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

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

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

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Timing of androgen deprivation therapy use and fracture risk among elderly men with prostate cancer in the United States

Purpose Fractures are a recognized consequence of androgen deprivation therapy (ADT); however, less is known about the incidence of fracture in relation to the timing of ADT use or the impact of fracture on mortality in men with prostate cancer. Methods Using data from the Surveillance, Epidemiology, and End Results–Medicare linked database, we estimated adjusted hazard ratios (aHRs) using time‐dependent Cox regression for fracture incidence related to the recency of exposure and dose among prostate cancer patients on gonadotropin‐releasing hormone (GnRH) agonists, as well as mortality associated with fractures. Results In our cohort of 80 844 patients, ADT was associated with an increased rate of fracture in both non‐metastatic patients (aHR = 1.34; 95% confidence interval [CI] = 1.29–1.39) and metastatic patients (aHR = 1.51; 95%CI = 1.36–1.67). Fracture rates increased with increasing cumulative GnRH dose but decreased with increasing number of months since last use in each dose category. The mortality rate doubled for men experiencing a fracture after their diagnosis compared with that for men who did not experience a fracture (aHR = 2.05; 95%CI = 1.98–2.12). Conclusions ADT in elderly men with prostate cancer increased the incidence of fractures, and the effect appears to diminish with increasing time since the last dose of a GnRH agonist. Experiencing a fracture after the diagnosis of prostate cancer was associated with decreased survival. Copyright © 2011 John Wiley & Sons, Ltd.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90397/1/pds2258.pd

Survival and cost‐effectiveness of sorafenib therapy in advanced hepatocellular carcinoma: An analysis of the SEER–Medicare database

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135309/1/hep28881-sup-0001-suppinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135309/2/hep28881_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135309/3/hep28881.pd

The temporal and long‐term impact of donor body mass index on recipient outcomes after kidney transplantation – a retrospective study

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Prevalence of renal impairment and use of nephrotoxic agents among patients with bone metastases from solid tumors in the United States

The renal status of patients with bone metastases secondary to solid tumors and their treatment with nephrotoxic agents is not well characterized. This retrospective study analyzed electronic medical records data from US‐based oncology clinics to identify adult (age ≥18) solid tumor patients with first bone metastasis diagnosis and ≥1 serum creatinine recorded between January 1, 2009 and December 31, 2013. Patients with multiple myeloma, multiple primary tumor types, acute renal failure, and/or end‐stage renal disease were excluded. Using the Chronic Kidney Disease Epidemiology Collaboration formula, we determined the prevalence of renal impairment (RI: single estimated glomerular filtration rate [eGFR] value <60 mL/min per 1.73 m2) and chronic kidney disease (CKD: ≥2 eGFR values <60, at least 90 days apart). We also examined the use of intravenous bisphosphonates (IV BP) and other nephrotoxic agents. Approximately half of the 11,809 patients were female. Breast (34%) and lung (28%) tumors were the most common. At bone metastasis diagnosis, mean age was 67 years and 24% of patients exhibited RI. The 5‐year prevalence was 43% for RI and 71% for CKD among RI patients. Nearly half (46%) of CKD patients received IV BP in the 12 months following their confirming eGFR and 13% of these patients received at least one other nephrotoxic agent during that period. This is the first US‐based study to examine the prevalence of RI among patients with bone metastases from solid tumors. RI is common at bone metastases diagnosis, and a substantial proportion of patients develop RI or CKD as their disease progresses. Whenever possible, treatments that are potentially less damaging for the kidney should be considered for patients with or predisposed to RI.In patients with bone metastases secondary to solid tumors, the 5‐year prevalence was 43% for renal impairment (RI) and 71% for chronic kidney disease among evaluable RI patients. Whenever possible, treatments that are potentially less damaging for the kidney should be considered for patients with or predisposed to RI.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111794/1/cam4403.pd

In-Hospital and 1-Year Mortality Trends in a National Cohort of US Veterans with Acute Kidney Injury

BACKGROUND AND OBJECTIVES: AKI, a frequent complication among hospitalized patients, confers excess short- and long-term mortality. We sought to determine trends in in-hospital and 1-year mortality associated with AKI as defined by Kidney Disease Improving Global Outcomes consensus criteria. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study used data from the national Veterans Health Administration on all patients hospitalized from October 1, 2008 to September 31, 2017. AKI was defined by Kidney Disease Improving Global Outcomes serum creatinine criteria. In-hospital and 1-year mortality trends were analyzed in patients with and without AKI using Cox regression with year as a continuous variable. RESULTS: We identified 1,688,457 patients and 2,689,093 hospitalizations across the study period. Among patients with AKI, 6% died in hospital, and 28% died within 1 year. In contrast, in-hospital and 1-year mortality rates were 0.8% and 14%, respectively, among non-AKI hospitalizations. During the study period, there was a slight decline in crude in-hospital AKI-associated mortality (hazard ratio, 0.98 per year; 95% confidence interval, 0.98 to 0.99) that was attenuated after accounting for patient demographics, comorbid conditions, and acute hospitalization characteristics (adjusted hazard ratio, 0.99 per year; 95% confidence interval, 0.99 to 1.00). This stable temporal trend in mortality persisted at 1 year (adjusted hazard ratio, 1.00 per year; 95% confidence interval, 0.99 to 1.00). CONCLUSIONS: AKI associated mortality remains high, as greater than one in four patients with AKI died within 1 year of hospitalization. Over the past decade, there seems to have been no significant progress toward improving in-hospital or long-term AKI survivorship