Cynthia D. O'Malley

Survival differences among Asian subpopulations in the United States after prostate, colorectal, breast, and cervical carcinomas

Information is limited for Asian subgroups regarding survival after diagnosis of the common cancers amenable to routine screening. The authors examined survival after carcinomas of the prostate, colon/rectum, breast, and cervix separately for Chinese, Japanese, Filipinos, and non‐Hispanic whites in the United States.

Socioeconomic Status and Breast Carcinoma Survival in Four Racial/Ethnic Groups A Population-Based Study

Although overall survival for invasive breast carcinoma remains high, black women experience poorer survival than whites. Less is known about the survival of Hispanics and Asians, who may share clinical and socioeconomic risk factors similar to blacks. To better understand racial/ethnic survival patterns, we investigated the effect of socioeconomic status (SES) and disease stage on racial/ethnic differences in breast carcinoma survival in a large population‐based cohort.

Survival by histologic subtype in stage IV nonsmall cell lung cancer based on data from the Surveillance, Epidemiology and End Results Program

Background: The role of histology in the targeted management of nonsmall cell lung cancer (NSCLC) has garnered renewed attention in recent years. We provide contemporary population-based estimates of survival and an assessment of important prognostic factors in stage IV NSCLC by major histologic subtype. Methods: Using data from the Surveillance, Epidemiology and End Results (SEER) Program, we stratified 51,749 incident stage IV NSCLC patients (1988–2003 with follow-up through 2006) by major histologic subtype. We used Kaplan–Meier and Cox proportional hazards methods to describe overall survival and the prognostic influence of select patient, tumor, and treatment characteristics for each histologic subgroup. Results: Survival was highest in patients with bronchioloalveolar adenocarcinoma (1-year survival: 29.1%) and lowest in those with large cell tumors (1-year survival: 12.8%). Diagnosis in later years, female gender, younger age, either Asian/Pacific Islander or Hispanic race/ethnicity, lower tumor grade, and surgery or beam radiation as part of first-line treatment were generally independently associated with a decreased risk of death, but the prognostic significance of some of these factors (age, ethnicity, tumor grade) varied according to histologic subtype. Conclusion: Findings demonstrate a poor prognosis across histologic subtypes in stage IV NSCLC patients but highlight differences in both absolute survival and the relative importance of select prognostic factors by histologic subclassification. More research using other sources of population-based data could help clarify the role of histology in the presentation, management, and prognosis of late-stage NSCLC.

Influence of the gynecologic oncologist on the survival of ovarian cancer patients

OBJECTIVE: To estimate the influence of gynecologic oncologists on the treatment and outcome of patients with ovarian cancer. METHODS: Data were obtained from California Cancer Registry from 1994 to 1996. Kaplan-Meier and Cox proportional hazard methods were used for analyses. RESULTS: Of 1,491 patients, the median age was 65 years (range: 13–100). Only 34.1% received care by gynecologic oncologists (group A) while 65.9% were treated by others (group B). Women in group A were more affluent (P<.001), were more educated (P=.036), were classified as white-collar employees (P=.128), and lived in urban regions (P<.001) compared with group B. Patients who saw gynecologic oncologists were more likely to have surgery as their initial treatment (91.9% versus 69.1%; P<.001), present with advanced (stage III-IV) cancers (78.2% versus 70.5%; P<.001), have more grade 3 tumors (61.7% versus 39.9%; P=.048), and receive chemotherapy (90.0% versus 70.1%; P<.001). Women in group B had a fourfold higher risk of having unstaged cancers (8.0% versus 2.1%; P<.001). The 5-year disease-specific survival of group A patients was 38.6% compared with 30.3% in group B (P<.001). On multivariable analysis, early stage, lower grade, and treatment by gynecologic oncologists were independent prognostic factors for improved survival. After adjusting for surgery and chemotherapy, there was no improvement in survival associated with care by gynecologic oncologists (hazard ratio=0.90, 95% confidence interval 0.78–1.03; P=.133). CONCLUSION: In this study of 1,491 women, those who were treated by gynecologic oncologists were more likely to undergo primary staging surgery and receive chemotherapy. Stage, grade of disease, and treatment by gynecologic oncologists were important prognosticators. LEVEL OF EVIDENCE: II

Longitudinal, population-based study of racial/ethnic differences in colorectal cancer survival: impact of neighborhood socioeconomic status, treatment and comorbidity

BackgroundColorectal cancer, if detected early, has greater than 90% 5-year survival. However, survival has been shown to vary across racial/ethnic groups in the United States, despite the availability of early detection methods.MethodsThis study evaluated the joint effects of sociodemographic factors, tumor characteristics, census-based socioeconomic status (SES), treatment, and comorbidities on survival after colorectal cancer among and within racial/ethnic groups, using the SEER-Medicare database for patients diagnosed in 1992–1996, and followed through 1999.ResultsUnadjusted colorectal cancer-specific mortality rates were higher among Blacks and Hispanic males than whites (relative rates (95% confidence intervals) = 1.34 (1.26–1.42) and 1.16 (1.04–1.29), respectively), and lower among Japanese (0.78 (0.70–0.88)). These patterns were evident for all-cause mortality, although the magnitude of the disparity was larger for colorectal cancer mortality. Adjustment for stage accounted for the higher rate among Hispanic males and most of the lower rate among Japanese. Among Blacks, stage and SES accounted for about half of the higher rate relative to Whites, and within stage III colon and stages II/III rectal cancer, SES completely accounted for the small differentials in survival between Blacks and Whites. Comorbidity did not appear to explain the Black-White differentials in colorectal-specific nor all-cause mortality, beyond stage, and treatment (surgery, radiation, chemotherapy) explained a very small proportion of the Black-White difference. The fully-adjusted relative mortality rates comparing Blacks to Whites was 1.14 (1.09–1.20) for all-cause mortality and 1.21 (1.14–1.29) for colorectal cancer specific mortality. The sociodemographic, tumor, and treatment characteristics also had different impacts on mortality within racial/ethnic groups.ConclusionIn this comprehensive analysis, race/ethnic-specific models revealed differential effects of covariates on survival after colorectal cancer within each group, suggesting that different strategies may be necessary to improve survival in each group. Among Blacks, half of the differential in survival after colorectal cancer was primarily attributable to stage and SES, but differences in survival between Blacks and Whites remain unexplained with the data available in this comprehensive, population-based, analysis.

Patterns of Chemotherapy Use for Women With Ovarian Cancer: A Population-Based Study

PURPOSE To evaluate adherence to published recommendations for chemotherapy for ovarian cancer patients in the general community and to identify factors associated with its use. PATIENTS AND METHODS The study population consisted of 2,150 women residing in Northern California with a first diagnosis of primary epithelial ovarian cancer between January 1994 and December 1996. Patients were identified through the California Cancer Registry and their physicians were surveyed to supplement registry treatment information. RESULTS Almost 89% of women younger than 75 years with International Federation of Gynecology and Obstetrics stage III or IV tumors received chemotherapy, with levels of treatment highest for women diagnosed at stage III. Patients 75 years of age and older were significantly less likely than younger women to receive chemotherapy (58.2% v 86.1%; P =.001) regardless of stage at diagnosis. Approximately 20% of patients younger than 55 years with early-stage (stage IC and II) cancer received no chemotherapy. Treatment in an American College of Surgeons hospital and treatment by a gynecologic oncologist increased the likelihood of receiving chemotherapy. Hospitalization for comorbid illness, race/ethnicity, census-based measures of socioeconomic status, and size or teaching status of hospital were all unrelated to probability of treatment after adjustment for other factors. Reasons reported most frequently by physicians for no treatment were lack of clinical indication and patient refusal. CONCLUSION The results of this study suggest that, despite scientific evidence and published guidelines that advocate chemotherapy for most women with ovarian cancer, some groups of women did not receive optimum treatment.

Declining rates of osteoporosis management following fragility fractures in the U.S., 2000 through 2009.

BACKGROUND Clinical practice recommendations state that patients with fragility fractures should be evaluated for osteoporosis and treated for the disease if it is present. The purpose of this study was to assess osteoporosis evaluation and treatment patterns for patients with fragility fractures and assess whether anti-osteoporosis pharmacotherapy initiated immediately following a fragility fracture is associated with improved adherence to the treatment protocol. METHODS This retrospective cohort study involved data from a large commercially insured population seen in the period from 2001 through 2009. Patients were community-dwelling individuals aged fifty years or older who had a new low-energy fracture at the hip, vertebra, wrist, or humerus with no evidence of a fragility fracture, osteoporosis treatment, malignant disease, or Paget disease for twelve months preceding the fracture. Rates of diagnostic testing and pharmacotherapy for osteoporosis within twelve months post-fracture were evaluated. Patients treated with oral bisphosphonates were evaluated to determine whether twelve-month adherence to the treatment protocol differed between those who had initiated therapy sooner (at zero to ninety days) and those who initiated it later (at ninety-one to 365 days) following the fracture. RESULTS The 88,571 women and 41,984 men had an average age of 72.3 years and 70.5 years, respectively. Nineteen percent (16,464) of the women and 10% (4014) of the men initiated osteoporosis pharmacotherapy, and 30% (26,481) of the women and 15% (6427) of the men underwent diagnostic testing and/or pharmacotherapy following fracture. Treatment rates were highest following vertebral fracture and lowest following wrist or humeral fracture. Treatment rates significantly decreased over time (from 2001 through 2009). The average twelve-month adherence (medication possession ratio) was 56% and 61% among women and men, respectively. Adherence was similar between patients who had initiated treatment sooner after the fracture and those who had initiated it later after the fracture. CONCLUSIONS Clinical guidelines for evaluation and treatment following fragility fracture were met for less than one-third of women and less than one-sixth of men. While primary fracture prevention remains the ideal, secondary prevention is critical and there is a need to reverse the downward trend in adherence to post-fracture guidelines.

Cancer surveillance research : a vital subdiscipline of cancer epidemiology

Public health surveillance systems relevant to cancer, centered around population-based cancer registration, have produced extensive, high-quality data for evaluating the cancer burden. However, these resources are underutilized by the epidemiology community due, we postulate, to under-appreciation of their scope and of the methods and software for using them. To remedy these misperceptions, this paper defines cancer surveillance research, reviews selected prior contributions, describes current resources, and presents challenges to and recommendations for advancing the field. Cancer surveillance research, in which systematically collected patient and population data are analyzed to examine and test hypotheses about cancer predictors, incidence, and outcomes in geographically defined populations over time, has produced not only cancer statistics and etiologic hypotheses but also information for public health education and for cancer prevention and control. Data on cancer patients are now available for all US states and, within SEER, since 1973, and have been enhanced by linkage to other population-based resources. Appropriate statistical methods and sophisticated interactive analytic software are readily available. Yet, publication of papers, funding opportunities, and professional training for cancer surveillance research remain inadequate. Improvement is necessary in these realms to permit cancer surveillance research to realize its potential in resolving the growing cancer burden.

Breast implants following mastectomy in women with early-stage breast cancer: prevalence and impact on survival

BackgroundFew studies have examined the effect of breast implants after mastectomy on long-term survival in breast cancer patients, despite growing public health concern over potential long-term adverse health effects.MethodsWe analyzed data from the Surveillance, Epidemiology and End Results Breast Implant Surveillance Study conducted in San Francisco–Oakland, in Seattle–Puget Sound, and in Iowa. This population-based, retrospective cohort included women younger than 65 years when diagnosed with early or unstaged first primary breast cancer between 1983 and 1989, treated with mastectomy. The women were followed for a median of 12.4 years (n = 4968). Breast implant usage was validated by medical record review. Cox proportional hazards models were used to estimate hazard rate ratios for survival time until death due to breast cancer or other causes for women with and without breast implants, adjusted for relevant patient and tumor characteristics.ResultsTwenty percent of cases received postmastectomy breast implants, with silicone gel-filled implants comprising the most common type. Patients with implants were younger and more likely to have in situ disease than patients not receiving implants. Risks of breast cancer mortality (hazard ratio, 0.54; 95% confidence interval, 0.43–0.67) and nonbreast cancer mortality (hazard ratio, 0.59; 95% confidence interval, 0.41–0.85) were lower in patients with implants than in those patients without implants, following adjustment for age and year of diagnosis, race/ethnicity, stage, tumor grade, histology, and radiation therapy. Implant type did not appear to influence long-term survival.ConclusionsIn a large, population-representative sample, breast implants following mastectomy do not appear to confer any survival disadvantage following early-stage breast cancer in women younger than 65 years old.

Medicaid status and stage at diagnosis of cervical cancer

OBJECTIVES We examined whether Medicaid beneficiaries are more likely to be diagnosed with late-stage cervical cancer than women not enrolled in Medicaid. METHODS Using the California Cancer Registry-Medicaid linked file, we identified 4682 women diagnosed during 1996-1999 with invasive cervical cancer. Multivariate logistic regression was used to evaluate the association between late-stage diagnosis and prediagnosis Medicaid status. RESULTS Late-stage disease was diagnosed in 51% of Medicaid and 42% of non-Medicaid women. Relative to women without Medicaid coverage, adjusted odds ratios for late-stage diagnosis were 2.8 times higher among women enrolled in Medicaid at the time of their diagnosis and 1.3 times higher among those intermittently enrolled before being diagnosed. Vietnamese women were less likely than White women to have advanced disease; the adjusted odds for women in other racial/ethnic groups did not differ from those among Whites. Women of low socioeconomic status and older women were at increased risk. CONCLUSIONS Women intermittently enrolled in Medicaid or not enrolled until their diagnosis were at greatest risk of a late-stage diagnosis, suggesting that more outreach to at-risk women is needed to ensure access to screening services.