which no evidence supports benefit and decisions about noncurative treatments reported more physician control, which suggests that patients may not want the responsibility of deciding on treatments that will not cure them. Better strategies for shared decision making may be needed when there is no evidence to support benefit of a treatment or when patients have terminal illnesses that cannot be cured.
PMCID: PMC2954135  PMID: 20713872
22.  Patients' Experiences With Care for Lung Cancer and Colorectal Cancer: Findings From the Cancer Care Outcomes Research and Surveillance Consortium 
Journal of Clinical Oncology  2010;28(27):4154-4161.
To assess patients' experiences with cancer care, ratings of their quality of care, and correlates of these assessments.
Patients and Methods
For 4,093 patients with lung cancer and 3,685 patients with colorectal cancer in multiple US regions and health care delivery systems, we conducted telephone surveys of patients or their surrogates in English, Spanish, or Chinese at 4 to 7 months after diagnosis. The surveys assessed ratings of the overall quality of cancer care and experiences with three domains of interpersonal care (physician communication, nursing care, and coordination and responsiveness of care).
English-speaking Asian/Pacific Islander patients and Chinese-speaking patients and those in worse health reported significantly worse adjusted experiences with all three domains of interpersonal care, whereas white, black, and Hispanic patients reported generally similar experiences with interpersonal care. The overall quality of cancer care was rated as excellent by 44.4% of patients with lung cancer and 53.0% of patients with colorectal cancer, and these ratings were most strongly correlated with positive experiences with coordination and responsiveness of care (Spearman rank coefficients of 0.49 and 0.42 for lung and colorectal cancer, respectively). After multivariate adjustment, excellent ratings were less common for each cancer among black patients, English-speaking Asian/Pacific Islander patients, Chinese-speaking patients, and patients reporting worse health status (all P ≤ .05).
Patients' reports and ratings of care differed significantly by race, language, and health status. Efforts to improve patients' experiences with cancer care should focus on problems affecting Asian and Pacific Islander patients and those in worse health.
PMCID: PMC2953972  PMID: 20713876
23.  Early dissemination of bevacizumab for advanced colorectal cancer: a prospective cohort study 
BMC Cancer  2011;11:354.
We describe early dissemination patterns for first-line bevacizumab given for metastatic colorectal cancer treatment.
We analyzed patient surveys and medical records for a population-based cohort with metastatic colorectal cancer treated in multiple regions and health systems in the United States (US). Eligible patients were diagnosed with metastatic colorectal cancer and initiated first-line chemotherapy after US Food & Drug Administration (FDA) bevacizumab approval in February 2004. First-line bevacizumab therapy was defined as receiving bevacizumab within 8 weeks of starting chemotherapy for metastatic colorectal cancer. We evaluated factors associated with first-line bevacizumab treatment using logistic regression.
Among 355 patients, 31% received first-line bevacizumab in the two years after FDA approval, including 26% of men, 41% of women, and 16% of those ≥ 75 years. Use rose sharply within 6 months after FDA approval, then plateaued. 20% of patients received bevacizumab in combination with irinotecan; 53% received it with oxaliplatin. Men were less likely than women to receive bevacizumab (adjusted OR 0.55; 95% CI 0.32-0.93; p = 0.026). Patients ≥ 75 years were less likely to receive bevacizumab than patients < 55 years (adjusted OR 0.13; 95% CI 0.04-0.46; p = 0.001).
One-third of eligible metastatic colorectal cancer patients received first-line bevacizumab shortly after FDA approval. Most patients did not receive bevacizumab as part of the regimen used in the pivotal study leading to FDA approval.
PMCID: PMC3174931  PMID: 21846341
24.  Physician and Practice Characteristics Influencing Tumor Board Attendance: Results From the Provider Survey of the Los Angeles Women's Health Study 
Journal of Oncology Practice  2011;7(2):103-110.
Multidisciplinary approaches to cancer care have shown improvements in the quality of care. The tumor board treatment planning approach provides a structure for engaging providers in discussions of cancer cases that are designed to enhance the quality of care.
Coordination of care has grown in importance with the advent of new modalities of treatment that require specialized expertise. In cancer care, multidisciplinary approaches have shown improvements in quality of care. Tumor boards may provide a mechanism for improving coordination of care. We evaluated physician and practice characteristics that predict frequency of tumor board attendance.
Materials and Methods:
This cross-sectional study used data obtained by surveying physicians of a population-based sample of women with incident breast cancer. Physicians were queried regarding tumor board attendance, specialty [medical oncologist (MO), radiation oncologist (RO), surgeon at a hospital with American College of Surgeons accreditation (ACOSSg) and surgeon without such affiliation (non-ACOSSg)], physician characteristics (gender, race/ethnicity, teaching involvement, patient volume, ownership interest) and practice setting (type, size, reimbursement method). Univariate, bivariate, and multivariate analyses were performed for the dependent variable characterizing provider report of frequency of tumor board attendance.
Most surveyed physicians (83%) report attending tumor board weekly (58%) or monthly (25%). Specialty and higher patient volumes are significant predictors of more frequent attendance. Compared with the most prevalent specialty category (low-volume ACOSSgs), high-volume MOs attend more frequently (P = .01) and low volume non-ACOSSgs attend less frequently (P = .00).
Tumor board provides a structure for engaging providers in discussion of cancer cases that is designed to enhance quality of care. Tumor board agendas and formalized institution-wide policies could be designed to engage low-frequency attendees as a means to improve quality measures, promote multidisciplinary care, and potentially improve health outcomes.
PMCID: PMC3051855  PMID: 21731518
25.  Discussions with Physicians about Hospice among Patients with Metastatic Lung Cancer 
Archives of internal medicine  2009;169(10):954-962.
Many terminally-ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a provider could increase awareness of hospice and possibly result in earlier use.
We used data on 1517 patients diagnosed with stage IV lung cancer from a multi-regional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health-care provider before an interview 4−7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record.
Half (53%) of patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within two months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than two years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate (DNR) preferences with a doctor had also discussed hospice.
Many patients diagnosed with metastatic lung cancer had not discussed hospice with a provider within 4−7 months of diagnosis. Increased communication with physicians could address patients’ lack of awareness about hospice and misunderstandings about prognosis.
PMCID: PMC2689617  PMID: 19468089
hospice; end-of-life care; lung neoplasms; surveys

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