Purpose To update the ASCO clinical practice guideline on adjuvant endocrine therapy on the basis of emerging data on the optimal duration of treatment, particularly adjuvant tamoxifen. Methods ASCO convened the Update Committee and conducted a systematic review of randomized clinical trials from January 2009 to June 2013 and analyzed three historical trials. Guideline recommendations were based on the Update Committee’s review of the evidence. Outcomes of interest included survival, disease recurrence, and adverse events. Results This guideline update reflects emerging data on duration of tamoxifen treatment. There have been five studies of tamoxifen treatment beyond 5 years of therapy. The two largest studies with longest reported follow-up show a breast cancer survival advantage with 10-year durations of tamoxifen use. In addition to modest gains in survival, extended therapy with tamoxifen for 10 years compared with 5 years was associated with lower risks of breast cancer recurrence and contralateral breast cancer.

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Adjuvant Endocrine Therapy for Women With Hormone Receptor–Positive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Focused Update

STUDY DESIGN Retrospective review of a prospective cohort. OBJECTIVE To determine the incidence, causes, and risk factors for 30-day unplanned readmissions after lumbar spine surgery. SUMMARY OF BACKGROUND DATA The rising costs associated with lumbar spinal surgery have received national attention. Recently, the government has chosen to target 30-day readmissions as a quality measure. Few studies have specifically analyzed the incidence, causes, and risk factors for readmission in a multicenter patient cohort. METHODS A large, multicenter clinical registry was queried for all patients undergoing lumbar spine surgery in 2012. Current Procedural Terminology codes were used to select patients undergoing lumbar discectomy, laminectomy, anterior and posterior fusions, and multilevel deformity surgery. Thirty-day readmissions rates and causes were identified and analyzed. Univariate and multivariate logistic regression analyses were used to identify patient characteristics, comorbidities, and operative variables predictive of readmission. RESULTS Overall, 695 of 15,668 patients undergoing lumbar spine surgery had unplanned 30-day hospital readmissions (4.4%). When separated by procedure type, readmissions were lowest after discectomy, 3.3%, and highest after deformity surgery, 9.0% (P < 0.001). The top causes for readmission were wound-related (38.6%), pain-related (22.4%), thromboembolic (9.4%), and systemic infections (8.0%). Predictors of readmission included advanced patient age more than 80 years (P = 0.03), African American race (P = 0.03), recent weight loss (P = 0.04), chronic obstructive pulmonary disorder (P < 0.01), history of cancer (P = 0.04), creatinine more than 1.2 (P < 0.01), elevated ASA class (P = 0.01), operative time more than 4 hours (P = 0.01), and prolonged hospital length of stay more than 4 days (P < 0.01). CONCLUSION Thirty-day unplanned readmission rates increased with procedure invasiveness. Both medical and surgical reasons contributed to readmission, many unavoidable. Surgeons should explore optimization measures for those at risk of early, unplanned readmission. LEVEL OF EVIDENCE 3.

Causes and risk factors for 30-day unplanned readmissions after lumbar spine surgery.

Purpose For breast cancer, guidelines direct the delivery of adjuvant systemic therapy on the basis of lymph node status, histology, tumor size, grade, and hormonal receptor status. We explored how race/ethnicity, insurance, census tract-level poverty and education, and hospital Commission on Cancer (CoC) status were associated with the receipt of guideline-concordant adjuvant systemic therapy. Methods Locoregional breast cancers diagnosed in 2004 (n = 6,734) were from the National Program of Cancer Registries–funded seven-state Patterns of Care study of the Centers for Disease Control and Prevention. Predictors of guideline-concordant (receiving/not receiving) adjuvant systemic therapy, according to National Comprehensive Cancer Network Guidelines, were explored by logistic regression. Results Overall, 35% of women received nonguideline chemotherapy, 12% received nonguideline regimens, and 20% received nonguideline hormonal therapy. Significant predictors of nonguideline chemotherapy included Medicaid in...

Influence of Race, Insurance, Socioeconomic Status, and Hospital Type on Receipt of Guideline-Concordant Adjuvant Systemic Therapy for Locoregional Breast Cancers

OBJECT The rate of 30-day readmissions is rapidly gaining significance as a quality metric and is increasingly used to evaluate performance. An analysis of the present 30-day readmission rate in the spine literature is needed to aid the development of policies to decrease the frequency of readmissions. The authors examine 2 questions: 1) What is the 30-day readmission rate as reported in the spine literature? 2) What study factors impact the rate of 30-day readmissions? METHODS This study was registered with Prospera (CRD42014015319), and 4 electronic databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) were searched for articles. A systematic review and meta-analysis was performed to assess the current 30-day readmission rate in spine surgery. Thirteen studies met inclusion criteria. The readmission rate as well as data source, time from enrollment, sample size, demographics, procedure type and spine level, risk factors for readmission, and causes of readmission were extrapolated from each study. RESULTS The pooled 30-day readmission rate was 5.5% (95% CI 4.2%-7.4%). Studies from single institutions reported the highest 30-day readmission rate at 6.6% (95% CI 3.8%-11.1%), while multicenter studies reported the lowest at 4.7% (95% CI 2.3%-9.7%). Time from enrollment had no statistically significant effect on the 30-day readmission rate. Studies including all spinal levels had a higher 30-day readmission rate (6.1%, 95% CI 4.1%-8.9%) than exclusively lumbar studies (4.6%, 95% CI 2.5%-8.2%); however, the difference between the 2 rates was not statistically significant (p = 0.43). The most frequently reported risk factors associated with an increased odds of 30-day readmission on multivariate analysis were an American Society of Anesthesiology score of 4+, operative duration, and Medicare/Medicaid insurance. The most common cause of readmission was wound complication (39.3%). CONCLUSIONS The 30-day readmission rate following spinal surgery is between 4.2% and 7.4%. The range, rather than the exact result, should be considered given the significant heterogeneity among studies, which indicates that there are factors such as demographics, procedure types, and individual institutional factors that are important and affect this outcome variable. The pooled analysis of risk factors and causes of readmission is limited by the lack of reporting in most of the spine literature.

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Thirty-day readmission rates in spine surgery: systematic review and meta-analysis

Purpose The Cancer and Leukemia Group B (CALGB) C9343 trial found that adjuvant radiation therapy (RT) provided minimal benefits for older women with breast cancer. Although treatment guidelines were changed to indicate that some women could forego RT, the impact of the C9343 results on clinical practice is unclear. Patients and Methods We used the Surveillance, Epidemiology, and End Results (SEER) –Medicare data set to assess the use of adjuvant RT in a sample of women ≥ 70 years old diagnosed with stage I breast cancer from 2001 to 2007 who fulfilled the C9343 inclusion criteria. We used log-binomial regression to estimate the relation between publication of C9343 and use of RT in the full sample and across strata of patient and health system characteristics. Results Of the 12,925 Medicare beneficiaries in our sample (mean age, 77.7 years), 76.5% received RT. Approximately 79% of women received RT before study publication compared with 75% after (adjusted relative risk of receiving RT postpublication v ...

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Assessing the Impact of a Cooperative Group Trial on Breast Cancer Care in the Medicare Population

http://content.stockpr.com/amedica/db/265/628/pdf/30_Day_Readmissions_After_Elective_Spine_Surgery_Medicare_Beneficiaries.pdf

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries.

BACKGROUND:

The authors sought to identify socioeconomic (SES) factors associated with adjuvant hormone therapy (HT) use among a contemporary population of older breast cancer survivors.



METHODS:

Telephone surveys were conducted among women (ages 65-89 years) residing in 4 states (California, Florida, Illinois, and New York) who underwent initial breast cancer surgery in 2003. Demographic, SES, and treatment information was collected.



RESULTS:

Of 2191 women, 67% received adjuvant HT with either tamoxifen or an aromatase inhibitor (AI); 71% of those women were on an AI. When adjusting for multiple demographic and SES factors, predictors of HT use were better education (high school degree or higher), better informational/emotional support, and younger age (ages 65-79 years). Race/ethnicity, income, and insurance coverage for medication costs were not associated with receiving HT. For those on HT, when adjusting for all other factors, women were more likely to receive an AI if they had insurance coverage for some or all medication costs, if they were wealthier, if they had better informational/emotional support, and if they were younger (ages 65-69 years).



CONCLUSIONS:

The majority of older women in this population-based cohort received adjuvant HT, and the adoption of AIs was early. The results indicted that providers should be aware that a woman's education level and support system influence her decision to take HT. Given the high cost of AIs, their benefits in postmenopausal women with hormone receptor-positive breast cancer, and the current finding that women with no insurance coverage for medication costs were significantly less likely to receive an AI, we recommend that policymakers address this issue. Cancer 2011. © 2010 American Cancer Society.

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Socioeconomic factors associated with adjuvant hormone therapy use in older breast cancer survivors.

To the Editor: Prior studies have shown that both tumor registry and administrative databases, including the National Cancer Institute’s Surveillance Epidemiology End Results (SEER) registry and Medicare data, provide valid, accurate and complete information on various treatment modalities for women with breast cancer.1–3 Another alternative to obtain this information is patient self-report. Three studies have shown that breast cancer survivors can accurately recall key treatment information.4–6 However, these studies are relatively small and include largely younger women. Validation of self-report of breast cancer treatments specifically in elderly women is important as over 40% of women with breast cancer are diagnosed at age 65 or older. We sought to determine whether a population-based cohort of older breast cancer survivors could accurately recall key treatment information.

Our study cohort consisted of 3,083 community-dwelling women (65–89 years) residing in 4 states (CA, FL, IL, NY), who underwent initial breast cancer surgery in 2003 and completed a telephone survey at approximately 30 months after breast cancer surgery.7 Self-reported data regarding treatment (breast surgery, radiation therapy, chemotherapy, and reconstructive surgery) were validated against Medicare claims data dated from 1 month prior to breast cancer diagnosis until the time of the survey.8 Agreement was assessed by Cohen’s kappa statistic.9

The mean age of the women when they completed the survey was 76 years (sd 5.5; range, 67–93 years); 94% were Caucasian and the majority were healthy (65% with no comorbidities). Half were married and 92% had at least a high school degree. The median annual household income in 2004 was $29,000. According to Medicare claims, 66% underwent breast-conserving surgery (BCS), 67% underwent radiation therapy, and 21% received chemotherapy. Only 4.6% (n = 143) of the cohort underwent breast reconstruction surgery.

Assuming Medicare claims as the gold standard, the validation of each item on the self-report questionnaire is summarized in Table 1. Overall, agreement was excellent for the four treatments examined. Kappa values varied between 0.83 for type of breast surgery and 0.95 for receipt of radiation therapy. Sensitivity (80%–99%), specificity (98%–99%), positive and negative predictive values (90%–99%) for self-report were high for all four treatments. Accuracy of self-report was not significantly affected by proxy response, patient age group, or educational status (data not shown).



Table 1

Agreement between Self-report and Medicare Claims for Initial Treatment of Breast Cancer*



The agreement for type of breast surgery is likely higher than what is reported. Of the 2,207 women who self-reported undergoing BCS, 214 had Medicare claims for mastectomy; 171 (80%) of these 214 women also had claims for BCS. Therefore, these 171 women presumably underwent initial BCS followed by mastectomy at a later date and were identified by our Medicare claims algorithm8 as total mastectomy cases. Our survey did not capture these 171 women as undergoing eventual mastectomy since a positive response to the BCS survey item was erroneously programmed to skip the next item about mastectomy. Therefore, these 171 women were placed in the BCS self-report group. If these 171 women are re-categorized as self-reported total mastectomy cases, then the sensitivity of self-report for mastectomy increases from 79.7% to 95.9% and the kappa improves from 0.83 to 0.96 (95% CI: 0.95 – 0.97). These values would represent the “best case” scenario and the true agreement likely falls somewhere between those reported in Table 1 and this “best case” scenario.

Our results confirm the validity of self-report described in previous smaller studies in elderly breast cancer survivors6 and younger women.4, 5 Several factors may explain the disagreement between self-report data and Medicare claims in our study. From a survey standpoint, errors may be attributed to biased self-report, women’s recall, or unclear wording of the survey items. We attempted to limit this bias by providing brief descriptions of each type of treatment, referencing the time frame of treatment, and wording questions at the 8th-grade level. Although we assumed that the Medicare claims data were correct, there are limitations of Medicare data regarding accuracy of coding, completeness of claims, and the potential for underreporting due to care provided by other agencies.1, 3

In summary, this study demonstrates that general information regarding several key cancer treatments was accurately reported 2–3 years later by a population-based cohort of over 3,000 elderly breast cancer survivors. Details regarding stage of disease and treatment would likely still need to be obtained from other sources. However, for investigators performing survey studies in breast cancer survivors which require only broad key treatment information (i.e. quality of life or patient satisfaction studies), patient self-report appears to be an excellent, lower-cost alternative for obtaining this information.

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Changbin Guo

Papers

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries.

Socioeconomic factors associated with adjuvant hormone therapy use in older breast cancer survivors.

Elderly breast cancer survivors accurately self-report key treatment information.

Risk of Lymphedema After Breast Cancer Surgery: Relationship Between Surgeon Specialization and the Number of Lymph Nodes Removed