Linda C. Harlan

Cervical cancer screening: who is not screened and why?

BACKGROUND The decline in death rates from cervical cancer in the United States has been widely attributed to the use of Papanicolaou (Pap) smears for early detection of cervical cancer. METHODS Pap smear screening rates, beliefs about appropriate screening intervals and factors affecting screening were examined using 1987 National Health Interview Survey data. RESULTS Results indicate that through age 69, Blacks are screened at similar or higher rates than Whites. Hispanics, particularly those speaking only or mostly Spanish, are least likely to have received a Pap smear within the last three years. Of women who had never heard of or never had a Pap smear, nearly 80 percent reported contact with a medical practitioner in the past two years, while more than 90 percent reported a contact in the past five years. Overall, the most frequently reported reason for not having a recent Pap smear was procrastinating or not believing it was necessary. CONCLUSIONS Thus, in developing screening programs, Hispanics, particularly Spanish speakers, must be targeted. In addition, educational programs should target unscreened women who forego the test due to underestimating its importance, procrastination, or because their medical care provider did not suggest the procedure. Women must be intensively educated that Pap smears should be scheduled routinely to detect asymptomatic cervical cancer.

Age, Sex, and Racial Differences in the Use of Standard Adjuvant Therapy for Colorectal Cancer

PURPOSE Dissemination of efficacious adjuvant therapies for resectable colorectal cancer has not been comprehensively described. Trends, patterns, and outcomes of adjuvant therapy for colorectal cancer, focusing on age, sex, and racial/ethnic differences, are reported. MATERIALS AND METHODS Population-based random samples of patients diagnosed with colorectal cancer diagnosed in nine geographic areas were collected annually between 1987 and 1991 and in 1995 (n = 4,706). Data were obtained from medical record reviews. Multiple logistic regression was used to assess the use of standard adjuvant chemotherapy for colon and rectal cancers. The Cox proportional hazards model was used to assess 9-year mortality. RESULTS From 1987 until 1995, the use of adjuvant therapy increased in all age groups. There was an increase starting in 1989 for colon and in 1988 for rectal cancer. Use of standard therapy was 78% for those younger than 55 years and 24% for those older than 80 years. White patients received standard therapy more frequently than African-Americans (odds ratio, 1.75; 95% confidence interval [CI], 1.09 to 2.83). All-cause and cancer-specific mortality exceeding 9 years were lower in those who received standard therapy (all-cause risk ratio [RR], 0.73; 95% CI, 0.61 to 0.88; cancer-specific RR, 0.87; 95% CI, 0.70 to 1.09). CONCLUSION Standard adjuvant therapies for colorectal cancer disseminated into community practices during the 1990s. However, evidence exists of differential use of therapies by older patients and by African-Americans. The use of standard therapies in the general population is associated with lower mortality. Improved dissemination of standard adjuvant therapies to all segments of the population could help reduce mortality.

Trends and black/white differences in treatment for nonmetastatic prostate cancer.

OBJECTIVES Controversy and uncertainty surround use of radical prostatectomy, radiation therapy, and conservative symptomatic management in treating elderly men with nonmetastatic prostate cancer. Prior studies have demonstrated variations in use of these therapies by patient age, race, and geographic region. This study examined trends in treatment for nonmetastatic prostate cancer in black and white men aged 65 and older during the period 1986 to 1993. The study also explored factors related to use of initial therapies in these men. METHODS A cohort of 52,915 men (48,410 white; 4,505 black) obtained from the linked SEER-Medicare dataset was used in an observational design. Various sociodemographic and clinical measures were incorporated in the analysis. RESULTS For both races, use of aggressive therapy had increased with time, although this trend appears to be slowing. Black men were less likely to undergo radical prostatectomy than were white men, but use of radiation therapy did not differ markedly by race. High socioeconomic status and a lack of comorbid conditions were among the factors predictive of aggressive therapy receipt. The relation between race and receipt of aggressive therapy was dependent on whether prostate cancer was detected by transurethral resection of the prostate. Sociodemographic and clinical characteristics explained approximately half the difference between black men and white men in radical prostatectomy use. CONCLUSIONS This study documents racial differences and changing practice patterns in the treatment of nonmetastatic prostate cancer in elderly men. Further research is required to more fully understand reasons for racial differences, as well as to promote rational use of health care resources.

Data sources for measuring comorbidity: a comparison of hospital records and medicare claims for cancer patients.

Background:Identifying appropriate comorbidity data sources is a key consideration in health services and outcomes research. Objective:Using cancer patients as an example, we compared comorbid conditions identified: 1) on the discharge facesheet versus full hospital medical record and 2) in the hospital record versus Medicare claims, both precancer diagnosis and associated with a cancer treatment-related index hospitalization. Methods:We used data from 1995 Surveillance, Epidemiology and End Results patterns of care studies for 1382 patients. Comorbid conditions were ascertained from the hospital record associated with the most definitive cancer treatment and Medicare claims. We calculated the prevalence for and assessed concordances among 12 conditions derived from the hospital record facesheet; full hospital record; Medicare claims precancer diagnosis, with and without a rule-out algorithm applied; and Medicare claims associated with an index hospitalization. Results:The proportion of patients with one or more comorbid conditions varied by data source, from 21% for the facesheet to 85% for prediagnosis Medicare claims without the rule-out algorithm. Condition prevalences were substantially lower for the facesheet compared with the full hospital record. For prediagnosis Medicare claims, condition prevalences were more than 1.7 times greater in the absence of an algorithm to screen for rule-out diagnoses. Measures assessing concordance between the full hospital record and prediagnosis Medicare claims (rule-out algorithm applied) showed modest agreement. Conclusions:The hospital record and Medicare claims are complementary data sources for identifying comorbid conditions. Comorbidity is greatly underascertained when derived only from the facesheet of the hospital record. Investigators using Part B Medicare claims to measure comorbidity should remove conditions that are listed for purposes of generating bills but are not true comorbidities.

Health Outcomes After External-Beam Radiation Therapy for Clinically Localized Prostate Cancer: Results From the Prostate Cancer Outcomes Study

PURPOSE Studies reporting effects of radiotherapy for prostate cancer on sexual, bowel, and urinary function have been conducted primarily in referral centers or academic institutions. Effects of external-beam radiotherapy for prostate cancer among a population-based cohort were assessed. PATIENTS AND METHODS The study population included 497 white, Hispanic, and African-American men with localized prostate cancer from six US cancer registries who were diagnosed between October 1, 1994, and October 31, 1995, and treated initially with external-beam radiotherapy. They were interviewed at regular intervals, and medical records were reviewed. Distributions of responses for bowel-, urinary-, and sexual-related functions at 6, 12, and 24 months after diagnosis and adjusted mean composite change scores for each domain were analyzed. RESULTS Declines of 28.9% in the sexual function score and 5.4% in the bowel function score occurred by 24 months, whereas at this time, the urinary function score was relatively unchanged. A total of 43% of those who were potent before diagnosis became impotent after 24 months. More than two thirds of the men were satisfied with their treatment and would make the same decision again. CONCLUSION Sexual function was the most adversely affected quality-of-life domain, with problems continuing to increase between 12 and 24 months. Bowel function problems increased at 6 months, with partial resolution observed by 24 months. Despite the side effects, satisfaction with therapy was high. These results are representative of men in community practice settings and may be of assistance to men and to clinicians when making treatment decisions.

Trends in Surgery and Chemotherapy for Women Diagnosed With Ovarian Cancer in the United States

PURPOSE We examined patterns of care in a population-based sample of 601 ovarian cancer patients diagnosed in 1991, and a sample of 566 women was selected in 1996 to examine trends in care. PATIENTS AND METHODS Patient cases were sampled from within the Surveillance, Epidemiology, and End Results program. Medical records were reabstracted, and treatment data were verified with the treating physician. RESULTS Across these two time periods, the percentage of women with presumptive stage I, II, and IV disease who received lymph node dissection increased. However, a significant number still were not precisely staged. More than 65% of women with ovarian cancer were given cyclophosphamide in 1991 compared with about 14% in 1996. Paclitaxel increased from 1% to 62% during that time. After adjusting for age, race or ethnicity, registry, income, insurance status, Charlson score, residency training program, and marital status, women with early-stage disease were significantly more often given National Institutes of Health Consensus Development Conference guideline therapy in 1996 than in 1991. However, for women with stage III and IV disease, the use of guideline therapy did not significantly increase. Older women and minorities consistently received less guideline therapy, and the lack of private insurance was an impediment for both Hispanic and non-Hispanic black women. CONCLUSION Despite guidelines presented by several organizations, significant numbers of women with ovarian cancer are not being provided with appropriate care. This is particularly true for older and minority women, especially those without private insurance. Educational strategies must be devised to increase the number of women receiving guideline therapy and decrease disparities across population groups.

Adjuvant Therapy for Breast Cancer: Practice Patterns of Community Physicians

PURPOSE We evaluated the use of adjuvant therapy for breast cancer using the National Institutes of Health (NIH) Consensus Development Conference statements as guideposts for assessing how rapidly community physicians adopt recommended therapies. PATIENTS AND METHODS Women with stage I through IIIA breast cancer diagnosed in 1987 through 1991 and in 1995 were randomly sampled from the population-based National Cancer Institute Surveillance, Epidemiology, and End-Results program. A total of 8,106 women were included in the study with younger women, < or = 50 years, being oversampled. Their treating physicians were asked to verify whether chemotherapy, hormonal therapy, or both were given. RESULTS After adjusting for clinical and nonclinical factors, the use of 1985 recommendations for adjuvant therapy in women with node-positive disease was already high at 80% in 1987 and increased slightly to 84% by 1995. Use of combined multidrug chemotherapy plus tamoxifen increased. In contrast, the use of 1990 recommendations for adjuvant therapy for node-negative disease was slightly less than 13% in 1987 and increased markedly to 57% by 1995. For women with node-negative tumors > or = 1 cm in size diagnosed in 1995, 40% received tamoxifen, 16% combination chemotherapy, and 7% both, an increase from 10%, 5%, and 0.4%, respectively, in 1987. CONCLUSION Community physicians began prescribing adjuvant chemotherapy and hormonal therapy in advance of publication of the NIH consensus statement in 1990. Adoption of recommended treatments for node-negative disease has been less complete compared with node-positive tumors, perhaps reflecting the more complex nature of the clinical trials data or the smaller anticipated benefit from adjuvant therapy for this disease subset.

Insurance Status and the Use of Guideline Therapy in the Treatment of Selected Cancers

PURPOSE This study estimates the impact of type of insurance coverage on the receipt of guideline therapy in a population-based sample of cancer patients treated in the community. PATIENTS AND METHODS Patients (n = 7,134) from the National Cancer Institutes Patterns of Care studies who were newly diagnosed with 11 different types of cancer were analyzed. The definition of guideline therapy was based on the National Comprehensive Cancer Network treatment recommendations. Insurance status was categorized as a mutually exclusive hierarchical variable (no insurance, any private insurance, any Medicaid, Medicare only, and all other). Multivariate analyses were used to examine the association between insurance and receipt of guideline therapy. RESULTS Adjusting for clinical and nonclinical variables, insurance status was a modest, although statistically significant, determinant of receipt of guideline therapy, with 65% of the privately insured patients receiving recommended therapy compared with 60% of patients with Medicaid. Seventy percent of the uninsured patients received guideline therapy, which was nonsignificantly different compared with private insurance. When stratified by race, insurance was a statistically significant predictor of the receipt of guideline therapy only for non-Hispanic blacks. CONCLUSION Overall, levels of guideline treatment were lower than expected and particularly low for patients with Medicaid or Medicare only. The use of guideline therapy for ovarian and cervical cancer patients and for patients with rectal cancers was unrelated to type of insurance. Of particular concern is the significantly lower use of guideline therapy for non-Hispanic black patients with Medicaid. After adjusting for other factors, only half of these patients received guideline therapy.

Racial/ethnic patterns of care for cancers of the oral cavity, pharynx, larynx, sinuses, and salivary glands.

BACKGROUND Among Americans, both incidence and mortality from cancers of the larynx, oral cavity, and pharynx are higher for African Americans than whites and for men than women. In addition, the 5-year survival rates for these sites are significantly lower for African Americans than whites for each disease stage, particularly among African American males. We examine racial/ethnic variation in tumor characteristics, treatment practices, and their relationship to survival for cancers of the oral cavity, pharynx, larynx, nasal cavity and salivary glands. METHODS Eligible individuals were age 20 or older and newly diagnosed with a primary invasive cancer of the oral cavity (excluding the lip), pharynx, larynx, sinuses or salivary glands in 1997 reported to one of nine National Cancer Institutes Surveillance Epidemiology and End Results Registries (SEER). Persons meeting the eligibility criteria for each registry were first stratified by race/ethnic group and stage then selected by random sampling within strata. RESULTS We found racial/ethnic differences in diagnoses at specific anatomic sites, disease stage and treatment. African Americans less frequently received a cancer directed treatment than both whites and Hispanics and when treated were generally less likely to receive cancer-directed surgery. In multivariate analysis, the receipt of any cancer directed treatment was significantly associated with race and age group. African Americans and Hispanics had poorer, but not significantly so, overall, but not cancer-specific, survival. CONCLUSION We found racial differences in the receipt of cancer treatment among patients diagnosed with selected head and neck cancers. We also found a less favorable distribution of stage for African Americans and Hispanics when compared with whites. The differences in stage we noted and the lower rates of oral cancer screening previously reported for these populations suggests that differential rates of early detection may contribute to racial differences in survival and mortality from cancers of the oral cavity and pharynx. Therefore, we conclude that more equitable receipt of cancer treatment along with preventive measures and earlier detection will help reduce racial/ethnic disparities in survival and mortality from cancers of the oral cavity, pharynx and larynx.

Food choices of whites, blacks, and Hispanics : data from the 1987 National Health Interview Survey

Dietary guidelines posit an association between diet and cancer. Different cancer mortality rates among whites, blacks, and Hispanics may be related to differences in diet. Food frequency data from the 1987 National Health Interview Survey on 20,143 adults were used to estimate the percentage of adults, by gender and race/ethnicity, who consume some 59 foods six or more times per year, median number of servings for consumers, and frequency of consumption of skin on poultry and fat on red meat. On the basis of percent consumption of these foods, women appear to have a more diverse diet than men. Women eat more fruits and vegetables, less meat, and fewer high-fat foods and drink fewer alcoholic beverages. Whites eat a more varied diet than blacks and Hispanics; blacks eat more fried and high-fat food; consumption of high-fat foods is lowest among Hispanics. Public health messages, especially those aimed at cancer prevention, should be targeted at increasing the overall consumption of fruits and vegetables, decreasing consumption of high-fat foods, especially among white and black men, and increasing consumption of those healthful foods already consumed by particular race/ethnicity groups.