Tracy Onega

Lung Cancer in a U.S. Population with Low to Moderate Arsenic Exposure

Background Little is known about the carcinogenic potential of arsenic in areas with low to moderate concentrations of arsenic (< 100 μg/L) in drinking water. Objectives We examined associations between arsenic and lung cancer. Methods A population-based case–control study of primary incident lung cancer was conducted in 10 counties in two U.S. states, New Hampshire and Vermont. The study included 223 lung cancer cases and 238 controls, each of whom provided toenail clippings for arsenic exposure measurement by inductively coupled–plasma mass spectrometry. We estimated odds ratios (ORs) of the association between arsenic exposure and lung cancer using unconditional logistic regression with adjustment for potential confounders (age, sex, race/ethnicity, smoking pack-years, education, body mass index, fish servings per week, and toenail selenium level). Results Arsenic exposure was associated with small-cell and squamous-cell carcinoma of the lung [OR = 2.75; 95% confidence interval (CI), 1.00–7.57] for toenail arsenic concentration ≥ 0.114 μg/g, versus < 0.05 μg/g. A history of lung disease (bronchitis, chronic obstructive pulmonary disease, or fibrosis) was positively associated with lung cancer (OR = 2.86; 95% CI, 1.39–5.91). We also observed an elevated risk of lung cancer among participants with a history of lung disease and toenail arsenic ≥ 0.05 μg/g (OR = 4.78; 95% CI, 1.87–12.2) than among individuals with low toenail arsenic and no history of lung disease. Conclusion Although this study supports the possibility of an increased risk of specific lung cancer histologic types at lower levels of arsenic exposure, we recommend large-scale population-based studies.

Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.

OBJECTIVES:Detection and removal of adenomas and clinically significant serrated polyps (CSSPs) is critical to the effectiveness of colonoscopy in preventing colorectal cancer. Although longer withdrawal time has been found to increase polyp detection, this association and the use of withdrawal time as a quality indicator remains controversial. Few studies have reported on withdrawal time and serrated polyp detection. Using data from the New Hampshire Colonoscopy Registry, we examined how an endoscopists withdrawal time in normal colonoscopies affects adenoma and serrated polyp detection.METHODS:We analyzed 7,996 colonoscopies performed in 7,972 patients between 2009 and 2011 by 42 endoscopists at 14 hospitals, ambulatory surgery centers, and community practices. CSSPs were defined as sessile serrated polyps and hyperplastic polyps proximal to the sigmoid. Adenoma and CSSP detection rates were calculated based on median endoscopist withdrawal time in normal exams. Regression models were used to estimate the association of increased normal withdrawal time and polyp, adenoma, and CSSP detection.RESULTS:Polyp and adenoma detection rates were highest among endoscopists with 9 min median normal withdrawal time, and detection of CSSPs reached its highest levels at 8–9 min. Incident rate ratios for adenoma and CSSP detection increased with each minute of normal withdrawal time above 6 min, with maximum benefit at 9 min for adenomas (1.50, 95% confidence interval (CI) (1.21, 1.85)) and CSSPs (1.77, 95% CI (1.15, 2.72)). When modeling was used to set the minimum withdrawal time at 9 min, we predicted that adenomas and CSSPs would be detected in 302 (3.8%) and 191 (2.4%) more patients. The increase in detection was most striking for the CSSPs, with nearly a 30% relative increase.CONCLUSIONS:A withdrawal time of 9 min resulted in a statistically significant increase in adenoma and serrated polyp detection. Colonoscopy quality may improve with a median normal withdrawal time benchmark of 9 min.

Bias Associated With Self-Report of Prior Screening Mammography

Background: Self-reported screening behaviors from national surveys often overestimate screening use, and the amount of overestimation may vary by demographic characteristics. We examine self-report bias in mammography screening rates overall, by age, and by race/ethnicity. Methods: We use mammography registry data (1999-2000) from the Breast Cancer Surveillance Consortium to estimate the validity of self-reported mammography screening collected by two national surveys. First, we compare mammography use from 1999 to 2000 for a geographically defined population (Vermont) with self-reported rates in the prior two years from the 2000 Vermont Behavioral Risk Factor Surveillance System. We then use a screening dissemination simulation model to assess estimates of mammography screening from the 2000 National Health Interview Survey. Results: Self-report estimates of mammography use in the prior 2 years from the Vermont Behavioral Risk Factor Surveillance System are 15 to 25 percentage points higher than actual screening rates across age groups. The differences in National Health Interview Survey screening estimates from models are similar for women 40 to 49 and 50 to 59 years and greater than for those 60 to 69, or 70 to 79 (27 and 26 percentage points versus 14, and 14, respectively). Overreporting is highest among African American women (24.4 percentage points) and lowest among Hispanic women (17.9) with non-Hispanic White women in between (19.3). Values of sensitivity and specificity consistent with our results are similar to previous validation studies of mammography. Conclusion: Overestimation of self-reported mammography usage from national surveys varies by age and race/ethnicity. A more nuanced approach that accounts for demographic differences is needed when adjusting for overestimation or assessing disparities between populations. (Cancer Epidemiol Biomarkers Prev 2009;18(6):1699–705)

Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions.

Study Design. Serial, cross-sectional, nationally representative surveys of noninstitutionalized US adults. Objective. To examine expenditures on common ambulatory health services for the management of back and neck conditions. Summary of Background Data. Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population. Methods. We used the Medical Expenditure Panel Survey to examine adult (aged 18 yr or older) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. Results. Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from

Patterns of Breast Magnetic Resonance Imaging Use in Community Practice

487 to

Cancer after Total Joint Arthroplasty: A Meta-analysis

950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. During the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; although physical therapy was the most costly service overall, in recent years those costs have contracted. Conclusion. Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions.

Breast cancer screening in an era of personalized regimens: A conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level

IMPORTANCE Breast magnetic resonance imaging (MRI) is increasingly used for breast cancer screening, diagnostic evaluation, and surveillance. However, we lack data on national patterns of breast MRI use in community practice. OBJECTIVE To describe patterns of breast MRI use in US community practice during the period 2005 through 2009. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using data collected from 2005 through 2009 on breast MRI and mammography from 5 national Breast Cancer Surveillance Consortium registries. Data included 8931 breast MRI examinations and 1,288,924 screening mammograms from women aged 18 to 79 years. MAIN OUTCOMES AND MEASURES We calculated the rate of breast MRI examinations per 1000 women with breast imaging within the same year and described the clinical indications for the breast MRI examinations by year and age. We compared women screened with breast MRI to women screened with mammography alone for patient characteristics and lifetime breast cancer risk. RESULTS The overall rate of breast MRI from 2005 through 2009 nearly tripled from 4.2 to 11.5 examinations per 1000 women, with the most rapid increase from 2005 to 2007 (P = .02). The most common clinical indication was diagnostic evaluation (40.3%), followed by screening (31.7%). Compared with women who received screening mammography alone, women who underwent screening breast MRI were more likely to be younger than 50 years, white non-Hispanic, and nulliparous and to have a personal history of breast cancer, a family history of breast cancer, and extremely dense breast tissue (all P < .001). The proportion of women screened using breast MRI at high lifetime risk for breast cancer (>20%) increased during the study period from 9% in 2005 to 29% in 2009. CONCLUSIONS AND RELEVANCE Use of breast MRI for screening in high-risk women is increasing. However, our findings suggest that there is a need to improve appropriate use, including among women who may benefit from screening breast MRI.

Race versus place of service in mortality among Medicare beneficiaries with cancer

Background: Some epidemiologic and laboratory studies have suggested that total joint arthroplasty could increase the risk of cancer. In this meta-analysis, we attempt to clarify the association of joint arthroplasty with subsequent cancer incidence. Methods: We identified population-based studies reporting standardized incidence ratios (SIR) for cancer following large joint arthroplasty. After summing the observed and expected numbers of cases across all qualifying studies, we calculated SIRs for all cancers, and for those at 28 anatomic sites. Latency analysis involving 175,166 patients characterized short-term and long-term cancer associations. Results: The analyses included 1,435,356 person-years of follow-up and 20,045 cases of cancer. Overall cancer risk among patients with arthroplasty was equal to that for the general population. The relative risk of lung cancer, reduced in the first 5 years after arthroplasty, increased significantly over time to approach that of the general population. Risks for all sites in the luminal gastrointestinal tract were significantly reduced by 10% to 20%; with relative risks that were generally stable over time. Increased risks were seen for cancer of the prostate (SIR, 1.12; 95% confidence interval, 1.08-1.16); similar relative risks were seen in each time period after the procedure. For melanoma, relative risks increased with follow-up to a SIR of 1.43 (95% confidence interval, 1.13-1.79) for 10 or more years after arthroplasty. There was a similar delayed emergence of increased risks for cancers of the urinary tract and oropharynx. The relative risk for bone cancer decreased with time after the procedure. Conclusions: There does not seem to be an overall increased risk of cancer following total joint arthroplasty. Although the risks of prostate cancer and melanoma seem to be elevated, there is no obvious mechanism for these associations. Reductions in risk for some malignancies may not be causal. (Cancer Epidemiol Biomarkers Prev 2006;15(8):1532–7)

Influence of NCI Cancer Center Attendance on Mortality in Lung, Breast, Colorectal, and Prostate Cancer Patients

Breast cancer screening holds a prominent place in public health, health care delivery, policy, and womens health care decisions. Several factors are driving shifts in how population‐based breast cancer screening is approached, including advanced imaging technologies, health system performance measures, health care reform, concern for “overdiagnosis,” and improved understanding of risk. Maximizing benefits while minimizing the harms of screening requires moving from a “1‐size‐fits‐all” guideline paradigm to more personalized strategies. A refined conceptual model for breast cancer screening is needed to align womens risks and preferences with screening regimens. A conceptual model of personalized breast cancer screening is presented herein that emphasizes key domains and transitions throughout the screening process, as well as multilevel perspectives. The key domains of screening awareness, detection, diagnosis, and treatment and survivorship are conceptualized to function at the level of the patient, provider, facility, health care system, and population/policy arena. Personalized breast cancer screening can be assessed across these domains with both process and outcome measures. Identifying, evaluating, and monitoring process measures in screening is a focus of a National Cancer Institute initiative entitled PROSPR (Population‐based Research Optimizing Screening through Personalized Regimens), which will provide generalizable evidence for a risk‐based model of breast cancer screening, The model presented builds on prior breast cancer screening models and may serve to identify new measures to optimize benefits‐to‐harms tradeoffs in population‐based screening, which is a timely goal in the era of health care reform. Cancer 2014;120:2955–2964.

National Performance Benchmarks for Modern Screening Digital Mammography: Update from the Breast Cancer Surveillance Consortium

Evidence suggests that excess mortality among African‐American cancer patients is explained in part by the healthcare setting. The objective of this study was to compare mortality among African‐American and Caucasian cancer patients and to evaluate the influence of attendance at a National Cancer Institute (NCI)‐designated comprehensive or clinical cancer center.