Xianglin L. Du

Use of surveillance for hepatocellular carcinoma among patients with cirrhosis in the United States

Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is recommended but may not be performed. The extent and determinants of HCC surveillance are unknown. We conducted a population‐based United States cohort study of patients over 65 years of age to examine use and determinants of prediagnosis surveillance in patients with HCC who were previously diagnosed with cirrhosis. Patients diagnosed with HCC during 1994‐2002 were identified from the linked Surveillance, Epidemiology, and End‐Results registry–Medicare databases. We identified alpha‐fetoprotein (AFP) and ultrasound tests performed for HCC surveillance, and examined factors associated with surveillance. We identified 1,873 HCC patients with a prior diagnosis of cirrhosis. In the 3 years before HCC, 17% received regular surveillance and 38% received inconsistent surveillance. In a subset of 541 patients in whom cirrhosis was recorded for 3 or more years prior to HCC, only 29% received routine surveillance and 33% received inconsistent surveillance. Among all patients who received regular surveillance, approximately 52% received both AFP and ultrasound, 46% received AFP only, and 2% received ultrasound only. Patients receiving regular surveillance were more likely to have lived in urban areas and had higher incomes than those who did not receive surveillance. Before diagnosis, approximately 48% of patients were seen by a gastroenterologist/hepatologist or by a physician with an academic affiliation; they were approximately 4.5‐fold and 2.8‐fold, respectively, more likely to receive regular surveillance than those seen by a primary care physician only. Geographic variation in surveillance was observed and explained by patient and physician factors. Conclusion: Less than 20% of patients with cirrhosis who developed HCC received regular surveillance. Gastroenterologists/hepatologists or physicians with an academic affiliation are more likely to perform surveillance. HEPATOLOGY 2010

Racial Disparity and Socioeconomic Status in Association With Survival in Older Men with Local/Regional Stage Prostate Cancer: Findings From a Large Community-Based Cohort

Few studies have examined the outcomes for Hispanic men with prostate carcinoma and incorporated socioeconomic factors in association with race/ethnicity in affecting survival, adjusting for factors on cancer stage, grade, comorbidity, and treatment.

Effects of individual-level socioeconomic factors on racial disparities in cancer treatment and survival: findings from the National Longitudinal Mortality Study, 1979-2003.

This is the first study to use the linked National Longitudinal Mortality Study and Surveillance, Epidemiology, and End Results (SEER) data to determine the effects of individual‐level socioeconomic factors (health insurance, education, income, and poverty status) on racial disparities in receiving treatment and in survival.

Meta-analysis of racial disparities in survival in association with socioeconomic status among men and women with colon cancer.

Few studies have addressed racial disparities in survival for colon cancer by adequately incorporating both treatment and socioeconomic factors, and the findings from those studies have been inconsistent. The objectives of the current study were to systematically review the existing literature and provide a more stable estimate of the measures of association between socioeconomic status and racial disparities in survival for colon cancer by undertaking a meta‐analysis.

Racial disparities and treatment trends in a large cohort of elderly black and white patients with nonsmall cell lung cancer

This study investigated whether there was a significant gap in receipt of treatment for nonsmall cell lung cancer (NSCLC) between blacks and whites, and whether the gap or disparity changed during the past 12 years from 1991 to 2002.

Impact of Treatment and Socioeconomic Status on Racial Disparities in Survival Among Older Women With Breast Cancer

Objective:To examine racial/ethnic disparities in mortality and survival in a large nationwide and population-based cohort of women with breast cancer after simultaneously controlling for differences in comorbidity, treatment, and socioeconomic status. Methods:A cohort of 35,029 women with stage I–IIIA breast cancer at age ≥65 from 1992 to 1999 was identified from the surveillance, epidemiology, and end results-medicare linked databases with up to 11 years of follow-up. Cox proportional hazard regression analysis was performed to determine the risk of all-cause and breast cancer-specific mortality. Results:African-American women with breast cancer were more likely to live in the poorest quartiles of socioeconomic status at the census tract level than whites (73.7% versus 20.7%, P < 0.001). Those living in communities with the lowest socioeconomic status were 11% more likely to die than those in the highest (hazard ratio, 1.10; 95% confidence interval, 1.04–1.16). The risk of dying changed slightly after controlling for race/ethnicity (1.11; 1.05–1.18). Compared with white women with breast cancer, crude hazard ratios of all-cause and breast cancer-specific mortality were 1.35 (1.27–1.45) and 1.83 (1.56–2.16) for African-Americans. After adjusting for treatment and socioeconomic status, hazard ratio of all-cause mortality was no longer significant in African-Americans (1.02; 0.84–1.10), whereas the risk of breast cancer-specific mortality was marginally higher in African-Americans (1.21; 1.01–1.46). Conclusions:Racial disparities in overall survival between African-American and white women with breast cancer were not present after controlling for treatment and socioeconomic status. Efforts to eliminate these barriers have important public health implications for reducing disparities in health outcomes.

Trends in colorectal cancer incidence by anatomic site and disease stage in the United States from 1976 to 2005.

ObjectiveThe objectives of the current study were to examine the trends in incidence rates of subsite-specific colorectal cancer at all stages in a large US population and to explore the impact of age and sex on colorectal cancer incidence. MethodsData were obtained from the Surveillance, Epidemiology, and End Results (SEER) 9 registries. Colorectal cancer incidence was divided into 3 anatomic subsite groupings: proximal colon, distal colon, and rectum. Incidence rates and relative risk were calculated using the SEER*Stat software provided by the National Cancer Institute. ResultsFrom 1976 to 2005, age-adjusted incidence of proximal colon, distal colon, and rectal cancers per 100,000 population have steadily decreased from 22.5, 18.8, and 19.2 to 21.1, 11.7, and 13.6, respectively, contributing to the overall decline in the incidence of colorectal cancer from 60.5 to 46.4. Distal colon cancer had the greatest incidence decline (−37.79%), whereas the most minimal change in the incidence rates occurred for proximal colon cancer (−6.37%) because of increased incidence rates of ascending colon (24.8%) and hepatic flexure (21.3%) over 30 years. The steadily increased proportion of proximal colorectal cancer subsites was observed in both men and women starting at age 50 although women experienced a greater increase than did men. ConclusionsOverall incidence rate of colorectal cancer decreased over the past 3 decades. The percent of ascending colon and hepatic flexure cancers diagnosed at early stages (localized and regional) increased. The finding on sex difference over years suggests that great attention should be paid in the future studies to male and female disparities.

External Validation of Medicare Claims for Breast Cancer Chemotherapy Compared With Medical Chart Reviews

Background:Although Medicare claims data have been increasingly used to examine the patterns and outcomes of cancer chemotherapy, their external validity has not been well studied. Objectives:We sought to validate Medicare claims for chemotherapy compared with medical chart reviews. Patients and Methods:We completed medical chart reviews for 1228 women who were diagnosed with breast cancer at age 65 and older between 1993 and 1999 in New Mexico that were linked with Medicare claims data, achieving an estimated sensitivity of more than 90% and a 0.05 level of precision. Results:Of the 150 subjects identified by Medicare claims as receiving chemotherapy within 6 months of diagnosis, 75% were confirmed by medical records as having received chemotherapy. Of the remaining 25% of cases without chart verification, (1) 33 cases had 7 or more claims for chemotherapy and also had specific chemotherapy drugs indicated in Medicare data, representing 22% (33/150) of all cases that received chemotherapy according to Medicare claims and (2) 4 cases had 1 to 6 claims for chemotherapy, representing 3% (4/150) of all cases with claims for chemotherapy. Of those 1078 subjects who did not receive chemotherapy according to Medicare claims, more than 99% were confirmed by chart reviews. Observed agreement on chemotherapy between Medicare claims and chart reviews was 94% and overall reliability (kappa) was 0.69 (95% confidence interval = 0.63–0.76). Conclusions:Of cases identified as receiving chemotherapy by Medicare claims, 97% had strong evidence and only 3% had weak evidence for receiving this therapy.

Population-Based Assessment of Surgical Treatment Trends for Patients With Melanoma in the Era of Sentinel Lymph Node Biopsy

PURPOSE The surgical staging of melanoma dramatically changed with the introduction of sentinel lymph node (SLN) biopsy. In this study, Surveillance, Epidemiology, and End Results (SEER) data were examined to determine how surgical treatment is being carried out and whether SLN biopsy is being performed in melanoma patients in conformance with National Comprehensive Cancer Network (NCCN) guidelines. PATIENTS AND METHODS The SEER database (1998 to 2001) was searched for all patients with invasive melanoma. NCCN guidelines were used to define optimal stage-specific surgical treatment. Treatment trends in patients with stages I to III disease were summarized, and multivariate analyses were performed to identify factors associated with nonadherence with treatment guidelines. RESULTS A total of 21,867 melanoma patients were identified; 18,499 of these patients met the inclusion criteria. The number of patients diagnosed with stage III melanoma increased by 55.7% over the study period, and this corresponded to a 53% increase in the number of SLN biopsies performed annually. The odds ratios for nonadherence were 2.32, 2.27, and 1.54 for stages IB, II, and III disease, respectively, compared with stage IA melanoma. Multivariate analyses revealed that age more than 65 years, marital status, minority populations, and primary tumor location were associated with nonadherence with guidelines. Treatment patterns among tumor registries also varied significantly. CONCLUSION Stage migration is evident in the SEER registries in consort with increasing use of SLN biopsy. Although treatment trends are improving, SLN biopsy continues to be underused, particularly in the elderly and minority populations, in patients with truncal and head/neck melanomas, and also in some geographic regions of the United States.

Ethnic variations in diagnosis, treatment, socioeconomic status, and survival in a large population-based cohort of elderly patients with non-Hodgkin lymphoma

There is a lack of research on ethnic disparities in survival among patients with non‐Hodgkin lymphoma (NHL), although these disparities have been documented for patients with many other tumors.