Tzy Mey Kuo

Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer.

Importance Patients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects. Objective To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance. Design, Setting, and Participants Population-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015. Exposures Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance. Main Outcomes and Measures Quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains—sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems—each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point. Results Of 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI, 27.8-39.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI, 8.7-14.8]) and brachytherapy (20.5 [95% CI, 15.1-25.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains. Conclusions and Relevance In this cohort of men with localized prostate cancer, each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.

Trends in stage‐specific incidence rates for urothelial carcinoma of the bladder in the United States: 1988 to 2006

Bladder cancer is notable for a striking heterogeneity of disease‐specific risks. Among the approximately 75% of incident cases found to be superficial to the muscularis propria at the time of presentation (non–muscle‐invasive bladder cancer), the risk of progression to the lethal phenotype of muscle‐invasive disease is strongly associated with stage and grade of disease. Given the suggestion of an increasing percentage of low‐risk cases in hospital‐based registry data in recent years, the authors hypothesized that population‐based data may reveal changes in the stage distribution of early‐stage cases.

Preoperatively Misclassified, Surgically Removed Benign Renal Masses: A Systematic Review of Surgical Series and United States Population Level Burden Estimate

PURPOSEnA significant proportion of renal masses removed for suspected malignancy are histologically benign with the probability inversely proportional to lesion size. To our knowledge the number of preoperatively misclassified benign renal masses treated with nephrectomy is currently unknown. Given the increasing incidence and decreasing average size of renal cell carcinoma, this burden is likely increasing. We estimated the population level burden of surgically removed, preoperatively misclassified benign renal masses in the United States.nnnMATERIALS AND METHODSnWe systematically reviewed the literature for studies of pathological findings of renal masses removed for suspected renal cell carcinoma based on preoperative imaging through July 1, 2014. We excluded studies that did not describe benign pathology and with masses not stratified by size, and in which pathology results were based on biopsy. SEER data were queried for the incidence of surgically removed renal cell carcinomas in 2000 to 2009.nnnRESULTSnA total of 19 studies of tumor pathology based on size met criteria for review. Pooled estimates of the proportion of benign histology in our primary analysis (American studies only and 1 cm increments) were 40.4%, 20.9%, 19.6%, 17.2%, 9.2% and 6.4% for tumors less than 1, 1 to less than 2, 2 to less than 3, 3 to less than 4, 4 to 7 and greater than 7, respectively. The estimated number of surgically resected benign renal masses in the United States from 2000 to 2009 increased by 82% from 3,098 to 5,624.nnnCONCLUSIONSnThese estimates suggest that the population level burden of preoperatively misclassified benign renal masses is substantial and increasing rapidly, paralleling increases in surgically resected small renal cell carcinoma. This study illustrates an important and to our knowledge previously unstudied dimension of overtreatment that is not directly quantified in contemporary surveillance data.

Comparative effectiveness of intensity-modulated radiotherapy and conventional conformal radiotherapy in the treatment of prostate cancer after radical prostatectomy.

IMPORTANCEnComparative effectiveness research of prostate cancer therapies is needed because of the development and rapid clinical adoption of newer and costlier treatments without proven clinical benefit. Radiotherapy is indicated after prostatectomy in select patients who have adverse pathologic features and in those with recurrent disease.nnnOBJECTIVESnTo examine the patterns of use of intensity-modulated radiotherapy (IMRT), a newer, more expensive technology that may reduce radiation dose to adjacent organs compared with the older conformal radiotherapy (CRT) in the postprostatectomy setting, and to compare disease control and morbidity outcomes of these treatments.nnnDESIGN AND SETTINGnData from the Surveillance, Epidemiology, and End Results-Medicare-linked database were used to identify patients with a diagnosis of prostate cancer who had received radiotherapy within 3 years after prostatectomy.nnnPARTICIPANTSnPatients who received IMRT or CRT.nnnMAIN OUTCOMES AND MEASURESnThe outcomes of 457 IMRT and 557 CRT patients who received radiotherapy between 2002 and 2007 were compared using their claims through 2009. We used propensity score methods to balance baseline characteristics and estimate adjusted incidence rate ratios (RRs) and their 95% CIs for measured outcomes.nnnRESULTSnUse of IMRT increased from zero in 2000 to 82.1% in 2009. Men who received IMRT vs CRT showed no significant difference in rates of long-term gastrointestinal morbidity (RR, 0.95; 95% CI, 0.66-1.37), urinary nonincontinent morbidity (0.93; 0.66-1.33), urinary incontinence (0.98; 0.71-1.35), or erectile dysfunction (0.85; 0.61-1.19). There was no significant difference in subsequent treatment for recurrent disease (RR, 1.31; 95% CI, 0.90-1.92).nnnCONCLUSIONS AND RELEVANCEnPostprostatectomy IMRT and CRT achieved similar morbidity and cancer control outcomes. The potential clinical benefit of IMRT in this setting is unclear. Given that IMRT is more expensive, its use for postprostatectomy radiotherapy may not be cost-effective compared with CRT, although formal analysis is needed.

Racial difference in histologic subtype of renal cell carcinoma.

In the United States, renal cell carcinoma (RCC) has rapidly increased in incidence for over two decades. The most common histologic subtypes of RCC, clear cell, papillary, and chromophobe have distinct genetic and clinical characteristics; however, epidemiologic features of these subtypes have not been well characterized, particularly regarding any associations between race, disease subtypes, and recent incidence trends. Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, we examined differences in the age‐adjusted incidence rates and trends of RCC subtypes, including analysis focusing on racial differences. Incidence rates increased over time (2001–2009) for all three subtypes. However, the proportion of white cases with clear cell histology was higher than among blacks (50% vs. 31%, respectively), whereas black cases were more likely than white cases to have papillary RCC (23% vs. 9%, respectively). Moreover, papillary RCC incidence increased more rapidly for blacks than whites (P < 0.01) over this period. We also observed that increased incidence of papillary histology among blacks is not limited to the smallest size strata. We observed racial differences in proportionate incidence of RCC subtypes, which appear to be increasing over time; this novel finding motivates further etiologic, clinical, molecular, and genetic studies.

Effects of Distance to Care and Rural or Urban Residence on Receipt of Radiation Therapy Among North Carolina Medicare Enrollees With Breast Cancer

BACKGROUND Distance to oncology service providers and rurality may affect receipt of guideline-recommended radiation therapy (RT), but the extent to which these factors affect the care of Medicare-insured patients is unknown. METHODS Using cancer registry data linked to Medicare claims from the Integrated Cancer Information and Surveillance System (ICISS), we identified all women aged 65 years or older who were diagnosed with stage I, II, or III breast cancer from 2003 through 2005, who had Medicare claims through 2006, and who were clinically eligible for RT. We geocoded the address of each RT service provider’s practice location and calculated the travel distance from each patient’s residential address to the nearest RT provider. We used ZIP codes to classify each patient’s residence as rural or urban according to rural-urban commuting area codes. We used generalized estimating equations models with county-level clustering and interaction terms between distance categories and rural-urban status to estimate the effect of distance to care and rural-urban status on receipt of RT. RESULTS In urban areas, increasing distance to the nearest RT provider was associated with a lower likelihood of receiving RT (odds ratio [OR] = 0.54; 95% confidence interval [CI], 0.30-0.97) for those living more than 20 miles from the nearest RT provider compared with those living less than 10 miles away. In rural areas, those living within 10-20 miles of the nearest RT provider were more likely to receive RT than those living less than 10 miles away (OR = 1.73; 95% CI, 1.08-2.76). LIMITATIONS Results may not be generalizable to areas outside North Carolina or to non-Medicare populations. CONCLUSIONS Coordinated outreach programs targeted differently to rural and urban patients may be necessary to improve the quality of oncology care.

Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population.

Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003-2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.

Building the Evidence for Decision-Making: The Relationship Between Local Public Health Capacity and Community Mortality

OBJECTIVESnWe examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina.nnnMETHODSnWe analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality.nnnRESULTSnSpending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and childrens services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05).nnnCONCLUSIONSnOur findings, in the context of other studies, provide support for investment in local public health services to improve community health.

Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50

Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p < 0.05). Of 56,151 privately-insured persons turning 50 years old who received CRC testing, 42% received colonoscopy, whereas 58% received FOBT/FIT, with significant regional variation. In multivariable models, females with private insurance had lower odds of colonoscopy than males (OR = 0.43; p < 0.05). People living 10–15 miles away from endoscopy facilities also had lower odds of colonoscopy than those living within 5 miles (OR = 0.91; p < 0.05). Both colonoscopy and FOBT/FIT are widely used in North Carolina among insured persons newly age-eligible for screening. The high level of FOBT/FIT use among privately insured persons and women suggests that renewed emphasis on FOBT/FIT as a viable screening alternative to colonoscopy may be important.

Cost-Effectiveness Analysis of Four Simulated Colorectal Cancer Screening Interventions, North Carolina

Introduction Colorectal cancer (CRC) screening rates are suboptimal, particularly among the uninsured and the under-insured and among rural and African American populations. Little guidance is available for state-level decision makers to use to prioritize investment in evidence-based interventions to improve their population’s health. The objective of this study was to demonstrate use of a simulation model that incorporates synthetic census data and claims-based statistical models to project screening behavior in North Carolina. Methods We used individual-based modeling to simulate and compare intervention costs and results under 4 evidence-based and stakeholder-informed intervention scenarios for a 10-year intervention window, from January 1, 2014, through December 31, 2023. We compared the proportion of people living in North Carolina who were aged 50 to 75 years at some point during the window (that is, age-eligible for screening) who were up to date with CRC screening recommendations across intervention scenarios, both overall and among groups with documented disparities in receipt of screening. Results We estimated that the costs of the 4 intervention scenarios considered would range from