J O U RN A L OF GE RI A TR IC O N CO LOG Y 6 ( 20 1 5 ) 8 5 –92
Available online at www.sciencedirect.com
ScienceDirect
Preventive care in older cancer survivors Lisa M. Lowensteina , Jennifer Andreozzi Ouelleta , William Dale b , Lin Fana , Supriya Gupta Mohilea,⁎ a
James Wilmot Cancer Center, University of Rochester, Rochester, NY, USA Department of Medicine, Section of Geriatrics and Palliative Medicine, The University of Chicago, Chicago, IL, USA
b
AR TIC LE I N FO
ABS TR ACT
Article history:
Objective: To study factors that influence receipt of preventive care in older cancer survivors.
Received 4 July 2014
Methods: We analyzed a nationally representative sample of 12,458 older adults from the 2003
Received in revised form
Medicare Current Beneficiary Survey. Factors associated with non-receipt of preventive care
29 September 2014
were explored among cancer and non-cancer survivors, using logistic regression.
Accepted 9 December 2014
Results: Among the cancer survivors, 1883 were diagnosed >1 year at survey completion. A
Available online 24 December 2014
cancer history was independently associated with receipt of mammogram (AOR = 1.57, 95% CI = 1.34–1.85), flu shot (AOR = 1.33, 95% CI = 1.16–1.53), measurement of total cholesterol in
Keywords:
the previous six months (AOR = 1.20, 95% CI = 1.07–1.34), pneumonia vaccination (AOR = 1.33,
Preventive medicine
95% CI = 1.18–1.49), bone mineral density (BMD) testing (AOR = 1.38, 95% CI = 1.21–1.56), and
Cancer
lower endoscopy (AOR = 1.46, 95% CI = 1.29–1.65). However, receipt of preventive care was not
Survivors
optimal among older cancer survivors with only 51.2% of the female cancer survivors received a mammogram, 63.8% of all the cancer survivors received colonoscopy, and 42.5% had BMD testing. Among the cancer survivors, factors associated with non-receipt of mammogram included age ≥85 years (AOR = 0.43, 95% CI = 0.26–0.74), and scoring ≥three points on the Vulnerable Elders Survey-13 (AOR = 0.94, 95% CI = 0.80–1.00). Factors associated with non-receipt of colonoscopy included low education (AOR = 0.43, 95% CI = 0.27–0.68) and rural residence (AOR = 0.51, 95% CI = 0.34–0.77). Factors associated with non-receipt of BMD testing included age ≥70 (AOR = 0.59, 95% CI = 0.39–0.90), African American race (AOR = 0.51, 95% CI = 0.27–0.95), low education (AOR = 0.23, 95% CI = 0.14–0.38), and rural residence (AOR = 0.43, 95% CI = 0.27–0.70). Conclusion: Although older cancer survivors are more likely to receive preventive care services than other older adults, factors other than health status considerations (e.g., education, rural residence) are associated with non-receipt of preventive care services. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Improvements in the early diagnosis and treatment of cancer have led to a rapidly growing population of cancer survivors. More than half of all cancer survivors are living well beyond five years after a cancer diagnosis and in 2009
the cancer survivor population in the US exceeded 13.7 million.1,2 Over 60% of cancer survivors are aged 65 and above, and 57% of all newly diagnosed cancer occur in people over age 65 years of age.3 Improving the quality of care for older cancer survivors is becoming increasingly important.
⁎ Corresponding author at: James P. Wilmot Cancer Center, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA. Tel.: + 1 585 275 9319; fax: + 1 585 273 1042. E-mail address: [email protected] (S. Gupta Mohile).
http://dx.doi.org/10.1016/j.jgo.2014.12.003 1879-4068/© 2014 Elsevier Ltd. All rights reserved.
86
JO U RN A L OF GE RI A TR IC O N COL O G Y 6 (2 0 1 5 ) 8 5 –9 2
The health of older patients with cancer is heterogeneous, and many have chronic conditions that affect their care. Cancer treatment can lead to an increase in comorbid conditions.4 Studies show that chronic medical conditions and second primary cancers are more common among cancer survivors than persons without a history of cancer.5–8 For example, chronic medical conditions such as hypertension, heart disease, metabolic syndrome, and chronic obstructive pulmonary disease have been found to be more prevalent in cancer survivors.5,9 Although recently cancer screening for older patients, especially those aged 75 and over, has been questioned and remains controversial. The benefits of cancer screening in cancer survivors may be higher due to their higher risk of cancer development.3,10 Studies show that the receipt of preventive care services is likely low in cancer survivors. Previous studies reveal conflicting results on whether cancer survivors receive increased or decreased preventive care services compared to those without cancer. In addition, previous studies have included survivors of all ages, which limit our understanding of receipt of preventive care services by patients over age 65. Persons aged 65 and older comprise a large proportion of cancer survivors, have unique healthcare needs, and contribute the most to health care costs.11 In this study we utilized a large, nationally representative, population-based survey, the Medicare Current Beneficiary Survey (MCBS), to assess the prevalence of receipt of preventive care services and to examine factors associated with non-receipt of various preventive services in older cancer survivors. This study builds upon our previous work with MCBS that demonstrated older cancer survivors have a higher likelihood of chronic conditions and frailty than their age-matched peers without cancer.4 The primary objectives were to compare the prevalence of receipt of preventive care in elderly cancer survivors with the prevalence of receipt in those without cancer and to identify factors independently associated with non-receipt of preventive care in older cancer survivors. The information gained from this study could help guide interventions designed to improve preventive care of older cancer survivors.
2. Materials and Methods 2.1. Data Source and Study Sample 2.1.1. Data Source We used cross sectional data from the 2003 MCBS, a nationally representative in-person survey of randomly sampled Medicare beneficiaries. The MCBS is administered by the Federal Centers for Medicare and Medicaid Services (CMS). Participants completed a baseline interview and three follow-up interviews per year over four years. Data were collected through personal interviews of the beneficiary or a proxy chosen by the beneficiary if he/she was physically or mentally unable to do the interview. On average, approximately 12% of the community interviews in each round were conducted by proxy.12 The Access to Care files contain information collected in the fall interview and include information on beneficiaries' demographics, socioeconomic status, and indicators of health
status and functional status. Interviewees were requested to have their medical records on hand at the time of the interview.
2.1.2. Study Sample The sample of respondents from the year 2003 MCBS Access to Care survey was drawn from the Medicare enrollment file to be representative of the Medicare population as a whole. The oldest age group (85 years and over) were over-sampled to permit more detailed analysis of this sub-population. Samples were selected by using a stratified, multistage probability sample design. The response rates for the MCBS were over 80%.13 For this study, we restricted our analysis to communitydwelling Medicare beneficiaries who were 65 years or older (n = 12,016). The sample of patients with a history of cancer was created by including those who responded both affirmatively to the question “Has a doctor ever told you that you had any kind of cancer, malignancy or tumor other than skin cancer?” and negatively to the question “Was your diagnosis of cancer made within the last year?” The analytic sample had a total of 1882 people with a history of cancer and 10,133 people without a history of cancer.
2.2. Variables 2.2.1. Dependent Variables The dependent variables we examined included the receipt of the following preventive care practices: blood pressure measurement within the previous six months, a cholesterol measurement within the previous six months, a flu vaccination within one year, pneumonia vaccination ever received, discussion of a fall with a physician following a fall, a bone mineral density (BMD) test ever received, a mammogram within one year in women and completion of a lower endoscopy (sigmoidoscopy or colonoscopy) in the past. These dependent variables were obtained from MCBS questions.
2.2.2. Independent Variables We studied the independent impact of various factors on the receipt of each of the preventive care services listed above. Our primary independent variable of interest was a self-reported history of cancer, which identified survey participants who were cancer survivors. Others included age (65–69, 70–74, 75–79, 80–84, ≥85), gender, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), body mass index (BMI), region (urban, large rural, small rural, remote rural areas), education (less than 9th grade, 9th grade–high school, some college, associate degree and above), marital status (married vs not married), income (
Available online at www.sciencedirect.com
ScienceDirect
Preventive care in older cancer survivors Lisa M. Lowensteina , Jennifer Andreozzi Ouelleta , William Dale b , Lin Fana , Supriya Gupta Mohilea,⁎ a
James Wilmot Cancer Center, University of Rochester, Rochester, NY, USA Department of Medicine, Section of Geriatrics and Palliative Medicine, The University of Chicago, Chicago, IL, USA
b
AR TIC LE I N FO
ABS TR ACT
Article history:
Objective: To study factors that influence receipt of preventive care in older cancer survivors.
Received 4 July 2014
Methods: We analyzed a nationally representative sample of 12,458 older adults from the 2003
Received in revised form
Medicare Current Beneficiary Survey. Factors associated with non-receipt of preventive care
29 September 2014
were explored among cancer and non-cancer survivors, using logistic regression.
Accepted 9 December 2014
Results: Among the cancer survivors, 1883 were diagnosed >1 year at survey completion. A
Available online 24 December 2014
cancer history was independently associated with receipt of mammogram (AOR = 1.57, 95% CI = 1.34–1.85), flu shot (AOR = 1.33, 95% CI = 1.16–1.53), measurement of total cholesterol in
Keywords:
the previous six months (AOR = 1.20, 95% CI = 1.07–1.34), pneumonia vaccination (AOR = 1.33,
Preventive medicine
95% CI = 1.18–1.49), bone mineral density (BMD) testing (AOR = 1.38, 95% CI = 1.21–1.56), and
Cancer
lower endoscopy (AOR = 1.46, 95% CI = 1.29–1.65). However, receipt of preventive care was not
Survivors
optimal among older cancer survivors with only 51.2% of the female cancer survivors received a mammogram, 63.8% of all the cancer survivors received colonoscopy, and 42.5% had BMD testing. Among the cancer survivors, factors associated with non-receipt of mammogram included age ≥85 years (AOR = 0.43, 95% CI = 0.26–0.74), and scoring ≥three points on the Vulnerable Elders Survey-13 (AOR = 0.94, 95% CI = 0.80–1.00). Factors associated with non-receipt of colonoscopy included low education (AOR = 0.43, 95% CI = 0.27–0.68) and rural residence (AOR = 0.51, 95% CI = 0.34–0.77). Factors associated with non-receipt of BMD testing included age ≥70 (AOR = 0.59, 95% CI = 0.39–0.90), African American race (AOR = 0.51, 95% CI = 0.27–0.95), low education (AOR = 0.23, 95% CI = 0.14–0.38), and rural residence (AOR = 0.43, 95% CI = 0.27–0.70). Conclusion: Although older cancer survivors are more likely to receive preventive care services than other older adults, factors other than health status considerations (e.g., education, rural residence) are associated with non-receipt of preventive care services. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Improvements in the early diagnosis and treatment of cancer have led to a rapidly growing population of cancer survivors. More than half of all cancer survivors are living well beyond five years after a cancer diagnosis and in 2009
the cancer survivor population in the US exceeded 13.7 million.1,2 Over 60% of cancer survivors are aged 65 and above, and 57% of all newly diagnosed cancer occur in people over age 65 years of age.3 Improving the quality of care for older cancer survivors is becoming increasingly important.
⁎ Corresponding author at: James P. Wilmot Cancer Center, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA. Tel.: + 1 585 275 9319; fax: + 1 585 273 1042. E-mail address: [email protected] (S. Gupta Mohile).
http://dx.doi.org/10.1016/j.jgo.2014.12.003 1879-4068/© 2014 Elsevier Ltd. All rights reserved.
86
JO U RN A L OF GE RI A TR IC O N COL O G Y 6 (2 0 1 5 ) 8 5 –9 2
The health of older patients with cancer is heterogeneous, and many have chronic conditions that affect their care. Cancer treatment can lead to an increase in comorbid conditions.4 Studies show that chronic medical conditions and second primary cancers are more common among cancer survivors than persons without a history of cancer.5–8 For example, chronic medical conditions such as hypertension, heart disease, metabolic syndrome, and chronic obstructive pulmonary disease have been found to be more prevalent in cancer survivors.5,9 Although recently cancer screening for older patients, especially those aged 75 and over, has been questioned and remains controversial. The benefits of cancer screening in cancer survivors may be higher due to their higher risk of cancer development.3,10 Studies show that the receipt of preventive care services is likely low in cancer survivors. Previous studies reveal conflicting results on whether cancer survivors receive increased or decreased preventive care services compared to those without cancer. In addition, previous studies have included survivors of all ages, which limit our understanding of receipt of preventive care services by patients over age 65. Persons aged 65 and older comprise a large proportion of cancer survivors, have unique healthcare needs, and contribute the most to health care costs.11 In this study we utilized a large, nationally representative, population-based survey, the Medicare Current Beneficiary Survey (MCBS), to assess the prevalence of receipt of preventive care services and to examine factors associated with non-receipt of various preventive services in older cancer survivors. This study builds upon our previous work with MCBS that demonstrated older cancer survivors have a higher likelihood of chronic conditions and frailty than their age-matched peers without cancer.4 The primary objectives were to compare the prevalence of receipt of preventive care in elderly cancer survivors with the prevalence of receipt in those without cancer and to identify factors independently associated with non-receipt of preventive care in older cancer survivors. The information gained from this study could help guide interventions designed to improve preventive care of older cancer survivors.
2. Materials and Methods 2.1. Data Source and Study Sample 2.1.1. Data Source We used cross sectional data from the 2003 MCBS, a nationally representative in-person survey of randomly sampled Medicare beneficiaries. The MCBS is administered by the Federal Centers for Medicare and Medicaid Services (CMS). Participants completed a baseline interview and three follow-up interviews per year over four years. Data were collected through personal interviews of the beneficiary or a proxy chosen by the beneficiary if he/she was physically or mentally unable to do the interview. On average, approximately 12% of the community interviews in each round were conducted by proxy.12 The Access to Care files contain information collected in the fall interview and include information on beneficiaries' demographics, socioeconomic status, and indicators of health
status and functional status. Interviewees were requested to have their medical records on hand at the time of the interview.
2.1.2. Study Sample The sample of respondents from the year 2003 MCBS Access to Care survey was drawn from the Medicare enrollment file to be representative of the Medicare population as a whole. The oldest age group (85 years and over) were over-sampled to permit more detailed analysis of this sub-population. Samples were selected by using a stratified, multistage probability sample design. The response rates for the MCBS were over 80%.13 For this study, we restricted our analysis to communitydwelling Medicare beneficiaries who were 65 years or older (n = 12,016). The sample of patients with a history of cancer was created by including those who responded both affirmatively to the question “Has a doctor ever told you that you had any kind of cancer, malignancy or tumor other than skin cancer?” and negatively to the question “Was your diagnosis of cancer made within the last year?” The analytic sample had a total of 1882 people with a history of cancer and 10,133 people without a history of cancer.
2.2. Variables 2.2.1. Dependent Variables The dependent variables we examined included the receipt of the following preventive care practices: blood pressure measurement within the previous six months, a cholesterol measurement within the previous six months, a flu vaccination within one year, pneumonia vaccination ever received, discussion of a fall with a physician following a fall, a bone mineral density (BMD) test ever received, a mammogram within one year in women and completion of a lower endoscopy (sigmoidoscopy or colonoscopy) in the past. These dependent variables were obtained from MCBS questions.
2.2.2. Independent Variables We studied the independent impact of various factors on the receipt of each of the preventive care services listed above. Our primary independent variable of interest was a self-reported history of cancer, which identified survey participants who were cancer survivors. Others included age (65–69, 70–74, 75–79, 80–84, ≥85), gender, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), body mass index (BMI), region (urban, large rural, small rural, remote rural areas), education (less than 9th grade, 9th grade–high school, some college, associate degree and above), marital status (married vs not married), income (
