Efficacy of a Smoking Cessation Intervention for Survivors of Cervical Intraepithelial Neoplasia or Cervical Cancer: A Randomized Controlled Trial.

PURPOSE: Women who smoke and have a history of cervical intraepithelial neoplasia (CIN) or cervical cancer represent a vulnerable subgroup at elevated risk for recurrence, poorer cancer treatment outcomes, and decreased quality of life. The purpose of this study was to evaluate the long-term efficacy of Motivation And Problem Solving (MAPS), a novel treatment well-suited to meeting the smoking cessation needs of this population. METHODS: Women who were with a history of CIN or cervical cancer, age 18 years and older, spoke English or Spanish, and reported current smoking (≥100 lifetime cigarettes plus any smoking in the past 30 days) were eligible. Participants (N = 202) were recruited in clinic in Oklahoma City and online nationally and randomly assigned to (1) standard treatment (ST) or (2) MAPS. ST consisted of repeated referrals to a tobacco cessation quitline, self-help materials, and combination nicotine replacement therapy (patch plus lozenge). MAPS comprised all ST components plus up to six proactive telephone counseling sessions over 12 months. Logistic regression and generalized estimating equations evaluated the intervention. The primary outcome was self-reported 7-day point prevalence abstinence from tobacco at 18 months, with abstinence at 3, 6, and 12 months and biochemically confirmed abstinence as secondary outcomes. RESULTS: There was no significant effect for MAPS over ST at 18 months (14.2% v 12.9%, P = .79). However, there was a significant condition × assessment interaction (P = .015). Follow-up analyses found that MAPS (v ST) abstinence rates were significantly greater at 12 months (26.4% v 11.9%, P = .017; estimated OR, 2.60; 95% CI, 1.19 to 5.89). CONCLUSION: MAPS led to a greater than two-fold increase in smoking abstinence among survivors of CIN and cervical cancer at 12 months. At 18 months, abstinence in MAPS declined to match the control condition and the treatment effect was no longer significant.

Association of Bone Mineral Density Testing With Risk of Major Osteoporotic Fractures Among Older Men Receiving Androgen Deprivation Therapy to Treat Localized or Regional Prostate Cancer.

Importance: Bone health screening is recommended for patients with prostate cancer who are initiating treatment with androgen deprivation therapy (ADT); however, bone mineral density screening rates in the US and their association with fracture prevention are unknown. Objective: To assess dual-energy x-ray absorptiometry (DXA) screening rates and their association with fracture rates among older men with prostate cancer initiating treatment with androgen deprivation therapy. Design, Setting, and Participants: This retrospective nationwide population-based cohort study used data from the Surveillance, Epidemiology, and End Results database and the Texas Cancer Registry linked with Medicare claims. Participants comprised 54 953 men 66 years or older with prostate cancer diagnosed between January 2005 and December 2015 who initiated treatment with ADT. Data were censored at last enrollment in Medicare and analyzed from January 1 to September 30, 2021. Exposures: Dual-energy x-ray absorptiometry screening within 12 months before and 6 months after the first ADT claim. Main Outcomes and Measures: Frequencies of DXA screening and fracture (any fracture and major osteoporotic fracture) and overall survival were calculated. The association between DXA screening and fracture was evaluated using a multivariable Cox proportional hazards model with propensity score adjustment. Results: Among 54 953 men (median age, 74 years; range, 66-99 years) with prostate cancer, 4689 (8.5%) were Hispanic, 6075 (11.1%) were non-Hispanic Black, 41 453 (75.4%) were non-Hispanic White, and 2736 (5.0%) were of other races and/or ethnicities (including 121 [0.2%] who were American Indian or Alaska Native; 1347 [2.5%] who were Asian, Hawaiian, or Pacific Islander; and 1268 [2.3%] who were of unknown race/ethnicity). Only 4362 men (7.9%) received DXA screening. The DXA screening rate increased from 6.8% in 2005 to 8.4% in 2015. Lower screening rates were associated with being single (odds ratio [OR], 0.89; 95% CI, 0.81-0.97; P = .01) and non-Hispanic Black (OR, 0.80; 95% CI, 0.70-0.91; P < .001), living in small urban areas (OR, 0.77; 95% CI, 0.66-0.90; P = .001) and areas with lower educational levels (OR, 0.75; 95% CI, 0.67-0.83; P < .001), and receiving nonsteroidal androgens (OR, 0.57; 95% CI, 0.39-0.84; P = .004). Overall, 9365 patients (17.5%) developed fractures after initial receipt of ADT. The median time to first fracture was 31 months (IQR, 15-56 months). In the multivariable model with propensity score adjustment, DXA screening was not associated with fracture risk at any site (hazard ratio [HR], 0.96; 95% CI, 0.89-1.04; P = .32) among men without previous fractures before receipt of ADT. However, previous DXA screening was associated with a decreased risk of major fractures (HR, 0.91; 95% CI, 0.83-1.00; P = .05) after propensity score adjustment. Conclusions and Relevance: In this study, low DXA screening rates were observed among older men with localized or regional prostate cancer after initiation of treatment with ADT. Despite low rates of screening, evaluation of bone mineral density with a DXA scan was associated with lower risk of major fractures. These findings suggest that DXA screening is important for the prevention of major fractures among older men with prostate cancer and that implementation strategies are needed to adopt bone health screening guidelines in clinical practice.

The impact of head and neck radiotherapy on salivary flow and quality of life: Results of the ORARAD study.

OBJECTIVES: Salivary hypofunction and xerostomia, are common side effects of radiotherapy, negatively impacting quality of life. The OraRad study presents results on the longitudinal impact of radiotherapy on salivary flow and patient-reported outcomes. PATIENTS AND METHODS: Prospective, multicenter cohort study of 572 patients receiving curative-intent head and neck radiotherapy (RT). Stimulated salivary flow (SSF) rate and patient-reported outcomes were measured prior to RT and at 6- and 18-months post-RT. Linear mixed effects models examined the relationship between RT dose and change in salivary flow, and change in patient-reported outcomes. RESULTS: 544 patients had baseline salivary flow measurement, with median (IQR) stimulated flow rate of 0.975 (0.648, 1.417) g/min. Average RT dose to parotid glands was associated with change in salivary flow post-RT (p < 0.001). Diminished flow to 37% of pre-RT level was observed at 6 months (median: 0.358, IQR: 0.188 to 0.640 g/min, n = 481) with partial recovery to 59% of pre-RT at 18 months (median: 0.575, IQR: 0.338 to 0.884 g/min, n = 422). Significant improvement in patient-reported swallowing, senses (taste and smell), mouth opening, dry mouth, and sticky saliva (p-values < 0.03) were observed between 6 and 18 months post-RT. Changes in swallowing, mouth opening, dry mouth, and sticky saliva were significantly associated with changes in salivary flow from baseline (p-values < 0.04). CONCLUSION: Salivary flow and patient-reported outcomes decreased as a result of RT, but demonstrated partial recovery during follow-up. Continued efforts are needed to improve post-RT salivary function to support quality of life.

Tooth Failure Post-Radiotherapy in Head and Neck Cancer: Primary Report of the Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (OraRad) Study.

PURPOSE: To elucidate long-term sequelae of radiation therapy (RT) in head and neck cancer (HNC) patients, a multicenter, prospective study, Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (OraRad), was established with tooth failure as its primary outcome. We report tooth failure and associated risk factors. METHODS AND MATERIALS: Demographics and cancer and dental disease characteristics were documented in 572 HNC patients at baseline and 6, 12, 18, and 24 months after RT. Eligible patients were aged 18 or older, diagnosed with HNC, and receiving RT to treat HNC. Tooth failure during follow-up was defined as losing a tooth or having a tooth deemed hopeless. Analyses of time to first tooth-failure event and number of teeth that failed used Kaplan-Meier estimators, Cox regression, and generalized linear models. RESULTS: At 2 years, the estimated fraction of tooth failure was 17.8% (95% confidence interval, 14.3%-21.3%). The number of teeth that failed was higher for those with fewer teeth at baseline (P < .0001), greater reduction in salivary flow rate (P = .013), and noncompliance with daily oral hygiene (P = .03). Patients with dental caries at baseline had a higher risk of tooth failure with decreased salivary flow. Patients who were oral-hygiene noncompliant at baseline but compliant at all follow-up visits had the fewest teeth that failed; greatest tooth failure occurred in participants who were noncompliant at baseline and follow-up. CONCLUSIONS: Despite pre-RT dental management, substantial tooth failure occurs within 2 years after RT for HNC. Identified factors may help to predict or reduce risk of post-RT tooth failure.

Evaluation of the Efficacy of a Smoking Cessation Intervention for Cervical Cancer Survivors and Women With High-Grade Cervical Dysplasia: Protocol for a Randomized Controlled Trial.

BACKGROUND: The prevalence of smoking among cervical cancer survivors is strikingly high, yet no smoking cessation interventions to date have specifically targeted this population. This paper describes the study design, methods, and data analysis plans for a randomized clinical trial designed to evaluate the efficacy of a theoretically and empirically based Motivation And Problem Solving (MAPS) approach for promoting and facilitating smoking cessation among cervical cancer survivors. MAPS is a comprehensive, dynamic, and holistic intervention that incorporates empirically supported cognitive behavioral and social cognitive theory-based treatment strategies within an overarching motivational framework. MAPS is designed to be appropriate for all smokers regardless of their motivation to change and views motivation as dynamically fluctuating from moment to moment throughout the behavior change process. OBJECTIVE: This 2-group randomized controlled trial compares the efficacy of standard treatment to MAPS in facilitating smoking cessation among women with a history of high-grade cervical dysplasia or cervical cancer. METHODS: Participants (N=202) are current smokers with a history of high-grade cervical dysplasia or cervical cancer recruited nationally and randomly assigned to one of two treatment conditions: (1) standard treatment (ST) or (2) MAPS. ST consists of repeated letters referring participants to their state's tobacco cessation quitline, standard self-help materials, and free nicotine replacement therapy when ready to quit. MAPS has all ST components along with 6 proactive telephone counseling sessions delivered over 12 months. The primary outcome is abstinence from tobacco at 18 months. Secondary outcomes include abstinence over time across all assessment points, abstinence at other individual assessment time points, quit attempts, cigarettes per day, and use of state quitlines. Hypothesized treatment mechanisms and cost-effectiveness will also be evaluated. RESULTS: This study was approved by the institutional review boards at the University of Texas MD Anderson Cancer Center, the University of Oklahoma Health Sciences Center, and Moffitt Cancer Center. Participant enrollment concluded at Moffitt Cancer Center in January 2020, and follow-up data collection was completed in July 2021. Data analysis is ongoing. CONCLUSIONS: This study will yield crucial information regarding the efficacy and cost-effectiveness of a MAPS approach for smoking cessation tailored to the specific needs of women with a history of high-grade cervical dysplasia or cervical cancer. Findings indicating that MAPS has substantially greater efficacy than existing evidence-based tobacco cessation treatments would have tremendous public health significance. TRIAL REGISTRATION: ClinicalTrials.gov NCT02157610; https://clinicaltrials.gov/ct2/show/NCT02157610. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34502.

Greater preferences for death in hospital and mechanical ventilation at the end of life among non-whites recently diagnosed with cancer.

PURPOSE: Non-white cancer patients receive more aggressive care at the end-of-life (EOL). This may indicate low quality EOL care if discordant with patient preferences. We investigated preferred potential place of death and preferences regarding use of mechanical ventilation in a cohort of Texas cancer patients. METHODS: A population-based convenience sample of recently diagnosed cancer patients from the Texas Cancer Registry was surveyed using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about preferences regarding location of death and mechanical ventilation were the outcome measures of this investigation. Inverse probability weighting analysis was used to construct multivariable logistic regression examining the associations of covariates. RESULTS: Of the 1460 respondents, a majority (82%) preferred to die at home compared to 8% who preferred dying at the hospital. In total, 25% of respondents expressed a preference for undergoing mechanical ventilation at the EOL. Adjusted analysis showed increased preference among Black (OR = 1.81; 95% CI: 1.19-2.73) and other non-white, non-Hispanic race individuals (OR = 3.53; 95% CI: 1.99-6.27) for dying at a hospital. Males, married individuals, those of higher education and poor self-reported health showed significantly higher preference for dying at home. Non-white respondents of all races were more likely to prefer mechanical ventilation at the EOL as were individuals who lived with another person at home. CONCLUSION: Non-white cancer patients were more likely to express preferences coinciding with aggressive EOL care including dying at the hospital and utilizing mechanical ventilation. These findings were independent of other sociodemographic characteristics, including decisional self-efficacy.

Lower Levels of Trust in the Medical Profession Among White, Younger, and More-educated Individuals With Cancer.

INTRODUCTION: Levels of medical mistrust have historically been higher among racial/ethnic minority patients compared with whites, largely owing to societal and health system inequities and history of discrimination or experimentation. However, recently trust in physicians has declined in the United States in general. We investigated trust in physicians among a large cohort of cancer patients residing in Texas. METHODS: A sample of recently diagnosed cancer patients in Texas were identified from the Texas Cancer Registry with 1344 patients returning surveys between March 2017 and March 2020. The multiscale inventory was mailed to each individual and included the Trust in the Medical Profession Scale which assesses levels of agreement with 11 trust-related statements. Multivariable linear regression models were constructed to assess the adjusted relationship between trust in the medical profession aggregate score and sociodemographic and clinical factors. RESULTS: A total of 1250 surveys were evaluable for trust in the medical profession. The mean aggregate trust score for all patients was 37.3 (95% confidence interval: 36.8-37.7). Unadjusted trust scores were higher for Hispanic (40.5) and black (38.2) respondents compared with white (36.4) (P<0.001). Multivariable analyses showed white, younger, more-educated, or those with lower levels of self-reported health estimated toward lower adjusted scores for trust in the medical profession. CONCLUSIONS: We observed relatively higher levels of medical mistrust among white, younger, more-educated individuals with cancer or those with poorer health. While the relatively higher trust among minority individuals is encouraging, these findings raise the possibility that recent societal trends toward mistrust in science may have implications for cancer care.

Preferences for More Aggressive End-of-life Pharmacologic Care Among Racial Minorities in a Large Population-Based Cohort of Cancer Patients.

CONTEXT: Minority patients receive more aggressive and potentially suboptimal care at the end of life (EOL). We investigated preferences about pharmacologic interventions at the EOL and their potential variation by sociodemographic factors among recently diagnosed cancer patients. METHODS: A population-based cross-sectional survey of cancer patients identified through the Texas Cancer registry was conducted using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about potential pharmacologic interventions at the EOL were the focus of this investigation. Inverse probability weighted multivariate analysis examined associations of sociodemographic characteristics, health literacy, and trust in medical professionals with pharmacologic preferences. RESULTS: Of the 1480 included responses, 13.3% stated they would take a medication that may prolong life at the cost of feeling worse. Adjusted analyses showed Black or Hispanic race/ethnicity, living with another person, and having a higher trust score were more likely to express this preference. In contrast, 41-65 years (vs. 21-40 years), living in a rural area, and adequate or unknown health literacy were less likely to express this preference. Overall 16% of respondents were opposed to potentially life shortening palliative drugs. In adjusted analysis Black or Hispanic respondents were more likely to be opposed to potentially life shortening drugs although age 65-79 and ≥college education were associated with a decreased likelihood of opposition to this item. CONCLUSION: Black and Hispanic cancer patients were more likely to express preferences toward more aggressive EOL pharmacologic care. These findings were independent of other sociodemographic characteristics, health literacy and trust in the medical profession.

Bone Mineral Density at the Time of Initiating Aromatase Inhibitor Therapy Is Associated With Decreased Fractures in Women With Breast Cancer.

Women with estrogen receptor-positive breast cancer who receive an aromatase inhibitor (AI) are at risk for fractures. We aim to determine if dual-energy X-ray absorptiometry (DXA) scans made at the time of AI initiation are associated with decreased fractures. We retrospectively identified 25,158 women with local or regional breast cancer diagnosed between 2005 and 2013 who received AI therapy between 2007 and 2013 from the Medicare-linked Surveillance, Epidemiology, and End Results Program and Texas Cancer Registry databases. We defined baseline DXA screening using claims made between 1 year before and 6 months after each patient's first AI claim to examine determinants of baseline screening using a multivariable GENMOD model. We included a propensity score adjustment in Cox proportional hazard models to assess the association between time-varying DXA screening and the risk of fractures. Additionally, we compared the use of antiresorptive therapy drugs between the two groups. Of the study cohort, 14,738 (58.6%) received DXA screening. The screening rates increased annually from 52.1% in 2007 to 61.7% in 2013. Higher screening rates were observed in patients with younger age, married status, non-Hispanic white race, localized disease, fewer comorbidities, more than one type of aromatase inhibitor drug claim, no state buy-in (surrogate for low socioeconomic status), higher education level, and prior osteoporosis diagnosis. Baseline DXA screening was associated with decreased risk of subsequent fractures (hazard ratio = 0.91; 95% confidence interval, 0.86-0.97, p < .001) after multivariable and propensity score adjustment. Bone-modifying drugs were prescribed to 4440 (30.1%) patients with screening compared with 1766 (16.9%) without (p < .001). Of the 4440 patients who received treatment, 95% received bisphosphonates. Our study demonstrated baseline DXA screening was associated with a decreased risk of fractures and a higher likelihood of receiving antiresorptive therapies. Improvement of the baseline DXA screening is still needed in practice. © 2021 American Society for Bone and Mineral Research (ASBMR).

Epidemiologic factors in patients with advanced head and neck cancer treated with radiation therapy.

BACKGROUND: Approximately 50% of patients with head and neck cancer (HNC) initially were seen with advanced disease. We aimed to evaluate the association of epidemiologic factors with advanced HNC at diagnosis. METHODS: The OraRad multicenter prospective cohort study enrolled HNC patients receiving curative-intent radiation therapy. Factors assessed for association with advanced HNC presentation at diagnosis included demographics, social and medical history, cancer characteristics, human papilloma virus (HPV) status, and dental disease measures. RESULTS: We enrolled 572 participants; 77% male and mean (SD) age of 61.7 (11.2) years. Oropharyngeal squamous cell carcinomas (88% HPV-related) were seen with smaller tumors, but more frequent nodal involvement. Private medical insurance and no Medicaid were associated with smaller tumors. A higher dental disease burden was associated with larger tumors. CONCLUSIONS: Insurance status, cancer type/location, and dental disease are associated with advanced HNC and may represent potentially modifiable factors or factors to be considered in the screening process of new lesions.

Hospice enrollment among cancer patients in Texas covered by Medicare managed care and traditional fee-for-service plans: a statewide population-based study.

PURPOSE: Although rates of hospice use have increased over time, insurance plan- and racial/ethnic-based disparities in rates have been reported in the USA. We hypothesized that increased rates of hospice use would reduce or eliminate insurance plan-based disparities and that racial/ethnic disparities would be eliminated in managed care (MC) insurance plans. METHODS: We studied the use of hospice care in the final 30 days of life among 40,184 elderly Texas Medicare beneficiaries who died from primary breast, colorectal, lung, pancreas, or prostate cancer between January 1, 2007 and December 31, 2013, using statewide Medicare claims linked to cancer registry data. Rates of hospice use were computed by race/ethnicity and insurance plan (MC or fee-for-service (FFS)). We used logistic regression to account for the impact of confounding factors. RESULTS: Rates of hospice use increased significantly over time, from 68.9% in 2007 to 76.1% in 2013. By 2013, differences in hospice use rates between MC and FFS plans had been reduced from 10% to < 5%. However, after accounting for insurance plan and confounding factors, racial/ethnic minority beneficiaries' hospice use was significantly lower than non-Hispanic white beneficiaries' (p < 0.0001). This disparity was observed among both FFS and MC beneficiaries. CONCLUSIONS: Hospice use in the final 30 days of life has increased among elderly cancer patients in Texas, virtually eliminating the difference between FFS and MC insurance plans. Despite these positive trends, racial/ethnic-based disparities persist. These disparities are not explained by confounding factors. Future research should address social and behavioral influences on end-of-life decisions.

Costs of Oral Complications of Cancer Therapies: Estimates and a Blueprint for Future Study.

Oral complications of cancer treatment are common; however, their clinical and economic importance is often underappreciated. We reviewed the literature on the economic implications of oral complications, updating a previous report in the predecessor to this issue. We searched the Medline and Scopus databases for papers published as of December 31, 2017 that described the economic consequences of preventing and managing oral complications and reviewed the literature reporting the costs of oral mucositis, xerostomia, and osteonecrosis. Cost estimates were inflated to 2017 US dollars. We identified 16 papers describing the cost of managing mucositis, eight describing the cost of osteoradionecrosis, one describing the cost of bisphosphonate-associate osteonecrosis of the jaw, and four describing the cost of xerostomia. The incremental cost of oral mucositis was approximately $5000-$30 000 among patients receiving radiation therapy and $3700 per cycle among patients receiving chemotherapy. The incremental cost of mucositis-related hospitalization among stem cell transplant recipients exceeded $70 000. Conservative management of osteoradionecrosis (antibiotics, debridement) costs $4000-$35 000, although estimates as high as $74 000 have been reported. Hyperbaric oxygen therapy may add $10 000-$50 000 to the cost of therapy. Sialogogues are required for years for the management of xerostomia at a cost of $40-$200 per month. Serious (hospitalization, hyperbaric oxygen therapy) or long-term (sialogogues) outcomes are the major drivers of cost. Future research should address patients' out-of-pocket costs and the costs of oral complications of new treatments. Multisite studies, particularly those conducted by cooperative groups, should be prioritized.

Trends in Volume-Outcome Relationship in Gastrectomies in Texas.

BACKGROUND: We previously reported a significant volume-outcome relationship in mortality rates after gastrectomies for gastric cancer patients in Texas (1999-2001). We aimed to identify whether changes in the volume distribution of gastrectomies occurred, whether volume-outcome relationships persisted, and potential changes in the factors influencing volume-outcome relationships. METHODS: We performed a population-based study using the Texas Inpatient Public Use Data File between 2010 and 2015. Hospitals were classified as high-volume centers (HVCs, > 15 cases per year), intermediate-volume centers (IVCs, 3-15 cases per year), and low-volume centers (LVCs, < 3 cases per year). We conducted multivariate analyses to evaluate factors associated with inpatient mortality and adverse events. RESULTS: We identified 2733 gastric cancer patients who underwent gastrectomy at 193 hospitals. Fewer hospitals performed gastrectomy than previously (193 vs. 214). There were more HVCs (5 vs. 2) and LVCs (142 vs. 134), but fewer IVCs (46 vs. 78). The proportion of patients who underwent gastrectomy at HVCs and LVCs increased, while the proportion at IVCs decreased. HVCs maintained lower in-hospital mortality rates than IVCs or LVCs, although mortality rates decreased in both LVCs and IVCs. In adjusted multivariate analyses, treatment at HVCs remained a strong predictor for lower rates of mortality (odds ratio [OR] 0.39, p = 0.019) and adverse events (OR 0.56, p = 0.013). CONCLUSION: Despite improvements, patient morbidity and mortality at LVCs and IVCs remain higher than at HVCs, demonstrating that volume-outcome relationships still exist for gastrectomy and that opportunities for improvement remain.

Readmission Patterns After GI Cancer Hospitalizations: The Medical Versus Surgical Patient.

PURPOSE: Readmission within 30 days has been used as a metric for quality of care received at hospitals for certain diagnoses. In the era of accountability, value-based care, and increasing cancer costs, policymakers are looking into cancer readmissions as well. It is important to describe the readmission profile of patients with cancer in the most clinically relevant approach to inform policy and health care delivery that can positively impact patient outcomes. PATIENTS AND METHODS: We conducted a retrospective cohort study using linked Texas Cancer Registry and Medicare claims data. We included elderly Texas residents diagnosed with GI cancer and identified risk factors for unplanned readmission using generalized estimating equations, comparing medical with surgical cancer-related hospitalizations. RESULTS: We analyzed 69,693 hospitalizations from 31,736 patients. The unplanned readmission rate was higher after medical hospitalizations than after surgical hospitalizations (21.6% v 13.4%, respectively). Shared risk factors for readmission after medical and surgical hospitalizations included advanced disease stage, high comorbidity index, and emergency room visit and radiation therapy within 30 days before index hospitalization. Several other associated factors and reasons for readmission were noted to be unique to medical or surgical hospitalizations alone. CONCLUSION: Unplanned readmissions among elderly patients with GI cancer are more common after medical hospitalizations compared with surgical hospitalizations. There are shared risk factors and unique risk factors for these hospitalizations that can inform policy, health care delivery, and interventions to reduce readmissions. Other findings underscore the importance of care coordination and comorbidity management in this patient population.

Impact of Rheumatoid Arthritis on the Mortality of Elderly Patients Who Develop Cancer: A Population-Based Study.

OBJECTIVE: Comorbidity among cancer patients poses additional risks for mortality. The possible impact of rheumatoid arthritis (RA) on cancer patient survival is unclear. Our objective was to examine survival among elderly patients with RA who develop cancer. METHODS: Patients diagnosed with breast, prostate, colorectal, or lung cancer between 2001 and 2010 were identified from the Texas Cancer Registry and Medicare-linked databases. The cohort was categorized into 3 groups according to the number of claims patients had with a diagnosis of RA in the year prior to the cancer diagnosis: 2-RA (patients with ≥2 claims), 1-RA (1 claim), and no claims. Overall survival was estimated for these groups and for each cancer, using Cox proportional hazards models adjusting for covariates. RESULTS: The cohort included 139,097 patients with cancer (35,026 breast, 43,181 prostate, 31,103 colorectal, and 29,787 lung); 1.7% had 1 RA claim, and 1.1% had 2 or more. Adjusted hazard ratios for patients in the 2-RA group were 1.41 (95% confidence interval [95% CI] 1.21-1.65) for breast and 1.53 (95% CI 1.26-1.85) for prostate. No significant differences were observed for those with colorectal or lung cancer. CONCLUSION: Mortality was increased by 40% and 50%, respectively, in elderly patients with RA who developed breast or prostate cancer, after controlling for other comorbidities. This association was not seen in cancers with shorter survival time (colorectal or lung). Research is needed to determine whether the increased risk is related to comorbid burden or to differential utilization of cancer or rheumatoid therapies in patients with both diseases.

Health disparities and impact on outcomes in children with primary central nervous system solid tumors.

OBJECTIVE Health disparities in access to care, early detection, and survival exist among adult patients with cancer. However, there have been few reports assessing how health disparities impact pediatric patients with malignancies. The objective in this study was to examine the impact of racial/ethnic and social factors on disease presentation and outcome for children with primary CNS solid tumors. METHODS The authors examined all children (age ≤ 18 years) in whom CNS solid tumors were diagnosed and who were enrolled in the Texas Cancer Registry between 1995 and 2009 (n = 2421). Geocoded information was used to calculate the driving distance between a patient's home and the nearest pediatric cancer treatment center. Socioeconomic status (SES) was determined using the Agency for Healthcare Research and Quality formula and 2007-2011 US Census block group data. Logistic regression was used to determine factors associated with advanced-stage disease. Survival probability and hazard ratios were calculated using life table methods and Cox regression. RESULTS Children with advanced-stage CNS solid tumors were more likely to be < 1 year old, Hispanic, and in the lowest SES quartile (all p < 0.05). The adjusted odds ratios of presenting with advanced-stage disease were higher in children < 1 year old compared with children > 10 years old (OR 1.71, 95% CI 1.06-2.75), and in Hispanic patients compared with non-Hispanic white patients (OR 1.56, 95% CI 1.19-2.04). Distance to treatment and SES did not impact disease stage at presentation in the adjusted analysis. Furthermore, 1- and 5-year survival probability were worst in children 1-10 years old, Hispanic patients, non-Hispanic black patients, and those in the lowest SES quartile (p < 0.05). In the adjusted survival model, only advanced disease and malignant behavior were predictive of mortality. CONCLUSIONS Racial/ethnic disparities are associated with advanced-stage disease presentation for children with CNS solid tumors. Disease stage at presentation and tumor behavior are the most important predictors of survival.

Health Disparities Influence Childhood Melanoma Stage at Diagnosis and Outcome.

OBJECTIVE: To identify health disparities in pediatric patients with melanoma that affect disease presentation and outcome. STUDY DESIGN: This was a retrospective cohort study of all persons aged ≤18 years diagnosed with melanoma and enrolled in the Texas Cancer Registry between 1995 and 2009. Socioeconomic status (SES) and driving distance to the nearest pediatric cancer treatment center were calculated for each patient. Logistic regression was used to determine factors associated with advanced-stage disease. Life table methods and Cox regression were used to estimate survival probability and hazard ratios. RESULTS: A total of 185 adolescents (age >10 years) and 50 young children (age ≤10 years) were identified. Hispanics (n = 27; 12%) were 3 times more likely than non-Hispanic whites (n = 177; 75%) to present with advanced disease (OR, 3.8; 95% CI, 1.7-8.8). Young children were twice as likely as adolescents to present with advanced disease (OR, 2.2; 95% CI, 1.1-4.3). Distance to treatment center and SES did not affect stage of disease at presentation. Hispanics and those in the lowest SES quartile had a significantly higher mortality risk (hazard ratios, 3.0 [95% CI, 1.2-7.8] and 4.3 [95% CI, 1.4-13.9], respectively). In the adjusted survival model, only advanced disease was predictive of mortality (P < .001). CONCLUSION: Hispanics and young children with melanoma are more likely to present with advanced disease, and advanced disease is the single most important predictor of survival. Heightened awareness among physicians is needed to facilitate early detection of melanoma within these groups.

Functional Impairment and Physical Activity Adherence Among Gynecologic Cancer Survivors: A Population-Based Study.

OBJECTIVE: Adherence to physical activity guidelines after cancer diagnosis improves physical functioning. The purpose of this study was to estimate the prevalence of physical activity in a population-based sample of gynecologic cancer survivors (GCSs) and to examine the association between functional impairment and adherence to physical activity guidelines. METHODS: Using the 2009 Behavioral Risk Factor Surveillance System survey, we identified 5,015 GCSs aged 20 years or older who were 1 year or more after diagnosis. We used multinomial logistic regression with survey weighting to examine the association between functional impairment and adherence to physical activity guidelines (using 3 levels: sedentary, somewhat active, and meeting physical activity guidelines), controlling for demographic and clinical factors. RESULTS: We found that 55% of GCSs did not adhere to physical activity guidelines and that 38% reported functional impairment. Gynecologic cancer survivors with functional impairment were less likely to meet guidelines (adjusted odds ratio [AOR], 0.34; 95% confidence interval [CI], 0.25-0.47) or to be somewhat active (AOR, 0.43; 95% CI, 0.31-0.59) compared with those without impairment. Having more than high school education (AOR, 1.66; 95% CI, 1.15-2.40), fewer comorbidities (AOR, 0.55; 95% CI, 0.33-0.91), and not being obese (OR, 0.53; 95% CI, 0.36-0.77) were associated with meeting physical activity guidelines compared with being sedentary. CONCLUSIONS: Gynecologic cancer survivors do not meet physical activity guidelines and experience functional impairment, which is associated with lower adherence to physical activity recommendations. Prospective studies are needed to better elucidate the relation between functional impairment and physical activity.

Granulocyte growth factor use in elderly patients with non-Hodgkin's lymphoma in the United States: adherence to guidelines and comparative effectiveness.

PURPOSE: The efficacy of prophylactic granulocyte colony-stimulating factors (G-CSFs) among elderly patients with non-Hodgkin's lymphoma (NHL) receiving CHOP-based chemotherapy has been demonstrated in clinical trials, and G-CSFs are recommended in guidelines. We studied guideline adherence and the effectiveness of G-CSFs in the general population. METHODS: We used inpatient and outpatient claims from nationally representative databases linked to cancer information from tumor registries. Patients (N = 5884) diagnosed with NHL between 2001 and 2007 who were older than 65 years and who received CHOP-based chemotherapy were included. Adherence to guidelines was measured as the use of G-CSFs within 7 days of the first dose of chemotherapy. The measures of effectiveness were fever, infection, and death during cycle 1 of chemotherapy and time to cycle 2. Multiple-variable models of these outcomes were developed using logistic regression, controlling for demographic, clinical, and provider factors. RESULTS: G-CSF use increased from 32 % in 2001 to 72 % in 2007. Patients who received G-CSFs were significantly less likely to have outpatient encounters for infection than those who did not receive early G-CSFs (35 vs 47 %; p < 0.0001). Inpatient encounters for infection were similarly prevalent among patients who did or did not receive early G-CSFs (5 vs 4 %; p = 0.2). There was no association between G-CSF use and death during cycle 1. CONCLUSIONS: Adherence to guidelines increased after publication of clinical trials and exceeded 70 % after publication of guidelines. G-CSFs were effective in preventing outpatient encounters for fever or infection, but not inpatient encounters or deaths during cycle 1.

Radiation modality use and cardiopulmonary mortality risk in elderly patients with esophageal cancer.

BACKGROUND: It is currently unclear whether the superior normal organ-sparing effect of intensity-modulated radiotherapy (IMRT) compared with 3-dimensional radiotherapy (3D) has a clinical impact on survival and cardiopulmonary mortality in patients with esophageal cancer (EC). METHODS: The authors identified 2553 patients aged > 65 years from the Surveillance, Epidemiology, and End Results (SEER)-Medicare and Texas Cancer Registry-Medicare databases who had nonmetastatic EC diagnosed between 2002 and 2009 and were treated with either 3D (2240 patients) or IMRT (313 patients) within 6 months of diagnosis. The outcomes of the 2 cohorts were compared using inverse probability of treatment weighting adjustment. RESULTS: Except for marital status, year of diagnosis, and SEER region, both radiation cohorts were well balanced with regard to various patient, tumor, and treatment characteristics, including the use of IMRT versus 3D in urban/metropolitan or rural areas. IMRT use increased from 2.6% in 2002 to 30% in 2009, whereas the use of 3D decreased from 97.4% in 2002 to 70% in 2009. On propensity score inverse probability of treatment weighting-adjusted multivariate analysis, IMRT was not found to be associated with EC-specific mortality (hazard ratio [HR], 0.93; 95% confidence interval [95% CI], 0.80-1.10) or pulmonary mortality (HR, 1.11; 95% CI, 0.37-3.36), but was significantly associated with lower all-cause mortality (HR, 0.83; 95% CI, 0.72-0.95), cardiac mortality (HR, 0.18; 95% CI, 0.06-0.54), and other-cause mortality (HR, 0.54; 95% CI, 0.35-0.84). Similar associations were noted after adjusting for the type of chemotherapy, physician experience, and sensitivity analysis removing hybrid radiation claims. CONCLUSIONS: In this population-based analysis, the use of IMRT was found to be significantly associated with lower all-cause mortality, cardiac mortality, and other-cause mortality in patients with EC.