Journal of the National Cancer Institute Advance Access originally published online on December 25, 2007
JNCI Journal of the National Cancer Institute 2008 100(1):21-31; doi:10.1093/jnci/djm271
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© The Author 2007. Published by Oxford University Press.
ARTICLES |
Absence of Cancer Diagnosis and Treatment in Elderly Medicaid-Insured Nursing Home Residents
Affiliations of authors: Department of Health Administration (CJB, JPC, CL) and Massey Cancer Center (CJB), Virginia Commonwealth University, Richmond, VA
Correspondence to: Cathy J. Bradley, PhD, Department of Health Administration and Massey Cancer Center, Virginia Commonwealth University, Grant House, 1008 Clay Street, PO Box 980203, Richmond, VA 23298-0203 (e-mail: cjbradley{at}vcu.edu).
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ABSTRACT |
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Background: Little is known about the effect cancer has on the lives of nursing home patients and the quality of care, including palliative care, delivered to them.
Methods: Using a statewide population-based dataset assembled from the Michigan Tumor Registry and Medicare records, we identified 1907 elderly Medicaid-insured nursing home residents who were diagnosed with cancer between 1997 and 2000. Logistic regression models were used to estimate odds ratios (ORs) and relative risks (RRs) according to age, race, sex, income, comorbidity, and cancer site for late or unstaged cancer at diagnosis, death within 3 months of diagnosis, receipt of hospice care, and—for patients diagnosed with early-stage breast, colorectal, lung, or prostate cancer—the likelihood of cancer-directed surgery. All statistical tests were two-sided.
Results: Nursing home residents diagnosed with cancer had a preponderance of late or unstaged disease (62%), high mortality within 3 months of diagnosis (48%), and low hospice use if they had distant-stage cancer (28%). Only 22% received cancer-directed surgery, 61% of which was confined to breast cancer patients, and only 6% of patients received chemotherapy and/or radiation. Older age was positively associated with late or unstaged cancer and with death within 3 months of diagnosis. Patients aged 71–75 years were more likely to have cancer-directed surgery than patients aged 86 years and older (OR = 2.83, 95% confidence interval [CI] = 1.26 to 6.32; RR = 1.37, 95% CI = 1.08 to 1.75). African American patients were less likely to receive surgery (OR = 0.51, 95% CI = 0.26 to 0.99; RR = 0.80, 95% CI = 0.62 to 1.03) than white patients. Other demographic characteristics and comorbid conditions had little predictive value with regard to cancer treatment or hospice use in nursing home patients.
Conclusions: Very few cancer services are provided to Medicaid-insured nursing home patients, despite the fact that many of these patients likely experienced cancer-related symptoms and marked physical decline before diagnosis and death. A middle ground between what would be considered guideline treatment practices and the apparent absence of diagnosis and treatment is needed.
Prior knowledge The extent and quality of cancer care provided to nursing home patients have not been carefully assessed. Study design Regression models based on federal (Medicaid and Medicare) and state (Michigan Tumor Registry) databases were used to analyze the frequency of cancer-related medical care among nursing home residents according to age, race, and other variables. Contribution The study provides quantitative information needed to assess the extent of cancer care delivered to nursing home residents. Implications A preponderance of late or unstaged disease, high mortality within a few months of cancer diagnosis, and low rates of hospice use and cancer treatment warrant the attention of the medical community. Limitations Information on patient or family preferences for treatment was not available and the study was restricted to Michigan Medicaid patients and thus not representative of the entire nursing home population.
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The prevalence of cancer in nursing home patients is approximately 1 in 10 (1), but elderly nursing home patients have received little attention in cancer outcomes research. Instead, most studies that have addressed cancer diagnosis, treatment efficacy, guideline care, survival, and even disparities in cancer detection, treatment, and survival have focused on younger populations residing in the community (2–7). As the US population ages, more and more people will become nursing home residents (8), many of whom will be diagnosed with, and eventually die from, cancer (9,10). Little is known about the effect cancer has on the lives of nursing home patients and the quality of care, including palliative care, delivered to them (11,12).
Late cancer stage at diagnosis and the absence of cancer treatment is associated with race and ethnicity (13–19), low socioeconomic status (20–22), and the presence of comorbid conditions (23–25), including dementia and Alzheimer disease (26,27). However, in elderly nursing home residents, these factors may have less influence on cancer detection and treatment than does life expectancy (28), the ability to withstand and benefit from treatment, and the presence of a patient advocate (eg, family member).
Nationwide, Medicaid is the predominant payer for long-term residential nursing home care, with approximately 36% of Medicaid payments for nursing home care (29). Patients insured by both Medicare and Medicaid (often referred to as dually eligible) have very low incomes––73% have annual income below $10000 compared with 12% of all other Medicare beneficiaries (30). These patients tend to be the frailest of the frail elderly, and more than 30% of them require assistance to perform three or more activities of daily living (31). Despite these residents’ need for care and its potential benefits, the ability of nursing homes to respond with high-quality service is often lacking (32,33) and nursing home staff may not recognize and treat cancer and/or its symptoms in the residents.
We examined cancer care delivered to nursing home patients, the vast majority of whom are adults aged 80 years or older. Using a unique statewide population-based dataset, we assessed four cancer care outcomes in Medicaid-insured nursing home patients. The first was stage of cancer at diagnosis (including prevalence of cancer for which the exact stage was not determined), under the assumption that cancer stage is the single best indicator of prognosis (34). Here, we examined not only the prevalence of late-stage cancer but also the prevalence of cancers for which the exact stage had not been determined. A diagnosis of late- or invasive but unknown-stage cancer influences the type and extent of cancer treatment recommended and is an indication that early detection techniques (ie, screening) may not have been employed before disease symptoms. Although it is possible that some of the cancers that are "unstaged" could be early-stage disease, the mortality following diagnosis suggests that these cancers are advanced. Staging is predictive of treatment delivery because diagnostic tests required for staging are generally performed in patients for whom treatment is planned (34). The second outcome was death within 3 months of diagnosis. The third was receipt of hospice care, which past studies have found to be surprisingly low (29%) in nursing home cancer patients (1). Finally, assuming that some cancers will be diagnosed at a stage at which surgery can provide extended survival and/or improved quality of life, we examined as a fourth outcome the likelihood of cancer-directed surgery. We limited the analysis of this outcome to patients diagnosed with early-stage breast, colorectal, lung, or prostate cancer—sites for which surgery has been shown to be efficacious for early-stage disease. Using the four outcomes, we sought to understand the patterns of care provided to nursing home cancer patients.
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Subjects and Methods |
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Data
We used statewide Medicaid and Medicare data merged with the Michigan Tumor Registry to extract a study sample of patients with a first primary cancer diagnosis. External audit findings have found that the Michigan Cancer Surveillance Program, which maintains the Michigan Tumor Registry, successfully abstracts greater than 95% of all cancer cases diagnosed in the state. This study was approved by institutional review boards at the Michigan Department of Community Health, Michigan State University, and Virginia Commonwealth University.
Patients in the Tumor Registry were matched to the Michigan state segment of the Medicare Denominator File for the years 1996 through 2000 using the patients’ Social Security numbers. Vital status was available in the tumor registry for all patients through December 2003. From the statewide Medicare files, we extracted all claims for inpatient, outpatient, physician, and hospice services during the study period for all patients that correctly matched to the Michigan state segment of the Medicare Denominator File (approximately 89% of patients) and enrolled in Medicare Parts A and B and in a fee-for-service plan. Medicare Part A covers inpatient care in hospitals, short-term skilled nursing facilities, and hospice care, whereas Part B covers medical services like doctors’ visits, outpatient care, and other medical services. Michigan proved to be an ideal state for merging cancer registry and Medicare data because less than 3% of Michigan Medicare beneficiaries were enrolled in managed care. Therefore, Medicare claims were available for the vast majority of Medicare-insured Michigan residents.
Medicaid-insured patients were identified by matching the Medicaid eligibility files against the tumor registry, using either deterministic or probabilistic methods. The total number of incorrect matches produced by either method was approximately 1%, and the correct prediction rate of those identified as being Medicaid insured was 93%. Nursing home residency was determined from the Medicaid monthly eligibility file and the Medicaid nursing home claim file. To be considered nursing home residents, patients had to have claims for nursing home services within 6 months before the month of diagnosis. Comparable nursing home residency data were not available for Medicare beneficiaries who were not also enrolled in Medicaid. The process for linking the Tumor Registry, Medicare, and Medicaid datasets is described more fully elsewhere (35).
To this linked tumor registry, Medicare, and Medicaid file, we added data from the 1990 Census Summary File using patient address information recorded in the tumor registry. The Census Summary File provided information on median income that households within a census tract earned, which is correlated with cancer stage (36). We used the data from the 1990 census instead of the 2000 census because we obtained a better match to patients in our sample. For patients with data in both the 1990 and 2000 census files, their census tract characteristics (eg, income and education) were qualitatively similar.
Sample Selection
We limited the sample to nursing home residents diagnosed with cancer between January 1, 1997, and December 31, 2000, to have at least 1 year of claims history before the month of diagnosis with which to estimate patients’ comorbidity burden. A total of 1907 nursing residents were identified. Our sample included 142 patients who became eligible for Medicaid following the diagnosis of cancer. We created a dichotomous variable to identify these patients because their Medicaid enrollment was most likely spurred by their cancer diagnosis. Therefore, they may be systematically different from nursing home cancer patients who are insured by Medicaid at the time of diagnosis.
Using logistic regressions that controlled for covariates, we estimated adjusted odds ratios (ORs) for the following dependent variables: late or invasive but unknown stage of cancer, death within 3 months of diagnosis, receipt of hospice services, and receipt of cancer-directed surgery.
Cancer stage was identified from the tumor registry. The tumor registry records an invasive but unknown stage for all patients with invasive disease but for whom a stage was not identified. The tumor registry also records regional or distant-stage disease, which is defined according to the Surveillance, Epidemiology, and End Results (SEER) summary stage. Certain cancers, such as leukemia, lymphoma, pancreatic cancer, and brain cancer, are typically not staged. Therefore, we removed patients with these cancers from the analysis of cancer stage.
Because nearly half of the patients in our sample died 3 months following a cancer diagnosis (48%) and approximately 85% died by December 2003, we chose death within 3 months following diagnosis as the second outcome.
Given the high mortality rate among patients in the nursing home sample, we chose as a third outcome the use of hospice services before death. The criterion for hospice use was one or more claims for hospice services in the Medicare claim file. We limited the sample to patients with distant or invasive but unknown-stage cancer because they are least likely to benefit from treatment with curative intent, have short life expectancies, and are, therefore, optimal candidates for hospice care.
The fourth outcome was the prevalence of cancer-directed treatment. Cancer-directed treatments were defined as surgery, chemotherapy, or radiation. We examined these treatments and found that the vast majority of nursing home patients (93%) did not receive chemotherapy or radiation. Therefore, in a multivariable analysis, we assessed the likelihood of cancer-directed surgery only and not other forms of treatment. For this analysis, we limited the sample to patients diagnosed with cancer at the most common sites—breast, colon/rectum, lung, and prostate–who had in situ, local, or regional-stage disease. Surgery can alleviate symptoms and possibly extend life for patients with these cancer sites and stages. The International Classification of Diseases (ICD), Current Procedural Terminology, Healthcare Common Procedural Coding System (HCPCS) codes used to identify cancer treatments are given in the appendix.
Statistical Analysis
We controlled for patient characteristics and census tract income. Patient characteristics included age (66–70, 71–75, 76–80, 81–85, and 
86 years), race (white and African American or other), sex, and comorbidity. To estimate patient comorbidity burden, we used the Deyo et al. (37) and Klabunde et al. (38) adaptation of the Charlson Comorbidity Index (39), which has been used to explain the probability and extent of cancer treatment (38). However, in elderly cancer patients, the Charlson Comorbidity score does not adequately reflect functional ability or predict tolerance to treatment (40,41). We identified patients diagnosed with Alzheimer disease or dementia using the following ICD-9 codes: 331.0 (Alzheimer disease) (26,27); 331.x (frontotemporal dementia, senile degeneration of the brain, hydrocephalus [communicating and obstructive], and cerebral degeneration); 290.0 (dementias and senile psychotic conditions); and 797 (senility without mention of psychosis).
Variables for census tract income were obtained from the 1990 Census Summary File. The income categories (in dollars) were: 
25000, 25001–35000, 35001–45000, and >45000. We also created a variable to indicate missing income information.Income information was considered to be missing if the patient’s address was either absent or incorrectly coded in the dataset. Census tract income was missing for fewer than 9% of the patients.
All analyses were conducted using SAS, version 9.1. The statistical significance of the association of the independent variables with the dependent variable was assessed with the chi-square likelihood ratio test. Adjusted odds ratios and relative risks (RRs) and 95% confidence intervals (CIs) were estimated for equations that predicted the likelihood of late or unstaged cancer, death within 3 months following diagnosis, hospice use, and cancer-directed surgery. The odds ratios and relative risks were qualitatively similar. Therefore, we focus the discussion on the odds ratios but report relative risks in the tables. All reported P values correspond to two-sided tests. The threshold for statistical significance was set at an alpha level of .05. To put the distribution of cancer stage at diagnosis for nursing home residents in perspective, we compared their distribution of cancer stage at diagnosis with the cancer stage distribution in Michigan dual eligible community residents and Medicare-only beneficiaries diagnosed during the same time period.
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Results |
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A little more than one-third of the patients were aged 86 years or older (Table 1). The majority of the patients were white, were female, resided in census tracts with household incomes less than $35000, and had one or more comorbid conditions. Approximately one-fourth of the patients were diagnosed with Alzheimer disease and/or dementia.
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Cancers were most prevalent at the following sites: breast (14%), colon/rectum (17%), lung (15%), and prostate (10%). The majority (62%) of cancers were diagnosed with a SEER summary stage of distant or invasive but unknown. Invasive but unknown-stage disease accounted for 43% of all cancer diagnoses. Given the prevalence of unstaged cancers, one might have expected a higher proportion in the sample of leukemia or other hematologic cancers that are not staged, but instead relatively few patients were diagnosed with these diseases. Finally, the vast majority of the patients (85%) had died by the end of the study period in December 2003, and 48% had died within 3 months of diagnosis. Mean survival following diagnosis was 9 months.
Patients who enrolled in Medicaid following a cancer diagnosis were similar to patients who enrolled in Medicaid before their diagnosis with the following exceptions: they were more likely to be white, to have fewer comorbid conditions, and to be diagnosed with colorectal cancer than patients who enrolled in Medicaid before diagnosis. Patients who enrolled in Medicaid after diagnosis survived an average of 18 months, compared with 8 months for those enrolled in Medicaid before diagnosis. Patients that enrolled in Medicaid following diagnosis, by definition, had to survive long enough to be enrolled in Medicaid, that is, 3 months or more following diagnosis.
We compared the stage at diagnosis among nursing home residents with other Michigan community dual-eligible beneficiaries and Medicare-only beneficiaries who were also diagnosed with cancer during the same time period (Fig. 1). Relative to other elderly residents, a much larger proportion of nursing home residents had unstaged cancers and few had in situ or local-stage cancers. Nursing home residency is unknown in the Medicare-only beneficiaries included in Fig. 1, and nursing home residents in the Medicare sample would tend to diminish the differences between this group and Medicaid nursing home residents.
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There were no differences in the receipt of treatment or hospice use by Medicaid enrollment category. Therefore, we report the number and percentages for the full sample, excluding those patients without any medical claims (Table 2). Only 7% of all patients received chemotherapy and/or radiation. Among patients with breast, colorectal, lung, or prostate cancer, 22% received cancer-directed surgery. Patients with local-stage disease were most likely to have surgery. The majority of surgeries (61%) were performed on women with breast cancer; surgeries were performed to a much lesser extent (23%) on patients with colorectal cancer. Only 28% of all patients received hospice care.
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We calculated the odds ratios, relative risks, and 95% confidence intervals for late or invasive but unknown cancer stage, death within 3 months following diagnosis, and receipt of hospice service according to age, race, sex, census tract income, comorbidity score, Alzheimer disease, and cancer site and stage (Table 3). Relative to patients aged 86 years and older, patients aged 76–80 years and patients aged 81–85 years were less likely to be diagnosed with late or unstaged cancer at diagnosis (OR = 0.57, 95% CI = 0.41 to 0.79, and OR = 0.63, 95% CI = 0.47 to 0.84, respectively). Relative to women with breast cancer, patients with colorectal (OR = 1.63, 95% CI = 1.13 to 2.37), lung (OR = 5.25, 95% CI = 3.28 to 8.39), prostate (OR = 1.69, 95% CI = 1.03 to 2.77), and other (OR = 2.43, 95% CI = 1.72 to 3.44) cancers were more likely to be diagnosed with late or unstaged cancer. In contrast, patients with urinary bladder cancer were much less likely to have their cancer diagnosed at late stage than were women with breast cancer (OR = 0.25, 95% CI = 0.14 to 0.46). Thus, age and cancer site were statistically significantly associated with late or unstaged cancer.
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All patients younger than 81 years were less likely to die within 3 months of diagnosis than those aged 81 years or older (P < .05). Alzheimer disease was positively associated with death within 3 months following diagnosis (OR = 1.33, 95% CI = 1.04 to 1.70). Patients with colorectal, lung, pancreas, and other gastrointestinal cancers and patients diagnosed with leukemia or cancer at other sites were more likely to die within 3 months of diagnosis than were women with breast cancer. Patients with regional, distant, or invasive but unknown-stage disease were more likely to die within 3 months of diagnosis than were patients with in situ or local-stage cancer (OR = 1.70, 95% CI = 1.15 to 2.51; OR = 6.06, 95% CI = 4.20 to 8.77; and OR = 9.12, 95% CI = 6.76 to 12.3, respectively).
Because 48% of the patients died within 3 months of diagnosis, hospice care may have been appropriate for many of the patients in our sample. To examine hospice use among the most likely patient candidates, we limited the analysis to patients with distant or invasive, but unknown-stage cancer because these patients are not treated with intent to cure. A consistent predictive relationship between hospice use and variables for patient age, comorbidity, Medicaid eligibility, and census tract income was not observed. However, African American/other than white race was positively associated with hospice use (OR = 1.57, 95% CI = 1.16 to 2.13).
We calculated the likelihood of cancer-directed surgery for patients diagnosed with in situ, local, or regional-stage breast, colorectal, lung, or prostate cancer (Table 4). Patients aged 71–75 years were more likely to have cancer-directed surgery than patients aged 86 years and older (OR = 2.83, 95% CI = 1.26 to 6.32; RR = 1.37, 95% CI = 1.08 to 1.75). The odds ratio for patients aged 66–70 years was also greater than 1 and approached statistical significance (OR = 2.86, 95% CI = 0.96 to 8.54). African Americans/races other than white were less likely to receive cancer-directed surgery than whites (OR = 0.51, 95% CI = 0.26 to 0.99), although race was not statistically significant in the relative risk estimations (RR = 0.80, 95% CI = 0.62 to 1.03). Patients with colorectal, lung, or prostate cancer were considerably less likely to receive cancer-directed surgery than were women with breast cancer.
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Discussion |
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TopAbstractContext and CaveatsSubjects and MethodsResultsDiscussionFundingAppendix: description of codes...ReferencesNotes |
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This study reports patterns of cancer diagnosis, survival, hospice use, and treatment for a population-based sample of Medicaid-insured nursing home patients. These nursing home patients had a preponderance of late or unstaged disease, high mortality within only a few months of diagnosis, low hospice use, and very little cancer-directed treatment—even among patients with early-stage cancer where treatment can alleviate symptoms (eg, bleeding and discomfort associated with colon cancer) and possibly extend life. Older age was positively associated with late-stage diagnosis and death within 3 months of diagnosis and negatively associated with cancer-directed surgery. African American/other race was positively associated with hospice use. Unlike what has been observed in studies that were not specific to nursing home patients (2–7), demographic characteristics and comorbid conditions were not associated with cancer detection, treatment, survival, or hospice use in nursing home residents.
Late and unstaged cancer was far more prevalent in nursing home patients than in other elderly patients residing in Michigan. This finding may be explained in part by the clinical characteristics of the nursing home patients. A study of screening mammography in frail elderly women found that they were more likely to be harmed (eg, unnecessary biopsy, emotional stress) than helped by breast cancer screening (28). Other factors specific to nursing homes may contribute to late staging. A survey of Directors of Nursing in 41 nursing homes in the Midwest found that the majority of facilities lacked policies regarding breast and prostate cancer screening (10). This lack of policy guidelines may reflect the questionable benefits and potential harm associated with screening elderly patients. It is also possible that nursing homes are challenged in their ability to provide day-to-day care. Therefore, cancer-related services may receive a low priority. Whatever the reason for the low rates of screening and staging, the apparent practice of ignoring cancer in nursing home patients is not likely to be in their best interests. If cancer is not adequately diagnosed, it may not be recognized as the source of pain or discomfort expressed by nursing home patients. As a result, its symptoms may not be treated appropriately.
Almost half of the cancer patients in our sample died within 3 months of diagnosis. In nearly all cases, cancer was noted as the underlying cause of death. Such a high short-term mortality rate, which could reflect late stage at diagnosis or the absence of treatment, would be considered to be unacceptable in other patient populations. Furthermore, accompanying the high mortality rate was a low rate of hospice use. In other studies, hospice use has been associated with appropriate pain management (1) and increased satisfaction with end-of-life care (42).
Only a fraction of patients with early-stage breast, colorectal, prostate, or lung cancer received cancer-directed surgery, and it was primarily given to women with breast cancer. Consistent with other studies of elderly African American cancer patients (43–45), people of African American/nonwhite race in general were less likely to receive surgery than were white patients, but the reason (whether quality of care, patient preference, or comorbid conditions) for this difference is unknown. Although the majority of patients were not treated with intent to cure, patients’ clinical and social circumstances may have been such that invasive treatments would have been not only futile but also detrimental.
This study has several limitations. First, it was specific to Michigan and, as such, may not be applicable to other states or regions. However, identification of Medicaid-insured nursing home patients, their cancer attributes (site, stage, date of diagnosis), and complete treatment information can only be done at the state level. Second, had we been able to identify private-pay nursing homes patients, we may have observed differences in diagnosis, mortality, and treatment patterns by payer type. Although such an analysis may have been informative, the differences according to payer type may be driven more by selection into a payer group (Medicaid vs private payer) than the characteristics of the payer (eg, low reimbursement rates). In other words, to qualify for Medicaid, patients have to be medically needy. Medically needy patients have very low incomes (often below $10000 per year), may have few assets and experience social conditions (eg, low educational attainment) that are correlated with poor health. These conditions, rather than Medicaid reimbursement, may account for the type of care received. Although our findings are specific to Medicaid patients, this population accounts for approximately half of all nursing home patients (46).
Third, we did not have information on patient and family preferences for treatment or caregiver availability. Studies suggest that the preferences of cancer patients’ and/or their physicians’ for treatment vary by patient age (9) with preferences leaning toward less aggressive or palliative care for older adults. Information on the presence of a caregiver who could act as a patient advocate may have offered insight into the preferences of the family and their ability to assist the cancer patient.
Fourth, this study did not take into account organizational characteristics such as availability of services, size, and practice patterns that are predictive of nursing home quality and hospice use (47). Finally, care patterns may have changed since the study time period (1997–2000). However, such changes are unlikely because payment and staffing resources for nursing home care have not become more plentiful in the last decade, and although there have been efforts to improve quality of care in nursing homes, these efforts address basic day-to-day care such as preventing pressure ulcers (48).
From these observational data, we cannot draw definitive conclusions about the quality of cancer care delivered to nursing home patients. Nevertheless, our study suggests that very few cancer services in the area of detection, treatment, and hospice care are provided to Medicaid-insured nursing home patients even though many of these patients would have experienced cancer-related symptoms (eg, pain, obstruction, fatigue, and weight loss) and marked physical decline before diagnosis and death (49). Further investigation is needed to establish guidelines for cancer-related care, including cancer detection, for frail elderly patients. Control of pain symptoms, in particular, has been shown to be inadequate among nursing home cancer patients (1) and should be the focus of future investigations. As part of the establishment of guidelines for elderly patients, the economic and social implications of change in clinical practice need to be investigated.
Finally, one interpretation of our findings might be that nursing home patients with cancer are "better off" because cancer, unlike some other diseases, appears to quickly end lives that may be plagued by considerable suffering. This opinion should be viewed in the context of society's continual struggle with when to end patients’ medical treatments and the viewpoint that nursing homes serve patients awaiting death. However, the absence of treatment may not reduce suffering. Nursing homes, unlike hospices, are not designed to cater exclusively to the dying. Also, unlike hospices, nursing homes provide care for patients with chronic conditions other than cancer (eg, cardiovascular disease, diabetes). Yet, cancer appears to be ignored, suggesting that guidelines for the recognition and treatment of cancer in frail elderly patients are needed and should be communicated to health care professionals, patients, and caregivers. An aging population, coupled with trends in cancer diagnosis and treatment, will shift more cancer care (particularly the care of second primary cancers) to nursing homes and make investigations into the care of nursing home cancer patients particularly relevant. At present, nursing homes may be unequipped to recognize and care for their residents with cancer.
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Funding |
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This research was supported by National Cancer Institute grant, R01-CA101835-01 In-Depth Examination of Disparities in Cancer Outcomes, Cathy J. Bradley, Principal Investigator.
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Appendix: Description of Codes Used to Identify Surgery, Chemotherapy, and Radiation |
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NOTES |
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TopAbstractContext and CaveatsSubjects and MethodsResultsDiscussionFundingAppendix: description of codes...ReferencesNotes |
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The authors take full responsibility for the study design, data collection, analysis and interpretation of the data, the decision to submit the manuscript for publication, and the writing of the manuscript.
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Manuscript received May 31, 2007; revised October 11, 2007; accepted November 16, 2007.
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