Publications by authors named "Amy J Davidoff"

112 Publications

ACA Medicaid expansion association with racial disparity reductions in timely cancer treatment.

Am J Manag Care 2021 07;27(7):274-281

Flatiron Health, Inc, 233 Spring St, Fifth Fl, New York, NY 10025. Email:

Objectives: Racial disparities in cancer care and outcomes remain a societal challenge. Medicaid expansion through the Affordable Care Act was intended to improve health care access and equity. This study aimed to assess whether state Medicaid expansions were associated with a reduction in racial disparities in timely treatment among patients diagnosed with advanced cancer.

Study Design: This difference-in-differences study analyzed deidentified electronic health record-derived data. Patients aged 18 to 64 years with advanced or metastatic cancers diagnosed between January 1, 2011, and January 31, 2019, and receiving systemic therapy were included.

Methods: The primary end point was receipt of timely treatment, defined as first-line systemic therapy starting within 30 days after diagnosis of advanced or metastatic disease. Racial disparity was defined as adjusted percentage-point (PP) difference for Black vs White patients, adjusted for age, sex, practice setting, cancer type, stage, insurance marketplace, and area unemployment rate, with time and state fixed effects.

Results: The study included 30,310 patients (12.3% Black race). Without Medicaid expansion, Black patients were less likely to receive timely treatment than White patients (43.7% vs 48.4%; adjusted difference, -4.8 PP; P < .001). With Medicaid expansion, this disparity was diminished and lost significance (49.7% vs 50.5%; adjusted difference, -0.8 PP; P = .605). The adjusted difference-in-differences estimate was a 3.9 PP reduction in racial disparity (95% CI, 0.1-7.7 PP; P = .045).

Conclusions: Medicaid expansion was associated with reduced Black-White racial disparities in receipt of timely systemic treatment for patients with advanced or metastatic cancers.
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http://dx.doi.org/10.37765/ajmc.2021.88700DOI Listing
July 2021

Development and evaluation of a proxy for baseline ECOG PS in advanced non-small cell lung cancer, bladder cancer, and melanoma: An electronic health record study.

Pharmacoepidemiol Drug Saf 2021 Sep 24;30(9):1233-1241. Epub 2021 Jun 24.

Yale University School of Public Health, New Haven, Connecticut, USA.

Purpose: Eastern Cooperative Oncology Group performance status (ECOG PS) is an important predictor for receipt of treatment and overall survival (OS) but is often unreported in routine care. We developed a proxy for baseline ECOG PS using electronic health records (EHRs).

Methods: We analyzed patients who were diagnosed with advanced non-small cell lung cancer (aNSCLC), advanced bladder cancer (aBCa), and advanced melanoma (aMEL) between 2011 and 2018 and had a baseline (reported between diagnosis and treatment) ECOG PS in a real-world database. We used stepwise multivariable logistic regression to model associations between baseline ECOG PS good (<2) versus poor (≥2) and sociodemographic, clinical, and laboratory measures in each cancer type. Predictive accuracy of classifying ECOG PS was assessed. We tested the association between OS and observed and predicted ECOG PS.

Results: In total, 20 697 aNSCLC patients, 2627 aBCa patients, and 2558 aMEL patients constituted the study population. Percentage of patients with poor ECOG PS ranged from 15.3% (aMEL) to 28.5% (aNSCLC). Poor ECOG PS was associated with more comorbid conditions, older age, lower body mass index, metastases, and abnormal laboratory indicators. Overall prediction accuracy using a 0.50 cutpoint was 73.3% for NSCLC, 73.8% for aBCa, and 85.4% for aMEL. The association of OS with ECOG PS was consistent between the observed and proxy measures.

Conclusions: In the EHR-derived data, clinical, sociodemographic, and laboratory information were used to assign ECOG PS and enhance the use of real-world data in outcome studies.
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http://dx.doi.org/10.1002/pds.5309DOI Listing
September 2021

The Association Between the Affordable Care Act and Insurance Status, Stage and Treatment in Patients with Testicular Cancer.

Urol Pract 2020 Jul 1;7(4):252-258. Epub 2020 Jul 1.

Yale Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center.

Purpose: We aimed to determine whether insurance expansions implemented through the Affordable Care Act (ACA) were associated with changes in coverage status, disease stage, and treatment of younger adults with testicular germ cell tumors (GCT).

Materials And Methods: We identified men aged 18-64 diagnosed with testicular GCTs between 2010 and 2015 in the National Cancer Data Base. We defined time periods as: pre-ACA (2010-2013) and post-ACA (2014-2015) and used difference-in-differences (DID) modeling to examine associations between state Medicaid expansion status and changes in insurance, stage at diagnosis, and treatment.

Results: Following the ACA, the proportion of patients with any health insurance increased 3.7% (95% CI 3-4.5) in Medicaid expansion states and 3.0% (95% CI 1.5-4.5) in non-expansion states, mainly by gaining Medicaid and private insurance, respectively. The largest increases occurred in low-income patients, where Medicaid expansion was associated with an adjusted increase of 14.5 percentage points (95% CI 7.2-21.8) in Medicaid coverage following the ACA. We did not observe reductions in late-stage diagnoses during the observation period. Changes in the proportion of patients receiving chemotherapy or radiation for advanced-stage cancers were ongoing prior to the ACA and differed between expansion and non-expansion states, limiting assessment of ACA-related effects on individual treatments.

Conclusions: Post-ACA, the proportion of newly diagnosed testicular cancer patients with health insurance increased, with the largest effects seen among lowest income individuals. Our findings that changes in practice preceded the ACA and differed by expansion status highlight the need for caution in assessing the legislation's impact.
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http://dx.doi.org/10.1097/upj.0000000000000109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130174PMC
July 2020

Fine-tuning the cardiac O-GlcNAcylation regulatory enzymes governs the functional and structural phenotype of the diabetic heart.

Cardiovasc Res 2021 Feb 8. Epub 2021 Feb 8.

School of Biosciences, Parkville, Victoria, Australia, 3010.

Aims: The glucose-driven enzymatic modification of myocardial proteins by the sugar moiety, β-N-acetylglucosamine (O-GlcNAc), is increased in pre-clinical models of diabetes, implicating protein O-GlcNAc modification in diabetes-induced heart failure. Our aim was to specifically examine cardiac manipulation of the two regulatory enzymes of this process on the cardiac phenotype, in the presence and absence of diabetes, utilising cardiac-targeted recombinant-adeno-associated viral-vector-6 (rAAV6)-mediated gene delivery.

Methods And Results: In human myocardium, total protein O-GlcNAc modification was elevated in diabetic relative to non-diabetic patients, and correlated with left ventricular (LV) dysfunction. The impact of rAAV6-delivered O-GlcNAc transferase (rAAV6-OGT, facilitating protein O-GlcNAcylation), O-GlcNAcase (rAAV6-OGA, facilitating de-O-GlcNAcylation) and empty vector (null) were determined in non-diabetic and diabetic mice. In non-diabetic mice, rAAV6-OGT was sufficient to impair LV diastolic function and induce maladaptive cardiac remodelling, including cardiac fibrosis and increased Myh-7 and Nppa pro-hypertrophic gene expression, recapitulating characteristics of diabetic cardiomyopathy. In contrast, rAAV6-OGA (but not rAAV6-OGT) rescued LV diastolic function and adverse cardiac remodelling in diabetic mice. Molecular insights implicated impaired cardiac PI3K(p110α)-Akt signalling as a potential contributing mechanism to the detrimental consequences of rAAV6-OGT in vivo. In contrast, rAAV6-OGA preserved PI3K(p110α)-Akt signalling in diabetic mouse myocardium in vivo and prevented high glucose-induced impairments in mitochondrial respiration in human cardiomyocytes in vitro.

Conclusion: Maladaptive protein O-GlcNAc modification is evident in human diabetic myocardium, and is a critical regulator of the diabetic heart phenotype. Selective targeting of cardiac protein O-GlcNAcylation to restore physiological O-GlcNAc balance may represent a novel therapeutic approach for diabetes-induced heart failure.

Translational Perspective: There remains a lack of effective clinical management of diabetes-induced cardiac dysfunction, even via conventional intensive glucose-lowering approaches. Here we reveal that the modification of myocardial proteins by O-GlcNAc, a glucose-driven process, is not only increased in human diabetic myocardium, but correlates with reduced cardiac function in affected patients. Moreover, manipulation of the two regulatory enzymes of this process exert opposing influences on the heart, whereby increasing O-GlcNAc transferase (OGT) is sufficient to replicate the cardiac phenotype of diabetes (in the absence of this disease), while increasing O-GlcNAc-ase (OGA) rescues diabetes-induced impairments in both cardiac dysfunction and remodelling. Cardiac O-GlcNAcylation thus represents a novel therapeutic target for diabetes-induced heart failure.
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http://dx.doi.org/10.1093/cvr/cvab043DOI Listing
February 2021

End-of-life patterns of symptom management and cancer-directed care among Medicare beneficiaries with lung cancer: a claims-based analysis.

Support Care Cancer 2021 Jul 3;29(7):3921-3932. Epub 2021 Jan 3.

Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA.

Background: Rather than early hospice enrollment, most Medicare beneficiaries receive "usual care" in the last months of life, outside of the hospice setting. While care intensity during the last weeks of life has been studied extensively, patterns of symptom management services (SMS) and/or cancer-directed therapies (CDT) received over a 6-month end-of-life period have not.

Methods: This retrospective study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify decedents diagnosed with lung cancer at age ≥ 66 years between January 2007 and December 2013 who survived ≥ 6 months from diagnosis. Medicare claims identified receipt of SMS and/or CDT. We created monthly indicators for care content (SMS-only, CDT-only, or both; otherwise full-month hospice or inpatient/skilled nursing). Multinomial logistic regression estimated associations between sociodemographics and comorbidity, with care content in the final month.

Results: Between 6 and 1 months before death, full-month hospice and inpatient/skilled nursing increased; CDT decreased from 31.9 to 18.5%; SMS increased from 86.6 to 97.7%. Relative to full-month hospice, the percentage of patients receiving SMS-only was higher for males, unmarried, younger age, and higher comorbidity; the percentage receiving CDT was also higher for males, unmarried, and younger age, but decreased with increasing comorbidity and over calendar time.

Conclusion: Among lung cancer decedents observed in the outpatient, nonhospice setting, SMS receipt increased and was nearly universal as death approached. CDT diminished dramatically over the end-of-life period. Associations between sociodemographic characteristics and care setting suggest differences in care preferences or access barriers. Claims represent an important resource for characterizing end-of-life care patterns.
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http://dx.doi.org/10.1007/s00520-020-05964-2DOI Listing
July 2021

Patterns of medication use at end of life by pediatric inpatients with cancer.

Pediatr Blood Cancer 2021 May 11;68(5):e28837. Epub 2020 Dec 11.

Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.

Objective: To describe medication utilization patterns by pediatric inpatients with cancer during their last week of life.

Methods: This retrospective study used data from the Vizient Clinical Database/Resource Manager, a national compilation of clinical and resource use data from over 100 academic medical centers and affiliates. Patients (0-21 years) with malignancy who died during hospitalization (2010-2017) were included (N = 1659). Medications were categorized as opioid, benzodiazepine, gastrointestinal related, chemotherapy, anti-infectives, or vasopressors. Exposure to each group was ascertained for all patients at 1 week and 1 day prior to death. Factors associated with exposure were examined using generalized estimating equations, and summarized using adjusted odds ratios (aORs).

Results: Over the last week of life, there was increased use of opioids (76% to 82%, aOR = 1.55, P < .001) and benzodiazepines (53% to 66%, aOR = 1.36, P = .02), while gastrointestinal-related medication use decreased (92% to 89%, aOR = 0.69, P = .001). Patients had decreased exposure to chemotherapy (10% to 5%, aOR = 0.46, P < .001) and anti-infectives (82% to 73%, aOR = 0.41, P = .002). Vasopressor use increased as death approached (15% to 28%, aOR = 1.67, P = .04). Factors significantly associated with exposure varied with medication category, and included age, race, length of stay, malignancy type, death in the intensive care unit, history of hematopoietic stem cell transplant, and do-not-resuscitate status.

Conclusion: During the week preceding death, administration of symptom management medications increased for children with cancer, but use was not universal. Potentially life-sustaining medications were often continued. Variability in utilization suggests differences in provider/family decision making that warrant further study to develop an evidence-based approach to end-of-life care.
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http://dx.doi.org/10.1002/pbc.28837DOI Listing
May 2021

A framework for cancer health economics research.

Cancer 2021 Apr 25;127(7):994-996. Epub 2020 Nov 25.

Department of Health Policy and Management, Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, Georgia.

Lay Summary: Cancer has substantial economic impacts for patients, their families and/or caregivers, employers, and the health care system. However, there is only limited understanding of how economic issues can affect access to cancer care services and the receipt of high-quality cancer care. Health economics research in cancer is particularly timely due to the large and increasing number of patients with cancer and cancer survivors, but there are many factors that may create barriers to performing cancer health economics research. This commentary has identified important topics and questions in cancer health economics research and will assist in the development of this critical field.
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http://dx.doi.org/10.1002/cncr.33343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035130PMC
April 2021

Adoption of Immune Checkpoint Inhibitors and Patterns of Care at the End of Life.

JCO Oncol Pract 2020 11 17;16(11):e1355-e1370. Epub 2020 Jul 17.

Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT.

Purpose: As immune checkpoint inhibitors (ICIs) have transformed the care of patients with cancer, it is unclear whether treatment at the end of life (EOL) has changed. Because aggressive therapy at the EOL is associated with increased costs and patient distress, we explored the association between the Food and Drug Administration (FDA) approvals of ICIs and treatment patterns at the EOL.

Methods: We conducted a retrospective, observational study using patient-level data from a nationwide electronic health record-derived database. Patients had advanced melanoma, non-small-cell lung cancer (NSCLC; cancer types with an ICI indication), or microsatellite stable (MSS) colon cancer (a cancer type without an ICI indication) and died between 2013 and 2017. We calculated annual proportions of decedents who received systemic cancer therapy in the final 30 days of life, using logistic regression to model the association between the post-ICI FDA approval time and use of systemic therapy at the EOL, adjusting for patient characteristics. We assessed the use of chemotherapy or targeted/biologic therapies at the EOL, before and after FDA approval of ICIs using Pearson chi-square test.

Results: There was an increase in use of EOL systemic cancer therapy in the post-ICI approval period for both melanoma (33.9% to 43.2%; < .001) and NSCLC (37.4% to 40.3%; < .001), with no significant change in use of systemic therapy in MSS colon cancer. After FDA approval of ICIs, patients with NSCLC and melanoma had a decrease in the use of chemotherapy, with a concomitant increase in use of ICIs at the EOL.

Conclusion: The adoption of ICIs was associated with a substantive increase in the use of systemic therapy at the EOL in melanoma and a smaller yet significant increase in NSCLC.
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http://dx.doi.org/10.1200/OP.20.00010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189605PMC
November 2020

Patterns of Opioid Prescribing among Medicare Advantage Beneficiaries with Pain and Cardiopulmonary Conditions.

J Palliat Med 2021 02 14;24(2):195-204. Epub 2020 Jul 14.

Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA.

Pain is common among patients with cardiopulmonary conditions; however, there are increasing concerns, but limited research, regarding use of opioids for pain in patients with noncancer conditions. To compare patterns of opioid prescribing among older adults reporting pain with cardiopulmonary conditions and/or cancer. Observational study using data from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey resource linked to Medicare Part D prescription claims. We identified patients who self-reported moderate-to-severe pain interference with daily activities. Patients were stratified by (1) self-reported history of cardiopulmonary conditions; (2) were within five years of cancer diagnosis; (3) had both conditions; or (4) neither. We characterized opioid prescribing within 30 days of survey and one-year follow-up using logistic regression and Cox proportional hazard time-to-event analyses. Of 10,516 patients with moderate-to-severe pain (1758 cardiopulmonary conditions, 3383 cancer, 2861 both, 2514 neither), 46% were aged ≥75 years, 65% were non-Hispanic white, and 10% non-Hispanic black. At survey, 1627 (15.5%) received opioids. Adjusted proportions of opioid use were lower for patients with cardiopulmonary conditions only (14%) compared with cancer only (17%;  < 0.001) and both conditions (17%;  < 0.001) but higher than patients with neither condition (13.1%;  < 0.001). There was no difference in time to initiation of opioids at follow-up among patients with cardiopulmonary conditions only, relative to cancer only (adjusted hazard ratio 1.03; 95% confidence interval 0.88-1.21). Opioid use is lower among patients with pain and cardiopulmonary conditions relative to patients with cancer. Findings emphasize the importance of pain assessment and management for patients with cardiopulmonary conditions.
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http://dx.doi.org/10.1089/jpm.2020.0193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7840305PMC
February 2021

Did quality of life for older cancer survivors improve with the turn of the century in the United States?

J Geriatr Oncol 2021 01 10;12(1):102-105. Epub 2020 Jun 10.

Yale School of Medicine, 333 Cedar St, New Haven, CT, USA; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale, 333 Cedar St, New Haven, CT, USA; Yale Cancer Center, 333 Cedar St, New Haven, CT, USA; Department of Therapeutic Radiology at Yale School of Medicine, PO Box 208040, New Haven, CT, USA. Electronic address:

Objectives: Although survival after a cancer diagnosis has improved considerably over the past 20 years, little is known about trends in health-related quality-of-life (HRQOL) for older prostate, breast, and lung cancer survivors.

Methods: Using a population-based registry with longitudinal patient reported outcomes (the National Cancer Institute Surveillance, Epidemiology and End Results database linked to Medicare Health Outcomes Survey), we analyzed Medicare Advantage patients diagnosed with cancer during 1998-2011, who completed surveys regarding HRQOL through 2013. 'Early Era' patients were treated during 1998-2003; 'Late Era' patients were treated during 2006-2011. After propensity score matching, post-diagnosis changes in health utility (HU), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated and compared between the two eras.

Result: We identified 208 older patients with prostate, 276 with breast and 76 with lung cancer who were treated in the 'Early Era' and matched to equal numbers in the 'Late Era'. Mean age of patients in early and late era was 72 and 73 years, respectively. The mean post-diagnosis decline in health utility for patients treated in the 'Late Era' was not significantly different from the 'Early Era' for any cancer (Prostate [early vs. late]: -0.06 vs. -0.03, p = .09; Breast: -0.03 vs. -0.04, p = .65; Lung: -0.07 vs. -0.07, p = .95); nor for Physical Component Summary or Mental Component Summary scores.

Conclusion: Older patients treated for prostate, breast or lung cancer in the later era reported similar outcomes of changes in HRQOL compared to earlier era patients.
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http://dx.doi.org/10.1016/j.jgo.2020.05.010DOI Listing
January 2021

Cost-effectiveness of first-line vs third-line ibrutinib in patients with untreated chronic lymphocytic leukemia.

Blood 2020 10;136(17):1946-1955

Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT.

The ALLIANCE A041202 trial found that continuously administered ibrutinib in the first-line setting significantly prolonged progression-free survival compared with a fixed-duration treatment of rituximab and bendamustine in older adults with chronic lymphocytic leukemia (CLL). In this study, we created a Markov model to assess the cost-effectiveness of ibrutinib in the first-line setting, compared with a strategy of using ibrutinib in the third-line after failure of time-limited bendamustine and venetoclax-based regimens. We estimated transition probabilities from randomized trials using parametric survival modeling. Lifetime direct health care costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated from a US payer perspective. First-line ibrutinib was associated with an improvement of 0.26 QALYs and 0.40 life-years compared with using ibrutinib in the third-line setting. However, using ibrutinib in the first-line led to significantly higher health care costs (incremental cost of $612 700), resulting in an ICER of $2 350 041 per QALY. The monthly cost of ibrutinib would need to be decreased by 72% for first-line ibrutinib therapy to be cost-effective at a willingness-to-pay threshold of $150 000 per QALY. In a scenario analysis where ibrutinib was used in the second-line in the delayed ibrutinib arm, first-line ibrutinib had an incremental cost of $478 823, an incremental effectiveness of 0.05 QALYs, and an ICER of $9 810 360 per QALY when compared with second-line use. These data suggest that first-line ibrutinib for unselected older adults with CLL is unlikely to be cost-effective under current pricing. Delaying ibrutinib for most patients with CLL until later lines of therapy may be a reasonable strategy to limit health care costs without compromising clinical outcomes.
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http://dx.doi.org/10.1182/blood.2020004922DOI Listing
October 2020

Chromosome 1 abnormalities and survival of patients with multiple myeloma in the era of novel agents.

Blood Adv 2020 05;4(10):2245-2253

Cancer Outcomes, Public Policy, and Effectiveness Research Center and.

Chromosome 1 abnormalities (C1As) are common genetic aberrations among patients with multiple myeloma (MM). We aimed to evaluate the significance of C1As among a contemporary cohort of patients with MM in the United States. We used electronic health records from the Flatiron Health database to select patients newly diagnosed with MM from January 2011 to March 2018 who were tested using fluorescence in situ hybridization within 90 days of diagnosis. We characterized patients as having documented C1As or other high-risk chromosomal abnormalities (HRCAs) as defined by the Revised-International Staging System (R-ISS) such as del(17p), t(14;16), and t(4;14). We used Kaplan-Meier methods to compare overall survival (OS) of patients with or without C1As and stratified log-rank tests (with the presence of HRCAs as a stratifying variable). We used Cox proportional hazards regression models to compare OS, adjusting for age, sex, stage, HRCAs, and type of first-line therapy. Of 3578 eligible patients, 844 (24%) had documented C1As. Compared with patients without C1As, patients with C1As were more likely to have higher stage (R-ISS stage III; 18% vs 12%), to have HRCAs (27% vs 14%), and to receive combinations of proteasome inhibitors and immunomodulatory agents (41% vs 34%). Median OS was lower for patients with C1As (46.6 vs 70.1 months; log-rank P < .001). C1As were independently associated with worse OS (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-2.69; P < .001), as were older age, higher R-ISS stage, HRCAs, and immunoglobulin A isotype. C1As were associated with inferior OS, independent of other HRCAs, despite greater use of novel therapies. Clinical trials testing newer therapies for high-risk MM should incorporate patients with C1As.
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http://dx.doi.org/10.1182/bloodadvances.2019001425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252537PMC
May 2020

Clinical outcomes of older patients with AML receiving hypomethylating agents: a large population-based study in the United States.

Blood Adv 2020 05;4(10):2192-2201

Cancer Outcomes, Public Policy, and Effectiveness Research Center.

The hypomethylating agents (HMAs) azacitidine and decitabine have been the de facto standard of care for patients with acute myeloid leukemia (AML) who are unfit for intensive therapy. Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 2263 older adults (age ≥66 years) diagnosed with AML during 2005-2015 who received a first-line HMA; 1154 (51%) received azacitidine, and 1109 (49%) received decitabine. Median survival from diagnosis was 7.1 and 8.2 months (P < .01) for azacitidine- and decitabine-treated patients, respectively. Mortality risk was higher with azacitidine vs decitabine (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.01-1.21; P = .02). The findings were similar when evaluating only patients completing ≥4 cycles (42% of patients treated with either azacitidine or decitabine). These findings lost significance when evaluating those completing a standard 7-day schedule of azacitidine (34%) vs 5-day schedule for decitabine (66%) (HR, 0.95; 95% CI, 0.83-1.08; P = .43). Red blood cell (RBC) transfusion independence (TI) was achieved in one-third of patients with no difference between the 2 HMAs. In conclusion, the majority of older AML patients did not receive the minimum of 4 cycles of HMA often needed to elicit clinical benefit. We observed no clinically meaningful differences between azacitidine- and decitabine-treated patients in their achievement of RBC TI or survival.
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http://dx.doi.org/10.1182/bloodadvances.2020001779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252544PMC
May 2020

Patterns of care and clinical outcomes with cytarabine-anthracycline induction chemotherapy for AML patients in the United States.

Blood Adv 2020 04;4(8):1615-1623

Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT; and.

Cytarabine-anthracycline based intensive induction chemotherapy (IC) remains the standard of care for remission induction among fit patients with newly diagnosed acute myeloid leukemia (AML) in the United States (US). However, the mortality rate outside of clinical IC trials, predictors of death, and resource utilization during admission for IC have not been thoroughly examined. We used the Premier Healthcare database to identify adult patients (aged 18-89 years) treated with cytarabine-anthracycline-based IC during their first recorded inpatient stay for AML during the contemporary period of 2010 to 2017. We identified factors associated with inpatient death or discharge to hospice, using multivariable logistic regression models. We also assessed the patterns of inpatient healthcare resource utilization. A total of 6442 patients with AML from 313 hospitals who were treated with IC were identified. Median age was 61 years (interquartile range [IQR], 50-68 years), and 56% were men. Median length of stay was 29 (IQR, 25-38) days, with rates of in-hospital death and discharge to hospice of 12.3% and 3.7% (17.9% and 6.3% among patients aged ≥65 years), respectively. Predictors of in-hospital death or discharge to hospice included older age, geographic region, and lower hospital volume. During admission, 28.0%, 12.6%, and 4.0% of patients required treatment in intensive care units, mechanical ventilation, and dialysis, respectively. Despite improvements in supportive care in the contemporary era, inpatient mortality during first hospitalization for adult patients with AML treated with IC in the US remains high particularly among older patients.
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http://dx.doi.org/10.1182/bloodadvances.2020001728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189301PMC
April 2020

Severe functional limitation due to pain & emotional distress and subsequent receipt of prescription medications among older adults with cancer.

J Geriatr Oncol 2020 07 10;11(6):960-968. Epub 2020 Mar 10.

Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, Yale Cancer Center, 333 Cedar Street, New Haven, CT 06510, USA; Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA.

Background: Certain cancer types and subsequent treatment can cause or worsen pain and emotional distress, leading to functional limitation, particularly among a growing population of older adults with cancer.

Methods: We constructed a national sample of older adult Medicare beneficiaries with cancer using the 2007-2012 Surveillance, Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database linked to Medicare Part D enrollment and prescription claims data. MHOS survey responses described functional limitations due to pain and emotional distress. Using multivariable logistic regression, we estimated the association between participant characteristics and patient-reported functional limitation due to pain and emotional distress and subsequent prescription medication use.

Results: Among 9105 older adults with cancer, aged 66-102 years (y), 68.6% reported moderate to severe functional limitation due to pain, and 48.3% reported moderate to severe functional limitation due to emotional distress. Nearly 10% reported severe functional limitation due to co-occurring symptoms of pain and emotional distress. Significant predictors of severe functional limitation due to co-occurring symptoms included age ≥ 80y (ref: 66-69y, adjusted relative risk (aRR): 1.74; 95% confidence interval (CI) 1.39-2.18, p < .001), stage IV disease at diagnosis (ref: stage I, aRR: 2.08; CI 1.52-2.86, p < .001), and lung cancer (ref: breast cancer, aRR: 1.84; CI 1.30-2.61, p < .001). Among 892 participants reporting co-occurring symptoms, 32.5% received neither pain nor emotional distress prescription medication.

Conclusions: Functional limitation due to pain and emotional distress persist among older adults with cancer, particularly octogenarians. Efforts to identify and target unmet supportive care needs to maintain functional independence are needed.
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http://dx.doi.org/10.1016/j.jgo.2020.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346676PMC
July 2020

Hypomethylating agent (HMA) therapy use and survival in older adults with Refractory Anemia with Excess Blasts (RAEB) in the United States (USA): a large propensity score-matched population-based study.

Leuk Lymphoma 2020 05 26;61(5):1178-1187. Epub 2019 Dec 26.

Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.

Hypomethylating agents (HMA) showed overall survival (OS) benefits in patients with higher-risk myelodysplastic syndromes (HR-MDS) in clinical trials. We conducted a retrospective cohort study of Surveillance, Epidemiology, and End Results (SEER)-Medicare data of patients ≥66 years diagnosed with refractory anemia with excess blasts (RAEB), a proxy for HR-MDS, in 01/2001-04/2004 (pre-period) or 01/2006-12/2011 (post-period). Association between post-period diagnosis and OS was examined using propensity scores (PS)-matched samples. Among 1876 RAEB patients, median OS was 9 months and 30.8% received HMAs (3.6% in pre-period; 43.0% in post-period) with no association between post-period diagnosis and OS. In the top PS quartile, post-period diagnosis was associated with a 74% lower risk of death (Hazard ratio [HR] = 0.26, 95%-CI: 0.10-0.69,  = 0.007), while outcomes were worse in the lowest PS quartile (HR = 2.80, 95%-CI: 1.06-7.36,  = 0.037). HMA lead to a 3-month OS benefit for patients most likely to receive HMA but not for unselected RAEB cohort.
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http://dx.doi.org/10.1080/10428194.2019.1703970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735409PMC
May 2020

Precision Medicine in Oncology II: Economics of Targeted Agents and Immuno-Oncology Drugs.

J Clin Oncol 2020 02 5;38(4):351-358. Epub 2019 Dec 5.

Yale University, New Haven, CT.

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http://dx.doi.org/10.1200/JCO.19.01573DOI Listing
February 2020

Patterns of Symptom Management Medication Receipt at End-of-Life Among Medicare Beneficiaries With Lung Cancer.

J Pain Symptom Manage 2020 04 26;59(4):767-777.e1. Epub 2019 Nov 26.

Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA; Yale School of Public Health, New Haven, Connecticut, USA; Yale Cancer Center, New Haven, Connecticut, USA. Electronic address:

Context: Older adults with advanced lung cancer experience high symptom burden at end of life (EOL), yet hospice enrollment often happens late or not at all. Receipt of medications to manage symptoms in the outpatient setting, outside the Medicare hospice benefit, has not been described.

Objectives: We examined patterns of symptom management medication receipt at EOL for older adults who died of lung cancer.

Methods: This retrospective cohort used the Surveillance, Epidemiology, and End Results-Medicare database to identify decedents diagnosed with lung cancer at age 67 years and older between January 2008 and December 2013 who survived six months and greater after diagnosis. Using Medicare Part B and D claims, we identified monthly receipt of outpatient medications for symptomatic management of pain, emotional distress, fatigue, dyspnea, anorexia, and nausea/vomiting. Multivariable logistic regression estimated associations between medication receipt and patient demographic characteristics, comorbidity, and concurrent therapy.

Results: Of the 16,246 included patients, large proportions received medications for dyspnea (70.7%), pain (62.5%), and emotional distress (49.4%), with lower prevalence for other symptoms. Medication receipt increased from six months to one month before death. Women and dual Medicaid enrolled were more likely to receive medications for pain, emotional distress, dyspnea, and nausea/vomiting. Receipt of symptom management medications decreased with increasing age and racial/ethnical minorities.

Conclusion: Symptom management medication receipt was common and increasing toward EOL. Lower use by males, older adults, and nonwhites may reflect poor access or poor patient-provider communication. Further research is needed to understand these patterns and assess adequacy of symptom management in the outpatient setting.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.11.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338983PMC
April 2020

Patterns of pain medication use associated with reported pain interference in older adults with and without cancer.

Support Care Cancer 2020 Jul 21;28(7):3061-3072. Epub 2019 Oct 21.

The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.

Context: Concerns about the adequacy of pain management among older adults are increasing, particularly with restrictions on opioid prescribing.

Objectives: To examine associations between prescription pain medication receipt and patient-reported pain interference in older adults with and without cancer.

Methods: Using the 2007-2012 Surveillance Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database linked to Medicare Part D prescription claims, we selected MHOS respondents (N = 15,624) aged ≥ 66 years, ≤ 5 years of a cancer diagnosis (N = 9105), or without cancer (N = 6519). We measured receipt of opioids, non-steroidal anti-inflammatory drugs, and antiepileptics, and selected antidepressants within 30 days prior to survey. Patient-reported activity limitation due to pain (pain interference) within the past 30 days was summarized as severe, moderate, or mild/none. Logistic regression using predictive margins estimated associations between pain interference, cancer history, and pain medication receipt, adjusting for socio-demographics, chronic conditions, and Part D low-income subsidy.

Results: Severe or moderate pain interference was reported by 21.3% and 46.1%, respectively. Pain medication was received by 21.5%, with 11.6% receiving opioids. Among adults reporting severe pain interference, opioid prescriptions were filled by 27.0% versus 23.8% (p = 0.040) with and without cancer, respectively. Over half (56%) of adults reporting severe pain in both groups failed to receive any prescription pain medication.

Conclusions: Older adults with cancer were more likely to receive prescription pain medications compared with adults without cancer; however, many older adults reporting severe pain interference did not receive medications. Improved assessment and management of pain among older adults with and without cancer is urgently needed.
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http://dx.doi.org/10.1007/s00520-019-05074-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338979PMC
July 2020

Physician Experience and Risk of Rituximab Discontinuation in Older Adults With Non-Hodgkin's Lymphoma.

J Natl Compr Canc Netw 2019 10;17(10):1194-1202

Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University; and.

Background: Provider experience, or clinical volume, is associated with improved outcomes in many complex healthcare settings. Despite increased complexity of anticancer therapies, studies evaluating physician-level experience and cancer treatment outcomes are lacking.

Methods: A population-based study was conducted of older adults (aged ≥66 years) diagnosed with B-cell non-Hodgkin's lymphoma in 2004 through 2011 using SEER-Medicare data. Analysis focused on outcomes in patients receiving rituximab, the first approved monoclonal anticancer immunotherapy. We hypothesized that lower physician experience using rituximab and managing its infusion-related reactions would be associated with early treatment discontinuation. A 12-month look-back from each initiation of rituximab was used to categorize physician volume (0, 1-2, or ≥3 initiations per year). Modified Poisson regression was used to account for provider-level correlation and estimated relative risk (RR) of early rituximab discontinuation (<3 cycles within 180 days of rituximab initiation). Cox proportional hazards were used to measure the impact of rituximab discontinuation on survival.

Results: Among 15,110 patients who initiated rituximab with 2,684 physicians, 7.6% experienced early rituximab discontinuation. Approximately one-fourth of patients (26.1%) initiated rituximab with a physician who had no rituximab initiations during the preceding 12 months. Compared with patients treated by physicians who had ≥3 rituximab initiations in the prior year, those treated by physicians without initiations were 57% more likely to experience early discontinuation (adjusted RR [aRR], 1.57; 95% CI, 1.35-1.82; P<.001 for 0 vs ≥3, and aRR, 1.19; 95% CI, 1.03-1.37; P=.02 for 1-2 vs ≥3). Additionally, rituximab discontinuation was associated with higher risk of death (adjusted hazard ratio, 1.39; 95% CI, 1.28-1.52; P<.001).

Conclusions: Lower oncologist experience with rituximab was associated with increased risk of early rituximab discontinuation in Medicare beneficiaries with non-Hodgkin's lymphoma. Physician-level volume may be an important factor in providing high-quality cancer care in the modern era.
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http://dx.doi.org/10.6004/jnccn.2019.7314DOI Listing
October 2019

Association of provider experience and clinical outcomes in patients with myelodysplastic syndromes receiving hypomethylating agents.

Leuk Lymphoma 2020 02 1;61(2):397-408. Epub 2019 Oct 1.

Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.

Population level survival of patients with myelodysplastic syndromes (MDS) treated with hypomethylating agents (HMA) is inferior to clinical trials. Using SEER-Medicare data, we identified 2086 MDS patients diagnosed in 2004-13, aged ≥66 years at diagnosis, and receiving ≥1 HMA cycle after 2005. We used multivariate logistic regression and Cox proportional hazards models to assess the impact of provider experience on persistent HMA therapy and overall survival (OS), respectively. Median number of HMA cycles was 4 and median OS was 10 months. Thirty-two percent of patients were treated by providers with ≥1 prior HMA initiation in the last 2 years and were more likely to receive ≥4 cycles of HMA therapy (OR = 1.29, 95% CI = 1.06-1.57;  = .01). No significant association was found between MDS or HMA initiation volume and survival. In conclusion, while HMA initiation volume was associated with persistent HMA treatment, neither MDS nor HMA initiation volumes were associated with OS in older MDS patients.
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http://dx.doi.org/10.1080/10428194.2019.1663423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732188PMC
February 2020

Temporal patterns and predictors of receiving no active treatment among older patients with acute myeloid leukemia in the United States: A population-level analysis.

Cancer 2019 12 4;125(23):4241-4251. Epub 2019 Sep 4.

Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.

Background: The majority of patients with acute myeloid leukemia (AML) are aged >65 years at the time of diagnosis and are not actively treated. The objective of the current study was to determine the prevalence, temporal trends, and factors associated with no active treatment (NAT) among older patients with AML in the United States.

Methods: A retrospective analysis was performed of Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 14,089 patients with AML residing in the United States who were diagnosed with AML at age ≥66 years during 2001 through 2013. NAT was defined as not receiving any chemotherapy, including hypomethylating agents. Multivariable logistic regression models were used to analyze sociodemographic, clinical, and provider characteristics associated with NAT.

Results: The percentage of patients with NAT decreased over time from 59.7% among patients diagnosed in 2001 to 42.8% among those diagnosed in 2013. The median overall survival for the entire cohort was 82 days from the time of diagnosis. Patients treated with NAT had worse survival compared with those receiving active treatment. Variables found to be associated with higher odds of NAT included older age, certain sociodemographic characteristics (household income within the lowest quartile, residence outside the Northeast region of the United States, and being unmarried), and clinical factors (≥3 comorbidities, the presence of mental disorders, recent hospitalization, and disability).

Conclusions: Greater than one-half of older patients with AML residing in the United States do not receive any active leukemia-directed therapy despite the availability of lower intensity therapies such as hypomethylating agents. Lack of active therapy receipt is associated with inferior survival. Identifying predictors of NAT might improve the quality of care and survival in this patient population, especially as novel therapeutic options with lower toxicity are becoming available.
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http://dx.doi.org/10.1002/cncr.32439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733320PMC
December 2019

Underutilization of guideline-recommended supportive care among older adults with multiple myeloma in the United States.

Cancer 2019 Nov 5;125(22):4084-4095. Epub 2019 Aug 5.

Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.

Background: With improving survival for patients with multiple myeloma (MM), supportive care that is focused on optimizing quality of life and minimizing treatment-related toxicities is increasingly important. The extent to which patients with MM are receiving recommended supportive care is unknown.

Methods: This study used the Surveillance, Epidemiology, and End Results-Medicare database to identify older adults (age ≥66 years) diagnosed with MM in 2008-2013 who had received active treatment and survived 1 year or longer after their diagnosis. Outcomes of interest included guideline-recommended supportive care, which was defined as 1) bone-modifying drugs (BMDs) within the 12 months after the diagnosis, 2) influenza vaccination in the first season after the diagnosis, and 3) concomitant use of prophylactic antivirals with proteasome inhibitors. Multivariable logistic regression models were used to evaluate associations between patient/facility-level characteristics and supportive care use.

Results: Among 1996 patients receiving MM-directed therapy, 64%, 52%, and 49% received BMDs, an influenza vaccination, and antiviral prophylaxis, respectively. Non-Hispanic black patients (odds ratio [OR] vs white patients, 0.63; 95% confidence interval [CI], 0.46-0.88) and patients with baseline renal impairment (OR, 0.43; 95% CI, 0.34-0.54) had lower odds of BMDs. Non-Hispanic blacks (OR, 0.52; 95% CI, 0.37-0.73) and those with dual Medicaid enrollment (OR, 0.76; 95% CI, 0.58-0.99) had lower odds of influenza vaccination. Treatment in a community-based setting was associated with reduced odds of antiviral prophylaxis (OR, 0.58; 95% CI, 0.46-0.72).

Conclusions: Substantial underutilization of guideline-recommended supportive care was observed among older adults with MM in the United States, and this was associated with both patient and facility characteristics. Targeted interventions are needed to improve supportive care for patients with MM.
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http://dx.doi.org/10.1002/cncr.32428DOI Listing
November 2019

Association Between Ownership of Imaging Equipment and Appropriateness of Staging Positron-Emission Tomography in Non-Hodgkin Lymphoma.

JNCI Cancer Spectr 2019 Jun 11;3(2):pkz030. Epub 2019 May 11.

Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT.

Physician ownership of imaging equipment has been shown to be associated with greater use of low-value imaging. However, it is unclear whether ownership also influences utilization of appropriate imaging. We conducted a cohort study of older adults diagnosed with three non-Hodgkin lymphomas with distinct guideline recommendations concerning the use of positron emission tomography (PET) during staging (recommended, not recommended, or equivocal). We found patients who were treated by oncologists with PET ownership were more likely to receive a staging PET regardless of lymphoma subtype. However, the difference in utilization by ownership status was smallest (6%, 95% confidence interval = 2% to 11%, = .01) in the setting of diffuse large B cell lymphoma, where consensus guidelines recommend routine use of PET. Overall, removing financial incentives related to imaging self-referral may reduce utilization during cancer care, with the potential for greatest impact on imaging of equivocal or low clinical utility.
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http://dx.doi.org/10.1093/jncics/pkz030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6649837PMC
June 2019

Cancer History, Health Insurance Coverage, and Cost-Related Medication Nonadherence and Medication Cost-Coping Strategies in the United States.

Value Health 2019 07 16;22(7):762-767. Epub 2019 May 16.

Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA, USA.

Objectives: To evaluate the relationship between cancer history and cost-related medication nonadherence (CRN) as well as cost-coping strategies, by health insurance coverage.

Methods: We used the 2013 to 2016 National Health Interview Survey to identify adults aged 18 to 64 years with (n = 3599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included (1) CRN, measured as skipping, taking less, or delaying medication because of cost, and (2) cost-coping strategies, measured as requesting lower cost medication or using alternative therapies to save money. Separate multivariable logistic regressions were used to calculate the adjusted odds ratios (AORs) of CRN and cost-coping strategies associated with cancer history, stratified by insurance.

Results: Cancer survivors were more likely than adults without a cancer history to report CRN (AOR 1.26; 95% confidence interval [CI] 1.10-1.43) and cost-coping strategies (AOR 1.10; 95% CI 0.99-1.19). Among the privately insured, the difference in CRN by cancer history was the greatest among those enrolled in high-deductible health plans (HDHPs) without health savings accounts (HSAs) (AOR 1.78; 95% CI 1.30-2.44). Among adults with HDHP and HSA, cancer survivors were less likely to report cost-coping strategies (AOR 0.62; 95% CI 0.42-0.90). Regardless of cancer history, CRN and cost-coping strategies were the highest for those uninsured, enrolled in HDHP without HSA, and without prescription drug coverage under their health plan (all P<.001).

Conclusions: Cancer survivors are prone to CRN and more likely to use cost-coping strategies. Expanding options for health insurance coverage, use of HSAs for those with HDHP, and enhanced prescription drug coverage may effectively address CRN.
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http://dx.doi.org/10.1016/j.jval.2019.01.015DOI Listing
July 2019

RBC transfusion independence among lower risk MDS patients receiving hypomethylating agents: a population-level analysis.

Leuk Lymphoma 2019 12 7;60(13):3181-3187. Epub 2019 Jun 7.

Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.

Most patients with lower risk myelodysplastic syndromes (LR-MDS) become red blood cell (RBC) transfusion dependent at some time during their disease course. Hypomethylating agents (HMAs) are frequently used in this setting; however, reported rates of in RBC transfusion independence (TI) achieved with HMA therapy vary significantly between studies. Here we study the real-life clinical effectiveness of HMA in inducing RBC TI in anemic LR-MDS patients using the Surveillance, Epidemiology and End Results (SEER)-Medicare database. We find that approximately 40% of LR-MDS patients who were receiving RBC transfusions and 33% who were dependent on RBC transfusions at HMA initiation ultimately achieved TI. The receipt of ≥3 transfusions in the 8-week period before HMA initiation was significantly associated with lower odds of achieving TI. Our study provides important population level estimates of clinical effectiveness of HMAs in LR-MDS.
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http://dx.doi.org/10.1080/10428194.2019.1622700DOI Listing
December 2019

Impact of Hydroxyurea on Survival and Risk of Thrombosis Among Older Patients With Essential Thrombocythemia.

J Natl Compr Canc Netw 2019 03;17(3):211-219

Department of Chronic Disease Epidemiology, Yale School of Public Health.

ABSTRACTBackground: Current guidelines recommend hydroxyurea (HU) as frontline therapy for patients with high-risk essential thrombocythemia (ET) to prevent thrombosis. However, little is known about the impact of HU on thrombosis or survival among these patients in the real-world setting.

Patients And Methods: A retrospective cohort study was conducted of older adults (aged ≥66 years) diagnosed with ET from 2007 through 2013 using the linked SEER-Medicare database. Multivariable Cox proportional hazards regression models were used to assess the effect of HU on overall survival, and multivariable competing risk models were used to assess the effect of HU on the occurrence of thrombotic events.

Results: Of 1,010 patients, 745 (73.8%) received HU. Treatment with HU was associated with a significantly lower risk of death (hazard ratio [HR], 0.52; 95% CI, 0.43-0.64; P<.01). Every 10% increase in HU proportion of days covered was associated with a 12% decreased risk of death (HR, 0.88; 95% CI, 0.86-0.91; P<.01). Compared with nonusers, HU users also had a significantly lower risk of thrombotic events (HR, 0.51; 95% CI, 0.41-0.64; P<.01).

Conclusions: Although underused in our study population, HU was associated with a reduced incidence of thrombotic events and improved overall survival in older patients with ET.
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http://dx.doi.org/10.6004/jnccn.2018.7095DOI Listing
March 2019

Reply to H.J.A. Adams et al.

J Clin Oncol 2019 04 11;37(10):853-854. Epub 2019 Feb 11.

Scott F. Huntington, MD, Yale University, New Haven, CT; Gottfried von Keudell, MD, PhD, Memorial Sloan Kettering Cancer Center, New York, NY; Amy J. Davidoff, PhD, Yale University School of Public Health, New Haven, CT; Cary P. Gross, MD, Yale University School of Medicine, New Haven, CT; and Sapna A. Prasad, PhD, Yale-New Haven Hospital, New Haven, CT.

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http://dx.doi.org/10.1200/JCO.18.02297DOI Listing
April 2019

Medical financial hardship among cancer survivors in the United States.

Cancer 2019 05 21;125(10):1737-1747. Epub 2019 Jan 21.

Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia.

Background: The current study examined medical financial hardship in cancer survivors and those without a cancer history in the United States.

Methods: The 2013 to 2016 National Health Interview Survey was used to identify cancer survivors (stratified by ages 18-49 years [1424 survivors], ages 50-64 years [2916 survivors], and ages ≥65 years [6014 survivors]) and individuals without a cancer history (ages 18-64 years [66,951 individuals], ages 50-64 years [31,741 individuals], and ages ≥65 years [25,744 individuals]). Medical financial hardship was categorized into 3 domains: 1) material (eg, problems paying medical bills); 2) psychological (eg, worrying about paying medical bills); and 3) behavioral (eg, delaying/forgoing care due to cost). Generalized ordinal logistic regressions were used to examine the associations between cancer history, hardship, and health insurance deductibles/health savings accounts (among privately insured cancer survivors aged 18-64 years only).

Results: Compared with those without a cancer history, cancer survivors were more likely to report any material (ages 18-49 years: 43.4% vs 30.1%; ages 50-64 years: 32.8% vs 27.8%; and ages ≥65 years: 17.3% vs 14.7%), psychological (ages 18-49 years: 53.5% vs 47.1%), and behavioral (ages 18-49 years: 30.6% vs 21.8%; and ages 50-64 years: 27.2% vs 23.4%) measure of financial hardship, and multiple domains of hardship (age groups 18-49 years and 50-64 years; all P < .01). Among privately insured survivors, having a high-deductible health plan without a health savings account was found to be associated with greater hardship compared with having low-deductible insurance.

Conclusions: Younger cancer survivors are particularly vulnerable to material, psychological, and behavioral medical financial hardship. Interventions designed to reduce financial hardship should consider multiple domains of hardship as well as insurance benefit design.
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http://dx.doi.org/10.1002/cncr.31913DOI Listing
May 2019

Trends in Antineoplastic Receipt after Medicare Payment Reform: Implications for Future Oncology Payment Design.

J Cancer Policy 2018 Sep 28;17:51-58. Epub 2016 Sep 28.

Department of Health Policy and Management, Yale University School of Public Health.

Background: The Medicare Modernization Act (MMA) reduced reimbursement for many antineoplastics delivered in outpatient settings, altering practice patterns for some cancers. To further evaluate the MMA's effect, we focus on colon cancer, where longstanding fluorouracil-based regimens were augmented in 2004 with 3 newly-approved drugs (oxaliplatin, bevacizumab, and/or cetuximab). Staggered implementation of MMA reimbursement changes (physician offices implemented reimbursement changes in 2005 vs hospital outpatient departments(OPD) in 2006) provide a natural experiment to examine policy effects.

Methods: Using the 2000-2009 SEER-Medicare data, we examined antineoplastic use among 59,642 stage II-IV colon cancer patients. Using multivariate logistic regression models, we conducted difference-in-differences analyses to examine an interaction between time (pre-post MMA) and setting (physician offices versus OPDs) on antineoplastic receipt, adjusting for patient and cancer characteristics. A significant interaction indicates different practice patterns in physician offices versus OPD during the staggered implementation.

Results: After the reimbursement change in 2007-09 relative to 2000-03, use of fluorouracil-based therapy decreased slightly (Marginal Probability(MP): -0.07 stage II; -0.05 stage III; -0.05 stage IV; p< 0.01), while use of new drugs increased substantially (MP: 0.48 stage II; 0.69 stage III, 0.79 stage IV; p< 0.01). The interaction between MMA implementation and physician office setting was significant when examining use of new agents for Stage IV disease only.

Conclusions: Our results indicate that providers responded to reimbursement changes after the MMA by increasing use of newly approved agents, but the magnitude of the response was small and limited to individuals diagnosed with Stage IV disease.
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http://dx.doi.org/10.1016/j.jcpo.2016.09.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6191052PMC
September 2018
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