Comorbid disease and cancer: the need for more relevant conceptual models in health services research.
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Comorbidity↗
Biomedical subjects
James S Goodwin
Publications and source records attributed to James S Goodwin.
Cardiac morbidity of adjuvant radiotherapy for breast cancer.
PURPOSE: Adjuvant breast irradiation has been associated with an increase in cardiac mortality, because left-sided breast radiation can produce cardiac damage. The purpose of this study was to determine whether modern adjuvant radiotherapy is associated with increased risk of cardiac morbidity. PATIENTS AND METHODS: Data from the Surveillance, Epidemiology, and End Results-Medicare database were used for women who were diagnosed with nonmetastatic breast cancer from 1986 to 1993, had known disease laterality, underwent breast surgery, and received adjuvant radiotherapy. The Cox proportional-hazards model was used to compare patients with left- versus right-sided breast cancer for the end points of hospitalization with the following discharge diagnoses (International Classification of Diseases, 9th Revision codes): ischemic heart disease (410-414, 36.0, and 36.1), valvular heart disease (394-397, 424, 35), congestive heart failure (428, 402.01, 402.11, 402.91, and 425), and conduction abnormalities (426, 427, 37.7-37.8, and 37.94-37.99). RESULTS: Eight thousand three hundred sixty-three patients had left-sided breast cancer, and 7,907 had right-sided breast cancer. Mean follow-up was 9.5 years (range, 0 to 15 years). There were no significant differences in patients with left- versus right-sided cancers for hospitalization for ischemic heart disease (9.9% v 9.7%), valvular heart disease (2.9% v 2.8%), conduction abnormalities (9.7% v 9.6%), or heart failure (9.7% v 9.7%). The adjusted hazard ratio for left- versus right-sided breast cancer was 1.05 (95% CI, 0.94 to 1.16) for ischemic heart disease, 1.07 (95% CI, 0.89 to 1.30) for valvular heart disease, 1.07 (95% CI, 0.96 to 1.19) for conduction abnormalities, and 1.05 (95% CI, 0.95 to 1.17) for heart failure. CONCLUSION: With up to 15 years of follow-up there were no significant differences in cardiac morbidity after radiation for left- versus right-sided breast cancer.
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Impact of osteoarthritis on the rehabilitation of patients following a stroke.
OBJECTIVE: To determine if functional gain for patients following stroke rehabilitation is adversely affected by osteoarthritis (OA). METHODS: A retrospective cohort analysis was conducted using data collected between 1994 and 2001 from a large national registry of US rehabilitation inpatients. Outcome variables were functional status (the Functional Independence Measure [FIM Instrument]) at discharge and followup, FIM gain during and after rehabilitation, length of stay, and discharge setting. The primary predictor variable was the presence of OA. Covariates were age, sex, race, other comorbidities, type of stroke, length of stay, and time to followup. Analysis was by multivariable regression. RESULTS: Data from 3,094 patients with OA and 44,943 patients without OA admitted following a stroke to inpatient rehabilitation facilities were analyzed. In unadjusted analyses, OA was associated with significantly higher FIM ratings than patients without OA at admission (mean +/- SD 65.7 +/- 19.2 versus 63.1 +/- 20.5; P < 0.001) and discharge (mean +/- SD 89.2 +/- 21.8 versus 87.7 +/- 23.0; P < 0.001), but with lower FIM ratings at followup (mean +/- SD 97.7 +/- 24.7 versus 99.7 +/- 24.9; P < 0.001). In multivariate analyses, adjusting for potential confounders, OA was associated with a 1.62-day increase in length of stay (95% confidence interval [95% CI] 1.15, 2.08) and a 1.37 smaller improvement in FIM scores between admission and followup (95% CI 0.62, 2.12). This smaller increase in FIM instrument score was caused by less improvement in FIM after discharge. CONCLUSION: OA impairs recovery from stroke. This is compensated for by longer length of stay for inpatient medical rehabilitation. Reimbursement systems may need to consider the impact of OA as a comorbid condition in patients receiving stroke rehabilitation.
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The effect of socioeconomic factors on incidence, stage at diagnosis and survival of cutaneous melanoma.
Melanoma represents a significant and growing public health burden worldwide, especially in Caucasian populations. The purpose of this review is to summarize the literature on the relationship between socioeconomic status (SES) and incidence, stage at diagnosis and survival from melanoma. Although differences across countries exist on the relationship of SES to specific behaviors or risk factors, our principal findings are: melanoma is more common in high SES than in low SES populations; and low SES populations present with later stages at diagnosis and experience worse survival rates from melanoma than high SES populations. Potential explanations for these findings are that high SES individuals may have a higher susceptibility and exposure (e.g., risk behaviors) for developing melanoma, and low SES individuals may have less access to educational campaigns and screening examinations and effective treatment. These differences reflect a disparity in melanoma outcomes across diverse SES populations in many countries.
Humans↗
Increasing use of gonadotropin-releasing hormone agonists for the treatment of localized prostate carcinoma.
BACKGROUND: The role of androgen deprivation therapy in prostate carcinoma is controversial in earlier stages of disease. The authors examined the time trends and patterns of use for androgen deprivation in the form of gonadotropin-releasing hormone (GnRH) agonists or orchiectomy, in population-based tumor registries. METHODS: Data were obtained from the linked Surveillance, Epidemiology and End Results-Medicare database. A total of 100,274 men with prostate carcinoma diagnosed from 1991 through 1999 were selected. The main outcome was the proportion of men who received >/= 1 dose of a GnRH agonist in the first 6 months of diagnosis. This was plotted by year and stratified for age, grade, stage as well as primary versus adjuvant usage. Multiple logistic regression was used to examine predictors of GnRH agonist use in the subset of patients with localized cancer. RESULTS: There was a consistent increase in GnRH agonist use by year for all ages, stages, and grades. Even in men >/= 80 years with localized stage and low to moderate grade tumors, primary GnRH agonist use increased over the study period, from 3.7% in 1991 to 30.9% in 1999 (P < 0.001). The multivariable analysis showed that significant variability in GnRH agonist use existed among SEER geographic regions. CONCLUSIONS: The use of GnRH agonists for prostate carcinoma increased dramatically during the 1990s. This increase occurred across all stages and histologic grades of prostate carcinoma, and was greatest in patients >/= 80 years.
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Risk of cardiac death after adjuvant radiotherapy for breast cancer.
BACKGROUND: Women with breast cancer who are treated with adjuvant radiation have a decreased risk of local recurrence but an increased risk of mortality from ischemic heart disease. Patients with left-sided breast tumors receive a higher dose of radiation to the heart than patients with right-sided tumors. Because radiation techniques have improved over time, we investigated whether the risk of death from ischemic heart disease after adjuvant breast radiotherapy decreased over time. METHODS: We used the 12-registry 1973-2000 dataset from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Women (n = 27,283) treated with adjuvant radiation for breast cancer diagnosed in 1973-1989 were included in the study. Ischemic heart disease mortality was calculated at 15 years and compared for women diagnosed during 1973-1979, 1980-1984, and 1985-1989. Cox proportional hazards models were used to calculate the hazard of death from ischemic heart disease for women diagnosed 1973-1988 and censored at 12 years. All statistical tests were two-sided. RESULTS: There were no differences in age, race/ethnicity, disease stage, or follow-up time between the 13 998 women with left-sided and 13 285 with right-sided cancer. For women diagnosed in 1973-1979, there was a statistically significant difference in 15-year mortality from ischemic heart disease between patients with left-sided (13.1%, 95% confidence interval [CI] = 11.6 to 14.6) and those with right-sided (10.2%, 95% CI = 8.9 to 11.5) breast cancer (P = .02); no such difference was found for women diagnosed in 1980-1984 (9.4%, [95% CI = 8.1 to 10.6] versus 8.7% [95% CI = 7.4 to 10.0], respectively, P = .64) or 1985-1989 (5.8% [95% CI = 4.8 to 6.8] versus 5.2% [95% CI = 4.4 to 5.9], respectively, P = .98). In the Cox model, the hazard ratio [HR] for ischemic heart disease mortality for women with left-sided versus women with right-sided disease was 1.50 (95% CI = 1.19 to 1.87) in 1979. With each succeeding year after 1979, the hazard of death from ischemic heart disease for women with left-sided versus those with right-sided disease declined by 6% (HR = 0.94, 95% CI = 0.91 to 0.98). CONCLUSIONS: Risk of death from ischemic heart disease associated with radiation for breast cancer has substantially decreased over time.
Adult↗
Neighborhood composition and incidence of cancer among Hispanics in the United States.
BACKGROUND: Hispanics in the United States have a 33% lower age-adjusted incidence of cancer and a 38% lower cancer mortality rate compared with non-Hispanic whites. This may be secondary to health behaviors that vary with residential and economic assimilation. The authors investigated whether cancer incidence among Hispanics increased with residential and economic assimilation into mainstream culture. METHODS: Data from the Surveillance, Epidemiology, and End Results program (SEER) and the U.S. Census Bureau were used to compare cancer incidence rates and rate ratios as a function of percentage of Hispanics and income of Hispanics in a census tract. Type of cancer was identified with a site recode variable in the SEER data set. Cases with in situ prostate and cervical carcinoma were excluded. Hispanic ethnicity in SEER was identified by medical record review and Hispanic surname lists. The study also used income of Hispanics living in the census tract, age at diagnosis, and stratification by gender. RESULTS: The incidence of breast, colorectal, and lung carcinoma among Hispanics increased as the percentage of Hispanics in the census tract decreased and as tract Hispanic income increased. For example, there was a 39% reduction in breast carcinoma and a 38% reduction in male colorectal carcinoma when the Hispanic population in high-density Hispanic neighborhoods in the lowest income quartile was contrasted to Hispanics living in tracts with the lowest total percentage of Hispanics in the highest income quartile. CONCLUSIONS: The lower cancer rates among Hispanics relative to non-Hispanic whites in the United States may dissipate as Hispanics become more assimilated into the mainstream society.
Acculturation↗
Risk of fracture after androgen deprivation for prostate cancer.
BACKGROUND: The use of androgen-deprivation therapy for prostate cancer has increased substantially over the past 15 years. This treatment is associated with a loss of bone-mineral density, but the risk of fracture after androgen-deprivation therapy has not been well studied. METHODS: We studied the records of 50,613 men who were listed in the linked database of the Surveillance, Epidemiology, and End Results program and Medicare as having received a diagnosis of prostate cancer in the period from 1992 through 1997. The primary outcomes were the occurrence of any fracture and the occurrence of a fracture resulting in hospitalization. Cox proportional-hazards analyses were adjusted for characteristics of the patients and the cancer, other cancer treatment received, and the occurrence of a fracture or the diagnosis of osteoporosis during the 12 months preceding the diagnosis of cancer. RESULTS: Of men surviving at least five years after diagnosis, 19.4 percent of those who received androgen-deprivation therapy had a fracture, as compared with 12.6 percent of those not receiving androgen-deprivation therapy (P<0.001). In the Cox proportional-hazards analyses, adjusted for characteristics of the patient and the tumor, there was a statistically significant relation between the number of doses of gonadotropin-releasing hormone received during the 12 months after diagnosis and the subsequent risk of fracture. CONCLUSIONS: Androgen-deprivation therapy for prostate cancer increases the risk of fracture.
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Relationship of depression to patient satisfaction: findings from the barriers to breast cancer study.
OBJECTIVE: Examine the association between depressive symptoms and patient satisfaction for older women with a diagnosis of breast cancer. METHODS: Prospective study of 210 women aged 65 or older from southeast Texas newly diagnosed with breast cancer. Baseline (<2 months after diagnosis) and 12 month follow-up interviews were conducted face-to-face to collect information on sociodemographic characteristics, physical and emotional health, use of health services and satisfaction with medical care. Data analyses included descriptive statistics, chi2 analysis, and multivariate logistic regression analysis. RESULTS: Average age at baseline interview was 71.8 years (SD 6.6). The sample was 70.5% non-Hispanic white, 61.0% were unmarried, and 85.2% reported no ADL limitations. Logistic regression analysis showed a significant association between increasing depressive symptoms at baseline and lower patient satisfaction at follow-up. Each unit increase in depressive symptoms at baseline was associated with a 6% decrease in the predicted odds of being "very satisfied" with medical care at follow up (OR = 0.94, 95% CI = 0.89, 0.99), after adjusting for age, marital status, race/ethnicity, stage of diagnosis and other relevant factors. Similarly, patients who had an increase in CES-D score between baseline and follow-up interview were less likely to be satisfied with their medical care at follow up. CONCLUSION: Increasing depressive symptoms are associated with lower patient satisfaction. Early recognition and treatment of depressive symptoms may improve patients' well being and perception about quality of medical care.
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The influence of marital status on the stage at diagnosis, treatment, and survival of older women with breast cancer.
Research indicates an association between marital status and health but this link has not been thoroughly explored. Our goal was to examine the association of marital status on the diagnosis, treatment, and survival of older women with breast cancer and the potential role socioeconomic status, education level, and comorbidities may play in explaining these associations. Retrospective cohort study using linked Medicare and National Cancer Institute Surveillance, Epidemiology, and End Results cancer registry. The sample consisted of 32,268 women aged 65 years and older who received a diagnosis of breast cancer from 1991 to 1995. Information available through 1998 allowed for 3 years of follow-up. Results showed that unmarried women were more likely to be diagnosed with breast cancer stage II-IV versus stage I and in situ (OR 1.17; CI95 1.12, 1.23). Unmarried women diagnosed with stage I or II breast cancer were less likely to receive definitive therapy (OR 1.24; CI95 1.17, 1.31). Even after controlling for cancer stage and size at diagnosis and treatment received, unmarried women were at an increased risk of death from breast cancer (HR 1.25; CI95 1.14, 1.37). Socioeconomic variables and comorbidity had little impact on the relationship between marital status and survival. Older married women were at decreased risk for mortality after a diagnosis of breast cancer. Many of the health benefits enjoyed by married women are likely derived from increased social support and social networks.
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Postoperative delirium in the older patient.
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Aronow's "Should the NCEP III guidelines be changed in elderly and younger persons at high risk for cardiovascular events?" What do we do for the very old?
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Adult↗
Diabetes mellitus and incidence of lower body disability among older Mexican Americans.
BACKGROUND: Little is known about the effect of diabetes mellitus on subsequent lower body disability in older Mexican Americans, one of the fastest growing ethnic groups in the United States. The aim of this study is to examine the relationship between diabetes mellitus and incident lower body disability over a 7-year follow-up period. METHODS: Ours was a 7-year prospective cohort study of 1835 Mexican-American individuals > or = 65 years old, nondisabled at baseline, and residing in five Southwestern states. Measures included self-reported physician diagnosis of diabetes, stroke, heart attack, hip fracture, arthritis, or cancer. Disability measures included activities of daily living (ADLs), mobility tasks, and an 8-foot walk test. Body mass index, depressive symptoms, and vision function were also measured. RESULTS: At 7-year follow-up, 48.7% of diabetic participants nondisabled at baseline developed limitations in one or more measures of lower body function. Cox proportional regression analyses showed that diabetic participants were more likely to report any limitation in lower body ADL function (hazard ratio [HR] = 2.05, 95% confidence interval [CI], 1.58-2.67), mobility tasks (HR = 1.69, 95% CI, 1.39-2.04), and 8-foot walk (HR = 1.46, 95% CI, 1.15-1.85) compared with nondiabetic participants, after controlling for relevant factors. Older age and having one or more diabetic complications were significantly associated with increased risk of limitations in any lower body ADL and mobility task at follow-up. CONCLUSION: Older Mexican Americans with diabetes mellitus are at high risk for development of lower body disability over time. Awareness of disability as a potentially modifiable complication and use of interventions to reduce disability should become health priorities for older Mexican Americans with diabetes.
Activities of Daily Living↗
Weight change and lower body disability in older Mexican Americans.
OBJECTIVES: To examine the association between 2-year weight change and onset of lower body disability over time in older Mexican Americans. DESIGN: Data were from the Hispanic Established Population for the Epidemiological Study of the Elderly (1993-2001). Weight change was examined by comparing baseline weight to weight at 2-year follow-up. Incidence of lower body disability was studied from the end of this period through an additional 5 years. SETTING: Five southwestern states: Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: One thousand seven hundred thirty-seven noninstitutionalized Mexican-American men and women aged 65 and older who reported no limitation in activities of daily living (ADLs) and were able to perform the walk test at 2-year follow-up. MEASUREMENTS: In-home interviews assessed sociodemographic factors, self-reported physician diagnoses of medical conditions (arthritis, diabetes mellitus, heart attack, stroke, hip fracture, and cancer), self-reported ADLs, depressive symptoms, and number of hospitalizations. Cognitive function, handgrip muscle strength, and body mass index (BMI) were obtained. The outcomes were any limitation of lower body ADL (walking across a small room, bathing, transferring from a bed to a chair, and using the toilet) and limitation on the walk test over subsequent 5-year follow-up period. General Estimation Equation (GEE) was used to estimate lower body disability over time. RESULTS: Weight change of 5% or more occurred in 42.3% of the participants; 21.7% lost weight, 20.6% gained weight, and 57.7% had stable weight. Using GEE analysis, with stable weight as the reference, weight loss of 5% or more was associated with greater risk of any lower body ADL limitation (odds ratio (OR)=1.43, 95% confidence interval (CI)=1.06-1.95) and walking limitation (OR=1.35, 95% CI=1.03-1.76) after controlling for sociodemographic variables and BMI at baseline. Weight gain of 5% or more was associated with greater risk of any lower body ADL limitation (OR=1.39, 95% CI=1.02-1.89), after controlling for sociodemographic variables and BMI at baseline. When medical conditions, handgrip muscle strength, high depressive symptomatology, cognitive function, and hospitalization were added to the equation, the relationship between 2-year weight change (>5% loss or >5% gain) and lower body disability decreased. CONCLUSION: Health conditions and muscle strength partially mediate the association between weight loss or gain and future loss of ability to walk and independently perform ADLs.
Activities of Daily Living↗
Positive affect and disability among older Mexican Americans with arthritis.
OBJECTIVE: To examine the relationship between positive affect and subsequent functional disability in older Mexican Americans with self-reported physician-diagnosed arthritis. METHODS: We conducted a 2-year prospective cohort study using a population-based sample of 1,084 noninstitutionalized Mexican American subjects aged > or =65 years residing in 5 southwestern states. Measures included self-reported diagnoses of various medical conditions, functional ability, body mass index, and ratings of positive and negative affect. RESULTS: For 937 subjects with arthritis who reported no limitations in activities of daily living (ADLs) at baseline, 697 remained ADL independent, 84 became ADL dependent, 41 died, and 115 were lost to followup 2 years later. There was a significant association between high positive affect (score = 12) and reduced risk of ADL disability 2 years later, controlling for baseline sociodemographic variables, medical conditions, and negative affect (odds ratio 0.46, 95% confidence interval 0.22-0.94). There was an interaction effect between positive affect and sex, with positive affect having a larger effect in reducing risk of ADL dependence in men than in women. CONCLUSION: High positive affect was associated with lower incidence of ADL disability in older Mexican Americans with self-reported physician-diagnosed arthritis. The strength of the positive affect is stronger in men than in women.
Activities of Daily Living↗
Robine and Michel's "Looking forward to a general theory on population aging": commentary.
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Aged↗
University of Texas Medical Branch at Galveston.
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Curriculum↗
Decreasing variation in the use of hospice among older adults with breast, colorectal, lung, and prostate cancer.
BACKGROUND: Utilization of hospice services has been shown to vary by place of residence and patient characteristics. OBJECTIVES: The purpose of this study was to examine whether such variation has changed over time. Hospice utilization is examined as a function of sociodemographic characteristics, geographic location, type of insurance, and year of death. RESEARCH DESIGN: This study used a retrospective cohort design. SUBJECTS: We used data from the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database to study hospice utilization in subjects aged 67 and older diagnosed with breast, colorectal, lung, or prostate cancer from 1991 to 1996 and who died between 1991 and 1999. RESULTS: Of the 170,136 subjects aged 67 and older who died from 1991 through 1999, 51,345 (30.2%) were enrolled in hospice before they died. Hospice utilization varied significantly by patient characteristics, including type of insurance, age, marital status, race and ethnicity, gender, urban versus rural residence, type of cancer, income level, and education level. This variation, however, decreased over time for subgroups defined by type of insurance, marital status, urban residence, and income. Variation in hospice use increased over time as a function of age and type of cancer. There was no change in variation in use in blacks compared with non-Hispanic whites over time. CONCLUSIONS: The variation in hospice use by several patient characteristics is decreasing over time, a finding consistent with the manner in which new medical technologies diffuse.
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