BACKGROUND:: Recent guidelines recommend longer Pap test intervals. However, physicians and patients may not be adopting these recommendations. OBJECTIVES:: Identify (1) physician and practice characteristics associated with recommending a less frequent interval, and (2) characteristics associated with women's willingness to adhere to a 3-year interval. RESEARCH DESIGN:: We used 2 national surveys:(1) a 2006/2007 National Survey of Primary Care Physicians for physician cervical cancer screening practices (N = 1114), and (2) the 2005 Health Information Trends Survey for women's acceptance of longer Pap intervals (N = 2206). MEASURES AND METHODS:: Physician recommendation regarding Pap intervals was measured using a clinical vignette involving a 35-year-old with no new sexual partners and 3 consecutive negative Pap tests; associations with independent variables were evaluated with logistic regression. In parallel models, we evaluated women's willingness to follow a 3-year Pap test interval. RESULTS:: A minority of physicians (32%) have adopted-but more than half of women are willing to adopt-3-year Pap test intervals. In adjusted models, physician factors associated with less frequent screening were: serving a higher proportion of Medicaid patients, white, non-Hispanic race, fewer years since medical school graduation, and US Preventive Services Task Force being very influential in physician clinical practice. Women were more willing to follow a 3-year interval if they were older, but less willing if they had personal or family experiences with cancer or followed an annual Pap test schedule. CONCLUSIONS:: Many women are accepting of a 3-year interval for Pap tests, although most primary care physicians continue to recommend shorter intervals.

Abstract:This study expands on a previous report (focusing on health insurance status and race/ethnicity) to present effects of age, socioeconomic status, hospital type, and other factors (e.g., type of Medicaid and Medicare coverage, insurance-by-race/ethnicity interactions) on advanced-stage (III/IV) at prostate cancer diagnosis. Invasive (Stages I-IV) prostate cancer cases diagnosed during 1998-2004 were extracted from the National Cancer Database (N=687,464). Independent of health-insurance and race/ethnicity, socioeconomic status was a significant predictor of advanced stage at diagnosis, with patients residing in areas with lower socioeconomic characteristics having significantly increased odds. Those treated at community-cancer-centers had significantly decreased odds (versus teaching/research-facilities). Significantly increased odds were also observed among uninsured-Blacks, Medicare-insured-Blacks, Medicaid-insured-Blacks, Medicare-insured-Hispanics, and Medicare-insured-other-racial/ethnic-minorities 65 years old and older (versus corresponding White-populations). The impact of prostate cancer screening on reducing mortality remains debatable. Still, our results suggest improvements in multiple factors that affect access-to-care may achieve earlier diagnosis and, therefore, a potentially more treatable disease.

ABSTRACT We analyzed the utilization trend for immunotherapy as initial treatment in the United States and estimated the cost impact of three cancers for which the majority of newly approved immunotherapies were indicated: non-Hodgkin's lymphoma (NHL), metastatic breast cancer (MBC), and metastatic colorectal cancer (MCRC). Utilization was highly concentrated, with four cancers accounting for 70-80% of use. On the basis of the pattern in 2004 (22.9% NHL, 3.2% MCRC, and 3.3% MBC), immunotherapy was associated with $285,$73, and $12 million cost increase for NHL, MCRC, and MBC, respectively. Costs for these cancers would have exceeded $1.82 billion had 50% of eligible patients received immunotherapy.

Background:Cervical cancer screening guidelines were substantially revised in 2002 and 2003. Little information is available about primary care physicians' current Papanicolaou (Pap) test screening practices, including initiation, frequency, and stopping.Objective:To assess current Pap test screening practices in the United States.Design:Cross-sectional survey.Setting:Nationally representative sample of physicians during 2006 to 2007.Participants:1212 primary care physicians.Measurements:The survey included questions about physician and practice characteristics and recommendations for Pap screening presented as clinical vignettes describing women by age and by sexual and screening histories. A composite measure-guideline-consistent recommendations-was created by using responses to vignettes in which major guidelines were uniform.Results:Most physicians reported providing Pap tests to their eligible patients (91.0%[95% CI, 89.0% to 92.6%]). Among Pap test providers (n = 1114), screening practices, including number of tests ordered or performed, use of patient reminder systems, and cytology method used, varied by physician specialty (P < 0.001). Although most Pap test providers reported that screening guidelines were very influential in their clinical practice, few had guideline-consistent recommendations for starting and stopping Pap screening across multiple vignettes (22.3%[CI, 19.9% to 25.0%]). Guideline-consistent recommendations varied by specialty (obstetrics/gynecology, 16.4%; internal medicine, 27.5%; and family or general practice, 21.1%). Compared with obstetricians/gynecologists, internal medicine specialists and family or general practice specialists were more likely to have guideline-consistent screening recommendations (odds ratio, 1.98 [CI, 1.22 to 3.23] and 1.45 [CI, 0.99 to 2.13], respectively) in multivariate analysis.Limitation:Physician self-report may reflect idealized rather than actual practice.Conclusion:Primary care physicians' recommendations for Pap test screening are not consistent with screening guidelines, reflecting overuse of screening. Implementation of effective interventions that focus on potentially modifiable physician and practice factors is needed to improve screening practice.Primary Funding Source:National Cancer Institute, Centers for Disease Control and Prevention, and Agency for Healthcare Research and Quality.

The reliability of recall patient reported outcomes, such as health-related quality of life, satisfaction and symptoms, varies substantially. The objectives of this special report are to identify key issues to consider in study design and provide suggestions for minimizing bias in studies including patient reported outcomes. A MEDLINE search identified several areas in which patient recall is subject to bias. Concordance between patient recall and baseline assessments (e.g., prior to an event or medical intervention) for these patient reported outcomes varies depending on the event being recalled, time since the event, and patient clinical and demographic characteristics. Symptom recall tends to be better than recall of health-related quality of life or pain intensity. Specific questionnaire techniques may help minimize the impact of recall bias. Further research is required to determine what factors or patient characteristics predict improved recall and what techniques minimize recall bias.

BACKGROUND:: To the authors' knowledge, little work has been done to estimate the time costs associated with informal caregiving for cancer survivors. METHODS:: Data from a national survey of caregivers of cancer patients in 2003 to 2006 were used to estimate the time associated with informal caregiving in the 2 years after patient diagnosis with bladder, breast, colorectal, kidney, lung, melanoma of the skin, ovarian, prostate, or uterine cancer, or non-Hodgkins lymphoma (NHL). Caregivers reported the duration and daily intensity of caregiving as well as the types and frequency of support provided. The median wage rate in 2006 ($16.28) was used to value caregiver time, and other methods to value time were evaluated with sensitivity analyses. RESULTS:: On average, caregivers provided care for 8.3 hours per day for 13.7 months. The number of months and daily hours spent caregiving were the highest for cancer survivors diagnosed with distant disease compared with survivors with regional or localized disease (P <.05). Approximately half of caregivers provided emotional, instrumental, tangible, or medical support, although the frequency varied dramatically. Informal caregiver time costs over the 2-year period after diagnosis were the highest for caregivers of patients diagnosed with lung ($72,702; 95% confidence interval [95% CI],$56,814-$88,590) and ovarian ($66,210; 95% CI,$40,750-$91,670) cancers and NHL ($59,613; 95% CI,$43,423-$75,803) and the lowest for caregivers of patients with breast cancer ($38,334; 95% CI,$31,442-$45,226). CONCLUSIONS:: Time spent by informal caregivers was substantial and was an important component of the burden of cancer care. Incorporation of the value of informal caregiver time will be important when evaluating the costs and benefits of cancer control interventions. Cancer 2009;115(18 suppl):4362-73.(c) 2009 American Cancer Society.

CONTEXT: Immunotherapy represents a newer modality for cancer treatment with substantial health benefits. However, the high costs of immunotherapy may create access barriers. OBJECTIVE: To examine factors associated with the utilization of immunotherapy among newly diagnosed cancer patients. DESIGN AND SETTING: Analysis of a large national cancer registry data, the National Cancer Data Base, that represents approximately 75% of newly diagnosed cancer patients in the US. PATIENTS: Patient diagnosed with non-Hodgkin lymphoma (NHL), metastatic breast cancer (MBC), or metastatic colorectal cancer (MCRC). MAIN OUTCOME MEASURES: Factors associated with utilization of immunotherapy in NHL, MBC, or MCRC. RESULTS: The study included 207,581 and 42,804 patients diagnosed with NHL and MBC between 1998 and 2004, respectively (based on approval of rituximab in 1997 and trastuzumab in 1998); and 16,027 patients diagnosed with MCRC in 2004 (based on approval of cetuximab and bevacizumab in 2004). Immunotherapy use varied significantly by age, race, insurance status, year of diagnosis, and type of treatment facilities, with largest effects observed in years of diagnosis, followed by insurance status. Among young cancer patients, we found that compared with uninsured patients, the odds of receiving immunotherapy were 1.61, and 2.13 for privately insured MBC, and MCRC patients, respectively, and were in the range of 1.13 to 19.23 for privately insured NHL patients. For elderly NHL patients, those with secondary insurance in addition to Medicare were 1.26 to 8.24 times more likely to receive immunotherapy than those with Medicare alone. CONCLUSIONS: The disparities observed in this study suggest that additional efforts are required to ensure that all cancer patients receive timely and appropriate treatment.

PURPOSE: Treatment options in patients with renal cell carcinoma have changed in recent years. However, few studies include detailed information on patient, clinical and health system characteristics in the evaluation of surgical management and the use of systemic therapies in community practice. MATERIALS AND METHODS: We evaluated surgical management and the use of systemic treatments in a national population based sample of 1,263 patients with renal cell carcinoma newly diagnosed in 2004. Patients were identified from the Surveillance, Epidemiology and End Results Program as part of the Patterns of Care studies. We used descriptive statistics to assess treatment in the entire sample and logistic regression analysis to evaluate the associations between patient demographic, clinical and health system characteristics, and surgery in the subset of 1,032 patients who were potentially eligible for partial or radical nephrectomy and an open or laparoscopic procedure. RESULTS: Surgical treatment in 64.7% of patients (95% CI 60.0%, 69.1%) was radical nephrectomy and most underwent an open rather than a laparoscopic procedure. Although the proportion of all patients receiving systemic treatments was small, 34.3%(95% CI 23.1, 47.5) of those with stage IV disease received systemic treatment. Few patients participated in clinical trials. On multivariate analysis patients who were female, nonwhite, with larger tumors, without comorbid conditions and treated at hospitals without a residency training program were more likely to undergo radical rather than partial nephrectomy (p <0.05). Patients with larger tumors treated at smaller hospitals were more likely to undergo an open rather than a laparoscopic procedure (p <0.05). CONCLUSIONS: In 2004 open radical nephrectomy was the most common surgical management for renal cell carcinoma. Few patients received systemic therapy. Patient demographic, clinical and health system characteristics were associated with surgery. Evaluation of the diffusion of surgical management and newer systemic agents, and trial participation in community practice will be important for future research.