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Ashish Rai, Xuesong Han, Zhiyuan Zheng, K. Robin Yabroff, and Ahmedin Jemal

Background: Despite the surge of interest in improving provider communication, empirical research is sparse on the determinants and outcomes of cancer survivors' satisfaction with healthcare provider communication. Methods: Longitudinal Medical Expenditure Panel Survey data spanning 2008 through 2014 was used to identify 4,588 respondents who were ever diagnosed with cancer. A composite score was generated by combining 5 measures of satisfaction. We used multivariate logistic regressions and 2-part models to examine the associations between satisfaction ratings and outcomes, including general, mental, and physical health; office visits; and total healthcare, drug, and out-of-pocket expenditures. Results: The study sample comprised 2,257 nonelderly (age 18–64 years) and 2,331 elderly (age ≥65 years) respondents. Among both age groups, higher satisfaction was associated with fewer comorbidities, fewer year 1 office visits, and absence of year 1 emergency department visits. Membership of higher satisfaction tertile in year 1 was associated with better year 2 mental health (tertile 1 [T1]: predictive margin [PM], 27.1%; tertile 2 [T2]: PM, 35.5%; P=.013; tertile 3 [T3]: PM, 37.0%; P=.005) and general health (T1 [ref]: PM, 30.3%; T3: PM, 38.9%; P=.007) among the elderly. Greater satisfaction was associated with fewer year 2 office visits (T1 [ref]: PM, 7.42 visits; T3: PM, 6.26 visits; P=.038) among the nonelderly; and lower year 2 healthcare expenditures (T1 [ref]: PM, $34,071; T3: PM, $26,995; P=.049) among the elderly. Conclusions: We identified potential differences in cancer survivors' needs and expectations of provider communication based on comorbidities and baseline service use. These results emphasize the need for individualized communication strategies for patients with cancer and survivors shaped by their distinct requirements. Our findings of better health, lower service use, and lower expenditures among more satisfied cancer survivors suggest that interventions to improve provider communication could lead to a more efficient use of healthcare resources.

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Helmneh M. Sineshaw, K. Robin Yabroff, V. Liana Tsikitis, Ahmedin Jemal, and Timur Mitin

Background: Elderly patients with rectal cancer have been excluded from randomized studies, thus little is known about their early postoperative mortality, which is critical for informed consent and treatment decisions. This study examined early mortality after surgery in elderly patients with locally advanced rectal cancer (LARC). Methods: Using the National Cancer Database, we identified patients aged ≥75 years, diagnosed with clinical stage II/III rectal cancer who underwent surgery in 2004 through 2015. Descriptive analyses determined proportions and trends and multivariable logistic regression analyses were performed to determine factors associated with early mortality after rectal cancer surgery. Results: Among 11,794 patients with rectal cancer aged ≥75 years, approximately 6% underwent local excision and 94% received radical resection. Overall 30-day, 90-day, and 6-month postoperative mortality rates were 4.2%, 7.8%, and 11.5%, respectively. Six-month mortality varied by age (8.4% in age 75–79 years to 18.3% in age ≥85 years), and comorbidity score (10.1% for comorbidity score 0 to 17.7% for comorbidity score ≥2). Six-month mortality declined from 12.3% in 2004 through 2007 to 10.2% in 2012 through 2015 (P trend=.0035). Older age, higher comorbidity score, and lower facility case volume were associated with higher 6-month mortality. Patients treated at NCI-designated centers had 30% lower odds of 6-month mortality compared with those treated at teaching/research centers. Conclusions: Six-month mortality rates after surgery among patients aged ≥75 years with LARC have declined steadily over the past decade in the United States. Older age, higher comorbidity score, and care at a low-case-volume facility were associated with higher 6-month mortality after surgery. This information is necessary for informed consent and decisions regarding optimal management of elderly patients with LARC.

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Zhiyuan Zheng, Ahmedin Jemal, Reginald Tucker-Seeley, Matthew P. Banegas, Xuesong Han, Ashish Rai, Jingxuan Zhao, and K. Robin Yabroff

Background: A cancer diagnosis can impose substantial medical financial burden on individuals and may limit their ability to work. However, less is known about worry for nonmedical financial needs and food insecurity among cancer survivors. Methods: The National Health Interview Survey (2013–2017) was used to identify cancer survivors (age 18–39 years, n=771; age 40–64 years, n=4,269; age ≥65 years, n=7,101) and individuals without a cancer history (age 18–39 years, n=53,262; age 40–64 years, n=60,141; age ≥65 years, n=30,261). For both cancer survivors and the noncancer group, adjusted proportions were generated for (1) financial worry (“very/moderately/not worried”) about retirement, standard of living, monthly bills, and housing costs; and (2) food insecurity (“often/sometimes/not true”) regarding whether food would run out, the fact that food bought did not last, and the inability to afford balanced meals. Further adjusted analyses examined intensity measures (“severe/moderate/minor or none”) of financial worry and food insecurity among cancer survivors only. Results: Compared with individuals without a cancer history, cancer survivors aged 18 to 39 years reported consistently higher “very worried” levels regarding retirement (25.5% vs 16.9%; P<.001), standard of living (20.4% vs 12.9%; P<.001), monthly bills (14.9% vs 10.3%; P=.002), and housing costs (13.6% vs 8.9%; P=.001); and higher “often true” levels regarding worry about food running out (7.9% vs 4.6%; P=.004), food not lasting (7.6% vs 3.3%; P=.003), and being unable to afford balanced meals (6.3% vs 3.4%; P=.007). Findings were not as consistent for cancer survivors aged 40 to 64 years. In contrast, results were generally similar for adults aged ≥65 years with/without a cancer history. Among cancer survivors, 57.6% (age 18–39 years; P<.001), 51.9% (age 40–64 years; P<.001), and 23.8% (age ≥65 years; referent) reported severe/moderate financial worry intensity, and 27.0% (age 18–39 years; P<.001), 14.8% (age 40–64 years; P<.001), and 6.3% (age ≥65 years; referent) experienced severe/moderate food insecurity intensity. Lower income and higher comorbidities were generally associated with greater intensities of financial worry and food insecurity in all 3 age groups. Conclusions: Younger cancer survivors experience greater financial worry and food insecurity. In addition to coping with medical costs, cancer survivors with low income and multiple comorbidities struggle to pay for daily living needs, such as food, housing, and monthly bills.

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Kathryn J. Ruddy, Lindsey Sangaralingham, Rachel A. Freedman, Sarah S. Mougalian, Heather Neuman, Caprice Greenberg, Ahmedin Jemal, Narjust Duma, Tufia C. Haddad, Valerie Lemaine, Karthik Ghosh, Tina J. Hieken, Katie Hunt, Celine Vachon, Cary P. Gross, and Nilay D. Shah

Background: Guidelines recommend annual mammography after curative-intent treatment for breast cancer. The goal of this study was to assess contemporary patterns of breast imaging after breast cancer treatment. Methods: Administrative claims data were used to identify privately insured and Medicare Advantage beneficiaries with nonmetastatic breast cancer who had residual breast tissue (not bilateral mastectomy) after breast surgery between January 2005 and May 2015. We calculated the proportion of patients who had a mammogram, MRI, both, or neither during each of 5 subsequent 13-month periods. Multinomial logistic regression was used to assess associations between patient characteristics, healthcare use, and breast imaging in the first and fifth years after surgery. Results: A total of 27,212 patients were followed for a median of 2.9 years (interquartile range, 1.8–4.6) after definitive breast cancer surgery. In year 1, 78% were screened using mammography alone, 1% using MRI alone, and 8% using both tests; 13% did not undergo either. By year 5, the proportion of the remaining cohort (n=4,790) who had no breast imaging was 19%. Older age was associated with an increased likelihood of mammography and a decreased likelihood of MRI during the first and fifth years. Black race, mastectomy, chemotherapy, and no MRI at baseline were all associated with a decreased likelihood of both types of imaging. Conclusions: Even in an insured cohort, a substantial proportion of breast cancer survivors do not undergo annual surveillance breast imaging, particularly as time passes. Understanding factors associated with imaging in cancer survivors may help improve adherence to survivorship care guidelines.

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Walburga Yvonne Joko-Fru, Mirko Griesel, Nikolaus Christian Simon Mezger, Lucia Hämmerl, Tobias Paul Seraphin, Jana Feuchtner, Henry Wabinga, Guy N’da, Assefa Mathewos, Bakarou Kamaté, Judith Nsonde Malanda, Freddy Houéhanou Rodrigue Gnangnon, Gladys Chebet Chesumbai, Anne Korir, Cesaltina Lorenzoni, Annelle Zietsman, Margaret Ziona Borok, Biying Liu, Christoph Thomssen, Paul McGale, Ahmedin Jemal, Donald Maxwell Parkin, and Eva Johanna Kantelhardt

Background: Breast cancer (BC) is the most common cancer in sub-Saharan Africa (SSA). However, little is known about the actual therapy received by women with BC and their survival outcome at the population level in SSA. This study aims to describe the cancer-directed therapy received by patients with BC at the population level in SSA, compare these results with the NCCN Harmonized Guidelines for SSA (NCCN Harmonized Guidelines), and evaluate the impact on survival. Methods: Random samples of patients with BC (≥40 patients per registry), diagnosed from 2009 through 2015, were drawn from 11 urban population–based cancer registries from 10 countries (Benin, Congo, Cote d’Ivoire, Ethiopia, Kenya, Mali, Mozambique, Namibia, Uganda, and Zimbabwe). Active methods were used to update the therapy and outcome data of diagnosed patients (“traced patients”). Excess hazards of death by therapy use were modeled in a relative survival context. Results: A total of 809 patients were included. Additional information was traced for 517 patients (63.8%), and this proportion varied by registry. One in 5 traced patients met the minimum diagnostic criteria (cancer stage and hormone receptor status known) for use of the NCCN Harmonized Guidelines. The hormone receptor status was unknown for 72.5% of patients. Of the traced patients with stage I–III BC (n=320), 50.9% received inadequate or no cancer-directed therapy. Access to therapy differed by registry area. Initiation of adequate therapy and early-stage diagnosis were the most important determinants of survival. Conclusions: Downstaging BC and improving access to diagnostics and care are necessary steps to increase guideline adherence and improve survival for women in SSA. It will also be important to strengthen health systems and facilities for data management in SSA to facilitate patient follow-up and disease surveillance.