Annual Meeting Proceedings Part 1 - American Society of Clinical ...

382s Health Services Research
6000 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
Racial disparities in breast cancer survival. Presenting Author: Jeffrey H.
Silber, The Children’s Hospital of Philadelphia and The University of
Pennsylvania Perelman School of Medicine, Philadelphia, PA
Background: Reducing racial disparities in breast cancer survival has been a
federal priority since the early 1990’s. We present a new method to assess
disparities using sequential multivariate matching. We ask if racial disparities
have increased or decreased over time and if so, what were potential
reasons for such changes. Methods: We studied all women over 65 years of
age in the Medicare fee for service system diagnosed with breast cancer
between 1991 and 2005 who were treated in one of 12 SEER sites (the
sites in SEER since 1991). There were 5,251 black patients (74% early
stage (I-III), 9% late stage (IV) and 17% missing stage) and 72,695 white
patients (81% early stage, 5% late stage and 14% missing stage). All black
cases represented the focal group for all matches. Using multivariate
matching and the propensity score, white controls were matched to blacks
in steps: (1) White controls matched to black cases on age and year of
diagnosis; (2) Age, year of diagnosis, and stage; (3): Age, year, stage,
estrogen receptor status, grade, and 30 comorbidities. We then compare
5-year survival in the Pre and Post-Taxane periods (1991-1998, 1999-
2005). Results: When whites were matched to blacks on age and diagnosis
year, 5-year Kaplan-Meier survival was 69.2% vs. 56.7%, P � 0.0001.
Matching additionally on stage, differences � 64.1% vs. 56.7%, P �
0.0001; Matching further on tumor characteristics and 30 comorbidities,
the disparity reduced to 61.6% vs. 56.7%, P � 0.0001. Comparing trends
over time, white-black differences in survival matched for age and year were
67.6% vs. 55.2% (P � 0.0001) in the pre-Taxane era (difference �
12.4%) and 71.2% vs. 58.7% (P � 0.0001) in the post Taxane era
(difference � 12.5%); age and year matched paired racial differences were
not different across eras (P � 0.389). Conclusions: While there may have
been some improvements in overall survival, racial disparities in breast
cancer survival have not improved, despite important policy initiatives and
treatment advances. Adjusting for presentation at diagnosis does reduce
differences in survival, but even these differences remain large and
significant, suggesting that differences in both presentation and treatment
given presentation are contributing to this disparity.
6002 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
An international study of multitrial data investigating quality of life and
symptoms as prognostic factors for survival in different cancer sites.
Presenting Author: Chantal Quinten, European Organisation for Research
and Treatment of Cancer Headquarters, Brussels, Belgium
Background: The prognostic value for survival of HRQOL data derived from
self-report questionnaires, has been well documented in cancer research.
The objective of this study was to examine the prognostic value of HRQOL
parameters for different cancer sites using one standardized and validated
patient self-assessment tool. Methods: A total of 11 different cancer sites,
pooled from 30 European Organisation for Research and Treatment of
Cancer (EORTC) Randomized Controlled Trials (RCTs), were selected for
this study. For each cancer site, univariate and multivariate Cox proportional
hazard modeling was used to assess the prognostic value (p�0.05) of
15 HRQOL parameters, assessed with the EORTC QLQ-C30 at baseline
before randomization, for overall survival. Models were adjusted for the
parameters age, gender, distant metastasis, World Health Organization
performance status and stratified by clinical study. Results: A total of 7,417
patients completed the EORTC QLQ-C30 before randomization. For brain
cancer cognitive functioning (CF) (hazard ratio (HR) �0.95; p�.0001) was
prognostic. For breast cancer nausea and vomiting (NV) (HR�1.17;
p�0.0011) was a prognostic indicator. For colorectal cancer physical
functioning (PF) (HR�0.93; p�.0001), NV (HR�1.07; p�.0001), and
appetite loss (AP) (HR�1.07; p�.0001) predicted survival. For esophageal
cancer PF (HR�0.88; p�0.0072) and for head and neck cancer NV
(HR�1.14; p�0.0097) were prognostic. For lung cancer PF (HR�0.94;
p�0.0006) and pain (HR�1.08; p�0.0001), for melanoma dyspnea
(HR�1.06; p�.0001), for ovarian cancer NV (HR�1.2; p�.0001), for
pancreatic cancer global QOL (HR�0.83; p�0.0073), for prostate cancer
role functioning (RF) (HR�0.96; p�0.006) and AP (HR�1.07; p�.0001),
and for testis cancer RF (HR�0.81; p�0.0144) were predictors of
survival. Conclusions: Our findings show that different HRQOL parameters
provide prognostic information for survival for patients with different tumor
sites and that no single HRQOL scale can predict survival in all cancer
patients. Thus, each cancer site needs careful examination and no single
QOL paramenter can predict survival in all cancer diseases.
6001 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
Competing causes of mortality in long-term survivors of head and neck
cancer. Presenting Author: Shrujal S. Baxi, Memorial Sloan-Kettering
Cancer Center, New York, NY
Background: Most head and neck cancers (HNC) recur within the first 3 yrs
of diagnosis. Patients who live beyond this time point continue to have an
excess risk of mortality. We investigated the causes of mortality in 3-yr
survivors of HNC. Methods: We completed a retrospective cohort study
using the Surveillance Epidemiology and End Results (SEER) database. We
identified patients with a diagnosis of non-metastatic HNC between 1992
and 2005 who survived 3 yrs from diagnosis. The primary outcome was
death from all-causes, HNC, non-HNC malignancy, cardiovascular disease
(CVD), and pulmonary disease (PD). We estimated the age-adjusted
standardized mortality ratio (SMR; observed-to-expected (O/E)) and the
absolute excess risk (AER; O-E), for all-cause and cause-specific mortality
compared to US population data. Results: 31,772 long-term survivors were
identified with disease arising in the larynx (40%), oral cavity (29%),
oropharynx (26%), nasopharynx (3%) and hypopharynx (1%). In this
cohort, 8191 (26%) were female, 3021 (10%) were black and 15,321
(48%) were younger than 60 yrs. In this cohort, 16,697 (53%) had
locally-advanced disease and 8353 (26%), 8721(27%) and 13,919
(44%) received radiation alone, surgery alone or both. With a median
follow-up of 6.4 years (3-17 years), there were 10,757 deaths due to: HNC
(24%), non-HNC malignancy (31%), CVD (21%), PD (6%), and other
causes (19%). Compared to the US population, the all-cause SMR was 5.4
(95% CI 5.3-5.6) with an AER of 336 deaths per 10,000 person-years (py).
The greatest excess risk was attributable to non-HNC malignancies (956
per 10,000 py), CVD (533 per 10,000 py) and pulmonary disease (136 per
10,000 py). Conclusions: HNC survivors experience excess mortality
compared to the general population. Competing causes of mortality
challenge long-term survival. Additional analytic studies with detailed data
on tobacco history, treatment characteristics and co-morbidities are
required to further evaluate associations with specific causes of death and
individualize risk in this heterogenous population of survivors.
6003 Oral Abstract Session, Sat, 3:00 PM-6:00 PM
Regional variation in Medicare spending and survival among older adults
with advanced cancer. Presenting Author: Gabriel Brooks, Dana-Farber
Cancer Institute, Boston, MA
Background: There is substantial regional variation in medical spending in
the United States. Whether this variation extends to spending for cancer
care and is associated with cancer survival outcomes is unknown. Methods:
Patients aged 65 and older with incident advanced cancer were identified
from the Surveillance, Epidemiology and End Results (SEER)-Medicare
linked database. Advanced cancers included lung (stage IIIB/IV), pancreas
(stage III/IV) colorectal, breast and prostate (stage IV). Medicare spending
from 2 months pre-diagnosis until death or 12 months post-diagnosis was
totaled in 2010 USD for Medicare-enrolled advanced cancer patients from
80 hospital referral regions (HRR’s). HRRs were then ranked by mean
composite 14-month spending and grouped into quintiles. The hazard ratio
for death was assessed in each disease cohort for the comparison between
the quintiles with lowest (Q1, referent) and highest (Q5) composite
spending. Results: Mean composite 14-month spending ranged from
$143,870 to $303,902 in HRR’s with the lowest and highest spending
(Mason City, IA and Los Angeles, CA). As shown in the table, increased
spending was associated with decreased risk of death for lung, colorectal
and pancreas cancer but not for prostate or breast cancer. Conclusions:
There is substantial regional variation in Medicare spending for patients
with advanced cancer. This variation is associated with modest differences
in risk of death between the lowest and highest quintiles of spending for
lung, colorectal and pancreas cancer.
Cohort Patients
Mean spending
Cohort Quintile 1 Quintile 5 Q1/Q5
ratio
HR for death,
Q5 vs Q1 p
Lung 36,312 $236,553 $192,477 $292,213 1.52 0.91 (0.87-0.94) �.0001
Colorectal 9,912 $315,087 $261,545 $370,685 1.42 0.90 (0.83-0.97) 0.008
Pancreas 6,993 $220,424 $169,396 $278,345 1.64 0.84 (0.78-0.91) �.0001
Prostate 5,596 $153,376 $117,055 $195,460 1.67 1.09 (0.91-1.30) 0.363
Breast 3,344 $222,661 $173,479 $270,266 1.56 1.01 (0.87-1.19) 0.859
Composite 62,157 $229,058 $183,615 $281,740 1.53 NA NA
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