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Purpose Young women are at increased risk for developing more aggressive subtypes of breast cancer. Although previous studies have shown a higher risk of breast cancer recurrence and death among young women with early-stage breast cancer, they have not adequately addressed the role of tumor subtype in outcomes. Methods We examined data from women with newly diagnosed stage I to III breast cancer presenting to one of eight National Comprehensive Cancer Network centers between January 2000 and December 2007. Multivariable Cox proportional hazards models were used to assess the relationship between age and breast cancer–specific survival. Results A total of 17,575 women with stage I to III breast cancer were eligible for analysis, among whom 1,916 were ≤ 40 years of age at diagnosis. Median follow-up time was 6.4 years. In a multivariable Cox proportional hazards model controlling for sociodemographic, disease, and treatment characteristics, women ≤ 40 years of age at diagnosis had greater breast cancer mortality (hazard ratio [HR], 1.4; 95% CI, 1.2 to 1.7). In stratified analyses, age ≤ 40 years was associated with statistically significant increases in risk of breast cancer death among women with luminal A (HR, 2.1; 95% CI, 1.4 to 3.2) and luminal B (HR 1.4; 95% CI, 1.1 to 1.9) tumors, with borderline significance among women with triple-negative tumors (HR, 1.4; 95% CI, 1.0 to 1.8) but not among those with human epidermal growth factor receptor 2 subtypes (HR, 1.2; 95% CI, 0.8 to 1.9). In an additional model controlling for detection method, young age was associated with significantly increased risk of breast cancer death only among women with luminal A tumors. Conclusion The effect of age on survival of women with early breast cancer seems to vary by breast cancer subtype. Young age seems to be particularly prognostic in women with luminal breast cancers.

BACKGROUND The optimal treatment for patients with brain metastases remains controversial as the use of stereotactic radiosurgery (SRS) alone, replacing whole-brain radiation therapy (WBRT), has increased. This study determined the patterns of care at multiple institutions before 2010 and examined whether or not survival was different between patients treated with SRS and patients treated with WBRT. METHODS This study examined the overall survival of patients treated with radiation therapy for brain metastases from non–small cell lung cancer (NSCLC; initially diagnosed in 2007-2009) or breast cancer (initially diagnosed in 1997-2009) at 5 centers. Propensity score analyses were performed to adjust for confounding factors such as the number of metastases, the extent of extracranial metastases, and the treatment center. RESULTS Overall, 27.8% of 400 NSCLC patients and 13.4% of 387 breast cancer patients underwent SRS alone for the treatment of brain metastases. Few patients with more than 3 brain metastases or lesions ≥ 4 cm in size underwent SRS. Patients with fewer than 4 brain metastases less than 4 cm in size (n = 189 for NSCLC and n = 117 for breast cancer) who were treated with SRS had longer survival (adjusted hazard ratio [HR] for NSCLC, 0.58; 95% confidence Interval [CI], 0.38-0.87; P = .01; adjusted HR for breast cancer, 0.54; 95% CI, 0.33-0.91; P = .02) than those treated with WBRT. CONCLUSIONS Patients treated for fewer than 4 brain metastases from NSCLC or breast cancer with SRS alone had longer survival than those treated with WBRT in this multi-institutional, retrospective study, even after adjustments for the propensity to undergo SRS. Cancer 2016;122:2091–100. © 2016 American Cancer Society.

BACKGROUND Shared decision-making is an important component of patient-centered care and is associated with improved outcomes. To the authors' knowledge, little is known concerning the extent and predictors of the involvement of a patient's family in decisions regarding cancer treatments. METHODS The Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is a large, multiregional, prospective cohort study of the cancer care and outcomes of patients with lung and colorectal cancer. Participants reported the roles of their families in decision-making regarding treatment. Multinomial logistic regression was used to assess patient factors associated with family roles in decisions. RESULTS Among 5284 patients, 80 (1.5%) reported family-controlled decisions, with the highest adjusted rates (12.8%) noted among non-English-speaking Asians. Among the 5204 remaining patients, 49.4% reported equally sharing decisions with family, 22.1% reported some family input, and 28.5% reported little family input. In adjusted analyses, patients who were married, female, older, and insured more often reported equally shared decisions with family (all P

Background. The EQ-5D and SF-6D are 2 health-related quality-of-life indexes that provide preference-weighted measures for use in cost-effectiveness analyses. Methods. The National Cancer Institute’s Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium included the EQ-5D and SF-12v2 in their survey of newly diagnosed lung cancer patients. Utilities were calculated from patient-provided scores for each domain of the EQ-5D or the SF-6D. Utilities were calculated for categories of cancer type, stage, and treatment. Results. There were 5015 enrolled lung cancer patients with a baseline survey in CanCORS; 2396 (47.8%) completed the EQ-5D, and 2344 (46.7%) also completed the SF-12v2. The mean (standard deviation) utility from the EQ-5D was 0.78 (0.18), and from the SF-6D (derived from SF-12v2) was 0.68 (0.14). The EQ-5D demonstrated a ceiling effect, with 20% of patients reporting perfect scores, translating to a utility of 1.0. No substantial SF-6D floor effects were noted. Utilities increased with age and decreased with stage and comorbidities. Patient-reported (EQ-5D) visual analog scale scores for health status had a moderate ( r = 0.48, p < 0.0001) positive correlation with utilities. A subset ( n = 1474) completed follow-up EQ-5D questionnaires 11–13 months after diagnosis. Among these patients, there was a nonsignificant decrease in mean utility for stage IV and an increase in mean utility for stages I, II, and III. Conclusion. This study generated a catalog of community-weighted utilities applicable to societal-perspective cost-effectiveness analyses of lung cancer interventions and compared utilities based on the EQ-5D and SF-6D. Potential users of these scores should be aware of the limitations and think carefully about their use in specific studies.

ContextRelatively few data are available about symptoms among cancer patients.ObjectivesTo describe the prevalence and severity of symptoms among a large, representative cohort of newly diagnosed cancer patients.MethodsWe collected survey data about symptoms (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, and diarrhea) from 5422 patients with incident lung and colorectal cancer from the diverse, nationally representative Cancer Care Outcomes Research and Surveillance Consortium cohort. We described the prevalence of any symptoms and moderate/severe symptoms approximately four to six months after diagnosis. We used logistic regression to identify patient and clinical characteristics associated with symptoms, and calculated adjusted proportions of patients with symptoms.ResultsIn total, 5067 (93.5%) patients reported at least one symptom in the four weeks before their survey, with 51% reporting at least one moderate/severe symptom. Lung cancer patients reported more symptoms than colorectal cancer patients. Patients who received treatment or had more comorbidities were more likely to report symptoms. For example, after adjustment, patients who received chemotherapy during the six weeks before the survey were more likely than others to report at least one symptom (97.3% vs. 90.8%, P

Background Invasive procedures are resource intense and may be associated with substantial morbidity. These harms must be carefully balanced with the benefits gained in life expectancy and quality of life. Prior research has demonstrated an increasing aggressiveness of care in cancer patients at the end-of-life. To better characterize surgical care in this setting, we sought to examine trends in the use of invasive procedures in patients diagnosed with metastatic cancer on presentation. Materials and methods Using Surveillance Epidemiology and End Results -Medicare data, we identified invasive procedure claims from 1994–2009 for patients diagnosed with incident stage IV breast, colorectal, lung, and prostate cancer patients in 1995–2006. We grouped procedures into surgically relevant categories, using an adaptation of the Clinical Classifications Software, and measured utilization and relative changes over time. Results Of stage IV patients diagnosed in 2002–2006, 96% underwent a procedure during the course of their cancer care including 63% after the diagnostic period, and 25% in the last month of life. Between 1996 and 2006, minimal change was observed in utilization during the diagnostic period (+1.5%). However, there were significant increases during continuing care (+20.7%) and the last month of life (+21.5%). Procedures consistent with primary tumor resection decreased, whereas those with probable palliative intent and those unrelated to cancer increased. Conclusions Nearly all patients who present with metastatic cancer undergo invasive procedures. Although overall utilization is increasing, the specific procedure types indicate that it may be appropriate, enhancing the quality of life in this vulnerable population.

Background:A substantial proportion of cancer-related mortality is attributable to recurrent, not de novo metastatic disease, yet we know relatively little about these patients. To fill this gap, investigators often use administrative codes for secondary malignant neoplasm or chemotherapy to identif

Fee-for-service (FFS) Medicare expenditures for advanced imaging studies (defined as computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET] scans, and nuclear medicine studies [NM]) rapidly increased in the past two decades for patients with cancer. Imaging rates are unknown for patients with cancer, whether under or over age 65 years, in health maintenance organizations (HMOs), where incentives may differ.Incident cases of breast, colorectal, lung, prostate, leukemia, and non-Hodgkin lymphoma (NHL) cancers diagnosed in 2003 and 2006 from four HMOs in the Cancer Research Network were used to determine 2-year overall mean imaging counts and average total imaging costs per HMO enrollee by cancer type for those under and over age 65.There were 44,446 incident cancer patient cases, with a median age of 75 (interquartile range, 71-81), and 454,029 imaging procedures were performed. The mean number of images per patient increased from 7.4 in 2003 to 12.9 in 2006. Rates of imaging were similar across age groups, with the exception of greater use of echocardiograms and NM studies in younger patients with breast cancer and greater use of PET among younger patients with lung cancer. Advanced imaging accounted for approximately 41% of all imaging, or approximately 85% of the $8.7 million in imaging expenditures. Costs were nearly $2,000 per HMO enrollee; costs for younger patients with NHL, leukemia, and lung cancer were nearly $1,000 more in 2003.Rates of advanced imaging appear comparable among FFS and HMO participants of any age with these six cancers.

Purpose Although predictive multiplex somatic genomic tests hold the potential to transform care by identifying targetable alterations in multiple cancer genes, little is known about how physicians will use such tests in practice. Participants and Methods Before the initiation of enterprise-wide multiplex testing at a major cancer center, we surveyed all clinically active adult cancer physicians to assess their current use of somatic testing, their attitudes about multiplex testing, and their genomic confidence. Results A total of 160 physicians participated (response rate, 61%): 57% were medical oncologists; 29%, surgeons; 14% radiation oncologists; 37%, women; and 83%, research principal investigators. Twenty-two percent of physicians reported low confidence in their genomic knowledge. Eighteen percent of physicians anticipated testing patients infrequently (≤ 10%), whereas 25% anticipate testing most patients (≥ 90%). Higher genomic confidence was associated with wanting to test a majority of patients (adjusted odds ratio [OR], 6.09; 95% CI, 2.1 to 17.5) and anticipating using actionable (adjusted OR, 2.46; 95% CI, 1.2 to 5.2) or potentially actionable (adjusted OR, 2.89; 95% CI, 1.1 to 7.9) test results to inform treatment recommendations. Forty-two percent of physicians endorsed disclosure of uncertain genomic findings to patients. Conclusion Physicians at a tertiary-care National Cancer Institute–designated comprehensive cancer center varied considerably in how they planned to incorporate predictive multiplex somatic genomic tests into practice and in their attitudes about the disclosure of genomic information of uncertain significance. Given that many physicians reported low genomic confidence, evidence-based guidelines and enhanced physician genomic education efforts may be needed to ensure that genomically guided cancer care is adequately delivered.

Purpose Although radiation therapy (RT) can palliate symptoms and may prolong life, it is not curative for patients with metastatic lung cancer. We investigated patient expectations about the goals of RT for incurable lung cancers. Patients and Methods The Cancer Care Outcomes Research and Surveillance Consortium enrolled a population- and health system–based cohort of patients diagnosed with lung cancer from 2003 to 2005. We identified patients with stage wet IIIB or IV lung cancer who received RT and answered questions on their expectations about RT. We assessed patient expectations about the goals of RT and identified factors associated with inaccurate beliefs about cure. Results In all, 384 patients completed surveys on their expectations about RT. Seventy-eight percent of patients believed that RT was very or somewhat likely to help them live longer, and 67% believed that RT was very or somewhat likely to help them with problems related to their cancer. However, 64% did not understand that RT was not at all likely to cure them. Older patients and nonwhites were more likely to have inaccurate beliefs, and patients whose surveys were completed by surrogates were less likely to have inaccurate beliefs. Ninety-two percent of patients with inaccurate beliefs about cure from RT also had inaccurate beliefs about chemotherapy. Conclusion Although patients receiving RT for incurable lung cancer believe it will help them, most do not understand that it is not at all likely to cure their disease. This indicates a need to improve communication regarding the goals and limitations of palliative RT.

Purpose Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare. Patients and Methods Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results–Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use. Results Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients. Conclusion Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.

BACKGROUND Randomized trials report equivalent efficacy among various combinations of platinum-based regimens in advanced non–small cell lung cancer (NSCLC). Their relative effectiveness and comparability based on squamous versus nonsquamous histology is uncertain. METHODS The authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data to identify first-line chemotherapy agents administered to Medicare beneficiaries with stage IIIB or IV NSCLC diagnosed from 2000 to 2007. Overall survival was compared between patients who received the 3 most common regimens: carboplatin-paclitaxel, carboplatin-gemcitabine, and carboplatin-docetaxel. Stratified analyses distinguished between the outcomes of patients with squamous versus nonsquamous cell histology. Multivariable Cox proportional hazards models and propensity score analyses facilitated adjustment for imbalance in measurable patient characteristics. RESULTS Of the 15,318 patients who received first-line chemotherapy, 43.1% received carboplatin-paclitaxel, 14.3% received carboplatin-gemcitabine, 8.5% received carboplatin-docetaxel, and 34.1% received other regimens. The median survival was 8.0 months (interquartile range [IQR], 3.5-17.4 months) for carboplatin-paclitaxel, 7.3 months (IQR, 3.4-15.2 months) for carboplatin-gemcitabine, and 7.5 months (IQR, 3.2-16.0 months) for carboplatin-docetaxel. Both multivariable and propensity score-adjusted Cox models demonstrated a slight inferiority associated with carboplatin-gemcitabine or carboplatin-docetaxel versus carboplatin-paclitaxel, with a hazard ratio of 1.10 (95% confidence interval, 1.04-1.15) and 1.09 (95% confidence interval, 1.02-1.16), respectively, in propensity score-stratified models. Among the subgroup of 2063 patients with squamous carcinoma, propensity score-stratified analyses had a higher risk of death (hazard ratio, 1.20; 95% confidence interval, 1.07-1.35) associated with carboplatin-gemcitabine versus carboplatin-paclitaxel. CONCLUSIONS Carboplatin-paclitaxel was associated with slightly better survival compared with carboplatin-gemcitabine or carboplatin-docetaxel within the Medicare population with advanced NSCLC, and this was most pronounced for patients who had squamous cell histology. Cancer 2013;119:2048–2060. © 2013 American Cancer Society.

Learning Objectives Identify predictors of excessive risk perception in women with a distant history of DCIS. Explain the importance of educating women with a history of DCIS about reasonable assessments of their risk for future breast cancer. Introduction. Previous research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk for future breast cancer at the time of diagnosis and soon thereafter. This study aims to evaluate risk perceptions after 5 years. Patients and Methods. In a longitudinal cohort study, we mailed long-term follow-up surveys to 315 women who had previously responded to a survey 18 months after they were diagnosed with DCIS, excluding those who had experienced recurrence and those not treated at our institution. We evaluated risk perceptions with items used previously in the cohort. Results. One hundred ninety-three women (61%) responded. The median time since diagnosis was 5.9 years. We excluded 12 because of recurrence. Of the 181 remaining, 32% perceived at least a moderate 5-year risk for developing DCIS again, 43% perceived at least a moderate lifetime risk for developing DCIS again, 27% perceived at least a moderate 5-year risk for invasive breast cancer, 38% perceived at least a moderate lifetime risk for invasive breast cancer, and 24% perceived at least a moderate risk for DCIS spreading to other body parts. In a multivariate model, worse financial status and higher perceived risk in the previous survey were the only predictors of at least a moderate perception of risk for DCIS spreading. Conclusion. Women with a history of DCIS continue to harbor inaccurate perceptions of their risk for future breast cancer events even 5 years after diagnosis.

Purpose: Only 2% to 5% of adult patients with cancer enroll onto clinical trials. We assessed simultaneously characteristics of patients and their physicians that may be independently associated with participation. Methods: CanCORS, a National Cancer Institute (NCI) –funded population-based observational cohort study of newly diagnosed patients with lung and colorectal cancers, sampled patients across five geographic areas, five health care delivery systems, and 15 Veterans Administration hospitals. We linked patient survey and medical record data with physician survey data to examine correlates of trial enrollment. Results: Among 9,901 patients, 5.3% enrolled onto trials. Of the 9,901 patients, we linked 6,506 patients to one medical oncologist, surgeon, or radiation oncologist (physicians, N 1,325) who responded to the physician survey and was considered their primary cancer clinician decision maker. Patient age, race, disease stage, geographic region, and health insurance were independently associated with trial enrollment. Physician factors independently associated with patient trial enrollment were being a medical oncologist, practicing at an NCI-designated cancer center, taking the lead in discussing trials with patients, and receiving increased income from trial enrollment. After simultaneously adjusting for patient and physician characteristics, only being a physician practicing at an NCI-designated cancer center (odds ratio [OR], 1.65; 95% CI, 1.19 to 2.27) and patient female sex (OR, 1.36; 95% CI, 1.10 to 1.68), age 70 versus 50 years (OR, 0.28; 95% CI, 0.16 to 0.48), and advanced disease (OR, 1.85; 95% CI, 1.45 to 2.37) remained independently associated with trial enrollment. Conclusion: Both practice environment and patient clinical and demographic characteristics are associated with cancer clinical trial enrollment; simultaneous intervention may be required when trying to increase enrollment rates.

Purpose Randomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non–small-cell lung cancer (NSCLC). Patients and Methods From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression. Results Of 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associated with younger age at diagnosis and receipt of chemotherapy and surgery to metastatic sites. Among patients receiving palliative bone RT, only 6% received single-fraction treatment. Among patients receiving palliative chest RT, 42% received more than 20 fractions. Patients treated in integrated networks were more likely to receive lower doses and fewer fractions to the bone and chest. Conclusion When palliative RT is used in patients with metastatic NSCLC, a substantial proportion of patients receive a greater number of treatments and higher doses than supported by current evidence, suggesting an opportunity to improve care delivery.

Purpose The indications for treatment of brain metastases from non-small cell lung cancer (NSCLC) with stereotactic radiosurgery (SRS) remain controversial. We studied patterns, predictors, and cost of SRS use in elderly patients with NSCLC. Methods and Materials Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we identified patients with NSCLC who were diagnosed with brain metastases between 2000 and 2007. Our cohort included patients treated with radiation therapy and not surgical resection as initial treatment for brain metastases. Results We identified 7684 patients treated with radiation therapy within 2 months after brain metastases diagnosis, of whom 469 (6.1%) cases had billing codes for SRS. Annual SRS use increased from 3.0% in 2000 to 8.2% in 2005 and varied from 3.4% to 12.5% by specific SEER registry site. After controlling for clinical and sociodemographic characteristics, we found SRS use was significantly associated with increasing year of diagnosis, specific SEER registry, higher socioeconomic status, admission to a teaching hospital, no history of participation in low-income state buy-in programs (a proxy for Medicaid eligibility), no extracranial metastases, and longer intervals from NSCLC diagnosis. The average cost per patient associated with radiation therapy was 2.19 times greater for those who received SRS than for those who did not. Conclusions The use of SRS in patients with metastatic NSCLC increased almost 3-fold from 2000 to 2005. In addition, we found significant variations in SRS use across SEER registries and socioeconomic quartiles. National practice patterns in this study suggested both a lack of consensus and an overall limited use of the approach among elderly patients before 2008.

Introduction: Population based studies (eg, Hershman et al. BCRT 2006 and Lohrisch et al. JCO 2006) showed poorer survival associated with long delays in adjuvant chemotherapy (CTX) initiation following definitive surgery (DS) for women with breast cancer (BC). Delays in CTX following diagnosis (DX) have not been evaluated. The ASCO/NCCN quality measures (QMs) recommend CTX Methods: 4,608 women with stage I-III HER2 negative breast cancer diagnosed between 2000 and 2006 at 8 NCCN centers were identified using the NCCN outcomes database. Patients with T3/4 disease or who received neoadjuvant therapy were excluded. The association between CTX timing and OS was evaluated using multivariate Cox models adjusted for CTX type, age, race, BMI, residential distance, insurance, SES, comorbidity, ER/PR, LVI, grade, T stage, and N stage. The impact of CTX timing was evaluated using a >90-day (d) DS-to-CTX threshold, based on poor outcomes observed in prior studies, and a >120d DX-to-CTX threshold, based on the ASCO/NCCN QMs. Results: Median follow-up was 7.2 years and OS at 7 years was 89%. Overall, 401 (8.7%) patients received CTX >120d after DX and 113 (2.4%) patients received CTX >90d after DS. The DX-to-CTX interval was more strongly correlated with the DX-to-DS (r = 0.74) interval than DS-to-CTX (r = 0.54) interval. A >90d DS-to-CTX interval was significantly associated with poorer survival (HR: 1.65, 95% CI 1.04–2.60, p = 0.03) in adjusted analyses. Shorter DS-to-CTX thresholds of >60d (n = 636, HR: 1.13, 95% CI: 0.89–1.43, p = 0.319) or >75d (n = 273, HR: 1.05, 95% CI 0.74–1.49, p = 0.76) were not associated with OS. The association between a >120d DX-to-CTX interval and OS was not statistically significant (HR: 1.32, 95% CI 0.99–1.76, p = 0.06). Patients who received CTX >135d (n = 231, HR 1.25, 95% CI: 0.87–1.81, p = 0.22) or >150d (n = 128, HR 1.15, 95% CI: 0.59–2.24, p = 0.69) after DX did not display an increased risk of death. Excluding pathological staging factors from the model had no effect on the results. In subgroup analyses stratified by ER/PR, LVI, grade, T stage or N stage, a >120d delay in CTX did not display significant associations with OS. Among ER/PR negative patients, the association between a >120d delay and OS was borderline non-significant after adjusting the p-value for multiple hypothesis testing using the false discovery rate method (HR: 1.80, 95% CI: 1.16–2.79, p = 0.09). Conclusion: Consistent with previous studies, CTX delays of >90 days following surgery were associated with poorer survival. OS was not significantly compromised in patients with DX-to-CTX intervals >120 days although this analysis may have limited power to detect small effects. More variation in the DX-to-CTX interval was attributed to pre-surgery time which may explain the differences observed between the DX-to-CTX and DS-to-CTX intervals. Among patients with ER/PR negative disease, a non-significant association between OS and a >120 day DX-to-CTX interval was observed that warrants further examination. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-13-05.

Dramatic advances in genomic technology stand to revolutionize cancer care; however, little is known about patients' understanding and acceptance of personalized medicine and widespread genetic testing (GT). Patients and Methods: We conducted a formative, semi- structured interview study with a random sample of patients with lung, colorectal, and breast cancers to assess awareness of personalized medicine and GT and attitudes about somatic GT. Willingness to undergo GT was elicited through hypothetic scenarios. Results: Sixty-nine patients participated; 71% were women; 42% were black; median age was 59 years; and 42% had an education level college. We found that a majority of patients either were not aware of the term "personalized medicine" or defined it in unexpected ways. Although many patients identified relevant benefits of somatic testing (eg, informs treatment), many patients also expressed significant concerns (ie, psychological harm and discrimination). A majority of patients expressed a willingness to undergo somatic (predictive, 96%, prognostic, 93%) and germline (cancer risk without incidental information, 87%; cancer risk with incidental information, 81%; pharmacoge- netic, 91%) testing; however, far fewer patients expressed a willingness to undergo full genome sequencing (62%). Reluc- tance was attributed to concerns over incidental findings, infor- mation overload, and the lack of a clear benefit. Conclusion: Many patients relayed misunderstandings about somatic testing and a reluctance to undergo full sequencing; oncologists must carefully consider how they present testing to patients so that concerns over discrimination and psychological harm do not hinder test uptake. More work is needed to identify effective ways to communicate complex genomic concepts to patients and research participants.

BACKGROUND. Trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive breast cancer is highly efficacious yet costly and time-intensive, and few data are available about its use. The authors of this report examined receipt and completion of adjuvant trastuzumab by race/ethnicity and education for women with HER2-positive disease. METHODS. The National Comprehensive Cancer Network Breast Cancer Outcomes Database was used to identify 1109 women who were diagnosed with stage I through III, HER2-positive breast cancer during September 2005 through December 2008 and were followed for ≥1 year. The authors used multivariable logistic regression to assess the association of race/ethnicity and education with the receipt of trastuzumab and, among those women who initiated trastuzumab, with the completion of > 270 days of therapy. RESULTS. The cohort was 75% white, 8% black, and 9% Hispanic; and 20% of women had attained a high school degree or less. Most women (83%) received trastuzumab, and no significant differences were observed according to race/ethnicity or socioeconomic status. Among the women who initiated trastuzumab, 73% of black women versus 87% of white women (P = .007) and 70% of women with less than a high school education versus 90% of women with a college degree completed > 270 days of therapy (P = .006). In adjusted analyses, black women (vs white women) and women without a high school degree (vs those with a college degree) had lower odds of completing therapy (black women: odds ratio, 0.45; 95% confidence interval, 0.27-074; white women: odds ratio, 0.27, 95% confidence interval, 0.14-0.51). CONCLUSIONS. Differences in completing trastuzumab therapy were observed according to race and educational attainment among women who received treatment at National Comprehensive Cancer Network centers. Efforts to assure the appropriate use of trastuzumab and to understand treatment barriers are needed and may lead to improved outcomes. The authors report differences in the rate at which patients complete treatment with trastuzumab according to race and education among women who receive treatment at National Comprehensive Cancer Network centers. Efforts to assure the appropriate use of trastuzumab and to understand treatment barriers are needed and may lead to improved outcomes. Cancer 2013. © 2012 American Cancer Society.

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving1 line of chemotherapy and receiving combination chemotherapy.Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of1 line of chemotherapy or combination chemotherapy.The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

The natural history model underlying the MGH Lung Cancer Policy Model (LCPM) does not include the two-stage clonal expansion model employed in other CISNET lung models. We used the LCPM to predict numbers of U.S. lung cancer deaths for ages 30-84 between 1975 and 2000 under four scenarios as part of the comparative modeling analysis described in this issue. The LCPM is a comprehensive microsimulation model of lung cancer development, progression, detection, treatment, and survival. Individual-level patient histories are aggregated to estimate cohort or population-level outcomes. Lung cancer states are defined according to underlying disease variables, test results, and clinical events. By simulating detailed clinical procedures, the LCPM can predict benefits and harms attributable to a variety of patient management practices, including annual screening programs. Under the scenario of observed smoking patterns, predicted numbers of deaths from the calibrated LCPM were within 2% of observed over all years (1975-2000). The LCPM estimated that historical tobacco control policies achieved 28.6% (25.2% in men, 30.5% in women) of the potential reduction in U.S. lung cancer deaths had smoking had been eliminated entirely. The hypothetical adoption in 1975 of annual helical CT screening of all persons aged 55-74 with at least 30 pack-years of cigarette exposure to historical tobacco control would have yielded a proportion realized of 39.0% (42.0% in men, 33.3% in women). The adoption of annual screening would have prevented less than half as many lung cancer deaths as the elimination of cigarette smoking.

Purpose: The prevalence and severity of pain have not been well described among oncology patients in ambulatory care. To better understand the burden of pain among patients with advanced cancer, we examined the prevalence of pain reported during office and treatment visits. Methods: A retrospective study of 4,014 patients with advanced disease (stage 4 at diagnosis or metastatic progression) who completed an ambulatory visit between 2004 and 2006 was conducted at a comprehensive cancer center in Boston, Massachusetts. Results: At their first visit during the study period, 74% of patients reported no pain (0 score); 12%, low pain (1 to 3 score); 9%, moderate pain (4 to 6 score); and 5%, severe pain (7 to 10 score). The prevalence of pain was highest among patients who wereyoungerthan60yearsofage,werenonwhite,didnotspeak English as their primary language, or were covered by Medicaid, received free care, or paid their own health care costs. Patients with thoracic, breast, and head and neck cancers had higher pain scores than those with other diseases. Pain was reported more frequently among patients whose diagnosis or metastatic progression occurred less than 3 months before the reported pain score. In multivariable regression analysis, age, race, cancer type, and time since diagnosis/progression were identified as important factors associated with severe pain. Conclusion: Younger age, minority race, and recent onset of advanced disease are associated with severe pain among patients with cancer. Recognizing these high-risk groups could inform targeted interventions to address pain care in ambulatory patients with advanced cancer.

BACKGROUND: The number of women diagnosed with ductal carcinoma in situ (DCIS) is increasing. Although many eventually develop a second breast cancer (SBC), little is known about the characteristics of SBCs. The authors described the characteristics of SBC and examined associations between the pathologic features of SBC and index DCIS cases. METHODS: Women were identified in the National Comprehensive Cancer Network Outcomes Database who were diagnosed with DCIS from 1997 to 2008 and underwent lumpectomy and who subsequently developed SBC (including DCIS or invasive disease that occurred in the ipsilateral or contralateral breast). The Fisher exact test and the Spearman test were used to examine associations between the pathologic characteristics of SBC and index DCIS cases. RESULTS: Among 2636 women who underwent lumpectomy for DCIS, 150 (5.7%) experienced an SBC after a median of 55.5 months of follow-up. Of these 150 women, 105 (70%) received adjuvant radiotherapy, and 50 (33.3%) received tamoxifen for their index DCIS. SBCs were ipsilateral in 54.7% of women and invasive in 50.7% of women. Among the index DCIS cases, 60.6% were estrogen receptor (ER)-positive, and 54% were high grade, whereas 77.5% of SBCs were ER-positive, and 48.2% were high grade. Tumor grade (P = .003) and ER status (P = .02) were associated significantly between index DCIS and SBC, whereas tumor size was not (P = .87). CONCLUSIONS: After breast conservation for DCIS, SBC in either breast exhibited pathologic characteristics similar to the index DCIS, suggesting that women with DCIS may be at risk for developing subsequent breast cancers of a similar phenotype. Cancer 2012. © 2012 American Cancer Society.

BACKGROUND: Although pain is common among patients with advanced cancer, little is known about longitudinal variability in pain intensity. For this report, the authors examined variability in pain intensity over 24 months among ambulatory patients with advanced stage cancers, associations between patient characteristics and within-patient pain variability, and the relation of pain variability to overall survival. METHODS: The sample comprised 949 patients with solid tumors who received care and reported pain scores in at least 3 different months within 24 months of their initial stage IV diagnosis during the period from 2004 to 2006. Pain intensity was measured using a scale ranging from 0 (no pain) to 10 (worst pain). Pain variability was defined as the standard deviation of the maximum monthly pain scores and was dichotomized at the 50th percentile into high and low variability groups. RESULTS: Considerable between-patient differences in pain variability (range, 0-5.77) were observed. Nonwhites, patients with a stage IV cancer diagnosed within the previous 3 months, and those with moderate or severe pain at baseline were more likely to experience high pain variability. Although patients with head and neck cancer generally had the highest pain variability, the intensity of their pain typically decreased over the disease course. High pain variability with worsening pain trajectory was associated with increased risk of death. CONCLUSIONS: Longitudinally, pain intensity was highly variable among patients with stage IV cancer. Minority patients, newly diagnosed patients, patients with head and neck cancer, and patients with moderate or severe pain at baseline were at higher risk of large fluctuations in pain intensity. Cancer 2012. © 2012 American Cancer Society.

Context Pain is common among patients with advanced cancer despite the dissemination of clinical pain care guidelines. Objectives We sought to assess the quality of pain care among patients with advanced disease. Methods We reviewed the records of 85 adult ambulatory patients with advanced breast, lung, and gastrointestinal cancer treated in 2004–2006. Patients' screening pain intensity scores were at least 7 of 10. Nurse reviewers completed medical record reviews of care rendered at the index visit and over the subsequent 30 days based on the 2004 National Comprehensive Cancer Network pain guideline. An expert panel then rated the quality of the evaluation, treatment, and overall pain care. We used a multivariable model to analyze guideline compliance and resolution of severe pain. Results Among advanced cancer patients with severe pain, clinicians adjusted pain medications only half the time and made few timely referrals for pain-related consultations. By 30 days after the index visit, 34% of patients continued to report severe pain. The expert panel judged the overall quality of pain care as "fair" or "poor" in about two-thirds of cases because more timely and effective intervention could have reduced the severity and duration of pain. Resolution of severe pain was associated with adjustment of pain medications at the index visit (adjusted odds ratio 3.8, 95% CI 1.3–10.6). Conclusion There is room for improvement in the pain care of patients with advanced cancer. Additional research is needed to understand the reasons for poor performance.

Agreat deal of effort is currently being devoted to helping health care purchasers, both patients and payers identify hospitals providing better quality care. The term “center of excellence” is often used to promote a given institution as having expertise in a particular area. Within oncology, the National Cancer Institute (NCI) Cancer Centers Program identifies centers of excellence primarily based on their research programs, but it also emphasizes the association between strong research and excellence in clinical care, education, community outreach and other critical components of cancer care.1 The NCI designates institutions as either comprehensive cancer centers, which demonstrate significant research activities in each of 3 major areas—laboratory-based research, population-based research, and clinical research—and which have substantial multidisciplinary research efforts or cancer centers, which are primarily focused in one or more of these scientific areas. As of 2010, the NCI recognizes 44 comprehensive cancer centers and 20 cancer centers. Institutions with NCI-designated cancer center status are expected to be a major source of discovery in cancer, including the development of more effective approaches to care and the creation of effective research dissemination strategies.2 Previous studies have shown improved surgical outcomes at NCI-designated cancer centers, particularly for 30-day mortality rates.3–5 These studies also reported improved long-term outcomes for colon and rectal cancer at NCI-designated cancer centers, but long-term survival was similar for other cancer sites. Little work has investigated differences between NCI-designated cancer centers and other institutions on process measures, or whether the appropriate care is provided.6,7 Concordance with practice guidelines is currently one approach to determining whether appropriate care was provided. The goal of practice guidelines is to close the gap that exists between best evidence and current practice.8–10 However, due to increasing pressure to define and measure appropriate care, guideline creation has often outpaced evidence generation. As a result, many guidelines are based on less than level 1 evidence11 and often rely on expert consensus.12 Prior research has shown that lower-level evidence can lead to surgical practice that is less adherent to guidelines and results in greater variability in care among institutions.13,14 Little is currently known about the role that center of excellence status may play in this observed increase in institutional variation when strong evidence is lacking. Eleven practice guidelines for 5 cancer sites (thyroid, gastric, rectal, colon, or breast cancer) that are commonly treated by general surgeons and general surgery subspecialists, including surgical oncologists and breast, endocrine, and colorectal surgeons, were identified previously by our group.15 These guidelines were further examined to determine the role of NCI-designation in institutional variation for guidelines based on level of evidence. We hypothesize that when there is strong evidence to support a guideline, there will be general consensus, minimizing practice variation between NCI-designated centers and other institutions. However, when a guideline is based on less definitive evidence, greater variation based on NCI-designation will be observed. A better understanding of the relationship between level of evidence and guideline concordance will shed important light on institutional variation in the surgical care of cancer patients. If our hypothesis is true, institutions that are not NCI-designated cancer centers are providing appropriate care when there is high quality evidence to support it, providing reassurance to patients and providers that care is equivalent for these cases. When the supporting evidence is less clear, it is a greater leap to equate guideline concordance with higher quality care because the right approach to care has not been definitely determined.

BACKGROUND: The objective of this study was to describe clinicopathologic features, patterns of recurrence, and survival according to breast cancer subtype with a focus on triple-negative tumors. METHODS: In total, 15,204 women were evaluated who presented to National Comprehensive Cancer Network centers with stage I through III breast cancer between January 2000 and December 2006. Tumors were classified as positive for estrogen receptor (ER) and/or progesterone receptor (PR) (hormone receptor [HR]-positive) and negative for human epidermal growth factor receptor 2 (HER2); positive for HER2 and any ER or PR status (HER2-positive); or negative for ER, PR, and HER2 (triple-negative). RESULTS: Subtype distribution was triple-negative in 17% of women (n = 2569), HER2-positive in 17% of women (n = 2602), and HR-positive/HER2-negative in 66% of women (n = 10,033). The triple-negative subtype was more frequent in African Americans compared with Caucasians (adjusted odds ratio, 1.98; P < .0001). Premenopausal women, but not postmenopausal women, with high body mass index had an increased likelihood of having the triple-negative subtype (P = .02). Women with triple-negative cancers were less likely to present on the basis of an abnormal screening mammogram (29% vs 48%; P < .0001) and were more likely to present with higher tumor classification, but they were less likely to have lymph node involvement. Relative to HR-positive/HER2-negative tumors, triple-negative tumors were associated with a greater risk of brain or lung metastases; and women with triple-negative tumors had worse breast cancer-specific and overall survival, even after adjusting for age, disease stage, race, tumor grade, and receipt of adjuvant chemotherapy (overall survival: adjusted hazard ratio, 2.72; 95% confidence interval, 2.39-3.10; P < .0001). The difference in the risk of death by subtype was most dramatic within the first 2 years after diagnosis (overall survival for 0-2 years: OR, 6.10; 95% confidence interval, 4.81-7.74). CONCLUSIONS: Triple-negative tumors were associated with unique risk factors and worse outcomes compared with HR-positive/HER2-negative tumors. Cancer 2012. © 2012 American Cancer Society.

Objective To determine the association between patient characteristics at diagnosis of premenopausal breast cancer, including gravidity, parity, age at menarche, age at first birth, alcohol use, smoking history, weight, height, and body mass index (BMI), with the development of persistent chemotherapy-related amenorrhea (CRA) in follow-up. Design Retrospective cohort study. Setting Dana Farber Cancer Institute and Brigham and Women’s Hospital. Patient(s) Premenopausal women with breast cancer. Intervention(s) We identified all premenopausal women who received standard adjuvant chemotherapy during 1997–2005 for whom menstrual data were available. Multivariable logistic regression models evaluating persistent amenorrhea at ≥6 month after completion of chemotherapy were conducted. Main Outcome Measure(s) Persistent chemotherapy-related amenorrhea (CRA) at ≥6 months from completion of chemotherapy. Result(s) A total of 431 women met eligibility criteria and had ≥6-months’ follow-up. Women with older (>13 years) vs. younger (12–13 years) age at menarche were more than twice as likely to remain amenorrheic. Current smokers had 2.4 greater odds of CRA vs. never smokers, although this association was not statistically significant (95% confidence interval, 0.86–6.75). Conclusion(s) Few identifiable factors contribute to the variability in CRA among premenopausal women after adjuvant chemotherapy for breast cancer. Further research to improve the prediction of CRA, premature menopause, and infertility in young breast cancer survivors is warranted.

Item does not contain fulltext OBJECTIVE: Health information-seeking behaviors (HISBs) are associated with active participation in cancer care decisions which, in turn, may positively impact health outcomes. The goal of this study was to develop a taxonomy of topics for which post-treatment cancer patients sought information, and to explore HISB patterns by sociodemographic factors and cancer type. METHODS: We examined how health information seeking is associated with social determinants in a survey of 521 post-treatment cancer patients. RESULTS: Four major topics of interest were found: disease/treatment, self-care management, health services, and work/finance. Assessment of the relationship between social determinants and these four topics showed associations for (1) HISBs on disease/treatment topics decreased with age and increased with education; (2) HISBs on self-care management increased with education and varied by cancer type; (3) HISBs on health services increased with education; and (4) HISBs on work/finance decreased with age and wealth, but increased with debt. CONCLUSION: These results demonstrate one pathway through which social determinants may drive communication inequalities, which may result in increased disparities in health outcomes. PRACTICE IMPLICATIONS: Further exploration of the relationship between social determinants and information-seeking among post-treatment cancer patients may contribute to the development of strategies to reduce health disparities. 01 december 2011

Background Inflammatory breast cancer (IBC) is a unique clinicopathologic entity that is characterized by rapid progression and aggressive behavior from the onset. The clinical presentation consists of erythema, rapid enlargement of the breast, skin ridging, and a characteristic peau d'orange appearance of the skin secondary to dermal lymphatic tumor involvement. Because of its uncommon presentation leading to frequent misdiagnosis, most reports are from small single institution series which describe a predictable pattern of recurrence in spite of appropriate multidisciplinary treatments. We sought to confirm these observations using the large multi-institutional National Comprehensive Cancer Network (NCCN) outcomes database. Methods: Patients (pts) with newly diagnosed IBC treated between 1999 and 2009 at 12 participating NCCN institutions were identified. The clinical diagnoses of IBC was based on the AJCC definition and staged as clinical T4d, N0-3, M0-1. The baseline pathological characteristics included histological type, estrogen receptor (ER), progesterone-receptor (PR), and HER-2/neu status. Pts were classified as receiving multimodality therapy if they received two of the following three treatments: surgery (lumpectomy or mastectomy), perioperative (neoadjuvant or adjuvant) systemic therapy, or perioperative radiation therapy. Results: We identified a cohort of 673 pts with newly diagnosed IBC with a median follow-up of 28.9 months. Of which 195 (29%) had metastatic disease at presentation. The median age at presentation was 52.6 years. Caucasians were 79.4% of the cohort, African American 9.7%, and 11.0% other ethnic groups. Invasive ductal type comprised 84% of histologies. Biomarker assessment revealed ER+ (44.7%), PR+ (34.3%), and Her2/neu+ (33.4%). LVI was documented in 53.3%. Of stage III patients, 75.7% pts received perioperative radiation, 82% received perioperative systemic therapy and 70.7% underwent surgery. All three modalities were received by 64.4% of women. Of the stage III pts, 203 recurred. The most frequent sites of recurrence for were CNS (20.2%), bone (17.2%), chest wall (13.8%), lung (12.3%), liver (11.3%), distant (7.4%) and regional lymph nodes (6.9%). With a median of 30 and 20 months of follow-up for stage III & IV respectively, the median survival was 66 months (95% CI 54–107) for stage III pts and 26 months (95% CI: 22–33) for stage IV Among the 82% of stage III pts who received multimodality therapy, the 5 year and 10 year OS of 62% and 47%. Discussion: This is a large retrospective multiinstitutional study that confirms the aggressive clinical features, recurrence patterns and adverse prognosis of IBC described in previous single institution series. Even with aggressive multimodal therapy, the long term survival of IBC shorter is than non-IBC. Future investigations are needed to address the aggressive biology of IBC to improve diagnosis and therapy. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-20-02.

Background Racial/ethnic disparities in breast cancer care are well documented. Although adjuvant trastuzumab has been shown to improve disease outcomes for women with Human Epidermal Growth Factor Receptor 2 (HER2)-positive cancers, the ‘real world’ utilization and toxicity of adjuvant trastuzumab are unknown. Because therapy involves one year of treatment and the costs of treatment are high, a risk for treatment disparity exists. We examined differences in receipt and completion of adjuvant trastuzumab by race/ethnicity, education, employment, and insurance for women diagnosed with HER2−positive breast cancer. Methods Using the National Comprehensive Cancer Network (NCCN) Breast Cancer Outcomes Database, we identified 1,146 women with stage I-III HER-2 positive breast cancer who presented to participating NCCN institutions during 2005–2008. In multivariable logistic analyses, we assessed the effect of race/ethnicity on the likelihood of trastuzumab therapy, and among women who initiated trastuzumab, the likelihood of completing ≥ 270 days of therapy, adjusting for center, diagnosis year, age, insurance, comorbidity, education, employment, and tumor characteristics. We also examined reasons for discontinuation of therapy among those who stopped treatment prematurely. Results Among patients eligible for this analysis, 75% women were Caucasian, 9% were African-American, and 9% were Hispanic. Most women had managed care insurance (71%) and were employed/student (52%). About one-third (36%) had a college degree and 39% had a high school education or less. Overall, most women (82%) received neo/adjuvant trastuzumab and there were no racial/ethnic differences in receipt of therapy (adjusted odds ratio [OR] 1.11, 95% confidence interval [CI] .72-1.71 for African-American and OR 1.39, 95% CI .76-2.54 for Hispanic, versus Caucasian women). Among the 769 women who initiated neo/adjuvant trastuzumab and had ≥ 365 days of follow-up, 84% completed ≥ 270 days of trastuzumab. Rates of completion were lower for African-American (72%) and Hispanic (82%) women than Caucasian women (85%). In adjusted analyses, African-American women but not Hispanic women had lower odds of completing therapy compared with Caucasian women (OR .45, 95% CI .29-.70, p=0.0003). Indemnity insurance (versus managed care) was associated with lower odds of trastuzumab completion, as was having a high school education or less (versus college education). Among the 123 women who did not complete trastuzumab, 26% stopped early for toxicity, and this occurred more frequently for African-American women than Caucasian women (50% vs. 21%), but small sample precluded a meaningful test for statistical significance. Conclusion: Compared with Caucasian women, African-American women had similar rates of initiation of adjuvant trastuzumab but much lower rates of completion that were not explained by differences in education, employment, or insurance. Because of the significant benefits conferred by adjuvant trastuzumab therapy for HER2−positive breast cancer, interventions to assure completion of therapy could lead to improved outcomes. Further exploration of racial differences in toxicity and tolerance of therapy are also warranted. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-02.

Background: Previous research has suggested that young age at diagnosis is an independent risk factor for breast cancer recurrence and death in women with early stage breast cancer. However, young women are more likely to have aggressive subtypes of breast cancer. No prior studies have adequately controlled for tumor phenotype, including HER-2/neu (HER2) status, in particular. Recent evidence has suggested that the prognostic effect of young age varies by tumor subtype. Methods: We examined data from women with newly diagnosed Stage 1–3 breast cancer presenting to one of 8 NCCN centers between January 2000 and December 2007. Multivariate Cox proportional hazards models were used to assess the relationship between age and breast cancer specific survival, controlling for known prognostic factors and treatment. In addition, we conducted stratified analyses by estrogen receptor (ER) and HER2 status. Results: 19,633 women with Stage 1–3 breast cancer eligible for analysis including 2,177 (11%) who were age 40 years or younger at diagnosis. Younger women were more likely to be non-white or Hispanic, more educated, employed, and to have higher stage, high grade, ER-negative, progesterone receptor (PR) negative, and HER2−positive disease, and treated with chemotherapy and trastuzumab (all variables P< 0.0001 by Chi-Square test). 5-year survival among younger women was 94.1 (95% Confidence Interval [CI] 92.9−95.3) and 96.3 (95% CI 95.9−96.6) for older women. In a multivariate Cox proportional hazards model controlling for sociodemographic, disease, and treatment characteristics, women age < 40 or younger at diagnosis had increased mortality compared to older women (Hazard Ratio [HR] 1.26, 95% CI 1.02−1.56). In stratified analyses, age 40 or less was associated with increased mortality among women with ER-positive disease (HR 1.44, 95% CI 1.01−2.05), but was not among those with ER-negative disease (HR 1.15, 95% CI 0.85−1.55). Younger age was associated with a statistically significant increase in mortality among women with HER2−negative disease (HR 1.29, 95% CI 1.00−1.68), but this difference did not reach statistical significance among those with HER2−positive disease (HR 1.30, 95% CI 0.82−2.09). Conclusions: The effect of age on short-term survival of women with early breast cancer appears to vary by breast cancer subtype, particularly ER status. Further research to elucidate differences in breast cancer biology and efficacy of therapy within tumor types by age is warranted. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-05.

Introduction A randomized trial has demonstrated that lung cancer screening reduces mortality. Identifying participant and program characteristics that influence the cost-effectiveness of screening will help translate trial results into benefits at the population level. Methods Six U.S. cohorts (men and women aged 50, 60, or 70 years) were simulated in an existing patient-level lung cancer model. Smoking histories reflected observed U.S. patterns. We simulated lifetime histories of 500,000 identical individuals per cohort in each scenario. Costs per quality-adjusted life-year gained ($/QALY) were estimated for each program: computed tomography screening; stand-alone smoking cessation therapies (4–30% 1-year abstinence); and combined programs. Results Annual screening of current and former smokers aged 50 to 74 years costs between $126,000 and $169,000/QALY (minimum 20 pack-years of smoking) or $110,000 and $166,000/QALY (40 pack-year minimum), when compared with no screening and assuming background quit rates. Screening was beneficial but had a higher cost per QALY when the model included radiation-induced lung cancers. If screen participation doubled background quit rates, the cost of annual screening (at age 50 years, 20 pack-year minimum) was below $75,000/QALY. If screen participation halved background quit rates, benefits from screening were nearly erased. If screening had no effect on quit rates, annual screening costs more but provided fewer QALYs than annual cessation therapies. Annual combined screening/cessation therapy programs at age 50 years costs $130,500 to $159,700/QALY, when compared with annual stand-alone cessation. Conclusions The cost-effectiveness of computed tomography screening will likely be strongly linked to achievable smoking cessation rates. Trials and further modeling should explore the consequences of relationships between smoking behaviors and screen participation.

Background Patients’ motivations for participation in cancer clinical trials are incompletely understood. Even less is known about the factors that influence participants’ motivations for enrolling in trials. Purpose We studied the reasons why adult patients and parents of pediatric patients agree to participate in cancer trials. We focused on the role of altruism across all phases of trial. Methods We surveyed adult patients and parents of pediatric patients participating in phase I, II, or III cancer clinical trials. We asked respondents why they agreed to enroll, and examined correlates of altruistic motivation using univariate and multivariate analyses. Results Among 205 adults and 48 parents of children participating in cancer trials, 47% reported that altruistic motivations were ‘very important’ to their decisions to enroll. In multivariate analysis with phase III trial participants as the reference group, phase I trial participants least often identified altruism as a ‘very important’ motivation for enrolling (phase I OR 0.4, 95% CI (confidence interval) 0.2–0.8; phase II OR 0.9, 95% CI 0.5–1.5, overall P = 0.017). Thirty-three respondents (13%) reported being motivated primarily by altruism. In multivariate analysis, participants with poor prognoses—defined as an expected 5-year disease-free survival of ≤10%—reported altruism as their primary motivation less often than those with better prognoses (OR 0.2, 95% CI 0.1–0.5, P = 0.001). Altruistic motivations did not differ between adult patients and parents of pediatric participants. Limitations The data are derived from related academic medical centers in one city, and the study sample reflects limited sociodemographic diversity, thereby limiting generalizability to other settings. Conclusions Although cancer trial participants commonly report that altruism contributed to their decision to enroll, it is rarely their primary motivation for study participation. Participants in early phase trials and those with poor prognoses are least often motivated by altruism.

Recently observed trends toward increasingly aggressive end-of-life care may reflect providers' concerns that hospice may hasten death.Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 7879 patients aged 65 years or older who died of advanced non-small-cell lung cancer from 1991 through 1999 after surviving for at least 3 months from their cancer diagnoses. Length of hospice admission post-cancer diagnosis and indicators of aggressive end-of-life care were ascertained based on claims data. We evaluated overall survival and care near death after controlling for baseline characteristics by using propensity score (PS) and instrumental variable analyses (IVA).Hospice patients were older, more likely to be non-Hispanic white and female, more likely to reside in urban areas with high hospice availability and higher socioeconomic status, more likely to be treated in a teaching hospital, and received less aggressive end-of-life care compared to nonhospice patients. Among hospice patients, those experiencing short-term hospice admissions within 3 days of death were more likely to be male, reside in urban areas, be treated in a teaching hospital, and receive more aggressive end-of-life care. PS analysis found that survival favored hospice patients slightly relative to nonhospice patients by 5.0 percentage points (25.7% versus 20.7%) at 1 year and 1.4 percentage points (6.9% versus 5.5%) at 2 years postdiagnosis (p 0.001), while there was no significant difference between those with short- and longer duration hospice stays (p = 1.00). IVA confirmed these findings.Hospice enrollment did not compromise length of survival following advanced lung cancer diagnosis.

BACKGROUND: The benefit of adding radiation therapy after excision of ductal carcinoma in situ (DCIS) is widely debated. Randomized clinical trials are underpowered to delineate long-term outcomes after radiation. METHODS: The authors of this report constructed a Markov decision model to simulate the clinical course of DCIS in a woman aged 60 years who received treatment with either of 2 breast-conserving strategies: excision alone or excision plus radiation therapy. Sensitivity analyses were used to study the influence of risk of local recurrence, likelihood of invasive disease at recurrence, surgical choice at recurrence, and patient age at diagnosis on treatment outcomes. RESULTS: The addition of radiation therapy was associated with slight improvements in invasive disease-free and overall survival. However, radiation therapy decreased the chance of having both breasts intact over a patient's lifetime. Radiation therapy improved survival by 2.1 months for women who were diagnosed with DCIS at age 60 years but decreased the chance of having both breasts by 8.6% relative to excision alone. The differences in outcomes between the treatment strategies became smaller with increasing age at diagnosis. Sensitivity analyses revealed a greater benefit for radiation with an increased likelihood of invasive recurrence. The decrement in breast preservation with radiation therapy was mitigated by an increased likelihood of mastectomy at the time of recurrence or new breast cancer diagnosis. CONCLUSIONS: The current analysis quantified the benefits of radiation after excision of DCIS but also revealed that radiation therapy may increase the likelihood of eventual mastectomy. Therefore, the authors concluded that patient age and preferences should be considered when making the decision to add or forgo radiation for DCIS. Cancer 2012;. © 2011 American Cancer Society.

Myeloid colony-stimulating factors (CSFs) decrease the risk of febrile neutropenia (FN) from high-risk chemotherapy regimens administered to patients at 20% or greater risk of FN, but little is known about their use in clinical practice. We evaluated CSF use in a multiregional population-based cohort of lung and colorectal cancer patients (N = 1849). Only 17% (95% confidence interval [CI] = 8% to 26%) patients treated with high-risk chemotherapy regimens received CSFs, compared with 18% (95% CI = 16% to 20%) and 10% (95% CI = 8% to 12%) of patients treated with intermediate- (10%–20% risk of FN) and low-risk (

Purpose Financial concerns represent a major stressor for families of children with cancer but remain poorly understood among those with terminally ill children. We describe the financial hardship, work disruptions, income loss, and coping strategies of families who lost children to cancer. Methods Retrospective cross-sectional survey of 141 American and 89 Australian bereaved parents whose children died between 1990 and 1999 and 1996 to 2004, respectively, at three tertiary-care pediatric hospitals (two American, one Australian). Response rate: 63%. Results Thirty-four (24%) of 141 families from US centers and 34 (39%) of 88 families from the Australian center reported a great deal of financial hardship resulting from their children's illness. Work disruptions were substantial (84% in the United States, 88% in Australia). Australian families were more likely to report quitting a job (49% in Australia v 35% in the United States; P = .037). Sixty percent of families lost more than 10% of their annual income as a result of work disruptions. Australians were more likely to lose more than 40% of their income (34% in Australia v 19% in the United States; P = .035). Poor families experienced the greatest income loss. After accounting for income loss, 16% of American and 22% of Australian families dropped below the poverty line. Financial hardship was associated with poverty and income loss in all centers. Fundraising was the most common financial coping strategy (52% in the United States v 33% in Australia), followed by reduced spending. Conclusion In these US and Australian centers, significant household-level financial effects of a child's death as a result of cancer were observed, especially for poor families. Interventions aimed at reducing the effects of income loss may ease financial distress.

Background Clinical trials are central to pediatric oncology, yet the process and outcomes of informed consent are poorly understood. We evaluated correlates of understanding among parents of pediatric trial participants, and explored differences in the process and outcome of informed consent between parents and a comparison group of adult participants. Procedure We administered the Quality of Informed Consent (QuIC) to parents of children who were newly enrolled onto a cancer trial. We identified independent correlates of knowledge among parents, and compared parents' knowledge to that of a contemporaneous group of adult participants, using multiple linear regression models. Results Parents (n = 47) were less likely than adult participants (n = 204) to report having enough time to learn about the trial (64% vs. 87%, P = 0.001) or sufficient opportunity for questions (79% vs. 93%, P = 0.01), and reported lower overall satisfaction with the consent process (71% vs. 90%, P = 0.002). The mean parental knowledge score was 73.6 (95% confidence interval [CI] 69.5–77.8, theoretical maximum 100). Knowledge did not differ between parents and adult trial participants. In multivariate analysis, two predictors were significantly associated with higher parent knowledge scores: consent sought by the study's principal investigator (increment 13.6, CI 2.7–24.6) and physician-reported poor prognosis (increment 13.8, 95% CI 5.4–22.1). Conclusions Although we observed no differences in knowledge between parents of pediatric cancer trial participants and their adult counterparts, parents report more problems with the informed consent process for their trials. The increased prevalence of problems is likely due to clinical and contextual differences between pediatric and adult trials. Pediatr Blood Cancer 2011; 57: PPL–1004. © 2011 Wiley-Liss, Inc.

Background: Research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk of future breast cancer events. However, no prior studies have evaluated risk perceptions in long-term follow-up. Methods: As part of a multicenter longitudinal cohort study, we mailed long-term follow-up surveys to 315 of 392 women who had previously responded to a survey 18 months after they were diagnosed with DCIS (33 of the 392 were excluded because they were receiving follow-up care at outside centers, and 44 because of recurrence/death). We evaluated psychosocial distress by Hospitalized Anxiety and Depression Scale (HADS) and Revised Impact of Events Scale (RIES), quality of life (QOL) by Short Form Health Survey (SF-36), and risk perceptions with items used previously in the cohort. Results: One hundred ninety-three women (61%) responded. They were a median age of 53 yrs (range 31-89) and a median of 5.8 yrs from diagnosis (range 4.3-7.0). Twelve were excluded due to report of recurrence. Of the 181 remaining, 32% perceived at least a moderate risk of developing DCIS again within 5 yrs; 43% perceived at least a moderate lifetime risk of developing DCIS again; 27% perceived at least a moderate risk of developing invasive breast cancer within 5 yrs; 38% perceived at least a moderate lifetime risk of developing invasive breast cancer; 24% perceived at least a moderate risk of DCIS spreading to other parts of their bodies. For qualitative responses of ≥ moderate perceived risk, median quantitative risk perception was 10% regarding 5-yr risk of DCIS or invasive cancer, 20% regarding lifetime risk, and 50% pertaining to risk of DCIS spreading. The proportion of women reporting ≥ moderate perceived risk of DCIS spreading remained stable over time (25% at baseline; 26% at 18 mos), but this proportion decreased for other perceptions of risk (e.g., at baseline and 18 mos, 51% and 50% of these same women perceived ≥ moderate risk of developing DCIS again within 5 yrs). In a multivariable model, worse financial status (OR 2.6, 95% CI 1.3-5.3) and higher perceived risk on earlier surveys (OR 24.4, 95% CI 12.7-47.2) were the only predictors of ≥ moderate perception of risk of DCIS spreading to other parts of the body in long-term follow-up. Non-significant covariates included age, race, education, grade of DCIS, comedonecrosis, mastectomy, radiation, marital status, employment status, comorbidity, and HADS and RIES scores. This contrasted with earlier survey data, which demonstrated an association between higher risk perceptions and anxiety by HADS and RIES. In long-term follow-up, only 7% were found to be anxious (HADS Anxiety ≥11) and 0.6% were depressed (HADS Depression ≥11). Median SF-36 scores were 48.9 (range 15.7-58.2) and 47.1 (range 23.6-60.3) for the physical and mental components, respectively, consistent with overall good QOL. Conclusions: Women with a history of DCIS continue to harbor inaccurate perceptions of risk of future breast cancer events even at 6 yrs follow-up. Future research should evaluate how these excessive risk perceptions impact health behaviors. Interventions to improve risk perceptions are warranted. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-15-01.

Purpose To identify the frequency of and factors associated with changes in employment among cancer survivors. Methods This prospective cohort study took place in the context of the population-based Cancer Care Outcomes Research and Surveillance Consortium. Patients with nonmetastatic lung or colorectal cancer who survived approximately 15 months after diagnosis without cancer recurrence provided their self-reported employment status, employment experiences, and changes in insurance coverage at 4 and 15 months after diagnosis. Multiple logistic regression was used to relate sociodemographic and disease factors to the probability of labor force departure. Results Among 2,422 eligible patients, employment declined from 3% to 31% over the 15 months after cancer was diagnosed. Labor force departures attributable to cancer occurred in 17% of those employed at baseline. Factors associated with significantly higher rates of labor force departure were lung versus colon cancer, stage III versus I or II disease, lower educational and income levels, and, among colorectal patients, older age. Married women were significantly more likely than unmarried women to leave the workforce. Only 2% of patients lacked health insurance during the study period. Conclusion Most employed patients with nonmetastatic lung or colorectal cancer return to work, but approximately one sixth of patients leave the workforce, particularly those with worse prognoses or lower socioeconomic status. Potential economic effects must be considered in management decisions about cancer.

Purpose Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences. Methods This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians. Results Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences. Conclusion Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.

BACKGROUND: Little information is available regarding the effects of new adjuvant treatment regimens on menstrual functioning in premenopausal women with early breast cancer. METHODS: The authors conducted a retrospective review of data from premenopausal women who received treatment for early breast cancer to evaluate the rates of amenorrhea in follow-up. The women who were included received treatment with either doxorubicin and cyclophosphamide (AC) or combined AC and paclitaxel (T) (AC-T) given either every 3 weeks, or as a dose-dense (DD) regimen, or as AC followed by weekly T with trastuzumab or followed by trastuzumab (AC-T+trastuzumab). A multivariate logistic regression analysis was conducted to evaluate amenorrhea during follow-up. RESULTS: Of 431 patients who were eligible for analysis, the average age at diagnosis was 13 years (range, 25-55 years), 61% of women received AC only, and 39% received AC-T. Of the 39% who received AC-T, 49% of women received DD therapy, 14% received AC-T+trastuzumab, and 71% of all patients received tamoxifen (TAM). The median follow-up was 33 months (range, 6-114 months). After adjusting for age, weight, gravidity, parity, age at menarche, smoking, alcohol use, TAM use, type and regimen of chemotherapy, and use of trastuzumab, the likelihood of remaining amenorrheic was not statistically different in patients who received AC-T versus AC (odds ratio [OR], 1.59; 95% confidence interval [CI], 0.8-3.2), DD treatment versus treatment every 3 weeks (OR, 0.56; 95% CI, 0.25-1.3), or AC-T + trastuzumab (OR, 0.6; 95% CI, 0.22-1.61). Amenorrhea was associated significantly with TAM use and age at diagnosis. CONCLUSIONS: Recent advances in the adjuvant treatment of early breast cancer do not appear to have increased the risk of amenorrhea in premenopausal women. Cancer 2010. © 2010 American Cancer Society.

The purpose of this study was to investigate prevention decision making among women at high risk for breast cancer, including patient preferences for preventive interventions, patient understanding of disease risk, and patient preferences for risk communication methods, and the corresponding physician understanding of these factors. A prospective interview and survey study was conducted of consecutive new patients seen at a cancer risk and prevention clinic and their physicians. One hundred and forty-six of 217 eligible patients participated and completed all components of the study (67%), and they were seen by a four physicians. Women’s preferences for prevention intervention varied widely across women but were stable across time. Physicians were very often unable to predict their patients’ preferences for prevention efforts. Patients overestimated their risk of disease, and physicians overestimated the decrease in perceived risk resulting from counseling (p

Cancer is a growing global health issue, and many countries are ill-prepared to deal with their current cancer burden let alone the increased burden looming on the horizon. Growing and aging populations are projected to result in dramatic increases in cancer cases and cancer deaths particularly in low- and middle-income countries. It is imperative that planning begin now to deal not only with those cancers already occurring but also with the larger numbers expected in the future. Unfortunately, such planning is hampered, because the magnitude of the burden of cancer in many countries is poorly understood owing to lack of surveillance and monitoring systems for cancer risk factors and for the documentation of cancer incidence, survival and mortality. Moreover, the human resources needed to fight cancer effectively are often limited or lacking. Cancer diagnosis and cancer care services are also inadequate in low-and middle-income countries. Late-stage presentation of cancers is very common in these settings resulting in less potential for cure and more need for symptom management. Palliative care services are grossly inadequate in low- and middle-income countries, and many cancer patients die unnecessarily painful deaths. Many of the challenges faced by low- and middle-income countries have been at least partially addressed by higher income countries. Experiences from around the world are reviewed to highlight the issues and showcase some possible solutions.

Purpose Although cancer-related direct-to-consumer advertising (CR-DTCA) is prevalent, little is known about cancer patients' experiences with this controversial medium of medical communication. Methods We administered a 41-item, mailed questionnaire to consecutive patients with breast and hematologic malignancies who were undergoing active treatment at our institution. We assessed awareness of CR-DTCA within the prior year, perceptions of CR-DTCA, and CR-DTCA–prompted patient and provider behaviors. Results We received 348 completed questionnaires (response rate, 75.0%). Overall, 86.2% reported being aware of CR-DTCA, most frequently from television (77.7%). Awareness did not vary with clinical or sociodemographic factors except that patients were more likely to be aware of CR-DTCA for products specific to their cancer types (P < .0001). A majority of those aware reported that CR-DTCA made them “aware of treatments they did not know about” (62.2%), provided information in “a balanced manner” (65.2%), and helped them to have “better discussions” with their provider (56.8%). These perceptions were significantly more favorable among those who had not graduated from college (P < .05 for each). Overall, 11.2% reported that CR-DTCA made them “less confident” in their providers' judgment. Of those aware, 17.3% reported talking to their provider about an advertised medication, although less than one fifth of those reported receiving a prescription for the advertised medication. Conclusion The patients in our cohort were highly aware of CR-DTCA. CR-DTCA was found to be accessible and useful; however, it decreased some patients' confidence in their providers' judgment. CR-DTCA prompted a modest amount of patient-provider discussion but infrequent patient-reported changes in therapy.

Prior research has documented racial disparities in patterns of care and outcomes for women with breast cancer.To assess whether black women receive care from lower-quality or lower-volume hospitals and if such differences explain disparities in receipt of definitive primary breast cancer therapy.Observational study of a population-based sample of breast cancer patients included in the SEER-Medicare database.Fifty five thousand four hundred seventy white or black women aged65 diagnosed with stage I/II breast cancer during 1992-2002.Surgery at a high-quality hospital (top quartile rates of radiation after breast-conserving surgery) or high volume (top quartile) hospital and receipt of definitive primary therapy (mastectomy or breast-conserving surgery with radiation).Black women were significantly less likely than white women to be treated at high-quality hospitals (adjusted odds ratio [OR] 0.60; 95% confidence interval [CI]: 0.40-0.87) but not high-volume hospitals (adjusted OR 0.85; 95% CI: 0.54-1.34). Black women were less likely than white women to receive definitive primary therapy, a finding partially explained by having surgery at a high-quality hospital but not by having surgery at a high-volume hospital.Older black women were more likely than white women to undergo breast cancer surgery at hospitals with lower rates of radiation following breast-conserving surgery, and this explains some of the reported racial disparities previously observed in receipt of definitive therapy for early-stage breast cancer. Interventions to help hospitals treating large numbers of black women improve rates of radiation after breast-conserving surgery may help to decrease racial disparities in care.

After the first report of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial, adjuvant aromatase inhibitor use increased rapidly among National Comprehensive Cancer Network member institutions. Increased aromatase inhibitor use was associated with older age, vascular disease, overexpression of human epidermal growth factor receptor 2 (HER2), or more advanced stage, and substantial variation was seen among institutions. This article examines adjuvant endocrine therapy in postmenopausal women after the first report of the trial, identifies temporal relationships in aromatase inhibitor use, and examines characteristics associated with choice of endocrine therapy among 4044 postmenopausal patients with hormone receptor-positive nonmetastatic breast cancer presenting from July 1997 to December 2004. Multivariable logistic regression analysis examined temporal associations and characteristics associated with aromatase inhibitor use. Time-trend analysis showed increased aromatase inhibitor and decreased tamoxifen use after release of ATAC results (P < .0001). In multivariable regression analysis, institution (P

To study surgeons' versus oncologists' preferences for adjuvant chemotherapy for elderly patients with stage III colon cancer, as population studies indicate that such patients are less likely to receive treatment.A vignette-based survey was mailed to a nationally representative sample of 1,000 general surgeons and 1,000 oncologists in the United States. Patient age, comorbidity level, and preference were varied across eight vignettes. Physician preference for referral (surgeons) or treatment (oncologists) was measured using a 7-point Likert scale. Mixed-effects linear regression was used to evaluate the results.One thousand twenty-nine surveys were returned (response rate of 54%). Among surgeons, increasing age and more severe comorbidity resulted in lower likelihood of referral to oncologist: mean difference in preference scores for vignettes describing a 61-year-old versus an 83-year-old patient (adjusted for comorbidity) was 0.77 (p0.0001); mean difference in scores between vignettes describing a patient with none versus severe comorbidity, adjusted for age, was 1.94 (p0.0001). Among oncologists, patient age and comorbidity interacted significantly (p0.0001) to affect oncologists' preferences: both increasing age and more severe comorbidity resulted in decreased preference for recommending adjuvant chemotherapy, but oncologists were more heavily influenced by comorbidity at younger patient age. Patient preference against therapy also affected physicians' recommendations (p0.0001), but the magnitude of effect was small relative to age and comorbidity.Patient age and comorbidity level influence both types of physicians' preferences about adjuvant chemotherapy for colon cancer and might explain some of the patterns of care seen for this disease in population-based studies.