Unstaged Cancer Research Articles

Alzheimer's disease and related dementias is a risk factor for lower utilization of breast cancer screening and unstaged cancer diagnosis: Observational study from SEER-Medicare 2004–2016 data

Alzheimer's disease and related dementias is a risk factor for lower utilization of breast cancer screening and unstaged cancer diagnosis: Observational study from SEER-Medicare 2004–2016 data

Improving documentation of cancer staging at an academic cancer center utilizing an EMR-based system with public accountability.

197 Background: Accurate TNM staging of malignancy is essential to quality care of cancer patients but maintaining consistent documentation of appropriate staging remains a challenge. We identified documentation of TNM staging at our institution to be below target levels. We sought to improve documentation of staging in all patients at our cancer center with a diagnosis of malignancy by implementing both automated and manual reminders through our electronic medical record (EMR) software (Epic), as well as by using team accountability. Methods: We defined an expectation that all patients seen at UC San Diego Moores Cancer Center with a billing diagnosis of malignancy would have TNM staging documented in the EMR within 1 month of their initial visit. The project started in 1/2016, with a phased rollout to individual teams, including education and outreach prior to the start of performance tracking. We used the AJCC staging module in Epic and focused on all new patient visits with a billing diagnosis of malignancy. Providers were asked to add this diagnosis to the problem list and then document the stage using the AJCC staging module in EPIC. We tracked compliance by individual provider and by team and emailed performance reports to all providers on a monthly basis. To facilitate compliance, we initiated automatic Epic messages to providers for an unstaged cancer diagnosis on the problem list and followed up with a personal email from administrative staff if documentation was not completed in a timely manner. Results: At the initiation of this project, there was no standardized documentation of cancer staging. The project was phased in with the skin cancer and head and neck cancers teams in phase I. Compliance in the initial month of measurement was 28%. Within 3 months of implementation of the project, compliance was over 50%, and within 27 months, over 90%. Compliance has remained > 90% since. For 3/2020, 368 patients were eligible for staging and 98% were staged within a month of their visit. Conclusions: Documentation of TNM staging of malignancy was significantly improved by both automated and personal reminders with a vital component of team accountability. Further efforts to improve the current practice and culture of documentation for diagnosed cancer patients remains a crucial aspect of quality and safety.

Effect of physician-level performance feedback on pattern of structured cancer stage entry.

141 Background: In contrast to unstructured free text, structured entry of cancer type and stage facilitates easy utilization of this clinically important data to accurately identify patient population, measure and report performance on outcomes and quality of care as well as for various clinical decision support systems. There is significant variation in physician utilization of Electronic Medical Record based staging modules which capture the data in structured form. The aim of study is to increase structured cancer staging by providing performance feedback to individual physicians. Methods: An EPIC based physician performance feedback report was developed consisting of staging tool utilization performance captured by percentage of staged patients out of all the patients seen by the provider as well as the MRN link (to act upon) of the un-staged patients with stageable cancer diagnosis using criteria: 1) un-staged cancer on the problem list 2) active treatment plan and 3) seen by provider in last one year. Reports were sent monthly to the providers starting 11/1/2015. Pre-intervention structured staging rates were compared with 6- and 12-month post-intervention rates. Results: EPIC patient data was used to determine the number of patients eligible for staging. In 12 months prior to the intervention, 36% (n = 414/1164) of patients eligible for staging were staged in the structured staging module. After the intervention, the 6- and 12-month staging rates were 60% (n = 836/1387) and 68% (n = 1084/1585), respectively, suggesting an absolute improvement of 89% in structured stage entry. Conclusions: Performance feedback to oncology providers resulted in behavior change and dramatically improved rates of structured cancer staging. Availability of such structured data is essential for development, implementation and evaluation of various quality improvement interventions and strategies such as quality reporting, outcomes analysis, practice patterns, and other population health initiatives. Incremental and large-scale improvement in care processes and outcomes may be achieved through such individual-level feedback mechanisms and contribute to learning health care systems.

Unstaged cancer: Long-term decline in incidence by site and by demographic and socioeconomic characteristics.

The study of trends in stage at diagnosis contributes to understand disease burden and the effects of cancer control activities. However, a proportion of cancers reported to registries have insufficient information to assign stage. The limited research addressing unstaged cancers has noted racial and socioeconomic disparities. Long-term incidence trends for unstaged cancers have not been described. We examined long-term trends in diagnosis of unstaged cancers in the U.S. Surveillance, Epidemiology and End Results (SEER) reporting areas. Incidence of unstaged invasive cancers for primary sites that have a staging scheme was analyzed for the years 1992-2011. JoinPoint regression was used to describe incidence rate trends of unstaged cancers, with analysis stratified by cancer site and by socioeconomic and demographic variables. From 1992 to 1996, 8.6% of invasive cancers were unstaged. A steep decline in the incidence of unstaged cancers, represented by an annual percent change (APC) of -9.16%, was observed from 1997 to 2001, followed by a modest decline. By the end of the study period, 2007-2011, unstaged cancers represented 4.9% of invasive cancers. Unstaged cancers are disproportionately more common for older individuals and those in lower socioeconomic communities. The incidence of unstaged cancers decreased markedly over the period studied. Change in ability to assign stage was seen, possibly related to increased use of advanced imaging like PET scans, and should be considered when evaluating changes in cancer stage distributions over time.

An electronic intervention to improve structured cancer stage data capture.

151 Background: Cancer Staging is critical for prognosticating, treatment planning, outcomes analysis, registry reporting and clinical trial eligibility determination. Oncology EHRs have structured staging modules but use by physicians is inconsistent. Typically, stage is entered as unstructured free text in clinical notes and cannot be used for reporting. Instead, institutions depend the tumor registry (TR) which typically lag 6 months behind. Our Cancer Committee determined that real-time capture of structured cancer staging was an imperative. Methods: We created an EPIC best practice advisory (BPA) decision support tool that requires physicians to enter cancer stage if the following criteria are met: 1)unstaged cancer on the problem list 2)EPIC staging module exists for that cancer 3)physician is from a specialty with staging expertise. This BPA was implemented 12/18/14. If physicians chose not to stage they had to enter a reason why. Choices were: 1) cancer diagnosed before 2014, at which the BPA was permanently removed 2) staging studies not yet completed, at which the BPA fired at a future encounter 3) Not a staging provider, at which the BPA no longer fires for that individual provider 4) Cannot stage: document reason, at which the BPA was permanently removed. Results: We used TR data to determine the number of patients who were eligible for staging. In 12 months prior to the intervention, 1480/5222, or 28% of patients who were eligible for staging were staged in the structured staging module. After we launched the intervention, between 12/18/14 and 4/30/15, 1654/1831 or 90% of eligible patients were staged electronically. This is an absolute improvement of > 200% Conclusions: Electronic decision support can dramatically improve rates of structured staging. Such data allows automated reports for clinical trial screening, outcomes analysis, quality comparisons, and reporting. We are now building automated reports for: clinical trial eligibility, Commission on Cancer/ QOPI breast, colon and lung measures, rates of palliative care consultation for advanced disease and outcome measures like disease free interval by stage and overall survival.

Accuracy and completeness of the New Zealand Cancer Registry for staging of invasive breast cancer

PurposePopulation based cancer registries are an invaluable resource for monitoring incidence and mortality for many types of cancer. Research and healthcare decisions based on cancer registry data rely on the case completeness and accuracy of recorded data. This study was aimed at assessing completeness and accuracy of breast cancer staging data in the New Zealand Cancer Registry (NZCR) against a regional breast cancer register. MethodologyData from 2562 women diagnosed with invasive primary breast cancer between 1999 and 2011 included in the Waikato Breast Cancer Register (WBCR) were used to audit data held on the same individuals by the NZCR. WBCR data were treated as the benchmark. ResultsOf 2562 cancers, 315(12.3%) were unstaged in the NZCR. For cancers with a known stage in the NZCR, staging accuracy was 94.4%. Lower staging accuracies of 74% and 84% were noted for metastatic and locally invasive (involving skin or chest wall) cancers, respectively, compared with localized (97%) and lymph node positive (94%) cancers. Older age (>80 years), not undergoing therapeutic surgery and higher comorbidity score were significantly (p<0.01) associated with unstaged cancer. The high proportion of unstaged cancer in the NZCR was noted to have led to an underestimation of the true incidence of metastatic breast cancer by 21%. Underestimation of metastatic cancer was greater for Māori (29.5%) than for NZ European (20.6%) women. Overall 5-year survival rate for unstaged cancer (NZCR) was 55.9%, which was worse than the 5-year survival rate for regional (77.3%), but better than metastatic (12.9%) disease. ConclusionsUnstaged cancer and accuracy of cancer staging in the NZCR are major sources of bias for the NZCR based research. Improving completeness and accuracy of staging data and increasing the rate of TNM cancer stage recording are identified as priorities for strengthening the usefulness of the NZCR.

Unstaged cancer in a population-based registry: Prevalence, predictors and patient prognosis

Purpose: Information on cancer stage at diagnosis is critical for population studies investigating cancer care and outcomes. Few studies have examined the factors which impact (1) staging or (2) outcomes for patients who are registered as having unknown stage. This study investigated (1) the prevalence of unknown stage at diagnosis on the New Zealand Cancer Registry (NZCR); (2) explored factors which predict unknown stage; (3) described receipt of surgery and (4) survival outcomes for patients with unknown stage. Methods: Patients diagnosed with the most prevalent 18 cancers between 2006 and 2008 (N=41,489) were identified from the NZCR, with additional data obtained from mortality and hospitalisation databases. Logistic and Cox regression were used to investigate predictors of unknown stage and patient outcomes. Results: (1) Three distinct groups of cancers were found based on proportion of patients with unknown stage (low=up to 33% unknown stage; moderate=33–64%; high=65%+). (2) Increasing age was a significant predictor of unknown stage (adjusted odds ratios [ORs]: 1.18–1.24 per 5-year increase across groups). Patients with substantive comorbidity were more likely to have unknown stage but only for those cancers with a low (OR=2.65 [2.28–3.09]) or moderate (OR=1.17 [1.03–1.33]) proportion of patients with unknown stage. (3) Patients with unknown stage were significantly less likely to have received definitive surgery than those with local or regional disease across investigated cancers. (4) Patients with unknown stage had 28-day and 1-year survival which was intermediate between regional and distant disease. Discussion: We found that stage completeness differs widely by cancer site. In many cases, the proportion of unknown stage on a population-based register can be explained by patient, service and/or cancer related factors.

Diagnostic bedside EUS in the intensive care unit: a single-center experience

The knowledge of bedside diagnostic EUS in critically ill patients is limited. To investigate the indications, feasibility, safety, and clinical utility of diagnostic EUS in the intensive care unit (ICU). Retrospective. Tertiary-care referral teaching hospital. All consecutive patients who had EUS done in the ICU within a 6-year period. Bedside EUS and EUS-guided FNA. EUS indications, complications, and impact on management. A total of 64 EUS procedures were performed in 63 patients (38 men, 25 women; age range 27-78 years); 1 patient underwent 2 separate EUS procedures. EUS was performed while the patients were mechanically ventilated in 70% (45/64) of cases. Indications for EUS included jaundice (n = 24), mass of unknown etiology (n = 25), unexplained pancreatitis (n = 7), and staging of known cancer (n = 3). In 5 cases, EUS was used as an alternative to other imaging modalities because of morbid obesity (n = 3) or contraindication to intravenous contrast material (n = 2). Complications included reversible oxygen desaturation (n = 4), nonsustained ventricular tachycardia (n = 1), and transient hypotension (n = 1). Overall, EUS influenced management in 97% (62/64) of cases. Retrospective, single-center study. ICU-based EUS can be performed with few intraprocedural complications and can be a valuable diagnostic modality in the ICU setting. It appears to be particularly useful for determining the etiology of jaundice, masses of unknown etiology, and pancreatitis. It may have particular value as a diagnostic technique on selected patients with unstaged cancer and when morbid obesity or the inability to use intravenous contrast material precludes the use of other imaging modalities in the critically ill patient.

Cancer Often Goes Untreated in LTC Residents

Cancer Often Goes Untreated in LTC Residents

Unstaged cancer in the United States: a population-based study

BackgroundThe current study examines unstaged disease for 18 cancer sites in the United States according to the influence of age, sex, race, marital status, incidence, and lethality.MethodsAnalyses are based on 1,040,381 male and 1,011,355 female incident cancer cases diagnosed during 2000 through 2007. Data were collected by population-based cancer registries in the National Cancer Institute's Surveillance, Epidemiology, and End Results Program.ResultsThe level of unstaged disease was greater in more lethal cancers (e.g., liver, esophagus, and pancreas) compared with less deadly cancers (i.e., colon, urinary bladder, and female breast). Unstaged disease increased with age and is greater among non-married patients. Blacks compared with whites experienced significantly higher levels of unstaged cancers of the stomach, rectum, colon, skin (melanoma), urinary bladder, thyroid, breast, corpus, cervix, and ovaries, but lower levels of unstaged liver, lung and bronchial cancers. Males compared with females experienced significantly lower levels of unstaged cancers of the liver, pancreas, esophagus, and stomach, but significantly higher levels of unstaged lung and bronchial cancer and thyroid cancer. The percent of unstaged cancer significantly decreased over the study period for 15 of the 18 cancer sites.ConclusionTumor staging directly affects treatment options and survival, so it is recommended that further research focus on why a decrease in unstaged disease did not occur for all of the cancer sites considered from 2000 to 2007, and why there are differential levels of staging between whites and blacks, males and females for several of the cancer sites.

Renal cancer paradox

To compare temporal trends in the incidence and mortality of renal cell cancer among blacks and whites for clues to etiologic differences. We examined trends in age-adjusted and age-specific Surveillance Epidemiology and End Results incidence and US mortality rates for renal cancer for 1973 through 2007, as well as nephrectomy rates from surgery codes for kidney cancer for 2000 through 2007. For nearly four decades, incidence rates for renal cell cancer have been rising more rapidly among blacks than whites, leading to a shift in excess from among whites to among blacks, almost entirely accounted for by an excess of localized disease. The incidence patterns are puzzling, as localized renal cell cancer is primarily detected incidentally by imaging, to which blacks have historically had less access. In contrast to the incidence patterns, there has been an unexpected convergence of renal cancer mortality rates, which have been virtually identical among blacks and whites since the early 1990 s. Nephrectomy rates, regardless of stage, were lower among blacks than among whites, despite almost identical cause-specific survival rates in both races. The identical mortality patterns, combined with higher and more rapidly increasing incidence and lower rates of nephrectomies among blacks, suggest that renal cell cancer may tend to be a less aggressive tumor in blacks. This hypothesis is supported by the favorable stage distribution among blacks and their higher survival for distant and unstaged cancer. Further research into the enigmatic descriptive epidemiology and the biology and natural history of renal cell cancer may shed light on the etiology of this malignancy and its more frequent occurrence among black Americans.

Organizational Characteristics and Cancer Care for Nursing Home Residents

We evaluate whether organization, market, policy, and resident characteristics are related to cancer care processes and outcomes for dually eligible residents of Michigan nursing homes who entered facilities without a cancer diagnosis but subsequently developed the disease. DATA SOURCES/STUDY DESIGN/DATA COLLECTION: Using data from the Michigan Tumor Registry (1997-2000), Medicare claims, Medicaid cost reports, and the Area Resource File, we estimate logistic regression models of diagnosis at or during the month of death and receipt of pain medication during the month of or month after diagnosis. Approximately 25 percent of the residents were diagnosed at or near death. Only 61 percent of residents diagnosed with late or unstaged cancer received pain medication during the diagnosis month or the following month. Residents in nursing homes with lower staffing and in counties with fewer hospital beds were more likely to be diagnosed at death. After the Balanced Budget Act (BBA), residents were more likely to be diagnosed at death. Nursing home characteristics and community resources are significantly related to the cancer care residents receive. The BBA was associated with an increased likelihood of later diagnosis of cancer.

Absence of Cancer Diagnosis and Treatment in Elderly Medicaid-Insured Nursing Home Residents

Little is known about the effect cancer has on the lives of nursing home patients and the quality of care, including palliative care, delivered to them. Using a statewide population-based dataset assembled from the Michigan Tumor Registry and Medicare records, we identified 1907 elderly Medicaid-insured nursing home residents who were diagnosed with cancer between 1997 and 2000. Logistic regression models were used to estimate odds ratios (ORs) and relative risks (RRs) according to age, race, sex, income, comorbidity, and cancer site for late or unstaged cancer at diagnosis, death within 3 months of diagnosis, receipt of hospice care, and--for patients diagnosed with early-stage breast, colorectal, lung, or prostate cancer--the likelihood of cancer-directed surgery. All statistical tests were two-sided. Nursing home residents diagnosed with cancer had a preponderance of late or unstaged disease (62%), high mortality within 3 months of diagnosis (48%), and low hospice use if they had distant-stage cancer (28%). Only 22% received cancer-directed surgery, 61% of which was confined to breast cancer patients, and only 6% of patients received chemotherapy and/or radiation. Older age was positively associated with late or unstaged cancer and with death within 3 months of diagnosis. Patients aged 71-75 years were more likely to have cancer-directed surgery than patients aged 86 years and older (OR = 2.83, 95% confidence interval [CI] = 1.26 to 6.32; RR = 1.37, 95% CI = 1.08 to 1.75). African American patients were less likely to receive surgery (OR = 0.51, 95% CI = 0.26 to 0.99; RR = 0.80, 95% CI = 0.62 to 1.03) than white patients. Other demographic characteristics and comorbid conditions had little predictive value with regard to cancer treatment or hospice use in nursing home patients. Very few cancer services are provided to Medicaid-insured nursing home patients, despite the fact that many of these patients likely experienced cancer-related symptoms and marked physical decline before diagnosis and death. A middle ground between what would be considered guideline treatment practices and the apparent absence of diagnosis and treatment is needed.

Older Survivors and Cancer Care

The current sizeable population of cancer survivors has brought to the forefront key issues related to treatment decisions, management of adverse consequences of cancer and its treatment, and complex health needs related to cancer and other chronic comorbid conditions ( 1 ). Although improvements in cancer diagnosis, early detection, and treatment have led to dramatically increasing numbers of cancer survivors, cancer continues to be the second most common cause of death in the United States, and an estimated 1 444 920 new patients are expected to be diagnosed with cancer during this year alone ( 2 ). Cancer survivorship research focuses on the health and life of individuals living with the late or long-term effects of can cer or its treatment(s). By defi nition, patients living with advanced disease are cancer survivors. Individuals older than age 65 account for 60% of the estimated 10.8 million cancer survivors in the United States today ( 1 ). With the aging of the population, a rising trend in numbers of older cancer survivors is expected. Given the median age at diagnosis (67 years; all sites combined) and increasing survival estimates, comorbid conditions, especially among older survivors, are and will be an important factor in treatment decisions, posttreatment follow-up care, and palliative care ( 3 , 4 ). Studies have demonstrated that the presence of comorbid health conditions and perceived health vulnerability of the elderly by physicians can lead to under- or less aggressive treatment of the elderly, with resulting poor prognoses. Comorbidity in older patients may limit the ability to obtain (or for patients to undergo procedures that furnish) prognostic information (eg, axillary lymph node dissection), minimize treatment options (eg, breast-conserving therapy), and increase the risk of death from causes other than cancer ( 5 ). We propose that “cancer-related care” can be envisioned at four levels: 1) acute treatment of the cancer; 2) surveillance and follow-up care for disease recurrence, management of adverse treatment – related consequences and noncancer comorbidities; 3) palliative care for advanced cancer; and 4) end-of-life care. Supportive and palliative care have been recognized as important components of quality care for all cancer patients, particularly for those with advanced or incurable disease ( 6 , 7 ). Although it is increasingly accepted that quality palliative care should be provided through an interdisciplinary team approach with a focus on comfort and quality of life ( 8 ), the lack of a strong evidence-based foundation for this important area of research may result in missed treatment opportunities, the provision of nonbenefi cial and burdensome interventions, and over- or undertreatment ( 9 , 10 ). Within palliative surgery and other invasive specialty areas, specifi c concerns include the risks of major morbidity and mortality associated with many cancer-specifi c treatment approaches and the impact of decreased or severely restricted decision-making capacity among patients, especially those who are frail and elderly. The diversity of ethnic, cultural, and religious backgrounds of patients experiencing life- threatening illness at older ages adds further complexity to the provision of acceptable and optimal cancerrelated care. The fact that the Medicaid-insured nursing home patients studied by Bradley et al. ( 11 ), as reported in this issue of the Journal, had a preponderance of late and unstaged disease, high mortality within a few months of diagnosis, low hospice utilization, and little cancer-directed treatment is of concern, and future studies should further examine these issues. Timely cancer treatment and the alleviation of symptoms have the potential to extend life and enhance the quality of survival. Especially noteworthy are the fi ndings that 1) relative to patients aged 86 years and older (the fastestgrowing segment of the US population), patients aged 76 – 80 years and 81 – 85 years were less likely to be diagnosed with late or unstaged cancer at diagnosis; and 2) compared with patients with breast cancer, patients with colorectal, lung, prostate, and other cancers were more likely to be diagnosed with late or unstaged cancer. These results in particular underscore the fact that within the overarching category of “older survivors”, complexities related to early detection and management of the disease increase with age. In addition, some cancers other than breast cancer tended to have been diagnosed relatively late in this study, highlighting the need for vigilance toward possible cancer-related symptoms for some common cancers. These fi ndings also might refl ect the impact of established guidelines and practices relating to mammograms, as opposed to inconsistencies regarding prostate-specifi c antigen testing, colonoscopy, and screening for lung cancer.

Examining the characteristics of unstaged colon and rectal cancer cases

Background: There are only three published studies that have examined unstaged cancers, including breast, prostate and colorectal cancer, but none have specifically examined which aspects of tumor staging were missing. The objective of the study was to identify which stage components were missing, to characterize and to identify predictors of unstaged cancer, and to evaluate prognosis of unstaged in colon and rectal cancer patients. Methods: Data on all colon and rectal cancer cases diagnosed during 1991 to 2002 were identified from the Surveillance, Epidemiology and End Results (SEER) database. Information included in the analysis encompassed socio-demographics; tumor size (T); number of lymph nodes (N); metastases (M); SEER summary stage; SEER sites; cancer treatment; month and year of diagnosis; and last date known alive. Results: The study included 128,418 colon and 44,616 rectal cancer patients. Overall, 5.1% of colon and 7.8% of rectal cancer patients were unstaged. Compared to staged cases, both unstaged colon and rectal cancer cases were more likely to be older, African American, female, diagnosed in the Northeast and South, and have unknown treatment (all p < 0.001). The stage component of M was found to be the factor missing most frequently which attributed most to being unstaged. Survival was significantly higher in unstaged and the overall cohort compared to distant staged colon and rectal cancer patients (both p < 0.001) except for patients ≥ 65 years old ( p > 0.99). Conclusions: Given that unstaged cases differ from staged, the findings have methodological implications in accounting for unstaged cases in epidemiological and health services research.

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.

Cancer Incidence in Kentucky, Pennsylvania, and West Virginia: Disparities in Appalachia

Composed of all or a portion of 13 states, Appalachia is a heterogeneous, economically disadvantaged region of the eastern United States. While mortality from cancer in Appalachia has previously been reported to be elevated, rates of cancer incidence in Appalachia remain unreported. To estimate Appalachian cancer incidence by stage and site and to determine if incidence was greater than that in the United States. Using 1994--1998 data from the central registries of Kentucky, Pennsylvania, and West Virginia, age-adjusted incidence rates were calculated for the rural and nonrural regions of Appalachia. These state rates were compared to rates from the Surveillance, Epidemiology, and End Results (SEER) program for the same years by calculating the adjusted rate ratio (RR) and a 95% confidence interval (CI). Both the entire and rural Appalachian regions had an adjusted incidence rate for all cancer sites similar to the SEER rate (RR = 1.00 [95% CI, 1.00-1.01] and RR = 0.99 [95% CI, 0.99-1.00], respectively). However, incidence of cancer of the lung/ bronchus, colon, rectum, and cervix in Appalachia was significantly elevated (RR = 1.22 [95% CI, 1.20-1.23], 1.13 [95% CI, 1.11-1.14], 1.19 [95% CI, 1.16-1.22], and 1.12 [95% CI, 1.07-1.17], respectively). Incidence of cancer of the lung/bronchus and cervix in rural Appalachia was even more elevated (RR = 1.34 [95% CI, 1.31-1.36] and 1.29 [95% CI, 1.21-1.38], respectively). Incidence of unstaged disease for all cancer sites in Appalachia (RR = 1.06 [95% CI, 1.05-1.08]), particularly rural Appalachia (RR = 1.28 [95%CI, 1.25-1.301), was elevated. Cancer incidence in Appalachia was not found to be elevated. However, incidence of cancer of the lung/bronchus, colon, rectum, and cervix was elevated in Appalachia. The rates of unstaged cancer of every examined site were elevated in rural Appalachia, suggesting a lack of access to cancer health care.

Disparities in the Risk of Cancer of the Colon and Rectum Remaining Unstaged After Diagnosis

Background: Survival from cancer of the colon and rectum is significantly affected by the stage at which it is diagnosed; however, a substantial number of patients remain unstaged after diagnosis. In central cancer registry data, African Americans and rural residents are more likely than Caucasians and urban residents, respectively, to be unstaged at the time of diagnosis. Aim: To estimate the excess risk of unstaged cancer of the colon and rectum among African Americans in a large rural region of the U.S. Methods: Data from central cancer registries (1994-98), health care providers, and the U.S. Census in a three-state region that included a large rural geographic area were analyzed using unadjusted and adjusted hierarchical, logistic regression. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated with SAS software version 8. Results: From 1994-98, 2792 cases of colon and 1519 cases of rectal cancer were unstaged, 6.2 and 9.0 percent of all cases, respectively. Unstaged colon cancer was 1.28 (95% CI 1.11-1.35) and unstaged rectum cancer was 1.01 (0.91-1.14) times more likely in the rural areas than in the nonrural areas. For both colon and rectal cancer, African Americans from rural areas were more likely than Caucasians to have unstaged colon cancer (African Americans, OR=1.49; Caucasians OR=1.28) and rectum cancer (African Americans, OR=1.32; Caucasians OR=1.04). Significant interaction was found for rurality and race, as well as rurality and poverty. Conclusions: After controlling for health care access and demographic variables, these data suggest that persons from rural areas are significantly more likely to have colon and rectum cancer remain unstaged, and in these rural regions, African Americans are even more likely to remain unstaged than are Caucasians. Factors that may contribute to these disparities include patient preference for treatment, provider recommendations about treatment, and unmeasured patient psychosocial issues. The significance of these factors and the overall effect of unstaged disease on health disparities in cancer of the colon and rectum may warrant further investigation.

Rising incidence of intrahepatic cholangiocarcinoma in the United States: a true increase?

Background/ Aims: The incidence of intrahepatic cholangiocarcinoma (ICC) has been reported to be increasing in the USA. The aim of this study is to examine whether this is a true increase or a reflection of improved detection or reclassification. Methods: Using data from the Surveillance Epidemiology and End Results (SEER) program, incidence rates for ICC between 1975 and 1999 were calculated. We also calculated the proportions of cases with each tumor stage, microscopically confirmed cases, and the survival rates. Results: A total of 2864 patients with ICC were identified. The incidence of ICC increased by 165% during the study period. Most of this increase occurred after 1985. There were no significant changes in the proportion of patients with unstaged cancer, localized cancer, microscopic confirmation, or with tumor size <5 cm during the period of the most significant increase. The 1-year survival rate increased significantly from 15.8% in 1975–1979 to 26.3% in 1995–1999, while 5-year survival rate remained essentially the same (2.6 vs. 3.5%). Conclusions: The incidence of ICC continues to rise in the USA. The stable proportions over time of patients with early stage disease, unstaged disease, tumor size <5 cm, and microscopic confirmation suggest a true increase of ICC.

Should the Presence of Lymphvascular Space Involvement Be Used to Assign Patients to Adjuvant Therapy Following Hysterectomy for Unstaged Endometrial Cancer?

The authors conducted a retrospective review of the medical charts of all patients who underwent surgical treatment of invasive adenocarcinoma of the endometrium between 1998 and 2000 at the James Cancer Hospital of Ohio State University College of Medicine. Data from the records of 366 patients who had surgical evaluation of the pelvic lymph nodes were evaluated to investigate the association of lymphvascular space involvement (LVSI) and lymph node metastases from endometrial cancer. The median age at diagnosis was 62 years (range, 27-90). The histological diagnosis was adenocarcinoma in 316 women; 52 patients also had areas of nonendometrioid histology, including uterine papillary serous adenocarcinoma (N = 21 ), clear-cell carcinoma (N = 14), and mixed epithelial adenocarcinoma (N = 17). Forty-four percent of patients were grade 1, 29% were grade 2, and 27% grade 3. Tumor invasion was confined to the inner third of the myometrium in 25% of the women, to the middle third in 43%, and to the outer third in 32%. LVSI was seen in one fourth of the cases, and the mean number of lymph nodes removed was 21.6. Forty-six women (13%) had metastases to the pelvic nodes (pelvic nodes only, N = 32; pelvic and para-aortic nodes, N = 14). More than one third of the patients (245 of 366) had stage 1 disease, 29 had stage II, 80 had stage III, and 12 women were stage IV. Ninety-two patients (25%) had tumor emboli in the lymphvascular spaces of the myometrium, and 46 of these patients had metastatic disease in the pelvic lymph nodes (P <.001). After statistical analysis, the association of LVSI with lymph node metastases remained significant (P <.001). Myometrial invasion was also found to have a significant association with positive pelvic nodes (P <.05 for invasion into the inner third of the myometrium, P <.01 for invasion into the middle third, and P <.001 in the outer third). When both variables were compared, LVSI was significantly associated with deeply invasive tumors (P <.001). Multivariate analysis, which included LVSI, tumor grade, patient age, depth of tumor invasion, and lymph node yield, found depth of invasion and LVSI to be significant predictors of metastatic disease in the pelvic lymph nodes (P <.004 and P <.04, respectively).