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Patterns of Use of Chemotherapy for Breast Cancer in Older Women: Findings From Medicare Claims Data

From the Department of Internal Medicine, Department of Preventive Medicine and Community Health, and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX.

Address reprint requests to Xianglin Du, MD, PhD, Department of Internal Medicine, 3.134 Jennie Sealy Hospital, University of Texas Medical Branch, Galveston, TX 77555-0460; email: xdu{at}utmb.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: There is little population-based information available on the use of chemotherapy in women with breast cancer. This study describes the use of chemotherapy through analysis of Medicare claims and determines the correlates of chemotherapy use.

PATIENTS AND METHODS: We used the merged Surveillance, Epidemiology, and End Results–Medicare database and identified women 65 years of age diagnosed with breast cancer in 1991 and 1992. Chemotherapy was ascertained from Medicare claims through procedure codes for chemotherapy made within 24 months of the diagnosis.

RESULTS: In women with stages I, II, III, and IV breast cancer, the percentage receiving chemotherapy within 24 months of diagnosis was 5.1%, 19.5%, 33.9%, and 35.2%, respectively. Most women receiving chemotherapy had two to 12 claims; the median number was eight. Use of chemotherapy decreased significantly with age across all tumor stages; eg, in women with stage III cancer, the use of chemotherapy declined from 49% in those aged 65 to 69 years to 10% in those 80 years old. In a multivariate analysis, there was little variation by ethnicity. Chemotherapy use was highest (70%) in women aged 65 to 69 years with node-positive and estrogen receptor–negative tumors and lowest (5%) in those with node-negative and estrogen receptor–positive tumors. Compared with those without comorbid diseases, patients with a comorbidity score of 2 had significantly lower use of chemotherapy.

CONCLUSION: Medicare claims data seem to provide valuable information on the use of chemotherapy for breast cancer in older women. However, external validation of the accuracy and completeness of these data is required before any firm conclusion can be drawn.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
META-ANALYSES of 47 randomized clinical trails of chemotherapy involving 19,000 women with early-stage breast cancer demonstrated a significant improvement in both recurrence-free and overall survival.^1,2 For example, in women with cancer localized to the breast, chemotherapy produced an absolute improvement of 7% to 11% in 10-year survival for those younger than 50 years of age and of 2% to 3% for those 50 to 69 years of age.² Because of its proven efficacy, chemotherapy is recommended to be offered to all premenopausal women with stage II or higher stage breast cancer and to premenopausal and postmenopausal women with estrogen receptor–negative tumors greater than 1 cm in size regardless of lymph node status.^3-8 Because few data are available on the efficacy of chemotherapy in women 70 years old,^1,2 recommendations on chemotherapy use in this population are not as clear cut; most authorities stress the need for making a decision based on the particular condition of the individual patient.^3-5

Little information is available on the actual use of chemotherapy in the community.^9-19 In a pilot study initiated by the National Cancer Institute and conducted in 17 hospitals, the use of chemotherapy in women 65 to 74 years of age with breast cancer was 4% for local stage, 55% for regional stage, and 49% for distant stage.⁹ In a national, hospital-based survey of patterns of care for breast cancer conducted by the Commission on Cancer of the American College of Surgeons, 47% of women with breast cancer of all ages (median age, 64 years) used either chemotherapy or tamoxifen in 1990,¹⁰ but the stage-specific rate of chemotherapy in this report was not given. A hospital-based study in Massachusetts and Minnesota showed that 94% to 97% of younger premenopausal women with positive lymph nodes received chemotherapy.¹⁹ In a medical record review for women 65 years of age with breast cancer diagnosed in a large health maintenance organization (HMO), the use of chemotherapy was 13%.¹² Other studies showed that the receipt of chemotherapy decreased with age.^14-18 The data are scarce on the use of chemotherapy from population-based studies. The Surveillance, Epidemiology, and End Results (SEER) program, a national, population-based cancer registry, no longer reports data on chemotherapy because of concerns about completeness.^20,21 Therefore, this study aims to use the SEER-Medicare linked data to describe the use of chemotherapy through analysis of Medicare claims and to determine the correlates of chemotherapy use.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Data Sources
We used the merged SEER-Medicare database for this analysis. The SEER program, supported by the National Cancer Institute, includes population-based tumor registries in selected geographic areas: the metropolitan areas of San Francisco/Oakland, Detroit, Atlanta, and Seattle; Los Angeles county; the San Jose-Monterey area; and the states of Connecticut, Iowa, New Mexico, Utah, and Hawaii.²² These areas cover approximately 14% of the United States population.²² The registries ascertain all newly diagnosed (incident) breast cancer cases from multiple reporting sources such as hospitals; outpatient clinics; laboratories; private medical practitioners; nursing homes, convalescent homes, and hospices; and autopsy reports and death certificates.²³ Information includes tumor location, size, American Joint Committee on Cancer stage, axillary node status, and estrogen receptor status; demographic characteristics such as age, sex, race, and marital status; and types of treatment provided within 4 months after the date of diagnosis.²³

The Medicare Program is administered by the Health Care Financing Administration (HCFA). The program covers hospital, physician, and other medical services for more than 97% of persons 65 years of age.²¹ The Medicare claims data used in the study included the following three files:²⁴ (1) Medicare Provider Analysis and Review file, which contains inpatient hospital claims; (2) the Hospital Outpatient Standard Analytic File, which contains the claims for outpatient facility services; and (3) the 100% Physician/Supplier file, which contains the claims for physicians and other professional services. These data are available for all beneficiaries starting in 1991, and their Medicare claims are available through 1994. To allow 2 years of Medicare claims for chemotherapy after diagnosis, we identified cases diagnosed in 1991 and 1992.

Cases reported by the SEER registries from 1973 to 1993 have been matched against Medicare’s master enrollment file. Of persons 65 years of age appearing in the SEER records, Medicare eligibility could be identified for 94% of these cases. The method of linking these data has been described by Potosky et al.²¹

Study Population
The study population consisted of all female patients 65 years of age who were diagnosed with breast cancer in 1991 and 1992. Women who did not have full coverage of both Medicare Part A and Part B or who were members of HMOs were excluded because claims from these organizations may not be complete. Thus 10,604 patients with stages I to IV breast cancer were available for the analysis. Patient and tumor characteristics such as age, race, marital status, tumor stage, and geographic areas are available from the SEER data.

Chemotherapy
The procedures and revenue center codes for chemotherapy administration made within 24 months of diagnosis of breast cancer were assessed. These codes included the International Classification of Diseases (9th edition, clinical modification [ICD-9-CM]) procedure code of 9925 for a hospital inpatient or outpatient facility claim of chemotherapy (injection or infusion of cancer chemotherapeutic substance)²⁵; the common procedure terminology codes of 96400 to 96549, J9000 to J9999, and Q0083 to Q0085 for a physician or outpatient claim of chemotherapy administration^26,27; and the revenue center codes of 0331 (chemotherapy injected), 0332 (chemotherapy oral), and 0335 (chemotherapy intravenous) for an outpatient claim of chemotherapy.²⁸ The ICD-9-CM V codes²⁵ of V58.1, V66.2, or V67.2 for follow-up examination or care after chemotherapy were also used, which generated two additional cases in the category of receiving chemotherapy within 6 months of diagnosis.

Surgery and Radiation Therapy
In SEER, cancer-directed surgery was defined as either mastectomy (total, subcutaneous, radical, or modified radical mastectomy) or breast-conserving surgery (BCS)(segmental mastectomy, lumpectomy, quadrantectomy, tylectomy, wedge resection, nipple resection, excisional biopsy, or partial mastectomy unspecified). The radiation therapy included beam radiation, radioactive implants, radioisotopes, or other radiation as documented in SEER.²³

Comorbidity Index
Comorbidity was ascertained from Medicare claims data through diagnoses or procedures made 2 years before the diagnosis of breast cancer. We used the comorbidity index created by Charlson²⁹ and later validated by Romano et al using the ICD-9-CM diagnosis and procedure codes.³⁰ Both the Medicare inpatient and outpatient claims were searched for comorbid conditions not including breast cancer diagnosis codes (ICD-9-CM codes of 174x). Patients who had no inpatient or outpatient Medicare claims during this period were coded as a separate category.

Analyses
Because SEER reported only the month and year of diagnosis of breast cancer, we arbitrarily defined the day of diagnosis in SEER as the 15th of the month. For inpatient claims for chemotherapy, diagnosis was defined as the date of admission. For outpatient and physician claims, diagnosis was defined as the earliest date of service. Chemotherapy was defined if there was at least one claim for chemotherapy within specified time periods after diagnosis (6 months or 24 months).

The odds ratios of receiving chemotherapy in women with various patient and tumor characteristics were generated from multivariate logistic regression analyses. These analyses adjusted for age, race, marital status, tumor stage, tumor size, node status and estrogen-receptor status, and comorbidity indices, which are considered to likely affect the use of chemotherapy in women with breast cancer. All computer programming and analyses were completed using the SAS system (SAS Institute, Cary, NC).³¹

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Table 1 presents how claims for chemotherapy were identified through the six types of codes in Medicare. According to the combined results from all six different types of codes in Medicare, 1,129 patients (10.6%) were identified as receiving chemotherapy within 6 months of diagnosis. Most cases were identified by both common procedure terminology codes and HCFA Coding System-J codes. Other codes also contributed to the completeness of the information on chemotherapy (Table 1). For example, the revenue center codes identified four additional cases with receipt of chemotherapy that otherwise would have been missed if only the other five codes were used.

View larger version (22K): [in this window] [in a new window]   Fig 1. Cumulative percentage by stage of women with breast cancer diagnosed in 1991 and 1992 who had claims for chemotherapy in Medicare submitted within 24 months after diagnosis of breast cancer.

View larger version (30K): [in this window] [in a new window]   Fig 2. Number of claims for chemotherapy in Medicare within 24 months after diagnosis in women with stages I, II, III, and IV breast cancer. The mean number of claims for chemotherapy was 10 (SD = 9.8, median = 8).

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

There are several reasons to believe that Medicare claims data may produce valid information about receipt of chemotherapy. First, our findings were similar to other smaller community-based surveys of patterns of care for breast cancer in older women.^12,13 For example, a community-based survey found that of 130 patients aged 65 years with newly diagnosed breast cancer in Philadelphia in 1993 to 1994, 13% used chemotherapy,¹² which is comparable to the overall rate of 10.6% found in our study. Second, the patterns of chemotherapy use would be expected. That is, chemotherapy use was higher in advanced stages, it increased in women with estrogen receptor–negative tumors, and it decreased markedly in women 70 years. The fact that women with stage IV were actually slightly less likely than women with stage III cancer to receive chemotherapy is consistent with reports in younger women.¹¹ Third, the distribution of total number of chemotherapy treatment received is comparable to current standard of care, which recommends four, six, or 12 cycles of chemotherapy depending on the specific agents used.^3,4,32,33 The median number of claims for chemotherapy within 24 months after diagnosis was eight, with 67% of women receiving two to 12 treatments (Fig 2).

How complete is the information on chemotherapy in the Medicare claims? There are theoretical reasons to believe they might be complete. For example, the claims are directly tied to reimbursement for the provider and facility. In addition, other investigations into the validity of using Medicare data to identify the receipt of radiation therapy³⁴ and the type of surgery^35,36 after the diagnosis of breast cancer have found them to be more than 92% complete when compared with SEER data. However, in this study, we have no source of comparison to use as a gold standard, because SEER data are considered incomplete on chemotherapy.^20,21 Indeed, information on chemotherapy is not even included in the SEER public use data set. Nevertheless, the fact that Medicare data demonstrate good validity in other aspects of breast cancer care (radiation therapy, BCS, and mastectomy)^34,35 may provide indirect support for the validity of the information for chemotherapy in Medicare. However, there remain reasons for concern that the Medicare data may not be complete. Younger patients who recently became eligible for Medicare coverage at ages 65 to 66 years might have less complete information for Medicare claims records, because some who continue to work after age 65 (or who have a spouse who continues to work) may have employer-funded health benefits and may not immediately use Medicare.³⁴ In addition, if patients switched their care to HMOs or received care in Veterans Affairs hospitals after the year of their diagnosis, they may have missing information in the Medicare claims.³⁵ As previously demonstrated, Medicare data provide reasonably accurate and complete information on invasive surgeries.^35,36 However, Medicare information on procedures other than invasive surgeries was found to be less accurate.³⁶

In the absence of an external standard of comparison, certain internal consistencies provide indirect evidence for both the accuracy and completeness of the Medicare data on chemotherapy. One way to verify consistency is to identify certain subgroups of subjects that might be expected to show a high use of chemotherapy. For example, one group that should have a very high rate of chemotherapy use is women aged 65 through 69 years with node-positive but estrogen receptor–negative tumors. We found that 70% of these women were identified as receiving chemotherapy by the Medicare data versus 5% of similarly aged women with node-negative and estrogen receptor–positive tumors (Table 3). Such internal consistencies support the validity of the information on chemotherapy in Medicare claims data.

It is important to understand the limitations of this study. The study findings were only applied to women 65 years of age who are not HMO members and who have both Medicare Part A and Part B coverage. Second, we used cases with breast cancer diagnosed in the early 1990s. The information may not be the same as in the later years. Third, part of the information on chemotherapy may represent treatment of recurrent disease, not primary disease. For this reason, we restricted most of our analyses to chemotherapy received within 6 months of diagnosis. From the professional charge claims, we found that for some patients (12%), there are multiple line-items of service claims with payment on the same day associated with chemotherapy administration (data not shown). For others, there was one claim with a total amount of dollars for all services that were related to such a therapy. Some doctors may bill for the entire course of chemotherapy in one or two bills. However, in this study, the main interest was to see whether Medicare data could be used to identify women who had ever used chemotherapy within a certain time period after diagnosis, regardless of the number of courses or cycles of therapy. This would understandably be more accurate than identifying the true number of cycles of chemotherapy. Fourth, it is difficult to imagine this high percentage (12%) of women receiving just one treatment. Some may have experienced a toxicity that precluded further treatment. Also, the one claim may have represented more than one chemotherapy treatment. Fifth, data on comorbidity from this claims-based administrative database are less complete than data obtained from the medical chart reviews. Finally, a major concern is that the information on chemotherapy in Medicare claims data has not been validated against an external source such as medical chart review, as discussed above. Until such a validation study is performed, it is impossible to directly assess the accuracy and completeness of the information on chemotherapy in the Medicare claims.

Medicare claims data might be used to provide a population-based assessment of use of chemotherapy in the community. There are clear recommendations on the use of chemotherapy in women with breast cancer aged 65 through 69 years, but recommendations for women 70 years of age are less clear cut.^1-4 Thus greater variation among providers, facilities, and geographic areas in the use of chemotherapy in women 70 years of age compared with those who are 65 to 69 years of age might be expected. The claims data might be used to assess how well recommendations are being followed in the community for 65- to 69-year-old women. In addition, Medicare claims data on chemotherapy should allow for population-based effectiveness studies.

In conclusion, Medicare claims data seem to provide valuable information on chemotherapy for breast cancer, which is potentially important for describing the patterns of care in the population and for determining the effectiveness of chemotherapy in the community. However, external validation of the accuracy and completeness of these data is an important step before any firm conclusion can be drawn with confidence.

	ACKNOWLEDGMENTS

 
Submitted May 4, 2000; accepted November 15, 2000.

Supported by grants from the Department of Defense (grant no. DAMD17-99-1-9397), the National Cancer Institute (grant no. CA871773), and the Sealy and Smith Foundation, Galveston, TX.

We thank Dong Zhang, PhD, for his data management and analytic support and Joan Warren, PhD, and Jean Freeman, PhD, for their helpful comments. We acknowledge the efforts of the Applied Research Branch, Division of Cancer Prevention and Population Science, National Cancer Institute; the Office of Information Services, and the Office of Strategic Planning, Health Care Financing Administration; Information Management Services, Inc.; and the SEER Program tumor registries in the creation of the SEER-Medicare Database.

	NOTES

 
This study used the Linked SEER-Medicare Database. The interpretation and reporting of these data are the sole responsibilities of the authors.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
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