Steven B. Zeliadt

Influence of Publication of US and European Prostate Cancer Screening Trials on PSA Testing Practices

In 2009, results from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial indicated no difference in mortality between the screening and the control groups (rate ratio = 1.13, 95% confidence interval = 0.75 to 1.70), whereas those from the European Randomized study of Screening for Prostate Cancer trial indicated a 20% reduction in mortality among the screening group (rate ratio = 0.80, 95% confidence interval = 0.65 to 0.98). In this study, we examined whether prostate-specific antigen (PSA) testing has changed following these publications. The primary outcome measure was the proportion of men seen at least once in a primary care or urology clinic between August 1, 2004, and March 31, 2010, who received a PSA test. Following the publications, PSA use declined slightly-by 3.0 percentage points and 2.7 percentage points among men aged 40-54 and 55-74 years, respectively. PSA testing among men older than 75 years initially declined slightly following the recommendations by the US Preventive Services Task Force in 2008 and continued to decline after the trial publications.

Prostate Cancer Mortality following Active Surveillance versus Immediate Radical Prostatectomy

Propose: Active surveillance has been endorsed for low-risk prostate cancer, but information about long-term outcomes and comparative effectiveness of active surveillance is lacking. The purpose of this study is to project prostate cancer mortality under active surveillance followed by radical prostatectomy versus under immediate radical prostatectomy. Experimental design: A simulation model was developed to combine information on time from diagnosis to treatment under active surveillance and associated disease progression from a Johns Hopkins active surveillance cohort (n = 769), time from radical prostatectomy to recurrence from cases in the CaPSURE database with T-stage ≤ T2a (n = 3,470), and time from recurrence to prostate cancer death from a T-stage ≤ T2a Johns Hopkins cohort of patients whose disease recurred after radical prostatectomy (n = 963). Results were projected for a hypothetical cohort aged 40 to 90 years with low-risk prostate cancer (T-stage ≤ T2a, Gleason score ≤ 6, and prostate-specific antigen level ≤ 10 ng/mL). Results: The model projected that 2.8% of men on active surveillance and 1.6% of men with immediate radical prostatectomy would die of their disease in 20 years. Corresponding lifetime estimates were 3.4% for active surveillance and 2.0% for immediate radical prostatectomy. The average projected increase in life expectancy associated with immediate radical prostatectomy was 1.8 months. On average, the model projected that men on active surveillance would remain free of treatment for an additional 6.4 years relative to men treated immediately. Conclusions: Active surveillance is likely to produce a very modest decline in prostate cancer-specific survival among men diagnosed with low-risk prostate cancer but could lead to significant benefits in terms of quality of life. Clin Cancer Res; 18(19); 5471–8. ©2012 AACR.

Trends in treatment costs for localized prostate cancer: the healthy screenee effect.

Objective:We sought to obtain estimates of trends in initial treatment costs during the prostate-specific antigen (PSA) era that account for the changing patient case-mix associated with screening. Subjects:We used reimbursement claims for Medicare-eligible subjects diagnosed with nonmetastatic prostate cancer between 1991 and 1999. Patients were grouped by initial treatment, with 17,846 receiving radical prostatectomy (RP), 25,933 receiving external beam radiotherapy (XRT), and 4525 receiving brachytherapy (BT). Methods:Cancer-attributable costs were computed by subtracting noncancer costs from total Medicare reimbursements among newly diagnosed cancer patients. Noncancer costs were estimated in 2 ways: (1) average costs among age-matched, cancer-free control subjects (control method) and (2) projections based on claims from subjects before diagnosis (prediagnosis method). Adjusted annual percent change in cancer-attributable costs was calculated using multivariate generalized linear models. Results:Noncancer costs increased at a much lower rate among men prior to diagnosis (3.8% annually) than among the general Medicare population (10.9%). The 2 approaches yielded different results; RP costs declined by 2.4% annually (prediagnosis method) versus 6.2% (control method); XRT costs declined by 1.5% versus 5.8%; and BT costs declined by 4.1% versus 8.3%. Conclusions:Because of self-selection of PSA screening, men diagnosed with prostate cancer today are now healthier overall than men in the general population and are considerably healthier than men diagnosed previously. Estimates of cancer-attributable costs that do not account for this healthy selection effect are likely to be biased. Declines in cancer-attributable treatment costs are evident even after accounting for a healthy screenee effect, suggesting that there has been a real reduction in cancer treatment costs.

Attitudes and Perceptions About Smoking Cessation in the Context of Lung Cancer Screening

IMPORTANCE Broad adoption of lung cancer screening may inadvertently lead to negative population health outcomes if it is perceived as a substitute for smoking cessation. OBJECTIVE To understand views on smoking cessation from current smokers in the context of being offered lung cancer screening as a routine service in primary care. DESIGN, SETTING, AND PARTICIPANTS As an ancillary study to the launch of a lung cancer screening program at 7 sites in the Veterans Health Administration, 45 in-depth semi-structured qualitative interviews about health beliefs related to smoking and lung cancer screening were administered from May 29 to September 22, 2014, by telephone to 37 current smokers offered lung cancer screening by their primary care physician. Analysis was conducted from June 15, 2014, to March 29, 2015. MAIN OUTCOMES AND MEASURES Attitudes and perceptions about the importance of smoking cessation in the context of lung cancer screening. RESULTS Lung cancer screening prompted most current smokers to reflect for the first time on what smoking means for their current and future health. However, 17 of 35 (49%) participants described mechanisms whereby screening lowered their motivation for cessation, including the perception that undergoing an imaging test yields the same health benefits as smoking cessation. Other misperceptions include the belief that everyone who participates in screening will benefit; the belief that screening and being able to return for additional screening offers protection from lung cancer; the perception by some individuals that findings from screenings have saved their lives by catching their cancer early when indeterminate findings are identified that can be monitored rather than immediately treated; and a reinforced belief in some individuals that a cancer-free screening test result indicates that they are among the lucky ones who will avoid the harms of smoking. CONCLUSIONS AND RELEVANCE In this qualitative, lung cancer screening prompted many current smokers to reflect on their health and may serve as a potential opportunity to engage patients in discussions about smoking cessation. However, several concerning pathways were identified in which screening, when offered as part of routine care and described as having proven efficacy, may negatively influence smoking cessation. Health care professionals should be aware that the opportunity for early detection of lung cancer may be interpreted as a way of avoiding the harms of smoking. To promote cessation, discussions should focus on the emotional response to screening rather than clinical details (eg, nodule size) and address misperceptions about the value of early detection so that screening does not lower motivation to quit smoking.

Provider and partner interactions in the treatment decision‐making process for newly diagnosed localized prostate cancer

Study Type – Patient experience (non‐consecutive cohort)

Access to information sources and treatment considerations among men with local stage prostate cancer.

OBJECTIVES To determine the role of information sources in the treatment decision-making process of men diagnosed with local stage prostate cancer. Diagnosed men have access to a large number of information sources about therapy, including print and broadcast media, the Internet, books, and friends with the disease. METHODS Prospective survey of men with local stage prostate cancer in 3 geographically separate regions was carried out. Most men were surveyed after diagnosis but before starting therapy. RESULTS On average, men with local prostate cancer consulted nearly 5 separate sources of information before treatment. The most common source of information was the patients physician (97%), followed by lay-literature (pamphlets, videos) (76%), other health professionals (71%), friends with prostate cancer (67%), and the Internet (58%). Most men rated the sources they consulted as helpful. Consulting the Internet was associated with considering more treatment options. Several information sources were significantly associated with considering particular treatments, but the magnitude of association was small in relation to patient age, comorbidity, and Gleason score. More than 70% of men stated that they were considering or planning only one type of therapy. CONCLUSIONS Men with local stage prostate cancer consult a wide range of information sources. Nonphysician information sources appear to influence their treatment considerations, but to a smaller degree than clinical factors.

Hyperglycemia and prostate cancer recurrence in men treated for localized prostate cancer

Background:Obesity is consistently linked with prostate cancer (PCa) recurrence and mortality, though the mechanism is unknown. Impaired glucose regulation, which is common among obese individuals, has been hypothesized as a potential mechanism for PCa tumor growth. In this study, we explore the relationship between serum glucose at time of treatment and risk of PCa recurrence following initial therapy.Methods:The study group comprised 1734 men treated with radical prostatectomy (RP) or radiation therapy (RT) for localized PCa between 2001–2010. Serum glucose levels closest to date of diagnosis were determined. PCa recurrence was determined based on PSA progression (nadir PSA+2 for RT; PSA⩾0.2 for RP) or secondary therapy. Multivariate Cox regression was performed to determine whether glucose level was associated with biochemical recurrence after adjusting for age, race, body mass index, comorbidity, diagnosis of diabetes, Gleason Sum, PSA, treatment and treatment year.Results:Recurrence was identified in 16% of men over a mean follow-up period of 41 months (range 1–121 months). Those with elevated glucose (⩾100 mg/dl) had a 50% increased risk of recurrence (HR 1.5, 95% CI: 1.1–2.0) compared with those with a normal glucose level (<100 mg/dl). This effect was seen in both those undergoing RP (HR 1.9, 95% CI: 1.0–3.6) and those treated with RT (HR 1.4, 95% CI: 1.0–2.0).Conclusions:Glucose levels at the time of PCa diagnosis are an independent predictor of PCa recurrence for men undergoing treatment for localized disease.

Characteristics and well-being of informal caregivers: Results from a nationally-representative US survey

Objectives Given ongoing concerns about high levels of burden reported among some informal caregivers, the goal of this study was to characterize their sociodemographics, health, and well-being. Methods Using cross-sectional data from a large nationally representative survey in the United States (N = 438,712) we identified adults who provided informal care to friends or family members with a health problem, long-term illness, or disability. Descriptive statistics and propensity matching were used to characterize caregivers and compare their health and social support to sociodemographically-similar adults who were not caregivers. Logistic regression models examined associations between caregiving and respondents’ mental health, general health, perceived social support, and sleep problems. Results A total of 111,156 (25.3%) participants reported being caregivers, most of whom reported good mental health (90%) good general health (83%), and adequate social support (77%). After adjusting for respondents’ gender, caregivers reported worse mental health than non-caregivers (odds ratio (OR) = 1.35, 95% confidence interval (CI) = 1.31–1.39 for >15 days poor mental health in the past month) but better general health (OR = 0.96, 95%CI = 0.94–0.98 for fair or poor health). Men caregivers reported somewhat worse overall health than non-caregivers (OR = 1.09, 95%CI = 1.05–1.13) whereas women reported better overall health. Discussion Although reporting good overall well-being, caregivers remain vulnerable for worse outcomes than non-caregivers. Caregiving is associated with poor mental health, and may have additional impacts on the physical health of caregiving men.

Disenrollment from Medicaid after recent cancer diagnosis.

Objectives:We examine the frequency with which newly diagnosed cancer patients are covered by Medicaid in Washington State and the duration of coverage. Methods:Medicaid enrollment and claims files were linked to the Washington State Cancer Registry to identify all Medicaid enrollees with breast, cervical, lung, colorectal, and prostate cancer between 1997 and 2002. Results:We identified 5009 newly diagnosed cancer patients covered by Medicaid, approximately 13% of the total cases diagnosed in subjects less than 65 years of age in Washington State. The majority, 2866 (57%), enrolled in Medicaid around the time of diagnosis; the remainder had been enrolled at least 3 months before diagnosis. Persons enrolled at diagnosis had later-stage cancer; those enrolled before diagnosis had more noncancer comorbidities. Overall, 18% had disenrolled by 6 months after diagnosis; 34% by 1 year; and 54% by 2 years. Conclusions:Medicaid patients with cancer in Washington State experience a high rate of disenrollment within 1 year after diagnosis. Further research is needed to determine whether disenrollment compromises initial therapy or follow-up care.

Discontinuation of Radiation Treatment among Medicaid‐Enrolled Women with Local and Regional Stage Breast Cancer

Abstract:  For women with nonmetastatic breast cancer, radiation therapy is recommended as a necessary component of the breast conserving surgery (BCS) treatment option. The degree to which Medicaid‐enrolled women complete recommended radiation therapy protocols is not known. We evaluate radiation treatment completion rates for Medicaid enrollees aged 18–64 diagnosed with breast cancer. We determine clinical and socio‐demographic factors associated with not starting treatment, and with interruptions or not completing radiation treatment. Using data from the Washington State Cancer Registry linked to Medicaid enrollment and claims records, we identified Medicaid enrollees diagnosed with breast cancer from 1997 to 2003 who received BCS. Among the 402 women who met inclusion criteria, 105 (26%) did not receive any radiation. Factors significantly associated with not receiving radiation included in situ disease and non‐English as a primary language. Among those who received at least one radiation treatment, 65 (22%) failed to complete therapy and 71 (24%) patients had at least one 5 to 30 day gap in treatment. We found no significant predictors of interruptions in treatment or early discontinuation. A substantial proportion of Medicaid‐insured women who are eligible for radiation therapy following BCS either fail to receive any treatment, experience significant interruptions during therapy, or do not complete a minimum course of treatment. More effort is needed to ensure this vulnerable population receives adequate radiation following BCS.