Kim F. Rhoads

Understanding racial disparities in cancer treatment and outcomes.

o p p f r 2 w i t t t recent report from the Institute of Medicine documents idespread racial disparities in medical treatment and ealth outcomes. Such disparities are particularly apparent mong patients with cancer. For many types of cancer, lack Americans have markedly higher cancer-specific ortality rates than members of other racial and ethnic roups—more than 2-fold higher in some instances. Exess cancer mortality in this group is partly attributable to igher cancer incidence rates. However, increased cancer ortality among black patients is also due in large part to orse prognoses among those already diagnosed. Reasons for higher mortality among minorities encomass both patient factors and provider and health care sysem effects. Patient factors include characteristics associted with decreased longevity, such as socioeconomic status SES), health behaviors, and comorbid conditions. At the rovider level, higher cancer mortality may reflect underse of screening, resulting in later stage at diagnosis, and nderuse of cancer-directed surgery and adjuvant therapy. inally, racial disparities may be associated with differences n the quality of care delivered by providers and by the elected settings where black patients cluster for care. Some f these settings have been associated with higher cancer ortality rates and may be less likely to provide high uality comprehensive, transitional, and follow-up care afer surgery.

Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes

INTRODUCTION There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes. METHODS The California Cancer Registry was used to identify patients treated for PC from 2001 to 2006. Only hospitals with ≥ 400 beds were included to limit evaluation to centres possessing resources to provide multimodality care (n= 50). Risk-adjusted multivariable models evaluated predictors of adherence to stage-specific NCCN guidelines for PC and mortality. RESULTS In all, 3706 patients were treated for PC in large hospitals during the study period. Compliance with NCCN guidelines was only 34.5%. Patients were less likely to get recommended therapy with advanced age and low socioeconomic status (SES). Using multilevel analysis, controlling for patient factors (including demographics and comorbidities), hospital factors (e.g. size, academic affiliation and case volume), compliance with NCCN guidelines was associated with a reduced risk of mortality [odds ratio (OR) for death 0.64 (0.53-0.77, P < 0.0001)]. CONCLUSIONS There is relatively poor overall compliance with the NCCN PC guidelines in Californias large hospitals. Higher compliance rates are correlated with improved survival. Compliance is an important potential measure of the quality of care.

Quality of Colon Cancer Outcomes in Hospitals with a High Percentage of Medicaid Patients

BACKGROUND There is evidence that patients with Medicaid insurance suffer worse outcomes from surgical conditions; but there is little research about whether this reflects clustering of such patients at hospitals with worse outcomes. We assess the outcomes of patients with colon and rectal cancers at hospitals with a high proportion of Medicaid patients. STUDY DESIGN California Cancer Registry patient-level records were linked to discharge abstracts from Californias Office of Statewide Health Planning and Development. All operative California Cancer Registry patients from 1998 and 1999 were included. Hospitals with > 40% Medicaid patients were labeled high Medicaid hospitals (HMH). We analyzed the odds of mortality at 30 days, 1, and 5 years for colon cancer and rectal cancer separately. Multilevel logistic regression models were constructed, using MLwiN 2.0, to include patient and hospital-level characteristics. RESULTS Thirty-day mortality after colon operation was worse in HMH (1% versus 0.6%; p = 0.04); as was 1-year mortality (3.4% versus 2.4%; p = 0.001). There was no substantial difference in rates of 5-year mortality. Individuals who were insured by Medicaid had worse outcomes at 5 years. Adjustment for surgical volume eliminated the effect of HMH at 30 days (1% versus 0.7%; p = 0.45) but not at 1 year (3.4% versus 2.5%; p = 0.01). Adjustment for academic affiliation did not alter these results. There were an insufficient number of rectal cancer patients to detect any differences by hospital type. CONCLUSIONS HMH have higher postoperative colon cancer mortality rates at 30 days and 1 year but not at 5 years. The early effect can be explained by surgical volume, but additional research is needed to determine which factors contribute to differences in intermediate outcomes after operations in HMH settings.

How Do Integrated Health Care Systems Address Racial and Ethnic Disparities in Colon Cancer

PURPOSE Colorectal cancer (CRC) disparities have persisted over the last two decades. CRC is a complex disease requiring multidisciplinary care from specialists who may be geographically separated. Few studies have assessed the association between integrated health care system (IHS) CRC care quality, survival, and disparities. The purpose of this study was to determine if exposure to an IHS positively affects quality of care, risk of mortality, and disparities. PATIENTS AND METHODS This retrospective secondary-data analysis study, using the California Cancer Registry linked to state discharge abstracts of patients treated for colon cancer (2001 to 2006), compared the rates of National Comprehensive Cancer Network (NCCN) guideline-based care, the hazard of mortality, and racial/ethnic disparities in an IHS versus other settings. RESULTS More than 30,000 patient records were evaluated. The IHS had overall higher rates of adherence to NCCN guidelines. Propensity score-matched Cox models showed an independent and protective association between care in the IHS and survival (hazard ratio [HR], 0.87; 95% CI, 0.85 to 0.90). This advantage persisted across stage groups. Black race was associated with increased hazard of mortality in all other settings (HR, 1.15; 95% CI, 1.04 to 1.27); however, there was no disparity within the IHS for any minority group (P > .11 for all groups) when compared with white race. CONCLUSION The IHS delivered higher rates of evidence-based care and was associated with lower 5-year mortality. Racial/ethnic disparities in survival were absent in the IHS. Integrated systems may serve as the cornerstone for developing accountable care organizations poised to improve cancer outcomes and eliminate disparities under health care reform.

What factors influence minority use of National Cancer Institute-designated cancer centers?

National Cancer Institute (NCI) cancer centers provide high‐quality care and are associated with better outcomes. However, racial and ethnic minority populations tend not to use these settings. The current study sought to understand what factors influence minority use of NCI cancer centers.

Racial and ethnic differences in lymph node examination after colon cancer resection do not completely explain disparities in mortality

In 1999, a multidisciplinary panel of experts in colorectal cancer reviewed the relevant medical literature and issued a consensus recommendation for a 12‐lymph node (LN) minimum examination after resection for colon cancer. Some authors have shown racial/ethnic differences in receipt of this evidence‐based care. To date, however, none has investigated the correlation between disparities in LN examination and disparities in outcomes after colon cancer treatment.

Lymph Node Count From Neck Dissection Predicts Mortality in Head and Neck Cancer

Purpose Multiple smaller studies have demonstrated an association between overall survival and lymph node (LN) count from neck dissection in patients with head and neck cancer. This is a large cohort study to examine these associations by using a national cancer database. Patients and Methods The National Cancer Database was used to identify patients who underwent upfront nodal dissection for mucosal head and neck squamous cell carcinoma between 2004 and 2013. Patients were stratified by LN count into those with < 18 nodes and those with ≥ 18 nodes on the basis of prior work. A multivariable Cox proportional hazards regression model was constructed to predict hazard of mortality. Stratified models predicted hazard of mortality both for patients who were both node negative and node positive. Results There were 45,113 patients with ≥ 18 LNs and 18,865 patients with < 18 LNs examined. The < 18 LN group, compared with the ≥ 18 LN group, had more favorable tumor characteristics, with a lower proportion of T3 and T4 lesions (27.9% v 39.8%), fewer patients with positive nodes (46.6% v 60.5%), and lower rates of extracapsular extension (9.3% v 15.1%). Risk-adjusted Cox models predicting hazard of mortality by LN count showed an 18% increased hazard of death for patients with < 18 nodes examined (hazard ratio [HR] 1.18; 95% CI, 1.13 to 1.22). When stratified by clinical nodal stage, there was an increased hazard of death in both groups (node negative: HR, 1.24; 95% CI, 1.17 to 1.32; node positive: HR, 1.12; 95% CI, 1.05 to 1.19). Conclusion The results of our study demonstrate a significant overall survival advantage in both patients who are clinically node negative and node positive when ≥ 18 LNs are examined after neck dissection, which suggests that LN count is a potential quality metric for neck dissection.

Age and genetics: how do prognostic factors at diagnosis explain disparities in acute myeloid leukemia?

Objectives:Survival disparities in acute myeloid leukemia (AML) among blacks and Hispanics have been described but not studied extensively in adults. Although younger age and cytogenetic profiles of t(8;21) and acute promyelocytic leukemia (APL) subtypes of AML are associated with improved survival, these factors have not been investigated by race. The purpose is to evaluate whether the observed survival differences for blacks and Hispanics with AML are attributable to older age at diagnosis or lower rates of favorable cytogenetic profiles at diagnosis. The hypothesis is that survival disparities for blacks and Hispanics with AML will be explained by older age at diagnosis and lower rates of favorable cytogenetics. Methods:Patients with AML were identified in the Surveillance Epidemiology and End Results database (1999 to 2008). Kaplan-Meier (KM) survival curves predicted survival by race/ethnicity, stratified by age. Cox proportional hazard models estimated mortality by race with adjustment for age, sex, year of diagnosis, t(8;21), and APL subtypes. Results:A total of 25,692 patients were included. Blacks and Hispanics were diagnosed at younger ages (younger than 61 y), and had higher rates of t(8;21) and APL compared with non-Hispanic whites (NHWs). The overall KM curve shows that NHWs had a worse survival compared with other races/ethnicities. However, when KM curves were stratified by age, blacks and Hispanics had worse survival in younger age categories (younger than 61 y). In multivariable models, black race was associated with an increased risk of death compared with NHWs (HR, 1.10; 95% CI, 1.04-1.16). Adjustment for t(8;21) and APL subtypes did not attenuate the disparity. Conclusions:Despite younger age and higher prevalence of favorable cytogenetics at diagnosis, blacks and Hispanics have an increased mortality from AML compared with other racial/ethnic groups. Future studies should investigate other factors that may influence outcomes among minority populations.

How Do Differences in Treatment Impact Racial and Ethnic Disparities in Acute Myeloid Leukemia

Background: We previously demonstrated disparate acute myelogenous leukemia (AML) survival for black and Hispanic patients; these differences persisted despite younger ages and higher prevalence of favorable cytogenetics in these groups. This study determined: (i) whether there are differences in treatment delivered to minorities, and (ii) how these differences affect outcomes in AML. We hypothesize that differences in treatment explain some proportion of survival disparities. Methods: We used California Cancer Registry data linked to hospital discharge abstracts for patients with AML (1998–2008). Logistic regression models estimated odds of treatment (chemotherapy and/or hematopoietic stem cell transplant) by race/ethnicity. Cox proportional hazard models estimated mortality by race after adjustment for treatment. Results: We analyzed 11,084 records. Black race was associated with lower odds of chemotherapy [OR, 0.74; 95% confidence interval (CI), 0.61–0.91]. Black and Hispanic patients had decreased odds of transplant [(OR, 0.64; 95% CI, 0.46–0.87); (OR, 0.74; 95% CI, 0.62–0.89), respectively]. Black patients had increased hazard of mortality (HR, 1.14; 95% CI, 1.04–1.25) compared with whites. Adjustment for receipt of any treatment resulted in decreased mortality (HR, 1.09; 95% CI, 1.00–1.20) for black patients. Conclusions: AML treatment differences for black patients explain some proportion of the disparity. Future AML disparities studies should investigate socioeconomic and other characteristics. Impact: Study findings may better elucidate drivers of disparities in AML. Cancer Epidemiol Biomarkers Prev; 24(2); 344–9. ©2015 AACR.

Predictors of postoperative urinary retention after colorectal surgery.

BACKGROUND: National quality initiatives have mandated the earlier removal of urinary catheters after surgery to decrease urinary tract infection rates. A potential unintended consequence is an increased postoperative urinary retention rate. OBJECTIVE: The aim of this study was to determine the incidence and risk factors for postoperative urinary retention after colorectal surgery. DESIGN: This was a prospective observational study. SETTINGS: A colorectal unit within a single institution was the setting for this study. PATIENTS: Adults undergoing elective colorectal operations were included. INTERVENTIONS: Urinary catheters were removed on postoperative day 1 for patients undergoing abdominal operations, and on day 3 for patients undergoing pelvic operations. Postvoid residual and retention volumes were measured. MAIN OUTCOME MEASURES: The primary outcomes measured were urinary retention and urinary tract infection. RESULTS: The overall urinary retention rate was 22.4% (22.8% in the abdominal group, 21.9% in the pelvic group) and was associated with longer operative time and increased perioperative fluid administration. Mean operative time for those with retention was 2.8 hours and, for those without retention, the mean operative time 2.2 hours (abdominal group 2 hours vs 1.4 hours, pelvic group 3.9 hours vs 3.1 hours, p ⩽ 0.02). Patients with retention received a mean of 2.7L during the operation, whereas patients without retention received 1.8L (abdominal group 1.9L vs 1.4L, pelvic group 3.6L vs 2.2L, p < 0.01). In the abdominal group, patients with and without retention also received different fluid volumes on postoperative days 1 (2.2L vs 1.7L, p = 0.004) and 2 (1.6L vs 1L, p = 0.05). Laparoscopic abdominal group had a 40% retention rate in comparison with 12% in the open abdominal group (p = 0.004). Age, sex, preoperative radiation therapy, preoperative prostatism, preoperative diagnosis, and level of anastomosis were not associated with retention. The urinary tract infection rate was 4.9%. LIMITATION: The lack of documentation of preoperative urinary function was a limitation of this study. CONCLUSIONS: The practice of earlier urinary catheter removal must be balanced with operative time and fluid volume to avoid high urinary retention rates. Also important is increased vigilance for the early detection of retention.