Current Research

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Understanding Cancer Care

Prior work in the social sciences suggests that individuals are profoundly affected by the actions of their peers; we posit that the same principle applies to how physicians care for their patients with cancer. This proposal aims to apply this concept of “social contagion” to cancer practice, shedding new light on the role of physicians and physician patient-sharing networks in the adoption of unproven technologies and the abandonment of proven ineffective treatments in cancer care. This work has the potential to transform the field of cancer care by identifying a novel level of behavior change: the diffusion of practices through networks of physicians.

Funding source: National Institutes of Health (National Cancer Institute)

Principal Investigator: Cary Gross

COPPER’s grant through the American Cancer Society will examine patterns of Gene Expression Profile (GEP) use among women diagnosed with breast cancer at the population level. We will specifically look at the adoption of the Oncotype Dx test, and other tests coming into the market during the study period. Through this grant we will assess independent patient and hospital factors associated with adoption, if these newer technologies are contributing to disparities in breast cancer care, and if GEP testing follows current guideline recommendations.

Funding source: American Cancer Society

Principal Investigator: Cary Gross

Breast ultrasound and MRI for cancer screening is not fully covered by most insurance plans, so some state legislatures have enacted laws requiring insurance companies to cover the procedures. Our study will assess the impact of enacted states laws on breast cancer screening, patient out-of-pocket costs and women’s knowledge about breast density. We will use health insurance claims to evaluate whether the use of the new screening modalities among women in their 40s and 50s has increased over time. We will also conduct a survey on a national sample of women in their 40s to evaluate women’s knowledge about breast density, breast cancer risk, and the impact of out of pocket cost on screening decisions.

Funding source: American Cancer Society

Principal Investigator: Cary Gross

The objective of this grant is to gain a better understanding of the contemporary use of active surveillance in prostate cancer and barriers to its use. The study will determine the national trends of active surveillance among men with prostate cancer in Medicare and privately insured patient populations. We will also perform a national survey of radiation oncologists and urologists to identify the barriers to active surveillance in the management of prostate cancer.

Funding source: ASCO Conquer Cancer Foundation (Career Development Award)

Principal Investigator: Simon Kim

Rituximab has been shown to improve the survival of patients with B cell malignancies, however, infusion related side-effects frequently lead to early rituximab discontinuation. Using the SEER-Medicare dataset, we will analyze real-world administration of rituximab in older adults to evaluate determinants of variation in rituximab administration. Our analysis explores the recently identified relationship between provider lymphoma volume and patient outcomes and our findings could inform future interventions designed to improve the quality of lymphoma care.

Funding source: Yale Cancer Center

Principal Investigator: Scott Huntington

This project is designed to evaluate the risk factors for myeloproliferative neoplasms in a large, prospective cohort with over 600,000 participants and to assess the patterns of care and clinical outcomes of patients in a separate population-based cohort of Medicare beneficiaries diagnosed with myeloproliferative neoplasms. 

Funding source: Frederick A. DeLuca Foundation

Principal Investigator: Xiaomei Ma & Nikolai Podoltsev 

Advanced imaging is universally obtained during the management of non-Hodgkin lymphoma, with lymphoma patients undergoing more imaging on average than individuals with other cancer subtypes. While advanced imaging has clearly improved NHL staging and treatment response assessment, a portion of imaging obtained during routine NHL management offers little utility. Using the SEER-Medicare dataset, our study will measure imaging utilization throughout the continuum of lymphoma care in older adults, with particular attention to low value PET-based imaging obtained in the post-treatment surveillance period. Our study aims to identify system and provider-level factors associated with imaging of low clinical utility, thereby informing future interventions designed to improve the value of cancer care.

Funding source: Yale Center for Clinical Investigation 

Principal Investigator: Scott Huntington

Insurance coverage is critical to early diagnosis, timely and appropriate treatment, and protection from financial burden for adults diagnosed with cancer.  The ACA generated the largest expansions in free or subsidized insurance eligibility for working-aged adults since the implementation of Medicaid. In addition, there are a variety of provisions that may enhance access for adults with a cancer history. Early evidence suggests that rates of uninsurance have declined substantially, but there is little evidence on the coverage impacts for cancer survivors, or the downstream effects on access to care and financial well-being. The purpose of this study is to fill that gap, using data from multiple years of the National Health Interview Survey linked to state policy data and local contextual characteristics. This research is in collaboration with researchers from the National Cancer Institute, Centers for Disease Control and Prevention, and the American Cancer Society.  

Funding source: Internal

Principal Investigator: Amy Davidoff

Digital breast tomosynthesis (DBT), sometimes known as “3D mammography”, is a relatively new imaging modality used for breast cancer screening. Data from nonrandomized studies suggest that compared to 2D mammography alone, use of DBT increases the cancer detection rate and decreases the recall rate.  While these findings have generated enthusiasm about DBT’s potential as an improvement over 2D mammography, there are no long term data to support DBT’s effectiveness in improving health outcomes. Accordingly, the US Preventive Services Task Force and other guideline-making organizations do not recommend DBT for screening in average risk women. The goal of this study is to characterize the use, outcomes, and costs of DBT for breast cancer screening in a contemporary cohort of privately insured women. We will specifically evaluate DBT uptake by patients and providers, costs, including out of pocket costs, and screening outcomes, including downstream health care utilization. Our goal is to understand the economic and clinical impact of this new screening technology. 

Funding source: Yale Center for Clinical Investigation 

Principal Investigator: Ilana Richman


Access, adequacy and effectiveness of medication therapy for symptom palliation is of critical importance to cancer patients and clinicians, and to policy makers assessing the Medicare Part D program. This study uses linked SEER-Medicare Health Outcomes Study data, with a further linkage to Part D claims. The study aims to examine patterns of depression and pain among older adults with cancer compared to similar adults without a cancer diagnosis; examine patterns of medication therapy to treat common patient-reported outcomes such as bodily pain and depression among older adults with cancer, and examine whether changes in reported pain, depression, functional status, and global HRQoL measures are associated with medication therapy. 

Funding source: National Institutes of Health (National Cancer Institute)

Principal Investigator: Amy Davidoff

Historically, hospice has been central to the provision of palliative care at end-of-life (EOL), and hospice enrollment for adults with advanced cancer has been used as a marker of high quality EOL care. However, several changes have occurred over the past decade that have underscored the distinction between hospice services and palliative care. There has been a growing awareness of the importance of palliative care across the trajectory of serious and potentially terminal illnesses. Several studies have found that incorporating palliative care during early periods of active cancer therapy improves quality of life, reduces costs, and may extend survival. In parallel, there is a growing supply of palliative care specialists, and increased pressure on oncologists to integrate palliative care within their practices. Yet relatively little is known about the impact of these changes. Several studies have separately examined patterns of cancer-directed therapy, palliative care, and hospice use, but no population-based studies have examined temporal patterns to identify concurrent palliative and cancer-directed therapy. The overarching goal of this study is to characterize the landscape of palliative care received by Medicare beneficiaries diagnosed with cancer, and to examine the association between specialty palliative care and quality outcomes at the end-of-life. More specifically, the study uses data on beneficiaries diagnosed with stage 3 or 4 lung cancer, identified in the Surveillance, Epidemiology and End Results (SEER)-Medicare database. In the study we will characterize palliative care services, including hospice, and cancer-directed therapy (chemotherapy or radiation) received over the course of the final 6 months prior to death. We will also examine the association between specialty palliative care visits and patterns of separate or concurrent palliative care, and selected poor-quality EOL outcomes. 

Funding source: Lung Cancer Research Foundation 

Principal Investigator: Amy Davidoff

In recent years there has been a dramatic expansion in the use advanced diagnostic tests for men with prostate cancer including MRI and genomic testing. This pilot study funded by the Yale Center for Clinical Investigation (YCCI) supports a one year project to understand national utilization patterns of prostate MRI and genomic testing among men who are newly diagnosed with prostate cancer. Using national data from both Medicare and privately-insured patients we will study which patients receive testing, which providers order these tests, and how prostate MRI and genomic profiling affect clinical management decisions. 

Funding source: Yale Center for Clinical Investigation 

Principal Investigator: Michael Leapman

Improving Decision-Making

The lack of routine, complete collection and use of PROs relevant to patients and caregivers for patients with metastatic breast cancer is a major deficit in the current cancer care delivery system.  We aim to bring together a diverse team of providers and patients to create an innovative approach to optimizing the care of metastatic breast cancer patients through improving patients’ knowledge of and engagement in their care, and communication between providers and patients. Our project focuses on building stakeholder partnerships to facilitate the integration of PRO information into clinical care, in order to assess, manage, and mitigate adverse effects of metastatic breast cancer treatment. 

Funding source: National Comprehensive Cancer Network & Pfizer

Principal Investigator: Cary Gross

We aim to develop an individualized decision analysis-based decision aid to help older women with early stage breast cancer decide whether to receive radiotherapy.

Funding source: Agency for Healthcare Research and Quality (Career Development Award)

Principal Investigator: Shiyi Wang

The goal of this study is to help doctors predict which patients 65 years and above are more likely to tolerate chemotherapy for stages I to III breast cancer with minimal side effects. Dr. Gross is PI at Yale, which is one of ten sites participating in this research project coordinated by City of Hope National Medical Center in California. We plan to enroll a total of 40 women at Yale as part of 500 women who will participate in the study. Clinical Trial information.

Funding source: National Institutes of Health (National Institute on Aging)

Principal Investigator: Cary Gross (site PI)

Outcomes & Effectiveness

Anthracycline-based chemotherapy has been a mainstay of adjuvant breast cancer treatment for over twenty years, but a feared side effect of anthracyclines is cardiotoxicity. The aims of this study are to examine the use of chemotherapy regimens with and without anthracyclines in Medicare beneficiaries as well as to determine what patient, clinical, and provider factors are associated with the adoption of each type of regimen. In addition, we will compare survival and the incidence of major toxicities among chemotherapy patients treated with and without anthracyclines. The proposed analysis assessing outcomes associated with chemotherapy regimens is the first of its kind to be completed using Medicare claims.

Funding source: CT Breast Health Initiative

Principal Investigator: Sarah Mougalian

The overarching goal of this study is to compare benefits, treatment burdens, and side effects between less-intensive treatment strategies among older DCIS patients. We aim to identify the population for whom less-intensive treatments may be appropriate. For more information, click here.

Funding source: Patient-Centered Outcomes Research Institute

Principal Investigator: Shiyi Wang

Uterine power morcellation is a technique of tissue removal that enables completion of laparoscopic hysterectomy and myomectomy with small incisions, helping improve patient recovery compared to traditional abdominal surgery. However, recent concern about possible spread of occult (i.e., preoperatively undetected) uterine cancer into the peritoneal cavity during power morcellation caused the U.S. Food and Drug Administration (FDA) issuing a safety warning against use of power morcellation in hysterectomy and myomectomy. This study capitalizes on existing, large health care databases to examine the prevalence and characteristics of occult uterine cancer in women undergoing hysterectomy or myomectomy for presumed benign indications and assess the impact of uncontained power morcellation on cancer prognosis, practice changes following the FDA warning, and associated impact on patient safety and health care costs.

Funding source: Agency for Healthcare Research and Quality (AHRQ)

Principal Investigator: Xiao Xu

Unlike many solid tumors, treatment for acute myeloid leukemia (AML) is often urgent and provided in the inpatient setting. Not all patients receive aggressive therapy – due to age or underlying fitness for cytotoxic chemotherapy regimens. Little is known about patterns of inpatient AML treatment, complications, and short term mortality. This study will use detailed data from the Premier Perspectives database to characterize patterns of induction therapy, complications, and in-hospital mortality for AML. By triangulating with data from SEER-Medicare, we seek to develop population-level estimates of inpatient and outpatient treatment and outcomes. 

Funding Source: Celgene Corporation 

Principal Investigator: Xiaomei Ma

Developing New Methods

This project aims to develop novel statistical methods to handle spatial uncertainty in the event locations when conducting cancer research, allowing researchers to take advantage of the full spectrum of available data at both an individual level and a group/regional level. 

Funding source: National Institutes of Health (National Cancer Institute)

Principal Investigator: Xiaomei Ma (Co-PI)