Impact of care at NCI comprehensive cancer centers (NCICCC) on outcomes in children, adolescents, and young adults (AYA) with central nervous system tumors (CNSt).

Abstract

123 Background: AYA (15-39yo) have not seen the same survival improvement as younger cancer patients with similar diagnoses (dx), leaving an AYA Gap. Treatment on pediatric trials is associated with superior survival in 15-21yo. However, impact of care at NCICCC for complex diseases with poor prognosis that require evidence-based care available at NCICCC (e.g. CNSt), remain unstudied. Methods: We constructed a cohort of 560 children (0-14yo) and 785 AYA with newly-dx CNSt, reported to the LA County (LAC) cancer registry between 1998 and 2008. While 82% of children (0-14y) and 65% of young AYA (15-18y) were treated at one of 3 NCICCC or 3 COG sites in LAC, only 17% of older AYA (19-39y) were treated at one of 3 NCICCC. We sought to determine the impact of NCICCC/COG on overall survival (OS) and barriers to access to care at NCICCC/COG in AYA with CNSt. Since distance to NCICCC/COG could serve as a barrier to accessing care, Geographic Information Systems were used to derive distance between patient’s residence to the nearest NCICCC/COG. Results: OS rates were uniformly good for children and AYA with grade 1 CNSt (96 vs. 89% at 5y, p=0.2) and uniformly poor for children and AYA with grade 3/4 CNSt (43 vs. 43% at 5y, p=0.6). Among patients with WHO grade 2 CNSt, AYA had worse outcome (HR=1.9, p<0.01) after adjustment for race/ ethnicity, SES, and gender. This difference in outcome between AYA and children was abrogated by care at NCICCC (HR 1.4, p=0.2). Furthermore, patients cared at non-NCICCC saw worse outcome (HR=1.6, p=0.04). Compared with children, young AYA (15-18yo) were less likely to receive care at NCICCC (OR=0.3, p=0.02); race/ ethnicity, SES and distance to NCICCC did not influence care at NCICCC. Among older AYA (19-39yo), low SES (OR 0.4, p=0.01), public/ no insurance (OR 0.3, p<0.01) and longer distance to NCICCC (5-12mi: OR=0.3 , p<0.01; >12mi OR 0.5 , p=0.05) reduced likelihood to receive care at NCICCC. Conclusions: Population-based data reveal that receipt of care at NCICCC abrogates the inferior outcome in AYA with WHO grade 2 CNSt. Young AYA are less likely to use NCICCC than children, as are older AYA with low SES, public/ no insurance, or living > 5 miles from an NCICCC.