Heather Taffet Gold

CUNY Graduate Center, New York City, New York, United States

Are you Heather Taffet Gold?

Claim your profile

Publications (30)142.12 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To understand decision making concerning adoption and nonadoption of accelerated partial breast radiotherapy (RT) prior to long-term randomized trial evidence.
    Medical decision making : an international journal of the Society for Medical Decision Making. 07/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: To examine public and media response to the United States Preventive Services Task Force's (USPSTF) draft (October 2011) and finalized (May 2012) recommendations against prostate-specific antigen (PSA) testing using Twitter, a popular social network with over 200 million active users. We used a mixed methods design to analyze posts on Twitter, called "tweets." Using the search term "prostate cancer," we archived tweets in the 24 hour periods following the release of the USPSTF draft and finalized recommendations. We recorded tweet rate per hour and developed a coding system to assess type of user and sentiment expressed in tweets and linked articles. After the draft and finalized recommendations, 2042 and 5357 tweets focused on the USPSTF report, respectively. Tweet rate nearly doubled within two hours of both announcements. Fewer than 10% of tweets expressed an opinion about screening, and the majority of these were pro-screening during both periods. In contrast, anti-screening articles were tweeted more frequently in both draft and finalized study periods. From the draft to the finalized recommendations, the proportion of anti-screening tweets and anti-screening article links increased (p= 0.03 and p<0.01, respectively). There was increased Twitter activity surrounding the USPSTF draft and finalized recommendations. The percentage of anti-screening tweets and articles appeared to increase, perhaps due to the interval public comment period. Despite this, most tweets did not express an opinion, suggesting a missed opportunity in this important arena for advocacy.
    BJU International 03/2014; · 3.05 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Effective breast cancer management is more complex with diabetes present and may contribute to poor outcomes. Therefore, we conducted two simultaneous systematic reviews to address the association of diabetes with (1) treatment patterns in breast cancer patients and (2) breast cancer recurrence rates or breast cancer-specific and all-cause mortality. We searched major databases for English language peer-reviewed studies through November 2013, which addressed either of the above research questions, following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method. Analyses compared treatment patterns or health outcomes for breast cancer subjects with and without diabetes. We used STROBE quality criteria and conducted a random-effects meta-analysis of all-cause mortality. The review yielded 11 publications for question 1 and 26 for question 2, with nine overlapping. Treatment studies showed chemotherapy was less likely in patients with diabetes. Of 22 studies, 21 assessing all-cause mortality indicated a statistically significant increased overall mortality for patients with diabetes (hazard ratios: 0.33-5.40), with meta-analysis of eligible studies indicating a 52 % increased risk. Nine studies assessing breast cancer-specific mortality had inconsistent results, with five showing significantly increased risk for diabetes patients. Results were inconsistent for recurrence and metastases. The majority of studies reported detrimental associations between diabetes and optimal treatment or all-cause mortality among women with breast cancer. Divergence in variable and outcomes inclusion and definitions, potential participation bias in individual studies, and differing analytic methods make inferences difficult. This review illuminates the importance of the impact of diabetes on breast cancer patients and explicitly recognizes that co-management of conditions is necessary to prevent excess morbidity and mortality.
    Breast Cancer Research and Treatment 01/2014; · 4.47 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a “medical arms race” influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one. Methods We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the “neighborhood effect” on the acquisition of the surgical robot while adjusting simultaneously for known confounders. Results After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot (OR=1.71, 95% CI: 1.07–2.72, p=0.02). Conclusion There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.
    Healthcare. 01/2014; 2(2):152–157.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Annual surveillance mammograms in older long-term breast cancer survivors are recommended, but this recommendation is based on little evidence and with no guidelines on when to stop. Surveillance mammograms should decrease breast cancer mortality by detecting second breast cancer events at an earlier stage. We examined the association between surveillance mammography beyond 5 years after diagnosis on breast cancer-specific mortality in a cohort of women aged ≥65 years diagnosed 1990-1994 with early stage breast cancer. Our cohort included women who survived disease free for ≥5 years (N = 1,235) and were followed from year 6 through death, disenrollment, or 15 years after diagnosis. Asymptomatic surveillance mammograms were ascertained through medical record review. We used Cox proportional hazards regression stratified by follow-up year to calculate the association between time-varying surveillance mammography and breast cancer-specific and other-than-breast mortality adjusting for site, stage, primary surgery type, age and time-varying Charlson Comorbidity Index. The majority (85 %) of the 1,235 5-year breast cancer survivors received ≥1 surveillance mammogram in years 5-9 (yearly proportions ranged from 48 to 58 %); 82 % of women received ≥1 surveillance mammogram in years 10-14. A total of 120 women died of breast cancer and 393 women died from other causes (average follow-up 7.3 years). Multivariable models and lasagna plots suggested a modest reduction in breast cancer-specific mortality with surveillance mammogram receipt in the preceding year (IRR 0.82, 95 % CI 0.56-1.19, p = 0.29); the association with other-cause mortality was 0.95 (95 % CI 0.78-1.17, p = 0.64). Among older breast cancer survivors, surveillance mammography may reduce breast cancer-specific mortality even after 5 years of disease-free survival. Continuing surveillance mammography in older breast cancer survivors likely requires physician-patient discussions similar to those recommended for screening, taking into account comorbid conditions and life-expectancy.
    Breast Cancer Research and Treatment 10/2013; · 4.47 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening. A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level. Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11). Medicare prostate cancer screening-related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis. Cancer 2013;. © 2013 American Cancer Society.
    Cancer 10/2013; · 5.20 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND Little is known about the cost to Medicare of breast cancer screening or whether regional-level screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women. METHODS Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screening-related cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs. RESULTS In the United States, the annual costs to fee-for-service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were $1.08 billion and $1.36 billion, respectively. For women 75 years or older, annual screening-related expenditures exceeded $410 million. Age-standardized screening-related cost per beneficiary varied more than 2-fold across regions (from $42 to $107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.78 [95% CI, 1.40-2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs ($151 vs $115; P = .20). CONCLUSIONS The cost to Medicare of breast cancer screening exceeds $1 billion annually in the fee-for-service program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes.
    JAMA Internal Medicine 01/2013; · 10.58 Impact Factor
  • Heather Taffet Gold, Mary Katherine Hayes
    [Show abstract] [Hide abstract]
    ABSTRACT: Accelerated partial breast radiotherapy (RT) strategies (3-D conformal external-beam RT (3-D CRT) and brachytherapy with balloon catheter) reduce time and transportation burdens of whole breast RT for breast cancer. Long-term clinical trial evidence is unavailable for accelerated modalities, but uncertainty might be acceptable for patients likely to receive suboptimal whole breast RT. The objective of this study is to assess the cost effectiveness of accelerated partial breast RT compared to on-time and delayed whole breast RT. The design used in this study is decision analytic Markov model. The data sources are published literature; and national/federal sources. The target population of this study is a hypothetical cohort of 60 years old women previously treated with breast-conserving surgery for node-negative, estrogen receptor-positive breast cancer with tumors <1 cm. The time horizon is 15 years, and the perspective is societal. The interventions are whole breast RT, 3-D CRT, and brachytherapy breast irradiation. The outcome measures are costs (2008 US$), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. The base-case results were: 3-D CRT was the preferred strategy, costing on average $10,800 and yielding 11.21 QALYs. On-time whole breast RT costs $368,000/QALY compared to 3-D CRT, above the $100,000/QALY WTP threshold. 3-D CRT was also preferred over delayed whole breast RT. Brachytherapy was never preferred. Sensitivity analysis indicated that the results were sensitive to the rate of recurrence outside the initial tumor quadrant ("elsewhere failure") in one-way analysis. Probabilistic sensitivity analysis indicated that results were sensitive to parameter uncertainty, and that the elsewhere-failure rate and treatment preferences may drive results. The limitation of this study is that efficacy estimates are derived from studies that may not fully represent the population modeled. As a conclusion, 3-D CRT was preferred to whole breast RT and for women likely to delay RT, indicating that 3-D CRT could be targeted more efficiently before randomized trial evidence.
    Breast Cancer Research and Treatment 09/2012; 136(1):221-9. · 4.47 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background/Aims Cervical cancer screening is performed to detect pre-cancerous cervical intraepithelial neoplasia or invasive cancerous cervical lesions prior to the onset of symptoms so they can be removed before the cancer has developed or spread. With the addition of high-risk human papillomavirus (HPV) testing to the long-established Papanicolaou (Pap) smear, national and health plan screening guidelines have been regularly updated in recent years. Guidelines on screening frequency and follow-up protocols have also changed over time and will likely continue to do so as HPV vaccination becomes more widespread. Here we describe patterns and results of cervical cancer testing and follow-up over a 10-year period within four geographically-dispersed U.S. managed care organizations. Methods Using data collected by the SEARCH: Screening Effectiveness And Research in Community-Based Healthcare project, we analyzed electronic medical record data on all women aged 20-65 during the period 1998-2007 across four HMORN sites. We created standardized files for Pap smear dates and results; cervical histology dates, types, and results; and HPV test dates and results. We also collected Virtual Data Warehouse data on HPV vaccinations, and selected diagnosis and procedure codes. We calculated rates of Pap testing, HPV testing, colposcopy, and cervical histology (biopsy and treatment). We also calculated rates for Pap testing we classified as "screening." Among women who had Pap tests in 2002 and 2007 and no abnormal test directly preceding the index test, we examined patterns of screening frequency. We also examined frequencies and trends in the results of "screening" Pap testing and cervical histology. Results Overall, annual Pap testing rates decreased and HPV testing rates dramatically increased over the 10 years, while rates of colposcopy, cervical histology, and cervical treatment did not display obvious patterns. Trends varied by age group and health plan. Pap screening frequency differed by health plan; overall, in 2007 a higher proportion of subjects had longer screening intervals (2 years or greater) than in 2002. Information on patterns of Pap and histology results will be presented. Discussion Evaluating trends in cervical cancer testing and follow-up may highlight opportunities to optimize cervical cancer screening delivery in community-based settings.
    Clinical Medicine &amp Research 08/2012; 10(3):150-1.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The definitive local therapy options for early-stage breast cancer are mastectomy and breast-conserving surgery followed by radiation therapy. Older women and those with comorbidities frequently receive breast-conserving surgery alone. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of definitive therapy have not been well-studied. In a cohort of 1,837 women aged 65 years and older receiving treatment for early-stage breast cancer in 6 integrated health care delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving nondefinitive local therapy and assessed the impact on breast cancer recurrence within levels of severity, defined as level of risk for recurrence. Age and comorbidity were associated with receipt of nondefinitive therapy. Compared with those at low risk, women at the highest risk were less likely to receive nondefinitive therapy (odds ratio = 0.32; 95% CI, 0.22-0.47), and women at moderate risk were about half as likely (odds ratio = 0.54; 95% CI, 0.35-0.84). Nondefinitive local therapy was associated with higher rates of recurrence among women at moderate (hazard ratio = 5.1; 95% CI, 1.9-13.5) and low risk (hazard ratio = 3.2; 95% CI, 1.1-8.9). The association among women at high risk was weak (hazard ratio = 1.3; 95% CI, 0.75-2.1). Among these older women with early-stage breast cancer, decisions about therapy partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk, omitting definitive local therapy was associated with increased recurrence.
    Journal of the American College of Surgeons 12/2011; 213(6):757-65. · 4.50 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background/Aims Mastectomy and breast conserving surgery followed by radiotherapy are considered initial guideline therapies for early stage breast cancer with randomized trials demonstrating reduced risk of recurrence. However, older women and those with comorbidities frequently receive only breast conserving surgery. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of guideline therapy have not been well studied. Methods In the population-based BOW cohort of 1837 women age=65 years receiving initial treatment for early stage breast cancer in 6 integrated healthcare delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving less than guideline therapy. We also assessed the impact of less than guideline therapy on breast cancer recurrence stratified by breast cancer severity (low, moderate, or high risk for recurrence using the 1992 St Gallen criteria). Results Age and comorbidity were independently associated with receipt of less than guideline therapy after controlling for breast cancer severity and race. However, compared to those at lowest risk for recurrence, women at the highest risk were unlikely to receive less than guideline therapy (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.21, 0.46) while women at moderate risk were about half as likely (OR 0.55, CI 0.36, 0.85). During follow-up, 295 women had a breast cancer recurrence. Using Cox regression modeling stratified by the 3 levels of risk for recurrence, non-receipt of guideline therapy was associated with recurrence among women at moderate (HR 5.10, CI 1.93, 13.49) and even low risk (HR 3.24, CI 1.15, 9.12). The elevated hazard rate ratio was not observed for the high risk level group (HR 1.29, CI 0.78, 2.15). Age and comorbidity were not associated with recurrence in any of the analyses. Conclusions Among these older women with early stage breast cancer, decisions about guideline therapy appear to have partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk of recurrence, omitting guideline therapy placed them at elevated risk of recurrence.
    Clinical Medicine &amp Research 11/2011; 9(3-4):144.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Analysis of observational cohort data is subject to bias from unobservable risk selection. The authors compared econometric models and treatment effectiveness estimates using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare claims data for women diagnosed with ductal carcinoma in situ. Treatment effectiveness estimates for mastectomy and breast-conserving surgery (BCS) with or without radiotherapy were compared using three different models: simultaneous-equations model, discrete-time survival model with unobserved heterogeneity (frailty), and proportional hazards model. Overall trends in disease-free survival (DFS), or time to first subsequent breast event, by treatment are similar regardless of the model, with mastectomy yielding the highest DFS over 8 years of follow-up, followed by BCS with radiotherapy, and then BCS alone. Absolute rates and direction of bias varied substantially by treatment strategy. DFS was underestimated by single-equation and frailty models compared with the simultaneous-equations model and randomized controlled trial results for BCS with radiotherapy and overestimated for BCS alone.
    Medical Care Research and Review 05/2011; 68(6):627-49. · 3.01 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The high incidence of ductal carcinoma in situ (DCIS) and variations in its treatment motivate inquiry into the comparative effectiveness of treatment options. Few such comparative effectiveness studies of DCIS, however, have been performed with detailed information on clinical and treatment attributes. We collected detailed clinical, nonclinical, pathological, treatment, and long-term outcomes data from multiple medical records of 994 women who were diagnosed with DCIS from 1985 through 2000 in Monroe County (New York) and the Henry Ford Health System (Detroit, MI). We used ipsilateral disease-free survival models to characterize the role of treatments (surgery and radiation therapy) and margin status (positive, close [<2 mm], or negative [≥2 mm]) and logistic regression models to characterize the determinants of treatments and margin status, including the role of surgeons. All statistical tests were two-sided. Treatments and margin status were statistically significant and strong predictors of long-term disease-free survival, but results varied substantially by surgeon. This variation by surgeon accounted for 15%-35% of subsequent ipsilateral 5-year recurrence rates and for 13%-30% of 10-year recurrence rates. The overall differences in predicted 5-year disease-free survival rates for mastectomy (0.993), breast-conserving surgery with radiation therapy (0.945), and breast-conserving surgery without radiation therapy (0.824) were statistically significant (P(diff) < .001 for each of the differences). Similarly, each of the differences at 10 years was statistically significant (P < .001). Our work demonstrates the contributions of treatments and margin status to long-term ipsilateral disease-free survival and the link between surgeons and these key measures of care. Although variation by surgeon could be generated by patients' preferences, the extent of variation and its contribution to long-term health outcomes are troubling. Further work is required to determine why women with positive margins receive no additional treatment and why margin status and receipt of radiation therapy vary by surgeon.
    CancerSpectrum Knowledge Environment 01/2011; 103(2):92-104. · 14.07 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To identify factors associated with delayed radiotherapy (RT) in older women with early-stage breast cancer. We studied 541 women age >or=65 years diagnosed with early-stage breast cancer in 1990-1994 at 5 integrated healthcare delivery systems and treated with breast-conserving surgery and RT, but not chemotherapy. We examined whether demographic, tumor, or treatment characteristics were associated with RT delays of >8 weeks postsurgery using chi(2) tests and multivariable logistic regression. Seventy-six women (14%) had delayed RT, with a median delay of 14 weeks. Even though they had insurance and access to care, nonwhite and Hispanic women were much more likely than white women to have delayed RT (odds ratio = 3.3; 95% confidence interval = 1.7, 10) in multivariable analyses that controlled for demographic and clinical variables. Timely RT should be facilitated through physician and patient education, navigation, and notification programs to improve quality of care. Queues for RT appointments should be evaluated on an ongoing basis to ensure adequate access. Future research should examine modifiable barriers to RT timeliness and whether delays impact long-term outcomes.
    The American journal of managed care 11/2009; 15(11):785-9. · 2.12 Impact Factor
  • Source
    Deborah Braccia, Patricia Stone, Heather Taffet Gold
    Journal of Clinical Oncology 11/2009; 28(3):e47. · 18.04 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Some women with early-stage breast cancer are at higher risk of recurrence and can benefit from chemotherapy. We describe patterns of referral, receipt, and completion of chemotherapy among older women at high risk of recurrence. A total of 2,124 women age 65 years or older who were diagnosed with early-stage breast cancer between 1990 and 1994 and 1996 to 1999 were included; 1,090 of these were at high risk of recurrence. We reviewed medical records to categorize chemotherapy outcomes as follows: did not discuss or were not referred to a medical oncologist (n = 133); discussed and/or referred to a medical oncologist but received no chemotherapy (n = 742); received an incomplete chemotherapy course (n = 29), or received a completed chemotherapy course (n = 186). Overall, 19.7% of high-risk women received any chemotherapy, and 86.5% of these women completed their chemotherapy courses. Just greater than 10% of high-risk women did not have a discussion about chemotherapy as part of breast cancer treatment documented in the medical record; these women also received fewer diagnostic assessments of their initial tumors. Individuals who receive chemotherapy for early-stage breast cancer are a select subgroup of patients at high risk of recurrence. This study identifies characteristics of women who were referred for and who received chemotherapy, and this study plays an important role in understanding generalizability of studies that examine chemotherapy treatment effectiveness. Outcomes after breast cancer could continue to be improved with increased receipt of chemotherapy among older women at high risk of breast cancer recurrence.
    Journal of Clinical Oncology 09/2009; 27(27):4508-14. · 18.04 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: As information is disseminated about best practices, variations in patterns of care should diminish over time. To test the hypotheses that differences in rates of a surgical procedure are associated with type of insurance in an era of evolving practice guidelines and that insurance and site differences diminish with time as consensus guidelines disseminate among the medical community. We use lymph node dissection among women with ductal carcinoma in situ (DCIS) as an example of a procedure with uncertain benefit. Using a sample of 1051 women diagnosed from 1985 through 2000 at 2 geographic sites, we collected detailed demographic, clinical, pathologic, and treatment information through abstraction of multiple medical records. We specified multivariate logistic models with flexible functions of time and time interactions with insurance and treatment site to test hypotheses. Lymph node dissection rates varied significantly according to site of treatment and insurance status after controlling for clinical, pathologic, treatment, and demographic characteristics. Rates of lymph node dissection decreased over time, and differences in lymph node dissection rates according to site and generosity of insurance were no longer significant by the end of the study period. We have demonstrated that rates of a discretionary surgical procedure differ according to nonclinical factors, such as treatment site and type of insurance, and that such unwarranted variation decreases over time with diminishing uncertainty and in an era of diffusion of clinical guidelines.
    Medical care 08/2009; 47(7):749-57. · 3.24 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The objective of this study was to examine the cost effectiveness of using a pharmacogenetic test for uridine diphosphate glycosyltransferase 1A1*28 (UGT1A1*28) variant homozygosity before administering irinotecan to patients with metastatic colorectal cancer. A decision-analytic model from the Medicare payer perspective followed hypothetical patients who were treated with combined 5-fluorouracil, leucovorin, and irinotecan. Under usual care, patients received a full dose of irinotecan. With genetic testing, irinotecan dosage was reduced 25% in homozygotes with the UGT1A1*28 variant allele. Test performance, chemotherapy toxicity, and quality-of-life weights were derived from clinical literature and product labels, and costs were derived from 2007 Medicare fee schedules. Chemotherapy efficacy after dose reduction, adverse event risk, and other parameters were varied in 1-way and probabilistic sensitivity analyses. The authors also calculated the value of investing in further studies of chemotherapy efficacy after homozygote dose reductions. Pretreatment genetic testing costs less ($272 savings per patient tested) and yields slightly improved quality-adjusted life expectancy (0.1 quality-adjusted day per patient tested; approximately 2 quality-adjusted hours). Results depended on treatment efficacy but not adverse event risk assumptions. The results indicated that testing would avoid 84 cases of severe neutropenia, including 4.4 deaths. At a threshold of $100,000 per quality-adjusted life year, the therapeutic efficacy of irinotecan in homozygotes after dose reduction had to be > or =98.4% of full-dose efficacy for genetic testing to remain preferred. Future studies to determine whether this efficacy level can be achieved have an economic value of $22 million. The current results indicated that pharmacogenetic testing for UGT1A1*28 variant homozygosity may be cost effective, but only if irinotecan dose reduction in homozygotes does not reduce efficacy. Future studies to evaluate reduced-dose efficacy in homozygotes should be considered.
    Cancer 06/2009; 115(17):3858-67. · 5.20 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To examine the effect of socioeconomic factors on survival in black and white patients with local or regional prostate cancer. All cases (n = 2046) of clinically localized prostate cancer diagnosed from 1990 to 2000 at the Henry Ford Health System and the Henry Ford Medical Group, equal access health centers, were included. Data on the stage, grade, age at diagnosis, socioeconomic status, treatment given, comorbidities, and vital statistics were gathered from the Henry Ford Medical Group tumor registry and computerized databases, pathologic reports, patient charts, Surveillance, Epidemiology, and End Results database, and the national death registry. The endpoints were the overall and cancer-specific survival. Survival was calculated using Cox proportional hazards regression models. Of the 2046 cases, 1243 were white and 803 were black. Black patients were more likely to have lower incomes, a greater baseline prostate-specific antigen level, and greater comorbidities. They were also more likely to undergo radiotherapy and less likely to undergo radical prostatectomy. Univariate analysis, with white race as the baseline hazard, showed that black patients had significantly increased cancer-specific (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.01-2.13) and overall (HR 1.29, 95% CI 1.09-1.53) mortality. However, adjusting for insurance status and income on multivariate analysis revealed no significant differences in cancer-specific (HR 1.04, 95% CI 0.66-1.64) and overall (HR 0.96, 95% CI 0.78-1.18) survival. In this cohort, socioeconomic factors were sufficient to explain the disparity in survival between white and black patients. Survival differences disappeared after adjusting for income status on multivariate analysis.
    Urology 02/2009; 73(3):624-30. · 2.42 Impact Factor
  • Source
    Heather Taffet Gold, Huong T Do, Andrew W Dick
    [Show abstract] [Hide abstract]
    ABSTRACT: The study aimed to identify factors associated with less-than-optimal radiotherapy (RT) and its impact on disease-free survival in women aged 66+ years diagnosed with stage I breast cancer or ductal carcinoma in situ (DCIS). The subjects were women diagnosed from 1991 to 1999 in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database who underwent breast-conserving surgery and RT within 12 months postdiagnosis. The authors conducted descriptive and multivariate survival analyses, and considered age, race, poverty, marital status, comorbidity indices, rural/urban, radiation oncologist density, comedo necrosis histology (DCIS only), chemotherapy receipt (stage I only), and RT completion (3+ weeks of treatment) and delay (8+ weeks postsurgery without chemotherapy; 4+ weeks postchemotherapy). Of 7791 subjects, 16% experienced RT delay, and 3% had incomplete RT. Subjects with stage I disease who were more likely to delay RT were of black race (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.17-2.08), whereas women in areas of high radiation oncologist density were less likely to delay (OR, 0.73; 95% CI, 0.66-0.81). Those living in high poverty areas were less likely to complete RT (P < .03), as were those undergoing chemotherapy (OR, 1.82; 95% CI, 1.15-2.88). Stage I breast cancer patients with delayed RT were more likely to experience a subsequent breast event (OR, 1.14; 95% CI, 1.00-1.30), and those with incomplete RT had a higher rate of overall mortality (OR, 1.32; 95% CI, 1.06-1.63). Factors associated with lower subsequent breast events included older age, lower poverty, and being married. RT delays of 12+ weeks (or 8+ weeks postchemotherapy) had a strongly negative impact on subsequent events (OR, 3.94; 95% CI, 2.51-6.17 for DCIS; OR, 2.77; 95% CI, 1.84-2.59 for stage I). RT should be facilitated to ensure completion and timeliness, especially for early invasive breast cancer patients.
    Cancer 10/2008; 113(11):3108-15. · 5.20 Impact Factor

Publication Stats

201 Citations
142.12 Total Impact Points

Institutions

  • 2014
    • CUNY Graduate Center
      New York City, New York, United States
  • 2011
    • Worcester Polytechnic Institute
      Worcester, Massachusetts, United States
  • 2004–2011
    • Weill Cornell Medical College
      • • Department of Urology
      • • Department of Public Health
      • • Division of Outcomes and Effectiveness Research
      New York City, New York, United States
  • 2009
    • Group Health Cooperative
      • Group Health Research Institute
      Seattle, Washington, United States
    • University of Michigan
      • Division of Hematology and Oncology
      Ann Arbor, MI, United States
  • 2004–2007
    • Cornell University
      • Department of Public Health
      Ithaca, NY, United States