Clinical outcomes of hematopoietic growth factors and the value of neoadjuvant chemotherapy in a large cohort of elderly patients with advanced ovarian cancer

Erythropoietin stimulating agent (ESA) and granulocyte colony stimulating factor (CSF) are hematopoietic growth factors used to treat chemotherapy related bone-marrow suppression in cancer patients. While successful use has been demonstrated in controlled experimental trials of patients with advanced stage ovarian cancer, little is known about the usefulness and safety of these agents in routine clinical practice. Notably, there has also been a slight deviance in the standard-line of treatment for advanced ovarian cancer in recent years; wherein the tumor lump is treated by administering first-line neoadjuvant chemotherapy compared to primary debulking surgery. While, an on-going deliberation on the usefulness of this practice continues till date, none have studied the monetary feasibility of the procedure. The objectives of this dissertation were to conduct a population-based analysis to evaluate the effectiveness and adverse-events associated with growth factor use in a cohort of elderly women with advanced stage ovarian cancer. In addition, the project also estimated the cost-effectiveness of administering neoadjuvant chemotherapy (NAC) compared to primary debulking surgery (PDS), using data from the linked Surveillance Epidemiology and End Results (SEER)-Medicare database. The first study explored the effectiveness of ESA (i.e., epoetin-alfa and darbepoetin-alfa) and CSF (i.e., filgrastim and pegfilgrastim) in reducing blood transfusion needs and neutropenia incidence, respectively, and also assessed the effect of these agents on overall survival. Depending on the number of claims administered, use of an ESA lowered the need for blood transfusion by 48-78%, and use of a CSF reduced the incidence of neutropenia by 68-98%. An overall survival advantage was observed among patients who received CSF only; while, those who received ESA only experienced a higher mortality after 24 months. The second study assessed the risk of thromboembolic and pulmonary toxicities in patients who received ESA and/or CSF. Of 8,188 patients included, 24% received ESA only, 13% CSF received only and 30% received ESA+CSF. The cumulative-incidence of thromboembolic and pulmonary toxicities at two and six-months of follow-up was highest among patients who received ESA+CSF, with deep vein thrombosis, stroke, myocardial infarction, dyspnea/ respiratory abnormalities, anaphylaxis/ allergic reactions and other/ unclassified events occurring more commonly. The multivariate Cox regression model showed that patients who received ESA+CSF were at a 1.2 times higher risk of a thromboembolic event; which may be up to 5-folds higher in patients who were \u3e85 years. However, there was no significant difference in the risk of pulmonary toxicities depending on growth factor use. The third study estimated the cost-effectiveness of NAC compared to PDS from a payer perspective. Of 4,843 cases that were included, 12% received NAC before surgery and 88% received PDS. Patients who received NAC incurred an average lifetime cost that was $17,417 more than those who received PDS. At only 0.1 incremental life-year gained, the ICER estimate was$174,173. On stratifying the analysis by risk groups (categorized based on tumor stage, patient age and comorbidity score), the incremental costs and gain in life-years in the high risk subgroup treated with NAC was $34,390 and 0.8 life-years, resulting in an ICER of$42,987. However, NAC use was dominated by PDS in the non-high risk subgroup (i.e., more costly, less effective). In conclusion, the population-based effectiveness of hematopoietic growth factors in elderly patients with advanced ovarian cancer is consistent with evidence from clinical trials and currently existing clinical guidelines. Since patients who receive both ESA and CSF may be at an increased risk of thromboembolic toxicities, the risk-benefit ratio must be carefully evaluated prior to administering these agents. This is particularly important for patients aged 85 years and over. Finally, the use of NAC prior to surgery may be a cost-effective treatment approach for patients in the high risk subgroup, at the ‘traditional’ levels of willingness to pay; though, similar outcomes are not supported for the overall ovarian cancer sample or patients in the non-high risk subgroup

Attitudes of south asian women to breast health and breast cancer screening: Findings from a community based sample in the United States

Background: Breast cancer incidence is increasing among South Asian migrants to the United States (US). However, their utilization of cancer screening services is poor. This study characterizes attitudes of South Asians towards breast health and screening in a community sample. Materials and Methods: A cross-sectional survey based on the Health Belief Model (HBM) was conducted among South Asians (n=124) in New Jersey and Chicago. The following beliefs and attitudes towards breast cancer screening were assessed-health motivation, breast self-examination confidence, breast cancer susceptibility and fear, and mammogram benefits and barriers. Descriptive statistics and Spearman rank correlation coefficients were computed for HBM subscales. Findings: Mean age of participants was 36 years with an average 10 years stay in the US. Most women strived to care for their health (3.82±1.18) and perceived high benefits of screening mammography (3.94±0.95). However, they perceived lower susceptibility to breast cancer in the future (2.30±0.94). Conclusions: Increasing awareness of breast cancer risk for South Asian women may have a beneficial effect on cancer incidence because of their positive attitudes towards health and breast cancer screening. This is especially relevant because South Asians now constitute one of the largest minority populations in the US and their incidence of breast cancer is steadily increasing

Association of medication adherence quality measures for diabetes, hypertension, and hyperlipidemia with cognitive decline

Background: While diabetes, hypertension, and hyperlipidemia each are associated with increased risk of cognitive decline, little is known regarding how nonadherence to medications for these conditions is associated with cognitive decline risk. Methods: We identified patients enrolled in a Medicare Advantage Prescription Drug plan who were eligible for inclusion in the CMS Star Medication Adherence quality measures for diabetes, hypertension, and hyperlipidemia in 2018, 2019, and 2020. To achieve an adherence quality measure, patients had to meet 80% of the proportion of days for the medication. We used propensity score with inverse probability of treatment weighting to balance outcomes for baseline characteristics and logistic regression models to compare odds of cognitive decline outcomes across patient groups. Results: The study population of 99,774 individuals had a mean age of 71.0 years and was 49.1% female, 73.9% White, and 17.8% Black, with 62.0% living in an urban setting. Compared with patients who missed zero adherence measures, those who missed one measure had 23%–33% increased odds of cognitive decline (any decline OR = 1.23; dementia OR = 1.33; Alzheimer's disease OR = 1.27; all P values <0.01). Patients who missed 2–3 measures had 37%–96% increased odds of cognitive decline (any decline OR = 1.37; dementia OR = 1.58; Alzheimer's disease OR = 1.96; all P values <0.01). Patients who missed ≥4 adherence measures had the greatest odds of cognitive decline (any decline OR = 1.64; dementia OR = 2.05; Alzheimer's disease OR = 2.48; all P values <0.01). Conclusion: Not achieving CMS Star Medication Adherence quality measures for diabetes, hypertension, and hyperlipidemia therapies was associated with increased risk of cognitive decline outcomes

Impact of a Mobile Phone Intervention to Reduce Sedentary Behavior in a Community Sample of Adults: A Quasi-Experimental Evaluation

Background: Greater time spent sedentary is linked with increased risk of breast, colorectal, ovarian, endometrial, and prostate cancers. Given steadily increasing rates of mobile phone ownership, mobile phone interventions may have the potential to broadly influence sedentary behavior across settings. Objective: The purpose of this study was to examine the short-term impact of a mobile phone intervention that targeted sedentary time in a diverse community sample. Methods: Adults participated in a quasi-experimental evaluation of a mobile phone intervention designed to reduce sedentary time through prompts to interrupt periods of sitting. Participants carried mobile phones and wore accelerometers for 7 consecutive days. Intervention participants additionally received mobile phone prompts during self-reported sitting and information about the negative health impact of prolonged sedentariness. The study was conducted from December 2012 to November 2013 in Dallas, Texas. Linear mixed model regression analyses were conducted to evaluate the influence of the intervention on daily accelerometer-determined estimates of sedentary and active time. Results: Participants (N=215) were predominantly female (67.9%, 146/215) and nonwhite (black: 50.7%, 109/215; Latino: 12.1%, 26/215; other: 5.6%, 12/215). Analyses revealed that participants who received the mobile phone intervention had significantly fewer daily minutes of sedentary time (B=–22.09, P=.045) and more daily active minutes (B=23.01, P=.04) than control participants. Conclusions: A simple mobile phone intervention was associated with engaging in less sedentary time and more physical activity. Findings underscore the potential impact of mobile phone interventions to positively influence sedentary behavior and physical activity