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Background Gains in cancer detection and treatment have meant that more patients are now living with both cancer and other chronic health conditions, which may become burdensome. We used the Patient Experience with Treatment and Self-Management (PETS) framework to study challenges in self-management and its impact on health among survivors of women’s cancers who are caring for other chronic health conditions. Methods Applicability of the PETS domains among survivors of women’s cancers with comorbidities was assessed in focus groups to create the study survey. Women surviving primary breast, cervical, ovarian, or endometrial/uterine cancer treated between 6 months and 3 years prior at two large healthcare systems in Virginia were mailed study invitation letters to complete a telephone-based survey. The survey included questions on cancer treatment history, comorbid conditions prior to cancer, treatment and self-management experiences, health literacy, financial security, and items on self-management activities, self-management difficulties and self-management impact (i.e., role/social activity limitations and physical/mental exhaustion). Additionally, general health was assessed with items from the Patient-Reported Outcomes Measurement Information System (PROMIS). Hierarchical regression models and path analysis were used to examine correlates of self-management impact on general physical health (GPH) and mental health (GMH). Results Of 1448 patients contacted by mail, 274 (26%) returned an interest form providing their consent to be contacted. Of these, 183 completed the survey. Reasons for non-completion included ineligibility (42), unable to be reached (33) and refusal (6). The majority were survivors of breast (58%) or endometrial/uterine cancer (28%), and 45% resided in non-urban locations. After adjusting for age, race, and cancer type, survivors with higher self-management difficulty reported higher self-management impact, which was associated with lower perceived general health. Reports of higher self-management impact was associated with being single or unmarried, white race, fulltime employed, higher financial insecurity, lower health literacy and more comorbidities. In path analysis, self-management impact was a significant mediator in the association of comorbidity and financial insecurity on GPH and GMH. Conclusions Among survivors of women’s cancer, pre-diagnosis comorbidity, health literacy, and financial security are associated with psychosocial impact of self-management and general physical and mental health in the 6 month to 3-year period after cancer treatment has ended. The impact of self-management on psychosocial functioning is an important factor among cancer survivors caring for multiple chronic health conditions. This study provides evidence on the importance of assessing cancer survivors’ self-management difficulties such as in future interventions to promote health and wellness.

Supplemental Digital Content is available in the text, To expand our prior statewide analysis of care distribution for locally advanced cervical cancer in Virginia to include 2 more states and to develop a tool for predicting quality of care. Complete treatment was defined as receiving chemotherapy (CT), brachytherapy (BT), and external beam radiotherapy. State cancer registry databases yielded a three-state cohort of 3197 women diagnosed with locally advanced cervical cancer from 2000 to 2013. A logistic regression evaluated predictors for receipt of BT, CT, and high (2–3 modalities received) versus low (0–1 modalities received) quality care. A Cox proportional hazards models determined predictors of survival. Finally, a predictive model was developed and preliminarily validated using our cohort. Only 35.3% of the cohort received complete treatment and only 57.3% received BT. Significant predictors of lower odds of receiving high quality care varied by state but included: 66+ age at diagnosis as compared to 18 to 42, 42 to 53, or 53 to 66; cancer stage IVA as compared to IIIx, IIx, or IB2; public insurance with supplement as compared to private; treatment at a low volume facility; and closer distance quintiles to a high volume treatment center as compared to the furthest quintile. Significant predictors of worse survival varied by state but included: low quality score (0–1 modalities received); 2000 to 2004 or 2005 to 2009 year of diagnosis as compared to 2010 to 2013; 66+ age at diagnosis as compared to 18 to 42, 42 to 53, or 53 to 66; cancer stage IVA as compared to IIIx, IIx, or IB2; treatment at a low volume facility; and unmarried/unknown marital status as compared to married. Our treatment quality prediction tool included age, age2, treatment at high volume facility, and cancer stage and demonstrated 78.2% sensitivity and a 62.9% specificity. Only 35.3% of patients received complete guidelines-concordant treatment. Additionally, in 2/3 states it appeared that BT usage may have decreased during the study period. Our predictive model may help identify patients/regions at risk of receiving low quality care to target interventions aimed at improving cervical cancer treatment quality and survival.

While geographic disparities in cancer treatment are documented, little research has investigated patients' willingness to travel longer distances for treatment at higher-quality hospitals. Even fewer studies have compared metropolitan and non-metropolitan patients on this dimension. Using population-based data from the Appalachian counties of four states, we identified all hospitals within a plausible driving distance of each newly diagnosed colon cancer patient and estimated conditional logit models of hospital choices for cancer surgery. Two sets of important findings emerged. First, both metropolitan and non-metropolitan patients chose higher-quality over lower-quality hospitals, and were willing to travel farther to use high-quality facilities. Second, non-metropolitan patients were not willing to travel farther than their metropolitan counterparts to hospitals that were more desirable along most dimensions, but non-metropolitan patients were willing to travel farther to high-volume hospitals. These findings show how travel distances to high-quality hospitals contribute to geographic disparities in colon cancer treatment.

INTRODUCTION AND OBJECTIVES:Comparative effectiveness of RP and IMRT for PCa have been poorly studied, and limited by poor measurement of patient comorbidities. We sought to examine survival differ...

Purpose To document cancer-related health disparities in Appalachia. Methods The current study investigated disparities in cancer incidence, mortality, and staging between rural Appalachians and those living outside of rural Appalachia. To accomplish this, mortality data for the United States from 1969 to 2011 were obtained from the National Center for Health Statistics (NCHS) using SEER*Stat. These data were used to compare trends in mortality between rural Appalachians, urban Appalachians, rural non-Appalachians, and urban non-Appalachians. Cancer incidence trends, staging, and survivorship data were compared across regions using the SEER-18 Program, which represented 28% of the US population and includes 2 Appalachian states: Georgia and Kentucky. Results Cancer mortality rates declined in all regions, but disparities remained such that rural Appalachia has the highest incidence, while urban non-Appalachia has the lowest. In all but 1 state, rural Appalachians had higher cancer mortality rates than urban non-Appalachians. Cancer incidence declined for all regions except rural Appalachia. Rural Appalachians had lower rates of early stage breast cancer diagnoses than their urban non-Appalachian counterparts. Finally, rural Appalachians had lower 3- and 5-year survival rates than their urban non-Appalachian counterparts. Conclusions Rural Appalachians are faced with poorer cancer-related health outcomes across the continuum of cancer care. A systematic effort is needed to reduce the burden of cancer for rural Appalachia. Additional research should explore reasons for the disparities that were observed.

To determine the extent to which initial therapy for nonmetastatic prostate cancer was concordant with nationally recognized guidelines using supplemented cancer registry data and what factors were associated with receipt of nonguideline-concordant care.Initial therapy for 8229 nonmetastatic prostate cancer cases diagnosed in 2004 from cancer registries in 7 states was abstracted as part of the Centers for Disease Control's Patterns of Care Breast and Prostate Cancer study conducted during 2007 to 2009. The National Comprehensive Cancer Network clinical practice guidelines version 1.2002 was used as the standard of care based on recurrence risk group and life expectancy (LE). A multivariable model was used to determine risk factors associated with receipt of nonguideline-concordant care.Nearly 80% with nonmetastatic prostate cancer received guideline-concordant care for initial therapy. Receipt of nonguideline-concordant care (including receiving either less aggressive therapy or more aggressive therapy than indicated) was related to older age, African American race/ethnicity, being unmarried, rural residence, and especially to being in the high recurrence risk group where receiving less aggressive therapy than indicated occurred more often than receiving more aggressive therapy (adjusted OR=4.2; 95% CL, 3.5-5.2 vs. low-risk group). Compared with life table estimates adjusted for comorbidity, physicians tended to underestimate LE.Receipt of less aggressive therapy than indicated among high-risk group men with5-year LE based on life table estimates adjusted for comorbidity was a concern. Physicians may tend to underestimate 5-year survival among this group and should be alerted to the importance of recommending aggressive therapy when warranted. However, based on more recent guidelines, among those with low-risk disease, the proportion considered to be receiving less aggressive therapy than indicated may now be lower because active surveillance is now considered appropriate.

This study evaluated spatial access to mammography centers in Appalachia using both traditional access measures and the two-step floating catchment area (2SFCA) method. Ratios of county mammography centers to women age 45 and older, driving time to nearest mammography facility, and various 2SFCA approaches were compared throughout Pennsylvania, Ohio, Kentucky, and North Carolina. Closest travel time measures favored urban areas. The 2SFCA method produced varied results depending on the parameters chosen. Appalachia areas had greater travel times to their closest mammography center. Appalachia areas in OH and NC had worse 2SFCA scores than non-Appalachia areas of the same states. A relative 2SFCA approach, the spatial access ratio method, was recommended because it helped minimize the differences between various 2SFCA approaches.

Tobacco use after a cancer diagnosis can increase risk of disease recurrence, increase the likelihood of a second primary cancer, and negatively impact treatment efficacy. The implementation of system-wide comprehensive tobacco cessation in the oncology setting has historically been low, with over half of cancer clinicians reporting that they do not treat or provide a referral to cessation resources. This quality improvement study evaluated the procedures for assessing and documenting tobacco use among cancer survivors and referring current smokers to cessation resources at the University of Virginia Cancer Center. Process mapping revealed 20 gaps across two major domains: electronic health record (EHR), and personnel barriers. The top identified priority was inconsistent documentation of tobacco use status as it impacted several downstream gaps. Eleven of the 20 gaps were deemed a high priority, and all were addressed during the implementation of the resulting Tobacco Treatment Program. Prioritized gaps were addressed using a combination of provider training, modifications to clinical workflow, and EHR modifications. Since implementation of solutions, the number of unique survivors receiving cessation treatment has increased from 284 survivors receiving cessation support during Year 1 of the initiative to 487 in Year 3. The resulting Tobacco Treatment Program provides a systematic, personalized, and sustainable comprehensive cessation program that optimizes the multifaceted workflow of the Cancer Center and has the potential to reduce tobacco use in a population most in need of cessation support.

Introduction: The National Cancer Institute (NCI) Center to Reduce Center Health Disparities (CRCHD) Geographic Management of Cancer Health Disparities Program (GMaP) initiated in 2009 brings together investigators, trainees, students, and community health educators to network and share information, scientific resources, and tools to promote cancer and cancer health disparities research, as well as community education outreach within and across regions. To reach their goals, CRCHD initiated 7 GMaP regional “hubs” across the United States to enhance their capacity in areas of disparities research, contribute to the next generation of researchers, and achieve measurable reductions in cancer health disparities. Each hub is led by Regional Coordinating Directors (RCDs) who facilitate connections, provide funding and training resources and “leverage the strengths of its people, programs, and resources to provide greater access to cancer information.” Methods: The GMaP Region 1 North (R1N) hub is based at the Markey Cancer Center in Lexington, Kentucky. R1N partners with Johns Hopkins University's Sidney Kimmel Comprehensive Cancer Center, the University of South Carolina, and the University of Virginia Cancer Center to serve Delaware, Kentucky, Maryland, Maine, New Hampshire, Vermont, Virginia, West Virginia, Washington, DC, and West Virginia. The overall goal of GMaP R1N is to enhance the capacity of regional cancer centers, associated academic partners, community partners, and early-stage investigators to contribute to the reduction of cancer health disparities in the region. As part of the Continuing Umbrella of Research Experiences (CURE) Program, GMaP R1N promotes the F31, K series, and Diversity Supplement funding opportunities to potential applicants. R1N implemented pilot awards and travel scholarships for CURE-eligible candidates; developed a listserv to communicate with researchers, trainees, and potential applicants; and maintains regular contact with trainees to answer questions and encourage applications for NCI CURE Program and other grant opportunities. Results: R1N awarded 11 pilot projects, 22 travel scholarships, helped identify mentors and 146 potential applicants for NCI CURE Program grants, and collaborated with points of contact (POC) at colleges and universities, including Historically Black Colleges and Universities to identify potential applicants for NCI CURE and other funding. Conclusions: Methods have been successful in increasing interest in NCI Cancer health disparities training opportunities. RCDs are critical in establishing and maintaining linkages to support mentor-mentee relationships supported by available funding mechanisms; to engage institutional support for pre- and post-award activities, especially for new investigators; and for shrinking delays in the IRB review and approval process. RCDs have identified process barriers and work with regional POCs to eliminate these barriers and increase efficiencies to further the GMaP mission. Citation Format: Marcela Blinka, Mark Cromo, Julia F. Houston, Mark Dignan, Nathan Vanderford, B. Mark Evers, Janice Bowie, Adrian Dobs, James Hebert, Tisha Felder, Roger Anderson. Results to date: Efforts to increase cancer health disparities training in Geographic Management of Cancer Health Disparities Program Region 1 North [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A068.

Objective: While the incidence of epithelial ovarian cancer (EOC) is lower among African American (AA) women compared with European American (EA) women, AA women have markedly worse outcomes. In this study, we describe individual, social, and societal factors in health-related quality of life (HRQL) in AA women diagnosed with EOC in the African American Cancer Epidemiology Study (AACES) that we hypothesize may influence a patient's capacity to psychosocially adjust to a diagnosis of cancer. Methods: There were 215 invasive EOC cases included in the analysis. HRQL was measured using the SF-8 component scores for physical (PCS) and mental (MCS) health. We used least squares regression to test the effects of individual dispositional factors (optimism and trait anxiety); social level (perceived social support); and societal-level factors (SES defined as low family income and low educational attainment, and perceived discrimination) on HRQL, while adjusting for patient age, tumor stage, body mass index, and comorbidity. Mediation analysis was applied to test whether social support and physical activity buffer impacts of EOC on HRQL. Results: Optimism, trait anxiety, social support, poverty, and past perceived discrimination were significantly associated with HRQL following diagnosis of EOC. Specifically, higher family income, lower phobic anxiety, and higher social support were associated with better wellbeing on the MCS and PCS (p

INTRODUCTION: We sought to identify the role of provider and facility characteristics in receipt of radical prostatectomy (RP) or external beam radiation therapy (EBRT) and adherence to quality of care measures in men with localized prostate cancer (PCa) MATERIALS AND METHODS: Subjects included 2861 and 1630 men treated with RP or EBRT respectively for localized PCa whose records were re-abstracted as part of the Centers for Disease Control and Prevention Breast and Prostate Patterns of Care Study. We utilized multivariable generalized estimating equation (GEE) regression analysis to assess patient, clinical, and provider (year of graduation, urologist density) and facility (group vs. solo, academic/teaching status, for-profit status, distance to treatment facility) characteristics that predicted use of RP versus EBRT as well as quality of care outcomes. RESULTS: Multivariable analysis revealed that Group (vs. solo) practice was associated with a decreased risk of RP (odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.25-0.91). Among RP patients with low risk disease, receipt of a bone scan that was not recommended was significantly predicted by race and insurance status. Surgical quality of care measures were associated with physician’s year of graduation and receiving care at a teaching facility. CONCLUSIONS: In addition to demographic factors, we found that provider and facility characteristics were associated with treatment choice and specific quality of care measures. Long term follow-up is required to determine if quality of care indicators are related to prostate cancer outcomes.

PURPOSE The 2-step floating catchment area (2SFCA) method of measuring access to care has never been used to study cancer disparities in Appalachia. First, we evaluated the 2SFCA method in relation to traditional methods. We then examined the impact of access to mammography centers and primary care on late-stage breast cancer diagnosis and receipt of adjuvant hormonal therapy. METHODS Cancer registries from Pennsylvania, Ohio, Kentucky, and North Carolina were linked with Medicare data to identify the stage of breast cancer diagnosis for Appalachia women diagnosed between 2006 and 2008. Women eligible for adjuvant therapy had stage I, II, or III diagnosis; mastectomy or breast-conserving surgery; and hormone receptor-positive breast cancers. Geographically weighted regression was used to explore nonstationarity in the demographic and spatial access predictor variables. RESULTS Over 21% of 15,299 women diagnosed with breast cancer had late-stage (stages III-IV) diagnosis. Predictors included age at diagnosis [odds ratio (OR)=0.86; P

There are wide disparities in breast cancer-specific survival by patient sociodemographic characteristics. Women of lower income, for instance, have higher relapse and death rates from breast cancer. One possible contributing factor for this disparity is low use of adjuvant endocrine therapy-an extremely efficacious therapy in women with early stage, hormone receptor positive breast cancer, the most common subtype of breast cancer. Alone, adjuvant endocrine therapy decreases breast cancer recurrence by 50% and death by 30%. Data suggest that low use of adjuvant endocrine therapy is a potentially important and modifiable risk factor for poor outcome in low-income breast cancer patients.

Background: Disparities exist in breast cancer outcomes by age, geographic location, and socioeconomic status, but there is little data regarding contributing factors to disparities within Appalachia. Underuse of adjuvant endocrine therapy for breast cancer can contribute to disparities. We studied older women within four states of Appalachia and explored adherence and persistence rates for adjuvant endocrine therapy. Methods: The study group consisted of women with stage I-III breast cancer diagnosed 2008-2009 in North Carolina, Pennsylvania, Kentucky, and Georgia, who were continuously enrolled in Part D Medicare and filled a prescription for tamoxifen, anastrozole, letrozole, or exemestane. Adherence rate is defined by medication possession ratio (MPR=sum of days supply for all claims during the calendar year after first prescription). Persistence rate was defined as absence of a 90 day or greater gap in prescription coverage since the first prescription fill. Univariate analyses by Kruskall-Wallis nonparametric test were performed. Variables included age, year of diagnosis, Charlson comorbidity score, Medicaid/Medicare versus Medicare insurance status, rural versus urban residence, county-level economic status (Appalachia Regional Commission: Distressed, At risk, Transitional, or Competitive), state, stage (1, 2A, 2B, or 3), and breast conserving surgery (BCS) versus mastectomy. Results: We identified 726 eligible cases. Mean age was 75.1 years (range 41-98); 97.9% were white; 47.9% had rural residence, 9.5% lived in distressed counties, 29.1% were dual-Medicaid/Medicare insured, mean Charlson comorbidity score was 1.66, and tumor was stage 1 in 56.6%, 2 in 33.6%, and 3 in 9.8%. Mean MPR was 57% (SD 0.27). Persistence rate at 6-months was 79% (SD 0.41) and at 12-months was 36% (SD 0.48). MPR varied significantly within age groups (p=0.01), county-level economic status levels (p=0.01), and Singh Index Area Deprivation tertiles (p=0.01). Mean MPR increased with increasing age: 48% for age 40--65, 55% for age 66-75, 59% for age 76-85, and 63% for age 86 and older. MPR was highest among those in the Competitive ARC class at median levels of 64%, versus 53% in Distressed, 58% in At Risk, and 58% in Transitional. Greatest area deprivation tertile also coincided with lower mean and median MPR adherence. Persistence at 12 months varied significantly among age groups (p=0.01), and type of surgery (p=0.04). Persistence rates were lower in younger cases: 23% for age 40-65, 34% for age 66-75, 37% for age 76-85, and 49% for age 86 and older. Persistence rates were 32% in those who had BCS and 42% in mastectomy. Persistence rates varied significantly among comorbidity levels (p=0.0260); but, after adjusting for age and using logistic regression, this association was only marginally significant (p=0.05). Adjusted expected persistence increased as comorbidity score increased: 28% for 0; 35% for 1; and 39% for 2 or more. Conclusions: Among this group of women within four states in Appalachia with Medicare Part D who filled a prescription for endocrine therapy, overall adherence and persistence rates were low. Higher adherence and persistence rates were seen in older age groups. Citation Format: Gretchen G Kimmick, Fabian Camacho, Roger T Anderson. Rates of adherence and persistence to adjuvant endocrine therapy among women enrolled in Medicare Part D in a four-state region of Appalachia [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-17.

David T Eton,1,2 Jennifer L Ridgeway,1,2 Jason S Egginton,1,2 Kristina Tiedje,3 Mark Linzer,4,5 Deborah H Boehm,4 Sara Poplau,6 Djenane Ramalho de Oliveira,7 Laura Odell,8 Victor M Montori,1,9 Carl R May,10 Roger T Anderson11 1Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; 2Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; 3Department of Sociology and Anthropology, Université Lumière Lyon 2, Lyon, France; 4Division of General Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; 5University of Minnesota Medical School, University of Minnesota, Minneapolis, MN, USA; 6Minneapolis Medical Research Foundation, Minneapolis, MN, USA; 7Department of Social Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; 8Pharmacy Services, Mayo Clinic, Rochester, MN, USA; 9Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; 10Faculty of Health Sciences and NIHR CLAHRC Wessex, University of Southampton, Southampton, UK; 11School of Medicine, University of Virginia, Charlottesville, VA, USA Purpose: The workload of health care and its impact on patient functioning and well-being is known as treatment burden. The purpose of this study was to finalize a conceptual framework of treatment burden that will be used to inform a new patient-reported measure of this construct. Patients and methods: Semi-structured interviews were conducted with 50 chronically ill patients from a large academic medical center (n=32) and an urban safety-net hospital (n=18). We coded themes identifying treatment burden, with the themes harmonized through discussion between multiple coders. Four focus groups, each with five to eight participants with chronic illness, were subsequently held to confirm the thematic structure that emerged from the interviews. Results: Most interviewed patients (98%) were coping with multiple chronic conditions. A preliminary conceptual framework using data from the first 32 interviews was evaluated and was modified using narrative data from 18 additional interviews with a racially and socioeconomically diverse sample of patients. The final framework features three overarching themes with associated subthemes. These themes included: 1) work patients must do to care for their health (eg, taking medications, keeping medical appointments, monitoring health); 2) challenges/stressors that exacerbate perceived burden (eg, financial, interpersonal, provider obstacles); and 3) impacts of burden (eg, role limitations, mental exhaustion). All themes and subthemes were subsequently confirmed in focus groups. Conclusion: The final conceptual framework can be used as a foundation for building a patient self-report measure to systematically study treatment burden for research and analytical purposes, as well as to promote meaningful clinic-based dialogue between patients and providers about the challenges inherent in maintaining complex self-management of health. Keywords: treatment burden, conceptual framework, adherence, questionnaire, self-management, multi-morbidity

Background: The study was conducted in support of an R01-funded project, “Patterns of Patient Care in Appalachia”. Most counties within Appalachia are designated as medically underserved, have sparse health care resources and lack integrated care systems. This study determined the extent of geographical differences among American Cancer Society (ACS) patient navigation resources (navigator and/or cancer resource center) in Appalachia. Specifically, this study investigated if there were barriers to access to ACS patient navigation for cancer care in the Appalachia region of PA, KY, OH, and NC. Results: Of the cancer care centers and hospitals in the Appalachia region studied, (n=232), web-based data informed that facilities (n=186, 80.0%) did not have ACS patient navigation resources compared to Appalachia cancer care centers and hospitals with ACS PN services = 20%. KY had fewer ACS PN centers (5) compared to PA (20), with Pittsburgh (Allegheny county) containing a noticeable cluster of ACS PN facilities (N = 6 out of 18 total). KY also had the lowest rates (12.5%) of facilities with ACS patient navigators. North Carolina had the highest rate of facilities with ACS patient navigation services compared to OH, KY, and PA (32.2%). The proportion of facilities with ACS PN were proportionately less for facilities located in non-Metropolitan areas (15%) compared to those located in metropolitan areas (26%, chi-square p = 0.0339). Significance: Two overarching results were identified in this study. Firstly, a large number of cancer care centers in the Appalachian region do not have ACS patient navigator services which enable patients to gain individualized assistance, overcome barriers that hinder access to care and access to information about the illness and services available. Secondly, the lack of standards and curriculum for patient navigators indicates there is considerable variation in level of exposure for each patient navigator.

We describe individual, area, and provider characteristics associated with care patterns for early-stage breast cancer in Appalachian counties of Kentucky, North Carolina, Ohio, and Pennsylvania.Cases of stages I to III breast cancer from 2006 to 2008 were linked to Medicare claims occurring within 1 year of diagnosis. Rates of guideline-concordant endocrine therapy (n = 1,429), chemotherapy (n = 1,480), and radiation therapy (RT) after breast-conserving surgery were studied; RT was studied in women age ≥ 70 years with stage I estrogen receptor (ER) -positive/progesterone receptor (PR) -positive cancer, for whom RT was optional (n = 1,108), and in all others, for whom RT was guideline concordant (n = 1,422). Univariable and multivariable analyses were performed. Independent variables included age, race, county-level economic status, state, surgeon graduation year and volume, comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, trastuzumab use, and surgery type.Population mean age was 74 years; 97% were white. For endocrine therapy, chemotherapy, and RT, guideline concordance was 76%, 48%, and 83%, respectively. Where it was optional, 77% received RT. Guideline-concordant endocrine therapy was lower in North Carolina versus Pennsylvania (odds ratio [OR], 0.60; 95% CI, 0.41 to 0.88) and higher if surgeon graduated between 1984 and 1988 versus ≥ 1989 (OR, 1.58; 95% CI, 1.06 to 2.34). Guideline-concordant chemotherapy varied significantly by state, county-level economic status, and surgeon volume. In guideline-concordant RT, lower surgeon volume (v highest) predicted RT use (OR, 1.63; 95% CI, 1.61 to 2.36). In optional RT, North Carolina residence (v Pennsylvania; OR, 0.29; 95% CI, 0.17 to 0.48) and counties with higher economic status (OR, 0.61; 95% CI, 0.40 to 0.94) predicated RT omission.Notable variation in care by geographic and surgical provider characteristics provides targets for further research in underserved areas.

To evaluate variations in the use of adjuvant endocrine therapy (AET) by race and geography, this research examined their influence on initiation and adherence to AET in female Medicare enrollees with breast cancer, diagnosed between 2007 and 2011. Using SEER (Surveillance, Epidemiology, and End Results Program)-Medicare data from 2007 to 2001, logistic regressions with random intercept for county of residence were used to predict AET initiation during 1st year and AET adherence assessed by the medication possession ratio (MPR) during year after initiation in a sample of fee-for-service medicare beneficiaries. Part D enrollment was required for the examination of adherence. Independent variables examined were race (black, white, or other) and geographical indicators (area deprivation, non-metropolitan status, and physician shortage). Overall, 23% of patients did not initiate AET within 1 year and 26% of the initiation sample was not adherent to AET, with average follow-up time among initiators of 141 days and an average MPR of 0.84. Significant heterogeneity (P

Purpose To examine local definitive therapy for non-metastatic breast cancer using the Centers for Disease Control and Prevention’s National Program of Cancer Registries Patterns of Care Breast and Prostate Cancer (POCBP) study.

Purpose The objective was to examine the impact of regular primary care encounters (PCE) on early breast cancer detection in an Appalachian sample of Medicare beneficiaries diagnosed 2006-2008. Determinants of PCE were investigated and a mediation analysis was conducted where PCE was a mediator to cancer stage. Methods A total of 3,589 cases were identified from Appalachian areas in Pennsylvania, Kentucky, Ohio, and North Carolina, and health care services were examined 2 months to 2 years prior to diagnosis. A regular care PCE variable was constructed with 4 ordinal levels: none, any, “annual,” and “semi-annual.” Association of PCE with stage, mortality and covariables was conducted using ordinal logistic regressions and Cox Proportional Hazards survival models. Results Sixty-eight percent of the cases had semi-annual PCE. Regular PCE was strongly associated with late-stage cancer rates (39%-13% by increasing PCE level, P < .0001) and 5-year all-cause mortality (42%-24%, P < .0001). Subgroup analysis revealed variations by hypertension and urban status, with nonhypertensives with no PCE being at particularly increased risk. Significant determinants of PCE included age, rural/urban status, comorbidity, dual Medicaid insurance, Appalachian region economic classification, state, select comorbidities, hypertension, and minimum distance to provider. Mediation analysis results were consistent with lower number of comorbidities leading to increased late cancer detection due to patients having a decreased PCE. Conclusion PCE is an important determinant of cancer detection, with a dose-response relationship. Variations exist by geography and hypertension. Comorbidity may influence both PCE and late-stage rates with partial mediation through PCE.

Objectives. We assessed how the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) reporting guideline was used by authors and journal editors in journals’ instructions to authors. We also evaluated its impact on reporting completeness and study quality. Methods. We extracted data from publications that cited TREND on how TREND was used in those reports; we also extracted information on journals’ instructions to authors. We then undertook a case–control study of relevant publications to evaluate the impact of using TREND. Results. Between 2004 and 2013, TREND was cited 412 times, but it was only evidently applied to study reports 47 times. TREND was specifically mentioned 14 times in the sample of 61 instructions to authors. Some evidence suggested that use of TREND was associated with more comprehensive reporting and higher study quality ratings. Conclusions. TREND appeared to be underutilized by authors and journal editors despite its potential application and benefits. We found evidence that suggested that using TREND could contribute to more transparent and complete study reports. Even when authors reported using TREND, reporting completeness was still suboptimal.

Purpose The mortality rate of laryngeal cancer has been trending downward with the use of more effective surgical, radiation, and systemic therapies. Although the best treatment for this disease is not entirely clear, there is a growing consensus on the value of primary radiotherapy as an organ preservation strategy. This study examines urban-rural differences in the use of radiotherapy as the primary treatment for early stage laryngeal cancer in Pennsylvania. Experimental Design The sample was drawn from the Pennsylvania tumor registry, which lists 2,437 laryngeal cancer patients diagnosed from 2001 to 2005. We selected 1,705 adults with early stage squamous cell carcinoma of the larynx for our analysis. Demographic data and tumor characteristics were included as control variables in multivariate analyses. Rurality was assigned by ZIP code of patient residence. Results Controlling for demographic and clinical factors, rural patients were less likely than urban patients to receive radiotherapy as the primary treatment modality for early stage larynx cancer (OR 0.740, 95% CI 0.577-0.949, P = .0087). No other associations between rural status and treatment choice were statistically significant. Conclusions Relatively fewer rural patients with larynx cancer are treated primarily with radiation therapy. Further investigations to describe this interaction more thoroughly, and to see if this observation is found in larger population data sets, are warranted.

Objectives: To explore the relationship between level and type of comorbidity and guideline-concordant care for early-stage breast cancer. Design: Cross-sectional. Setting: National Program of Cancer Registry (NPCR) Breast and Prostate Cancer Patterns of Care study, which re-abstracted medical records from 2004 in seven cancer registries. Participants: Individuals with stage 0�III breast cancer. Measurements: Multicomponent guideline-concordant management was modeled based on tumor size, node status, and hormone receptor status, according to consensus guidelines. Comorbid conditions and severity were measured using the Adult Comorbidity Evaluation Index (ACE-27). Multivariate logistic regression models determined factors associated with guideline-concordant care and included overall ACE-27 scores and 26 separate ACE comorbidity categories, age, race, stage, and source of payment. Results: The study sample included 6,439 women (mean age 58.7, range 20�99; 76% white; 44% with no comorbidity; 70% estrogen- or progesterone-receptor positive, or both; 31% human epidermal growth factor receptor 2 positive). Care was guideline concordant in 60%. Guideline concordance varied according to overall comorbidity burden (70% for none; 61% for minor; 58% for moderate, 43% for severe; P < .05). In multivariate analysis, the presence of hypertension (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.01�1.30) predicted guideline concordance, whereas dementia (OR = 0.45, 95% CI = 0.24�0.82) predicted lack of guideline concordance. Older age (?50) and black race were associated with less guideline concordance, regardless of comorbidity level. Conclusion: When reporting survival outcomes in individuals with breast cancer with comorbidity, adherence to care guidelines should be among the covariates.

Background: Although there are known to be disparities by socioeconomic status (SES) in breast cancer presentation, this has not been as well studied in the elderly. We examined older women in North Carolina (NC) using insurance status as an indicator of SES. Dual Medicaid/Medicare (dMM) status was used as a surrogate for low SES and Medicare only (M) as a surrogate for higher SES. Methods: From the 1999-2002 NC Central Cancer Registry, we identified women age ≥65 years presenting with nonmetastatic breast cancer, having surgery within 60 days of diagnosis, no neoadjuvant therapy, and insured by Medicare only or dual Medicaid/Medicare. We used Chi-square tests to compare demographic and tumor characteristics, including: age, race, ACE comorbidity index, tumor size, lymph node status (LN), ER/PR status and HER2 status. Results: We identified n = 3088 women with mean age 75 (SD 6.69) years, including 560 dMM and 2528 M insured women. We found that the dMM patients were older than M patients, with 57.7% ≥75 years, vs. 42.6% (p Conclusions: We found that in a population of elderly breast cancer patients, lower SES as defined by Medicaid insurance status was associated with older age, African American race and more advanced comorbidity. These same patients presented with move advanced disease, characterized by larger tumors and more LN involvement. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-10.

Background: Lower SES is associated with worse breast cancer outcomes in general. Disparities by SES have not been well studied in older cancer patients. Here, we examined differences in presentation and treatment patterns by SES in older cancer patients. Methods: The NPCR's Patterns of Care study reabstracted the medical records of breast cancer cases diagnosed in 2004 from 7 state cancer registries. For this study, we included women ≥65 years old with stage 0-III breast cancer. SES was defined by insurance status: non-poor if Medicare (M) or poor if Medicare plus Medicaid (dMM). Receipt of adjuvant chemotherapy, radiation (RT) after breast conserving surgery (BCS), and endocrine therapy were compared by insurance status. We used multiple logistic regression to evaluate the role of age, race, comorbidity and tumor characteristics in the differences in receipt of treatment components, both in separate models by insurance status and then in a pooled model that included insurance status as a predictor. Results: Included were 1,844 women, with insurance status M in 1,585 and dMM in 259. Patients with dMM (vs M) were more likely nonwhite (38.1% vs 10.1%, p Conclusions: Despite presenting with higher stage and larger tumors, older breast cancer patients with dual-Medicare-Medicaid insurance were less likely than those with Medicare-only to receive adjuvant chemotherapy, controlling for age, race, comorbidity and tumor characteristics. Research is needed to further explore the disparity in adjuvant chemotherapy use among poor older patients. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-05.

To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.Central cancer registry data (2006-2008) from three Appalachian states were linked to Medicare claims and census data.Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.

Background Despite growing utilization of accelerated partial breast irradiation using brachytherapy (APBI-Brachy) for elderly breast cancer patients, there are limited data from randomized Phase III trials to support its routine use. This study uses population-based data to examine whether APBI-Brachy results in comparable survival rates compared with whole breast irradiation (WBI). Methods A sample of 29,647 female patients diagnosed with nonmetastatic breast cancer in 2002–2007 treated with breast-conserving surgery and radiotherapy was identified in the Surveillance, Epidemiology, and End Results Program-Medicare data set. Log-rank tests, Cox proportional hazards models, instrumental variable analysis, and subgroup analysis were used to study the comparative effectiveness of APBI-Brachy and WBI. Results During a median followup of 3.6 and 4.8 years, 123 (7.7%) and 3438 (13.6%) patients died after APBI-Brachy and WBI, respectively. Recurrence-free survival ( p = 0.9711) and overall survival rates ( p = 0.0551) did not differ significantly between the two radiation modalities. After accounting for tumor characteristics, patient characteristics, community factors, and comorbidities, the recurrence-free survival (hazard ratio, 1.05; 95% confidence interval, 0.90–1.23; p = 0.5125) and overall survival (hazard ratio, 0.87; 95% confidence interval, 0.72–1.04; p = 0.1332) rates were still not significantly different between patients treated with APBI-Brachy and WBI. Conclusion Partial breast brachytherapy and WBI resulted in similar recurrence-free and overall survival rates in this cohort of elderly breast cancer patients, even after adjustment for the more favorable characteristics of patients in the former group. These findings will need to be confirmed by the randomized trials comparing these modalities.

Thyroid cancer is the most common endocrine malignancy, with differentiated thyroid cancer (DTC) comprising ~93% of all thyroid cancers. While most cases of DTC are curable with the use of surgery and radioactive iodine (RAI) ablation of the remaining thyroid remnant, prognosis is dire and treatment options limited when DTC becomes RAI-refractory (RAI-R). Standard cytotoxic chemotherapy has limited efficacy, making enrollment in clinical trials of novel targeted therapies the preferred treatment approach. Thus, we conducted a comprehensive systematic review of the clinical trial scientific literature with a focus on efficacy, safety, and economics to identify all potential treatment options that have been or are currently being evaluated for the treatment of RAI-R DTC.Embase.com (including Medline), Medline In-Process and other nonindexed citations, the Cochrane Libraries, ClinicalTrials.gov, and relevant recent conference proceedings were searched using predefined search criteria. Important inclusion criteria included English language, randomized controlled studies or interventional single-arm studies only, and studies of drug therapies only. Search results were screened utilizing the discretion of multiple researchers, and key data were abstracted.Forty-five unique trials (16 full-text, 4 conference abstracts, and 25 ClinicalTrials.gov entries) were included in the clinical review. No studies that met criteria for inclusion in the economic review were identified. Among 20 trials with results available, all were Phase II and only one was randomized. The most commonly studied drugs were tyrosine kinase inhibitors (TKIs); other drugs included celecoxib, doxorubicin with interferon alpha-2b, rosiglitazone, selumetinib (AZD6244), thalidomide, VEGF trap, and vorinostat. Overall, efficacy and safety profiles were specific to treatment regimen, with objective response rates (ORR) ranging from 0% on gefitinib, rosiglitazone, VEGF trap, and vorinostat to 50% on lenvatinib, a TKI.Limited clinical research and no economic research has been conducted in RAI-R DTC. Certain treatments, notably TKIs, have shown promise in Phase II trials, and two Phase III randomized placebo-controlled trials are ongoing. New research on the economic and humanistic burden of RAI-R DTC must be paired with the clinical evidence currently in development to examine the existing burden and future promise in treating patients with RAI-R DTC.

To examine the relationship between radiation therapy resources and guideline-concordant radiotherapy after breast-conserving surgery (BCS) in Kentucky.The SEER registry and Area Resource File provided county-level data describing cancer care resources and socioeconomic conditions of Kentucky residents.The outcome variable was rate of BCS without radiotherapy in each county for 2000-2007. Eight-year weighted average rates of radiation therapy providers and hospitals per 100,000 residents were explanatory variables of interest. Exploratory spatial data analyses and spatial econometric models were estimated.Appalachian counties in Kentucky had significantly fewer radiation oncologists, hospitals with radiation therapy facilities, and surgeons per 100,000 residents than non-Appalachian counties. The likelihood of BCS without radiation was significantly higher among Appalachian compared to non-Appalachian women (42.5 percent vs. 29.0 percent, p .001). Higher proportions of women not receiving recommended radiotherapy after BCS were clustered in Eastern Kentucky around Lexington. This geographic disparity was partially explained by significantly fewer radiation therapy facilities in Appalachian Kentucky in adjusted analyses.Scarce radiation therapy resources in Appalachian Kentucky are associated with disparities in receipt of guideline-concordant radiotherapy, suggesting that policy action is needed to improve the cancer treatment infrastructure in disadvantaged mountainous areas.

Purpose To determine the impact of longer periods between biopsy-confirmed breast cancer diagnosis and the initiation of treatment (Dx2Tx) on survival. Patients and Methods This study was a noninterventional, retrospective analysis of adult female North Carolina Medicaid enrollees diagnosed with breast cancer from January 1, 2000, through December, 31, 2002, in the linked North Carolina Central Cancer Registry–Medicaid Claims database. Follow-up data were available through July 31, 2006. Cox proportional hazards regression models were constructed to evaluate the impact on survival of delaying treatment ≥ 60 days after a confirmed diagnosis of breast cancer. Results The study cohort consisted of 1,786 low-income, adult women with a mean age of 61.6 years. A large proportion of the patients (44.3%) were racial minorities. Median time from biopsy-confirmed diagnosis to treatment initiation was 22 days. Adjusted Cox proportional hazards regression showed that although Dx2Tx length did not affect survival among those diagnosed at early stage, among late-stage patients, intervals between diagnosis and first treatment ≥ 60 days were associated with significantly worse overall survival (hazard ratio [HR], 1.66; 95% CI, 1.00 to 2.77; P = .05) and breast cancer–specific survival (HR, 1.85; 95% CI, 1.04 to 3.27; P = .04). Conclusion One in 10 women waited ≥ 60 days to initiate treatment after a diagnosis of breast cancer. Waiting ≥ 60 days to initiate treatment was associated with a significant 66% and 85% increased risk of overall and breast cancer–related death, respectively, among late-stage patients. Interventions designed to increase the timeliness of receiving breast cancer treatments should target late-stage patients, and clinicians should strive to promptly triage and initiate treatment for patients diagnosed at late stage.

PURPOSE: The purpose of this study was to develop and validate a new comprehensive patient-reported measure of treatment burden-the Patient Experience with Treatment and Self-management (PETS). METHODS: A conceptual framework was used to derive the PETS with items reviewed and cognitively tested with patients. A survey battery, including a pilot version of the PETS, was mailed to 838 multi-morbid patients from two healthcare institutions for validation. RESULTS: A total of 332 multi-morbid patients returned completed surveys. Diagnostics supported deletion and consolidation of some items and domains. Confirmatory factor analysis supported a domain model for scaling comprised of 9 factors: medical information, medications, medical appointments, monitoring health, interpersonal challenges, medical/healthcare expenses, difficulty with healthcare services, role/social activity limitations, and physical/mental exhaustion. Scales showed good internal consistency (α range 0.79-0.95). Higher PETS scores, indicative of greater treatment burden, were correlated with more distress, less satisfaction with medications, lower self-efficacy, worse physical and mental health, and lower convenience of healthcare (Ps

Introduction Cancer has become the leading cause of death in China. Several knowledge gaps exist with respect to the patterns of cancer care and disparities in China. Chinese healthcare researchers do not have access to cancer research data of high quality. Only cancer incidence and mortality rates have been analysed in China while the patterns of cancer screening and treatment and disparities have not been rigorously examined. Potential disparities in cancer care by socioeconomic status have not been analysed in the previous literature. Population-based estimates of cancer care costs remain unexamined in China. This project will depict the pattern of cancer screening, incidence and treatment in Shandong province and enhance our understanding of causes of disparities in cancer control. Methods and analysis We will create the first linked database of cancer registry and health insurance claims in China. We obtained cancer registry data on breast, gastrointestinal and lung cancer incidence from 2011 to 2014 and their health insurance claims information from 6 cities/counties of 10.63 million population and validated it with hospital discharge data. A 1600 participant survey will be administered to collect additional information of patients’ socioeconomic status, employment and cancer care costs. Frequency analysis, spatial data exploratory analysis, multivariate logistic regression with instrumental variable, generalised linear regression and subgroup analysis will be used to analyse the following: the receipt of cancer screening, stage at diagnosis, guideline-concordant treatment and cancer care costs. Patient characteristics, tumour features, hospital characteristics, patient comorbidities and county-level descriptors will be used as covariates in the multivariate analysis. Ethics and dissemination The Institutional Review Board of the School of Public Health of Shandong University approved this study (20140201). Data compiled from this project will be made available to all Chinese healthcare researchers. Study results will be disseminated through peer-reviewed publications and presentations at national and international meetings.

Despite being generally accepted that delays in diagnosing breast cancer are of prognostic and psychological concern, the influence of hospital characteristics on such delays remains poorly understood, especially in rural and underserved areas. However, hospital characteristics have been tied to greater efficiency and warrant further investigation as they may have implications for breast cancer care in these areas.Study data were derived from the Kentucky, North Carolina, Ohio, and Pennsylvania state central cancer registries (2006-2008). We then linked Medicare enrollment files and claims data (2005-2009), the Area Resource File (2006-2008), and the American Hospital Association Annual Survey of Hospitals (2007) to create an integrated data set. Hierarchical linear modeling was used to regress the natural log of breast cancer diagnosis delay on a number of hospital-level, demographic, and clinical characteristics.The baseline study sample consisted of 4,547 breast cancer patients enrolled in Medicare that lived in Appalachian counties at the time of diagnosis. We found that hospitals with for-profit ownership (P.01) had shorter diagnosis delays than their counterparts. Estimates for comprehensive oncology services, system membership and size were not statistically significant at conventional levels.Some structural characteristics of hospitals (eg, for-profit ownership) in the Appalachian region are associated with having shorter delays in diagnosing breast cancer. Researchers and practitioners must go beyond examining patient-level demographic and tumor characteristics to better understand the drivers of timely cancer diagnosis, especially in rural and underserved areas.

Background Appalachia is a largely rural, mountainous, poor and underserved region of the United States. Adherence to adjuvant endocrine therapy among Appalachian women with breast cancer is suboptimal. Objectives To explore small-area geographic variations and clustering patterns of breast cancer patient adherence to adjuvant endocrine therapy and associated factors in Appalachia. Methods In this retrospective study, we analyzed Medicare claims data linked with cancer registries from four Appalachian states (PA, OH, KY, and NC) in 2006–2008. We included adult women who were diagnosed with stage I–III, hormone-receptor positive, primary breast cancer and who newly started adjuvant endocrine therapy after the primary treatment for breast cancer. Hot spot analysis was conducted to explore geographic variations in adjuvant endocrine therapy adherence. Geographically weighted logistic regression (GWLR) was used to examine whether the impacts of factors associated with adherence varied across the region. Results Breast cancer patients living in PA and OH showed higher adherence to adjuvant endocrine therapy than those living in KY and NC. We identified clusters of high adherence in most of PA but poor adherence in Erie County, PA and in Buncombe, Transylvania, Henderson, and Polk Counties, NC. Adherence to adjuvant endocrine therapy was significantly associated with the Health Professional Shortage Area designation, catastrophic coverage, dual-eligibility status of Medicaid and Medicare, adjuvant endocrine therapy drug class, and side effects. And among these factors, the impacts of dual-eligibility status and the use of pain medications to treat side effects on adherence were more pronounced in KY and NC than in PA. Conclusions There were significant geographic disparities in adherence to adjuvant endocrine therapy in the Appalachian counties in PA, OH, KY, and NC. This study explored these geographic areas with poor adherence as well as geographically varying effects of predictors on adherence; our results may provide more localized information that may be used to improve adjuvant therapy use and breast cancer care in these high-risk and underserved areas.

Purpose: The goal of this research was to examine spatial access to primary care physicians in Appalachia using both traditional access measures and the 2-step floating catchment area (2SFCA) method. Spatial access to care was compared between urban and rural regions of Appalachia. Methods: The study region included Appalachia counties of Pennsylvania, Ohio, Kentucky, and North Carolina. Primary care physicians during 2008 and total census block group populations were geocoded into GIS software. Ratios of county physicians to population, driving time to nearest primary care physician, and various 2SFCA approaches were compared. Results: Urban areas of the study region had shorter travel times to their closest primary care physician. Provider to population ratios produced results that varied widely from one county to another because of strict geographic boundaries. The 2SFCA method produced varied results depending on the distance decay weight and variable catchment size techniques chose. 2SFCA scores showed greater access to care in urban areas of Pennsylvania, Ohio, and North Carolina. Conclusion: The different parameters of the 2SFCA method—distance decay weights and variable catchment sizes—have a large impact on the resulting spatial access to primary care scores. The findings of this study suggest that using a relative 2SFCA approach, the spatial access ratio method, when detailed patient travel data are unavailable. The 2SFCA method shows promise for measuring access to care in Appalachia, but more research on patient travel preferences is needed to inform implementation.

PurposeInflammatory breast cancer (IBC) is an aggressive subtype of breast cancer for which treatments vary, so we sought to identify factors that affect the receipt of guideline-concordant care.MethodsPatients diagnosed with IBC in 2004 were identified from the Breast and Prostate Cancer Data Quality and Patterns of Care Study, containing information from cancer registries in seven states. Variation in guideline-concordant care for IBC, based on National Comprehensive Cancer Network (NCCN) guidelines, was assessed according to patient, physician, and hospital characteristics.ResultsOf the 107 IBC patients in the study without distant metastasis at the time of diagnosis, only 25.8% received treatment concordant with guidelines. Predictors of non-concordance included patient age (≥70 years), non-white race, normal body mass index (BMI 18.5-25 kg/m(2)), patients with physicians graduating from medical school >15 years prior, and smaller hospital size (

IN BRIEF Our study demonstrates strong associations of diabetes symptoms and distress with female sex, higher BMI, history of neuropathy, and current depressive symptoms. Many diabetes-specific symptoms may be significantly shaped by factors such as depression and obesity.

Diabet. Med. 29, e67–e74 (2012) Abstract Aims Post-hoc evaluation of relationships between first-year change in glycaemic control (HbA1c) and change in patient-reported outcomes among ACCORD health-related quality of life (HRQoL) substudy participants. Methods Data from 2053 glycaemia-trial subjects were analysed. We assessed physical and mental health status (36-Item Short Form Health Survey, Version-2), symptom count and severity (Diabetes Symptoms Distress Checklist) and treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire). Linear mixed models were used to test relationships between 1-year changes in HbA1c and patient reported outcomes sequentially adjusting for correlates (baseline characteristics, baseline patient reported outcomes, treatment assignment, frequency of clinical contact and post-randomization weight change plus new complications). Results Poorer baseline control of HbA1c and cardiovascular disease risk factors predicted greater one-year improvements in treatment satisfaction. Similarly, poorer baseline patient reported outcome scores all individually predicted greater 1-year improvement in that same outcome. Accounting for baseline and post-randomization characteristics and treatment arm, 1-year change in HbA1c was unrelated to changes in overall physical or mental health; however, every one percentage-point (10.9 mmol/mol) reduction in HbA1c was associated with lower symptom count (β = 0.599; P = 0.012), lower symptom distress (β = 0.051; P = 0.001), and higher treatment satisfaction (β = −2.514; P

OBJECTIVES: Epidemiologic studies report that lack of adjuvant radiation (RT) after breast conserving surgery (BCS) is associated with higher short-term mortality. It is generally accepted that adjuvant RT decreases risk of breast cancer recurrence and thereby lowers long-term mortality; here, we explore reasons for its relationship to short-term mortality. MATERIALS AND METHODS: We studied 1,583 publically insured women who had BCS between 1998 and 2002 (mean 71.8 years, range 27-101), of whom 1,346 (85%) received RT. Multivariate analyses with Cox Proportional Hazards and Logistic Regression models included: age; race; comorbidity; insurance status; tumor size; number of nodes positive; hormone receptor status; receipt of radiation; adjuvant chemotherapy; preventive care - including mammography, Pap smear and primary care visits; and hospitalization. RESULTS: At a mean follow-up of 52.8 months, overall mortality was significantly lower in those who received RT (HR 0.45, p0.0001) and higher with older age (HR 1.05, p0.0001) and greater comorbidity (HR 1.16, p=0.0007). Local recurrence was less with receipt of optimal radiation (HR 0.47; p=0.03). Breast cancer event, as determined by a clinically logical algorithm to detect breast cancer recurrence and death, however, was not significantly associated with receipt of RT (OR 1.32, p=0.2). CONCLUSION: These results imply that the higher short-term mortality in women not receiving RT after BCS is related to factors other than breast cancer recurrence.

Background: Appalachia has poorer cancer outcomes, but little research has been done regarding availability of cancer care resources in this region and how resource availability may relate to cancer outcomes. This study 1) examines associations between radiation therapy resources and receipt of radiotherapy after BCS in counties within Kentucky — a SEER state; and 2) describes spatial patterning of breast cancer treatment resources in all 13 Appalachian states. Methods: For the Kentucky analyses, county-level data from the Area Resource File and SEER registry are analyzed. Bivariate analyses and spatial lag regression using a 6-nearest neighboring counties matrix are conducted. The sample includes stage I or II primary breast cancer patients age 18+ years diagnosed in Kentucky during 2000–2007. The dependent variable is the county-level percentage of patients received BCS without radiation; independent variables include density of radiation therapy providers and facilities and other socioeconomic covariates. For the analyses of entire Appalachian region, descriptive analyses and exploratory spatial data analysis are conducted including 420 Appalachian counties and 644 non-Appalachian counties in 13 states. Results: In Kentucky 16.44% of 17,227 early stage breast cancer patients received BCS without radiation therapy (21.08% in Appalachia versus 14.80% in non-Appalachia, p Conclusions: Appalachian counties, especially in central Appalachia, have fewer breast cancer treatment resources than non-Appalachian counties, and resource availability is associated with cancer health disparities. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-04.

To demonstrate the validity and internal consistency of a multi-item scale measuring women's satisfaction with health care received in the weeks following childbirth for both themselves and their newborns. Data are from 1,154 women delivering healthy singletons or twins recruited for a randomized trial. Satisfaction with care items were selected from prior research, including the previously validated Primary Care Satisfaction Survey for Women (PCSSW) and studies of postpartum care. After randomly splitting the sample (1:1) for cross-validation purposes, Exploratory (EFA) and Confirmatory factor analysis (CFA) on ordinal data using the WLSMV estimator available in the MPLUS statistical modeling program were conducted. A CFA was also conducted on available data at 2 weeks and 2 months after discharge in order to examine internal consistency at follow-up. A one factor model with 11 items was selected, with the main factor explaining 83% of total 11-item variation in the overall sample. The Cronbach's alpha for the final 11-item scale at baseline and follow-up time periods was 0.96. High correlations with overall trust in provider (Spearman rho = 0.78) and quality of healthcare (0.75) supported convergent validity. The baseline mean score was 47.9 with a standard deviation of 7.13 and a possible range of 11 (low) to 55 (high satisfaction). This validated scale is a new tool for measuring satisfaction with health care received during the postpartum period for mothers and their newborns. This tool will be useful in studies assessing quality of care and the outcomes of postpartum health care interventions, and it is the first tool to focus on care for the mother-baby unit.

OBJECTIVE To compare the effect of intensive versus standard glycemic control strategies on health-related quality of life (HRQL) in a substudy of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. RESEARCH DESIGN AND METHODS A randomly selected subsample of 2,053 ACCORD participants enrolled in the HRQL substudy was assessed at baseline and 12-, 36-, and 48-month visits. HRQL assessment included general health status (the 36-Item Short Form Health Survey [SF-36]), diabetes symptoms (the Diabetes Symptom Distress Checklist), depression (Patient Health Questionnaire [PHQ]-9), and treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire [DTSQ]). Repeated-measures ANOVA models were used to estimate change in HRQL outcomes by treatment group over 48 months adjusting for model covariates. The effects of early discontinuation of the ACCORD intensive glycemic control arm on study results were explored. RESULTS A total of 1,956 (95%) completed the self-report HRQL instrument(s) at baseline. The intensive arm had a larger decrease in SF-36 physical health component score than the standard arm (−1.6 vs. −1.1, P = 0.0345). Treatment satisfaction (DTSQ) showed larger improvement with intensive than standard (P = 0.0004). There were no differences in mean scores of the Diabetes Symptom Checklist and PHQ-9. Effects of participant transition following discontinuation of the intensive arm on HRQL were not significant. CONCLUSIONS The ACCORD trial strategy of intensive glycemic control did not lead to benefits in HRQL and was associated with modest improvement in diabetes treatment satisfaction. Thus patient acceptability was apparently not compromised with intensive and complex interventions such as those used in ACCORD.

Background: The incidence of epithelial ovarian cancer (EOC) is lower among African-American (AA) women compared to European American (EA) women (9.8 vs. 13.0 cases/100,000), but AA women have markedly worse outcomes. The purpose of this study is to describe the health-related quality of life (HRQL) in AA women with EOC and its correlates using data from a multisite population-based case-control study of invasive EOC in AA women, the African American Cancer Epidemiology Study (AACES). Methods: 215 cases completed a first annual follow-up questionnaire, including the HRQL and psychosocial surveys Results: Higher household family income, lower phobic anxiety, higher social support, and higher leisure physical activity levels were associated with higher MCS and PCS (p < 0.01). Higher perceived discrimination was associated with both lower MCS and PCS, while higher optimism (LOTR) was associated with higher MCS. In multivariable analyses including all predictors, CCI-PA and LOTR remained significant predictors of MCS (p < 0.01), and BMI, phobic anxiety, and social support predicted PCS (p < 0.001). Conclusion: Prediagnosis characteristics and exposures of AA women with EOC are important predictors of HRQL after cancer diagnosis, and in AACES were more important than tumor characteristics. Cancer survivorship programs that enhance patients' social support and physical activity could have important benefits by reducing emotional distress and increasing perceived vitality. Citation Format: Roger T. Anderson, Fabian Camacho, Elisa Bandera, Ellen Funkhouser, Patricia Moorman, Lisa Paddock, Lauren C. Peres, Edward Peters, Sarah E. Abbott, Anthony J. Alberg, Jill Barnholtz-Sloan, Melissa Bondy, Michele L. Cote, Ann Schwartz, Paul Terry, Joellen Schildkraut. Correlates of health-related quality of life among African-American survivors of ovarian cancer: Results from the AACES Study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C42.

Background: Under the Affordable Care Act (ACA), Medicare beneficiaries can receive annual wellness visits (AWV) to configure or update a personalized prevention plan. Previous data show the use of AWVs rose from about 7 percent overall (3.2 million visits) in 2011 to 20 percent (10.4 million visits) in 2016, but patterns of rural uptake of AWV have not been examined nor their potential to reduce rural disparities in cancer screening. Methods: We examined physician and outpatient claims for rural and urban beneficiaries enrolled in Medicare 5% FFS (“Fee for Service”) from 2011-2014 among beneficiaries with >1 year prior enrollment. Beneficiaries were classified into three groups based on previous care patterns: patients with annual health care visits but no AWV (controls); those without previous screening but who attended a subsequent AWV; and those with a previous screening episode with a subsequent AWV. Confounders considered included beneficiary race (white, black, other), gender, age category at reference, Charlson comorbidity score, reference date, National County Economic Distress from Appalachian Regional Commission, and NCHS rural urban status. Outcomes included receipt of colorectal (CRC) and breast (BC) cancer screenings, as well as a bundle of 7 recommended preventative services relating to cardiovascular disease, cancer, diabetes, and bone density. Results: Per beneficiary, AWVs were more likely to occur in metropolitan regions and regions with higher socioeconomic indices, along with individual characteristics such as white ethnicity, female gender, and older age groups. By 2014, the AWV utilization rates in metropolitan residents were 60% higher than rural residents. For both urban and rural US populations, screening access for those without an AWV was significantly lower than with an AWV. For CRC and BC screening, having an AWV was associated with a greater than two-fold increase screening compared to controls (p < .001). Only 20% of the control group had 1 of 7 possible preventive services examined compared to > 80% of the other patient groups. We examine evidence of the impact of ACA on access to screening in rural Appalachia to identify policy and implementation research solutions for the well-documented higher late-stage cancer burden in this region. Conclusions: Our findings strongly suggest that AWVs can be used to reduce disparities in preventive services, such as cancer screenings and vaccinations, especially in disadvantaged groups that tend to lack prior preventive services. However, rural beneficiaries have fewer opportunities to have an AWV. Policies to increase AWV penetration may involve increasing access through community health workers, practice-based supports, and increased financial incentives. Given the size of the screening effects found in this study together with the underutilization of AWV by rural populations, we believe policy seeking to expand the use of AWVs may help with early detection of cancer to improve survival. Citation Format: Roger T. Anderson, Fabian Camacho, Aaron Yao. Rural disparities in uptake of well visits and access to cancer screening in Medicare under the Affordable Care Act [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr IA28.

Introduction: Smoking in the United States has steadily declined over the past several years; however, rural Virginia Appalachian communities have a substantially higher than average smoking prevalence than the rest of the country. A major challenge in providing effective and sustainable cigarette-cessation services to Virginia Appalachia is the geographic and economic diversity of the region, combined with much of the population residing in poor, medically underserved rural areas. Previous research has suggested that community health workers (CHWs) may be valuable in regions with limited financial and medical resources by acting as a bridge between patients and providers when access is limited by distance, health care provider shortages, and cultural stigma. The purpose of this study was to assess the feasibility and success of using CHWs for smoking-cessation services in two Virginia Appalachian health care settings. Methods: Study enrollees were recruited from two sites: a local-family-owned pharmacy and a Federally Qualified Health Center (FQHC) in the Appalachian region of Virginia. Inclusion criteria were daily adult smokers (18+) who were patients at the clinic or the community pharmacy, and self-identified as ready to quit in the next 30 days. Enrollees were defined as individuals for whom a consent form and baseline assessment were completed. Enrollees were subset into a participant group defined as enrollees who completed at least the first session of the eight-session intervention plan. We used an intention-to-treat framework in calculating enrollee and participant quit rates. The program was designed to have eight sessions, with scheduling at the discretion of the CHW and participant. Sessions five and eight were to be completed by the respective health care provider for the clinic and pharmacy. Sessions one and two were completed by the CHW in person with the participant, and sessions three, four, six, and seven were completed by the CHW over the phone. During the sessions, CHWs helped participants develop skills in identifying and addressing barriers to a successful cigarette quit, providing support in adhering to their quit plan, and discussing challenges and barriers they were facing in their quit attempt. Results: Twenty-three individuals were enrolled in the study, with twenty distinguished as participants. The enrollee quit rate was 22%, with a participant quit rate of 25%. Overall, we found a statistically significant decrease in all participants' average cigarettes smoked per day over the eight sessions. Almost all participants failed to complete sessions 5 and 8 with their health care provider. All participants highly rated the program with 100% satisfaction on flexibility of scheduling, level of comfort, positivity, and helpfulness of the CHW. Conclusion: The use of CHWs in Virginia Appalachian communities within our pilot study for cigarette cessation services appears promising. Challenges were noted in attendance to sessions five and eight in the clinic setting. This may speak to the difficulty of going back to their care provider due to challenges in scheduling, concerns about cost of visit, and transportation. The flexibility of working with CHWs, in their own community, over meeting with care providers may provide a benefit to the use of CHWs in future smoking-cessation programs. Future research should explore expanded integration of CHWs into comprehensive tobacco-cessation services in health care settings including the cost-benefit analysis and sustainability of the CHW model. Citation Format: Lindsay Hauser, Catherine Labgold, Roger Anderson, Fabian Camacho. Community health worker led smoking cessation intervention in Virginia Appalachia [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B21.

127 Background: Combined with RT, ADT is a highly effective and utilized treatment for men with localized PC, but some studies suggest that use of ADT leads to increased CVD. We explored the association between ADT and CVD in men receiving RT for localized PC in the National Program for Cancer Registry’s (NPCR) Breast and Prostate Cancer Patterns of Care (POC) study. Methods: From 7 population-based cancer registries, we constructed a sample of men with localized PC treated with definitive RT, stratified by race/ethnicity. Cases diagnosed in 2004 were followed through 2009. Comorbidity, at or before diagnosis, was quantified using the Adult Comorbidity Evaluation 27; subcategories were combined into CV disease (CVD = myocardial infarction, coronary artery disease, congestive heart failure, arrhythmia), CVD-equivalents (CVE = peripheral artery disease and stroke) and CV-risk factors (CVRF = hypertension, diabetes, obesity). Cause of death was determined from the National Death Index data and linkage with vital statistics data. Rates of CV death, in those receiving RT alone versus RT+ADT, were compared in univariate and multivariable analyses. Results: The sample included 2,413 men with mean age 67.7 years (range 39-94), 54.5% white non-Hispanic, 997 received RT alone and 1,416 received RT+ADT. Five-year CVD was 2.3% with RT alone and 3.4% with RT+ADT. In univariate analysis, the following predicted higher CVD with ADT: age < 60 (OR 1.42, p = 0.04), white (OR 2.06, p = 0.001), divorced/separated/widowed (OR 1.29, p = 0.02), insured by Medicare (OR 1.64, p = 0.04), living in mixed urban-rural area (OR 1.87, p = 0.03), higher education level (OR 1.56, p = 0.05), high socioeconomic status (OR 1.70, p = 0.03), no or mild comorbidity level (OR 2.14, p = 0.05 and OR 1.66, p = 0.02, respectively), low PSA (OR 5.44, p = 0,02), and Gleason score 3 (OR 2.12, p = 0.02). In multivariate analysis, use of ADT did not significantly predict hazard of death from heart disease (HR 1.21, p = 0.28) or PC (HR 0.76, p = 0.34). Conclusions: After controlling for confounding variables, use of ADT was not associated with increased risk of CVD in men receiving radiation as definitive therapy for localized PC.

Purpose This study examined patient and provider characteristics associated with being prescribed an aromatase inhibitor (AI) vs tamoxifen-only therapy among a cohort of postmenopausal North Carolina Medicaid enrollees diagnosed with hormone receptor–positive breast cancer. Methods A logistic regression model was built to determine the odds of an individual ever receiving an AI during the study period using data from the Linked North Carolina Central Cancer Registry-Medicaid Claims database. Results A total of 452 patients were included, of which 307 (67.9%) and 145 (32.1%) received tamoxifen only and AI (alone or in combination) therapy, respectively. Results of the final logistic model revealed that odds of receiving an AI generally increased over the study period; however, patients who lived in urban areas had 1.86 (95% CI, 1.20-2.89) times the odds of ever receiving some form of AI therapy compared to patients who lived in rural areas. Additionally, patients with distant stage or unstaged breast cancer (opposed to local stage) had 2.15 (95% CI, 1.39-3.32) times the odds of ever receiving an AI. Conclusions Result suggest that the use of AI therapy is becoming more widespread over time; however, differences in the type of antiestrogenic treatment prescribed based on urban/rural status may represent disparities in access to advanced care. Furthermore, it may be the case that women with local-stage breast cancer are not being treated aggressively enough with novel antiestrogenic drug therapies.