June 28, 2016

Across North Carolina, the risk of death from the most common form of acute leukemia in adults was significantly higher in three regions of the state, according to a retrospective study by researchers from the University of North Carolina Lineberger Comprehensive Cancer Center.

Dr. Ethan Basch, headshot

Dr. Ethan Basch

Dr. Anne Marie Meyer, headshot

Dr. Anne Marie Meyer

Anne Marie Meyer, PhD, research assistant professor of epidemiology at UNC Gillings School of Global Public Health, and Ethan M. Basch, MD, MSc, professor of health policy and management at the Gillings School, are co-authors of the study. Meyer is a UNC Lineberger member and director of the Integrated Cancer Information and Surveillance System (ICISS), housed in UNC Lineberger. Basch is professor of hematology and oncology in the UNC School of Medicine and director of UNC Lineberger’s Cancer Outcomes Research Program.

In “Statewide Geographic Variation in Outcomes for Adults with Acute Myeloid Leukemia in North Carolina, published online June 28 in the journal Cancer, the study authors report that adults treated with chemotherapy in the hospital for acute myeloid leukemia (AML), between 2003 to 2009 had a statistically significant higher risk of death if they lived in northeastern North Carolina from Wilson to Roanoke Rapids, in a region around Greenville, or in a region around Wake County, including Durham County. Those differences remained even after researchers controlled for other factors that might help drive the increases.

“The geographic survival disparities we found could not be explained by other sociodemographic variables or proximity to experienced treating facilities,” said the study’s first author, Ashley Freeman, MD, clinical fellow in the UNC School of Medicine’s Division of Hematology and Oncology. “This raises the possibility that more complex features of the local health care infrastructure, including provider referral and practice patterns, are affecting patient outcomes.”

Overall across the United States, survival rates have improved for AML since 1975, with about 27 percent of patients living five years, according to 2006-2012 data from the NCI Surveillance, Epidemiology and End Results (SEER) Program. However, incidence of the disease has been rising in the last decade. Researchers have seen survival differences by race and insurance type, and at UNC Lineberger, researchers wanted to investigate whether survival also varied based upon where patients were living in North Carolina at the time of their diagnosis.

To study death rates from the cancer across North Carolina, researchers analyzed data for 900 adults diagnosed with AML between 2003 and 2009. They used UNC Lineberger’s ICISS, a database that links claims insurance claims information to a state information database called the N.C. Cancer Registry.

They assessed the risk of death in nine regions defined by the North Carolina Area Health Education Centers (AHEC) Program, which was established in 1972 to address physician shortages and the uneven distribution of health-care services in North Carolina.

“We looked at geographic disparities because we are trying to improve outcomes for all [North Carolinians], consistent with the mission of our cancer center,” said William A. Wood, MD, UNC Lineberger member and associate professor in the UNC School of Medicine’s Division of Hematology and Oncology. “We also are trying to find situations in which disparities shouldn’t exist, but do, for arbitrary reasons – such as where a patient happens to live – so that we can figure out how to improve equity across the state.”

The researchers determined that a region around Greensboro had the lowest risk of death for AML patients who received chemotherapy treatment in a hospital. Compared to the Greensboro region, they found the risk of death was four times higher in an area of northeastern North Carolina that included Roanoke Rapids, Rocky Mount and Wilson – the highest in the state. The risk was more than two times greater in the eastern region of the state around Greenville, and nearly twice as high in the region around Wake County.

“There are areas of the state where there is an elevated mortality, and we need to better understand the factors that are driving that – whether they’re environmental, patient- or provider-related,” said study co-author Meyer.

Nearly half of patients in the study received their care at hospitals not affiliated with one of the state’s three National Cancer Institute (NCI) comprehensive cancer centers. The researchers did not find a statistically significant link between the distance from the home of patients to their treating facility or nearest NCI-designated center and risk of death when they controlled for region. There was also not a link between higher risk of death at one year for treatment at an NCI-designated cancer center versus at a different treatment center.

There were regional differences in health-care resources, Freeman said. “Area L,” which is the name assigned to the region in northeastern North Carolina that spans from Wilson to Roanoke Rapids, for example, has one of the lowest proportions of general practitioner physicians and radiation oncologists, as well as the highest burden of disease. The researchers did find that patients with a more serious prognosis were more likely to be treated an NCI-designated comprehensive cancer center.

However, the reasons are not clear why the disparities continued even after researchers controlled for regional factors such as poverty or education, Wood said. The researchers believe other factors could be involved, including the providers’ experience with treating rare or complex diseases or how supportive care is delivered. Although there was not a significant association between treatment at an NCI-designated center and survival, there may be other features of treatment facilities, such as patient volume and academic affiliation, that are important for patient outcomes. The next step is to identify those factors and then develop programs to try to close the gaps, he said.

“The message here is that acute myeloid leukemia is representative of diseases that are uncommon, involve high- complexity care, and have high risk for morbidity and mortality,” Wood said. “If we can figure out how to coordinate and improve delivery of effective interventions for this disease throughout the state of North Carolina, then we may be able to develop a model for improving outcomes in many other diseases throughout the state as well.”

Other co-authors include Andrew B. Smitherman, MD, of the UNC School of Medicine’s Division of Pediatric Hematology/Oncology; Lei Zhou, MSc, of UNC’s ICISS; and Thomas C. Shea, MD, of the UNC School of Medicine’s Division of Hematology/Oncology.

This news originally was posted by UNC Lineberger.

Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or dpesci@unc.edu


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