B. Ashleigh Guadagnolo

Disparities in Stage at Diagnosis, Treatment, and Survival in Nonelderly Adult Patients With Cancer According to Insurance Status

PURPOSE The purpose of this study was to determine the association of insurance status with disease stage at presentation, treatment, and survival among the top 10 most deadly cancers using the SEER database. PATIENTS AND METHODS A total of 473,722 patients age 18 to 64 years who were diagnosed with one of the 10 most deadly cancers in the SEER database from 2007 to 2010 were analyzed. A Cox proportional hazards model was used for multivariable analyses to assess the effect of patient and tumor characteristics on cause-specific death. RESULTS Overall, patients with non-Medicaid insurance were less likely to present with distant disease (16.9%) than those with Medicaid coverage (29.1%) or without insurance coverage (34.7%; P < .001). Patients with non-Medicaid insurance were more likely to receive cancer-directed surgery and/or radiation therapy (79.6%) compared with those with Medicaid coverage (67.9%) or without insurance coverage (62.1%; P < .001). In a Cox regression that adjusted for age, race, sex, marital status, residence, percent of county below federal poverty level, site, stage, and receipt of cancer-directed surgery and/or radiation therapy, patients were more likely to die as a result of their disease if they had Medicaid coverage (hazard ratio [HR], 1.44; 95% CI, 1.41 to 1.47; P < .001) or no insurance (HR, 1.47; 95% CI, 1.42 to 1.51; P < .001) compared with non-Medicaid insurance. CONCLUSION Among patients with the 10 most deadly cancers, those with Medicaid coverage or without insurance were more likely to present with advanced disease, were less likely to receive cancer-directed surgery and/or radiation therapy, and experienced worse survival.

Osteosarcoma of the jaw/craniofacial region: Outcomes after multimodality treatment

The current study was performed to evaluate outcomes in patients with osteosarcoma of the head and neck (OHN) who were treated with surgery with or without radiotherapy (RT).

Improved survival using intensity-modulated radiation therapy in head and neck cancers: a SEER-Medicare analysis.

Intensity‐modulated radiation therapy (IMRT) is a technologically advanced, and more expensive, method of delivering radiation therapy with a goal of minimizing toxicity. It has been widely adopted for head and neck cancers; however, its comparative impact on cancer control and survival remains unknown. The goal of this analysis was to compare the cause‐specific survival (CSS) for patients with head and neck cancers treated with IMRT versus non‐IMRT from 1999 to 2007.

Medical Mistrust and Less Satisfaction With Health Care Among Native Americans Presenting for Cancer Treatment

Purpose. To assess barriers to cancer care among Native Americans, whose health outcomes compare unfavorably with those of the general U.S. population. Methods and patients. We undertook a comparative community-based participatory research project in which newly-diagnosed cancer patients were prospectively surveyed using novel scales for medical mistrust and satisfaction with health care. Socio-demographic information was obtained. Mean scale scores for mistrust and satisfaction were analyzed by race. Multivariable models were used to adjust for income, education level, and distance lived from cancer care institute. Results. Participation refusal rate was 38%. Of 165 eligible patients, 52 were Native American and 113 where non-Hispanic White. Native Americans expressed significantly higher levels of mistrust (p =.0001) and lower levels of satisfaction (p = .0001) with health care than Whites. In multivariable analyses, race was the only factor found to be significantly predictive of higher mistrust and lower satisfaction scores. Conclusion. Native Americans exhibit higher medical mistrust and lower satisfaction with health care.

Use of Radiation Therapy in the Last 30 Days of Life Among a Large Population-Based Cohort of Elderly Patients in the United States

PURPOSE Our goal was to evaluate use and associated costs of radiation therapy (RT) in the last month of life among those dying of cancer. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare linked databases to analyze claims data for 202,299 patients dying as a result of lung, breast, prostate, colorectal, and pancreas cancers from 2000 to 2007. Logistic regression modeling was used to conduct adjusted analyses of potential impacts of demographic, health services, and treatment-related variables on receipt of RT and treatment with greater than 10 days of RT. Costs were calculated in 2009 dollars. RESULTS Among the 15,287 patients (7.6%) who received RT in the last month of life, its use was associated with nonclinical factors such as race, gender, income, and hospice care. Of these patients, 2,721 (17.8%) received more than 10 days of treatment. Nonclinical factors that were associated with greater likelihood of receiving more than 10 days of RT in the last 30 days of life included: non-Hispanic white race, no receipt of hospice care, and treatment in a freestanding, versus a hospital-associated facility. Hospice care was associated with 32% decrease in total costs of care in the last month of life among those receiving RT. CONCLUSION Although utilization of RT overall was low, almost one in five of patients who received RT in their final 30 days of life spent more than 10 of those days receiving treatment. More research is needed into physician decision making regarding use of RT for patients with end-stage cancer.

Outcomes after definitive treatment for cutaneous angiosarcoma of the face and scalp

The aim of the present analysis was to retrospectively evaluate outcomes in patients with cutaneous angiosarcoma of the face/scalp treated curatively with surgery, radiation therapy (RT), or a combination of surgery and RT.

Evaluation of trends in the use of intensity-modulated radiotherapy for head and neck cancer from 2000 through 2005 socioeconomic disparity and geographic variation in a large population-based cohort

The current study was conducted to evaluate trends in utilization of intensity‐modulated radiotherapy (IMRT) for head and neck cancer (HNC).

Involving American Indians and medically underserved rural populations in cancer clinical trials

Purpose To assess cancer clinical trial recruitment and reasons for nonaccrual among a rural, medically underserved population served by a community-based cancer care center. Methods We prospectively tracked clinical trial enrollment incidence among all new patients presenting at the Rapid City Regional Cancer Care Institute. Evaluating physicians completed questionnaires for each patient regarding clinical trial enrollment status and primary reasons for nonenrollment. Patients who identified as American Indian were referred to a program where patients were assisted in navigating the medical system by trained, culturally competent staff. Results Between September 2006 and January 2008, 891 new cancer patients were evaluated. Seventy-eight patients (9%; 95% confidence intervals, 7—11%) were enrolled on a clinical treatment trial. For 73% (95% confidence intervals, 69—75%) of patients (646 of 891) lack of relevant protocol availability or protocol inclusion criteria restrictiveness was the reason for nonenrollment. Only 45 (5%; 95% confidence intervals, 4—7%) patients refused enrollment on a trial. Of the 78 enrolled on a trial, 6 (8%; 95% confidence intervals, 3—16%) were American Indian. Three additional American Indian patients were enrolled under a nontreatment cancer control trial, bringing the total percentage enrolled of the 94 American Indians who presented to the clinic to 10% (95% confidence intervals, 5—17%). Limitations Eligibility rates were unable to be calculated and cross validation of the number in the cohort via registries or ICD-9 codes was not performed. Conclusion Clinical trial participation in this medically underserved population was low overall, but approximately 3-fold higher than reported national accrual rates. Lack of availability of protocols for common cancer sites as well as stringent protocol inclusion criteria were the primary obstacles to clinical trial enrollment. Targeted interventions using a Patient Navigation program were used to engage AI patients and may have resulted in higher clinical trial enrollment among this racial/ethnic group. Clinical Trials 2009; 6: 610—617. http://ctj.sagepub.com

Association Between Geographic Access to Cancer Care, Insurance, and Receipt of Chemotherapy: Geographic Distribution of Oncologists and Travel Distance

PURPOSE Geographic access to care may be associated with receipt of chemotherapy but has not been fully examined. This study sought to evaluate the association between density of oncologists and travel distance and receipt of adjuvant chemotherapy for colon cancer within 90 days of colectomy. PATIENTS AND METHODS Patients in the National Cancer Data Base with stage III colon cancer, diagnosed between 2007 and 2010, and age 18 to 80 years were selected. Generalized estimating equation clustering by hospital service area was conducted to examine the association between geographic access and receipt of oncology services, controlling for patient sociodemographic and clinical characteristics. RESULTS Of 34,694 patients in the study cohort, 75.7% received adjuvant chemotherapy within 90 days of colectomy. Compared with travel distance less than 12.5 miles, patients who traveled 50 to 249 miles (odds ratio [OR], 0.87; P=.009) or ≥250 miles (OR, 0.36; P<.001) had decreased likelihood of receiving adjuvant chemotherapy. Density level of oncologists was not statistically associated with receipt of adjuvant chemotherapy (low v high density: OR, 0.98; P=.77). When stratifying analyses by insurance status, non-privately insured patients who resided in areas with low density of oncologists were less likely to receive adjuvant chemotherapy (OR, 0.85; P=.03). CONCLUSION Increased travel burden was associated with a decreased likelihood of receiving adjuvant chemotherapy, regardless of insurance status. Patients with nonprivate insurance who resided in low-density oncologist areas were less likely to receive adjuvant chemotherapy. If these findings are validated prospectively, interventions to decrease geographic barriers may improve the timeliness and quality of colon cancer treatment.

Metrics for evaluating patient navigation during cancer diagnosis and treatment: crafting a policy-relevant research agenda for patient navigation in cancer care

Racial and ethnic minorities as well as other vulnerable populations experience disparate cancer‐related health outcomes. Patient navigation is an emerging health care delivery innovation that offers promise in improving quality of cancer care delivery to these patients who experience unique health‐access barriers. Metrics are needed to evaluate whether patient navigation can improve quality of care delivery, health outcomes, and overall value in health care during diagnosis and treatment of cancer.