Variations in gastric cancer care

BACKGROUND:

Race is associated with patterns of presentation and survival outcomes of gastric cancer in the United States. However, the impact of race on the receipt of guideline‐recommended care is not well characterized. By using current recommendations, the authors examined the association between race and guideline‐recommended treatments and identified factors that are predictive of variations in gastric cancer care.

METHODS:

By using the National Cancer Database for 1998 through 2005, 106,002 patients with gastric adenocarcinoma were identified. Multivariate analysis techniques were used to examine the association between race, the receipt of guideline‐recommended care, and survival after adjusting for covariates.

RESULTS:

Although African‐American and Hispanic patients were more likely to undergo adequate lymphadenectomy (≥15 lymph nodes) and to receive care at comprehensive cancer centers and high‐volume facilities (for all, P ≤ .001), they were less likely to receive adjuvant multimodality therapy for American Joint Committee on Cancer stage IB through IV, lymph node‐negative (M0) disease. Up to 60% of all patients who underwent gastrectomy failed to receive adequate lymphadenectomy and adjuvant multimodality therapy. The delivery of multimodality therapy varied significantly by stage and lymph node evaluation (P ≤ .001). These findings persisted on our multivariate analyses, indicating that African‐American and Hispanic patients received adequate lymph node evaluation (P ≤ .001), whereas they were associated with receiving no adjuvant multimodality therapy (P ≤ .025).

CONCLUSIONS:

There were significant variations in treatment for gastric cancer among ethnic groups in the United States. It was noteworthy that, although nonwhite race was associated with improved surgical care, gastric cancer care remained suboptimal overall. Cancer programs need to identify procedures to maximize the delivery of adequate gastric cancer care to all patients. Cancer 2010. © 2010 American Cancer Society.     

Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward

BACKGROUND.

Acute palliative care units (APCUs) are gaining popularity in tertiary care centers. In this study, the authors examined the impact of opening an APCU on administrative outcomes for a general oncology ward (GOW) at a comprehensive cancer center.

METHODS.

The GOW database was reviewed for 3 periods: June 2000 through May 2002 (before the APCU opened), June 2002 through May 2004 (transitional period, including APCU opening in a temporary location), and June 2004 through May 2006 (after opening of the APCU). Data were extracted on demographics, reasons for admission, admission type, waiting time for admission, length of stay (LOS), overstay (>2 days over expected LOS), death rate, and discharge destination. Linear regression analysis and the Cochran‐Armitage test were used for data analysis.

RESULTS.

There were 5340 admissions: The median patient age was 60 years, and 55% of patients were women. The most common primary cancers were head and neck (22%), gynecologic (21%), gastrointestinal (13%), and lung (12%). There were significant trends on the GOW in decreased admissions for palliative care (12.2%, 9.6%, and 7.9%, respectively, for the 3 periods; P < .0001), fewer inpatient deaths (11.4%, 8.6%, and 6.1%, respectively; P < .0001), and fewer patients with prolonged waits for a bed on a palliative care unit (3.4%, 3%, and 1.7%, respectively; P = .002). Admissions increased for interventions (10.4%, 17.3%, and 22.5%, respectively, for the 3 periods; P < .0001) and for chemotherapy (6.8%, 6.6%, and 9.7%, respectively; P = .001).

CONCLUSIONS.

After the opening of an APCU at the authors' cancer center, the GOW experienced a decrease in administrative endpoints related to palliative and end‐of‐life care and an increase in endpoints related to cancer‐directed interventions. Prospective studies with clinical endpoints will be required to determine whether this specialization of inpatient care improves quality of life, quality of death, and psychosocial well being. Cancer 2008. © 2008 American Cancer Society.     

Hematology/oncology fellows' training in palliative care: results of a national survey

BACKGROUND:

Palliative care is recognized as integral to the practice of oncology, yet many oncologists report inadequate training in critical palliative care domains, such as symptom management, psychosocial care, and communication skills. The authors of this report sought to assess the quantity and quality of palliative care education within oncology fellowships.

METHODS:

Second‐year oncology fellows completed a 104‐item survey that was modified and adapted from a national survey of medical students and residents. Items allowed comparison between palliative care and nonpalliative care topics.

RESULTS:

Of 402 eligible fellows, 63.2% responded (n = 254). Respondents were: 52% men, 62% Caucasian, and 64% US medical school graduates. Twenty‐six percent had completed a palliative care rotation. Fellows rated the overall quality of fellowship teaching more highly than teaching on palliative care (3.7 v 3.0 on a 1‐5 scale; t = 10.2; P < .001). Rates of being observed (81%) and receiving feedback (80%) on an end‐of‐life communication skill were high. Psychosocial needs of patients received some attention: Fifty‐seven percent of fellows reported that they were conveyed as a core competency, but only 32% of fellows received explicit education on assessing and managing depression at the end of life. Fellows rarely reported receiving explicit education on opioid rotation (33%). Fellows scored a median of 2 of 4 items that tested basic palliative care knowledge, and only 23% correctly performed an opioid conversion.

CONCLUSIONS:

Fellows rated the quality of palliative care education as inferior to overall oncology training and may benefit from more teaching on pain management, psychosocial care, and communication skills. Cancer 2011;. © 2011 American Cancer Society.     

On-site adequacy evaluations performed by cytotechnologists: correlation with final interpretations of 5241 image-guided fine-needle aspiration biopsies

BACKGROUND:

Practice patterns regarding on‐site assessment of the adequacy of image‐guided fine‐needle aspiration biopsies (FNABs) vary among laboratories, but in many laboratories primary responsibility rests with the cytotechnologists. On‐site evaluation provides feedback on the need for additional passes and facilitates triaging of the specimen for time‐sensitive ancillary studies. Prior studies have suggested that cytotechnologists can assess the initially obtained specimens correctly, but they are few in number and limited by small size. The purpose of this study was to assess the frequency with which our cytotechnologists were able to correctly assess specimens as adequate using a large‐scale database that included a wide range of image‐guided FNABs.

METHODS:

The frequency that on‐site adequacy assessments of 5241 image‐guided FNABs were correct was determined by correlating the cytotechnologists' assessments of adequacy with the final cytologic interpretation. An adequacy assessment was considered correct if the FNAB was ultimately reported as satisfactory and unequivocally benign or malignant. An adequate reading on a case that was ultimately reported as unsatisfactory, atypical, or suspicious was deemed “incorrect.” The effect of imaging modality was also analyzed.

RESULTS:

Of 5241 FNABs, 2784 (53%) were interpreted as adequate on site. Of these, 2637 (95%) were correctly considered adequate. Of the common biopsy sites sampled, the adequacy assessments for liver FNABs demonstrated the highest frequency for being correctly considered adequate (97%) and those for kidney FNABs showed the lowest (90%). Imaging modality had no effect on accuracy.

CONCLUSIONS:

Cytotechnologists are almost always correct when assessing initial FNAB samples as adequate. Cancer (Cancer Cytopathol) 2012;. © 2011 American Cancer Society.     

Efficacy of radiotherapy for painful bone metastases during the last 12 weeks of life

BACKGROUND:

Radiotherapy is an effective treatment for painful bone metastases. Whether this applies also in patients with limited survival remains to be investigated. This study analyzed the effect of radiotherapy for painful bone metastases in patients with a survival ≤12 weeks.

METHODS:

In the Dutch Bone Metastasis Study, 1157 patients with painful bone metastases were randomized to single fraction (1 × 8 grays [Gy]) or multiple fraction (6 × 4 Gy) radiotherapy. Patients who died within 12 weeks after randomization were included in this analysis. Patients were classified as responders or nonresponders, based on their pain response to radiotherapy. This response was calculated considering changes in pain intensity (measured with an 11‐point numeric rating scale) and analgesic usage. Cox proportional hazards models were used to analyze pain response and survival.

RESULTS:

Two hundred seventy‐4 patients were included in this analysis. At randomization, the mean pain intensity score (±standard deviation) was 7 (±2). The proportion showing a pain response did not differ between the single fraction and multiple fraction groups. Toward death, pain intensity score decreased to 5 (±3) in responders (45%), whereas in nonresponders (55%) no change was observed. Despite the benefit in responders, in 60% of all patients pain intensity remained 5 after randomization.

CONCLUSIONS:

Pain responded in about half of the patients who survived ≤12 weeks after randomization into the Dutch Bone Metastasis Study. When considering radiotherapy, single fraction should be preferred. Additional palliative measures remain essential for adequate pain control. Cancer 2010. © 2010 American Cancer Society.     

Identifikation nicht heilbarer Krebspatienten mit Palliativbedarf durch Screening

Background

The German S3 guideline on palliative care requires that symptoms and needs of patients with incurable cancerous diseases should be regularly assessed, irrespective of the tumor-specific treatment. Self-report questionnaires for palliative medicine are available for screening, such as the Edmonton Symptom Assessment Scale (ESAS), which is used in oncology centers in Canada in the context of a quality management initiative.

Aims and method

Implemention of the ESAS as a screening method for patients with metastases in lung cancer centers, colorectal cancer centers, in centers for neuro-oncological cancer and in the skin cancer center at the Mainfranken Comprehensive Cancer Center.

Results

From a total of 839 patient sceened, 79.6?% patients reported at least 1 out of 10 symptoms with moderate or severe intensity (ESAS item score ≥4), which indicates the need for a more detailed clinical assessment or intervention. The most prevalent symptoms were impairment of general well-being, fatigue and exhaustion, loss of appetite and dyspnea. Of the patients 40.4?% showed at least 1 symptom with severe intensity (ESAS score ≥7) with an ensuing need for an intervention.

Conclusions

A large proportion of patients reported a significant symptom burden. It should be further discussed whether clinical assessment and subsequent interventions can be provided by general palliative care teams and at what stage the inclusion of specialized teams is necessary.

     

Gabapentin for the treatment of pain syndrome related to radiation‐induced mucositis in patients with head and neck cancer treated with concurrent chemoradiotherapy

BACKGROUND:

This retrospective study evaluated the efficacy of gabapentin for the treatment of pain syndromes related to radiation‐induced mucositis in patients with head and neck cancers treated with concurrent chemoradiation.

METHODS:

Data from 42 patients with head and neck malignancies treated with concurrent chemoradiotherapy using an intensity‐modulated radiotherapy technique were analyzed. Gabapentin was initiated in the second week of radiotherapy. Opiates were prescribed in addition to gabapentin as clinically indicated to obtain adequate pain control.

RESULTS:

At a median dose of 2700 mg/day of gabapentin, only 33% and 55% of patients required additional low‐dose narcotic medications for pain control during the third and fourth week of treatment, respectively, despite exhibiting a grade 2 or higher mucositis in 71% and 86% of the patients, respectively. Furthermore, during the last weeks of treatment, 71% of the patients required additional low‐dose opiates for adequate pain control, despite the presence of grade 2 or higher mucositis in 95% and 100% of patients at Weeks 5 and 6, respectively. Only 1 patient had a treatment‐related interruption of >3 days during chemoradiotherapy.

CONCLUSIONS:

Gabapentin appears to be promising in reducing the need for high total doses of opioids and avoiding unplanned treatment interruptions for patients with head and neck malignancies treated with concurrent chemoradiotherapy and should be further evaluated prospectively in controlled clinical trials. Cancer 2010. © 2010 American Cancer Society.     

Mental health,treatment preferences,advance care planning,location, and quality of death in advanced cancer patients with dependent children

BACKGROUND:

Clinicians observe that advanced cancer patients with dependent children agonize over the impact their death will have on their children. The objective of this study was to determine empirically whether advanced cancer patients with and without dependent children differ in treatment preferences, mental health, and end‐of‐life (EOL) outcomes.

METHODS:

Coping with Cancer is a National Cancer Institute/National Institute of Mental Health‐funded, multi‐institutional, prospective cohort study of 668 patients with advanced cancer. Patients with and without dependent children were compared on rates of psychiatric disorders, advance care planning (ACP), EOL care, quality of their last week of life, and location of death.

RESULTS:

In adjusted analyses, patients with advanced cancer who had dependent children were more likely to meet panic disorder criteria (adjusted odds ratio [AOR], 5.41; 95% confidence interval [95% CI], 2.13–13.69), more likely to be worried (mean difference in standard deviations [δ], 0.09; P = .006), and more likely to prefer aggressive treatment over palliative care (AOR, 1.77; 95% CI, 1.07–2.93). Patients with dependent children were less likely to engage in ACP (eg, do not resuscitate orders: AOR, 0.44; 95% CI, 0.26–0.75) and had a worse quality of life in the last week of life (δ, 0.15; P = .007). Among spousal caregivers, those with dependent children were more likely to meet criteria for major depressive disorder (AOR, 4.53; 95% CI, 1.47–14) and generalized anxiety disorder (AOR, 3.95; 95% CI, 1.29–12.16).

CONCLUSIONS:

Patients with dependent children were more anxious, were less likely to engage in ACP, and were more likely to have a worse quality of life in their last week of life. Advanced cancer patients and spousal caregivers with dependent children represent a particularly distressed group that warrants further clinical attention, research, and support. Cancer 2009. © 2009 American Cancer Society.     

Timing of palliative care referral and symptom burden in phase 1 cancer patients

BACKGROUND:

Phase 1 trials offer patients with advanced cancer the opportunity to pursue life‐prolonging cancer treatments. In the current study, the timing of referral and symptom burden between patients referred to palliative care by phase 1 oncologists and those referred by non‐phase 1 oncologists were compared.

METHODS:

All 57 patients with advanced solid tumors who were referred by phase 1 oncologists to the palliative care outpatient clinic at The University of Texas M. D. Anderson Cancer Center (MDACC) between 2007 and 2008 were included. The comparison cohort was comprised of 114 non‐phase 1 patients who were stratified by age, sex, and cancer diagnosis in a 1:2 ratio. Information regarding patient characteristics, Edmonton Symptom Assessment Scale (ESAS), timing of referral, and survival was retrieved.

RESULTS:

Both cohorts had the following matched characteristics: average age of 57 years, with44% of the patients being female and 47% having gastrointestinal cancers. At the time of palliative care consultation, patients referred by phase 1 oncologists were more likely than patients referred by non‐phase 1 oncologists to have a better performance status (Eastern Cooperative Oncology Group 0–1: 61% vs 36% [P = .003). The ESAS was not significantly different with the exception of better well‐being in the phase 1 cohort (mean, 4.5 vs 5.5; P = .03). No difference was found for the duration between registration at MDACC and palliative care consultation (13 months vs 11 months; P = .41) and overall survival from the time of palliative care consultation (5 months vs 4 months; P = .69).

CONCLUSIONS:

Outpatients referred to palliative care by phase 1 oncologists were found to have a better performance status but similar symptom burden compared with patients referred by non‐phase 1 oncologists. Patients with phase 1 involvement did not appear to have delayed palliative care referral compared with non‐phase 1 patients. The results of the current study support the development of a simultaneous care model. Cancer 2010. © 2010 American Cancer Society.     

Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers

BACKGROUND:

Delirium has been the most frequent neuropsychiatric complication in patients with advanced cancer. This exploratory study aimed to determine the proportion of patients who were able to recall their experience of delirium and the level of distress experienced by patients, family caregivers, and healthcare professionals.

METHODS:

Patients with advanced cancer who had completely recovered from an acute delirium episode, had Memorial Delirium Assessment Scale score <13, and had a family caregiver present during the delirium were studied. Patients were given the Delirium Experience Questionnaire. Patients' and family caregivers' demographics, and the frequency and distress associated with different delirium symptoms were also collected. Bedside nurses and palliative care specialists reported the frequency of recalled delirium symptoms and their distress score.

RESULTS:

A total of 99 patient/family caregiver dyads participated in the study. The main identified causes for delirium were opioids, infection, brain metastases, hypercalcemia, and dehydration. There were 73 patients (74%) who remembered the episode of being delirious, with 59 of 73 patients (81%) reporting the experience as distressing (median distress level of 3). The median overall delirium distress score was higher in family caregivers (median, 3; 25%‐75% quartile, 2‐4) than in patients (median, 2; 25%‐75% quartile, 0‐3) (P = .0004). Bedside nurses and palliative care specialists expressed low median overall delirium distress scores (median, 0; 25%‐75% quartile 0‐1).

CONCLUSIONS:

The majority of patients with advanced cancer recalled their experience of delirium, causing moderate to severe distress in both patients and family caregivers. Appropriate interventions to reduce this distress are needed. Cancer 2009. © 2009 American Cancer Society.     

An Ethnographic Study of Barriers to Cancer Pain Management and Opioid Availability in India

Background.

The world’s global cancer burden disproportionally affects lower income countries, where 80% of patients present with late-stage disease and have limited access to palliative care and effective pain-relieving medications, such as morphine. Consequently, millions die each year with unrelieved pain.

Objective.

The objective of this study was to examine barriers to opioid availability and cancer pain management in India, with an emphasis on the experiences of nurses, who are often the front-line providers of palliative care.

Methods.

Fifty-nine participants were recruited using a purposive, snowball sampling strategy. Ethnographic data collection included in-depth, semistructured interviews (n = 54), 400+ hours of participant observation, and review of documents over 9 months at a government cancer hospital in South India. Systematic qualitative analysis led to identification of key barriers that are exemplified by representative quotes.

Results.

Morphine is more available at this study site than in most of India, but access is limited to patients seen by the palliative care service, and significant gaps in supply still occur. Systems to measure and improve pain outcomes are largely absent. Key barriers related to pain management include the role of nursing, opioid misperceptions, bureaucratic hurdles, and sociocultural/infrastructure challenges.

Implications.

Interventions must streamline process details of morphine procurement, work within the existing sociocultural infrastructure to ensure opioids reach patients most in need, target unexpected audiences for symptom management education, and account for role expectations of health care providers.

Conclusion.

Macro- and micro-level policy and practice changes are needed to improve opioid availability and cancer pain management in India.     

The Frequency,Characteristics, and Outcomes Among Cancer Patients With Delirium Admitted to an Acute Palliative Care Unit

Background.

Delirium is a common neuropsychiatric condition seen in patients with severe illness, such as advanced cancer. Few published studies are available of the frequency, course, and outcomes of standardized management of delirium in advanced cancer patients admitted to acute palliative care unit (APCU). In this study, we examined the frequency, characteristics, and outcomes of delirium in patients with advanced cancer admitted to an APCU.

Methods.

Medical records of 609 consecutive patients admitted to the APCU from January 2011 through December 2011 were reviewed. Data on patients’ demographics; Memorial Delirium Assessment Scale (MDAS) score; palliative care specialist (PCS) diagnosis of delirium; delirium etiology, subtype, and reversibility; late development of delirium; and discharge outcome were collected. Delirium was diagnosed with MDAS score ≥7 and by a PCS using Diagnostic and Statistical Manual, 4th edition, Text Revision criteria. All patients admitted to the APCU received standardized assessments and management of delirium per best practice guidelines in delirium management.

Results.

Of 556 patients in the APCU, 323 (58%) had a diagnosis of delirium. Of these, 229 (71%) had a delirium diagnosis on admission and 94 (29%) developed delirium after admission to the APCU. Delirium reversed in 85 of 323 episodes (26%). Half of patients with delirium (n = 162) died. Patients with the diagnosis of delirium had a lower median overall survival than those without delirium. Patients who developed delirium after admission to the APCU had poorer survival (p ≤ .0001) and a lower rate of delirium reversal (p = .03) compared with those admitted with delirium.

Conclusion.

More than half of the patients admitted to the APCU had delirium. Reversibility occurred in almost one-third of cases. Diagnosis of delirium was associated with poorer survival.

Implications for Practice:

Delirium is the most common neuropsychiatric condition in patients with severe medical illness and those at the end of life. It can be a source of distress for patients, their families, and the medical team. When missed, or if symptoms are misinterpreted, delirium may also lead to unnecessary interventions. This underlines the importance of diagnosis and detection of delirium in populations that are at increased risk. This study has important implications in practice, as it can assist clinicians in making decisions regarding other medical interventions, advance care planning, and communicating with families relating to end-of-life issues.     

Complementary therapies for children undergoing stem cell transplantation

BACKGROUND:

Children undergoing stem cell transplant (SCT) experience high levels of somatic distress and mood disturbance. This trial evaluated the efficacy of complementary therapies (massage, humor therapy, relaxation/imagery) for reducing distress associated with pediatric SCT.

METHODS:

Across 4 sites, 178 pediatric patients scheduled to undergo SCT were randomized to a child‐targeted intervention involving massage and humor therapy, the identical child intervention plus a parent intervention involving massage and relaxation/imagery, or standard care. Randomization was stratified by site, age, and type of transplant. The interventions began at admission and continued through SCT Week +3. Primary outcomes included patient and parent reports of somatic distress and mood disturbance obtained weekly from admission through Week +6 using the Behavioral, Affective, and Somatic Experiences Scales. Secondary outcomes included length of hospitalization, time to engraftment, and usage of narcotic analgesic and antiemetic medications.

RESULTS:

A mixed model approach was used to assess longitudinal trends of patient and parent report outcomes and to test differences between groups on these measures. Significant changes across time were observed on all patient and parent report outcomes. However, no significant differences between treatment arms were found on the primary outcomes. Similarly, no significant between‐group differences were noted on any of the medical variables as secondary outcomes.

CONCLUSIONS:

Results of this multisite trial failed to document significant benefits of complementary interventions in the pediatric SCT setting. Cancer 2010. © 2010 American Cancer Society.     

Methadone initiation and rotation in the outpatient setting for patients with cancer pain

BACKGROUND:

Methadone is an effective and inexpensive opioid for cancer pain treatment. It has been reported as difficult to use in the outpatient setting because of its variable relative potency and long half‐life. The purpose of this study was to determine the outcome of methadone initiation or rotation for cancer pain treatment in outpatient settings.

METHODS:

Chart review was done of 189 consecutive patients who underwent methadone initiation or rotation at the authors' palliative care outpatient center. Data were collected regarding demographic and clinical characteristics, symptoms, and opioid side effects at baseline and for 2 follow‐up visits (F1, F2). Failure was defined as methadone discontinuation by the palliative care physician or patient's hospitalization for uncontrolled pain or methadone‐related side effects at F1.

RESULTS:

One hundred (53%) initiations and 89 (47%) rotations were conducted. Success rates for methadone initiation and rotation were 82 of 89 (92%) and 85 of 100 (84%), respectively. Mean (standard deviation) age was 60 (11) years. One hundred (53%) patients were women, 138 (73%) were white, and 182 (96%) had solid cancers. The main reason for rotation was pain (65 of 89 patients, 47%). Median (interquartile range, IQR) pain scores (Edmonton Symptom Assessment Scale/0‐10) were 6 (5‐8), 4 (3‐6), and 3 (2‐5) at baseline, F1, and F2, respectively (P < .0001). Median (IQR) daily methadone dose for initiation and rotation was 10 (5‐15) mg and 15 (10‐30) mg at F1 (P < .0001) and 10 (8‐15) mg and 18 (10‐30) mg at F2 (P < .0001), respectively. Constipation and nausea improved (P < .005) after initiation/rotation to methadone. Frequency of sedation, hallucinations, myoclonus, and delirium did not increase after initiation/rotation to methadone.

CONCLUSIONS:

Outpatient methadone initiation and rotation for cancer pain treatment were safe, with high success rates and low side effect profiles. Cancer 2010. © 2010 American Cancer Society.     

Lack of benefit of central nervous system prophylaxis for diffuse large B-cell lymphoma in the rituximab era: findings from a large national database

BACKGROUND:

Little is known about the utility of central nervous system (CNS) prophylaxis for diffuse large B‐cell lymphoma (DLBCL) in the rituximab era. The objective of this study was to characterize patterns of CNS prophylaxis for patients who received combined rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R‐CHOP) chemotherapy using the National Comprehensive Cancer Network Non‐Hodgkin Lymphoma Outcomes Database, a prospective cohort study that collects clinical and outcomes data for patients at 7 participating centers.

METHODS:

Patients who were eligible for this analysis presented with newly diagnosed DLBCL between January 2001 and July 2008, had no evidence of baseline CNS disease, and had received R‐CHOP within 180 days of diagnosis. The authors assessed incidence and covariates of prophylaxis, prophylaxis modality, and, using propensity score analysis, outcomes such as overall survival.

RESULTS:

Of 989 eligible patients, 117 received CNS prophylaxis (11.8%), most intrathecally (71.8%). Involvement of bone marrow, other high‐risk site, >1 extranodal site, higher International Prognostic Index score, and higher stage were associated individually with the receipt of prophylaxis (all P < .0001). At a median follow‐up of 2.5 years, there were 20 CNS recurrences (2% [95% confidence interval, 1.1%‐2.9%]) among all patients, and overall survival was not affected by prophylaxis.

CONCLUSIONS:

Given the overall low rate of CNS recurrence and lack of prophylaxis‐associated survival benefit, the current data called into question the practice of CNS prophylaxis in the rituximab era. Cancer 2011. © 2011 American Cancer Society.     

Cost-effectiveness of epidermal growth factor receptor mutation testing and first-line treatment with gefitinib for patients with advanced adenocarcinoma of the lung

BACKGROUND:

Epidermal growth factor receptor (EGFR) testing and first‐line therapy with gefitinib for patients with activating mutations is quickly becoming the standard option for the treatment of advanced lung adenocarcinoma. Yet, to date, little is known about the cost‐effectiveness of this approach.

METHODS:

A decision‐analytic model was developed to determine the cost‐effectiveness of EGFR testing and first‐line treatment with gefitinib for those patients who harbor activating mutations versus standard care, which includes first‐line treatment with chemotherapy followed by gefitinib as second‐line treatment. The model uses clinical and outcomes data from randomized clinical trials and societal costs from Singapore cancer centers. Health effects were expressed as quality‐adjusted life‐years. All costs and cost‐effectiveness ratios were expressed in 2010 Singapore dollars. Sensitivity and different scenarios analyses were conducted.

RESULTS:

EGFR testing and first‐line treatment with gefitinib is a dominant strategy (with lower costs and greater effectiveness) compared with standard care. Because the primary savings result from not providing gefitinib to those who are not likely to benefit, this finding holds regardless of the prevalence of activating mutations. In a secondary analysis, first‐line treatment with gefitinib was also dominant when compared with first‐line chemotherapy in patients with activating EGFR mutations.

CONCLUSIONS:

This strategy can be considered a new standard of care and should be of great interest for health care payers and decision makers in an era in which our greatest challenge is to balance hard‐won and incremental, yet small, improvements in patient outcomes with exponentially rising costs. Cancer 2012;. © 2011 American Cancer Society.     

Surgical treatment of colon cancer in patients aged 80 years and older

BACKGROUND:

Age‐related disparities in colon cancer treatment exist, with older patients being less likely to receive recommended therapy. However, to the authors' knowledge, few studies to date have focused on receipt of surgery. The objective of the current study was to describe patterns of surgery in patients aged ≥ 80 years with colon cancer and examine outcomes with and without colectomy.

METHODS:

Medicare beneficiaries aged ≥ 80 years with colon cancer who were diagnosed between 1992 and 2005 were identified from the Surveillance, Epidemiology, and End Results‐Medicare database. Multivariable logistic regression analysis was used to assess factors associated with nonoperative management. Kaplan‐Meier survival analysis determined 1‐year overall and colon cancer‐specific survival.

RESULTS:

Of 31,574 patients, 80% underwent colectomy. Approximately 46% were diagnosed during an urgent/emergent hospital admission, with decreased 1‐year overall survival (70% vs 86% for patients diagnosed during an elective admission) noted among these individuals. Factors found to be most predictive of nonoperative management included older age, black race, more hospital admissions, use of home oxygen, use of a wheelchair, being frail, and having dementia. For both operative and nonoperative patients, the 1‐year overall survival rate was lower than the colon cancer‐specific survival rate (operative patients: 78% vs 89%; nonoperative patients: 58% vs 78%).

CONCLUSIONS:

The majority of older patients with colon cancer undergo surgery, with improved outcomes noted compared with nonoperative management. However, many patients who are not selected for surgery die of unrelated causes, reflecting good surgical selection. Patients undergoing surgery during an urgent/emergent admission have an increased short‐term mortality risk. Because the earlier detection of colon cancer may increase the percentage of older patients undergoing elective surgery, the findings of the current study may have policy implications for colon cancer screening and suggest that age should not be the only factor driving cancer screening recommendations. Cancer 2013. © 2012 American Cancer Society.     

Racial segregation and disparities in breast cancer care and mortality

BACKGROUND.

Questions have existed as to whether residential segregation is a mediator of racial/ethnic disparities in breast cancer care and breast cancer mortality, or has a differential effect by race/ethnicity.

METHODS.

Data from the Surveillance, Epidemiology, and End Results–Medicare database on white, black, and Hispanic women aged 66 to 85 years with breast cancer were examined for the receipt of adequate breast cancer care.

RESULTS.

Blacks were less likely than whites to receive adequate breast cancer care (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.71‐0.86). Individuals, both black and white, who lived in areas with greater black segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.64‐0.82). Black segregation was a mediator of the black/white disparity in breast cancer care, explaining 8.9% of the difference. After adjustment, adequate care for Hispanics did not significantly differ from whites, but individuals, both Hispanic and white, who lived in areas with greater Hispanic segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.61‐0.89). Although Blacks experienced greater breast cancer mortality than whites, black segregation did not substantially mediate the black‐white disparity in survival, and was not significantly associated with mortality (hazards ratio, 1.03; 95% CI, 0.87‐1.21). Breast cancer mortality did not differ between Hispanics and whites.

CONCLUSIONS.

Among seniors, segregation mediates some of the black‐white disparity in breast cancer care, but not mortality. Individuals who live in more segregated areas are less likely to receive adequate breast cancer care. Cancer 2008. © 2008 American Cancer Society.