Elena B. Elkin

Expert groups and national guidelines recommend individualized decision making about screening mammography for women in their 40s at low-to-average risk of breast cancer. We created Breast Screening Decisions (BSD), a personalized, web-based decision aid, to help women decide when to start and how often to have routine screening mammograms. We evaluated BSD in a large, prospective pilot trial of women and their clinicians. Women ages 40–49 were invited to use BSD before a scheduled preventive care visit. One month post-visit, users were asked about decisional conflict, knowledge, perceptions and worry about breast cancer and screening. They were also asked whether they had a screening mammogram since their visit, scheduled an appointment for a screening mammogram, or if they were planning to schedule an appointment within the next six months. Women who responded “no” to each of these successive questions were considered to have no plan for a screening mammogram within the next 6 months, unless they explicitly stated that they were unsure about screening mammography. Clinicians were surveyed regarding mammography discussions and perceived patient knowledge and anxiety. Of 1,100 women invited to use BSD, 253 accessed the website, and 168 were eligible to participate in the pilot study. One-fifth had a family history of breast cancer, and at least 76% had any prior mammogram. At follow-up, 88% of BSD users reported discussing mammography at their visit, and 77% said they had a screening mammogram since the visit or that they made or were planning to make a screening mammogram appointment. The average decisional conflict score was 22.5, within the threshold for implementing decisions. Decisional conflict scores were lowest in women who said that they had or planned to have a mammogram (mean 21.4, 95% CI 18.3-24.6), higher in those who did not (mean 24.8, 95% CI 19.2-30.5), and highest in those who were unsure (mean 31.5, 95% CI 13.9-49.1). Most BSD users expressed accurate perceptions of their breast cancer risk and the benefits and limitations of screening. A web-based decision aid may support informed, individualized decisions about screening mammography and facilitate discussions about screening between women in their 40s and their clinicians.

CONTEXT AND QUESTION ASKED: In patients with metastatic cancer, chemotherapy may provide symptom control, prevent complications, prolong life, or improve quality of life. Except in rare cases, however, patients with metastatic disease will not be cured. In older patients with metastatic cancer, hospitalization for treatment toxicity may reduce the quality of an already limited life expectancy. We evaluated the association between chemotherapy for metastatic cancer and risk of hospitalization. MAIN CONCLUSION: Hospitalizations are common in patients with incurable advanced malignancies and are more likely among those who receive chemotherapy. APPROACH: In the linked SEER-Medicare dataset, we identified Medicare beneficiaries aged 66 years or older with a primary diagnosis of metastatic breast, colorectal, ovarian, bladder, lung, pancreas, esophageal, stomach, or prostate cancer between 2001 and 2009 who died by the end of 2010. Chemotherapy recipients and nonrecipients were pair-matched by age, sex, race, comorbidity, geographic region and survival duration. The primary endpoint was hospital admission, identified in inpatient claims between cancer diagnosis and the first of hospice admission or death. We also identified the subset of admissions associated with a primary or secondary diagnosis code suggestive of an adverse effect of chemotherapy. The association between chemotherapy and hospitalization was estimated in separate multivariable Cox proportional-hazards regression models for each cancer site, accounting for the matched-pairs design and controlling for unmatched demographic and disease characteristics. RESULTS: Of 18,486 patients who received chemotherapy for metastatic cancer, 92% were hospitalized at least once for any reason, including 51% hospitalized for a likely toxicity. The corresponding rates among matched non-recipients were 83% and 34% (Figure). In nearly all cancers, chemotherapy recipients had a greater risk of hospitalization for a likely toxicity or for any cause. Chemotherapy recipients had substantially higher hospitalization for infection or fever (21% v 15%), hematologic complications (11% v 3%), dehydration (13% v 6%), and PE or DVT (9% v 4%) compared with nonrecepients. Chemotherapy was associated with a significantly increased risk of likely toxicity-related hospitalization in nearly all cancers, controlling for sociodemographic characteristics and other treatment. The association was greatest in patients with metastatic esophageal cancer (adjusted hazard ratio, 2.00; 95% CI, 1.11 to 3.60) and smallest in patients with metastatic prostate cancer (adjusted hazard ratio, 1.22; 95% CI, 1.01 to 1.47). INTERPRETATION: Older patients receiving chemotherapy for incurable advanced cancers are at high risk of hospitalization, of which a non-negligible proportion is likely attributable to adverse effects of treatment. Infection, fever, dehydration, and hematologic complications constitute a large proportion of these events, some of which may be preventable through evidence-based patient management, prophylactic interventions, and effective outpatient care. Our findings might be limited to older patients with advanced cancer who have a generally poor prognosis or limited expected survival. SIGNIFICANCE OF FINDINGS: Understanding the common reasons for hospital admissions and developing toxicity management programs and educational resources may help patients and their families make informed treatment decisions, minimize adverse effects and reduce hospitalizations in this population with limited life expectancy. [Figure: see text]

Background: Identifying unwarranted variation in health care can highlight opportunities to reduce harm. One often discretionary process in oncology is use of implanted ports to administer intravenous chemotherapy. While there are benefits, ports carry risks. This study’s objective was to assess provider-driven variation in port use among cancer patients receiving chemotherapy. Research Design: Retrospective assessment using population-based SEER-Medicare data to assess differences in port use across health care providers of older adults with cancer. Participants included over 18,000 patients ages 66 and older diagnosed with breast, colorectal, lung, or pancreatic cancer in 2005–2007, treated by approximately 2900 providers. We identified port use for patients receiving treatment from hospital outpatient facilities versus physicians’ offices. Our main analysis assessed the likelihood of a patient receiving a port given port use by the provider’s last patient. For a subset of high-use providers, we examined individual provider-level variation by estimating the risk-adjusted likelihood of insertion. Results: Patients receiving chemotherapy in hospital outpatient facilities were significantly less likely to receive a port than those treated in physicians’ offices, with adjusted odds ratios (AOR) varying from 0.50 to 0.75 across cancer sites. Implanting a port was associated with increased likelihood of port insertion in the provider’s next patient (AOR varied from 1.71 to 2.25). Significant between-provider variation was found among providers with at least 10 patients. Conclusions: Our findings support the idea that there is provider-driven variation in the use of ports for chemotherapy administration. This variation highlights an opportunity to standardize practice and reduce unnecessary use.

Advances in treatment have increased childhood cancer 5-year survival rates to greater than 80%. However, children previously treated with radiation are at significantly increased risk of developing subsequent neoplasms, the most common of which are skin cancers. The National Cancer Institute and Children’s Oncology Group have issued recommendations for survivors treated with radiation to perform monthly skin self-examinations and receive a physician skin examination at least annually, as early detection has demonstrated markedly improved outcomes in the diagnosis and treatment of skin cancers. The goal of the present study is to increase rates of skin self-examinations and clinical skin examinations among adult survivors of childhood cancer treated with radiation. This randomized controlled trial uses a 3-group comparative effectiveness design comparing: (1) Patient Activation and Education (PAE) including text messaging, print and web-based tutorials over 12 months; (2) PAE plus physician activation (PAE + MD) adding physician activation/educational materials about survivors’ increased skin cancer risk and conducting full-body skin exams; and (3) PAE plus physician activation, plus teledermoscopy (PAE + MD + TD) adding participant receipt of a dermatoscope intended to empower them to photograph suspect moles or lesions for review by the study dermatologist. The current study addresses barriers to screening in this population by providing educational and motivational information for both survivors and physicians regarding the value of periodic skin examinations. It also utilizes innovative mobile health technology to encourage and motivate (that is activate) survivors to conduct skin self-examinations, request physician exams, and obtain treatment when worrisome lesions are found. Finally, as a comparative effectiveness trial, this study isolates the effects of adding specific components to the patient activation intervention to test the most effective intervention for enhancing skin examination vigilance among this high-risk group. Clinicaltrials.gov: NCT02046811 ; Registration date: 22 January 2014.

125 Background: Long-term central venous catheters (CVCs) facilitate venous access to administer intravenous fluids and treatments such as chemotherapy. However, CVCs can also be a source of harmful bloodstream infections, a risk that may be underappreciated. Our objective was to assess the impact of long-term CVC use on the risk of infections in a population-based cohort of cancer patients. Methods: Retrospective analysis using the population-based SEER-Medicare dataset for patients over age 65, diagnosed from 2005 to 2007 with invasive colorectal cancer (n = 36,272), head and neck cancers (n = 8,459), lung cancer (n = 56,770), pancreatic cancer (n = 10,536), or non-Hodgkin lymphoma (n = 14,432), or invasive or non-invasive breast cancer (n = 42,271). Cox proportional hazards regression was used to examine the impact of CVC use on infection risk, with CVC exposure treated as a time-varying predictor. We used multivariable analysis and propensity score methods to control for patient characteristics. Results: Adjusting for demographic and disease characteristics, long-term CVCs significantly increased the risk of infection by at least 40%, across all cancer types (Table). The greatest effect of CVCs on infection risk was in patients with breast cancer. Conclusions: Long-term CVC use is associated with an increased risk of infections for older adults with cancer. Careful assessment of the need for long-term CVCs, and targeted strategies to reduce infections for patients requiring their use, are critical to improving cancer care quality. [Table: see text]

BACKGROUND: Rates of screening mammography have plateaued, and the number of mammography facilities has declined in the past decade. The objective of this study was to assess changes over time and geographic disparities in the availability of mammography services.METHODS: Using information from the US Food and Drug Administration and the US Census, county‐level mammography capacity was defined as the number of mammography machines per 10,000 women aged ≥ 40 years. Cross‐sectional variation and longitudinal changes in capacity were examined in relation to county characteristics.RESULTS: Between 2000 and 2010, the number of mammography facilities declined 10% from 9434 to 8469, the number of mammography machines declined 10% from 13,100 to 11,762, and the median county mammography capacity decreased nearly 20% from 1.77 to 1.42 machines per 10,000 women aged ≥ 40 years. In cross‐sectional analysis, counties with greater percentages of uninsured residents, less educated residents, greater population density, and higher managed care penetration had lower mammography capacity. Conversely, counties with more hospital beds per 100,000 population had higher capacity. High initial mammography capacity, growth in both the percentage of the population aged ≥ 65 years and the percentage living in poverty, and increased managed care penetration were all associated with a decrease in mammography capacity between 2000 and 2010. Only the percentage of rural residents was associated with an increase in capacity.CONCLUSIONS: Geographic variation in mammography capacity and declines in capacity over time are associated with demographic, socioeconomic, and health care market characteristics. Maldistribution of mammography resources may explain geographic disparities in breast cancer screening rates. Cancer 2013;119:3847–3853. © 2013 American Cancer Society.

Screening mammography is a cornerstone of preventive health care for adult women in the United States. As rates of screening mammography have declined and plateaued in the past decade, access to services remains a concern. In 2011, we repeated a survey of mammography facilities initially surveyed in 2008 in six states. The availability of digital mammography increased and appointment wait times generally improved between the two survey periods, but more facilities required payment upfront. Provisions of the federal healthcare reform law that eliminate cost sharing for selected preventive health services may improve access to screening mammography and prevent further declines in the rate of breast cancer screening.