Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that ...cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.
To analyze trends in invasive cervical cancer incidence by age, histology, and race over a 35-year period (1973-2007) in order to gain insight into changes in the presentation of cervical cancer.
...Data from the nine Surveillance, Epidemiology, and End Results (SEER) registries that continuously collected information on invasive cervical cancer were analyzed for trends. Standardized to the 2000 U.S population, annual age-adjusted incidence rates were estimated by race and histologic subtype. Histologic subtype was classified into squamous, adenocarcinoma, and adenosquamous.
Overall incidence rates for invasive cervical cancer decreased by 54% over the 35 years, from 13.07/100,000 (1973-1975) to 6.01/100,000 (2006-2007), and the incidence rates declined by 51% and 70.2%, respectively, among whites and blacks. The incidence rates for squamous carcinoma decreased by 61.1% from 10.2/100,000 (1973-1975) to 3.97/100,000 (2006-2007). Incidence rates for adenosquamous cell carcinomas decreased by 16% from 0.27/100,000 (1973-1975) to 0.23/100,000 (2006-2007), and incidence rates for adenocarcinomas increased by 32.2% from 1.09/100,000 (1973-1975) to 1.44/100,000 (2006-2007). This increase in adenocarcinomas was due to an increase in incidence in white women; a decrease in incidence was observed for black women.
Although marked reductions in the overall and race-specific incidence rates of invasive cervical cancer have been achieved, they mask important variation by histologic subtype. These findings suggest that alternatives to Pap smear-based screening, such as human papillomavirus (HPV) testing and HPV vaccination, need to be prioritized if adenocarcinomas of the cervix are to be controlled.
Medicare and Medicaid dually eligible beneficiaries (duals) could experience Medicaid coverage changes without losing Medicaid. It is unknown whether health care use and clinical outcomes among ...elderly duals with coverage changes would be like those among duals without coverage changes or duals ever lost Medicaid and whether various types of unstable coverage due to income/asset changes are associated with worse clinical outcomes.
Examine the associations of unstable Medicaid coverage with clinical outcomes among older Medicare beneficiaries.
Population-based cohort study.
A total of 131,202 women newly diagnosed with breast cancer at 65 years and older between 2007 and 2015 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked database.
We examined 2 types of unstable Medicaid coverage: (1) those who had changes in the types of Medicaid support they received and (2) those who ever lost Medicaid. We examined outcomes that predict better cancer survival and involve the use of inpatient and outpatient services and prescription drugs: early diagnosis, receiving surgery, receiving radiation, hormonal therapy adherence, and discontinuation. We used logistic regressions to estimate the predicted probabilities of outcomes for dual groups.
Duals had poorer outcomes than those who were "never dual." Women with the 2 types of unstable Medicaid coverage had similarly worse outcomes than those with stable coverage. Those with stable coverage had similar outcomes regardless of the generosity of Medicaid support.
These patterns are concerning and, in the context of well-defined clinical guidelines for beneficial treatments that extend survival, point to the importance of stable insurance coverage and income.
Purpose
Appendiceal cancer
is a rare and potentially aggressive malignancy. The objectives of this study were to characterize secular demographic patterns of disease and to determine survival by ...using a population-based data source.
Methods
Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of patients treated from 2000–2009.
Results
We identified 4765 patients with appendiceal cancer. The incidence of appendiceal cancer increased by 54 % from 2000 (0.63 per 100,000) to 2009 (0.97 per 100,000 population). Incidence rates increased across all tumor types, stages, age groups, and gender. The most common malignancies were mucinous adenocarcinoma (38 %), followed by carcinoids (28 %), adenocarcinoma-not otherwise specified (NOS) (27 %), and signet ring cell adenocarcinoma (7 %). Larger tumor size and older patient age were significantly associated with higher relative odds of distant disease at diagnosis (
P
< 0.0001). Patient and demographic characteristics were significantly associated with higher relative hazard of death (
P
< 0.0001).
Conclusions
Although appendiceal cancer is rare, the incidence increased significantly in the USA from 2000 to 2009. The cause of this trend is not obvious. We did not observe increases differentially associated with stage, histology, or demographic characteristics. Further investigation is needed to examine factors underlying this increase.
Adherence to aromatase inhibitors (AIs) and tamoxifen has considerable survival benefits for postmenopausal women diagnosed with hormone receptor-positive breast cancer. Reduced out-of-pocket costs ...and treatment-related side effects could increase therapy adherence. Given that individuals' side effect profiles could differ across AIs, generic AI entry could facilitate switching between AIs to manage side effects and improve adherence.
From Surveillance, Epidemiology, and End Results-Medicare, we selected women first diagnosed with hormone receptor-positive breast cancer at age 65+ years and initiated an AI within 1 year of diagnosis between January 1, 2007, and May 31, 2008, or June 1, 2011, and December 31, 2012, and followed them for up to 2 years (N = 20 677). We estimated changes in probabilities of adherence with and without switching for Part D enrollees with and without the low-income subsidy (LIS vs non-LIS) before and after generic entry using linear probability models. Tests of statistical significance are 2-sided.
After generic entry reduced out-of-pocket costs of AIs (larger reduction for non-LIS), the percentage of women who ever switched from one AI to another AI increased from 8.8% to 14.6% for non-LIS and from 7.3% to 12.5% for LIS. Adherence without switching increased by 8.0 percentage points (pp) for non-LIS (P < .001) but decreased by 4.9 pp (P < .001) for LIS. Adherence with switching increased for both non-LIS (6.4 pp, P < .001) and LIS (4.4 pp, P < .001).
Increased switching after generic entry contributed to increased adherence, suggesting switching allowed better management of treatment-related side effects. Subsidized women also experienced increased adherence with switching after generic entry, suggesting that patients and physicians might not understand Part D benefit design when making decisions.
Abstract
Background
The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER)-Medicare–linked database was first created almost 30 years ago. Over time, additional data have ...been added to the SEER-Medicare database, allowing for expanded insights into the delivery of health care across the cancer continuum from screening to end of life.
Methods
This article includes an overview of the current SEER-Medicare database, presenting potential users with an introduction to how the data can facilitate innovative epidemiologic and health services research studies. With a focus on the population 65 years and older, this article presents descriptive data on beneficiary demographics, cancer characteristics, service settings, Medicare coverage (eg, Parts A, B, C, and D), and use (number of services or bills) from 2011 to 2015.
Results
From 2011 to 2015, 857 056 cancer patients and 601 470 population-based noncancer controls were added to the database. The database includes detailed tumor characteristics and clinical assessments for cancer cases, and demographics and health-care use (eg, hospitals, outpatient facilities, individual providers, hospice, home health-care providers, and pharmacies) for both cases and controls. Although characteristics varied overall between cases and controls, sufficient cancer-specific matched controls are available. Roughly 60% of cases were enrolled in fee for service at cancer diagnosis. The annual average number of claims per case was 60.7 and 92.3 during the year before and after cancer diagnosis, respectively, and 127.5 during the year before death.
Conclusions
The large sample size and diverse array of data on cancer patients and noncancer controls in the SEER-Medicare database make it a unique resource for conducting cancer health services research.
Background The National Institutes of Health Office of Medical Applications of Research commissioned a structured literature review on the incidence, treatment, and outcomes of ductal carcinoma in ...situ (DCIS) as a background article for the State of the Science Conference on Diagnosis and Management of DCIS. Methods Published studies were identified and abstracted from MEDLINE and other sources. We include articles published between 1965 and January 31, 2009; 374 publications were identified that addressed DCIS incidence, staging, treatment, and outcomes in adult women. Results In the United States, DCIS incidence rose from 1.87 per 100 000 in 1973–1975 to 32.5 in 2004. Incidence increased in all ages but more so in women older than 50 years. Increased use of mammography explains some but not all of the increased incidence. Risk factors for incident DCIS include older age and family history. Although tamoxifen treatment prevented both invasive breast cancer and DCIS, raloxifene treatment decreased incidence of invasive breast cancer but not DCIS. Among patients with DCIS, magnetic resonance imaging was more sensitive than mammography for detecting multicentric disease and estimating tumor size. Because about 15% of patients with DCIS identified on core needle biopsy are diagnosed with invasive breast cancer after excision or mastectomy, the accuracy of sentinel lymph node biopsy after excision is relevant to surgical management of DCIS. Most studies demonstrated that sentinel lymph node biopsy is feasible after breast-conserving surgery (BCS). Younger age, positive surgical margins, tumor size and grade, and comedo necrosis were consistently related to DCIS recurrence. DCIS outcomes after either mastectomy or BCS plus radiation therapy were superior to BCS alone. Tamoxifen treatment after DCIS diagnosis reduced risk of recurrent disease. Conclusions Scientific questions deserving further investigation include the relationship between mammography use and DCIS incidence and whether imaging technologies and treatment guidelines can be modified to focus on lesions that are most likely to become clinically problematic.
Abstract Background Prostate cancer is the second most common cancer in men and has high survivorship, yet little is known about the long-term risk of urinary adverse events (UAEs) after treatment. ...Objective To compare the long-term UAE incidence across treatment and control groups. Design, setting, and participants Using a matched-cohort design, we identified elderly men treated with external-beam radiotherapy (EBRT; n = 44 318), brachytherapy (BT; n = 14 259), EBRT+BT ( n = 11 835), radical prostatectomy (RP; n = 26 970), RP+EBRT ( n = 1557), or cryotherapy ( n = 2115) for non-metastatic prostate cancer and 144 816 non-cancer control individuals from the population-based Surveillance, Epidemiology, and End Results-Medicare linked data from 1992–2007 with follow-up through 2009. Outcome measures and statistical analysis The incidence of treated UAEs and time from cancer treatment to first UAE were analyzed in terms of propensity-weighted survival. Results Median follow-up was 4.14 yr. At 10 yr, all treatment groups experienced higher propensity-weighted cumulative UAE incidence than the control group (16.1%; hazard risk HR 1.0), with the highest incidence for RP+EBRT (37.8%; HR 3.19, 95% confidence interval CI 2.79–3.66), followed by BT+EBRT (28.4%; HR 1.97, CI 1.85–2.10), RP (26.6%; HR 2.44, CI 2.34–2.55), cryotherapy (23.4%; HR 1.56, CI 1.30–1.87), BT (19.8%; HR 1.43, CI 1.33–1.53), and EBRT (19.7%; HR 1.11, CI 1.07–1.16). Bladder outlet obstruction was the most common event. Conclusions Men undergoing RP, RP+EBRT, and BT+EBRT experienced the highest UAE risk at 10 yr, although UAEs accrued differently over extended follow-up. The significant background UAE rate among non-cancer control individuals yields a risk attributable to prostate cancer treatment that is 17% lower than prior estimates. Patient summary We show that treatment for prostate cancer, especially combinations of two treatments such as radiation and surgery, carries a significant risk of urinary adverse events such as urethral stricture. This risk increases with time since treatment, emphasizing that treatments have long-term effects.
Many patients with unilateral breast cancer choose contralateral prophylactic mastectomy to prevent cancer in the opposite breast. The purpose of our study was to determine the use and trends of ...contralateral prophylactic mastectomy in the United States.
We used the Surveillance, Epidemiology and End Results database to review the treatment of patients with unilateral breast cancer diagnosed from 1998 through 2003. We determined the rate of contralateral prophylactic mastectomy as a proportion of all surgically treated patients and as a proportion of all mastectomies.
We identified 152,755 patients with stage I, II, or III breast cancer; 4,969 patients chose contralateral prophylactic mastectomy. The rate was 3.3% for all surgically treated patients; 7.7%, for patients undergoing mastectomy. The overall rate significantly increased from 1.8% in 1998 to 4.5% in 2003. Likewise, the contralateral prophylactic mastectomy rate for patients undergoing mastectomy significantly increased from 4.2% in 1998 to 11.0% in 2003. These increased rates applied to all cancer stages and continued to the end of our study period. Young patient age, non-Hispanic white race, lobular histology, and previous cancer diagnosis were associated with significantly higher rates. Large tumor size was associated with a higher overall rate, but with a lower rate for patients undergoing mastectomy.
The use of contralateral prophylactic mastectomy in the United States more than doubled within the recent 6-year period of our study. Prospective studies are needed to understand the decision-making processes that have led to more aggressive breast cancer surgery.
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