Eduardo C. Gonzalez

Effects of health insurance and race on breast carcinoma treatments and outcomes

The authors hypothesized that insurance payer and race would influence the care and outcomes for patients with breast carcinoma.

Effects of Physician Supply on Early Detection of Breast Cancer

Background: There are few studies examining the effects of physician supply on health-related outcomes. We hypothesized that increasing physician supply and, in particular, increasing primary care supply would be related to earlier detection of breast cancer. Methods: Information on incident cases of breast cancer occurring in Florida in 1994 (n = 11,740) was collected from the state cancer registry. Measures of physician supply were obtained from the 1994 AMA Physician Masterfile. The effects of physician supply on the odds of late-stage diagnosis were examined using multiple logistic regression. Results: There was no relation between overall physician supply and stage of breast cancer of diagnosis. Each 10th percentile increase in primary care physician supply, however, resulted in a 4% increase in the odds of early-stage diagnosis (adjusted odds ratio = 1.04, 95% confidence interval = 1.01-1.06). Conclusions: The supply of primary care physicians was significantly associated with earlier stage of breast cancer at diagnosis. This study suggests that an appropriate balance of primary care and specialty physician supply might be an important predictor of health outcomes.

Predictors of proximal vs. distal colorectal cancers

BACKGROUND: Because proximal colorectal cancers have a tendency to present at a more advanced stage and thus have a poorer prognosis, it is important to understand the factors associated with the development of proximal colorectal cancer. We hypothesized that older age, female gender, and the presence of comorbid illness would be associated with proximal cancers. METHODS: Incident cases of colorectal cancer (n=9,550) occurring in 1994 were identified from Floridas population-based statewide cancer registry. We categorized colorectal cancers as either proximal (cecum, ascending colon, and transverse colon) or distal (descending colon, sigmoid colon, rectosigmoid, and rectum). Multiple logistic regression analysis was used to determine the multivariable relationship between clinical characteristics and the odds of a proximal-occurring lesion. RESULTS: Four characteristics emerged as independent predictors of a proximal lesion. Each year of increasing age was associated with a 2.2 percent increase in the odds of a proximal lesion, whereas female gender was associated with a 38 percent increase in the odds of a proximal lesion. The presence of a comorbid condition was associated with a 28 percent greater odds of a proximal lesion, and, finally, black, non-Hispanic race was associated with a 24 percent greater odds of a proximal lesion. CONCLUSIONS: We found that increasing age, female gender, black, non-Hispanic race, and the presence of comorbid illnesses were factors associated with a greater likelihood of developing colorectal cancer in a proximal location. Further studies will be required to confirm these findings and to establish the mechanism by which comorbidity influences the site of colorectal cancer development.

Primary Care Utilization and Colorectal Cancer Incidence and Mortality Among Medicare Beneficiaries: A Population-Based, Case–Control Study

BACKGROUND Utilization of primary care may decrease colorectal cancer (CRC) incidence and death through greater receipt of CRC screening tests. OBJECTIVE To examine the association of primary care utilization with CRC incidence, CRC deaths, and all-cause mortality. DESIGN Population-based, case-control study. SETTING Medicare program. PARTICIPANTS Persons aged 67 to 85 years diagnosed with CRC between 1994 and 2005 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions matched with control patients (n = 205,804 for CRC incidence, 54,160 for CRC mortality, and 121,070 for all-cause mortality). MEASUREMENTS Primary care visits in the 4- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality, and all-cause mortality. RESULTS Compared with persons having 0 or 1 primary care visit, persons with 5 to 10 visits had lower CRC incidence (adjusted odds ratio [OR], 0.94 [95% CI, 0.91 to 0.96]) and mortality (adjusted OR, 0.78 [CI, 0.75 to 0.82]) and lower all-cause mortality (adjusted OR, 0.79 [CI, 0.76 to 0.82]). Associations were stronger in patients with late-stage CRC diagnosis, distal lesions, and diagnosis in more recent years when there was greater Medicare screening coverage. Ever receipt of CRC screening and polypectomy mediated the association of primary care utilization with CRC incidence. LIMITATION This study used administrative data, which made it difficult to identify potential confounders and prevented examination of the content of primary care visits. CONCLUSION Medicare beneficiaries with higher utilization of primary care have lower CRC incidence and mortality and lower overall mortality. Increasing and promoting access to primary care in the United States for Medicare beneficiaries may help decrease the national burden of CRC. PRIMARY FUNDING SOURCE American Cancer Society.

Influence of Primary Care on Breast Cancer Outcomes Among Medicare Beneficiaries

PURPOSE We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes. METHODS Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994–2005, we examined the total number of office visits to primary care physicians and non–primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations. RESULTS Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non–primary care physician visits. Results were similar when women with DCIS were included in the analysis. CONCLUSIONS Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician’s ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

The use and outcomes of outpatient mastectomy in Florida

BACKGROUND To identify patient characteristics associated with outpatient mastectomies and their outcomes. METHODS Patients diagnosed with breast cancer and treated with mastectomies in Florida in 1994 were identified from state discharge abstracts and the state tumor registry. The relationship between clinical/demographic characteristics and the odds of having an outpatient mastectomy was identified using multiple logistic regression. Outcomes were assessed by calculating the risk of being rehospitalized within 30 days of discharge. RESULTS Twenty percent of mastectomies were performed on an outpatient basis. Outpatient mastectomies were more likely to be performed on women who were older, who lived in higher income communities, or who were uninsured. Health insurance type was not associated with having an outpatient mastectomy. Women undergoing outpatient mastectomy were more likely to be readmitted within 30 days of discharge; however, the excess risk was very small (0.7%). CONCLUSIONS The risks from outpatient mastectomy are small. Ongoing monitoring of outcomes and assessment of patient satisfaction are needed.

The effects of primary care on breast cancer mortality and incidence among Medicare beneficiaries

Primary care physician (PCP) services may have an impact on breast cancer mortality and incidence, possibly through greater use of screening mammography.

The Influence of Dermatologist and Primary Care Physician Visits on Melanoma Outcomes Among Medicare Beneficiaries

Background: Ambulatory visits to dermatologists and primary care physicians (PCPs) may improve melanoma outcomes through early detection. We sought to measure the effect of dermatologist and PCP visits on melanoma stage at diagnosis and mortality. Methods: We used data from the database linking Surveillance Epidemiology and End Results (SEER) and Medicare data (1994 to 2005) to examine patterns of dermatologist and PCP ambulatory visits before diagnosis for 18,884 Medicare beneficiaries with invasive melanoma or unknown stage at diagnosis. Visits were assessed during the 2-year time interval before the month of diagnosis. We examined whether dermatologist and PCP visits were associated with diagnosis of thinner melanomas (defined as local stage tumors having Breslow thickness <1 mm) and lower melanoma mortality. Results: Medicare beneficiaries visiting both a dermatologist and PCP before diagnosis had greater odds of diagnosis of a thin melanoma (adjusted odds ratio, 1.26; 95% confidence interval, 1.12–1.41) and lower melanoma mortality (adjusted hazard ratio 0.66, 95% confidence interval, 0.57–0.76) compared with those without such visits. The mortality findings were attenuated once stage at diagnosis was adjusted for in the multivariable model. Conclusion: Improved melanoma outcomes among Medicare beneficiaries may depend on adequate access and use of dermatologist and PCP services.

Office-based Ultrasound in Sports Medicine Practice

Increasing knowledge, interest, and visibility in the field of sports medicine has equipped clinicians in the field with a novel array of diagnostic and therapeutic options but has also provided a higher level of complexity in patient care. True understanding of the vast spectrum of radiographic technology available to the sports clinician has become more critical than ever. Advances particularly in the areas of magnetic resonance imaging, diagnostic office ultrasound, and 3-dimensional reconstruction computed tomography, as well as nuclear medicine, offer the clinician a myriad of diagnostic options in patient evaluation. As these advances accumulate, the challenge to optimize care, contain cost, and interpret the extensive data generated becomes even more difficult to manage. Improving technology, education, and application of office ultrasound offers an interesting new tool for the bedside evaluation in real time of dynamic motion and pathology of sports-related injuries. As studies continue to validate ultrasounds effectiveness in diagnosing injuries to the upper and lower extremities compared with more costly magnetic resonance imaging and more invasive exploratory surgery, its promise as a cost-effective diagnostic tool is growing. A particularly promising development in the care of sports injuries is the expansion of injection therapies, and in-office ultrasound provides assurance that prolotherapy, platelet-rich plasma, dry needling, corticosteroid, and viscosupplementation are delivered accurately and safely. Communication with patients continues to increase in complexity because a greater understanding of the presence of radiographic abnormalities irrelevant to the current complaint is gained. All the accumulated data must then be interpreted and communicated to the patient with a firm understanding of not only the patient history and physical examination but also the availability, indications, contraindications, sensitivity, specificity, and even the cost implications of the spectrum of diagnostic options.

Abstract B68: The influence of primary care on breast cancer outcomes among Medicare beneficiaries

Introduction: Primary care physicians (PCP) are integral in the early detection of cancer. Patients who are referred to a PCP, or who are assigned a PCP, are more likely to undergo most forms of cancer screening including mammograms and clinical breast examinations. PCPs may also ensure more timely diagnosis after screening abnormalities and prevent diagnostic delay. The Medicare-SEER database was used to explore the possibility of an association between primary care visits and breast cancer outcomes. With the usage of Medicare-SEER data, age, gender, and racial disparities exist. Methods: A retrospective cohort study design was used to evaluate 109,188 women that were Medicare beneficiaries and diagnosed with breast cancer in SEER registries during the years of 1994–2005. This data was used to analyze the association between primary care encounters and breast cancer outcomes. Health services related to cancer prevention and screening have been shown to occur in the ambulatory setting. The total number of ambulatory physician encounters and the percentage of such encounters with a primary care physician (PCP) were examined over a 24 month period before cancer diagnosis. Women with invasive cancers odds of late American Joint Commission on Cancer (AJCC) stage at diagnosis (stages III and IV vs. stages I and II) and survival (breast cancer specific and all cause) were examined using logistic regression and proportional hazards models respectively. Whether including non-invasive cancers (such as ductal carcinoma in situ, DCIS) would alter results and whether prior mammography was a potential mediator of associations was also explored. Results: Increasing numbers of ambulatory physician encounters were associated with improved breast cancer outcomes. In addition, subjects having between 40 and 60 percent of all encounters with PCPs were most likely to have had prior mammograms, least likely diagnosed at late stage, and to have lower breast cancer and all-cause mortality. Prior mammography mediated these associations in part but not completely. Results were unchanged when women with DCIS were included in the analysis. The average age of women involved in this study was 77 years old and 86 percent of the sample were non-minority. Conclusions: Although there is the existence of age, racial, and gender disparities because of the use of the Medicare-SEER data, using this information helps to identify better care tactics for aging women. Medicare beneficiaries with breast cancer had better outcomes if they had greater use of ambulatory care and care that was balanced between primary and specialty providers. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B68.