Abstract
Purpose
Elderly women diagnosed with metastatic breast cancer (MBC) are living longer, however their primary care management may be sub-optimal. Influenza results in preventable hospitalizations and deaths. Guidelines recommend the influenza vaccine for those > 65 years and those with cancer but use is unknown.
Methods
A retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. Patients were included if they were diagnosed with MBC from 1/1/2008–12/31/2017 and were ≥ 65 years of age. The primary outcome was influenza vaccine use among patients surviving ≥ 3-years. We conducted multivariable analyses using demographic and clinical factors to identify associations with vaccine use. We compared utilization to cancer-free controls.
Results
We identified 1,970 patients with MBC that survived for ≥ 3 years. The median age at diagnosis was 73 years. Furthermore, 1,742 (88%) patients were White, and 153 (8%) patients were Black. Only 1,264 (64%) received an influenza vaccine at least one time and 51% received the vaccine at least two times. A multivariable model found lower odds of vaccine receipt for Black patients (OR = 0.48; 95% CI 0.34–0.68, p < 0.001) and higher odds for patients that saw primary care in the year prior to diagnosis (OR = 1.91, 95% CI 1.57–2.33, p < 0.001). Patients with MBC had lower odds of vaccine use compared to cancer free controls (OR = 0.85, 95% CI 0.74–0.97, p < 0.001).
Conclusion
Over 1/3 of long-term MBC survivors in our cohort did not receive the influenza vaccine. Black patients are about half as likely to be vaccinated. Given the known benefit of the vaccine, improving uptake could be an important strategy to improve outcomes.
Keywords: Metastatic breast cancer, Influenza vaccine, Primary care, Survivorship, SEER-Medicare
Introduction
Long-term survivors with metastatic cancer are a growing constituent of our elderly population. Many individuals will now live for years with advanced disease, owing to the advancements in new therapies [1]. For example, in a meta-analysis of patients with metastatic breast cancer (MBC), median survival increased from 20 to 31 months in patients with de novo metastatic cancer and from 21 to 38 months for patients with recurrent, metastatic cancer between 1990 and 2010 [2]. Cancer survivorship is an emerging area of discussion, and recent research has highlighted some of the challenges with the anticipated growth in the number of cancer survivors and the aging of the survivor population. This rapidly growing population poses new questions to the medical and public health fields, including addressing the physical, practical, financial, and emotional challenges that these individuals face [1]. However, survivors with metastatic cancer have not been well studied.
One important question pertains to the use and value of primary care and prevention and screening for other medical conditions among individuals living with metastatic cancer. These patients may have frequent visits with their oncologist and limited contact with primary care clinicians. The U.S Preventive Services Task Force and Centers for Disease Control and Prevention have specific guidelines on routine screenings for early detection of cancer including breast, colorectal, lung, and cervical cancers and chronic diseases such as high cholesterol and diabetes to detect diseases earlier on when treatment works best. They additionally recommend vaccinations against influenza and pneumococcal disease for certain age groups to reduce incidence and prevent morbidity and mortality. There is limited research aimed at addressing these guidelines amongst patients with a life-threatening condition, however as patients are now living longer with metastatic cancer, they are at risk of poor outcomes from non-cancer conditions [3, 4]. This is particularly important for elderly patients who are often diagnosed with more indolent disease but have higher rates of comorbidity.
Every year influenza results in hundreds of thousands of hospitalizations and tens of thousands of deaths in the United States [5–8]. Notably, the highest rates of hospitalization and death occur among persons aged ≥ 65 years [5–8]. Guidelines recommend receipt of the influenza vaccine annually for patients over the age of 65, as well as for patients with cancer based on studies that have shown an over 40% reduction in hospitalizations and nearly 60% reduction in the odds of intensive care unit admission [9, 10].
Since there are limited contraindications to influenza vaccination, and it is effective, we sought to explore influenza vaccine utilization in elderly patients who are long-term survivors with MBC. We selected patients with MBC as this is a sizeable constituency of the population of long-term survivors with metastatic cancer and their utilization of primary care services may be suboptimal.
Methods
Study Population and Data Collection
A retrospective cohort study was conducted using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. The SEER Program is an epidemiologic surveillance system consisting of population-based tumor registries that collect information on newly diagnosed cancer patients in the United States [11]. The SEER-Medicare cancer file is limited to Medicare beneficiaries and enables claims-based identification of demographic and clinical information on patients with cancer aged 65 or older.
Patients from the SEER-Medicare linked data were included in the study if they were diagnosed with MBC from 1/1/2008 to 12/31/2017, were ≥ 65 years of age, and had continuous Medicare Parts A and B enrollment for 12 months prior to diagnosis and at least two months after. We excluded patients enrolled in a Medicare health maintenance organization (HMO). We also excluded patients with other primary cancers, patients whose reporting source of death was autopsy or death certificate, whose reason for entitlement was not age, and whose date of death differed by > three months between SEER and Medicare. We developed two distinct cohorts with the patients that met these inclusion criteria to explore the long-term survivor population (Fig. 1). The first cohort included patients with MBC meeting our inclusion criteria surviving ≥ 3-years from their time of diagnosis (diagnosed up to the end of 2016) and the second cohort included patients surviving ≥ 5-years (diagnosed up to the end of 2014). The patients in these two cohorts were only followed for the first three and five years after their metastatic cancer diagnosis.
Fig. 1.
Consort Diagram
The institutional review board at Columbia University Irving Medical Center reviewed and approved the research team’s procedures for using SEER-Medicare data.
Outcomes and covariates
Our primary outcome of interest was influenza vaccine use identified via CPT codes (90,630, 90,653, 90,654, 90,655, 90,656, 90,657, 90,658, 90,660, 90,662, 90,672, 90,673, 90,674, 90,682, 90,685, 90,686, 90,687, 90,688, 90,689, 90,694, 90,756, Q2033, Q2034, Q2035, Q2036, Q2037, Q2038, Q2039, G0008) (Supplementary Table 1). We quantified any influenza vaccine use (at least once over the observation period) and multiple vaccine use in the ≥ 3 and ≥ 5-year cohorts.
Demographic covariates included age at diagnosis (65–69,70–74, 75–79, and ≥ 80 years), sex, year of diagnosis, marital status (married, single, other), race (Black, White, or other), ethnicity (Hispanic-Latino, non-Hispanic-Latino), hospital location (urban, rural), and dual status eligibility (elderly patients that are eligible for both Medicare Part A and/or B and Medicaid). Tumors were categorized as hormone receptor (estrogen receptor and/or progesterone receptor) positive, negative, or unknown. Other tumor demographics included HER2 status (positive, negative, or unknown), tumor grade (1, 2, 3, or unknown), and receipt of chemotherapy. We did not include oral hormonal and targeted therapies as co-variates since this would require Medicare Part D eligibility and limit our sample size. We also evaluated claims for a primary care visit in the year prior to diagnosis. To determine primary care usage, patients were flagged if both a provider specialty code and a place of service code were identified on a claim in the carrier file (Supplementary Table 1).
Cancer Free Controls
We conducted a matched analysis to non-cancer controls using the random 5% sample of Medicare beneficiaries residing in the SEER areas. Each patient in the cohort was individually matched 1:1 by year of birth, sex, race, and SEER registry. Controls were all ≥ 65 years of age in the year of diagnosis and had continuous enrollment in Medicare parts A and B, but not an HMO for the same period as their respective case. Each control was evaluated for the same duration as the matched patient with cancer. Co-variates of marital status, ethnicity, and hospital location were not available for the cancer free controls.
Statistical analysis
Univariate analyses were performed to compare influenza vaccination utilization among patients with different demographic and clinical characteristics. We used t tests for continuous variables and χ2 tests for categorical variables. Multivariable logistic regression was used to determine the association between clinical, demographic, and tumor factors and influenza vaccine utilization in the two cohorts. A matched logistic regression was also used to compare cases and controls, when controlling for age, race, dual status, sex, and year of diagnosis. Primary care visit in the year prior to diagnosis was also controlled for in an additional analysis within this logistic regression.
All analyses were conducted with SAS version 9.4 software (SAS Institute, Cary, NC). All statistical tests were two-sided, with α < 0.05.
Results
We identified 1,970 patients with MBC that survived for at least three years after diagnosis during the study period. Baseline characteristics of this cohort are shown in Table 1. Only 31 (2%) patients were male and the median age at diagnosis was 73 years (range 65, 100). In this cohort, 1,742 (88%) patients were White, and 153 (8%) patients were Black; 1,862 (95%) patients were non-Hispanic. 1,549 (79%) patients had received chemotherapy and 1,281 (65%) patients had at least one primary care visit in the year prior to their metastatic cancer diagnosis. Only 1,264 (64%) patients received an influenza vaccination at least one time over three years and 1,007 (51%) received the vaccine at least two times during the three years of follow-up.
Table 1.
Demographic and clinical characteristics of long-term survivors of metastatic breast cancer and cancer-free controls
| ≥ 3-year survival cohort (N = 1,970) N (%) | Cancer-free controls (N = 1966) N (%) | |
|---|---|---|
| Influenza vaccination | 1264 (64) | 1,334 (68) |
| Yes (%) | ||
| Age | ||
| 65–69 | 526 (27) | 513 (26) |
| 70–74 | 580 (29) | 582 (30) |
| 75–79 | 410 (21) | 408 (21) |
| 80+ | 454 (23) | 463 (23) |
| Sex | ||
| Male | 31 (2) | 31 (2) |
| Female | 1939 (98) | 1935 (98) |
| Race | ||
| White | 1742 (88) | 1741 (88) |
| Black | 153 (8) | 152 (8) |
| Other | 75 (4) | 73 (4) |
| Ethnicity | ||
| Non-Spanish-Hispanic-Latino | 1862 (95) | N/A |
| Spanish-Hispanic-Latino | 108 (5) | N/A |
| Urban Rural | ||
| Metropolitan | 1940 (98) | N/A |
| Rural | 30 (2) | N/A |
| Dual status | ||
| No | 1759 (89) | 1760 (90) |
| Yes | 211 (11) | 206 (10) |
| ER/PR Status* | ||
| Negative | 157 (8) | N/A |
| Positive | 1240 (63) | N/A |
| HER2 Status** | ||
| Negative | 803 (41) | N/A |
| Positive | 251 (13) | N/A |
| Chemotherapy | ||
| No | 421 (21) | N/A |
| Yes | 1549 (79) | N/A |
| PCP visit year prior to diagnosis | ||
| No | 689 (35) | 430 (22) |
| Yes | 1281 (65) | 1536 (78) |
Missing values: 573 patients
Missing values: 916 patients
In an unadjusted analysis, we found that Black race (46% vs. 66%, p < 0.001) compared to White race was significantly associated with decreased vaccine use (Fig. 2). Unadjusted analyses also demonstrated that chemotherapy use (65% vs. 59%, p = 0.021) and a primary care visit in the year prior to diagnosis (70% vs. 54%, p < 0.001) were significantly associated with increased vaccine use. A multivariable model demonstrated significantly lower odds of influenza vaccine receipt for Black patients (OR = 0.48; 95% CI 0.34–0.68, p < 0.001) (Table 2). The model additionally demonstrated higher odds of influenza vaccine receipt for patients that had a visit with a primary care clinician in the year prior to diagnosis (OR = 1.91, 95% CI 1.57–2.33, p < 0.001), and those who had received chemotherapy compared to those who had not (OR = 1.35, 95% CI 1.06–1.71, p = 0.014).
Fig. 2.
Influenza Vaccine Utilization by Race in Long-Term Survivors of Metastatic Breast Cancer
Table 2.
Multivariable analysis of factors associated with influenza vaccine utilization in long-term survivors of metastatic breast cancer
| ≥ 3-year survival cohort (N = 1,970) | ||||
|---|---|---|---|---|
| Received vaccine N (%) | Did not receive vaccine N (%) | OR (95% CI) | P-value | |
| Total Number | 1264 (64) | 706 (36) | N/A | N/A |
| Age | ||||
| 65–69 | 323 (61) | 203 (39) | Reference | N/A |
| 70–74 | 379 (65) | 201 (35) | 1.22 (0.95–1.58) | 0.118 |
| 75–79 | 257 (63) | 153 (37) | 1.07 (0.81–1.41) | 0.644 |
| 80+ | 305 (67) | 149 (33) | 1.30 (0.98–1.73) | 0.071 |
| Race | ||||
| White | 1143 (66) | 599 (34) | Reference | N/A |
| Black | 71 (46) | 82 (54) | 0.48 (0.34–0.68) | < 0.001 |
| Other | 50 (67) | 25 (33) | 1.10 (0.66–1.83) | 0.722 |
| Ethnicity | ||||
| Non-Spanish-Hispanic-Latino | 1201 (65) | 661 (35) | Reference | N/A |
| Spanish-Hispanic-Latino | 63 (58) | 45 (42) | 0.77 (0.51–1.16) | 0.212 |
| Urban Rural | ||||
| Rural | 18 (60) | 12 (40) | Reference | N/A |
| Metropolitan | 1246 (64) | 694 (36) | 1.25 (0.59–2.66) | 0.560 |
| Dual status | ||||
| No | 1144 (65) | 615 (35) | Reference | N/A |
| Yes | 120 (57) | 91 (43) | 0.79 (0.58–1.07) | 0.131 |
| ER/PR Status | ||||
| Positive | 782 (63) | 458 (37) | Reference | N/A |
| Negative | 100 (64) | 57 (36) | 1.14 (0.78–1.66) | 0.497 |
| HER2 Status | ||||
| Positive | 150 (60) | 101 (40) | Reference | N/A |
| Negative | 521 (65) | 282 (35) | 1.35 (0.99–1.84) | 0.061 |
| Chemotherapy | ||||
| No | 250 (59) | 171 (41) | Reference | N/A |
| Yes | 1014 (65) | 535 (35) | 1.35 (1.06–1.71) | 0.014 |
| PCP visit year prior to diagnosis | ||||
| No | 371 (54) | 318 (46) | Reference | N/A |
| Yes | 893 (70) | 388 (30) | 1.91 (1.57–2.33) | < 0.001 |
Co-variates of sex, marital status, year of diagnosis, state, and tumor grade were also included in the multivariable analysis but not shown here
The ≥ 5-year survival cohort included 792 patients with a median age at diagnosis of 73 years. In this cohort, 707 (89%) patients were White, and 51 (6%) patients were Black; 755 (95%) patients were non-Hispanic. Only 568 (72%) received at least one vaccination and 492 (62%) received the vaccine at least two times during the five years of follow-up. A multivariable model demonstrated significantly higher odds of receipt for those with primary care visits (69% vs. 49%; OR = 1.98, 95% CI 1.43–2.76, p < 0.001). Significant differences were not found in the multivariable model amongst those of Black vs. White race (57% vs. 73%; OR = 0.55, 95% CI 0.3–1.02, p = 0.06) or those who had received chemotherapy (Supplementary Table 2).
The matched control sample of patients followed for three years included 1,966 patients that shared similar baseline demographic characteristics to the cases as seen in Table 1. In this cohort, 1,334 (68%) received a vaccination at least one time and 1,105 (56%) received the vaccine at least two times during three years of follow-up. A multivariable model in the 3-year cancer-free controls similarly demonstrated lower odds of influenza vaccine receipt for Black patients (OR = 0.45; 95% CI 0.32–0.63, p < 0.001) and higher odds of receipt for patients that had a primary care visit in the year prior (OR = 2.76, 95% CI 2.21–3.45, p < 0.001) (Table 3). Notably, patients with MBC in the 3-year survival cohort had lower odds of influenza vaccination compared to the cancer free controls (OR = 0.85, 95% CI 0.74–0.97, p < 0.001), despite frequent evaluation by a physician. When this model was adjusted for primary care visits in the year prior to diagnosis, no significant difference was seen.
Table 3.
Multivariable analysis of factors associated with influenza vaccine utilization in cancer free controls
| ≥ 3-year cohort (N = 1966) | ||||
|---|---|---|---|---|
| Received vaccine N (%) | Did not receive vaccine N (%) | OR (95% CI) | P-value | |
| Total Number | 1,334 (68) | 632 (32) | N/A | N/A |
| Age | ||||
| 65–69 | 323 (63) | 190 (37) | Reference | N/A |
| 70–74 | 394 (68) | 188 (32) | 1.28 (0.99–1.66) | 0.059 |
| 75–79 | 279 (68) | 129 (32) | 1.33 (1.00–1.76) | 0.053 |
| 80+ | 338 (73) | 125 (27) | 1.58 (1.19–2.09) | 0.001 |
| Race | ||||
| White | 1213 (70) | 528 (30) | Reference | N/A |
| Black | 74 (49) | 78 (51) | 0.45 (0.32–0.63) | < 0.001 |
| Other | 47 (64) | 26 (36) | 0.93 (0.56–1.56) | 0.788 |
| Dual Status | ||||
| No | 1212 (69) | 548 (31) | Reference | N/A |
| Yes | 122 (59) | 84 (41) | 0.78 (0.57–1.07) | 0.128 |
| PCP visit year prior to index | ||||
| No | 211 (49) | 219 (51) | Reference | N/A |
| Yes | 1123 (73) | 413 (27) | 2.76 (2.21–3.45) | < 0.001 |
Co-variates of sex and year of diagnosis were also included in the multivariable analysis but not shown here
The matched control sample of patients followed for five years included 790 patients. 603 (76%) received at least one vaccination and 542 (69%) received the vaccine at least two times during the five years of follow-up. A multivariable model in the cancer-free controls in the 5-year cohort also demonstrated higher odds of vaccine receipt for patients that had a primary care visit in the year prior (OR = 2.85, 95% CI 1.96–4.14, p < 0.001). Patients with MBC in the 5-year survival cohort again had lower odds of influenza vaccination compared to cancer free controls (OR = 0.79, 95% CI 0.63–0.99, p < 0.001); this difference was no longer seen when adjusted for primary care visits in the year prior to diagnosis.
Discussion
We found that more than 1/3 of long-term elderly survivors with MBC in our SEER-Medicare dataset do not receive the influenza vaccine after diagnosis. Furthermore, Black patients were half as likely to receive the influenza vaccine as White patients. We would have expected that patients with advanced breast cancer who were being followed closely would have higher vaccination use, however, compared to matched controls, MBC patients had lower odds of receiving the influenza vaccine.
The prognosis associated with metastatic cancer is variable and changing, with 5-year survival ranging from about 6% for lung cancer to 30% for prostate cancer [3, 12, 13]. With substantial advancements in treatments, there have been significant improvements in survival rates. In fact, an adjusted analysis in a recent real-world study demonstrated a median overall survival of nearly 60 months for patients with MBC treated with an aromatase inhibitor and CDK 4/6 inhibitor [14]. Researchers at the National Cancer Institute estimated that as of 2018, there were 623,405 people in the United States living with the most prevalent metastatic cancers — breast, prostate, lung, colorectal, bladder cancer or metastatic melanoma — and that number is expected to increase to 693,452 by the year 2025 [15]. This emergence of a growing population of people living with metastatic cancer has raised questions about the unique needs of these individuals and how to improve their care. This includes management of chronic conditions and primary care, psychosocial support, financial support, and communication around goals of care. The literature on health care maintenance including screening and preventive interventions is especially limited. One study published over 10 years ago in the United States described secondary cancer screening among patients with advanced cancer and concluded that this practice was overutilized; another study published five years ago in Canada derived similar conclusions [3, 4]. Unfortunately, there remains a scarcity of knowledge about the needs of these survivors. In response, in May 2021, the National Cancer Institute convened a meeting of experts including clinicians, researchers, survivors, and advocates to identify evidence gaps. One of the main identified research areas was health care delivery including health promotion and understanding care patterns and care utilization of survivors with metastatic cancer [16].
The geriatric population of cancer patients is also growing; in fact, as of 2021 more than 50% of all new cancers globally (9.9 million) were diagnosed in individuals aged 65 and older [17]. Older adults also carry a higher burden of comorbidity and frailty compared with younger adults [18]. Furthermore, elderly adults may be discouraged from seeking medical attention or unable to navigate the health care system adequately. Limited access can be the result of a myriad of factors including insurance status, mobility limitations, and cognitive impairment [19]. The geriatric population of survivors with metastatic cancer poses a unique challenge as this population is medically and socially complex and its care needs are poorly understood and evolving. We sought to characterize one aspect of their care by exploring the utilization of a guideline-based routine preventive measure.
We found that over a third of long-term survivors with MBC in our dataset do not receive the influenza vaccine. This was an important discovery as this population is more vulnerable to morbidity and mortality associated with the virus [5–8]. In fact, patients with MBC are often on CDK 4/6 inhibitors which are immunosuppressive. A recent study estimated influenza vaccination rates across different cancer types and all stages in the United States using the National Health Interview Survey and found that 64% of 5053 individuals with self-reported cancer received the vaccine between 2016 and 2017 [20]. While our findings in the MBC population were similar numerically, it is important to note that we explored at least one vaccination across a three-year study period as opposed to a one-year period.
Furthermore, our finding that matched cancer-free controls were significantly more likely to receive the vaccine was unexpected. Despite frequent contact with the health care system, patients with MBC were less likely to receive the influenza vaccine. With the knowledge that the significant difference was no longer seen when primary care visits were adjusted for, our findings point towards a potential access discrepancy and a missed opportunity. This simple, low-risk primary care intervention could therefore be undertaken by the oncologist in addition to the primary care clinician. However, the importance and role of primary care in patients with advanced cancer diagnoses should not be underestimated and patients should be encouraged to maintain both aspects of their medical care if possible. Successful strategies to improve influenza vaccination rates should also be considered and could potentially be adopted into oncology practices. In one study, the implementation of an active choice intervention in the electronic health record that prompted medical assistants to ask patients about influenza vaccination during check-in and template vaccination orders for clinicians to review during the visit resulted in significantly higher influenza vaccination rates [21]. Furthermore, recent digital interventions including monthly messages through an online health platform in the Unites States and electronic letters in Denmark significantly increased influenza vaccine uptake [22, 23].
We also found racial disparities in influenza vaccine utilization in the MBC population. Despite comparable survival and likely frequency of medical visits in our study cohorts, Black patients were about half as likely to receive the influenza vaccine as White patients. Unfortunately, racial disparities in cancer care are widespread and remain a persistent challenge. Multiple other adverse outcomes including earlier onset, advanced stage at diagnosis, aggressive tumor subtype, and shorter survival are also seen in Black patients compared to White patients [24]. Furthermore, these disparities are seen in influenza vaccination across the United States in all individuals. A recent report by the Centers for Disease Control and Prevention noted lower influenza vaccination proportions amongst Black (42%) and Hispanic patients (38%) compared to White (54%) and non-Hispanic Asian (54%) patients [25]. Age-adjusted influenza hospitalization rates were also higher among Black and Hispanic adults compared with White adults between 2009 and 2022. Notably, the disparity in vaccine utilization by race and ethnicity was present even among those who reported having medical insurance, a primary care clinician, and a routine medical visit in the past year.
One limitation of our study was the inability to assess hospitalizations and mortality directly due to influenza-related illnesses and the impact of vaccination on these outcomes in our study cohorts. Since our cohorts included patients with MBC, this diagnosis would likely supersede an influenza diagnosis and make it difficult to determine outcomes based on SEER-Medicare claims data. Furthermore, the case-control comparison of vaccination between patients with MBC and matched cancer free controls had an inherent bias making it more challenging to draw definitive conclusions from this analysis. Significant differences were no longer seen after adjusting for primary care visits which suggests that primary care visits may be a confounding variable with influenza vaccine utilization. Finally, our results were based on claims data and could have underestimated the overall utilization of the influenza vaccine in instances when a claim may not be submitted, for example, in immunizations provided through grocery store clinics. Furthermore, claims data does not provide information on vaccine acceptance and may miss instances where a vaccine was offered and declined.
In conclusion, in this retrospective cohort study of elderly patients who are long-term survivors with MBC, we identified underutilization of the influenza vaccine. Our findings demonstrate primary care utilization disparities in the MBC population and indicate a need for educational and policy-based interventions. Given the frequent contact that patients with MBC have with their oncologists, simple primary care interventions such as the influenza vaccine could be undertaken by oncologists in the community in addition to primary care clinicians.
Supplementary Material
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10549-023-07109-5.
Acknowledgements
The funder did not play a role in the design of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; and the decision to submit the manuscript for publication.
This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.
The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Sect. 103885; Centers for Disease Control and Prevention’s (CDC) National Program of Cancer Registries, under cooperative agreement 1NU58DP007156; the National Cancer Institute’s Surveillance, Epidemiology and End Results Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors.
Funding
This work was supported by the Breast Cancer Research Foundation (DLH) and the American Cancer Society (DLH). Support for data acquisition provided by the Herbert Irving Comprehensive Cancer Center (P30CA013696).
Abbreviations
- MBC
Metastatic breast cancer
- SEER
Surveillance, Epidemiology, and End Results
- HMO
Health maintenance organization
Footnotes
Competing Interests The authors of this manuscript do not have any relevant conflicts of interest to disclose.
Ethics approval This is an observational study. The Columbia University Irving Medical Center Institutional Review board has confirmed that no ethical approval is required.
Data Availability
The data that support the findings of this study are available from Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the authors with the permission of the SEER program.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available from Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the authors with the permission of the SEER program.