Effectiveness of fecal immunochemical testing in reducing colorectal cancer mortality from the One Million Taiwanese Screening Program.

BACKGROUND: The effectiveness of fecal immunochemical testing (FIT) in reducing colorectal cancer (CRC) mortality has not yet been fully assessed in a large, population-based service screening program. METHODS: A prospective cohort study of the follow-up of approximately 5 million Taiwanese from 2004 to 2009 was conducted to compare CRC mortality for an exposed (screened) group and an unexposed (unscreened) group in a population-based CRC screening service targeting community residents of Taiwan who were 50 to 69 years old. Given clinical capacity, this nationwide screening program was first rolled out in 2004. In all, 1,160,895 eligible subjects who were 50 to 69 years old (ie, 21.4% of the 5,417,699 subjects of the underlying population) participated in the biennial nationwide screening program by 2009. RESULTS: The actual effectiveness in reducing CRC mortality attributed to the FIT screening was 62% (relative rate for the screened group vs the unscreened group, 0.38; 95% confidence interval, 0.35-0.42) with a maximum follow-up of 6 years. The 21.4% coverage of the population receiving FIT led to a significant 10% reduction in CRC mortality (relative rate, 0.90; 95% confidence interval, 0.84-0.95) after adjustments for a self-selection bias. CONCLUSIONS: This large, prospective Taiwanese cohort undergoing population-based FIT screening for CRC had the statistical power to demonstrate a significant CRC mortality reduction, although the follow-up time was short. Although such findings are informative for health decision makers, continued follow-up of this large cohort will be required to estimate the long-term impact of FIT screening if the covered population is expanded.

Screening frequency and atypical cells and the prediction of cervical cancer risk.

OBJECTIVE: To evaluate the screening efficacy and importance of atypical squamous cells and atypical glandular cells in predicting subsequent cervical cancer risk. METHODS: This national cohort study in Taiwan analyzed associations between Pap test screening frequency and findings in 1995-2000 and subsequent risk of squamous cell carcinoma and adenocarcinoma after 2002. Women aged 30 years or older in 1995 without a cervical cancer history were included. Multivariate-adjusted hazard ratios and their 95% confidence intervals (CIs) were assessed using Cox regression analysis. RESULTS: During a total follow-up of 31,693,980 person-years in 2002-2008, 9,471 squamous cell carcinoma and 1,455 adenocarcinoma cases were newly diagnosed, resulting in 2,067 deaths. The risk of developing and dying from squamous cell carcinoma decreased significantly with increasing attendance frequency between 1995 and 2000 (all P values for trend<.001). Women who attended more than three screenings in 1995-2000 had 0.69-fold and 0.35-fold decrease in incidence and mortality of adenocarcinoma, respectively, compared with women who never attended any screenings. Abnormal cytologic findings were significant predictors of the incidence and mortality of cervical cancers. The adjusted hazard ratio (95% CI) of developing squamous cell carcinoma was 29.94 (22.83-39.25) for atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions, and the adjusted hazard ratio (95% CI) of developing adenocarcinoma was 49.43 (36.49-66.97) for atypical glandular cells. CONCLUSION: Significant reductions in cervical adenocarcinoma occurred in women who attend three or more annual screenings in 6 years. High-grade atypical squamous cells and atypical glandular cells are important predictors of subsequent adenocarcinoma and squamous cell carcinoma. LEVEL OF EVIDENCE: II.

Use of chemotherapy at the end of life among Taiwanese cancer decedents, 2001-2006.

INTRODUCTION: The availability of new chemotherapeutic agents has lengthened the treatment timeline for advanced cancers and increases the likelihood of receiving chemotherapy near death. Use of chemotherapy near the end of life may not benefit cancer patients. However, no population-based study has examined the determinants for continuing chemotherapy at the end of life for all ages and cancer groups as well as for a whole country. This population-based study assessed the association between continuation of chemotherapy in the last month of life and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and healthcare resource availability at the hospital and regional levels. MATERIALS AND METHODS: Retrospective population-based cohort study using administrative data among 204 850 Taiwanese cancer decedents in 2001-2006. RESULTS: Rates of continued chemotherapy in the last month of life for each study year were 17.5%, 17.4%, 17.3%, 19.0%, 20.0%, and 21.0%, respectively and have remained steady since 2001. Taiwanese cancer patients had greater odds for continuation of chemotherapy in the last month of life if they were male [adjusted odds ratio (AOR) 1.19, 95% confidence interval (CI) 1.13-1.25], younger, single [1.21 (1.09-1.35)], had lower comorbidity levels, were diagnosed with hematologic malignancies [1.90 (1.09-1.35)] and breast cancer [1.24 (1.08-1.43)], had metastatic disease [1.36 (1.27-1.46)], and survived < 1 year but longer than two months post-diagnosis. The odds for continued chemotherapy in patients' last month was significantly increased by being cared for by a medical oncologist [3.49 (3.04-3.99)] or in a teaching hospital [1.39 (1.11-1.74)] and with the highest intensity of total inpatient hospital beds [1.63 (0.99-2.68)], but was not influenced by regional healthcare resources (total hospital and hospice beds). CONCLUSION: The relative risk for continuation of chemotherapy in the last month of life was determined by patient demographics and disease characteristics, physician specialty, and healthcare resources at the primary hospital level.

Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001-2006.

BACKGROUND: With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated. PURPOSE: To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients. METHODS: Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001-2006. Age was categorized as 18-64, 65-74, 75-84, and ≥85 years. RESULTS: Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18-64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life. CONCLUSION: Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.

Impact of availability of an inpatient hospice unit on the parent hospital's quality of palliative care for Taiwanese cancer decedents, 2001-2006.

CONTEXT: Hospice care has increasingly been shown to affect quality of palliative care at both the individual and institutional levels. However, an institutional effect has only been addressed in single comprehensive cancer centers/selected community hospitals. OBJECTIVES: To investigate the impact of an inpatient hospice unit on the parent hospital's quality of palliative care. METHODS: This was a retrospective cohort study using administrative data from the entire population of 204,850 Taiwanese pediatric and adult cancer patients who died in 2001-2006. Outcome variables were adjusted by multivariate logistic regression for five groups of confounding variables: 1) patient demographics and disease characteristics, 2) primary hospital characteristics, 3) primary physician specialty, 4) health care resources at the hospital and regional levels, and 5) historical trend. RESULTS: Taiwanese cancer patients who received primary care in a hospital with an inpatient hospice unit (whether or not they received hospice care) were significantly less likely to be intubated (adjusted odds ratio [AOR]: 0.71; 95% confidence interval [CI]: 0.58, 0.86) and use mechanical ventilation support (AOR: 0.70; 95% CI: 0.56, 0.87) in their last month of life. They also were more likely to use hospice care before death (AOR: 3.51; 95% CI: 1.57, 7.86). Furthermore, if they used hospice care, they tended to be referred earlier than cancer patients being cared for in a hospital without an inpatient hospice unit. CONCLUSION: Integrating both acute care and palliative care approaches to caring for terminally ill cancer patients in the same hospital may influence the quality of palliative care throughout the hospital as evidenced by our findings that these patients have lower likelihood of being intubated with mechanical ventilation support in the last month of life, greater propensity to receive hospice care in the last year of life, and a trend toward earlier referral to hospice care. The generalizability of these results may be limited to patients who died of a noncancer cause and by the two groups not being exactly matched for patients' characteristics.

Hospice utilization in Taiwan by cancer patients who died between 2000 and 2004.

To facilitate utilization of hospice services, Taiwan uses the National Health Insurance (NHI) as a major policy instrument. To evaluate the effect of this policy on hospice utilization by cancer patients during their final year of life, a retrospective cohort study was conducted by linking individual patient-level data from the National Register of Deaths Database and the NHI claims database to examine changes in the rates of hospice utilization, durations of patient survival (DOS) after enrollment, and the rates of late referrals to hospice care from 2000 to 2004. Among the 103,097 cancer patients who died between 2000 and 2004, the rate of hospice utilization during their final year of life grew substantially from 5.5% to 15.4%. However, Taiwanese cancer patients were enrolled in hospice care close to death (median DOS ranged from 14 to 47 days). Except for the small proportion of patients who received both inpatient hospice care and hospice home care, one-third to one-fourth of cancer decedents died within 7 days after being enrolled in hospice care. Although the rate of late referrals to hospice care did not vary much over time, the mean DOS for hospice care changed significantly. Many Taiwanese cancer patients who could potentially benefit from hospice care do not receive it in time. Further research is warranted to investigate factors influencing hospice use and the timing of hospice referrals to facilitate appropriate use of hospice care for cancer patients in Taiwan.

Congruence of knowledge, experiences, and preferences for disclosure of diagnosis and prognosis between terminally-ill cancer patients and their family caregivers in Taiwan.

BACKGROUND: Over the last 40 years, studies have shown cultural differences in attitudes toward truth telling at the end-of-life. Nevertheless, the argument that cancer patients from an Asian culture have different preferences about information disclosure that necessitate significantly modifying information disclosure practices has not been validated by direct investigation from patients' points of view. METHODS: Six hundred seventeen dyads of patient-designated family caregivers across 21 hospitals throughout Taiwan were surveyed and interviewed by a semistructured interview guide. Percentage of agreement, kappa coefficients, McNemar tests, and paired t-tests were conducted to examine the extent of congruence of knowledge, experiences, and preferences for disclosure of diagnosis and prognosis between the dyads. RESULTS: There were substantial discrepancies in the knowledge and experiences of being informed about the diagnosis and prognosis between Taiwanese terminally-ill cancer patients and their family caregivers (kappa values ranged from 0.08 to 0.44). Cancer patients strongly proclaimed their superior rights to be informed about their disease over their family and preferred their physicians to inform themselves before releasing any information to their family caregivers. CONCLUSION: The arguments that cancer patients from an Asian culture (i.e., Chinese/Taiwanese culture) have different preferences regarding being informed of their diagnosis and prognosis and that family members have legitimate superior power in decision making could not be supported by data from this group of terminally-ill cancer patients. Physicians need to respect patients' preferences rather than routinely taking the family's opinions into consideration first in the event of disagreement. Equipped with adequate information, terminally-ill cancer patients from Asia may have better opportunities to make end-of-life care decisions that are in accord with their wishes.

Efficacy and cost-effectiveness of nationwide cervical cancer screening in Taiwan.

The annual cervical screening programme using the Papanicolaou (Pap) smear test was launched for women aged 30 years and over from 1995 in Taiwan. This study aimed to evaluate the Taiwanese cervical screening policy and to make recommendations based on the empirical findings from cervical screening data between 1995 and 1998. We used a stochastic process to model the natural history of precancerous lesions and cervical cancer. Based on the estimated results, Monte-Carlo computer simulation was used to evaluate the effectiveness in terms of the reduction in incidence of and mortality from cervical cancer for screening regimes with different screening intervals. Annual Pap smear screening with 100% compliance was estimated to lead to an approximate 80% reduction in deaths from cervical cancer. With 50% compliance, around a 40% reduction was expected. Triennial screening with high compliance was as effective as annual screening with low compliance, and more cost-effective. Based on the observed Taiwan Pap smear-screening programme between 1995 and 1998, with 44.5% women attending at least once, there was an estimated reduction of 16% in deaths from cervical carcinoma. The estimated effectiveness was greater when the period was extended to 2001, in which period 61% of women attended at least once. The screening programme by 2001 was estimated to reduce cervical cancer mortality by 50% (95% confidence interval: 29-65%). The incremental cost-effectiveness was estimated as 8174 dollars per additional life-year gained. In conclusion, triennial screening targeting women aged 30-69 is recommended, along with efforts to enhance the compliance rate.