Publications by authors named "Theresa H M Keegan"

175 Publications

Racial Disparities in Children, Adolescents, and Young Adults with Hodgkin Lymphoma Enrolled in the New York State Medicaid Program.

J Adolesc Young Adult Oncol 2021 Oct 8. Epub 2021 Oct 8.

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

We examined the impact of race/ethnicity and age on survival in a publicly insured cohort of children and adolescent/young adults (AYA; 15-39 years) with Hodgkin lymphoma, adjusting for chemotherapy using linked Medicaid claims. We identified 1231 Medicaid-insured patients <1-39 years diagnosed with classical Hodgkin lymphoma between 2005 and 2015, in the New York State Cancer Registry. Chemotherapy regimens were based on contemporary therapeutic regimens. Cox proportional hazards regression models quantified associations of patient, disease, and treatment variables with overall survival (OS) and disease-specific survival (DSS), and are presented as hazard ratios (HR) with confidence intervals (95% CIs). At median follow-up of 6.6 years,  = 1108 (90%) patients were alive; 5-year OS was 92% in children <15 years. In multivariable models, Black (vs. White) patients had 1.6-fold increased risk of death (HR: 1.58, 95% CI: 1.02-2.46;  = 0.042). Stage III/IV (vs. I/II) was associated with 1.9-fold increased risk of death (HR: 1.86, 95% CI: 1.25-2.78;  = 0.002) and treatment at a non-National Cancer Institute (NCI) affiliate was associated with worse DSS (HR: 2.71, 95% CI: 1.47-4.98;  = 0.001). In this Medicaid-insured cohort of children and AYAs with Hodgkin lymphoma, Black race/ethnicity remained associated with inferior OS in multivariable models adjusted for disease, demographic, and treatment data. Further work is needed to identify dimensions of health care access not mediated by insurance, as findings suggest additional factors are contributing to observed cancer disparities in vulnerable pediatric and AYA populations.
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http://dx.doi.org/10.1089/jayao.2021.0131DOI Listing
October 2021

Initial cancer treatment and survival in children, adolescents, and young adults with Hodgkin lymphoma: A population-based study.

Cancer 2021 Sep 8. Epub 2021 Sep 8.

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

Background: Hodgkin lymphoma (HL) is a treatable tumor affecting children, adolescents and young adults (AYAs; 15-39 years old). Population-based studies report worse survival for non-White children and AYAs but have limited data on individual therapeutic exposures. This study examined overall and HL-specific survival in a population-based cohort of patients while adjusting for sociodemographic factors and treatment.

Methods: Data for 4807 patients younger than 40 years with HL (2007-2017) were obtained from the California Cancer Registry. Individual treatment information was extracted from text fields; chemotherapy regimens were defined by standard approaches for pediatric and adult HL. Multivariable Cox models examined the influence of patient and treatment factors on survival.

Results: At a median follow-up of 4.4 years, 95% of the patients were alive. Chemotherapy differed by age, with 70% of 22- to 39-year-olds and 41% of <22-year-olds receiving doxorubicin, bleomycin, vinblastine, and dacarbazine (P < .001). In multivariable models, older patients (22-39 vs < 21 y; hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.11-2.10), Black (vs White patients); HR, 1.90; 95% CI, 1.25-2.88), and Hispanic patients (HR, 1.45; 95% CI, 1.06-1.99) experienced worse survival; among those < 21 y, Black race was associated with a 3.3-fold increased risk of death (HR, 3.26; 95% CI, 1.43-7.42).

Conclusions: In children and AYAs with HL, older age and non-White race/ethnicity predicted worse survival after adjustments for treatment data. Further work is needed to identify the biological and nonbiological factors driving disparities in these at-risk populations.
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http://dx.doi.org/10.1002/cncr.33868DOI Listing
September 2021

Frontline treatment patterns and outcomes among older adults with acute myeloid leukemia: A population-based analysis in the modern era.

Cancer 2021 Aug 26. Epub 2021 Aug 26.

Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University Medical Center, Stanford, California.

Background: Traditionally, conventional induction chemotherapy has been the primary frontline treatment for acute myeloid leukemia (AML); however, older adults are often poor chemotherapy candidates. Recently, several nonconventional frontline AML regimens, including hypomethylating agents, the BCL-2 inhibitor venetoclax, and targeted therapies, have emerged, and they may offer new options for older adults. This study was aimed at describing treatment patterns and outcomes of older adult AML in a modern population-based cohort.

Methods: This study evaluated patients aged ≥60 years with a first primary diagnosis of AML (2014-2017) in the California Cancer Registry linked to inpatient hospitalizations. Multivariable regression examined factors associated with the frontline treatment regimen and survival.

Results: In all, 3068 patients were included; 36% received frontline therapy with a conventional chemotherapy backbone, 42% received nonconventional therapy, and 22% received no treatment. The use of nonconventional therapy increased over time from 38% of patients in 2014 to 47% in 2017 (P < .001). In multivariable analyses, receipt of treatment was associated with an age younger than 80 years, fewer than 2 comorbidities, and care at a National Cancer Institute-designated cancer center (NCI-CC). Compared with conventional chemotherapy, nonconventional therapy was associated with Black race/ethnicity, public health insurance, fewer hospital admissions, and fewer inpatient days. Receiving frontline therapy at an NCI-CC was independently associated with superior overall survival.

Conclusions: Using a population-based approach, this study has demonstrated that patterns of care for frontline AML treatment in older adults are changing, with increasing use of nonconventional therapies. A significant proportion of older adults remain untreated. At the population level, there remain opportunities to increase therapy access for older adults with AML.
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http://dx.doi.org/10.1002/cncr.33873DOI Listing
August 2021

Symptomatic presentation of cervical cancer in emergency departments in California.

Cancer Causes Control 2021 Dec 23;32(12):1411-1421. Epub 2021 Aug 23.

California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA.

Purpose: Through screening and HPV vaccination, cervical cancer can mostly be prevented or detected very early, before symptoms develop. However, cervical cancer persists, and many women are diagnosed at advanced stages. Little is known about the degree to which U.S. women may begin their diagnostic workup for cervical cancer in Emergency Departments (ED). We sought to quantify the proportion of women presenting symptomatically in the ED prior to their diagnosis with cervical cancer and to describe their characteristics and outcomes.

Methods: We identified women diagnosed from 2006 to 2017 with cervical cancer in the California Cancer Registry. We linked this cohort to statewide ED discharge records to determine ED use and symptoms present at the encounter. Multivariable logistic regression models examined associations with ED use and multivariable Cox proportional hazards regression models examined associations with survival.

Results: Of the more than 16,000 women with cervical cancer in the study cohort, 28% presented symptomatically in the ED prior to diagnosis. Those presenting symptomatically were more likely to have public (odds ratio [OR] 1.16; 95% confidence interval [CI] 1.06-1.27) or no insurance (OR 4.81; CI 4.06-5.71) (vs. private), low socioeconomic status (SES) (OR 1.76; CI 1.52-2.04), late-stage disease (OR 5.29; CI 4.70-5.96), and had a 37% increased risk of death (CI 1.28-1.46).

Conclusion: Nearly a third of women with cervical cancer presented symptomatically, outside of a primary care setting, suggesting that many women, especially those with low SES, may not be benefiting from screening or healthcare following abnormal results.
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http://dx.doi.org/10.1007/s10552-021-01489-zDOI Listing
December 2021

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

Am J Prev Med 2021 Aug 14. 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
August 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

ASO Visual Abstract: Secondary Breast Cancer Sociodemographic Characteristics and Survival by Age Group.

Ann Surg Oncol 2021 Jul 22. Epub 2021 Jul 22.

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

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http://dx.doi.org/10.1245/s10434-021-10389-0DOI Listing
July 2021

ASO Author Reflections: Decreased Survival from Secondary Breast Cancer in Women of All Ages.

Ann Surg Oncol 2021 Jul 19. Epub 2021 Jul 19.

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

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http://dx.doi.org/10.1245/s10434-021-10399-yDOI Listing
July 2021

Secondary Breast Cancer Sociodemographic Characteristics and Survival by Age Group.

Ann Surg Oncol 2021 Jun 29. Epub 2021 Jun 29.

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

Background: Secondary cancers account for 16% of all new cancer diagnoses, with breast cancer (BC) the most common secondary cancer. We have shown that secondary BC has unique characteristics and decreased survival compared with primary BC in adolescent and young adults (AYA; 15-39 years old). However, older BC populations are less well studied.

Methods: Females (age ≥ 15 years) diagnosed with primary BC during 1991-2015 (n = 377,167) and enrolled in the California Cancer Registry were compared with those with secondary BC (n = 37,625) by age (15-39, 40-64, ≥ 65 years). We examined BC-specific survival (BCSS) accounting for other causes of death as a competing risk using multivariable Cox proportional hazards regression.

Results: Most secondary BC patients were of older age (15-39, n = 777; 40-64, n = 15,848; ≥ 65, n = 21,000). Compared with primary BC treatment, secondary BCs were more often treated with mastectomy and less often with chemotherapy and/or radiation. BCSS was shorter in secondary BC patients than primary BC patients, but the survival difference between secondary and primary BC diminished with age [15-39 hazard ratio (HR): 2.09, 95% confidence interval (CI) 1.83-2.39; 40-64 HR: 1.51; 95% CI 1.44-1.58; ≥ 65 HR: 1.14; 95% CI 1.10-1.19]. Survival differences were most pronounced in women with hormone receptor positive disease and Hispanic and Asian/Pacific Islanders 40-64 years of age.

Conclusions: When BC is diagnosed following a prior cancer of any organ site, BCSS is worse than when compared with patients for whom BC is the primary diagnosis, suggesting that we may need to tailor our treatments for women with secondary BC.
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http://dx.doi.org/10.1245/s10434-021-10340-3DOI Listing
June 2021

Treatment Patterns and Survival in Older Adults with Diffuse Large B-cell Lymphoma: A Population-Based Study.

J Registry Manag 2020 ;47(3):135-145

Background And Objective: Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma, with a median age of diagnosis of 66 years. Anthracycline-containing regimens are the most common treatments, but toxicity concerns can limit their use in patients older than 80 years. Understanding treatment patterns and associated survival in adults older than 80 years (vs adults aged 65-80 years) can help determine effective management strategies in this population. We sought to describe the impact of age on treatment regimens used and associated survival in older adults with DLBCL.

Methods: Data for 17,859 patients aged ≥65 years diagnosed with DLBCL from 2006 to 2017 were obtained from the California Cancer Registry. Detailed treatment information for each patient was extracted from treatment text fields. Multivariable logistic regression models examined characteristics associated with no treatment and multivariable Cox proportional hazards regression models examined the influence of treatment on overall survival and cancer specific survival.

Results: Across both examined age groups (65-80 years and older than 80 years), the most common treatment was anthracycline-containing regimens followed by other drug combinations. For patients older than 80 years, fewer received anthracyclines (32.4%) and more received other drug combinations (17.6%) or had no treatment (13.1%) vs those aged 65-80 years (61.6% anthracyclines, 10.4% other combinations, 5% no treatment). Women were less likely to receive treatment, as were those who were older, had more comorbidities, received treatment at non-National Cancer Institute designated cancer centers, or were diagnosed more recently. For patients older than 80 years, anthracyclines and R-CVP conferred a survival advantage compared to other combinations.

Conclusion: In this large, population-based group of older adults with DLBCL, patients older than 80 years were less likely to receive initial treatment and more likely to receive other drug combinations despite a survival advantage with more standard anthracycline and nonanthracycline regimen protocols.
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June 2021

Chronic medical conditions and late effects after acute myeloid leukaemia in adolescents and young adults: a population-based study.

Int J Epidemiol 2021 05;50(2):663-674

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

Background: Curative-intent treatment of acute myeloid leukaemia (AML) can lead to multiple chronic medical conditions ('late effects'). Little is known about the burden of late effects in adolescent and young adult (AYA, 15-39 years) survivors of AML. We aimed to estimate the cumulative incidence and investigate the main predictors of late effects among these patients.

Methods: During 1996-2012, 1168 eligible AYAs with AML who survived ≥2 years after diagnosis were identified in the California Cancer Registry. Late effects were reported from State hospital discharge data, and patients were followed through 2014. Hazard ratios and 95% confidence intervals of late effects occurrence were estimated using Cox proportional hazard models, adjusted for sociodemographic and clinical factors.

Results: The most common late effects at 10 years after diagnosis were: endocrine (26.1%), cardiovascular (18.6%) and respiratory (6.6%), followed by neurologic (4.9%), liver/pancreatic (4.3%), renal (3.1%), avascular necrosis (2.7%) and second primary malignancies (2.4%). Of 1168 survivors, 547 (46.8%) received a haematopoietic stem cell transplant (HSCT). After multivariable adjustments, AYAs who underwent HSCT or had a non-favourable risk AML experienced ∼2-fold or higher increased likelihood of all late effects. Additionally, AYAs of Hispanic, Black or Asian/Pacific Islander (vs non-Hispanic White) race/ethnicity and those who resided in lower socio-economic neighbourhoods were at higher risk of numerous late effects.

Conclusions: Our findings underscore the need for long-term surveillance for the prevention, early detection and treatment of late effects, and can inform the development of AYA-focused consensus-based guidelines that will ultimately improve the quality of life and survival of these young vulnerable patients.
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http://dx.doi.org/10.1093/ije/dyaa184DOI Listing
May 2021

Additional medical costs of chronic conditions among adolescent and young adult cancer survivors.

J Cancer Surviv 2021 Apr 26. Epub 2021 Apr 26.

Graduate Group of Epidemiology, University of California, Davis, One Shields Avenue, Davis, CA, 95616, USA.

Purpose: Adolescent and young adult (AYA) cancer survivors are more likely to have multiple chronic conditions compared to AYAs without history of cancer. The financial hardship of chronic conditions associated with cancer can substantially impact cancer survivors. We aim to assess health risk behaviors and health care access factors associated with increased medical expenses in AYA cancer survivors.

Methods: We utilized 2011-2016 Medical Expenditure Panel Survey (MEPS) data to identify the prevalence of chronic conditions, health risk behaviors, and health care access in 2326 AYA cancer survivors. The association between health risk behaviors, health care access factors, and chronic conditions with medical expenditures was assessed using multivariable regression with gamma distribution and log link. Analyses were adjusted for age, sex, race/ethnicity, education, and marital status. Expenses were adjusted for inflation to 2016 dollars.

Results: Most AYA cancer survivors had ≥1 chronic condition (74%) and were diagnosed with cancer ≥10 years prior to the survey (76%). AYA cancer survivors with chronic conditions spent an additional $2777 (95% CI, $480 to $5958) annually compared to survivors with no chronic conditions. Additional annual expenses also were associated with physical inactivity ($3558; 95% CI, $2200 to $4606) and being unable to get care when needed ($1291; 95% CI, $198 to 3335).

Conclusions: Chronic conditions are associated with a substantial increase in medical expenses well after cancer diagnosis in AYA cancer survivors.

Implication For Cancer Survivors: Getting care when needed and adopting healthy behaviors, particularly exercise, may reduce medical expenses associated with chronic conditions in AYAs.
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http://dx.doi.org/10.1007/s11764-021-01044-4DOI Listing
April 2021

Influence of Socioeconomic Status on Incident Medical Conditions in Two-Year Survivors of Adolescent or Young Adult Differentiated Thyroid Cancer.

J Adolesc Young Adult Oncol 2021 Oct 28;10(5):521-533. Epub 2021 Jan 28.

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

We sought to enumerate secondary medical conditions from hospitalization records in adolescent and young adult (AYA) differentiated thyroid cancer (DTC) survivors and identify characteristics of patients with increased likelihood of subsequent medical diagnoses. Using data from the California Cancer Registry and statewide hospitalization data, we examined incident oncologic, endocrine, pulmonary, hematologic, and cardiovascular diagnoses in 12,312 AYA (aged 15-39) patients diagnosed with DTC in 1996-2012 and surviving >2 years after diagnosis with follow-up through 2014. We calculated the cumulative incidence of each condition accounting for the competing risk of death and used multivariable Cox proportional hazards regression to evaluate sociodemographic and clinical characteristics associated with each incident condition. The 10-year cumulative incidences of multiple medical conditions were particularly high in blacks and Hispanics. Asian/Pacific Islander survivors were most likely to develop subsequent cancers. Men had higher rates of cardiovascular and diabetes diagnoses than women, but lower rates of asthma and cytopenias. Low socioeconomic status and/or public or no insurance were associated with a higher risk of several diagnoses. More extensive disease stage and thyroid surgery increased the risk of calcium and phosphorus metabolism disorders. Neck reoperation associated with the risk of cytopenias, as well as subsequent endocrine, cardiovascular, and respiratory diagnoses. The incidence of medical conditions after thyroid cancer diagnosis and treatment differ among racial/ethnic groups and sexes. Those residing in lower socioeconomic neighborhoods, those with public or no insurance, and those who require further neck surgery have substantially higher burdens of subsequent medical diagnoses.
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http://dx.doi.org/10.1089/jayao.2020.0142DOI Listing
October 2021

Racial/Ethnic Disparities in Survival after Breast Cancer Diagnosis by Estrogen and Progesterone Receptor Status: A Pooled Analysis.

Cancer Epidemiol Biomarkers Prev 2021 02 18;30(2):351-363. Epub 2020 Dec 18.

Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background: Limited studies have investigated racial/ethnic survival disparities for breast cancer defined by estrogen receptor (ER) and progesterone receptor (PR) status in a multiethnic population.

Methods: Using multivariable Cox proportional hazards models, we assessed associations of race/ethnicity with ER/PR-specific breast cancer mortality in 10,366 California women diagnosed with breast cancer from 1993 to 2009. We evaluated joint associations of race/ethnicity, health care, sociodemographic, and lifestyle factors with mortality.

Results: Among women with ER/PR breast cancer, breast cancer-specific mortality was similar among Hispanic and Asian American women, but higher among African American women [HR, 1.31; 95% confidence interval (CI), 1.05-1.63] compared with non-Hispanic White (NHW) women. Breast cancer-specific mortality was modified by surgery type, hospital type, education, neighborhood socioeconomic status (SES), smoking history, and alcohol consumption. Among African American women, breast cancer-specific mortality was higher among those treated at nonaccredited hospitals (HR, 1.57; 95% CI, 1.21-2.04) and those from lower SES neighborhoods (HR, 1.48; 95% CI, 1.16-1.88) compared with NHW women without these characteristics. Breast cancer-specific mortality was higher among African American women with at least some college education (HR, 1.42; 95% CI, 1.11-1.82) compared with NHW women with similar education. For ER/PR disease, breast cancer-specific mortality did not differ by race/ethnicity and associations of race/ethnicity with breast cancer-specific mortality varied only by neighborhood SES among African American women.

Conclusions: Racial/ethnic survival disparities are more striking for ER/PR than ER/PR breast cancer. Social determinants and lifestyle factors may explain some of the survival disparities for ER/PR breast cancer.

Impact: Addressing these factors may help reduce the higher mortality of African American women with ER/PR breast cancer.
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http://dx.doi.org/10.1158/1055-9965.EPI-20-1291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867638PMC
February 2021

The influence of the Affordable Care Act-Dependent Care Expansion on insurance coverage among young cancer survivors in California: an updated analysis.

Cancer Causes Control 2021 Jan 6;32(1):95-101. Epub 2020 Nov 6.

Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, 4501 X Street, Suite 3016, Sacramento, CA, 95817, USA.

Purpose: To assess changes in health insurance coverage for young cancer patients pre- and post- the Affordable Care Act-Dependent Care Expansion (ACA-DCE) implementation in California. Further, we examined differences in insurance coverage by socioeconomic and race/ethnicity.

Methods: Data were obtained from the California Cancer Registry and Medicaid enrollment files, from 2005 to 2014. We conducted difference-in-difference analyses among 7042 cancer patients aged 22-25 years ("intervention group") and 25,269 aged 26-34 years ("control group"). We also examined the independent and combined effects of race/ethnicity and neighborhood socioeconomic status (nSES) on insurance coverage.

Results: After the ACA-DCE implementation, we observed a 52.7% reduction in the proportion of uninsured and a 35.7% increase in the proportion of privately insured patients. There was also a 17.3% reduction in Medicaid at cancer diagnosis and a 27.5% reduction in discontinuous Medicaid enrollment. However, these benefits were limited to patients of non-Hispanic White, Hispanic and Asian/Pacific Islander race/ethnicity living in higher nSES, with no differences in insurance enrollment among young adults who lived in low nSES or those of Black race/ethnicity.

Conclusion: The ACA-DCE broadened insurance coverage for young adults with cancer in California. Yet, only certain subgroups of patients have benefited from this policy.
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http://dx.doi.org/10.1007/s10552-020-01360-7DOI Listing
January 2021

Prepubertal Internalizing Symptoms and Timing of Puberty Onset in Girls.

Am J Epidemiol 2021 02;190(3):431-438

Stressful environments have been associated with earlier menarche. We hypothesized that anxiety, and possibly other internalizing symptoms, are also associated with earlier puberty in girls. The Lessons in Epidemiology and Genetics of Adult Cancer From Youth (LEGACY) Girls Study (2011-2016) included 1,040 girls aged 6-13 years at recruitment whose growth and development were assessed every 6 months. Prepubertal maternal reports of daughter's internalizing symptoms were available for breast onset (n = 447), pubic hair onset (n = 456), and menarche (n = 681). Using Cox proportional hazard regression, we estimated prospective hazard ratios and 95% confidence intervals for the relationship between 1 standard deviation of the percentiles of prepubertal anxiety, depression, and somatization symptoms and the timing of each pubertal outcome. Multivariable models included age, race/ethnicity, study center, maternal education, body mass index percentile, and family history of breast cancer. Additional models included maternal self-reported anxiety. A 1-standard deviation increase in maternally reported anxiety in girls at baseline was associated with earlier subsequent onset of breast (hazard ratio (HR) = 1.22, 95% confidence interval (CI): 1.09, 1.36) and pubic hair (HR = 1.15, 95% CI: 1.01, 1.30) development, but not menarche (HR = 0.94, 95% CI: 0.83, 1.07). The association of anxiety with earlier breast development persisted after adjustment for maternal anxiety. Increased anxiety in young girls may indicate risk for earlier pubertal onset.
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http://dx.doi.org/10.1093/aje/kwaa223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086416PMC
February 2021

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

Characteristics and Outcomes for Secondary Breast Cancer in Childhood, Adolescent, and Young Adult Cancer Survivors Treated with Radiation.

Cancer Epidemiol Biomarkers Prev 2020 09;29(9):1767-1774

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

Background: Radiotherapy is used to treat many adolescent and young adult (AYA) and childhood cancer patients and is a risk factor for secondary breast cancer. While premenopausal breast cancer is inherently more aggressive, no studies to date have evaluated the characteristics and breast cancer-specific survival (BCSS) of premenopausal secondary breast cancer after radiotherapy in AYA and childhood cancer survivors.

Methods: Female patients ages 12 to 50 diagnosed with primary breast cancer from 1988 to 2014 ( = 107,751) were obtained from the California Cancer Registry and compared with similar aged patients with secondary breast cancer who were treated with radiotherapy for their primary tumor ( = 1,147) from ages 12 to 39. We examined BCSS using multivariable Cox proportional hazards regression.

Results: The secondary breast cancer cohort was more likely to be Hispanic or Black, be 35 to 45 years of age, have earlier stage tumors, be higher grade, have no lymph node involvement, and be hormone receptor negative. All women showed worse BCSS for large tumor size, lymph node involvement, and hormone receptor-negative status. BCSS was worse for women with secondary breast cancer both overall (hazard ratio, 1.98; 95% confidence interval, 1.77-2.23) and in all subgroups considered. Associations were most pronounced in Hispanics, Asian/Pacific Islanders, and younger women, as well as those with earlier stage, lymph node-negative, and hormone receptor-positive disease.

Conclusions: BCSS is significantly decreased among all survivors of childhood and AYA cancer treated with radiotherapy that develop a secondary breast cancer, including women with good prognostic features.

Impact: Therefore, we may need to consider alternative and even more aggressive treatment in what were considered low-risk populations previously.
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http://dx.doi.org/10.1158/1055-9965.EPI-20-0260DOI Listing
September 2020

Breast Cancer Population Attributable Risk Proportions Associated with Body Mass Index and Breast Density by Race/Ethnicity and Menopausal Status.

Cancer Epidemiol Biomarkers Prev 2020 10 29;29(10):2048-2056. Epub 2020 Jul 29.

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

Background: Overweight/obesity and dense breasts are strong breast cancer risk factors whose prevalences vary by race/ethnicity. The breast cancer population attributable risk proportions (PARP) explained by these factors across racial/ethnic groups are unknown.

Methods: We analyzed data collected from 3,786,802 mammography examinations (1,071,653 women) in the Breast Cancer Surveillance Consortium, associated with 21,253 invasive breast cancers during a median of 5.2 years follow-up. HRs for body mass index (BMI) and breast density, adjusted for age and registry were estimated using separate Cox regression models by race/ethnicity (White, Black, Hispanic, Asian) and menopausal status. HRs were combined with observed risk-factor proportions to calculate PARPs for shifting overweight/obese to normal BMI and shifting heterogeneously/extremely dense to scattered fibroglandular densities.

Results: The prevalences and HRs for overweight/obesity and heterogeneously/extremely dense breasts varied across races/ethnicities and menopausal status. BMI PARPs were larger for postmenopausal versus premenopausal women (12.0%-28.3% vs. 1.0%-9.9%) and nearly double among postmenopausal Black women (28.3%) than other races/ethnicities (12.0%-15.4%). Breast density PARPs were larger for premenopausal versus postmenopausal women (23.9%-35.0% vs. 13.0%-16.7%) and lower among premenopausal Black women (23.9%) than other races/ethnicities (30.4%-35.0%). Postmenopausal density PARPs were similar across races/ethnicities (13.0%-16.7%).

Conclusions: Overweight/obesity and dense breasts account for large proportions of breast cancers in White, Black, Hispanic, and Asian women despite large differences in risk-factor distributions.

Impact: Risk prediction models should consider how race/ethnicity interacts with BMI and breast density. Efforts to reduce BMI could have a large impact on breast cancer risk reduction, particularly among postmenopausal Black women.
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http://dx.doi.org/10.1158/1055-9965.EPI-20-0358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541499PMC
October 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

Hospital Characteristics and Breast Cancer Survival in the California Breast Cancer Survivorship Consortium.

JCO Oncol Pract 2020 06;16(6):e517-e528

Stanford Cancer Institute, Stanford, CA.

Introduction: Racial/ethnic disparities in breast cancer survival are well documented, but the influence of health care institutions is unclear. We therefore examined the effect of hospital characteristics on survival.

Methods: Harmonized data pooled from 5 case-control and prospective cohort studies within the California Breast Cancer Survivorship Consortium were linked to the California Cancer Registry and the California Neighborhoods Data System. The study included 9,701 patients with breast cancer who were diagnosed between 1993 and 2007. First reporting hospitals were classified by hospital type-National Cancer Institute (NCI) -designated cancer center, American College of Surgeons (ACS) Cancer Program, other-and hospital composition of the neighborhood socioeconomic status and race/ethnicity of patients with cancer. Multivariable Cox proportional hazards models adjusted for clinical and patient-level prognostic factors were used to examine the influence of hospital characteristics on survival.

Results: Fewer than one half of women received their initial care at an NCI-designated cancer center (5%) or ACS program (38%) hospital. Receipt of initial care in ACS program hospitals varied by race/ethnicity-highest among non-Latina White patients (45%), and lowest among African Americans (21%). African-American women had superior breast cancer survival when receiving initial care in ACS hospitals versus other hospitals (non-ACS program and non-NCI-designated cancer center; hazard ratio, 0.67; 95% CI, 0.55 to 0.83). Other hospital characteristics were not associated with survival.

Conclusion: African American women may benefit significantly from breast cancer care in ACS program hospitals; however, most did not receive initial care at such facilities. Future research should identify the aspects of ACS program hospitals that are associated with higher survival and evaluate strategies by which to enhance access to and use of high-quality hospitals, particularly among African American women.
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http://dx.doi.org/10.1200/OP.20.00064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8462568PMC
June 2020

First-Line Systemic Treatments for Stage IV Non-Small Cell Lung Cancer in California: Patterns of Care and Outcomes in a Real-World Setting.

JNCI Cancer Spectr 2019 Sep 4;3(3):pkz020. Epub 2019 Apr 4.

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

Background: Multiple systemic treatments have been developed for stage IV non-small cell lung cancer (NSCLC), but their use and effect on outcomes at the population level are unknown. This study describes the utilization of first-line systemic treatments among stage IV NSCLC patients in California and compares survival among treatment groups.

Methods: Data on 17 254 patients diagnosed with stage IV NSCLC from 2012 to 2014 were obtained from the California Cancer Registry. Systemic treatments were classified into six groups. The Kaplan-Meier method and multivariable Cox proportional hazards models were used to compare survival between treatment groups.

Results: Fifty-one percent of patients were known to have received systemic treatment. For patients with nonsquamous histology, pemetrexed regimens were the most common treatment (14.8%) followed by tyrosine kinase inhibitors (11.9%) and platinum doublets (11.5%). Few patients received pemetrexed/bevacizumab combinations (4.5%), bevacizumab combinations (3.6%), or single agents (1.7%). There was statistically significantly better overall survival for those on pemetrexed regimens (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.80 to 0.92), bevacizumab regimens (HR = 0.73, 95% CI = 0.65 to 0.81), pemetrexed/bevacizumab regimens (HR = 0.68, 95% CI = 0.61 to 0.76), or tyrosine kinase inhibitors (HR = 0.62, 95% CI = 0.57 to 0.67) compared with platinum doublets. The odds of receiving most systemic treatments decreased with decreasing socioeconomic status. For patients with squamous histology, platinum doublets were predominant (33.7%) and were not found to have statistically significantly different overall survival from single agents.

Conclusions: These population-level findings indicate low utilization of systemic treatments, survival differences between treatment groups, and evident treatment disparities by socioeconomic status.
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http://dx.doi.org/10.1093/jncics/pkz020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050031PMC
September 2019

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

Impaired Immune Health in Survivors of Diffuse Large B-Cell Lymphoma.

J Clin Oncol 2020 05 21;38(15):1664-1675. Epub 2020 Feb 21.

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

Purpose: Therapeutic advances for diffuse large B-cell lymphoma (DLBCL) have led to an increasing number of survivors. Both DLBCL and its treatments perturb the immune system, yet little is known about immune health during extended survivorship.

Methods: In this retrospective cohort study, we compared 21,690 survivors of DLBCL from the California Cancer Registry (CCR) to survivors of breast, prostate, head and neck, and melanoma cancers. We linked their CCR records to a statewide database documenting hospital, emergency room, and ambulatory surgery visits and investigated the incidence of autoimmune conditions, immune deficiencies, and infections 1-10 years after cancer diagnosis.

Results: We found elevated incidence rate ratios (IRRs) for many immune-related conditions in survivors of DLBCL compared with other cancer survivors, including significantly and consistently elevated IRRs for viral and fungal pneumonias (up to 10.8-fold), meningitis (up to 5.3-fold), as well as humoral deficiency (up to 17.6-fold) and autoimmune cytopenias (up to 12-fold). IRRs for most conditions remained high even in the late survivorship period (5-10 years after cancer diagnosis). The elevated risks could not be explained by exposure to chemotherapy, stem-cell transplantation, or rituximab, except for IRRs for humoral deficiency, which were consistently higher after the incorporation of rituximab into DLBCL treatments.

Conclusion: To our knowledge, this is the largest cohort study with extended follow-up to demonstrate impaired immune health in survivors of DLBCL. The observed persistent, elevated risks for autoimmune diseases, immune deficiencies, and infectious conditions may reflect persistent immune dysregulation caused by lymphoma or treatment and may lead to excess morbidity and mortality during survivorship. Improved understanding of these risks could meaningfully improve long-term care of patients with DLBCL.
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http://dx.doi.org/10.1200/JCO.19.01937DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238489PMC
May 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

Pre-diagnosis health-related quality of life and survival in older women with endometrial cancer.

Support Care Cancer 2020 Oct 1;28(10):4901-4909. Epub 2020 Feb 1.

Public Health Institute, Cancer Registry of Greater California, 1750 Howe Ave. Ste. 550, Sacramento, CA, 95825, USA.

Purpose: Health-related quality of life (HRQOL) is an important prognostic factor in cancer patients. To date, no other studies have assessed the association between HRQOL measured before diagnosis and survival in older women with endometrial cancer.

Methods: The Surveillance, Epidemiology, and End Results - Medicare Health Outcomes Survey linked database was used to identify 995 women who were at least 65 years old and completed a survey before diagnosis with endometrial cancer. We obtained scores for 10 HRQOL scales, as measured by Medical Outcomes Study Short Form-36 and Veterans RAND 12-Item Survey, and data on activities of daily living (ADLs) impairments and depressive symptoms. Fine and Gray competing risks regression and Cox proportional hazards were used to estimate the association of HRQOL with endometrial cancer-specific and overall survival, respectively.

Results: Women who died had worse pre-diagnosis HRQOL than women who were still alive at the end of the study period. For every five-point increase in HRQOL score, overall survival improved by 5-9%. The strongest associations were observed for vitality (HR = 0.91, 95% CI 0.86, 0.97, p = 0.0021) and physical functioning (HR = 0.92, 95% CI 0.87, 0.97, p = 0.0010). ADL impairments were generally not predictive of survival, though depressive symptoms were significantly associated with increased hazard of death from all causes (HR = 1.34, 95% CI 1.00, 1.79, p = 0.0466).

Conclusion: HRQOL measured before diagnosis with endometrial cancer has prognostic value. Having measures of HRQOL available at diagnosis may facilitate timely supportive care to improve survival.
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http://dx.doi.org/10.1007/s00520-020-05324-0DOI Listing
October 2020

Changes in health-related quality of life in older women after diagnosis with gynecologic cancer.

Gynecol Oncol 2020 02 2;156(2):475-481. Epub 2019 Dec 2.

Public Health Institute, Cancer Registry of Greater California, Sacramento, CA, United States of America; Department of Public Health Sciences, University of California Davis, Davis, CA, United States of America.

Purpose: The impact of gynecologic cancer on health-related quality of life (HRQOL) is not fully understood. To our knowledge, this is the first longitudinal study to measure HRQOL changes from before to after gynecologic cancer diagnosis in older women.

Methods: Data were obtained from the Surveillance, Epidemiology, and End Results - Medicare Health Outcomes Survey database. Women aged 65 and older who were diagnosed with cervical, ovarian, or uterine cancer between baseline and follow-up surveys (n = 248; mean time from diagnosis = 12.54 ± 7.11 months) were propensity-matched to cancer-free controls (n = 1240). Logistic regression was used to assess risk of functional impairments and depressive symptoms at follow-up. Changes in HRQOL, as measured by the Medical Outcomes Study Short Form-36 and Veterans RAND 12-Item Survey, were estimated with mixed effects linear models.

Results: Women who were within 12 months of diagnosis and women diagnosed with regional/distant disease had significantly greater odds than controls of impairment at follow-up. HRQOL declines were greatest in those with advanced disease, with the most notable changes from baseline to follow-up observed for role limitations due to emotional problems (-8.60 vs. -3.42 in controls), general health (-7.76 vs 0.10), and physical functioning (-7.70 vs. -1.67). There were significant decreases in physical functioning and role limitations due to emotional problems for all cancer patients regardless of time since diagnosis.

Conclusions: Gynecologic cancer has significant impacts on physical and mental aspects of HRQOL in older women. Interventions are needed to reduce pain, provide support, and prepare patients for changes in functioning and health.
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http://dx.doi.org/10.1016/j.ygyno.2019.11.033DOI Listing
February 2020
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