Projects

• Project 1: Evaluation of Cancer Screening Practices

   

  PI: James S. Goodwin, MD

  Despite considerable research on the underutilization of appropriate cancer screening focusing on the patient, physician, and health system factors that contribute to screening disparities very little similar work has been performed on overutilization of screening and inappropriate screening. Such work is important because reductions in overutilization can free up resources to remedy the underutilization of cancer screening in disadvantaged populations. Texas is an ideal state to examine both underutilization and overutilization of testing, because it is large, ethnically, and economically diverse, and has dramatic contextual variations in overall per-patient Medicare expenditures.

  For three screening modalities (PSA, mammography, and colonoscopy) addressed the following:

  • Systematically described the use of cancer screening in Texas.
  • Investigated patient, provider, medical system, geographical, and time factors (2001 through 2012) that predict optimal utilization (vs. over or underutilization) of cancer screening.
  • Investigated outcomes of screening, focusing on benefits and harms associated with optimal utilization vs. overutilization or underutilization of cancer screening.
  • With PSA we concentrated on overutilization by evaluating its use in men with an average life expectancy of fewer than 10 years based on age and comorbidity.
  • With colonoscopy, we assessed both underutilization and overutilization. Overutilization of colonoscopy is defined as shorter than recommended intervals between screening and also by screening in populations with less than a ten-year life expectancy.
  • With mammography we also assessed both overutilization and underutilization, studying its use in women aged 40 and older stratified into cohorts of different average life expectancies.
• Project 2: Assessing the Quality of Cancer Treatment in Texas

  PI: Sharon Giordano, MD, MPH

  No data source currently exists for measuring the quality of cancer treatment in Texas. Although the Texas Cancer Registry collects some treatment information, the focus is on cancer incidence, staging, and survival. As with most cancer registries, treatment data are often missing and of unknown accuracy and completeness. However, these treatment data can be supplemented and completed using other data sources. We proposed to link the Texas Cancer Registry with Medicare, Medicaid, and private insurance databases to assess treatment patterns for patients in Texas. From Medicare, Medicaid, and insurance claims records, we are able to evaluate the use and type of surgery, chemotherapy, and radiotherapy for Texas patients with cancer.

  Our specific aims were:

  • Determine the agreement of the Texas Cancer Registry and claims databases for the rates of surgery, chemotherapy, and radiotherapy use for patients in Texas with colorectal, lung, breast, prostate, and pancreatic cancer.
  • Evaluate the quality of cancer treatment in the state of Texas by studying adherence to evidence-based treatment guidelines for patients with colorectal, lung, breast, prostate, and pancreatic cancer.
  • Determine the variation in the quality of cancer treatment across geographic regions of Texas and assess how variation in the availability of cancer specialists influences the quality of care.

  The information learned from this study increases the completeness of the data in the Texas Cancer Registry, provides information on patterns of cancer treatment in Texas and identifies potential gaps in the quality of cancer treatment in Texas. We are able to identify areas of Texas where cancer patients are underserved due to a lack of specialists. Previous studies have shown profound variation in cancer care by geography, provider, and patient. Therefore, these data on cancer care in Texas are essential to target resources and policies to the populations and geographic areas that would benefit the most.

• Project 3: Quality of Post-Treatment Surveillance of Cancer Patients in Texas

  PI: Hemalkumar B. Mehta, PhD

  The primary goal of surveillance following curative treatment for cancer, regardless of site, is to detect local recurrence or distant disease at a time when survival can be prolonged by interventions designed to cure or at least treat the disease more effectively than when discovered later. Evidence-based recommendations regarding surveillance can decrease variations in care, limit unnecessary care, and serve to facilitate the delivery of necessary care. The availability of evidence-based recommendations varies significantly among different cancer types. Based on randomized, controlled data, the surveillance recommendations for breast and colorectal cancer are clear. In contrast, few to no evidence-based recommendations exist for post-treatment surveillance for cancers such as lung and pancreas. In national studies using both administrative data and single-institution data, we and others have identified wide variation in post-treatment surveillance with respect to evidence-based recommendations. Despite clear recommendations, surveillance practices vary significantly by patient demographics, cancer type, and the type and number of physicians (primary care physicians vs. specialists) performing the surveillance.

  We initially used the Texas Cancer Registry and linked Medicare, Medicaid, and private insurance claims data from 2000-2012 to address the following specific aims:

  • Describe the patterns of surveillance testing after curative treatment for breast and colorectal cancer patients compared to available evidence-based recommendations and describe the cost of guideline adherent and non-adherent post-treatment surveillance.
  • Describe the patterns of surveillance testing after curative treatment for non-small cell lung and pancreatic cancer patients.
  • Describe physician visits after curative-intent cancer treatment, including the proportion of patients with regular visits to primary care physicians, surgeons, medical oncologists, and/or radiation oncologists, as well as the proportion of patients who see multiple provider types for each of the four cancers.
  • Assess the effects of patient characteristics, provider characteristics, health care delivery factors, and time on guideline-adherent surveillance testing, overuse of testing, and underuse of testing.

  Our analysis allows us to examine the reasons for both overuse and underuse of surveillance tests and will yield important information to guide state-level decision-making and allocation of resources to optimize post-treatment cancer surveillance in Texas.

  We ask questions including, but not limited to, the following:

  • Is there significant ethnic variation in post-treatment surveillance?
  • Does the overuse of post-treatment surveillance correlate with high per capita Medicare spending in different geographic regions?
  • How do surveillance patterns differ by physician specialty?
  • Does care by multiple providers lead to repetitive or duplicative testing?

  Given the lack of evidence-based recommendations, we cannot evaluate the overuse or underuse of post-treatment surveillance in lung and pancreatic cancer. However, studying the patterns of post-treatment surveillance for these unstudied cancers will allow us to describe current patterns and identify potential overuse, such as repetitive testing.

• Project 4: Quality of Supportive Cancer Care in Texas

  PI: Linda Elting, DrPH

  High-quality cancer care is a priority for the nation owing to cancer’s high prevalence and mortality. Over the last three decades, many treatments and care strategies have shown promise for improving cancer outcomes and quality of care. Most efforts to measure and improve the quality of cancer care have focused on the entire US. We proposed to link cancer-specific information from the Texas Cancer Registry (TCR) to Medicare, Medicaid, and private insurance claims, creating a unique resource for quality measurement for Texas. We use these data to assess the quality of supportive cancer care of Texans and to target knowledge translation activities to populations that will benefit.

  Our goal is to conduct actionable, policy-relevant quality of cancer care research about Texas to inform our integrated knowledge translation plan. To accomplish this goal we identify gaps in quality in which we can intervene to improve quality. Interventions could be directly targeted at providers or patients (providing feedback on adherence and outcomes for the state or regions, predefined order sets, electronic guidelines, or patient guides), or through policy (identifying gaps in insurance coverage of supportive care). A secondary goal is to develop methods and experience with the new data sets that can be generalized to future studies of the comparative effectiveness and quality of cancer care.

  We focus on 5 indicators of quality supportive care across the cancer care continuum: emesis prevention and infection prevention during initial cancer treatment, surveillance of bone health and cardiac health during and after treatment, and appropriate delivery of hospice/palliative care at the end of life.

  Describe the quality of supportive cancer care among Texas residents and changes in quality of care over time (2001-2012).

  Quality of care will be measured as adherence to national guidelines for emesis and infection prevention, surveillance for bone and cardiac health, and delivery of end of life care. Describe variation in guideline adherence related to patient or provider demographic factors, provider specialty and experience, practice environment, and geographic region of Texas. Compare the clinical outcomes (effectiveness) and the average cost of care of patients with guideline adherent and non-adherent care overall and changes over time.

Projects

• Project 1: Cancer Screening in Texas

  PI: James S. Goodwin, MD

  Project 1 was on screening for cancer. Its major new emphasis was on lung cancer screening with low dose CT (LDCT), which had recently been approved by CMS and insurance companies. There were a number of concerns that impacted the translation of an evidence-based preventive medicine activity into community practice. Prime among them for lung cancer screening was the potential harm done by invasive testing subsequent to false positive LDCTs, which might have been higher in community practice than in the randomized controlled trials (RCT). Another concern was that physicians might substitute routine diagnostic chest CTs for screening LDCT, analogous to what had occurred with screening colonoscopy. The use of a diagnostic lung CT code could circumvent the strict criteria established by CMS for reimbursement. If the CMS screening criteria were ignored, the risk/benefit ratio was likely to be adversely altered. The preliminary data demonstrated a substantial increase in the number of smokers receiving diagnostic lung CTs after the publication of the LDCT trial in 2011.

  A major question involved the implementation of the counseling/shared decision-making (SDM) visit mandated by CMS prior to LDCT screening. The question was who performed the SDM: the patient's PCP or the radiology facility? And how was that process perceived by patients? Those and related questions were addressed with two types of studies. First, Texas Medicare charge data from 2009-2019 were systematically analyzed to determine the patterns of counseling/SDM and also the receipt of LDCT lung cancer screening. The analysis examined how these patterns varied by patient characteristics and also assessed false positive rates and downstream testing, and how this varied by the radiology facility and physician network.

  A second effort was to design and implement a survey of patients who had undergone counseling/SDM with or without subsequent LDCT screening to explore their experience with SDM and LDCT screening. As a comparison, patients likely to qualify for LDCT screening but who had not yet received it were also surveyed. These analyses provided important information on false positive rates and subsequent testing as LDCT was implemented in the community, as well as the acceptance and effectiveness of the counseling/SDM visit in informing patients about the benefits and risks of lung cancer screening.

• Project 2: Providing Evidence for Individualized Decision Making About Chemotherapy in Older Patients

  PI: Sharon H. Giordano, MD, MPH

  Older cancer patients face difficult choices regarding chemotherapy treatment. First, they must decide whether or not to undergo chemotherapy. Ideally, this decision will be made based on the patient's values and preferences after considering the magnitude of chemotherapy benefit, the risk and severity of toxicity, and the patient's expected remaining life span. Second, if a patient decides to receive chemotherapy, he/she may have options of different chemotherapy regimens that offer similar survival benefit but differ in toxicity. Currently, these decisions are challenging because of the lack of data on chemotherapy-related outcomes. For example, what is the interaction of individual patient characteristics and specific type of chemotherapy on a patient's functional status two years post-diagnosis?

  We proposed to comprehensively evaluate outcomes among a population-based cohort of older patients with colorectal, breast, and lung cancer who were treated with chemotherapy. We assessed the toxicity experienced by older patients with invasive colorectal, breast, and lung cancer during initial chemotherapy using TCR-Medicare and SEER-Medicare data, and how the toxicity varied by the type of chemotherapy. We also described patient-reported outcomes among older cancer survivors in Texas with local and regional stage colorectal and breast cancer by surveying patients 24 months after diagnosis. We assessed how those outcomes varied by use and type of chemotherapy and by patient race/ethnicity.

  We analyzed data from the Texas Cancer Registry and SEER linked to Medicare claims, and data from questionnaires that we sent to patients identified by the Texas Cancer Registry. Overall, this novel approach greatly increased our understanding of the experiences of a diverse cohort of older cancer survivors and provided the important evidence to support individualized decision-making on systemic treatments among older cancer patients.

• Project 3: Assisting Cancer Patients with Surgery and Radiation Treatment Choices

  PI: Benjamin D. Smith, MD

  Patients diagnosed with cancer frequently encounter situations where they can choose between two or more local-regional treatment strategies that confer similar survival yet differ with regard to their invasiveness and/or complication profile. However, the available evidence base often lacks the type of granular, patient-centered detail needed to determine which treatment is most likely to achieve an individual patient's desired outcome. Two common cancers in Texas are exemplary of this problem. For breast cancer, patients with early disease may choose between breast conserving surgery followed by whole breast irradiation (BCS+WBI) or mastectomy followed by breast reconstruction (without radiation). For oropharyngeal cancer, another common cancer in Texas and important source of treatment-related morbidity in working-age adults, patients with local or local-regional disease may choose between transoral surgery (TrS) (with or without radiation therapy [RT]) or RT alone. Yet for both cancers, evidence comparing patient-reported outcomes after either treatment is very limited.

  The objective of this project was to develop and implement a model for gathering patient-centered evidence and making it available to support personalized, preference-sensitive decision-making in cancer patients. We conducted qualitative research to inform the development of survey instruments to measure outcomes most relevant to patients. We then deployed these instruments to survey large, population-based cohorts of cancer survivors and finally applied survey findings to create a website named PROVIDE (Patient-Reported Outcome eVIDEnce calculator) that generated personalized outcome estimates and preference-sensitive comparisons of outcomes for newly diagnosed patients. To achieve our objective, we chose to study breast and oropharyngeal cancer as two model cancers.

  We recruited patients from diverse practice settings to participate in semi-structured interviews to identify relevant outcomes and inform survey instrument development. We then partnered with the Texas Cancer Registry to conduct large, population-based surveys of breast and oropharyngeal cancer survivors. We used these findings to generate personalized outcome estimates in PROVIDE. Demonstrating the viability of this model promoted a novel, patient-centered paradigm for promoting personalized, preference-sensitive decision-making in cancer care.;

• Project 4: Investigating Patient Preferences Regarding End-of-Life Care Among Cancer Patients in Texas

  PI: Beverly (Ashleigh) Guadagnolo, MD, MPH

  Projects 1-3 investigate individual patient preferences regarding risks and benefits of cancer care from screening through survivorship. Project 4 extends this theme through the cancer care continuum by examining patient-centered preferences and decision-making factors contributing to end-of-life (EOL) cancer care. Findings from our first 5 years' research revealed that racial/ethnic minority patients and Medicaid enrollees dying of cancer in Texas disproportionately experienced low quality end-of-life (EOL care). We hypothesize that these disparities result from differences in EOL care preferences as well as mediating factors such as trust in medical professionals, health literacy, and decisional self-efficacy. The growing racial/ethnic and socioeconomic diversity of Texas make examination of this hypothesis crucial to improvements in EOL care in the state.

  We administered a previously validated survey about patient preferences for the aggressiveness of end-of-life (EOL) care to a cohort of newly diagnosed cancer patients. We investigated variation in preferences for EOL care in Texas with respect to age, race/ethnicity, gender, income, education, marital status, geographic variables, religiosity, health-related functional status, and cancer-related disease status (diagnosis of early-stage cancer vs. advanced-stage cancer). We used previously validated instruments assessing trust in medical professionals, health literacy, and decisional self-efficacy among Texans with cancer to determine whether there were racial/ethnic or socio-economic differences in these domains and whether these domains were associated with preferences regarding EOL care.

  Finally, we performed a longitudinal cohort study of Texas Cancer Registry (TCR) decedents with advanced cancer who completed the surveys for Aims 1 and 2. We subsequently analyzed both survey and insurance claims data to ascertain whether EOL care was concordant with preferences. We assessed whether any associations between preferences and care aggressiveness were mediated by levels of trust in the medical profession, health literacy, or decisional self-efficacy.