Regional differences in health services can point to disparities in access to healthcare. The authors performed a population-based cohort study to examine differences in ovarian cancer treatment and mortality according to geographic region.
The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify 4589 women aged ≥65 years with ovarian cancer diagnosed between 1998 and 2002 who had Medicare claims filed from 1998 to 2005. Hospital Referral Region (HRR) was assigned according to patient zip code. The authors calculated the proportion of women in each HRR who underwent cancer-directed surgery. With HRR as the predictor of interest, mortality and the receipt of cancer-directed surgery were described in multivariate analyses.
Among 4589 women with ovarian cancer, 3286 underwent cancer-directed surgery. The receipt of cancer-directed surgery varied by HRR (range, 53%-88%). Women were less likely to undergo cancer-directed surgery if they were older, nonwhite, had higher stage disease, or had more comorbidities. For example, white women were more likely to undergo such surgery (odds ratio, 1.41; 95% confidence interval, 1.10-1.82) compared with all nonwhite women. HRR was a significant predictor of cancer-directed surgery (P = .01). A significant correlation was observed between HRR and all-cause mortality (P = .02); however, after adjusting for cancer-directed surgery, that correlation was no longer significant (P = .10).
There was regional variation in mortality among Medicare recipients with ovarian cancer, and access to cancer-directed surgery explained some of that variation. Improving access to high-quality cancer surgery for ovarian cancer may improve outcomes, particularly for minorities and for older women.
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"Such regional differences in health services can point to disparities in access to health care, and only a handful of studies have addressed this question in ovarian cancer. Fairfield and coworkers studied 4589 patients from the SEER database (1998–2002) and found that hospital referral region was associated with the likelihood of cancer directed surgery but not chemotherapy use . Hospital referral regions also significantly predicted all-cause mortality; however, after adjusting for cancer-directed surgery, that correlation was no longer significant. "
[Show abstract][Hide abstract] ABSTRACT: To determine the impact of geographic location on advanced-stage ovarian cancer care adherence to National Comprehensive Cancer Network (NCCN) guidelines in relation to race and socioeconomic status (SES).
Patients diagnosed with Stage IIIC/IV epithelial ovarian cancer (1/1/96-12/31/06) were identified from the California Cancer Registry. Generalized additive models were created to assess the effect of spatial distributions of geographic location, proximity to a high-volume hospital (≥20 cases/year), distance travelled to receive care, race, and SES on adherence to NCCN guidelines, with simultaneous smoothing of geographic location and adjustment for confounding variables. Disparities in geographic predictors of treatment adherence were analyzed with the x(2) test for equality of proportions.
Of the 11,770 patients identified, 45.4% were treated according to NCCN guidelines. Black race (OR=1.49, 95%CI=1.21-1.83), low-SES (OR=1.46, 95%CI=1.24-1.72), and geographic location ≥80km/50mi from a high-volume hospital (OR=1.88, 95%CI=1.61-2.19) were independently associated with an increased risk of non-adherent care, while high-volume hospital treatment (OR=0.59, 95%CI=0.53-0.66) and travel distance to receive care ≥32km/20mi (OR=0.80, 95%CI=0.69-0.92) were independently protective. SES was inversely associated with location ≥80km/50mi from a high-volume hospital, ranging from 6.3% (high-SES) to 33.0% (low-SES) (p<0.0001). White patients were significantly more likely to travel ≥32km/20mi to receive care (21.8%) compared to Blacks (14.4%), Hispanics (15.9%), and Asian/Pacific Islanders (15.5%) (p<0.0001).
Geographic proximity to a high-volume hospital and travel distance to receive treatment are independently associated with NCCN guideline adherent care for advanced-stage ovarian cancer. Geographic barriers to standard ovarian cancer treatment disproportionately affect racial minorities and women of low-SES.
[Show abstract][Hide abstract] ABSTRACT: Pharmaceutical products are often present in wastewater treatment effluents, rivers and lakes. A wide variety of drugs have been found in waterways of many countries, including analgesics, antibiotics and antiepileptics. The adsorption of four common pharmaceuticals present in surface-waters, trimethoprim (antibiotic), carbamazepine (antiepileptic), ketoprofen and naproxen (analgesics) onto Amberlite XAD-7 (an acrylic ester resin) has been investigated. Adsorption experiments were carried out at different pH conditions and the experimental equilibrium data were fitted to the Langmuir, Freundlich and Dubinin-Radushkevich models. For the same experimental conditions (pH 7) the estimated adsorption capacities are from 97 mg g(-1) for carbamazepine >54 mg g(-1) for trimethoprim >45 mg g(-1) for ketoprofen and approximate to 43 mg g(-1) for naproxen. The influence of adsorption pH was established for each compound. The investigation indicates that the mean sorption energy (E=8.3-10.1 kJ mol(-1)) characterizes a physical adsorption and the surface of the resin is energetically heterogeneous. On the other hand, the work studies the effect of the presence of other drugs in solution on the individual adsorption process. The comparison of Freundlich-parameters shows that the adsorption capacity decreases as expected for neutral and acidic drugs and increases for the case of trimethoprim (a basic drug).
[Show abstract][Hide abstract] ABSTRACT: Optimal care for most patients with advanced ovarian cancer generally includes both surgery and chemotherapy. Little is known about the proportion of women in the US who receive combination care or the sequence in which this care is delivered. This study evaluated patterns of care, frequency of completion of recommended therapy and factors associated with sequencing of therapy.
Using the Surveillance, Epidemiology and End-Results data we identified a cohort of 8211 women aged 65 and above with stage III/IV epithelial ovarian cancer diagnosed between 1995 and 2005. Receipt of chemotherapy or surgery was identified using Medicare claims. Logistic regression was used to evaluate factors associated with sequencing of treatment and the receipt of surgery.
3241 (39.1%) had surgery and at least 6 cycles of chemotherapy in either order. Surgery was performed initially in 4827 (58.8%) women and 3658/4827 (75.8%) had subsequent chemotherapy. 2017 (24.6%) had primary chemotherapy and 649/2017 (32.2%) of these women had subsequent surgery. Advanced age, African American race, stage IV disease, non-married status and increasing medical comorbidity were all associated with the failure to receive both surgery and at least 6 cycles of chemotherapy (all p<0.01).
The majority of women with advanced ovarian cancer in the Medicare population do not receive both combination therapy with surgery and at least 6 cycles of chemotherapy. A large proportion of women are receiving chemotherapy as primary treatment for advanced ovarian cancer, and the majority of these patients do not have cancer-directed surgery.