Does the time of day or weekday affect screening accuracy?

BACKGROUND:

Workload is extensively regulated in gynecologic cytology. However, sensitive monitors of excessive workload are not available.

METHODS:

We measured the variation in abnormal (atypical squamous cells [ASC], low‐grade squamous intraepithelial lesion [LSIL], and high‐grade squamous intraepithelial lesion [HSIL]) rates for 4 cytotechnologists (CTs) among different days of the week and at different times during the day while they were performing primary screening with the ThinPrep Imaging System.

RESULTS:

Three of 4 CTs detected significantly less abnormal cases on 1 day of the week than another (1 Monday, 2 Friday). Two of those CTs detected significantly fewer total abnormal cases in the afternoon than in the morning; this was strongly correlated with increased speed in the afternoon and decreased detection of ASC cases. HPV + rates for ASC cases dropped as the abnormal rate dropped. The third CT detected significantly fewer ASC cases in the morning; this was counterbalanced by an increase detection of LSIL cases, suggesting a shift in diagnostic threshold between the AM and PM . The difference in abnormal detection rates between morning and afternoon correlated with a false‐negative fraction of 0.96.

CONCLUSIONS:

There are significant differences in detection rates of abnormal cases between days of the week and the morning and afternoon. Correlating abnormal rates and workload between the morning and afternoon may represent a sensitive way to detect excessive workload. Because individual CTs may have different responses to workload and no overall pattern emerged, data on their workload and performance need to be tracked individually. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Does where you live play an important role in cancer incidence in the U.S.?

Some studies have shown disproportionate cancer incidence burden in rural areas which may be attributable partly due to the use of ‘rural’ as a generic term implying homogeneity of risk/protective factors across wide geographic spans. Counties in SEER 18 registries (years 2001-2011) were classified by their Rural-Urban Continuum Code (RUCC) and aggregated into urban, adjacent rural, and non-adjacent rural and were also aggregated into 3 regions: North, South, and West. Two-way ANCOVA was performed with region and RUCC as factors with adjustment for rates of common risk factors obtained from the County Health Rankings (2013). RUCC has a significant effect on incidence rate in urban areas on breast (P =0.001) and prostate (P =0.009). Colorectal significantly varies by region (P<0.0001), and the effect of rurality significantly varies across regions with North highest (P=0.0005). Lung rates significantly vary across both region and RUCC (P<0.0001 and P=0.0001, respectively). The analysis shows that risk-adjusted cancer incidence varies significantly across regions. However, we also found that rural cancer incidence significantly varied across otherwise-similar rural areas implying that ‘rural’ is not a homogeneous classification.     

Does deprivation affect breast cancer management?

We evaluated whether social deprivation affected decision-making for breast cancer surgery. Of 3419 patients, 53.6% had mastectomy and this was predicted by deprivation, age, tumour size and hospital, all of which retained significance on multivariate analysis, except deprivation. Pathological characteristics and surgical decision-making determined choice of operation not deprivation.     

Does diet affect breast cancer risk?

The role of specific dietary factors in breast cancer causation is not completely resolved. Results from prospective studies do not support the concept that fat intake in middle life has a major relation to breast cancer risk. However, weight gain in middle life contributes substantially to breast cancer risk. Alcohol is the best established dietary risk factor, probably by increasing endogenous estrogen levels. Hypotheses relating diet during youth to risk decades later will be difficult to test. Nevertheless, available evidence is strong that breast cancer risk can be reduced by avoiding weight gain during adult years, and by limiting alcohol consumption.     

Patterns of care survey (PCS) in lung cancer: how well does current U.S. practice with chemotherapy in the non-metastatic setting follow the literature?

BACKGROUND: In LD-SCLC, combined modality therapy has emerged as the standard of practice in good performance status (PS) patients (pts). Pignon's meta-analysis [N Engl J Med 1992;327:1618-24] showed that combination chemotherapy (CT) and thoracic radiation (XRT) in LD-SCLC yielded an absolute 5.4% increase in 3-year survival versus chemotherapy alone. Concurrent chemoradiation upfront has generated the highest survival rates [Murray. J Clin Oncol 1993;11:336-44; Jeremic. J Clin Oncol 1996;15:893-900; Takada. J Clin Oncol 2002;20:3054-60]. In stage III NSCLC, multiple studies have shown therapeutic superiority for combination chemotherapy and XRT versus RT alone; and recent literature suggests a therapeutic advantage for concurrent chemoradiation versus chemotherapy followed by XRT [Curran. ASCO 2000;19:484a; Furuse. JCO 1999;17:2692-9; Zatloukal. ASCO 2002;A-1159]. Data are less secure regarding the role of chemotherapy in stage I and II NSCLC. MATERIAL AND METHODS: A stratified two-step cluster sampling technique was used for data collection. Five hundred and forty-one individuals diagnosed between 1998 and 1999 with lung cancer, either LD-SCLC or stages I-III NSCLC were sampled from 58 institutions featuring radiotherapy facilities, giving a weighted sample size (wss) of 42,335 patients. All pts had Karnofski performance status (KPS) >or=60. We determined the percentage who received chemotherapy; the nature of chemotherapy and its timing with respect to XRT. SUDAAN statistical software was used to allow the incorporation of the design elements and weights to reflect the relative contribution of each institution and each patient in the analysis RESULTS: Of 72 (wss=6138) pts with LD-SCLC, 100% received XRT and 95% received chemotherapy (CT); 66% received concurrent (con) CT and XRT, of whom 29% also received CT pre XRT; 22% received CT post XRT as well, and 23% received both: 63% received sequential CT-->XRT+/-con CT; and 38% received some CT after XRT. Fifty-two percent received cisplatin (DDP), and 38% received carboplatin (CBDCA); 73% received etoposide (VP-16), while 10% received paclitaxel. Of 469 pts (wss=36,197) with NSCLC, 52% received CT, including 30% with stage I disease, 48% with stage II NSCLC, 60% with stage III NSCLC, and 50% with unknown stage. Thirty-nine percent received sequential CT-->XRT+/-CT, of whom 49% received CT pre XRT only. Seventy-four percent received con CT and XRT; and 27% received posterior CT, of whom 84% also received con CT/XRT. Forty-five received some CT in the pre-op setting and 15% in the post-op setting. Twelve percent received DDP-based therapy, while only 13% and 7% received VP-16 or vincas, respectively; 67% received CBDCA. Seventy-two percent received taxanes, of whom 96% received paclitaxel. Gemcitabine was administered to 3% of NSCLC pts. CONCLUSIONS: Combined modality therapy is typically employed in the therapy of LD-SCLC and LA-NSCLC. The majority of those treated for SCLC receive concurrent CT/XRT, while nearly 3/4 of those treated with CT and XRT for LA-NSCLC received concurrent CT/XRT. Current practice in the US generally matches evidence-based literature, although a significant percentage of practitioners substitute CBDCA for DDP in both venues and use paclitaxel in lieu of vincas or etoposide in NSCLC.     

Does the method of detection of breast cancer affect subsequent psychiatric morbidity?

The aim of this prospective study was to compare the prevalence of psychiatric morbidity following diagnosis of breast cancer between a group of women presenting with screen-detected cancer and a group presenting with symptomatic disease. Psychiatric symptoms were elicited using the Structured Clinical Interview (SCID) and classified according to DSM-III criteria. 61 (46%) of 132 women interviewed experienced an episode of psychiatric disorder between 1 month before diagnosis and 12 months post-diagnosis. There was no association between detection by screening of breast cancer and psychiatric disorder (Odds Ratio (OR) 0.8, 95% Confidence Interval (CI) 0.4-1.8 P=0.7). The occurrence of an episode of psychiatric disorder was associated with a previous history of treatment for psychological problems (OR 2.4, 95% CI 1.1-5.5, P=0.02). The results suggest there is no increased risk of developing psychiatric morbidity associated with the detection of cancer through the National Breast Screening Programme.     

The American Cancer Society challenge goals. How far can cancer rates decline in the U.S. by the year 2015?

BACKGROUND: Cancer incidence and mortality rates both began to decline in the U. S. in the early 1990s. Recognizing the unprecedented potential benefits of accelerating this decline, the American Cancer Society (ACS) has set ambitious challenge goals for the American public for a 25% reduction in cancer incidence rates and a 50% reduction in cancer mortality rates by the year 2015. This analysis examined the feasibility of reaching those goals by estimating future changes in cancer rates that can result from past and future reductions in cancer risk factors. METHODS: Estimates for future declines in cancer risk factors in the U. S. under alternative scenarios were applied to conservative population-attributable risk estimates for cancer incidence and mortality rates in 1990 to estimate cancer rate trends in the year 2015. RESULTS: If the current trends toward a decline in the prevalence of cancer risk factors continue over the next decade, by the year 2015 one can expect a 13% decline in cancer incidence rates and a 21% decline in cancer mortality rates below their 1990 levels. With redoubled efforts to reduce the prevalence of known cancer risk factors further, by the year 2015 cancer incidence rates could be reduced by 19% and cancer mortality rates reduced by 29%. Such redoubled efforts would equate to approximately 100,000 cancer cases and 60,000 cancer deaths prevented each year by the year 2015. CONCLUSIONS: Past reductions in cancer risk factors in the U.S. population have led to recent declines in the rates of cancer incidence and mortality in the U.S. Redoubled efforts to act on current knowledge regarding how to prevent, detect, and treat cancer can result in attaining approximately 80% of the ACS challenge goal for cancer incidence rates and 60% of the ACS challenge goal for cancer mortality rates by the year 2015. New findings from cancer research are needed and will have to be applied quickly if the ACS challenge goals are to be met fully.     

The patient protection and affordable care act: how will it affect private health insurance for cancer patients?

The Patient Protection and Affordable Care Act will make health coverage more available and affordable while also strengthening regulations on the scope of private health insurance coverage. Most of the law's key provisions take effect in 2014, at which time health insurers will be barred from charging more or denying coverage for individuals with a pre-existing condition. Also in 2014, qualifying individuals will receive subsidies to purchase private insurance through newly created health insurance exchanges. New rules related to caps on benefits and stronger rights to appeal insurance company decisions take effect in 2010. In 2014, all insurance policies sold to individuals and small groups will have to cover an essential benefits package defined by the federal government. Although many Patient Protection and Affordable Care Act provisions do not apply to all types of private coverage, overall the law will provide more protections to cancer patients and survivors in the private health insurance marketplace.     

Colorectal cancer screening among Latinos from U.S. cities along the Texas–Mexico border

Colorectal cancer (CRC) screening rates are comparatively low for U.S. Hispanics. To learn more about the factors influencing CRC screening among Hispanics living along the U.S.–Mexico border, 12 focus groups were conducted with Hispanic men and women aged 50 years and older in three Texas counties; Cameron County (Brownsville), Webb County (Laredo), and El Paso County, (El Paso). The focus group guide contained questions about health care behavior, knowledge about CRC, experiences with cancer, and factors that influence CRC screening. A total of 92 individuals participated with the majority aged 50–69 (75%). Twenty percent were born in the United States and 51% had lived in the United States for more than 20 years. Participants had low levels of education, income, and insurance coverage. The analysis revealed several overarching and contextual themes relating to knowledge, attitudes, beliefs, and emotions about cancer and CRC screening. A prevalent theme that emerged from all groups was frustration and a lack of confidence in the U.S. healthcare system. Few participants had been advised by their providers to obtain CRC screening. Lack of patient knowledge about colorectal cancer and screening appeared to be a critical factor influencing screening. Themes about death and pain due to cancer were prevalent as were cultural factors such as machismo and embarrassment. System level barriers such as cost, medical insurance and transportation also impacted screening. These findings suggest that strategies are needed to educate Hispanic residents of border communities about CRC and to motivate them to undergo CRC screening. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention.     

Initial care and outcome of glioblastoma multiforme patients in 2 diverse health care scenarios in Brazil: does public versus private health care matter?

Background

The aim of this study was to describe the epidemiological and survival features of patients with glioblastoma multiforme treated in 2 health care scenarios—public and private—in Brazil.

Methods

We retrospectively analyzed clinical, treatment, and outcome characteristics of glioblastoma multiforme patients from 2003 to 2011 at 2 institutions.

Results

The median age of the 171 patients (117 public and 54 private) was 59.3 years (range, 18–84). The median survival for patients treated in private institutions was 17.4 months (95% confidence interval, 11.1–23.7) compared with 7.1 months (95% confidence interval, 3.8–10.4) for patients treated in public institutions (P < .001). The time from the first symptom to surgery was longer in the public setting (median of 64 days for the public hospital and 31 days for the private institution; P = .003). The patients at the private hospital received radiotherapy concurrent with chemotherapy in 59.3% of cases; at the public hospital, only 21.4% (P < .001). Despite these differences, the institution of treatment was not found to be an independent predictor of outcome (hazard ratio, 1.675; 95% confidence interval, 0.951–2.949; P = .074). The Karnofsky performance status and any additional treatment after surgery were predictors of survival. A hazard ratio of 0.010 (95% confidence interval, 0.003–0.033; P < .001) was observed for gross total tumor resection followed by radiotherapy concurrent with chemotherapy.

Conclusions

Despite obvious disparities between the hospitals, the medical assistance scenario was not an independent predictor of survival. However, survival was directly influenced by additional treatment after surgery. Therefore, increasing access to resources in developing countries like Brazil is critical.     

How much of US health care spending provides direct care or benefit to patients?

Plans to optimize health care in the United States highlight the high cost but rarely explore opportunities for redirecting resources within the existing system to increase access to care while lowering spending. This analysis indicates that, of the total national health care expenditures of $3.21 trillion in 2015, only $1.4 trillion to $2.86 trillion was used to provide care to patients. This range was reached by the subtraction of excess spending in 7 categories. Thus, many opportunities exist to repurpose wasted expenditures to increase access to health care without the need for additional funding.