乌鸦传媒

Patients who died within a month of cancer surgery had unfavorable social and demographics that appeared to confer high risk, a review of records for more than 1 million people showed.

The patients at highest risk of early death tended to be unmarried, uninsured, nonwhite, male, older, less education, poorer, and to have more advanced disease at surgery. The results suggest that reducing sociodemographic disparities in cancer care, including access, has the potential to improve cancer outcomes, Brandon A. Mahal, a medical student at Harvard University, reported at the American Society of Clinical Oncology .

The study was among several presentations at the symposium in Boston.

Sociodemographics, Cancer, and Mortality Risk

Death within 1 month of surgery is considered treatment related and represents a key quality metric in healthcare, although factors associated with early death after surgery for cancer have not been well defined.

Mahal, a research fellow at Dana-Farber Cancer Institute, and colleagues searched the (SEER) database to identify patients who underwent surgery from 2004 to 2011 for the most common and/or fatal cancers. The search yielded 1.1 million patients.

Narrowing the focus to patients who died within 1 month of surgery resulted in 53,498 (4.8%) patients for the primary analysis. By means of logistic regression analysis, investigators identified four significant predictors of an increased likelihood of dying within a month of surgery:

• Nonwhite race: OR 1.13 (P<0.001)
• Male sex: OR 1.11 (P<0.001)
• Older age: OR 1.02 (P<0.001)
• Advance-stage disease: OR 1.89 (P<0.001)

The analysis also revealed several factors associated with a significantly lower risk of death within 1 month of surgery: married patients (OR 0.80, P<0.001), insured patients (OR 0.88, P<0.001), ≥50th percentile of income (OR 0.95, P<0.001), and ≥50th percentile in education (OR 0.98, P=0.043).

Adherence to Hormonal Therapy

Patients with breast cancer were more likely to remain adherent to hormonal therapy if they received the Medicare Part D low-income subsidy, a study of 23,000 older breast cancer survivors showed.

Adherence to hormonal therapy improved significantly across all racial/ethnic groups when women received the , with absolute differences ranging from 9% to 16%. Adherence remained better over time among subsidy recipients, although rates declined in all groups.

"Patients are more likely to take their medications if they are able to afford them," of the University of Illinois-Chicago, said in a statement. "Our study shows that federal policy interventions that help cover out-of-pocket costs have the potential to reduce the breast cancer outcome gap by race and ethnicity."

Studies have consistently shown that black patients with breast cancer have worse outcomes than do white patients. Access to care, quality of care, and socioeconomic factors have been implicated in the disparity. However, income and out-of-pocket costs have received relatively little attention as contributing factors.

Biggers, who was at the Medical College of Wisconsin in Milwaukee while participating in the study, and colleagues analyzed a national sample of Medicare Part D enrollees who underwent breast-conserving surgery for early breast cancer during 2006-2007. They identified women treated with tamoxifen or an aromatase inhibitor within 1 year of surgery.

Data analysis included 23,298 women, 27.2% of whom received the Medicare Part D low-income subsidy. The proportion of patients who received hormonal therapy did not differ significantly across racial groups, but the proportion receiving the subsidy ranged from 20.6% of white women to 69.7% of black patients. Out-of-pocket costs ranged from $155 to $428 annually, depending on the agent used.

During the first year of hormonal treatment, small but statistically significant differences in adherence (medication possession rate ≤80%) existed by race: 64.2% of white patients, 63.2% of blacks, and 66.7% of Hispanics. Adherence rates were substantially lower among patients who did not receive the subsidy, regardless of race or ethnicity.

In the subgroup of patients who did not receive the low-income subsidy, adherence was 62% among white women versus 55% for black and Hispanic women. Comparing adherence with and without the subsidy, investigators found across-the-board differences: 71% versus 62% among white women, 67% versus 55% among black women, and 71% versus 55% among Hispanic women.

Oncologists and Tumor Boards

Patients with advanced colorectal or small cell lung cancer (SCLC) had better survival when their oncologists participated at least weekly in meetings, according to a study of 4,600 patients and 1,600 oncologists.

Frequent oncologist participation in tumor boards was associated with about a 30% reduction in the mortality hazard for patients with stage IV colorectal cancer and about a 40% reduction in the hazard for extensive SCLC. Oncologists who participated in weekly tumor boards also were more likely to discuss and refer patients to clinical trials and to pursue curative surgery for patients with early-stage non-small cell lung cancer (NSCLC).

"Patients with disease subtypes for which we found a link between physician tumor board participation and improved outcomes may want to ask their doctor if their case will be reviewed at a multidisciplinary meeting," , of the University of Texas MD Anderson Cancer Center in Houston, said in a statement.

"However, this was not a randomized study; as there were few associations overall between tumor boards and patient survival, our findings cannot demonstrate conclusively that physician tumor board participation directly affects patient outcomes."

Less-than-weekly attendance at tumor boards was not associated with improved outcomes for any type of cancer, he noted.

Kehl reported findings from a study that aimed to determine oncologists' frequency and type of participation in tumor boards and the relationship of participation to patient outcomes.

The study showed that 96% of oncologists participated in some type of tumor board, and 54% of the oncologists participated at least weekly in one or more tumor boards. More than 80% of the tumor board meetings addressed treatment planning, and 87% of the meetings included reviews of a variety of cancer types. But in 59% of cases, the meetings were limited to challenging cases.

Patients whose oncologists participated in weekly tumor boards had a 60% greater likelihood of enrolling in a clinical trial, as compared with patients whose oncologists participated less frequently or not at all. Kehl and colleagues interpreted the finding as indicating that identifying clinical trials for patients might be a key function of tumor boards.

Weekly tumor-board participation by oncologists increased likelihood that patients would receive treatment consistent with clinical guidelines, such as surgery with curative intent for patients with stage I/II NSCLC, but only if the meetings included evaluation and discussion of patients' prior treatment.

Use of curative-intent surgery was less likely if oncologists attended tumor boards less often and if the tumor boards included evaluation of a variety of tumor types.