High-Intensity End-of-Life Care Among Patients With GI Cancer in Puerto Rico: A Population-Based Study.

PURPOSE: High-intensity care with undue suffering among patients with cancer at the end of life (EoL) is associated with poor quality of life. We examined the pattern and predictors of high-intensity care among patients with GI cancer in Puerto Rico. METHODS: This population-based study of data from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database examined patients with GI cancer who died between 2009 and 2017. EoL care intensity indicators include the following services in the last month before death: emergency room (ER) visits, hospitalizations, intensive care unit (ICU) admissions, life-extending procedures, death in an acute care setting, and the use of chemotherapy in the last 14 days. We used logistic regression models to examine factors associated with EoL care. RESULTS: Four thousand six hundred twenty-nine patients with GI cancer were included in the analysis. We found that 11.0% of patients received chemotherapy, 17.3% had > 1 hospitalization, 9.3% were in the ICU, 18.0% had > 1 ER visit, 39.3% died in an acute care setting, and 8.6% received life-extending procedures. A compound indicator of the aggressiveness of care showed that 54.5% of patients had at least one of the selected aggressive indicators. The multivariable model showed that female patients, patients ≥ 60 years of age, patients enrolled in Medicaid, patients dually eligible for both Medicare and Medicaid, and patients who survived > 1 year were less likely to receive aggressive EoL care. CONCLUSION: Our findings support the urgent need to improve EoL care in Puerto Rico. Further studies are warranted to fully understand EoL care in patients with cancer in Puerto Rico.

Incidence of thyroid cancer in Puerto Rico and the US by racial/ethnic group, 2011-2015.

BACKGROUND: Puerto Rico has the highest incidence rate of thyroid cancer (TC) in the Americas and the third highest rate worldwide. The purpose of this study was to compare the burden of TC between the population of PR and United States (US) non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and US Hispanics (USH) during the period 2011-2015. METHODS: TC data for the period 2011-2015 was obtained from the Puerto Rico Central Cancer Registry (PRCCR) and the Surveillance Epidemiology and Ends Results Program (SEER) 18 Registries Research Data. TC was categorized in: papillary carcinoma (PTC), and other TC histologic types. Data was analyzed by sex, age groups, and histologic type. Racial/ethnic differences by sex, age, and histologic types were assessed using the Standardized Rate Ratio (SRR) and its 95% CI. RESULTS: During the period 2011-2015 there were 5175 and 65,528 cases of TC diagnosed in PR and the US, respectively. The overall age-adjusted incidence rate of PTC was almost two-fold higher in PR than in the US (25.8/100,000 vs. 12.9/100,000). Among PR women, the incidence rate of PTC was 40.0/100,000 compared to 19.4/100,000 in US. PR women had 83% increased risk of being diagnosed with PTC than NHW women, a 2.25-fold increased risk than USH, and 3.45-fold increased risk than NHB women. For men, PR had 34% increased risk of being diagnosed with PTC than NHW men, 2.2-fold increased risk than USH men, and 3.2-fold higher risk than in NHB men. CONCLUSION: Further research is needed to understand this disparity in the island. This research should address the extent of overdiagnosis in PR, the role of health insurance status and insurance type, characteristics of the healthcare delivery system as well as the role of patient and environmental factors.

Underuse of Radiation Therapy After Breast Conservation Surgery in Puerto Rico: A Puerto Rico Central Cancer Registry-Health Insurance Linkage Database Study.

PURPOSE: To identify rates of postoperative radiation therapy (RT) after breast conservation surgery (BCS) in women with stage I or II invasive breast cancer treated in Puerto Rico and to examine the sociodemographic and health services characteristics associated with variations in receipt of RT. METHODS: The Puerto Rico Central Cancer Registry-Health Insurance Linkage Database was used to identify patients diagnosed with invasive breast cancer between 2008 and 2012 in Puerto Rico. Claims codes identified the type of surgery and the use of RT. Logistic regression models were used to examine the independent association between sociodemographic and clinical covariates. RESULTS: Among women who received BCS as their primary definitive treatment, 64% received adjuvant RT. Significant predictors of RT after BCS included enrollment in Medicare (odds ratio [OR], 2.14; 95% CI, 1.46 to 3.13; P ≤ .01) and dual eligibility for Medicare and Medicaid (OR, 1.61; 95% CI, 1.14 to 2.27; P < .01). In addition, it was found that RT was more likely to have been received in certain geographic locations, including the Metro-North (OR, 2.20; 95% CI, 1.48 to 3.28; P < .01), North (OR, 1.78; 95% CI, 1.20 to 2.64; P < .01), West (OR, 4.04; 95% CI, 2.61 to 6.25; P < .01), and Southwest (OR, 2.79; 95% CI, 1.70 to 4.59; P < .01). Furthermore, patients with tumor size > 2.0 cm and ≤ 5.0 cm (OR, 0.61; 95% CI, 0.40 to 0.93; P = .02) and those with tumor size > 5.0 cm (OR, 0.37; 95% CI, 0.15 to 0.92; P = .03) were found to be significantly less likely to receive RT. CONCLUSION: Underuse of RT after BCS was identified in Puerto Rico. Patients enrolled in Medicare and those who were dually eligible for Medicaid and Medicare were more likely to receive RT after BCS compared with patients with Medicaid alone. There were geographic variations in the receipt of RT on the island.

Invasive cancer incidence - Puerto Rico, 2007-2011.

UNLABELLED: Cancer is a leading cause of morbidity and death in Puerto Rico. To set a baseline for identifying new trends and patterns of cancer incidence, Puerto Rico Central Cancer Registry staff and CDC analyzed data from Puerto Rico included in U.S. Cancer Statistics (USCS) for 2007-2011, the most recent data available. This is the first report of invasive cancer incidence rates for 2007-2011 among Puerto Rican residents by sex, age, cancer site, and municipality. Cancer incidence rates in Puerto Rico were compared with those in the U.S. population for 2011. A total of 68,312 invasive cancers were diagnosed and reported in Puerto Rico during 2007-2011. The average annual incidence rate was 330 cases per 100,000 persons. The cancer sites with the highest cancer incidence rates included prostate (152), female breast (84), and colon and rectum (43). Cancer incidence rates varied by municipality, particularly for prostate, lung and bronchus, and colon and rectum cancers. In 2011, cancer incidence rates in Puerto Rico were lower for all cancer sites and lung and bronchus, but higher for prostate and thyroid cancers, compared with rates within the U.S. POPULATION: Identifying these variations can aid evaluation of factors associated with high incidence, such as cancer screening practices, and development of targeted cancer prevention and control efforts. Public health professionals can monitor cancer incidence trends and use these findings to evaluate the impact of prevention efforts, such as legislation prohibiting tobacco use in the workplace and public places and the Puerto Rico Cessation Quitline in decreasing lung and other tobacco-related cancers.

Geographic distribution of risk of death due to homicide in Puerto Rico, 2001–2010 / Distribución geográfica del riesgo de muerte por homicidio en Puerto Rico,2001–2010

Objective. To raise awareness of the impact of homicides in Puerto Rico based on the findings of the spatial and temporal distribution of homicides and the use of firearms, by age and gender, using reports of interpersonal violent deaths from the Institute of Forensic Science (IFS) headquartered in San Juan, Puerto Rico. Methods. This was a descriptive study of all homicide incidents in Puerto Rico reported by the IFS for the period 2001–2010. For each of the 8 542 cases, data analyzed included age, sex, municipality of incident, date of death, and mechanism. Crude sex- and age-specific mortality rates for Puerto Rico and for each municipality per year and for the 10-year period were calculated. Cumulative rate and cumulative risks were estimated and defined as lifetime risk. The relative distribution of cumulative rates for each municipality was categorized into quartiles of highest to lowest risk and displayed as a map. Results. The risk of homicide death among males is 13 times greater than among females. The highest rates were observed among males 20–24 years of age (198.4 homicides per 100 000). In any given year, firearms were used in at least 80% of homicides. The average lifetime risk of homicide death for males is 1 in 34. Conclusions. Young adult males with access to firearms are at greatest risk of homicide in Puerto Rico. Also, highly urbanized municipalities are at highest risk; however, certain nonurban municipalities along the coast also have a very high homicide risk. Top priorities should be applying the WHO “ecological model” for violent injury prevention and establishing a surveillance system that will assist in identifying the role that socioeconomics, illegal firearms trade, and drug trafficking are playing.

Objetivo. Concientizar sobre la repercusión de los homicidios en Puerto Rico con base en los resultados de la distribución espacial y temporal de los homicidios y el uso de las armas de fuego, según la edad y el sexo, a partir de los informes del Instituto de Ciencias Forenses (ICF), con sede en San Juan, Puerto Rico, sobre defunciones por violencia interpersonal. Métodos. Estudio descriptivo de todos los incidentes de homicidio ocurridos en Puerto Rico informados por el ICF durante el período del 2001 al 2010. La edad, el sexo, el municipio del incidente, la fecha de muerte y el mecanismo fueron los datos analizados en cada uno de los 8 542 casos. Se calcularon las tasas brutas de mortalidad específicas de cada sexo y edad en Puerto Rico y en cada municipio, por año y durante el período de 10 años. Se calcularon también las tasas y los riesgos acumulados y se definieron como riesgo durante toda la vida. La distribución relativa de las tasas acumuladas para cada municipio se clasificó en cuartiles, del riesgo más alto al más bajo, y se ilustró en un mapa. Resultados. El riesgo de muerte por homicidio en varones es 13 veces mayor que en mujeres. Las tasas más elevadas se observaron en hombres de 20 a 24 años de edad (198,4 homicidios por 100 000). Cualquiera que fuera el año escogido, en al menos 80% de los homicidios se utilizaron armas de fuego. En varones, el riesgo promedio de morir por homicidio durante toda la vida es de 1/34. Conclusiones. Los jóvenes varones adultos con acceso a las armas de fuego están sometidos a un mayor riesgo de homicidio en Puerto Rico. Además, en los municipios muy urbanizados el riesgo es más alto; sin embargo, en ciertos municipios no urbanos de la costa también hay un riesgo de homicidio muy alto. Las máximas prioridades deben ser aplicar el “modelo ecológico” de la OMS para prevenir las lesiones violentas y establecer un sistema de vigilancia que ayude a determinar la función que desempeñan las condiciones socioeconómicas, el comercio ilegal de armas de fuego y el tráfico de drogas.

Geographic distribution of risk of death due to homicide in Puerto Rico, 2001-2010.

OBJECTIVE: To raise awareness of the impact of homicides in Puerto Rico based on the findings of the spatial and temporal distribution of homicides and the use of firearms, by age and gender, using reports of interpersonal violent deaths from the Institute of Forensic Science (IFS) headquartered in San Juan, Puerto Rico. METHODS: This was a descriptive study of all homicide incidents in Puerto Rico reported by the IFS for the period 2001-2010. For each of the 8 542 cases, data analyzed included age, sex, municipality of incident, date of death, and mechanism. Crude sex- and age-specific mortality rates for Puerto Rico and for each municipality per year and for the 10-year period were calculated. Cumulative rate and cumulative risks were estimated and defined as lifetime risk. The relative distribution of cumulative rates for each municipality was categorized into quartiles of highest to lowest risk and displayed as a map. RESULTS: The risk of homicide death among males is 13 times greater than among females. The highest rates were observed among males 20-24 years of age (198.4 homicides per 100 000). In any given year, firearms were used in at least 80% of homicides. The average lifetime risk of homicide death for males is 1 in 34. CONCLUSIONS: Young adult males with access to firearms are at greatest risk of homicide in Puerto Rico. Also, highly urbanized municipalities are at highest risk; however, certain non-urban municipalities along the coast also have a very high homicide risk. Top priorities should be applying the WHO "ecological model" for violent injury prevention and establishing a surveillance system that will assist in identifying the role that socioeconomics, illegal firearms trade, and drug trafficking are playing.