Serious postoperative infections following resection of common solid tumors: outcomes, costs, and impact of hospital surgical volume.

PURPOSE: Unlike infections related to chemotherapy-induced neutropenia, postoperative infections occurring in patients with solid malignancy remain largely understudied. Our aim is to evaluate the outcomes and the volume-outcomes relationship associated with postoperative infections following resection of common solid tumors. METHODS: We used Texas Discharge Data to study patients undergoing resection of cancer of the lung, esophagus, stomach, pancreas, colon, or rectum from 01/2002 to 11/2006. From their billing records, we identified ICD-9 codes indicating a diagnosis of serious postoperative infection (SPI), i.e., bacteremia/sepsis, pneumonia, and wound infection, occurring during surgical admission or leading to readmission within 30 days of surgery. Using regression-based techniques, we estimated the impact of SPI on mortality, resource utilization, and costs, as well as the relationship between hospital volume and SPI, after adjusting for confounders and data clustering. RESULTS: SPI occurred following 9.4 % of the 37,582 eligible tumor resections and was independently associated with nearly 12-fold increased odds of in-hospital mortality [95 % confidence interval (95 % CI), 7.2-19.5, P < 0.001]. Patients with SPI required six additional hospital days (95 % CI, 5.9-6.2) at an incremental cost of $16,991 (95 % CI, $16,495-$17,497). Patients who underwent resection at high-volume hospitals had a 16 % decreased odds of developing SPI than those at low-volume hospitals (P = 0.03). CONCLUSIONS: Due to the substantial burden associated with SPI following common solid tumor resections, hospitals must identify more effective prophylactic measures to avert these potentially preventable infections. Additional volume-outcomes research is needed to identify infection prevention processes that can be transferred from high- to lower-volume providers.

Time trends and geographic variation in use of minimally invasive breast biopsy.

BACKGROUND: Current guidelines recommend minimally invasive breast biopsy (MIBB) as the gold standard for the diagnosis of breast lesions. The purpose of this study was to describe geographic patterns and time trends in the use of MIBB in Texas. METHODS: We used 100% Texas Medicare claims data (2000-2008) to identify women older than 66 years of age who underwent breast biopsy. Biopsies were classified as open or MIBB. Time trends, racial/ethnic variation, and geographic variation in the use of biopsy techniques were examined. RESULTS: A total of 87,165 breast biopsies were performed on 75,518 breast masses in 67,582 women; 65.8% of the initial biopsies were MIBB. Radiologists performed 70.3% and surgeons performed 26.2% of MIBB. Surgeons performed 94.2% of open biopsies. Hispanic women were less likely to undergo MIBB (55.9%) compared with white (66.6%) and black (68.9%) women (p < 0.0001). Women undergoing MIBB were also more likely to live in metropolitan areas and have higher income and educational levels (p < 0.0001). The rate of MIBB increased from 44.4% in 2001 to 79.1% in 2008 (p < 0.0001). There are clear geographic patterns in MIBB use, with highest use near major cities. Although rates are increasing overall, rates of improvement in the use of MIBB vary considerably across geographic regions and remain persistently low in more rural areas. CONCLUSIONS: Despite an increase in the use of MIBB over time, MIBB use was consistently lower than recommended. We must identify specific barriers in rural areas to effectively change practice and achieve the statewide goal of 90% MIBB.

415 patients with adenosquamous carcinoma of the pancreas: a population-based analysis of prognosis and survival.

BACKGROUND: Adenosquamous carcinoma of the pancreas is rare. Our understanding of the disease and its prognosis comes mainly from small retrospective studies. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2007), we identified patients with adenosquamous carcinoma (n = 415) or adenocarcinoma (n = 45,693) of the pancreas. The demographics, tumor characteristics, resection status, and survival were compared between the groups. RESULTS: Compared with patients with adenocarcinoma, patients with adenosquamous carcinoma were more likely to have disease located in the pancreatic body and tail (44.6% versus 53.5%, P < 0.0001). While the stage distribution was similar between the two groups, adenosquamous carcinomas were more likely to be poorly differentiated (71% versus 45%, P < 0.0001), node positive (53% versus 47%, P < 0.0001), and larger (5.7 versus 4.3 cm, P < 0.0001). For locoregional disease, resection increased over time from 26% in 1988 to 56% in 2007. The overall 2-y survival was 11% in both groups. Following resection, patients with adenosquamous carcinoma had worse 2-y survival (29% versus 36%, P < 0.0001). Resection was the strongest independent predictor of survival for patients with locoregional pancreatic adenosquamous carcinoma (HR 2.35, 95% CI = 1.47-3.76). CONCLUSIONS: This is the first population-based study to evaluate outcomes in adenosquamous carcinoma of the pancreas. Compared with pancreatic adenocarcinoma, adenosquamous carcinoma was more likely to occur in the pancreatic tail, be poorly differentiated, larger, and node positive. The long-term survival following surgical resection is significantly worse for adenosquamous cancers; however, patients with adenosquamous carcinoma can still benefit from surgical resection, which is the strongest predictor of survival.

End-of-life care in Medicare beneficiaries dying with pancreatic cancer.

BACKGROUND: The authors' goal was to characterize hospice enrollment and aggressiveness of care for pancreatic cancer patients at the end of life. METHODS: Surveillance, Epidemiology, and End Results and linked Medicare claims data (1992-2006) were used to identify patients with pancreatic cancer who had died (n = 22,818). The authors evaluated hospice use, hospice enrollment ≥ 4 weeks before death, and aggressiveness of care as measured by receipt of chemotherapy, acute care hospitalization, and intensive care unit (ICU) admission in the last month of life. RESULTS: Overall, 56.9% of patients enrolled in hospice, and 35.9% of hospice users enrolled for 4 weeks or more. Hospice use increased from 36.2% in 1992-1994 to 67.2% in 2004-2006 (P < .0001). Admission to the ICU and receipt of chemotherapy in the last month of life increased from 15.5% to 19.6% (P < .0001) and from 8.1% to 16.4% (P < .0001), respectively. Among patients with locoregional disease, those who underwent resection were less likely to enroll in hospice before death and much less likely to enroll early. They were also more likely to receive chemotherapy (14% vs 9%, P < .0001), be admitted to an acute care hospital (61% vs 53%, P < .0001), and be admitted to an ICU (27% vs 15%, P < .0001) in the last month of life. CONCLUSIONS: Although hospice use increased over time, there was a simultaneous decrease in early enrollment and increase in aggressive care at the end of life for patients with pancreatic cancer.

Mammography capacity impact on screening rates and breast cancer stage at diagnosis.

BACKGROUND: Mammography capacity in the U.S. reportedly is adequate, but has not been examined in nonmetropolitan areas. This study examined the relationships between in-county mammography facilities and rates of mammography screening and late-stage diagnosis of breast cancers. METHODS: The association between a mammography facility in the county of residence (2002-2004) and the odds of screening within 2 years were examined (in 2007) among Texas women aged >40 years who responded to the 2004 Behavioral Risk Factor Surveillance System survey, using multivariate logistic regression to control for age, race, ethnicity, education, income, self-reported health, insurance, and usual source of care. Similarly, the association between an in-county mammography facility and the odds of diagnosis with locally advanced or disseminated disease was examined among Texas women aged >40 years who developed breast cancer in 2004. RESULTS: Half of the 254 counties in Texas had no mammography facility. After controlling for confounding factors, an in-county facility was associated with significantly higher odds of screening (OR=3.27; p=0.03) and lower odds of late-stage breast cancer at diagnosis (OR=0.36; 95% CI=0.26-0.51; p<0.001). The risks of late-stage diagnosis were higher for African-American women (OR=1.52; 95% CI=1.22-1.89; p<0.001) and Hispanic women (OR=1.23; 95% CI=0.99-1.53; p=0.06) than for white women. CONCLUSIONS: Although mammography capacity in the U.S. may be adequate on average, the unequal distribution of facilities results in large rural areas without facilities. Screening rates in these areas are suboptimal and are associated with late-stage diagnosis of breast cancer.

Hospitalizations for infection in cancer patients: impact of an aging population.

GOAL OF WORK: The aim of this study was to assess the impact of an aging US population on inpatient costs and resource utilization in cancer patients admitted for infection. MATERIALS AND METHODS: From the Texas inpatient public use files (Texas Health Care Information Collection), which include all hospitals except federal institutions, we selected residents with cancer who also had a principal or admitting diagnosis of pneumonia, bacteremia/sepsis, or other documented infection in 2001. Selected admission records were directly adjusted by projected age-specific cancer prevalence totals for years 2006 and 2025 using surveillance epidemiology end results (SEER) and US census data. Charges were inflated to 2006 consumer price index for medical care then converted to costs using Texas Medicare cost-to-charge ratios. RESULTS: Over 9% of nearly 200,000 Texans admitted for infection in 2001 also had cancer. Projecting these results nationally, 318,000 discharges in cancer patients at a cost of $3.1 billion (B, 95% CI $2.8B, $3.4B) and 2.3 million (M) bed days would have been attributed to infections in 2006. By the year 2025, adjusting only for the aging population, costs could increase 45% to $4.5B (95% CI $4.1B, $4.9), with 27% more (3.4 M) hospital bed days occupied. CONCLUSIONS: Consequent to an aging population and the resulting increase in cancer prevalence, the healthcare burden of managing hospital admissions for infection in the vulnerable cancer population could be greatly magnified unless risk-based treatment and preventive strategies such as appropriate immunizations and infection control measures are implemented.

Clinical model of cost of bladder cancer in the elderly.

OBJECTIVES: To develop a population-based clinical model of bladder cancer (BC) care costs and identify cost drivers. METHODS: We retrospectively reviewed a cohort of 4863 patients with BC identified from the linked Surveillance, Epidemiology and End Results-Medicare database, aged at least 65 years and diagnosed between 1994 and 1996. We collected the records of Medicare reimbursements (a surrogate of costs) through 1998 and classified them into clinically relevant intervals and care types by disease invasiveness to derive the cumulative costs of care. We calculated the incremental resource use costs using sex and age-matched controls from a 5% general population sample and compared similarly matched patients with other cancer (OC). We inflated all costs to 2006 U.S. dollars. RESULTS: The annual cost of care for all patients with muscle-invasive BC (MIBC) was $35.72M (95% confidence interval $35.69M to $35.75M), 70% more than the $21.03M (95% confidence interval $21.00M to $21.05M) for patients with non-MIBC. The major cost drivers, regardless of disease stage, were diagnostic/surveillance and complications, accounting for up to 43% and 37% of BC care costs, respectively. Comorbidity-adjusted incremental annual resource costs per patient with MIBC were more than four times greater than those for patients with non-MIBC, similar to those of OC controls (P = 0.490-0.913), except for inpatient (P = 0.002) and hospice (P <0.001) costs, which were both statistically significantly lower. Annual adjusted incremental Medicare reimbursements totaled $36.3M for non-MIBC and $96.1 million for MIBC. CONCLUSIONS: The results of this study have indicated that a reduction of BC care costs could be realized with strategies inhibiting disease progression and reducing the occurrence and severity of complications.

In-hospital complications of autologous hematopoietic stem cell transplantation for lymphoid malignancies: clinical and economic outcomes from the Nationwide Inpatient Sample.

BACKGROUND: Autologous hematopoietic stem cell transplantation (auto HSCT) is standard of care therapy for multiple myeloma and Hodgkin and non-Hodgkin lymphomas in front-line and salvage settings, respectively. Complications remain common, but population-based estimates of their frequency and relative contribution to cost are not available. METHODS: A retrospective cohort comprised of 8891 patients with multiple myeloma and lymphoma admitted to US hospitals for auto HSCT over a 2-year period (2000-2001) was extracted from the Nationwide Inpatient Sample (NIS). Patient characteristics, vital status, and total hospital charges were obtained directly from the NIS. Transplant characteristics and outcomes were identified by ICD-9-CM codes. Mean hospital charges were examined by outcome and transformed into cost by using Medicare cost-to-charge ratios. Factors associated with hospital cost, length of stay, and in-hospital mortality were explored by using multivariate regression. RESULTS: The mean hospital cost for auto HSCT during this period was $51,312. Significant complications were documented for >50% of admissions. Infectious complications (~60%) and stomatitis (~40%) were the most frequent, and both were associated with increased hospital costs (range, $15,000 to $50,000). In-hospital mortality was rare (<5%) but was associated with markedly increased cost when it occurred. Pretransplant conditioning with total body irradiation was strongly associated with infectious complications, higher cost, and death. CONCLUSIONS: Adverse events are both common and costly after auto HSCT. Strategies to minimize complications could significantly reduce not only morbidity and mortality but also the cost of the procedure. Administrative data can be profitably exploited to investigate outcomes in this population.

Psychosocial and economic impact of cancer.

This article explores the psychosocial and economic implications of cancer and their relevance to the clinician. After a general overview of the topic, the authors focus on aspects of particular importance to the dental professional, including the psychosocial and economic implications of the oral complications of cancer and its therapy, head and neck cancers, and special issues among children with cancer and cancer survivors.

Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies.

PURPOSE: To study the risk, outcomes, and costs of radiation-induced oral mucositis (OM) among patients receiving radiotherapy (RT) to head and neck primary cancers. METHODS AND MATERIALS: A retrospective cohort consisting of 204 consecutive head-and-neck cancer patients who received RT with or without chemotherapy during 2002 was formed; their records were reviewed for clinical and resource use information. Patients who had received prior therapy, had second primary cancers, or received palliative radiation therapy were excluded. The risk of OM was analyzed by multiple variable logistic regression. The cost of care was computed from the provider's perspective in 2006 U.S. dollars and compared among patients with and without OM. RESULTS: Oral mucositis occurred in 91% of patients; in 66% it was severe (Grade 3-4). Oral mucositis was more common among patients with oral cavity or oropharynx primaries (odds ratio [OR], 44.5; 95% confidence interval [CI], 5.2 to >100; p < 0.001), those who received chemotherapy (OR = 7.8; 95% CI, 1.5-41.6; p = 0.02), and those who were treated with altered fractionation schedules (OR = 6.3; 95% CI, 1.1-35.1; p = 0.03). Patients with OM were significantly more likely to have severe pain (54% vs. 6%; p < 0.001) and a weight loss of > or =5% (60% vs. 17%; p < 0.001). Oral mucositis was associated with an incremental cost of $1700-$6000, depending on the grade. CONCLUSIONS: Head-and-neck RT causes OM in virtually all patients. Oral mucositis is associated with severe pain, significant weight loss, increased resource use, and excess cost. Preventive strategies are needed.

Cost-effectiveness of influenza vaccination in working-age cancer patients.

BACKGROUND: Despite recommendations to immunize all patients at an increased risk of influenza complications, the vaccine utilization among high-risk nonelderly adults remains low and its cost-effectiveness is unclear. In the current study, the authors analyzed the cost-effectiveness of influenza vaccination in working-age (ages 20-64 years) cancer patients. METHODS: The authors developed a decision-analytic model, from the societal perspective, using epidemiologic, vaccine effectiveness, resource utilization, cost, survival, and utility data from published sources, supplemented with data collected from the authors' own institutional accounting system. Two strategies were compared: influenza vaccination of working-age cancer patients and no vaccination. The base-case patient was assumed to be a 51-year-old cancer patient (the mean age for the National Cancer Institute's Surveillance, Epidemiology, and End Results [SEER] population of working-age patients within 5 years of cancer diagnosis). RESULTS: The effectiveness of the influenza vaccine was 6.02 quality-adjusted life-years (QALYs) at a cost of $30.10. The effectiveness of the no vaccination strategy was 6.01 QALYs at a cost of $27.86. Compared with the no vaccination strategy, the incremental cost-effectiveness ratio of vaccinating working-age cancer patients would be $224.00 per QALY gained. Using the benchmark of $50,000 per QALY, the model was only sensitive to changes in cancer survival (threshold of 2.8 months). CONCLUSIONS: The influenza vaccine is cost-effective for working-age cancer patients with a life expectancy of >or=3 months. All working-age cancer patients who are within 5 years of cancer diagnosis and have a life expectancy of at least 3 months should be vaccinated against influenza.

Clinical model of lifetime cost of treating bladder cancer and associated complications.

OBJECTIVES: To estimate the lifetime cost of bladder cancer and the contribution of complications to the total costs. METHODS: We reviewed the medical records of a retrospective cohort of 208 patients with bladder cancer who registered at our comprehensive cancer center from 1991 to 1999. We multiplied the number of resources used during management of bladder cancer by their unit charges. We converted charges into costs using the Medicare cost-to-charge ratio and inflated these to 2005 U.S. dollars. We estimated future costs by creating two extreme hypothetical scenarios. In the best-case scenario, we assumed patients with superficial disease developed recurrences at the cohort's mean rate and that patients with muscle-invasive disease were disease free after definitive therapy. Survival was based on the U.S. life expectancy in both cases. In the worst-case scenario, we assumed patients with superficial disease developed muscle-invasive disease and that all patients subsequently died of bladder cancer. RESULTS: The average cost of bladder cancer was 65,158 dollars among the cohort patients. Sixty percent of this cost (39,393 dollars) was associated with surveillance and treatment of recurrences, and 30% (19,811 dollars) was attributable to complications. The lifetime cost of bladder cancer was lower for the worst-case scenario (99,270 dollars) than for the best-case scenario (120,684 dollars). However, a greater proportion of the costs were attributable to complications with the worst-case scenario (43%, 42,290 dollars) compared with the best (28%, 34,169 dollars). CONCLUSIONS: The management of bladder cancer and its associated complications results in a major economic burden. More cost-effective surveillance strategies and approaches for preventing complications are crucial to minimizing the disease's clinical and economic consequences.

Epidemiology of treatment-associated mucosal injury after treatment with newer regimens for lymphoma, breast, lung, or colorectal cancer.

GOALS OF WORK: Oral and gastrointestinal (GI) mucositis are frequent complications of chemotherapy and radiotherapy for cancer, contributing to not only the morbidity of treatment but its cost as well. The risk associated with specific chemotherapeutic agents, alone and in combination, has been characterized previously. In the current study, we sought to estimate the risk associated with newer regimens for the treatment of non-Hodgkin's lymphoma (NHL) and common solid tumors. METHODS: We reviewed published studies reporting phase II and III clinical trials of dose-dense regimens for breast cancer and NHL, TAC (docetaxel, adriamycin, cyclophosphamide) chemotherapy for breast cancer, and infusional 5-fluorouracil-based regimens for colorectal cancer. Platinum-, gemcitabine-, and taxane-based regimens for lung cancer, either alone or in combination with radiotherapy, were also considered. Using modified meta-analysis methods, we calculated quality-adjusted estimates of the risk for oral and GI mucositis by tumor type and regimen. Case reports are used to emphasize the relevance of the findings for patient care. MAIN RESULTS: Our findings demonstrate that mucosal toxicity remains an important complication of cancer treatment. Moreover, innovations in drug combinations, scheduling, or mode of administration significantly modulate the risk for both oral and GI mucositis. CONCLUSIONS: Ongoing review of the clinical trial experience will remain important as newer, targeted agents enter standard clinical practice.

Epidemiology and outcomes of serious influenza-related infections in the cancer population.

BACKGROUND: Although patients with cancer generally respond favorably to vaccination, they may not receive annual influenza vaccinations. The current population-based study described the epidemiology and outcomes of potentially preventable, serious influenza-related infections in patients with cancer. METHODS: From the Nationwide Inpatient Sample, the authors created a subsample that included discharges with any International Classification of Diseases, ninth revision, diagnosis code for cancer and principal diagnosis code for influenza, bronchopneumonia, or pneumonia caused by an unspecified organism. From the latter two diagnosis codes, the authors estimated excess cases during the influenza season for each year and stratum, then selected a random sample from fall and winter discharges. Subset analyses included weighted sample means, frequencies, and analysis of variance values. The authors converted charges to costs using cost-to-charge ratios and inflated these to 2003 U.S. dollars. Hospitalization and mortality rates were calculated using 5-year cancer prevalence estimates. RESULTS: The estimated mean annual hospital discharges of patients with cancer with potentially preventable, serious influenza-related infections numbered 16,000. The average length and cost per stay were 6 days and > USD 6300, respectively. Approximately 9% of patients died in the hospital and 31% needed further skilled care. The estimated age-specific rates for hospitalization and death per 100,000 in the prevalent cancer population were 219 and 17.4, respectively, for patients age < 65 years and 623 and 59.4, respectively, for those age > or = 65 years. Hospitalization costs averaged USD 1300 more for patients age < 65 years. CONCLUSIONS: Death from influenza-related infections occurred in an estimated 9% of patients with cancer hospitalized for such. Using recommended vaccination schedules for patients with cancer and their contacts reduced hospitalizations, treatment delays, and deaths in this highly susceptible population.

Scope and epidemiology of cancer therapy-induced oral and gastrointestinal mucositis.

OBJECTIVE: To discuss the scope and epidemiology of cancer therapy-induced mucositis. DATA SOURCE: Peer-reviewed articles and book chapters. CONCLUSION: Mucositis is a frequent and costly complication of cancer treatment. The risk of cancer therapy-induced mucositis varies depending on a number of patient- and treatment-related factors. IMPLICATIONS FOR NURSING PRACTICE: An awareness of the risk factors associated with mucositis will allow nurses to identify cancer patients at greatest risk and incorporate supportive care measures into their management plans.

High prevalence of hypothyroidism among patients with cutaneous melanoma.

We have previously reported a high prevalence of hypothyroidism among patients with uveal melanoma. The objectives of the present study were to determine if a similar pattern of thyroid pathology exists among patients with cutaneous melanoma as well. To address this question, the medical records of all patients registered at the University of Texas M.D. Anderson Cancer Center with a diagnosis of cutaneous melanoma during the years 1997 and 1998 were examined for a history of overt hypothyroidism, defined as a requirement for thyroid hormone replacement. Data regarding stage and site of the primary tumor were obtained for these patients and for age/gender matched euthyroid controls from the same melanoma study population. Among 1,580 cutaneous melanoma patients (948 M/632 F), 111 (7.0%) gave a history of hypothyroidism [23/948 M (2.4%) and 88/632 F (13.9%)]. The prevalences of hypothyroidism for both males and females were significantly higher than those reported for the general population. Characteristics of the primary tumor did not differ between cases and controls, although there was a trend for a lower rate of primary tumor ulceration among the hypothyroid case subjects. We conclude that hypothyroidism of varied etiologies is common among patients with cutaneous melanoma. These data suggest that melanoma may be responsive to hormones of the thyroid hormone control loop, raising many questions of clinical and biologic importance.

Differences in Breast Cancer Treatment and Survival Between Older and Younger Women.

The study aim was to compare breast cancer treatment and survival between older and younger women treated at the University of Texas M. D. Anderson Cancer Center over a 30-year period, 1958-1987. Data were obtained from the Medical Informatics Tumor Registry and were examined by 15-year time periods. Treatments were stratified by no surgery, surgery alone, or surgery and additional treatment. Mantel-Haenszel chi-square statistics and actuarial life tables were used for comparisons. Among 3,382 women treated for breast cancer, treatment differed by age groups (p < 0.01). The most consistent finding by disease stage was that older women were less likely to receive treatment in addition to surgery compared to younger women (p < 0.01-0.05). Among women with local or regional involvement who received surgery and additional treatment, 5-year survival was similar regardless of age group. However, among women with distant disease who received surgery and additional treatment, 5-year survival differed significantly by age group (p = 0.03); women in the 65- to 74-year age group experienced the best survival. In this hospital population, older women with breast cancer who received surgery and additional treatment experienced similar, sometimes better, 5-year survival compared with younger women, which suggests that older women, in some cases, may benefit from combined modality treatment for breast cancer.