John Fulton

The Impact of Socioeconomic Status on Survival After Cancer in the United States : Findings From the National Program of Cancer Registries Patterns of Care Study

Understanding the ways in which socioeconomic status (SES) affects mortality is important for defining strategies to eliminate the unequal burden of cancer by race and ethnicity in the United States.

Subsite‐specific incidence rate and stage of disease in colorectal cancer by race, gender, and age group in the United States, 1992–1997

Subsite specific incidence rates of colorectal cancer vary considerably by age, gender, and race. This variation may be related not only to distinctions in exposure to genetic and environment factors but also to current strategies of early detection screening. Patterns of stage of disease in anatomic subsite may reflect the effect of screening. This study used the largest aggregation of cancer incidence data in the U.S. to examine subsite specific incidence rates of colorectal cancer and the relation of stage of disease to anatomic subsites by race, gender, and age group.

Women's decision making about mammography: a replication of the relationship between stages of adoption and decisional balance.

The motivational and cognitive processes of behavior change in the area of screening mammography were investigated. A total of 676 women, 40 to 79 years old, were recruited for telephone interview through random selection from designated census tracts and were asked questions that assessed mammography stage-of-adoption and decisional balance constructs from the trans-theoretical model of behavior change. Two definitions of stage of adoption were used. Analysis of covariance showed that a history of regular screening and an intention to continue having the exam were associated with a more favorable decisional balance. Results replicated a prior investigation and demonstrated the usefulness of stage of adoption and decisional balance as guides for designing stage-matched interventions to increase rates of mammography.

Comparison of Laboratory Diagnostic Procedures for Detection of Mycoplasma pneumoniae in Community Outbreaks

BACKGROUND Mycoplasma pneumoniae continues to be a significant cause of community-acquired pneumonia (CAP). A more definitive methodology for reliable detection of M. pneumoniae is needed to identify outbreaks and to prevent potentially fatal extrapulmonary complications. METHODS We analyzed 2 outbreaks of CAP due to M. pneumoniae. Nasopharyngeal and/or oropharyngeal swab specimens and serum samples were obtained from persons with clinically defined cases, household contacts, and asymptomatic individuals. Real-time polymerase chain reaction (PCR) for M. pneumoniae was performed on all swab specimens, and the diagnostic utility was compared with that of 2 commercially available serologic test kits. RESULTS For cases, 21% yielded positive results with real-time PCR, whereas 81% and 54% yielded positive results with the immunoglobulin M and immunoglobulin G/immunoglobulin M serologic tests, respectively. For noncases, 1.8% yielded positive results with real-time PCR, whereas 63% and 79% yielded serologically positive results with the immunoglobulin M and immunoglobulin G/immunoglobulin M kits, respectively. The sensitivity of real-time PCR decreased as the duration between symptom onset and sample collection increased, with a peak sensitivity of 48% at 0-21 days. A specificity of 43% for the immunoglobulin M antibody detection assay was observed for persons aged 10-18 years, but the sensitivity increased to 82% for persons aged 19 years. DISCUSSION Thorough data analysis indicated that no single available test was reliable for the identification of an outbreak of CAP due to M. pneumoniae. A combination of testing methodologies proved to be the most reliable approach for identification of outbreaks of CAP due to M. pneumoniae, especially in the absence of other suspected respiratory pathogens.

Treatment Variation by Insurance Status for Breast Cancer Patients

Abstract:  Few studies have examined the relationship of insurance status with the presentation and treatment of breast cancer. Using a state cancer registry, we compared tumor presentation and surgical treatments at presentation by insurance status (private insurance, Medicare, Medicaid, or uninsured). Student’s t‐test, Chi‐square test, and ANOVA were used for comparison. P‐values reflect a comparison to insured patients. From 1996 to 2005, there were 6876 cases of invasive breast cancer with either private (n = 3975), Medicare (n = 2592), Medicaid (n = 193), or no insurance (n = 116). The median age (years) at presentation was 55 for private, 76 for Medicare, 54 for Medicaid and 54 for uninsured. The mean and median tumor size (mm) were 18.5 and 15 for private; 20.9 and 15 for Medicare; 24.2 and 18 for Medicaid; and 29.5 and 17 for uninsured, respectively; (p < 0.001 for all). Fewer women with Medicare and Medicaid presented with node negative breast cancers: private, 73.4% node negative; Medicare, 79.5% (p < 0.001); Medicaid, 60.9% (p < 0.001); and uninsured, 58% (p = 0.005). Significantly more uninsured women had no surgical treatment of their breast cancer: 15.5% versus 4.3% for private (p < 0.001). Among women with non‐metastatic T1/T2 tumors, 71.5% with private insurance underwent breast‐conserving surgery (BCS), compared with 64.2% of Medicare (p < 0.001), 65% of Medicaid (p = 0.097), and 65.4% of uninsured (p = 0.234). The rate of reconstruction following mastectomy was higher for private insurance (36.6%), compared with Medicare (3.8%, p < 0.0001), Medicaid (26.1%, p = 0.31), and uninsured (5.0%, p = 0.0038). The presentation of breast cancer in women with no insurance and Medicaid is significantly worse than those with private insurance. Of concern are the lower proportions of BCS and reconstruction among patients who are uninsured or have Medicaid. Reduction of disparities in breast cancer presentation and treatment may be possible by increasing enrollment of uninsured, program‐eligible women in a state‐supported screening and treatment program.

Decreased breast cancer tumor size, stage, and mortality in Rhode Island: an example of a well-screened population.

BACKGROUND Since the 1980s, Rhode Island has achieved one of the highest mammography screening rates in the nation. The objective of this study was to determine the effect of high mammography rates on breast cancer presentation and outcomes. METHODS Using the Rhode Island Cancer Registry, the incidence of DCIS and invasive cancer, tumor size, stage, rate of BCS and mortality from breast cancer were determined from 1987 to 2001. RESULTS Over 80% of Rhode Island women report routine mammography. From 1987 to 2001, there were 1,660 cases of DCIS and 11,301 cases of invasive breast cancer. Although the overall incidence of invasive cancer was stable, the median diameter decreased from 2 cm to 1.5 cm with a significant decrease in the incidence of stage III and IV cancers. There was an increase in BCS for women 50 to 64 years of age with stage I and II disease and for women older than 65 years with stage I disease. Disease-specific mortality decreased by 25%. CONCLUSIONS High mammography rates in Rhode Island are associated with smaller and earlier-stage breast cancers. This largely accounts for the decreased mortality from breast cancer and the increased rate of BCS.

Factors associated with initial treatment and survival for clinically localized prostate cancer: results from the CDC-NPCR Patterns of Care Study (PoC1)

BackgroundDespite the large number of men diagnosed with localized prostate cancer, there is as yet no consensus concerning appropriate treatment. The purpose of this study was to describe the initial treatment patterns for localized prostate cancer in a population-based sample and to determine the clinical and patient characteristics associated with initial treatment and overall survival.MethodsThe analysis included 3,300 patients from seven states, diagnosed with clinically localized prostate cancer in 1997. We examined the association of sociodemographic and clinical characteristics with four treatment options: radical prostatectomy, radiation therapy, hormone therapy, and watchful waiting. Diagnostic and treatment information was abstracted from medical records. Socioeconomic measures were derived from the 2000 Census based on the patients residence at time of diagnosis. Vital status through December 31, 2002, was obtained from medical records and linkages to state vital statistics files and the National Death Index. Multiple logistic regression analysis and Cox proportional hazards models identified factors associated with initial treatment and overall survival, respectively.ResultsPatients with clinically localized prostate cancer received the following treatments: radical prostatectomy (39.7%), radiation therapy (31.4%), hormone therapy (10.3%), or watchful waiting (18.6%). After multivariable adjustment, the following variables were associated with conservative treatment (hormone therapy or watchful waiting): older age, black race, being unmarried, having public insurance, having non-screen detected cancer, having normal digital rectal exam results, PSA values above 20, low Gleason score (2-4), comorbidity, and state of residence. Among patients receiving definitive treatment (radical prostatectomy or radiation therapy), older age, being unmarried, PSA values above 10, unknown Gleason score, state of residence, as well as black race in patients under 60 years of age, were associated with receipt of radiation therapy. Overall survival was related to younger age, being married, Gleason score under 8, radical prostatectomy, and state of residence. Comorbidity was only associated with risk of death within the first three years of diagnosis.ConclusionsIn the absence of clear-cut evidence favoring one treatment modality over another, it is important to understand the factors that inform treatment selection. Since state of residence was a significant predictor of both treatment as well as overall survival, true regional differences probably exist in how physicians and patients select treatment options. Factors affecting treatment choice and treatment effectiveness need to be further explored in future population-based studies.

Breast cancer survival in the US and Europe: A CONCORD high-resolution study.

Breast cancer survival is reportedly higher in the US than in Europe. The first worldwide study (CONCORD) found wide international differences in age‐standardized survival. The aim of this study is to explain these survival differences. Population‐based data on stage at diagnosis, diagnostic procedures, treatment and follow‐up were collected for about 20,000 women diagnosed with breast cancer aged 15–99 years during 1996–98 in 7 US states and 12 European countries. Age‐standardized net survival and the excess hazard of death up to 5 years after diagnosis were estimated by jurisdiction (registry, country, European region), age and stage with flexible parametric models. Breast cancers were generally less advanced in the US than in Europe. Stage also varied less between US states than between European jurisdictions. Early, node‐negative tumors were more frequent in the US (39%) than in Europe (32%), while locally advanced tumors were twice as frequent in Europe (8%), and metastatic tumors of similar frequency (5–6%). Net survival in Northern, Western and Southern Europe (81–84%) was similar to that in the US (84%), but lower in Eastern Europe (69%). For the first 3 years after diagnosis the mean excess hazard was higher in Eastern Europe than elsewhere: the difference was most marked for women aged 70–99 years, and mainly confined to women with locally advanced or metastatic tumors. Differences in breast cancer survival between Europe and the US in the late 1990s were mainly explained by lower survival in Eastern Europe, where low healthcare expenditure may have constrained the quality of treatment.

Colorectal cancer survival in the USA and Europe: a CONCORD high-resolution study

Objectives To assess the extent to which stage at diagnosis and adherence to treatment guidelines may explain the persistent differences in colorectal cancer survival between the USA and Europe. Design A high-resolution study using detailed clinical data on Dukes’ stage, diagnostic procedures, treatment and follow-up, collected directly from medical records by trained abstractors under a single protocol, with standardised quality control and central statistical analysis. Setting and participants 21 population-based registries in seven US states and nine European countries provided data for random samples comprising 12 523 adults (15–99 years) diagnosed with colorectal cancer during 1996–1998. Outcome measures Logistic regression models were used to compare adherence to ‘standard care’ in the USA and Europe. Net survival and excess risk of death were estimated with flexible parametric models. Results The proportion of Dukes’ A and B tumours was similar in the USA and Europe, while that of Dukes’ C was more frequent in the USA (38% vs 21%) and of Dukes’ D more frequent in Europe (22% vs 10%). Resection with curative intent was more frequent in the USA (85% vs 75%). Elderly patients (75–99 years) were 70–90% less likely to receive radiotherapy and chemotherapy. Age-standardised 5-year net survival was similar in the USA (58%) and Northern and Western Europe (54–56%) and lowest in Eastern Europe (42%). The mean excess hazard up to 5 years after diagnosis was highest in Eastern Europe, especially among elderly patients and those with Dukes’ D tumours. Conclusions The wide differences in colorectal cancer survival between Europe and the USA in the late 1990s are probably attributable to earlier stage and more extensive use of surgery and adjuvant treatment in the USA. Elderly patients with colorectal cancer received surgery, chemotherapy or radiotherapy less often than younger patients, despite evidence that they could also have benefited.

Reporting cutaneous melanoma to cancer registries in the United States

BACKGROUND Central cancer registries provide data to monitor incidence rates of cutaneous melanoma. OBJECTIVE The aim of this study was to assess the completeness of melanoma reporting in the United States. METHODS Data provided by central cancer registries were used to calculate age-adjusted, average annual incidence rates and were compared by time period (1992-1994, 1995-1997), stage, and program (Surveillance Epidemiology and End Results [SEER] and National Program of Cancer Registries [NPCR]). Completeness was measured with incidence/mortality ratio. RESULTS Incidence rates among whites for 1995-1997 from SEER registries ranged from 11.8 to 33.9 per 100,000 population; 18 of 40 NPCR registries were within this range. For 1992-1994, 8 of 30 NPCR registries were within the range of SEER incidence rates. NPCR registry incidence rates were generally higher for 1995-1997 than 1992-1994. The percentage of cases of localized melanoma did not increase substantially in most SEER registries over the study period, but some NPCR registries had substantial increases. Among NPCR registries that had incidence rates comparable with those of SEER in 1995-1997, the incidence/mortality ratios were generally lower among NPCR registries than SEER registries. CONCLUSION Although melanoma incidence rates are generally increasing, part of the increases in incidence rates reported by NPCR registries over the study time period are likely due to increased case ascertainment and reporting.