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ABSTRACT: The objective of this study was to examine patterns of care and survival in a population-based sample of patients with head and neck cancer (HNC) who were treated in the community or in hospitals that had residency training programs.
Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program were used to sample 1317 patients aged ≥20 years with invasive squamous HNC who were diagnosed during 2004 and who had vital status available through 2008.
Treatment and survival were influenced by tumor site and disease stage. Patients who had stage I/II cancer of the oral cavity generally underwent surgery; patients with stage III oral cavity disease underwent surgery and received radiation; and patients with stage IV oral cavity disease underwent surgery and received chemoradiation. Patients with early stage cancer of the oropharynx either underwent surgery or received radiation and chemotherapy, and patients with late/unstaged oropharyngeal disease primarily received radiation and chemotherapy. Patients with early stage cancer of the larynx mainly received radiation alone, and patients with late stage laryngeal disease generally received chemoradiation. Cisplatin-based regimens were used most frequently. Overall, taxanes were used in 32% of regimens, and cetuximab was used in <3% of regimens. Patients aged ≥50 years, those with a Charlson comorbidity score ≥1, those with stage IV disease, and those with cancer located in the oral cavity or larynx had poorer survival. Although facilities with residency training programs treated more black patients and more patients with late stage disease, when adjusted for other factors, survival rates were similar to those reported in facilities with no such programs.
Therapy generally followed accepted standards for 2004. Findings in particular tumor sites and stages may reflect the variability that still exists for the treatment of HNC. The use of taxanes and cetuximab is expected to increase based on new evidence of benefit. Reducing treatment-related toxicities and long-term functional deficits will be critical and especially important with the increase in human papillomavirus-related cancers. In addition, further attempts to improve survival for older patients are needed. Cancer 2012. © 2012 American Cancer Society.
Cancer 01/2012; 118(18):4452-61. · 4.77 Impact Factor
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ABSTRACT: Because adolescent and young adult (AYA) patients with cancer have experienced variable improvement in survival over the past two decades, enhancing the quality and timeliness of cancer care in this population has emerged as a priority area. To identify current trends in AYA care, we examined patterns of clinical trial participation, time to treatment, and provider characteristics in a population-based sample of AYA patients with cancer.
Using the National Cancer Institute Patterns of Care Study, we used multivariate logistic regression to evaluate demographic and provider characteristics associated with clinical trial enrollment and time to treatment among 1,358 AYA patients with cancer (age 15 to 39 years) identified through the Surveillance, Epidemiology, and End Results Program.
In our study, 14% of patients age 15 to 39 years had enrolled onto a clinical trial; participation varied by type of cancer, with the highest participation in those diagnosed with acute lymphoblastic leukemia (37%) and sarcoma (32%). Multivariate analyses demonstrated that uninsured, older patients and those treated by nonpediatric oncologists were less likely to enroll onto clinical trials. Median time from pathologic confirmation to first treatment was 3 days, but this varied by race/ethnicity and cancer site. In multivariate analyses, advanced cancer stage and outpatient treatment alone were associated with longer time from pathologic confirmation to treatment.
Our study identified factors associated with low clinical trial participation in AYA patients with cancer. These findings support the continued need to improve access to clinical trials and innovative treatments for this population, which may ultimately translate into improved survival.
Journal of Clinical Oncology 09/2011; 29(30):4045-53. · 18.37 Impact Factor
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ABSTRACT: To describe therapy and changes in therapy over time for women diagnosed with ductal carcinoma in situ (DCIS) and treated in the community setting. Women aged 20 or older diagnosed with DCIS in this study were sampled from the population-based Surveillance, Epidemiology and End Results Program. A total of 770, 1055, 480, and 404 women with DCIS were selected in 1991, 1995, 2000, or 2005, respectively. Most women do not have nodal sampling, but between 2000 and 2005 there was an increase in the use of sentinel node biopsy, 9 and 22%, respectively. Of the DCIS patients, 80% had no or unknown HER-2 assays, 12% were postitive, 7% negative, and 1% equivocal. After adjusting for tumor size, age, race, marital status, and insurance there has been a decrease in mastectomy since 1991. Of women with DCIS 36% were given tamoxifen in 2000; in 2005 this decreased to about 21%. However, in 2005 we see the use of aromatase inhibitors in nearly 4% of patients. HER-2 testing is increasingly performed for women with DCIS. Despite positive HER-2 tests no women received trastuzumab as of 2005. Despite the lack of clinical trials evidence, aromatase inhibitors are being prescribed for women with DCIS.
Breast Cancer Research and Treatment 10/2010; 127(1):251-7. · 4.43 Impact Factor
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ABSTRACT: Imatinib is a highly effective treatment for chronic myeloid leukemia. It was approved by the Food and Drug Administration in 2001 and thereafter rapidly became front-line therapy. This study characterized the prevailing chronic myeloid leukemia therapies in the United States and assessed the impact of imatinib on chronic myeloid leukemia survival and mortality rates in the general population.
Investigators with the National Cancer Institute's Patterns of Care study reviewed medical records and queried physicians regarding therapy for 423 patients with chronic myeloid leukemia diagnosed in 2003 who were randomly selected from cancer registries in the Surveillance, Epidemiology, and End Results Program. Characteristics associated with the receipt of imatinib were documented, as were survival differences between those who received imatinib and those who did not. Population-based data were used to assess chronic myeloid leukemia survival and mortality rates in time periods before and after the introduction of imatinib.
Imatinib was administered to 76% of patients in the Patterns of Care study. Imatinib use was inversely associated with age: 90%, 75%, and 46% for patients ages 20 to 59 years, 60 to 79 years, and 80 or more years, respectively. Elderly patients who received imatinib survived significantly longer than those who did not. After adjusting for age, imatinib use did not vary significantly by race/ethnicity, socioeconomic status, urban/rural residence, presence of comorbid conditions, or insurance status. Overall, chronic myeloid leukemia survival in the Surveillance, Epidemiology, and End Results population improved, and mortality in the United States declined dramatically during the period when imatinib became widely available; these improvements diminished with increasing age.
Age disparities in treatment with imatinib likely contributed to worse survival for many elderly patients with chronic myeloid leukemia.
The American journal of medicine 08/2010; 123(8):764.e1-9. · 4.47 Impact Factor
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ABSTRACT: Breast cancer in men is rare, so clinical trials are not practical. Recommendations suggest treating men who are diagnosed with breast cancer using the guidelines for postmenopausal women; however, to date, no population-based studies have evaluated patterns of care.
To examine characteristics, treatment, and survival among men with newly diagnosed breast cancer, in 2003 and 2004, 512 men were identified from the Surveillance, Epidemiology and End Results Program. Data were reabstracted and therapy was verified through the patients' treating physicians.
The majority of men (79%) were diagnosed through discovery of a breast lump or other signs/symptoms. Among men who had invasive disease, 86% underwent mastectomy, 37% received chemotherapy, and 58% received hormone therapy. In multivariate analysis, tumor size (P=.01) and positive lymph node status (P<.0001) were associated positively with the use of chemotherapy, whereas age group (P<.0001) and current unmarried status (P=.01) had negative associations. Among men who had invasive, estrogen receptor (ER)-positive/borderline tumors, the use of tamoxifen or aromatase inhibitors (AIs) was associated with age group (P=.05). Among men who had invasive disease, cancer mortality was associated with tumor size (P<.0001). Among men with ER-positive/borderline disease, increased cancer mortality was associated with tumor size (P<.0001), current unmarried status (P=.04), and decreased mortality with tamoxifen (P=.04).
Tumor characteristics and marital status were the primary predictors of therapy and cancer mortality among men with breast cancer. Although AIs are not currently recommended, they are commonly prescribed. However, their use did not result in a decrease in cancer mortality. Research must examine the efficacy of AIs with and without gonadotropin-releasing hormone analogues.
Cancer 08/2010; 116(15):3558-68. · 4.77 Impact Factor
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ABSTRACT: Testicular cancer is the most common cancer in men age 25 to 35 years. We examined therapy, compliance with guidelines, and survival in a population based sample of men newly diagnosed with testicular cancer.
We analyzed the National Cancer Institute's (NCI) patterns of care data on 702 men diagnosed with testicular cancer in 1999. These studies supplement routine data collection by verifying therapy with the patients' treating physicians. Follow-up for vital status was available through December 31, 2004.
The majority of the men with seminoma were diagnosed while their cancer was localized and more than 80% of received orchiectomy with radiation. For men with seminoma and nonseminoma germ cell tumors (NSGCT), the percent receiving chemotherapy increased markedly as stage increased. More than 90% of men with regional and distant NSGCT received chemotherapy. Less than 25% of men with localized NSGCT received orchiectomy and retroperitoneal lymph node dissection (RPLND), about 40% had surveillance following an orchiectomy alone, and 30% received orchiectomy and chemotherapy.
The majority of these patients received therapy consistent with guidelines. While there was no significant difference in the use of RPLND in men with localized NSGCT by geographic region, chemotherapy use varied widely. Over 90% of men with localized or regional disease diagnosed in 1999 were alive at the end of 2004. The excellent survival rates point to the need to monitor for late effects of therapy.
Urologic Oncology 10/2008; 27(6):604-10. · 3.22 Impact Factor
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ABSTRACT: Over the past decade, clinical trials have proved the efficacy of treatments for colorectal cancer (CRC). This study tracks dissemination of these treatments for patients diagnosed with stage II and III disease and compares risk of death for those who received guideline therapy to those who did not.
We conducted a stratified randomly sampled, population-based study of CRC treatment trends in the United States. Multivariate models were used to explore patient characteristics associated with receipt of treatments. We pooled data with a previous study-patients diagnosed in 1987-1991 and 1995. Cox proportional hazards models were used to assess observed cause-specific and all-cause mortality.
In 2000, guideline therapy receipt decreased among stage III rectal cancer patients, but increased for stage III colon and stage II rectal cancer patients. As age increased, likelihood of receiving guideline treatment decreased (p < 0.0001). Overall, race/ethnicity was significantly associated with guideline therapy (p = 0.04). Rectal patients were less likely to have received guideline treatment. Consistent with randomized clinical trial findings, all-cause mortality was lower in patients who received guideline therapy, regardless of Charlson comorbidity score.
Mortality was decreased in patients receiving guideline therapy. Although, rates of guideline-concordant therapy are low in community clinical practice, they are apparently increasing. Newer treatment (oxaliplatin, capecitabine) started to disseminate in 2000. Racial disparities, present in 1995, were not detected in 2000. Age disparities remain despite no evidence of greater chemotherapy-induced toxicity in the elderly. More equitable receipt of cancer treatment to all segments of the community will help to reduce mortality.
The American Journal of Gastroenterology 11/2006; 101(10):2308-18. · 7.28 Impact Factor
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ABSTRACT: We describe trends in the use of chemotherapy and hormonal therapy by nodal and estrogen receptor (ER) status in women with early-stage breast cancer.
Cases were randomly sampled from the population-based Surveillance, Epidemiology and End Results (SEER) program and physician verified treatment was examined. A total of 9,481 women, aged 20 years and older, diagnosed with early-stage breast cancer in 1987 to 1991, 1995, and 2000 were included in the study.
The use of chemotherapy plus tamoxifen increased between 1995 and 2000 for women with node-negative, ER-positive breast cancer > or = 1 cm (8% to 21%). Nearly 23% of women with node-negative and ER-positive tumors > or = 1 cm received no adjuvant therapy. The use of chemotherapy alone increased to nearly 60% in women with node-negative, ER-negative tumors > or = 1 cm (48% to 59%). However, in 2000, 16% of women with node-positive and ER-negative tumors received no adjuvant therapy and an additional 6% received tamoxifen alone. The influence of age can clearly be seen. Chemotherapy is given much less often in women 70 years or older.
The results from SEER areas across the United States suggest that physicians quickly responded to publications and guidelines regarding breast cancer therapy. The lack of definitive findings from clinical trials on the use of adjuvant therapy in women 70 years and older may explain the lower use in this group of women.
Journal of Clinical Oncology 02/2006; 24(6):872-7. · 18.37 Impact Factor
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ABSTRACT: This study estimates the impact of type of insurance coverage on the receipt of guideline therapy in a population-based sample of cancer patients treated in the community.
Patients (n = 7,134) from the National Cancer Institute's Patterns of Care studies who were newly diagnosed with 11 different types of cancer were analyzed. The definition of guideline therapy was based on the National Comprehensive Cancer Network treatment recommendations. Insurance status was categorized as a mutually exclusive hierarchical variable (no insurance, any private insurance, any Medicaid, Medicare only, and all other). Multivariate analyses were used to examine the association between insurance and receipt of guideline therapy.
Adjusting for clinical and nonclinical variables, insurance status was a modest, although statistically significant, determinant of receipt of guideline therapy, with 65% of the privately insured patients receiving recommended therapy compared with 60% of patients with Medicaid. Seventy percent of the uninsured patients received guideline therapy, which was nonsignificantly different compared with private insurance. When stratified by race, insurance was a statistically significant predictor of the receipt of guideline therapy only for non-Hispanic blacks.
Overall, levels of guideline treatment were lower than expected and particularly low for patients with Medicaid or Medicare only. The use of guideline therapy for ovarian and cervical cancer patients and for patients with rectal cancers was unrelated to type of insurance. Of particular concern is the significantly lower use of guideline therapy for non-Hispanic black patients with Medicaid. After adjusting for other factors, only half of these patients received guideline therapy.
Journal of Clinical Oncology 01/2006; 23(36):9079-88. · 18.37 Impact Factor
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ABSTRACT: New therapies have enhanced treatment of non-Hodgkin's lymphoma (NHL), but extent of treatment use in community practice is unknown. We conducted a population-based study of NHL patients diagnosed in 1999 with histologically confirmed NHL (n = 947) residing in areas covered by the Surveillance, Epidemiology, and End Results program. We performed analyses to study factors associated with receipt of chemotherapy, radiation, and rituximab, and examine factors associated with mortality. Most patients presented with B-cell lymphoma (n = 828). Approximately 20% of patients received no therapy, over 60% received chemotherapy, and 12% received rituximab, alone or in combination. Patients aged 75 +, and males were less likely to have received chemotherapy (p = 0.01). There were no significant associations between receipt of rituximab and the factors analyzed. Patients who presented with B-symptoms or unknown B-symptom status were less likely to receive radiation (OR = 0.32 and 0.47, respectively, p = 0.0002) than asymptomatic patients. Cause-specific and all-cause mortality were significantly associated with patient age, race/ethnicity, gender, marital status, co-morbid conditions, and histological subgroup. Hispanic and African-Americans, patients age 75 +, males, unmarried patients, or patients with B-symptoms had higher risk of death from NHL and all-cause (p < 0.01). This is the first population-based study examining therapy received for many histological subtypes of NHL.
Hematological Oncology 06/2005; 23(2):73-81. · 2.47 Impact Factor
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ABSTRACT: Non-Hispanic black women are less often diagnosed with endometrial cancer than are non-Hispanic white women, but are more likely to die of their disease. Reasons for this disparity in outcome are not well understood.
The Surveillance, Epidemiology, and End-Results Program data were used to sample women newly diagnosed in 1998 with cancer of the corpus uteri. A total of 711 women with no previous diagnosis of cancer were selected. Women with sarcoma were not eligible for the study. We then sought to verify the therapy provided each woman with her treating physician.
Non-Hispanic black women were diagnosed with higher stage, grade, poor histologic subtype, and greater extension of the tumor than were non-Hispanic white women. Hispanic women were diagnosed with more favorable tumor characteristics than non-Hispanic black women, but less favorable than non-Hispanic white women. The use of radiation and chemotherapy increased with stage.
Our study did not show any difference in recommended therapy for women with uterine adenocarcinoma among NH black women, NH white women, and Hispanic women. We must look for other factors, therefore, to explain the disparities in cancer outcome observed among NH black women with endometrial cancer.
Gynecologic Oncology 04/2005; 96(3):741-8. · 3.89 Impact Factor
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ABSTRACT: The age specific breast cancer incidence rate for African-American women under age 35 is more than twice the rate for white women of similar age, and the mortality rate is more than three times higher. To determine factors that may explain racial/ethnic variation in outcomes among young women diagnosed with breast cancer, the authors examined the clinical presentation, treatment, and survival of African-American, Hispanic, and white women under age 35 years.
Surveillance, Epidemiology, and End Results (SEER) Program data for 1990-1998 and SEER Patterns of Care data for 1990, 1991, and 1995 were used for this analysis. Multivariate logistic regression analyses were performed to examine factors associated with the receipt of selected breast cancer treatments. Kaplan-Meier survival analyses and Cox proportional hazards regression analyses were used to examine 5-year overall survival and disease-specific survival.
The authors found racial/ethnic variation in clinical presentation, treatment, and survival. Both African-American and Hispanic women presented with higher disease stage and a higher prevalence of adverse prognostic indicators compared to white women. African-American and Hispanic women received cancer-directed surgery and radiation less frequently after undergoing breast-conserving surgery. Racial/ethnic differences in clinical presentation and treatment were associated with poorer overall survival in unadjusted analyses. African-American and Hispanic women also had poorer overall survival after controlling for clinical and demographic characteristics and type of treatment.
Future research studies should further examine the factors that influence racial/ethnic differences in incidence, clinical presentation, and treatment differentials among young women diagnosed with breast cancer. A better understanding of these factors will facilitate the development of strategies to help eliminate this health disparity.
Cancer 02/2003; 97(1):134-47. · 4.77 Impact Factor
