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Purpose: Surveillance, Epidemiology, and End Results (SEER) cancer registries provides information about survival duration and cause of death for cancer patients. Baseline demographic and tumor characteristics such as age, sex, race, year of diagnosis, and tumor stage can inform the expected survival time of patients, but their associations with survival may not be constant over the post-diagnosis period., Methods: Using SEER data, we examined if there were time-varying associations of patient and tumor characteristics on survival, and we assessed how these relationships differed across 14 cancer sites. Standard Cox proportional hazards models were extended to allow for time-varying associations and incorporated into a competing-risks framework, separately modeling cancer-specific and other-cause deaths. For each cancer site and for each of the five factors, we estimated the relative hazard ratio and absolute hazard over time in the presence of competing risks., Results: Our comprehensive consideration of patient and tumor characteristics when estimating time-varying hazards showed that the associations of age, tumor stage at diagnosis, and race/ethnicity with risk of death (cancer-specific and other-cause) change over time for many cancers; characteristics of sex and year of diagnosis exhibit some time-varying patterns as well. Stage at diagnosis had the largest associations with survival., Conclusion: These findings suggest that proportional hazards assumptions are often violated when examining patient characteristics on cancer survival post-diagnosis. We discuss several interesting results where the relative hazards are time-varying and suggest possible interpretations. Based on the time-varying associations of several important covariates on survival after cancer diagnosis using a pan-cancer approach, the likelihood of the proportional hazards assumption being met or corresponding interpretation should be considered in survival analyses, as flawed inference may have implications for cancer care and policy., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: For patients with thyroid cancer, distant metastasis is a significant predictor of poor outcome. Since distant metastasis occurs in less than 10% of patients with differentiated thyroid cancer, correlates of survival in this vulnerable patient population remain understudied. This study aimed to identify prognostic groups among patients with differentiated thyroid cancer and distant metastases and to determine the role of, and interactions between, patient and tumor characteristics in determining survival. Methods: We identified adult patients diagnosed with differentiated thyroid cancer with distant metastases from the U.S. SEER-17 cancer registry (2010-2019). Analyses were performed using Cox proportional hazards regression, survival trees, and random survival forest. Relative importance of patient and tumor factors important for disease-specific and overall survival was assessed based on the random survival forest analyses. Results: Cohort consisted of 2411 patients with differentiated thyroid cancer with distant metastases followed for a median of 62 months. Most common histopathologic subtype (86.0%) was papillary thyroid cancer, and the most common sites of distant metastasis were the lungs (33.7%) and bone (18.9%). Cox proportional hazards model illustrated significant associations between survival and the following: patient age ( p < 0.001), tumor size ( p < 0.01), and site of distant metastasis ( p < 0.05). Survival tree analyses identified three distinct prognostic groups based on disease-specific survival (DSS) (5-year survival of the prognostic groups was 92%, 64%, and 41%; p < 0.001) and four distinct prognostic groups based on overall survival (OS) (5-year survival of the prognostic groups was 96%, 84%, 57%, and 31%; p < 0.001). The first split in the survival trees for DSS and OS was by age at diagnosis (≤57 years vs. ≥58 years) with subsequent splits based on presence/absence of lung metastases, tumor size (≤4 cm vs. >4 cm), and patient age. A total of 558 patients (23.1%) died from thyroid cancer, and 757 patients (31.4%) died from all causes during the study period. Conclusions: This study identifies distinct prognostic groups for patients with differentiated thyroid cancer with distant metastases and highlights the importance of patient age, lung metastases, and tumor size for determining both disease-specific and overall survival. These findings inform risk stratification and treatment decision-making in this understudied patient population.

Importance: Racial and ethnic disparities have been observed in the outpatient visit rates for specialist care, including cancer care; however, little is known about patients' experience at the critical step of attempting to access new clinic appointments for cancer care., Objective: To determine simulated English-speaking, Spanish-speaking, and Mandarin-speaking patient callers' ability to access new clinic appointments for 3 cancer types (colon, lung, and thyroid cancer) that disproportionately impact Hispanic and Asian populations., Design, Setting, and Participants: This cross-sectional audit study was conducted between November 2021 and March 2023 using 479 clinic telephone numbers that were provided by the hospital general information personnel at 143 hospitals located across 12 US states. Using standardized scripts, trained research personnel assigned to the roles of English-speaking, Spanish-speaking, and Mandarin-speaking patients called the telephone number for a clinic that treats colon, lung, or thyroid cancer to inquire about a new clinic appointment. Data analysis was conducted from June to September 2023., Main Outcomes and Measures: The primary outcome was whether the simulated patient caller was able to access cancer care (binary variable, yes or no), which was defined to include being provided with a clinic appointment date or scheduling information. Multivariable logistic regression analysis was performed to determine factors independently associated with simulated patient callers being able to access cancer care., Results: Of 985 total calls (399 English calls; 302 Spanish calls; 284 Mandarin calls), simulated patient callers accessed cancer care in 409 calls (41.5%). Differences were observed based on language type, with simulated English-speaking patient callers significantly more likely to access cancer care compared with simulated Spanish-speaking and Mandarin-speaking patient callers (English, 245 calls [61.4%]; Spanish, 110 calls [36.4%]; Mandarin, 54 calls [19.0%]; P < .001). A substantial number of calls ended due to linguistic barriers (291 of 586 Spanish or Mandarin calls [49.7%]) and workflow barriers (239 of 985 calls [24.3%]). Compared with English-speaking simulated patient callers, the odds of accessing cancer care were lower for Spanish-speaking simulated patient callers (adjusted odds ratio [aOR], 0.34; 95% CI, 0.25-0.46) and Mandarin-speaking simulated patient callers (aOR, 0.13; 95% CI, 0.09-0.19). Compared with contacting clinics affiliated with teaching hospitals, callers had lower odds of accessing cancer care when contacting clinics that were affiliated with nonteaching hospitals (aOR, 0.53; 95% CI, 0.40-0.70)., Conclusions and Relevance: In this cross-sectional audit study, simulated patient callers encountered substantial barriers when attempting to access clinic appointments for cancer care. These findings suggest that interventions focused on mitigating these barriers are necessary to increase access to cancer care for all patients.

Background: Patients with limited English proficiency, a vulnerable patient population, remain understudied in the literature addressing cancer disparities. Although it is well documented that language discordance between patients and physicians negatively impacts the quality of patient care, little is known about how patients' preferred spoken language impacts their access to cancer care., Patients and Methods: Between November 2021 and June 2022, we conducted an audit study of 144 hospitals located across 12 demographically diverse states. Using a standardized script, trained investigators assigned to the roles of English-speaking, Spanish-speaking, and Mandarin-speaking patients called the hospital general information telephone line seeking to access care for 3 cancer types that disproportionately impact Hispanic and Asian populations (colon, lung, and thyroid cancer). Primary outcome was whether the simulated patient caller was provided with the next steps to access cancer care, defined as clinic number or clinic transfer. We used chi-square tests and logistic regression analysis to test for associations between the primary outcome and language type, region type, hospital teaching status, and cancer care requested. We used multivariable logistic regression analysis to determine factors associated with simulated patient callers being provided the next steps., Results: Of the 1,296 calls, 52.9% (n=686) resulted in simulated patient callers being provided next steps to access cancer care. Simulated non-English-speaking (vs English-speaking) patient callers were less likely to be provided with the next steps (Mandarin, 27.5%; Spanish, 37.7%; English, 93.5%; P<.001). Multivariable logistic regression found significant associations of the primary outcome with language spoken (Mandarin: odds ratio [OR], 0.02 [95% CI, 0.01-0.04] and Spanish: OR, 0.04 [95% CI, 0.02-0.06] vs English) and hospital teaching status (nonteaching: OR, 0.43 [95% CI, 0.32-0.56] vs teaching)., Conclusions: Linguistic disparities exist in access to cancer care for non-English-speaking patients, emphasizing the need for focused interventions to mitigate systems-level communication barriers.

Background: Although barriers to trial accrual are well-reported, few studies have explored trial eligibility and trial offers as potential drivers of disparities in cancer clinical trial enrollment., Methods: We identified patients with gastrointestinal (GI) or head/neck (HN) malignancies who were seen as new patients at the University of Michigan Health Rogel Cancer Center in 2016. By exhaustive review of the electronic medical record, we assessed the primary outcomes: (1) eligibility for, (2) documented offer of, and (3) enrollment in a clinical trial. All 41 of the clinical trials available to these patients were considered. Independent variables included clinical and non-clinical patient-related factors. We assessed associations between these variables and the primary outcomes using multivariable regression., Results: Of 1446 patients, 43% were female, 15% were over age 75, 6% were Black. 305 (21%) patients were eligible for a clinical trial. Among eligible patients, 154 (50%) had documentation of a trial offer and 90 (30%) enrolled. Among the GI cohort, bivariate analyses demonstrated that older age was associated with decreased trial eligibility. Bivariate analyses also demonstrated that Black race was associated with increased trial offer. After adjustment, patients 75 or older were less likely to be eligible for a clinical trial in the GI cohort; however, we found no significant associations between race and any of the outcomes after adjustment. Among eligible GI patients, we found no significant associations between non-clinical factors and enrollment. Among the HN cohort, bivariate analyses demonstrated that female sex, older age, Black race, and unpartnered marital status were associated with decreased likelihood of trial offer; however, we found no significant associations between race, age, and marital status and any of the outcomes after adjustment. We found no significant associations between non-clinical factors and eligibility after adjustment; however, women were less likely to be offered and to enroll in a clinical trial in the HN cohort., Conclusion: Factors associated with eligibility, documented offer, and enrollment differed between disease site cohorts at our institution. Future work is needed to ensure the equitable inclusion of women and elderly patients in clinical trials., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Importance: Partners of colorectal cancer (CRC) survivors play a critical role in diagnosis, treatment, and survivorship. While financial toxicity (FT) is well documented among patients with CRC, little is known about long-term FT and its association with health-related quality of life (HRQoL) among their partners., Objective: To understand long-term FT and its association with HRQoL among partners of CRC survivors., Design, Setting, and Participants: This survey study incorporating a mixed-methods design consisted of a mailed dyadic survey with closed- and open-ended responses. In 2019 and 2020, we surveyed survivors who were 1 to 5 years from a stage III CRC diagnosis and included a separate survey for their partners. Patients were recruited from a rural community oncology practice in Montana, an academic cancer center in Michigan, and the Georgia Cancer Registry. Data analysis was performed from February 2022 to January 2023., Exposures: Three components of FT, including financial burden, debt, and financial worry., Main Outcomes and Measures: Financial burden was assessed with the Personal Financial Burden scale, whereas debt and financial worry were each assessed with a single survey item. We measured HRQoL using the PROMIS-29+2 Profile, version 2.1. We used multivariable regression analysis to assess associations of FT with individual domains of HRQoL. We used thematic analysis to explore partner perspectives on FT, and we merged quantitative and qualitative findings to explain the association between FT and HRQoL., Results: Of the 986 patients eligible for this study, 501 (50.8%) returned surveys. A total of 428 patients (85.4%) reported having a partner, and 311 partners (72.6%) returned surveys. Four partner surveys were returned without a corresponding patient survey, resulting in a total of 307 patient-partner dyads for this analysis. Among the 307 partners, 166 (56.1%) were aged younger than 65 years (mean [SD] age, 63.7 [11.1] years), 189 (62.6%) were women, and 263 (85.7%) were White. Most partners (209 [68.1%]) reported adverse financial outcomes. High financial burden was associated with worse HRQoL in the pain interference domain (mean [SE] score, -0.08 [0.04]; P = .03). Debt was associated with worse HRQoL in the sleep disturbance domain (-0.32 [0.15]; P = .03). High financial worry was associated with worse HRQoL in the social functioning (mean [SE] score, -0.37 [0.13]; P = .005), fatigue (-0.33 [0.15]; P = .03), and pain interference (-0.33 [0.14]; P = .02) domains. Qualitative findings revealed that in addition to systems-level factors, individual-level behavioral factors were associated with partner financial outcomes and HRQoL., Conclusions and Relevance: This survey study found that partners of CRC survivors experienced long-term FT that was associated with worse HRQoL. Multilevel interventions for both patients and partners are needed to address factors at individual and systemic levels and incorporate behavioral approaches.

Background: We investigated whether partner (spouse or intimate partner) engagement in colorectal cancer (CRC) surveillance is associated with patient receipt of surveillance., Methods: From 2019 to 2020 we surveyed Stage III CRC survivors diagnosed 2014-2018 at an academic cancer center, a community oncology practice and the Georgia SEER registry, and their partners. Partner engagement was measured across 3 domains: Informed about; Involved in; and Aware of patient preferences around surveillance. We evaluated bivariate associations between domains of partner engagement and independent partner variables. Analysis of variance and multivariable logistic regression were used to compare domains of engagement with patient-reported receipt of surveillance., Results: 501 patients responded (51% response rate); 428 had partners. 311 partners responded (73% response rate). Partners were engaged across all domains. Engagement varied by sociodemographics. Greater partner involvement was associated with decreased odds of receipt of composite surveillance (OR 0.67, 95% CI 0.48-0.93) and trended towards significance for decreased odds of receipt of endoscopy (OR 0.60, 95% CI 0.34-1.03) and CEA (OR 0.75, 95% CI 0.55-1.04). Greater partner awareness was associated with increased odds of patients' receipt of endoscopy (OR 2.18, 95% CI 1.15-4.12) and trended towards significance for increased odds of receipt of composite surveillance (OR 1.30, 95% CI 0.91-2.04)., Conclusion: Partners are engaged (informed, involved, and aware) in CRC surveillance. Future research to develop dyadic interventions that capitalize on the positive aspects of partner engagement may help partners effectively engage in surveillance to improve patient care., (© 2022. The Author(s).)

Introduction: Important differences exist between the presentation, treatment, and survivorship of patients and survivors with blood cancers. Furthermore, existing research in financial toxicity has not fully addressed the relationship between medical care utilization and patient-reported outcomes of financial barriers and distress. We answered these questions by using a nationally representative survey. Methods: Respondents with blood cancers and solid tumors from the National Health Interview Survey were identified (2014−2020). We identified 23 survey questions as study outcomes and grouped them into three domains of medical care utilization, financial barriers to care, and financial distress. Associations between the three domains and associations of study outcomes between cancer types were examined using weighted univariate analyses and multivariable linear and logistic regressions. Results: The final study group consisted of 6248 respondents with solid tumors and 398 with blood cancers (diagnosed ≤ 5 years). Across all respondents with cancer, higher medical care utilization is generally associated with increased financial barriers to care. Compared to respondents with solid tumors, respondents with blood cancers had a higher level of medical care utilization (β = 0.36, p = 0.02), a lower level of financial barriers to care (β = −0.19, p < 0.0001), and a higher level of financial distress in affording care (β = 0.64, p = 0.03). Conclusions: Patients and survivors with blood cancers and solid tumors demonstrate divergent patterns in care utilization, financial barriers, and financial distress. Future research and interventions on financial toxicity should be tailored for individual cancer groups, recognizing the differences in medical care utilization, which affect the experienced financial barriers.

Background: Little is known about how cancer impacts the employment status of patients' family supporters, or about associations between patients' health-related quality of life, perceived financial burden, and supporters' employment trajectory., Methods: We surveyed patients with early stage breast cancer reported to the Georgia and Los Angeles SEER registries in 2014-15, and their spouse/partner or other family supporters. Patients and supporters were asked about employment impacts of the patient's cancer, and descriptive analyses of supporters' employment trajectories were generated. We measured patients' health-related quality of life (HRQoL) using the PROMIS scale for global health. We measured patients' perceived financial burden attributed to cancer by asking them two questions regarding (i) their financial status since their breast cancer diagnosis and (ii) how much it was impacted by their breast cancer and treatment. Associations between patients' HRQoL, perceived financial burden, and supporters' employment status were assessed using linear mixed model regression analyses., Results: In total, 2502 patients (68% response rate) and 1203 supporters (70% response rate) responded; 1057 paired patient-supporter dyads were included. Similar proportions of spouse/partner and other family supporters reported missed work and lost employment due to patients' cancer. After adjustment, lower HRQoL and an increased odds of perceived financial burden among patients were associated with changes in other family supporters' employment (both p < 0.05), but not with changes in spouses'/partners' employment. Lower HRQoL was also associated with changes in patients' own employment among patients with both types of supporters (both p < 0.001). An increased odds of perceived financial burden among patients was associated with changes in patients' employment only in those supported by other family members (p < 0.001)., Conclusions: Both spouse/partner and other family supporters faced adverse employment outcomes due to patients' cancer. This contributes to worse HRQoL and greater perception of financial burden among patients, especially those whose supporter is not a spouse/partner., (© 2022 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Purpose: Abiraterone and enzalutamide are commonly used oral cancer therapies for patients with prostate cancer, both with potentially high out-of-pocket costs for patients. We investigated the prevalence of financial assistance mechanisms used to alleviate out-of-pocket costs and the association of these mechanisms with timing of treatment initiation of abiraterone or enzalutamide., Methods: Using data from the medical center's specialty pharmacy, we identified first prescriptions for abiraterone or enzalutamide between January 1, 2017, and March 31, 2019. Prescriptions dispensed at an external pharmacy or that were discontinued for reasons unrelated to cost were excluded. Patient demographics, insurance coverage, out-of-pocket cost, and number of days between prescribed date and pill-to-mouth date were collected., Results: Among 220 prescriptions in our final cohort, 185 were filled through our internal specialty pharmacy, 23 through a manufacturer-sponsored patient assistance program (PAP), and 12 were never filled because of cost. One third of the prescriptions in our final cohort (n = 66) were filled with financial assistance: PAP (10%), copay cards (9%), and grants (11%). The median amount of assistance received for the first fill was $2,860 US dollars (USD) (interquartile range $1,856-$10,717 USD). Prescriptions with an out-of-pocket cost < $100 USD were filled in the shortest time (median 5 days), whereas those filled through a PAP had the longest time to initiation (median 30.5 days)., Conclusion: Among patients prescribed oral therapies for prostate cancer at a single institution, one third of patients received financial assistance. Although receiving assistance is likely to improve financial toxicity, waiting for assistance may lead to longer time to initiation of medication., Competing Interests: Andrea R. RomanConsulting or Advisory Role: AbbVie/Genentech, Karyopharm TherapeuticsNo other potential conflicts of interest were reported.

Background: Little is known about financial hardship among Hispanic women with thyroid cancer. The goal of this study was to determine the prevalence of financial hardship and to identify correlates of financial hardship in this understudied patient group. Methods: We surveyed Hispanic women who had diagnoses of thyroid cancer reported to the Los Angeles Surveillance Epidemiology and End Results (SEER) registry in 2014-2015, and who had previously completed our thyroid cancer survey in 2017-2018 ( N  = 273; 80% response rate). Acculturation was assessed with the Short Acculturation Scale for Hispanics (SASH). Patients were asked about three outcome measures since their thyroid cancer diagnosis: (i) financial status, (ii) insurance status, and (iii) material measures of financial hardship, collapsed into a single composite measure of financial hardship. We used multivariable logistic regression to identify correlates of financial hardship. Results: Patients' median age at diagnosis was 47 years (range 20-79 years); 49% were low-acculturated and 47% reported financial hardship. Since their thyroid cancer diagnosis, 31% and 12% of the cohort reported being worse off regarding financial and insurance status, respectively. In multivariable analysis, high-acculturated older women were less likely to experience financial hardship compared with high-acculturated 20-year-old women. While financial hardship decreased with age for high-acculturated women ( p  = 0.002), financial hardship remained elevated across all age groups for low-acculturated women ( p  = 0.54). Conclusions: Our findings suggest that across all age groups, low-acculturated Hispanic women with thyroid cancer are vulnerable to financial hardship, emphasizing the need for tailored patient-focused interventions.

Objectives: Following treatment of Stage III colorectal cancer, guidelines recommend 3-5 years of surveillance for recurrence. However, over half of the 1.2 million U.S. survivors of colorectal cancer fail to receive guideline-concordant surveillance. In light of growing recognition that members of couples are interdependent and influence each other's health behaviors, we sought to describe, in their own words, the perspectives of spouses/partners on their engagement in patients' surveillance., Methods: We conducted in-person, semi-structured interviews with 10 survivors of stage III colorectal cancer and their partners, together and separately. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes pertaining to partner engagement. Findings were validated through triangulation between study team members and triangulation between dyadic and individual interviews, and through an extensive search of transcripts for disconfirming evidence., Results: We identified three overarching domains of partner engagement in surveillance. First, psychosocial engagement included promoting patient participation in surveillance, showing care and concern, and attending to partner self-care. Second, information-seeking and dyadic communication focused on gathering information, staying informed about test results, and communicating about surveillance. Third, instrumental engagement referred to any explicit, objective activities such as scheduling appointments, attending appointments, and managing responsibilities at home. Participants shared strategies, examples, and in some cases unmet needs., Conclusions: This study generated new, clinically meaningful knowledge about the ways in which partners engage in patients' surveillance. Opportunities to leverage partners as informal resources in surveillance include development of dyadic interventions to help partners engage most effectively., (© 2021 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Purpose: Although many studies clearly demonstrate disparities in cancer clinical trial enrollment, there is a lack of consensus on potential causes. Furthermore, virtually nothing is known about associations between patients' decision-making style and their participation in clinical trials., Methods: Women with newly diagnosed, stage 0-II breast cancer reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries in 2013-2014 were surveyed approximately seven months after diagnosis. We investigated two primary outcome variables: (1) invitation to participate in a clinical trial, (2) participation in a clinical trial. We evaluated bivariate associations using Chi-squared tests and used multivariable logistic regression models to investigate associations between patient variables, including decision-making style, and the primary outcomes., Results: 2578 patients responded (71% response rate); 30% were > age 65, 18% were black, 18% were Latina, 29% had ≤ high school education. 10% of patients reported invitation to participate in a clinical trial; 5% reported participation in a clinical trial. After adjustment younger age, receipt of chemotherapy or radiation, disease stage, and a more rational (versus more intuitive) decision-making style were associated with a higher odds of invitation to participate. Being married was associated with a higher odds of participation; having an annual family income ≥ $40,000 was associated with a lower odds of participation., Conclusions: 10% of patients reported invitation to participate in a clinical trial, and half of these reported participation. Invitation to participate varied by age and decision-making style, and participation varied by marital status and income.

Background: Social support, which is partly emotional support, is associated with adherence to colorectal cancer (CRC) treatment, quality of life, and survival. We hypothesized that the needs, sources, and availability of emotional support would vary by race and income among CRC patients and sought to quantify the emotional support and the perceived adequacy of support reported by patients., Methods: We surveyed CRC patients from Detroit and Georgia Surveillance, Epidemiology and End Results registries about the quantity and quality of emotional support received from different sources. We tested differences using the chi-square test, t -tests, and logistic regression., Results: There were 1909 patients who met inclusion criteria and 1301 (68%) completed surveys. Among respondents, 68% were white, 25% black, and 7% other. Black patients were more likely to be female and younger and reported lower annual income and education. Patients reported high support from several sources. Among those with a spouse/partner (58%), 95% reported high levels of support; however, older, black, female, or lower income patients were less likely to have spouses/partners ( P < .001). Patients also endorsed high support from family (88.6%), important others (82.9%), and clinicians (71.3%). Black patients were less likely than white patients to report support that was "just right" ( P < .001)., Discussion: Most patients reported high emotional support from at least 1 source. Black patients were most at risk for low support or unmet support needs. Spouse/partner support was important but only available to 58% of respondents. Patients at risk for unmet emotional support needs may benefit from additional support resources.

Background: Partnered status is an independent predictor of clinical outcomes, including overall survival, among patients with cancer. However, the mechanisms by which partnered status impacts survival are not fully understood and to the authors' knowledge the associations between partnered status and the specific attributes of chemotherapy have not been studied to date., Methods: The current study was an observational study of patients with resected American Joint Committee on Cancer (AJCC) stage III colon cancer diagnosed from 2008 through 2015 and recruited from an academic cancer center and 2 large community oncology practices. Outcome measures were specific attributes of adjuvant chemotherapy. Partnered status (partnered vs unpartnered) was the primary independent variable. Bivariate comparisons between independent variables and the primary outcomes were performed. Associations between partnered status and the outcomes also were analyzed using multivariable generalized estimating equations using a logit link., Results: Data were collected from 436 patients. Of these patients, approximately 65% were from community oncology practices. Approximately 62% were partnered (married or living with a partner), and approximately 86% received adjuvant chemotherapy. Among these individuals, 87% received multiagent chemotherapy and 65% completed 6 months of therapy. Partnered patients were found to have a higher odds of completing chemotherapy (odds ratio, 1.98; 95% CI, 1.04-3.77)., Conclusions: In this innovative investigation of the associations between partnered status and specific attributes of curative-intent chemotherapy, approximately 35% of patients terminated chemotherapy early. Having a partner increased the odds of completing therapy, which may be one mechanism through which having a partner improves disease-specific outcomes among patients with colon cancer. Identifying those aspects of partner support that can be reproduced with community or clinical personnel may help unpartnered patients to complete the recommended course of curative-intent chemotherapy., (© 2019 American Cancer Society.)

Background: Patients with breast cancer involve multiple decision support persons (DSPs) in treatment decision making, yet little is known about DSP engagement in decision making and its association with patient appraisal of the decision process., Methods: Patients newly diagnosed with breast cancer reported to Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries in 2014-2015 were surveyed 7 months after their diagnosis. The individual most involved in each respondent's decision making (the key DSP) was surveyed. DSP engagement was measured across 3 domains: 1) informed about decisions, 2) involved in decisions, and 3) aware of patient preferences. Patient decision appraisal included subjective decision quality (SDQ) and deliberation. This study evaluated bivariate associations with chi-square tests between domains of DSP engagement and independent DSP variables. Analysis of variance and multivariable logistic regression were used to compare domains of DSP engagement with patient decision appraisal., Results: In all, 2502 patients (68% response rate) and 1203 eligible DSPs (70% response rate) responded. Most DSPs were husbands/partners or daughters, were white, and were college graduates. Husbands/partners were more likely to be more informed, involved, and aware (all P values < .01). English- and Spanish-speaking Latinos had a higher extent of (P = .02) but lower satisfaction with involvement (P < .01). A highly informed DSP was associated with higher odds of patient-reported SDQ (odds ratio, 1.46; 95% confidence interval, 1.03-2.08; P = .03). A highly aware DSP was associated with higher odds of patient-reported deliberation (odds ratio, 1.83; 95% confidence interval, 1.36-2.47; P < .01)., Conclusions: In this population-based study, informal DSPs were engaged with and positively contributed to patients' treatment decision making. To improve decision quality, future interventions should incorporate DSPs., (© 2019 American Cancer Society.)

Adjuvant fluoropyrimidine-based chemotherapy has been the standard of care for resected stage III colon cancer since the 1990s; the evolution from 12 to 6 months of fluoropyrimidine therapy and the addition of oxaliplatin to fluoropyrimidine therapy have led to the current accepted standard. However, controversies remain. What is the benefit of adjuvant chemotherapy in stage II disease, and in whom? What is the optimal duration of adjuvant chemotherapy? How should patients with early-stage colon cancer be followed after surgery and adjuvant treatment? Recent evidence has emerged to help inform these important questions, including the International Duration Evaluation of Adjuvant therapy (IDEA) collaboration, which is the largest, prospective study in colon cancer with 12,834 patients. This review discusses current and future risk stratification strategies in stage II disease: the optimal duration of adjuvant oxaliplatin-containing chemotherapy in stage II and III disease according to the IDEA study, and the recent evidence and updated recommendations for surveillance of early-stage colon cancer after resection.

Despite advances over the past 20 years in colorectal cancer (CRC) screening, diagnosis, and treatment, survival outcomes remain suboptimal. Five-year survival for patients with locally advanced CRC is 69%; 5-year survival drops to 12% for patients with metastatic disease. Novel, effective systemic therapies are needed to improve long-term outcomes. In this review, we describe currently available systemic therapies for the treatment of locally advanced and metastatic CRC and discuss emerging therapies, including encouraging advances in identifying novel targeted agents and exciting responses to immunotherapeutic agents.

Background: Surveillance, Epidemiology, and End Results (SEER) public research database does not include chemotherapy data due to concerns for incomplete ascertainment. To compensate for perceived lack of data quality many researchers use SEER-Medicare linked data, limiting studies to persons over age 65. We sought to determine current SEER ascertainment of chemotherapy receipt in two relatively large SEER registries compared to patient-reported receipt and to assess patterns of under-ascertainment., Methods: In 2011-14, we surveyed patients with Stage III colorectal cancer reported to the Georgia and Metropolitan Detroit SEER registries. 1301/1909 eligible patients responded (68% response rate). Survey responses regarding treatment and sociodemographic factors were merged with SEER data. We compared patient-reported chemotherapy receipt with SEER recorded chemotherapy receipt. We estimated multivariable regression models to assess associations of under-ascertainment in SEER., Results: Eighty-five percent of patients reported chemotherapy receipt. Among those, 10% (n = 104) were under-ascertained in SEER (coded as not receiving chemotherapy). In unadjusted analyses, under-ascertainment was more common for older patients (11.8% age 76+ vs. < 9% for all other ages, p = 0.01) and varied with SEER registries (10.2% Detroit vs. 6.8% Georgia; p = 0.04). On multivariable analyses, chemotherapy under-ascertainment did not vary significantly by any patient attributes., Conclusion: We found a 10% rate of under-ascertainment of adjuvant chemotherapy for resected, stage III colorectal cancer in two SEER registries. Chemotherapy under-ascertainment did not disproportionately affect any patient subgroups. Use of SEER data from select registries is an important resource for researchers investigating contemporary chemotherapy receipt and outcomes.

A "health shock," that is, a large, unanticipated adverse health event, can have long-term financial implications for patients and their families. Colorectal cancer is the third most commonly diagnosed cancer among men and women and is an example of a specific health shock. We examined whether specific benefits (employer-based health insurance, paid sick leave, extended sick leave, unpaid time off, disability benefits) are associated with job retention after diagnosis and treatment of colorectal cancer. In 2011-14, we surveyed patients with Stage III colorectal cancer from two representative SEER registries. The final sample was 1301 patients (68% survey response rate). For this study, we excluded 735 respondents who were not employed and 20 with unknown employment status. The final analytic sample included 546 respondents. Job retention in the year following diagnosis was assessed, and multivariable logistic regression was used to evaluate associations between job retention and access to specific employment benefits. Employer-based health insurance (OR = 2.97; 95% CI = 1.56-6.01; P = 0.003) and paid sick leave (OR = 2.93; 95% CI = 1.23-6.98; P = 0.015) were significantly associated with job retention, after adjusting for sociodemographic, clinical, geographic, and job characteristics., (© 2018 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Purpose: Work loss is one of many personal costs for patients with cancer and their families. Many women with breast cancer face long-term job loss that stems from their diagnoses. However, little is known about the economic and employment outcomes of partners of women with breast cancer., Methods: Women with nonmetastatic breast cancer identified by the Detroit and Los Angeles SEER registries between June 2005 and February 2007 were surveyed at both 9 months and 4 years after diagnosis. Partners were surveyed 4 years after patients' diagnoses. Nonretired partners were asked about employment and financial consequences that stemmed from the patients' breast cancer diagnoses and treatments., Results: A total of 517 (67%) of 774 eligible partners completed the survey; 32% reported worsened financial status attributed to patients' breast cancers. Two hundred forty nonretired partners worked during the year after the patients' diagnoses; 90% were still working 4 years postdiagnosis. A total of 32% of partners decreased their work hours as a result of patients' breast cancer diagnoses and treatments; 64% of partners reported that, as a result of patients' breast cancer diagnoses and treatments, it was very/extremely important to keep working to keep health insurance. Overall, 51% of partners reported that it was very/extremely important to avoid changing jobs, because they were worried about loss of health insurance., Conclusion: Nearly one third of partners reported that their financial status was worse because of the patient's breast cancer, although most remained working 4 years after a diagnosis. Partners may continue to work longer than desired to compensate for a loss of financial resources in the family.

Background: Little is known about the size and characteristics of the decision-support networks of women newly diagnosed with breast cancer and whether their involvement improves breast cancer treatment decisions., Methods: A population-based sample of patients newly diagnosed with breast cancer in 2014 and 2015, as reported to the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries, were surveyed approximately 7 months after diagnosis (N = 2502; response rate, 68%). Network size was estimated by asking women to list up to 3 of the most important decision-support persons (DSPs) who helped them with locoregional therapy decisions. Decision deliberation was measured using 4 items assessing the degree to which patients thought through the decision, with higher scores reflecting more deliberative breast cancer treatment decisions. The size of the network (range, 0-3 or more) was compared across patient-level characteristics, and adjusted mean deliberation scores were estimated across levels of network size using multivariable linear regression., Results: Of the 2502 women included in this analysis, 51% reported having 3 or more DSPs, 20% reported 2, 18% reported 1, and 11% reported not having any DSPs. Married/partnered women, those younger than 45 years, and black women all were more likely to report larger network sizes (all P < .001). Larger support networks were associated with more deliberative surgical treatment decisions (P < .001)., Conclusions: Most women engaged multiple DSPs in their treatment decision making, and involving more DSPs was associated with more deliberative treatment decisions. Future initiatives to improve treatment decision making among women with breast cancer should acknowledge and engage informal DSPs. Cancer 2017;123:3895-903. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Purpose: Surveillance PET after curative-intent treatment of non-small-cell lung cancer (NSCLC) or colorectal cancer (CRC) is not clearly supported by available evidence or the Choosing Wisely campaign. However, the frequency of PET imaging during the surveillance period is relatively unknown., Methods: Using Surveillance, Epidemiology, and End Results-Medicare data, 65,748 patients aged 66 years or older who were diagnosed with stage I to IIIA NSCLC or stage I to III CRC from 2001 through 2009 and who underwent surgical resection were identified. Trends in "any PET" or "PET-only" use 6 to 18 months postoperatively were assessed., Results: Any PET use more than doubled over the study period. Eleven percent of patients with NSCLC and 4% of those with CRC diagnosed in 2001 received any PET, compared with 25% of patients with NSCLC and 13% of those with CRC in 2009 (P < .001 for both). Higher stage disease was correlated with higher PET utilization and faster growth in use over the study period. PET-only use also increased over the study period, especially in higher stage disease. Fewer than 2% of patients diagnosed with stage IIIA NSCLC in 2001 received PET only, compared with 15% of patients diagnosed in 2009 (P = .014). Similarly, 1% of patients diagnosed with stage III CRC in 2001 received PET only, compared with 8% of patients diagnosed in 2009 (P < .001)., Conclusions: PET utilization during the surveillance period increased between 2001 and 2009. Further research is needed to determine the factors driving use of surveillance PET and to examine relationships between PET and patient outcomes., (Published by Elsevier Inc.)

Background: Little is known about recent trends in surveillance among the more than 1 million US colorectal cancer (CRC) survivors. Moreover, for stage I disease, which accounts for more than 30% of survivors, the guidelines are limited, and the use of surveillance has not been well studied. Guidelines were changed in 2005 to include recommendations for computed tomography (CT) surveillance in select patients, but the impact of these changes has not been explored., Methods: A retrospective analysis of patients who were identified in the Survival, Epidemiology, and End Results-Medicare database and underwent resection of stage I to III CRC between 2001 and 2009 was performed. The receipt of guideline-determined sufficient surveillance, including office visits, colonoscopy, carcinoembryonic antigen (CEA) testing, and CT imaging, in the 3 years after resection was evaluated., Results: The study included 23,990 colon cancer patients and 5665 rectal cancer patients. Rates of office visits and colonoscopy were high and stable over the study period. Rates of CEA surveillance increased over the study period but remained low, even for stage III disease. Rates of CT imaging increased gradually during the study period, but the 2005 guideline change had no effect. Stage II patients, including high-risk patients, received surveillance at significantly lower rates than stage III patients despite similar recommendations. Conversely, up to 30% of stage I patients received nonrecommended CEA testing and CT imaging., Conclusions: There continues to be substantial underuse of surveillance for CRC survivors and particularly for stage II patients, who constitute almost 40% of survivors. The 2005 guideline change had a negligible impact on CT surveillance. Conversely, although guidelines are limited, many stage I patients are receiving intensive surveillance., (© 2015 American Cancer Society.)

Background: Patients with cancer frequently transition between different types of specialists and across care settings. This study explored how frequently the surgical and medical oncology care of stage III colon cancer patients occurred across more than 1 hospital and whether this was associated with mortality and costs., Methods: This was a retrospective Surveillance, Epidemiology, and End Results-Medicare cohort study of 9075 stage III colon cancer patients diagnosed between 2000 and 2009 who had received both surgical and medical oncology care within 1 year of their diagnosis. Patients were assigned to the hospital at which they had undergone their cancer surgery and to their oncologist's primary hospital, and then they were characterized according to whether these hospitals were the same or different. Outcomes included all-cause mortality, subhazards for colon cancer-specific mortality, and costs of care at 12 months., Results: Thirty-seven percent of the patients received their surgical and medical oncology care from different hospitals. Rural patients were less likely than urban patients to receive medical oncology care from the same hospital (odds ratio, 0.62; 95% confidence interval, 0.43-0.90). Care from the same hospital was not associated with reduced all-cause or colon cancer-specific mortality but resulted in lower costs (8% of the median cost) at 12 months (dollars saved, $5493; 95% confidence interval, $1799-$9525)., Conclusions: The delivery of surgical and medical oncology care at the same hospital was associated with lower costs; however, reforms seeking to improve outcomes and lower costs through the integration of complex care will need to address the significant proportion of patients receiving care at more than 1 hospital., (© 2015 American Cancer Society.)

Purpose: Collaboration between specialists is essential for achieving high-value care in patients with complex cancer needs. We explore how collaboration between oncologists and surgeons affects mortality and cost for patients requiring multispecialty cancer care., Patients and Methods: This was a retrospective cohort study of patients with stage III colon cancer from SEER-Medicare diagnosed between 2000 and 2009. Patients were assigned to a primary treating surgeon and oncologist. Collaboration between surgeon and oncologist was measured as the number of patients shared between them; this has been shown to reflect advice seeking and referral relationships between physicians. Outcomes included hazards for all-cause mortality, subhazards for colon cancer-specific mortality, and cost of care at 12 months., Results: A total of 9,329 patients received care from 3,623 different surgeons and 2,319 medical oncologists, representing 6,827 unique surgeon-medical oncologist pairs. As the number of patients shared between specialists increased from to one to five (25th to 75th percentile), patients experienced an approximately 20% improved survival benefit from all-cause and colon cancer-specific mortalities. Specifically, for each additional patient shared between oncologist and surgeon, all-cause mortality improved by 5% (hazard ratio, 0.95; 95%CI, 0.92 to 0.97), and colon cancer-specific mortality improved by 5% (subhazard ratio, 0.95; 95% CI, 0.91 to 0.97). There was no association with cost., Conclusion: Specialist collaboration is associated with lower mortality without increased cost among patients with stage III colon cancer. Facilitating formal and informal collaboration between specialists may be an important strategy for improving the care of patients with complex cancers., (Copyright © 2015 by American Society of Clinical Oncology.)

Purpose: The relationship between oncologic hospital academic status and the value of care for stage II and III colon cancer is unknown., Methods: Retrospective SEER-Medicare analysis of patients age ≥ 66 years with stage II or III colon cancer and seen by medical oncology. Eligible patients were diagnosed 2000 to 2009 and followed through December 31, 2010. Hospitals reporting a major medical school affiliation in the NCI Hospital File were classified as academic medical centers. The association between hospital academic status and survival was assessed using Kaplan-Meier curves and Cox proportional hazards models. The association with mean cost of care was estimated using generalized linear models with log link and gamma family and with cost of care at various quantiles using quantile regression models., Results: Of 24,563 eligible patients, 5,707 (23%) received care from academic hospitals. There were no significant differences in unadjusted disease-specific median survival or adjusted risk of colon cancer death by hospital academic status (stage II hazard ratio = 1.12; 95% CI, 0.98 to 1.28; P = .103; stage III hazard ratio = 0.99; 95% CI, 0.90 to 1.08; P = .763). Excepting patients at the upper limits of the cost distribution, there was no significant difference in adjusted cost by hospital academic status., Conclusion: We found no survival differences for elderly patients with stage II or III colon cancer, treated by a medical oncologist, between academic and nonacademic hospitals. Furthermore, cost of care was similar across virtually the full range of the cost distribution., (Copyright © 2015 by American Society of Clinical Oncology.)

Background: Despite improved survival with chemotherapy for stage III colorectal cancer (CRC), patients may suffer substantial economic hardship during treatment. Methods for quantifying financial burden in CRC patients are lacking., Objective: To derive and validate a novel patient-reported measure of personal financial burden during CRC treatment., Data Collection: Within a population-based survey of patients in the Detroit and Georgia Surveillance, Epidemiology and End Results regions diagnosed with stage III CRC between 2011 and 2013, we asked 7 binary questions assessing effects of disease and treatment on personal finances., Data Analysis: We used factor analysis to compute a composite measure of financial burden. We used χ tests to evaluate relationships between individual components of financial burden and chemotherapy use with χ analyses. We used Mantel-Haenszel χ trend tests to examine relationships between the composite financial burden metric and chemotherapy use., Results: Among 956 patient surveys (66% response rate), factor analysis of 7 burden items yielded a single-factor solution. Factor loadings of 6 items were >0.4; these were included in the composite score. Internal consistency was high (Cronbach α=0.79). The mean financial burden score among all respondents was 1.72 (range, 0-6). The 812 (85%) who reported chemotherapy use had significantly higher financial burden scores than those who did not (mean burden score 1.88 vs. 0.88, P<0.001)., Conclusions: Financial burden is high among CRC patients, particularly those who use adjuvant chemotherapy. We encourage use of our instrument to validate our measure in the identification of patients in need of additional financial support during treatment.

Background: The effect of care setting on value of colon cancer care is unknown., Methods: A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥ 66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File., Results: Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P < .001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P < .001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P < .001)., Conclusions: Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers., (© 2014 American Cancer Society.)

Background: Patients with colorectal cancer (CRC) may suffer significant economic hardship during treatment. Complications are common after surgery for CRC and may exacerbate the financial burden of CRC even further., Methods: Within a population-based survey of patients with stage III CRC, the authors investigated the effects of disease and treatment on personal finances and computed a composite measure of financial burden. Correlations were examined between components of financial burden and patient-reported postoperative complications using chi-square analyses, and Mantel-Haenszel chi-square tend tests were used to evaluate correlations between composite financial burden scores and surgical complications, controlling for patient characteristics and other factors by using multivariable Poisson regression., Results: Among 937 respondents, 224 (24%) reported complications after surgery. Those with complications had significantly higher composite financial burden (P < .001 for trend): they were more likely to spend savings (40% vs 31%; P  = .01), borrow or take loans (18% vs 11%; P = .007), fail to make credit card payments (18% vs 11%; P = .005), reduce spending for food or clothes (38% vs 27%; P = .001), and decrease recreational activities (41% vs 33%; P = .03). They took significantly longer to return to work (P  = .009) and were more likely to experience significant worry about finances (61% vs 52%; P = .01)., Conclusions: Complications after surgery for CRC result in significant personal financial consequences as well as morbidity. Financial stress impairs quality of life and may prevent adherence to recommended treatments. Therefore, patients who suffer complications may require not just additional clinical care but also economic support and services., (© 2014 American Cancer Society.)

Background: Trust in physicians is an essential part of therapeutic relationships. Complications are common after colorectal cancer procedures, but little is known of their effect on patient-surgeon relationships. We hypothesized that unexpected complications impair trust and communication between patients and surgeons., Methods: We performed a population-based survey of surgically diagnosed stage III colorectal cancer patients in the Surveillance Epidemiology and End Results registries for Georgia and Metropolitan Detroit between August 2011 and October 2012. Using published survey instruments, we queried subjects about trust in and communication with their surgeon. The primary predictor was the occurrence of an operative complication. We examined patient factors associated with trust and communication then compared the relationship between operative complications and patient-reported trust and communication with their surgeons., Results: Among 622 preliminary respondents (54% response rate), 25% experienced postoperative complications. Those with complications were less likely to report high trust (73% vs 81%, P = .04) and high-quality communication (80% vs 95%, P < .001). Complications reduced trust among only 4% of patient-surgeon dyads with high-quality communication, whereas complications diminished patients' trust in 50% with poorer communication (P < .001). After controlling for communication ratings, we found there was no residual effect of complications on trust (P = .96)., Conclusion: Most respondents described trust in and communication with their surgeons as high. Complications were common and were associated with lower trust and poorer communication. However, the relationship between complications and trust was modified by communication. Trust remained high, even in the presence of complications, among respondents who reported high levels of patient-centered communication with their surgeons., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Although germ cell tumors (GCT) are among the most curable solid tumors, a subset of patients with GCT experience relapse or progression despite appropriate cisplatin-based therapy or first-line salvage therapy. This article describes the molecular mechanisms of cisplatin resistance, outlines single-agent chemotherapy and combination chemotherapy regimens that are active against GCT in the third-line or later setting, discusses the use of drug therapy for treating growing teratoma syndrome and teratoma with malignant transformation, outlines novel agents used to treat GCT, and highlights ongoing clinical trials and future directions in the treatment of refractory GCT., (Copyright © 2011 Elsevier Inc. All rights reserved.)