Nicola Schussler

Costs of Treatment for Elderly Women With Early-Stage Breast Cancer in Fee-for-Service Settings

PURPOSE This study provides population-based estimates of the treatment costs for elderly women with early-stage breast cancer, with emphasis on costs of modified radical mastectomy (MRM) compared with breast-conserving surgery (BCS) and radiation therapy (RT). PATIENTS AND METHODS Women with breast cancer from the Surveillance, Epidemiology, and End Results cancer registries were linked with their Medicare claims, 1990 through 1998. Each claim was assigned to an initial, continuing, or terminal care phase after a cancer diagnosis. Mean monthly phase-specific costs were determined for all health care and for treatment related only to cancer. Cumulative long-term costs of care that accrue during a womens remaining lifetime were calculated by treatment group. RESULTS Initial care costs for the 6 months after diagnosis for women who underwent BCS with RT were approximately

Breast-Cancer-Specific Mortality in Patients Treated Based on the 21-Gene Assay: A SEER Population-Based Study

450 per month higher than for women with MRM. During the continuing-care phase, costs for women undergoing BCS with RT were significantly less expensive than for MRM cases. The two groups had similar costs in the terminal-care phase. Assuming the same survival distributions, long-term costs for women undergoing BCS with RT were not statistically different than for women undergoing MRM. CONCLUSION Although mastectomy was less costly in the initial phase, the lifetime costs of BCS with RT and mastectomy were equivalent. Thus, womens preferences, resources to cover out-of-pocket costs, and life situations should be the major factors addressed in shared decision making about treatment options.

Breast cancer specific mortality in patients with early-stage hormone receptor–positive invasive breast cancer and oncotype DX recurrence score results in the SEER database.

The 21-gene Recurrence Score assay is validated to predict recurrence risk and chemotherapy benefit in hormone-receptor-positive (HR+) invasive breast cancer. To determine prospective breast-cancer-specific mortality (BCSM) outcomes by baseline Recurrence Score results and clinical covariates, the National Cancer Institute collaborated with Genomic Health and 14 population-based registries in the the Surveillance, Epidemiology, and End Results (SEER) Program to electronically supplement cancer surveillance data with Recurrence Score results. The prespecified primary analysis cohort was 40–84 years of age, and had node-negative, HR+, HER2-negative, nonmetastatic disease diagnosed between January 2004 and December 2011 in the entire SEER population, and Recurrence Score results (N=38,568). Unadjusted 5-year BCSM were 0.4% (n=21,023; 95% confidence interval (CI), 0.3–0.6%), 1.4% (n=14,494; 95% CI, 1.1–1.7%), and 4.4% (n=3,051; 95% CI, 3.4–5.6%) for Recurrence Score <18, 18–30, and ⩾31 groups, respectively (P<0.001). In multivariable analysis adjusted for age, tumor size, grade, and race, the Recurrence Score result predicted BCSM (P<0.001). Among patients with node-positive disease (micrometastases and up to three positive nodes; N=4,691), 5-year BCSM (unadjusted) was 1.0% (n=2,694; 95% CI, 0.5–2.0%), 2.3% (n=1,669; 95% CI, 1.3–4.1%), and 14.3% (n=328; 95% CI, 8.4–23.8%) for Recurrence Score <18, 18–30, ⩾31 groups, respectively (P<0.001). Five-year BCSM by Recurrence Score group are reported for important patient subgroups, including age, race, tumor size, grade, and socioeconomic status. This SEER study represents the largest report of prospective BCSM outcomes based on Recurrence Score results for patients with HR+, HER2-negative, node-negative, or node-positive breast cancer, including subgroups often under-represented in clinical trials.

Author Correction: Breast-cancer-specific mortality in patients treated based on the 21-gene assay: a SEER population-based study

176 Background: NCIs SEER Program provides cancer incidence and survival statistics for ~28% of the US. New research models are needed to characterize the use and impact of genomic tests on patient outcomes. Genomic Health and SEER collaborated to electronically supplement SEER registries with Recurrence Score (RS) results, and have evaluated breast cancer specific mortality (BCSM) in early stage hormone receptor (HR)+ HER2- invasive breast cancer. METHODS Pts were eligible for pre-specified node negative (N-) disease analysis if HR+, HER2- (by RT-PCR), no prior malignancy, 40-85 years of age, and diagnosed between Jan 2004 (Oncotype DX available Jan 2004) and Dec 2011 (SEER survival analysis complete through 2012). BCSM was defined as previously described (Howlader et al, JNCI 2010). Additional analyses of BCSM were performed for pts with N+ disease. RESULTS Of 169,158 eligible N- pts, 38,568 (23%) had a RS, increasing from 2% in 2004 to 35% in 2011. Pts with RS had median age of 57yr, were 99.4% female, 84% white, 29% grade 1 & 54% grade 2, 25% < 1cm & 53% 1-2cm. Median FU was 39mo. 8,239 pts had > 5yrs follow-up. Among RS < 18 (N = 21,023), RS 18-30 (N = 14,494) and RS ≥ 31 (N = 3,051) pts, chemotherapy use was reported in 7%, 34%, & 69%, respectively, and 5yr N- BCSM was 0.4% (95% CI, 0.3-0.6), 1.4% (95% CI, 1.1-1.7) and 4.4% (95% CI,3.4-5.6), respectively. Multivariate showed that RS was significantly associated with BCSM after adjusting for age, grade, and tumor size (p < 0.001), and when stratified by treatment (p < 0.001). BCSM results in additional N- subgroups (e.g., socioeconomic), and in > 60,000 N+ pts will be presented. CONCLUSIONS 5yr survival outcomes are excellent in the over 21,000 N- pts with RS < 18 disease. RS ≥ 31 disease is associated with greater 5yr mortality despite addition of chemotherapy. The large sample size of this population-based observational study provides important information on prospective outcomes in subsets of pts that are often underrepresented in randomized clinical trials.

Cancer registry-survey data linkages to measure patient-centered quality of care: SEER-MHOS and SEER-CAHPS.

In the original version of the published article, line three of the third paragraph of the methods stated “Excluding patients with micrometastatic disease, the 5-year BCSM for patients with Recurrence Score results <18 and 1–3 positive nodes (n = 2,617) was 1.3% (95% CI, 0.6–2.9%).” To improve clarity this statement has been replaced with “Excluding patients with micrometastatic disease, there were 2,617 patients with 1–3 positive nodes. Of these, 1,487 also had Recurrence Score results <18 with 5-year BCSM of 1.3% (95% CI, 0.6–2.9%).” The original version of the published article also contained an error in the second sentence of the Figure 2 legend describing the mutation status of the patient population examined. The sentence in the original published version of the article stated “Patients with HR+, HER2-positive, node-negative…” this has been changed to “Patients with HR+, HER2-negative, node-negative…”. This has been corrected in the PDF and HTML versions of this paper.

Use of SEER-Medicare data for measuring cancer surgery.

303 Background: Limited opportunities exist to conduct population-based surveillance of cancer patient-reported outcomes. Data from the National Cancer Institutes Surveillance Epidemiology and End Results (SEER) program has recently been linked with data from two Centers for Medicare & Medicaid Services quality improvement surveys: the Medicare Health Outcomes Survey (MHOS) and the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. We provide an overview of the data available, recent findings, and priority areas for future research. METHODS Since 1998, the MHOS has conducted 2-wave/biennial surveys of individuals ages 65+ and individuals with disabilities enrolled in Medicare Advantage (MA) health plans on aspects of health-related quality of life, functional status, comorbidities, and symptoms. Fourteen cohorts are available, representing over 126K patients with cancer and over 1.9 million MA enrollees without a history of cancer. The SEER-MHOS publicly available data resource has produced over 40 data use agreements and 19 publications. SEER-CAHPS links cancer registry data with cross-sectional survey data of Medicare beneficiaries (both fee-for-service and MA) that contain information on patient experiences with care, including access to needed and timely care, doctor communication, health plan customer service, and care coordination. The current linkage contains survey data from 1998 to 2010 and includes over 150K and 570K respondents with and without a history of cancer, respectively. Plans to launch the publicly available resource are underway. RESULTS Recent findings include the impact of diagnosis and treatment on health-related quality of life in older cancer survivors, physical health impairments and variation of treatment received, the impact of cancer on activities of daily living, and variations in care ratings between participants with and without cancer across the cancer control continuum. CONCLUSIONS The SEER-MHOS and SEER-CAHPS linked data resources provide population-based surveillance data on cancer patient-reported outcomes which allow unprecedented opportunities to evaluate national quality improvement activities.