Ohio Cancer Incidence Surveillance System Research Articles

Abstract D074: Variations in genomic testing across cancer sites and by demographic characteristics

Abstract Study Objective: Genomic testing is essential to identify the best treatment modalities for certain cancers; yet, its uptake has been relatively low, especially among disadvantaged subgroups of the population. The aim of this study is to identify demographic and clinical factors associated with receipt of genomic testing in Ohioans diagnosed with either incident female breast, kidney, bladder, prostate, colorectal, or lung cancer. Methods: We used data from the 2009 linked Ohio Cancer Incidence Surveillance System and Medicare files, and identified genomic testing using the appropriate procedure codes in claims data. Our study population included 10,945 patients. Independent variables examined were age at diagnosis (< 65, 65-74, 75+), sex, race (White or All Other), dual enrollment in the Medicare and Medicaid program (or ‘dual’) as a marker for low income and heightened vulnerability, and advanced stage at diagnosis (Regional/Distant versus Local stage). We conducted multivariable logistic regression analysis to identify correlates of genomic testing by cancer site. Results: For all cancer sites combined, 11.1% were younger than 65, and 40.6% were older than 75 years of age. Eighty eight percent were White, 47.0% were women, 13.9% were duals, and one third were diagnosed with advanced-stage cancer. Overall, only 19.5% underwent genomic testing, ranging from a low of 6.7% in prostate cancer patients, to a high of 39.3% in breast cancer patients. In addition, we observed considerable variation in genomic testing by age, race, sex, dual status, and cancer stage across cancer sites. Adjusting for the independent variables listed above, being 75 years of age or older was significantly and positively associated with increased likelihood of undergoing genomic testing in breast (adjusted odds ratio: 1.17, 95% confidence interval: 1.04, 1.32), kidney and bladder combined (1.29 (1.09, 1.53)), and prostate cancer patients (1.45 (1.12, 1.89)). Advanced-stage disease was associated with increased likelihood of genomic testing in breast and colorectal cancer patients (1.40 (1.17, 1.67) and 3.07 (2.30, 4.11), respectively), but with decreased likelihood in kidney and bladder cancer patients (0.66 (0.48, 0.91)). Finally, we note that White patients with lung cancer were significantly more likely than others to undergo genomic testing (2.49 (1.29, 4.78)). Conclusion: Our data from 2009 provide baseline statistics on genomic testing uptake in Ohio. Data for subsequent years will help us to assess trends in providing personalized medicine. Citation Format: Siran Koroukian, Weichuan Dong, Johnie Rose, Fredrick Schumacher, Sarah Markt. Variations in genomic testing across cancer sites and by demographic characteristics [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D074.

Abstract C057: Neighborhood disadvantage is associated with liver cancer treatment and survival

Abstract Liver cancer is the 5th leading cause of cancer mortality in the United States and is predicted to increase in the US as a consequence of the opioid epidemic. Associations between individual-level risk factors, such as socioeconomic status, and liver cancer survival have been explored; however, the role of neighborhood-level factors, such as neighborhood deprivation, are noticeably absent from the literature. We explored the association between greater neighborhood deprivation and disparities in tumor characteristics, treatment and 5-year survival among primary liver cancer patients in Ohio diagnosed between 2003 and 2016 using data from the Ohio Cancer Incidence Surveillance System. We restricted our sample to only patients who were 18 years older and who could be geographically linked to a census tract based on their address at diagnosis. We created a neighborhood deprivation index (NDI) using nine variables at the Census tract level including: % less than high school diploma, % college graduates, % at or below the federal poverty line, % unemployed, median household income, % vacancy, % owner occupied unites, median house/unit value and % African American. We used principal component analysis to create the index and derived quintiles of deprivation with the higher quintiles reflective of areas with higher deprivation. We examined associations between tumor characteristics and NDI quintile using chi-square tests and ANOVA. We examined concordance with treatment guidelines as binary variable using log-binomial regression. For 5-year survival we utilized Cox proportional hazard models. Confounding variables for each regression model were selected using Directed Acyclic Graphs. After exclusion criteria were applied, 8,208 primary liver cancer patients were included in the study. We observed no statistically significant differences in tumor characteristics by quintile of NDI. However, we found a clear gradient between levels of deprivation and decrease likelihood of receiving guideline-concordant care. Specifically, between the most and least deprived areas, a 25% lower risk (Risk ratio [RR]=0.75; 95% Confidence Interval [CI]=0.67, 0.85) of receiving guideline-concordant care was observed in our adjusted log-binomial regression model. In adjusted survival models we observed an increased risk of death comparing the most and least deprived areas (Hazard ratio [HR]=1.14, 95% CI=1.02, 1.27). Our study suggests a potential negative effect of neighborhood deprivation on treatment concordance and liver cancer survival. Interventions targeting disparities in liver cancer should focus on not only individual level factors but address larger neighborhood level factors as well. Future analyses are needed to confirm these disparities observed and determine if similar neighborhood level effects occur in other cancer disparities. This study includes data provide by the Ohio Department of Health which should not be considered an endorsement of this study or its conclusions. Citation Format: Robert B Hood, Ashley Felix. Neighborhood disadvantage is associated with liver cancer treatment and survival [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C057.

Esophageal Adenocarcinoma: Opportunities for Targeted Prevention in Ohio.

Objective:The incidence of esophageal adenocarcinoma, one of the most lethal gastroenterological diseases, has been increasing since the 1960s. Prevention of esophageal adenocarcinoma is important because no early detection screening programs have been shown to reduce mortality. Obesity, gastroesophageal reflux disease, and tobacco smoking are risk factors for esophageal adenocarcinoma. Due to the high prevalence in Ohio of obesity (32.6%) and cigarette smoking (21.0%), this study sought to identify trends and patterns of these risk factors and esophageal adenocarcinoma in Ohio as compared with the United States.Methods:Data from the Ohio Cancer Incidence Surveillance System, Surveillance Epidemiology and End Results Program (SEER), and Behavioral Risk Factor Surveillance System were used. Incidence rates overall, by demographics and by county, as well as trends in incidence of esophageal adenocarcinoma and the percent of esophageal adenocarcinoma among esophageal cancers were examined. Trends in obesity and cigarette smoking in Ohio, and the prevalence of each by county, were reported.Results:There was an increasing trend in esophageal adenocarcinoma incidence in Ohio. Ohio’s average annual esophageal adenocarcinoma incidence rate was higher than the SEER rate overall and for each sex, race, and age group in 2009 to 2013. There was also an increasing prevalence of obesity in Ohio. Although the prevalence of cigarette smoking has been stable, it was high in Ohio compared with the United States.Conclusions:Health care providers and researchers should be aware of the esophageal adenocarcinoma incidence rates and risk factor patterns and tailor interventions for areas and populations at higher risk.

The Breast and Cervical Cancer Early Detection Program, Medicaid, and breast cancer outcomes among Ohio's underserved women.

As an organized screening program, the national Breast and Cervical Cancer Early Detection Program (BCCEDP) was launched in the early 1990s to improve breast cancer outcomes among underserved women. To analyze the impact of the BCCEDP on breast cancer outcomes in Ohio, this study compared cancer stages and mortality across BCCEDP participants, Medicaid beneficiaries, and "all others." This study linked data across the Ohio Cancer Incidence Surveillance System, Medicaid, the BCCEDP database, death certificates, and the US Census and identified 26,426 women aged 40 to 64 years who had been diagnosed with incident invasive breast cancer during the years 2002-2008 (deaths through 2010). The study groups were as follows: BCCEDP participants (1-time or repeat users), Medicaid beneficiaries (women enrolled in Medicaid before their cancer diagnosis [Medicaid/prediagnosis] or around the time of their cancer diagnosis [Medicaid/peridiagnosis]), and all others (women identified as neither BCCEDP participants nor Medicaid beneficiaries). The outcomes included advanced-stage cancer at diagnosis and mortality. A multivariable logistic and survival analysis was conducted to examine the independent association between the BCCEDP and Medicaid status and the outcomes. The percentage of women presenting with advanced-stage disease was highest among women in the Medicaid/peridiagnosis group (63.4%) and lowest among BCCEDP repeat users (38.6%). With adjustments for potential confounders and even in comparison with Medicaid/prediagnosis beneficiaries, those in the Medicaid/peridiagnosis group were twice as likely to be diagnosed with advanced-stage disease (adjusted odds ratio, 2.20; 95% confidence interval, 1.83-2.66). Medicaid/peridiagnosis women are at particularly high risk to be diagnosed with advanced-stage disease. Efforts to reduce breast cancer disparities must target this group of women before they present to Medicaid. Cancer 2017;123:3097-106. © 2017 American Cancer Society.

Cancer outcomes in low-income elders: is there an advantage to being on Medicaid?

Because of reduced financial barriers, dual Medicare-Medicaid enrollment of low-income Medicare beneficiaries may be associated with receipt of definitive cancer treatment and favorable survival outcomes. We used a database developed by linking records from the Ohio Cancer Incidence Surveillance System with Medicare and Medicaid files, death certificates, and U.S. Census data. The study population included community-dwelling Medicare fee-for-service beneficiaries, age 66 years or older, with low incomes, residing in Ohio, and diagnosed with incident loco-regional breast (n=838), colorectal (n=784), or prostate cancer (n=946) in years 1997-2001. We identified as "duals" Medicare beneficiaries who were enrolled in Medicaid at least three months prior to cancer diagnosis. Multivariable logistic regression and survival models were developed to analyze the association between dual status and (1) receipt of definitive treatment; and (2) overall and disease-specific survival, after adjusting for tumor stage and patient covariates. DUAL STATUS WAS ASSOCIATED WITH A SIGNIFICANTLY LOWER LIKELIHOOD TO RECEIVE DEFINITIVE TREATMENT AMONG COLORECTAL CANCER PATIENTS (ADJUSTED ODDS RATIO: 0.60, 95% Confidence Interval, or CI, [0.38, 0.95]), but not among breast or prostate cancer patients. Furthermore, dual status was associated with decreased overall survival among prostate cancer patients (Adjusted Hazard Ratio, or AHR, 1.45, 95% CI [1.05, 2.02]), and decreased disease-specific survival among colorectal cancer patients (AHR: 1.52 [1.05, 2.19]). Enrollment of low-income Medicare beneficiaries in Medicaid is not associated with favorable treatment patterns or survival outcomes. Differences in health and functional status between community-dwelling duals and non-duals might help explain the observed disparities.

Survival disparities by Medicaid status

A study was undertaken to compare survival and 5-year mortality by Medicaid status in adults diagnosed with 8 select cancers. Linking records from the Ohio Cancer Incidence Surveillance System (OCISS) with Ohio Medicaid enrollment data, the authors identified Medicaid and non-Medicaid patients aged 15 to 54 years and diagnosed with the following incident cancers in the years 1996-2002: cancer of the testis; Hodgkin and non-Hodgkin lymphoma; early stage melanoma, colon, lung, and bladder cancer; and pediatric malignancies (n = 12,703). Medicaid beneficiaries were placed in the pre-diagnosis group if they were enrolled in Medicaid at least 3 months before cancer diagnosis, and in the peri/post-diagnosis group if they enrolled in Medicaid upon or after being diagnosed with cancer. The authors also linked the OCISS with death certificates and data from the US Census. By using Cox and logistic regression analysis, they examined the association between Medicaid status and survival and 5-year mortality, respectively, after adjusting for patient covariates. Nearly 11% of the study population were Medicaid beneficiaries. Of those, 45% were classified in the peri/post-diagnosis group. Consistent with higher mortality, findings from the Cox regression model indicated that compared with non-Medicaid, patients in the Medicaid pre-diagnosis and peri/post-diagnosis groups experienced unfavorable survival outcomes (adjusted hazard ratio [AHR], 1.52; 95% confidence interval [CI], 1.27-1.82 and AHR, 2.01; 95% CI, 1.70-2.38, respectively). Medicaid status was associated with unfavorable survival, even after adjusting for confounders. The findings reflect the vulnerability of Medicaid beneficiaries and possible inadequacies in the process of care.

Treatment and survival patterns in relation to multimorbidity in patients with locoregional breast and colorectal cancer

PURPOSE: To examine the effects of the occurrence and co-occurrence of comorbidities (COM), functional limitations (FL), and geriatric syndromes (GS) on treatment and outcomes in older cancer patients. MATERIALS AND METHODS: We used records from the Ohio Cancer Incidence Surveillance System linked with Medicare data, clinical assessment data from the home health care Outcomes and Assessment Information Set, and death certificate data. Our patient population included fee-for-service HHC Medicare beneficiaries diagnosed with incident loco-regional breast or colorectal cancer in years 1999-2001 (n=1236). We grouped patients according to the presence of multimorbidity: (0): none of COM, FL, or GS; (1): occurrence - but no co-occurrence - of COM, FL, or GS; (2): co-occurrence of any two of COM, FL, and GS; and (3): co-occurrence of all three of COM, FL, and GS. Our outcomes were receipt of standard treatment, as well as overall survival (OS) and disease-specific survival (DSS) through 2005. Multivariable regression models were developed to analyze the independent association between multimorbidity and the outcomes, before and after adjusting for age. RESULTS: The effect of multimorbidity on our outcomes was attenuated considerably by age. Adjusting for age and compared with no multimorbidity (0), high multimorbidity (3) remained significantly and negatively associated with receipt of standard treatment (adjusted odds ratio: 0.57, 95% Confidence Interval (CI): 0.33, 0.97). Furthermore, high multimorbidity (3) was associated with increased hazard for OS, but not for DSS (adjusted hazard ratio and 95% CI: 2.15 (1.58, 2.93) for three entities). CONCLUSION: Multimorbidity is significantly and independently associated with cancer treatment and OS, but not DSS.

Abstract A62: Survival outcomes in patients with curable cancers: Disparities by Medcaid status

Abstract Study Aim: To compare 5-year survival, by Medicaid status, in adults diagnosed with a curable cancer, defined as 5-year survival without relapse. We hypothesized that adjusting for patient attributes, as well as cancer site and stage, Medicaid beneficiaries affected with these cancer experienced greater mortality than their non-Medicaid counterparts. Methods: Using a database developed by linking records from the Ohio Cancer Incidence Surveillance System (OCISS) with Ohio Medicaid and death certificate files, we identified individuals 15-54 years of age and diagnosed with any of the following incident cancers in the years 1996-2002: cancer of the testis; Hodgkin's and non-Hodgkin's lymphoma; early-stage colon, lung, and bladder cancer; pediatric malignancies; and early-stage melanoma (n=13,004). Medicaid status was ascertained if the patient was enrolled in Medicaid in the year s/he was diagnosed with cancer. Death certificate data were used to ascertain the patient's vital status through 2007, and to retrieve the date and cause of death. The individual's income was approximated to that of the census block group in which s/he resided at the time of diagnosis. Using logistic regression analysis and Cox regression models, respectively, we examined the association between Medicaid status and each of 5-year mortality and hazard of death after adjusting for patient demographics, income, geographic area of residence, and cancer site and stage at diagnosis. Results: There were 12,703 subjects in our population 60% of whom were 40 years of age or older; 57% were male; 6% were African American, and 10% were identified as Medicaid beneficiaries. The most common types/anatomic sites of cancer were melanoma (36.4%), colon (22.3%), testis (14.5), and Hodgkin's (7.0%), and non-Hodgkin's lymphoma (9.1 %). The proportion of patients dying of cancer within 5 years of diagnosis was highest among African Americans (18.3%), Medicaid beneficiaries (21.9%), those diagnosed with lung cancer (33.9%) or pediatric malignancies (31.2%), and those diagnosed with more advanced stages of cancer (20.9% and 22.2% among those diagnosed with regional, and distant-stage cancer, respectively). The findings from the multivariable logistic analysis indicated that Medicaid beneficiaries were nearly twice as likely as their non-Medicaid counterparts to die of cancer within the 5 years following diagnosis (adjusted odds ratio: 1.84,95% Confidence Interval: 1.54,2.21). Similarly, results obtained from the survival analysis indicated that Medicaid beneficiaries experienced significantly greater hazard of death from cancer (adjusted hazard ratio: 1.78 (1.53,2.07)). Conclusion: Consistent with our hypothesis, we found Medicaid status to be associated with significantly greater likelihood of 5-year cancer specific mortality and hazard of death, even after adjusting for potential confounders. In addition to serving the poor and the disabled, the Medicaid program is the primary safety net to the near poor who resort to it when they are diagnosed with a catastrophic disease such as cancer. In this study, nearly 45% of Medicaid patients joined the program upon, or after being diagnosed with cancer. Future studies should determine to what extent higher mortality among Medicaid beneficiaries is attributed to advanced cancer stage at diagnosis or cancer relapse due to inadequate treatment and surveillance. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A62.

State-wide application of breast and colon cancer quality measures (QMs) using linked claims and registry data.

6004 Background: The National Quality Forum (NQF) endorsed QMs for breast and colorectal (CR) cancer in 2007. Application by cancer registries may yield inaccurately low measures of QM concordance because of incomplete data on systemic therapy and radiation. Linkage of registry data to insurance claims may provide a more robust measure of quality at the community level. This study examined concordance with NQF QMs using payer claims linked to the National Cancer Data Base and the Ohio Cancer Incidence Surveillance System (combined data = REG). Methods: Claims from United Healthcare and Anthem Blue Cross Blue Shield of Ohio were linked to REG for patients treated in Ohio during 2004-06 for breast and CR cancer. Cases with fewer than 270 days of claims were excluded. Concordance with NQF QM's was assessed by examining radiation, chemotherapy, and endocrine therapy defined from REG and claims as treatment actually administered. Results: The claims-registry linkage identified 2,447 women with stage 0–III breast cancer and 668 patients with stage 0–III CR cancer. The Table shows concordance with NQF QMs. Conclusions: Linkage of claims to registries allows more accurate community-wide assessment of quality of cancer care. Concordance with NQF QMs among insured patients in Ohio was very high. Efforts to expand claims-registry linkages are warranted for quality assessment. NQF measure N cases Concordance with NQF QMs by data source Registry only Claims only Claims + registry Stage I-III breast cancer; breast-conserving surgery; age < 70; radiation < 365 days of diagnosis (Dx) 932 84% 95% 96% T1cN0M0 and stage II-III breast cancer; hormone receptor negative; age < 70; chemotherapy < 120 days of Dx 267 77% 92% 94% T1cN0M0 and stage II-III breast cancer; hormone receptor positive; endocrine therapy < 365 days of Dx 613 61% 84% 92% Stage III colon cancer; age < 80 chemotherapy < 120 days of Dx 161 82% 91% 96% Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration UnitedHealthCare

Comorbidities, Functional Limitations, and Geriatric Syndromes in Relation to Treatment and Survival Patterns Among Elders With Colorectal Cancer

To examine patterns of colorectal cancer (CRC) treatment and survival in relation to comorbidities (COM), functional limitations (FL), and geriatric syndromes (GS). Our study population consisted of Ohio elders diagnosed with incident invasive CRC in the period August 1999 to November 2001 and admitted to home health care (HHC) in the 30 days before or after cancer diagnosis (n = 1009). We used data from the Ohio Cancer Incidence Surveillance System, vital records, and Medicare administrative data, including the HHC Outcome and Assessment Information Set (OASIS), which includes detailed clinical data for HHC patients. Counts of COM, FL, and GS at baseline were retrieved from the OASIS. Multivariable logistic and survival models were developed to examine the association between clinical attributes and outcomes, adjusting for demographic covariates and cancer stage. Comorbidities were associated with increased likelihood of surgery-only, but not with surgery + chemotherapy. Both FL and GS were associated with lower likelihood to undergo surgery-only or surgery + chemotherapy. Two or more GS was associated with disease-specific mortality (adjusted hazard ratio [AHR]: 2.71; 95% confidence interval [CI]: 1.80-4.07) and overall mortality (AHR: 2.34; 95% CI: 1.74-3.15). Two or more FL was associated with overall mortality (AHR: 1.33; 95% CI: 1.10-1.62), but not with disease-specific mortality. COM was not associated with overall mortality, but was negatively associated with disease-specific mortality at borderline level of significance (AHR: 0.78; 95% CI: 0.61-1.00). Our findings demonstrate the importance of accounting for FL and GS, in addition to COM, when studying cancer-related outcomes in elders.

Assessment and Interpretation of Comorbidity Burden in Older Adults with Cancer

To evaluate the associations between comorbidities, functional limitations, geriatric syndromes, treatment patterns, and outcomes in a population-based cohort of older patients diagnosed with colorectal cancer and receiving home health care. Retrospective study. Data from the Ohio Cancer Incidence Surveillance System, Medicare claims and enrollment files, and the home health care Outcome and Assessment Information Set. Ohio residents diagnosed with incident colorectal cancer in 1999 to 2001 and receiving home health care in the 30 days before or after cancer diagnosis (N=957). Outcome measures included receipt of cancer treatment and survival through 2005. Not having surgery was associated negatively with comorbidities but positively with functional limitations and geriatric syndromes. Receipt of chemotherapy was negatively associated with comorbidities and functional limitations. The presence of two or more geriatric syndromes was significantly associated with unfavorable survival outcomes when analyzing overall survival and disease-specific survival (DSS). Having limitations in two or more activities of daily living was associated with unfavorable overall survival but not with DSS. Comorbity was associated with favorable DSS at borderline level of statistical significance but not with overall survival. The findings highlight the importance of incorporating functional limitations and geriatric syndrome data in geriatric oncology outcomes studies.

Correlates of hospice use in elders with cancer

9579 Background: Use of hospice has remained relatively low. We aim to identify correlates of hospice in elders with cancer, hypothesizing that the presence of functional limitations and geriatric syndromes are associated with hospice use, independently of age and comorbidities. Methods: The study population included Ohio residents age 65 years or older, diagnosed with breast (n=774), prostate (n=271), or colorectal cancer (n=1,011) during the period 07/1999–12/2001, receiving care through the Medicare fee-for-service system, and first receiving home health care (HHC) in the 30 days before or after cancer diagnosis. This strategy was aimed at obtaining clinical data at baseline, as documented in the HHC Outcome Assessment Information Set (OASIS). Our data source consisted of records from the Ohio Cancer Incidence Surveillance System (OCISS) linked with Medicare data, and the OASIS. In addition to descriptive analyses, multivariable logistic regression analysis was conducted to evaluate the association between hospice use, comorbidity, functional limitations, and geriatric syndromes, after adjusting for patient and tumor attributes. Results: Respectively across the anatomic cancer sites, hospice was used by 9.8%, 22.5%, and 25.1%, of patients. Hospice use increased significantly with age, and was higher among men than women. No differences in hospice use were observed by race, Medicaid status, or the presence of comorbidities. Conversely, hospice use was significantly higher (p &lt; 0.001) among patients with functional limitations (24.0% vs. 16.5% in all others), and those with geriatric syndromes (23.8% vs. 15.3% in all others). Results from the multivariable logistic regression analysis indicated that comorbidities and functional limitations were not associated with hospice use, whereas patients with geriatric syndromes were 1.5 times as likely as those without geriatric syndromes to use hospice (adjusted odds ratio (AOR): 1.5, 95% confidence interval (1.2–1.9). Conclusions: The findings highlight the importance of clinical data that extend beyond comorbidities, when analyzing hospice use. Given marked differences in the disease trajectory across the anatomical cancer sites, future studies should analyze these associations separately in breast, prostate, and colorectal cancer patients. No significant financial relationships to disclose.

Ability of Medicare Claims Data to Identify Nursing Home Patients

There are currently no Medicare claims-based algorithms to identify patients receiving nursing home care (NHC). This constitutes an important limitation in outcome studies using population-based data. To assess the ability of claims data to identify patients receiving NHC, using the nursing home Minimum Data Set (MDS) as the gold standard. We hypothesized that physician claims carrying relevant Evaluation and Management (E&M) procedure codes would be an adequate source to identify nursing home patients. Cross-sectional study using the Ohio Cancer-Aging Linked Database, developed by linking records from the Ohio Cancer Incidence Surveillance System with multiple sources of data, including Medicare enrollment and claims files, and the MDS. Patients 65 years of age or older residing in Ohio, and diagnosed with incident breast, prostate, or colorectal cancer during years 1997-2001. We limited our study cohort to fee-for-service patients receiving NHC during calendar year 2002, with a look-back period in the claims data to November 2001. Sensitivity and positive predictive value (PPV). Sensitivity, or the proportion of patients identified through the MDS file who were also successfully identified through the claims data was 88.1%. PPV, or the proportion of patients with the relevant E&M codes who were also identified in the MDS file was 83.9%. Carrier files may be an acceptable data source to identify nursing home patients, paving the way for future risk adjustment techniques to account for nursing home status.

Radiotherapy and Survival in Prostate Cancer Patients: A Population-Based Study

To investigate the association of overall and disease-specific survival with the five standard treatment modalities for prostate cancer (CaP): radical prostatectomy (RP), brachytherapy (BT), external beam radiotherapy, androgen deprivation therapy, and no treatment (NT) within 6 months after CaP diagnosis. The study population included 10,179 men aged 65 years and older with incident CaP diagnosed between 1999 and 2001. Using the linked Ohio Cancer Incidence Surveillance System, Medicare, and death certificate files, overall and disease-specific survival through 2005 among the five clinically accepted therapies were analyzed. Disease-specific survival rates were 92.3% and 23.9% for patients with localized vs. distant disease at 7 years, respectively. Controlling for age, race, comorbidities, stage, and Gleason score, results from the Cox multiple regression models indicated that the risk of CaP-specific death was significantly reduced in patients receiving RP or BT, compared with NT. For localized disease, compared with NT, in the monotherapy cohort, RP and BT were associated with reduced hazard ratios (HR) of 0.25 and 0.45 (95% confidence intervals 0.13-0.48 and 0.23-0.87, respectively), whereas in the combination therapy cohort, HR were 0.40 (0.17-0.94) and 0.46 (0.27-0.80), respectively. The present population-based study indicates that RP and BT are associated with improved survival outcomes. Further studies are warranted to improve clinical determinates in the selection of appropriate management of CaP and to improve predictive modeling for which patient subsets may benefit most from definitive therapy vs. conservative management and/or observation.

Breast cancer treatment and survival outcomes in relation to age and care settings

6583 Background: Breast cancer treatment and outcomes have been examined by age, but not by care setting - a construct that reflects patients' level of dependence that may not be captured through comorbidity measures. This study aims at filling this knowledge gap. Methods: Using the Cancer-Aging Linked Database (CALD), developed by linking the Ohio Cancer Incidence Surveillance System, Medicare and Medicaid files, home health care Outcome Assessment Information Set, long-term care Minimum Data Set, death certificates, and U.S. Census data, we identified women ≥65 years old diagnosed with local or regional stage breast cancer from July 2000 through December 2001, with deaths through December 2005. Multivariable logistic regression and Cox-proportional hazards models were developed to assess the association between age (age ≥ 80 versus younger), care settings (community dwelling (CD), home health care (HHC), or nursing home care (NHC)), and outcomes of interest after adjusting for patient covariates. Results: Of 3,050 patients, 33% were ≥80 years, 6% received HHC, and 3% received NHC. Patients who were less likely to receive lumpectomy with radiotherapy (versus mastectomy) were older, (versus younger, Adjusted odds ratio (AOR) = 0.54, 95% confidence interval (CI) =0.44–0.65); received NHC (versus CD, AOR = 0.24, CI=0.10–0.58); had regional disease (versus local, AOR=0.25, CI=0.20–0.31); and had negative hormone-receptor status (versus positive, AOR=0.50, CI=0.36–0.67). Older patients and those who received NHC were nearly twice as likely as their younger and community dwelling counterparts, respectively, to undergo lumpectomy without radiotherapy. Receipt of lumpectomy with radiotherapy was associated with favorable breast cancer survival. Conclusions: Careful evaluation to identify the oldest old, and nursing home patients who can and do receive lumpectomy with radiotherapy may improve breast cancer survival in this vulnerable population. No significant financial relationships to disclose.

Polypharmacy in elders with cancer: An analysis of the Ohio medicaid population

19550 Background: Polypharmacy in the elderly complicates therapy, increases cost of treatment and is a challenge to healthcare agencies. However, the impact of polypharmacy on the care of the older cancer patient has been poorly described. The objective of this study was to characterize the use of pharmacy drugs in the month preceding cancer diagnosis among Ohio Medicaid beneficiaries 65 years of age or older, and diagnosed with incident breast, prostate, or colorectal cancer during the study period 1997–2001. Methods: Medicaid beneficiaries were identified by linking data from the Ohio Cancer Incidence Surveillance System (OCISS) with Medicaid enrollment and claims files on a year-by-year basis. Because of potentially incomplete claims history, the study was limited to patients who were enrolled in Medicaid continuously in the year preceding initial cancer diagnosis. Additionally, those with spenddown or nursing home stay in that time frame were excluded from the analysis. Demographics, anatomic cancer site and stage were retrieved from the OCISS, and all non-pharmacy claims for services received in the year prior to cancer diagnosis were accounted for in deriving the Charlson comorbidity score. Results: The study population included 652 patients: 282 with incident breast cancer, 111 with prostate cancer, and 259 with colorectal cancer. The median age was 73, 74, and 75 years among breast, prostate, and colorectal cancer patients, respectively. Nearly 45% were prescribed at least one type of medication in the month preceding cancer diagnosis. Of those with any prescription in that time period, nearly 49% were prescribed 5 or more types of medications. The most commonly prescribed types of medication were narcotic analgesics, diuretics and potassium replacement, anti- hypertensive agents, laxatives, antianxiety drugs, and antidpressants. No significant variations in the use of medications were observed across the different subgroups of the study population. Conclusions: Polpypharmacy (5 or more types of medication) was present in more than 22% of patients in this study population. The effects of polpypharmacy above and beyond that of comorbidities, disability, and other geriatric syndromes, relative to cancer-related outcomes should be determined. No significant financial relationships to disclose.

A comparison of spatial clustering and cluster detection techniques for childhood leukemia incidence in Ohio, 1996 – 2003

BackgroundSpatial cluster detection is an important tool in cancer surveillance to identify areas of elevated risk and to generate hypotheses about cancer etiology. There are many cluster detection methods used in spatial epidemiology to investigate suspicious groupings of cancer occurrences in regional count data and case-control data, where controls are sampled from the at-risk population. Numerous studies in the literature have focused on childhood leukemia because of its relatively large incidence among children compared with other malignant diseases and substantial public concern over elevated leukemia incidence. The main focus of this paper is an analysis of the spatial distribution of leukemia incidence among children from 0 to 14 years of age in Ohio from 1996–2003 using individual case data from the Ohio Cancer Incidence Surveillance System (OCISS).Specifically, we explore whether there is statistically significant global clustering and if there are statistically significant local clusters of individual leukemia cases in Ohio using numerous published methods of spatial cluster detection, including spatial point process summary methods, a nearest neighbor method, and a local rate scanning method. We use the K function, Cuzick and Edward's method, and the kernel intensity function to test for significant global clustering and the kernel intensity function and Kulldorff's spatial scan statistic in SaTScan to test for significant local clusters.ResultsWe found some evidence, although inconclusive, of significant local clusters in childhood leukemia in Ohio, but no significant overall clustering. The findings from the local cluster detection analyses are not consistent for the different cluster detection techniques, where the spatial scan method in SaTScan does not find statistically significant local clusters, while the kernel intensity function method suggests statistically significant clusters in areas of central, southern, and eastern Ohio. The findings are consistent for the different tests of global clustering, where no significant clustering is demonstrated with any of the techniques when all age cases are considered together.ConclusionThis comparative study for childhood leukemia clustering and clusters in Ohio revealed several research issues in practical spatial cluster detection. Among them, flexibility in cluster shape detection should be an issue for consideration.

Complexity of care needs and unstaged cancer in elders: A population-based study

Background: Little is known about the contribution of older patients’ complexity of care needs (COCN) to unstaged cancer, or incomplete evaluation of the extent of disease. We aimed at examining the association between the patients’ COCN at baseline and unstaged cancer. Methods: The study used linked databases consisting of the Ohio Cancer Incidence Surveillance System (OCISS), Medicare and Medicaid enrollment files, the home health care Outcome and Assessment Information Set (OASIS), and the Long Term Care Minimum Data Set (MDS). The study population included patients 65 years of age or older diagnosed with incident breast ( n = 4404), prostate ( n = 5334), or colorectal cancer ( n = 4822) in year 2000. The outcome of interest was unstaged cancer. Patients were identified with high COCN if they were admitted to a nursing home, with moderate COCN if they received home health services, and with low COCN if they were neither admitted to a nursing home nor received home health services, at baseline, or in the 6 months prior to cancer diagnosis. We employed logistic regression analyses to evaluate the independent association between COCN and unstaged cancer after adjusting for patient demographics and socioeconomic attributes. Results: The proportion of unstaged cases increased significantly with older age, by Medicaid status, and by COCN at baseline. Compared with patients with low COCN, those with higher complexity were four to five times as likely to have unstaged cancer. Conclusion: The occurrence of unstaged cancer follows a systematic pattern of increase by age, Medicaid status, and COCN at baseline.

Comorbidity, Disability, and Geriatric Syndromes in Elderly Cancer Patients Receiving Home Health Care

To assess the prevalence of comorbidity, disability, and geriatric syndromes, or a combination thereof, in elders with cancer receiving home health care (HHC). Using the Ohio Cancer Incidence Surveillance System, we identified Ohio residents 65 years of age or older who were diagnosed with incident breast (n = 952), prostate (n = 324), or colorectal cancer (n = 1,276) during the 28-month study period, August 1999 through November 2001. We used the Outcome and Assessment Information Set, a database compiling comprehensive assessment forms completed for all HHC patients, to group individuals in independent and overlapping categories of comorbidity, disability, and geriatric syndromes on the basis of the patients' clinical condition 14 days before the date of the assessment. The proportion with no comorbidity, disability, or geriatric syndromes was 26.4% in breast cancer patients, 12.0% in prostate cancer patients, and 14.0% in colorectal cancer patients. The proportion of patients presenting all three entities at once was 11.7%, 24.7%, and 15.7%, respectively, in three cancer sites. As expected, the proportion of patients with no comorbidity, disability, or geriatric syndromes declined gradually with increasing age, and that of patients with all three entities was highest among patients 85 years or older. The proposed taxonomy will help us gain a more nuanced understanding of older cancer patients' clinical presentation and may lead to a more accurate identification of older patients who might benefit from standard cancer treatment, and those who might experience adverse outcomes.

Ability of Medicaid claims data to identify incident cases of breast cancer in the Ohio Medicaid population.

The use of Medicaid data to study cancer-related outcomes would be highly desirable. However, the accuracy of Medicaid claims data in the identification of incident cases of breast cancer is unknown. (1) To estimate the sensitivity of Medicaid claims data for case ascertainment of breast cancer, and (2) to determine the positive predictive value (PPV) of diagnostic and procedure codes retrieved from Medicaid claims, using the Ohio Cancer Incidence Surveillance System (OCISS) as the gold standard. The study used the linked OCISS and Medicaid enrollment files, 1997-1998 (n = 1,648). The claims search yielded 2,635 incident cases, of which 1,132 were also identified through the OCISS-Medicaid files. Sensitivity and PPV of Medicaid data were calculated in subgroups of the population. The overall sensitivity was 68.7 percent, but varied greatly across the subgroups of the population. It was lower among women enrolled in Medicaid only for part of the study year than those enrolled in Medicaid for 12 months of the study year (56.7 percent and 78.0 percent respectively, p < 0.0001), and lower among those who are dual Medicare-Medicaid eligible compared to those not participating in the Medicare program (63.1 percent and 78.6 percent respectively, p < 0.0001). The overall PPV was 43.0 percent, increasing up to 86.6 percent in the presence of procedure codes indicating the presence of mastectomy and lumpectomy, in addition to that of breast cancer diagnosis. The sensitivity of Medicaid claims for case ascertainment of breast cancer is somewhat low, but improves considerably when accounting for women enrolled in Medicaid for the entire duration of the study year. The PPV is poor due to a high rate of false positives. The higher PPV obtained in the presence of procedure codes, in addition to diagnosis codes, will help researchers to correctly identify incident cases of breast cancer using Medicaid claims data.