Original Article
National Trends in Pancreatic Cancer Outcomes and Pattern of Care Among Medicare Beneficiaries, 2000 Through 2010 Yun Wang, PhD1; Deborah Schrag, MD, MPH2,3; Gabriel A. Brooks, MD2,3; and Francesca Dominici, PhD1
BACKGROUND: Pancreatic cancer is a major cause of morbidity and mortality in the Medicare population. Whether the health care burden of pancreatic cancer has changed over the last decade is unknown. METHODS: The authors used Medicare data from 2000 to 2010 to identify beneficiaries aged 65 years who were hospitalized for the management of pancreatic cancer. Annual trends were estimated for the age-sex-race–adjusted initial hospitalization rate, the age-sex-race-comorbidity–adjusted 1-year mortality rate after initial hospitalization, age-sex-race-comorbidity–adjusted procedure rates, 1-year all-cause rehospitalizations after initial pancreatic cancer hospitalization, and mean inflation-adjusted Medicare payment for initial hospitalization. RESULTS: A total of 130,728 patients had 1 hospitalizations for pancreatic cancer and were identified from 56,642,071 beneficiaries during the study period. The age-sexrace–adjusted rate of initial hospitalization for pancreatic cancer was 50 per 100,000 person-years in 2010, representing a 0.5% annual increase since 2000 (95% confidence interval [95% CI], 0.3%-0.7%). In the same period, the age-sex-race-comorbidity–adjusted 1-year mortality rate decreased by 4.4% (95% CI, 3.9%-4.9%), and the age-sex-race-comorbidity–adjusted surgical resection rate increased by 6.9% (95% CI, 6.4%-7.5%). The mean inflation-adjusted Medicare payment for the initial hospitalization decreased, from $14,118 in 2000 to $13,318 in 2010, and the number of 1-year all-cause rehospitalizations after the initial hospitalization increased from 0.75 per patient in 2000 to 0.82 per patient in 2009 (all P 80% of patients die within a year of diagnosis, and 98% die within 5 years. The majority of patients with pancreatic cancer in the United States are elderly, with a median age at diagnosis of 72 years.3 The American Cancer Society reports that the pancreatic cancer incidence rate is increasing, with annual increases of 1.0% and 0.8% per year in women and men, respectively, reported since 1998.4 Continued increases in incidence are expected as the US population continues to age. In January 2013, the Recalcitrant Cancer Research Act was signed into law to accelerate funding for pancreatic cancer research.5 To the best of our knowledge, little is known regarding how the health care burden has changed over the last decade for patients with pancreatic cancer, and there is a paucity of data regarding spatial variations in pancreatic cancer treatment and outcomes. Previous studies have reported older data with limited coverage of the entire Medicare population.6-11 The last decade has brought a multitude of changes that affect pancreatic cancer care, including increased use of abdominal imaging, a general shift toward outpatient oncology care, a renewed emphasis on end-of-life care, and increased scrutiny of the quality and cost-effectiveness of cancer care.12-16 The effects of these changes on clinical and economic outcomes in pancreatic cancer remain largely unknown. In the current study, we used the 100% Medicare administrative claims data from the Centers for Medicare and Medicaid Services (CMS) to estimate trends in the burden of pancreatic cancer in the Medicare fee-for-service population
Corresponding author: Francesca Dominici, PhD, Department of Biostatistics, Harvard School of Public Health, 655 Huntington Ave, Boston, MA 02115; Fax: (617) 432-5619; [email protected] 1
Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts; 2Department of Medicine, Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
3
Additional Supporting Information may be found in the online version of this article. DOI: 10.1002/cncr.28537, Received: August 22, 2013; Revised: October 3, 2013; Accepted: October 25, 2013, Published online December 30, 2013 in Wiley Online Library (wileyonlinelibrary.com)
1050
Cancer
April 1, 2014
Trends in Pancreatic Cancer 2000-2010/Wang et al
from 2000 to 2010 across states/regions and age-sex-race subgroups. We evaluated trends in the initial pancreatic cancer hospitalization rate; the 1-year mortality rate after initial hospitalization; and patterns of care, including 1-year surgical or nonsurgical procedure rates, major discharge dispositions, length of stay (LOS), Medicare expenditures, and postdiagnosis rehospitalizations. The results of the current study describe recent changes in the patterns of care and outcomes for patients with pancreatic cancer and provide important context to help prioritize future effectiveness research for the treatment of this common and lethal malignancy. MATERIALS AND METHODS Study Sample
Using Medicare beneficiary denominator files from the CMS, we identified all Medicare beneficiaries aged 65 years who were enrolled in the Medicare fee-for-service plan between January 2000 and December 2010. We calculated person-years for beneficiaries to account for new enrollment, disenrollment, or death during the study period. We linked beneficiaries with Medicare inpatient claims data from the CMS to identify patients with pancreatic cancer with a principal discharge diagnosis of 157.xx, according to the International Classification of Diseases, Ninth Revision, Clinical Modification. We identified all unique patients who had at least 1 hospitalization for pancreatic cancer between January 1, 2000 and December 31, 2010. If a patient had > 1 pancreatic cancer hospitalization during the entire study period, the first hospitalization was selected. Patient Characteristics and Comorbidities
Patient demographic information included age, sex, race (white, black, or other), and the state of residence. Common clinical comorbidities for elderly patients were identified using the hierarchical condition categories method17 that uses principal and secondary diagnosis codes from hospitalizations within the 12 months before the index hospitalization. Data from 1999 were used for patients hospitalized with pancreatic cancer in 2000. Outcomes
We defined the pancreatic cancer initial hospitalization rate by dividing the total number of patients with pancreatic cancer in each year by the corresponding person-years of Medicare fee-for-service beneficiaries for that year. We defined the 1-year mortality rate as all-cause deaths within 365 days from the date of the initial pancreatic cancer Cancer
April 1, 2014
admission divided by the total number of patients with pancreatic cancer with an index hospitalization within a given year. Procedures included: 1) resections (total pancreatectomy; radical pancreaticoduodenectomy; and proximal, distal, radical subtotal, and partial pancreatectomy); 2) palliative surgical bypass (gastrojejunostomy, biliary-enteric bypass, hepaticojejunostomy, or gastrojejunostomy and biliary-enteric bypass together); and 3) stent/biliary drainage procedures (duct exploration for relief of obstruction other than calculus, insertion of a choledochohepatic tube for decompression, incision of other bile ducts for relief of obstruction, endoscopic insertion of a tube into a bile duct, replacement of a tube in a biliary or pancreatic duct, and biliary drainage [percutaneous or endoscopic]) according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes listed in the online supporting information18,19 within 1-year from the initial date of pancreatic cancer hospitalization. Major discharge dispositions included discharge to home, homecare, intermediate-care facility/ skilled nursing facility, hospice, and in-hospital death. LOS was defined as the difference between the discharge and admission dates plus 1. Patients with a LOS of > 100 days were considered as outliers and excluded from the LOS analysis. Medicare expenditures were calculated as the mean Medicare reimbursement per patient for the initial hospitalization, adjusting for the annual Consumer Price Index inflation rate reported by the Bureau of Labor Statistics of the United States Department of Labor (bls.gov/data/inflation_calculator.htm) and using the 2000 expenditure as a baseline. The number of rehospitalizations was defined as 1-year cumulative unplanned allcause hospitalizations after the initial hospitalization. Data from 2010 were used for reporting the 1-year mortality rate, procedure rates, and number of rehospitalizations for patients hospitalized in 2009. Statistical Analysis
The hospitalization rate at the national and state levels was age-standardized to the 2000 Medicare population aged 65 years and expressed as per 100,000 personyears. We fitted a mixed-effects model with a Poisson link function and state-specific random intercepts to estimate the trend in the initial hospitalization rate, adjusting for age-sex-race. Time was modeled as an ordinal variable ranging from 0 to 10, corresponding to the years 2000 to 2010. The incidence rate ratio for the time variable was used to represent the age-sex-race–adjusted annual trend in the hospitalization rate. We fitted the mixed-effects model with a logit link function to estimate the trend in 1051
Original Article TABLE 1. Pancreatic Cancer Hospitalization and Mortality Rates Hospitalization Rate per 100,000 Person-Years (95% CI) Patient Groups Overall 64 y 98.5% of Medicare fee-for-service patients were hospitalized after receiving a diagnosis of pancreatic cancer. The lack of cancer registry information in the current study data precluded our ability to account for the stage or histology of the cases of pancreatic cancer in our risk adjustments. It also precluded our ability to assess the changes in the use of other nonsurgical therapies, such as radiotherapy and chemotherapy, which could impact on the mortality rate as well. Our 1year mortality rate measured survival from the date of the initial hospitalization for pancreatic cancer, a time point that may not correspond to the date of diagnosis. Nevertheless, the difference in magnitude between the 1-year mortality rate from pancreatic cancer admission and from pancreatic cancer diagnosis appears to be small. The 1year mortality rate for patients aged 65 years reported from a SEER-Medicare analysis was reported to be 81.4% between 1988 and 2008,4 whereas we found a 1-year mortality rate of 80.9% from 2000 to 2009. Finally, because we relied on billing codes used by hospitals to obtain Cancer
April 1, 2014
reimbursement, we cannot be certain whether the variation we described represents significant differences in disease burden or regional variations in coding practices. The very large size of our data set and the availability of data over multiple years suggest that our findings are reflective of meaningful outcomes. In conclusion, between 2000 and 2010, the initial hospitalization rate for pancreatic cancer increased considerably within the Medicare fee-for-service population, whereas the 1-year mortality rate declined significantly over the same period. Patients were more likely to undergo curative-intent surgical resection, substituting for palliative surgical bypass. The health and economic burden of pancreatic cancer in the United States is substantial, and additional nationwide efforts are required to fight this disease. FUNDING SUPPORT No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES Drs. Dominici and Wang are partially funded by the National Cancer Institute (P01 CA134294; Principal Investigator: Dr. Lin and co-Principal Investigator: Dr. Dominici) and the Agency for Healthcare Research and Quality (K18 HS021991 to Dr. Dominici).
REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2013;62:10-29. 2. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63:11-30. 3. Howlader N, Noone AM, Krapcho M, et al, eds. SEER Cancer Statistics Review, 1975-2008. Bethesda, MD: National Cancer Institute; 2011. seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission. Accessed October 20, 2011. 4. American Cancer Society. Cancer Facts & Figures 2011. cancer.org/ Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures2011. Accessed October 18, 2011. 5. Recalcitrant Cancer Research Act of 2012, S.3566, 112th Congress, 2012. 6. Zhang J, Dhakal I, Ning B, Kesteloot H. Patterns and trends of pancreatic cancer mortality rates in Arkansas, 1969-2002: a comparison with the US population. Eur J Cancer Prev. 2008;17:18-27. 7. Zhang J, Dhakal I, Yan H, Phillips M, Kesteloot H; SEER Cancer Registries. Trends in pancreatic cancer incidence in nine SEER Cancer Registries, 1973-2002. Ann Oncol. 2007;18:1267-1279. 8. Baxter NN, Whitson BA, Tuttle TM. Trends in the treatment and outcome of pancreatic cancer in the United States. Ann Surg Oncol. 2007;14:1320-1326. 9. Shaib YH, Davila JA, El-Serag HB. The epidemiology of pancreatic cancer in the United States: changes below the surface. Aliment Pharmacol Ther. 2006;24:87-94. 10. Edwards BK, Brown ML, Wingo PA, et al. Annual report to the nation on the status of cancer, 1975-2002, featuring population-based trends in cancer treatment. J Natl Cancer Inst. 2005;97:1407-1427. 11. Polednak AP. Trends in incidence rates of tobacco-related cancer, selected areas, SEER Program, United States, 1992-2004. Prev Chronic Dis. 2009;6:A16.
1057
Original Article 12. Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297:267-277. 13. Abbott DE, Merkow RP, Cantor SB, et al. Cost-effectiveness of treatment strategies for pancreatic head adenocarcinoma and potential opportunities for improvement. Ann Surg Oncol. 2012;19:36593667. 14. Barr TR, Towle EL. Oncology practice trends from the national practice benchmark, 2005 through 2010. J Oncol Pract. 2011;7:286-290. 15. Kolodziej M, Hoverman JR, Garey JS, et al. Benchmarks for value in cancer care: an analysis of a large commercial population. J Oncol Pract. 2011;7:301-306. 16. Karapanos K, Nomikos IN. Current surgical aspects of palliative treatment for unresectable pancreatic cancer. Cancers (Basel). 2011;3: 636-651. 17. Pope GC, Kautter J, Ellis RP, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev. 2004;25:119-141. 18. Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998;228:429-438. 19. Reddy DM, Townsend CM, Kuo YF, Freeman JL, Goodwin JS, Riall TS. Readmission after pancreatectomy for pancreatic cancer in Medicare patients. J Gastrointest Surg. 2009;13:1963-1974; discussion 1974-1975. 20. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011; 364:2128-2137.
1058
21. Levy DT, Nikolayev L, Mumford E. Recent trends in smoking and the role of public policies: results from the SimSmoke tobacco control policy simulation model. Addiction. 2005;100:1526-1536. 22. Daniel CR, Cross AJ, Koebnick C, Sinha R. Trends in meat consumption in the United States. Public Health Nutr. 2011;14:575-583. 23. Looker HC, Krakoff J, Andre V, et al. Secular trends in treatment and control of type 2 diabetes in an American Indian Population: a 30-year longitudinal study Diabetes Care. 2010;33:2383-2389. 24. Li D, Xie K, Wolff R, Abbruzzese JL. Pancreatic cancer. Lancet. 2004;363:1049-1057. 25. Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27:2758-2765. 26. Winter JM, Cameron JL, Campbell KA, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10:1199-1210; discussion 1210-1211. 27. Pancreatic Cancer Action Network. Pancreatic Cancer Incidence and Death Rate on the Rise as Overall Cancer Death Rates Continue to Decline.pancan.org/section_about/news_press_center/2011_press_rele ases/06_17_11_pr.php. Accessed October 26, 2011. 28. Hewitt M, Simone JV, eds. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press; 1999. 29. McKoy JM, Samaras AT, Bennett CL. Providing cancer care to a graying and diverse cancer population in the 21st century: are we prepared? J Clin Oncol. 2009:27:2745-2746. 30. Pancreatic Cancer Action Network. The Alarming Rise of Pancreatic Cancer Deaths in the United States: Why We Need to Stem the Tide Today.pancan.org/section_research/reports/pdf/incidence_ report_2012.pdf. Accessed January 30, 2013.
Cancer
April 1, 2014
National Trends in Pancreatic Cancer Outcomes and Pattern of Care Among Medicare Beneficiaries, 2000 Through 2010 Yun Wang, PhD1; Deborah Schrag, MD, MPH2,3; Gabriel A. Brooks, MD2,3; and Francesca Dominici, PhD1
BACKGROUND: Pancreatic cancer is a major cause of morbidity and mortality in the Medicare population. Whether the health care burden of pancreatic cancer has changed over the last decade is unknown. METHODS: The authors used Medicare data from 2000 to 2010 to identify beneficiaries aged 65 years who were hospitalized for the management of pancreatic cancer. Annual trends were estimated for the age-sex-race–adjusted initial hospitalization rate, the age-sex-race-comorbidity–adjusted 1-year mortality rate after initial hospitalization, age-sex-race-comorbidity–adjusted procedure rates, 1-year all-cause rehospitalizations after initial pancreatic cancer hospitalization, and mean inflation-adjusted Medicare payment for initial hospitalization. RESULTS: A total of 130,728 patients had 1 hospitalizations for pancreatic cancer and were identified from 56,642,071 beneficiaries during the study period. The age-sexrace–adjusted rate of initial hospitalization for pancreatic cancer was 50 per 100,000 person-years in 2010, representing a 0.5% annual increase since 2000 (95% confidence interval [95% CI], 0.3%-0.7%). In the same period, the age-sex-race-comorbidity–adjusted 1-year mortality rate decreased by 4.4% (95% CI, 3.9%-4.9%), and the age-sex-race-comorbidity–adjusted surgical resection rate increased by 6.9% (95% CI, 6.4%-7.5%). The mean inflation-adjusted Medicare payment for the initial hospitalization decreased, from $14,118 in 2000 to $13,318 in 2010, and the number of 1-year all-cause rehospitalizations after the initial hospitalization increased from 0.75 per patient in 2000 to 0.82 per patient in 2009 (all P 80% of patients die within a year of diagnosis, and 98% die within 5 years. The majority of patients with pancreatic cancer in the United States are elderly, with a median age at diagnosis of 72 years.3 The American Cancer Society reports that the pancreatic cancer incidence rate is increasing, with annual increases of 1.0% and 0.8% per year in women and men, respectively, reported since 1998.4 Continued increases in incidence are expected as the US population continues to age. In January 2013, the Recalcitrant Cancer Research Act was signed into law to accelerate funding for pancreatic cancer research.5 To the best of our knowledge, little is known regarding how the health care burden has changed over the last decade for patients with pancreatic cancer, and there is a paucity of data regarding spatial variations in pancreatic cancer treatment and outcomes. Previous studies have reported older data with limited coverage of the entire Medicare population.6-11 The last decade has brought a multitude of changes that affect pancreatic cancer care, including increased use of abdominal imaging, a general shift toward outpatient oncology care, a renewed emphasis on end-of-life care, and increased scrutiny of the quality and cost-effectiveness of cancer care.12-16 The effects of these changes on clinical and economic outcomes in pancreatic cancer remain largely unknown. In the current study, we used the 100% Medicare administrative claims data from the Centers for Medicare and Medicaid Services (CMS) to estimate trends in the burden of pancreatic cancer in the Medicare fee-for-service population
Corresponding author: Francesca Dominici, PhD, Department of Biostatistics, Harvard School of Public Health, 655 Huntington Ave, Boston, MA 02115; Fax: (617) 432-5619; [email protected] 1
Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts; 2Department of Medicine, Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
3
Additional Supporting Information may be found in the online version of this article. DOI: 10.1002/cncr.28537, Received: August 22, 2013; Revised: October 3, 2013; Accepted: October 25, 2013, Published online December 30, 2013 in Wiley Online Library (wileyonlinelibrary.com)
1050
Cancer
April 1, 2014
Trends in Pancreatic Cancer 2000-2010/Wang et al
from 2000 to 2010 across states/regions and age-sex-race subgroups. We evaluated trends in the initial pancreatic cancer hospitalization rate; the 1-year mortality rate after initial hospitalization; and patterns of care, including 1-year surgical or nonsurgical procedure rates, major discharge dispositions, length of stay (LOS), Medicare expenditures, and postdiagnosis rehospitalizations. The results of the current study describe recent changes in the patterns of care and outcomes for patients with pancreatic cancer and provide important context to help prioritize future effectiveness research for the treatment of this common and lethal malignancy. MATERIALS AND METHODS Study Sample
Using Medicare beneficiary denominator files from the CMS, we identified all Medicare beneficiaries aged 65 years who were enrolled in the Medicare fee-for-service plan between January 2000 and December 2010. We calculated person-years for beneficiaries to account for new enrollment, disenrollment, or death during the study period. We linked beneficiaries with Medicare inpatient claims data from the CMS to identify patients with pancreatic cancer with a principal discharge diagnosis of 157.xx, according to the International Classification of Diseases, Ninth Revision, Clinical Modification. We identified all unique patients who had at least 1 hospitalization for pancreatic cancer between January 1, 2000 and December 31, 2010. If a patient had > 1 pancreatic cancer hospitalization during the entire study period, the first hospitalization was selected. Patient Characteristics and Comorbidities
Patient demographic information included age, sex, race (white, black, or other), and the state of residence. Common clinical comorbidities for elderly patients were identified using the hierarchical condition categories method17 that uses principal and secondary diagnosis codes from hospitalizations within the 12 months before the index hospitalization. Data from 1999 were used for patients hospitalized with pancreatic cancer in 2000. Outcomes
We defined the pancreatic cancer initial hospitalization rate by dividing the total number of patients with pancreatic cancer in each year by the corresponding person-years of Medicare fee-for-service beneficiaries for that year. We defined the 1-year mortality rate as all-cause deaths within 365 days from the date of the initial pancreatic cancer Cancer
April 1, 2014
admission divided by the total number of patients with pancreatic cancer with an index hospitalization within a given year. Procedures included: 1) resections (total pancreatectomy; radical pancreaticoduodenectomy; and proximal, distal, radical subtotal, and partial pancreatectomy); 2) palliative surgical bypass (gastrojejunostomy, biliary-enteric bypass, hepaticojejunostomy, or gastrojejunostomy and biliary-enteric bypass together); and 3) stent/biliary drainage procedures (duct exploration for relief of obstruction other than calculus, insertion of a choledochohepatic tube for decompression, incision of other bile ducts for relief of obstruction, endoscopic insertion of a tube into a bile duct, replacement of a tube in a biliary or pancreatic duct, and biliary drainage [percutaneous or endoscopic]) according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes listed in the online supporting information18,19 within 1-year from the initial date of pancreatic cancer hospitalization. Major discharge dispositions included discharge to home, homecare, intermediate-care facility/ skilled nursing facility, hospice, and in-hospital death. LOS was defined as the difference between the discharge and admission dates plus 1. Patients with a LOS of > 100 days were considered as outliers and excluded from the LOS analysis. Medicare expenditures were calculated as the mean Medicare reimbursement per patient for the initial hospitalization, adjusting for the annual Consumer Price Index inflation rate reported by the Bureau of Labor Statistics of the United States Department of Labor (bls.gov/data/inflation_calculator.htm) and using the 2000 expenditure as a baseline. The number of rehospitalizations was defined as 1-year cumulative unplanned allcause hospitalizations after the initial hospitalization. Data from 2010 were used for reporting the 1-year mortality rate, procedure rates, and number of rehospitalizations for patients hospitalized in 2009. Statistical Analysis
The hospitalization rate at the national and state levels was age-standardized to the 2000 Medicare population aged 65 years and expressed as per 100,000 personyears. We fitted a mixed-effects model with a Poisson link function and state-specific random intercepts to estimate the trend in the initial hospitalization rate, adjusting for age-sex-race. Time was modeled as an ordinal variable ranging from 0 to 10, corresponding to the years 2000 to 2010. The incidence rate ratio for the time variable was used to represent the age-sex-race–adjusted annual trend in the hospitalization rate. We fitted the mixed-effects model with a logit link function to estimate the trend in 1051
Original Article TABLE 1. Pancreatic Cancer Hospitalization and Mortality Rates Hospitalization Rate per 100,000 Person-Years (95% CI) Patient Groups Overall 64 y 98.5% of Medicare fee-for-service patients were hospitalized after receiving a diagnosis of pancreatic cancer. The lack of cancer registry information in the current study data precluded our ability to account for the stage or histology of the cases of pancreatic cancer in our risk adjustments. It also precluded our ability to assess the changes in the use of other nonsurgical therapies, such as radiotherapy and chemotherapy, which could impact on the mortality rate as well. Our 1year mortality rate measured survival from the date of the initial hospitalization for pancreatic cancer, a time point that may not correspond to the date of diagnosis. Nevertheless, the difference in magnitude between the 1-year mortality rate from pancreatic cancer admission and from pancreatic cancer diagnosis appears to be small. The 1year mortality rate for patients aged 65 years reported from a SEER-Medicare analysis was reported to be 81.4% between 1988 and 2008,4 whereas we found a 1-year mortality rate of 80.9% from 2000 to 2009. Finally, because we relied on billing codes used by hospitals to obtain Cancer
April 1, 2014
reimbursement, we cannot be certain whether the variation we described represents significant differences in disease burden or regional variations in coding practices. The very large size of our data set and the availability of data over multiple years suggest that our findings are reflective of meaningful outcomes. In conclusion, between 2000 and 2010, the initial hospitalization rate for pancreatic cancer increased considerably within the Medicare fee-for-service population, whereas the 1-year mortality rate declined significantly over the same period. Patients were more likely to undergo curative-intent surgical resection, substituting for palliative surgical bypass. The health and economic burden of pancreatic cancer in the United States is substantial, and additional nationwide efforts are required to fight this disease. FUNDING SUPPORT No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES Drs. Dominici and Wang are partially funded by the National Cancer Institute (P01 CA134294; Principal Investigator: Dr. Lin and co-Principal Investigator: Dr. Dominici) and the Agency for Healthcare Research and Quality (K18 HS021991 to Dr. Dominici).
REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2013;62:10-29. 2. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63:11-30. 3. Howlader N, Noone AM, Krapcho M, et al, eds. SEER Cancer Statistics Review, 1975-2008. Bethesda, MD: National Cancer Institute; 2011. seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission. Accessed October 20, 2011. 4. American Cancer Society. Cancer Facts & Figures 2011. cancer.org/ Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures2011. Accessed October 18, 2011. 5. Recalcitrant Cancer Research Act of 2012, S.3566, 112th Congress, 2012. 6. Zhang J, Dhakal I, Ning B, Kesteloot H. Patterns and trends of pancreatic cancer mortality rates in Arkansas, 1969-2002: a comparison with the US population. Eur J Cancer Prev. 2008;17:18-27. 7. Zhang J, Dhakal I, Yan H, Phillips M, Kesteloot H; SEER Cancer Registries. Trends in pancreatic cancer incidence in nine SEER Cancer Registries, 1973-2002. Ann Oncol. 2007;18:1267-1279. 8. Baxter NN, Whitson BA, Tuttle TM. Trends in the treatment and outcome of pancreatic cancer in the United States. Ann Surg Oncol. 2007;14:1320-1326. 9. Shaib YH, Davila JA, El-Serag HB. The epidemiology of pancreatic cancer in the United States: changes below the surface. Aliment Pharmacol Ther. 2006;24:87-94. 10. Edwards BK, Brown ML, Wingo PA, et al. Annual report to the nation on the status of cancer, 1975-2002, featuring population-based trends in cancer treatment. J Natl Cancer Inst. 2005;97:1407-1427. 11. Polednak AP. Trends in incidence rates of tobacco-related cancer, selected areas, SEER Program, United States, 1992-2004. Prev Chronic Dis. 2009;6:A16.
1057
Original Article 12. Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297:267-277. 13. Abbott DE, Merkow RP, Cantor SB, et al. Cost-effectiveness of treatment strategies for pancreatic head adenocarcinoma and potential opportunities for improvement. Ann Surg Oncol. 2012;19:36593667. 14. Barr TR, Towle EL. Oncology practice trends from the national practice benchmark, 2005 through 2010. J Oncol Pract. 2011;7:286-290. 15. Kolodziej M, Hoverman JR, Garey JS, et al. Benchmarks for value in cancer care: an analysis of a large commercial population. J Oncol Pract. 2011;7:301-306. 16. Karapanos K, Nomikos IN. Current surgical aspects of palliative treatment for unresectable pancreatic cancer. Cancers (Basel). 2011;3: 636-651. 17. Pope GC, Kautter J, Ellis RP, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev. 2004;25:119-141. 18. Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998;228:429-438. 19. Reddy DM, Townsend CM, Kuo YF, Freeman JL, Goodwin JS, Riall TS. Readmission after pancreatectomy for pancreatic cancer in Medicare patients. J Gastrointest Surg. 2009;13:1963-1974; discussion 1974-1975. 20. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011; 364:2128-2137.
1058
21. Levy DT, Nikolayev L, Mumford E. Recent trends in smoking and the role of public policies: results from the SimSmoke tobacco control policy simulation model. Addiction. 2005;100:1526-1536. 22. Daniel CR, Cross AJ, Koebnick C, Sinha R. Trends in meat consumption in the United States. Public Health Nutr. 2011;14:575-583. 23. Looker HC, Krakoff J, Andre V, et al. Secular trends in treatment and control of type 2 diabetes in an American Indian Population: a 30-year longitudinal study Diabetes Care. 2010;33:2383-2389. 24. Li D, Xie K, Wolff R, Abbruzzese JL. Pancreatic cancer. Lancet. 2004;363:1049-1057. 25. Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27:2758-2765. 26. Winter JM, Cameron JL, Campbell KA, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10:1199-1210; discussion 1210-1211. 27. Pancreatic Cancer Action Network. Pancreatic Cancer Incidence and Death Rate on the Rise as Overall Cancer Death Rates Continue to Decline.pancan.org/section_about/news_press_center/2011_press_rele ases/06_17_11_pr.php. Accessed October 26, 2011. 28. Hewitt M, Simone JV, eds. Ensuring Quality Cancer Care. Washington, DC: The National Academies Press; 1999. 29. McKoy JM, Samaras AT, Bennett CL. Providing cancer care to a graying and diverse cancer population in the 21st century: are we prepared? J Clin Oncol. 2009:27:2745-2746. 30. Pancreatic Cancer Action Network. The Alarming Rise of Pancreatic Cancer Deaths in the United States: Why We Need to Stem the Tide Today.pancan.org/section_research/reports/pdf/incidence_ report_2012.pdf. Accessed January 30, 2013.
Cancer
April 1, 2014
