Breast cancer outcomes among older women: HMO, fee-for-service, and delivery system comparisons.

OBJECTIVE: To analyze the relationship of health insurance status and delivery systems to breast cancer outcomes--stage at diagnosis, treatment selected, survival--focusing on comparisons among women aged 65 or more having Medicare alone, Medicare/Medicaid, or Medicare with group model HMO, non-group model HMO, or private fee-for-service (FFS) supplement. DESIGN: Retrospectively defined cohort from Sacramento, Calif, regional cancer registry. SETTING: Thirteen-county region in northern California with mature managed care market. PATIENTS: Female invasive breast cancer patients aged 65 or more (N = 1,146), diagnosed 1987-1993. MEASUREMENTS AND MAIN RESULTS: Health insurance was determined from hospital records. Outcomes were analyzed with multivariate regression models, controlling for age, ethnicity, time, and SES measures. Stage I diagnosis was more likely among group model HMO patients than among private FFS insured (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.84 to 2.40). Stage I tumors were significantly less likely for Medicaid patients (OR, 0.50; 95% CI, 0.31 to 0.82). Use of breast-conserving surgery plus radiation (BCS+) varied significantly by hospital type (including HMO-owned and various-sized community hospitals) and time. Survival of patients with private FFS, group-, and non-group model HMO insurance was not significantly different, but was for those with Medicaid or Medicare alone. CONCLUSIONS: This study sheds new light on the relationship of insurance to stage and survival among older breast cancer patients, highlighting the importance of distinguishing types of HMOs and types of FFS plans. These outcomes do not differ significantly between women with Medicare who are in HMOs and those with private FFS supplemental insurance. However, patients with Medicare/Medicaid or Medicare alone are at risk for poorer outcomes.

The relationship of HMOs, health insurance, and delivery systems to breast cancer outcomes.

BACKGROUND: The current climate of anger and frustration with managed care has heightened interest in the quality of health care provided by managed-care plans, particularly health maintenance organizations (HMOs). This breast cancer outcomes study, investigating relationships of health insurance and delivery systems to stage at diagnosis, treatment selected, and survival, is based in a heavily penetrated, highly competitive HMO market. METHODS: Data for 1,788 residents of northern California younger than 65 years of age at diagnosis (1987-1993) were provided by a population-based cancer registry. Patient insurance included fee-for-service (FFS), group-model HMO, nongroup HMO, publicly insured, and uninsured. Diagnosis and treatment occurred in 73 hospitals (large, medium/moderately small, or very small community, rural, teaching, or HMO-owned hospitals). Regression models examined relationships of insurance and hospital type to 3 outcomes (stage, treatment, and survival), controlling for age, ethnicity, education, neighborhood occupational class, and time period. RESULTS: Early diagnosis was as likely for group-model and nongroup-model HMO-insured patients as for the private FFS-insured patients. In 1987-1990, HMO-owned hospitals were leaders in treating 46% of early-stage breast cancers with breast-conserving surgery plus radiation (BCS+); by 1991-1993, the most significant increases in BCS+ use occurred at teaching and large community hospitals. Survival of group-model HMO, nongroup-model HMO, and FFS patients was not significantly different. Publicly insured/uninsured patients had more stage III/IV disease (OR=2.01, P = 0.006) and greater all-cause mortality (risk ratio 1.46, P = 0.015). CONCLUSIONS: Group-model and nongroup-model HMO patients are similar to FFS-insured patients in stage at diagnosis and survival outcomes. Treatment selection is related to hospital type rather than insurance coverage.

The relationship of blood- and urine-boron to boron exposure in borax-workers and usefulness of urine-boron as an exposure marker.

Daily dietary-boron intake and on-the-job inspired boron were compared with blood- and urine-boron concentrations in workers engaged in packaging and shipping borax. Fourteen workers handling borax at jobs of low, medium, and high dust exposures were sampled throughout full shifts for 5 consecutive days each. Airborne borax concentrations ranged from means of 3.3 mg/m3 to 18 mg/m3, measured gravimetrically. End-of-shift mean blood-boron concentrations ranged from 0.11 to 0.26 microgram/g; end-of-shift mean urine concentrations ranged from 3.16 to 10.72 micrograms/mg creatinine. Creatinine measures were used to adjust for differences in urine-specific gravity such that 1 ml of urine contains approximately 1 mg creatinine. There was no progressive increase in end-of-shift blood- or urine-boron concentrations across the days of the week. Urine testing done at the end of the work shift gave a somewhat better estimate of borate exposure than did blood testing, was sampled more easily, and was analytically less difficult to perform. Personal air samplers of two types were used: one, the 37-mm closed-face, two-piece cassette to estimate total dust and the other, the Institute of Occupational Medicine (IOM) sampler to estimate inspirable particulate mass. Under the conditions of this study, the IOM air sampler more nearly estimated human exposure as measured by blood- and urine-boron levels than did the sampler that measured total dust.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment differences and other prognostic factors related to breast cancer survival. Delivery systems and medical outcomes.

OBJECTIVE: To determine differences in and relative importance of treatment modalities by hospital type and their effect on survival of breast cancer patients. DESIGN: Cohort of population-based cancer registry breast cancer patients diagnosed from 1984 through 1990. The analysis was done within this cohort, stratified by hospital type and treatment modality. SETTING: Orange County, California, residents diagnosed and treated for breast cancer in 126 hospitals (small community, large community, health maintenance organization [HMO], or teaching). PATIENTS: A total of 5892 non-Hispanic white women with no known prior cancer and with localized or regional, histologically confirmed breast cancer. MAIN OUTCOME MEASURES: Effects of treatment modality and hospital type on survival. Adjustments for differences in age, tumor size, number of positive lymph nodes, and histology were included in the analysis. RESULTS: Use of recommended breast-conserving surgery (BCS) was greatest among teaching hospitals, where more than 50% of patients with localized disease received BCS between 1988 and 1990 and 40% to 50% with regional disease received BCS between 1984 and 1990. At nonteaching hospitals, 30% or less of patients received BCS between 1984 and 1989, regardless of stage. Rates of survival after BCS were at least as good as rates of survival after total mastectomy, other factors being equal. Survival rates varied by hospital type for patients with localized disease, with significantly better rates at large community hospitals and significantly worse rates at HMO hospitals in comparison with small hospitals. Patients with regional disease at large hospitals had a significant survival advantage. CONCLUSIONS: Greater use of BCS is strongly urged. Overall, large community hospitals had significantly better survival rates than small community and HMO hospitals. Further follow-up will determine if treatment and survival differences by hospital type persist.

The association of bladder cancer risk with ethnicity, gender, and smoking.

This study examined patterns of invasive bladder cancer by ethnicity and gender. Odds ratios were computed by comparing 593 patients of known smoking status and diagnosed during the period from 1984 to 1988 with a randomly selected referent group using a logistic regression model that adjusted for differences in age and current occupation. Age-adjusted incidence rates for non-Hispanic whites were approximately twice those of Hispanics and Asian and Pacific Islanders. After adjustment for smoking and occupational exposures, the risks did not differ significantly, indicating that ethnic differences in bladder cancer incidence may be related to smoking and occupational exposures. The odds ratio for males relative to females was 5.95 (95% confidence interval (CI), 4.36 to 8.12), after adjustment for ethnicity, smoking status, occupation, and age, suggesting that gender differences not previously identified may play an important role in the etiology of bladder cancer. Odds ratios associated with amount smoked per day, for current smokers relative to nonsmokers, ranged from 1.04 for those smoking less than 1 pack per day (95% CI, 0.62 to 1.71) to 6.84 for those smoking 2 or more packs per day (95% CI, 4.67 to 10.03).

Five-year follow-up study of hearing loss at several locations within a large automobile company.

This longitudinal epidemiologic study was designed to investigate hearing loss over a 5-year period among noise-exposed employees of a large automobile company and to assess effectiveness of hearing conservation programs at locations representing the spectrum of operations (assembly, light manufacturing, heavy manufacturing and machining, metal fabrication, and founding). Based on computerized audiometric test data, the study summarizes methodology developed for measuring occupational hearing loss and its application in evaluating programs at these locations, which had maximal 8-hr time-weighted average (TWA) noise exposures ranging from 104 to 110 dB(A). Methods presented here provide for consideration of age and hearing level of study subjects at baseline audiogram and clearly demonstrate the extent of hearing loss during the study period. Among five study locations, the average hearing loss at 2,000-4,000 Hz in the worst-loss ear ranged from 3.4 to 6.2 dB over the follow-up period; after adjustment for presbycusis, the loss was less than 2 dB at all but one location, which showed a loss of nearly 4 dB. In comparison to a control group of nonnoise-exposed employees, hearing conservation programs at four of the five locations were judged to be effective. One location, a metal fabrication plant with a large percentage of employees having an 8-hr TWA noise exposure over 90 dB(A), was particularly noted for the effectiveness of its program.

Occupation and bladder cancer risk.

This study examines the estimated risk of bladder cancer associated with various occupations among 1,465 cases identified in Orange County, California, during 1984-1988. The annual age-adjusted incidence rate per 100,000 population in Orange County was similar to that of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute: 25.7 in males and 6.2 in females. Cases were compared with a sample of Orange County residents relative to broad category of current occupation, adjusted for age and cigarette smoking. The estimated relative risks were significant for males in machine trades (relative risk (RR) = 2.69, 95% confidence interval (CI) 1.24-5.82) and processing occupations (RR = 5.77, 95% CI 1.43-23.27) and for females in machine trades (RR = 8.34, 95% CI 1.14-61.17) and homemakers (RR = 5.37, 95% CI 2.40-11.99) as compared with individuals of the same sex in professional, technical, and managerial occupations.

Comparison of adenocarcinoma and squamous cell carcinoma of the uterine cervix: a population-based epidemiologic study.

OBJECTIVE: Our objective was to compare epidemiologic and clinical characteristics of adenocarcinoma with those of squamous cell carcinoma of the cervix, with respect to risk by ethnic group, age at diagnosis, stage of disease at diagnosis, and survival. STUDY DESIGN: All data were obtained from the Cancer Surveillance Program of Orange County, California, from 1984 through 1989. A total of 152 cases of adenocarcinoma and 457 of squamous cell carcinoma of the uterine cervix were included. RESULTS: Adenocarcinoma of the cervix was diagnosed at a younger age and an earlier stage than squamous cell carcinoma. Hispanics have the highest risk for squamous cell carcinoma, whereas Asians have the highest risk for adenocarcinoma compared with whites. No differences were observed between the two histologic types in prognosis and survival. CONCLUSION: Differences between the two histologic types of cervix cancer were found in the age at diagnosis, the extent of disease, and the ethnic distribution. In spite of these differences, prognosis and survival were not affected by histologic type.

A comparison of several measures of exposure to arsenic. Matched case-control study of copper smelter employees.

To explore the relation between respiratory cancer mortality and exposure to airborne arsenic, methods of conditional logistic regression analysis are applied to a matched case-control study of copper smelter employees in Montana. With follow-up data for the period 1938-1977, several measures of arsenic exposure are compared. For men first employed prior to 1925, three measures--the category of maximum arsenic exposure, cumulative arsenic exposure, and time-weighted average arsenic exposure--are good predictors of respiratory cancer mortality. Within this group, there was a significantly elevated relative risk of respiratory cancer mortality associated with medium and heavy exposure to arsenic. For men first employed during 1925-1947, time-weighted average exposure to arsenic (adjusted for age at first employment) is the best predictor. In this group, men with heavy arsenic exposure and initially employed at 16.9 years had a relative risk of 6.0 in comparison to the baseline group with only light exposure to arsenic and initially employed at 31.9 years. No particular advantage is found in lagging exposures 10 years prior to death of the case in each matched set.

Cumulative exposure to arsenic and its relationship to respiratory cancer among copper smelter employees.

To explore the role of arsenic as a human carcinogen, the respiratory cancer mortality experience (1938 to 1977) of 8,045 while male smelter employees in Montana was examined relative to cumulative exposure to arsenic trioxide and was compared with that of the white male population of the same region. Exposure to arsenic was estimated for various work areas from industrial hygiene reports of average concentrations present in the smelter. Respiratory cancer mortality was analyzed further by time period of first employment and maximum lifetime exposure to arsenic trioxide. When exposure was estimated with arithmetic means of measured concentrations among men first employed prior to 1925, respiratory cancer mortality increased linearly with increasing cumulative exposure group, ranging from two to nine times expected; among those first employed in the period 1925 to 1947 it also increased linearly with increasing cumulative exposure group.

Arsenic and respiratory cancer in humans: follow-up of copper smelter employees in Montana.

As a follow-up to an earlier study concerned with the role of arsenic in human carcinogenesis, the mortality experience during 1938-77 of 8,045 white male smelter employees in Montana exposed to arsenic trioxide was compared to that of the white male population of the same region. The excess mortality among smelter employees was due largely to respiratory cancer and diseases of the heart. Respiratory cancer mortality was analyzed with reference to period of first employment, length of employment, and degree of exposure to arsenic trioxide and sulfur dioxide. The excess in respiratory cancer was seven to eight times that expected among men first employed prior to 1925 who were heavily or moderately exposed to arsenic trioxide; it was more than four times that expected among men heavily exposed and first employed in 1925-47, and it decreased in direct proportion to degree of arsenic trioxide exposure. Inhaled arsenic trioxide was strongly implicated as the primary agent associated with the excess respiratory cancer, with sulfur dioxide perhaps enhancing the effect.

Parity and blood pressure among four race-stress groups of females in Detroit.

Blood pressures (BPs) of 755 Detroit, Michigan, area females have been analyzed in relation to parity, race and residential stress. Mean BP values have been adjusted by standard methods of covariance analysis for differing effects of age and body size among various groups being compared. Adjusted systolic and diastolic BPs are found to be significantly different for black and white females. A residential stress effect is also seen for systolic BP among white females. However, none of the regression relationships between BP and parity is found to be significant in the race-stress groups included in the study. Thus, neither the consideration of race and stress nor adjustments for age and body size appear to add new information to the complex subject of BP as it relates to childbearing.