Reimbursement cuts and changes in urologist use of androgen deprivation therapy for prostate cancer

Abstract Background We examined the impact of urologist academic affiliation on use of androgen deprivation therapy (ADT) for prostate cancer before and after major reimbursement cuts for ADT in hopes of better understanding the influence of financial incentives on its use. In particular, we hypothesized that if financial incentive was the predominant factor driving use, we should see a narrowing in the previously documented gap of ADT use between non-academic and academic urologists following the reimbursement cuts. Methods With the Surveillance, Epidemiology and End-Results (SEER)-Medicare linked database we examined use of ADT for potentially inappropriate indications (primary therapy of localized, lower risk tumors) among patients of 2214 urologists over the period 2000–2002 and 2004–2007, representing eras before and after reimbursement cuts. Multi-level logistic regression models were used to estimate the likelihood of ADT use adjusted for patient, tumor and urologist characteristics (academic affiliation, board certification, years in practice and patient panel size). Results Overall, ADT use peaked in 2002 at 46.6% of patients, but dropped dramatically in 2005, with a slow continued decrease through 2007 to 31.1%. A similar pattern was evident within most strata of urologist characteristics, including academic affiliation. In the multilevel model, patients of non-academic urologists had a 30% higher odds of receiving ADT than those of academic urologists in both the eras before and after the reimbursement cuts. Conclusion A similar proportionate drop in use of ADT among both academic and non-academic urologists following reimbursement cuts suggests that factors other than financial incentives may have played a role.http://deepblue.lib.umich.edu/bitstream/2027.42/110976/1/12894_2015_Article_20.pd

Functional Improvement in Older Adults after a Falls Prevention Pilot Study

Falls are a costly, disabling, and life-threatening risk in the elderly. Improvements in physical function, balance, lower extremity strength, and health-related quality of life are hypothesized to help mitigate fall risk. In this pilot study, six women and men with an average age of 81 years participated in a 6-week exercise and education program created to reduce risk of falls. Evaluations were made at baseline and at 6 weeks on four tests: the Functional Status Questionnaire, the Berg Balance Scale (BBS), the Six-minute Walk Test, and the World Health Organization Quality of Life–BREF 26-question test. Scores indicated significant improvement in functional physical status (activities of daily living), balance, distance walked in 6 min, and quality of life in the physical health domain. The size of this study limits the generalizability of its findings, but its evidence warrants undertaking a larger trial

Gonadotropin-releasing hormone agonist use in men without a cancer registry diagnosis of prostate cancer

<p>Abstract</p> <p>Background</p> <p>Use of gonadotropin-releasing hormone (GnRH) agonists has become popular for virtually all stages of prostate cancer. We hypothesized that some men receive these agents after only a limited work-up for their cancer. Such cases may be missed by tumor registries, leading to underestimates of the total extent of GnRH agonist use.</p> <p>Methods</p> <p>We used linked Surveillance, Epidemiology and End-Results (SEER)-Medicare data from 1993 through 2001 to identify GnRH agonist use in men with either a diagnosis of prostate cancer registered in SEER, or with a diagnosis of prostate cancer based only on Medicare claims (from the 5% control sample of Medicare beneficiaries residing in SEER areas without a registered diagnosis of cancer). The proportion of incident GnRH agonist users without a registry diagnosis of prostate cancer was calculated. Factors associated with lack of a registry diagnosis were examined in multivariable analyses.</p> <p>Results</p> <p>Of incident GnRH agonist users, 8.9% had no diagnosis of prostate cancer registered in SEER. In a multivariable logistic regression model, lack of a registry diagnosis of prostate cancer in GnRH agonist users was significantly more likely with increasing comorbidity, whereas it was less likely in men who had undergone either inpatient admission or procedures such as radical prostatectomy, prostate biopsy, or transurethral resection of the prostate.</p> <p>Conclusion</p> <p>Reliance solely on tumor registry data may underestimate the rate of GnRH agonist use in men with prostate cancer.</p

Cause of Death in Older Men After the Diagnosis of Prostate Cancer

To compare survival and cause of death in men aged 65 and older diagnosed with prostate cancer and with survival and cause of death in a noncancer control population. DESIGN : Retrospective cohort from a population-based tumor registry linked to Medicare claims data. SETTING : Eleven regions of the Surveillance, Epidemiology and End Results (SEER) Tumor Registry. PARTICIPANTS : Men aged 65 to 84 (N=208,601) diagnosed with prostate cancer from 1988 through 2002 formed the basis for different analytical cohorts. MEASUREMENTS : Survival as a function of stage and tumor grade (low, Gleason grade<7; moderate, grade=7; and high, grade=8–10) was compared with survival in men without any cancer using Cox proportional hazards regression. Cause of death according to stage and tumor grade were compared using chi-square statistics. RESULTS : Men with early-stage prostate cancer and with low- to moderate-grade tumors (59.1% of the entire sample) experienced a survival not substantially worse than men without prostate cancer. In those men, cardiovascular disease and other cancers were the leading causes of death. CONCLUSION : The excellent survival of older men with early-stage, low- to moderate-grade prostate cancer, along with the patterns of causes of death, implies that this population would be well served by an ongoing focus on screening and prevention of cardiovascular disease and other cancers.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66098/1/j.1532-5415.2008.02091.x.pd

Hepatitis B vaccination in human immunodeficiency virus-infected adults receiving hemodialysis

Hepatitis B vaccination in human immunodeficiency virus-infected adults receiving hemodialysis.BackgroundThe Centers for Disease Control and Prevention (CDC) recommends hepatitis B virus (HBV) immunization for all hemodialysis (HD) patients because they are at high risk of infection. Several studies have shown that the development of protective antibody titers after HBV vaccination is much lower in HD patients. We hypothesized that human immunodeficiency virus (HIV) infection in patients with end-stage renal disease (ESRD) would further impair the immune response to hepatitis B vaccination.MethodsWe performed a retrospective cohort study of patients undergoing long-term hemodialysis from 1990 to 2002 at the United States-based dialysis facilities of Gambro Corporation, North America. The response rate defined as an increase in anti-HBs levels ≥10 mIU/L after a month of the third dose of HBV vaccination was determined in HIV-infected and a randomly selected group of ESRD patients. The demographic information, laboratory data, and hepatitis B surface antibody (anti-HBs) titers were recorded from the Gambro Corporation database on these patients.ResultsOf the 347 adult HIV ESRD patients, 116 received three doses of recombinant hepatitis B vaccination. Seventy percent were male, and the majority (86%) were black. Of the 116 patients who received three doses of HBV vaccination, 62 (53.4%) developed protective antibody titers. This was comparable to the response rate of 50.4% in the randomly selected 220 non-HIV hemodialysis patients. Among HIV ESRD patients, the mean hemoglobin (Hgb) was higher in patients who developed protective antibody titers (Hgb 11.61 ± 2 vs. 10.55 ± 1.86,P value <0.01). On multivariate logistic regression analysis, higher Hgb was associated with protective antibody titers (odds ratio: 1.34, 95% CI 0.99–1.72). Seventy percent of the HIV-infected responders maintained protective antibody titers 6 months after vaccination.ConclusionHepatitis B vaccination should be offered to all HIV-infected ESRD patients because over half of the patients with HIV and ESRD can develop protective antibodies

Treatment patterns and outcomes in patients with Pancoast tumors: a national cancer database analysis

Background: Pancoast tumors represent 5% of non-small cell lung cancers. Complete surgical resection and no lymph node involvement are important positive prognostic factors. Previous literature has identified neoadjuvant chemoradiation treatment, followed by surgical resection, as the standard of care. But many institutions choose upfront surgery. Our goal was to identify the treatment patterns and outcomes in patients with node-negative Pancoast tumors using the National Cancer Database (NCDB). Methods: The NCDB was queried from 2004 through 2017 to identify all patients who had undergone surgery for a Pancoast tumor. Treatment patterns, including the percentage of patients who received neoadjuvant treatment, were recorded. Logistic regression and survival analyses were used to determine outcomes based on different treatment patterns. Secondary analyses were performed on the cohort who received upfront surgery. Results: A total of 2,910 patients were included in the study. Overall 30- and 90-day mortality were 3% and 7% respectively. Only 25% (717/2,910) of the group received neoadjuvant chemoradiation treatment prior to surgery. Patients who received neoadjuvant chemoradiation treatment experienced significantly improved 90-day survival (P\u3c0.01) and overall survival (P\u3c0.01). When analyzing the cohort who received upfront surgery, there was a statistically significant difference in survival based on adjuvant treatment pattern (P\u3c0.01). Patients in this group who received adjuvant chemoradiation had the best survival, whereas patients who received adjuvant radiation only or no treatment had the worst outcomes. Conclusions: Patients with Pancoast tumors receive neoadjuvant chemoradiation treatment in only a quarter of cases nationally. Patients who received neoadjuvant chemoradiation treatment had improved survival compared to patients who had upfront surgery. Similarly, when surgery is performed first, adjuvant chemoradiation treatment improved survival compared to other adjuvant strategies. These results suggest underutilization of neoadjuvant treatment for patients with node-negative Pancoast tumors. Future studies with a more clearly defined cohort are needed to assess the treatment patterns being utilized on patients with node-negative Pancoast tumors. It will be beneficial to see whether neoadjuvant treatment for Pancoast tumors has increased in recent years

Risk of colorectal cancer in men on long-term androgen deprivation therapy for prostate cancer

Background Androgen deprivation with gonadotropin-releasing hormone (GnRH) agonists or orchiectomy is a common but controversial treatment for prostate cancer. Uncertainties remain about its use, particularly with increasing recognition of serious side effects. In animal studies, androgens protect against colonic carcinogenesis, suggesting that androgen deprivation may increase the risk of colorectal cancer. Methods We identified 107 859 men in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database who were diagnosed with prostate cancer in 1993 through 2002, with follow-up available through 2004. The primary outcome was development of colorectal cancer, determined from SEER files on second primary cancers. Cox proportional hazards regression was used to assess the influence of androgen deprivation on the outcome, adjusted for patient and prostate cancer characteristics. All statistical tests were two-sided. Results Men who had orchiectomies had the highest unadjusted incidence rate of colorectal cancer (6.3 per 1000 person-years; 95% confidence interval [CI] = 5.3 to 7.5), followed by men who had GnRH agonist therapy (4.4 per 1000 person-years; 95% CI = 4.0 to 4.9), and men who had no androgen deprivation (3.7 per 1000 person-years; 95% CI = 3.5 to 3.9). After adjustment for patient and prostate cancer characteristics, there was a statistically significant dose-response effect (Ptrend = .010) with an increasing risk of colorectal cancer associated with increasing duration of androgen deprivation. Compared with the absence of these treatments, there was an increased risk of colorectal cancer associated with use of GnRH agonist therapy for 25 months or longer (hazard ratio [HR] = 1.31, 95% CI = 1.12 to 1.53) or with orchiectomy (HR = 1.37, 95% CI = 1.14 to 1.66). Conclusion Long-term androgen deprivation therapy for prostate cancer is associated with an increased risk of colorectal cance

Changing Population of Liver Transplant Recipients in the Era of Direct-acting Antiviral Therapy

Background and Aims: With the availability of direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection and changing liver disease etiology for liver transplantation (LT), data on the changes in LT recipient population in the DAA era are scanty. Methods: The United Network for Organ Sharing (UNOS) registry (01/2007 to 06/2018) was used to develop a retrospective cohort of LT recipients for HCV, alco-hol-associated liver disease (ALD), and non-alcoholic steato-hepatitis (NASH). LT recipients in the DAA era (2013-2018) were compared with those in the pre-DAA era (2007-2012) era for recipient characteristics. Chi-square and analysis of variance were the statistical tests used for categorical and con-tinuous variables, respectively. Results: Of 40,309 LT recipients (21,110 HCV, 7586 NASH, and 11,713 ALD), the 21,790 in the DAA era (9432 HCV, 7240 ALD, and 5118 NASH) were more likely to be older, female, obese, diabetic, have acute-on-chronic liver failure with a higher model for end-stage liver disease score, receive grafts with a lower donor risk index, and have waited on the LT list for a shorter period compared with their pre-DAA era counterparts. Specific to ALD, LT recipients with alcohol hepatitis were more likely to be younger at the time of LT. Of 9895 LT recipients with hepatocellular carci-noma, recipients in the DAA era were observed to have a higher proportion of HCV (43% vs. 32%,

Probing Primordial Gravitational Waves: Ali CMB Polarization Telescope

In this paper, we will give a general introduction to the project of Ali CMB Polarization Telescope (AliCPT), which is a Sino-US joint project led by the Institute of High Energy Physics (IHEP) and has involved many different institutes in China. It is the first ground-based Cosmic Microwave Background (CMB) polarization experiment in China and an integral part of China's Gravitational Waves Program. The main scientific goal of AliCPT project is to probe the primordial gravitational waves (PGWs) originated from the very early Universe. The AliCPT project includes two stages. The first stage referred to as AliCPT-1, is to build a telescope in the Ali region of Tibet with an altitude of 5,250 meters. Once completed, it will be the worldwide highest ground-based CMB observatory and open a new window for probing PGWs in northern hemisphere. AliCPT-1 telescope is designed to have about 7,000 TES detectors at 90GHz and 150GHz. The second stage is to have a more sensitive telescope (AliCPT-2) with the number of detectors more than 20,000. Our simulations show that AliCPT will improve the current constraint on the tensor-to-scalar ratio $r$ by one order of magnitude with 3 years' observation. Besides the PGWs, the AliCPT will also enable a precise measurement on the CMB rotation angle and provide a precise test on the CPT symmetry. We show 3 years' observation will improve the current limit by two order of magnitude.Comment: 11 pages, 7 figures, 2 table

Use of BRCA Mutation Test in the US, 2004-2014

Introduction BRCA mutation testing has been used for screening women at high risk of breast and ovarian cancer and for selecting the best treatment for those with breast cancer. To optimize the infrastructure and medical resources allocation for genetic testing, it is important to understand the use of BRCA mutation testing in the U.S. health system. Methods This retrospective cohort study included 53,254 adult women with insurance claims for BRCA mutation testing between 2004 and 2014 from ClinformaticsTM Data Mart Database. Data analysis was performed in 2016. This study assessed trends in the use of BRCA mutation testing in women with previously diagnosed breast or ovarian cancer and those without (unaffected women). Results Between 2004 and 2014, of those receiving BRCA testing, the proportion of BRCA tests performed in unaffected women increased significantly (p\u3c0.001), from 24.3% in 2004 to 61.5% in 2014. An increase in the proportion of BRCA tests used in unaffected women was found in each characteristic subgroup. In 2014, most subgroups had a proportion surpassing 50%, except for those aged 51–65 years and those without a family history of breast cancer. There was a much lower proportion of those aged 20–40 years among tested women with previously diagnosed breast or ovarian cancer than in unaffected women (17.6% vs 41.7%, p\u3c0.001). Conclusions During the past decade, the role of BRCA testing has gradually shifted from being used primarily in cancer patients to being used in unaffected women in the U.S