Anita Ambs

Trends in Colorectal Cancer Test Use among Vulnerable Populations in the United States

Background: Evaluating trends in colorectal cancer (CRC) screening use is critical for understanding screening implementation, and whether population groups targeted for screening are receiving it, consistent with guidelines. This study examines recent national trends in CRC test use, including among vulnerable populations. Methods: We used the 2000, 2003, 2005, and 2008 National Health Interview Survey to examine national trends in CRC screening use overall and for fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy. We also assessed trends by race/ethnicity, educational attainment, income, time in the United States, and access to health care. Results: During 2000 to 2008, significant declines in FOBT and sigmoidoscopy use and significant increases in colonoscopy use and in the percentages of adults up-to-date with CRC screening occurred overall and for most population subgroups. Subgroups with consistently lower rates of colonoscopy use and being up-to-date included Hispanics; people with minimal education, low income, or no health insurance; recent immigrants; and those with no usual source of care or physician visits in the past year. Among up-to-date adults, there were few subgroup differences in the type of test by which they were up-to-date (i.e., FOBT, sigmoidoscopy, or colonoscopy). Conclusions: Although use of CRC screening and colonoscopy increased among U.S. adults, including those from vulnerable populations, 45% of adults aged 50 to 75—or nearly 35 million people—were not up-to-date with screening in 2008. Impact: Continued monitoring of CRC screening rates among population subgroups with consistently low utilization is imperative. Improvement in CRC screening rates among all population groups in the United States is still needed. Cancer Epidemiol Biomarkers Prev; 20(8); 1611–21. ©2011 AACR.

The role of primary care physicians in cancer care.

ABSTRACTBACKGROUNDThe demand for oncology services in the United States (US) is increasing, whereas a shortage of oncologists looms. There is the need for a better understanding of the involvement of primary care physicians (PCPs) in cancer care.OBJECTIVETo characterize the role of PCPs in cancer care, compare it with that of oncologists, and identify factors explaining greater PCP involvement in cancer care.DESIGNNational survey of physicians caring for cancer patients conducted by the Cancer Care Outcomes Research and Surveillance Consortium.PARTICIPANTS1694 PCPs; 1621 oncologists.MEASUREMENTSQuestionnaires mailed during 2005 and 2006 examined the participation of physicians in 12 aspects of care for cancer patients.MAIN RESULTSOver 90% of PCPs fulfilled general medical care roles for patients with cancer such as managing comorbid conditions, chronic pain, or depression; establishing do-not-resuscitate status; and referring patients to hospice. Oncologists were less involved in these roles. Determining the treatment preferences of individual patients and deciding on the use of surgery were the only cancer care roles in which ≥50% of PCPs participated. Twenty-two percent of PCPs reported no direct involvement in cancer care roles while 19% reported heavy involvement. PCPs who were aged ≥50 years, were internists or geriatricians, taught medical students, saw more cancer patients, or experienced referral barriers fulfilled more roles. Rural practice location was not associated with greater PCP involvement in cancer care.CONCLUSIONSPCPs across the US have an active role in cancer patient management. Determining the optimal interface between PCPs and oncologists in delivering and coordinating cancer care is an important area for future research.

Dietary Supplement Use in Individuals Living with Cancer and Other Chronic Conditions: A Population-Based Study

OBJECTIVE Cancer survivors are increasingly turning to complementary and alternative medicine (CAM) to manage short- and long-term treatment sequelae. Population-based data on relative use of dietary supplements among cancer survivors compared to those without a cancer history is lacking. Our objective was to compare supplement use among those with and without cancer and among those with and without other chronic conditions, and to identify correlates of supplement use by cancer status. DESIGN Cross-sectional, population-based survey of participants in the 2003 CAM supplement to the 2001 California Health Interview Survey. SUBJECTS Participants reporting a cancer diagnosis on the 2001 California Health Interview Survey or newly reported diagnosis on the 2003 survey (n=1,844) plus a random oversampling of racial/ethnic minorities (n=7,343). MEASURES Self-reported use of a multivitamin and 27 vitamins, minerals, herbs, and other natural products during the preceding 12 months. STATISTICAL ANALYSES Logistic regression analyses were performed with control for potential confounders. RESULTS Adults with cancer or other chronic conditions had higher prevalence of supplement use than those reporting no illness. The independent effect of cancer was associated with vitamin use, whereas living with other chronic conditions was associated with all types of supplement use, except multivitamins. Correlates of supplement use were similar between cancer survivors and cancer-free individuals-being a woman, advancing age, and greater physical activity, fruit and vegetable intake, and other CAM use. Among cancer survivors, non-Hispanic whites had the lowest prevalence of herbal supplement use. CONCLUSIONS These results indicate that having a chronic medical condition is the major factor associated with supplement use. A diagnosis of cancer, by itself, does not have an independent effect on supplement use. This suggests that most supplement use among cancer survivors is directed at dealing with or preventing the exacerbation of a comorbid condition. Consumers and health professionals should be aware that there is limited information on the effects of dietary supplements taken concurrently with prescription and other over-the-counter medications.

Dietary Fiber, Carbohydrates, Glycemic Index and Glycemic Load in Relation to Breast Cancer Prognosis in the HEAL Cohort

Background: Dietary intake of fiber, carbohydrate, glycemic index (GI), and glycemic load (GL) may influence breast cancer survival, but consistent and convincing evidence is lacking. Methods: We investigated associations of dietary fiber, carbohydrates, GI, and GL with breast cancer prognosis among n = 688 stage 0 to IIIA breast cancer survivors in the Health, Eating, Activity, and Lifestyle (HEAL) study. Premenopausal and postmenopausal women from Western Washington State, Los Angeles County, and New Mexico participated. Usual diet was assessed with a food frequency questionnaire. Total mortality, breast cancer mortality, nonfatal recurrence, and second occurrence data were obtained from SEER (Surveillance, Epidemiology, and End Results) registries and medical records. Cox proportional hazards regression estimated multivariate-adjusted hazard ratios and 95% confidence intervals (CI). Results: During a median of 6.7 years follow-up after diagnosis, n = 106 total deaths, n = 83 breast cancer-specific deaths, and n = 82 nonfatal recurrences were confirmed. We observed an inverse association between fiber intake and mortality. Multivariate-adjusted hazard rate ratios (HRR) comparing high to low intake were 0.53 (95% CI 0.23–1.23) and 0.75 (95% CI 0.43–1.31). A threshold effect was observed whereby no additional benefit was observed for intakes of 9 g/d or more. Fiber intake was suggestively inversely associated with breast cancer-specific mortality (HRR = 0.68, 95% CI 0.27–1.70) and risk of nonfatal recurrence or second occurrence (HRR = 0.68, 95% CI 0.27–1.70), but results were not statistically significant. Conclusion: Dietary fiber was associated with a nonsignificant inverse association with breast cancer events and total mortality. Further studies to assess and confirm this relationship are needed in order to offer effective dietary strategies for breast cancer patients. Impact: Increasing dietary fiber may an effective lifestyle modification strategy for breast cancer survivors. Cancer Epidemiol Biomarkers Prev; 20(5); 890–9. ©2011 AACR.

Health-related quality of life in older adult survivors of selected cancers: Data from the SEER-MHOS linkage

Research on health‐related quality of life (HRQOL) among older adult cancer survivors is mostly confined to breast cancer, prostate cancer, colorectal cancer, and lung cancer, which account for 63% of all prevalent cancers. Much less is known about HRQOL in the context of less common cancer sites.

A Health Services Research Agenda for Cellular, Molecular and Genomic Technologies in Cancer Care

Background: In recent decades, extensive resources have been invested to develop cellular, molecular and genomic technologies with clinical applications that span the continuum of cancer care. Methods: In December 2006, the National Cancer Institute sponsored the first workshop to uniquely examine the state of health services research on cancer-related cellular, molecular and genomic technologies and identify challenges and priorities for expanding the evidence base on their effectiveness in routine care. Results: This article summarizes the workshop outcomes, which included development of a comprehensive research agenda that incorporates health and safety endpoints, utilization patterns, patient and provider preferences, quality of care and access, disparities, economics and decision modeling, trends in cancer outcomes, and health-related quality of life among target populations. Conclusions: Ultimately, the successful adoption of useful technologies will depend on understanding and influencing the patient, provider, health care system and societal factors that contribute to their uptake and effectiveness in ‘real-world’ settings.

Serum Vitamin D and Breast Density in Breast Cancer Survivors

Background: Vitamin D influences cellular proliferation and proliferation-related breast tissue characteristics, such as mammographic breast density. Little is known about vitamin D status, assessed by serum 25-hydroxyvitamin D [25(OH)D], and its relationship to breast density in breast cancer survivors. Methods: Participants were 426 postmenopausal breast cancer survivors from the Health, Eating, Activity, and Lifestyle Study. Women from New Mexico, Los Angeles, and western Washington were enrolled postdiagnosis. Data for this report are from an examination conducted 24 months postenrollment. Participants completed health-related questionnaires, gave fasting blood samples, and completed height and weight measurements. Serum [25(OH)D] was assayed by radioimmunoabsorbant assay. Breast dense area and percent density were measured from postdiagnosis-digitized mammograms. Multivariate linear regression tested associations of serum [25(OH)D] with mammographic breast density measures. Results: Of the 426 participants, 22.8% were African-American, 11.3% were Hispanic, and 62.8% were non-Hispanic white. We observed no associations of serum [25(OH)D] with either breast density or breast dense area. Among women with vitamin D deficiency (serum [25(OH)D], <16.0 ng/mL; n = 103), mean percent breast density was 8.0%, and among those with sufficient status (n = 99; serum [25(OH)D], ≥32.0 ng/mL), mean percent density was 8.5%. Breast dense area averaged 27.2 and 26.2 cm2 for women with vitamin D deficiency and sufficiency, respectively. Conclusion: Data from this multiethnic cohort of breast cancer survivors do not support the hypothesis that serum vitamin D, [25(OH)D], is associated with breast density in cancer survivors. Cancer Epidemiol Biomarkers Prev; 19(2); 412–7

Unveiling SEER-CAHPS®: A New Data Resource for Quality of Care Research

ABSTRACTBACKGROUNDSince 1990, the National Cancer Institute (NCI) and Centers for Medicare and Medicaid Services (CMS) have collaborated to create linked data resources to improve our understanding of patterns of care, health care costs, and trends in utilization. However, existing data linkages have not included measures of patient experiences with care.OBJECTIVETo describe a new resource for quality of care research based on a linkage between the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient surveys and the NCI’s Surveillance, Epidemiology and End Results (SEER) data.DESIGNThis is an observational study of CAHPS respondents and includes both fee-for-service and Medicare Advantage beneficiaries with and without cancer. The data linkage includes: CAHPS survey data collected between 1998 and 2010 to assess patient reports on multiple aspects of their care, such as access to needed and timely care, doctor communication, as well as patients’ global ratings of their personal doctor, specialists, overall health care, and their health plan; SEER registry data (1973–2007) on cancer site, stage, treatment, death information, and patient demographics; and longitudinal Medicare claims data (2002–2011) for fee-for-service beneficiaries on utilization and costs of care.PARTICIPANTSIn total, 150,750 respondents were in the cancer cohort and 571,318 were in the non-cancer cohort.MAIN MEASURESThe data linkage includes SEER data on cancer site, stage, treatment, death information, and patient demographics, in addition to longitudinal data from Medicare claims and information on patient experiences from CAHPS surveys.KEY RESULTSSizable proportions of cases from common cancers (e.g., breast, colorectal, prostate) and short-term survival cancers (e.g., pancreas) by time since diagnosis enable comparisons across the cancer care trajectory by MA vs. FFS coverage.CONCLUSIONSSEER-CAHPS is a valuable resource for information about Medicare beneficiaries’ experiences of care across different diagnoses and treatment modalities, and enables comparisons by type of insurance.

Religious and spiritual practices and identification among individuals living with cancer and other chronic disease.

Religion and spirituality in the context of health care are poorly understood, particularly for individuals with chronic illness. Using data from the 2003 Complementary and Alternative Medicine supplement to the 2001 California Health Interview Survey, we examined whether cancer survivors (n = 1,777) and individuals with other chronic illnesses (n = 4,784) were either more likely to identify themselves as religious and spiritual or more likely to use religious and spiritual practices for health purposes than individuals with no disease (n = 2,342). We observed that cancer survivors and individuals with chronic illnesses were more likely than those with no disease to use religious and spiritual prayer and healing practices. Individuals with chronic diseases were not inherently more likely to identify themselves as religious than were healthy individuals and were only slightly more likely to identify themselves as spiritual. These findings indicate that individuals with cancer and other chronic illnesses may be using religious and spiritual practices as a way to cope with their illness. Future research should continue to examine whether and how religious and spiritual practices are used as complementary or alternative medicine, and health care professionals should ask their patients about such use.

Health-related quality of life in older adult survivors of selected cancers: data from the SEER-MHOS linked data resource

Research on health‐related quality of life (HRQOL) among older adult cancer survivors is mostly confined to breast cancer, prostate cancer, colorectal cancer, and lung cancer, which account for 63% of all prevalent cancers. Much less is known about HRQOL in the context of less common cancer sites.