IMPORTANCE Breast cancer in women between the ages of 15 and 39 years (adolescents and young adults AYAs) constitutes 5% to 6% of all breast cancer cases in the United States. Breast cancer in AYA ...women has a worse prognosis than in older women. Five-year survival rates are lowest for AYA women, and only a few studies have examined the impact of delay in treatment, race/ethnicity, and other socioeconomic factors on survival in AYA women. OBJECTIVE To examine the impact of treatment delay time (TDT), race/ethnicity, socioeconomic status, insurance status, cancer stage, and age on the survival from breast cancer among AYA women. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective case-only study of 8860 AYA breast cancer cases diagnosed from 1997 to 2006 using the California Cancer Registry database. EXPOSURE Treatment delay time was defined as the number of weeks between the date of diagnosis and date of definitive treatment. Kaplan-Meier estimation was used to generate survival curves, and a multivariate Cox proportional hazards regression model was performed to assess the association of TDT with survival while accounting for covariates (age, race/ethnicity, socioeconomic status, insurance status, cancer stage American Joint Committee on Cancer, tumor markers, and treatment). MAIN OUTCOMES AND MEASURES Five-year survival rates for breast cancer as influenced by host factors, tumor factors, and TDT. RESULTS Treatment delay time more than 6 weeks after diagnosis was significantly different (P < .001) between racial/ethnic groups (Hispanic, 15.3% and African American, 15.3% compared with non-Hispanic white, 8.1%). Women with public or no insurance (17.8%) compared with those with private insurance (9.5%) and women with low socioeconomic status (17.5%) compared with those with high socioeconomic status (7.7%) were shown to have TDT more than 6 weeks. The 5-year survival in women who were treated by surgery and had TDT more than 6 weeks was 80% compared with 90% (P = .005) in those with TDT less than 2 weeks. In multivariate analysis, longer TDT, estrogen receptor negative status, having public or no insurance, and late cancer stage were significant risk factors for shorter survival. CONCLUSIONS AND RELEVANCE Young women with breast cancer with a longer TDT have significantly decreased survival time compared with those with a shorter TDT. This adverse impact on survival was more pronounced in African American women, those with public or no insurance, and those with low SES.
The results of this large study involving more than 64,500 U.S. women in the general population and 28 genes that have been previously implicated in conferring risk of breast cancer (when variant) ...have implications for the interpretation of results obtained by multigene panel testing.
Background The regional impact of care at a National Cancer Institute Comprehensive Cancer Center (NCI-CCC) on adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment ...guidelines and survival is unclear. Study Design We performed a retrospective population-based study of consecutive patients diagnosed with epithelial ovarian cancer between January 1, 1996 and December 31, 2006 in southern California. Patients were stratified according to care at an NCI-CCC (n = 5), non-NCI high-volume hospital (≥10 cases/year, HVH, n = 29), or low-volume hospital (<10 cases/year, LVH, n = 158). Multivariable logistic regression and Cox-proportional hazards models were used to examine the effect of NCI-CCC status on treatment guideline adherence and ovarian cancer-specific survival. Results A total of 9,933 patients were identified (stage I, 22.8%; stage II, 7.9%; stage III, 45.1%; stage IV, 24.2%), and 8.1% of patients were treated at NCI-CCCs. Overall, 35.7% of patients received NCCN guideline adherent care, and NCI-CCC status (odds ratio OR 1.00) was an independent predictor of adherence to treatment guidelines compared with HVHs (OR 0.83, 95% CI 0.70 to 0.99) and LVHs (OR 0.56, 95% CI 0.47 to 0.67). The median ovarian cancer-specific survivals according to hospital type were: NCI-CCC 77.9 (95% CI 61.4 to 92.9) months, HVH 51.9 (95% CI 49.2 to 55.7) months, and LVH 43.4 (95% CI 39.9 to 47.2) months (p < 0.0001). National Cancer Institute Comprehensive Cancer Center status (hazard ratio HR 1.00) was a statistically significant and independent predictor of improved survival compared with HVH (HR 1.18, 95% CI 1.04 to 1.33) and LVH (HR 1.30, 95% CI 1.15 to 1.47). Conclusions National Cancer Institute Comprehensive Cancer Center status is an independent predictor of adherence to ovarian cancer treatment guidelines and improved ovarian cancer-specific survival. These data validate NCI-CCC status as a structural health care characteristic correlated with superior ovarian cancer quality measure performance. Increased access to NCI-CCCs through regional concentration of care may be a mechanism to improve clinical outcomes.
Abstract Objective To characterize the impact of hospital and physician ovarian cancer case volume on survival for advanced-stage disease and investigate socio-demographic variables associated with ...access to high-volume providers. Methods Consecutive patients with stage IIIC/IV epithelial ovarian cancer (1/1/96–12/31/06) were identified from the California Cancer Registry. Disease-specific survival analysis was performed using Cox-proportional hazards model. Multivariate logistic regression analyses were used to evaluate for differences in access to high-volume hospitals (HVH) (≥ 20 cases/year), high-volume physicians (HVP) (≥ 10 cases/year), and cross-tabulations of high- or low-volume hospital (LVH) and physician (LVP) according to socio-demographic variables. Results A total of 11,865 patients were identified. The median ovarian cancer-specific survival for all patients was 28.2 months, and on multivariate analysis the HVH/HVP provider combination (HR = 1.00) was associated with superior ovarian cancer-specific survival compared to LVH/LVP (HR = 1.31, 95%CI = 1.16–1.49). Overall, 2119 patients (17.9%) were cared for at HVHs, and 1791 patients (15.1%) were treated by HVPs. Only 4.3% of patients received care from HVH/HVP, while 53.1% of patients were treated by LVH/LVP. Both race and socio-demographic characteristics were independently associated with an increased likelihood of being cared for by the LVH/LVP combination and included: Hispanic race (OR = 1.72, 95%CI = 1.22–2.42), Asian/Pacific Islander race (OR = 1.57, 95%CI = 1.07–2.32), Medicaid insurance (OR = 2.51, 95%CI = 1.46–4.30), and low socioeconomic status (OR = 2.84, 95%CI = 1.90–4.23). Conclusions Among patients with advanced-stage ovarian cancer, the provider combination of HVH/HVP is an independent predictor of improved disease-specific survival. Access to high-volume ovarian cancer providers is limited, and barriers are more pronounced for patients with low socioeconomic status, Medicaid insurance, and racial minorities.
Multi-systemic biological risk (MSBR), a proxy for allostatic load, is a composite index of biomarkers representing dysregulation due to responses to chronic stress. This study examined the ...association of an MSBR index with cancer mortality. The sample included n = 13,628 adults aged 20-90 from the NHANES III Linked Mortality File (1988-1994). The MSBR index included autonomic (pulse rate, blood pressure), metabolic (HOMA
, triglycerides, waist circumference), and immune (white blood cell count, C-reactive protein) markers. We fit Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CI) of overall cancer mortality risk, according to quartiles (q) of the index. In multivariable models, compared to those in q1, q4 had a 64% increased risk for cancer mortality (HR = 1.64, 95% CI:1.13-2.40). The immune domain drove the association (HR per unit = 1.19, 95% CI:1.07-1.32). In stratified analyses, the HR for those with a BMI ≥ 25 was 1.12 per unit (95% CI:1.05-1.19) and those with a BMI < 25 was 1.04 per unit (95% CI:0.92-1.18). MSBR is positively associated with risk for cancer mortality in a US sample, particularly among those who are overweight or obese. The utilization of standard clinical measures comprising this index may inform population cancer prevention strategies.
OBJECTIVE:To evaluate the association of sociodemographic and hospital characteristics with adherence to National Comprehensive Cancer Network treatment guidelines for stage IB–IIA cervical cancer ...and to analyze the relationship between adherent care and survival.
METHODS:This is a retrospective population-based cohort study of patients with stage IB–IIA invasive cervical cancer reported to the California Cancer Registry from January 1, 1995, through December 31, 2009. Adherence to National Comprehensive Cancer Network guideline care was defined by year- and stage-appropriate surgical procedures, radiation, and chemotherapy. Multivariate logistic regression, Kaplan-Meier estimate, and Cox proportional hazard models were used to examine associations between patient, tumor, and treatment characteristics and National Comprehensive Cancer Network guideline adherence and cervical cancer–specific 5-year survival.
RESULTS:A total of 6,063 patients were identified. Forty-seven percent received National Comprehensive Cancer Network guideline–adherent care, and 18.8% were treated in high-volume centers (20 or more patients/year). On multivariate analysis, lowest socioeconomic status (adjusted odds ratio OR 0.69, 95% CI 0.57–0.84), low–middle socioeconomic status (adjusted OR 0.76, 95% CI 0.64–0.92), and Charlson-Deyo comorbidity score 1 or higher (adjusted OR 0.78, 95% CI 0.69–0.89) were patient characteristics associated with receipt of nonguideline care. Receiving adherent care was less common in low-volume centers (45.9%) than in high-volume centers (50.9%) (effect size 0.90, 95% CI 0.84–0.96). Death from cervical cancer was more common in the nonadherent group (13.3%) than in the adherent group (8.6%) (effect size 1.55, 95% CI 1.34–1.80). Black race (adjusted hazard ratio 1.56, 95% CI 1.08–2.27), Medicaid payer status (adjusted hazard ratio 1.47, 95% CI 1.15–1.87), and Charlson-Deyo comorbidity score 1 or higher (adjusted hazard ratio 2.07, 95% CI 1.68–2.56) were all associated with increased risk of dying from cervical cancer.
CONCLUSION:Among patients with early-stage cervical cancer, National Comprehensive Cancer Network guideline-nonadherent care was independently associated with increased cervical cancer–specific mortality along with black race and Medicaid payer status. Nonadherence was more prevalent in patients with older age, lower socioeconomic status, and receipt of care in low-volume centers. Attention should be paid to increase guideline adherence.
Background: Poor survival among colorectal cancer (CRC) cases has been associated with African-American race and low socioeconomic status
(SES). However, it is not known whether the observed poor ...survival of African-American CRC cases is due to SES itself and/or
treatment disparities. We set out to determine this using data from the large, population-based California Cancer Registry
database.
Methods: A case-only analysis of CRC was conducted including all age groups using California Cancer Registry data from 1994 to 2003,
including descriptive analysis of relevant clinical variables, race, and SES. CRC-specific survival univariate analyses were
conducted using the Kaplan-Meier method. Multivariate survival analyses were done using Cox proportional hazards ratios (HR).
Results: Incident cases of colon (90,273) and rectal (37,532) cancer were analyzed, including 91,739 (71.8%) non-Hispanic Whites,
8,535 (6.7%) African-Americans, 14,943 (11.7%) Hispanics, 3,564 (2.8%) Chinese, and 7,950 (6.2%) non-Chinese Asians. African-Americans
had a greater proportion of metastatic stage at presentation ( P < 0.0001) and decreased CRC-specific survival ( P < 0.0001 for colon and rectal cancer). After adjustment for age, sex, histology, site within the colon, and stage, African-Americans
colon: HR, 1.19; 95% confidence interval (95% CI), 1.14-1.25; rectum: HR, 1.27; 95% CI, 1.17-1.38 had an increased risk
of death compared with Caucasians. However, after further adjustment for SES and treatment, the risk of death for African-Americans
compared with Caucasians was substantially diminished (colon: HR, 1.08; 95% CI, 1.03-1.13; rectum: HR, 1.11; 95% CI, 1.02-1.20).
Conclusion: Among CRC cases, disparities in treatment and SES largely explain the observed decreased survival of African-Americans, underscoring
the importance of health disparity research in this disease. (Cancer Epidemiol Biomarkers Prev 2008;17(8):1950–62)
Purpose Due to the widespread use of computerized tomography, the diagnosis of small renal cancers (3 cm or less) within the T1a classification continues to increase. Current treatment of these ...tumors includes radical nephrectomy, partial nephrectomy and thermal ablation. We used the SEER (Surveillance, Epidemiology, and End Results) Program to compare treatment modalities for these cancers based on 1 cm increments in tumor size. We examined overall survival, cancer specific survival, survival from cardiovascular disease and race based treatment disparities. Materials and Methods In the SEER database we identified 17,716 renal cancers 3 cm or less diagnosed from 2005 to 2010 treated with radical nephrectomy, partial nephrectomy or thermal ablation. Overall survival, cancer specific survival and cardiovascular survival were determined for each treatment group, and then substratified by size in centimeters, tumor grade, age, geographical location and ethnicity. Survival was analyzed using Kaplan-Meier methods, multivariate proportional hazards models and a propensity score weighted approach. Results Overall survival, cancer specific survival and cardiovascular survival were better for partial nephrectomy than radical nephrectomy in all circumstances. Thermal ablation showed equivalent overall survival to partial nephrectomy for tumors 2 cm or less. Notably, radical nephrectomy for renal tumors 3 cm or less was applied in a disparately larger number of black patients (OR 1.63, 95% CI 1.47–1.81) and Hispanic patients (OR 1.28, 95% CI 1.14–1.44). Conclusions Radical nephrectomy should be avoided for all tumors 3 cm or less. For renal cancers 2 cm or less partial nephrectomy and thermal ablation are equally effective. For tumors 2.1 to 3 cm partial nephrectomy is better than thermal ablation. We identified significant racial treatment disparities that negatively impact survival in black and Hispanic patients.
Objective We sought to investigate the impact of race, socioeconomic status (SES), and health care system characteristics on receipt of specific components of National Comprehensive Cancer Network ...guideline care for stage IIIC/IV ovarian cancer. Study Design Patients diagnosed with stage IIIC/IV epithelial ovarian cancer between Jan. 1, 1996, through Dec. 31, 2006, were identified from the California Cancer Registry. Multivariate logistic regression analyses evaluated differences in surgery, chemotherapy, and treatment sequence according to race, increasing SES (SES-1 to SES-5), and provider annual case volume. Results A total of 11,865 patients were identified. Median age at diagnosis was 65.0 years. The overall median cancer-specific survival was 28.2 months. African American race (odds ratio OR, 2.04; 95% confidence interval CI, 1.45–2.87) and care by a low-volume physician (OR, 19.72; 95% CI, 11.87–32.77) predicted an increased risk of not undergoing surgery. Patients with SES-1 (OR, 0.71; 95% CI, 0.60–0.85) and those treated at low-volume hospitals (OR, 0.88; 95% CI, 0.77–0.99) or by low-volume physicians (OR, 0.80; 95% CI, 0.70–0.92) were less likely to undergo debulking surgery. African American race (OR, 1.55; 95% CI, 1.24–1.93) and SES-1 (OR, 1.80; 95% CI, 1.35–2.39) were both significant predictors of not receiving chemotherapy. African American patients were also more likely than whites to receive no treatment (OR, 2.08; 95% CI, 1.45–2.99) or only chemotherapy (OR, 1.55; 95% CI, 1.10–2.18). Patients with low SES were more likely to receive no treatment (OR, 1.95; 95% CI, 1.44–2.64) or surgery without chemotherapy (OR, 1.67; 95% CI, 1.38–2.03). Conclusion Among patients with advanced-stage ovarian cancer, African American race, low SES, and treatment by low-volume providers are significant and independent predictors of receiving no surgery, no debulking surgery, no chemotherapy, and nonstandard treatment sequences.
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