Mary C. Schroeder

Initial Surgery and Survival in Stage IV Breast Cancer in the United States, 1988-2011.

IMPORTANCE Management of the primary tumor site in patients with metastatic breast cancer remains controversial. OBJECTIVE To evaluate the patterns of receipt of initial breast surgery for female patients with stage IV breast cancer in the United States, with particular attention to women who survived at least 10 years. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) program. Female patients diagnosed as having stage IV breast cancer between 1988 and 2011 and who did not receive radiation therapy as part of the first course of treatment were included (N = 21 372). Kaplan-Meier estimates of median survival and descriptive statistics were used to compare patient and tumor characteristics by receipt of breast surgery at diagnosis. A Royston-Parmar survival model and logistic regression analysis assessed demographic and clinical factors associated with survival and prolonged survival (of at least 10 years). MAIN OUTCOMES AND MEASURES Differences in survival, particularly survival of at least 10 years, by receipt of initial surgery to the primary tumor. RESULTS Among the 21 372 patients, the median survival increased from 20 months (1988-1991) to 26 months (2007-2011). During this time, the rate of surgery declined (odds ratio [OR], 0.16; 95% CI, 0.12-0.21). Even so, receipt of surgery was associated with improved survival in multivariate analysis, which controlled for patient and clinical characteristics, along with time period (hazard ratio, 0.60; 95% CI, 0.57-0.63). For women diagnosed as having cancer before 2002 (n = 7504), survival of at least 10 years was seen in 9.6% (n = 353) and 2.9% (n = 107) of those who did and did not receive surgery, respectively (OR, 3.61; 95% CI, 2.89-4.50). In multivariate analysis, survival of at least 10 years was associated with receipt of surgery (odds ratio, 2.80; 95% CI, 2.08-3.77), hormone receptor-positive disease (OR, 1.76; 95% CI, 1.25-2.48), older age (OR, 0.41; 95% CI, 0.32-0.54), larger tumor size (OR, 0.37; 95% CI, 0.27-0.51), marital status of being separated at the time of diagnosis (OR, 0.67; 95% CI, 0.51-0.88), and more recent year of diagnosis (OR, 1.43; 95% CI, 1.02-1.99). CONCLUSIONS AND RELEVANCE Survival in stage IV breast cancer has improved and is increasingly of prolonged duration, particularly for some women undergoing initial breast surgery. As systemic therapy advances provide better control of distant disease in stage IV breast cancer, and as women present with lower distant disease burdens, these findings on initial surgery to the primary tumor may be of importance.

Prevalence of vitreous floaters in a community sample of smartphone users.

AIM To estimate the prevalence and risk factors for vitreous floaters in the general population. METHODS An electronic survey was administered through a smartphone app asking various demographic and health questions, including whether users experience floaters in their field of vision. Multivariate logistic regression analysis was used to determine risk factors. RESULTS A total of 603 individuals completed the survey, with 76% reporting that they see floaters, and 33% reporting that floaters caused noticeable impairment in vision. Myopes were 3.5 times more likely (P=0.0004), and hyperopes 4.4 times more likely (P=0.0069) to report moderate to severe floaters compared to those with normal vision. Floater prevalence was not significantly affected by respondent age, race, gender, and eye color. CONCLUSION Vitreous floaters were found to be a very common phenomenon in this non-clinical general population sample, and more likely to be impairing in myopes and hyperopes.

Effect of Hospitalization on Inappropriate Prescribing in Elderly Medicare Beneficiaries

To determine whether acute hospitalization is associated with a change in potentially inappropriate medication (PIM) use and whether use varies across geographic region.

Primary Breast Lymphoma in the United States: 1975–2013

Background Primary breast lymphoma (PBL) has gained attention with the description of breast implant-associated anaplastic large cell lymphoma (ALCL). Less is known about PBL incidence, treatment, and survival by lymphoma subtype. Methods The Surveillance, Epidemiology, and End Results (SEER) registry database was queried for patients with PBL as first malignancy, with attention to non-Hodgkin Lymphoma PBL subtypes: diffuse large B-cell lymphoma (DLBCL), follicular lymphoma, marginal zone lymphoma (MZL), and ALCL. Incidence was estimated by age and subtype with joinpoint analyses, along with initial local therapy. Five-year relative and overall survival estimates were compared using z and two-sided log-rank tests. Results PBL incidence (per 1 000 000 women) increased from 0.66 (1975-1977) to 2.96 (2011-2013) with an annual percentage change (APC) of 5.3% (95% confidence interval [CI] = 3.8% to 6.9%, P <  .001) from 1975 to 1999 and no statistically significant change thereafter. Incidence continues to increase for women younger than age 50 years (APC = 2.8%, 95% CI = 1.0% to 4.6%, P = .003) and for ALCL-PBL (APC = 11.8%, 95% CI = 0.2% to 24.9%, P =  .047) and MZL-PBL (APC = 2.3%, 95% CI = -0.2% to 4.9%, P =  .07), with the latter increasing significantly from 1995 to 2013 (APC = 7.5%, 95% CI = 3.4% to 11.8%, P =  .001). Surgery and surgery with radiation declined from 2000 to 2013 as initial local therapy for PBL. Five-year relative survival for PBL improved markedly over four decades and was superior for stage I DLBCL-PBL and stage I follicular PBL than for corresponding systemic presentations. Conclusions PBL has increased in incidence over the last four decades and continues to increase for younger women and for some subtypes. The rise in imaging and procedures to the breast might enhance diagnostic sensitivity for PBL. Further study of the etiologies of PBL is needed.

Statin use after acute myocardial infarction by patient complexity: are the rates right?

Background:Guidelines suggest statin use after acute myocardial infarction (AMI) should be close to universal in patients without safety concerns yet rates are much lower than recommended, decline with patient complexity, and display substantial geographic variation. Trial exclusions have resulted in little evidence to guide statin prescribing for complex patients. Objective:To assess the benefits and risks associated with higher rates of statin use after AMI by baseline patient complexity. Research Design:Sample includes Medicare fee-for-service patients with AMIs in 2008–2009. Instrumental variable estimators using variation in local area prescribing patterns by statin intensity as instruments were used to assess the association of higher statin prescribing rates by statin intensity on 1-year survival, adverse events, and cost by patient complexity. Results:Providers seem to have individualized statin use across patients based on potential risks. Higher statin rates for noncomplex AMI patients were associated with increased survival rates with little added adverse event risk. Higher statin rates for complex AMI patients were associated with tradeoffs between higher survival rates and higher rates of adverse events. Conclusions:Higher rates of statin use for noncomplex AMI patients are associated with outcome rate changes similar to existing evidence. For the complex patients in our study, who were least represented in existing trials, higher statin-use rates were associated with survival gains and higher adverse event risks not previously documented. Policy interventions promoting higher statin-use rates for complex patients may need to be reevaluated taking careful consideration of these tradeoffs.

Evaluating Workplace Mandates with Flows versus Stocks: An Application to California Paid Family Leave

Employer mandates and other labor demand/supply shocks typically have small effects on wages and employment. These effects should be more discernible using data on employment transitions and wages among new hires rather than incumbents. The Quarterly Workforce Indicators (QWI) dataset provides county by quarter by demographic group data on the number and earnings of new hires, separations, and recalls (i.e., extended leaves). We use the QWI to examine the labor market effects of Californias paid family leave (CPFL) policy. Implemented in July 2004, it was the first such policy mandated in the U.S. The analysis compares outcomes for young women in California to those for other workers in California and to workers throughout the U.S. Relative earnings for young female new hires were largely unaffected by CPFL. We find strong evidence that separations (of at least three months) and hiring of young women increased substantively. Many young women who separated later returned to the same firm. CPFL appears to have led not only to increased time with children, but also to a decline in job lock, enhanced mobility, and increased worker flows following universal paid family leave.

Phantom Prescribing: Examining the Frequency of Antimicrobial Prescriptions Without a Patient Visit

OBJECTIVE To investigate the scale of antimicrobial prescribing without a corresponding visit, and to compare the attributes of patients who received antimicrobials with a corresponding visit with those who did not have a visit. DESIGN Retrospective cohort. METHODS We followed up 185,010 Medicare patients for 1 year after an acute myocardial infarction. For each antimicrobial prescribed, we determined whether the patient had an inpatient, outpatient, or provider claim in the 7 days prior to the antimicrobial prescription being filled. We compared the proportions of patient characteristics for those prescriptions associated with a visit and without a visit (ie, phantom prescriptions). We also compared the rates at which different antimicrobials were prescribed without a visit. RESULTS We found that of 356,545 antimicrobial prescriptions, 14.75% had no evidence of a visit in the week prior to the prescription being filled. A higher percentage of patients without a visit were identified as white (P<.001) and female (P<.001). Patients without a visit had a higher likelihood of survival and fewer additional cardiac events (acute myocardial infarction, cardiac arrest, stroke, all P<.001). Among the antimicrobials considered, amoxicillin, penicillin, and agents containing trimethoprim and methenamine were much more likely to be prescribed without a visit. In contrast, levofloxacin, metronidazole, moxifloxacin, vancomycin, and cefdinir were much less likely to be prescribed without a visit. CONCLUSIONS Among this cohort of patients with chronic conditions, phantom prescriptions of antimicrobials are relatively common and occurred more frequently among those patients who were relatively healthy. Infect Control Hosp Epidemiol 2017;38:273-280.

Association Between Preadmission Functional Status and Use and Effectiveness of Secondary Prevention Medications in Elderly Survivors of Acute Myocardial Infarction

To determine whether function‐related indicators (FRIs), derived from preadmission claims data, help explain the frequent practice of forgoing secondary prevention medications observed in Medicare.

Geographic variation in the use of adjuvant therapy among elderly patients with resected non-small cell lung cancer

OBJECTIVES The purpose of this study was to assess to what extent geographic variation in adjuvant treatment for non-small cell lung cancer (NSCLC) patients would remain, after controlling for patient and area-level characteristics. MATERIALS AND METHODS A retrospective cohort of 18,410 Medicare beneficiaries with resected, stage I-IIIA NSCLC was identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Adjuvant therapies were classified as adjuvant chemotherapy (ACT), postoperative radiation therapy (PORT), or no adjuvant therapy. Predicted treatment probabilities were estimated for each patient given their clinical, demographic, and area-level characteristics with multivariate logistic regression. Area Treatment Ratios were used to estimate the propensity of patients in a local area to receive an adjuvant treatment, controlling for characteristics of patients in the area. Areas were categorized as low-, mid- and high-use and mapped for two representative SEER registries. RESULTS Overall, 10%, 12%, and 78% of patients received ACT, PORT and no adjuvant therapy, respectively. Age, sex, stage, type and year of surgery, and comorbidity were associated with adjuvant treatment use. Even after adjusting for patient characteristics, substantial geographic treatment variation remained. High- and low-use areas were tightly juxtaposed within and across SEER registries, often within the same county. In some local areas, patients were up to eight times more likely to receive adjuvant therapy than expected, given their characteristics. On the other hand, almost a quarter of patients lived in local areas in which patients were more than three times less likely to receive ACT than would be predicted. CONCLUSION Controlling for patient and area-level covariates did not remove geographic variation in adjuvant therapies for resected NSCLC patients. A greater proportion of patients were treated less than expected, rather than more than expected. Further research is needed to better understand its causes and potential impact on outcomes.

Serum Vitamin D Levels Affect Pathologic Complete Response in Patients Undergoing Neoadjuvant Systemic Therapy for Operable Breast Cancer

Introduction: There has been increasing interest in the potential benefit of vitamin D in improving breast cancer outcome. Preclinical studies suggest that vitamin D enhances chemotherapy‐induced cell death. We investigated the impact of serum vitamin D levels during neoadjuvant chemotherapy (NAC) on the rates of achieving pathologic complete response (pCR) after breast cancer NAC. Patients and Methods: Patients from 1 of 2 Iowa registries who had serum vitamin D level measured before or during NAC were included. French patients enrolled onto a previous study of the impact of NAC on vitamin D and bone metabolism were also eligible for this study. Vitamin D deficiency was defined as < 20 ng/mL. pCR was defined as no residual invasive disease in breast and lymph nodes. A Firth penalized logistic regression multivariable model was used. Results: The study included 144 women. There was no difference between the French and Iowan cohorts with regard to age at diagnosis (P = .20), clinical stage (P = .22), receptor status (P = .32), and pCR rate (P = .34). French women had lower body mass index (mean 24.8 vs. 28.8, P < .01) and lower vitamin D levels (mean 21.5 vs. 27.5, P < .01) compared to Iowan patients. In multivariable analysis, after adjusting for the effects of cohort, clinical stage, and receptor status, vitamin D deficiency increased the odds of not attaining pCR by 2.68 times (95% confidence interval, 1.12‐6.41, P = .03). Conclusion: Low serum vitamin D levels were associated with not attaining a pCR. Prospective trials could elucidate if maintaining vitamin D levels during NAC, a highly modifiable variable, may be utilized to improve cancer outcomes.