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Background: Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown., Methods: A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files., Results: One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57-0.93; P = 0.01), but not for adenocarcinoma of the cardia., Conclusions: Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk., (Copyright 2002 American Cancer Society.DOI 10.1002/cncr.10646)

Background: To the authors' knowledge, national-level population-based data regarding prostate carcinoma incidence and detection currently are not available. The availability of such data could identify those regions with a disproportionately high cancer incidence as well as the population-level association between prostate carcinoma detection and incidence., Methods: Inpatient, hospital outpatient, and physician/supplier Medicare claims from 1997 were used to identify incident cases of prostate carcinoma in men age > or = 65 years and to calculate state and county-level incidence rates. The 1991 and 1997 claims data were used to determine small area rates of prostate-specific antigen (PSA) testing and prostate biopsy and to determine their correlation with incidence., Results: The calculated incidence rates for 1997 were 890 per 100,000 and 1196 per 100,000, respectively, in white males and African-American males and varied substantially between counties (i.e., 25--75th percentile, 676--1124 per 100,000). Rates of PSA and prostate biopsy increased markedly from 1991 to 1997 in both white men (1580 per 100,000 to 24,286 per 100,000) and African-American men (1277 per 100,000 to 15,190 per 100,000), and considerable variation in detection between counties was observed. Counties that had higher rates of prostate biopsy also had higher age-adjusted incidence rates, and county-level PSA testing was found to be associated with incidence in African-American patients, but not in white patients., Conclusions: Medicare claims may provide an alternative source of population-based data, particularly for areas in which registry data are not readily available or are of limited scope. In addition, claims provide otherwise unavailable national data concerning cancer detection., (Copyright 2001 American Cancer Society.)

Background: To the authors' knowledge, physician attitudes and reported practices regarding colorectal carcinoma screening have not been studied in areas of highest risk for cancer death., Methods: Medicare claims were used to calculate colorectal carcinoma 2-year case-fatality rates for counties with >100 incident cases of colorectal carcinoma between 1991-1993. All 2682 practicing primary care physicians in 20 counties with the lowest case-fatality rates (mean of 29.9%) and 19 counties with the highest case-fatality rates (mean of 47.8%) were surveyed regarding their screening procedures and attitudes., Results: Among the 972 respondents (36.1%), the reported use of fecal occult blood testing (FOBT) and flexible sigmoidoscopy was similar in the low and high case-fatality counties. However, physicians who practiced in the high case-fatality counties were less likely to be trained in and to perform sigmoidoscopy themselves (37.0% vs. 45.6%; P<0.01). Moreover, practitioners in the high case-fatality counties were more likely than the other physicians to consider or plan enhanced FOBT and sigmoidoscopic screening in the near future. FOBT and sigmoidoscopy screening rates at the county level were associated negatively with cancer incidence rates, case-fatality rates, and metastatic disease rates, suggesting a potentially protective effect., Conclusions: Geographically targeted interventions are a potentially cost-effective strategy for focusing additional screening services on the highest risk populations. The primary care clinicians in these high risk areas are logical partners for these interventions by virtue of their high degree of readiness to change their current screening practices., (Copyright 1999 American Cancer Society.)

Background: There are a paucity of data supporting the routine use of follow-up testing to detect recurrent disease after potentially curative initial surgery in patients with nonmetastatic colorectal carcinoma., Methods: Using the population-based Surveillance, Epidemiology, and End Results (SEER) registry, all patients age > or =65 years with local or regional colorectal carcinoma who were diagnosed in 1991, underwent surgical resection, and survived at least 6 months after diagnosis were identified. All inpatient, hospital outpatient, and physician/supplier Medicare claims from 6 months after diagnosis through 1994 were examined for follow-up procedures of interest. Procedure use during follow-up was compared across patient groups using both bivariate and multivariate analyses., Results: A total of 5716 patients were identified, with 1.3% found to have developed subsequent primary tumors of the colon or rectum, and 74% surviving through 1994. One or more procedures of interest were performed in 88% of patients; the most commonly performed tests were liver enzymes, chest X-rays, colonoscopy, and computed tomography scans. Lower rates of testing generally were observed with older age groups, patients with fewer comorbidities, and patients who did not survive through the follow-up period. Among all procedures studied, there also was significant variation in the rates of testing across the 9 SEER areas, varying from 1.5-fold to 3.6-fold. The geographic variation persisted in multivariate models adjusting for potentially confounding factors., Conclusions: The current study found significant variability in the use of follow-up procedures, with the most striking differences apparent across geographic regions. Further studies are needed to determine the underlying reasons for the disparities, as well as the impact of surveillance on patient outcomes.

Background: Population-based cancer registries that can be used to compare cancer incidence and mortality across regions of the U.S. are currently lacking. The authors conducted this study to validate Medicare claims as a measure of county-level colorectal carcinoma incidence among older Americans. Variations found among counties are described in this article., Methods: A total of 183,174 hospitalized patients age 65 years in 1991-1993 with newly diagnosed colorectal carcinoma who resided in one of 480 large counties were identified in Medicare files. The county-level truncated age, race, and gender adjusted incidence rates for the population age 65 years, the proportion of patients with a code indicating distant metastases, and the 2-year case-fatality rates were determined. Corresponding rates from the SEER database were compared., Results: The median truncated adjusted 3-year incidence rate was 870 per 100,000 (Quartile 1-Quartile 3, 779-955), with almost twofold differences among counties even after the exclusion of outliers. The median proportion of patients with codes indicating distant metastases was 23.4% (range, 10.2-46.9%; Quartile 1-Quartile 3, 20.8-25.8), and the average 2-year case-fatality rate was 39.2% (range, 26.5-51.4%; Quartile 1-Quartile 3, 37.0-41.6). Medicare files tended to underestimate the truncated incidence rate according to SEER, but among counties the two sets of rates were closely correlated (r = 0.94, P < 0.0001)., Conclusions: Medicare files are a potential alternative source of national data for the study of colorectal carcinoma incidence among the elderly at the county level. The data also suggest significant variations among counties in colorectal carcinoma incidence, stage, and mortality that could be used in public health initiatives.

Background: Population-based screening programs with flexible sigmoidoscopy have been advocated as a means to reduce the death rate from colorectal cancer. Because other studies have suggested a greater prevalence of lesions inaccessible to sigmoidoscopy in older patients, the expected yield of this procedure may differ in these subgroups., Methods: A 100% sample of Medicare beneficiaries 65 years or older with a first known diagnosis of colorectal cancer in 1987 was studied. Tumor site was divided into rectum, distal colon (distal to splenic flexure) and proximal colon. The analysis was also stratified by sex, race, and presence or absence metastatic disease, and incidence rates at each site by 5-year age group were calculated., Results: Among the 75,266 patients studied, the incidence of colorectal cancer increased from 1.59 patients/1000 in patients age 65-69 years to 3.87 patients/1000 in patients age 85 years and older. Although the incidence rates at all three sites increased, the increment was greatest for proximal tumors. The incidence trends with age also persisted in an analysis of only metastatic lesions. Moreover, incidence rates were consistently higher in men than in women and higher in whites than in blacks at all sites, though the age-related increase in incidence was consistent among all four groups., Conclusions: The proportion of tumors beyond the reach of sigmoidoscopy increased with age, as did the actual incidence of accessible lesions. These patterns were also consistent in subgroup analyses. As the age-related increase in incidence was observed for metastatic tumors at all sites in the colon, age-related differences in screening and diagnostic evaluation alone do not adequately explain the findings. These data underscore the need for further studies of the relative benefits of cancer screening and pathogenic factors in tumor development in different subgroups of the older population.

In patients with multiple sclerosis (MS), the apparently uninvolved cerebral white matter between demyelinated plaques may have biochemical abnormalities. To what degree the changes in the white matter contribute to symptomatology in MS is unknown. In 39 patients with multiple sclerosis, and in 39 age-matched nondiseased volunteers, T1 and T2 were calculated from spin-echo images in four regions of apparently uninvolved white matter. In three of four white matter areas, the average T1 and T2 were significantly longer in the patients than in the controls. The T1 correlated with the disability, measured by the Kurtzke Extended Disability Status Scale, although the correlation was marginally significant. The results suggest that in patients with MS, white matter disease that is not visualized in MR as distinct foci of abnormal signal intensity may contribute to disease burden and disability.

Recurrence of carcinoma of the breast after radical mastectomy was associated with preoperative body weight among patients observed for up to 24 years. Patients who had no axillary lymph node metastases and who weighed 130 pounds or less had an accumulative recurrence free survival superior to that of heavier patients. The advantage was unassociated with significant differences in menopausal status, clinical stage, or tumor size. High fat diet and large body mass have been linked epidemiologically with high risk for breast cancer; whatever biologic mechanisms are involved may also promote growth of residual tumor after potentially curative surgery. Diet and weight reduction may represent empirical means for improving the prognosis of heavy individuals with early stages of breast cancer.

Transplantation into lethally irradiated mice of hematopoietic and lymphoid cells from immature donors which hypothetically will not mount a cell mediated attack against simultaneously inoculated human tumor cells has resulted in tumor engraftment and growth in long-term surviving radiation chimeras. Twenty-four hours after lethal irradiation, A or CBA mice were given iv injections of 2 X 10(7) fetal liver cells from syngeneic donors of 14, 16, or 18 days of embryonation and sc injections of 1, 3, or 6 X 10(6) human choriocarcinoma (C-1, C-2, and C-3) cells or human breast carcinoma (B-1) cells that had been maintained in culture. Palpable tumors greater than or equal to 5 mm were noted in 18/22 mice injected with C-1, 9/16 with C-2, 10/10 with C-3, and 18/30 with B-1. Tumors of 17 (31%) of mice remained palpable until death of the animal or until termination of the experiment 100 days post inoculation. Histologic study of autopsy specimens revealed malignant tumors with occasional pulmonary metastases. Human chorionic gonadotropin was found in the serum of mice that received choriocarcinoma cells.