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1.  Expectations About the Effectiveness of Radiation Therapy Among Patients With Incurable Lung Cancer 
Journal of Clinical Oncology  2013;31(21):2730-2735.
Although radiation therapy (RT) can palliate symptoms and may prolong life, it is not curative for patients with metastatic lung cancer. We investigated patient expectations about the goals of RT for incurable lung cancers.
Patients and Methods
The Cancer Care Outcomes Research and Surveillance Consortium enrolled a population- and health system–based cohort of patients diagnosed with lung cancer from 2003 to 2005. We identified patients with stage wet IIIB or IV lung cancer who received RT and answered questions on their expectations about RT. We assessed patient expectations about the goals of RT and identified factors associated with inaccurate beliefs about cure.
In all, 384 patients completed surveys on their expectations about RT. Seventy-eight percent of patients believed that RT was very or somewhat likely to help them live longer, and 67% believed that RT was very or somewhat likely to help them with problems related to their cancer. However, 64% did not understand that RT was not at all likely to cure them. Older patients and nonwhites were more likely to have inaccurate beliefs, and patients whose surveys were completed by surrogates were less likely to have inaccurate beliefs. Ninety-two percent of patients with inaccurate beliefs about cure from RT also had inaccurate beliefs about chemotherapy.
Although patients receiving RT for incurable lung cancer believe it will help them, most do not understand that it is not at all likely to cure their disease. This indicates a need to improve communication regarding the goals and limitations of palliative RT.
PMCID: PMC3709058  PMID: 23775958
2.  Underuse of Hospice Care by Medicaid-Insured Patients With Stage IV Lung Cancer in New York and California 
Journal of Clinical Oncology  2013;31(20):2569-2579.
Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare.
Patients and Methods
Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results–Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use.
Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients.
Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.
PMCID: PMC3699723  PMID: 23733768
3.  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
4.  Palliative Radiation Therapy Practice in Patients With Metastatic Non–Small-Cell Lung Cancer: A Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study 
Journal of Clinical Oncology  2013;31(5):558-564.
Randomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non–small-cell lung cancer (NSCLC).
Patients and Methods
From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression.
Of 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associated with younger age at diagnosis and receipt of chemotherapy and surgery to metastatic sites. Among patients receiving palliative bone RT, only 6% received single-fraction treatment. Among patients receiving palliative chest RT, 42% received more than 20 fractions. Patients treated in integrated networks were more likely to receive lower doses and fewer fractions to the bone and chest.
When palliative RT is used in patients with metastatic NSCLC, a substantial proportion of patients receive a greater number of treatments and higher doses than supported by current evidence, suggesting an opportunity to improve care delivery.
PMCID: PMC3565181  PMID: 23295799
5.  Representativeness of Participants in the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium Relative to the Surveillance, Epidemiology and End Results (SEER) Program 
Medical care  2013;51(2):e9-15.
The research goals of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium are to determine how characteristics and beliefs of patients, providers, and health-care organizations influence the treatments and outcomes of individuals with newly diagnosed lung and colorectal cancers. Because CanCORS results will inform national policy, it is important to know how they generalize to the United States population with these cancers.
Research Design
This study assessed the representativeness of the CanCORS cohort of 10,547 patients with lung cancer (LC) or colorectal cancer (CRC) enrolled between 2003 and 2005. We compared characteristics (gender, race, age and disease stage) to the Surveillance, Epidemiology and End Results (SEER) population of 234,464 patients with new onset of these cancers during the CanCORS recruitment period.
The CanCORS sample is well matched to the SEER Program for both cancers. In CanCORS, 41% LC / 47% CRC were female versus 47% LC / 49% CRC in SEER. African American, Hispanic and Asian cases differed by no more than 5 percentage points between CanCORS and SEER. The SEER population is slightly older, with the percentage of patients over 75 years 33.1% LC / 37.3% CRC in SEER versus 26.9% LC / 29.4% in CanCORS, and also has a slightly higher proportion of early stage patients. We also found that the CanCORS cohort was representative within specific SEER regions that map closely to CanCORS sites.
This study demonstrates that the CanCORS Consortium was successful in enrolling a demographically representative sample within the CanCORS regions.
PMCID: PMC3654676  PMID: 22406968
Lung Cancer; Colorectal Cancer; Cancer Populations
6.  Continued Use of Trastuzumab Beyond Disease Progression in the National Comprehensive Cancer Network: Should We Practice Ahead of the Evidence? 
The Oncologist  2011;16(5):559-565.
Data from the National Comprehensive Cancer Network's Breast Cancer Outcomes Database were used to characterize the use of trastuzumab beyond disease progression in National Comprehensive Cancer Network centers prior to the 2009 publication supporting it use.
The role of continued trastuzumab after progression in women with human epidermal growth factor receptor (HER)-2+ metastatic breast cancer is controversial. Controlled clinical trials that establish a benefit from continued trastuzumab have been difficult to complete.
In the National Comprehensive Cancer Center Network (NCCN) Breast Cancer Outcomes Database, we identified women treated with trastuzumab for metastatic or relapsed HER-2+ breast cancer at eight NCCN centers who subsequently progressed. Patients were eligible for this analysis if they initiated treatment at an NCCN institution between July 1997 and December 2004, received trastuzumab-containing treatment, and progressed while on therapy. We calculated the proportion of patients who received trastuzumab after progression, and in a multivariate analysis assessed the association of patient and provider characteristics with continued trastuzumab therapy.
Our final cohort consisted of 218 women who experienced disease progression while on trastuzumab-containing therapy. Of these, 168 (77%) continued trastuzumab. Of these, 36 patients (17%) received therapy as part of a clinical trial. The only factors significantly associated with continuation of trastuzumab beyond progression were the presence of bone metastases and more recent year of development of progressive disease.
Prior to the availability of any high-quality evidence supporting this practice, over three quarters of patients treated with trastuzumab for HER-2+ metastatic breast cancer at eight NCCN centers continued therapy beyond progression. Further work is needed to understand how physicians adopt new treatments when there is ambiguity surrounding their benefit.
PMCID: PMC3228199  PMID: 21450786
7.  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
8.  Adoption of Gene Expression Profile Testing and Association With Use of Chemotherapy Among Women With Breast Cancer 
Journal of Clinical Oncology  2012;30(18):2218-2226.
Gene expression profile (GEP) testing is a relatively new technology that offers the potential of personalized medicine to patients, yet little is known about its adoption into routine practice. One of the first commercially available GEP tests, a 21-gene profile, was developed to estimate the benefit of adjuvant chemotherapy for hormone receptor–positive breast cancer (HR-positive BC).
Patients and Methods
By using a prospective registry data set outlining the routine care provided to women diagnosed from 2006 to 2008 with HR-positive BC at 17 comprehensive and community-based cancer centers, we assessed GEP test adoption and the association between testing and chemotherapy use.
Of 7,375 women, 20.4% had GEP testing and 50.2% received chemotherapy. Over time, testing increased (14.7% in 2006 to 27.5% in 2008; P < .01) and use of chemotherapy decreased (53.9% in 2006 to 47.0% in 2008; P < .01). Characteristics independently associated with lower odds of testing included African American versus white race (odds ratio [OR], 0.70; 95% CI, 0.54 to 0.92) and high school or less versus more than high school education (OR, 0.63; 95% CI, 0.52 to 0.76). Overall, testing was associated with lower odds of chemotherapy use (OR, 0.70; 95% CI, 0.62 to 0.80). Stratified analyses demonstrated that for small, node-negative cancers, testing was associated with higher odds of chemotherapy use (OR, 11.13; 95% CI, 5.39 to 22.99), whereas for node-positive and large node-negative cancers, testing was associated with lower odds of chemotherapy use (OR, 0.11; 95% CI, 0.07 to 0.17).
There has been a progressive increase in use of this GEP test and an associated shift in the characteristics of and overall reduction in the proportion of women with HR-positive BC receiving adjuvant chemotherapy.
PMCID: PMC3397718  PMID: 22585699
9.  Outpatient Use of Low Molecular Weight Heparin Monotherapy for First-Line Treatment of Venous Thromboembolism in Advanced Cancer 
The Oncologist  2012;17(3):419-427.
Evidence-based treatment guidelines recommend low molecular weight heparin monotherapy for cancer-associated venous thromboembolism (VTE). This analysis assessed the first-line treatment strategies for VTE in patients with advanced solid tumors and found that only 25% of patients received guideline-recommended low molecular weight heparin. Future studies should explore reasons underlying the underutilization of this preferred evidence-based treatment as well as the comparative effectiveness of low molecular weight heparin versus warfarin-based anticoagulation in real-world cancer patients with VTE.
Evidence-based treatment guidelines recommend low molecular weight heparin (LMWH) monotherapy for cancer-associated venous thromboembolism (VTE). This analysis assessed the first-line treatment strategies for VTE in patients with advanced solid tumors.
Using administrative data from advanced lung, prostate, colon, or breast cancer patients diagnosed between January 2000 and December 2007 at four HMOs with integrated delivery systems, patients with an inpatient or outpatient VTE diagnosed within 2 years after cancer diagnosis and an outpatient purchase of warfarin, LMWH, and/or fondaparinux anticoagulant within 7 days of the VTE diagnosis were identified. First-line outpatient VTE pharmacological treatment and factors independently associated with receipt/non-receipt of LMWH monotherapy were assessed.
Overall, 25% of the 1,089 eligible patients received LMWH monotherapy as primary VTE treatment. The percentage increased steadily over time from 18% among patients diagnosed in 2000 to 31% among those diagnosed in 2007. Factors associated with LMWH monotherapy included VTE diagnosis year, chemotherapy within 60 days prior to VTE diagnosis, history of VTE prior to cancer diagnosis, and invasive surgery in the 90 days following VTE diagnosis. Colorectal and prostate cancer patients versus lung cancer patients and stage III versus stage IV patients were less likely to be treated with LMWH monotherapy.
Adoption of LMWH monotherapy as initial treatment for cancer-associated VTE was low but increased steadily over the study period. Future studies should explore reasons underlying the underutilization of this preferred evidence-based treatment as well as the comparative effectiveness of LMWH versus warfarin-based anticoagulation in real-world cancer patients with VTE.
PMCID: PMC3316928  PMID: 22334451
Venous thromboembolism; Anticoagulants; Neoplasms; Ambulatory care
10.  Disparities in Oncologic Surgery 
World journal of surgery  2008;32(4):522-528.
Surgical oncology is one of the most frequently studied surgical specialties with regard to disparities in quality of care. There is variation in the care received according to nonclinical factors such as age, race and ethnicity, education, income, and even geographic region. Differences exist with regard to who gets treatment, what treatment is received, and the outcomes of those treatments. Although the existence of such disparities is no longer in doubt, the etiology is still being investigated. Ongoing research and quality improvement initiatives move beyond the mere description of existing disparities in one of three ways: (1) identifying and understanding the factors that lead to disparities; (2) advancing available methods to measure and track disparities; and (3) developing an approach to improvement. In this article, we start out by offering a framework to describe potential factors that lead to disparities, using examples from surgical oncology. We then describe the approaches to measuring and tracking disparities that are being used in research and quality improvement. Finally, we attempt to illustrate how all of these factors interact and offer some potential strategies to close the gap and alleviate disparities within the discipline.
PMCID: PMC4195237  PMID: 18197450
11.  Measuring Disease-Free Survival and Cancer Relapse Using Medicare Claims From CALGB Breast Cancer Trial Participants (Companion to 9344) 
To determine the accuracy with which Medicare claims data measure disease-free survival in elderly Medicare beneficiaries with cancer, we performed a criterion validation study. We merged gold-standard clinical trial data of 45 elderly patients with node-positive breast cancer who were treated on the Cancer and Leukemia Group B (CAL-GB) adjuvant breast trial 9344 with Centers for Medicare and Medicaid Services (CMS) data files and compared the results of a CMS-based algorithm with the CALGB disease-free survival information to determine sensitivity and specificity. For 5-year disease-free survival, the sensitivity of the CMS-based algorithm was 100% (95% confidence interval [CI] = 81% to 100%), the specificity was 97% (95% CI = 83% to 100%), and the area under the receiver operator curve was 97% (95% CI = 90% to 100%). For 2-year disease-free survival, the test characteristics were less favorable: sensitivity was 83% (95% CI = 36% to 100%), specificity was 95% (95% CI = 83% to 100%), and area under the receiver operator curve was 84% (95% CI = 66% to 100%).
PMCID: PMC4158031  PMID: 16985253
12.  Measuring Clinically Significant Chemotherapy-Related Toxicities Using Medicare Claims From Cancer and Leukemia Group B (CALGB) Trial Participants 
Medical care  2008;46(3):303-308.
Because the elderly are underrepresented on clinical trials, physicians have few sources of information to estimate the risks (ie, toxicities) and benefits of chemotherapy administration to the elderly.
Our goal was to determine whether the standard measures of toxicity used in clinical trials could be captured from observational Medicare claims data.
We identified 175 elderly clinical trial patients treated on 2 Cancer and Leukemia Group B (CALGB) trials (9344, adjuvant breast study and 9730, advanced lung cancer study) and merged participants’ CALGB data with their Medicare data. From CALGB data, we identified the most frequent Extended Clinical Toxicity Critieria grade III/IV toxicities. We reviewed diagnostic and procedure codes from Medicare manuals, developed algorithms to measure the toxicities, and then finalized the algorithms after empiric review of patients’ codes. We compared results of Medicare algorithms to gold standard CALGB toxicity information to calculate test characteristics.
CALGB data documented that 15 grade III/IV chemotherapy-related toxicities occurred in ≥3% of the 175 patients: white blood cell, hemoglobin, platelets, anorexia, nausea, vomiting, diarrhea, stomatitis, sensory neuropathy, motor neuropathy, motor or sensory neuropathy, dyspnea, hyperglycemia, infection, and malaise. Vomiting was the only toxicity identified by the Medicare-based algorithm with a sensitivity, specificity, and area under the receiver operator curve of ≥80%.
The results of this preliminary study suggest that Medicare diagnostic and procedure codes may be of only limited value in measuring clinically significant chemotherapy-related toxicities in elderly Medicare beneficiaries. Future research includes confirming these findings in a larger and more diverse sample.
PMCID: PMC4158032  PMID: 18388845
elderly; chemotherapy; Medicare; validation; toxicity; cancer
13.  Variation in the Utilization of Reconstruction Following Mastectomy in Elderly Women 
Annals of surgical oncology  2012;20(6):1872-1879.
Regardless of their age, women who choose to undergo postmastectomy reconstruction report improved quality of life as a result. However, actual use of reconstruction decreases with increasing age. Whereas this may reflect patient preference and clinical factors, it may also represent age-based disparity.
Women aged 65 years or older who underwent mastectomy for DCIS/stage I/II breast cancer (2000–2005) were identified in the SEER-Medicare database. Overall and institutional rates of reconstruction were calculated. Characteristics of hospitals with higher and lower rates of reconstruction were compared. Pseudo-R2 statistics utilizing a patient-level logistic regression model estimated the relative contribution of institution and patient characteristics.
A total of 19,234 patients at 716 institutions were examined. Overall, 6 % of elderly patients received reconstruction after mastectomy. Institutional rates ranged from zero to >40 %. Whereas 53 % of institutions performed no reconstruction on elderly patients, 5.6 % performed reconstructions on more than 20 %. Although patient characteristics (%ΔR2 = 70 %), and especially age (%ΔR2 = 34 %), were the primary determinants of reconstruction, institutional characteristics also explained some of the variation (%ΔR2 = 16 %). This suggests that in addition to appropriate factors, including clinical characteristics and patient preferences, the use of reconstruction among older women also is influenced by the institution at which they receive care.
Variation in the likelihood of reconstruction by institution and the association with structural characteristics suggests unequal access to this critical component of breast cancer care. Increased awareness of a potential age disparity is an important first step to improve access for elderly women who are candidates and desire reconstruction.
PMCID: PMC4066451  PMID: 23263733
14.  Validating Billing/Encounter Codes as Indicators of Lung, Colorectal, Breast, and Prostate Cancer Recurrence using Two Large Contemporary Cohorts 
Medical care  2012;10.1097/MLR.0b013e318277eb6f.
A substantial proportion of cancer-related mortality is attributable to recurrent, not de novo metastatic disease, yet we know relatively little about these patients. To fill this gap, investigators often use administrative codes for secondary malignant neoplasm or chemotherapy to identify recurrent cases in population-based datasets. However, these algorithms have not been validated in large, contemporary, routine care cohorts.
To evaluate the validity of secondary malignant neoplasm and chemotherapy codes as indicators of recurrence after definitive local therapy for stage I-III lung, colorectal, breast, and prostate cancer.
Research Design, Subjects & Measures
We assessed the sensitivity, specificity, and positive predictive value (PPV) of these codes 14- and 60-months after diagnosis using two administrative datasets linked with gold-standard recurrence status information: CanCORS/Medicare (diagnoses 2003-2005) and HMO/Cancer Research Network (diagnoses 2000-2005).
We identified 929 CanCORS/Medicare patients and 5298 HMO/CRN patients. Sensitivity, specificity, and PPV ranged widely depending on which codes were included and the type of cancer. For patients with lung, colorectal, and breast cancer, the combination of secondary malignant neoplasm and chemotherapy codes was the most sensitive (75%-85%); no code-set was highly sensitive and highly specific. For prostate cancer, no code-set offered even moderate sensitivity (≤19%).
Secondary malignant neoplasm and chemotherapy codes could not identify recurrent cancer without some risk of misclassification. Findings based on existing algorithms should be interpreted with caution. More work is needed to develop a valid algorithm that can be used to characterize outcomes and define patient cohorts for comparative effectiveness research studies.
PMCID: PMC3600389  PMID: 23222531
15.  Regional Variation in Spending and Survival for Older Adults With Advanced Cancer 
Medicare spending varies substantially across the United States. We evaluated the association between mean regional spending and survival in advanced cancer.
We identified 116 523 subjects with advanced cancer from 2002 to 2007, using Surveillance, Epidemiology and End Results (SEER)–Medicare linked data. Subjects were aged 65 years and older with non–small cell lung, colon, breast, prostate, or pancreas cancer. Of these subjects, 61 083 had incident advanced-stage cancer (incident cohort) and 98 935 had death from cancer (decedent cohort); 37% of subjects were included in both cohorts. Subjects were linked to one of 80 hospital referral regions within SEER areas. We estimated mean regional spending in both cohorts. We assessed the primary outcome, survival, in the incident cohort; the exposure measure was the quintile of regional spending in the decedent cohort. Survival in quintiles 2 through 5 was compared with that in quintile 1 (lowest spending quintile) using Cox regression models.
From quintile 1 to 5, mean regional spending increased by 32% and 41% in the incident and decedent cohorts (incident cohort: $28 854 to $37 971; decedent cohort: $27 446 to $38 630). The association between spending and survival varied by cancer site and quintile; hazard ratios ranged from 0.92 (95% confidence interval [CI] = 0.82 to 1.04, pancreas cancer quintile 5) to 1.24 (95% CI = 1.11 to 1.39, breast cancer quintile 3). In most cases, differences in survival between quintile 1 and quintiles 2 through 5 were not statistically significant.
There is substantial regional variation in Medicare spending for advanced cancer, yet no consistent association between mean regional spending and survival.
PMCID: PMC3691948  PMID: 23482657
16.  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
17.  Long-Term Risk Perceptions of Women With Ductal Carcinoma In Situ 
The Oncologist  2013;18(4):362-368.
Recurrence risk perceptions after 5 years were evaluated in women with a history of ductal carcinoma in situ. Many women were found to harbor inaccurate perceptions of their risk for future breast cancer events even 5 years after diagnosis.
Learning Objectives
Identify predictors of excessive risk perception in women with a distant history of DCIS.Explain the importance of educating women with a history of DCIS about reasonable assessments of their risk for future breast cancer.
Previous research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk for future breast cancer at the time of diagnosis and soon thereafter. This study aims to evaluate risk perceptions after 5 years.
Patients and Methods.
In a longitudinal cohort study, we mailed long-term follow-up surveys to 315 women who had previously responded to a survey 18 months after they were diagnosed with DCIS, excluding those who had experienced recurrence and those not treated at our institution. We evaluated risk perceptions with items used previously in the cohort.
One hundred ninety-three women (61%) responded. The median time since diagnosis was 5.9 years. We excluded 12 because of recurrence. Of the 181 remaining, 32% perceived at least a moderate 5-year risk for developing DCIS again, 43% perceived at least a moderate lifetime risk for developing DCIS again, 27% perceived at least a moderate 5-year risk for invasive breast cancer, 38% perceived at least a moderate lifetime risk for invasive breast cancer, and 24% perceived at least a moderate risk for DCIS spreading to other body parts. In a multivariate model, worse financial status and higher perceived risk in the previous survey were the only predictors of at least a moderate perception of risk for DCIS spreading.
Women with a history of DCIS continue to harbor inaccurate perceptions of their risk for future breast cancer events even 5 years after diagnosis.
PMCID: PMC3639521  PMID: 23568001
Carcinoma; Intraductal; Noninfiltrating; Survivors; Anticipation; Psychological; Anxiety
18.  Medicare Breast Surgery Fees and Treatment Received by Older Women with Localized Breast Cancer 
Health Services Research  2003;38(2):553-573.
To determine whether area-level Medicare physician fees for mastectomy and breast conserving surgery were associated with treatment received by Medicare beneficiaries with localized breast cancer and to compare these results with an earlier analysis conducted using small areas (three-digit zip codes) as the unit of observation.
Data Source
Medicare claims and physician survey data for a national sample of elderly (aged 67 or older) Medicare beneficiaries with localized breast cancer treated in 1994 (unweighted n=1,787).
Study Design
Multinomial logistic regression analysis was used to estimate a model of treatment received as a function of Medicare fees, controlling for other area economic factors, patient demographic and clinical characteristics, physician experience, and region.
Principal Findings
In 1994, average Medicare fees (adjusted for the effects of modifiers and procedure mix) for mastectomy (MST) and breast conserving surgery (BCS) were $904 and $305, respectively. Holding other fees and factors fixed, a 10 percent increase in the BCS fee increased the odds of breast conserving surgery with radiation therapy relative to mastectomy to 1.34 (p=0.02), while a 10 percent decrease in the MST fee increased the odds of breast conserving surgery with radiation therapy to 1.86 (p<0.01).
Among older women with localized breast cancer, financial incentives appear to influence the use of mastectomy and breast conserving surgery with radiation therapy. This finding is consistent with the hypothesis that physicians are responsive to financial incentives when the alternative procedures have clinically equivalent outcomes and the patient's clinical condition does not dominate the treatment choice. We also find that the fee effects derived from this analysis of individual data with more precise measurement of both diagnosis and treatment are qualitatively similar to the results of the small-area analysis. This suggests that the earlier study was not severely affected by ecological bias or other data limitations inherent in Medicare claims data.
PMCID: PMC1360902  PMID: 12785561
Breast cancer; breast surgery fees; older women; economics; Medicare
19.  Relationship Between Reproductive History, Anthropometrics, Lifestyle Factors, and the Likelihood of Persistent Chemotherapy-Related Amenorrhea in Women with Premenopausal Breast Cancer 
Fertility and sterility  2012;97(1):154-159.
To determine the association between patient characteristics at diagnosis of premenopausal breast cancer including gravidity, parity, age at menarche, age at first birth, alcohol use, smoking history, weight, height, and body mass index (BMI) with the development of persistent chemotherapy-related amenorrhea (CRA) in follow-up.
Retrospective Cohort
Dana Farber Cancer Institute (DFCI) and Brigham and Women’s Hospital (BWH)
Premenopausal women with breast cancer
We identified all premenopausal women who received standard adjuvant chemotherapy from 1997-2005 for whom menstrual data were available. Multivariable logistic regression models evaluating persistent amenorrhea at ≥ 6 month after completing chemotherapy were conducted.
431 women met eligibility criteria and had ≥ 6 month follow-up. Women with older (age >13 years) versus younger (12-13 years) age at menarche were more than twice as likely to remain amenorreheic (p-value, test for linear trend = 0.03). Current smokers had 2.4 greater odds of CRA versus never smokers, although this association was not statistically significant (95% CI=0.86-6.75).
Few identifiable factors contribute to the variability in CRA among premenopausal women following adjuvant chemotherapy for breast cancer. Further research to improve the prediction of CRA, premature menopause and infertility in young breast cancer survivors is warranted.
PMCID: PMC3963606  PMID: 22192139
Chemotherapy-related amenorrhea; breast cancer; gravidity; parity; lifestyle factors; premature menopause
20.  Long-Term Follow-Up and Individual Item Analysis of Quality of Life Assessments Related to Laparoscopic-Assisted Colectomy in the COST Trial 93-46-53 (INT 0146) 
Annals of surgical oncology  2011;18(9):2422-2431.
Postoperative outcomes of patients undergoing laparoscopic-assisted colectomy (LAC) have shown modest improvements in recovery but only minimal differences in quality of life (QOL) compared with open colectomy. We therefore sought to assess the effect of LAC on QOL in the short and long term, using individual item analysis of multi-item QOL assessments.
QOL variables were analyzed in 449 randomized patients from the COST trial 93-46-53 (INT 0146). Both cross-sectional single-time and change from baseline assessments were run at day 2, week 2, month 2, and month 18 postoperatively in an intention-to-treat analysis using Wilcoxon rank-sum tests. Stepwise regression models were used to determine predictors of QOL.
Of 449 colon cancer patients, 230 underwent LAC and 219 underwent open colectomy. Subdomain analysis revealed a clinically moderate improvement from baseline for LAC in total QOL index at 18 months (P = 0.02) as well as other small symptomatic improvements. Poor preoperative QOL as indicated by a rating scale of ≤ 50 was an independent predictor of poor QOL at 2 months postoperatively. QOL variables related to survival were baseline support (P = 0.001) and baseline outlook (P = 0.01).
Eighteen months after surgery, any differences in quality of life between patients randomized to LAC or open colectomy favored LAC. However, the magnitude of the benefits was small. Patients with poor preoperative QOL appear to be at higher risk for difficult postoperative courses, and may be candidates for enhanced ancillary services to address their particular needs.
PMCID: PMC3947623  PMID: 21452066
21.  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
22.  Use of Adjuvant Trastuzumab in Women with Human Epidermal Growth Factor Receptor 2 (HER2)-Positive Breast Cancer by Race/Ethnicity and Education within the National Comprehensive Cancer Network 
Cancer  2012;119(4):839-846.
Trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive breast cancer is highly efficacious yet costly and time-intensive, and few data are available about its utilization. We examined receipt and completion of adjuvant trastuzumab by race/ethnicity and education for women with HER2-positive disease.
Using the National Comprehensive Cancer Network (NCCN) Breast Cancer Outcomes Database, we identified 1,109 women diagnosed with stage I–III, HER2-positive breast cancer during September 2005 through December 2008 who were followed for ≥1 year. We assessed the association of race/ethnicity and education with receipt of trastuzumab, and among women who initiated trastuzumab, with completion of >270 days of therapy, using multivariable logistic regression.
The cohort was 75% white, 8% black, and 9% Hispanic; 20% attained a high school degree or less. Most women (83%) received trastuzumab, with no significant differences by race/ethnicity or SES. Among women initiating trastuzumab, 73% of black women vs. 87% of white women (p=.007) and 70% of women with less than high school education vs. 90% of women with a college degree completed >270 days of therapy (p=.006). In adjusted analyses, black (vs. white) women and those without a high school degree (vs. college degree) had lower odds of completing therapy (odds ratio [OR]=.45, 95% confidence interval [CI]=.27–.74 and OR=0.27, 95% CI=.14–.51, respectively).
We observed differences in trastuzumab completion by race and educational attainment for women treated at NCCN centers. Efforts to assure appropriate utilization of trastuzumab and understand treatment barriers are needed and could lead to improved outcomes.
PMCID: PMC3565006  PMID: 23011924
breast cancer; disparities; trastuzumab; race; socioeconomic status
23.  Use of stereotactic radiosurgery for brain metastases from non-small cell lung cancer in the United States 
The indications for treatment of brain metastases from non-small cell lung cancer (NSCLC) with stereotactic radiosurgery (SRS) remain controversial. Here, we studied patterns, predictors, and cost of SRS utilization in elderly patients with NSCLC.
Methods and Materials
Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we identified patients with NSCLC, who were diagnosed with brain metastases between 2000 and 2007. Our analytic cohort included patients treated with radiation therapy, and not surgical resection, as initial treatment for brain metastases.
We identified 7684 patients treated with radiation therapy within 2 months after brain metastases diagnosis, of whom 469 (6.1%) had billing codes for SRS. Annual SRS use increased from 3.0% in 2000 to 8.2% in 2005 and varied from 3.4% to 12.5% by specific registry site. After controlling for clinical and sociodemographic characteristics, SRS use was significantly associated with increasing year of diagnosis, specific SEER registry, higher socioeconomic status, admission at a teaching hospital, no history of participation in low-income state buy-in programs, no extracranial metastases, and longer interval from NSCLC diagnosis. The average cost per patient associated with radiation therapy was 2.19 times greater for those who received SRS compared to those who did not.
The use of SRS in patients with metastatic NSCLC increased almost 3- fold from 2000 to 2005. In addition, we found significant variation of SRS utilization across SEER registries and socioeconomic quartiles. National practice patterns suggest both a lack of consensus and overall limited use of the approach among elderly patients before 2008.
PMCID: PMC3728282  PMID: 23058058
Stereotactic Radiosurgery; Health Services Research; Cost Analysis; Brain Metastases; Non-Small Cell Lung Cancer
24.  Time to Adjuvant Chemotherapy for Breast Cancer in National Comprehensive Cancer Network Institutions 
High-quality care must be not only appropriate but also timely. We assessed time to initiation of adjuvant chemotherapy for breast cancer as well as factors associated with delay to help identify targets for future efforts to reduce unnecessary delays.
Using data from the National Comprehensive Cancer Network (NCCN) Outcomes Database, we assessed the time from pathological diagnosis to initiation of chemotherapy (TTC) among 6622 women with stage I to stage III breast cancer diagnosed from 2003 through 2009 and treated with adjuvant chemotherapy in nine NCCN centers. Multivariable models were constructed to examine factors associated with TTC. All statistical tests were two-sided.
Mean TTC was 12.0 weeks overall and increased over the study period. A number of factors were associated with a longer TTC. The largest effects were associated with therapeutic factors, including immediate postmastectomy reconstruction (2.7 weeks; P < .001), re-excision (2.1 weeks; P < .001), and use of the 21-gene reverse-transcription polymerase chain reaction assay (2.2 weeks; P < .001). In comparison with white women, a longer TTC was observed among black (1.5 weeks; P < .001) and Hispanic (0.8 weeks; P < .001) women. For black women, the observed disparity was greater among women who transferred their care to the NCCN center after diagnosis (P interaction = .008) and among women with Medicare vs commercial insurance (P interaction < .001).
Most observed variation in TTC was related to use of appropriate therapeutic interventions. This suggests the importance of targeted efforts to minimize potentially preventable causes of delay, including inefficient transfers in care or prolonged appointment wait times.
PMCID: PMC3611850  PMID: 23264681
25.  Pathologic Characteristics of Second Breast Cancers After Breast Conservation for Ductal Carcinoma in Situ 
Cancer  2012;118(24):6022-6030.
The number of women diagnosed with ductal carcinoma in situ (DCIS) is increasing. While many eventually develop second breast cancers (SBC), little is known about the characteristics of SBC. We describe the characteristics of SBC and examine associations between the pathologic features of SBC and index DCIS cases.
We identified women in the National Comprehensive Cancer Network Outcomes Database diagnosed with DCIS from 1997–2008 and treated with lumpectomy who subsequently developed SBC (including DCIS or invasive disease occurring in the ipsilateral or contralateral breast). Fisher exact and Spearman tests were used to examine associations between the pathologic characteristics of SBC and index DCIS cases.
Among 2,636 women who received lumpectomy for DCIS, 150 (5.7%) experienced an SBC after a median of 55.5 months of follow-up. Of these 150 women, 105 (70.0%) received adjuvant radiotherapy and 50 (33.3%) received tamoxifen for their index DCIS. SBCs were ipsilateral in 54.7% of cases and invasive in 50.7% of cases. Among index DCIS cases, 60.6% were estrogen receptor (ER) positive and 54.0% were high grade, while 77.5% of SBCs were ER-positive and 48.2% were high grade. Grade (P = .003) and ER status (P = .02) were significantly associated between index DCIS and SBC; tumor size was not (P = .87).
After breast conservation for DCIS, SBC in either breast exhibits pathologic characteristics similar to the index DCIS, suggesting that women with DCIS may be at risk for developing subsequent breast cancers of a similar phenotype.
PMCID: PMC3496800  PMID: 22674478
DCIS; Breast conserving therapy; Lumpectomy; Radiation; Tamoxifen; Second breast cancer; Contralateral breast cancer; Grade; Estrogen receptor

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