Publications by authors named "Ted Wun"

114 Publications

Incidence and Outcomes Associated with 6841 Isolated Distal Deep Vein Thromboses in Patients with 13 Common Cancers.

Thromb Haemost 2022 Jan 17. Epub 2022 Jan 17.

Hematology/Oncology, University of California Davis Health System, Sacramento, United States.

Introduction: The epidemiology of isolated distal deep venous thrombosis (iDDVT) among cancer patients is not well described, particularly the incidence of recurrent venous thromboembolism (rVTE) and effect on mortality by cancer type.

Methods: The cumulative incidence (CI) of iDDVT was determined for patients with 13 common cancers between 2005-2017 using the California Cancer Registry linked to the California Patient Discharge and Emergency Department Utilization datasets. The CI of rVTE was calculated and association of incident CAT location with rVTE was determined using Cox proportional hazards regression models. The association of incident cancer-associated venous thrombosis (CAT) location with overall and cancer-specific mortality was determined using Cox models, stratified by cancer site, and adjusted for individual characteristics.

Results: Among 942,109 cancer patients, CAT occurred in 62,003 (6.6%): of these, 6,841 (11.0%) were iDDVT. Compared to more proximal sites of CAT, iDDVT was associated with similar risk for rVTE. IDDVT was associated with increased mortality across all cancer types when compared to patients without CAT (HR 1.56-4.60). The effect of iDDVT on mortality was similar to that of proximal DVT (pDVT) for most cancers except lung, colorectal, bladder, uterine, brain, and myeloma, where iDDVT was associated with a lesser association with mortality.

Conclusion: iDDVT represented 11% of CAT. The risk of rVTE after iDDVT was similar to other sites of CAT and rVTE occurred in more proximal locations after an incident iDDVT. IDDVT was associated with increased mortality and this effect was similar to that of PE or pDVT for most cancer types.
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http://dx.doi.org/10.1055/a-1742-0177DOI Listing
January 2022

Impact of COVID-19 on Hematology-Oncology Trainees: A Quantitative and Qualitative Assessment.

JCO Oncol Pract 2022 Jan 6:OP2100630. Epub 2022 Jan 6.

Division of Hematologic Malignancies, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA.

Purpose: Graduate medical and research training has drastically changed during the COVID-19 pandemic, with widespread implementation of virtual learning, redeployment from core rotations to the care of patients with COVID-19, and significant emotional and physical stressors. The specific experience of hematology-oncology (HO) fellows during the COVID-19 pandemic is not known.

Methods: We conducted a mixed-methods study using a survey of Likert-style and open-ended questions to assess the training experience and well-being of HO fellows, including both clinical and postdoctoral trainee members of the American Society of Hematology and ASCO.

Results: A total of 2,306 surveys were distributed by e-mail; 548 (23.8%) fellows completed the survey. Nearly 40% of fellows felt that they had not received adequate mental health support during the pandemic, and 22% reported new symptoms of burnout. Pre-existing burnout before the pandemic, COVID-19-related clinical work, and working in a primary research or nonclinical setting were associated with increased burnout on multivariable logistic regression. Qualitative thematic analysis of open-ended responses revealed significant concerns about employment after training completion, perceived variable quality of virtual education and board preparation, loss of clinical opportunities to prepare for independent clinical practice, inadequate grant funding opportunities in part because of shifting research priorities, variable productivity, and mental health or stress during the pandemic.

Conclusion: HO fellows have been profoundly affected by the pandemic, and our data illustrate multiple avenues for fellowship programs and national organizations to support both clinical and postdoctoral trainees.
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http://dx.doi.org/10.1200/OP.21.00630DOI Listing
January 2022

Second primary malignancy risk after Hodgkin lymphoma treatment among HIV-uninfected and HIV-infected survivors.

Leuk Lymphoma 2022 Jan 6:1-11. Epub 2022 Jan 6.

Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis, School of Medicine, Sacramento, CA, USA.

We compared secondary primary malignancy risk (SPM) in HIV-uninfected and HIV-infected Hodgkin lymphoma (HL) survivors. We used data from the California Cancer Registry on patients diagnosed with HL from 1990 to 2015 (all ages included), and standardized incidence ratios (SIRs) and multivariable competing risk models for analyses. Of 19,667 survivors, 735 were HIV-infected. Compared with the general population, the risk of SPM was increased by 2.66-fold in HIV-infected and 1.92-fold in HIV-uninfected survivors. Among HIV-infected survivors, median time to development of SPM was shorter (5.4 years) than in HIV-uninfected patients (8.1 years). Additionally, the highest risk of SPM was observed <2 years after diagnosis in HIV-infected survivors (SIR = 4.47), whereas risk was highest ≥20 years after diagnosis (SIR = 2.39) in HIV-uninfected survivors. The risk of SPMs persisted for decades and was higher among HIV-infected survivors, suggesting that these patients should benefit from long-term surveillance and cancer prevention practices.
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http://dx.doi.org/10.1080/10428194.2021.2020775DOI Listing
January 2022

Treatment at Specialized Cancer Centers Is Associated with Improved Survival in Adolescent and Young Adults with Soft Tissue Sarcoma.

J Adolesc Young Adult Oncol 2021 Dec 15. Epub 2021 Dec 15.

Division of Hematology/Oncology, Center for Oncology, Hematology Outcomes Research and Training (COHORT), University of California Davis School of Medicine, Sacramento, California, USA.

Soft tissue sarcomas (STS) are a heterogeneous group of tumors whose management benefits from a multidisciplinary therapeutic approach. Published data suggest that cancer treatment at a specialized cancer center (SCC) can improve survival in other cancers. Therefore, we examined the impact of the location of treatment on survival in children and adolescents and young adults (AYAs) with STS. We performed a population-based analysis of children and AYAs hospitalized within 1 year of diagnosis with first primary STS (2000-2014) using the California Cancer Registry linked with hospitalization data. Patients were categorized based on receiving all inpatient treatments at a SCC versus part/none. Multivariable Cox proportional hazards regression identified factors associated with overall and STS-specific survival by age group. Results are presented as adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Of the 1,674 patients with STS, 142 were children (0-14) and 1,532 were AYAs (15-39) and 89.4% and 40.4% received all inpatient treatments at a SCC, respectively. Overall, the 5-year survival was improved for patients who received all inpatient care at a SCC (59.8% vs. those who received part/none, 50.7%). Multivariable regression analysis found that having all treatments at a SCC was associated with better overall survival (HR, 0.79, CI: 0.65-0.95) in AYAs, but not in children. Our findings demonstrate that treatment for STS at a SCC is associated with better survival in AYAs. Eliminating barriers to treatment of AYAs with STS at SCCs could improve survival in this population.
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http://dx.doi.org/10.1089/jayao.2021.0110DOI Listing
December 2021

Biomarker Signatures in Cancer Patients With and Without Venous Thromboembolism Events: A Substudy of CASSINI.

Blood Adv 2021 Nov 22. Epub 2021 Nov 22.

Cleveland Clinic, Cleveland, Ohio, United States.

Cancer is associated with an increased risk of venous thromboembolism (VTE). In the CASSINI study, ambulatory cancer patients with a Khorana risk score ≥2 had a reduced risk of VTE while receiving rivaroxaban. This analysis used blood samples from CASSINI to compare biomarker levels between patients with and without VTE. VTE occurred in 62 patients during the 6 months of CASSINI (cases), and they were matched by age, sex, cancer type, tumor stage, and Khorana score to 62 controls. Baseline blood samples were analyzed for 280 biomarkers, and biomarker distribution was compared using the Wilcoxon rank sum test between groups defined by VTE occurrence and vital status. Sparse Bayesian regression modeling was used to select a joint panel of potential VTE biomarkers. Biomarkers with the largest differences in baseline distribution among cancer patients with and without VTE included decreases in stromal cell-derived factor-1 (SDF-1), thyroid-stimulating hormone (TSH), and monocyte chemotactic protein 4 and increases in growth hormone (GH) and interleukin-1 receptor type 1 (IL-1R1). Between survivors and those who died, significantly different biomarkers included ST2, IL-8, and C-reactive protein. Regression analyses also identified decreases in SDF-1 and TSH. Pathway analysis indicated enrichment of cytokine and chemokine activity with IL-1R1, SDF-1, and GH, which are the strongest predictors of VTE or death. Our analyses highlight the interactions between hemostatic and inflammatory processes and identify candidate biomarkers of cancer-associated VTE. Prospective studies will determine clinical relevance of these biomarkers. This trial was registered at www.clinicaltrials.gov as #NCT02555878.
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http://dx.doi.org/10.1182/bloodadvances.2021005710DOI Listing
November 2021

Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California.

Int J Cancer 2021 Nov 20. Epub 2021 Nov 20.

Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis Comprehensive Cancer Center, Sacramento, California, USA.

Adolescents and young adults (AYAs, 15-39 years) are the largest uninsured population in the Unites States, increasing the likelihood of late-stage cancer diagnosis and poor survival. We evaluated the associations between the Affordable Care Act (ACA), insurance coverage, stage at diagnosis and survival among AYAs with lymphoma. We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non-Hodgkin (NHL; n = 5959) or Hodgkin (n = 5378) lymphoma pre-ACA and in the early and full ACA eras. Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsurance, other public and private. We used multivariable regression models for statistical analyses. The proportion of AYAs uninsured/Medicaid enrolled at diagnosis decreased from 13.4% pre-ACA to 9.7% with full ACA implementation, while continuous Medicaid increased from 9.3% to 29.6% during this time (P < .001). After full ACA, AYAs with NHL were less likely to be diagnosed with Stage IV disease (adjusted odds ratio [aOR] = 0.84, 95% confidence interval [CI] = 0.73-0.97). AYAs with lymphoma were more likely to receive care at National Cancer Institute-Designated Cancer Centers (aOR = 1.42, 95% CI = 1.28-1.57) and had lower likelihood of death (adjusted hazard ratio = 0.54, 95% CI = 0.46-0.63) after full ACA. However, AYAs from the lowest socioeconomic neighborhoods, racial/ethnic minority groups and those with Medicaid continued to experience worse survival. In summary, AYAs with lymphomas experienced increased access to healthcare and better clinical outcomes following Medicaid expansion under the ACA. Yet, socioeconomic and racial/ethnic disparities remain, calling for additional efforts to decrease health inequities among underserved AYAs with lymphoma.
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http://dx.doi.org/10.1002/ijc.33880DOI Listing
November 2021

Building an institutional K awardee program at UC Davis through utilization of CTSA resources.

J Clin Transl Sci 2021 13;5(1):e171. Epub 2021 Aug 13.

Office of Research, School of Medicine, University of California, Davis, Sacramento, CA, USA.

NIH offers multiple mentored career development award mechanisms. By building on the UC Davis Clinical and Translational Science Center (CTSC) from its initial NIH funding in 2006, we created an institution-wide K scholar resource. We investigated subsequent NIH funding for K scholars and to what extent CTSC research resources were used. Using NIH RePORTER, we created a database of UC Davis investigators who obtained K01, K08, K23, K25, or K99, as well as institutional KL2 or K12 awards and tracked CTSC research resource use and subsequent funding success. Overall, 94 scholars completed K training between 2007 and 2020, of which 70 participated in one of four institutional, NIH-funded K programs. An additional 103 scholars completed a mentored clinical research training program. Of 94 K awardees, 61 (65%) later achieved NIH funding, with the majority receiving a subsequent individual K award. A higher proportion (73%) of funded scholars used CTSC resources compared to unfunded (48%). Biostatistics and Biomedical Informatics were most commonly used and 55% of scholars used one or more CTSC resource. We conclude that institutional commitment to create a K scholar platform and use of CTSC research resources is associated with high NIH funding rates for early career investigators.
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http://dx.doi.org/10.1017/cts.2021.839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8532183PMC
August 2021

The incidence of cancer-associated thrombosis is increasing over time.

Blood Adv 2022 Jan;6(1):307-320

Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California Davis School of Medicine, Sacramento, CA; and.

Cancer-associated thrombosis (CAT) is an important cause of morbidity and mortality for patients with malignancy and varies by primary cancer type, stage, and therapy. We aimed to characterize the incidence, risk factors, temporal trends, and the effect on mortality of CAT. The California Cancer Registry was linked to the statewide hospitalization database to identify individuals with the 13 most common malignancies diagnosed between 2005 and 2017 and determine the 6- and 12-month cumulative incidence of CAT by venous thromboembolism (VTE) location, tumor type, and stage after adjusting for competing risk of death. Cox proportional hazard regression models were used to determine risk factors associated with CAT and the effect of CAT on all-cause mortality. 942 019 patients with cancer were identified; 62 003 (6.6%) had an incident diagnosis of CAT. Patients with pancreatic, brain, ovarian, and lung cancer had the highest, and patients with breast and prostate cancer had the lowest 12-month cumulative incidence of CAT. For most malignancies, men, those with metastatic disease and more comorbidities, and African Americans (vs non-Hispanic Whites) were at highest risk for CAT. Patients diagnosed with cancer between 2014 and 2017 had a higher risk of CAT compared with those diagnosed between 2005 and 2007. CAT was associated with increased overall mortality for all malignancies (HR ranges 1.89 to 4.79). The incidence of CAT increased over time and was driven by an increase in pulmonary embolism±deep vein thrombosis (PE±DVT). CAT incidence varies based on tumor type and stage and on individual risk factors including gender, race/ethnicity, and comorbidities. For all tumor types, CAT is associated with an increased mortality.
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http://dx.doi.org/10.1182/bloodadvances.2021005590DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8753193PMC
January 2022

Urban-Rural Variations in Quality of Care Among Patients With Cancer in California.

Am J Prev Med 2021 12 14;61(6):e279-e288. Epub 2021 Aug 14.

California Cancer Reporting and Epidemiologic Surveillance (CalCARES) Program, UC Davis Comprehensive Cancer Center, UC Davis Health, Sacramento, California; Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, California.

Introduction: Previous research suggests cancer patients living in rural areas have lower quality of care, but population-based studies have yielded inconsistent results. This study examines the impact of rurality on care quality for 7 cancer types in California.

Methods: Breast, ovarian, endometrial, cervix, colon, lung, and gastric cancer patients diagnosed from 2004 to 2017 were identified in the California Cancer Registry. Multivariable logistic regression and proportional hazards models were used to assess effects of residential location on quality of care and survival. Stratified models examined the impact of treatment at National Cancer Institute designated cancer centers (NCICCs). Quality of care was evaluated using Commission on Cancer measures. Medical Service Study Areas were used to assess urban/rural status. Data were collected in 2004-2019 and analyzed in 2020.

Results: 989,747 cancer patients were evaluated, with 14% living in rural areas. Rural patients had lower odds of receiving radiation after breast conserving surgery compared to urban residents. Colon and gastric cancer patients had 20% and 16% lower odds, respectively, of having optimal surgery. Rural patients treated at NCICCs had greater odds of recommended surgery for most cancer types. Survival was similar among urban and rural subgroups.

Conclusions: Rural residence was inversely associated with receipt of recommended surgery for gastric and colon cancer patients not treated at NCICCs, and for receiving recommended radiotherapy after breast conserving surgery regardless of treatment location. Further studies investigating the impact of care location and availability of supportive services on urban-rural differences in quality of care are warranted.
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http://dx.doi.org/10.1016/j.amepre.2021.05.021DOI Listing
December 2021

Early mortality and survival improvements for adolescents and young adults with acute promyelocytic leukemia in California: an updated analysis.

Haematologica 2021 Jul 29. Epub 2021 Jul 29.

Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Comprehensive Cancer Center, Sacramento-CA.

Not available.
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http://dx.doi.org/10.3324/haematol.2021.278851DOI Listing
July 2021

Impact of location of inpatient cancer care on patients with Ewing sarcoma and osteosarcoma-A population-based study.

Pediatr Blood Cancer 2021 07 15;68(7):e28998. Epub 2021 Mar 15.

Center for Oncology Hematology Outcomes Research and Training and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, California, USA.

Background: Ewing sarcoma (EWS) and osteosarcoma (OS) require multidisciplinary treatment. Care at specialized cancer centers (SCC: Children's Oncology Group affiliated and/or National Cancer Institute-designated cancer center) has been found to improve outcomes in patients with leukemia, but studies have not considered location of care and outcomes in EWS and OS patients, an ideal group to evaluate given their specialized multidisciplinary treatment needs.

Methods: Patients hospitalized with primary EWS and OS (2000-2014) were identified using the California Cancer Registry linked with hospitalization data. Patients were divided into age groups (0-18, 19-39, ≥40 years), and classified on whether they received all versus part/none of their inpatient treatment at a SCC within 1 year of diagnosis. Multivariable Cox proportional hazards regression identified factors associated with survival.

Results: There were 531 ES and 959 OS patients. Five-year overall survival was better for patients with EWS (all: 63% vs. part/none: 42%) and OS (all: 64% vs. part/none: 47%) who received all of their treatment at a SCC. After adjusting for sociodemographic and clinical factors, receiving all inpatient cancer treatment at a SCC was associated with superior overall survival (EWS HR: 0.49, CI 0.37-0.67; OS HR: 0.78, CI 0.63-0.97).

Conclusion: Our results suggest that treatment for EWS and OS at a SCC is associated with significantly improved survival even after adjustment for known prognostic factors. The superior survival among those treated at SCCs may be due to having greater access to clinical trials and services at SCCs.
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http://dx.doi.org/10.1002/pbc.28998DOI Listing
July 2021

Incidence of Upper Extremity Deep Vein Thrombosis in Acute Leukemia and Effect on Mortality.

TH Open 2020 Oct 28;4(4):e309-e317. Epub 2020 Oct 28.

Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States.

The cumulative incidence, risk factors, rate of subsequent venous thromboembolism (VTE) and bleeding and impact on mortality of isolated upper extremity deep vein thrombosis (UE DVT) in acute leukemia are not well-described. The California Cancer Registry, used to identify treated patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) diagnosed between 2009 and 2014, was linked with the statewide hospitalization database to determine cumulative incidences of UE DVT and subsequent VTE and bleeding after UE DVT diagnosis. Cox proportional hazards regression models were used to assess the association of UE DVT on the risk of subsequent pulmonary embolism (PE) or lower extremity deep vein thrombosis (LE DVT) and subsequent bleeding, and the impact of UE DVT on mortality. There were 5,072 patients identified: 3,252 had AML and 1,820 had ALL. Three- and 12-month cumulative incidences of UE DVT were 4.8% (95% confidence interval [CI]: 4.1-5.6) and 6.6% (95% CI: 5.8-7.5) for AML and 4.1% (95% CI: 3.2-5.1) and 5.9% (95% CI: 4.9-7.1) for ALL, respectively. Twelve-month cumulative incidences of subsequent VTE after an incident UE DVT diagnosis were 5.3% for AML and 12.2% for ALL. Twelve-month cumulative incidences of subsequent bleeding after an incident UE DVT diagnosis were 15.4% for AML and 21.1% for ALL. UE DVT was associated with an increased risk of subsequent bleeding for both AML (hazard ratio [HR]: 2.07; 95% CI: 1.60-2.68) and ALL (HR: 1.62; 95% CI: 1.02-2.57) but was not an independent risk factor for subsequent PE or LE DVT for either leukemia subtype. Isolated incident UE DVT was associated with increased leukemia-specific mortality for AML (HR: 1.42; 95% CI: 1.16-1.73) and ALL (HR: 1.80; 95% CI: 1.31-2.47). UE DVT is a relatively common complication among patients with AML and ALL and has a significant impact on bleeding and mortality. Further research is needed to determine appropriate therapy for this high-risk population.
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http://dx.doi.org/10.1055/s-0040-1718883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593117PMC
October 2020

Disparities in the Occurrence of Late Effects following Treatment among Adolescent and Young Adult Melanoma Survivors.

Cancer Epidemiol Biomarkers Prev 2020 11 20;29(11):2195-2202. Epub 2020 Aug 20.

Comprehensive Cancer Center, University of California, Davis, Sacramento, California.

Background: Melanoma is the third most common cancer in the adolescent and young adult (AYA) population; however, no studies have addressed the occurrence of adverse health conditions following melanoma treatment in these survivors.

Methods: Data for patients ages 15 to 39 years diagnosed with cutaneous melanoma from 1996 to 2012 and surviving ≥2 years were obtained from the California Cancer Registry and linked to statewide hospitalization data. The influence of age at diagnosis, sex, race/ethnicity, neighborhood socioeconomic status (SES), health insurance, and surgery on the development of adverse health conditions was evaluated using Cox proportional hazards regression models.

Results: Of 8,259 patients, 35.3% were male, 83.3% were non-Hispanic White, 82.4% had private health insurance, and 60.5% were considered high SES. In Cox regression models, males had an increased risk of developing adverse health conditions across all systems, including cardiac [HR, 1.73, 95% confidence interval (CI), 1.47-2.03], lymphedema (HR, 1.56; 95% CI, 1.37-1.77), hematologic disorders (HR, 1.17; 95% CI, 1.03-1.33), major infection/sepsis (HR, 1.59; 95% CI, 1.39-1.82), and second cancers (HR, 1.51; 95% CI, 1.31-1.74). Patients with public/no insurance (vs. private) had a greater risk of developing all studied adverse health conditions, including subsequent cancers (HR, 2.34; 95% CI, 1.94-2.82). AYA patients residing in low SES neighborhoods had similar increased risk of developing adverse health conditions.

Conclusions: Of AYA melanoma survivors, males, those with public/no health insurance, and those living in low SES neighborhoods had a greater likelihood of developing adverse health conditions.

Impact: Strategies to improve surveillance and secondary prevention of these adverse health conditions are needed among AYA melanoma survivors, specifically for the at-risk populations identified.
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http://dx.doi.org/10.1158/1055-9965.EPI-20-0427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641994PMC
November 2020

Impact of insurance type and timing of Medicaid enrollment on survival among adolescents and young adults with cancer.

Pediatr Blood Cancer 2020 09 26;67(9):e28498. Epub 2020 Jun 26.

California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Health, Institute for Population Health Improvement, Sacramento, California.

Background: Adolescents and young adults (AYAs) with public or no insurance experience later stage at diagnosis and worse overall survival compared with those with private insurance. However, prior studies have not distinguished the survival impact of continuous Medicaid coverage prior to diagnosis compared with gaining Medicaid coverage at diagnosis.

Methods: We linked a cohort of AYAs aged 15-39 who were diagnosed with 13 common cancers from 2005 to 2014 in the California Cancer Registry with California Medicaid enrollment files to ascertain Medicaid enrollment, with other insurance determined from registry data. We used Cox proportional hazards regression to evaluate the impact of insurance on survival, adjusting for clinical and demographic characteristics.

Results: Among 62 218 AYAs, over 65% had private/military insurance, 10% received Medicaid at diagnosis, 13.2% had continuous Medicaid, 4.1% had discontinuous Medicaid, 1.7% had other public insurance, 3% were uninsured, and 2.6% had unknown insurance. Compared with those with private/military insurance, individuals with Medicaid insurance had significantly worse survival regardless of when coverage began (received Medicaid at diagnosis: hazard ratio [95% confidence interval]: 1.51 [1.42-1.61]; continuously Medicaid insured: 1.42 [1.33-1.52]; discontinuous Medicaid: 1.64 [1.49, 1.80]). Analyses of those with Medicaid insurance only demonstrated slightly worse cancer-specific survival among those with discontinuous Medicaid or enrollment at diagnosis compared with those with continuous enrollment, but results were not significant stratified by cancer site.

Conclusions And Relevance: AYAs with Medicaid insurance experience worse cancer-specific survival compared with those with private/military insurance, yet continuous enrollment demonstrates slight survival improvements, providing potential opportunities for future policy intervention.
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http://dx.doi.org/10.1002/pbc.28498DOI Listing
September 2020

High incidence of venous thromboembolism and major bleeding in patients with primary CNS lymphoma.

Leuk Lymphoma 2020 11 23;61(11):2605-2613. Epub 2020 Jun 23.

Division of Hematology Oncology, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California Davis School of Medicine, Sacramento, CA, USA.

Venous thromboembolism (VTE) and major bleeding in primary central nervous system lymphoma (PCNSL) patients are not well described. We identified 992 PCNSL patients using the California Cancer Registry (2005-2014). The cumulative incidence of VTE and major bleeding was determined using California hospitalization data. The 12-month cumulative incidence of VTE was 13.6% (95% confidence interval (CI) 11.5-15.8%); chemotherapy and radiation therapy were associated with increased risk of VTE (hazard ratio (HR) 2.41, CI 1.31-4.46 and HR 1.56, CI 1.08-2.25, respectively). The 12-month cumulative incidence of major bleeding was 12.4% (CI 10.1-14.6%). Pulmonary embolism (PE) and proximal deep vein thrombosis were associated with increased risk of major bleeding, likely due to anticoagulation. PE (HR 1.61, CI 1.11-2.33, =.011) and major bleeding (HR 2.36, CI 1.82-3.06, <.0001) were associated with increased mortality. This study highlights the high incidence of both VTE and major bleeding and the significant impact on survival for PCNSL patients.
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http://dx.doi.org/10.1080/10428194.2020.1780584DOI Listing
November 2020

Treatment Complications and Survival Among Children and Young Adults With Acute Lymphoblastic Leukemia.

JCO Oncol Pract 2020 10 11;16(10):e1120-e1133. Epub 2020 Jun 11.

Division of Health Policy and Management, Department of Public Health Sciences, University of California Davis School of Medicine, Sacramento, CA.

Purpose: We previously demonstrated lower early mortality for young adults (YAs) with acute lymphoblastic leukemia (ALL) who received induction treatment at specialized cancer centers (SCCs) versus community hospitals. The aim of this study is to determine the impact of inpatient location of treatment throughout therapy on long-term survival, complications, and cost-associations that have not yet been evaluated at the population level.

Methods: Using the California Cancer Registry linked to a hospitalization database, we identified patients, 0-39 years of age, diagnosed with first primary ALL who received inpatient treatment between 1991 and 2014. Patients were classified as receiving all or part or none of their inpatient treatment at an SCC within 3 years of diagnosis. Inverse probability-weighted, multivariable Cox regression models estimated the associations between location of treatment and sociodemographic and clinical factors with survival. We compared 3-year inpatient costs overall and per day by age group and location of care.

Results: Eighty-four percent (0-18 years; n = 4,549) of children and 36% of YAs (19-39 years; n = 683) received all treatment at SCCs. Receiving all treatment at an SCC was associated with superior leukemia-specific (hazard ratio [HR], 0.76; 95% CI, 0.67 to 0.88) and overall survival (HR, 0.87; 95% CI, 0.77 to 0.97) in children and in YAs (HR, 0.71; 95% CI, 0.61 to 0.83; HR, 0.70; 95% CI, 0.62 to 0.80) even after controlling for complications. The cost of inpatient care during the full course of therapy was higher in patients receiving all of their care at SCCs.

Conclusion: Our results demonstrate that inpatient treatment at an SCC throughout therapy is associated with superior survival; therefore, strong consideration should be given to referring these patients to SCCs.
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http://dx.doi.org/10.1200/JOP.19.00572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189609PMC
October 2020

Patient-reported outcomes in sickle cell disease and association with clinical and psychosocial factors: Report from the sickle cell disease implementation consortium.

Am J Hematol 2020 09 29;95(9):1066-1074. Epub 2020 Jun 29.

University of California San Francisco Benioff Children's Hospital Oakland, Oakland, California.

Understanding patient experiences, quality of life, and treatment needs in individuals with sickle cell disease (SCD) is essential in promoting health and well-being. We used measures from the Adult Sickle Cell Quality of Life Measurement Information System (ASCQ-Me), Patient Reported Outcomes Measurement Information System (PROMIS), and Quality of Life in Neurological Disorders (NeuroQol) to evaluate pain impact, sleep impact, social functioning, depressive symptoms, tiredness, and cognitive function (collectively, patient reported outcomes [PROs]) and to identify associated demographic and clinical characteristics. Participants (n = 2201) between 18 and 45 years were recruited through the eight Sickle Cell Disease Implementation Consortium (SCDIC) sites. In multivariate models, PROs were significantly associated with one another. Pain impact was associated with age, education, employment, time since last pain attack, hydroxyurea use, opioid use, sleep impact, social functioning, and cognitive function (F = 88.74, P < .0001). Sleep impact was associated with household income, opioid use, pain impact, social functioning, depressive symptoms, and tiredness (F = 101.40, P < .0001). Social functioning was associated with employment, pain attacks in the past year, autoimmune/inflammatory comorbidities, pain impact, sleep impact, depressive symptoms, tiredness, and cognitive function (F = 121.73, P < .0001). Depressive symptoms were associated with sex, sleep impact, social functioning, tiredness, and cognitive function (F = 239.51, P < .0001). Tiredness was associated with sex, education, sleep impact, social functioning, depressive symptoms, and cognitive function (F = 129.13, P < .0001). These findings reflect the baseline PRO assessments among SCDIC registry participants. Further research is needed to better understand these outcomes and new targets for interventions to improve quality of life and function in people with SCD.
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http://dx.doi.org/10.1002/ajh.25880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141351PMC
September 2020

Integration of Mobile Health Into Sickle Cell Disease Care to Increase Hydroxyurea Utilization: Protocol for an Efficacy and Implementation Study.

JMIR Res Protoc 2020 Jul 14;9(7):e16319. Epub 2020 Jul 14.

Bethesda, MA, United States.

Background: Hydroxyurea prevents disease complications among patients with sickle cell disease (SCD). Although its efficacy has been endorsed by the National Health Lung and Blood Institute evidence-based guidelines, its adoption is low, both by patients with SCD and providers. Mobile health (mHealth) apps provide benefits in improving medication adherence and self-efficacy among patients with chronic diseases and have facilitated prescription among medical providers. However, mHealth has not been systematically tested as a tool to increase hydroxyurea adherence nor has the combination of mHealth been assessed at both patient and provider levels to increase hydroxyurea utilization.

Objective: This study aims to increase hydroxyurea utilization through a combined two-level mHealth intervention for both patients with SCD and their providers with the goals of increasing adherence to hydroxyurea among patients and improve hydroxyurea prescribing behavior among providers.

Methods: We will test the efficacy of 2 mHealth interventions to increase both patient and provider utilization and knowledge of hydroxyurea in 8 clinical sites of the NHLBI-funded Sickle Cell Disease Implementation Consortium (SCDIC). The patient mHealth intervention, InCharge Health, includes multiple components that address memory, motivation, and knowledge barriers to hydroxyurea use. The provider mHealth intervention, Hydroxyurea Toolbox (HU Toolbox), addresses the clinical knowledge barriers in prescribing and monitoring hydroxyurea. The primary hypothesis is that among adolescents and adults with SCD, adherence to hydroxyurea, as measured by the proportion of days covered (the ratio of the number of days the patient is covered by the medication to the number of days in the treatment period), will increase by at least 20% after 24 weeks of receiving the InCharge Health app, compared with their adherence at baseline. As secondary objectives, we will (1) examine the change in health-related quality of life, acute disease complications, perceived health literacy, and perceived self-efficacy in taking hydroxyurea among patients who use InCharge Health and (2) examine potential increases in the awareness of hydroxyurea benefits and risks, appropriate prescribing, and perceived self-efficacy to correctly administer hydroxyurea therapy among SCD providers between baseline and 9 months of using the HU Toolbox app. We will measure the reach, adoption, implementation, and maintenance of both the InCharge Health and the HU Toolbox apps using the reach, effectiveness, adoption, implementation, and maintenance framework and qualitatively evaluate the implementation of both mHealth interventions.

Results: The study is currently enrolling study participants. Recruitment is anticipated to be completed by mid-2021.

Conclusions: If this two-level intervention, that is, the combined use of InCharge Health and HU Toolbox apps, demonstrates efficacy in increasing adherence to hydroxyurea and prescribing behavior in patients with SCD and their providers, respectively, both apps will be offered to other institutions outside the SCDIC through a future large-scale implementation-effectiveness study.

Trial Registration: ClinicalTrials.gov NCT04080167; https://clinicaltrials.gov/ct2/show/NCT04080167.

International Registered Report Identifier (irrid): DERR1-10.2196/16319.
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http://dx.doi.org/10.2196/16319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388044PMC
July 2020

Homocysteine is associated with severity of microvasculopathy in sickle cell disease patients.

Br J Haematol 2020 08 19;190(3):450-457. Epub 2020 Apr 19.

Department of Medical Pathology and Laboratory Medicine, University of California, Davis, CA, USA.

The pathophysiology of sickle cell disease (SCD) includes vasculopathy as well as anaemia. Elevated plasma homocysteine is a risk factor for vascular disease and may be associated with increased risk of vascular complications in SCD patients. In the present study, microvascular characteristics were assessed in the bulbar conjunctiva of 18 paediatric and 18 adult SCD patients, using the non-invasive technique of computer-assisted intravital microscopy. A vasculopathy severity index (SI) was computed to quantify the degree of microvasculopathy in each patient. Plasma homocysteine and several of its determinants [serum folate and vitamin B12, plasma pyridoxal-5'-phosphate (vitamin B6 status) and creatinine (kidney function)] were measured. Age was strongly correlated with microvasculopathy in the SCD patients, with the SI increasing about 0·1 unit per one-year increase in age (P < 0·001). After adjusting for age, gender, B-vitamin status and creatinine, homocysteine concentration was directly correlated with severity index (P < 0·05). Age and homocysteine concentration were independent predictors of microvasculopathy in SCD patients. It remains to be determined whether lowering homocysteine concentrations using appropriate B-vitamin supplements (folate and vitamins B12 and B6) - particularly if started early in life - could ameliorate microvasculopathy and its associated complications in SCD patients.
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http://dx.doi.org/10.1111/bjh.16618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415728PMC
August 2020

Bleeding in patients with sickle cell disease: a population-based study.

Blood Adv 2020 03;4(5):793-802

Center for Oncology Hematology Outcomes Research and Training, Division of Hematology Oncology, University of California, Davis School of Medicine, Davis, CA; and.

Bleeding is a known complication of sickle cell disease (SCD) and includes hemorrhagic stroke, hematuria, and vitreous hemorrhage. However, the incidence of bleeding events in patients with SCD has not been well described. We present a retrospective, population-based study examining the cumulative incidence of bleeding in 6423 patients with SCD from 1991 to 2014. We also studied risk factors associated with bleeding and the effects of bleeding on mortality, using Cox proportional hazards regression models. We used California emergency department and hospitalization databases to identify patients with SCD with intracranial hemorrhage, gastrointestinal (GI) bleeding, hemophthalmos, gross hematuria, epistaxis, menorrhagia, and other bleeding events. The cumulative incidence of any first bleeding event at age 40 years was 21% (95% confidence interval [CI], 19.8%-22.3%), increasing with age to 41% by age 60 years (95% CI, 38.8%-43.1%). The majority of bleeding events were GI (41.6%), particularly from the upper GI tract. A higher bleeding risk was associated with increased frequency of hospitalization (hazard ratio [HR], 2.16; 95% CI, 1.93-2.42), venous thromboembolism 180 days before bleeding event (HR, 4.24; 95% CI, 2.86-6.28), osteonecrosis of the femoral head (HR, 1.25; 95% CI, 1.08-1.46), and ischemic stroke (HR, 1.65; 95% CI, 1.20-2.26). Bleeding was also associated with a twofold increased risk for death (HR, 2.09; 95% CI, 1.82-2.41) adjusted for other SCD-related complications. Our novel finding of a high incidence of bleeding in patients with SCD, particularly from the upper GI tract, suggests that patients with SCD may be predisposed to bleeding, with possible etiologies including increased use of nonsteroidal anti-inflammatory drugs, mucosal infarction from vascular occlusion by sickled red blood cells, and increased stress ulceration from frequent hospitalization.
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http://dx.doi.org/10.1182/bloodadvances.2019000940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065478PMC
March 2020

Chronic medical conditions and late effects following non-Hodgkin lymphoma in HIV-uninfected and HIV-infected adolescents and young adults: a population-based study.

Br J Haematol 2020 08 20;190(3):371-384. Epub 2020 Feb 20.

Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California, Davis, School of Medicine, Sacramento, CA, USA.

Little is known about the incidence of late effects following non-Hodgkin lymphoma (NHL) among adolescent and young adult (AYA, 15-39 years) survivors. Using data from the California Cancer Registry linked to hospital discharge, we estimated the cumulative incidence of late effects at 10 years among AYAs diagnosed with NHL during 1996-2012, who survived ≥2 years. Cox proportional-hazards models were used to investigate the influence of sociodemographic and clinical factors on the occurrence of late effects. Of 4392 HIV-uninfected patients, the highest incident diseases were: endocrine (18·5%), cardiovascular (11·7%), and respiratory (5·0%), followed by secondary primary malignancy (SPM, 2·6%), renal and neurologic (2·2%), liver/pancreatic (2·0%), and avascular necrosis (1·2%). Among the 425 HIV-infected survivors, incidence was higher for all late effects, especially over threefold increased risk of SPM, compared to HIV-uninfected patients (8·1% vs. 2·6%). In multivariable models for HIV-uninfected patients, public or no health insurance (vs. private), residence in lower socioeconomic neighbourhoods (vs. higher), and receipt of a haematopoietic stem cell transplant were associated with a greater risk of most late effects. Our findings of substantial incidence of late effects among NHL AYA survivors emphasise the need for longterm follow-up and appropriate survivorship care to reduce morbidity and mortality in this vulnerable population.
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http://dx.doi.org/10.1111/bjh.16539DOI Listing
August 2020

Splenectomy and the incidence of venous thromboembolism and sepsis in patients with autoimmune hemolytic anemia.

Blood Cells Mol Dis 2020 03 28;81:102388. Epub 2019 Nov 28.

Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, United States of America; Clinical and Translational Science Center, University of California, Davis, United States of America.

Introduction: The impact of splenectomy on venous thrombosis (VTE), abdominal thrombosis (abVTE) and sepsis in autoimmune hemolytic anemia (AIHA) is unclear.

Methods: Using the California Discharge Dataset 1991-2014, 4756 AIHA patients were identified. Cumulative incidences (CI) of VTE, abVTE, and sepsis were determined in patients with and without splenectomy. Using propensity score matching adjusted for competing risk of death, the association between VTE, abVTE and sepsis with splenectomy was determined.

Results: In those without splenectomy, the CIs of VTE, abVTE, and sepsis were 1.4%, 0.2%, and 4.3% respectively, compared to 4.4%, 3.0% and 6.7% with splenectomy. Splenectomy was associated with increased risk for VTE in immediate (HR 2.66, CI 1.36-5.23) and late (HR 3.29, CI 2.10-5.16) post-operative periods. AbVTE was increased in immediate post-operative period (HR 34.11, CI 4.93-236.11). Sepsis was only increased in late post-operative period (HR 2.20, CI 1.75-2.77). In multivariate models, older age, having >1 comorbidity and having VTE, abVTE, and sepsis were associated with increased mortality. Splenectomy was not associated with increased mortality.

Discussion: Splenectomy in AIHA was associated with significant early thrombotic risk and long-term morbidity. Future research should evaluate the role of splenectomy in AIHA patients, and potential long-term thrombotic and antibiotic prophylaxis.
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http://dx.doi.org/10.1016/j.bcmd.2019.102388DOI Listing
March 2020

Safety of light emitting diode-red light on human skin: Two randomized controlled trials.

J Biophotonics 2020 03 8;13(3):e201960014. Epub 2019 Dec 8.

Department of Dermatology, University of California, Davis, Sacramento, California.

Therapeutic applications of light emitting diode-red light (LED-RL) are expanding, yet data on its clinical effects are lacking. Our goal was to evaluate the safety of high fluence LED-RL (≥160 J/cm ). In two phase I, single-blind, dose escalation, randomized controlled trials, healthy subjects received LED-RL or mock irradiation to the forearm thrice weekly for 3 weeks at fluences of 160-640 J/cm for all skin types (STARS 1, n = 60) and at 480-640 J/cm for non-Hispanic Caucasians (STARS 2, n = 55). The primary outcome was the incidence of adverse events (AEs). The maximum tolerated dose was the highest fluence that did not elicit predefined AEs. Dose-limiting AEs, including blistering and prolonged erythema, occurred at 480 J/cm in STARS 1 (n = 1) and 640 J/cm in STARS 2 (n = 2). AEs of transient erythema and hyperpigmentation were mild. No serious AEs occurred. We determined that LED-RL is safe up to 320 J/cm for skin of color and 480 J/cm for non-Hispanic Caucasian individuals. LED-RL may exert differential cutaneous effects depending on race and ethnicity, with darker skin being more photosensitive. These findings may guide future studies to evaluate the efficacy of LED-RL for the treatment of various diseases.
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http://dx.doi.org/10.1002/jbio.201960014DOI Listing
March 2020

A phase II study of bortezomib in combination with pegylated liposomal doxorubicin for acute myeloid leukemia.

Am J Hematol 2019 11 20;94(11):E291-E294. Epub 2019 Aug 20.

Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California.

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http://dx.doi.org/10.1002/ajh.25605DOI Listing
November 2019

Detecting opioid metabolites in exhaled breath condensate (EBC).

J Breath Res 2019 10 3;13(4):046014. Epub 2019 Oct 3.

Department of Mechanical and Aerospace Engineering, One Shields Avenue, University of California Davis, Davis, CA 95616, United States of America.

Exhaled breath condensate (EBC) collection provides a promising matrix for bioanalysis of endogenous biomarkers of health and also for exogenous compounds like drugs. There is little information regarding drugs and their metabolites contained in breath, as well as their pharmacokinetics. In this present work, we use a simple and non-invasive technique to collect EBC from chronic pain patients using different analgesic opioid drugs to manage pain. Six patients received continuous infusion of morphine and hydromorphone intravenously (IV), together with other analgesic drugs (IV and orally). Repeated sampling of serum and EBC was done at two time points separated by 90 min. The EBC was collected using a glass tube surrounded by dry ice, and an ethanol solvent wash of the glass was performed after EBC extraction to retrieve the apolar compounds stuck to the glass surface. All samples were analyzed with liquid chromatography coupled to mass spectrometry (LC-MS/MS) to identify possible metabolites present in the sample, and to quantify the drugs being used. Several metabolites, such as normorphine (norM), norhydromorphone (norHM) and dihydromorphone (diHM) were detected in both fractions, while hydromorphone 3-glucuronide (HM 3G) was only detected in the solvent rinse fraction. Results were correlated to explain the pharmacokinetics of the main drugs administered. This pilot study presented promising correlations between drug concentrations in blood and breath at different time points for norM, norHM and HM 3G.
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http://dx.doi.org/10.1088/1752-7163/ab35fdDOI Listing
October 2019

Biomarkers of Cancer-Associated Thromboembolism.

Cancer Treat Res 2019 ;179:69-85

Division of Hematology and Oncology, UC Davis School of Medicine, UC Davis Cancer Center, 4501 X Street, Sacramento, CA, 95817, USA.

Venous thromboembolism is known to be associated with an increase in morbidity and mortality in patients with malignancy. Predictive laboratory biomarkers of venous thromboembolism (VTE) have long been sought after to improve outcomes and help guide clinical decision making. Previously studied biomarkers include C reactive protein (CRP), tissue factor expressing microparticles (TF MP), D-dimer, soluble P-selectin (sP-selectin), plasminogen activator inhibitor 1 (PAI-1), factor VIII, platelet count, and leukocyte counts. This chapter will focus on these possible biomarkers for cancer-associated thrombosis (CAT) with particular emphasis on the pathophysiology behind thrombosis formation as well as data from clinical studies in patients with malignancy. The incorporation of the above biomarkers into risk assessment tools to predict CAT will also be reviewed, as will risk factors for recurrent VTE in patients with malignancy. Further studies are ongoing to develop readily available biomarkers that can be incorporated into future risk assessment models with the goal of reducing morbidity and mortality due to cancer-associated thrombosis.
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http://dx.doi.org/10.1007/978-3-030-20315-3_5DOI Listing
September 2019

High incidence of venous thromboembolism recurrence in patients with sickle cell disease.

Am J Hematol 2019 08 12;94(8):862-870. Epub 2019 Jun 12.

Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California.

Previous reports show increased incidence of venous thromboembolism [VTE, deep-vein thrombosis (DVT) and pulmonary embolus (PE)] in sickle cell disease (SCD) patients. The incidence, time course, and risk factors for VTE recurrence have been less well described. We determined the cumulative incidence of first VTE recurrence and bleeding in a cohort of SCD patients with incident VTE. Risk factors for recurrence and bleeding were also determined using multivariable Cox regression models, adjusting for gender, race/ethnicity, era of incident VTE, location and hospitalization-associated status of incident VTE, and SCD-related complications. Results are presented as adjusted hazard ratios (HR) and 95% confidence intervals (CI). Among 877 SCD patients with an incident VTE, the 1-year and 5-year cumulative incidence of recurrence was 13.2% (95% CI 11.0%-15.5%) and 24.1% (95% CI 21.2%-27.1%). Risk factors for VTE recurrence included more severe SCD (HR = 2.41; CI: 1.67-3.47), lower extremity DVT as the incident event (HR = 1.64; CI: 1.17-2.30), and pneumonia/acute chest syndrome (HR = 1.68; CI: 1.15-2.45). The cumulative incidence of bleeding was 4.9% (CI 3.5%-6.4%) at 6 months and 7.9% (CI: 6.2%-9.8%) at 1 year. More severe SCD (HR = 1.61; CI: 1.11-2.35) was associated with bleeding. The high incidence of VTE recurrence in patients with SCD suggests that extended anticoagulation may be indicated; however, this must be weighed against a relatively high risk of bleeding. Prospective, randomized studies of anticoagulation in SCD patients with VTE are needed.
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http://dx.doi.org/10.1002/ajh.25508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876692PMC
August 2019

The Epidemiology of Cancer-Associated Venous Thromboembolism: An Update.

Semin Thromb Hemost 2019 Jun 30;45(4):321-325. Epub 2019 Apr 30.

Division of Hematology and Oncology, UC Davis School of Medicine, Sacramento, California.

The incidence of venous thromboembolism (VTE) is known to be higher in patients with malignancy as compared with the general population. It is important to understand and review the epidemiology of VTE in cancer patients because it has implications regarding treatment and prognosis. Multiple studies have shown that cancer patients who develop VTE are at higher risk for mortality. This article will focus on an update regarding the epidemiology of cancer-associated thrombosis (CT). The authors will describe factors associated with CT risk including cancer type and stage at the time of diagnosis, race and ethnicity, and cancer-directed therapy. In addition, recurrent thrombosis and the effect of thromboembolism on survival in cancer patients will also be addressed.
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http://dx.doi.org/10.1055/s-0039-1688494DOI Listing
June 2019

Impact of Health Insurance on Stage at Cancer Diagnosis Among Adolescents and Young Adults.

J Natl Cancer Inst 2019 11;111(11):1152-1160

Background: Uninsured adolescents and young adults (AYAs) and those with publicly funded health insurance are more likely to be diagnosed with cancer at later stages. However, prior population-based studies have not distinguished between AYAs who were continuously uninsured from those who gained Medicaid coverage at the time of cancer diagnosis.

Methods: AYA patients (ages 15-39 years) with nine common cancers diagnosed from 2005 to 2014 were identified using California Cancer Registry data. This cohort was linked to California Medicaid enrollment files to determine continuous enrollment, discontinuous enrollment, or enrollment at diagnosis, with other types of insurance determined from registry data. Multivariable logistic regression was used to evaluate factors associated with later stages at diagnosis.

Results: The majority of 52 774 AYA cancer patients had private or military insurance (67.6%), followed by continuous Medicaid (12.4%), Medicaid at diagnosis (8.5%), discontinuous Medicaid (3.9%), other public insurance (1.6%), no insurance (2.9%), or unknown insurance (3.1%). Of the 13 069 with Medicaid insurance, 50.1% were continuously enrolled. Compared to those who were privately insured, AYAs who enrolled in Medicaid at diagnosis were 2.2-2.5 times more likely to be diagnosed with later stage disease, whereas AYAs discontinuously enrolled were 1.7-1.9 times and AYAs continuously enrolled were 1.4-1.5 times more likely to be diagnosed with later stage disease. Males, those residing in lower socioeconomic neighborhoods, and AYAs of Hispanic or black race and ethnicity (vs non-Hispanic white) were more likely to be diagnosed at a later stage, independent of insurance.

Conclusions: Our findings suggest that access to continuous medical insurance is important for decreasing the likelihood of late stage cancer diagnosis.
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http://dx.doi.org/10.1093/jnci/djz039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855930PMC
November 2019
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